Preterm Birth and Other Measures of Infant Biological Vulnerability: Associations with Maternal Sensitivity and Infant Cognitive Development.

INTRODUCTION: Low birth weight (LBW), biological vulnerability that includes preterm birth (PTB) and small for gestational age (SGA), is associated with reduced maternal sensitivity ("making accurate inferences about an infant's physical and emotional needs and responding appropriately") and impaired infant cognitive development. However, research does not examine if preterm birth, SGA, or both drive these associations. This study separated these measures of biological vulnerability to examine associations of LBW, PTB, and SGA with maternal sensitivity and infant cognitive development (controlling for maternal depression, breastfeeding, and demographic covariates). METHODS: The sample included 6900 9-month-old infants from the Early Childhood Longitudinal Study-Birth Cohort and used birth certificate data, maternal interviews, assessments of maternal sensitivity and infant cognitive development. Multiple linear regressions examined LBW, PTB, and SGA associations with concurrent measures of maternal sensitivity and infant cognition. RESULTS: Of the biological vulnerabilities, preterm birth had the strongest negative association with maternal sensitivity (F1,6450 = 29.48 versus 15.33 and 5.51, ps < .001) and infant cognitive development (F1,6450) = 390.65 versus 248.02 and 14.43, ps < .001). In the final regression model, preterm birth and maternal sensitivity were uniquely associated with infant cognitive development (R2 = .05, p < .001), after controlling for maternal depression, breastfeeding, and demographics. CONCLUSION: In this nationally representative infant sample infants, PTB had a stronger negative association with both maternal sensitivity and infant cognitive development in comparison to SGA or LBW. The LBW designation combines infants born preterm with SGA infants, potentially minimizing differences in developmental outcomes of PTB and SGA infants.

Association between caregiver and household alcohol use and child behavior problems in KwaZulu Natal, South Africa.

We explored the association between household alcohol use and behavior problems among South-African children, using data from the Asenze study, a population-based cohort of South African children and their caregivers. Household alcohol use and child behavior were assessed when children were 6-8 years old. To examine the association, we performed linear regressions. The sample included 1383 children with complete data under the care of 1251 adults. Children living in a household where self-reported caregiver alcohol use was scored as hazardous (4.6%) had higher levels of problem behavior (ß = 1.94, 95% CI 0.06-3.82). There were no statistically significant associations between reported hazardous alcohol use by another member of the household (14.5%) and child problem behavior. Hazardous household alcohol use was associated with child problem behavior and this effect appeared to be mainly driven by primary caregiver use.

Does breastfeeding account for the association between maternal sensitivity and infant cognitive development in a large, nationally representative cohort?

BACKGROUND: Previous research has established that exposure to high maternal sensitivity is positively associated with advances in infant cognitive development. However, there are many fixed and modifiable factors that influence this association. This study investigates whether the association between maternal sensitivity and infant cognitive development in the first year of life is accounted for by other factors, such as breastfeeding, maternal depressive symptoms, maternal alcohol use, infant birth weight or demographic covariates. METHODS: Using data from the Early Childhood Longitudinal Study-Birth (ECLS-B) Cohort, a nationally representative sample of U.S. born children, multi-variable regression analyses was used to examine whether breastfeeding, maternal depressive symptoms and alcohol use were associated with maternal sensitivity, as measured by the Nursing Child Assessment Teaching Scale (NCATS), and with infant cognitive development, as measured by the Bayley Scales of Infant Development, Short Form, Research Edition, after controlling for demographic covariates (infant sex, maternal age, education, race/ethnicity, income, parity, family structure) and infant birth weight. RESULTS: Breastfeeding, depressive symptoms and alcohol use were not associated with maternal sensitivity scores after controlling for demographic covariates and infant birth weight. However, breastfeeding (ß = .079, p < .001), depressive symptoms (ß = -.035, p < .05), and maternal sensitivity (ß = .175, p < .001) were each significantly associated with infant cognitive development scores, even after controlling for demographic covariates and birthweight (R2 = .053, p < .001). The association between maternal sensitivity and infant cognitive development did not attenuate after adjusting for breastfeeding. Instead, both sensitivity and breastfeeding independently contributed to higher infant cognitive development scores. CONCLUSION: Maternal sensitivity and breastfeeding are separate means to advancing infant cognitive development. This study is significant because it is the first to examine breastfeeding, maternal depressive symptoms and alcohol use together, upon the association between maternal sensitivity and infant cognitive development, after adjusting for demographic covariates and infant birthweight. Maternal sensitivity, a measurable quality, advances infants' cognitive development. Moreover, sensitivity and breastfeeding had independent effects upon cognitive development after controlling for multiple fixed and modifiable covariates. Understanding factors impacting the association between sensitivity and infant cognitive development provide avenues for developing more effective parenting interventions.

Adverse childhood experiences (ACEs) and child behaviour problems in KwaZulu-Natal, South Africa.

BACKGROUND: Adverse childhood events (ACEs) are associated with negative health effects in adulthood. Despite knowledge of these later impacts, little is known about the earlier effect of ACEs on later child behaviour in low- and middle-income countries (LMIC). METHODS: The population-based Asenze cohort study was implemented in a peri-rural area of KwaZulu-Natal, South Africa, comprising five Zulu tribal areas. Two waves of data were examined: family information and ACEs exposure when children were on average 5 years old and child behaviour problems (Strengths and Difficulties Questionnaire [SDQ]) approximately 2 years later (average age 7 years). Logistic regression analysis was used to examine unadjusted and adjusted relationships between cumulative ACEs experienced and the SDQ total scores (dichotomized as top 10% vs. the rest) as well as selected SDQ subscales. RESULTS: A significant relationship between increased ACE exposure and SDQ total score was observed. The same relationship was also seen for the SDQ emotional symptoms and conduct problem subscales, but not for hyperactivity. The results of a sensitivity analysis excluding intimate partner violence from the ACEs measure demonstrated similar results. CONCLUSIONS: There is an association between exposure to ACEs and later child behaviour problems within this LMIC population demonstrating an early negative impact for ACEs. While previous research has focused on the effects of ACEs on adult health, this study provided evidence for an earlier relationship between ACEs and child behaviour problems that may be a part of the mechanism through which later health effects arise.

Reducing neurodevelopmental disorders and disability through research and interventions.

We define neurodevelopment as the dynamic inter-relationship between genetic, brain, cognitive, emotional and behavioural processes across the developmental lifespan. Significant and persistent disruption to this dynamic process through environmental and genetic risk can lead to neurodevelopmental disorders and disability. Research designed to ameliorate neurodevelopmental disorders in low- and middle-income countries, as well as globally, will benefit enormously from the ongoing advances in understanding their genetic and epigenetic causes, as modified by environment and culture. We provide examples of advances in the prevention and treatment of, and the rehabilitation of those with, neurodevelopment disorders in low- and middle-income countries, along with opportunities for further strategic research initiatives. Our examples are not the only possibilities for strategic research, but they illustrate problems that, when solved, could have a considerable impact in low-resource settings. In each instance, research in low- and middle-income countries led to innovations in identification, surveillance and treatment of a neurodevelopmental disorder. These innovations have also been integrated with genotypic mapping of neurodevelopmental disorders, forming important preventative and rehabilitative interventions with the potential for high impact. These advances will ultimately allow us to understand how epigenetic influences shape neurodevelopmental risk and resilience over time and across populations. Clearly, the most strategic areas of research opportunity involve cross-disciplinary integration at the intersection between the environment, brain or behaviour neurodevelopment, and genetic and epigenetic science. At these junctions a robust integrative cross-disciplinary scientific approach is catalysing the creation of technologies and interventions for old problems. Such approaches will enable us to achieve and sustain the United Nations moral and legal mandate for child health and full development as a basic global human right.

A focus on adolescence to reduce neurological, mental health and substance-use disability.

Globally, there is a crucial need to prioritize research directed at reducing neurological, mental health and substance-use disorders in adolescence, which is a pivotal age for the development of self-control and regulation. In adolescence, behaviour optimally advances towards adaptive long-term goals and suppresses conflicting maladaptive short-lived urges to balance impulsivity, exploration and defiance, while establishing effective societal participation. When self-control fails to develop, violence, injury and neurological, mental health and substance-use disorders can result, further challenging the development of self-regulation and impeding the transition to a productive adulthood. Adolescent outcomes, positive and negative, arise from both a life-course perspective and within a socioecological framework. Little is known about the emergence of self-control and regulation in adolescents in low- and middle-income countries where enormous environmental threats are more common (for example, poverty, war, local conflicts, sex trafficking and slavery, early marriage and/or pregnancy, and the absence of adequate access to education) than in high-income countries and can threaten optimal neurodevelopment. Research must develop or adapt appropriate assessments of adolescent ability and disability, social inclusion and exclusion, normative development, and neurological, mental health and substance-use disorders. Socioecological challenges in low- and middle-income countries require innovative strategies to prevent mental health, neurological and substance-use disorders and develop effective interventions for adolescents at risk, especially those already living with these disorders and the consequent disability.

A Systematic Review of Household and Family Alcohol Use and Childhood Neurodevelopmental Outcomes in Low- and Middle-Income Countries.

Childhood exposure to alcohol misuse by household adults has been related to childhood developmental delay, cognitive impacts, mental illness, and problem behaviours. Most evidence comes from high income countries. This systematic review only included studies from low- and middle-income countries (LMICs). Five databases were searched from 1990-2020. Twenty-eight studies of children 0-12 years were included, with 42,599 participants from 11 LMICs. The most common outcome was behavioural problems/disorders (19 studies). Despite varying study designs, this review found that alcohol misuse by household members in LMICs is associated with adverse child neurodevelopmental outcomes, although casual inferences cannot be drawn in the absence of well conducted prospective studies. Statistically significant correlations were described between parental alcohol misuse and child emotional and behavioural difficulties, cognitive delay, and risky behaviours. In future, prospective cohort studies are recommended, with adjustment for confounders.

A Systematic Review of Household and Family Alcohol Use and Adolescent Behavioural Outcomes in Low- and Middle-Income Countries.

Exposure to alcohol misuse is considered an adverse childhood experience impacting on neurodevelopmental and behavioural outcomes in adolescents including substance use, mental illness, problem behaviours, suicidality, and teenage pregnancy. Most research on this issue has focussed on higher income countries, whereas patterns of alcohol use and related factors may be different in low- and middle-income countries (LMICs). This systematic review therefore seeks to collate all published studies from 1990-2020 on the topic set in LMICs. 43 studies were included, totalling 70,609 participants from 18 LMICs. Outcomes assessed included: substance use; depression/anxiety; suicidal ideation; problem behaviour; emotional dysfunction; teenage pregnancy; and self-harm. Despite heterogeneity in the studies identified, this review documented some association between exposure to household alcohol misuse and adverse adolescent outcomes in LMICs, including mental health problems, problem behaviours, and suicidality. The mechanisms leading to these outcomes are likely varied, and further research in different socio-economic and cultural contexts, particularly in the form of longitudinal studies, is called for.

Cognitive and Language Development at Age 4-6 Years in Children HIV-Exposed But Uninfected Compared to Those HIV-Unexposed and to Children Living With HIV.

Perinatal HIV infection is associated with delayed neurocognitive development, but less is known about children perinatally HIV-exposed but uninfected (CHEU). We compared cognitive and language outcomes in 4-6-year old CHEU versus children HIV-unexposed and uninfected (CHUU) and children living with HIV (CLHIV). We enrolled 1,581 children (77% of the child population) in five communities in KwaZulu-Natal, South Africa. Children completed: Grover-Counter Scale of cognitive development, sub-scales of the Kaufman Assessment Battery for Children, Reynell Developmental Language Scales. HIV status of children and primary caregivers was determined by repeated rapid tests or report of prior testing. We conducted a cross-sectional multivariable linear regression on 922 dyads with complete data (257 CHEU, 627 CHUU, 38 CLHIV). On all outcome measures, CHEU and CHUU groups had comparable scores; CLHIV scored significantly lower. Emerging global progress toward the elimination of vertical HIV transmission may not only reduce mortality, but also positively impact child development.

Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development.

OBJECTIVE: To investigate the relationship between prenatal geophagy, maternal prenatal haematological indices, malaria, helminth infections and cognitive and motor development among offspring. METHODS: At least a year after delivery, 552 of 863 HIV-negative mothers with singleton births who completed a clinical trial comparing the efficacy of sulfadoxine-pyrimethamine and mefloquine during pregnancy in Allada, Benin, responded to a nutrition questionnaire including their geophagous habits during pregnancy. During the clinical trial, helminth infection, malaria, haemoglobin and ferritin concentrations were assessed at 1st and 2nd antenatal care visits (ANV) and at delivery. After the first ANV, women were administered daily iron and folic acid supplements until three what? post-delivery. Singleton children were assessed for cognitive function at age 1 year using the Mullen Scales of Early Learning. RESULTS: The prevalence of geophagy during pregnancy was 31.9%. Pregnant women reporting geophagy were more likely to be anaemic (AOR = 1.9, 95% CI [1.1, 3.4]) at their first ANV if they reported geophagy at the first trimester. Overall, prenatal geophagy was not associated with maternal haematological indices, malaria or helminth infections, but geophagy during the third trimester and throughout pregnancy was associated with poor motor function (AOR = -3.8, 95% CI [-6.9, -0.6]) and increased odds of geophagous behaviour in early childhood, respectively. CONCLUSIONS: Prenatal geophagy is not associated with haematological indices in the presence of micronutrient supplementation. However, it may be associated with poor child motor function and infant geophagy. Geophagy should be screened early in pregnancy.

Factors associated with the health and cognition of 6-year-old to 8-year-old children in KwaZulu-Natal, South Africa.

OBJECTIVE: To investigate 6-year-old to 8-year-old children's health, nutritional status and cognitive development in a predominantly rural area of KwaZulu-Natal, South Africa. METHODS: Cohort study of 1383 children investigating the association of demographic variables (area of residence, sex, pre-school education, HIV status, height for age and haemoglobin level) and family variables (socioeconomic status, maternal and paternal level of education), with children's cognitive performance. The latter was measured using the Grover-Counter Scale of Cognitive Development and subtests of the Kaufman Assessment Battery for Children, second edition (KABC-II). General linear models were used to determine the effect of these predictors. RESULTS: Area of residence and height-for-age were the statistically significant factors affecting cognitive test scores, regardless of attending pre-school. Paternal level of education was also significantly associated with the cognitive test scores of the children for all three cognitive test results, whereas HIV status, sex and their socioeconomic status were not. CONCLUSION: Children with low cognitive scores tended to be stunted (low height-for-age scores), lacked pre-school education and were younger. Area of residence and their parents' educational level also influenced their cognition.

Validation of the Client Diagnostic Questionnaire to Assess Mental Health in South African Caregivers of Children.

BACKGROUND: Given the high prevalence of mental health (MH) and substance abuse problems in low-to-middle income countries, the scarcity of MH professionals and the negative impact of psychiatric disorders on caregivers of young children, there is significant need for brief evidence-based screening tools for lay counselors to assist with MH assessment. This study aimed to validate a brief screening tool to assess psychiatric and substance use disorders, the Client Diagnostic Questionnaire (CDQ), in South Africa (SA). METHODS: Data are from a longitudinal study of health and psychosocial needs in preschool children in SA. Participants included 322 Zulu-speaking, female caregivers. Following procedures of the US CDQ validation study, lay counselors interviewed participants using the translated Zulu CDQ. Subsequently a psychologist conducted a full psychiatric assessment guided by the CDQ questions. Analyses examined sensitivity, specificity and overall accuracy, comparing lay counselor and psychologist assessment. RESULTS: Sensitivity (73%), specificity (81%) and overall accuracy (79%) were good for the variable indicating presence of 'any diagnosis.' Among those cases identified by the psychologist as having any psychiatric diagnosis, over 70% were correctly identified by lay counselors using the CDQ (i.e., positive predictive value was greater than 70%). The false positive rate was relatively low (19%). Specificity for 'any disorder' (including substance use) and 'any psychiatric disorder' were 81% and 79%. CONCLUSIONS: The isiZulu CDQ is a sensitive and valid MH diagnostic screener that can be used by lay counselors with limited MH training to identify those in need of treatment and target extremely scarce MH professionals. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: South Africa (SA), a country heavily impacted by poverty, HIV and the legacy of Apartheid, has a high prevalence of mental health (MH) and substance abuse problems. In SA and other low-and-middle-income-countries (LMIC) there is a dearth of MH professionals. This study examined use and validity of the Client Diagnostic Questionnaire (CDQ), a brief diagnostic MH screening tool designed for use by lay counselors in HIV-affected populations. Comparing lay counsellor diagnoses on the CDQ to clinician assessment, sensitivity, specificity and overall accuracy were good at the level of 'any diagnosis.' The CDQ can be used effectively in SA and other LMIC with limited MH services to enable appropriate and efficient referral of individuals in primary care settings, supporting caregivers and the children in their care.

Screening Caregivers of Children for Risky Drinking in KwaZulu-Natal, South Africa.

Background and Objectives Alcohol abuse, a significant health problem in South Africa, affects the ability of adults to care for children. Little is known regarding risky alcohol use among child caregivers there. A large population-based study examined the prevalence of, and factors associated with, risky drinking among caregivers of young children in KwaZulu-Natal, South Africa comparing the use of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-C screens for hazardous or harmful drinking (referred to here as risky drinking). Methods 83 % of child caregivers from five tribal areas were interviewed using the 10-question AUDIT to screen for risky drinking. The AUDIT-C screen, a subset of AUDIT questions, targets alcohol consumption and binge drinking. Factors associated with risky drinking were investigated using logistic regression. Results 1434 caregivers participated, 98 % female. Sixteen percent reported ever drinking alcohol. Based on AUDIT criteria for risky drinking, 13 % of the sample scored as moderate drinkers, 2 % as hazardous users, and 1 % as harmful or dependent users (identifying 3 % as risky drinkers). Using AUDIT-C criteria to identify risky drinking significantly increased the proportion of caregivers identified as risky drinkers to 9 %. In multivariate analyses, factors associated with risky drinking were similar in both screens: partner violence, smoking, HIV-infection, caring for a child with disabilities. Conclusions for Practice Since the AUDIT-C identified risky alcohol use not otherwise detected with the full AUDIT, and since resources for screening in health care settings is limited, the AUDIT-C may be a more appropriate screen in populations where binge drinking is common.

Screening women for intimate partner violence in healthcare settings.

BACKGROUND: Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for IPV rather than asking only women with symptoms (case-finding). Here, we examine the evidence for whether screening benefits women and has no deleterious effects. OBJECTIVES: To assess the effectiveness of screening for IPV conducted within healthcare settings on identification, referral, re-exposure to violence, and health outcomes for women, and to determine if screening causes any harm. SEARCH METHODS: On 17 February 2015, we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, six other databases, and two trial registers. We also searched the reference lists of included articles and the websites of relevant organisations. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials assessing the effectiveness of IPV screening where healthcare professionals either directly screened women face-to-face or were informed of the results of screening questionnaires, as compared with usual care (which could include screening that did not involve a healthcare professional). DATA COLLECTION AND ANALYSIS: Two authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the odds ratio (OR). For continuous data, either a mean difference (MD) or standardised mean difference (SMD) was calculated. All are presented with a 95% confidence interval (CI). MAIN RESULTS: We included 13 trials that recruited 14,959 women from diverse healthcare settings (antenatal clinics, women's health clinics, emergency departments, primary care) predominantly located in high-income countries and urban settings. The majority of studies minimised selection bias; performance bias was the greatest threat to validity. The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision.We excluded five of 13 studies from the primary analysis as they either did not report identification data, or the way in which they did was not consistent with clinical identification by healthcare providers. In the remaining eight studies (n = 10,074), screening increased clinical identification of victims/survivors (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence).Subgroup analyses suggested increases in identification in antenatal care (OR 4.53, 95% CI 1.82 to 11.27, two studies, n = 663, moderate quality evidence); maternal health services (OR 2.36, 95% CI 1.14 to 4.87, one study, n = 829, moderate quality evidence); and emergency departments (OR 2.72, 95% CI 1.03 to 7.19, three studies, n = 2608, moderate quality evidence); but not in hospital-based primary care (OR 1.53, 95% CI 0.79 to 2.94, one study, n = 293, moderate quality evidence).Only two studies (n = 1298) measured referrals to domestic violence support services following clinical identification. We detected no evidence of an effect on referrals (OR 2.24, 95% CI 0.64 to 7.86, low quality evidence).Four of 13 studies (n = 2765) investigated prevalence (excluded from main analysis as rates were not clinically recorded); detection of IPV did not differ between face-to-face screening and computer/written-based assessment (OR 1.12, 95% CI 0.53 to 2.36, moderate quality evidence).Only two studies measured women's experience of violence (three to 18 months after screening) and found no evidence that screening decreased IPV.Only one study reported on women's health with no differences observable at 18 months.Although no study reported adverse effects from screening interventions, harm outcomes were only measured immediately afterwards and only one study reported outcomes at three months.There was insufficient evidence on which to judge whether screening increases uptake of specialist services, and no studies included an economic evaluation. AUTHORS' CONCLUSIONS: The evidence shows that screening increases the identification of women experiencing IPV in healthcare settings. Overall, however, rates were low relative to best estimates of prevalence of IPV in women seeking healthcare. Pregnant women in antenatal settings may be more likely to disclose IPV when screened, however, rigorous research is needed to confirm this. There was no evidence of an effect for other outcomes (referral, re-exposure to violence, health measures, lack of harm arising from screening). Thus, while screening increases identification, there is insufficient evidence to justify screening in healthcare settings. Furthermore, there remains a need for studies comparing universal screening to case-finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing in order to inform IPV identification policies in healthcare settings.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse.

BACKGROUND: Intimate partner abuse is common worldwide, damaging the short- and long-term physical, mental, and emotional health of survivors and children. Advocacy may contribute to reducing abuse, empowering women to improve their situation by providing informal counselling and support for safety planning and increasing access to different services. Advocacy may be a stand-alone service, accepting referrals from healthcare providers, or part of a multi-component (and possibly multi-agency) intervention provided by service staff or others. OBJECTIVES: To assess the effects of advocacy interventions within or outside healthcare settings in women who have experienced intimate partner abuse. SEARCH METHODS: In April 2015, we searched CENTRAL, Ovid MEDLINE, EMBASE, and 10 other databases. We also searched WHO ICTRP, mRCT, and UK Clinical Research Network (UKCRN), and examined relevant websites and reference lists with forward citation tracking of included studies. For the original review we handsearched six key journals. We also contacted first authors of eligible papers and experts in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing advocacy interventions for women with experience of intimate partner abuse versus no intervention or usual care (if advocacy was minimal and fewer than 20% of women received it). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias and undertook data extraction. We contacted authors for missing information needed to calculate statistics for the review and looked for adverse events. MAIN RESULTS: We included 13 trials involving 2141 participants aged 15 to 65 years, frequently having low socioeconomic status.The studies were quite heterogeneous in terms of methodology, study processes and design, including with regard to the duration of follow-up (postintervention to three years), although this was not associated with differences in effect. The studies also had considerable clinical heterogeneity in relation to staff delivering advocacy; setting (community, shelter, antenatal, healthcare); advocacy intensity (from 30 minutes to 80 hours); and abuse severity. Three trials evaluated advocacy within multi-component interventions. Eleven measured some form of abuse (eight scales), six assessed quality of life (three scales), and six measured depression (three scales). Countries and ethnic groups varied (one or more minority ethnic groups in the USA or UK, and local populations in Hong Kong and Peru). Setting was associated with intensity and duration of advocacy.Risk of bias was high in five studies, moderate in five, and low in three. The quality of evidence (considering multiple factors such as risk of bias, study size, missing data) was moderate to low for brief advocacy and very low for intensive advocacy. Incidence of abuse Physical abuseModerate quality pooled data from two healthcare studies (moderate risk of bias) and one community study (low risk of bias), all with 12-month follow-up data, showed no effect on physical abuse for brief (< 12 hours) advocacy interventions (standardised mean difference (SMD) 0.00, 95% confidence interval (CI) - 0.17 to 0.16; n = 558). One antenatal study (low risk of bias) showed an association between brief advocacy and reduced minor physical abuse at one year (mean difference (MD) change - 1.00, 95% CI - 1.82 to - 0.18; n = 110). An antenatal, multi-component study showed a greater likelihood of physical abuse ending (odds ratio (OR) 0.42, 95% CI 0.23 to 0.75) immediately after advocacy (number needed to treat (NNT) = 8); we cannot exclude impact from other components.Low to very low quality evidence from two intensive advocacy trials (12 hours plus duration) showed reduced severe physical abuse in women leaving a shelter at 24 months (OR 0.39, 95% CI 0.20 to 0.77; NNT = 8), but not at 12 or 36 months. Sexual abuseMeta-analysis of two studies (n = 239) showed no effect of advocacy on sexual abuse (SMD - 0.12, 95% CI - 0.37 to 0.14), agreeing with the change score (MD - 0.07, 95% CI - 0.30 to 0.16) from a third study and the OR (0.96, 95% CI 0.44 to 2.12) from a fourth antenatal, multi-component study. Emotional abuseOne study in antenatal care, rated at low risk of bias, showed reduced emotional abuse at ≤ 12-month follow-up (MD (change score) - 4.24, 95% CI - 6.42 to - 2.06; n = 110). Psychosocial health Quality of lifeMeta-analysis of two studies (high risk of bias) showed intensive advocacy slightly improved overall quality of life of women recruited from shelters (MD 0.23, 95% CI 0.00 to 0.46; n = 343) at 12-month follow-up, with greater improvement in perceived physical quality of life from a primary care study (high risk of bias; MD 4.90, 95% CI 0.98 to 8.82) immediately postintervention. Depression Meta-analysis of two studies in healthcare settings, one at high risk of bias and one at moderate risk, showed that fewer women developed depression (OR 0.31, 95% CI 0.15 to 0.65; n = 149; NNT = 4) with brief advocacy. One study at high risk of bias reported a slight reduction in depression in pregnant women immediately after the intervention (OR 0.51, 95% CI 0.20 to 1.29; n = 103; NNT = 8).There was no evidence that intensive advocacy reduced depression at ≤ 12-month follow-up (MD - 0.14, 95% CI - 0.33 to 0.05; 3 studies; n = 446) or at two years (SMD - 0.12, 95% CI - 0.36 to 0.12; 1 study; n = 265). Adverse effectsTwo women died, one who was murdered by her partner and one who committed suicide. No evidence links either death to study participation. AUTHORS' CONCLUSIONS: Results suggest some benefits from advocacy. However, most studies were underpowered. Clinical and methodological heterogeneity largely precluded pooling of trials. Therefore, there is uncertainty about the magnitude of benefit, the impact of abuse severity, and the setting.Based on the evidence reviewed, intensive advocacy may improve short-term quality of life and reduce physical abuse one to two years after the intervention for women recruited from domestic violence shelters or refuges. Brief advocacy may provide small short-term mental health benefits and reduce abuse, particularly in pregnant women and for less severe abuse.

Adolescent relationship violence and acculturation among NYC Latinos.

Acculturation has been shown to positively and negatively affect Latino health. Little research investigates the overlap between acculturation and the different types of relationship violence among Latino youth and most research in this area predominantly involves Mexican-American samples. The current study examined associations between indices of acculturation (language use at home, chosen survey language, and nativity) and relationship physical violence and sexual coercion, both received and delivered, among predominantly Dominican and Puerto Rican adolescents from New York City. From 2006 to 2007, 1,454 adolescents aged 13-21 years in New York City completed an anonymous survey that included the Conflict in Adolescent Relationships Inventory which estimates experiences of physical violence and sexual coercion, both received and delivered, in the previous year. This analysis includes bivariate and multivariate methods to test the associations between language use at home, chosen survey language, and nativity with the different types of relationship violence. Among females, there is a significant association between language use at home and overall level of acculturation with delivering and receiving relationship physical violence; however, we did not find this association in delivering and receiving relationship sexual coercion. We found no association between acculturation and any type of relationship violence among males. Among Latina females, language spoken at home is an indicator of other protective factors of physical relationship violence. Future research in this area should explore the potential protective factors surrounding relationship violence among Latina females of various subgroups using comprehensive measures of acculturation, household composition and family engagement.

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

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

Compliance with referrals for non-acute child health conditions: evidence from the longitudinal ASENZE study in KwaZulu Natal, South Africa.

BACKGROUND: Caregiver compliance with referrals for child health services is essential to child health outcomes. Many studies in sub-Saharan Africa have examined compliance patterns for children referred for acute, life-threatening conditions but few for children referred for non-acute conditions. The aims of this analysis were to determine the rate of referral compliance and investigate factors associated with referral compliance in KwaZulu Natal, South Africa. METHODS: From September 2008-2010, a door-to-door household survey was conducted to identify children aged 4-6 years in outer-west eThekwini District, KwaZulu-Natal, South Africa. Of 2,049 identified, informed consent was obtained for 1787 (89%) children who were then invited for baseline assessments. 1581 children received standardized medical and developmental assessments at the study facility (Phase 1). Children with anemia, suspected disorders of vision, hearing, behavior and/or development and positive HIV testing were referred to local health facilities. Caregiver-reported compliance with referrals was assessed 18-24 months later (Phase 2). Relationships between socio-demographic factors and referral compliance were evaluated using chi-square tests. RESULTS: Of 1581 children, 516 received referrals for ≥1 non-acute conditions. At the time of analysis, 68% (1078 /1581) returned for Phase 2. Analysis was limited to children assessed in Phase 2 who received a referral in Phase 1 (n = 303). Common referral reasons were suspected disorders of hearing/middle ear (22%), visual acuity (12%) and anemia (14%). Additionally, children testing positive for HIV (6.6%) were also referred. Of 303 children referred, only 45% completed referrals. Referral compliance was low for suspected disorders of vision, hearing and development. Referral compliance was significantly lower for children with younger caregivers, those living in households with low educational attainment and for those with unstable caregiving. CONCLUSIONS: Compliance with referrals for children with non-acute conditions is low within this population and appears to be influenced by caregiver age, household education level and stability of caregiving. Lack of treatment for hearing, vision and developmental problems can contribute to long-term cognitive difficulties. Further research is underway by this group to examine caregiver knowledge and attitudes about referral conditions and health system characteristics as potential determinants of referral compliance.

Mental health disorders among caregivers of preschool children in the Asenze study in KwaZulu-Natal, South Africa.

Given the existing evidence linking parental depression with infant and early child development, our aim was to describe the burden of mental health disorders among caregivers of young children aged 4-6 years living in an environment of poverty and high HIV seroprevalence. We analyzed baseline data from an epidemiologic study of the health and psychosocial needs of preschool-aged children. Primary caregivers of index children recruited from a household survey were screened for common mental disorders using the Client Diagnostic Questionnaire (CDQ). Sociodemographic, HIV and general health surveys were also conducted. Many caregivers (449/1,434; 31.3 %) screened positive for at least one psychiatric disorder on the CDQ, with post-traumatic-stress-disorder being the most common. Caregivers who screened positive for any disorder were more likely to be older, to have no individual sources of income and to have less formal education. Presence of a disorder was also significantly associated with lower employment levels within the household and death of a young child within the household. Known HIV-infected caregivers were more likely to have any mood disorder than caregivers who previously tested negative. The data support the need for mental health treatment interventions in South Africa, particularly interventions directed at PTSD and depression, and that take into account the high burden of poverty, HIV and childhood mortality. Given the limited formal mental health structure in South Africa to address these highly prevalent disorders; community-based mental health supports, available through decentralized health systems many be critical to delivering accessible interventions.

Community engagement to enhance child survival and early development in low- and middle-income countries: an evidence review.

As part of a broader evidence summit, USAID and UNICEF convened a literature review of effective means to empower communities to achieve behavioral and social changes to accelerate reductions in under-5 mortality and optimize early child development. The authors conducted a systematic review of the effectiveness of community mobilization and participation that led to behavioral change and one or more of the following: child health, survival, and development. The level and nature of community engagement was categorized using two internationally recognized models and only studies where the methods of community participation could be categorized as collaborative or shared leadership were eligible for analysis. The authors identified 34 documents from 18 countries that met the eligibility criteria. Studies with shared leadership typically used a comprehensive community action cycle, whereas studies characterized as collaborative showed clear emphasis on collective action but did not undergo an initial process of community dialogue. The review concluded that programs working collaboratively or achieving shared leadership with a community can lead to behavior change and cost-effective sustained transformation to improve critical health behaviors and reduce poor health outcomes in low- and middle-income countries. Overall, community engagement is an understudied component of improving child outcomes.