Risk for Severe Intimate Partner Violence in Nairobi's Informal Settlements: Tailoring the Danger Assessment to Kenya.

INTRODUCTION: Understanding the risk for severe intimate partner violence (IPV) can help women and providers assess danger. The validated, widely used Danger Assessment (DA) developed for this purpose has not been tested in a low- and middle-income country (LMIC). We tailored the DA to Nairobi, Kenya, and prospectively evaluated baseline danger against severe IPV at 3-month follow-up. METHODS: We used data from the myPlan Kenya trial conducted in 3 informal settlements in Nairobi, Kenya, from 2017 to 2018. DA items were refined through formative and pilot phases, yielding minor wording modifications. Quantitative analyses prospectively evaluated baseline DA against severe IPV at 3-month follow-up to understand the predictive effect of the (1) original 20-item DA, (2) 16-item Kenya-DA (highest relative risk ratios [RRR] with severe IPV), and (3) 16-item Kenya-DA weighted (weighting based on strength of RRRs). Diagnostic criteria, including C-statistics, sensitivity, specificity, receiver operating characteristic curve, and area under the curve, were examined; logistic regressions quantified the odds of each metric predicting severe IPV at follow-up. RESULTS: The original 20-item DA produced the highest specificity (75.41%) and lowest sensitivity (57.14%), resulting in the overall lowest C-statistic. Compared to the 16-item Kenya-DA, the Kenya-DA weighted produced slightly higher sensitivity (66.67% vs. 64.29%) and specificity (77.05% vs. 72.13%), resulting in the highest C-statistic (0.78 vs. 0.75). All versions successfully predicted severe IPV at 3-month follow-up (original DA: odds ratio [OR]=1.26, 95% confidence interval [CI]=1.12, 1.41, P<.001; Kenya-DA: OR=1.33, 95% CI=1.16, 1.53, P<.001; Kenya-DA weighted: OR=1.19, 95% CI=1.10, 1.28, P<.001). Several factors identified as homicide risk factors in other settings were not prospectively associated with severe IPV. CONCLUSION: Within a high-danger LMIC context, all 3 DA configurations performed well diagnostically. We recommend the 16-item Kenya-DA given the value for simplicity and field implementation, whereas the Kenya-DA weighted can add accuracy for research purposes.

Reproductive Coercion, Intimate Partner Violence, and Unintended Pregnancy Among Latina Women.

Reproductive coercion (RC) describes a range of behaviors that restrict reproductive autonomy including pregnancy coercion, birth control sabotage, and controlling the outcome of a pregnancy. RC is associated with pregnancies that are mistimed and unwanted (i.e., unintended). Past research demonstrates that Latina women have higher risk for RC and for unintended pregnancy. This cross-sectional descriptive study with Latina women (n = 482) examined prevalence and risk factors for RC, evaluated the association of RC and unintended pregnancy among women with a past-year pregnancy, and explored use of safety and harm reduction strategies. A tablet survey was administered to women attending a community health center, between the ages of 15 and 45, who self-identified as Latina and who had a dating or sexual partner in the past year. Approximately one in six (16.8%) experienced past-year RC and risk factors included younger age (adjusted odds ratio [AOR] = 0.95, 95% confidence interval [CI] = [0.91, 1.00], p = .038) and concurrent intimate partner violence (IPV; AOR = 4.47, 95% CI = [2.06, 9.70], p < .001). IPV questions were specific to the partner involved with RC behaviors. For the 185 participants who reported a past-year pregnancy, RC was associated with lower pregnancy planning scores (ß = -.27, 95% CI = [-0.41, -0.13], p < .001). The combination of experiencing RC and IPV appeared particularly potent in lowering pregnancy planning scores (ß = -.15, 95% CI = [-0.29, 0.00], p = .052). Approximately 10.6% of participants engaged in harm reduction strategies, most commonly ending an unhealthy or abusive relationship (6.1%) and using less detectable methods of contraception so that partners would not find out (3.4%). The study articulates the risk of RC and its intersection with IPV and unintended pregnancy for Latina women. Providers working with racially and ethnically marginalized women have an important role in promoting safety and harm reduction strategies that include offering less detectable methods of contraception and support in leaving unhealthy and abusive relationships.

Gendered health, economic, social and safety impact of COVID-19 on adolescents and young adults in Nairobi, Kenya.

BACKGROUND: Infectious disease outbreaks like COVID-19 and their mitigation measures can exacerbate underlying gender disparities, particularly among adolescents and young adults in densely populated urban settings. METHODS: An existing cohort of youth ages 16-26 in Nairobi, Kenya completed a phone-based survey in August-October 2020 (n = 1217), supplemented by virtual focus group discussions and interviews with youth and stakeholders, to examine economic, health, social, and safety experiences during COVID-19, and gender disparities therein. RESULTS: COVID-19 risk perception was high with a gender differential favoring young women (95.5% vs. 84.2%; p<0.001); youth described mixed concern and challenges to prevention. During COVID-19, gender symmetry was observed in constrained access to contraception among contraceptive users (40.4% men; 34.6% women) and depressive symptoms (21.8% men; 24.3% women). Gender disparities rendered young women disproportionately unable to meet basic economic needs (adjusted odds ratio [aOR] = 1.21; p<0.05) and in need of healthcare during the pandemic (aOR = 1.59; p<0.001). At a bivariate level, women had lower full decisional control to leave the house (40.0% vs. 53.2%) and less consistent access to safe, private internet (26.1% vs. 40.2%), while men disproportionately experienced police interactions (60.1%, 55.2% of which included extortion). Gender-specific concerns for women included menstrual hygiene access challenges (52.0%), increased reliance on transactional partnerships, and gender-based violence, with 17.3% reporting past-year partner violence and 3.0% non-partner sexual violence. Qualitative results contextualize the mental health impact of economic disruption and isolation, and, among young women, privacy constraints. IMPLICATIONS: Youth and young adults face gendered impacts of COVID-19, reflecting both underlying disparities and the pandemic's economic and social shock. Economic, health and technology-based supports must ensure equitable access for young women. Gender-responsive recovery efforts are necessary and must address the unique needs of youth.

Acceptability of a feasibility randomized clinical trial of a microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices (EMERGE) in young adults: a mixed methods assessment.

BACKGROUND: Acceptability is a critical requisite in establishing feasibility when planning a larger effectiveness trial. This study assessed the acceptability of conducting a feasibility randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults, aged 18 to 24, in Baltimore, Maryland. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. METHODS: Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19). The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Qualitative and quantitative post-intervention, in-person interviews were used in addition to process documentation of study methods. RESULTS: Our results found that the study design and interventions showed promise for being acceptable to economically-vulnerable African-American young adults. The largely positive endorsement suggested that factors contributing to acceptability included perceived economic potential, sexual health education, convenience, incentives, and encouraging, personalized feedback to participants. Barriers to acceptability for some participants included low cell phone connectivity, perceived payment delays, small cohort size, and disappointment with one's randomization assignment to comparison group. Use of peer referral, network, or wait-list designs, in addition to online options may enhance acceptability in a future definitive trial. Expanding administrative and mentoring support may improve overall experience. CONCLUSION: Microenterprise interventions are acceptable ways of providing young adults with important financial and sexual health content to address HIV risks associated with economic vulnerability. TRIAL REGISTRATION: ClinicalTrials.gov. NCT03766165 . Registered 04 December 2018.

Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study.

BACKGROUND: Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings. OBJECTIVE: This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys. METHODS: We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback. RESULTS: Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives. CONCLUSIONS: Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors. TRIAL REGISTRATION: ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871.

Microenterprise Intervention to Reduce Sexual Risk Behaviors and Increase Employment and HIV Preventive Practices Among Economically-Vulnerable African-American Young Adults (EMERGE): A Feasibility Randomized Clinical Trial.

Economic vulnerability, such as homelessness and unemployment, contributes to HIV risk among U.S. racial minorities. Yet, few economic-strengthening interventions have been adapted for HIV prevention in this population. This study assessed the feasibility of conducting a randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Primary feasibility objectives assessed recruitment, randomization, participation, and retention. Secondary objectives examined employment, sexual risk behaviors, and HIV preventive behaviors. Outcome assessments used an in-person pre- and post-intervention interview and a weekly text message survey. Several progression criteria for a definitive trial were met. Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19) of which 95% were retained. The comparison intervention enhanced willingness to be randomized and reduced non-participation. Mean age of participants was 21.0 years; 35% were male; 81% were unemployed. Fifty-eight percent (58%) of experimental participants completed ≥ 70% of intervention activities, and 74% completed ≥ 50% of intervention activities. Participation in intervention activities and outcome assessments was highest in the first half (~ 10 weeks) of the study. Seventy-one percent (71%) of weekly text message surveys received a response through week 14, but responsiveness declined to 37% of participants responding to ≥ 70% of weekly text message surveys at the end of the study. The experimental group reported higher employment (from 32% at baseline to 83% at week 26) and lower unprotected sex (79% to 58%) over time compared to reported changes in employment (37% to 47%) and unprotected sex (63% to 53%) over time in the comparison group. Conducting this feasibility trial was a critical step in the process of designing and testing a behavioral intervention. Development of a fully-powered effectiveness trial should take into account lessons learned regarding intervention duration, screening, and measurement.Trial Registration ClinicalTrials.gov. NCT03766165. Registered 04 December 2018. https://clinicaltrials.gov/ct2/show/NCT03766165.

Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis.

BACKGROUND: The WHO elimination strategy for hepatitis C virus advocates scaling up screening and treatment to reduce global hepatitis C incidence by 80% by 2030, but little is known about how this reduction could be achieved and the costs of doing so. We aimed to evaluate the effects and cost of different strategies to scale up screening and treatment of hepatitis C in Pakistan and determine what is required to meet WHO elimination targets for incidence. METHODS: We adapted a previous model of hepatitis C virus transmission, treatment, and disease progression for Pakistan, calibrating using available data to incorporate a detailed cascade of care for hepatitis C with cost data on diagnostics and hepatitis C treatment. We modelled the effect on various outcomes and costs of alternative scenarios for scaling up screening and hepatitis C treatment in 2018-30. We calibrated the model to country-level demographic data for 1960-2015 (including population growth) and to hepatitis C seroprevalence data from a national survey in 2007-08, surveys among people who inject drugs (PWID), and hepatitis C seroprevalence trends among blood donors. The cascade of care in our model begins with diagnosis of hepatitis C infection through antibody screening and RNA confirmation. Diagnosed individuals are then referred to care and started on treatment, which can result in a sustained virological response (effective cure). We report the median and 95% uncertainty interval (UI) from 1151 modelled runs. FINDINGS: One-time screening of 90% of the 2018 population by 2030, with 80% referral to treatment, was projected to lead to 13·8 million (95% UI 13·4-14·1) individuals being screened and 350 000 (315 000-385 000) treatments started annually, decreasing hepatitis C incidence by 26·5% (22·5-30·7) over 2018-30. Prioritised screening of high prevalence groups (PWID and adults aged ≥30 years) and rescreening (annually for PWID, otherwise every 10 years) are likely to increase the number screened and treated by 46·8% and decrease incidence by 50·8% (95% UI 46·1-55·0). Decreasing hepatitis C incidence by 80% is estimated to require a doubling of the primary screening rate, increasing referral to 90%, rescreening the general population every 5 years, and re-engaging those lost to follow-up every 5 years. This approach could cost US$8·1 billion, reducing to $3·9 billion with lowest costs for diagnostic tests and drugs, including health-care savings, and implementing a simplified treatment algorithm. INTERPRETATION: Pakistan will need to invest about 9·0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030. FUNDING: UNITAID.

Longitudinal impacts of an online safety and health intervention for women experiencing intimate partner violence: randomized controlled trial.

BACKGROUND: Responding to intimate partner violence (IPV) and its consequences is made complex by women's diverse needs, priorities and contexts. Tailored online IPV interventions that account for differences among women have potential to reduce barriers to support and improve key outcomes. METHODS: Double blind randomized controlled trial of 462 Canadian adult women who experienced recent IPV randomly were assigned to receive either a tailored, interactive online safety and health intervention (iCAN Plan 4 Safety) or a static, non-tailored version of this tool. Primary (depressive symptoms, PTSD symptoms) and secondary (helpfulness of safety actions, confidence in safety planning, mastery, social support, experiences of coercive control, and decisional conflict) outcomes were measured at baseline and 3, 6, and 12 months later via online surveys. Generalized Estimating Equations were used to test for differences in outcomes by study arm. Differential effects of the tailored intervention for 4 strata of women were examined using effect sizes. Exit survey process evaluation data were analyzed using descriptive statistics, t-tests and conventional content analysis. RESULTS: Women in both tailored and non-tailored groups improved over time on primary outcomes of depression (p < .001) and PTSD (p < .001) and on all secondary outcomes. Changes over time did not differ by study arm. Women in both groups reported high levels of benefit, safety and accessibility of the online interventions, with low risk of harm, although those completing the tailored intervention were more positive about fit and helpfulness. Importantly, the tailored intervention had greater positive effects for 4 groups of women, those: with children under 18 living at home; reporting more severe violence; living in medium-sized and large urban centers; and not living with a partner. CONCLUSION: This trial extends evidence about the effectiveness of online safety and health interventions for women experiencing IPV to Canadian women and provides a contextualized understanding about intervention processes and effects useful for future refinement and scale up. The differential effects of the tailored intervention found for specific subgroups support the importance of attending to diverse contexts and needs. iCAN is a promising intervention that can complement resources available to Canadian women experiencing IPV. TRIAL REGISTRATION: Clinicaltrials.gov ID NCT02258841 (Prospectively Registered on Oct 2, 2014).

Comparative effectiveness of an economic empowerment program on adolescent economic assets, education and health in a humanitarian setting.

BACKGROUND: Adolescence is a critical period of human development, however, limited research on programs to improve health and well-being among younger adolescents living in conflict-affected and humanitarian settings exists. The purpose of this study was to assess the comparative effectiveness of an economic empowerment program on young adolescent outcomes in a complex humanitarian setting. METHODS: This longitudinal, mixed methods study examined the relative effectiveness of an integrated parent (Pigs for Peace, PFP) and young adolescent (Rabbits for Resilience, RFR) animal microfinance/asset transfer program (RFR + PFP) on adolescent outcomes of asset building, school attendance, mental health, experienced stigma, and food security compared to RFR only and PFP only over 24 months. A sub-sample of young adolescents completed in-depth qualitative interviews on the benefits and challenges of participating in RFR. RESULTS: Five hundred forty-two young adolescents (10-15 years) participated in three groups: RFR + PFP (N = 178), RFR only (N = 187), PFP only (N = 177). 501 (92.4%) completed baseline surveys, with 81.7% (n = 442) retention at endline. The group by time interaction (24 months) was significant for adolescent asset building (X2 = 16.54, p = .002), school attendance (X2 = 12.33, p = .015), and prosocial behavior (X2 = 10.56, p = .032). RFR + PFP (ES = 0.31, ES = 0.38) and RFR only (ES-0.39, ES = 0.14) adolescents had greater improvement in asset building and prosocial behavior compared to PFP only, respectively. The odds of missing two or more days of school in the past month were 78.4% lower in RFR only and 45.1% lower in RFR + PFP compared to PFP only. No differences between groups in change over time were found for internalizing behaviors, experienced stigma, or food security. Differences by age and gender were observed in asset building, prosocial behavior, school attendance, experienced stigma, and food security. The voices of young adolescents identified the benefits of the RFR program through their ability to pay for school fees, help their families meet basic needs, and the respect they gained from family and community. Challenges included death of rabbits and potential conflict within the household on how to use the rabbit asset. CONCLUSION: These findings underscore the potential for integrating economic empowerment programs with both parents and young adolescents to improve economic, educational, and health outcomes for young adolescents growing up in rural and complex humanitarian settings. TRIAL REGISTRATION: NCT02008695. Retrospectively registered 11 December 2013.

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial.

BACKGROUND: Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages ("nudges") that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. METHODS/DESIGN: In total, 40 young adults who are African-American, aged 18-24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group ("comparison") will receive text messages with information on job openings. The second group ("experimental") will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention. DISCUSSION: This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03766165 . Registered on 4 December 2018.

Effectiveness of the Communities Care programme on change in social norms associated with gender-based violence (GBV) with residents in intervention compared with control districts in Mogadishu, Somalia.

OBJECTIVE: Determine the effectiveness of the Communities Care programme (CCP) on change in harmful social norms associated with gender-based violence (GBV) and confidence in provision of services with residents in intervention compared with control district. We hypothesised that residents in the intervention district would report a decrease in support for harmful social norms and increase in confidence in services in comparison with control district. SETTING: The study was conducted in Mogadishu, Somalia. PARTICIPANTS: In the intervention district, 192 community members (50% women) completed baseline surveys with 163 (84.9%) retained at endline. In the control district, 195 community members (50% women) completed baseline surveys with 167 (85.6%) retained at endline. INTERVENTION: CCP uses facilitated dialogues with community members to catalyse GBV prevention actions and provides training to diverse sectors to strengthen response services for GBV survivors. RESULTS: Residents in the intervention district had significantly greater improvement in change in social norms: (1) response to sexual violence (b=-0.214, p=0.041); (2) protecting family honour (b=-0.558, p<0.001); and (3) husband's right to use violence (b=-0.309, p=0.003) compared with control district participants. The greatest change was seen in the norm of 'protecting family honour' with a Cohen's d effect size (ES) of 0.70, followed by the norm 'husband's right to use violence' (ES=0.38), and then the norm of 'response to sexual violence' (ES=0.28). Residents in intervention district had a significantly greater increase in confidence in provision of GBV services across diverse sectors than the control district (b=0.318, p<0.001) with an associated effect size of 0.67. There were no significant differences between residents in intervention and control districts on change in personal beliefs on the norms. CONCLUSION: The evaluation showed the promise of CCP in changing harmful social norms associated with GBV and increasing confidence in provision of services in a complex humanitarian setting.

Understanding How Solidarity Groups-A Community-Based Economic and Psychosocial Support Intervention-Can Affect Mental Health for Survivors of Conflict-Related Sexual Violence in Democratic Republic of the Congo.

Solidarity groups were established in eastern Democratic Republic of Congo to provide female survivors of conflict-related sexual violence an opportunity to generate income, establish networks of support, and cope with atrocities. Qualitative data were collected from 12 members of solidarity groups to explore factors that contributed to members' mental health. All women identified some improvement (physiological, psychological, economic, or social) since joining the solidarity group, but none of the women were free from ailments. Our findings suggest that a multifaceted intervention in women's own communities has the potential to improve multiple aspects of women's lives, including mental health.

The weWomen and ourCircle randomized controlled trial protocol: A web-based intervention for immigrant, refugee and indigenous women with intimate partner violence experiences.

Intimate partner violence (IPV), including homicides is a widespread and significant public health problem, disproportionately affecting immigrant, refugee and indigenous women in the United States (US). This paper describes the protocol of a randomized control trial testing the utility of administering culturally tailored versions of the danger assessment (DA, measure to assess risk of homicide, near lethality and potentially lethal injury by an intimate partner) along with culturally adapted versions of the safety planning (myPlan) intervention: a) weWomen (designed for immigrant and refugee women) and b) ourCircle (designed for indigenous women). Safety planning is tailored to women's priorities, culture and levels of danger. Many abused women from immigrant, refugee and indigenous groups never access services [WHY?] and research is needed to support interventions that are most effective and suited to the needs of abused women from these populations in the US. In this two-arm trial, 1250 women are being recruited and randomized to either the web-based weWomen or ourCircle intervention or a usual safety planning control website. Data on outcomes (i.e., safety, mental health and empowerment) are collected at baseline and at 3, 6, and 12 months post- baseline. It is anticipated that the findings will result in an evidence-based culturally tailored intervention for use by healthcare and domestic violence providers serving immigrant, refugee and indigenous survivors of IPV. The intervention may not only reduce risk for violence victimization, but also empower abused women and improve their mental health outcomes.

The relationship between parent mental health and intimate partner violence on adolescent behavior, stigma and school attendance in families in rural Democratic Republic of Congo.

BACKGROUND: Prolonged conflict and economic instability challenge the existing support networks in families and society places significant stress on both adults and adolescents. Exploring individual, family and social factors that increase the likelihood of or protect adolescents from negative outcomes are important to the development of evidence-based prevention and response programing in global settings. OBJECTIVE: Examine the relationship between parent mental health and experience/perpetration of intimate partner violence (IPV) and adolescent behaviors, stigma, and school attendance. The relationship is further examined for differences by gender. METHODS: Secondary analysis of data from an ongoing comparative effectiveness trial of a productive asset transfer program in eastern Democratic Republic of Congo (DRC). RESULTS: Three hundred and eighty-eight adolescent and parent dyads were included in the analysis. The analysis demonstrated that parent mental health and IPV can have a negative impact their children's well-being and the impact is different for boys and girls, likely linked to gender roles and responsibilities in the home and community. Social relationships of adolescents, as reported through experienced stigma, were negatively impacted for both boys and girls. Parent report of symptoms of PTSD and depression had a stronger negative effect on girls' outcomes, including experienced stigma, externalizing behaviors, and missed days of school than boys. For adolescent boys, their parent's report of IPV victimization/perpetration was associated with more negative behaviors at the 8-month follow-up assessment. CONCLUSION: The findings reinforce the critical importance of interventions that engage parents and their children in activities that advance health and improve relationships within the family.

Responding to intimate partner violence: Healthcare providers' current practices and views on integrating a safety decision aid into primary care settings.

Supportive care for survivors of intimate partner violence (IPV) remains limited in primary care settings. Low-income and Spanish-speaking survivors of IPV are even more disadvantaged, given the dearth of linguistically and culturally appropriate interventions for IPV. We conducted semi-structured individual interviews with 17 healthcare workers, including physicians, nurses, and social workers, to describe how healthcare workers serving primarily low-income, Latina populations are currently screening and responding to IPV disclosure, and to explore the acceptability of integrating an interactive, personalized safety decision aid application-myPlan app-into the clinic setting. Despite recognition of IPV as a problem, none of the clinical sites had a protocol to guide screening and response to IPV disclosure. Screening practices varied across the sites, sometimes conducted by medical assistants prior to the provider visit and other times by the physician or nurse provider. When IPV was disclosed, it was often during assessment for a presenting problem such as poor sleep or anxiety. Most healthcare workers felt that clinical and community resources were limited for their patients experiencing IPV. The "warm hand-off" to a social worker was the most common response strategy when possible; otherwise, women were given information about available resources such as hotlines and safe houses. We discuss structural, family, and individual barriers to accessing safety resources for underserved women and review how an easily accessible safety decision app, such as myPlan, could be a resource for women to safely tailor an action plan for her situation.

Efficacy of a Web-Based Safety Decision Aid for Women Experiencing Intimate Partner Violence: Randomized Controlled Trial.

BACKGROUND: Intimate partner violence (IPV) is a human rights violation and leading health burden for women. Safety planning is a hallmark of specialist family violence intervention, yet only a small proportion of women access formal services. A Web-based safety decision aid may reach a wide audience of women experiencing IPV and offer the opportunity to prioritize and plan for safety for themselves and their families. OBJECTIVE: The aim of this study was to test the efficacy of a Web-based safety decision aid (isafe) for women experiencing IPV. METHODS: We conducted a fully automated Web-based two-arm parallel randomized controlled trial (RCT) in a general population of New Zealand women who had experienced IPV in the past 6 months. Computer-generated randomization was based on a minimization scheme with stratification by severity of violence and children. Women were randomly assigned to the password-protected intervention website (safety priority setting, danger assessment, and tailored action plan components) or control website (standard, nonindividualized information). Primary endpoints were self-reported mental health (Center for Epidemiologic Studies Depression Scale-Revised, CESD-R) and IPV exposure (Severity of Violence Against Women Scale, SVAWS) at 12-month follow-up. Analyses were by intention to treat. RESULTS: Women were recruited from September 2012 to September 2014. Participants were aged between 16 and 60 years, 27% (111/412) self-identified as Maori (indigenous New Zealand), and 51% (210/412) reported at baseline that they were unsure of their future plans for their partner relationship. Among the 412 women recruited, retention at 12 months was 87%. The adjusted estimated intervention effect for SVAWS was -12.44 (95% CI -23.35 to -1.54) for Maori and 0.76 (95% CI -5.57 to 7.09) for non-Maori. The adjusted intervention effect for CESD-R was -7.75 (95% CI -15.57 to 0.07) for Maori and 1.36 (-3.16 to 5.88) for non-Maori. No study-related adverse events were reported. CONCLUSIONS: The interactive, individualized Web-based isafe decision aid was effective in reducing IPV exposure limited to indigenous Maori women. Discovery of a treatment effect in a population group that experiences significant health disparities is a welcome, important finding. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000708853; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612000708853 (Archived by Webcite at http://www.webcitation/61MGuVXdK).

Importance and Contribution of Community, Social, and Healthcare Risk Factors for Hepatitis C Infection in Pakistan.

Pakistan has a high prevalence of hepatitis C virus (HCV) infection, estimated at 4.9% (2,290/46,843) in the 2007 national HCV seroprevalence survey. We used data from this survey to assess the importance of risk factor associations with HCV prevalence in Pakistan. Exposures were grouped as community (going to the barbers, sharing smoking equipment, having an ear/nose piercing, tattoo, or acupuncture), healthcare (ever having hemodialysis, blood transfusion, or ≥ 5 injections in the last year), demographic (marital status and age), and socio-economic (illiterate or laborer). We used mutually adjusted multivariable regression analysis, stratified by sex, to determine associations with HCV infection, their population attributable fraction, and how risk of infection accumulates with multiple exposures. Strength of associations was assessed using adjusted odds ratios (aOR). Community [aOR females 1.5 (95% confidence interval [CI]: 1.2, 1.8); males 1.2 (1.1, 1.4)] and healthcare [females 1.4 (1.2, 1.6); males 1.2 (1.1, 1.4)] exposures, low socio-economic status [females 1.6 (1.3, 1.80); males 1.3 (1.2, 1.5)], and marriage [females 1.5 (1.2, 1.9); males 1.4 (1.1, 1.8)] were associated with increased HCV infection. Among married women, the number of children was associated with an increase in HCV infection; linear trend aOR per child 1.06 (1.01, 1.11). Fewer infections could be attributed to healthcare exposures (females 13%; males 6%) than to community exposures (females 25%; males 9%). Prevalence increased from 3% to 10% when cumulative exposures increased from 1 to ≥ 4 [aOR per additional exposure for females 1.5 (1.4, 1.6); males 1.2 (1.2, 1.3)]. A combination of community, healthcare, and other factors appear to drive the Pakistan HCV epidemic, highlighting the need for a comprehensive array of prevention strategies.

Randomised controlled trial of a livestock productive asset transfer programme to improve economic and health outcomes and reduce intimate partner violence in a postconflict setting.

BACKGROUND: Diverse economic empowerment programmes (eg, microcredit, village-led savings and loan, cash and productive asset transfers) for the poor have demonstrated mixed results as vehicles for improved economic stability, health and women's empowerment. However, limited rigorous evaluations exist on the impact of financial and non-financial outcomes of these programmes, especially in conflict-affected areas. METHODS: The team evaluated the effectiveness of an innovative livestock productive asset transfer intervention-Pigs for Peace (PFP)-on economic, health and women's empowerment outcomes with participants in households in 10 villages in Eastern Democratic Republic of Congo. Residual change analysis was used to examine the amount of change from baseline to 18 months between the intervention and delayed control groups, controlling for baseline scores. FINDINGS: The majority of the 833 household participants were women (84%), 25 years of age or older, married, had on average 3 children and had never attended school. At 18 months postbaseline, the number of participants in the PFP households having outstanding credit/loans was 24.7% lower than households in the control group (p=0.028), and they had an 8.2% greater improvement in subjective health (p=0.026), a 57.1% greater reduction in symptoms of anxiety (p=0.020) and a 5.7% greater improvement in symptoms of post-traumatic stress disorder (p<-0.001). At 18 months postbaseline, partnered women and men reported a reduction in experience and perpetration of all forms of intimate partner violence, although not statistically significant between groups. INTERPRETATION: The findings support scalability of a livestock productive asset transfer programme in rural and conflict-affected settings where residents have extremely limited access to financial institutions or credit programmes, health or social services and where social norms that sustain gender inequality are strong. TRIAL REGISTRATION NUMBER: NCT02008708.

Adult and adolescent livestock productive asset transfer programmes to improve mental health, economic stability and family and community relationships in rural South Kivu Province, Democratic Republic of Congo: a protocol of a randomised controlled trial.

INTRODUCTION: People living in poverty have limited access to traditional financial institutions. Microfinance programmes are designed to meet this gap and show promise in improving income, economic productivity and health. Our Congolese-US community academic research partnership developed two livestock productive asset transfer programmes, Pigs for Peace (PFP) and Rabbits for Resilience (RFR), to address the interlinked health, social and economic well-being of individuals, their families and communities. The community-based randomised controlled trials examine the effectiveness of PFP and RFR to improve health, economic stability, and family and community relationships among male and female adults and adolescents living in 10 rural, postconflict villages of eastern Democratic Republic of Congo. METHODS AND ANALYSIS: PFP participants include adult permanent residents of rural villages; adolescent participants in RFR include male and female adolescents 10-15 years old living in the selected rural villages. Participants were randomised to intervention or delayed control group. Participants in PFP completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postintervention. In RFR, participants completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postbaseline. The primary outcome of both trials, the change in baseline mental health distress at 18 months in the intervention group (adults, adolescents) compared to control group, is used to calculate sample size. ETHICS AND DISSEMINATION: The Johns Hopkins Medical Institute Internal Review Board approved this protocol. A committee of respected Congolese educators and community members (due to lack of local ethics review board) approved the study. The findings will provide important information on the potential for community-led sustainable development initiatives to build on traditional livelihood (livestock raising, agriculture) to have a sustained health, economic and social impact on the individual, family and community. TRIAL REGISTRATION NUMBER: NCT02008708, NCT02008695.