The feasibility and preliminary efficacy of narrative exposure therapy on post-traumatic stress disorder among Syrian refugees in Jordan.

Objectives: Post-traumatic stress disorder (PTSD), anxiety, and depression are common mental health disorders among refugees, and all require immediate mental health support to prevent short- and long-term detrimental health outcomes. The purpose of this study was to evaluate the feasibility and preliminary efficacy of narrative exposure therapy (NET) in reducing symptoms of PTSD, depression, and anxiety among Syrian refugees residing in Jordan. Methods: A two-arm randomized control trial was utilized. A total of 40 Syrian refugees aged 18 to 64 diagnosed with PTSD were randomly allocated to either the NET intervention group (n = 20) or the waitlist control group (n = 20) using a computer-generated allocation list with 1:1 allocation. PTSD symptoms were evaluated using the Arabic rendition of the Harvard Trauma Questionnaire, while depression and anxiety symptoms were appraised using the Arabic adaptation of the Hopkins Symptoms Checklist-25. Descriptive statistics were employed to characterize the sample and survey data. Independent t-tests were conducted to assess mean score differences in PTSD, anxiety, and depression between the intervention and control groups. Results: Post NET intervention, significant reductions in PTSD (t = -10.00, P < 0.001), anxiety (t = -9.46, P < 0.001), and depression (t = -6.00, P < 0.001) scores were observed in the intervention group compared to the control group. Effect sizes were moderate for the trauma (Cohen's d = 0.73) and depression (Cohen's d = 0.79) symptoms and notably large for anxiety symptoms (Cohen's d = 0.97). There were no adverse events related to study participation. The intervention achieved a 100% participant retention rate. Conclusions: The results pertaining to retention rate, adherence to the study protocol, data completeness, cultural congruence, and participants' satisfaction provided strong support for the future implementation of the full-scale RCT. NET may be a feasible and helpful approach for refugees and other patients with PTSD, anxiety, and depression.

Pregnant in a Pandemic: Mental Wellbeing and Associated Healthy Behaviors Among Pregnant People in California During COVID-19.

INTRODUCTION: Pregnancy is a time of increased vulnerability to mental health disorders. Additionally, the COVID-19 pandemic has increased the incidence of depression and anxiety. Thus, we aimed to assess mental health and associated healthy behaviors of pregnant people in California during the pandemic in order to contextualize prenatal well-being during the first pandemic of the twenty-first century. METHODS: We conducted an online cross-sectional study of 433 pregnant people from June 6 through July 29, 2020. We explored 3 hypotheses: (1) mental health would be worse during the pandemic than in general pregnant samples to date; (2) first-time pregnant people would have worse mental health; and (3) healthy behaviors would be positively related to mental health. RESULTS: Many of our participants (22%) reported clinically significant depressive symptoms and 31% reported clinically significant anxiety symptoms. Multiparous pregnant people were more likely to express worries about their own health and wellbeing and the process of childbirth than were primiparous pregnant people. Additionally, as pregnancy advanced, sleep and nutrition worsened, while physical activity increased. Lastly, anxious-depressive symptomology was significantly predictive of participant sleep behaviors, nutrition, and physical activity during the past week. DISCUSSION: Pregnant people had worse mental health during the pandemic, and this was associated with worse health-promoting behaviors. Given that the COVID-19 pandemic and associated risks are likely to persist due to low vaccination rates and the emergence of variants with high infection rates, care that promotes mental and physical well-being for the pregnant population should be a public health priority.

Maternal diet disrupts the placenta-brain axis in a sex-specific manner.

High maternal weight is associated with detrimental outcomes in offspring, including increased susceptibility to neurological disorders such as anxiety, depression and communicative disorders. Despite widespread acknowledgement of sex biases in the development of these disorders, few studies have investigated potential sex-biased mechanisms underlying disorder susceptibility. Here, we show that a maternal high-fat diet causes endotoxin accumulation in fetal tissue, and subsequent perinatal inflammation contributes to sex-specific behavioural outcomes in offspring. In male offspring exposed to a maternal high-fat diet, increased macrophage Toll-like receptor 4 signalling results in excess microglial phagocytosis of serotonin (5-HT) neurons in the developing dorsal raphe nucleus, decreasing 5-HT bioavailability in the fetal and adult brains. Bulk sequencing from a large cohort of matched first-trimester human samples reveals sex-specific transcriptome-wide changes in placental and brain tissue in response to maternal triglyceride accumulation (a proxy for dietary fat content). Further, fetal brain 5-HT levels decrease as placental triglycerides increase in male mice and male human samples. These findings uncover a microglia-dependent mechanism through which maternal diet can impact offspring susceptibility for neuropsychiatric disorder development in a sex-specific manner.

From hybrid to fully remote clinical trial amidst the COVID-19 pandemic: Strategies to promote recruitment, retention, and engagement in a randomized mHealth trial.

Clinical trials worldwide were disrupted when the COVID-19 pandemic began in early 2020. Most intervention trials moved to some form of remote implementation due to restrictions on in-person research activities. Although the proportion of remote trials is growing, they remain the vast minority of studies in part due to few successful examples. Our team transitioned Goals for Reaching Optimal Wellness (GROWell), an NIH-funded (R01NR017659) randomized control trial (RCT; ClinicalTrials.gov identifier NCT04449432) originally designed as a hybrid intervention, into a fully remote clinical trial. GROWell is a digital dietary intervention for people who enter pregnancy with overweight or obesity. Primary outcomes include gestational weight gain and six-month postpartum weight retention. Strategies that we have tested, refined, and deployed include: (a) use of a HIPAA-compliant, web-based participant recruitment and engagement platform; (b) use of a HIPAA-compliant digital health platform to disseminate GROWell and conduct study visits (c) interconnectivity of these two platforms for seamless recruitment, consent, enrollment, intervention delivery, follow-up, and study team blinding; (d) detailed SMS messages to address initial challenges with protocol adherence; (e) email notifications alerting the study team about missed participant surveys so they can follow-up; (f) remuneration using email gift cards with recipient choice of vendor; and (g) geotargeting social media campaigns to improve participation of Black Indigenous and People of Color Communities. These strategies have resulted in screen failure rates improving by 7%, study task adherence improving by an average of 20-30% across study visits, and study completion rates of 82%. Researchers may consider some or all of these approaches in future remote mHealth trials.

Measuring Evidence-Based Viral Respiratory Illness Mitigation Behaviors in Pregnant Populations: Development and Validation of a Short, Single-Factor Scale During the COVID-19 Pandemic.

OBJECTIVE: Researchers and public health professionals need to better understand individual engagement in coronavirus disease 2019 (COVID-19) mitigation behaviors to reduce the human and societal costs of the current pandemic and prepare for future respiratory pandemics. We suggest that developing measures of individual mitigation behaviors and testing them among high-risk individuals, including pregnant people, may help to reduce overall morbidity and mortality by quickly identifying targets for messaging around mitigation until sufficient vaccination uptake is reached. METHODS: We surveyed pregnant people in California over 2 waves of the COVID-19 pandemic to explore mitigation behaviors. We developed and validated a novel Viral Respiratory Illness Mitigation Scale (VRIMS). RESULTS: Seven measures loaded onto a single factor with good psychometric properties. The overall sample scale average was high over both waves, indicating that most pregnant Californians engaged in most of the strategies most of the time. Older participants, minoritized participants, those living in more urban contexts, and those surveyed during a surge reported engaging in these strategies most frequently. CONCLUSIONS: Clinicians and researchers should consider using reliable, validated measures like the VRIMS to identify individuals and communities that may benefit from additional education on reducing risk for COVID-19, future respiratory pandemics, or even seasonal flu.

Understanding COVID-19 vaccine uptake during pregnancy: 'Hesitance', knowledge, and evidence-based decision-making.

BACKGROUND: A key mitigation strategy to the COVID-19 pandemic has been the development and roll-out of vaccines. However, pregnant and lactating people were not included in initial vaccine trials and this population is hesitant to receive the vaccine, despite contrary recommendations from the American College of Obstetrics and Gynecology and the Centers for Disease Control and Prevention. Understanding the reasons behind this hesitancy is vital to promote vaccine uptake. METHODS: We surveyed pregnant people in California from December 2020 to January 2021 (n = 387) to describe cognitions and decision-making regarding COVID-19 vaccination. Using descriptive, regression-based analyses, we examined rates of planned uptake and reasoning among individuals who reported COVID-19 vaccine hesitancy. RESULTS: Overall, the pregnant Californians that we surveyed were aware of the COVID-19 vaccines. Of 387 participants, 43% reported planning to get the vaccine as soon as possible. The remaining 57% were hesitant: 27% responded that they would not receive the vaccine. Some demographic features did predict more COVID-19 vaccine hesitancy, particularly younger age (AOR = 0.95, p = 0.025) and living in a less urban context (AOR = 0.80, p = 0.041). Essential worker status also was associated with vaccine hesitancy. Having had, or intending to have, a flu vaccine was negatively associated with COVID-19 vaccine hesitancy (p < 0.001). The most commonly reported reason for COVID-19 vaccine hesitancy was "I don't know enough about the vaccine." Low levels of self-reported knowledge were highly predictive of hesitancy. CONCLUSIONS: Terms like "vaccine hesitance" and "anti-vax" do not adequately characterize decisions regarding delaying COVID-19 vaccination. Rather, these decisions are largely based on the lack of knowledge about the impacts of vaccination on pregnancy, fetal development, and later child wellbeing. This lack of knowledge should be countered by conversations between individual healthcare providers and their pregnant patients, and better inclusion of pregnant people and children in vaccine trials.

Equity in Genomics: A Brief Report on Cardiovascular Health Disparities in African American Adults.

BACKGROUND: African Americans are more likely to die from cardiovascular disease (CVD) than all other populations in the United States. Although technological advances have supported rapid growth in applying genetics/genomics to address CVD, most research has been conducted among European Americans. The lack of African American representation in genomic samples has limited progress in equitably applying precision medicine tools, which will widen CVD disparities if not remedied. PURPOSE: This report summarizes the genetic/genomic advances that inform precision health and the implications for cardiovascular disparities in African American adults. We provide nurse scientists recommendations for becoming leaders in developing precision health tools that promote population health equity. CONCLUSIONS: Genomics will continue to drive advances in CVD prevention and management, and equitable progress is imperative. Nursing should leverage the public's trust and its widespread presence in clinical and community settings to prevent the worsening of CVD disparities among African Americans.

Goals for Reaching Optimal Wellness (GROWell): A clinical trial protocol of a digital dietary intervention for pregnant and postpartum people with prenatal overweight or obesity.

BACKGROUND: Excess gestational weight gain (EGWG) is associated with multiple pregnancy complications and health risks for birthing people and their infants. Likewise, postpartum weight retention (PPWR), or not losing all pregnancy weight, has long-term health consequences. EGWG among people who enter pregnancy with overweight or obesity have worse obstetric outcomes and increased PPWR compared to women who gain within Institute of Medicine guidelines. METHODS: This study protocol describes the details of a blinded, randomized clinical trial of GROWell: Goals for Reaching Optimal Wellness, a mHealth tool designed to improve diet quality among people who enter pregnancy with overweight or obese BMIs to help them achieve appropriate GWG and safe postpartum pregnancy weight loss. Individuals with overweight and obesity will be randomly assigned to an attention control or intervention arm. The intervention group will receive personalized, goal-oriented text messages regarding dietary choices, while the attention control group will receive text messages about healthy pregnancy, labor, delivery, and early infancy. Both groups will complete online surveys at baseline, follow up, 3 and 6 months postpartum. RESULTS AND DISCUSSION: Currently, 162 subjects have been enrolled. Outcomes associated with GWG and pregnancy are expected in late 2023, while outcomes on postpartum weight retention GROWell adherence are expected in late 2024. The results of this trial will support the use of an evidence-based mHealth tool to be integrated into clinical practice to reduce EGWG and PPWR among pregnant people with overweight and obese BMIs, a resource that is currently lacking. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04449432. Registered on June 26, 2020.

Adverse Childhood Experiences and Cardiovascular Health: An Exploration of Protective Social Determinants Among Young Adult Black Women.

This study sought to advance the literature on Black women's cardiovascular health (CVH) by examining maternal relationship, religion and spirituality, and social connections as potential protective social determinants that buffer the stress of adverse childhood experiences (ACEs). The outcome was the American Heart Association's ideal CVH score. Neither maternal relationship nor religion/spirituality was able to buffer the stress of ACEs on ideal CVH. Findings are discussed in terms of cultural aspects of potential protective factors that are critical for future research. Identifying protective factors that may buffer the influence of ACEs on CVH remains a priority to promote health equity.

Perinatal health care access, childbirth concerns, and birthing decision-making among pregnant people in California during COVID-19.

BACKGROUND: During public health emergencies, including the COVID-19 pandemic, access to adequate healthcare is crucial for providing for the health and wellbeing of families. Pregnant and postpartum people are a particularly vulnerable subgroup to consider when studying healthcare access. Not only are perinatal people likely at higher risk for illness, mortality, and morbidity from COVID-19 infection, they are also at higher risk for negative outcomes due to delayed or inadequate access to routine care. METHODS: We surveyed 820 pregnant people in California over two waves of the COVID-19 pandemic: (1) a 'non-surge' wave (June 2020, n = 433), and (2) during a 'surge' in cases (December 2020, n = 387) to describe current access to perinatal healthcare, as well as concerns and decision-making regarding childbirth, over time. We also examined whether existing structural vulnerabilities - including acute financial insecurity and racial/ethnic minoritization - are associated with access, concerns, and decision-making over these two waves. RESULTS: Pregnant Californians generally enjoyed more access to, and fewer concerns about, perinatal healthcare during the winter of 2020-2021, despite surging COVID-19 cases and hospitalizations, as compared to those surveyed during the COVID-19 'lull' in the summer of 2020. However, across 'surge' and 'non-surge' pandemic circumstances, marginalized pregnant people continued to fare worse - especially those facing acute financial difficulty, and racially minoritized individuals identifying as Black or Indigenous. CONCLUSIONS: It is important for clinicians, researchers, and policymakers to understand whether and how shifting community transmission and infection rates may impact access to perinatal healthcare. Targeting minoritized and financially insecure communities for increased upstream perinatal healthcare supports are promising avenues to blunt the negative impacts of the COVID-19 pandemic on pregnant people in California.

Adverse Childhood Experiences and Blood Pressure in Women in the United States: A Systematic Review.

INTRODUCTION: Elevated blood pressure is a leading contributor to adverse cardiovascular outcomes. Some studies suggest there is an association between adverse childhood experiences (ACEs) and subsequent elevated blood pressure in adulthood. The literature specific to ACEs and blood pressure in women has not been synthesized; thus the purpose of this systematic review was to examine what is known about the association between ACEs and blood pressure in women living in the United States. METHODS: In collaboration with a medical librarian, a systematic search of the literature published between January 1998 and December 2019 was conducted. Original, peer-reviewed publications were identified from PubMed, CINAHL, and PsycINFO databases. Studies were excluded if they (1) were conducted outside the United States, (2) measured acute stress or adult stressors, or (3) measured childhood- or pregnancy-related outcomes. RESULTS: Of 1740 articles, 12 publications met criteria for inclusion in this study, 8 of which were from cohort studies. Racial and ethnic diversity was limited, with half of the articles in this review consisting of samples that were majority white. Of the studies that used a self-reported history of hypertension, 60% obtained significant associations with ACEs, compared with only 30% of the studies that had objective blood pressure data. ACEs were associated with lower blood pressure in 3 studies. DISCUSSION: More research is needed to elucidate the relationship between ACEs and elevated blood pressure. Inconsistencies in the findings may be related to the measurement of blood pressure, assessment of ACEs, and population characteristics. Future studies should incorporate diverse population-representative samples with consideration for sex- or race-specific stressors such as pregnancy or racism and their potential influence on blood pressure. Health care providers may consider the history of ACEs as part of screening for cardiovascular risk factors among female patients, especially younger women presenting with elevated blood pressure.

Social Adversity, Sleep Characteristics, and Elevated Blood Pressure Among Young Adult Black Females.

Purpose: We examined whether sleep characteristics and adverse social exposures were associated with elevated blood pressure (BP) in young adult black women. Methods: This is a cross-sectional analysis of existing data from 581 black females who participated in the National Longitudinal Study of Adolescent to Adult Health (Add Health). Adverse social exposures included child abuse, discrimination, perceived stress, social isolation, and subjective social status. Self-reported sleep characteristics were measures of duration, latency, continuity, and snoring. Logistic regression was used to evaluate the influence of social exposures and sleep characteristics on BP. Results: Among the women (mean age=29.1 years), 32.4% had elevated BP (≥130 systolic or ≥80 diastolic). In adjusted analysis, poor sleep continuity (adjusted odds ratio [aOR]=1.70, 95% confidence interval [CI]=1.07-2.70) and discrimination (aOR=1.61, 95% CI=1.00-2.58) were associated with higher odds of elevated BP, while more social isolation (aOR=0.69, 95% CI=0.48-0.99) was associated with lower odds of elevated BP. Conclusion: Poor sleep continuity and experiencing discrimination may represent key risk factors for hypertension in young black females. Unexpectedly, being more isolated was associated with lower BP. Future research should examine how to adapt current paradigms and measures of social connectedness, isolation, and stress to better elucidate the impact of these factors on the long-term health of young black females.

Feasibility of a text-based reduction intervention in helping rural and underserved smokeless tobacco users quit.

INTRODUCTION: Smokeless tobacco (ST) use significantly affects morbidity and mortality and remains disproportionally prevalent in rural and medically underserved communities. Few programs exist for rural smokeless tobacco users. Text-based interventions may increase the reach of cessation interventions; yet, none has tested them in ST users. We evaluated the feasibility, acceptability, and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) intervention in rural and underserved ST users. METHODS: ST users were randomized in 2:1 fashion to the SGR group (N = 65), a text-based reduction program plus text-based support counseling messages or text-based support messages only group (N = 33). We surveyed participants at 30-days post intervention initiation to assess feasibility and acceptability and examined self-report 7-day point prevalence cessation at 30-days and 6-months post intervention initiation in the two arms. RESULTS: We achieved benchmarks for feasibility and acceptability. Among the SGR participants 51% (n = 48) reported that intervention was useful in helping them quit, 83% (n = 48) indicated that they would recommend the intervention to a friend. Over 95% (n = 39) of SGR participants said that they read all alert texts. The SGR participants had a higher quit rate at 30-days compared to support messages alone (SGR = 21.5%, Control = 9.1%, p = 0.1627, Cohen's d equivalent = 0.56, medium effect). However, the quit rate at 6-months was 21% (p = 0.9703) for both groups. CONCLUSIONS: A text-based intervention was feasible and acceptable among underserved ST users. SGR helped promote short-term cessation. The text-based interventions both had long-term efficacy. Given that text-based interventions have the potential to increase reach in underserved ST users, further testing is warranted.

Understanding Social Determinants of Cardiometabolic Disease Risk in Rural Women.

Women living in rural America experience significant disparities in cardiometabolic diseases warranting research to aid in understanding the contextual factors that underlie the rural and urban disparity and in planning effective primary prevention interventions. While research has established a general understanding of cardiometabolic risks individually, the combination or bundling of these risk behaviors is not clearly understood. The purpose of this study is to explore the association of social determinants of health on obesity and adiposity related cardiometabolic disease risk among rural women. Data were from the multi-state Rural Families Speak about Health Study. A total of 399 women were included in the analyses. Data were collected using a self-administered questionnaire on women's demographics, economic stability, education, and health and healthcare. Food insecurity, education, healthcare access and comprehension health literacy were associated with higher obesity and adiposity-related cardiometabolic risk. Health behaviors, tobacco use and physical activity were not associated with higher cardiometabolic risk in this sample of rural women. This is one of the first studies to focus on multiple social determinants of health and cardiometabolic risk in rural American women. Understanding combinations of risk behaviors can assist health care providers and community health professionals in tailoring multiple health behavior change interventions to prevent cardiometabolic disease among rural women. The findings support a focus on community and societal level factors may be more beneficial for improving the cardiometabolic health of rural women.

The Co-occurrence of Daily Smoking, Binge Drinking and IPV Among Latino Expectant Fathers.

Many Latino men have multiple risk factors that predispose them to chronic disease morbidity and mortality, yet few have examined patterns in this population. We describe the co-occurrence of daily smoking, binge drinking, and intimate partner violence (IPV) behaviors among Latino expectant fathers and examine factors associated with the co-occurrence of these behaviors. We conducted a secondary analysis of baseline data from the Parejas Trial, a randomized controlled trial testing a culturally tailored couples-based smoking cessation intervention. We used Kruskal-Wallis test statistics to explore the relationship of the co-occurring behavior and demographic and cultural factors. All participants smoked as was a requirement of being in the trial, but only 39% smoked daily. Forty three percent of the participants engaged in one behavior, 32% engaged in two behaviors, and 5% engaged in three behaviors, with binge drinking being the most common co-occurring behavior. In the bivariate analysis, higher stress (p = 0.01) and having more children (p = 0.003) were found to be positively significantly associated with the number of behaviors. Helping Latino expectant fathers manage with their stress may serve as tailoring points for future interventions to reduce risk behaviors.

Depression in Arab Adolescents: A Qualitative Study.

Depression rates among Arab adolescents are expected to rapidly increase necessitating research-based data to aid in planning effective strategies to implement primary prevention and treatment interventions. The current study aimed to capture Jordanian adolescents' experience of depression, identify perceived contributing factors, and assess their attitudes toward depression interventions. An exploratory, qualitative design was used to collect data from 92 participants (age range = 14 to 17) through 12 focus groups. Two main analytical themes and related subthemes were identified. The first theme focused on participants' perceived mental health status, Being a Depressed Adolescent, with two related subthemes: Symptom Profiles and Feelings of Uncertainty and Perceived Roots of Depression. The second theme focused on the experience of Living With Depression and encapsulated two subthemes: Seeking Supportive Resources and Escaping From Labeling. The study revealed gender differences in the recognition of depression symptoms, willingness to seek care, the ability to communicate symptoms, expectations of care, and views on the best sources of help. For girls and boys, the fear of being labeled as mentally ill contributes to poor engagement in, adherence to, and use of mental health services. A comprehensive approach that considers Arab adolescents' beliefs, attitudes, and experiences in conjunction with the family and social context is needed to address the burden of adolescent depression in Arab nations. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 34-43.].

Acceptability and Feasibility of a Mindfulness-Based Intervention for Pain Catastrophizing among Persons with Sickle Cell Disease.

BACKGROUND: Few investigators have developed and tested nonpharmacological interventions for helping persons with sickle cell disease (SCD) manage persistent pain. AIMS: The purpose of this pilot study was to examine the feasibility and acceptability of a mindfulness-based intervention (MBI) in adults with SCD and chronic pain and to gather preliminary data on its efficacy. DESIGN: Data on feasibility and acceptability, including recruitment, retention, and attendance rates, were collected during a single-site, randomized control trial. Participants were randomly assigned to either a 6-session group telephonic MBI or a wait-listed control. Pain catastrophizing was assessed at baseline and at weeks 1, 3, and 6. SETTING: Outpatient, comprehensive, interdisciplinary sickle cell disease center in the Southeast. PARTICIPANTS/SUBJECTS: Adults at least 18 years of age with a self-reported diagnosis of sickle cell disease who self-identified as having chronic, non-cancer pain that persisted on most days for at least 6 months and adversely affected function and/or well-being. METHODS: Seventy-eight adults were recruited; 18 (23%) declined to participate; 60 were randomly assigned to either the MBI (N = 40) or control (N = 20). Of those, 14 (35%) from the MBI and 12 (60%) from the control group withdrew immediately after random allocation, resulting in 34 evaluable cases (MBI: N = 26; control: N = 8). RESULTS: Among the 26 assigned to MBI, the median number of sessions attended per person was 4; 7 (27%) attended all six sessions. Qualitative findings indicated that MBI participants viewed the program as acceptable and liked the telephonic format, community, and content. Reductions in pain catastrophizing outcomes were identified after intervention. CONCLUSIONS: An MBI is feasible and acceptable for persons with SCD experiencing chronic pain. A larger randomized controlled trial to establish MBI efficacy on pain and related outcomes for SCD will provide nonpharmacologic, behavioral pain management options for nurses and other clinicians caring for persons with SCD and chronic pain.

Comparison of the performance of the Beck Depression Inventory-II and the Center for Epidemiologic Studies-Depression Scale in Arab adolescents.

BACKGROUND AND PURPOSE: Few instruments have been established as valid and reliable to screen for depression among Arab adolescents. The purpose of this study was to examine and compare the performance of two of the most widely used depression screening instruments, the Beck Depression Inventory-II (BDI-II) and the Center for Epidemiologic Studies-Depression scale (CES-D), with Arab adolescents. METHODS: A nationwide school survey was conducted in Jordan. A total of 3,292 adolescents (1,766 females; 54%) aged 13-17 years completed and returned the survey that included the BDI-II, CES-D, sociodemographics, and health information. Comparisons were made between the BDI-II and CES-D on internal consistency and the reported prevalence of depression in the whole population and subgroups. Multivariate ordinary least squares and logistic regressions were used to assess factors associated with adolescent depression. Agreement regarding recommended cutoffs was also examined using Cohen's k. RESULTS: Depression prevalence was significantly higher with the CES-D compared to the BDI-II among the same set of sample subgroups. Depression scores from both instruments showed different statistical associations with established risk factors for adolescent depression. The two instruments showed a moderate agreement (kappa = 0.55), indicating that the instruments do not completely identify the same cases. Different cutoff scores of the CES-D seemed to perform better for different age groups. CONCLUSIONS: Our results varied systematically as a function of the measure used to identify depression prevalence. Caution in the interpretation of associations of depression scores with risk factors is required, as associations may be measurement artifacts. However, given the limited availability of mental health care resources in Arab countries, screening instruments like the BDI-II and CES-D may be a critical first step in preliminarily identifying cases, albeit neither can replace the clinical interview. We cautiously recommend using the CES-D with the risk of over diagnosing, but with the benefit of finding issues which are not typically addressed when there is a lack of mental health services. With the growing social and political unrest in Arab countries, increasing depression rates over time is expected to be a major public health issue. Methodical consideration for how to invest in community-based screening is warranted.

Psychosocial Correlates of Jordanian Adolescents' Help-Seeking Intentions for Depression: Findings From a Nationally Representative School Survey.

Little is known about help-seeking for depression among Jordanian adolescents who are a vulnerable population with high rates of depressive symptoms and few mental health services. The purpose of this study was to (1) explore Jordanian adolescents' helpseeking intentions for depression and (2) examine whether depression stigma, depression severity, or their interaction are associated with Jordanian adolescents' willingness to seek help for depression and the type of treatment they would seek. In collaboration with the Jordanian Ministry of Education, we conducted a nationally representative, school-based survey of adolescents aged 12-17 years ( N = 2,349). One fourth of the adolescents reported they would not seek professional help for depression, and those respondents had higher average depression scores. Among those adolescents willing to seek help, the most likely sources included family member (57%), school counselor (46%), psychiatrist (43%), religious leader (39%), and general health practitioner (28%). Lower stigma scores were associated with greater likelihood to seek psychotherapy or visit a psychiatrist, while higher stigma scores were associated with increased likelihood to seek help from a school counselor or a family member. Jordanian adolescents experience significant barriers to seeking professional help for depression. However, even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses should be leveraged along with counselors to address mental health issues in this vulnerable population.