Measuring sexual behavior stigma among cisgender men who have sex with men: an assessment of cross-country measurement invariance.

Objectives: Globally, cisgender men who have sex with men experience sexual stigma, but limited investigation of cross-population scale performance hinder comparisons. As measurement invariance is a necessary but seldom-established criterion of valid cross-cultural comparisons, we assessed invariance in scales of stigma related to sexual behavior across 9 countries. Methods: This secondary analysis used data collected from adult (mean age=29.6, standard deviation=12.5) cisgender men who have sex with men (n=8,669) in studies from 6 West African, 2 Southern African, and 1 North American country from 2012-2016. A common item set assessed 2 sexual behavior stigma domains. A sequential process was used to test the factor structure and measurement invariance, which included multigroup confirmatory factor analyses (CFA). Individual countries, items, living with HIV, and disclosure were explored as possible sources of noninvariance. Results: Goodness-of-fit statistics indicated adequate fit of the same 2-factor model in 7 of the 9 countries. The chi2 difference test comparing a constrained and unconstrained 7-country model in which loadings and thresholds were freely estimated was significant (p<0.001), indicating metric and scalar noninvariance, but removing the US provided evidence of invariance and freeing certain items led to a finding of partial invariance. Sexuality disclosure exhibited a direct relationship with select stigma items in several countries. Conclusions: Our findings point to the utility of the two stigma scale dimensions in making cross-country comparisons, but also to the necessity of assessing invariance with explicit attention to several factors including differential disclosure of sexuality across contexts to ensure valid comparisons.

Prevention and promotion effects of Self Help Plus: secondary analysis of cluster randomised controlled trial data among South Sudanese refugee women in Uganda.

INTRODUCTION: Evidence-based and scalable prevention and promotion focused mental health and psychosocial support interventions are needed for conflict-affected populations in humanitarian settings. This study retrospectively assessed whether participation in Self Help Plus (SH+) versus enhanced usual care (EUC) resulted in reduced incidence of probable mental disorder and increased positive mental health and well-being post-intervention among South Sudanese refugee women in Uganda. METHODS: This study used secondary data from treatment-oriented pilot (n=50) and fully-powered cluster randomised controlled trials (cRCT)s (n=694) of SH+ versus EUC. Data from baseline and post-intervention assessments were combined. A composite latent indicator for mental health problems was generated using mental health and well-being measures included in both cRCTs. In order to assess incidence, a binary variable approximating probable mental disorder was created to exclude those with probable mental disorder from the analysis sample and as the primary prevention outcome. The promotive effects of SH+ relative to EUC were examined in the same sample by assessing subjective well-being and psychological flexibility scale scores. RESULTS: A single factor for mental health problems was identified with all factor loadings >0.30 and acceptable internal consistency (α=0.70). We excluded 161 women who met criteria for probable mental disorder at baseline. Among those with at least moderate psychological distress but without probable mental disorder at baseline and with follow-up data (n=538), the incidence of probable mental disorder at post-intervention was lower among those who participated in SH+ relative to EUC (Risk ratio =0.16, 95% CI: 0.05 to 0.53). Participation in SH+ versus EUC was also associated with increased subjective well-being (ß=2.62, 95% CI: 1.63 to 3.60) and psychological flexibility (ß=4.55, 95% CI: 2.92 to 6.18) at post-intervention assessment. CONCLUSIONS: These results support the use and further testing of SH+ as a selective and indicated prevention and promotion focused psychosocial intervention in humanitarian settings. TRIAL REGISTRATION NUMBER: ISRCTN50148022.

Self-Help Plus for refugees and asylum seekers: an individual participant data meta-analysis.

QUESTION: Refugees and asylum seekers are at high risk of mental disorders due to various stressors before, during and after forceful displacement. The WHO Self-Help Plus (SH+) intervention was developed to manage psychological distress and a broad range of mental health symptoms in vulnerable populations. This study aimed to examine the effects and moderators of SH+ compared with Enhanced Care as Usual (ECAU) in reducing depressive symptoms among refugees and asylum seekers. STUDY SELECTION AND ANALYSIS: Three randomised trials were identified with 1795 individual participant data (IPD). We performed an IPD meta-analysis to estimate the effects of SH+, primarily on depressive symptoms and second on post-traumatic stress, well-being, self-identified problems and functioning. Effects were also estimated at 5-6 months postrandomisation (midterm). FINDINGS: There was no evidence of a difference between SH+ and ECAU+ in reducing depressive symptoms at postintervention. However, SH+ had significantly larger effects among participants who were not employed (ß=1.60, 95% CI 0.20 to 3.00) and had lower mental well-being levels (ß=0.02, 95% CI 0.001 to 0.05). At midterm, SH+ was significantly more effective than ECAU in improving depressive symptoms (ß=-1.13, 95% CI -1.99 to -0.26), self-identified problems (ß=-1.56, 95% CI -2.54 to -0.59) and well-being (ß=6.22, 95% CI 1.60 to 10.90). CONCLUSIONS: Although SH+ did not differ significantly from ECAU in reducing symptoms of depression at postintervention, it did present benefits for particularly vulnerable participants (ie, unemployed and with lower mental well-being levels), and benefits were also evident at midterm follow-up. These results are promising for the use of SH+ in the management of depressive symptoms and improvement of well-being and self-identified problems among refugees and asylum seekers.

Psychological flexibility in South Sudanese female refugees in Uganda as a mechanism for change within a guided self-help intervention.

OBJECTIVE: To examine the role of psychological flexibility as a potential mediator in the relationship between involvement in a guided self-help intervention, Self-Help Plus, and psychological distress in a sample of South Sudanese refugee women living in northern Uganda. METHOD: We conducted secondary analysis of data from a cluster randomized controlled trial conducted in 2018. We used multilevel mediation modeling to explore the relationship of psychological flexibility, as measured by the Acceptance and Action Questionnaire (AAQ-II), as a mediating factor in the relationship between Self-Help Plus involvement and general psychological distress as measured by the Kessler Psychological Distress Scale-6 (K6). RESULTS: We found strong multilevel mediation of decreased K6 scores in the treatment group by AAQ-II scores (multilevel b = -3.28). A more pronounced mediation effect was discovered immediately post intervention (b = -1.09) compared to 3-month follow-up (b = -0.84). This is in line with the current literature that demonstrates the role of psychological flexibility as a primary mechanism of change in ACT-based interventions. CONCLUSIONS: Psychological flexibility is a contributing component in the theory of change for this ACT-based intervention. Identifying the core components of interventions allows for more effective adaptation and implementation of relevant services, especially in low-resource contexts. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

HIV-related Stigma and Discrimination in Health Care and Health-related Quality of Life among People Living with HIV in England and Wales: A Latent Class Analysis.

Though life expectancy of people living with HIV (PLHIV) is now comparable to that of HIV-negative persons, their health-related quality of life (HRQoL) lags behind. Lower HRQoL among PLHIV may vary meaningfully, shaped in part by social factors, including stigma. Using data from Positive Voices, a national cross-sectional probability survey of adults ≥ 18 years living with HIV and accessing HIV care services in England and Wales (N = 4,422), we conducted latent class analysis on responses to a HRQoL measure (problems with mobility, usual activities, self-care, pain/discomfort, anxiety/depression) to identify HRQoL patterns, followed by multinomial logistic regression to examine relationships between HRQoL classes and a 4-item measure of HIV-related stigma and discrimination in health care. Four classes emerged: All Problems (18% prevalence); Pain and Distress (18%); Pain and Mobility (9%); No Problems (55%). Scale scores of HIV-related stigma and discrimination in health care were positively, significantly associated with membership in the All Problems (adjusted odds ratio [aOR] = 2.05; 95% confidence interval [CI] = 1.85, 2.28), Pain and Distress (aOR = 1.56; CI = 1.41, 1.73), and Pain and Mobility classes (aOR = 1.33; CI = 1.16, 1.52) compared to the No Problems class. A similar trend was observed for individual stigma and discrimination items. HRQoL among PLHIV in England and Wales varies and may be underpinned or exacerbated by HIV-related stigma and discrimination in health care. Ensuring stigma-mitigation interventions reach all health care systems/providers and emotional support services reach all PLHIV may improve HRQoL for PLHIV.

Associations between HIV testing and multilevel stigmas among gay men and other men who have sex with men in nine urban centers across the United States.

BACKGROUND: Complex manifestation of stigma across personal, community, and structural levels and their effect on HIV outcomes are less understood than effects in isolation. Yet, multilevel approaches that jointly assesses HIV criminalization and personal sexual behavior stigma in relation to HIV testing have not been widely employed or have only focused on specific subpopulations. The current study assesses the association of three types of MSM-related sexual behavior-related stigma (family, healthcare, general social stigma) measured at both individual and site levels and the presence/absence of laws criminalizing HIV transmission with HIV testing behaviors to inform HIV surveillance and prevention efforts among HIV-negative MSM in a holistic and integrated way. METHODS: We included nine National HIV Behavioral Surveillance (NHBS) 2017 sites: Baltimore, MD; Denver, CO; Detroit, MI; Houston, TX; Long Island/Nassau-Suffolk, NY; Los Angeles, CA; Portland, OR; San Diego, CA; and Virginia Beach and Norfolk, VA. Multivariable generalized hierarchical linear modeling was used to examine how sexual behavior stigmas (stigma from family, anticipated healthcare stigma, general social stigma) measured at the individual and site levels and state HIV criminalization legislation (no, HIV-specific, or sentence-enhancement laws) were associated with past-year HIV testing behaviors across sites (n = 3,278). RESULTS: The majority of MSM across sites were tested for HIV in the past two years (n = 2,909, 95.4%) with the average number of times tested ranging from 1.79 (SD = 3.11) in Portland, OR to 4.95 (SD = 4.35) in Los Angeles, CA. In unadjusted models, there was a significant positive relationship between stigma from family and being tested for HIV in the past two years. Site-level HIV-specific criminalization laws were associated with an approximate 5% reduction in the prevalence of receiving any HIV test in the past two years after individual level stigma and sociodemographic covariate adjustments (PR = 0.94, 95% CI, 0.90-0.99). CONCLUSIONS: Structural barriers faced by MSM persist and ending the HIV epidemic in the US requires a supportive legal environment to ensure effective engagement in HIV services among MSM. Home-based solutions, such as self-testing, used to deliver HIV testing may be particularly important in punitive settings while legal change is advocated for on the community and state levels.

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

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

Quantitative methods for climate change and mental health research: current trends and future directions.

The quantitative literature on climate change and mental health is growing rapidly. However, the methodological quality of the evidence is heterogeneous, and there is scope for methodological improvement and innovation. The first section of this Personal View provides a snapshot of current methodological trends and issues in the quantitative literature on climate change and mental health, drawing on literature collected through a previous scoping review. The second part of this Personal View outlines opportunities for methodological innovation concerning the assessment of the relationship between climate change and mental health. We then highlight possible methodological innovations in intervention research and in the measurement of climate change and mental health-related variables. This section draws upon methods from public mental health, environmental epidemiology, and other fields. The objective is not to provide a detailed description of different methodological techniques, but rather to highlight opportunities to use diverse methods, collaborate across disciplines, and inspire methodological innovation. The reader will be referred to practical guidance on different methods when available. We hope this Personal View will constitute a roadmap and launching pad for methodological innovation for researchers interested in investigating a rapidly growing area of research.

Global priorities for climate change and mental health research.

BACKGROUND: Compared with other health areas, the mental health impacts of climate change have received less research attention. The literature on climate change and mental health is growing rapidly but is characterised by several limitations and research gaps. In a field where the need for designing evidence-based adaptation strategies is urgent, and research gaps are vast, implementing a broad, all-encompassing research agenda will require some strategic focus. METHODS: We followed a structured approach to prioritise future climate change and mental health research. We consulted with experts working across mental health and climate change, both within and outside of research and working in high, middle, and low-income countries, to garner consensus about the future research priorities for mental health and climate change. Experts were identified based on whether they had published work on climate change and mental health, worked in governmental and non-governmental organisations on climate change and mental health, and from the professional networks of the authors who have been active in the mental health and climate change space. RESULTS: Twenty-two experts participated from across low- and middle-income countries (n = 4) and high-income countries (n = 18). Our process identified ten key priorities for progressing research on mental health and climate change. CONCLUSION: While climate change is considered the biggest threat to global mental health in the coming century, tackling this threat could be the most significant opportunity to shape our mental health for centuries to come because of health co-benefits of transitioning to more sustainable ways of living. Research on the impacts of climate change on mental health and mental health-related systems will assist decision-makers to develop robust evidence-based mitigation and adaptation policies and plans with the potential for broad benefits to society and the environment.

Metrics of Sexual Behavior Stigma Among Cisgender Men Who Have Sex With Men in 9 Cities Across the United States.

Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to local surveys administered in 2017 at 9 sites in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system, which uses venue-based, time-sampling procedures to survey cisgender MSM in US Census Metropolitan Statistical Areas. We performed exploratory factor analytical procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; and Virginia Beach-Norfolk, Virginia) and pooled responses to the survey items. A 3-factor solution-"stigma from family" (α = 0.70), "anticipated health-care stigma" (α = 0.75), and "general social stigma" (α = 0.66)-best fitted the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the United States experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking trends in stigma over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the United States.

Disclosure of same-sex practices and experiences of healthcare stigma among cisgender men who have sex with men in five sub-Saharan African countries.

BACKGROUND: For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma. METHODS: We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d'Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data. RESULTS: Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations. CONCLUSIONS: Research to determine the factors driving disclosure's differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA.

A randomized-controlled trial of community-based transdiagnostic psychotherapy for veterans and internally displaced persons in Ukraine.

BACKGROUND: There is limited research on community-based mental health interventions in former Soviet countries despite different contextual factors from where most research has been conducted. Ongoing military conflict has resulted in many displaced persons and veterans and their families with high burdens of mental health problems. Lack of community-based services and poor uptake of existing psychiatric services led to the current trial to determine the effectiveness of the common elements treatment approach (CETA) on anxiety, depression, and posttraumatic stress symptoms (PTS) among conflict affected adults in Ukraine. METHODS: We conducted a three-armed randomized-controlled trial of CETA delivered in its standard form (8-12 sessions), a brief form (five-sessions), and a wait-control condition. Eligible participants were displaced adults, army veterans and their adult family members with elevated depression and/or PTS and impaired functioning. Treatment was delivered by community-based providers trained in both standard and brief CETA. Outcome data were collected monthly. RESULTS: There were 302 trial participants (n = 117 brief CETA, n = 129 standard CETA, n = 56 wait-controls). Compared with wait-controls, participants in standard and brief CETA experienced clinically and statistically significant reductions in depression, anxiety, and PTS and dysfunction (effect sizes d = 0.46-1.0-6). Comparing those who received standard CETA with brief CETA, the former reported fewer symptoms and less dysfunction with small-to-medium effect sized (d = 0.20-0.55). CONCLUSIONS: Standard CETA is more effective than brief CETA, but brief CETA also had significant effects compared with wait-controls. Given demonstrated effectiveness, CETA could be scaled up as an effective community-based approach.

Self-help plus for refugees and asylum seekers; study protocol for a series of individual participant data meta-analyses.

Background: Refugees and asylum seekers face various stressors due to displacement and are especially vulnerable to common mental disorders. To effectively manage psychological distress in this population, innovative interventions are required. The World Health Organization (WHO) Self-Help Plus (SH+) intervention has shown promising outcomes in reducing symptoms of common mental disorders among refugees and asylum seekers. However, individual participant differences in response to SH+ remain largely unknown. The Individual Participant Data (IPD) meta-analysis synthesizes raw datasets of trials to provide cutting-edge evidence of outcomes that cannot be examined by conventional meta-analytic approaches. Objectives: This protocol outlines the methods of a series of IPD meta-analyses aimed at examining the effects and potential moderators of SH+ in (a) reducing depressive symptoms at post-intervention and (b) preventing the six-month cumulative incidence of mental disorders in refugees and asylum seekers. Method: RCTs on SH+ have been identified through WHO and all authors have agreed to share the datasets of the trials. The primary outcomes of the IPD meta-analyses are (a) reduction in depressive symptoms at post-intervention, and (b) prevention of six-month cumulative incidence of mental disorders. Secondary outcomes include post-traumatic stress disorder symptoms, well-being, functioning, quality of life, and twelve-month cumulative incidence of mental disorders. One-stage IPD meta-analyses will be performed using mixed-effects linear/logistic regression. Missing data will be handled by multiple imputation. Conclusions: These results will enrich current knowledge about the response to SH+ and will facilitate its targeted dissemination. The results of these IPD meta-analyses will be published in peer-reviewed journals.

Antecedentes: Los refugiados y solicitantes de asilo enfrentan numerosos estresores debido al desplazamiento y son especialmente vulnerables a trastornos de salud mental comunes. Para poder manejar efectivamente el malestar psicológico en esta población, se requieren intervenciones innovadoras. La intervención Self- Help Plus (SH+) de la Organización Mundial de la Salud (OMS) ha mostrado resultados prometedores en la reducción de síntomas de trastornos de salud mental comunes entre refugiados y solicitantes de asilo. Sin embargo, las diferencias individuales de los participantes en respuesta a SH+ permanecen mayormente desconocida. El meta-análisis de Datos de Participantes Individuales (IPD) sintetiza bases de datos puros para proveer evidencia de resultados de vanguardia que no puede ser examinada mediante enfoques meta-analíticos convencionales.Objetivos: Este protocolo delinea los métodos de una serie de meta-análisis de IPD enfocados en examinar los efectos y potenciales moderadores de SH+ en (a) reducir síntomas depresivos en la post-intervención y (b) prevenir la incidencia acumulada de trastornos mentales en refugiados y solicitantes de asilo durante seis meses.Método: Se identificaron RCT sobre SH+ a través de la OMS y todos los autores acordaron compartir la base de datos de sus ensayos. Los resultados primarios de los meta-análisis de IPD son (a) reducción en síntomas depresivos después de la intervención, y (b) prevención de la incidencia acumulada de trastornos mentales en refugiados y solicitantes de asilo durante 6 meses. Entre los resultados secundarios de incluyó síntomas de trastorno de estrés postraumático, bienestar, funcionamiento, calidad de vida e incidencia acumulada de trastornos de salud mental durante 12 meses. Se realizaran meta-análisis de IPD de una etapa usando regresión linear/logística de efectos mixtos. Los datos faltantes se manejaran mediante imputación múltiple.Conclusiones: Estos resultados enriquecerán el conocimiento actual sobre la respuesta a SH+ y facilitarán su diseminación en su público objetivo. Los resultados de estos meta-análisis de IPD serán publicados en revistas revisadas por pares.

Climate Change and Mental Health: A Scoping Review.

Climate change is negatively impacting the mental health of populations. This scoping review aims to assess the available literature related to climate change and mental health across the World Health Organisation's (WHO) five global research priorities for protecting human health from climate change. We conducted a scoping review to identify original research studies related to mental health and climate change using online academic databases. We assessed the quality of studies where appropriate assessment tools were available. We identified 120 original studies published between 2001 and 2020. Most studies were quantitative (n = 67), cross-sectional (n = 42), conducted in high-income countries (n = 87), and concerned with the first of the WHO global research priorities-assessing the mental health risks associated with climate change (n = 101). Several climate-related exposures, including heat, humidity, rainfall, drought, wildfires, and floods were associated with psychological distress, worsened mental health, and higher mortality among people with pre-existing mental health conditions, increased psychiatric hospitalisations, and heightened suicide rates. Few studies (n = 19) addressed the other four global research priorities of protecting health from climate change (effective interventions (n = 8); mitigation and adaptation (n = 7); improving decision-support (n = 3); and cost estimations (n = 1)). While climate change and mental health represents a rapidly growing area of research, it needs to accelerate and broaden in scope to respond with evidence-based mitigation and adaptation strategies.

Brief report: HIV-related healthcare stigma/discrimination and unmet needs among persons living with HIV in England and Wales.

We characterized the prevalence of, and estimated associations between, (1) HIV-related healthcare stigma/discrimination and (2) unmet social, mental, and chronic condition healthcare needs among persons living with HIV (PLHIV) in England and Wales. We used data from Positive Voices 2017, a national, cross-sectional probability survey of PLHIV in England and Wales, in which N = 3,475 PLHIV provided complete data on demographic characteristics (control variables; age, ethnicity, gender, sexual identity), HIV-related healthcare stigma/discrimination (exposures; treated differently from other patients, care was refused/delayed, worried about being treated differently, avoided seeking needed care, all due to HIV status), and unmet needs (outcomes; unmet peer support, psychological care, management of chronic health conditions, and isolation help needs). Modified Poisson regression models with log links and robust variance estimators were used to produce prevalence ratios and 95% confidence intervals for unadjusted and adjusted associations between demographic characteristics, HIV-related healthcare stigma/discrimination (individual items and total scale score), and unmet needs variables. Two in five participants (40%) endorsed at least one HIV-related healthcare stigma/discrimination item; and 474 (14%), 428 (12%), 459 (13%), and 501 (14%) reported an unmet peer support, psychological care, chronic health condition management, and isolation help need, respectively. Each HIV-related healthcare stigma/discrimination item and the summed scale score were significantly, positively associated with all four unmet needs variables in unadjusted and adjusted models. Trainings for all healthcare workers in HIV-competent, non-stigmatizing care, as well as the development of engagement and delivery approaches for psychosocial care for PLHIV, are needed.

Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial.

BACKGROUND: Innovative solutions are required to provide mental health support at scale in low-resource humanitarian contexts. We aimed to assess the effectiveness of a facilitator-guided, group-based, self-help intervention (Self-Help Plus) to reduce psychological distress in female refugees. METHODS: We did a cluster randomised trial in rural refugee settlements in northern Uganda. Participants were female South Sudanese refugees with at least moderate levels of psychological distress (cutoff ≥5 on the Kessler 6). The intervention comprised access to usual care and five 2-h audio-recorded stress-management workshops (20-30 refugees) led by briefly trained lay facilitators, accompanied by an illustrated self-help book. Villages were randomly assigned to either intervention (Self-Help Plus or enhanced usual care) on a 1:1 basis. Within 14 villages, randomly selected households were approached. Screening of women in households continued until 20-30 eligible participants were identified per site. The primary outcome was individual psychological distress, assessed using the Kessler 6 symptom checklist 1 week before, 1 week after, and 3 months after intervention, in the intention-to-treat population. All outcomes were measured at the individual (rather than cluster) level. Secondary outcomes included personally identified problems, post-traumatic stress, depression symptoms, feelings of anger, social interactions with other ethnic groups, functional impairment, and subjective wellbeing. Assessors were masked to allocation. This trial was prospectively registered at ISRCTN, number 50148022. FINDINGS: Of 694 eligible participants (331 Self-Help Plus, 363 enhanced usual care), 613 (88%) completed all assessments. Compared with controls, we found stronger improvements for Self-Help Plus on psychological distress 3 months post intervention (ß -1·20, 95% CI -2·33 to -0·08; p=0·04; d -0·26). We also found larger improvements for Self-Help Plus 3 months post-intervention for five of eight secondary outcomes (effect size range -0·30 to -0·36). Refugees with different trauma exposure, length of time in settlements, and initial psychological distress benefited similarly. With regard to safety considerations, the independent data safety management board responded to six adverse events, and none were evaluated to be concerns in response to the intervention. INTERPRETATION: Self-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees. FUNDING: Research for Health in Humanitarian Crises (R2HC) Programme.

Measurement of Parenting Self-efficacy Among Female HIV-Affected Caregivers in Uganda.

OBJECTIVES: Parenting self-efficacy has been associated with positive parenting behaviors, fewer parental mental health problems, less family dysfunction, and better child development outcomes. The parenting sense of competence (PSOC) scale is commonly used to measure parenting self-efficacy in high-resource settings. This study sought to examine the factor structure, internal consistency, and convergent construct validity of the PSOC in a sample of predominantly HIV-infected women in Uganda. METHODS: Using data from 155 HIV-affected caregivers who participated in a randomized controlled trial of a parenting intervention, two and three factor models of a 16-item translated version of the PSOC were tested using confirmatory factor analysis. Multivariable regression models were used to examine relationships between parenting confidence (operationalized using the best-fitting PSOC model), caregiver mental health symptoms (depression and anxiety), social support, family dysfunction, and family wealth, after adjusting for covariates. RESULTS: Neither the two- nor three-factor models of the PSOC demonstrated adequate model fit; however, adequate model fit was demonstrated for a one-factor model that included only items from the PSOC efficacy subscale. Cronbach's alpha was 0.73 for this subscale. Correlates of parenting self-efficacy in this sample included caregiver depression, family dysfunction, and family wealth, but not caregiver anxiety or social support. CONCLUSIONS FOR PRACTICE: These findings lend support for future use of the PSOC efficacy subscale among HIV-affected caregivers of children in low-resource settings such as rural Uganda.

Characterizing Cross-Culturally Relevant Metrics of Stigma Among Men Who Have Sex With Men Across 8 Sub-Saharan African Countries and the United States.

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02-0.05; comparative fit index/Tucker-Lewis index = 0.97-1.00/0.94-1.00; standardized root mean square residual = 0.04-0.08), consisting of "stigma from family and friends," "anticipated health-care stigma," and "general social stigma," with internal consistency estimates across countries of α = 0.36-0.80, α = 0.72-0.93, and α = 0.51-0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions.

Early Childhood Development Caregiver Training and Neurocognition of HIV-Exposed Ugandan Siblings.

OBJECTIVE: Early childhood development (ECD) programs can enhance neurocognitive development outcomes through caregiver training. This study explores whether school-age siblings benefited from a program provided to HIV-infected caregivers and their preschool-aged target children. METHODS: Siblings of target 2- to 3-year-old children in ECD intervention households were evaluated at school age (5-12 years) on neurocognitive outcomes with the Kaufman Assessment Battery for Children (KABC), computerized Test of Variables of Attention, Behavior Rating Inventory for Executive Function (BRIEF; parent), and attention-deficit/hyperactivity disorder rating inventory (ADHD-R)-IV (parent). Households from 18 geographic clusters in eastern Uganda were randomized to individualized biweekly sessions of either (1) Mediational Intervention for Sensitizing Caregivers (MISC) training emphasizing cognitive stimulation/enrichment or (2) health/nutrition/development [Uganda Community-Based Association For Women & Children Welfare (UCOBAC)] program. Siblings with baseline and at least 1 follow-up assessment (n = 216) were included in the analysis. Three repeated postbaseline measures of sibling neurocognitive outcomes were analyzed using the linear mixed-effects model while adjusting for socioeconomic status and behavioral outcome at baseline. RESULTS: Siblings in the MISC arm had better performance on KABC sequential processing at 6 months (p = 0.02) and simultaneous processing at 12 months (p = 0.03). MISC mothers rated their children as having significantly more problems on the BRIEF and ADHD-RS-IV (p < 0.01) than UCOBAC mothers across all time points. CONCLUSION: Mediational Intervention for Sensitizing Caregivers training resulted in some short-term neurocognitive benefits for school-aged siblings, but these differences were not sustained at 1-year follow-up. Exploring potential impacts of parenting programs on other children in the home is an important development for the field.