Joy Noel Baumgartner

The Influence of Early Sexual Debut and Sexual Violence On Adolescent Pregnancy: A Matched Case-Control Study In Jamaica

CONTEXT Contraceptive knowledge and use at first sex have increased over time among Jamaican adolescents, yet high unintended pregnancy rates persist. More information on risk factors for adolescent pregnancy is needed to inform programs. METHODS Structured interviews were conducted with 15-17-year-old females-250 who were currently pregnant and 500 sexually experienced, but never-pregnant, neighborhood-matched controls. Bivariate and multivariate analyses were used to examine associations between adolescent pregnancy and early sexual debut, sexual coercion or violence and sexual risk-taking behaviors. RESULTS Greater proportions of pregnant youth than of their never-pregnant peers reported having had first sex by age 14 (54% vs. 41%), a first sexual partner who was five or more years older (33% vs. 20%) or multiple partners (63% vs. 50%); a greater proportion of never-pregnant youth had used contraceptives at first sex (88% vs. 80%). Almost half (49%) of all young women reported ever having experienced sexual coercion or violence. Compared with controls, pregnant youth had greater odds of having had an older partner at first sex and believing contraception is a womans responsibility (odds ratios, 1.3 and 2.1, respectively), and had lower odds of ever having experienced sexual violence and thinking that it is important to protect oneself against pregnancy (0.5 and 0.2, respectively). An interaction between early sexual debut and multiple partners was found. Having had multiple partners was associated with pregnancy only for youth with early sexual debut. CONCLUSIONS Encouraging adolescents to delay sexual debut and reduce their number of sexual partners may help prevent unintended pregnancies. Experiences of sexual coercion and violence were common among both groups, highlighting the need to address gender-based violence at the community level.

Experiences of Sexual Coercion Among Adolescent Women: Qualitative Findings From Rakai District, Uganda

Limited data from low-income countries are available on the continuum of coercive experiences, the contexts in which they occur, and how adolescent women perceive and respond to coercion. This article presents results from focus group discussions and in-depth interviews with pregnant and never pregnant sexually active female adolescents, aged 15 to 17, residing in Rakai District, Uganda, to examine sexual coercion, its context, and the links between coercion and adolescent reproductive health outcomes, including early sexual debut and pregnancy. Informants described multiple forms of sexual coercion, including coerced or forced intercourse, unwanted sexual touching, verbal harassment, and transactional sex. Sexual coercion was perceived to be a normal part of intimate relationships; in particular, informants felt that a woman’s lack of decision-making authority, including choices on sexual encounters, was implicit to marriage. This information may help violence prevention programs develop a range of strategies for addressing sexual coercion among adolescents.

Measuring social inclusion—a key outcome in global mental health

BACKGROUND Social inclusion is increasingly recognized as a key outcome for evaluating global mental health programmes and interventions. Whereas social inclusion as an outcome is not a new concept in the field of mental health, its measurement has been hampered by varying definitions, concepts and instruments. To move the field forward, this paper reviews the currently available instruments which measure social inclusion and are reported in the literature, realizing that no single measure will be appropriate for all studies or contexts. METHODS A systematic literature search of English language peer-reviewed articles published through February 2013 was undertaken to identify scales specifically developed to measure social inclusion or social/community integration among populations with mental disorders. RESULTS Five instruments were identified through the search criteria. The scales are discussed in terms of their theoretical underpinnings, domains and/or key items and their potential for use in global settings. Whereas numerous reviewed abstracts discussed mental health and social inclusion or social integration, very few were concerned with direct measurement of the construct. All identified scales were developed in high-income countries with limited attention paid to how the scale could be adapted for cross-cultural use. CONCLUSIONS Social inclusion is increasingly highlighted as a key outcome for global mental health policies and programmes, yet its measurement is underdeveloped. There is need for a global cross-cultural measure that has been developed and tested in diverse settings. However, until that need is met, some of the scales presented here may be amenable to adaptation.

Community Integration of Formerly Homeless Men and Women With Severe Mental Illness After Hospital Discharge

OBJECTIVE This exploratory study examined the impact of critical time intervention (CTI), a time-limited care coordination model, on community integration among formerly homeless adults with severe mental illness after discharge from inpatient psychiatric treatment. METHODS Data were from a randomized trial that enrolled 150 participants, 95 of whom completed 18-month outcome measures. Relationships between two components of community integration (social and physical) and demographic characteristics, symptom ratings, housing status, and treatment condition were examined. RESULTS Neither assignment to CTI nor housing stability was associated with integration outcomes. General and negative symptoms were inversely associated with both physical and social integration. CONCLUSIONS Although CTI and similar community support models may improve housing stability and reduce rehospitalization, they may not, by themselves, improve community integration. Future studies should focus on improving measurement of community integration so that it can be effectively studied as an important outcome of mental health interventions for this population.

“Being faithful” in a sexual relationship: perceptions of Tanzanian adolescents in the context of HIV and pregnancy prevention

Abstract Little is known about what adolescents think about faithfulness and partner reduction for HIV prevention (the “B” in the ABC HIV prevention behavior change strategy), including how they understand its implementation within relationships. In addition, because adolescents face the twin threats of HIV and unintended pregnancy, it is important to understand how adolescents may integrate their thinking on pregnancy prevention if they are using faithfulness or partner reduction as their HIV prevention strategy. This study gathered evidence by conducting 20 focus group discussions (FGDs) with 158 adolescents, aged 14–20. The FGDs were stratified by sex, age, current school attendance, rural or urban residence, and marital status. Results showed that the vast majority of groups felt that “B” messages are important and relevant for unmarried (as well as married) youth to hear for HIV prevention, but the messages need to be explicit (e.g., “being faithful means having only one tested sexual partner at a time”). Faithful relationships are perceived as ideal in terms of romantic expectations and HIV prevention, but were considered unrealistic if the relationship had a power imbalance. Adolescents acknowledged the risks of multiple partners and a few recognized that concurrent partnerships are riskier than serial partnerships. Condoms were given as the primary method for pregnancy prevention among youth, yet faithfulness was usually seen as precluding condom use and many youth considered condom use as evidence of a lack of faithfulness. Overall, adolescents recognized that practicing fidelity is complex. Young people need life skills education for how to establish and maintain faithful relationships with one tested partner and how to integrate condom use for pregnancy prevention within that relationship. Programs also need to more explicitly address the issues of trust and repeat HIV testing within “faithful” relationships which is an uncomfortable but necessary reality for many adolescents.

Commentary: Sir Arthur Mitchell—pioneer of psychiatric epidemiology and of community care

He alsomade contributions in many other fields, fromMedical Meteorology to Archeology, and was aProfessor of Ancient History.A large part of Mitchell’s work was devoted to whatwe would now call psychiatric epidemiology and psy-chiatric care in the community. With respect to psy-chiatric epidemiology, Mitchell’s study of people withmental illness living in the community is describedhere, and his study of mortality rates among psychi-atric patients is in the reprint that precedes this com-mentary.

Impact of a Provider Job Aid Intervention on Injectable Contraceptive Continuation in South Africa

Arriving late for scheduled contraceptive reinjections is common in many countries and contributes to discontinuation when providers are unsure how to manage such clients. A clinic-randomized cohort and cross-sectional study with more than 5,000 clients using injectable contraceptives was conducted in the Eastern Cape province of South Africa to test the effectiveness of a provider job aid for managing late-returning clients and promoting continued use of the method. A marginally significant difference in reinjection rates between intervention and control groups was found for those up to two weeks late, and reanalysis excluding one clinic that experienced stockout issues revealed a significant difference. The difference in reinjection rates for those 2-12 weeks late was also found to be significant. The one-reinjection cycle continuation rate for the intervention group was higher than that for the control group, but the difference was not statistically significant. Appropriate management of late-returning clients is critical, and this study illustrates that reinjection rates can be significantly increased with a low-resource provider job aid.

Maternal mental health in Amhara region, Ethiopia: a cross-sectional survey

Poor mental health, including suicidal thoughts, affects a substantial proportion of surveyed women who are up to 2 years postpartum in the Amhara region of Ethiopia. Opportunities for integrating basic psychosocial mental health services into maternal and child health services should be explored. Poor mental health, including suicidal thoughts, affects a substantial proportion of surveyed women who are up to 2 years postpartum in the Amhara region of Ethiopia. Opportunities for integrating basic psychosocial mental health services into maternal and child health services should be explored. ABSTRACT Background: Postpartum common mental disorders (CMD) such as depression and anxiety are increasingly recognized for their burden in low-resource countries such as Ethiopia. However, the magnitude of postpartum CMD in Ethiopia is not well-established. This short report describes the mental health status of women who had given birth in the last 24 months in the Amhara region of Ethiopia. Methods: A cross-sectional survey was conducted among 1,319 women aged 15–49 years old who had a delivery in the previous 24 months from 30 randomly selected kebeles (smallest administrative unit in Ethiopia) across Amhara region. The survey included the Self-Reporting Questionnaire (SRQ-20) developed by the World Health Organization—a CMD screening instrument that includes 20 yes/no questions on depression, anxiety, and somatic symptoms experienced in the last 30 days. We used 2 cutoff scores to determine probable cases of mental disorder: (1) 4/5 (≤ 4 “yes” responses = non-case, ≥ 5 “yes” responses = case) based on a study that validated the SRQ-20 against a diagnostic tool in Butajira, Ethiopia, and (2) a more conservative and commonly used 7/8 cutoff. Results: Among the 1,294 women who completed the full survey including the SRQ-20, 32.8% had probable CMD using the 4/5 cutoff score versus 19.8% using the more conservative 7/8 cutoff. About 15% of the women responded affirmatively that they had had suicidal thoughts. Conclusion: Poor mental health was common among the surveyed women who had given birth in the past 24 months in Amhara region, Ethiopia. Integrating mental health care into maternal and child health services could potentially alleviate the burden of CMD among women in the extended postpartum period.

Service delivery characteristics associated with contraceptive use among youth clients in integrated voluntary counseling and HIV testing clinics in Kenya

Abstract Youth attending voluntary counseling and HIV testing (VCT) services often have unmet need for contraception. Integrated family planning (FP) and HIV services can address dual HIV and unintended pregnancy prevention needs. However, little is known about which VCT service characteristics, such as quality of care, strength of FP-HIV service integration, and youth-friendliness, affect contraceptive behavior. This study explores the facility- and provider-level characteristics that may be associated with same day uptake or intention to use contraception after a VCT visit, and contraceptive use three months later among youth clients, controlling for client characteristics. This was a descriptive study conducted in 20 integrated VCT clinics across Kenya. Data collection included 20 structured clinic observations, 349 baseline interviews with male and female clients aged 15–24 after their VCT visit plus 277 follow-up interviews with clients three months later, and interviews with 46 providers who served the clients at the study clinics. Client, provider, and structured observation data were linked and multi-level logistic path models were used for analyses. Results revealed little evidence of specific service characteristics being associated with contraceptive behavior. However, VCT providers were not routinely screening for risk of unintended pregnancy or counseling on contraception. Results are likely a reflection of suboptimal integrated services. The clinics were serving youth with unmet contraceptive need and therefore integrated services should be strengthened overall to ensure no missed opportunities.

Comparing patterns of sexual risk among adolescent and young women in a mixed-method study in Tanzania: implications for adolescent participation in HIV prevention trials

Despite the disproportionate impact of HIV on women, and adolescents in particular, those below age 18 years are underrepresented in HIV prevention trials due to ethical, safety and logistical concerns. This study examined and compared the sexual risk contexts of adolescent women aged 15–17 to young adult women aged 18–21 to determine whether adolescents exhibited similar risk profiles and the implications for their inclusion in future trials.