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This randomized controlled trial tested the efficacy of a multi-session, evidence-based, lay counselor-delivered transdiagnostic therapy, the Common Elements Treatment Approach (CETA), in reducing unhealthy alcohol use and comorbidities among persons living with HIV (PLWH) in Zambia. Adult PLWH with (a) unhealthy alcohol use plus mental health or substance use comorbidities, or (b) severe unhealthy alcohol use were randomized to receive a single-session alcohol brief intervention (BI) alone or BI plus referral to CETA. Outcomes were measured at baseline and a 6-month follow-up and included Alcohol Use Disorders Identification Test (AUDIT) score (primary), depression and trauma symptoms, and other substance use (secondary). We enrolled 160 participants; 78 were randomized to BI alone and 82 to BI plus CETA. Due to COVID-19, the trial ended early before 36 participants completed. Statistically and clinically significant reductions in mean AUDIT score from baseline to 6-month follow-up were observed in both groups, however, participants assigned to BI plus CETA had significantly greater reductions compared to BI alone (- 3.2, 95% CI - 6.2 to - 0.1; Cohen's d: 0.48). The CETA effect size for AUDIT score increased in line with increasing mental health/substance use comorbidity (0 comorbidities d = 0.25; 1-2 comorbidities d = 0.36; 3+ comorbidities d = 1.6). Significant CETA treatment effects were observed for depression, trauma, and several other substances. BI plus referral to CETA was feasible and superior to BI alone for unhealthy alcohol use among adults with HIV, particularly among those with comorbidities. Findings support future effectiveness testing of CETA for HIV outcomes among PLWH with unhealthy alcohol use.Clinical Trials Number: NCT03966885.

AIMS: To examine changes in drinking behavior among United States (US) adults between March 10 and July 21, 2020, a critical period during the COVID-19 pandemic. DESIGN: Longitudinal, internet-based panel survey. SETTING: The Understanding America Study (UAS), a nationally representative panel of US adults age 18 or older. PARTICIPANTS: A total of 4298 US adults who reported alcohol use. MEASUREMENTS: Changes in number of reported drinking days from March 11, 2020 through July 21, 2020 in the overall sample and stratified by sex, age, race/ethnicity, household structure, poverty status, and census region. FINDINGS: Compared with March 11, the number of drinking days per week was significantly higher on April 1 by an average of 0.36 days (95% CI = 0.30, 0.43), on May 1 by an average of 0.55 days (95% CI = 0.47, 0.63), on June 1 by an average of 0.41 days (95% CI = 0.33, 0.49), and on July 1 by an average of 0.39 days (95% CI = 0.31, 0.48). Males, White participants, and older adults reported sustained increases in drinking days, whereas female participants and individuals living under the federal poverty line had attenuated drinking days in the latter part of the study period. CONCLUSIONS: Between March and mid-July 2020, adults in the United States reported increases in the number of drinking days, with sustained increases observed among males, White participants, and older adults.

Background For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma. Methods We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d’Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data. Results Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations. Conclusions Research to determine the factors driving disclosure’s differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA.

Background This study evaluated the test characteristics of brief versions of the Alcohol Use Disorders Identification Test (AUDIT), the AUDIT-C and AUDIT-3, compared to the full AUDIT in populations with heavy drinking living in Zambia and compared differences in effect size estimates when using brief versions in clinical trials. Methods Data were obtained from two randomized trials of the Common Elements Treatment Approach (CETA) for reducing unhealthy alcohol use among adult couples and people living with HIV (PLWH) in Zambia. The full AUDIT was administered to participants at baseline and at 6- or 12-month follow-up. Sensitivity and specificity of the brief versions were calculated in comparison to the full AUDIT. Mixed effects regression models were estimated to calculate the effect sizes from the trials using the brief versions and these were compared to the originally calculated effect sizes using the full version. Results The AUDIT-C performed well at cut-off ≥ 3 for both men (sensitivity: >80%; specificity: >76%) and women (sensitivity: >84%; specificity: >88%). The AUDIT-3 performed best at cut-off ≥ 1, but with comparatively reduced validity for men (sensitivity: >77%; specificity: ≥60%) and women (sensitivity: ≥72%; specificity: >62%). Effect sizes were different by up to 52% using the AUDIT-C and up to 60% for the AUDIT-3 compared to the AUDIT. Conclusions The AUDIT-C is recommended as a brief screening tool for community-based and clinic-based screening in Zambia among populations with high prevalence of unhealthy alcohol use. For research studies, the full AUDIT is recommended to calculate treatment effect.

OBJECTIVES: To describe, using mixed-methods, perceptions of access to sexually transmitted infection test results via electronic personal health record (PHR) and correlates of willingness to adopt its use. PARTICIPANTS: Students at a mid-Atlantic historically Black college. METHODS: Focus-groups and interviews were conducted to explore themes on sexual health-related PHR-use (n=35). Codes were operationalized into survey measures assessing beliefs in a cross-sectional sample (n=354). Exploratory factor analysis identified latent factors among survey items. Multiple logistic regression models measured correlates of adoption willingness. RESULTS: Three qualitative themes emerged on relative advantages, barriers, and functionality of PHRs. 57.6% of survey participants were willing to use PHRs for sexual health services. Reliable latent factors, centering on PHR convenience and functionality, were positively associated with adoption willingness. CONCLUSIONS: Data highlights interest among Black college-age youth in adopting PHRs for comprehensive sexual health-related services. Adoption may be boosted with tailored designs responsive to expressed service needs.

BACKGROUND Hazardous alcohol use is a predictor of intimate partner violence (IPV), and both are increasingly prevalent in sub-Saharan Africa. The accurate measurement of alcohol consumption is therefore critical in IPV intervention studies that target hazardous drinking. Collecting a collateral report in addition to self-report is one convergent validity approach to improve alcohol measurement. We investigated concordance between self- and partner-reported alcohol use among women who reported recent IPV and their male partners in Zambia. METHODS Data were from the baseline of a randomized IPV intervention trial of 247 heterosexual couples in which a woman has reported recent IPV and her male partner has recent hazardous alcohol use. Both partners completed the Alcohol Use Disorders Identification Test (AUDIT) in reference to their own drinking and in reference to their partner's drinking. We calculated percent agreement across a range of outcomes: any use, quantity, frequency, and hazardous use. We also compared self- and partner-reported AUDIT scores using t-tests. RESULTS Concordance was poor across most outcomes. Percent agreement with respect to the women's drinking ranged from 60% to 65% across outcomes and with respect to the men's drinking from 51% to 89%. Women's average partner-reported AUDIT score (20.7) was statistically significantly (p

Introduction Although the World Health Organization (WHO) has recommended guidelines for the treatment of opioid dependence, there are myriad challenges to successfully implementing such guidelines in resource constrained settings, such as in low and middle-income countries (LMICs). To highlight these challenges, this paper presents a clinical case study of an adolescent study participant in a randomized controlled trial comparing two counseling programs in Lusaka, Zambia. Case description This 15 year-old male reported smoking marijuana and heroin daily, and injecting heroin monthly (while needle sharing). The patient was linked to the only physician capable of treating heroin addiction in Zambia. The patient was placed on a 30-day detox regimen of Tramadol administered from home, as in-patient detox services are unavailable in Zambia. The patient experienced complications with out-patient detox, including a relapse that led to violent behavior and temporary incarceration. The patient's treatment regimen was altered to include Lorazepam, a mild sedative, and psychosocial counseling. After completing detox the client was prescribed Naltrexone for maintenance as Methadone is listed as a banned substance in Zambia, and Buprenorphine is not available and is cost prohibitive. Conclusions Despite a considerable amount of time and resources expended to successfully treat the patient, the majority of WHO guidelines for opioid dependence treatment were not attainable within the Zambian context. Additional research into the effectiveness and implementation of evidence-based interventions for substance use in LMICs is warranted., Highlights • The patient was treated for heroin dependence through an HIV focused RCT, trial funds allowed for a high level of service provision. • In-patient heroin detox services are not available in Zambia, it is performed as an out-patient procedure from home. • During detox the patient absconded from treatment, relapsed, and was incarcerated, creating unique barriers to treatment. • Despite considerable time and resources, the majority of WHO guidelines for opioid dependence treatment were not attainable.

BACKGROUND Intimate partner violence (IPV) and hazardous alcohol use are prevalent and co-occurring problems in low- and middle-income countries (LMICs). While limited evidence suggests that cognitive behavioral therapy (CBT) interventions can help address these problems, few randomized trials in LMICs have investigated moderators of treatment effectiveness. This study explores moderating factors impacting responsiveness to a CBT-based intervention for IPV and hazardous alcohol use among couples in Zambia. METHODS Data were obtained from a completed randomized trial of a CBT-based intervention, the Common Elements Treatment Approach (CETA), among 248 couples in Lusaka. Female experiences of IPV and male alcohol use were measured at baseline and 12 months post-baseline. Mixed effects regression models were used to evaluate each moderator: age, educational attainment, employment status, marital status, physical disability, HIV status, trauma exposure, depression, post-traumatic stress disorder, alcohol use disorder, and substance use. RESULTS Treatment effectiveness for male alcohol use was moderated by female substance use, with greater reductions among men whose partners reported using non-alcohol substances (e.g., cannabis) (p < 0.01). Other marginally significant moderators (p < 0.15) of change in male alcohol use included female education and male depression, substance use, and moderate-to-severe alcohol use at baseline. Female HIV status and depression were marginally significant moderators of change in IPV. CONCLUSIONS This study suggests that CETA may be especially effective for highly symptomatic individuals with comorbid mental and behavioral health problems, a promising finding given that such comorbidity is widespread in LMICs. Psychotherapeutic treatments that can flexibly and simultaneously address co-occurring problems are needed.

Background Patient portal modules, including electronic personal health records, health education, and prescription refill ordering, may be leveraged to address the sexually transmitted infection (STI) burden, including HIV, among gay, bisexual, and other sexual minority men (SMM). Theoretical frameworks in the implementation sciences highlight examining constructs of innovation attributes and performance expectations as key determinants of behavioral intentions and the use of new web-based health technologies. However, behavioral intentions to use patient portals for HIV and other STI prevention and care among SMM is understudied. Objective The aim of this study is to develop a brief instrument for measuring attitudes focused on using patient portals for STI prevention and care among a nationwide sample of SMM. Methods A total of 12 items of the American Men’s Internet Survey-Patient Portal Sexual Health Instrument (AMIS-PPSHI) were adapted from a previous study. Psychometric analyses of the AMIS-PPSHI items were conducted among a randomized subset of 2018 AMIS participants reporting web-based access to their health records (N=1375). Parallel analysis and inspection of eigenvalues in a principal component analysis (PCA) informed factor retention in exploratory factor analysis (EFA). After EFA, Cronbach α was used to examine the internal consistency of the scale and its subscales. Confirmatory factor analysis (CFA) was used to assess the goodness of fit of the final factor structure. We calculated the total AMIS-PPSHI scale scores for comparisons within group categories, including age, STI diagnosis history, recency of testing, serious mental illness, and anticipated health care stigma. Results The AMIS-PPSHI scale resulting from EFA consisted of 12 items and had good internal consistency (α=.84). The EFA suggested 3 subscales: sexual health engagement and awareness (α=.87), enhancing dyadic communication (α=.87), and managing sexual health care (α=.79). CFA demonstrated good fit in the 3-factor PPSHI structure: root mean square error of approximation=0.061, comparative fit index=0.964, Tucker-Lewis index=0.953, and standardized root mean square residual=0.041. The most notable differences were lower scores on the enhanced dyadic communication subscale among people living with HIV. Conclusions PPSHI is a brief instrument with strong psychometric properties that may be adapted for use in large surveys and patient questionnaires in other settings. Scores demonstrate that patient portals are favorable web-based solutions to deliver health services focused on STI prevention and care among SMM in the United States. More attention is needed to address the privacy implications of interpersonal use of patient portals outside of traditional health settings among persons with HIV.

Background Intimate partner violence (IPV) and unhealthy alcohol use are common yet often unaddressed public health problems in low- and middle-income countries. In a randomized trial, we found that the common elements treatment approach (CETA), a multi-problem, flexible, transdiagnostic intervention, was effective in reducing IPV and unhealthy alcohol use among couples in Zambia at a 12-month post-baseline assessment. In this follow-up study, we investigated whether treatment effects were sustained among CETA participants at 24-months post-baseline. Methods Participants were heterosexual couples in Zambia in which the woman reported IPV perpetrated by the male partner and in which the male had hazardous alcohol use. Couples were randomized to CETA or treatment as usual plus safety checks. Measures were the Severity of Violence Against Women Scale (SVAWS) and the Alcohol Use Disorders Identification Test (AUDIT). The trial was stopped early upon recommendation by the trial's DSMB due to CETA's effectiveness following the 12-month assessment. Control participants exited the study and were offered CETA. This brief report presents data from an additional follow-up assessment conducted among original CETA participants at a 24-month visit. Results There were no meaningful changes in SVAWS or AUDIT scores between 12- and 24-months. The within-group treatment effect for SVAWS from baseline to 24-months was d = 1.37 (p < 0.0001) and AUDIT was d = 0.85 (p < 0.0001). Conclusions The lack of change in levels of IPV and unhealthy alcohol use between the 12- and 24-month post-baseline timepoints suggests that treatment gains were sustained among participants who received CETA for at least two years from intervention commencement.

Background Alcohol abuse is common in Zambia and a growing threat to achieving the 90 90 90 treatment target to ending the HIV epidemic. Brief counselling is offered but has limited effectiveness possibly because it does not address the mental health issues that underpin drinking behavior. We assessed the frequency and nature of comorbid mental health issues in HIV-positive drinkers in Zambia. Methods As part of an ongoing randomized control trial (NCT03966885), we recruited HIV positive adults on ART who reported at least 1 alcoholic drink in the previous 3 months from two clinics in Lusaka, Zambia. Using audio computer assisted self-interviewers, we captured demographic information and screened for unhealthy alcohol use (AUDIT), depression (CES-D), trauma (HTQ) and other substance abuse (ASSIST). These instruments have previously been validated in Zambia. Established cut-offs were used to define unhealthy alcohol use (AU), depression (DEP), post-traumatic stress disorder (PTSD) and substance abuse (SU). Results Among 300 individuals reporting any alcohol use, 165 agreed to screening. 155 participants were recruited, including 93 men and 62 women. Nearly all screened 146 (94.2%) had unhealthy alcohol use and 9 (5.8%) had low to moderate alcohol scores. Comorbid mental health issues were present in 72 % of unhealthy drinkers, most commonly depression 46 (31.5 %) and trauma 35 (24 %). Non-alcohol substance use (7.6 %) comorbidities where less prevalent than mental health comorbidities among those with unhealthy alcohol use. Conclusions Among urban Zambian adults living with HIV who reported alcohol consumption at their ART clinic, unhealthy use was the norm; moderate alcohol use was rare. Comorbid mental health issues (particularly depression and trauma) are highly prevalent among unhealthy drinkers with HIV. These data suggest that all unhealthy drinkers should be screened for mental health issues. Key messages Alcohol Abuse In HIV Patients Is Common In Zambia. HIV Patients Abusing Alcohol Suffer From Depression and Trauma.

Highlights • Unhealthy alcohol use is common among persons living with HIV (PLWH). • In sub-Saharan Africa, there are limited treatment options for unhealthy alcohol use. • This RCT tests multiple interventions at reducing unhealthy alcohol use in SSA., Aims Prevalence of unhealthy alcohol use and co-occurring mental health problems is high among persons living with HIV (PLWH) in sub-Saharan Africa (SSA). Yet, there is a dearth of evidence-based treatment options that can address both unhealthy alcohol use and comorbidities in SSA HIV care settings. Recent studies testing single-session alcohol brief interventions (BIs) among PLWH in SSA have suggested that more robust treatments are needed. This paper describes the protocol of a pilot randomized controlled superiority trial that will test the effectiveness of an evidence-based transdiagnostic multi-session psychotherapy, the Common Elements Treatment Approach (CETA), compared to a control condition consisting of a single session brief alcohol intervention (BI) based on CETA, at reducing unhealthy alcohol use, mental health problems, and other substance use among PLWH in urban Zambia. Methods The study is a single-blind, parallel, individually randomized trial conducted in HIV treatment centers in Lusaka. 160 PLWH who meet criteria for unhealthy alcohol use + mental health or substance use comorbidities and/or have a more severe alcohol use disorder are eligible. Participants are randomized 1:1 to receive the single-session BI or CETA. Outcomes are assessed at baseline and a six-month follow-up and include unhealthy alcohol use, depression, trauma symptoms, and other substance use. Conclusions The trial is a first step in establishing the effectiveness of CETA at reducing unhealthy alcohol use and comorbidities among PLWH in SSA. If effectiveness is demonstrated, a larger trial featuring long-term follow-ups and HIV treatment outcomes will be undertaken.

Though substance use is common in displaced populations, the majority of existing research is among adults. This is a limitation because morbidity for substance use increases during adolescence, and an earlier age of onset of alcohol and drug abuse is associated with more severe substance use outcomes later in life. Despite the elevated risk of substance use and related consequences for children (0–18 years) and, more specifically, adolescents (10–19 years), most studies and prevention or treatment interventions in refugees have been restricted to adults. This chapter will review research on alcohol and other drug use among refugee children and adolescents resettled in low-, middle-, or high-income countries. Given the limited research in this population, we will also review relevant studies conducted among conflict-affected, disaster-affected, and immigrant children and adolescents and discuss how this information may be applicable to refugee children. We will conduct a scoping review of the academic and unpublished epidemiologic research to characterize the patterns and burden of substance use in refugee children and adolescents, risk and protective factors, and interventions that have been tested in refugee and comparable child and adolescent populations. We will present available evidence regarding the feasibility and effectiveness of substance abuse treatment and prevention strategies and discuss the implications of these findings for future research and practice.

There is a recognized need to better understand "essential ingredients" of psychological treatments, and refine interventions to be more scalable and sustainable. The goal of the present study was to look within a specific modular, flexible, multi-problem transdiagnostic psychological intervention -the Common Elements Treatment Approach (CETA) - and examine questions that would lead to optimizing CETA for scale up and sustainment. Utilizing data from two trials of CETA in two different countries (Thailand and Iraq), this manuscript aims to: 1) determine the "active treatment dose" or how many sessions are needed to achieve clinically meaningful change overall, in CETA); and 2) test how trajectories of client symptom change varied based on client characteristics and/or on delivery of certain elements. Results showed that overall 50% of CETA clients show some improvement after 4-6 sessions (1 SD) and large improvement (2 SD) after 7-10 sessions. Trajectories of change show steady symptom decline over time. Results support gradual exposure as one of the "active ingredients". Findings suggest that modular, flexible transdiagnostic models may allow for more efficient, targeted treatment as we gain more knowledge about key ingredients, their timing within treatment, and client outcomes.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the efficacy or effectiveness of psychosocial and pharmacologic interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs.

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02–0.05; comparative fit index/Tucker-Lewis index = 0.97–1.00/0.94–1.00; standardized root mean square residual = 0.04–0.08), consisting of “stigma from family and friends,” “anticipated health-care stigma,” and “general social stigma,” with internal consistency estimates across countries of α = 0.36–0.80, α = 0.72–0.93, and α = 0.51–0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions.

Background Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions. Methods We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations. Results Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes. Conclusions Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs. Electronic supplementary material The online version of this article (10.1186/s12916-019-1250-8) contains supplementary material, which is available to authorized users.

Ability to function in tasks and activities is an important aspect of daily living. There are factors that increase the risk for impaired functioning, such as experiences of domestic violence (DV) and other trauma types, and factors that provide a buffer to existing risks and allow the individual to continue and build functioning, such as access to social resources. This cross-sectional study investigated the direct effects of DV and access to social resources (perceived social support, social integration, and frequency of social contact), as well as their potential interactive effects, on daily functioning among 894 male and female trauma survivors who attended primary care clinics in Kurdistan, Iraq in 2009 and 2010. Experiencing DV was not associated with functioning for males (p=.15) or females (p=.60), suggesting that in the context of a trauma-affected sample, the experience of DV may not significantly increase the risk for functional impairment. Greater amounts of social integration were associated with less functional impairment among males (p

Background Both intimate partner violence (IPV) and alcohol misuse are highly prevalent, and partner alcohol misuse is a significant contributor to women’s risk for IPV. There are few evidence-based interventions to address these problems in low- and middle-income countries (LMICs). We evaluated the effectiveness of an evidence-based, multi-problem, flexible, transdiagnostic intervention, the Common Elements Treatment Approach (CETA) in reducing (a) women’s experience of IPV and (b) their male partner’s alcohol misuse among couples in urban Zambia. Methods and findings This was a single-blind, parallel-assignment randomized controlled trial in Lusaka, Zambia. Women who reported moderate or higher levels of IPV and their male partners with hazardous alcohol use were enrolled as a couple and randomized to CETA or treatment as usual plus safety checks (TAU-Plus). The primary outcome, IPV, was assessed by the Severity of Violence Against Women Scale (SVAWS) physical/sexual violence subscale, and the secondary outcome, male alcohol misuse, by the Alcohol Use Disorders Identification Test (AUDIT). Assessors were blinded. Analyses were intent-to-treat. Primary outcome assessments were planned at post-treatment, 12 months post-baseline, and 24 months post-baseline. Enrollment was conducted between May 23, 2016, and December 17, 2016. In total, 123 couples were randomized to CETA, 125 to TAU-Plus. The majority of female (66%) and a plurality of male (48%) participants were between 18 and 35 years of age. Mean reduction in IPV (via SVAWS subscale score) at 12 months post-baseline was statistically significantly greater among women who received CETA compared to women who received TAU-Plus (−8.2, 95% CI −14.9 to −1.5, p = 0.02, Cohen’s d effect size = 0.49). Similarly, mean reduction in AUDIT score at 12 months post-baseline was statistically significantly greater among men who received CETA compared to men who received TAU (−4.5, 95% CI −6.9 to −2.2, p < 0.001, Cohen’s d effect size = 0.43). The Data and Safety Monitoring Board recommended the trial be stopped early due to treatment effectiveness following the 12-month post-baseline assessment, and CETA was offered to control participants. Limitations of the trial included the lack of a true control condition (i.e., that received no intervention), self-reported outcomes that may be subject to social desirability bias, and low statistical power for secondary IPV outcomes. Conclusions Results showed that CETA was more effective than TAU-Plus in reducing IPV and hazardous alcohol use among high-risk couples in Zambia. Future research and programming should include tertiary prevention approaches to IPV, such as CETA, rather than offering only community mobilization and primary prevention. Trial registration The trial was registered on ClinicalTrials.gov (NCT02790827)., Author summary Why was this study done? Intimate partner violence (IPV) experienced by women is a highly prevalent global public health concern that is associated with substantial morbidity and mortality. In many low- and middle-income countries (LMICs), such as Zambia, there is a lack of evidence-based intervention approaches to prevent and reduce IPV. One key risk factor for a woman experiencing IPV is when her male partner has unhealthy alcohol use. We previously found that an evidence-based psychotherapy intervention delivered by lay counselors in LMICs (known as the Common Elements Treatment Approach [CETA]) was effective in reducing mental and behavioral health problems among violence-affected populations. What did the researchers do and find? We conducted a randomized controlled trial to evaluate the effectiveness of CETA in reducing IPV and hazardous alcohol use among couples in Zambia. We recruited heterosexual couples in which the woman reported experiencing recent IPV that was perpetrated by her current male partner and in which the man had recent hazardous alcohol use. Compared to usual care plus safety checks, our results showed that, 1 year following treatment commencement, CETA was clinically effective in reducing IPV experienced by women and men’s hazardous alcohol use. What do these findings mean? The findings suggest that a clinical psychotherapy treatment is one effective tool for reducing IPV in resource-limited settings. Given that IPV is such a complex social problem, future evaluations would benefit from combining primary, secondary, and tertiary prevention approaches to enhance effectiveness, such as combining CETA with effective economic interventions and potentially higher level psychological and/or psychiatric care when available and indicated.

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.

BackgroundDespite increasing evidence for the benefits of psychological treatments (PTs) in low- and middle-income countries, few national health systems have adopted PTs as standard care. We aimed to evaluate the effectiveness of a group interpersonal psychotherapy (IPT-G) intervention, when delivered by lay community health workers (LCHWs) in a low-resource government health system in Uganda. The intended outcome was reduction of depression among caregivers of children with nodding syndrome, a neuropsychiatric condition with high morbidity, mortality and social stigma.MethodsA non-randomized trial design was used. Caregivers in six villages (n = 69) received treatment as usual (TAU), according to government guidelines. Caregivers in seven villages (n = 73) received TAU as well as 12 sessions of IPT-G delivered by LCHWs. Primary outcomes were caregiver and child depression assessed at 1 and 6 months post-intervention.ResultsCaregivers who received IPT-G had a significantly greater reduction in the risk of depression from baseline to 1 month [risk ratio (RR) 0.25, 95% confidence interval (CI) 0.10–0.62] and 6 months (RR 0.33, 95% CI 0.11–0.95) post-intervention compared with caregivers who received TAU. Children of caregivers who received IPT-G had significantly greater reduction in depression scores than children of TAU caregivers at 1 month (Cohen's d = 0.57, p = 0.01) and 6 months (Cohen's d = 0.54, p = 0.03). Significant effects were also observed for psychological distress, stigma and social support among caregivers.ConclusionIPT-G delivered within a low-resource health system is an effective PT for common mental health problems in caregivers of children with a severe neuropsychiatric condition and has psychological benefits for the children as well. This supports national health policy initiatives to integrate PTs into primary health care services in Uganda.

Despite the burden of substance misuse in conflict-affected populations, prevention and treatment services are often unavailable or neglected in policy and public health practice. This chapter reviews: (1) the epidemiology of substance misuse; (2) evidence for treatment and prevention services; and (3) implementation considerations for substance use services in conflict-affected populations. Overall, there is a significant lack of research evaluating implementation and impact of alcohol and drug misuse prevention and treatment services in conflict and post-conflict settings. Existing research indicates that substance misuse is common in conflict settings and displaced populations, and implementation of prevention and treatment programs is feasible, highlighting the importance of strengthening knowledge on how best to address this critical public health concern.

Social desirability bias and underreporting of HIV risk behaviors are significant challenges to the accurate evaluation of HIV prevention programs for orphans and vulnerable children (OVC) in sub-Saharan Africa. Valid and reliable HIV risk behavior instruments are critical to address these challenges. We assessed the psychometric properties of two risk behavior measures, the World Aids Foundation Survey (WAF) and the Peer HIV Risk Behavior Screener (PHRBS), administered to 210 OVC in Zambia using Audio Computer Assisted Self-Interviewing. All WAF subscales exhibited good internal reliability (α > .80); only the Sexual Behavior Practices subscale strongly distinguished (P < .01) adolescents who engaged in HIV risk behaviors ("cases") from those who did not ("non-cases"). An 8-item version of the PHRBS, refined using exploratory factor analysis, demonstrated good internal reliability (α = 87), differentiated "cases" from "non-cases" (P < .01), and correlated strongly with the Sexual Behavior Practices subcale (r = .34, P < .01). Results suggest that report of peers' sexual behaviors can serve as a proxy for OVCs' own behavior in contexts where social desirability bias affects reporting.

Aims.Two large earthquakes in 2015 caused widespread destruction in Nepal. This study aimed to examine frequency of common mental health and psychosocial problems and their correlates following the earthquakes.Methods.A stratified multi-stage cluster sampling design was employed to randomly select 513 participants (aged 16 and above) from three earthquake-affected districts in Nepal: Kathmandu, Gorkha and Sindhupalchowk, 4 months after the second earthquake. Outcomes were selected based on qualitative preparatory research and included symptoms of depression and anxiety (Hopkins Symptom Checklist-25); post-traumatic stress disorder (PTSD Checklist-Civilian); hazardous alcohol use (AUDIT-C); symptoms indicating severe psychological distress (WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS)); suicidal ideation (Composite International Diagnostic Interview); perceived needs (Humanitarian Emergency Settings Perceived Needs Scale (HESPER)); and functional impairment (locally developed scale).Results.A substantial percentage of participants scored above validated cut-off scores for depression (34.3%, 95% CI 28.4–40.4) and anxiety (33.8%, 95% CI 27.6–40.6). Hazardous alcohol use was reported by 20.4% (95% CI 17.1–24.3) and 10.9% (95% CI 8.8–13.5) reported suicidal ideation. Forty-two percent reported that ‘distress’ was a serious problem in their community. Anger that was out of control (symptom from the WASSS) was reported by 33.7% (95% CI 29.5–38.2). Fewer people had elevated rates of PTSD symptoms above a validated cut-off score (5.2%, 95% CI 3.9–6.8), and levels of functional impairment were also relatively low. Correlates of elevated symptom scores were female gender, lower caste and greater number of perceived needs. Residing in Gorkha and Sindhupalchowk districts and lower caste were also associated with greater perceived needs. Higher levels of impaired functioning were associated with greater odds of depression and anxiety symptoms; impaired functioning was less strongly associated with PTSD symptoms.Conclusions.Four months after the earthquakes in Nepal, one out of three adults experienced symptoms of depression and distressing levels of anger, one out of five engaged in hazardous drinking, and one out of ten had suicidal thoughts. However, posttraumatic stress symptoms and functional impairment were comparatively less frequent. Taken together, the findings suggest that there were significant levels of psychological distress but likely low levels of disorder. The findings highlight the importance of indicated prevention strategies to reduce the risk of distress progressing to disorder within post-disaster mental health systems of care.

The Refugee Health Information System (RHIS) for humanitarian settings was developed by the United Nations High Commissioner for Refugees (UNHCR) in 2004. As of 2009, it contained seven categories related to mental, neurological and substance use (MNS) conditions: epilepsy/seizure, alcohol/substance use disorder, mental retardation/intellectual disability, psychotic disorder, severe emotional disorder, medically unexplained somatic complaint and other psychological complaint. During a recent overhaul of the RHIS, the MNS categories were revisited. This article describes the revision process and provides insights into how and why changes were made. Two rounds of consultations involving 34 expert reviewers in humanitarian mental health led to nine case definitions for MNS conditions in the new integrated RHIS (iRHIS): epilepsy/seizure, alcohol/substance use disorder; intellectual disability/developmental disorder; psychotic disorder (including mania); delirium/dementia; depression or other emotional disorder; other emotional complaint; medically unexplained somatic complaint; and self-harm/suicide. The use of additional specifiers enables dedicated mental health professionals in humanitarian settings to document a more refined diagnosis with a total of 22 different categories that made the system compatible with the modules of the Mental Health Gap Action Programme, without additional complexity. Key implications for practice The new iRHIS contains nine broad categories for MNS problems, reflecting consensus among humanitarian mental health practitioners. iRHIS allows health workers in refugee settings to more accurately classify patients with MNS problems. Specialized mental health workers in refugee settings can use additional specifiers in iRHIS to categorise their patients more precisely.

Background Since December 2013, an armed conflict in South Sudan has resulted in the displacement of over 2.2 million people, more than 270,000 of whom are presently in refugee settlements located throughout Uganda. Existing literature suggests that refugees are at increased risk for a range of mental health and psychosocial problems. There is international consensus on the importance of needs and resource assessments to inform potential mental health and psychosocial support (MHPSS) interventions. Methods We conducted a MHPSS needs and resource assessment in Rhino Camp refugee settlement in northern Uganda, between June and August 2014. We followed World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) guidelines for MHPSS needs assessments in humanitarian settings. The assessment used a range of methodologies including: 1) a desk (literature) review to understand the context for mental health service provision; 2) an analysis of data from existing health information systems (HIS); 3) an assessment of the current infrastructure for service provision using a shortened version of a Who does What Where until When (4Ws); and 4) semi-structured individual and group interviews (total n = 86) with key informants (n = 13) and general community members (individual interviews n = 28, four focus groups with n = 45). Results Data from the HIS indicated that visits to health centers in refugee settlements attributable to psychotic disorders, severe emotional disorders, and other psychological complaints increased following the refugee influx between 2013 and 2014, but overall help-seeking from health centers was low compared to estimates from epidemiological studies. In semi-structured interviews the three highest ranked mental health and psychosocial problems included “overthinking”, ethnic conflict, and child abuse. Other concerns included family separation, drug abuse, poverty, and unaccompanied minors. The 4Ws assessment revealed that there were very limited MHPSS services available in Rhino Camp. Conclusions The types of MHPSS problems among South Sudanese refugees in northern Uganda are diverse and the burden appears to be considerable, yet there are currently few available services. The assessment indicates the need for a range of services addressing social concerns as well as varied types of mental conditions. The idiom of “overthinking” may form a useful starting point for intervention development and mental health communication.

Objective Studies have suggested that alcohol use prevalence is increasing among Asian American adolescents and there may be significant differences between specific adolescent Asian American ethnicities. Method Data from the National Survey on Drug Use and Health (2002–2013) were used to estimate prevalence of alcohol use (lifetime, past-month, past-year) and problem (binge drinking, alcohol use disorder [AUD], and early initiation of use) outcomes among adolescent Asian American ethnicities. Results Filipino Americans had the highest prevalence of lifetime (29.3%) and past-month (10.3%) use; Korean Americans had the highest prevalence of past-year use (22.7%). Asian Indian Americans had the lowest prevalence of all three use indicators: 14.6%, 11.9%, and 4.9% for lifetime, past-year, and past-month, respectively. Korean Americans had the highest prevalence of binge drinking (5.4%), Filipino Americans had the highest prevalence of AUD (3.5%), and Vietnamese Americans had the highest prevalence of early initiation of use (13.5%). Asian Indian Americans had the lowest prevalence for all three alcohol problem indicators: 2.6%, 1.0%, and 4.9% for binge drinking, AUD, and early initiation of use, respectively. Conclusions Prevalence estimates of alcohol outcomes among Korean, Japanese, and Filipino American adolescents were high and similar to other racial groups that are often considered higher risk racial groups. Estimates among large subgroups with low alcohol use prevalence, Chinese and Asian Indian Americans, may mask high rates among other Asian ethnicities when alcohol use estimates are presented among Asians overall. When feasible, researchers should present alcohol use estimates disaggregated by specific Asian American ethnicities and investigate differences in risk factors across groups.

BACKGROUND: Substance and alcohol misuse is a global problem that increases the risk of HIV infection. This is a concern among orphans and vulnerable children (OVC) in sub-Saharan Africa who may have elevated substance use rates. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is a reliable and valid instrument of substance use among adults in primary care high-income settings. This study examined psychometric properties of the ASSIST among OVC in Zambia using Audio Computer Assisted Self-Interviewing (ACASI). METHODS: Baseline data from an ongoing randomized trial of interventions to reduce HIV risk behaviors were analyzed. The analysis included 502 OVC ages 13-17 living in low-income, high-density neighborhoods in Lusaka, Zambia. Internal consistency of the ASSIST was assessed and discriminant validity was measured using items from the Youth Self Report as criterion variables. RESULTS: Internal reliability was strong with a Cronbach's alpha of ≥0.80 for each of the specific substance scales and total substance involvement. For all substances except tobacco and sedatives, discriminant validity was demonstrated in distinguishing between low risk use and moderate use. Sensitivity and specificity analysis indicated adequate area under the curve across substance types (AUC range: 0.68-0.80). Discrimination between moderate and high risk was demonstrated for alcohol and total substance involvement. CONCLUSIONS: ASSIST administered via ACASI is a reliable instrument and an appropriate tool for distinguishing between low and hazardous substance use among adolescent OVC populations in sub-Saharan Africa. Additional examination is warranted to determine its ability to measure gradations of severity within hazardous use.Copyright © 2016 Elsevier Ireland Ltd. All rights reserved. Language: en

Background.Studies from low- and middle-income countries (LMIC) indicate that the use of audio computer-assisted self-interviewing (ACASI) is associated with more accurate reporting of sensitive behaviors (e.g. substance use and sexual risk behaviors) compared with interviewer-administered questionnaires. There is a lack of published information on the process of designing, developing, and implementing ACASI in LMIC. In this paper we describe our experience implementing an ACASI system for use with a population of orphans and vulnerable children in Zambia.Methods.A questionnaire of mental health, substance use, and HIV risk behaviors was converted into an ACASI system, tested in pilot and validity studies, and implemented for use in a randomized controlled trial. Successes, barriers, and challenges associated with each stage in the development and implementation of ACASI are described.Results.We were able to convert a lengthy and complex survey into an ACASI system that was feasible for use in Zambia. Lessons learned include the importance of: (1) piloting the written and electronic versions; (2) proper and extensive training for study assessors to use ACASI and for those doing voice recordings; and (3) attention to logistics such as appropriate space, internet, and power.Conclusions.We found that ACASI was feasible and acceptable in Zambia with proper planning, training, and supervision. Given mounting evidence indicating that ACASI provides more accurate self-report data and immediate data download compared with interview-administered measures, it may be an effective and economical alternative for behavioral health research studies in LMIC.

Importance Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence-based treatments for OVC in low-resource settings. Objective To evaluate the effectiveness of lay counselor–provided trauma-focused cognitive behavioral therapy (TF-CBT) to address trauma and stress-related symptoms among OVC in Lusaka, Zambia. Design, Setting, and Participants This randomized clinical trial compared TF-CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma-related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma-related symptoms. Analysis was with intent to treat. Interventions The intervention group received 10 to 16 sessions of TF-CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC. Main Outcomes and Measures The primary outcome was mean item change in trauma and stress-related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0-4) and functional impairment using a locally developed measure (range, 0-4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU. Results At follow-up, the mean item change in trauma symptom score was −1.54 (95% CI, −1.81 to −1.27), a reduction of 81.9%, for the TF-CBT group and −0.37 (95% CI, −0.57 to −0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was −0.76 (95% CI, −0.98 to −0.54), a reduction of 89.4%, and −0.54 (95% CI, −0.80 to −0.29), a reduction of 68.3%, for the TF-CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes ( P d ) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings. Conclusions and Relevance The TF-CBT adapted for Zambia substantially decreased trauma and stress-related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma. Trial Registration clinicaltrials.gov Identifier:NCT01624298

Background Population-based epidemiological research has established that refugees in low- and middle-income countries (LMIC) are at increased risk for a range of mental, neurological and substance use (MNS) problems. Improved knowledge of rates for MNS problems that are treated in refugee camp primary care settings is needed to identify service gaps and inform resource allocation. This study estimates contact coverage of MNS services in refugee camps by presenting rates of visits to camp primary care centers for treatment of MNS problems utilizing surveillance data from the Health Information System (HIS) of the United Nations High Commissioner for Refugees. Methods Data were collected between January 2009 and March 2013 from 90 refugee camps across 15 LMIC. Visits to primary care settings were recorded for seven MNS categories: epilepsy/seizure; alcohol/substance use; mental retardation/intellectual disability; psychotic disorder; emotional disorder; medically unexplained somatic complaint; and other psychological complaint. The proportion of MNS visits attributable to each of the seven categories is presented by country, sex and age group. The data were combined with camp population data to generate rates of MNS visits per 1,000 persons per month, an estimate of contact coverage. Results Rates of visits for MNS problems ranged widely across countries, from 0.24 per 1,000 persons per month in Zambia to 23.69 in Liberia. Rates of visits for epilepsy were higher than any of the other MNS categories in nine of fifteen countries. The largest proportion of MNS visits overall was attributable to epilepsy/seizure (46.91% male/35.13% female) and psychotic disorders (25.88% male/19.98% female). Among children under five, epilepsy/seizure (82.74% male/82.29% female) also accounted for the largest proportion of MNS visits. Conclusions Refugee health systems must be prepared to manage severe neuropsychiatric disorders in addition to mental conditions associated with stress. Relatively low rates of emotional and substance use visits in primary care, compared to high prevalence of such conditions in epidemiological studies suggest that many MNS problems remain unattended by refugee health services. Wide disparity in rates across countries warrants additional investigation into help seeking behaviors of refugees and the capacity of health systems to correctly identify and manage diverse MNS problems.

Background In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda. Methods In-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews. Results Practices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients. Conclusions Guidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0400-z) contains supplementary material, which is available to authorized users.