Disability status and multi-dimensional personal well-being among adolescents in the Southern Highlands Region of Tanzania: results of a cross-sectional study.

OBJECTIVE: Examine how disability status among adolescents is associated with the following domains of personal well-being: schooling, livelihoods, health, violence and psychosocial well-being. It is hypothesised that adolescents with a disability will have greater deficits in these areas of well-being compared with their healthier counterparts. DESIGN: Cross-sectional data from 2018 were obtained from the second round of an on-going study of adolescents living in poor households in two regions of the Southern Highlands of Tanzania (Iringa and Mbeya). We use the Washington Group (WG) Short Set indicators to measure disability and undertook logistic and linear multivariate regressions to understand the association between disability and the outcomes of interest. PARTICIPANTS: The sample included 2274 participants aged 15-20 years living in households participating in a government social protection programme targeted to households living in extreme poverty. RESULTS: Overall, 310 participants (14%) were classified as having disabilities. Outcomes not associated with disability status included literacy, schooling, livelihoods and self-efficacy. Adolescents with disabilities were less likely to report good or very good health (adjusted OR (aOR)=0.39, 95% CI 0.29 to 0.52) and had increased odds of reporting depressive symptoms in (aOR=1.46, 95% CI 1.11 to 1.90), emotional violence (aOR=2.18, 95% CI 1.49 to 3.20) and physical violence (aOR=1.71, 95% CI 1.13 to 2.59), compared with those without disabilities. Reports of depression were higher among men, and violence was more prevalent among women. Patterns of association were generally similar between men and women, although the association of disability with markers of well-being reached statistical significance more often among men. CONCLUSION: This study highlights areas where adolescents with disabilities are falling behind their peers in terms of personal well-being. These findings suggest that interventions may be needed to mainstream disability in programmes and policies aiming to improve well-being, mental health and violence prevention among adolescents. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry (PACTR201804003008116).

Exploring multilevel social determinants of depressive symptoms for Tanzanian adolescents: evidence from a cross-sectional study.

BACKGROUND: Depression has substantial and enduring impacts for adolescents, particularly those living in poverty. Yet, evidence on its determinants in low-income countries remains scarce. We examined the social determinants of depressive symptoms for Tanzanian adolescents. METHODS: We used cross-sectional data for 2458 adolescents (aged 14-19), to describe associations with depressive symptoms within and across five domains-demographic, economic, neighbourhood, environmental and social-cultural-using linear mixed models. We estimated depressive symptoms using the 10-item Centre for Epidemiological Studies Depression Scale, which ranges from 0 to 30 and increases with additional symptoms. RESULTS: Factors associated with depressive symptoms in the fully adjusted models included experiencing five or more household economic shocks (ß=2.40; 95% CI 1.48 to 3.32), experiencing droughts/floods (ß=0.76; 95% CI 0.36 to 1.17), being in a relationship (ß=1.82; 95% CI 1.30 to 2.33), and having moderate (ß=1.26; 95% CI 0.80 to 1.71) or low (ß=2.27; 95% CI 1.81 to 2.74) social support. Exclusive schooling was protective compared with being engaged in both school and paid work (ß=1.07; 95% CI 0.05 to 2.61) and not engaged in either (ß=0.73; 95% CI 0.24 to 1.22). Household size and relationship status were more important factors for girls, while employment status, and extreme precipitation were more important for boys. CONCLUSION: Mental health is associated with determinants from multiple domains. Results suggest that environmental shocks related to climate change contribute to poor mental health in adolescents, highlighting an important area for intervention and research.

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme.

OBJECTIVES: The study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme on health insurance enrolment. SETTING: The study was conducted in five districts implementing Ghana's LEAP 1000 programme in Northern and Upper East Regions. PARTICIPANTS: Women, from LEAP households, who were pregnant or had a child under 1 year and who participated in baseline and 24-month surveys (2497) participated in the study. INTERVENTION: LEAP provides bimonthly cash payments combined with a premium waiver for enrolment in NHIS to extremely poor households with orphans and vulnerable children, elderly with no productive capacity and persons with severe disability. LEAP 1000, the focus of the current evaluation, expanded eligibility in 2015 to those households with a pregnant woman or child under the age of 12 months. Over the course of the study, households received 13 payments. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes included current and ever enrolment in NHIS. Secondary outcomes include reasons for not enrolling in NHIS. We conducted a mixed-methods impact evaluation using a quasi-experimental design and estimated intent-to-treat impacts on health insurance enrolment among children and adults. Longitudinal qualitative interviews were conducted with an embedded cohort of 20 women and analysed using systematic thematic coding. RESULTS: Current enrolment increased among the treatment group from 37.4% to 46.6% (n=5523) and decreased among the comparison group from 37.3% to 33.3% (n=4804), resulting in programme impacts of 14 (95% CI 7.8 to 20.5) to 15 (95% CI 10.6 to 18.5) percentage points for current NHIS enrolment. Common reasons for not enrolling were fees and travel. CONCLUSION: While impacts on NHIS enrolment were significant, gaps remain to maximise the potential of integrated programming. NHIS and LEAP could be better streamlined to ensure poor households fully benefit from both services, in a further step towards integrated social protection. TRIAL REGISTRATION NUMBER: RIDIE-STUDY-ID-55942496d53af.

Perspectives of adolescent and young adults on poverty-related stressors: a qualitative study in Ghana, Malawi and Tanzania.

OBJECTIVES: To define key stressors experienced and coping behaviours within poor agrarian communities in sub-Saharan Africa. DESIGN: Descriptive qualitative study incorporating inductive thematic analysis. PARTICIPANTS: 81 participants purposely sampled, stratified by age (adolescents and young adults) and sex SETTING: The study was conducted in villages in Ghana, Malawi, and Tanzania. RESULTS: Stressors were thematically grouped into those directly related to poverty and the lack of basic necessities (eg, food insecurity), and additional stressors (eg, drought) that worsen poverty-related stress. Impacts on functioning, health and well-being and key coping behaviours, both positive and negative, were identified. The findings together inform a more nuanced view of stress within these contexts. CONCLUSION: Although participants were asked to provide general reflections about stress in their community, the salience of poverty-related stressors was ubiquitously reflected in respondents' responses. Poverty-related stressors affect development, well-being and gender-based violence. Future research should focus on interventions to alleviate poverty-related stress to achieve the United Nations Sustainable Development Goals.

List randomization for soliciting experience of intimate partner violence: Application to the evaluation of Zambia's unconditional child grant program.

Social scientists have increasingly invested in understanding how to improve data quality and measurement of sensitive topics in household surveys. We utilize the technique of list randomization to collect measures of physical intimate partner violence in an experimental impact evaluation of the Government of Zambia's Child Grant Program. The Child Grant Program is an unconditional cash transfer, which targeted female caregivers of children under the age of 5 in rural areas to receive the equivalent of US $24 as a bimonthly stipend. The implementation results show that the list randomization methodology functioned as planned, with approximately 15% of the sample identifying 12-month prevalence of physical intimate partner violence. According to this measure, after 4 years, the program had no measurable effect on partner violence. List randomization is a promising approach to incorporate sensitive measures into multitopic evaluations; however, more research is needed to improve upon methodology for application to measurement of violence.

Women's Individual Asset Ownership and Experience of Intimate Partner Violence: Evidence From 28 International Surveys.

OBJECTIVES: To assess the oft-perceived protective relationship between women's asset ownership and experience of intimate partner violence (IPV) in the previous 12 months. METHODS: We used international survey data from women aged 15 to 49 years from 28 Demographic and Health Surveys (2010-2014) to examine the association between owning assets and experience of recent IPV, matching on household wealth by using multivariate probit models. Matching methods helped to account for the higher probability that women in wealthier households also have a higher likelihood of owning assets. RESULTS: Asset ownership of any type was negatively associated with IPV in 3 countries, positively associated in 5 countries, and had no significant relationship in 20 countries (P < .10). Disaggregation by asset type, sole or joint ownership, women's age, and community level of women's asset ownership similarly showed no conclusive patterns. CONCLUSIONS: Results suggest that the relationship between women's asset ownership and IPV is highly context specific. Additional methodologies and data are needed to identify causality, and to understand how asset ownership differs from other types of women's economic empowerment.

Understanding the linkages between social safety nets and childhood violence: a review of the evidence from low- and middle-income countries.

As many as one billion children experience violence every year, and household- and community-level poverty are among the risk factors for child protection violations. Social safety nets (SSNs) are a main policy tool to address poverty and vulnerability, and there is substantial evidence demonstrating positive effects on children's health and human capital. This paper reviews evidence and develops a framework to understand linkages between non-contributory SSNs and the experience of childhood emotional, physical and sexual violence in low- and middle-income countries. We catalogue 14 rigorous impact evaluations, 11 of which are completed, analysing 57 unique impacts on diverse violence indicators. Among these impacts, approximately one in five represent statistically significant protective effects on childhood violence. Promising evidence relates to sexual violence among female adolescents in Africa, while there is less clear evidence of significant impacts in other parts of the developing world, and on young child measures, including violent discipline. Further, few studies are set up to meaningfully unpack mechanisms between SSNs and childhood violence; however, those most commonly hypothesized operate at the household level (through increases in economic security and reductions in poverty-related stress), the interpersonal level (improved parental behaviours, caregiving practices, improved psychosocial well-being) and at the child-level (protective education and decreases in problem or risky behaviours). It is important to emphasize that traditional SSNs are never designed with violence prevention as primary objectives, and thus should not be considered as standalone interventions to reduce risks for childhood violence. However, SSNs, particularly within integrated protection systems, appear to have potential to reduce violence risk. Linkages between SSNs and childhood violence are understudied, and investments should be made to close this evidence gap.

Equity and achievement in access to contraceptives in East Africa between 2000 and 2010.

OBJECTIVE: To examine trends in equity in contraceptive use, and in contraceptive-prevalence rates in six East African countries. METHODS: In this repeated cross-sectional study, Demographic and Health Surveys Program data from women aged 15-49 years in Ethiopia, Kenya, Malawi, Rwanda, Tanzania, and Uganda between 2000 and 2010 were analyzed. Individuals were ranked according to wealth quintile, stratified urban/rural populations, and calculated concentration index-a statistic integrating information from all wealth quintiles to analyze disparities. RESULTS: Equity and contraceptive-prevalence rates increased in most country regions over the study period. Notably, in rural Rwanda, contraceptive-prevalence rates increased from 3.9 to 44.0, and urban Kenya became the most equitable country region, with a concentration index of 0.02. The Pearson correlation coefficient between improvements in concentration index and contraceptive-prevalence rates was 0.52 (P=0.011). CONCLUSION: The results indicate that countries seeking to increase contraceptive use should prioritize equity in access to services and contraceptives.

A retrospective evaluation of the intrauterine device in a patient population in Buenos Aires, Argentina.

BACKGROUND: The intrauterine device (IUD) is a long-acting reversible contraceptive method that is safe for a wide range of women, including adolescents and nulliparous women. Globally, it is often underutilised due to misperceptions among patients. Examination of characteristics associated with IUD discontinuation including adverse effects and IUD expulsion can inform provider practices to improve contraception success and patient satisfaction with this method. We studied IUD performance at a public family planning clinic in Buenos Aires, Argentina, serving a predominantly immigrant, low-income population. METHODS: We conducted a retrospective evaluation of 1047 IUD insertions between 2002 and 2007 with 5 years of follow-up data. We performed bivariate and survival analysis to examine characteristics associated with IUD discontinuation: adverse outcomes including pain, bleeding, and IUD expulsion, and time to removal. FINDINGS: Of 1047 patients, only 188 (18%) had their IUD removed within 5 years. The main causes of IUD discontinuation were involuntary (38%) reasons such as an IUD expulsion and personal choice (34%) such as desiring pregnancy. CONCLUSIONS: Findings suggest overall good long-term performance with IUD insertion, with minimal complaints or adverse outcomes. These findings may help to support providers serving similar populations in promoting this method.

Childhood obesity and human capital accumulation.

The prevalence of childhood obesity has tripled in the United States over the last 25 years, and in addition to increased risks of many chronic diseases, obesity may also be linked to lower skill attainment, poor social competency, and poorer labor outcomes. Any causal links between obesity and human capital accumulation could have important consequences for both health and economic well-being over the life course. We investigate the association of obesity and cognitive and non-cognitive outcomes among US children and adolescents aged 5 to 19 using the Child Development Supplement of the Panel Survey of Income Dynamics. We perform OLS and individual fixed effects regressions to address unobserved time invariant heterogeneity in the relationship between overweight/obesity and abilities. Results provide limited support for the hypothesis that obesity negatively affects non-cognitive but not cognitive outcomes and suggest that discrimination rather than a biological mechanism contributes to negative outcomes found in the literature on adults.

Family poverty is associated with cytomegalovirus antibody titers in U.S. children.

OBJECTIVE: Early life environmental and psychological influences are thought to play an important role in the development of the immune system. Antibody response to latent herpesviruses has been used as an indirect measure of cell-mediated immune function but has seldom been applied to younger age groups. METHODS: We used data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) to test for an association between family poverty and continuous antibody response to cytomegalovirus in U.S. children aged 6-16 (N = 2,226) using ordinary least squares regression. RESULTS: Poverty was significantly associated with increased antibody levels among seropositive individuals. The association between income and antibody levels exhibited a threshold effect, with additional income beyond the poverty line not associated with increased antibody titers. This relationship was more robust among older compared with younger children. CONCLUSIONS: Early life social factors such as family poverty could have detrimental impacts on the developing immune system, with potentially important consequences for later life health outcomes. Exposure to socioeconomic stressors for longer periods during childhood may further enhance alterations in immune response to cytomegalovirus.

Abortion and women's roles in society: opinions from Tlaxcala, Mexico.

OBJECTIVE: We aim to assess the opinions of Mexicans in the state of Tlaxcala on abortion and other topics concerning women's reproductive health and status in society. MATERIAL AND METHODS: We summarize opinions on abortion and women's roles in society and perform logit regressions to assess characteristics correlated with support for abortion rights. RESULTS: A majority of respondents were against a woman's right to abortion when asked generally, but when asked about specific circumstances, a majority supported the right to abortion in five of the nine hypothetical circumstances proposed. In multivariate analysis, age, education, religion, religious service attendance, and views regarding women's roles in society had significant effects on support for the right to abortion. CONCLUSIONS: Our results demonstrate that residents of Tlaxcala view abortion as a personal decision and support a woman's right to abortion in more circumstances than currently allowed under state law.

Abortion and women's roles in society: opinions from Tlaxcala, Mexico / El aborto y el rol de las mujeres en la sociedad: resultados de una encuesta de opinión en Tlaxcala, México

OBJECTIVE: We aim to assess the opinions of Mexicans in the state of Tlaxcala on abortion and other topics concerning women's reproductive health and status in society. MATERIAL AND METHODS: We summarize opinions on abortion and women's roles in society and perform logit regressions to assess characteristics correlated with support for abortion rights. RESULTS: A majority of respondents were against a woman's right to abortion when asked generally, but when asked about specific circumstances, a majority supported the right to abortion in five of the nine hypothetical circumstances proposed. In multivariate analysis, age, education, religion, religious service attendance, and views regarding women's roles in society had significant effects on support for the right to abortion. CONCLUSIONS: Our results demonstrate that residents of Tlaxcala view abortion as a personal decision and support a woman's right to abortion in more circumstances than currently allowed under state law.

OBJETIVO: Describir opiniones sobre salud sexual y reproductiva, aborto y rol social de las mujeres entre un grupo de residentes de Tlaxcala, México. MATERIAL Y MÉTODOS: El análisis de regresión logística analizó características asociadas con una postura de apoyo al derecho al aborto. RESULTADOS: La mayoría no favoreció el derecho de las mujeres a interrumpir un embarazo cuando se preguntó de manera general. Al momento de circunscribirlo a circunstancias específicas, la mayoría estuvo a favor en cinco de las nueve de situaciones hipotéticas planteadas. En análisis multivariado, edad, escolaridad, religión, asistencia a servicios religiosos y opiniones sobre el rol social femenino fueron variables significativas del apoyo que se brinda a una mujer para ejercer su derecho a interrumpir un embarazo. CONCLUSIONES: Los residentes de Tlaxcala perciben el tema del aborto como una decisión personal y apoyan el derecho de una mujer a interrumpirlo especialmente bajo causales contempladas en la ley de Tlaxcala.