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Early adolescents (ages 10–14) living in low- and middle-income countries have heightened vulnerability to psychosocial risks, but available evidence from these settings is limited. This study used data from the Global Early Adolescent Study to characterize prototypical patterns of emotional and behavioral problems among 10,437 early adolescents (51% female) living in the Democratic Republic of Congo (DRC), Malawi, Indonesia, and China, and explore the extent to which these patterns varied by country and sex. LCA was used to identify and classify patterns of emotional and behavioral problems separately by country. Within each country, measurement invariance by sex was evaluated. LCA supported a four-class solution in DRC, Malawi, and Indonesia, and a three-class solution in China. Across countries, early adolescents fell into the following subgroups: Well-Adjusted (40–62%), Emotional Problems (14–29%), Behavioral Problems (15–22%; not present in China), and Maladjusted (4–15%). Despite the consistency of these patterns, there were notable contextual differences. Further, tests of measurement invariance indicated that the prevalence and nature of these classes differed by sex. Findings can be used to support the tailoring of interventions targeting psychosocial adjustment, and suggest that such programs may have utility across diverse cross-national settings.

Purpose: The purpose of this study was to validate recordings of the Spanish Pediatric Speech Recognition Threshold (SPSRT) test and Spanish Pediatric Picture Identification Test (SPPIT) for Spanish-speaking children using a native, bilingual Spanish–English male talker of Castilian peninsular dialect from Spain. Method: Seventy native Spanish-speaking children from a variety of countries participated. Fifty-eight participants had normal hearing, and the remaining 12 had mild hearing loss in at least one ear. Male talker recordings of the SPSRT and SPPIT were administered to obtain baseline validation data. Participants listened to the stimuli and pointed to the appropriate item on the picture boards that represented the word they heard. Results: Mean SRTs were within 5 dB of mean pure-tone averages resulting in a positive correlation. Performance–intensity functions for the SPPIT showed minimal significant differences across the three test lists, and performance increased as the sensation level increased. Conclusions: The male talker recordings of the SPSRT and SPPIT are valid speech perception picture-pointing assessments that can be used with Spanish-speaking children. The recordings present the Spanish target word while simultaneously presenting the English interpretation for ease of scoring.

Early adolescence (ages 10-14) is a critical period for psychosocial development, but few studies have focused on risk and protective factors for emergent psychosocial challenges among youth living in low- and middle-income countries. This study explored the contribution of social environmental factors to patterns of emotional and behavioral problems among early adolescents across four low- and middle-income countries.Participants were drawn from the Global Early Adolescent Study, and included 10,437 early adolescents from six low-resource urban settings in the Democratic Republic of Congo, Malawi, Indonesia, and China. Multivariate latent class regression was used to examine the associations between distinct patterns of emotional and behavioral problems and risk and protective factors across the family, peer, school, and neighborhood levels.Across countries, childhood adversity, peer bullying behaviors, and a perceived lack of school safety were consistently associated with emotional and behavioral problems. With some contextual variability, peer substance use and a perceived lack of neighborhood safety also emerged as significant risk factors. The magnitude of these associations was generally greatest among a subgroup of early adolescents with co-occurring emotional and behavioral problems.The overall consistency of findings across countries is suggestive of the generalizability of risk factors in early adolescence and indicates that interventions bolstering psychosocial adjustment among this age group may have applicability in diverse cross-national settings. Given the significance of peer bullying behaviors and school safety, multicomponent school-based interventions may be an especially applicable approach.

BackgroundIntegrating services for depression into primary care is key to reducing the treatment gap in low- and middle-income countries. We examined the value of providing the Healthy Activity Programme (HAP), a behavioral activation psychological intervention, within services for depression delivered by primary care workers in Chitwan, Nepal using data from the Programme for Improving Mental Health Care.MethodsPeople diagnosed with depression were randomized to receive either standard treatment (ST), comprised of psychoeducation, antidepressant medication, and home-based follow up, or standard treatment plus psychological intervention (T + P). We estimated incremental costs and health effects of T + P compared to ST, with quality adjusted life years (QALYs) and depression symptom scores over 12 months as health effects. Nonparametric uncertainty analysis provided confidence intervals around each incremental effectiveness ratio (ICER); results are presented in 2020 international dollars.ResultsSixty participants received ST and 60 received T + P. Implementation costs (ST = $329, T + P = $617) were substantially higher than service delivery costs (ST = $18.7, T + P = $22.4) per participant. ST and T + P participants accrued 46.5 and 49.4 QALYs, respectively. The ICERs for T + P relative to ST were $4422 per QALY gained (95% confidence interval: $2484 to $9550) – slightly above the highly cost-effective threshold – and −$53.21 (95% confidence interval: −$105.8 to −$30.2) per unit change on the Patient Health Questionnaire.ConclusionProviding HAP within integrated depression services in Chitwan was cost-effective, if not highly cost-effective. Efforts to scale up integrated services in Nepal and similar contexts should consider including evidence-based psychological interventions as a part of cost-effective mental healthcare for depression.

BackgroundDespite the growth of psychotherapy trials in low- and middle-income countries, there have been limited follow-up studies of more than 2 years. This study follows up female sexual violence survivors approximately 6 years after completing a 12-session group cognitive processing therapy (CPT) program in the eastern Democratic Republic of Congo.MethodsBaseline trial data were collected in December 2010 from 134 women in 7 study villages randomly allocated to CPT. Study women were over 18 years, reported personally experiencing or witnessing sexual violence, and reported elevated depression, anxiety and/or posttraumatic stress symptoms. Women were followed up (1) post-treatment (6-months after baseline); (2) 6 months later; (3) 12 months later; and (4) in March 2017 (6.3 years after baseline). At the long-term follow-up, 103 women (77%) in 6 of 7 CPT villages were re-assessed; one village was not visited due to ongoing insecurity.ResultsWe found strong continued intervention effects; nearly all women maintained treatment impacts over the first two years; at long-term follow-up, approximately half continued to maintain low symptom scores. Relapse rates for probable PTSD and probable depression and anxiety were 20%.ConclusionsThis study extends prior research to show that treatment impacts can be maintained for several years despite experiences of ongoing trauma. The women described continuing to meet with the women in their therapy group and using the skills they learned in the psychotherapy, providing evidence of the potential for these programs to provide valuable social supports and skills that people use as they continue to face adversity.

Neuropsychological Event Grading in SJLIFE

Medical Event Grading in SJLIFE

Characterization of toxicity associated with cancer and its treatment is essential to quantify risk, inform optimization of therapeutic approaches for newly diagnosed patients, and guide health surveillance recommendations for long-term survivors. The NCI Common Terminology Criteria for Adverse Events (CTCAE) provides a common rubric for grading severity of adverse outcomes in cancer patients that is widely used in clinical trials. The CTCAE has also been used to assess late cancer treatment-related morbidity but is not fully representative of the spectrum of events experienced by pediatric and aging adult survivors of childhood cancer. Also, CTCAE characterization does not routinely integrate detailed patient-reported and medical outcomes data available from clinically assessed cohorts. To address these deficiencies, we standardized the severity grading of long-term and late-onset health events applicable to childhood cancer survivors across their lifespan by modifying the existing CTCAE v4.03 criteria and aligning grading rubrics from other sources for chronic conditions not included or optimally addressed in the CTCAE v4.03. This article describes the methods of late toxicity assessment used in the St. Jude Lifetime Cohort Study, a clinically assessed cohort in which data from multiple diagnostic modalities and patient-reported outcomes are ascertained. Cancer Epidemiol Biomarkers Prev; 26(5); 666–74. ©2016 AACR.

Substance use and intimate partner violence (IPV) are both associated with psychological distress. This study examines the association between IPV victimization and psychological distress among peo...

Despite calls forincreased mental health programming in low-resource and humanitarian contexts and effectiveness trials of psychotherapy in these settings, little research exists on the extent to which providers and recipients continue to practice skills learned during trials of these programs. To understand if and how providers continued to use mental health intervention skills without ongoing institutional support following the completion of randomized controlled trials (RCTs), we analyzed data from semistructured interviews with six of seven providers who participated in an RCT of cognitive processing therapy (CPT) in the Democratic Republic of Congo 7 years prior. Provider interviews revealed continued knowledge of and, in some cases, the practice of core CPT skills as well as efforts to keep meeting with women in the community and a strong desire to learn new skills. Although financial limitations sometimes prohibited providers from formally convening CPT groups with women in need, participants maintained knowledge and skill use. Providers also reported feeling more valued in their communities, and they continued providing services beyond the planned intervention period despite a lack of ongoing support. In addition, participants described a strong desire to continue psychosocial interventions for trauma and learn more about this type of intervention. Reframing the evaluation of psychological interventions as program development and maintaining a strong working relationship with community partners may allow for increased sustainability of mental health services beyond the end of academic research studies in low-resource contexts.

BackgroundPublished by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.MethodsSeven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, andClinicalTrials.gov. We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.ResultsWe identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.ConclusionAlthough results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.Trial registrationPROSPERO registration number:CRD42017058287.

Bullying is a major public health concern for Indonesian adolescents, with well-documented links to a range of emotional and behavioral problems. Despite such evidence, few investigations have employed qualitative methods to illuminate youth’s own perceptions of bullying and its psychosocial correlates in this context. The current study aimed to address this gap through an exploration of Indonesian adolescents’ motivations, perceptions, and beliefs regarding bullying. Building on prior quantitative findings, an explanatory sequential mixed methods approach was used to better understand the myriad ways in which bullying ties into other psychosocial challenges. Qualitative interviews were conducted with a total of 45 adolescents ages 13 to 14 (25 girls and 20 boys) in two junior high schools in Semarang between October and December 2019. Interviews were audio-recorded, transcribed verbatim, and translated into English for analysis. Qualitative data were then coded using an inductive thematic analysis approach. Interviews yielded contextual insights into adolescents’ definitions of bullying including the distinction between “normal” and “serious” bullying; related risk behaviors; key drivers; social and emotional consequences; and coping strategies. Across these thematic categories, a number of noteworthy gender differences emerged, highlighting the role that underlying gender norms can play in driving bullying involvement. Further, findings emphasize the need to develop a locally valid definition of bullying which takes into account the ways in which emotional distress may be both a criterion and a consequence of bullying. Findings can be used to inform bullying prevention programs targeting Indonesian youth.

Objective: This article reports findings from a qualitative study that sought to identify and describe psychosocial and mental health consequences of conflict among internally displaced persons (IDPs) and military veterans in Ukraine. The study was the first phase of a clinical intervention trial and was designed to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, and guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons. Method: Free-list interviews (FLs), key informant interviews (KIIs), and focus group discussions (FDGs) were conducted with IDPs, military veterans, and providers working with these two groups. A total of 227 respondents were interviewed from two study regions in eastern Ukraine-Zaporizhia and Kharkiv-including 136 IDPs and 91 military veterans. Results: Both IDPs and veterans were described as experiencing high levels of psychological stress symptoms, including depression, isolation, anxiety, and intrusive memories. Although IDPs and veterans were exposed to different traumas, they both identified struggles with social adaptation, including feeling isolated and misunderstood by their communities. Both groups also described relational conflict within and outside the family. Social support mechanisms were considered essential for recovery, and positive social interaction was described as a key example of healthy functioning. Conclusion: Findings suggest a need for community-based programming that facilitates social adaptation, supports social network building, and helps engage conflict-affected people into mental health services. Programs that promote greater awareness, interaction, and understanding among the general public, military veterans, and IDPs are also warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups—consumers, providers, organization leaders, and policy makers—with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. Methods We compiled secondary data from seven studies across six LMIC—Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia—to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. Results All but one scale within the Provider and Consumer versions had Cronbach’s alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. Conclusion We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.

Background Integrating mental health services into primary care is a key strategy for reducing the mental healthcare treatment gap in low- and middle-income countries. We examined healthcare use and costs over time among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources. Methods Individuals diagnosed with depression at ten primary care facilities were randomized to receive a package of integrated care based on the Mental Health Gap Action Programme (treatment group; TG) or this package plus individual psychotherapy (TG + P); individuals with subclinical depressive symptoms received primary care as usual (UC). Primary outcomes were changes in use and health system costs of outpatient healthcare at 3- and 12-month follow up. Secondary outcomes examined use and costs by type. We used Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group, and with TG as reference. Results The study included 192 primary care service users (TG = 60, TG + P = 60, UC = 72; 86% female, 24% formally employed, mean age 41.1). At baseline, outpatient visits were similar (− 11%, p = 0.51) among TG + P and lower (− 35%, p = 0.01) among UC compared to TG. Visits increased 2.30 times (p p = 0.03) among TG + P, before returning to baseline levels among all groups at 12 months. Comparing TG + P to TG, costs were similar at baseline (− 1%, p = 0.97) and cost changes did not significantly differ at three (− 16%, p = 0.67) or 12 months (− 45%, p = 0.13). Costs among UC were 54% lower than TG at baseline (p = 0.005), with no significant differences in cost changes over follow up. Post hoc analysis indicated individuals not receiving psychotherapy used less frequent, more costly healthcare. Conclusion Delivering psychotherapy within integrated services for depression resulted in greater healthcare use without significantly greater costs to the health system or individual. Previous research in Chitwan demonstrated psychotherapy determined treatment effectiveness for people with depression. While additional research is needed into service implementation costs, our findings provide further evidence supporting the inclusion of psychotherapy within mental healthcare integration in Nepal and similar contexts.

Female sex workers (FSW) are a marginalized and vulnerable population at high risk of gender-based violence within and outside of their occupation. However, FSW remain underrepresented in the trauma and mental health literature. The aims of this study were to (a) characterize exposure to violence among street-based FSW, including violence type, patterns over the life course, and key perpetrator groups, and (b) examine the multivariate associations between posttraumatic stress disorder (PTSD) symptom severity and two constructs (revictimization across life stages and cumulative violence). Data were drawn from the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study, an observational community-based cohort of street-based FSW recruited through targeted sampling across Baltimore, Maryland (USA) in 2016 to 2017. PTSD symptom severity was measured using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5). At baseline, 61% of FSW screened positive for PTSD symptoms. The mean PCL-5 score was 38.6. We documented extensive histories of sexual and physical violence (lifetime: 81.8%; childhood and adult revictimization: 15.0% for sexual and 37.7% for physical). The vast majority of perpetrators were male and included paying clients, police officers, family members, and intimate partners. Exposure to childhood and adult sexual violence were independently associated with higher PTSD severity ( p < .05), with marginal associations observed for physical violence. Data supported a cumulative violence model of PTSD severity ( p < .05). Binge drinking also appeared to be a contributing factor ( p < .05). The levels of PTSD observed among our sample were comparable with that reported among treatment-seeking war veterans. Our findings underscore the urgent need for tailored trauma-informed interventions and policies to address violence among urban street-based FSW, a population experiencing extremely high levels of violence, PTSD, and substance use.

Purpose The purpose of this study was to construct a recorded speech recognition threshold (SRT) test for Spanish-speaking children utilizing a picture board and a picture-pointing task. Design The Spanish Pediatric Speech Recognition Threshold (SPSRT) test was developed and validated in this study. Test construction steps included (a) stimulus selection, (b) assessment of familiarity, (c) digital recording, (d) creation of pictures that accurately depicted the target word from the stimulus set, and (e) validation of the test and recordings. SRTs were obtained from 24 Spanish-speaking children whose 1st language was Spanish. Results Normative data are presented that validate the SPSRT and establish the baseline relationship between the pure-tone average and the SRT obtained with the SPSRT. Results indicated that the SPSRT obtained using this test should be within 2–12 dB of an individual's pure-tone average for Spanish-speaking children with normal hearing and minimal hearing loss. Conclusions The SPSRT was developed and validated as a picture-pointing Spanish SRT test to be used with Spanish-speaking children. The 2-channel recording contains an English translation track, making this test easy to administer and interpret for clinicians without knowledge of Spanish.

Stressors and trauma experienced by persons fleeing harm or persecution can cause elevated distress. This study assessed predictors of elevated distress among newly arrived refugees, asylees, and Special Immigrant Visa (SIV) holders in Maryland. A secondary analysis of Refugee Health Screener-15 data from 4385 refugees, asylees, and SIV holders arriving in Maryland from 2014 to 2017 was conducted. Mean scores were compared across immigrant groups, and positive screening predictors were identified using logistic regression. Mean scores were highest among SIV holders and lowest among asylees. Compared to refugees, SIV holders had greater odds of screening positive; significance was reduced after adjusting for covariates. A significant interaction term was found for SIV women, who had 1.74 greater odds than SIV males. Distress varied between immigrant groups, with asylees having lowest odds of screening positive. SIV women's significant results may owe to acculturation distress, disrupted gender expectations, and resettlement difficulties.

PURPOSE Children with average-risk medulloblastoma (MB) experience survival rates of ≥ 80% at the expense of adverse consequences of treatment. Efforts to mitigate these effects include deintensification of craniospinal irradiation (CSI) dose and volume. METHODS ACNS0331 (ClinicalTrials.gov identifier: NCT00085735 ) randomly assigned patients age 3-21 years with average-risk MB to receive posterior fossa radiation therapy (PFRT) or involved field radiation therapy (IFRT) following CSI. Young children (3-7 years) were also randomly assigned to receive standard-dose CSI (SDCSI; 23.4 Gy) or low-dose CSI (LDCSI; 18 Gy). Post hoc molecular classification and mutational analysis contextualized outcomes according to known biologic subgroups (Wingless, Sonic Hedgehog, group 3, and group 4) and genetic biomarkers. Neurocognitive changes and ototoxicity were monitored over time. RESULTS Five hundred forty-nine patients were enrolled on study, of which 464 were eligible and evaluable to compare PFRT versus IFRT and 226 for SDCSI versus LDCSI. The five-year event-free survival (EFS) was 82.5% (95% CI, 77.2 to 87.8) and 80.5% (95% CI, 75.2 to 85.8) for the IFRT and PFRT regimens, respectively, and 71.4% (95% CI, 62.8 to 80) and 82.9% (95% CI, 75.6 to 90.2) for the LDCSI and SDCSI regimens, respectively. IFRT was not inferior to PFRT (hazard ratio, 0.97; 94% upper CI, 1.32). LDCSI was inferior to SDCSI (hazard ratio, 1.67%; 80% upper CI, 2.10). Improved EFS was observed in patients with Sonic Hedgehog MB who were randomly assigned to the IFRT arm ( P = .018). Patients with group 4 MB receiving LDCSI exhibited inferior EFS ( P = .047). Children receiving SDCSI exhibited greater late declines in IQ (estimate = 5.87; P = .021). CONCLUSION Reducing the radiation boost volume in average-risk MB is safe and does not compromise survival. Reducing CSI dose in young children with average-risk MB results in inferior outcomes, possibly in a subgroup-dependent manner, but is associated with better neurocognitive outcome. Molecularly informed patient selection warrants further exploration for children with MB to be considered for late-effect sparing approaches.

We tested a model of dyadic interdependence in depression symptoms experienced by female caregivers living with HIV in Uganda (n = 288) and behavioral problems of their HIV-infected (n = 92) and perinatally HIV-exposed uninfected (HEU) children (n = 196). Three repeated measures of caregiver depression symptoms and child neurodevelopment and behavioral outcomes were related to their own outcomes at a previous time point (actor effects), and the outcomes of the other member of the dyad (partner effects). Caregiver depression and child behavioral problem were interdependent over the 24 months of observation. Caregiver depression at TEvaluamos la interdependencia en relaciones diádicas entre síntomas de depresión en mujeres viviendo con VIH en Uganda (n = 288) y medidas de neurodesarollo y comportamiento en sus hijos no infectados pero expuestos a VIH (HEU) (n = 196). Tres mediciones repetidas de síntomas de depresión en mujeres y de neurodesarollo y comportamiento en niños estuvieron relacionadas con sus propios resultados en mediciones anteriores (efecto de actor), y con los resultados del otro miembro de la pareja (efecto de pareja). Síntomas depresivos y problemas conductuales fueron interdependientes durante los 24 meses de observación. Síntomas depresivos en mujeres en T

Background Men living in low- and middle-income countries are unlikely to seek mental health care, where poor healthcare infrastructure, differences in illness conceptualization, and stigma can impact treatment seeking. Vulnerable groups, such as former political prisoners, are more likely than others to experience potentially traumatic events that may lead to negative mental health outcomes. To improve the likelihood of successful engagement of vulnerable men in psychotherapy, it is necessary to identify factors that influence treatment adherence, and to better understand men’s attitudes surrounding decisions to seek and initiate care. The purpose of this investigation was to explore themes of masculinity, treatment seeking, and differences between male former political prisoners who accepted and declined therapy in an urban low-income context. Methods We conducted a qualitative, interview-based investigation with 30 former political prisoners in Yangon, Myanmar who were eligible to receive mental health counseling provided by the non-governmental organization (NGO), Assistance Association for Political Prisoners. Men were initially screened using a composite questionnaire with items related to depression, anxiety, and posttraumatic stress symptom severity. After screening, if potential clients were identified as having probable mental health problems, they were asked if they would like to participate in a multi-session cognitive behavioral therapy program. Semi-structured, open-ended interviews were conducted with 15 participants who accepted and 15 participants who declined therapy. Interviews were transcribed and translated by local partners and thematically coded by the authors. We used thematic analysis to identify and explore differences in treatment-seeking attitudes between men who accepted and men who declined the intervention. Results Men described that being a community leader, self-reliance, morality, and honesty were defining characteristics of masculinity. A focus on self-correction often led to declining psychotherapy. A general lack of familiarity with psychological therapy and how it differed from locally available treatments (e.g. astrologists) was connected to stigma regarding mental health treatment. Conclusions Masculinity was described in similar terms by both groups of participants. The interpretation of masculine qualities within the context of help-seeking (e.g. self-reliance as refusing help from others versus listening to others and applying that guidance) was a driving factor behind men’s decision to enter psychotherapy.

Background Choroid plexus carcinoma (CPC) is a rare and aggressive tumor of infancy without a clear treatment strategy. This study describes the outcomes of children with CPC treated on the multi-institutional phase 2 SJYC07 trial and reports on the significance of clinical and molecular characteristics. Methods Eligible children Results Thirteen patients (median age: 1.41 years, range: 0.21–2.93) were enrolled; 5 IR, 8 HR. Gross-total resection or near-total resection was achieved in ten patients and subtotal resection in 3. Seven patients had TP53-mutant tumors, including 4 who were germline carriers. Five patients experienced progression and died of disease; 8 (including 5 HR) are alive without progression. The 5-year progression-free survival (PFS) and overall survival rates were 61.5 ± 13.5% and 68.4 ± 13.1%. Patients with TP53-wild-type tumors had a 5-year PFS of 100% as compared to 28.6 ± 17.1% for TP53-mutant tumors (P = .012). Extent of resection, metastatic status, and use of radiation therapy were not significantly associated with survival. Conclusions Non-myeloablative high-dose methotrexate–containing therapy with maximal surgical resection resulted in long-term PFS in more than half of patients with CPC. TP53-mutational status was the only significant prognostic variable and should form the basis of risk-stratification in future trials.

The study's objective was to determine the effectiveness of a task-sharing psychological treatment for perinatal depression using non-specialist community health workers. A double-blind individual randomised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha, Cape Town. Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale (EPDS) were randomised into the intervention arm (structured six-session psychological treatment) or the control arm (routine antenatal health care and three monthly phone calls). The primary outcome was response on the Hamilton Depression Rating Scale (HDRS) at three months postpartum (minimum 40% score reduction from baseline) among participants who did not experience pregnancy or infant loss (modified intention-to-treat population) (registered on Clinical Trials: NCT01977326). Of 2187 eligible women approached, 425 (19.4%) screened positive on the EPDS and were randomised; 384 were included in the modified intention-to-treat analysis (control: n = 200; intervention: n = 184). There were no significant differences in response on the HDRS at three months postpartum between the intervention and control arm. A task-sharing psychological treatment was not effective in treating depression among women living in Khayelitsha, South Africa. The findings give cause for reflection on the strategy of task-sharing in low-resource settings.

We sought to understand social representations of effective parenting and parenting self-efficacy among female HIV-affected caregivers in rural Eastern Uganda. We conducted in-depth interviews (n = 21) to describe parenting experiences and caregivers' perceptions of their own parenting abilities and to create vignettes for use in directed focus groups. We carried out open focus groups (n = 2) to gain social perspectives on parenting, and directed focus groups (n = 2) concentrated on parenting self-efficacy. Analysis involved memoing and inductive and deductive coding of transcripts. Caregivers' perceptions of their own parenting were grounded in parenting values such as providing children with basic needs, having well-behaved children, and having good relationships with children. Caregivers' perceptions were influenced by challenges, including single parenthood, living with HIV, limited family resources, and mental health problems. When facing challenges, caregivers relied on social support and faith as well as their own parenting confidence. Caregivers' perceptions of their parenting abilities were influenced by how they felt others perceived them, their satisfaction in the parenting role, their perseverance despite challenges, and the extent to which they had a vision for their family. Our findings contextualize parenting self-efficacy within parenting values, challenges, and social perceptions among HIV-affected caregivers in rural Uganda.Nos propusimos comprender las representaciones sociales de la crianza eficaz y la auto-efectividad en la crianza entre mujeres afectadas con VIH y que prestan cuidados en el área rural del este de Uganda. Realizamos entrevistas profundas (n = 21) para describir las experiencias de crianza y las percepciones de las cuidadoras sobre sus propias habilidades de crianza y para crear esbozos para usar en grupos de enfoque dirigidos. Llevamos a cabo grupos de enfoque a puertas abiertas (n = 2) para conocer las perspectivas sociales acerca de la crianza y dirigimos los grupos de enfoque (n = 2) concentrados en la auto-efectividad de la crianza. Los análisis incluyeron la toma de notas con reflexión y la codificación inductiva y deductiva de las transcripciones. Las percepciones de las cuidadoras acerca de sus propias crianzas se basaron en los valores de la crianza tales como proveerles a los niños las necesidades básicas, tener niños que se comportan bien, así como mantener buenas relaciones con sus niños. Los retos influyeron las percepciones de las cuidadoras; entre ellos se incluyeron el ser una madre sin pareja, vivir con VIH, los limitados recursos familiares y los problemas de salud mental. Cuando se encontraron con retos, las cuidadoras confiaron en el apoyo social y en la fe, así como en la confianza en su propia crianza. Las percepciones de las cuidadoras acerca de sus habilidades de crianza estuvieron influidas por cómo ellas sentían que otros las veían, su satisfacción en el papel de crianza, su perseverancia a pesar de los retos, así como hasta qué punto tenían una visión para su familia. Nuestros resultados contextualizan la auto-efectividad de la crianza dentro de los valores, retos y perspectivas sociales de la misma entre mujeres afectadas por VIH que prestan cuidado en el área rural de Uganda.Nous avons voulu comprendre la représentation sociale du parentage efficace et de l'auto-efficacité de parentage chez des femmes prenant soin d'enfants et affectées par le VIH dans l'Ouganda rural de l'est. Nous avons conduit des entretiens approfondis (n = 21) afin de décrire les expériences de parentage et les perceptions des personnes prenant soin d'enfants de leurs propres capacités au parentage et afin de créer des vignettes pouvant être utilisées dans des groupes de réflexion et de discussion dirigés (n = 1) se concentrant sur l'auto-efficacité de parentage. L'analyse a inclus l'enregistrement de notes et le codage inductif et déductif des retranscriptions. Les perceptions de personnes prenant soin des enfants de leur propre parentage étaient fondées sur les valeurs de parentage, telles que le fait d'offrir aux enfants les soins de base, d'avoir des enfants sages, et de maintenir de bonnes relations avec les enfants. Les perceptions des personnes prenant soin des enfants étaient influencées par les défis auxquelles elles faisaient face, y compris la monoparentalité, le fait de vivre avec le VIH, les ressources familiales limitées et les problèmes de santé mentale. Quand elles faisaient face à des défis, les femmes prenant soin d'enfants se reposaient sur le soutien social et leur foi, ainsi que sur leur propre confiance de parentage. Les perceptions de leurs capacités de parentage étaient influencées par la manière dont elles pensaient que les autres les percevaient, leur satisfaction dans leur rôle de parentage, leur persévérance en dépit des défis, et le degré auquel elles avaient une vision pour leur famille. Nos résultats contextualisent l'auto-efficacité de parentage au sein des valeurs de parentage, des défis et des perceptions sociales chez les femmes prenant soin d'enfants étant affectées par VIH dans l'Ouganda rural.Wir versuchten ein Verständnis über die sozialen Repräsentationen bezüglich effektiver Erziehung und elterlicher Selbstwirksamkeit von weiblichen HIV-infizierten Bezugspersonen im ländlichen Osten Ugandas zu erlangen. Wir führten ausführliche Interviews durch (n = 21) um Erziehungserfahrungen und die Wahrnehmung der eigenen Erziehungskompetenzen aus Sicht der Bezugspersonen zu beschreiben und um Vignetten für den Einsatz in gezielten Fokusgruppen zu erstellen. Wir führten offene Fokusgruppen (n = 2) durch, um soziale Perspektiven auf die Elternschaft zu gewinnen und gezielte Fokusgruppen (n = 2), die sich auf die elterliche Selbstwirksamkeit konzentrierten. Die Analyse umfasste Memoing und die induktive und deduktive Kodierung von Transkripten. Die Wahrnehmung der eigenen Erziehung durch die Bezugspersonen fundierte auf Erziehungswerten, wie z.B. der Versorgung der Kinder mit Grundbedürfnissen, gut erzogene Kinder und gute Beziehungen zu den Kindern. Die Wahrnehmung der Bezugspersonen wurde durch Herausforderungen beeinflusst, darunter das Alleinerziehen von Kindern, das Leben mit HIV, begrenzte Familienressourcen und psychische Probleme. Bei der Bewältigung von Herausforderungen verließen sich die Bezugspersonen auf soziale Unterstützung, ihren Glauben sowie auf ihr eigenes Vertrauen in ihre Erziehungskompetenz. Die Wahrnehmung der Erziehungskompetenzen der Bezugspersonen wurde beeinflusst von der Art und Weise, wie sie sich von anderen wahrgenommen fühlten, von ihrer Zufriedenheit mit der Elternrolle, von ihrer Ausdauer trotz Herausforderungen und von dem Ausmaß einer Vision für ihre Familie. Unsere Ergebnisse kontextualisieren die elterliche Selbstwirksamkeit innerhalb der elterlichen Werte, Herausforderungen und sozialen Wahrnehmungen bei den von HIV betroffenen Bezugspersonen im ländlichen Uganda.ウガンダ東部の貧困とＨＩＶ罹患状況下における育児の自己効力感:質的研究 我々は、ウガンダ東部の地方に住むＨＩＶに罹患した女性養育者における効果的な育児と、育児の自己効力感を示す社会的表象について解明しようとした。我々は、育児経験と養育者自身の育児能力の認識を描写し、指向型フォーカスグループで使用するビネット (記述された場面) を創ることを目的に心の深層に関するインタビュー (n = 21) を行った。育児についての社会的な考え方を得るオープンフォーカスグループ (n = 2) と、育児の自己効力感に集約した指向型フォーカスグループ (n = 2) を実施した。分析にはメモを作成し、帰納的および演繹的な記録のコード化を行った。養育者自身の自分の育児についての認識は、子どもに基本的なニーズを提供すること、行儀の良い子どもを持つこと、子どもとの良い関係性を持つことなどの、育児の価値観に基づいていた。養育者の認識は、片親であること、ＨＩＶを抱えて生きること、家族の資源が限られていること、メンタルヘルスの問題を含む課題をもつこと、により影響を受けていた。課題に直面したとき、養育者は自分の育児に対する自信と社会的支援と信仰に頼っていた。養育者の育児能力の認識は、他者が自分を認めてくれているときの感じ方、育児役割における満足度、課題の有無にかかわらない忍耐力、そして家族のための展望の程度に影響されていた。我々の調査結果から、ウガンダの地方におけるHIV罹患の養育者において、育児の価値観、課題、そして社会的認識における育児の自己効力感について説明できる。.烏干達東部貧困和艾滋病毒背景下的育兒自我效能:定性研究 我們試圖了解烏干達東部農村地區受艾滋病影響的女性照顧者的有效養育和養育自我效能的社會表徵。我們進行深入訪談 (n = 21) , 以描述育兒經歷和照顧者對自己養育能力的看法, 並創造用於定向焦點小組的短文。我們開展了開放焦點小組 (n = 2) , 以獲得關於養育和定向焦點小組 (n = 2) 的社會觀點, 集中於養育自我效能感。分析涉及成績單的備忘錄, 歸納和演繹編碼。看護者對自己養育子女的看法是基於養育子女的價值觀, 例如為孩子提供基本需求, 教導行為良好的孩子, 及與孩子建立良好的關係。照顧者的看法受到挑戰的影響, 包括單親家庭丶艾滋病病毒丶有限的家庭資源和心理健康問題。面對挑戰時, 照顧者依靠他人支持和信仰, 以及他們自己的養育信心。看護者對其養育能力的看法, 受到其他人對他們看法丶他們對養育子女的滿意度丶他們在遇到挑戰時的毅力以及他們對家庭有遠見程度的影響。我們的研究結果將烏干達農村地區受艾滋病影響的照顧者的養育價值觀丶挑戰和社會認知中的養育自我效能情境化。.الكفاية الذاتية في الرعاية الوالدية في سياق الفقر وفيروس نقص المناعة المكتسبة (HIV) في شرق أوغندا: دراسة وصفية سعت هذه الدراسة إلى فهم التمثيل الاجتماعي للرعاية الوالدية الفعالة والكفاية الوالديه الذاتية بين مقدمي الرعاية من الإناث المصابات بفيروس (HIV) في المناطق الريفية في شرق أوغندا. وتم إجراء مقابلات مفصلة (n = 21) لوصف تجارب الابوه والامومه وتصورات مقدمي الرعاية لقدراتهم في الرعاية الوالدية ولوضع نماذج لاستخدامها في مجموعات التركيز الموجهة. وبذلك تم عقد مجموعات التركيز المفتوحة (n = 2) للحصول على وجهات النظر الاجتماعية حول الابوه والامومه ومجموعات التركيز الموجهة (n = 2) والتي تركز على الكفاية الذاتية الوالدية. تضمن تحليل البيانات الترميز الاستقرائي والاستنتاجي لنص المقابلات الشخصية. وقد استندت تصورات مقدمي الرعاية عن الأبوة والأمومة على قيم الرعاية الوالدية ، مثل توفير الاحتياجات الاساسيه للأطفال ، والحصول على أطفال ذوي سلوكيات جيدة ، وإقامه علاقات جيدة مع الأطفال. وتأثرت تصورات مقدمي الرعاية بالتحديات ، بما في ذلك مشكلة العائل الوحيد ، والتعرض لفيروس (HIV) ، ومحدوديه موارد الاسره ، ومشاكل الصحة النفسية . وعند مواجهه التحديات ، يعتمد مقدمو الرعاية علي الدعم الاجتماعي والإيمان ، فضلا عن ثقتهم في قدراتهم في الرعاية الوالدية . وقد تأثرت تصورات مقدمي الرعاية لقدراتهم الابويه بكيفية إدراكهم لرؤية الآخرين لهم ، ورضاهم عن دور الأبوة والأمومة ، ومثابرتهم علي الرغم من التحديات ، ومدي ما لديهم من رؤية لأسرهم. وتضع نتائج الدراسة الكفاية الذاتية للوالدين في سياق قيم الأبوة والتحديات والتصورات الاجتماعية لدي مقدمي الرعاية المصابين بالفيروس في المناطق الريفية في أوغندا.

Purpose The purpose of this study was to construct and validate a recorded word recognition test for monolingual Spanish-speaking children utilizing a picture board and a picture-pointing task. Design The Spanish Pediatric Picture Identification Test was developed and validated in this study. Test construction steps included (a) producing new digital recordings of word lists created by Comstock and Martin (1984) using a bilingual Spanish–English female, (b) obtaining list equivalency, (c) creating digitally illustrated pictures representing the word lists, (d) validating the pictures using monolingual Spanish-speaking and bilingual Spanish–English children, and (e) re-establishing list equivalency and obtaining performance–intensity functions using a picture-pointing task with monolingual Spanish-speaking children and bilingual Spanish–English adults. Results Normative data for three Spanish word recognition lists were established. Performance–intensity functions at sensation levels from 0 to 40 dB SL in 8-dB steps were obtained, establishing list equivalency for Lists 1, 2, and 3. Conclusions The Spanish Pediatric Picture Identification Test was developed and validated as a picture-pointing task for word recognition with monolingual Spanish-speaking children. The two validated channel recordings include an English translation for ease of testing by clinicians lacking Spanish language skills. Future validation will be conducted with bilingual Spanish–English children with normal hearing and with hearing loss.

Background Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions. Methods PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR). Results A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven. Conclusion Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide. Electronic supplementary material The online version of this article (10.1186/s12916-018-1237-x) contains supplementary material, which is available to authorized users.

Background Low-grade gliomas (LGGs) and low-grade glioneuronal tumors (LGGNTs) diagnosed during the first year of life carry unique clinical characteristics and challenges in management. However, data on the treatment burden, outcomes, and morbidities are lacking. Methods A retrospective study of LGGs and LGGNTs diagnosed in patients younger than 12 months at St. Jude Children's Research Hospital (1986-2015) was conducted. Results For the 51 patients (including 31 males), the mean age at diagnosis was 6.47 months (range, 0.17-11.76 months), and the mean follow-up period was 11.8 years (range, 0.21-29.19 years). Tumor locations were hypothalamic/optic pathway (61%), hemispheric (12%), brainstem (12%), cerebellar (8%), and spinal (8%). There were 41 patients with histological diagnoses: 28 had World Health Organization grade 1 tumors, 6 had grade 2 tumors, and 7 had an LGG/LGGNT not definitively graded. Forty-one patients required an active intervention at diagnosis. Throughout their treatment course, 41 patients eventually underwent tumor-directed surgeries (median, 2 surgeries; range, 1-6), 39 received chemotherapy (median, 2 regimens; range, 1-13), and 21 received radiotherapy. Forty patients experienced disease progression (median, 2 progressions; range, 1-18). Ten patients died of progression (n = 5), malignant transformation (n = 2), a second cancer (n = 2), or a shunt infection (n = 1). The 10-year overall survival, progression-free survival, and radiation-free survival rates were 85% ± 5.3%, 16.9% ± 5.3%, and 51.2% ± 7.5%, respectively. Forty-nine patients experienced health deficits (eg, endocrinopathies, obesity, seizures, visual/hearing impairments, neurocognitive impairments, and cerebrovascular disease). Predictors of progression and toxicities were defined. Conclusions Infantile LGG/LGGNT is a chronic, progressive disease universally associated with long-term morbidities and requires multidisciplinary intervention.

PURPOSE: Low-grade gliomas (LGG) are a heterogeneous group of brain tumors, which are often assumed to have a benign course. Yet, children diagnosed and treated for LGG in infancy are at increased risk for neurodevelopmental disruption. We sought to investigate neuropsychological outcomes of infants diagnosed with LGG. METHODS: Between 1986 and 2013, 51 patients were diagnosed with LGG before 12 months of age and managed at St. Jude Children’s Research Hospital. Twenty-five of the 51 patients received a cognitive assessment (68% male; 6.8 ± 3.3 months at diagnosis; 10.5 ± 4.8 years at latest assessment). Approximately half the patients received radiation therapy (n = 12; aged 4.0 ± 3.0 years at radiation therapy), with a median of 2 chemotherapy regimens (range = 0 – 5) and 1 tumor directed surgery (range = 0 – 5). RESULTS: The analyses revealed performance below age expectations on measures of IQ, memory, reading, mathematics, and fine motor functioning as well as parent-report of attention, executive, and adaptive functioning. Following correction for multiple comparisons, a greater number of chemotherapy regimens was associated with lower scores on measures of IQ and mathematics. More tumor directed surgeries and presence of visual field loss were associated with poorer dominant hand fine motor control. Radiation therapy exposure was not associated with decline in neuropsychological performance. CONCLUSIONS: Children diagnosed with LGG in infancy experience substantial neuropsychological deficits. Treatment factors, including number of chemotherapy regimens and tumor directed surgeries, may increase risk for neurodevelopmental disruption and need to be considered in treatment planning.

World Health Organization (WHO) guidelines call for antiretroviral therapy (ART) for all people living with HIV (PLWH) regardless of CD4 cell count, a policy often referred to as ‘treat all’. This article seeks to: (1) provide an overview of mental health research among PLWH in sub-Saharan Africa (SSA) and interventions or strategies to address comorbid mental illness among those living with HIV; and (2) describe key mental health-related recommendations to inform the successful implementation and scale up of ‘treat all’ policies in SSA. An initial set of mental health-related research recommendations was developed by a working group comprising investigators affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Recommendations were shared with those who attended the All-Africa IeDEA Meeting in Kigali, Rwanda in November 2017 and refined following the meeting. Recommendations reflect a need for epidemiological research to examine the prevalence, incidence, and impact of mental health multimorbidities on HIV treatment outcomes, intervention research to examine the extent to which improving the mental health of people living with HIV enhances HIV treatment outcomes, and implementation science research to evaluate promising models of integrated mental health and HIV care. Key research recommendations can advance understanding and treatment of mental illness among those living with HIV in sub-Saharan Africa and beyond.

Very few studies of peer victimization have been conducted in low-resource countries, where cultural and contextual differences are likely to influence the dynamics of these experiences in ways that may reduce the generalizability of findings of the larger body of literature. Most studies in these settings are also subject to multiple design limitations that restrict our ability to understand the dynamics of peer victimization experiences. Person-centered approaches such as latent class analysis are an improvement on more traditional modeling approaches as they allow exploration of patterns of victimization experiences. The goal of the current study was to examine associations between patterns of peer victimization in adolescence and both concurrent and longitudinal psychosocial adjustment. Data were included for 3536 youth (49.6% female) in Ethiopia, India, Peru, and Vietnam to examine associations between adolescent peer victimization and indicators of poor psychosocial adjustment. Previously derived latent classes of peer victimization based on youth self-report of past-year exposure to nine forms of peer victimization at age 15 were used to predict self-reported emotional difficulties, self-rated health, and subjective wellbeing at ages 15 and 19 while controlling for sex. The findings show that at age 15, victimization was associated with higher emotional difficulties in all settings, lower subjective wellbeing in all except Peru, and lower self-rated health in Vietnam. At follow-up, all associations had attenuated and were largely non-significant. Sensitivity analyses confirmed the robustness of these results. These findings illustrate the multifinality of outcomes of peer victimization, suggesting social and developmental influences for potential pathways of resilience that hold promise for informing interventions and supports in both low and high resource settings.

Purpose Compared to photon-based radiotherapy, protons deliver less radiation to healthy tissue resulting in the potential reduction of late complications such as sensorineural hearing loss (SNHL). We report early auditory outcomes in children treated with proton radiotherapy (PRT) for craniopharyngioma. Method Conventional frequency (CF = 0.25–8.0 kHz) audiometry, extended high-frequency (EHF = 9.0–16.0 kHz) audiometry, distortion product otoacoustic emission (DPOAE) testing, and speech-in-noise (SIN) assessments were prospectively and longitudinally conducted on 74 children with a median of 2 post-PRT evaluations (range, 1–5) per patient. The median age at PRT initiation was 10 years, and median follow-up time was 2 years. Ototoxicity was classified using the Chang Ototoxicity Grading Scale (Chang & Chinosornvatana, 2010) and the American Speech-Language-Hearing Association (ASHA) criteria (ASHA, 1994). Comparisons were made between baseline and most recent DPOAE levels, with evidence of ototoxicity based on criterion reductions of ≥ 6 dB. The critical difference values for comparing SIN scores between two conditions (i.e., pre- and post-PRT) were used to determine a significant change between test scores. Results At last evaluation, no patients had SNHL in the CF range, and 2 patients had SNHL (Chang Grade 1a) in the EHF range. Based on the ASHA criteria, a decrease in hearing was observed in 0 patients in the CF range alone, in 9 patients in the EHF range alone, and in 15 patients in both the CF and EHF ranges. DPOAE levels decreased at a faster rate at higher versus lower frequencies. For 41 evaluable patients, SIN perception did not decline over time ( p = .6463). Conclusion At a median follow-up time of 2 years post-PRT, normal hearing was maintained within the CF range. However, subclinical decreases in hearing were observed, particularly in the EHF range and in the DPOAE level; thus, long-term follow-up is recommended to monitor for potential auditory late effects from PRT.

The global population of older adults (60 years and older) has been growing steadily; however, inadequate attention is given to the health needs of older persons, particularly within contexts of conflict and migration. This paper reports findings from the qualitative phase of an investigation assessing the mental health status of older adult internally displaced persons (IDPs) in Georgia, a country in the South Caucasus. The study aimed to assess community-wide social and health problems among older adult IDPs, with a focus on mental health problems and healthy functioning, as well as terminology used to describe these problems. Free-list interviews with older adult IDPs (n = 75) and key informant interviews with community members and service providers (n = 45) were conducted in 2010–2011 in three regions of Georgia: Tbilisi, Shida Kartli, and Samegrelo. Findings demonstrated that older IDPs experienced symptoms of distress that could be clustered into depression-like and anxiety-like syndromes. Participants described other psychosocial problems among older IDPs, including feelings of abandonment, isolation, and passivity, as well as conflicts in the family. All problems were linked with displacement-related experiences, such as difficulties with integration, grief, and war trauma. The expression of displacement-related problems was identified as an idiom of distress for this population. Older IDPs coped with these problems through social support mechanisms, including socializing, helping each other, working, and participating in the community. Key modalities for redressing older IDPs' psychosocial problems, improving quality of life, and achieving healthy ‘aging-in-displacement’ include: promoting social connectedness and community engagement, drawing on IDPs' skills, identifying new social roles, and strengthening social support networks.

Background In Ukraine, a large number of internally displaced persons (IDPs) and veterans experience social and psychological problems as a result of the ongoing conflict between Ukraine and Russia. Our purpose was to develop reliable and valid instruments to screen for common mental health and alcohol use problems in these populations. Methods We used a three-step process of instrument adaptation and testing. The instrument—the Mental Health Assessment Inventory (MHAI)—combines adapted standard screeners with items derived locally in Ukraine. A validity study was conducted using a sample of 153 adults (54% male) ages 18 years and older. All participants in the sample were IDPs or veterans living in or near the major urban areas of Kyiv and Zaporizhia. Reliability testing (internal consistency, test-retest) and validity testing (construct, criterion) of the MHAI were conducted using classical test theory. After initial testing, we used Item Response Theory (IRT) to shorten and further refine the instrument. Results The MHAI showed good internal consistency and test-retest reliability for the main outcomes: depression (α = 0.94; r = .84), post-traumatic stress (PTS; α = 0.97; r = 0.87), anxiety (α = 0.90; r = 0.80), and alcohol use (α = 0.86; r = 0.91). There was good evidence of convergent construct validity among the scales for depression, PTS, and anxiety, but not for alcohol use. Item Response Theory (IRT) analysis supported use of shortened versions of the scales for depression, PTS, and anxiety, as they retained comparable psychometric properties to the full scales of the MHAI. Conclusion The findings support the reliability and validity of the assessment—the MHAI—for screening of common mental health problems among Ukrainian IDPs and veterans. Use of IRT shortened the instrument to improve practicality and potential sustainability.

Perinatal mental health problems such as depression and anxiety are prevalent in low and middle-income countries. In Mali, the lack of mental health care is compounded by few studies on mental health needs, including in the perinatal period. This paper examines the ways in which perinatal women experience and express mental distress in rural Mali. We describe a process, relying on several different qualitative research methods, to identify understandings of mental distress specific to the Malian context. Participants included perinatal women, maternal health providers, and community health workers in rural southwest Mali. Participants articulated several idioms of distress, including geleya (difficulties), tooro (pain, suffering), hamin (worries, concerns), and dusukasi (crying heart), that occur within a context of poverty, interpersonal conflict, and gender inequality. These idioms of distress were described as sharing many key features and operating on a continuum of severity that could progress over time, both within and across idioms. Our findings highlight the context dependent nature of experiences and expressions of distress among perinatal women in Mali.

Incidence of depressive disorders and symptoms increases during the transition to adulthood. The parenting relationship is a potential target for interventions to reduce risk for depression in offspring during this time period, and a four-category typology of parenting styles (authoritative, permissive, authoritarian, and neglectful) has been found to correlate with offspring psychological functioning. The majority of studies, however, have examined this four-category parenting style typology in Western populations. We used the Cebu Longitudinal Health and Nutrition Survey (CLHNS) from the Philippines to assess associations between parenting styles reported by offspring at age 18 and depressive symptoms reported by offspring at age 21 ( N = 1,723). Using adjusted linear regression models, we found that authoritarian and neglectful mothering styles were positively associated with daughters' depressive symptoms, whereas authoritarian mothering was negatively associated with sons' depressive symptoms. Findings suggest both cross-cultural similarities and variability in positive parenting. Results may have implications for family-based depression prevention interventions in the Philippines.

Poor mental health detrimentally affects quality of life among women living with HIV/AIDS. An improved understanding of how coping and social support relate to depression and anxiety in this population can facilitate the design and implementation of appropriate mental health treatment and support services. Secondary analysis was conducted on baseline data from 288 HIV-positive women enrolled in a parenting intervention in Uganda. Depression and anxiety symptoms, social support, and coping were assessed with the Hopkins Symptom Checklist and adapted versions of the Multidimensional Scale for Perceived Social Support and Ways of Coping Questionnaire. General linear regression models were used to estimate associations between coping and mental health. Based on report of elevated symptoms, approximately 10% of women were categorized as having clinically-relevant depression or anxiety. Emotion-focused (EF: p

Background Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. Methods We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. Results Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3–17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7–14.1 years), and median age at surgery was 6.8 years (range, 0.7–14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). Conclusions Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

Summary Background Survivors of childhood cancer develop early and severe chronic health conditions (CHCs). A quantitative landscape of morbidity of survivors, however, has not been described. We aimed to describe the cumulative burden of curative cancer therapy in a clinically assessed ageing population of long-term survivors of childhood cancer. Methods The St Jude Lifetime Cohort Study (SJLIFE) retrospectively collected data on CHCs in all patients treated for childhood cancer at the St Jude Children's Research Hospital who survived 10 years or longer from initial diagnosis and were 18 years or older as of June 30, 2015. Age-matched and sex-frequency-matched community controls were used for comparison. 21 treatment exposure variables were included in the analysis, with data abstracted from medical records. 168 CHCs for all participants were graded for severity using a modified Common Terminology Criteria of Adverse Events. Multiple imputation with predictive mean matching was used for missing occurrences and grades of CHCs in the survivors who were not clinically evaluable. Mean cumulative count was used for descriptive cumulative burden analysis and marked-point-process regression was used for inferential cumulative burden analysis. Findings Of 5522 patients treated for childhood cancer at St Jude Children's Research Hospital who had complete records, survived 10 years or longer, and were 18 years or older at time of study, 3010 (54·5%) were alive, had enrolled, and had had prospective clinical assessment. 2512 (45·5%) of the 5522 patients were not clinically evaluable. The cumulative incidence of CHCs at age 50 years was 99·9% (95% CI 99·9–99·9) for grade 1–5 CHCs and 96·0% (95% CI 95·3–96·8%) for grade 3–5 CHCs. By age 50 years, a survivor had experienced, on average, 17·1 (95% CI 16·2–18·1) CHCs of any grade, of which 4·7 (4·6–4·9) were CHCs of grade 3–5. The cumulative burden in matched community controls of grade 1–5 CHCs was 9·2 (95% CI 7·9–10·6; p vs total study population) and of grade 3–5 CHCs was 2·3 (1·9–2·7, p vs total study population). Second neoplasms, spinal disorders, and pulmonary disease were major contributors to the excess total cumulative burden. Notable heterogeneity in the distribution of CHC burden in survivors with differing primary cancer diagnoses was observed. The cumulative burden of grade 1–5 CHCs at age 50 years was highest in survivors of CNS malignancies (24·2 [95% CI 20·9–27·5]) and lowest in survivors of germ cell tumours (14·0 [11·5–16·6]). Multivariable analyses showed that older age at diagnosis, treatment era, and higher doses of brain and chest radiation are significantly associated with a greater cumulative burden and severity of CHCs. Interpretation The burden of CHCs in survivors of childhood cancer is substantial and highly variable. Our assessment of total cumulative burden in survivors of paediatric cancer, with detailed characterisation of long-term CHCs, provide data to better inform future clinical guidelines, research investigations, and health services planning for this vulnerable, medically complex population. Funding The US National Cancer Institute, St Baldrick's Foundation, and the American Lebanese Syrian Associated Charities.

OBJECTIVE Early childhood development programs typically combine healthy nutrition and cognitive stimulation in an integrated model. We separately delivered these 2 components in a cluster-randomized controlled trial to evaluate their comparative effectiveness in promoting healthy child development and caregiver mental health. This is the first study to do so for HIV-affected children and their infected mothers. METHODS Two hundred twenty-one HIV-exposed but uninfected child (2-3 years old) and caregiver dyads in 18 geographic clusters in Eastern Uganda were randomized by cluster to receive biweekly individualized sessions of either (1) Mediational Intervention for Sensitizing Caregivers (MISC) training emphasizing cognitive stimulation or (2) Uganda Community Based Association for Child Welfare (UCOBAC) program that delivered health and nutrition training. Children were evaluated at baseline, 6 months, 1 year (training conclusion), and 1-year posttraining with the Mullen Scales of Early Learning (MSEL), the Color-Object Association Test for memory, the Early Childhood Vigilance Test of attention, and the Behavior Rating Inventory of Executive Function (BRIEF-parent). The Caldwell Home Observation for the Measurement of the Environment (HOME) was completed by observers to gauge caregiving quality after training. Caregiver depression/anxiety (Hopkins Symptom Checklist-25) and functionality (list of activities of daily living) were also evaluated. Data collectors were blinded to trial arm assignment. RESULTS Mediational Intervention for Sensitizing Caregivers resulted in significantly better quality of caregiving compared with UCOBAC midintervention with an adjusted mean difference (MadjDiff) of 2.34 (95% confidence interval [CI]: 1.54-3.15, p < .01), postintervention (MadjDiff = 2.43, 95% CI: 1.61-3.25, p < .01), and at 1-year follow-up (MadjDiff = 2.07, 95% CI: 1.23-2.90, p < .01). MISC caregivers reported more problems on the BRIEF for their child at 1-year posttraining only (p < .01). Caregiving quality (HOME) was significantly correlated with MSEL composite performance 1-year posttraining for both the MISC and the UCOBAC trial arms. Likewise, physical growth was significantly related to child development outcomes even though it did not differ between trial arms. CONCLUSION Even though MISC demonstrated an advantage of improving caregiving quality, it did not produce better child cognitive outcomes compared with health and nutrition training. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01640561.

To date global research on depression has used assessment tools based on research and clinical experience drawn from Western populations (i.e., in North American, European and Australian). There may be features of depression in non-Western populations which are not captured in current diagnostic criteria or measurement tools, as well as criteria for depression that are not relevant in other regions. We investigated this possibility through a systematic review of qualitative studies of depression worldwide. Nine online databases were searched for records that used qualitative methods to study depression. Initial searches were conducted between August 2012 and December 2012; an updated search was repeated in June of 2015 to include relevant literature published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles. A total of 16,130 records were identified and 138 met full inclusion criteria. Included studies were published between 1976 and 2015. These 138 studies represented data on 170 different study populations (some reported on multiple samples) and 77 different nationalities/ethnicities. Variation in results by geographical region, gender, and study context were examined to determine the consistency of descriptions across populations. Fisher’s exact tests were used to compare frequencies of features across region, gender and context. Seven of the 15 features with the highest relative frequency form part of the DSM-5 diagnosis of Major Depressive Disorder (MDD). However, many of the other features with relatively high frequencies across the studies are associated features in the DSM, but are not prioritized as diagnostic criteria and therefore not included in standard instruments. The DSM-5 diagnostic criteria of problems with concentration and psychomotor agitation or slowing were infrequently mentioned. This research suggests that the DSM model and standard instruments currently based on the DSM may not adequately reflect the experience of depression at the worldwide or regional levels.

Bullying is one of the most common forms of aggression experienced by school-aged youth, yet research is sparse in low- and middle-income countries (LMIC) where cultural and contextual factors may influence victimization dynamics. We aimed to examine correlates of victimization and the prevalence of specific victimizing behaviors among youth in four LMIC. Data were included from 3,536 youth collected as part of the ongoing Young Lives Study cohorts in Ethiopia, India (Andhra Pradesh), Peru, and Vietnam who reported frequency of past-year exposure to nine bullying behaviors at age 15. We calculated both total victimization scores and subtype victimization scores (physical, verbal, relational, and property) by summing the frequencies of experiencing each behavior and used hurdle modeling to examine, separately by country, associations between three demographic correlates (sex, urban/rural setting, and school enrollment) and both total and subtype victimization scores, adjusting for clustered sampling. Mean past-year victimization scores were 11.1 in Ethiopia, 13.4 in India, 14.9 in Peru, and 12.0 in Vietnam, indicating that the average youth in Ethiopia reported two victimization experiences in the past year, up to nearly six in Peru. With the exception of Peru, direct victimization was higher among boys compared with girls, whereas relational victimization was not associated with sex. Physical bullying was less common than other forms of bullying in Ethiopia, Peru, and Vietnam but had a similar frequency as other forms in India. The different patterns in victimization experiences across the samples suggest that culture and/or context may influence victimization dynamics and highlights the need to better understand patterns and variation of bullying victimization in LMIC.

Characterization of toxicity associated with cancer and its treatment is essential to quantify risk, inform optimization of therapeutic approaches for newly diagnosed patients, and guide health surveillance recommendations for long-term survivors. The NCI Common Terminology Criteria for Adverse Events (CTCAE) provides a common rubric for grading severity of adverse outcomes in cancer patients that is widely used in clinical trials. The CTCAE has also been used to assess late cancer treatment-related morbidity but is not fully representative of the spectrum of events experienced by pediatric and aging adult survivors of childhood cancer. Also, CTCAE characterization does not routinely integrate detailed patient-reported and medical outcomes data available from clinically assessed cohorts. To address these deficiencies, we standardized the severity grading of long-term and late-onset health events applicable to childhood cancer survivors across their lifespan by modifying the existing CTCAE v4.03 criteria and aligning grading rubrics from other sources for chronic conditions not included or optimally addressed in the CTCAE v4.03. This article describes the methods of late toxicity assessment used in the St. Jude Lifetime Cohort Study, a clinically assessed cohort in which data from multiple diagnostic modalities and patient-reported outcomes are ascertained. Cancer Epidemiol Biomarkers Prev; 26(5); 666–74. ©2016 AACR.

Background: While evidence is growing for the efficacy of trauma-focused mental health interventions in low- and middle-income countries, concerns have been raised about whether these types of interventions can be effectively delivered in contexts with ongoing conflict and violence. Cognitive Processing Therapy (CPT) has been shown to be effective in reducing sexual violence survivors’ psychological symptoms in eastern Democratic Republic of the Congo (DRC), a region with a history of chronic conflict. Objective: The purpose of the present study is to assess the degree to which exposure to different levels of ongoing insecurity impacts effectiveness of an evidence-based trauma-focused psychotherapy for sexual violence survivors. Method: Participants were 158 female sexual violence survivors receiving CPT in seven communities in South Kivu. Participants completed weekly assessments of their symptoms of PTSD and depression as part of CPT. Degree of site insecurity was categorized as high or low levels of ongoing insecurity based on information collected from supervisors and clinicians. Hierarchical linear modelling was used to examine change over time moderated by level of insecurity at the site. Results: Overall, women reported a significant reduction in psychological symptoms over time (b = −2.04, p

OBJECTIVES: Parenting self-efficacy has been associated with positive parenting behaviors, fewer parental mental health problems, less family dysfunction, and better child development outcomes. The parenting sense of competence (PSOC) scale is commonly used to measure parenting self-efficacy in high-resource settings. This study sought to examine the factor structure, internal consistency, and convergent construct validity of the PSOC in a sample of predominantly HIV-infected women in Uganda. METHODS: Using data from 155 HIV-affected caregivers who participated in a randomized controlled trial of a parenting intervention, two and three factor models of a 16-item translated version of the PSOC were tested using confirmatory factor analysis. Multivariable regression models were used to examine relationships between parenting confidence (operationalized using the best-fitting PSOC model), caregiver mental health symptoms (depression and anxiety), social support, family dysfunction, and family wealth, after adjusting for covariates. RESULTS: Neither the two- nor three-factor models of the PSOC demonstrated adequate model fit; however, adequate model fit was demonstrated for a one-factor model that included only items from the PSOC efficacy subscale. Cronbach’s alpha was 0.73 for this subscale. Correlates of parenting self-efficacy in this sample included caregiver depression, family dysfunction, and family wealth, but not caregiver anxiety or social support. CONCLUSIONS FOR PRACTICE: These findings lend support for future use of the PSOC efficacy subscale among HIV-affected caregivers of children in low-resource settings such as rural Uganda.

This chapter seeks to explore the need for the ongoing growth and development of collaborative efforts among institutions seeking to serve underserved and underprepared students, especially African American males, and their stakeholders. The chapter provides a brief historical context of public K-12 education and Historically Black Colleges and Universities. The objective is to provide context for today's academic challenges among African American males, subsequently providing alternatives to the current academic framework, revising the “pipeline” structure with an artery mode. This model reflects a holistic education framework that provides a strong cultural and social foundation; continuity in curriculum, education funding, and policy; and engages all constituents of the community, positively benefitting underserved families and students, particularly African American males.

Aims Patients with severe mental disorders in low-resource settings have limited access to services, resulting in overwhelming caregiving burden for families. In extreme cases, this has led to the long-term restraining of patients in their homes. China underwent a nationwide initiative to unlock patients and provide continued treatment. This study aims to quantify household economic burden in families after unlocking and treatment, and to identify factors associated with increased burden due to schizophrenia. Methods A total of 264 subjects were enrolled from three geographically diverse provinces in 2012. Subjects were patients with schizophrenia who were previously put under restraints and had participated in the ‘unlocking and treatment’ intervention. The primary outcome was the current household economic burden, obtained from past year financial information collected through on-site interview. Patient disease characteristics, treatment, outcomes and family caregiving burden were collected as well. Univariate and multivariate linear regression were used to construct risk factor models for indirect economic burden. Results After participating in the intervention, 85% of patients continued to receive mental health services, 70% used medication as prescribed and 80% were never relocked. Family members reported significantly decreased caregiving burden after receiving the intervention. Mean direct and indirect household economic burdens were CNY963 (US$31.7) and CNY11 724 (US$1670) per year, respectively, while family total income was on average CNY12 108 (US$1913) per year. Greater disease severity and poorer patient psychosocial function at time of study were found to be independent factors related to increased indirect burden. Conclusions The ‘unlocking and treatment’ intervention has improved the lives of patients and families. Indirect burden due to disease is still a major economic issue that needs to be addressed, potentially through improving treatment and patient functioning. Our findings contribute to the unravelling and eventual elimination of chronic restraining of mentally ill patients in low-resource settings.

OBJECTIVE: Early childhood development (ECD) programs can enhance neurocognitive development outcomes through caregiver training. This study explores whether school-age siblings benefited from a program provided to HIV-infected caregivers and their preschool-aged target children. METHODS: Siblings of target 2- to 3-year-old children in ECD intervention households were evaluated at school age (5–12 years) on neurocognitive outcomes with the Kaufman Assessment Battery for Children (KABC), computerized Test of Variables of Attention, Behavior Rating Inventory for Executive Function (BRIEF; parent), and attention-deficit/hyperactivity disorder rating inventory (ADHD-R)-IV (parent). Households from 18 geographic clusters in eastern Uganda were randomized to individualized biweekly sessions of either (1) Mediational Intervention for Sensitizing Caregivers (MISC) training emphasizing cognitive stimulation/enrichment or (2) health/nutrition/development [Uganda Community-Based Association For Women & Children Welfare (UCOBAC)] program. Siblings with baseline and at least 1 follow-up assessment (n = 216) were included in the analysis. Three repeated postbaseline measures of sibling neurocognitive outcomes were analyzed using the linear mixed-effects model while adjusting for socioeconomic status and behavioral outcome at baseline. RESULTS: Siblings in the MISC arm had better performance on KABC sequential processing at 6 months (p = 0.02) and simultaneous processing at 12 months (p = 0.03). MISC mothers rated their children as having significantly more problems on the BRIEF and ADHD-RS-IV (p < 0.01) than UCOBAC mothers across all time points. CONCLUSION: Mediational Intervention for Sensitizing Caregivers training resulted in some short-term neurocognitive benefits for school-aged siblings, but these differences were not sustained at 1-year follow-up. Exploring potential impacts of parenting programs on other children in the home is an important development for the field.

Background There is a need for accurate and efficient assessment tools that cover a range of mental health and psychosocial problems. Existing, lengthy self-report assessments may reduce accuracy due to respondent fatigue. Using data from a sample of adults enrolled in a psychotherapy randomized trial in Thailand and a cross-sectional sample of adolescents in Zambia, we leveraged Item Response Theory (IRT) methods to create brief, psychometrically sound, mental health measures. Methods We used graded-response models to refine scales by identifying and removing poor performing items that were not well correlated with the underlying trait, and by identifying well-performing items at varying levels of a latent trait to assist in screening or monitoring purposes. Results In Thailand, the original 17-item depression scale was shortened to seven items and the 30-item Posttraumatic Stress Scale (PTS) was shortened to 10. In Zambia, the Child Posttraumatic Stress Scale (CPSS) was shortened from 17 items to six. Shortened scales in both settings retained the strength of their psychometric properties. When examining longitudinal intervention effects in Thailand, effect sizes were comparable in magnitude for the shortened and standard versions. Conclusions Using Item Response Theory (IRT) we created shortened valid measures that can be used to help guide clinical decisions and function as longitudinal research tools. The results of this analysis demonstrate the reliability and validity of shortened scales in each of the two settings and an approach that can be generalized more broadly to help improve screening, monitoring, and evaluation of mental health and psychosocial programs globally.

This chapter discusses the concepts, definitions, measurement instruments, and sources of data bearing on global mental health and mental illness. The discussion reveals the limited use of system-level instruments and readily comparable global data to help guide international public mental health policy. The chapter includes selected data on mental health systems around the world and gives an overview of mental health–related activities by leading international agencies such as the World Health Organization (WHO) Department of Mental Health and Substance Abuse, the United Nations Interagency Task Force (UNIATF) on the Prevention and Control of Non-communicable Diseases, the United Nations International Children’s Educational Fund (UNICEF), the United Nations High Commissioner for Refugees (UNHCR), and a range of international research consortia. The presence or absence of mental health policy, the presence of law relevant to mental health, and the presence of mental health care facilities around the world are reviewed.