Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from ...studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity.
We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61-1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13-1.96). The magnitudes of the coefficients indicated that a one-standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity.
In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women's mental health should be explored.
Purpose
Mammography, the standard method of breast cancer screening, misses many cancers, especially in dense-breasted women. We compared the performance and diagnostic yield of mammography alone ...versus an automated whole breast ultrasound (AWBU) plus mammography in women with dense breasts and/or at elevated risk of breast cancer.
Methods
AWBU screening was tested in 4,419 women having routine mammography (Trial Registration: ClinicalTrials.gov Identifier: NCT00649337). Cancers occurring during the study and subsequent 1-year follow-up were evaluated. Sensitivity, specificity and positive predictive value (PPV) of biopsy recommendation for mammography alone, AWBU and mammography with AWBU were calculated.
Results
Breast cancer detection doubled from 23 to 46 in 6,425 studies using AWBU with mammography, resulting in an increase in diagnostic yield from 3.6 per 1,000 with mammography alone to 7.2 per 1,000 by adding AWBU. PPV for biopsy based on mammography findings was 39.0% and for AWBU 38.4%. The number of detected invasive cancers 10 mm or less in size tripled from 7 to 21 when AWBU findings were added to mammography.
Conclusion
AWBU resulted in significant cancer detection improvement compared with mammography alone. Additional detection and the smaller size of invasive cancers may justify this technology’s expense for women with dense breasts and/or at high risk for breast cancer.
Abstract Objective Self-management of risk behaviors is a cornerstone of future population health interventions. Using mobile phones for routine self-monitoring and feedback is a cost-efficient ...strategy for self-management and ecological momentary interventions (EMI). However, mobile health applications need to be designed to be highly attractive and acceptable to a broad range of user groups. To inform the design of an adaptable mobile health application we aimed to identify the dimensions and range of user preferences for application features by different user groups. Methods Five focus group interviews were conducted: two ( n = 9; n = 20) with people living with HIV (PLH) and three with young mothers ( n = 6; n = 8; n = 10). Thematic analyses were conducted on the focus group sessions’ notes and transcripts. Results Both groups considered customization of reminders and prompts as necessary, and goal setting, motivational messaging, problem solving, and feedback as attractive. For PLH, automated and location-based reminders for medication adherence and sharing data with healthcare providers were both acceptable and attractive features. Privacy protection and invasiveness were the primary concerns, particularly around location tracking, illegal drug use, and sexual partner information. Concerns were ameliorated by use scenario or purpose, monetary incentives, and password protection. Privacy was not a major concern to mothers who considered passwords burdensome. Mothers’ preferences focused on customization that supports mood, exercise and eating patterns, and especially using the mobile phone camera to photograph food to increase self-accountability. Conclusions Individualization emerged as the key feature and design principle to reduce user burden and increase attractiveness and acceptability. Mobile phone EMI uniquely enables individualization, context-aware and real-time feedback, and tailored intervention delivery.
Stata’s gsem command provides the ability to fit multilevel structural equation models (SEM) and related multilevel models. A motivating example is provided by multilevel mediation analyses (MA) ...conducted on patient data from Methadone Maintenance Treatment clinics in China. Multilevel MA conducted through the gsem command examined the mediating effects of patients’ treatment progression and rapport with counselors on their treatment satisfaction. Multilevel models accounted for the clustering of patient observations within clinics. SEM fit indices, such as the comparative fit index and the root mean squared error of approximation, are commonly used in the SEM model selection process. Multilevel models present challenges in constructing fit indices because there are multiple levels of hierarchy to account for in establishing goodness of fit. Level-specific fit indices have been proposed in the literature but have not been incorporated into the gsem command. I created the gsemgof command to fill this role. Model results from the gsem command are used to calculate the level-specific comparative fit index and root mean squared error of approximation fit indices. I illustrate the gsemgof command through multilevel MA applied to two-level Methadone Maintenance Treatment data.
Given rising incidence of Neisseria gonorrhoeae and Chlamydia trachomatis (GC/CT), development of efficacious screening strategies is critical to interruption of the infection cycle. However, a small ...proportion of nucleic acid amplification testing (NAAT) results are inconclusive-resulting in delays in diagnosis and treatment. As such, this study seeks to evaluate factors associated with inconclusive rectal GC/CT NAAT.
This is a retrospective chart review of individuals who received an inconclusive rectal GC/CT NAAT result at a single institution from 3/2016-6/2018. Inconclusive GC/CT NAAT was defined as presence of PCR amplification inhibitors using Roche Cobas v2.0 CT/NG assay. Clinical charts were abstracted for age, gender, HIV status, GC/CT (urogenital, rectal, pharyngeal) and syphilis screening results during the study period, clinic type (HIV clinic, university student health center, other), and whether repeat testing occurred within 6 months following an inconclusive result. Logistic regression analysis was used to calculate adjusted and unadjusted odds ratios of factors associated with receipt of repeat testing following an inconclusive rectal GC/CT NAAT result.
During the study period, 6.1% (852/14,015) of rectal GC/CT NAAT were inconclusive for one or both of GC and CT. Among the 413 patients whose inconclusive rectal GC/CT NAAT results that were included in our analysis, 66.6% (275/413) received repeat testing within 6 months, of which 8.7% (24/275) were positive (compared to 5.4% positivity rate of all rectal samples). In multivariable analysis, individuals living with HIV had lower odds of receiving repeat testing following inconclusive rectal GC/CT NAAT compared to HIV uninfected individuals (adj OR 0.25; p = 0.001).
Despite being disproportionately affected by the STI epidemic, individuals living with HIV had 75% lower odds of receiving repeat testing following inconclusive rectal GC/CT NAAT compared to HIV-uninfected individuals, representing potentially missed opportunities for treatment and prevention of ongoing STI transmission.
Food insecurity has emerged as an important, and potentially modifiable, risk factor for depression. Few studies have brought longitudinal data to bear on investigating this association in ...sub-Saharan Africa.
To estimate the association between food insufficiency and depression symptom severity, and to determine the extent to which any observed associations were modified by social support.
We conducted a secondary analysis of population-based, longitudinal data collected from 1238 pregnant women during a three-year cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 months, 18 months, and 36 months (85% retention). A validated, single-item food insufficiency measure inquired about the number of days of hunger in the past week. Depression symptom severity was measured using the Xhosa version of the 10-item Edinburgh Postnatal Depression Scale. In multivariable regression models with cluster-correlated robust estimates of variance, lagged food insufficiency had a strong and statistically significant association with depression symptom severity (β = 0.70; 95% CI, 0.46–0.94), suggesting a 6.5% relative difference in depression symptom severity per day of hunger. In stratified analyses, food insufficiency had a statistically significant association with depression only among women with low levels of instrumental support. Using quantile regression, we found that the adverse impacts of food insufficiency were experienced to a greater degree by women in the upper end of the conditional distribution of depression symptom severity. Estimates from fixed-effects regression models and fixed-effects quantile regression models, accounting for unobserved confounding by time-invariant characteristics, were similar.
Food insufficiency was associated with depression symptom severity, particularly for women in the upper end of the conditional depression distribution. Instrumental social support buffered women against the adverse impacts of food insufficiency.
•Food insufficiency is an important, modifiable risk factor for depression.•We investigate this association using longitudinal data from South Africa.•Food insufficiency has a strong association with depressive symptoms.•The estimates are robust to fixed effects and quantile specifications.
We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy ...through the infant's first year of life.
In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy.
WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months.
WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6-12 months.
ClinicalTrials.gov NCT00972699.
This paper examines inter-method reliability and validity of daily self-reports by smartphone application compared to 14-day recall web-surveys repeated over 6 weeks with people living with HIV ...(PLH). A participatory sensing framework guided participant-centered design prioritizing external validity of methods for potential applications in both research and self-management interventions. Inter-method reliability correlations were consistent with prior research for physical and mental health quality-of-life (r = 0.26–0.61), antiretroviral adherence (r = 0.70–0.73), and substance use (r = 0.65–0.92) but not for detailed sexual encounter surveys (r = 0.15–0.61). Concordant and discordant pairwise comparisons show potential trends in reporting biases, for example, lower recall reports of unprotected sex or alcohol use, and rounding up errors for frequent events. Event-based reporting likely compensated for modest response rates to daily time-based prompts, particularly for sexual and drug use behaviors that may not occur daily. Recommendations are discussed for future continuous assessment designs and analyses.
Self-monitoring by mobile phone applications offers new opportunities to engage patients in self-management. Self-monitoring has not been examined thoroughly as a self-directed intervention strategy ...for self-management of multiple behaviors and states by people living with HIV (PLH).
PLH (n = 50), primarily African American and Latino, were recruited from 2 AIDS services organizations and randomly assigned to daily smartphone (n = 34) or biweekly Web-survey only (n = 16) self-monitoring for 6 weeks. Smartphone self-monitoring included responding to brief surveys on medication adherence, mental health, substance use, and sexual risk behaviors, and brief text diaries on stressful events. Qualitative analyses examine biweekly open-ended user-experience interviews regarding perceived benefits and barriers of self-monitoring, and to elaborate a theoretical model for potential efficacy of self-monitoring to support self-management for multiple domains.
Self-monitoring functions include reflection for self-awareness, cues to action (reminders), reinforcements from self-tracking, and their potential effects on risk perceptions, motivations, skills, and behavioral activation states. Participants also reported therapeutic benefits related to self-expression for catharsis, nonjudgmental disclosure, and in-the-moment support. About one-third of participants reported that surveys were too long, frequent, or tedious. Some smartphone group participants suggested that daily self-monitoring was more beneficial than biweekly due to frequency and in-the-moment availability. About twice as many daily self-monitoring group participants reported increased awareness and behavior change support from self-monitoring compared with biweekly Web-survey only participants.
Self-monitoring is a potentially efficacious disruptive innovation for supporting self-management by PLH and for complementing other interventions, but more research is needed to confirm efficacy, adoption, and sustainability.
Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot ...study was developed to see whether PMTCT services provided by the South African Government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the USA. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n=160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa.
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