Can mental health treatments help prevent or reduce intimate partner violence in low- and middle-income countries? A systematic review.

BACKGROUND: Epidemiological research suggests an interrelationship between mental health problems and the (re)occurrence of intimate partner violence (IPV). However, little is known about the impact of mental health treatments on IPV victimization or perpetration, especially in low- and middle-income countries (LMIC). METHODS: We conducted a systematic review to identify prospective, controlled studies of mental health treatments in LMIC. We defined 'mental health treatment' as an intervention for individuals experiencing mental ill health (including substance misuse) including a substantial psychosocial or pharmacological component. Studies had to measure a mental health and IPV outcome. We searched across multi-disciplinary databases using a structured search strategy. Screening of title/abstracts and full-text eligibility assessments were conducted by two researchers independently, data were extracted using a piloted spreadsheet, and a narrative synthesis was generated. RESULTS: We identified seven studies reported in 11 papers conducted in five middle-income countries. With the exception of blinding, studies overall showed acceptable levels of risk of bias. Four of the seven studies focused on dedicated mental health treatments in various populations, including: common mental disorders in earthquake survivors; depression in primary care; alcohol misuse in men; and alcohol misuse in female adult sex workers. The dedicated mental health treatments targeting depression or alcohol misuse consistently reduced levels of these outcomes. The two studies targeting depression also reduced short-term IPV, but no IPV benefits were identified in the two alcohol-focused studies. The other three studies evaluated integrated interventions, in which a focus on substance misuse was part of efforts to reduce HIV/AIDS and violence against particularly vulnerable women. In contrast to the dedicated mental health interventions, the integrated interventions did not consistently reduce mental ill health or alcohol misuse compared to control conditions. CONCLUSIONS: Too few studies have been conducted to judge whether mental health treatments may provide a beneficial strategy to prevent or reduce IPV in LMIC. Key future research questions include: whether promising initial evidence on the effects of depression interventions on reducing IPV hold more broadly, the required intensity of mental health components in integrated interventions, and the identification of mechanisms of IPV that are amenable to mental health intervention.

Caregiver mental health and HIV-infected child wellness: perspectives from Ugandan caregivers.

Prior studies indicate a substantial link between maternal depression and early child health but give limited consideration to the direction of this relationship or the context in which it occurs. We sought to create a contextually informed conceptual framework of this relationship through semi-structured interviews with women that had lived experience of caring for an HIV-infected child while coping with depression and anxiety symptoms. Caregivers explained their role in raising healthy children as complex and complicated by poverty, stigma, and isolation. Caregivers discussed the effects of their own mental health on child well-being as primarily emotional and behavioral, and explained how looking after a child could bring distress, particularly when unable to provide desired care for sick children. Our findings suggest the need for investigation of the reciprocal effects of child sickness on caregiver wellness and for integrated programs that holistically address the needs of HIV-affected families.

Lessons learned evaluating the baby friendly spaces program for south Sudanese refugees in Gambella, Ethiopia: strengthening research and programmatic partnerships to address maternal and child health and psychosocial needs in humanitarian emergencies.

BACKGROUND: During humanitarian crises, women and children are particularly vulnerable to morbidity and mortality. To address this problem, integrated child health interventions that include support for the well-being of mothers must be adapted and assessed in humanitarian settings. Baby Friendly Spaces (BFS) is a holistic program that aims to improve the health and wellbeing of pregnant and lactating women and their children under two years of age by providing psychosocial support and enhancing positive infant and young child-care practices. Using a mixed-methods, pre-post design, this study explored ways to strengthen the implementation and acceptability of the BFS program, and assess outcomes associated with participation among South Sudanese mothers and their children living in the Nguenyyiel refugee camp in Gambella, Ethiopia. DISCUSSION: A stronger evidence-base for integrated maternal and child health interventions, like BFS, in humanitarian emergencies is needed, but effectively conducting this type of research in unstable settings means encountering and working through myriad challenges. In this paper we discuss lessons learned while implementing this study, including, challenges related to ongoing local political and tribal conflicts and extreme conditions; implementation of a new digital data monitoring system; staff capacity building and turnover; and measurement were encountered. Strategies to mitigate such challenges included hiring and training new staff members. Regular weekly skype calls were held between Action Against Hunger Paris headquarters, the Action Against Hunger team in Gambella and Johns Hopkins' academic partners to follow study implementation progress and troubleshoot any emerging issues. Staff capacity building strategies included holding brief and focused trainings continuously throughout the study for both new and current staff members. Lastly, we engaged local Nuer staff members to help ensure study measures and interview questions were understandable among study participants. CONCLUSIONS: Research focused on strengthening program implementation is critically important for improving maternal and child health in humanitarian emergencies. Research in such settings demands critical problem-solving skills, strong supervision systems, flexibility in timeline and logistics, and tailor-made training for program and research staff members and context- adapted strategies for retaining existing staff.

The impact of Cognitive Processing Therapy on stigma among survivors of sexual violence in eastern Democratic Republic of Congo: results from a cluster randomized controlled trial.

BACKGROUND: Sexual violence is associated with a multitude of poor physical, emotional, and social outcomes. Despite reports of stigma by sexual violence survivors, limited evidence exists on effective strategies to reduce stigma, particularly in conflict-affected settings. We sought to assess the effect of group Cognitive Processing Therapy (CPT) on stigma and the extent to which stigma might moderate the effectiveness of CPT in treating mental health problems among survivors of sexual violence in the Democratic Republic of Congo. METHODS: Data were drawn from 405 adult female survivors of sexual violence reporting mental distress and poor functioning in North and South Kivu. Women were recruited through organizations providing psychosocial support and then cluster randomized to group CPT or individual support. Women were assessed at baseline, the end of treatment, and again six months later. Assessors were masked to women's treatment assignment. Linear mixed-effect regression models were used to estimate (1) the effect of CPT on feelings of perceived and internalized (felt) stigma, and (2) whether felt stigma and discrimination (enacted stigma) moderated the effects of CPT on combined depression and anxiety symptoms, posttraumatic stress, and functional impairment. RESULTS: Participants receiving CPT experienced moderate reductions in felt stigma relative to those in individual support (Cohen's D = 0.44, p = value = 0.02) following the end of treatment, though this difference was no longer significant six-months later (Cohen's D = 0.45, p = value = 0.12). Neither felt nor enacted stigma significantly moderated the effect of CPT on mental health symptoms or functional impairment. CONCLUSIONS: Group cognitive-behavioral based therapies may be an effective stigma reduction tool for survivors of sexual violence. Experiences and perceptions of stigma did not hinder therapeutic effects of group psychotherapy on survivors' mental health. TRIAL REGISTRATION: ClinicalTrials.gov NCT01385163.

Testing the effectiveness of a transdiagnostic treatment approach in reducing violence and alcohol abuse among families in Zambia: study protocol of the Violence and Alcohol Treatment (VATU) trial.

BACKGROUND: Violence against women and girls (VAWG) is an urgent global health problem. Root causes for VAWG include the individual- and family-level factors of alcohol abuse, mental health problems, violence exposure, and related adverse experiences. Few studies in low- and middle-income countries (LMIC) have assessed the effectiveness of psychological interventions for reducing VAWG. This randomized controlled trial, part of the What Works to Prevent Violence Against Women and Girls consortium, examines the effectiveness of a common elements treatment approach (CETA) for reducing VAWG and comorbid alcohol abuse among families in Zambia. METHODS/DESIGN: Study participants are families consisting of three persons: an adult woman, her male husband or partner, and one of her children aged 8-17 (if available). Eligibility criteria include experience of moderate-to-severe intimate partner violence by the woman and hazardous alcohol use by her male partner. Family units are randomized to receive CETA or treatment as usual. The primary outcome is VAWG as measured by the Severity of Violence Against Women Scale, assessed along with secondary outcomes at 24 months post-baseline. Interim assessments are also conducted at 4-5 months (following CETA completion) and 12 months post-baseline. CONCLUSIONS: This ongoing trial is one of the first in sub-Saharan Africa to evaluate the use of an evidence-based common elements approach for reducing VAWG by targeting a range of individual- and family-level factors, including alcohol abuse. Results of this trial will inform policy on what interventions work to prevent VAWG in LMIC with local perspectives on scale up and wider implementation.

Executive function and attention-deficit/hyperactivity disorder in Ugandan children with perinatal HIV exposure.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is among the most commonly diagnosed mental disorders in childhood and is associated with substantial deficits in executive functioning and lost academic and occupational attainment. This study evaluates symptoms of ADHD and their association with neurocognitive deficits in a cohort of rural Ugandan children who were born to HIV-infected mothers. METHODS: We assessed ADHD symptoms and executive function (including memory and attention) in a non-clinical sample of children born to HIV-infected mothers in rural eastern Uganda. Analyses included assessments of the psychometric properties, factor structure, and convergent and discriminant validity of the ADHD measure (ADHD-Rating Scale-IV); and executive function deficits in children meeting symptom criteria for ADHD. RESULTS: 232 children [54% female; mean age 7.8 years (s.d. 2.0)] were assessed for ADHD and executive function deficits. The ADHD measure showed good internal consistency (α = 0.85.) Confirmatory factor analysis showed an acceptable fit for the diagnostic and statistical manual of mental disorders (DSM-5) two-factor model. Subjects meeting DSM-5 symptom criteria for ADHD had worse parent-rated executive function on six out of seven subscales. CONCLUSIONS: Our results demonstrate structural validity of the ADHD measure with this population, strong associations between ADHD symptom severity and poorer executive function, and higher levels of executive function problems in perinatally HIV-exposed Ugandan children with ADHD. These findings suggest that ADHD may be an important neurocognitive disorder associated with executive function problems among children in sub-Saharan African settings where perinatal HIV exposure is common.

Nutrition support for bone marrow transplant patients.

BACKGROUND: Bone marrow transplantation involves the administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop a poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is the first choice but is associated with an increased risk of infection. Enteral nutrition (EN) is an alternative, as is the addition of substrates e.g. glutamine to enteral and parenteral solutions. However, the relative effectiveness of these treatments is not clear. OBJECTIVES: To determine the efficacy of EN or PN support for patients receiving a bone marrow transplant. SEARCH STRATEGY: Trials were identified by searching the Cochrane Library (Issue 4, 2000 ), MEDLINE (1966-2000), EMBASE (1988-2000) and CINAHL (1982-2000 ). Reference lists of identified trials and conference proceedings were searched for relevant reports. Date of the most recent search: 2000. SELECTION CRITERIA: RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients were included. DATA COLLECTION AND ANALYSIS: Thirty five reports were identified, 11 were excluded. Two reviewers extracted data from 24 studies; 16 were allocated to four interventions: oral glutamine versus placebo; PN and glutamine versus standard PN; PN versus IV hydration; PN versus EN. Eight studies were other interventions. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. Trialists were contacted for unreported data. MAIN RESULTS: Two studies (82 subjects) found that glutamine mouthwash reduced days of neutropaenia (6.82 days, 95% CI (1.67-11.98) p=0.009) compared with placebo. Three studies (103 subjects) showed that patients receiving PN with glutamine had a reduced hospital stay, 6.62 d (95% CI 3.47, 9.77, P=0.00004) compared with patients receiving standard PN. Two studies (73 subjects) indicated that patients receiving PN plus glutamine had a reduced incidence of positive blood cultures (OR 0.23, 95% CI 0.08-0.65, p=0.006) compared to those receiving standard PN. One study, (25 subjects) showed patients receiving PN had a higher incidence of line infections (odds ratio 21.23, 95% CI 4.15,108.73, P=0.0002) compared to those receiving standard IV fluids. There were no evaluable data to compare PN with EN. REVIEWER'S CONCLUSIONS: Lack of evaluable data means that the relative effectiveness of EN versus PN cannot be evaluated. Further studies and missing data from completed trials need to be retrieved. Studies comparing PN with glutamine versus standard PN suggest that patients leave hospital earlier, and experience a reduced incidence of positive blood cultures, than those receiving standard PN. Patients with gastrointestinal failure should consider PN with the addition of glutamine if enteral feeding is not possible.

Torque-velocity relationships of the knee extensor and flexor muscles in individuals sustaining injuries of the anterior cruciate ligament.

Muscle deficits in 58 patients with chronic anterior cruciate ligament (ACL) insufficiency were evaluated after completion of a 6 month rehabilitation program. Quadriceps and hamstring torques were measured on a modified Cybex II isokinetic dynamometer. Twenty-nine of our patients were tested just prior to undergoing ACL reconstruction, and patients who were continuing to tolerate their conditions served as controls. For the surgical group, significant quadriceps deficits (P less than 0.01) were found for all speeds and at both the 30 and 60 degrees positions. The nonsurgical group had significant deficits at the 30 degrees position at 180 degrees/sec, and at 60 degrees for the 0 degree/sec and 30 degrees/sec. However, in comparing the two groups no significant differences were noted. Regarding hamstring deficits in the surgical group, significant deficits were seen only at 30 degrees of flexion at 180 degrees/sec. The nonsurgical group had similar deficits. Of interest was the observation that the hamstring:quadriceps (H:Q) ratio was found to be both speed-position dependent. Overall, no correlation was found between the presence of strength deficits following a rehabilitation program and the need for surgery.

Apparent digestibility and glycaemic responses to an experimental induced viscosity dietary fibre incorporated into an enteral formula fed to dogs cannulated in the ileum.

The purpose of this study was to evaluate the apparent digestibility and postprandial glycaemic responses of ileal-cannulated dogs when fed an experimental induced viscosity dietary fibre (IVF) incorporated into a liquid enteral formula. Dietary treatments were: (1) control; (2) Glucerna; (3) Glytrol; (4) IVF; and (5) Jevity. Diets varied in concentrations of crude protein (CP), fat, starch and total dietary fibre (TDF). Dry matter and starch intakes by dogs fed the Glucerna and Glytrol treatments were lower (P<0.05) than for those consuming the other diets. However, daily intakes of CP and fat followed a reverse trend. Digestibility of nutrients at the ileum was high (>80%) for all dietary treatments. Mineral absorption proximal to the ileum and from the total tract was not significantly different among treatments. Mean incremental area under the serum glucose response curves for dogs fed Glytrol, Glucerna, and IVF treatments were lower (P<0.05) than the control treatment. Induced viscosity fibre appears to have no negative effects on nutrient digestion throughout the gastrointestinal tract. Its ability to moderate serum glucose concentrations would make it a potentially good choice for a diabetic liquid formula.

Nutrient digestion by ileal cannulated dogs as affected by dietary fibers with various fermentation characteristics.

We studied the effects of dietary fibers with various fermentation characteristics on nutrient digestion at the distal ileum and in the total tract of dogs. The following high-protein (34%), high-fat (23%) diets were fed: 1) a control treatment (CON) with 0% supplemental fiber; 2) beet pulp (BP), 7.5%; 3) low-cellulose mixture (LCM), 2.5% cellulose + 5.0% pectin; 4) high-cellulose mixture (HCM), 5.0% cellulose + 2.5% pectin; or 5) Solka Floc (SF), 7.5% cellulose. Nutrient intakes by fiber-supplemented dogs were similar among treatment groups but greater (P < .05) than for dogs fed the control diet. Digestion of nutrients at the distal ileum was similar among groups except for fat: the dogs fed BP digested less fat than those fed the other sources of dietary fiber. Digestion of amino acids at the distal ileum was similar for all groups, except for lysine, which increased (P < .05) in digestibility as dietary cellulose concentration increased. Dogs consuming LCM had lower apparent ileal digestibility values for all nutrients, including most amino acids, than dogs consuming HCM or SF. Total tract digestion of DM and OM by dogs fed supplemental fiber was less (P < .05) than for dogs fed the control diet. The BP treatment was higher than other fiber treatments in total tract digestion of OM (P < .10) and total dietary fiber (P < .05). Total tract digestibilities of all nutrients exhibited either linear or quadratic responses to dietary cellulose concentrations. Apparent ileal and total tract nutrient digestion was influenced by the source of dietary fiber consumed.

Raw and rendered animal by-products as ingredients in dog diets.

Approximately 25 to 40% of the DM in premium dog diets is animal by-product. However, limited information is available regarding the composition and digestibility of these by-products, especially small intestinal digestibility. The effects of raw and rendered animal by-products incorporated into dog diets on nutrient digestion at the ileum and in the total tract were studied in this experiment. Diets fed contained various animal by-products including a rendered beef meat and bone meal (RMBM); fresh beef (FB); poultry by-product meal (PBPM); fresh poultry (FP); a plant-based control protein source, defatted soy flour (DS); and an animal-based control protein source, dehydrated whole egg (WE). The diets were extruded and kibbled. By-products varied widely in concentrations of OM, CP, amino acids, and fat. Nutrient intakes were numerically higher for FB than for all other treatments. All nutrient intakes were higher (P < .03) for the FB treatment than for the RMBM treatment. Digestibilities of DM, OM, CP, fat, and GE at the ileum were higher (P < .06) when dogs were fed diets containing FP than when fed diets containing PBPM. Amino acids were highly digestible at the ileum; however, digestibilities of all amino acids except cystine were higher (P < .04) for the diets incorporating FP vs PBPM. Total tract digestion was different among treatments for DM (P < .02), OM (P < .01), and GE (P < .02), and diets containing animal by-products were similar in total tract digestibility, greater than the DS control, and lower than the WE control. Rendering of poultry, but not beef, seemed to have a slight negative influence on small intestinal, but not total tract, digestibility by dogs.

Evaluation of selected high-starch flours as ingredients in canine diets.

Cereal grains represent 30 to 60% of the DM of many companion animal diets. Once incorporated into a diet, the starch component of these grains can provide an excellent source of ME. However, crystallinity and form of starch are variable and can cause incomplete digestion within the gastrointestinal tract. Diets fed in this experiment included one of six high-starch flours as the main source of carbohydrate. The flours originated from barley, corn, potato, rice, sorghum, and wheat. The diets were extruded and kibbled. Starch fraction concentrations of flours consisted of nearly 100% rapidly digestible starch (RDS) and slowly digestible starch (SDS) combined. Starch fraction concentrations of diets paralleled concentrations in flours. Flours varied widely in concentrations of CP, fat, starch, and total dietary fiber. Ileal OM and CP digestibilities were lowest for the potato flour treatment (74 and 64%, respectively). Ileal and total tract starch digestibilities were different (P<.05) among treatments; however, the starch component of all diets was nearly completely digested (>99%). Total tract digestibility of DM and OM was lowest for sorghum (80 and 84%, respectively) compared to all other diets. Crude protein digestibility was highest for corn (87%). Wet fecal weights tended (P<.08) to be greatest for dogs fed the barley treatment (175 g/d). However, dry fecal weights (dried at 55 degrees C) were greatest for dogs consuming the sorghum diet (51 g/d). Fecal scores were consistently greater (i.e., looser stools) for the barley treatment. Any of these flours could be used without negative effects on digestion at either the ileum or in the total tract. Fecal consistency data for dogs consuming the barley treatment indicate that diets containing large amounts (>50%) of barley may not be advantageous for dog owners who house their animals indoors for most of the day.

In vitro fermentation characteristics of native and processed cereal grains and potato starch using ileal chyme from dogs.

Two in vitro experiments were conducted to evaluate the ability of small intestinal bacteria of dogs to ferment native and extruded cereal grains and potato starch and cereal grain and potato flours. Substrates included barley, corn, potato, rice, sorghum, and wheat. In addition to testing native grains and flours, extruded substrates also were tested. Substrates were extruded at low temperatures (LT; 79 to 93 degrees C) and high temperatures (HT; 124 to 140 degrees C) using a Wenger extruder (model TX-52). Substrates varied widely in concentrations of rapidly digestible starch (RDS), slowly digestible starch (SDS), resistant starch (RS), and total starch (TS). Extrusion of most substrates at HT vs LT resulted in increased RDS and decreased RS concentrations. Organic matter disappearance (OMD) values attributed to microbial fermentation for a 5-h period were as high as 27% for native extruded substrates (LT potato starch) and 39% for potato flour. Average OMD was higher for cereal and potato flours than for native extruded substrates (29.9 vs 25.4%). Average molar percentages of short-chain fatty acids produced from all substrates fermented for 5 h were 73, 14, and 13% (acetate, propionate, and butyrate, respectively). Average lactate production for substrates ranked as follows: flours > native and extruded cereal grains and potato starch (0.33 and 0.18 mmol/g OM, respectively). In vitro microbial fermentation of starches by ileal bacteria can be substantial and is affected by differences in starch source, fraction, and processed form.

Soybean hulls as a dietary fiber source for dogs.

In Exp. 1, soybean hull samples were obtained from nine sources across the United States and analyzed for nutrient content to determine their suitability for inclusion in dog diets. Compositional data revealed variation in both the amount of total dietary fiber (TDF; 63.8 to 81.2%) in the soybean hulls and the ratio of insoluble:soluble fiber (5.0:1 to 15.4:1). Crude protein content varied widely among sources, ranging from 9.2 to 18.7%. An in vivo trial (Exp. 2) was conducted using a premium dog diet containing 3.0, 4.5, 6.0, 7.5, or 9.0% soybean hulls (DM basis). There was a negative linear effect (P < .05) of soybean hull inclusion in the diet on DM, OM, TDF, and GE total-tract digestibilities, as well as on calculated ME. Crude protein and fat digestibilities were unaffected by treatment. Based on these results, ileally cannulated dogs were fed diets containing 6.0, 7.5, or 9.0% soybean hulls (DM basis) in addition to diets containing either 0% supplemental fiber or 7.5% beet pulp (Exp. 3). Nutrient digestion at the ileum was unaffected by inclusion of supplemental fiber. Total tract digestion of DM, OM, and GE was lower ( P < .05) for diets containing supplemental fiber when compared with the diet containing 0% fiber. Crude protein and fat digestibilities were unaffected by treatment. There was no difference in nutrient digestibility between those diets containing soybean hulls and a diet containing beet pulp. Soybean hull inclusion in the diet resulted in a negative linear effect (P < .05) on calculated ME, in addition to lowering ME (P < .05) when compared with the 0% fiber control diet. Calculated ME for dogs fed a 7.5% beet pulp-containing diet was lower (P < .05) than that for dogs fed the soybean hull-containing diets. Results indicate that soybean hulls can be an effective dietary fiber source in dog diets.