Social protection as a strategy for HIV prevention, education promotion and child marriage reduction among adolescents: a cross-sectional population-based study in Lesotho.

BACKGROUND: Lesotho's government has shown consistent efforts to implement social protection programmes. However, while recent evidence established a positive causal relationship between some of these programmes and food security there is little evidence on the extent to which these initiatives are associated with better educational and sexual and reproductive health outcomes among vulnerable adolescents in Lesotho. METHODS AND FINDINGS: The study uses cross-sectional, nationally representative data from the 2018 Lesotho Violence Against Children and Youth Survey. Our research examined the association between social protection receipt and educational and sexual and reproductive health outcomes among adolescents and young people (13-24 years) living in poverty. We employed multivariate logistic regression controlling for age, orphanhood, HIV status and sex. Social protection receipt was defined as household receipt of financial support from a governmental, non-governmental, or community-based program that provides income. Additionally, we fitted a marginal effects model by sex. Among the 3,506 adolescent females and males living in the two lowest poverty quintiles, receipt of social protection was associated with improvements in multiple adolescent outcomes: higher odds of consistent condom use (aOR 1.64, 95% CI 1.17-2.29), educational attainment (aOR 1.79, 95% CI 1.36-2.36), and school enrolment (aOR 2.19, 95% CI 1.44-3.34). Stratified analyses by sex showed that social protection receipt was also associated with reduced likelihood of child marriage among females (aOR 0.59, 95% CI 0.42-0.83) and higher odds of educational attainment and school enrolment among males (aOR 2.53, 95% CI 1.59-4.03 and aOR 3.11, 95% CI 1.56-6.19, respectively). CONCLUSIONS: Our study provides evidence that social protection programs are associated with improved educational, sexual and reproductive health and child marriage prevention outcomes among adolescents living in poverty. Implementing and expanding such social protection initiatives could prove instrumental in improving the well-being of vulnerable adolescents. CONTRIBUTIONS: Social protection programs have been increasing in sub-Saharan African countries, playing a pivotal role in poverty reduction, with Lesotho being no exception. Despite the optimistic outlook brought about by the implementation of the National Social Protection Strategy Lesotho I (2014-19) and II (2021-2031), the impact of these programs on some specific outcomes that concern the lives of the most vulnerable adolescents in Lesotho remains to some extent unexplored. Additionally, Lesotho grapples with high rates of HIV, adolescent pregnancy, child marriage and early school dropout, which can further contribute to poor long-term health and social outcomes among adolescents. In this study, we used data from the 2018 Lesotho Violence Against Children and Youth Survey (VACS) to examine the association between receiving social protection and multiple adolescent outcomes: educational, sexual and reproductive. The findings revealed that social protection programs, particularly the existing government-provided cash transfers, are significantly associated with multiple better outcomes among adolescents living in the poorest households in Lesotho. Such cash transfer schemes in Lesotho are associated with improved sexual and reproductive health outcomes for adolescent females, including reduced child marriage rates, and improved educational outcomes for males. These findings indicate that government-led social protection programmes are positively associated with favourable outcomes that can improve the quality of life for adolescents in resource-limited settings.

Prevalence of Functional Disabilities and Associations Among Disabilities, Violence, and HIV Among Adolescents and Young Adults in Lesotho.

INTRODUCTION: Lesotho has the second-highest prevalence of HIV. Despite progress in achieving HIV epidemic control targets, inequities persist among certain groups, particularly associations between disability, HIV, and violence. We assessed the prevalence of disability and examined associations between disability and HIV and violence using data from the 2018 Lesotho Violence Against Children and Youth Survey (VACS). METHODS: Lesotho VACS was a nationally representative survey of females and males ages 13-24. We assessed the associations between disability status and HIV, sexual risk behaviours, and violence using logistic regression, incorporating survey weights. RESULTS: Weighted functional disability prevalence was 14.1% for females (95% confidence interval [CI] 12.7-15.4) and 7.3% for males (5.3-9.2). Compared with females with no disabilities, females with disabilities had higher odds of being HIV positive (adjusted odds ratio [aOR] 1.92, 1.34-2.76), having transactional sex (aOR 1.79, 1.09-2.95), and experiencing any lifetime violence (aOR 2.20, 1.82-2.65), sexual violence (aOR 1.77, 1.36-2.31), emotional violence (2.02. 1.61-2.53), physical violence (aOR 1.85, 1.54-2.24), witnessing interparental violence (aOR 1.71, 1.46-2.01), and witnessing community violence (aOR 1.52, 1.26-1.84). Males with disabilities had higher odds of having transactional sex (aOR 4.30, 1.35-13.73), having recent multiple sex partners (aOR 2.31, 1.13-4.75), experiencing emotional violence (aOR 2.85, 1.39-5.82), and witnessing interparental violence (aOR 1.78, 1.12-2.84). HIV models for males did not converge due to low numbers. CONCLUSION: Findings emphasize the importance of inclusion and accessibility for adolescents and young adults with disabilities in prevention and services for violence and HIV. Ending HIV in Lesotho depends on addressing the vulnerabilities that lead to potential infection including violence and ensuring equitable services for all.

Adverse childhood experiences, mental distress, self-harm and suicidality, and cumulative HIV risk by sex in Lesotho.

BACKGROUND: Adverse childhood experiences (ACEs) have been understudied in low- and middle-income countries, especially in sub-Saharan Africa. OBJECTIVES, PARTICIPANTS, SETTING: We explored associations between mental distress, self-harm or suicidality, and HIV risk and individual and cumulative ACEs (sexual, emotional, and physical violence; witnessing community and interparental violence; orphanhood) among youth aged 13-24 in Lesotho. METHODS: Multivariable logistic regressions stratified by sex using nationally representative 2018 Lesotho Violence Against Children and Youth Survey (nfemale = 7101; nmale = 1467) data. RESULTS: Over 75 % of males and females experienced at least 1 ACE. Among males, physical and community violence were significantly associated with mental distress; orphan status and emotional violence was associated with self-harm/suicidality. Males who witnessed interparental violence had higher odds of disclosing 2 types and 3 or more types of HIV risk versus none. Among females, being a double orphan and having experienced sexual, emotional, physical, community, and interparental violence were significantly associated with mental distress and any self-harm/suicidality in both models. Females who experienced physical violence had higher odds of disclosing 3 or more risk types versus no risk. Statistically significant associations emerged between cumulative ACEs and mental distress, self-harm/suicidality, and higher levels of HIV risk for both males and females. CONCLUSIONS: Differential patterns of associations between ACEs and mental health problems and HIV risk emerged by sex. Scalable, integrated individual and community efforts to prevent ACEs, provide mental health supports, and encourage safer sexual behaviors among those exposed are needed and could benefit youth in Lesotho.

Prevalence of Adverse Childhood Experiences in sub-Saharan Africa: A multicountry analysis of the Violence Against Children and Youth Surveys (VACS).

BACKGROUND: Adverse Childhood Experiences are traumatic events early in life and have been associated with significant negative health outcomes. OBJECTIVE: To estimate the prevalence of ACEs in five low- and middle-income sub-Saharan African countries. PARTICIPANTS AND SETTING: Nationally representative data from the Cote d'Ivoire (2018), Kenya (2019), Lesotho (2018), Mozambique (2019), and Namibia (2019) Violence Against Children and Youth Surveys (VACS) were used. Analyses were restricted to youth ages 18-24 years (n = 8766 females and 2732 males). METHODS: VACS data were analyzed to generate sex-stratified weighted prevalence of individual ACEs (including sexual, physical, and emotional violence; witnessing interparental violence and violence in the community; and orphanhood) and aggregate ACEs (total ACEs; 0, 1-2, and 3 or more), for each country and combined. RESULTS: The most common type of ACEs among both females and males was witnessing physical violence (males: 55.0 % [95 % CI: 51.1-58.8] and females: 37.2 % [95 % CI = 34.3-40.1]) followed by experiencing physical violence (males: 49.7 % [95 % CI = 45.5-53.9] and in females: 36.5 % [95 % CI = 33.8-39.2]). Prevalence of sexual violence was significantly higher in females than in males (16.0 % [95 % CI = 13.9-18.2] vs 8.3 % [95 % CI = 7.0-9.8]; p < 0.001). About 72 % of females and 82 % of males have experienced at least one form of ACE with 20 % of females and 24.2 % of males experiencing 3 or more ACEs. CONCLUSION: This study demonstrated that majority of the children in countries in sub-Saharan Africa have experienced multiple ACEs in their lifetime. Understanding the extent of the problem will help design early interventions to reduce childhood exposure to ACEs or mitigate against the harmful impact of ACEs.

Orphanhood vulnerabilities for violence and HIV by education, sex, and orphan type among 18-24-year-old youth: findings from the 2018 Lesotho violence against children and youth survey.

HIV and violence among orphans are key measures of vulnerability in low-resource settings. Although Lesotho has the second highest HIV adult prevalence rate (21.1%) in the world, and the prevalence of orphanhood (44.2%) and violence exposure (67.0%) is high, little research exist on orphanhood vulnerabilities for violence and HIV in Lesotho. Using data from 4,408 youth (18-24 years old) from Lesotho's 2018 Violence Against Children and Youth survey, a nationally representative cross-sectional household survey, the study examined associations among orphan status, violence, and HIV and assessed how associations differed by education, sex, and orphan type, using logistic regression. Orphans had higher odds of violence (aOR, 1.21; 95% CI, 1.01-1.46) and HIV (aOR, 1.69; 95% CI, 1.24-2.29). Having primary education or less (aOR, 1.43; 95% CI, 1.02-2.02), male sex (aOR, 1.74; 95% CI, 1.27-2.36), and being a paternal orphan (aOR, 1.43; 95% CI, 1.14-1.80) were significant interaction terms for violence. Orphans who completed primary school or less (aOR, 1.61; 95% CI, 1.09-2.39), female (aOR, 3.08; 95% CI, 2.14-4.42) and double orphans (aOR, 2.54; 95% CI, 1.56-4.13) had higher odds of HIV. These relationships highlight the importance of comprehensive strategies to support education and family strengthening for orphans as core violence and HIV prevention efforts.

Parental absence as an adverse childhood experience among young adults in sub-Saharan Africa.

BACKGROUND: Parental absence in childhood has been associated with multiple negative consequences, such as depression and anxiety in young adulthood. OBJECTIVE: To assess whether parental absence for six months or more in childhood is associated with poor mental health and substance use in young adulthood and whether parental absence accounts for additional variance beyond those explained by other adverse childhood experiences (ACEs) among youth in sub-Saharan Africa. PARTICIPANTS AND SETTINGS: We used combined Violence Against Children and Youth Survey (VACS) data from Cote d'Ivoire (2018), Lesotho (2018), Kenya (2019), Namibia (2019), and Mozambique (2019). Analyses were restricted to 18-24-year-olds (nf = 7699; nm = 2482). METHODS: We used logistic regression to examine sex-stratified relationships between parental absence in childhood (defined as biological mother or father being away for six months or more before age 18) and mental health problems and substance use and whether parental absence explained additional variance beyond those explained by other ACEs. RESULTS: In sub-Saharan Africa, parental absence in childhood was common (30.5 % in females and 25.1 % in males), significantly associated with poor mental health and substance use among females and males and accounted for additional variance beyond those explained by conventional ACEs. For example, after controlling for study covariates and other ACEs, females who experienced any parental absence had 1.52 (95 % CI = 1.02-2.26) higher odds of experiencing moderate/serious psychological distress compared with those who did not. CONCLUSION: The observed association between parental absence and poor mental health suggests that this experience has significant adverse consequences and merits consideration as an ACE.

Strong Father-Child Relationships and Other Positive Childhood Experiences, Adverse Childhood Experiences, and Sexual Risk Factors for HIV among Young Adults Aged 19-24 Years, Namibia, 2019: A Cross-Sectional Study.

Using cross-sectional data from the 2019 Namibia Violence Against Children and Youth Survey and sex-stratified multivariable models, we assessed the associations between four different positive childhood experiences (PCEs) and having ≥3 adverse childhood experiences (ACEs), including ≥3 ACE-PCE interaction terms, and seven sexual risk factors for HIV acquisition among young adults aged 19-24 years. One PCE, having a strong father-child relationship, was inversely associated with two risk factors among women (lifetime transactional sex (OR, 0.4; 95% CI, 0.2-0.7) and recent age-disparate sexual relationships (OR, 0.3; 95% CI, 0.2-0.5)), and significantly interacted with having ≥3 ACEs for three risk factors among women (not knowing a partner's HIV status, infrequently using condoms, and ever having an STI) and one among men (having multiple sexual partners in the past year). The other PCEs were significantly associated with ≤1 HIV risk factor and had no significant interaction terms. Strong father-child relationships may reduce HIV acquisition risk and mitigate the effect of childhood adversity on HIV risk among young adults in Namibia.

Population Estimates of HIV Risk Factors to Inform HIV Prevention Programming for Adolescent Girls and Young Women.

Violence Against Children and Youth Survey (VACS) data from seven countries were analyzed to estimate population-level eligibility for the President's Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) HIV prevention program for adolescent girls and young women (AGYW). The prevalence of overall eligibility and individual risk factors, including experiences of violence, social, and behavioral risks differ across countries and age groups. A large proportion of AGYW across all countries and age groups examined have at least one risk factor making them eligible for DREAMS. Experiencing multiple risks is also common, suggesting that researchers and programs could work together to identify combinations of risk factors that put AGYW at greatest risk of HIV acquisition, or that explain most new HIV infections, to more precisely target the most vulnerable AGYW. The VACS provides important data for such analyses to refine DREAMS and other youth programming.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting.

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Adverse Childhood Experiences Among US Adolescents Over the Course of the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVE: A national, longitudinal survey of US adolescents assessed adverse childhood experiences (ACEs) twice during the COVID-19 pandemic. Adolescents with more Wave 1 ACEs were expected to be more likely to experience additional ACEs at Wave 2. METHODS: Adolescents aged 13 to 18 (n = 727, Fall 2020; n = 569, Spring 2021) recruited via a national, probability-based panel (survey completion rate Wave 1, 62.1%; Wave 2, 78.3%) responded to questions about household challenges, violence or neglect, and community ACE exposure at Wave 1 and Wave 2 (since Wave 1). Unweighted frequencies and 95% confidence intervals of demographic characteristics and individual ACEs were calculated by using weighted data. Odds ratios examined associations between ACEs by Wave 1 and Wave 2. RESULTS: Among respondents of both survey waves (n = 506), 27.2% experienced violence or abuse, 50.9% experienced a household challenge, and 34.9% experienced a community ACE by Wave 1. By Wave 2, 17.6% experienced 1 new ACE, 6.1% experienced 2 new ACEs and 2.7% experienced 4 or more new ACEs. Those with ≥4 ACEs by Wave 1 were 2.71 times as likely as those with none to report a new ACE at Wave 2 (confidence interval: 1.18-6.24). CONCLUSIONS: This nationwide, longitudinal study of US adolescents measured exposure to ACEs early in and during the COVID-19 pandemic. Nearly one-third of adolescents experienced a new ACE between survey waves. Prevention and trauma-informed approaches in clinical, school, and community settings may be helpful.

Childhood Polyvictimization and Associated Health Outcomes: A Systematic Scoping Review.

Background: Polyvictimization, the experience of multiple types of victimization, is associated with detrimental health outcomes. Despite extensive research on the health consequences of polyvictimization, one challenge in understanding this literature lies in the varied operationalized definitions of polyvictimization and health outcomes. This scoping review provides the volume of the current literature on this topic, documents the varied constructs of polyvictimization and associated health outcomes, identifies knowledge gaps, and guides future research directions. Method: A systematic search of English-language original articles that presented quantitative associations of childhood polyvictimization and health outcomes was performed through six-database searches, a gray literature search, and citation mining from June 2020 to January 2021. The varied constructs of polyvictimization, health outcomes, and other study characteristics were extracted. Results: A total of 96 studies were included. Two ways of creating continuous variables (30.21%) and four ways of constructing categorical variables (72.92%) were identified for operationalizing polyvictimization. The majority of health outcomes were mental, behavioral, or social (96.88%), while slightly more than 10% of studies examined physical health (11.46%) or general health conditions (10.42%), respectively. More than half of studies used U.S. samples (56.25%). Conclusions: The varied constructs of polyvictimization suggests that there is a need to establish a valid polyvictimization construct that is consistently agreed upon in the research community. Findings summarize the specific health outcomes that can be targeted for further investigation and prevention efforts. Findings also suggest that the study of resilience and coping education for childhood polyvictims is sorely needed.

Patterns of gendered risk factors and associations with intimate partner violence and low educational attainment among adolescent girls and young women in Lesotho: A latent class analysis.

BACKGROUND: Globally, adolescent girls and young women (AGYW) are disproportionately impacted by economic, demographic, and social factors associated with a wide range of negative outcomes. OBJECTIVE: The objective of this study was to use latent class analysis (LCA) to identify groupings of AGYW in Lesotho based on patterns of gendered risk factors, and to assess the association between the identified groupings and intimate partner violence (IPV) and low educational attainment. PARTICIPANTS AND SETTING: Data were from the 2018 Lesotho Violence Against Children and Youth Survey. AGYW reported gendered risk factors: teen pregnancy, child marriage, intergenerational sex, early sexual debut, being HIV positive, transactional sex, endorsement of one or more negative traditional gender norms, and one or more norms supportive of violence against women. METHODS: LCA identified latent classes of eight gendered risk factors. Multivariable logistic regression assessed associations between latent classes and IPV victimization and low educational attainment. RESULTS: A three-class solution was selected, and classes were named as: Low Risk class, Behavioral Risk class, and Attitudinal Risk class. Odds of low educational attainment and IPV were higher in the Attitudinal Risk class than the Low Risk class. Odds of low educational attainment and IPV were higher in the Behavioral Risk class than the Low Risk class and the Attitudinal Risk class. CONCLUSIONS: In Lesotho, gendered risk factors form distinct classes that have variable associations with low educational attainment and IPV. LCA can be an important approach to better understand the complicated relationship gendered risk factors have with each other and with certain outcomes, to further elucidate the influence that gender has on the health of AGYW and to provide more targeted prevention programming.

Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students - Adolescent Behaviors and Experiences Survey, United States, January-June 2021.

Social and educational disruptions during the COVID-19 pandemic have exacerbated concerns about adolescents' mental health and suicidal behavior. Data from the 2021 Adolescent Behaviors and Experiences Survey (ABES) indicate that 37.1% of U.S. high school students reported poor mental health during the COVID-19 pandemic, with 19.9% considering and 9.0% attempting suicide in the preceding year (1). Adverse childhood experiences (ACEs)* are associated with poor mental health and suicidal behaviors (2,3), and high prevalence of some ACEs have been documented during the pandemic (4). ACEs are preventable, potentially traumatic events that occur in childhood (ages 0-17 years) such as neglect, experiencing or witnessing violence, or having a family member attempt or die by suicide. Also included are aspects of a child's environment that can undermine their sense of safety, stability, and bonding. Associations between ACEs occurring during the pandemic and mental health or suicidal behaviors among U.S. high school students were examined using ABES data. Experience of one to two ACEs was associated with poorer mental health and increased suicidal behaviors, and these deleterious outcomes increased with additional ACE exposure. After adjusting for demographic characteristics, adolescents who reported four or more ACEs during the pandemic had a prevalence of poor current mental health four times as high as, and a prevalence of past-year suicide attempts 25 times as high as, those without ACEs during the pandemic. Experience of specific ACE types (e.g., emotional abuse) was associated with higher prevalences of poor mental health and suicidal behaviors. Prevention and intervention strategies (5), including early identification and trauma-informed mental health service and support provision, for ACEs and their acute and long-term impacts could help address the U.S. child and adolescent mental health and suicide crisis.†.

Association between lifetime sexual violence victimization and selected health conditions and risk behaviors among 13-24-year-olds in Lesotho: Results from the Violence Against Children and Youth Survey (VACS), 2018.

BACKGROUND: Sexual violence is a serious public health concern worldwide. In Lesotho, one in seven women and one in twenty men aged 18 years and older experienced sexual violence during childhood. Sexual violence victimization may lead to long-term mental and physical health issues among victims, regardless of gender. OBJECTIVE: To estimate the prevalence of lifetime sexual violence victimization (SV) among 13-24-year-olds in Lesotho and assess its association with selected health conditions and risk behaviors. PARTICIPANTS AND SETTING: Data from 13 to 24-year-old participants (n = 8568) of the 2018 Lesotho Violence Against Children and Youth Survey were analyzed. METHODS: SV was defined as reporting one or more types of sexual violence at any age. Logistic regression analyses measured associations between SV and selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV), and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months). RESULTS: After controlling for study covariates, SV was significantly associated with self-harm behaviors, suicidal thoughts, ever having an STI, binge drinking in the past 30 days, infrequent condom use in the past 12 months, and multiple sex partners in the past 12 months for both males and females; and mental distress and transactional sex in the past 12 months for females. CONCLUSIONS: Preventing SV against children and youth in Lesotho may improve their health and wellbeing.

Summary of Guidance for Minimizing the Impact of COVID-19 on Individual Persons, Communities, and Health Care Systems - United States, August 2022.

As SARS-CoV-2, the virus that causes COVID-19, continues to circulate globally, high levels of vaccine- and infection-induced immunity and the availability of effective treatments and prevention tools have substantially reduced the risk for medically significant COVID-19 illness (severe acute illness and post-COVID-19 conditions) and associated hospitalization and death (1). These circumstances now allow public health efforts to minimize the individual and societal health impacts of COVID-19 by focusing on sustainable measures to further reduce medically significant illness as well as to minimize strain on the health care system, while reducing barriers to social, educational, and economic activity (2). Individual risk for medically significant COVID-19 depends on a person's risk for exposure to SARS-CoV-2 and their risk for developing severe illness if infected (3). Exposure risk can be mitigated through nonpharmaceutical interventions, including improving ventilation, use of masks or respirators indoors, and testing (4). The risk for medically significant illness increases with age, disability status, and underlying medical conditions but is considerably reduced by immunity derived from vaccination, previous infection, or both, as well as timely access to effective biomedical prevention measures and treatments (3,5). CDC's public health recommendations change in response to evolving science, the availability of biomedical and public health tools, and changes in context, such as levels of immunity in the population and currently circulating variants. CDC recommends a strategic approach to minimizing the impact of COVID-19 on health and society that relies on vaccination and therapeutics to prevent severe illness; use of multicomponent prevention measures where feasible; and particular emphasis on protecting persons at high risk for severe illness. Efforts to expand access to vaccination and therapeutics, including the use of preexposure prophylaxis for persons who are immunocompromised, antiviral agents, and therapeutic monoclonal antibodies, should be intensified to reduce the risk for medically significant illness and death. Efforts to protect persons at high risk for severe illness must ensure that all persons have access to information to understand their individual risk, as well as efficient and equitable access to vaccination, therapeutics, testing, and other prevention measures. Current priorities for preventing medically significant illness should focus on ensuring that persons 1) understand their risk, 2) take steps to protect themselves and others through vaccines, therapeutics, and nonpharmaceutical interventions when needed, 3) receive testing and wear masks if they have been exposed, and 4) receive testing if they are symptomatic, and isolate for ≥5 days if they are infected.

Disclosure and help-seeking behaviors related to sexual and physical violence in childhood and adolescence: Results from the Namibia Violence Against Children and Youth Survey.

BACKGROUND: Violence disclosure and help-seeking can mitigate adverse health effects associated with childhood violence, but little is known about facilitators and barriers of disclosure and help-seeking behaviors in sub-Saharan Africa. OBJECTIVE: To understand factors associated with disclosure and help-seeking to inform care. PARTICIPANTS AND SETTING: Participants aged 13-24 years old in the 2019 Namibia Violence Against Children and Youth Survey (VACS). METHODS: We assessed the prevalence of victimization, disclosure, and help-seeking and examined factors associated with violence disclosure and help-seeking, separately, by gender. RESULTS: 4211 girls and 980 boys participated in the Namibia VACS. The prevalence of childhood sexual violence differed significantly by gender (15.7% among girls, 9.8% among boys), but physical violence prevalence did not differ by gender. Among victims of sexual violence, 57.3% of girls disclosed and 10.4% sought help, compared with only 30.7% and 3.2% of boys. Among victims of physical violence, 61.1% of girls and 53.4% of boys disclosed, and 16.9% of girls and 17.7% of boys sought help. Older age, social support, and experiencing more types of violence were associated with sexual violence disclosure among boys, but none of these factors were associated with sexual violence disclosure among girls. Lower education, perpetrator type, and witnessing violence were associated with physical violence disclosure among girls, while peer support and perpetrator type were associated with physical violence disclosure among boys. CONCLUSIONS: Factors associated with childhood violence differed by gender and violence type in Namibia, highlighting a need for gender-specific violence services to facilitate violence disclosure and help-seeking.

Multiple Imputation of Missing Race and Ethnicity in CDC COVID-19 Case-Level Surveillance Data.

The COVID-19 pandemic has resulted in a disproportionate burden on racial and ethnic minority groups, but incompleteness in surveillance data limits understanding of disparities. CDC's case-based surveillance system contains case-level information on most COVID-19 cases in the United States. Data analyzed in this paper contain COVID-19 cases with case-level information through September 25, 2020, which represent 70.9% of all COVID-19 cases reported to CDC during the period. Case-level surveillance data are used to investigate COVID-19 disparities by race/ethnicity, sex, and age. However, demographic information on race and ethnicity is missing for a substantial percentage of COVID-19 cases (e.g., 35.8% and 47.2% of cases analyzed were missing race and ethnicity information, respectively). Our goal in this study was to impute missing race and ethnicity to derive more accurate incidence and incidence rate ratio (IRR) estimates for different racial and ethnic groups, and evaluate the results from imputation compared to complete case analysis, which involves removing cases with missing race/ethnicity information from the analysis. Two multiple imputation (MI) models were developed. Model 1 imputes race using six binary race variables, and Model 2 imputes race as a composite multinomial variable. Our evaluation found that compared with complete case analysis, MI reduced biases and improved coverage on incidence and IRR estimates for all race/ethnicity groups, except for the Non-Hispanic Multiple/other group. Our research highlights the importance of supplementing complete case analysis with additional methods of analysis to better describe racial and ethnic disparities. When race and ethnicity data are missing, multiple imputation may provide more accurate incidence and IRR estimates to monitor these disparities in tandem with efforts to improve the collection of race and ethnicity information for pandemic surveillance.

Experiences of participation in a population-based survey on violence: Emotional discomfort, disclosure concerns, and the perceived value of participation among adolescents and young adults.

The accurate measurement of violence depends on high-quality data collected using methods that ensure participant confidentiality, privacy, and safety. To assess survey participants' emotional distress, discomfort, and self-perceived value of participating in the Honduras (2017), El Salvador (2017), Cote d'Ivoire (2018), and Lesotho (2018) Violence Against Children and Youth Surveys, which include sensitive topics such as sexual, physical, and emotional violence, we investigated individual self-reported distress and perceived value of participation by age, sex, and other demographic factors. We also examined the associations between past experiences of violence and both self-reported distress and perceived value of survey participation. Few individuals reported distress or concerns about disclosure. Across countries, 82.9% (Cote d'Ivoire) to 96.1% (Honduras) of participants indicated they were not afraid that someone might overhear their answers, 82.5% (Cote d'Ivoire) to 98.0% (El Salvador) said participation was not upsetting or stressful, and 93.3% (Cote d'Ivoire) to 98.6% (Honduras) said participation was worthwhile. The value of these interviews may exceed the negative feelings that some questions potentially elicit and can contribute to improved responses to victims.