Adolescence and the risk of ART non-adherence during a geographically focused public health intervention: an analysis of clinic records from Nigeria.

The risk of poor antiretroviral therapy (ART) adherence among adolescents is a challenge to controlling HIV. This study aims to provide guidance for geographically focussed public health interventions to improve adherence. Through clinic records, it investigates adolescents' non-adherence risk and clinic-level differences in regions of Nigeria which were part of PEPFAR's geographical pivot. Records (n = 26,365) were selected using systematic random sampling from all PEPFAR-supported facilities (n = 175) in targeted Local Government Areas across three regions in Nigeria. Adolescents' risk of non-adherence was estimated using region-specific random-effects models accounting for clinic-level variation. These were adjusted for sex, whether a patient had to travel to a different region, clinic location (urban/rural), clinic type (primary, secondary, tertiary). Despite regional variations, adolescents were at higher risk of non-adherence compared to adults. A similar, but weaker, association was found for children. Patients attending tertiary facilities for ART in the South-South region exhibited very high risk of non-adherence. Adolescents and children are at an increased risk of poor ART adherence in rural regions of Nigeria. Regional differences and facility type are critical factors. Future public health programmes focused on the risk of poor adherence targeting "high-prevalence areas" should be sensitive to contextual differences and age-appropriate care.

Interventions to reduce gender-based violence among young people living with or affected by HIV/AIDS in low-income and middle-income countries.

OBJECTIVE(S): This study explored the effectiveness of gender-based violence (GBV) interventions on young people living with or affected by HIV in low- and middle-income countries (LMICs). DESIGN: Systematic review and meta-analysis. METHODS: We pre-registered a protocol, then searched 13 databases and grey literature. We screened randomized and quasi-experimental studies (n = 2199) of young people (aged 10-24) living with or affected by HIV in LMICs. Outcomes were GBV and/or GBV-related attitudes. We appraised the data for risk of bias and quality of evidence. Narrative syntheses and multilevel random effects meta-analyses were conducted. RESULTS: We included 18 studies evaluating 21 interventions. Intervention arms were categorized as: sexual health and social empowerment (SHSE; n = 7); SHSE combined with economic strengthening (n = 4); self-defence (n = 3); safer schools (n = 2); economic strengthening only (n = 2); GBV sensitization (n = 2) and safer schools and parenting (n = 1). Risk of bias was moderate/high and quality of evidence low. Narrative syntheses indicated promising effects on GBV exposure, but no or mixed effects on GBV perpetration and attitudes for self-defence and GBV sensitization interventions. Safer school interventions showed no effects. For SHSE interventions and SHSE combined with economic strengthening, meta-analyses showed a small reduction in GBV exposure but not perpetration. Economic-only interventions had no overall effect. CONCLUSION: SHSE, SHSE plus and self-defence and gender sensitization interventions may be effective for GBV exposure and GBV-related attitudes but not for GBV perpetration. However, the quality of evidence is poor. Future intervention research must include both boys and girls, adolescents living with HIV and key populations.

Intimate partner violence and receptive syringe sharing among women who inject drugs in Indonesia: A respondent-driven sampling study.

BACKGROUND: Intimate partner violence (IPV) and HIV are overlapping public health problems that disproportionately affect women who inject drugs. Little is known about the relationship between IPV and HIV-related unsafe injecting practices among women in low- and middle-income settings. This study investigated whether IPV victimisation was associated with receptive syringe sharing among women who inject drugs in Indonesia. METHODS: Respondent-driven sampling (RDS) was used to recruit 731 women aged 18+ years, injecting drugs in the preceding 12 months, and residing in Greater Jakarta or Bandung, West Java. Population estimates were derived using the RDS-II estimator. Multivariate logistic regressions assessed relationships between different forms of past-year IPV (i.e. psychological abuse, physical and/or injurious assault, forced sex) and receptive syringe sharing, controlling for city differences and sociodemographic cofactors. RESULTS: Overall, 21.1% of participants reported engaging in past-month receptive syringe sharing. In multivariate analyses controlling for all forms of IPV, receptive syringe sharing was significantly positively associated with experiencing psychological abuse (OR = 1.86; 95% CI = 1.06,3.24; p = 0.030), physical and/or injurious assault (OR = 1.73; 95% CI = 1.04,2.89; p = 0.034), and several covariates: injecting pharmaceuticals only (versus heroin only) (OR = 3.58; 95% CI = 1.66,7.69; p = 0.001), experiencing unstable housing and/or homelessness (OR = 2.89; 95% CI = 1.41,5.95; p = 0.004), and residing in Bandung, West Java (versus Greater Jakarta) (OR = 2.33; 95% CI = 1.40,3.90; p = 0.001). CONCLUSION: IPV is a significant risk factor for HIV-related injecting risk among women who inject drugs in Indonesia. These findings indicate the urgent need to scale up harm reduction interventions and align existing programs with IPV prevention and support services, with specific efforts targeting the needs of female injectors.

Docosahexaenoic acid for reading, working memory and behavior in UK children aged 7-9: A randomized controlled trial for replication (the DOLAB II study).

BACKGROUND: Omega-3 fatty acids are central to brain-development of children. Evidence from clinical trials and systematic reviews demonstrates the potential of long-chain Omega-3 supplementation for learning and behavior. However, findings are inconclusive and in need of robust replication studies since such work is lacking. OBJECTIVES: Replication of the 2012 DOLAB 1 study findings that a dietary supplementation with the long-chain omega-3 docosahexaenoic acid (DHA) had beneficial effects on the reading, working memory, and behavior of healthy schoolchildren. DESIGN: Parallel group, fixed-dose, randomized (minimization, 30% random element), double-blind, placebo-controlled trial (RCT). SETTING: Mainstream primary schools (n = 84) from five counties in the UK in 2012-2015. PARTICIPANTS: Healthy children aged 7-9 underperforming in reading (<20th centile). 1230 invited, 376 met study criteria. INTERVENTION: 600 mg/day DHA (from algal oil), placebo: taste/color matched corn/soybean oil; for 16 weeks. MAIN OUTCOME MEASURES: Age-standardized measures of reading, working memory, and behavior, parent-rated and as secondary outcome teacher-rated. RESULTS: 376 children were randomized. Reading, working memory, and behavior change scores showed no consistent differences between intervention and placebo group. Some behavioral subscales showed minor group differences. CONCLUSIONS: This RCT did not replicate results of the earlier DOLAB 1 study on the effectiveness of nutritional supplementation with DHA for learning and behavior. Possible reasons are discussed, particularly regarding the replication of complex interventions. TRIAL REGISTRATION AND PROTOCOL: www.controlled-trials.com (ISRCTN48803273) and protocols.io (https://dx.doi.org/10.17504/protocols.io.k8kczuw).

Editorial: Changes in the field: banning p-values (or not), transparency, and the opportunities of a renewed discussion on rigorous (quantitative) research.

Research transparency is becoming increasingly important across the social and medical sciences and thereby to the field of child and adolescent mental health. As the incoming associate editor for quantitative methods to CAMH, my contribution to the journal over the course of my editorship will be to encourage a discussion on research transparency and potential new types of submissions. Some editorials concerned with quantitative methods have recently taken rather stringent methodological stances, such as the one on "banning p-values" in the Journal of Basic and Applied Social Psychology and Political Analysis (Gill, Political Analysis, 2018, 26, 1; Trafimow & Marks, Basic and Applied Social Psychology, 2015, 37, 1). These editorials are part of a wider discussion in psychology, social sciences, public health, and the sciences more generally on the use of quantitative methods, and set the terms of the debate about the conditions for scientific research.

Emotional abuse of girls in Swaziland: prevalence, perpetrators, risk and protective factors and health outcomes.

BACKGROUND: Research on emotional child abuse in sub-Saharan Africa is scarce. Few studies thus far have examined prevalence, risk and protective factors for emotional child abuse or the associations between emotional abuse and girls' health. METHODS: A nationally representative two-stage, cluster-sampled, household survey of females aged 13-24 years (n = 1244) on childhood abuse victimisation was conducted. Participants completed interviewer-assisted questionnaires. Associations between emotional abuse and putative risk, and protective factors and health outcomes were analyzed using separate logistic regression models accounting for sampling design. Marginal effects of cumulative risk factors for emotional abuse victimisation were examined. RESULTS: Lifetime prevalence of emotional abuse was 28.5% with 58.3% of these girls reporting many abusive incidents. The most common perpetrators were female (27.8%) and male (16.7%) relatives and, more rarely, biological parents. Risk factors associated with emotional abuse were frequent caregiver changes (odds ratio (OR) 1.42, 95% confidence interval (CI) 1.03-1.970, poverty (OR 1.51, 95% CI 1.12-2.03), and physical abuse (OR 1.98, 95% CI 1.45-2.71) and sexual abuse (OR 2.22, 95% CI 1.57-3.10) victimisation. Being close to one's mother was a protective factor (OR 0.88, 95% CI 0.80-0.97). Risk for emotional abuse increased from 13% with no risk factors present to 58.4% -with all four risk factors present. Health outcomes associated with emotional child abuse were suicidal ideation (OR 1.85, 95% CI 1.30-2.63) and feeling depressed (OR 1.89, 95% CI 1.31-2.71). CONCLUSIONS: Girls in Swaziland experience high levels of emotional abuse victimisation. Emotional abuse is associated with economic disadvantage, family factors, other types of abuse victimisation and poor mental health. Therefore, a holistic approach to prevention is needed, incorporating poverty reduction and programmes to improve parent-child relationships, reduce the use of harsh criticism, and change parenting social norms.

Fatty acids and sleep in UK children: subjective and pilot objective sleep results from the DOLAB study--a randomized controlled trial.

Sleep problems in children are associated with poor health, behavioural and cognitive problems, as are deficiencies of long-chain omega-3 fatty acids such as docosahexaenoic acid. Theory and some evidence support a role for these fatty acids in sleep regulation, but this issue has received little formal investigation. We examined associations between blood fatty acid concentrations (from fingerstick blood samples) and subjective sleep (using an age-standardized parent questionnaire) in a large epidemiological sample of healthy children aged 7-9 years (n = 395) from mainstream UK schools. In a randomized controlled trial, we then explored whether 16-week supplementation (600 mg day(-1) ) with algal docosahexaenoic acid versus placebo might improve sleep in a subset of those children (n = 362) who were underperforming in reading. In a randomly selected subsample (n = 43), sleep was also assessed objectively via actigraphy. In 40% of the epidemiological sample, Child Sleep Habits Questionnaire scores indicated clinical-level sleep problems. Furthermore, poorer total sleep disturbance scores were associated weakly but significantly with lower blood docosahexaenoic acid (std coeff. -0.105*) and a lower docosahexaenoic acid : arachidonic acid ratio (std coeff. -0.119**). The treatment trial showed no significant effects on subjective sleep measures. However, in the small actigraphy subsample, docosahexaenoic acid supplementation led on average to seven fewer wake episodes and 58 min more sleep per night. Cautiously, we conclude that higher blood levels of docosahexaenoic acid may relate to better child sleep, as rated by parents. Exploratory pilot objective evidence from actigraphy suggests that docosahexaenoic acid supplementation may improve children's sleep, but further investigations are needed.

Low blood long chain omega-3 fatty acids in UK children are associated with poor cognitive performance and behavior: a cross-sectional analysis from the DOLAB study.

BACKGROUND: Omega-3 long-chain polyunsaturated fatty acids (LC-PUFA), especially DHA (docosahexaenonic acid) are essential for brain development and physical health. Low blood Omega-3 LC-PUFA have been reported in children with ADHD and related behavior/learning difficulties, as have benefits from dietary supplementation. Little is known, however, about blood fatty acid status in the general child population. We therefore investigated this in relation to age-standardized measures of behavior and cognition in a representative sample of children from mainstream schools. PARTICIPANTS: 493 schoolchildren aged 7-9 years from mainstream Oxfordshire schools, selected for below average reading performance in national assessments at age seven. METHOD: Whole blood fatty acids were obtained via fingerstick samples. Reading and working memory were assessed using the British Ability Scales (II). Behaviour (ADHD-type symptoms) was rated using the revised Conners' rating scales (long parent and teacher versions). Associations were examined and adjusted for relevant demographic variables. RESULTS: DHA and eicosapentaenoic acid (EPA), accounted for only 1.9% and 0.55% respectively of total blood fatty acids, with DHA showing more individual variation. Controlling for sex and socio-economic status, lower DHA concentrations were associated with poorer reading ability (std. OLS coeff. = 0.09, p = <.042) and working memory performance (0.14, p = <.001). Lower DHA was also associated with higher levels of parent rated oppositional behavior and emotional lability (-0.175, p = <.0001 and -0.178, p = <.0001). CONCLUSIONS: In these healthy UK children with below average reading ability, concentrations of DHA and other Omega-3 LC-PUFA were low relative to adult cardiovascular health recommendations, and directly related to measures of cognition and behavior. These findings require confirmation, but suggest that the benefits from dietary supplementation with Omega-3 LC-PUFA found for ADHD, Dyspraxia, Dyslexia, and related conditions might extend to the general school population.

Docosahexaenoic acid for reading, cognition and behavior in children aged 7-9 years: a randomized, controlled trial (the DOLAB Study).

BACKGROUND: Omega-3 fatty acids are dietary essentials, and the current low intakes in most modern developed countries are believed to contribute to a wide variety of physical and mental health problems. Evidence from clinical trials indicates that dietary supplementation with long-chain omega-3 may improve child behavior and learning, although most previous trials have involved children with neurodevelopmental disorders such as attention-deficit/hyperactivity disorder (ADHD) or developmental coordination disorder (DCD). Here we investigated whether such benefits might extend to the general child population. OBJECTIVES: To determine the effects of dietary supplementation with the long-chain omega-3 docosahexaenoic acid (DHA) on the reading, working memory, and behavior of healthy schoolchildren. DESIGN: Parallel group, fixed-dose, randomized, double-blind, placebo-controlled trial (RCT). SETTING: Mainstream primary schools in Oxfordshire, UK (n = 74). PARTICIPANTS: Healthy children aged 7-9 years initially underperforming in reading (≤ 33(rd) centile). 1376 invited, 362 met study criteria. INTERVENTION: 600 mg/day DHA (from algal oil), or taste/color matched corn/soybean oil placebo. MAIN OUTCOME MEASURES: Age-standardized measures of reading, working memory, and parent- and teacher-rated behavior. RESULTS: ITT analyses showed no effect of DHA on reading in the full sample, but significant effects in the pre-planned subgroup of 224 children whose initial reading performance was ≤ 20(th) centile (the target population in our original study design). Parent-rated behavior problems (ADHD-type symptoms) were significantly reduced by active treatment, but little or no effects were seen for either teacher-rated behaviour or working memory. CONCLUSIONS: DHA supplementation appears to offer a safe and effective way to improve reading and behavior in healthy but underperforming children from mainstream schools. Replication studies are clearly warranted, as such children are known to be at risk of low educational and occupational outcomes in later life. TRIAL REGISTRATION: ClinicalTrials.gov NCT01066182 and Controlled-Trials.com ISRCTN99771026.