Women and substance use disorders in low- and middle-income countries: A call for advancing research equity in prevention and treatment.

Although the prevalence of substance use disorders (SUDs) is higher among men, women with SUDs in low- and middle-income countries (LMICs) face unique challenges. Poverty and adversity, inequality of women, and disparities in access to treatment and prevention services exacerbate biological, psychological and social correlates of substance use disorders for women living in low-resource settings. Increasing the inclusion of women in research has long been a goal, though even high income countries struggle to achieve parity. In LMICs, women with SUDs are often neglected from global research due to underreporting and the disproportionate focus of global substance use research on men. We will discuss risk factors for SUDs that are particularly relevant for women residing in LMICs in order to gain insight into neglected areas of research and opportunities for prevention and treatment.

Stressful life events are associated with perinatal cigarette smoking.

Perinatal smoking, including smoking during pregnancy and postpartum smoking relapse, is a persistent public health problem. While childhood trauma has been linked to perinatal smoking, less is known about the association with more proximal stressful life events (SLEs). The objective of this study was to examine the association between SLEs that occurred during the year prior to childbirth with perinatal smoking. Using the Pregnancy Risk Assessment Monitoring System 2009-2011, perinatal smoking was assessed at three time points: (1) three months prior to pregnancy, (2) the last three months of pregnancy, and (3) two to six months postpartum. Survey respondents endorsed up to 13 SLEs (i.e., death of someone close). SLEs were analyzed individually, as well as using a cumulative score (range 0-13). Weighted analyses included unadjusted and adjusted logistic regression. Among those who smoked prior to pregnancy (n = 15,316), 48% (n = 7308) reported quitting smoking during pregnancy. Of those, 44% (n = 3126) reported postpartum smoking relapse. A total of 11 SLEs were associated with smoking during pregnancy and 2 SLEs were associated with postpartum smoking relapse. The odds of continued smoking during pregnancy was 12% higher for each SLE endorsed (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI]: 1.09, 1.15) and this association was attenuated in relation to the odds of postpartum smoking relapse (aOR = 1.03, 95% CI: 0.99, 1.08). SLEs are associated with perinatal smoking. Additional research is needed to elucidate the mechanisms of action and to develop interventions specific to the needs of women who experience SLEs.

Circulating orexin changes during withdrawal are associated with nicotine craving and risk for smoking relapse.

We examined the extent to which orexin measured during smoking and the early phase of abstinence was related to craving, withdrawal, stress hormones, and risk for smoking relapse in men and women. Considering its role in modulating nicotine-related reward, we predicted that a reduction in circulating orexin during withdrawal would be associated with increased craving and risk for smoking relapse. Two hundred and eighty five participants provided biological samples and self-report information to identify predictors of smoking relapse. All participants attended two laboratory sessions, which were before and after a period of required abstinence from smoking. After quitting, participants also attended four weekly sessions to track smoking relapse. Only smokers who relapsed within the follow-up period exhibited reduced orexin levels during the initial withdrawal period; ACTH, but not craving nor cortisol, increased across the abstinence period for successful abstainers but not for relapsers. Sex differences in orexin and craving or withdrawal associations also emerged. Adding sex, HPA hormones, and self-reported measures of craving and withdrawal as potential mediators had minimal effects on the above abstinence and orexin effects. These results provide the first evidence that circulating orexin may be a useful marker of risk for relapse; and sex, adrenal hormones, and self-reported craving and withdrawal were not mediators of this effect. The results point to a promising pathway to investigate objective biological markers for craving and smoking relapse and highlight the complexity of the neurobiology of relapse.

Childhood exposure to violence is associated with risk for mental disorders and adult's weight status: a community-based study in Tunisia.

BACKGROUND: We sought to investigate the relationship between social violence and adult overweight/obesity and the role of common mental disorders (CMD) in mediating this relationship. METHODS: A cross-sectional study was conducted from January to June 2016 in Tunisia. Participants were selected from randomly selected Primary Health Care Centers. The Arabic version of the Adverse Childhood Experiences-International Questionnaire (ACE-IQ) was used. RESULTS: A total of 2120 participants were included. Women exposed to social ACEs had higher rates of overweight/obesity than men (13.5 versus 9.5%; P = 0.004). For women, statistically significant partial mediation effects of CMD were observed for exposure to community violence (% mediated = 17.7%). For men, partial mediation was found for the exposure to peer violence (% mediated = 12.5%). CONCLUSION: Our results provide evidence of the independent increase of overweight/obesity after exposure to social ACEs. Efforts to uncover and address underlying trauma in health care settings may increase the effectiveness of obesity interventions.

Gender differences in adverse childhood experiences, collective violence, and the risk for addictive behaviors among university students in Tunisia.

Adverse childhood experiences (ACE) have been linked to a variety of addictive behaviors. The recent adaptation of the ACE measure by the World Health Organization (WHO) allows for the assessment of the negative role of additional adverse experiences, such as extra-familial violence. To date, the relationship between extra-familial violence and addictive behaviors has not been assessed. We report the contribution of ACEs, including the new scales for extra-familial violence, on the risk for mental health problems and addictive behaviors by gender in a sample of young adults in Tunisia. We conducted a cross sectional study in Tunisia during 2014, where we recruited 1200 young university adults who completed the validated Arabic version of the WHO ACE questionnaire in a university setting. Results indicated that intra-familial adversities were associated with increased risk for addictive behaviors, particularly in males. ACEs were also associated with increased risk for mental health problems with women showing more difficulties than men. Exposure to peer, community and collective violence was higher in males than in females and logistic regression confirms that exposure to extra-familial violence increased the risk for addictive behaviors both in male and females by two to three-fold. Mental health problems were associated with peer violence and substance abuse in males, but not in females. Results demonstrate for the first time the contribution of exposure to extra-familial violence on risk for addictive behaviors. Results highlight the need for addressing mental health and addiction in a community with high burden of adversity and violence.

Effects of 6-Week Use of Reduced-Nicotine Content Cigarettes in Smokers With and Without Elevated Depressive Symptoms.

BACKGROUND: The FDA recently acquired regulatory authority over tobacco products, leading to renewed interest in whether reducing the nicotine content of cigarettes would reduce tobacco dependence in the United States. Given the association between depressive symptoms and cigarette smoking, it is important to consider whether smokers with elevated depressive symptoms experience unique benefits or negative consequences of nicotine reduction. METHODS: In this secondary analysis of a randomized clinical trial that examined the effects of cigarettes varying in nicotine content over a 6-week period in non-treatment-seeking smokers, we used linear regression to examine whether baseline depressive symptom severity (scores on the Center for Epidemiologic Studies Depression Scale [CES-D]) moderated the effects of reduced-nicotine content (RNC) cigarettes, relative to normal-nicotine content (NNC) cigarettes, on smoking rates, depressive symptom severity, and related subjective and physiological measures. RESULTS: Of the 717 participants included in this analysis, 109 (15.2%) had CES-D scores ≥ 16, indicative of possible clinical depression. Relative to NNC cigarettes, RNC cigarettes reduced smoking rates, nicotine dependence, and cigarette craving, and these effects were not significantly moderated by baseline CES-D score. A significant interaction between baseline CES-D score and cigarette condition on week 6 CES-D score was observed (p < .05); among those with CES-D scores ≥ 16 at baseline, those assigned to RNC cigarettes had lower week 6 CES-D scores than those assigned to NNC cigarettes. Among those in the lowest nicotine content conditions, biochemically confirmed compliance with the RNC cigarettes was associated with an increase in CES-D score for those with baseline CES-D scores < 16 and no change in CES-D score for those with baseline CES-D scores ≥ 16. CONCLUSIONS: These findings provide initial evidence that a reduced-nicotine standard for cigarettes may reduce smoking, without worsening depressive symptoms, among smokers with elevated depressive symptoms. IMPLICATIONS: This secondary analysis of a recent clinical trial examined whether depressive symptom severity moderated the effects of reduced-nicotine cigarettes on smoking and depressive symptoms. Results indicate that, regardless of baseline depressive symptoms, participants randomized to reduced-nicotine cigarettes had lower smoking rates, nicotine intake, nicotine dependence, and craving at week 6 post-randomization than those assigned to normal-nicotine cigarettes. In participants with higher baseline depressive symptoms, those assigned to reduced-nicotine cigarettes had lower week 6 depressive symptoms than those assigned to normal-nicotine cigarettes. These results suggest that a nicotine reduction policy could have beneficial effects for smokers, regardless of depressive symptom severity.

Sex differences in hormonal responses to stress and smoking relapse: a prospective examination.

INTRODUCTION: Dysregulation in the hypothalamic-pituitary-adrenal axis has been shown to be associated with smoking relapse. No study has directly examined the role of sex differences in this relationship. METHODS: Nicotine dependent men (n = 52) and women (n = 46) interested in cessation completed 2 laboratory stress sessions during ad libitum smoking and after 48 hr of abstinence. The laboratory session included baseline, stress, and recovery periods. Blood and saliva samples were collected at the end of each period for the measurement of cortisol and adrenocorticotropic hormone. Self-report measures of craving and withdrawal symptoms were also collected. Participants attended 4 weekly follow-up sessions for counseling where they provided biological samples and self-report measures including smoking status. Relapse was defined by smoking cigarettes for 7 consecutive days post-cessation. RESULTS: Results showed that 60 participants relapsed during the 4-week period. Cox regression models from the abstinence session showed that cortisol levels regardless of source were predictive of relapse but the direction of prediction was sex dependent (Sex × Hormone, all ps < .05). Follow-up analyses further revealed that lower cortisol levels predicted relapse in men whereas greater cortisol levels predicted relapse in women (ps < .05). Enhanced craving predicted early smoking relapse in men but not in women (ps < .05). Data from the ad libitum session showed no differences in predicting relapse. CONCLUSION: These findings highlight that sex differences in the hormonal response to stress and subjective craving during nicotine withdrawal are critical predictors of risk for understanding early relapse.

Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design.

BACKGROUND: There are compelling theoretical and empirical reasons that link household food insecurity to mental distress in the setting where both problems are common. However, little is known about their association during pregnancy in Ethiopia. METHODS: A cross-sectional study was conducted to examine the association of household food insecurity with mental distress during pregnancy. Six hundred and forty-two pregnant women were recruited from 11 health centers and one hospital. Probability proportional to size (PPS) and consecutive sampling techniques were employed to recruit study subjects until the desired sample size was obtained. The Self Reporting Questionnaire (SRQ-20) was used to measure mental distress and a 9-item Household Food Insecurity Access Scale was used to measure food security status. Descriptive and inferential statistics were computed accordingly. Multivariate logistic regression was used to estimate the effect of food insecurity on mental distress. RESULTS: Fifty eight of the respondents (9%) were moderately food insecure and 144 of the respondents (22.4%) had mental distress. Food insecurity was also associated with mental distress. Pregnant women living in food insecure households were 4 times more likely to have mental distress than their counterparts (COR = 3.77, 95% CI: 2.17, 6.55). After controlling for confounders, a multivariate logistic regression model supported a link between food insecurity and mental distress (AOR = 4.15, 95% CI: 1.67, 10.32). CONCLUSION: The study found a significant association between food insecurity and mental distress. However, the mechanism by which food insecurity is associated with mental distress is not clear. Further investigation is therefore needed to understand either how food insecurity during pregnancy leads to mental distress or weather mental distress is a contributing factor in the development of food insecurity.

A population-based study of edentulism in the US: does depression and rural residency matter after controlling for potential confounders?

BACKGROUND: Oral health is an integral component of general health and well-being. While edentulism has been examined in relation to socioeconomic status, rural residency, chronic disease and mental health, no study that we know of has examined edentulism and these factors together. The objective of this study was to determine whether depression and rural residency were significantly associated with partial and full edentulism in US adults after controlling for potential confounders. METHODS: 2006 Behavioral Risk Factor Surveillance Survey (BRFSS) data were analyzed to identify factors associated with increased odds of partial or full edentulism. This year of BRFSS data was chosen for analysis because in this year the standardized and validated Personal Health Questionnaire-8 (PHQ-8) was used to measure current depression. This measure was part of the optional questions BRFSS asks, and in 2006 33 states and/or territories included them in their annual surveillance data collection. Bivariate and logistic regression analyses were performed on weighted BRFSS data. RESULTS: Logistic regression analysis using either full or partial edentulism as the dependent variable yielded that rural residency or living in a rural locale, low and/or middle socioeconomic status (SES), depression as measured by the PHQ-8, and African American race/ethnicity were all independent risk factors when controlling for these and a number of additional covariates. CONCLUSIONS: This study adds to the epidemiological literature by assessing partial and full edentulism in the US utilizing data from the CDC's Behavioral Risk Factor Surveillance System (BRFSS). Examining data collected through a large national surveillance system such as BRFSS allows for an analysis that incorporates an array of covariates not available from clinically-based data alone. This study demonstrated that current depression and rural residency are important factors related to partial and full edentulism after controlling for potential confounders.

Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: a population-based study using 2010 NAMCS data.

BACKGROUND: Non-malignant chronic pain (NMCP) is one of the most common reasons for primary care visits. Pain management health care disparities have been documented in relation to patient gender, race, and socioeconomic status. Although not studied in relation to chronic pain management, studies have found that living in a rural community in the US is associated with health care disparities. Rurality as a social determinant of health may influence opioid prescribing. We examined rural and non-rural differences in opioid prescribing patterns for NMCP management, hypothesizing that distinct from education, income, racial or gender differences, rural residency is a significant and independent factor in opioid prescribing patterns. METHODS: 2010 National Ambulatory Medical Care Survey (NAMCS) data were examined using bivariate and multivariate techniques. NAMCS data were collected using a multi-stage sampling strategy. For the multivariate analysis performed the SPSS complex samples algorithm for logistic regression was used. RESULTS: In 2010 an estimated 9,325,603 US adults (weighted from a sample of 2745) seen in primary care clinics had a diagnosis of NMCP; 36.4% were prescribed an opioid. For US adults with a NMCP diagnosis bivariate analysis revealed rural residents had higher odds of having an opioid prescription than similar non-rural adults (OR = 1.515, 95% CI 1.513-1.518). Complex samples logistic regression analysis confirmed the importance of rurality and yielded that US adults with NMCP who were prescribed an opioid had higher odds of: being non-Caucasian (AOR =2.459, 95% CI 1.194-5.066), and living in a rural area (AOR =2.935, 95% CI 1.416-6.083). CONCLUSIONS: Our results clearly indicated that rurality is an important factor in opioid prescribing patterns that cannot be ignored and bears further investigation. Further research on the growing concern about the over-prescribing of opioids in the US should now include rurality as a variable in data generation and analysis. Future research should also attempt to document the ecological, sociological and political factors impacting opioid prescribing and care in rural communities. Prescribers and health care policy makers need to critically evaluate the implications of our findings and their relationship to patient needs, best practices in a rural setting, and the overall consequences of increased opioid prescribing on rural communities.

Physical activity, fruit and vegetable intake, and smoking in working-aged adults: opportunities for prevention in primary care.

The purpose of this study was to document health behaviors (diet, physical activity, cigarette smoking) in working-aged adults with identified primary care providers. We surveyed 1,344 adults in Minnesota and North Dakota 25 to 64 years of age from Essentia Health primary care patient lists in May of 2012. A 21-page, self-administered questionnaire asking about their health habits was mailed to the sample three times during a three-month period. The response to the three mailings was 38.8%, with a final sample size of 522 completed surveys. Overall, 18.5% (95% CL = 18.2, 18.8) of men and 22.3% (95% CL = 22.0, 22.6) of women reported currently smoking. The BMI distribution (normal, overweight and obese) was 16.9%, 40.0% and 43.1%, respectively, for men and 32.8%, 31.7% and 35.5%, respectively, for women. Mean fruit and vegetable intake was significantly lower for men than women (mean = 1.92 servings a day for men and 2.15 for women). Physical inactivity was reported by 6.2% (95% CL = 6.0, 6.4) of the men and 7.2% (95% CL = 7.0, 7.4) of the women. After adjusting for the other variables, people in the older age groups were less likely to smoke (OR = 0.78, 95% CL = 0.65, 0.93) than those in the younger age groups, people living in rural areas were more likely to be obese (OR = 1.67, 95% CL = 1.16, 2.39) than those living in urban areas, and women were more likely than men to be inactive or have low levels of physical activity (OR = 1.47, 95% CL = 1.02, 2.11). These data highlight a number of modifiable risk factors for chronic diseases that primary care providers could address in order to improve long-term health outcomes.

Circulating ghrelin changes as a biomarker of the stress response and craving in abstinent smokers.

RATIONALE: There has been growing interest in the role of ghrelin in stress and addiction. Ghrelin regulates central reward mechanisms by mediating the mesolimbic dopaminergic system. Stress also induces neurophysiological activations related to drug reward. However, the extent to which psychosocial stress is associated with changes in ghrelin levels has not been tested in individuals with nicotine dependency undergoing withdrawal, a condition known to induce stress-like symptoms. OBJECTIVES: We investigated the association of stress-induced ghrelin, craving, and smoking lapse. METHODS: Thirty-six smokers attended a laboratory session that included acute stress tasks during the initial phase of quitting. Self-report measures and biochemical samples were collected for the assessment of smoking status. Blood samples for the measurement of ghrelin and self-report measures of craving were collected multiple times throughout the session RESULTS: Multivariate analysis of variance controlling for gender found a significant main effect of sampling time and lapse group (p < 0.05). Ghrelin levels significantly increased over the pre-stress and post-stress periods (ps < 0.001), suggesting a delayed stress response. Those who lapsed during the study had higher ghrelin levels than those who were able to successfully abstain. A ghrelin stress response was calculated and a significant association was found between this response and craving, which changed across time points (ps < 0.008). CONCLUSIONS: The results of this study demonstrate that ghrelin is sensitive to acute manipulation of stress and that there is potential usefulness for ghrelin as a marker of stress, craving, and smoking lapse.

Canadian Indigenous Cognitive Assessment (CICA): Inter-rater reliability and criterion validity in Anishinaabe communities on Manitoulin Island, Canada.

INTRODUCTION: Despite increasing dementia rates, few culturally informed cognitive assessment tools exist for Indigenous populations. The Canadian Indigenous Cognitive Assessment (CICA) was adapted with First Nations on Manitoulin Island, Canada, and provides a brief, multi-domain cognitive assessment in English and Anishinaabemowin. METHODS: Using community-based participatory research (CBPR) methods, we assessed the CICA for inter-rater and test-retest reliability in 15 individuals. We subsequently evaluated validity and established meaningful CICA cut-off scores in 55 individuals assessed by a geriatrician. RESULTS: The CICA demonstrated strong reliability (intra-class coefficient = 0.95 [0.85,0.98]). The area under the curve (AUC) was 0.98 (0.94, 1.00), and the ideal cut-point to identify likely cases of dementia was a score of less than or equal to 34 with sensitivity of 100% and specificity of 85%. DISCUSSION: When used with older First Nations men and women living in First Nations communities, the CICA offers a culturally safe, reliable, and valid assessment to support dementia case-finding.

Peace of mind: A community-industry-academic partnership to adapt dementia technology for Anishinaabe communities on Manitoulin Island.

INTRODUCTION: Aging Technologies for Indigenous Communities in Ontario (ATICON) explores the technology needs of Anishinaabe older adults in the Manitoulin region of Northern Ontario. Our program of research addresses inequitable access to supportive technologies that may allow Indigenous older adults to successfully age in place. METHODS: Using Indigenous research methodologies (IRM) and community-based participatory research (CBPR) we explored the acceptability of CareBand - a wearable location and activity monitoring device for people living with dementia using a LoRaWAN, a low-power wide-area network technology. We conducted key informant consultations and focus groups with Anishinaabe Elders, formal and informal caregivers, and health care providers (n = 29) in four geographically distinct regions. RESULTS: Overall, participants agreed that CareBand would improve caregivers' peace of mind. Our results suggest refinement of the technology is necessary to address the challenges of the rural geography and winter weather; to reconsider aesthetics; address privacy and access; and to consider the unique characteristics of Anishinaabe culture and reserve life. CONCLUSION: All three partners in this research, including the Indigenous communities, industry partner, and academic researchers, benefited from the use of CBPR and IRM. As CareBand is further developed, community input will be crucial for shaping a useful and valued device.

Developing the Canadian Indigenous Cognitive Assessment for Use With Indigenous Older Anishinaabe Adults in Ontario, Canada.

BACKGROUND AND OBJECTIVES: Dementia is a growing public health issue for aging Indigenous populations. Current cognitive assessments present varying degrees of cultural, educational, and language bias, impairing their application in Indigenous communities. Our goal is to provide Anishinaabe communities in Canada with a brief cognitive test that can be administered within the community setting by community health workers or professionals. The purpose of this study was to adapt the Kimberly Indigenous Cognitive Assessment (KICA) for use as a brief cognitive test with Anishinaabe populations in Canada. RESEARCH DESIGN AND METHODS: We used a community-based participatory research approach coupled with two-eyed seeing to provide an equitable space for Indigenous knowledge. Adaptation of the KICA was accomplished over 22 months using an iterative cycle of monthly consultations between an 11-member expert Anishinaabe language group (EALG) and the investigators, with ad hoc consultations with an Indigenous Elder, a community advisory council, and the KICA authors. Face validity was established with two pilot studies using cognitive interviewing with Indigenous older adults (n = 15) and a focus group consultation with local health professionals (n = 7). RESULTS: Each question of the KICA was scrutinized by the EALG for cultural appropriateness, language and translation, and cultural safety. Every domain required adaptation to reflect cultural values, specificity of language, tone, and a culturally safe approach. Orientation, verbal comprehension and fluency, praxis, and naming domains required the most adaptations. The first pilot for face validity resulted in additional changes; the second confirmed satisfactory adaptation of all changes. DISCUSSION AND IMPLICATIONS: The research resulted in the new Canadian Indigenous Cognitive Assessment. The findings reveal important cultural and linguistic considerations for cross-cultural cognitive assessment in Indigenous contexts. This new culturally appropriate and safe brief cognitive test may improve case finding accuracy and lead to earlier diagnosis and improved dementia care for Indigenous peoples.

Using novel mobile sensors to assess stress and smoking lapse.

Mobile sensors can now provide unobtrusive measurement of both stress and cigarette smoking behavior. We describe, here, the first field tests of two such methods, cStress and puffMarker, that were used to examine relationships between stress and smoking behavior and lapse from a sample of 76 smokers motivated to quit smoking. Participants wore a mobile sensors suite, called AutoSense, which collected continuous physiological data for 4 days (24-hours pre-quit and 72-hours post-quit) in the field. Algorithms were applied to the physiological data to create indices of stress (cStress) and first lapse smoking episodes (puffMarker). We used mixed effects interrupted autoregressive time series models to assess changes in heart rate (HR), cStress, and nicotine craving across the 4-day period. Self-report assessments using ecological momentary assessment (EMA) of mood, withdrawal symptoms, and smoking behavior were also used. Results indicated that HR and cStress, respectively, predicted smoking lapse. These results suggest that measures of traditional psychophysiology, such as HR, are not redundant with cStress; both provide important information. Results are consistent with existing literature and provide clear support for cStress and puffMarker in ambulatory clinical research. This research lays groundwork for sensor-based markers in developing and delivering sensor-triggered, just-in-time interventions that are sensitive to stress-related lapser risk factors.

Social and early life adversity and chronic health conditions among Tunisian adults.

Early life adversities (ELAs) are shown as significant risk factors for chronic health conditions (CHCs). ELAs include multiple types of abuse such as the social abuse (peer, community, and collective violence). The purpose is to describe the relationship between childhood social abuse and chronic conditions in adulthood among a sample of adults in Tunisia and to investigate the role of obesity and tobacco use as mediators of this association. A cross-sectional study was conducted in Tunisia, from January to June 2016 using the Arabic Adverse Childhood Experiences International Questionnaire (ACE-IQ). Items of social abuse (peer violence, witnessing community violence, and exposure to collective violence) were analyzed. A total of 2,120 adults were enrolled. After adjustment for age, gender, and intrafamilial ELA, social adversities were associated significantly with the selected CHC. Experiencing more than two social ELA increase the risk of occurrence of hypertension and coronary diseases. After accounting for the indirect effect of body mass index, statistically significant partial mediation effects were observed for the cumulative number of social ELA as the exposure variable and chronic diseases as the outcome variable (p ≤ .001; % mediated = 44.5%). These findings support an association between many chronic health disorders and childhood social abuse, independently of intrafamilial ACEs.

Impact of social violence and childhood adversities on pregnancy outcomes: a longitudinal study in Tunisia.

BACKGROUND: Accumulating research suggests that exposure to intra-familial adversities are significant risk factors for adverse pregnancy outcomes. However, the relationship between social violence (peer violence, witnessing community violence and exposure to collective violence) and pregnancy outcomes has not been extensively investigated. Our study aims to examine the association between social Adverse Childhood Experiences (ACEs) and pregnancy outcomes and to explore the role of depression during pregnancy as a mediator of this association. METHODS: We performed a prospective follow-up study of pregnant women in five Primary Health care Centers (PHC) in the region of Monastir (Tunisia) from September 2015 to August 2016. Enrolled women were followed during the second trimester, third trimester of pregnancy and during the postnatal period. Exposure to violence was assessed retrospectively using the validated Arabic version of the World Health Organization (WHO) ACE questionnaire. The Self Reporting Questionnaire 20-Item (SRQ-20) was used as a screening tool for depression during pregnancy. RESULTS: We recruited and followed a total of 593 women during the study period. Witnessing community violence was the most frequently reported social ACE among pregnant women (237; 40%), followed by peer violence (233; 39.3%). After adjustment for high risk pregnancies, environmental tobacco smoke, and intra-familial ACEs, the risk of premature birth was significantly associated with exposure to collective violence (P < 0.001) and witnessing community violence (P < 0.05). The risk of low birth weight was significantly associated with witnessing community violence (P < 0.001). In the mediation analysis, depression mediated significant proportions of the relationship between the cumulative number of ACEs and pregnancy outcomes. CONCLUSIONS: Social ACEs may have a long-term effect on maternal reproductive health, as manifested by offspring that were of reduced birth weight and shorter gestational age. A public health framework based on the collaboration between pediatric, psychiatric obstetrical health professionals, education professionals and policy makers could be applied to ensure primary prevention of childhood adversities and pay attention to expected mothers with history of exposure to such adversities.

Symptom severity predicts degree of T cell activation in adult women following childhood maltreatment.

Although depression is often associated with a reduction in cellular immune responses, other types of emotional disturbance and psychopathology can activate certain aspects of immunity. Activation markers on T cells, in particular, have been found to be elevated in post-traumatic stress states. However, little is known about the relationship between the severity of PTSD symptoms and the degree of change in T cell phenotypes, or about the potential role of neuroendocrine factors in mediating the association. Twenty-four women with a history of sexual trauma during childhood, including 11 who met diagnostic criteria for PTSD, were compared to 12 age-matched, healthy women without a history of maltreatment. The women provided fasted blood samples for enumeration of cell subsets by immunofluorescence and 24-h urine samples for analysis of catecholamine and cortisol levels. The percent of T cells expressing CD45RA, an early activation marker, was higher in the PTSD diagnosed women, and the levels correlated positively with intrusive symptoms and negatively with avoidant symptoms. These alterations in cell surface markers did not appear to be mediated by norepinephrine (NE) or cortisol, making them a distinctive and independent biomarker of arousal and disturbance in PTSD.