Nafisa Halim

Domestic violence and child nutrition in Liberia

Domestic violence against women is endemic globally and is an important social problem in its own right. A compounding concern is the impact of domestic violence against mothers on the nutritional status of their children. Liberia is an apt setting to examine this understudied topic, given the poor nutritional status of young children, high rate of domestic violence against women, and prolonged period of conflict that included systematic sexual violence against women. We expected that maternal exposure to domestic violence would predict lower anthropometric z-scores and higher odds of stunting, wasting, and underweight in children less than five years. Using data from 2467 mother-child dyads in the 2007 Liberia Demographic and Health Survey (LDHS) undertaken between December 24, 2006 and April 19, 2007, we conducted descriptive and multivariate analyses to examine the total, unadjusted and adjusted associations of maternal exposure to domestic violence with these anthropometric measures in children. Maternal reports of sexual domestic violence in the prior year predicted lower adjusted z-scores for height-for-age and weight-for-height as well as higher odds of stunting and underweight. The findings underscore the needs to (1) enhance and enforce conventional and customary laws to prevent the occurrence of domestic violence; (2) treat maternal survivors of domestic violence and screen their children for nutritional deficits; (3) heighten awareness of the intergenerational implications especially of recent sexual domestic violence; and (4) clarify the biological and behavior pathways by which domestic violence may influence child growth, thereby mitigating early growth failure and its adverse implications into adulthood.

The mCME Project: A Randomized Controlled Trial of an SMS-Based Continuing Medical Education Intervention for Improving Medical Knowledge among Vietnamese Community Based Physicians' Assistants.

Background Community health workers (CHWs) provide critical services to underserved populations in low and middle-income countries, but maintaining CHW’s clinical knowledge through formal continuing medical education (CME) activities is challenging and rarely occurs. We tested whether a Short Message Service (SMS)-based mobile CME (mCME) intervention could improve medical knowledge among a cadre of Vietnamese CHWs (Community Based Physician’s Assistants–CBPAs) who are the leading providers of primary medical care for rural underserved populations. Methods The mCME Project was a three arm randomized controlled trial. Group 1 served as controls while Groups 2 and 3 experienced two models of the mCME intervention. Group 2 (passive model) participants received a daily SMS bullet point, and were required to reply to the text to acknowledge receipt; Group 3 (interactive model) participants received an SMS in multiple choice question format addressing the same thematic area as Group 2, entering an answer (A, B, C or D) in their response. The server provided feedback immediately informing the participant whether the answer was correct. Effectiveness was based on standardized examination scores measured at baseline and endline (six months later). Secondary outcomes included job satisfaction and self-efficacy. Results 638 CBPAs were enrolled, randomized, and tested at baseline, with 592 returning at endline (93.7%). Baseline scores were similar across all three groups. Over the next six months, participation of Groups 2 and 3 remained high; they responded to >75% of messages. Group 3 participants answered 43% of the daily SMS questions correctly, but their performance did not improve over time. At endline, the CBPAs reported high satisfaction with the mCME intervention, and deemed the SMS messages highly relevant. However, endline exam scores did not increase over baseline, and did not differ between the three groups. Job satisfaction and self-efficacy scores also did not improve. Average times spent on self-study per week did not increase, and the kinds of knowledge resources used by the CBPAs did not differ between the three groups; textbooks, while widely available, were seldom used. Conclusions The SMS-based mCME intervention, while feasible and acceptable, did not result in increased medical knowledge. We hypothesize that this was because the intervention failed to stimulate lateral learning. For an intervention of this kind to be effective, it will be essential to find more effective ways to couple SMS as a stimulus to promote increased self-study behaviors. Trial Registration ClinicalTrials.gov NCT02381743

Intimate partner violence during pregnancy and perinatal mental disorders in low and lower middle income countries: A systematic review of literature, 1990–2017

Mental health consequences of intimate partner violence (IPV) against pregnant and postpartum women are poorly understood in low and lower-middle-income countries (LLMIC). We systematically reviewed the evidence from 24 studies (1990-2017) selected via a comprehensive search strategy with 14 inclusion, exclusion, and quality-control criteria to assess the extent to which intimate partner violence during pregnancy adversely affects perinatal mental disorders among participants in 10 LLMIC across 4 economic regions. Mostly cross-sectional, studies included 61-1369 participants selected randomly (88%) or non-randomly (12%) from purposively selected 1-6 clinics or 1-50 communities. Multivariate logistic regression was most frequently used (68%) for association estimates, adjusting for 3-16 socio-demographic variables pertinent to: women; husbands; and/or households. The prevalence of physical IPV ranged 2-35% among participants; sexual IPV ranged 9-40%; and psychological IPV ranged 22-65%. The prevalence of antenatal and postnatal depression ranged 15-65% and 5-35% among participants, respectively. Suicidal ideation ranged 5-11% during pregnancy and 2-22% during the postpartum period. Study participants who had experienced IPV had 1.69-3.76 and 1.46-7.04 higher odds of antenatal and postnatal depression compared to those who had not, depending on country, and IPV type and severity. Considering the strong association between IPV and mental disorders, efforts should focus on developing IPV interventions aimed at preventing pregnancy during IPV and promoting mental health resilience among pregnancy and postpartum women in low and lower-middle-income countries.

Fertility Decline, Girls’ Well-being, and Gender Gaps in Children’s Well-being in Poor Countries

The influences of recent dramatic declines in fertility on girls’ and boys’ well-being in poorer countries are understudied. In panels of 67–75 poorer countries, using 152–185 Demographic and Health Surveys spanning 1985–2008, we examined how declining total fertility and women’s increasing median age at first birth were associated with changes in girls’ well-being and gender gaps in children’s well-being, as reflected in their survival, nutrition, and access to preventive healthcare. In adjusted random-effects models, these changes in fertility were associated with gains in girls’ survival at ages 1–4 years, vaccination coverage at ages 12–23 months, and nutrition at 0–36 months (for women’s later first childbearing). Declining total fertility was associated with similar gains for boys and girls with respect to vaccination coverage but intensified gender gaps in mortality at ages 1–4 years and malnutrition at ages 0–36 months, especially in higher-son-preference populations. Later increases in women’s median age at first birth—reflecting more equitable gender norms—were associated with declines in these gaps. Promoting equitable investments in children through family planning programs in higher-fertility societies is warranted.

Childhood Trauma, Gender Inequitable Attitudes, Alcohol Use and Multiple Sexual Partners: Correlates of Intimate Partner Violence in Northern Tanzania:

Intimate partner violence (IPV), including physical, sexual, emotional, and economic violence, has profound immediate and long-term effects on individuals and communities worldwide. To date, few studies have focused on couples’ reporting of IPV. The aim of this article is to present the results of a survey of couples’ reporting of IPV and the individual, interpersonal, and social correlates of IPV in northern Tanzania. Four hundred fifty couples from Karatu District, Tanzania, completed a questionnaire measuring attitudes on gender norms and relations, men’s experience of childhood trauma, and men’s perpetration and women’s experience of IPV. We found high levels of acceptance and experience of IPV: 72% of men justified a husband’s perpetration of IPV, and 54% of men and 76% of women said that a woman should tolerate violence to keep her family together. The majority of women had ever experienced IPV (77.8%), and 73.6% and 69% had experienced IPV in the past 12 and 3 months, respectively. Men were significantly less likely to report that they had committed IPV: 63.6% ever, 48.9% in the past 12 months, and 46.2% in the past 3 months. Multivariate logistic regression found that younger men, men who reported gender inequitable attitudes, childhood trauma, multiple sexual partners, and alcohol use were significantly more likely to report IPV perpetration in the past 3 months. Younger women, and women with low levels of education and reported food shortages were significantly more likely to report IPV in the past 3 months. These results indicate that social and individual acceptance and justification of IPV are common. Experience of violence persists over time in many relationships. This study demonstrates the need for interventions that address individual-, interpersonal-, and community-level determinants of IPV, including attitudes regarding gender equity, exposure to violence as children and intergenerational violence, lack of education, and poverty.

Variability and validity of intimate partner violence reporting by couples in Tanzania

In recent years, major global institutions have amplified their efforts to address intimate partner violence (IPV) against women—a global health and human rights violation affecting 15–71% of reproductive aged women over their lifetimes. Still, some scholars remain concerned about the validity of instruments used for IPV assessment in population-based studies. In this paper, we conducted two validation analyses using novel data from 450 women-men dyads across nine villages in Northern Tanzania. First, we examined the level of inter-partner agreement in reporting of men’s physical, sexual, emotional and economic IPV against women in the last three and twelve months prior to the survey, ever in the relationship, and during pregnancy. Second, we conducted a convergent validity analysis to compare the relative efficacy of men’s self-reports of perpetration and women’s of victimization as a valid indicator of IPV against Tanzanian women using logistic regression models with village-level clustered errors. We found that, for every violence type across the recall periods of the last three months, the last twelve months and ever in the relationship, at least one in three couples disagreed about IPV occurrences in the relationship. Couples’ agreement about physical, sexual and economic IPV during pregnancy was high with 86–93% of couples reporting concordantly. Also, men’s self-reported perpetration had statistically significant associations with at least as many validated risk factors as had women’s self-reported victimization. This finding suggests that men’s self-reports are at least as valid as women’s as an indicator of IPV against women in Northern Tanzania. We recommend more validation studies are conducted in low-income countries, and that data on relationship factors affecting IPV reports and reporting are made available along with data on IPV occurrences. Keywords: Intimate partner violence; measurement; validity; survey research; Tanzania.

Incremental treatment costs for HIV-infected women initiating antiretroviral therapy during pregnancy: A 24-month micro-costing cohort study for a maternal and child health clinic in Kenya

Background To date, little information exists on the costs of providing antiretroviral therapy (ART) within maternal and child health (MCH) clinics in Kenya. The main objective of this analysis was to estimate the annual incremental cost of providing ART within a MCH clinic for adult women initiated on ART during pregnancy over the first one and two years on treatment. The study site was the District Hospital in Kericho, Kenya. Methods A micro-costing approach from the provider’s perspective, based on a retrospective review of patient medical records, was used to evaluate incremental costs of care (2012 USD). Cost per patient in two cohorts were evaluated: the MCH clinic group comprised of adult women who initiated ART at the site’s MCH clinic during pregnancy between 2008–2011; and for comparison, the ART clinic group comprised of adult, non-pregnant women who initiated ART at the site’s ART clinic during 2008–2011. The two groups were matched on age and baseline CD4 count at initiation. Retention at year one/two on ART was defined as having completed a clinic visit at 365/730 days on ART +/- 90 days. Results For patients defined as retained in care at year one, average incremental costs per patient were

Public Investments in Education and Children’s Academic Achievements

234 for the MCH clinic group (median: 215; IQR: 186, 282) and

mCME project V.2.0: randomised controlled trial of a revised SMS-based continuing medical education intervention among HIV clinicians in Vietnam

292 in the ART clinic group (median: 227; IQR: 178, 357). ARV and laboratory costs were less on average for the MCH clinic group compared to the ART clinic group (due to lower cost regimens and fewer tests), while personnel costs were higher for the MCH clinic group. Conclusions The annual incremental cost per patient of providing ART were similar in the two clinic settings in 2012. With shifts in recommended ARV regimens and lab monitoring over time, annual costs of care (using 2016 USD unit costs) have remained relatively constant in nominal terms for the MCH clinic group but have fallen substantially for the ART clinic group (from nominal

A Survey Experiment of Women’s Attitudes about Intimate Partner Violence against Women in Rural Bangladesh

292 in 2012 to nominal