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Highlights • We observed multiple CRP, EBV, and HCC trajectories, indicating within-population heterogeneity. • Refugees and non-refugee adolescents showed similar CRP and HCC trajectories. • Rising CRP levels were related to perceived stress, high HCC to insecurity. • Post-intervention, HCC reduced by more than one third, while CRP and EBV did not., Experiencing childhood adversity has been associated with significant changes in inflammation, cell-mediated immunocompetence, and cortisol secretion. Relatively few studies have examined, longitudinally, alterations to inflammatory processes during adolescence, especially outside Western contexts; none have evaluated biomarker trajectories for at-risk youth in response to a structured behavioral intervention. We conducted a randomized controlled trial evaluating the efficacy of a humanitarian intervention targeting stress-alleviation, with 12–18 year-old Syrian refugees (n = 446) and Jordanian non-refugees (n = 371) living side-by-side in war-affected communities in Jordan. We measured C-reactive protein (CRP), Epstein-Barr virus antibodies (EBV), and hair cortisol concentration (HCC) at three timepoints (pre/post intervention and 11 month follow-up), and assessed three main outcomes (psychosocial stress, mental health, and cognitive function). Using growth mixture models, regressions, and growth curve models, we identified three distinct trajectories for CRP, two for EBV, and three for HCC, and examined their associations with age, gender, BMI, poverty, and trauma. We found associations with BMI for CRP, refugee status for EBV, and BMI and gender with HCC trajectory. In terms of health outcomes, we found associations between rising CRP levels and perceived stress (B = −2.92, p = .007), and between HCC hypersecretion and insecurity (B = 7.21, p = .017). In terms of responses to the intervention, we observed no differential impacts by CRP or EBV trajectories, unlike HCC. These results suggest that commonly-assayed biomarkers do not associate with health outcomes and respond to targeted interventions in straightforward ways. Our study is the first to examine multiple biomarker trajectories in war-affected adolescents, in order to better evaluate the extent, timing, and malleability of the biological signatures of poverty, conflict, and forced displacement.

Children's environments - especially relationships with caregivers - sculpt not only developing brains but also multiple bio-behavioral systems that influence long-term cognitive and socioemotional outcomes, including the ability to empathize with others and interact in prosocial and peaceful ways. This speaks to the importance of investing resources in effective and timely programs that work to enhance early childhood development (ECD) and, by extension, reach communities at-scale. Given the limited resources currently devoted to ECD services, and the devastating impact of COVID-19 on children and communities, there is a clear need to spur government leaders and policymakers to further invest in ECD and related issues including gender and racial equity. This essay offers concrete examples of scholarly paradigms and leadership efforts that focus on child development to build a peaceful, equitable, just, and sustainable world. As scholars and practitioners, we need to continue to design, implement, assess, and revise high-quality child development programs that generate much-needed evidence for policy and programmatic changes. We must also invest in global partnerships to foster the next generation of scholars, practitioners, and advocates dedicated to advance our understanding of the bio-behavioral systems that underlie love, sociality, and peace across generations. Especially where supported by structural interventions, ECD programs can help create more peaceful, just, and socially equitable societies.

OBJECTIVES: Oxidative stress is hypothesized to contribute to age-related somatic deterioration. Both reproductive and ecological context may necessitate tradeoffs that influence this outcome. We examined whether measures of lifetime reproductive effort were related to levels of oxidative stress biomarkers in peri- and post-menopausal women and whether associations were moderated by rural or urban residence. METHODS: We surveyed 263 healthy women (age 62.1 ± 10.0 SD) from rural (N=161) and urban Poland (N=102), collecting sociodemographic data and urine samples to analyze biomarkers of oxidative stress (8-oxo-2’-deoxyguanosine, 8-OHdG) and antioxidative defense (copper-zinc superoxide dismutase, Cu-Zn SOD). Linear regression models, adjusted for residence, were used to test for associations between reproductive effort and 8-OHdG and Cu-Zn SOD. RESULTS: Univariate models demonstrated significant associations between gravidity and the biomarkers of oxidative stress (8-OHdG: R(2) = 0.042, p =

Major knowledge gaps remain concerning the most effective ways to address mental health and psychosocial needs of populations affected by humanitarian crises. The Research for Health in Humanitarian Crisis (R2HC) program aims to strengthen humanitarian health practice and policy through research. As a significant portion of R2HC’s research has focused on mental health and psychosocial support interventions, the program has been interested in strengthening a community of practice in this field. Following a meeting between grantees, we set out to provide an overview of the R2HC portfolio, and draw lessons learned. In this paper, we discuss the mental health and psychosocial support-focused research projects funded by R2HC; review the implications of initial findings from this research portfolio; and highlight four remaining knowledge gaps in this field. Between 2014 and 2019, R2HC funded 18 academic-practitioner partnerships focused on mental health and psychosocial support, comprising 38% of the overall portfolio (18 of 48 projects) at a value of approximately 7.2 million GBP. All projects have focused on evaluating the impact of interventions. In line with consensus-based recommendations to consider a wide range of mental health and psychosocial needs in humanitarian settings, research projects have evaluated diverse interventions. Findings so far have both challenged and confirmed widely-held assumptions about the effectiveness of mental health and psychosocial interventions in humanitarian settings. They point to the importance of building effective, sustained, and diverse partnerships between scholars, humanitarian practitioners, and funders, to ensure long-term program improvements and appropriate evidence-informed decision making. Further research needs to fill knowledge gaps regarding how to: scale-up interventions that have been found to be effective (e.g., questions related to integration across sectors, adaptation of interventions across different contexts, and optimal care systems); address neglected mental health conditions and populations (e.g., elderly, people with disabilities, sexual minorities, people with severe, pre-existing mental disorders); build on available local resources and supports (e.g., how to build on traditional, religious healing and community-wide social support practices); and ensure equity, quality, fidelity, and sustainability for interventions in real-world contexts (e.g., answering questions about how interventions from controlled studies can be transferred to more representative humanitarian contexts).

Deployment in a crisis zone is a perilous undertaking. Little is known right now about how humanitarian workers relate social and professional goals to lived experiences of high-risk environments. In South Sudan, ranked as the most dangerous country globally for aid workers, 20 international humanitarian staff were interviewed to examine their sense of place, well-being, and vocation, using thematic and interpretative phenomenological analysis. Subjectivities of humanitarian space hinged upon negotiating physical hardships and social relationships: Juba, the capital, was described as a 'prison' and a 'party hotspot'. For expatriate staff, making sense of spatial, social, and professional transience was sharply gendered and rooted in the subjectivities of risk-taking, crisis management, and career-building. Two policy measures are highlighted here to address the implications of transience for human well-being and organisational effectiveness. Efforts to support teams and structure work environments, altering the humanitarian and vocational bubble, will help to develop resilience at the heart of humanitarian systems.الانتشار في مناطق الأزمات هو عمل محفوف بالمخاطر. وحتى الآن، لا يُعرف سوى القليل عن كيفية ربط العاملين في المجال الإنساني بين الأهداف الاجتماعية والمهنية بالتجارب المعيشية في البيئات عالية الخطورة. ففي جنوب السودان، المصنف على أنه أخطر دولة بالنسبة لعمال الإغاثة على مستوى العالم، أجرينا مقابلات مع موظفين دوليين في المجال الإنساني (عددهم = 20) لفحص باستخدام التحليل الموضوعي والتفسيري للظواهر وإحساسهم بالمكان والرفاهية والوظيفة. توقفت السمات الشخصية للمساحات الإنسانية على التفاوض بشأن الصعوبات الجسدية والعلاقات الاجتماعية حيث وُصفت جوبا بكونها "سجن" و "بقعة ساخنة للحفلات." بالنسبة للموظفين المغتربين، كان فهم الزوال المكاني والاجتماعي والمهني مرتبطًا بشكل حاد بالنوع الاجتماعي ومتحدرا في السمات الذاتية للمخاطرة وإدارة الأزمات وبناء المسار الوظيفي. نسلط الضوء على اثنين من تدابير السياسة لمعالجة الآثار المترتبة على الزوال لكلا من رفاهية الإنسان والكفاءة التنظيمية. ستساعد الجهود المبذولة لدعم الفرق وهيكلة بيئات العمل، وتغيير الفقاعة الإنسانية والمهنية على بناء المرونة في قلب الأنظمة الإنسانية.在危机地区部署是件危险的事情。迄今为止，关于人道主义工作者如何将社会和职业目标与高风险环境的生活经验联系起来，我们知之甚少。南苏丹被评为全球援助工作者最危险的国家，我们采访了20名国际人道主义工作人员，利用主题和解释性现象学分析来考察他们的地点感、幸福感和职业感。人道主义空间的主观性取决于对物质困难和社会关系的谈判:朱巴被描述为“监狱”和“派对热点。” 对于外派员工来说，对空间、社会和职业短暂性的理解有明显的性别差异，根植于冒险、危机管理和职业生涯建设等主观活动。我们强调了两项政策措施以解决短暂性对人类福祉和组织效率的影响。努力支持团队和构建工作环境，改变人道主义和职业泡沫，将帮助 人道主义系统的核心建立弹性。.

Temporal examinations of the biological signature of stress or trauma in war-affected populations are seldom undertaken. Moreover, few studies have examined whether stress biomarkers track biological sensitivity to brief interventions targeting the improvement of psychosocial wellbeing. Our study is the first to prospectively examine, in war-affected adolescents, the associations between hair cortisol concentrations (HCC) and self-reports of stress, insecurity, posttraumatic reactions, and lifetime trauma. We conducted a randomized controlled trial to test the impact of an 8-week intervention based on profound stress attunement. We collected data for a gender-balanced sample of 733 Syrian refugee ( n = 411) and Jordanian non-refugee ( n = 322) adolescents (12–18 years), at three time-points. We used growth mixture models to classify cortisol trajectories, and growth models to evaluate intervention impact on stress physiology. We observed three trajectories of HCC: hypersecretion, medium secretion, and hyposecretion (9.6%, 87.5% and 2.9% of the cohort, respectively). For every one percent increase in levels of insecurity, adolescents were 0.02 times more likely to have a trajectory of hypersecretion (95% CI: 1.00, 1.03, p = 0.01). For each additional symptom of posttraumatic stress reported, they were 0.07 times less likely to show hyposecretion (95% CI: 0.89, 0.98, p = 0.01). Indeed, stronger posttraumatic stress reactions were associated with a pattern of within-individual cortisol dysregulation and medium secretion. Overall, HCC decreased by a third in response to the intervention (95% CI: −0.19, −0.03, p = 0.01). While the intervention decreased HCC for youth with hypersecretion and medium secretion, it increased HCC for youth with hyposecretion (95% CI: 0.22, 1.16, p = 0.004), relative to controls. This suggests a beneficial regularization of cortisol levels, corroborating self-reports of improved psychosocial wellbeing. We did not find evidence to suggest that gender, resilience, or posttraumatic stress disorder influenced the strength or direction of responses to the intervention. This robust impact evaluation exemplifies the utility of biomarkers for tracking physiological changes in response to interventions over time. It enhances the understanding of trajectories of endocrine response in adverse environments and patterns of stress responsivity to ecological improvement.

Early childhood trauma can have profound and lifelong effects on adult mental health and psychosocial wellbeing. Nevertheless, responses to trauma are highly variable. Genetic variants may help explain variation in responses to trauma by identifying alleles that associate with changes in mental health measures. Protective factors, such as resilience, likely also play an important role in responses to trauma. The effects of genetic variants, in combination with protective factors, on psychosocial health are not well understood, particularly in non-Western contexts. In this study, we test the relative influence of genetic variants of monoamine oxidase A (MAOA, a gene proposed to influence the impact of childhood trauma on adult violence and antisocial behavior), levels of resilience, and exposure to traumatic events on psychosocial stress and mental health trajectories over time. We use data from a cohort of 12-18-year-old Syrian refugees who were forcibly displaced to neighboring Jordan (n = 399). DNA samples and survey data on trauma exposure, resilience (CYRM-12), and psychosocial stress were collected at three time points: baseline, ~13 weeks, and ~48 weeks. Using multilevel models, we identified an association of MAOA variant, in males only, with symptom scores of psychosocial stress on the Perceived Stress Scale (PSS) over time (p = 8.1 x 10-4). We also found that resilience is strongly associated with PSS (p = 7.9 x 10-9), underscoring the importance of protective factors in influencing levels of psychosocial stress. Furthermore, there was an additive effect wherein the sharpest reductions in perceived psychosocial stress are seen in low-activity MAOA males with low trauma exposure or high resilience levels. Our results highlight the value of studies that integrate genetic and psychosocial factors to better understand complex phenotypes, such as responses to trauma in contexts of high trauma exposure.

In recent years, anthropologists have become increasingly present in medical humanitarian situations as scholars, consultants, and humanitarian practitioners and have acquired insight into medical humanitarian policy and practice. In 2012, we implemented a poll on anthropology, health, and humanitarian practice in which 75 anthropologists discussed their experiences in medical humanitarianism. Our goal was to move beyond the existing anarchy of individual voices in anthropological writing and gain an aggregate view of the perspective of anthropologists working in medical humanitarian contexts. Responses lead to six inductively derived thematic priorities. The findings illustrate how anthropologists perceive medical humanitarian practice; which aspects of medical humanitarianism should be seen as priorities for anthropological research; and how anthropologists use ethnography in humanitarian contexts.

Background: Humanitarian crises are associated with an increase in mental disorders and psychological distress. Despite the emerging consensus on intervention strategies in humanitarian settings, the field of mental health and psychosocial support (MHPSS) in humanitarian settings lacks a consensus-based research agenda. Methods: From August 2009 to February 2010, we contacted policymakers, academic researchers, and humanitarian aid workers, and conducted nine semistructured focus group discussions with 114 participants in three locations (Peru, Uganda, and Nepal), in both the capitals and remote humanitarian settings. Local stakeholders representing a range of academic expertise (psychiatry, psychology, social work, child protection, and medical anthropology) and organizations (governments, universities, nongovernmental organizations, and UN agencies) were asked to identify priority questions for MHPSS research in humanitarian settings, and to discuss factors that hamper and facilitate research. Results: Thematic analyses of transcripts show that participants broadly agreed on prioritized research themes in the following order: (1) the prevalence and burden of mental health and psychosocial difficulties in humanitarian settings, (2) how MHPSS implementation can be improved, (3) evaluation of specific MHPSS interventions, (4) the determinants of mental health and psychological distress, and (5) improved research methods and processes. Rather than differences in research themes across countries, what emerged was a disconnect between different groups of stakeholders regarding research processes: the perceived lack of translation of research findings into actual policy and programs; misunderstanding of research methods by aid workers; different appreciation of the time needed to conduct research; and disputed universality of research constructs. Conclusions: To advance a collaborative research agenda, actors in this field need to bridge the perceived disconnect between the goals of “relevance” and “excellence.” Research needs to be more sensitive to questions and concerns arising from humanitarian interventions, and practitioners need to take research findings into account in designing interventions. (Harv Rev Psychiatry 2012;20:25–36.)

We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive eff ect on the child’s psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identifi ed as aff ecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the eff ective integration of internally displaced and refugee children.

In the field of global mental health, there is a need for identifying core values and competencies to guide training programs in professional practice as well as in academia. This paper presents the results of interdisciplinary discussions fostered during an annual meeting of the Society for the Study of Psychiatry and Culture to develop recommendations for value-driven innovation in global mental health training. Participants (n = 48), who registered for a dedicated workshop on global mental health training advertised in conference proceedings, included both established faculty and current students engaged in learning, practice, and research. They proffered recommendations in five areas of training curriculum: values, competencies, training experiences, resources, and evaluation. Priority values included humility, ethical awareness of power differentials, collaborative action, and “deep accountability” when working in low-resource settings in low- and middle-income countries and high-income countries. Competencies included flexibility and tolerating ambiguity when working across diverse settings, the ability to systematically evaluate personal biases, historical and linguistic proficiency, and evaluation skills across a range of stakeholders. Training experiences included didactics, language training, self-awareness, and supervision in immersive activities related to professional or academic work. Resources included connections with diverse faculty such as social scientists and mentors in addition to medical practitioners, institutional commitment through protected time and funding, and sustainable collaborations with partners in low resource settings. Finally, evaluation skills built upon community-based participatory methods, 360-degree feedback from partners in low-resource settings, and observed structured clinical evaluations (OSCEs) with people of different cultural backgrounds. Global mental health training, as envisioned in this workshop, exemplifies an ethos of working through power differentials across clinical, professional, and social contexts in order to form longstanding collaborations. If incorporated into the ACGME/ABPN Psychiatry Milestone Project, such recommendations will improve training gained through international experiences as well as the everyday training of mental health professionals, global health practitioners, and social scientists.

In the spirit of critical reflection, we examine how the field of global health might surmount current challenges and prioritize its ethical mandate, namely to achieve, for all people, equity in health. We use the parlance of mastering deadly sins and striving for greater virtues in an effort to review what is needed to transform global health action. Global health falls prey to four main temptations: coveting silo gains, lusting for technological solutions, leaving broad promises largely unfulfilled, and boasting of narrow successes. This necessitates a change of heart: to keep faith with the promise it made, global health requires a realignment of core values and a sharper focus on the primacy of relationships with the communities it serves. Based on the literature to date, we highlight six steps to re-orienting global health action. Articulating a coherent global health agenda will come from principled action, enacted through courage and prudence in decision-making to foster people-centered systems of care over the entire lifespan. Keywords : equity; scale-up; leadership; health systems; global health; interventions (Published: 28 March 2014) Citation : Glob Health Action 2014, 7: 23411 - http://dx.doi.org/10.3402/gha.v7.23411

This study of two natural fertility Nepali groups, the Tamang and Kami, identifies biological and behavioral factors associated with population differences in fertility. Previous research had established that Tamang experience longer interbirth intervals than Kami despite similarly intense nursing practices, and bear considerably higher energy expenditure due to workload. This cross-sectional study of 71 breastfeeding women includes prolactin determinations on three blood spot samples collected 5, 30, and 50 minutes following a timed nursing bout, and data on maternal age, BMI, menstrual status, previous birth interval, parity, infant age, nursing bout length, and durations of supplementation and postpartum amenorrhea. The findings show that Tamang breastfeeding mothers have higher average prolactin levels than Kami for as long as 22 months postpartum. Tamang mothers sustain average prolactin levels above those of nonpregnant, nonlactating women for nearly 2 years postpartum, whereas prolactin levels among Kami breastfeeding mothers are the same as this latter group after 1 year postpartum. Furthermore, the findings indicate that Tamang mothers have higher average prolactin levels regardless of maternal age, physical status (BMI, weight, or height), or infant age, and the rate of decline in prolactin from 5 to 50 minutes after suckling is significantly greater for Kami than Tamang. Since factors associated with prolactin levels differ by group, the findings also emphasize that populations vary not only in the strength of effects that proximate determinants have on fertility regulation, but also in the pathways by which they exert their effects (direct physiological versus indirect behavioral). Am. J. Hum. Biol. 10:191-210, 1998. © 1998 Wiley-Liss, Inc.

Food shortages occur periodically and predictably in over- populated areas of the foothills of the Himalaya, leading to extensive outmigration and to indebtedness of farmers. A survey of four administrative areas and in-depth interviews of 120 households (a sample of diverse caste and ethnic groups, stratified by land area) was undertaken in two districts of western Nepal to document the severity of shortfall in local agricultural production and the range of household coping strategies. The duration of food shortages averaged 5 months of the year, but ranged enormously across households, with 4% of sample families being entirely landless. Out-migration, wage labor, petty trade, high-interest loans, and land mortgage were well-established coping strategies, beneficial for some families in generating income and the possibility for investment, but for others leading to progressively greater debt, economic marginalisation and impoverishment. This study highlights the importance of encouraging diversified strategies for subsistence farmers to ensure cash revenue, much of which is derived from debt and emigration, and reviews the geographical and socioeconomic factors influencing both constraints on household subsistence and responses to seasonal food deficits.

Resilience offers the promise of a paradigm shift in many fields of research, clinical practice, and policy. A lens on resilience shifts the focus of attention - from concerted efforts to appraise risk or vulnerability, towards concerted efforts to enhance strength or capability. It also shifts the focus of analysis - from asking relatively limited questions regarding health outcomes, such as what are the linkages between risk exposures and functional deficits, to asking more complex questions regarding wellbeing, such as when, how, why and for whom do resources truly matter. Thus we might ask when interventions are most effective, within the time frame of human development and evolutionary life history; and how do we best measure pathways of human experience, to uncover ways in which individuals and communities withstand adversity. To many, resilience is an intuitive, albeit opaque, concept - akin to fortitude in the face of adversity. We may have an intuitive grasp of what resilience means, but fall short of measuring it comprehensively and meaningfully (the same is true of risk). This Annual Research Review issue features ten articles from leaders in the field on how resilience can transform the field of child development. Each articulates important lessons on resilience some of which we editors wish to summarize at the outset. First, resilience is best understood as a process that unfolds over the course of development; consequently, we seek to understand human experience of adversity as pathways of risk and resilience. Second, research on resilience focuses attention on the biological and social trade-offs in human experience: issues of timing, process, and context to understand change or adaptability. Language: en

Continuous HR monitoring, in conjunction with self-reports and direct observation of physical activity, was undertaken in three samples of 10-13-year-old Nepali boys living in different physical and socioeconomic environments. A total of 134 daytime HR profiles were recorded from 67 boys (76 from 31 villagers, 39 from 20 urban middle-class schoolboys, and 19 from 16 homeless street boys). Habitual levels of physical activity were compared using mean daytime HR (bpm) and the following indicators: percentage time during which boys are active (HR> flex, defined as an individual's average between resting and exercising HR), moderately active (HR> flex + 20%, also HR> 119 bpm), and vigorously active (HR> 139 bpm) over 10 hours of daylight. Mean daytime HR (102 bpm) and percentage time spent vigorously active (4%) did not differ between samples, despite obvious differences in lifestyles; thus better indicators are needed to characterize levels of physical activity. Percentage time spent active (HR> flex) was significantly higher (P < 0.0001) for villagers participating in subsistence activities, as a result of low flex HR values, indicating a higher level of physical fitness. Evaluation of moderate physical activity was sensitive to the choice of indicator, either an individual calibrated (above flex) or an absolute threshold of HR elevation. The former may be more appropriate than the latter to compare physical activity levels in populations with different lifestyles and levels of physical fitness. © 1996 Wiley-Liss, Inc.

OBJECTIVES: Biocultural research remains a challenge in the field of global mental health. We sought to test associations between blood pressure and idioms of distress in a population survey. METHODS: We drew on a randomly selected sample of 991 adults (498 men, 493 women) in Afghanistan, for whom physiological and psychosocial data were systematically collected. Assessment of mental health (Self-Reported Questionnaire, Afghan Symptom Checklist) included conceptualizations of distress related to pressure (fishar), anxiety, and dysphoria, as well as dimensions of negative affect and aggression. We used principal component analysis to map survey responses to fishar, and multiple regressions to examine associations with systolic/diastolic blood pressure, controlling for age, body mass index, and wealth, and differentiating by gender, mental health, and medication. RESULTS: The Afghan sample averaged 129/80 mmHg, with 27.14% of hypertensive individuals. SBP showed inverse associations with reports of low fishar (β = -4.58, P CONCLUSIONS: Subjective reports of fishar map onto physiological blood pressure more robustly than other conceptualizations of mental distress related to anxiety, dysphoria, negative affect, or aggression. Our results point to the utility of mapping biological and cultural measures of stress and distress, advancing biopsychosocial understandings of wellbeing in global mental health surveys.© 2016 Wiley Periodicals, Inc. Language: en

Children and adolescents who are forcibly displaced represent almost half the world's internally displaced and refugee populations. We undertook a two-part systematic search and review of the evidence-base for individual, family, community, and societal risk and protective factors for the mental health outcomes of children and adolescents. Here we review data for displacement to low-income and middle-income settings. We draw together the main findings from reports to identify important issues and establish recommendations for future work. We draw attention to exposure to violence as a well established risk factor for poor mental health. We note the paucity of research into predictor variables other than those in the individual domain and the neglect of other variables for the assessment of causal associations, including potential mediators and moderators identifiable in longitudinal work. We conclude with research and policy recommendations to guide the development and assessment of effective interventions. © 2012 Elsevier Ltd.

Afghanistan leads global opium and cannabis production, amidst concerted efforts to improve the country's infrastructure. In this commentary, the evidence base for drivers of increased drug use in the context of deteriorating security is presented, government, donor, and civil society responses to date are described, and key areas for health policy response are summarized. Opiate use in Afghanistan shows disturbing trends: multiple substances are accessible at low cost and frequently used in combination, and injecting use has become more common. Pressures from both donor and governmental sectors have compromised innovations in programming. Further, civil unrest and resultant displacement have created challenges for programme implementation. Afghanistan urgently needs a well-funded, sustainable, comprehensive, and inclusive programme of drug dependency treatment, aftercare, and harm reduction services, as well as realistic, effective, and culturally salient primary prevention programmes. To date, drug dependence is not a prioritised issue, current programmes are under-resourced, and the continuum of care has a narrow scope generally limited to treatment. Unless this issue is addressed, the next generation of Afghans is poised to become a casualty of the opiate industry.

Objective: We conducted a longitudinal study to assess the impact of a hand-washing intervention on growth and biomarkers of child health in Nepali slums. This is the first study to evaluate the impact of hand-washing on markers of subclinical, asymptomatic infections associated with childhood growth faltering. Methods: We recruited a total sample of infants in the target age-range (3–12 months) living in the eight largest Kathmandu slums, allocating them to intervention (n = 45) and control (n = 43) groups. In intervention areas, a small-scale community-based hand-washing program was implemented for six months; in control areas, mothers continued their normal practices. Time series linear regression was used to assess the impact of the intervention on levels of morbidity, mucosal damage, immune stimulation and growth. Results: As expected, children with higher levels of mucosal damage exhibited worse growth over the period of the intervention (P = 0.01

Saudi parents who have received genetic counseling following the birth of a child affected by a neurometabolic disorder were interviewed during their visits to a specialist hospital. As is common in the West, understanding of heredity was often incompletely assimilated, and this was related to parental education level. Coping behaviors, however, were substantially different from those in the West. The wide range of attitudes recorded toward consanguineous marriage and future births was a reflection of the position of Saudi families in a society undergoing rapid change. (J Child Neurol 1992;7(Suppl):S69-S72.)

The impact of low hemoglobin levels on the work performance of 74 rural Nepali villagers was examined with a 3 minute exercise step test. Work output was standardized at 75 watts for men and 55 watts for women. Hemoglobin values ranged from 4.2-15.7 g/dl, and averaged 12.0 ± 2.7 g/dl for 35 men and 10.9 ± 1.72 g/dl for 39 women. Low hemoglobin levels significantly elevated the heart rates and recovery times of the men, but not of the women. A positive relationship with oxygen uptake and a negative one with net mechanical efficiency was found for men but not for women (anemic men appeared more efficient as they used up marginally less oxygen during exercise). Values are in good agreement with those recently published for Gurkha soldiers, but are at variance with those examining the step test performance of Nepali women. In the light of behavioral data on work patterns, mild anemia may have little impact on the performance of moderate self-paced physical activity. Nepali villagers pause frequently during the course of subsistence activities, a behavior which allows time for recovery from an elevated pulse rate. © 1992 Wiley-Liss, Inc.

The nursing behaviour of rural Nepali women, from two castes inhabiting the same village, is quantified on the basis of 2202 hr of continuous and direct day-time observation over 1 year. Feed duration, interval, total time and daily frequency are examined in relation to women's work, particularly the type of subsistence activity and seasonality. 'Opportunity' feeds are governed both by infant demands and maternal activity. Caste differences in birth intervals are also discussed.From 1982-1983, researchers observed working women from 2 castes (16 Tamang and 8 Kami) in Salme, Nepal for 11-13 hours/day to determine if breast feeding and working behaviors explain fertility differences between them. Work loads greatly increased for the agropastoralist Tamang women during the monsoon (p.0007), but not so for the low caste Kami women who worked mainly at home. Intervals between feeds and agricultural activities averaged 98 minutes while they averaged 47 minutes for husbandry activities (p.05). Neither affected feed duration. If Tamang women worked in a labor group rather than alone, they tended to provide shorter breast feeds only during the monsoon (p.05). Infant age greatly affected duration of breast feeds (p.0005), interval between feeds (p.004), and total frequency and nursing time (p.0001) among the Tamang. Seasonality did not affect these relationships, except for 3 year olds in which seasonality was significantly reduced during the monsoon. On the other hand, it did have a strong effect on interval (p.05), total frequency (p.01), and total time (p.001) for the Kami. Tamang women provided longer feeds for their infants than did the Kami women during the winter (p.0002), but differences between the 2 castes were minor during spring. Yet Tamang women breast feed their 2 year olds for shorter times than Kami women during the spring (p.01). Among the Kami, infant age did not affect duration, interval, total frequency, and total time. Therefore the 2 castes were not alike in how they planned feeds from day to day. In fact, the Kami women fed their children at very irregular intervals regardless of the child's age. As for Tamang women, intervals grew more irregular with increasing age of the child. Supplementary foods most likely accounted for the high variability between the 2 castes. No 3 year old Kami children were breast fed. The interval between feeds rose consistently with infant age for the Tamang but not for the Kami.

In-depth interviews of 36 Saudi families whose children suffered from neuro-metabolic disorders were conducted at a specialist hospital in Riyadh in order to examine parental understanding of disease and attitudes towards future births and consanguineous marriages. Parents had difficulty accepting a genetic explanation for diseases that did not affect all children at the time of birth; they also expressed religious or folk beliefs to account for illness. Coping behaviours included denial and resignation to the situation, divorce and remarriage. Some families adopted a cautious approach to cousin marriages and future births; this was significantly related to their education level, but not to previous infant deaths. Awareness of medical facts brought little emotional comfort to parents but allowed for preventive measures through screening adult carriers and identifying affected infants. This study presents new material from Saudi Arabia to strengthen current awareness that the range of religious beliefs, social attitudes and reproductive behaviours adopted by families in a society undergoing rapid change is of direct relevance to health care.

Afghanistan provides a unique setting in which to appraise psychosocial stress, given the context of persistent insecurity and widening economic inequality. In Kabul, people experience widespread frustrations, hinging on restricted opportunities for social advancement, education, and employment. We appraised social aspirations, every-day stressors, psychosocial distress, and mental health problems for a random sample of 161 male and female students at Kabul University. The survey featured both existing and newly-developed instruments (Self-Reported Questionnaire SRQ-20; Afghan Symptom Checklist; Afghan Daily Stressor Scale; and Social Aspirations and Frustrations), implementing both internationally-used and culturally-grounded measures of mental health assessment. We also included indicators of physical health (blood pressure, immune responses to Epstein-Barr virus (EBV), C-reactive protein, and body mass index), to map physiological function with reported psychosocial distress. This young, urban elite expressed major feelings of frustrations, related to physical, economic, social, and political stressors of day-to-day life in Kabul. There were striking gender differences for psychosocial and physiological markers of wellbeing; specifically, women showed poorer mental health (SRQ-20, P = 0.01) and elevated EBV antibody titers (P = 0.003). Both diastolic blood pressure (P = 0.018) and EBV (P = 0.038) were associated with a subscale of family stressors among women, but not among men, consistent with women's social vulnerabilities to stressful family dynamics. This is the first study to integrate approaches from anthropology, cross-cultural psychiatry, and human biology to document social stressors, psychosocial distress, and physiological wellbeing in the challenging setting of present-day Afghanistan.

Early childhood growth retardation persists in developing countries despite decades of nutritional interventions. Adequate food is necessary, but not sufficient, to ensure normal growth where there is ubiquitous exposure to infection. Pathways associated with infection, small intestinal mucosal damage and chronic immunostimulation remain largely undemonstrated in countries other than The Gambia. We conducted a longitudinal study of one squatter and one middle-class group (n 86, 3–18 month olds) to assess these relationships in Nepal. Growth, mucosal damage index (MDI; urinary lactose:creatinine ratio adjusted for body weight), morbidity reports, and blood concentrations of albumin, α-1-acid glycoprotein, IgG and Hb, were recorded monthly. Growth status worsened dramatically from 6 to 18 months, with squatters more stunted (height-for-age Z-score (HAZ), P Z-score (WAZ), P = 0·009) than middle class. IgG increased with age, was elevated in squatter children, and negatively related to WAZ (P = 0·034). MDI showed significant negative associations with growth performance, explaining 9 and 19 % of height and weight deficits (ΔHAZ, P = 0·004; ΔWAZ, P P

In 2004-05, Niger suffered a food crisis during which global attention focused on high levels of acute malnutrition among children. In response, decentralised emergency nutrition programmes were introduced into much of southern Niger. Child malnutrition, however, is a chronic problem and its links with food production and household food security are complex. This qualitative, anthropological study investigates pathways by which children are rendered vulnerable in the context of a nutritional 'emergency'. It focuses on household-level decisions that determine resource allocation and childcare practices in order to explain why practices apparently detrimental to children's health persist. Risk aversion, the need to maintain self-identity and status, and constrained decision making result in a failure to invest extra necessary resources in growth-faltering children. Understanding and responding to the social context of child malnutrition will help humanitarian workers to integrate their efforts more effectively with longer-term development programmes aimed at improving livelihood security.

SummaryStroke is an emerging problem in sub-Saharan Africa, about which little is known since most research to date has been based on retrospective, hospital-based studies. This anthropological work, designed to complement a large community-based project on stroke incidence, focuses on local understandings and treatment-seeking behaviours in urban (Dar-es-Salaam) and rural (Hai) areas of Tanzania. Semi-structured interviews (n=80) were conducted with 20 stroke patients, 20 relatives of stroke patients, ten traditional healers, and 30 other local residents. In contrast to common expectations, and literature that finds witchcraft beliefs to be most common in rural areas, stroke in urban Dar was widely believed to emanate from supernatural causes (demons and witchcraft), while in rural Hai, explanations drew mostly on ‘natural’ causes (hypertension, fatty foods, stress). These different beliefs and explanatory models fed into treatment-seeking behaviours. The first option in Hai was hospital treatment, while in Dar-es-Salaam, where belief in demons led to hospital avoidance, it was traditional healers. In both sites, multiple treatment options (serially or simultaneously) were the norm. Analysis of patient and carer narratives suggested that causation beliefs outweighed other factors, such as cost and distance, in shaping effective treatment. Three policy implications are drawn. First, as other studies have also shown, it is important to engage with, rather than dismiss, local explanations and interpretations of stroke. Stroke awareness messages need to take into account the geographical and belief systems differences. Developing an understanding of explanatory models that recognizes that local beliefs arise from dynamic processes of social interaction will be critical to designing effective interventions. Second, there is a clear role for multiple healing systems with possibility of cross-reference in the case of a chronic, disabling condition like stroke, since biomedical treatment cannot offer a ‘quick fix’ while traditional healers can help people come to terms with their condition. Third, issues of communication between health services and their patients are particularly critical.

The purpose of this paper is to analyse household decision-making regarding resource allocation in the aftermath of a food crisis in rural Niger. International attention had resulted in humanitarian agencies launching emergency nutrition programmes to alleviate persistently high levels of acute child malnutrition. We conducted participant observation, 93 in-depth interviews, 15 focus groups, 44 feeding and illness histories for children under 5, and debriefing sessions with local humanitarian staff. The impetus for this study came from observations of marked intra-household differences in child growth and health status, despite the caregivers' ethos of treating children equally. Egalitarian input, however, does not always result in equal outcomes: vulnerable children become “victims of non-discrimination” through a form of benign neglect engendered by pervasive poverty. The ethos and practices of equal investment in children are rooted in a need to balance the perceived risks to children with the preservation of long-term livelihoods. We discuss the mismatch of views between external interventions, which focus on saving individual children's lives, and local priorities, aimed at spreading risk. This mismatch is rooted in the different ways in which humanitarian agencies and local communities weigh up risks and vulnerabilities in matters of child health.

Contested reports associating the MMR vaccine with autism have resulted in diminished confidence and uptake of the vaccine in the UK. This postal survey of parent's decisions, attitudes and use of information about MMR immunisation was constructed from questions derived from in-depth qualitative work. The setting was a Primary Care Trust in northeast England (N=996). Both MMR-accepting and refusing parents were supportive of immunisation, yet the high level of concern about the safety of the vaccine expressed even by parents who had immunised their children is worrying in its implications for public confidence and trust in health care. The findings suggest that the ability of practitioners to provide effective professional advice about MMR vaccine could be undermined if a government were to directly promote the vaccine to parents. Practitioners should continue to provide parents with accurate information, while communicating respect for parents' intentions to protect their children's health.

Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the 'social lives' of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (p

The purpose of the study was to determine whether chronic immunostimulation could explain growth faltering in disadvantaged children in the UK, as it does in developing countries such as The Gambia. In all, 216 infants, age 10-21 months, were recruited when blood samples were taken for the routine or clinical purposes of a longitudinal study tracking a larger cohort of children. Aliquots of blood were collected on Guthrie cards to determine blood concentrations of albumin (Alb), alpha(1)-antichymotrypsin (ACT), and immunoglobulin G (IgG). Haemoglobin concentrations were determined by routine hospital laboratory analysis. Heights and weights were measured and converted to z-scores; birth weights were used with recruitment weight to calculate a 'thrive index' for each child. Age-corrected plasma IgG concentration was negatively associated with both height- and weight-for-age z-scores (P = 0.042 and 0.038, respectively) but not with the thrive index or body mass index z-scores. Blood haemoglobin levels were positively related to height- and weight-for age z-scores, as well as to the thrive index (P = 0.026, 0.014, and 0.007, respectively). Although significant, these relationships could only account for a small part the observed growth variation. Although the relationships were weak, the results suggest that some of the observed variation in growth of these UK infants may be explained on the basis of persistent immunostimulation or poor iron status. In terms of markers of immunostimulation (Alb, ACT, ACT:Alb ratio, IgG), both absolute levels and relationships with height-for-age are substantially different than those previously observed in cohort studies of infants in The Gambia.

Objectives: To describe the first-week feeding patterns for breast- vs bottle-fed babies, and their association with sustained breast-feeding and infant weight gain at 6 weeks. Design: A longitudinal cohort study. Setting: Feeding diaries were completed by mothers in an urban UK community shortly after birth; follow-up weight and feeding data were collected at routine health checks. Subjects: Mothers of 923 full-term infants born during the recruiting period agreed to join the study. In all, 502 usable diaries were returned from 54% of the cohort. Results: Breast-fed infants were fed more frequently (2.71 h between feeds) than bottle-fed infants (3.25 h between feeds) and mixed-fed infants (3.14 h between feeds) (P

This study examined the associations between severity of stunting, plasma protein concentrations and morbidity of 104 Nepali boys, aged 10-14 years, living in contrasting environments. Boys from a remote village were compared with three similarly aged urban groups: poor squatters, homeless street children, and middle-class schoolchildren. All but the middle-class group were stunted, particularly village boys whose mean height-for-age z-score (-2.97, SD 0.82) indicates severe growth retardation. Stunting was significantly associated with increased plasma levels of the acute-phase protein alpha1-antichymotrypsin itself inversely related to plasma levels of albumin. Plasma ACT levels of village children (mean 1.52 g/l, SD 0.43) were three to four times higher than those of squatters and homeless street children, and five times higher than those of middle-class boys. Despite being the most severely stunted and having the most abnormal plasma protein values, village children reported the lowest burden of disease, a contradiction which may reflect exposure to sub-clinical infections or habituation to illness and low expectation of treatment. This study draws attention to the strikingly high levels of ACT and of stunting in the rural sample, and cautions on the use of uncorroborated morbidity reports across different epidemiological and socio-ecological environments. Possible mechanisms to explain the impact of illness and inflammation on growth faltering are discussed.

The aim of the study was to determine the association between PRL responses to suckling and maintenance of postpartum amenorrhea among breastfeeding mothers. Three blood spot samples (5, 30, and 50 min following a timed nursing bout) were collected from 71 intensively breastfeeding Nepali women for PRL determination. Maternal age, BMI (weight/height2), menstrual status, caste, infant age, nursing bout length, and duration of supplementation were recorded at time of sample collection. Independent and paired t tests, linear regression analyses, and general linear models were used to evaluate differences between cycling (n = 36) and amenorrheic (n = 35) women and associations among variables. Logistic regression analyses were used to relate PRL measures to the odds of maintaining lactational amenorrhea. Amenorrheic breastfeeding mothers had higher (P.001) PRL levels at all 3 collection times than cycling breastfeeding mothers, and PRL levels declined with time since birth (P0.05). The odds (OR) of having ceased lactational amenorrhea was significantly higher (OR = 5.0, 95% Cl = 1.3-19.9) among mothers with lower PRL levels (or = 10 ng/mL) at 50 min post-sucking, and PRL at 50 min showed a significant dose response relationship with menstrual status. The association between 50 min PRL levels and lactational amenorrhea appears to be independent of time postpartum, maternal age, BMI, nursing bout length, and duration of supplementation. Among intensively nursing women, maintenance of elevated PRL levels across the interbout interval increases the odds of maintaining lactational amenorrhea.In August 1991, in Nepal, all women aged 19-45 from the Tamang caste (agro-pastoralists of Tibetan origin) and from the Kami caste (low-caste blacksmiths of Aryan origin) who were intensively breast feeding and lived in remote villages in the foothills of the Himalayas were included in a study aiming to examine the association between post-suckling prolactin (PRL) and menstrual status. The study also aimed to determine what PRL response time after suckling best predicts the odds of having resumed menses. There were 36 women whose menses had returned and 35 women who remained amenorrheic. 50-minute post-suckling PRL levels were more linked to menstrual status than 5-minute levels (odds ratio [OR] = 5 vs. 2.1). They (but not 5-minute post-suckling PRL levels) also had a significant dose relationship with menstrual status. During the first year postpartum, PRL levels were significantly higher at all three collection times (5, 30, or 50 minutes) in amenorrheic women than cycling women (p 0.001). PRL levels fell as infant age increased (16 ng/ml for 11 months or less, 13.7 ng/ml for 11-15 months, and 7.4 ng/ml for 15 months; p 0.05). At 50 minutes post-suckling, mothers with PRL levels at or below 10 ng/ml were much more likely to have returned to menses than those with higher levels (OR = 5; p = 0.041). The association between 50-minute PRL levels and lactational amenorrhea were independent of time postpartum, maternal age, body mass index, nursing bout length, and duration of supplementation. The maintenance of high PRL levels across the interbout interval increased the odds of maintaining lactational amenorrhea (p 0.05). In conclusion, intensively nursing women whose PRL levels remain high across the interbout interval are most likely to maintain lactational amenorrhea.

Wietse Tol and colleagues lay out a a consensus-based research agenda for mental health and psychosocial support in humanitarian settings.

Summary Background Studies in Afghanistan have shown substantial mental health problems in adults. We did a survey of young people (11–16 years old) in the country to assess mental health, traumatic experiences, and social functioning. Methods In 2006, we interviewed 1011 children, 1011 caregivers, and 358 teachers, who were randomly sampled in 25 government-operated schools within three purposively chosen areas (Kabul, Bamyan, and Mazar-e-Sharif municipalities). We assessed probable psychiatric disorder and social functioning in students with the Strength and Difficulties Questionnaire multi-informant (child, parent, teacher) ratings. We also used the Depression Self-Rating Scale and an Impact of Events Scale. We assessed caregiver mental health with both international and culturally-specific screening instruments (Self-Reported Questionnaire and Afghan Symptom Checklist). We implemented a checklist of traumatic events to examine the exposure to, and nature of, traumatic experiences. We analysed risk factors for mental health and reports of traumatic experiences. Findings Trauma exposure and caregiver mental health were predictive across all child outcomes. Probable psychiatric ratings were associated with female gender (odds ratio [OR] 2·47, 95% CI 1·65–3·68), five or more traumatic events (2·58, 1·36–4·90), caregiver mental health (1·11, 1·08–1·14), and residence areas (0·29, 0·17–0·51 for Bamyan and 0·37, 0·23–0·57 for Mazar-e-Sharif vs Kabul). The same variables predicted symptoms of depression. Two thirds of children reported traumatic experiences. Symptoms of post-traumatic stress were associated with five or more traumatic events (3·07, 1·78–5·30), caregiver mental health (1·06, 1·02–1·09), and child age (1·19, 1·04–1·36). Children's most distressing traumatic experiences included accidents, medical treatment, domestic and community violence, and war-related events. Interpretation Young Afghans experience violence that is persistent and not confined to acts of war. Our study emphasises the value of school-based initiatives to address child mental health, and the importance of understanding trauma in the context of everyday forms of suffering, violence, and adversity. Funding Wellcome Trust.

A time-allocation study conducted over a 1-year period among rural women in Nepal indicated that these women are able to perform rigorous subsistence labor during pregnancy and motherhood through cultural practices that facilitate a combining of economic and childcare duties. The fieldwork was conducted in 1982-83 in the predominately Tamang village of Salme. A total of 7678 hours of minute-by-minute observation were collected on Tamang women and their male kin from 43 households. The sample included 19 nonpregnant, nonlactating women and 24 pregnant or lactating mothers. Among the Tamang, agriculture is the responsibility of women, and nonpregnant and pregnant/lactating women devoted similar numbers of hours a day (5-8 hours, depending on the season) to working fields. In addition, there were no significant differences in the amount of time nonpregnant and pregnant/lactating women devoted to animal husbandry, mountain work, and travel. The Tamang women did not ease their workloads in the final weeks of pregnancy--a finding that is consistent with a practice of not making allowances in economic activity level for age, sex, physical fitness, or maternal status due to severe labor shortage and the tight time schedule inherent to agricultural production. On the other hand, there was evidence of behavioral flexibility to cope with the demands of women's dual roles. Mothers of infants take their babies to the fields with them and breastfeed during their rest periods. The use of mobile cattle shelters minimizes the amount of time that is spent away from children. Older children care for younger siblings--a phenomenon facilitated by the long interbirth intervals among the Tamang--and contractual exchanges take place among families. The health risk of this arrangement seems greatest for older children who are left behind during periods of intense agricultural activity and are often deprived of adequate nutrition.

Blood pressure and anthropometric measurements were taken for 231 children between 11 and 14 years in the Annapurna area of Central Nepal, a popular tourist destination. Children from villages on the tourist trail, whose lifestyles were generally more modernised, were compared with children from nearby villages off the tourist trail. Indications of greater modernisation on the trail included the findings that fathers of children living on the trail were less likely to work as farmers than fathers of those off the trail (P = 0.003), and children living on the trail were much more likely to have seen television (P < 0.001). Children on the tourist trail were taller and heavier (P < 0.001), and had higher body mass indices (P = 0.003) and biceps skinfolds (P = 0.005). They also had higher diastolic blood pressure than children living off the trail (P = 0.02). The differences in weight appeared to account for the effect of living on the trail on diastolic blood pressure, since when weight was added to the model it showed a significant association with diastolic blood pressure (P = 0.02) and the effect of location became nonsignificant. For the biceps skinfold and systolic blood pressure, there was a significant sex difference in the effect of living on the trail (P = 0.04 and P = 0.05 respectively), such that among girls there were greater increases associated with living on the trail than there were among boys. The findings suggest that lifestyle changes linked to the development of tourism in Nepal are associated from an early age with potentially deleterious changes in cardiovascular characteristics and demonstrate that such socioeconomic changes can have quite local effects. Am. J. Hum. Biol. 12:478-486, 2000. Copyright 2000 Wiley-Liss, Inc.

Background The relative performance of local and international assessment instruments is subject to ongoing discussion in transcultural research on mental health and psychosocial support. We examined the construct and external validity of two instruments, one developed for use in Afghanistan, the other developed by the World Health Organization for use in resource-poor settings. Methods We used data collected on 1003 Afghan adults (500 men, 503 women) randomly sampled at three sites in Afghanistan. We compared the 22-item Afghan Symptom Checklist (ASCL), a culturally-grounded assessment of psychosocial wellbeing, with Pashto and Dari versions of the 20-item Self-Reporting Questionnaire (SRQ-20). We derived subscales using exploratory and confirmatory factor analyses (EFA and CFA) and tested total and subscale scores for external validity with respect to lifetime trauma and household wealth using block model regressions. Results EFA suggested a three-factor structure for SRQ-20 - somatic complaints, negative affect, and emotional numbing - and a two-factor structure for ASCL - jigar khun (dysphoria) and aggression. Both factor models were supported by CFA in separate subsamples. Women had higher scores for each of the five subscales than men (p