Violent Discipline in North Kivu, Democratic Republic of Congo: The Role of Child Gender and Disability Status in Cross-sectional Analysis.

INTRODUCTION: Violence is used to punish or educate children across the world, with detrimental effects on their physical, emotional, and social health that persist into their adulthood. This study aimed to understand the use of violent discipline by caregivers in conflict-affected communities and how it varied by the child's gender and disability level. METHODS: Using cross-sectional data collected from 394 respondents (196 men and 198 women) in North Kivu, Democratic Republic of Congo, logistic generalized estimating equations stratified by gender assessed the association between past-three-month perpetration of violent discipline, caregiver demographics, conflict experiences, and disability attitudes, as well as child demographics of age, gender, disability level, and the interaction of gender and disability. RESULTS: Compared to women with boy children with no disability, odds of perpetration of violent discipline were higher among those with girl children with no disability (aOR: 2.24; 95%CI: 1.11-4.51) and boy children with moderate or severe disability (aOR: 2.91; 95%CI: 1.14-7.33), and the interaction of girl children with a moderate or severe disability showed a 7.80 increase in odds of perpetration; however, association with women's discriminatory disability attitudes was not significant. In contrast, the interaction of child gender and disability level were not significantly associated with perpetration of violent discipline for men, but disability attitudes were significantly associated (aOR: 1.07; 95%CI: 1.00-1.15). DISCUSSION: Results suggest that levels of violence in conflict-affected households in North Kivu, DRC are high, with women reporting higher levels of violent discipline overall, and amplified use of violence against girl children with disabilities. More research and programs with an intersectional lens are needed in conflict settings to better understand and address the use of violent discipline and underlying discriminatory norms around gender and disability.

SIGNIFICANCE: Violence against children in the home varies by gender and disability level. Evidence from predominantly Global North contexts demonstrates that children with disabilities are more likely to experience violence, with heightened risk for girls. Among conflict-affected communities in DRC, women had higher odds of using violence against girls and children with disabilities, and even higher for girl children with disabilities. Violence perpetration was also associated with the caregivers' conflict experiences. This suggests that to strengthen violence prevention in conflict settings, research and programs must be more accessible to and inclusive of people with disabilities and address inequitable gender norms.

Inclusion of Positive Self-reporting by Mothers of Substance Exposed Neonates Increases the Predictability of NAS Severity Over Toxicology Alone.

OBJECTIVES: The rise in opioid use among pregnant women has resulted in an increase in the incidence of neonatal abstinence syndrome (NAS). Despite the focus on opioid use, prenatal polysubstance exposure is often associated with NAS diagnosis and severity. Drug toxicology screens such as urine drug screens and umbilical cord toxicology are dependent upon the substance, timing, frequency, and dose to detect substances present and can underestimate the neonatal exposure. The aim of this study was to identify the predictability of the consequences of prenatal polysubstance exposure versus opioid only exposure based on toxicology and toxicology plus self-report. METHODS: Neonates > 35 weeks gestation with prenatal opioid exposure were included in this retrospective data analysis. NAS was identified using maternal urine drug screen (UDS) toxicology, self-reported exposure during pregnancy, and neonatal toxicology. Analysis was conducted using Stata 15.1 utilizing McNemar's test, chi-square for categorical outcomes, and Wilcoxon test for numerical outcomes. RESULTS: A statistically significant difference in length of stay and length of treatment with poly-exposed neonates was observed when maternal self-report was considered with toxicology, but not with toxicology alone. This trend was observed for cumulative hospital length of stay as well as length and dose of treatment. CONCLUSIONS FOR PRACTICE: The findings in this report demonstrate that self-report is important for identifying substance of exposure. Three substances in particular that often require a change in treatment paradigm went undetected by toxicology were Gabapentin (20.9% of the population), Heroin (20.5% of the population), and Benzodiazepines (8.5% of the population). A healthy rapport with patients is often critical to effective clinical practice. Women with substance use disorder anticipate negative reactions from healthcare providers. Empathetic interview techniques to facilitate accurate disclosure may be more important to the treatment of the exposed neonate.

Benzathine Penicillin G Shortage and Secondary Syphilis.

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. This disease is characterized by four different stages, each presenting with a variety of manifestations or asymptomatic disease. These stages can be further broken down into early-stage syphilis, which includes primary and secondary syphilis, and late-stage syphilis, which includes tertiary syphilis. It is crucial to recognize and treat syphilis early because the later stages of the disease are marked by irreversible damage to the central nervous system (CNS) and cardiovascular system, and can even increase mortality risk. The primary recommended treatment for early-stage syphilis is intramuscular (IM) benzathine penicillin G (BPG). In this case report, we present a patient with secondary syphilis who exhibited red papules and nonspecific skin eruptions. Due to the unavailability of BPG, the patient initially received doxycycline as an alternative treatment. After eight days of searching multiple facilities and pharmacies, a dose of BPG was finally located and administered to the patient. We highlight crucial information about the BPG shortage, including supply and demand challenges, infrastructure issues, and the broader impact on numerous other antimicrobials. We emphasize the importance of recognizing this issue and provide alternatives for managing the disease in resource-limited settings.

Effectiveness of a family violence prevention program on mental health outcomes for adult men and women in North Kivu, Democratic Republic of Congo: Insights from a pilot trial.

The eastern Democratic Republic of Congo (DRC) has faced dual burdens of poor mental health and heightened levels of violence against women and children within the home. Interventions addressing family violence prevention may offer a path to mitigate mental distress within the eastern DRC. This exploratory analysis uses data from a pilot cluster randomized controlled trial conducted in North Kivu, DRC, assessing the impact of Safe at Home, a violence prevention intervention. Mental health was assessed at endline using the Patient Health Questionnaire-4. Statistical analyses employed multilevel linear regression. Assuming successful randomization, impact of the Safe at Home intervention on mental health differed by participant gender. Women enrolled in the Safe at Home intervention reported statistically significant decreases in mental distress symptoms [ß (95%CI) = -1.01 (-1.85, -0.17)], whereas men enrolled in Safe at Home had similar scores in mental distress to the control group [ß (95%CI) = -0.12 (-1.32, 1.06)]. Ultimately, this exploratory analysis provides evidence of the potential for a family violence prevention model to improve women's mental health in a low-resource, conflict-affected setting, although further research is needed to understand the impact on men's mental health.

Preventing Co-occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Role of Family Functioning and Programmatic Reflections.

Co-occurring intimate partner violence (IPV) and child abuse occur at staggering levels in eastern Democratic Republic of Congo (DRC), yet little is known about the relationship between these forms of violence and a feminst-grounded conceptualization of family functioning nor how best to programmatically address these multiple forms of violence in the home. Analysis of cross-sectional baseline data from 203 adult couple dyads participating in a randomized controlled trial was undertaken to (1) understand the correlation of family functioning and violence in the home in North Kivu, DRC; (2) unpack potential shared correlates of violence in the home and family functioning, such as attitudes and behaviors; and (3) describe programmatic implications for delivering violence prevention programming that seeks to address multiple forms of violence in the home. Findings suggest over half of all families reported experiencing IPV against women or use of child abuse by any caregiver. Moderate levels of family functioning were also reported, although women reported lower levels. In adjusted models, a one-point change in family functioning score was associated with a 0.12 reduction in odds of co-occurring experience of IPV and use of child abuse for women, and a 0.03 reduction in odds of co-occurring perpetration for men. A focus on improving family functioning as a primary outcome, alongside explicit targeting of harmful gender norms and skills-based approaches, may be a promising avenue to integrate approaches from different violence prevention fields while maintaining a strong dedication to intersectional feminist-grounded approaches that allows for separate, but at times combined, approaches to reducing IPV and child abuse in the home.

Improving family functioning and reducing violence in the home in North Kivu, Democratic Republic of Congo: a pilot cluster-randomised controlled trial of Safe at Home.

OBJECTIVE: To test the effectiveness of the Safe at Home programme which was developed to improve family well-being and prevent multiple forms of violence in the home. DESIGN: Waitlisted pilot cluster randomised controlled trial. SETTING: North Kivu, Democratic Republic of Congo. PARTICIPANTS: 202 heterosexual couples. INTERVENTION: The Safe at Home programme. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was family functioning, with secondary outcomes of past-3 month co-occurring violence, intimate partner violence (IPV) and harsh discipline. Pathway mechanisms assessed included attitudes related to acceptance of harsh discipline, gender equitable attitudes, positive parenting skills and power sharing within the couple. RESULTS: No significant improvements in family functioning were documented for women (ß=1.49; 95% CI: -2.75 to 5.74; p=0.49) and men (ß=1.09; 95% CI: -3.13 to 4.74; p=0.69). However, women in Safe at Home reported a OR=0.15 (p=0.000), OR=0.23 (p=0.001) and OR=0.29 (p=0.013) change in co-occurring IPV and harsh discipline; physical/sexual/emotional IPV by their partner and use of physical and/or emotional harsh discipline against their child, respectively, as compared with women in the waitlisted group. Men participating in Safe at Home reported a OR=0.23 (p=0.005) change in perpetration of co-occurring violence, OR=0.26 (p=0.003) change in any form of IPV perpetration and OR=0.56 (p=0.19) change in use of harsh discipline against their child as compared with the waitlist arm. Positive changes were also noted in pathway variables around attitudes, skills and behaviours within couples. CONCLUSION: This pilot trial demonstrated the Safe at Home programme to be highly effective in preventing multiple forms of violence in the home and improving equitable attitudes and skills in couples. Future research should assess longitudinal impact and implementation at scale. TRIAL REGISTRATION NUMBER: NCT04163549.

Self-assembly of isomeric monofunctionalized thiophenes.

Controlling the self-assembly of thiophene-containing molecules and polymers requires a strong fundamental understanding of the relationship between molecular features and structure-directing forces. Here, the effects of ring-substitution position on the two-dimensional self-assembly of monosubstituted thiophenes at the phenyloctane/HOPG interface are studied using scanning tunneling microscopy (STM). The influence of π···π-stacking, hydrogen-bonding, and alkyl-chain interactions are explored computationally. Alteration of the amide attachment point from the 2- to the 3-position induces transformation from head-to-tail packing to head-to-head packing. This may be attributed to canceling of lateral dipoles.

Co-Occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Influence of Early Life Experiences of Abuse.

Little is known about co-occurring intimate partner violence (IPV) against women and child abuse within families in humanitarian settings. Baseline data from 203 couples in eastern Democratic Republic of Congo were analyzed to assess associations between childhood experiences of abuse with present co-occurring violence. Over half of women (56.1%) and men (50.5%) reported co-occurring violence. Adjusted models demonstrate experiencing physical abuse as a child was associated with greatest odds of recent co-occurring violence while witnessing parental IPV had mixed influence. Programmatic approaches focused on reducing early childhood violence may be promising to prevent both IPV and child abuse.

Developing an Inclusive Conceptual Model for Preventing Violence in the Home in Humanitarian Settings: Qualitative Findings From Myanmar and the Democratic Republic of Congo.

This qualitative study sought to explore the shared risk factors and social norms that may underpin the co-occurrence of intimate partner violence, child maltreatment, and violence against other marginalized household members in the home. Data are drawn from participants who completed either in-depth interviews (N = 51 men, N = 52 women participants) or focus groups (N = 22 men, N = 23 women participants) and were living in two distinct humanitarian settings: North Kivu, Democratic Republic of the Congo, and Northern Shan State and Southern Kachin State, Myanmar. Within this overarching objective, attention to these shared drivers for violence in the home, which may arise from people having multiple and interacting social identities, such as disability status, gender, and age, was explored through an inclusion lens and inductive coding approaches. Findings point to risk factors of violence in the home at all levels of the ecological model, which are underpinned at the macro level by gender inequality, armed conflict, and political instability, among other factors. With the community and family levels, gender inequality manifested in norms related to the acceptability of violence, family reputation, and aged and gendered power hierarchies within the home. Shared risk factors of violence at these levels also included displacement/migration-related stressors, inconsistent income, and lack of community resources to support families, especially for those with disabilities. At the most time-proximal level, interactions between role (non)fulfillment, inability of families to meet their basic needs, alcohol and substance abuse, and abusive expressions of anger were found to catalyze instances of violence in the home. The conceptual model also illuminates potential levers and inclusive entry points that prevent violence in the home for diverse women, children, persons with disabilities, and older persons. Key attention to addressing gender inequality and acceptance of violence must be a cornerstone of sustainable programming, alongside complementary approaches that address other shared risk factors.

Using oral anticoagulants among chronic kidney disease patients to prevent recurrent venous thromboembolism: A systematic review and meta-analysis.

INTRODUCTION: Chronic kidney disease (CKD) increases the risk of venous thromboembolism (VTE) among affected patients. Vitamin K antagonists (VKA) and warfarin remains the main stay of its treatment. Due to novelty and unclear risk-to-benefit ratio of direct oral anti-coagulants (DOAC), they remain underutilized in preventing VTE among CKD patients. We aim to assess the efficacy and safety of DOACs and other oral anticoagulants in preventing recurrent VTE among high-risk population. MATERIAL METHODS: We conducted a literature search using PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov for randomized controlled trials (RCTs) comparing anti-coagulants like DOAC, LMWH or VKA or any oral anti-coagulant (OAC) (This includes VKAs and DOACs) with either placebo or another anti-coagulant. Two independent reviewers screened the retrieved articles and extracted data using a piloted data extraction sheet. The primary outcome of interest was number of recurrent VTE and other side effects among CKD patients receiving respective treatment. Secondary outcomes were risk of major, non-major and intra-cranial bleed. RESULTS: We retrieved 7244 titles on initial search, reviewed full text of 818 articles, and selected 10 phase III RCTS for quantitative meta-analysis. Out of 36,326 patients in these trials, only 10,840 (29.8%) were evaluable. We stratified patients into four categories based on severity of renal impairment using serum creatinine clearance (SCr) as the marker e.g. mild (>50 - <80) moderate (>30 - ≤50) severe (<30) and any level (from <30 to <80). There was no difference between DOACs vs VKA in decreasing the risk of recurrent VTE among patients with mild (RR:0.86, 95% CI:0.61-1.22, I2 = 25%) moderate/severe (RR:0.72, 95% CI:0.44-1.17, I2 = 0%) or any level of renal impairment (RR:0.83, 95% CI:0.60-1.14, I2 = 34%). No difference in efficacy between LMWH vs VKA among patients with moderate (RR:2.40, 95% CI:0.44-12.96, I2 = 76%) and any level (RR:2.59, 95% CI:0.66-10.16, I2 = 71%) of renal impairment respectively. Similarly, no difference in efficacy between LMWH vs any OAC (This includes VKAs and edoxaban) among patients with (RR:2.16, 95% CI:0.66-7.-06, I2 = 51%) and any level (RR:1.48, 95% CI:0.79-2.78, I2 = 78%) of renal impairment. DOACs compared to VKAs had significantly lower risk of combined major and non-major bleeding (RR: 0.74, 95% CI:0.65-0.84, I2 = 26%), major bleeding (RR: 0.51, 95% CI:0.38-0.69, I2 = 7%) and non-major clinically relevant bleeding (RR: 0.73, 95% CI:0.57-0.94, I2 = 45%) respectively. Risk of intracranial bleeding was comparable (RR: 0.68, 95% CI:0.19-2.44, I2 = 0%). There was no difference in the risk of major bleeding between LMWH vs any OAC (RR: 0.83, 95% CI:0.46-1.51, I2 = 0%). CONCLUSION: DOACS and other anticoagulants (VKA and LMWH) showed no statistical difference in preventing recurrent VTEs among CKD patients but DOACs had significantly lower risk of major and non-major clinically relevant bleeding irrespective of the level of renal impairment compared to VKAs. There was no difference in risk of intra-cranial bleeding between DOACs and VKAs.

Disability status and violence against women in the home in North Kivu, Democratic Republic of Congo.

Few studies have investigated how women's disability status may influence violence against women within conflict settings. A mixed-methods analysis of formative qualitative research and cross-sectional baseline pilot data from a violence prevention program in North Kivu, eastern Democratic Republic of Congo (DRC), was used to examine violence against disabled adult women within the home. Logistic regression models were constructed to examine the relationship between past-month physical/sexual intimate partner violence, disability status, and older age (N = 98 women). Deductive thematic analysis of focus groups and individual interviews (N = 57 men, 59 women) was used to identify community norms and perceptions of violence against women with disabilities in the home. Women who reported mild disability reported higher experiences of past-month physical and/or sexual IPV (85.0%) compared to those who reported severe or no disability (76.5% vs. 70.8%, respectively). Older women with mild disability were more likely to report physical IPV compared to their younger counterparts as well (OR = 1.23, 95%CI: 1.01, 1.49, p < 0.039). Qualitative findings suggested family members may be deterred from perpetrating abuse against older women. These findings highlight a complex relationship between women's disability status and violence perpetration, underscoring the importance of having inclusive, contextual violence against women prevention and response programming in conflict settings.

Engaging men to transform inequitable gender attitudes and prevent intimate partner violence: a cluster randomised controlled trial in North and South Kivu, Democratic Republic of Congo.

INTRODUCTION: The study objective was to understand the effectiveness of Engaging Men through Accountable Practice (EMAP), a group-based discussion series which sought to transform gender relations in communities, on intimate partner violence (IPV), gender inequitable attitudes and related outcomes. METHODS: A two-armed, matched-pair, cluster randomised controlled trial was conducted between 2016 and 2018 in eastern Democratic Republic of Congo. Adult men (n=1387) and their female partners (n=1220) participated in the study. The primary outcomes of the study were female report of past year physical and/or sexual IPV and men's intention to commit violence. Secondary outcomes included men's gender attitudes, women's economic and emotional IPV, women's perception of negative male behaviours and perceived quality of the relationship. RESULTS: Men in EMAP reported significant reductions in intention to commit violence (ß=-0.76; SE=0.23; p<0.01), decreased agreement with any reason that justifies wife beating (OR=0.59; SE=0.08; p<0.01) and increased agreement with the ability of a woman to refuse sex for all reasons (OR=1.47; SE=0.24; p<0.05), compared with men in the control group. We found no statistically significant differences in women's experiences of IPV between treatment and control group at follow-up (physical or sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71). However, female partners of men in EMAP reported significant improvements to the quality of relationship (ß=0.28; p<0.05) and significant reductions in negative male behaviour (ß=-0.32; p<0.01). CONCLUSION: Interventions engaging men have the potential to change gender attitudes and behaviours in conflict-affected areas. However, while EMAP led to changes in gender attitudes and behaviours related to perpetration of IPV, the study showed no overall reduction of women's experience of IPV. Further research is needed to understand how working with men may lead to long-term and meaningful changes in IPV and related gender equitable attitudes and behaviours in conflict areas. TRIAL REGISTRATION NUMBER: NCT02765139.

Building caregivers' emotional, parental and social support skills to prevent violence against adolescent girls: findings from a cluster randomised controlled trial in Democratic Republic of Congo.

INTRODUCTION: Parenting programmes are increasingly popular for reducing children's exposure to interpersonal violence in low/middle-income countries, but there is limited evidence on their effectiveness. We investigated the incremental impact of adding a caregiver component to a life skills programme for adolescent girls, assessing girls' exposure to violence (sexual and others) and caregivers' gender attitudes and parenting behaviours. METHODS: In this two-arm, single-blinded, cluster randomised controlled trial, we recruited 869 adolescent girls aged 10-14 and 764 caregivers in South Kivu, Democratic Republic of Congo. Following a baseline survey, participants were divided into 35 clusters based on age, language and location. Eighteen clusters were randomised to the treatment arm and 17 clusters to the wait-list control arm. Adolescent girls in both arms received 32 life skills sessions; caregivers in the treatment arm received 13 complementary caregiver sessions. The primary outcome was girls' self-reported exposure to sexual violence in the last 12 months; secondary outcomes included self-reports of specific forms of sexual violence, physical and emotional violence, transactional sex, child marriage for girls and parenting behaviours for caregivers. Intent-to-treat and per-protocol analyses were conducted. RESULTS: At 12 months of follow-up, the intervention showed no impact on sexual violence (adjusted OR=0.95; 95% CI 0.65 to 1.37) or any secondary outcomes for girls. The intervention was associated with improved supportive parenting behaviours. Protocol adherence was also associated with improvements in these outcomes. CONCLUSION: While the caregiver curriculum improved some parenting outcomes, additional programmatic adaptations may be needed to reduce adolescent girls' violence exposure in humanitarian settings. TRIAL REGISTRATION NUMBER: NCT02384642.