Jennifer Bleck

Tip of the Iceberg: Reporting and Gender-Based Violence in Developing Countries

Gender-based violence (GBV) is widespread globally and has myriad adverse health effects but is vastly underreported. Few studies address the extent of reporting bias in existing estimates. We provide bounds for underestimation of reporting of GBV to formal and informal sources conditional on having experienced GBV and characterize differences between women who report and those who do not. We analyzed Demographic and Health Survey data from 284,281 women in 24 countries collected between 2004 and 2011. We performed descriptive analysis and multivariate logistic regressions examining characteristics associated with reporting to formal sources. Forty percent of women experiencing GBV previously disclosed to someone; however, only 7% reported to a formal source (regional variation, 2% in India and East Asia to 14% in Latin America and the Caribbean). Formerly married and never married status, urban residence, and increasing age were characteristics associated with increased likelihood of formal reporting. Our results imply that estimates of GBV prevalence based on health systems data or on police reports may underestimate the total prevalence of GBV, ranging from 11- to 128-fold, depending on the region and type of reporting. In addition, women who report GBV differ from those who do not, with implications for program targeting and design of interventions.

Exploring the co-morbidity of attention-deficit/hyperactivity disorder with eating disorders and disordered eating behaviors in a nationally representative community-based sample.

Emerging evidence signifies the co-occurrence of attention-deficit/hyperactivity disorder (ADHD) with clinical and sub-threshold disordered eating behaviors. However, many existing studies have assessed this co-occurrence among inpatient or intensive outpatient populations. The purpose of this study was to examine the co-occurrence of ADHD with clinical eating disorders and disordered eating behaviors in a nationally representative sample via a secondary data analysis of data from the National Longitudinal Study of Adolescent Health (n = 4,862; 2,243 males; 2,619 females). Results reveal that females have higher rates of co-occurrence of ADHD and diagnosed eating disorders than males (1.05% vs. 0.20%, p < .01). When controlling for age and race, ADHD predicted diagnosed eating disorders in females (incidence rate ratio (IRR): 2.06; 95% CI: 1.09-3.88; p < .05), but did not predict diagnosed eating disorders in males. With regard to disordered eating behaviors, when controlling for age, gender, and race, ADHD significantly predicted disordered eating behaviors (OR: 1.82; 95% CI: 1.21-2.74). When stratifying by type of disordered eating behavior, ADHD predicted binging and/or purging behavior (OR: 2.86; 95% CI: 1.78-4.61), but not restrictive behaviors. Implications of study findings pertain to both secondary/targeted prevention efforts in addition to tertiary prevention via patient-specific treatment plans.

A review of global access to emergency contraception

Emergency contraception has been known for several decades, and dedicated products have been on the market for close to 20 years. Yet it is unclear whether women, particularly in low‐resource countries, have access to this important second‐chance method of contraception.

Age and intimate partner violence: an analysis of global trends among women experiencing victimization in 30 developing countries

PURPOSE Young women are at elevated risk of violence victimization, yet generalizable evidence on age at which abuse first occurs is lacking. This analysis provides new descriptive evidence on age and duration into partnership of womens first intimate partner violence (IPV) victimization. METHODS Data come from ever married women ages of 15-49 years in nationally representative Demographic and Health Surveys in 30 countries collected from 2005 to 2014 in Africa, Asia, Eastern Europe, and Latin America and the Caribbean. Descriptive analysis is performed. RESULTS Approximately 29.0% (95% confidence interval [CI]: 28.8, 29.3) of women reported any physical or sexual IPV. Among ever married women who first experienced violence post-union, abuse began, on average, 3.5 years (95% CI 3.4, 3.5), after union formation. Approximately 38.5% (95% CI 37.9, 39.0) and 67.5% (95% CI 67.0, 68.1) of those ever experiencing abuse did so within 1 year and 3 years, respectively, of union formation. Regionally, average years into union of abuse initiation showed little variation and average age at first abuse among once married women is 22.1 years. CONCLUSIONS Results imply that primary prevention for IPV must take place on average before first union before age 19 years, to capture the most relevant and at risk target population. Resources allocated toward risk factors in childhood and adolescence may be most effective in combating initiation of IPV globally. Despite this finding, there remains a lack of evidence on effective interventions for primary prevention of abuse during womens early years in developing settings.

The Comorbidity of ADHD and Eating Disorders in a Nationally Representative Sample.

Evidence suggests a comorbidity of childhood attention-deficit/hyperactivity disorder (ADHD) and subsequent eating disorders. However, most studies have assessed this comorbidity among patient populations as opposed to nationally representative samples and have not explored differences by subtype of each disorder. The current study aims to investigate the association between both clinical (i.e., diagnosed) and subclinical (i.e., presence of behaviors but not all diagnostic criteria) ADHD and eating disorders via a secondary data analysis of the National Longitudinal Study of Adolescent Health (n = 12,262). Results reveal that those with clinical ADHD are more likely to experience (a) clinical eating disorder, (b) clinical-level binging and/or purging behaviors, and (c) clinical-level restrictive behaviors. Those with subclinical ADHD (both inattentive and hyperactive/impulsive) were more likely to experience subclinical binging and/or purging behaviors but not subclinical restrictive behaviors. Implications of study findings pertain to both secondary/targeted prevention of eating disorders and tertiary prevention via patient-specific treatment plans.

Evaluation of a theory-driven e-learning intervention for future oral healthcare providers on secondary prevention of disordered eating behaviors

Oral healthcare providers have a clinical opportunity for early detection of disordered eating behaviors because they are often the first health professionals to observe overt oral and physical signs. Curricula regarding early recognition of this oral/systemic medical condition are limited in oral health educational programs. Web-based learning can supplement and reinforce traditional learning and has the potential to develop skills. The study purpose was to determine the efficacy of a theory-driven Web-based training program to increase the capacity of oral health students to perform behaviors related to the secondary prevention of disordered eating behaviors. Using the Reach, Effectiveness, Adoption, Implementation and Maintenance evaluation framework, a longitudinal group-randomized controlled trial involving 27 oral health classes from 12 oral health education programs in the United States was implemented to assess the efficacy of the Web-based training on attitudes, knowledge, self-efficacy and skills related to the secondary prevention of disordered eating behaviors. Mixed-model analysis of covariance indicated substantial improvements among students in the intervention group (effect sizes: 0.51-0.83) on all six outcomes of interest. Results suggest that the Web-based training program may increase the capacity of oral healthcare providers to deliver secondary prevention of disordered eating behaviors. Implications and value of using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework are discussed.

Women’s Individual Asset Ownership and Experience of Intimate Partner Violence: Evidence From 28 International Surveys

Objectives To assess the oft-perceived protective relationship between womens asset ownership and experience of intimate partner violence (IPV) in the previous 12 months. Methods We used international survey data from women aged 15 to 49 years from 28 Demographic and Health Surveys (2010-2014) to examine the association between owning assets and experience of recent IPV, matching on household wealth by using multivariate probit models. Matching methods helped to account for the higher probability that women in wealthier households also have a higher likelihood of owning assets. Results Asset ownership of any type was negatively associated with IPV in 3 countries, positively associated in 5 countries, and had no significant relationship in 20 countries (P < .10). Disaggregation by asset type, sole or joint ownership, womens age, and community level of womens asset ownership similarly showed no conclusive patterns. Conclusions Results suggest that the relationship between womens asset ownership and IPV is highly context specific. Additional methodologies and data are needed to identify causality, and to understand how asset ownership differs from other types of womens economic empowerment.

Knowledge and use of emergency contraception: a multicountry analysis.

CONTEXT Globally, evidence on knowledge and use of emergency contraception from population-based data is limited, though such information would be helpful in increasing access to the method. We examined knowledge and use of emergency contraception in 45 countries using population-based survey data. METHODS Demographic and Health Survey (DHS) data on women aged 15-49 were analyzed by country in logistic regressions to identify associations between womens characteristics and their having heard of emergency contraception or having ever used it. Trends were examined, by region and globally, according to individual, household and community descriptors, including womens age, education, marital status, socioeconomic status, and urban or rural location. RESULTS The proportion of women who had heard of emergency contraception ranged from 2% in Chad to 66% in Colombia, and the proportion of sexually experienced women who had used it ranged from less than 0.1% in Chad to 12% in Colombia. The odds of having heard of or used the method generally increased with wealth, and although the relationship between marital status and knowing of the method varied by region, never-married women were more likely than married women to have used emergency contraception in countries where significant differences existed. In some countries, urban residence was associated with having heard of the method, but in only three countries were women from urban areas more likely to have used it. CONCLUSIONS Our findings support the need for broader dissemination of information on emergency contraception, particularly among low-income individuals. Variations in use and knowledge within regions suggest a need for programs to be tailored to country-level characteristics.

Psychosocial and Skill-based Differences between Dental and Dental Hygiene Students Regarding Secondary Prevention of Eating Disorders

Objective: A long-standing challenge in oral health education is preparing dental and dental hygiene students to address oral/systemic health issues with their patients, particularly regarding sensitive topics such as eating disorders. Oral health providers can play a key role in secondary prevention through early identification and referral of patients exhibiting signs of disordered eating behaviors. Dental and dental hygiene academic competencies include prevention counseling, health promotion, and interpersonal and communication skills, but there are differences across these groups in terms of whether they address oral signs of disordered eating behaviors with their patients. Methods: As part of a larger prospective study, the current study sought to determine the extent to which psychosocial and skill-based factors differ among dental and dental hygiene students in order to guide changes to academic training. A baseline Likert-type questionnaire was completed by dental (n=476) and dental hygiene (n=190) students from 27 oral health classes at 10 accredited dental and dental hygiene schools across the United States. Pretest data were analyzed to determine whether significant baseline differences exist between dental and dental hygiene students. Hierarchical linear models (HLM) were conducted using restricted maximum likelihood estimation. Results: No statistically significant differences between dental and dental hygiene students regarding knowledge of eating disorders and related oral manifestations. However, as compared with dental students, dental hygiene students were more likely to perceive they have a role in secondary prevention of eating disorders but reported less knowledge regarding appropriate procedures for secondary prevention and report higher self-efficacy regarding secondary prevention behaviors. Conclusion: Implications include the need for multi-disciplinary training for preparing dental and dental hygiene students to address sensitive oral/systemic health issues such as eating disorders with their patients.

Long-term association between developmental assets and health behaviors: an exploratory study

Introduction. Based on internal and external assets, the positive youth development approach aims to increase the capacity among adolescents to overcome challenges as they transition to adulthood. Developmental assets have been found to be positively associated with academic achievement, a variety of health promoting behaviors, and improved physical and mental health. The purpose of this exploratory study was to assess the long-term association between positive youth developmental assets with health risk and promoting behaviors. Method. A continuous scale of developmental assets was created using 30 items from Wave I of the National Longitudinal Study of Adolescent to Adult Health, when participants were in 7th to 12th grades. Health behavior outcomes including cigarette use, substance use, fast food consumption, and physical activity were measured at both Wave III (age 18-26) and Wave IV (age 24-32). Path analysis was employed to assess the relationship between these observed measures. Results. The well-fitted path model revealed associations between developmental assets with each health behavior at Wave III. Developmental assets indirectly influenced each health behavior and direct associations were observed between assets with substance use and physical activity at Wave IV. Conclusion. Findings provide additional support for the developmental assets approach to adolescent health. Implications include Healthy People 2020 objectives related to tobacco and alcohol use and nutrition and physical activity.