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Background: High rates of intimate partner violence (IPV) and mental disorders are present in Mozambique where there is a significant treatment gap. We aimed to report Mozambican community stakeholder perspectives of implementing couple-based interpersonal psychotherapy (IPT-C) in preparation for a pilot trial in Nampula City., Methods: We conducted 11 focus group discussions (6-8 people per group) and seven in-depth interviews with key informants in mental health or gender-based violence ( n  = 85) using purposive sampling. We used grounded theory methods to conduct an inductive coding and then deductively applied the consolidated framework for implementation research (CFIR)., Results: For the outer setting, local attitudes that stigmatize mental health conditions and norm IPV as well as an inefficient legal system were barriers. Stakeholders expressed high acceptability of IPT-C, although a lack of resources was a structural challenge for the inner setting. Adaptation of the approach to screen for and address potential mediators of IPV was important for adopting a multisectoral response to implementation and planning. Delivering IPT-C in the community and in collaboration with community stakeholders was preferable., Conclusion: Stakeholders recommended multilevel involvement and inclusion of community-based programming. Task shifting and use of technology can help address these resource demands., Competing Interests: The authors declare that they have no competing interests., (© The Author(s) 2024.)

Background: A central challenge to closing the mental health treatment gap in low- and middle-income countries (LMICs) is determining the most effective pathway for delivering evidence-based mental health services. We are conducting a cluster-randomized, Type 2 hybrid implementation-effectiveness trial across 20 districts of Mozambique called the Partnerships in Research to Implement and Disseminate Sustainable and Scalable EBPs (PRIDE) program. Following training of nonspecialized providers in facilitation of evidence-based treatments for mental health and informed by the Consolidated Framework for Implementation Research (CFIR), we identified how PRIDE compares to care as usual and the perceived barriers and facilitators of implementation and modifications needed for widescale service delivery and scale-up., Methods: We conducted rapid ethnographic assessment using freelisting among 34 providers, followed by four focus group discussions (n = 29 participants) with a subsample of psychiatric technicians and primary care providers from 14 districts in Nampula Province. We used Thematic Analysis to inductively apply open codes to transcripts and then deductively applied the CFIR domains and constructs to organize open codes., Results: The main Outer Setting constructs relevant to implementation were recognition that patient mental health needs were significant. Additionally, numerous community-level characteristics were identified as barriers, including distance between clinics; shortage of providers; and low awareness of mental health problems, stigma, and discrimination among community members towards those with mental health struggles. The PRIDE program was perceived to offer a relative advantage over usual care because of its use of task-sharing and treating mental illness in the community. PRIDE addressed Inner Setting barriers of having available resources and training and provider low self-efficacy and limited knowledge of mental illness. Providers recommended leadership engagement to give support for supervision of other task-shared professionals delivering mental healthcare., Conclusions: Primary care providers and psychiatric technicians in Mozambique perceived the relative advantage of the PRIDE program to address mental health treatment access barriers and offered recommendations for successful sustainment and scale up of integrated mental health care., (© 2024. The Author(s).)

There is a dearth of evidence indicating the effectiveness of psychological interventions targeting depression and/or posttraumatic stress disorder (PTSD) for Black women in the United States (US) exposed to intimate partner violence (IPV). We searched PubMed, MEDLINE, PsycINFO, EBSCOhost, Social Sciences, Social Sciences Full Text, Social Work Abstracts, and Cochrane databases between September 2021 and October 2022, for original studies of randomized control trials (RCTs) reporting depression and/or PTSD interventions delivered to US Black women with histories of IPV. Of the 1,276 articles, 46 were eligible and 8 RCTs were ultimately included in the review; interventions for depression (four interventions, n  = 1,518) and PTSD (four interventions, n  = 477). Among Depression and PTSD interventions (one intervention, n  = 208), Beck's Depression Inventory II indicated M  = 35.2, SD  = 12.6 versus M  = 29.5, SD  = 13.1, <.01, and Davidson Trauma Scale indicated M  = 79.4, SD  = 31.5 versus M  = 72.1, SD  = 33.5, <.01, at pre- and post-intervention respectively. Also, some interventions reported severity of depression M  = 13.9 ( SD  = 5.4) versus M  = 7.9 ( SD  = 5.7) < 0.01, and PTSD ( M  = 8.08 vs. M  = 14.13, F (1,117) = 9.93, p  < .01) at pre- and post-intervention respectively. Publication bias was moderate and varied between 12 and 17 via the Downs and Black Checklist for Methodological Rigor for RCTs. Psychological interventions targeting depression and/or PTSD for Black women with histories of IPV reflect moderate improvement. Interventions that account for cultural nuances specific to Black women are fundamental for improving outcomes for survivors presenting with depression and/or PTSD., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background and Aims: Health inequities related to alcohol use exist for transgender individuals. While the Thailand Ministry of Public Health recently published a clinical guideline to implement a Screening, Brief Intervention and Referral to Treatment (SBIRT) in primary care, there has been no study regarding transgender women's (TGW) alcohol use and the acceptability of implementing SBIRT in a Thai context, a gap this study aimed to fill., Design: A mixed-method approach was used. In the first phase, TGW service users and health-care providers (HCPs) completed a survey on the acceptability of prospective implementation of SBIRT. TGW service users completed the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). In the second phase, TGW service users, HCPs, clinic administrators and national-level alcohol, HIV and transgender health policymakers participated in in-depth qualitative interviews., Setting: The Tangerine Clinic, a transgender-led sexual health clinic in Bangkok, Thailand., Participants: In the first phase, TGW service users (n = 100) and HCP (n = 8) were surveyed. In the second phase, 22 stakeholders (n = 10 TGW service users; n = 8 HCP; n = 1 clinic administrator; n = 3 policymakers) were interviewed., Measurements: Simple proportions were calculated for each survey item. Differences in acceptability by various demographic factors were calculated using univariate analysis. The qualitative data were coded using thematic analysis and a deductive approach. The results were mapped to the Consolidated Framework for Implementation Research domains and constructs. The quantitative and qualitative results were triangulated to expand understanding., Findings: Fifty per cent of the TGW participants exhibited problematic drinking levels (AUDIT-C ≥ 4). Implementing SBIRT was highly acceptable, as more than 95% of participants reported agreeing or completely agreeing to receive SBIRT for alcohol use. Barriers, such as complexity, time constraint and lack of knowledge and skills, were anticipated. Adaptability, such as tailoring the content of brief intervention to suit TGW health needs and SBIRT to fit with existing clinic procedures, might facilitate successful implementation., Conclusion: Screening, Brief Intervention and Referral to Treatment (SBIRT) for alcohol use has the potential to be successfully implemented in transgender-led sexual health clinic settings, with some adaptations to overcome anticipated barriers., (© 2024 Society for the Study of Addiction.)

Background: Gender inequality may be associated with the burden of orofacial clefts (OFCs), particularly in low-and middle-income countries (LMICs). To investigate the OFCs' burden and its association with gender inequality in the Eastern Mediterranean region (EMR)., Methods: Country-specific data on the OFCs' prevalence and Disability-Adjusted Life Years (DALYs) from 1990 to 2019 were gathered from the Global Burden of Disease database by age and gender. Estimated annual percentage change (EAPCs) was used to investigate the OFCs' trends. The association of the Gender Inequality Index (GII) with prevalence and DALY rates was determined using multiple linear regression. Human Development Index (HDI), Socio-Demographic Index (SDI), and Gross Domestic Product (GDP) were also considered as potential confounders., Results: In 2019, the overall regional OFCs' prevalence and DALYs (per 100,000 person-years) were 93.84 and 9.68, respectively. During the 1990-2019 period, there was a decrease in prevalence (EAPC = -0.05%), demonstrating a consistent trend across genders. Moreover, within the same timeframe, DALYs also declined (EAPC = -2.10%), with a more pronounced reduction observed among females. Gender differences were observed in age-specific prevalence rates (p-value = 0.015). GII was associated with DALYs (β male = -0.42, p-value = 0.1; β female  = 0.48, p-value = 0.036) and prevalence (β male = -1.86, p-value < 0.001, β female = -2.07, p-value < 0.001)., Conclusions: Despite a declining prevalence, the burden of OFCs remained notably significant in the EMR. Gender inequality is associated with the burden of OFCs in the Eastern Mediterranean region. Countries in the region should establish comprehensive public policies to mitigate gender inequalities in healthcare services available for OFCs., (© 2024. The Author(s).)

A local insurgency has displaced many people in the northern Mozambican province of Cabo Delgado. The authors' global team (comprising members from Brazil, Mozambique, South Africa, and the United States) has been scaling up mental health services across the neighboring province of Nampula, Mozambique, now host to >200,000 displaced people. The authors describe how mental health services can be expanded by leveraging digital technology and task-shifting (i.e., having nonspecialists deliver mental health care) to address the mental health needs of displaced people. These methods can serve as a model for other researchers and clinicians aiming to address mental health needs arising from humanitarian disasters in low-resource settings., Competing Interests: The authors report no financial relationships with commercial interests.

Exposure to intimate partner violence (IPV) incurs significant public health consequences. Understanding risk markers can accelerate prevention and response efforts, important in settings like Sub-Saharan Africa (SSA) where resources are scarce. In this study, four databases were searched to identify studies that examined risk markers for male-to-female physical IPV. With application of the socioecological model, we analyzed 11 risk markers for male physical IPV perpetration (with 71 effect sizes) and 16 risk markers for female physical IPV victimization (with 131 effect sizes) in SSA from 51 studies. For male IPV perpetration, we found medium-to-large effect sizes for six risk markers: perpetrating emotional abuse and sexual IPV, witnessing parental IPV, being abused as a child, cohabitating (not married), and exhibiting controlling behaviors. We found small effect sizes for substance use. Employment, age, marital status, and education were not significant risk markers. For female IPV victimization, a medium effect size was found for post-traumatic stress symptoms. Small effect sizes were found for reporting depressive symptoms, being abused as a child, witnessing parental IPV, and reporting drug and alcohol use. Rural residence, approval of violence, length of relationship, income, education, employment, age, marital status, and religiosity were not significant risk markers. Findings highlight opportunities for screening and intervention at the couple level, show the need to test and incorporate interventions for IPV in mental health treatment, and emphasize the importance of further research on sociodemographic risk markers and the interventions that target them., Competing Interests: Declarations of Conflicts of InterestThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Most family violence research has been conducted in high-income countries, although family violence rates are higher in low- and middle-income countries (LMICs), and outcomes more severe. Given the strong associations of family violence with substance use and mental illness, the aim of this systematic review was to examine interventions that targeted familial violence and at least one other condition of substance use or mental illness to determine effective treatments in LMICs. We conducted a systematic review of interventions that addressed family violence and mental illness or substance use. A committee of three researchers independently screened titles and abstracts and conducted full-text eligibility assessments. Two researchers conducted a risk of bias assessment. Data were extracted using a structured spreadsheet and narratively synthesized. Our search identified 29 articles produced from 19 studies conducted in 13 LMICs. Most ( n  = 15) studies randomized to study condition. Lack of blinding was the most common threat. The external validity of studies was generally poor. Fourteen studies had a primary intervention target of family violence, mental health, substance use, economic improvement, or HIV. None of the studies showed improvements in all intervention areas. Child maltreatment was less likely to be addressed than intimate partner violence (IPV). Targeted interventions for substance and mental health mostly improved primary outcomes, although they were less effective in reducing IPV. Evidence-based treatments must be rigorously evaluated before innovations in implementation can occur. Interventions overwhelmingly addressed IPV victimization and should consider how to work with couples and include men and children., Competing Interests: The authors declare no competing interests exist., (© The Author(s) 2023.)

The burden of depression and anxiety disorders is high in sub-Saharan Africa, especially for people with HIV (PWH). The Patient Health Questionnaire-4 (PHQ-4) and Electronic Mental Wellness Tool-3 (E-mwTool-3) are ultra-brief screening tools for these disorders. We compared the performance of PHQ-4 and E-mwTool-3 for screening MINI-International Neuropsychiatric Interview diagnoses of depression and anxiety among a sample of individuals with and without HIV in two primary care clinics and one general hospital in Maputo City, Mozambique. Areas-under-the-curve (AUC) were calculated along with sensitivities and specificities at a range of cutoffs. For PWH, at a sum score cutoff of ≥ 1, sensitivities were strong: PHQ-4:Depression = 0.843; PHQ-4:Anxiety = 0.786; E-mwTool-3:Depression = 0.843; E-mwTool-3:Anxiety = 0.929. E-mwTool-3 performance was comparable to PHQ-4 among people with and without HIV., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The purpose of this study was to examine the impact of the COVID-19 pandemic on self-reported burnout of health workers, quality of care, and perceptions of COVID-19-related stigma in Mozambique., Method: We conducted a cross-sectional quantitative assessment of 170 frontline health workers in Nampula District, Mozambique, including 149 (87.6%) primary care providers and 21 (12.4%) mental health specialists., Results: Of the 170 frontline workers, only 10.1% of frontline workers were experiencing more professional burnout, whereas 33.3% felt it had lessened. The perceived impact on quality of care also varied, without any significant differences by sex, education level, or mental health training background. Compared to the beginning of the COVID-19 pandemic in March 2020, 42.3 and 38.1% providers felt that their ability to provide mental health and general health care, respectively, had worsened, compared to 57.7 and 61.9% who believed that either there was no change, or that the work had become easier. Likewise, 26.8% of providers felt that their ability to meet patients' needs had gotten more difficult, whereas 43.4% reported no change and 29.8% reported that it was easier. Twenty-two percent of providers reported an overall increase in caseloads since before the pandemic whereas the majority (67.9%) reported a decrease. Providers believed that 57.1% of people in general were afraid of people with COVID-19, 27.5% were afraid of a person recovered from COVID-19, and 39.9% were afraid of a person with family members with COVID-19. The perceived stigma about healthcare professionals was also low; only 27.4% believed that people in general were afraid of healthcare providers who deliver care to people with COVID-19., Conclusion: In contrast with other global studies, many healthcare workers in our sample reported a reduction in burnout, which may be associated with the lower overall caseloads seen during this period. Similarly, the quality of care was minimally impacted. More research is needed to determine whether the experience in Mozambique is unique, or similarly observed in other low-resource settings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Feliciano, Mootz, Suleman, Su, Khan, Gouveia, Santos, Wainberg and Sweetland.)

Introduction: Alcohol misuse and intimate partner violence (IPV) are major public health burdens with a well-established association. These problems are difficult to remedy individually and can exacerbate one another, compounding treatment complexity. Though scarce, integrated alcohol misuse and IPV treatments exist. Yet implementation remains inadequate. Thus, the current study applied the Consolidated Framework for Implementation Research (CFIR) to examine barriers and facilitators of implementing such integrated treatments., Methods: Through purposive sampling, we conducted in-depth interviews with diverse IPV and alcohol treatment experts (n = 21) whose ages ranged from 27 to 72 and who averaged 17 years of experience working in alcohol and IPV treatment. The research team conducted analysis using Grounded Theory Methods., Results: Experts identified barriers and facilitators for integrated treatment of alcohol misuse and IPV in three CFIR domains: intervention, inner setting and provider, and outer setting., Conclusions: Leveraging the facilitators of implementation and addressing barriers at multiple organizational and intervention levels through an implementation science lens can help to close the research-to-practice gap for integratively treating alcohol misuse and IPV., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Armed conflict and the HIV pandemic are significant global health issues. Evidence of the association between armed conflict and HIV infection has been conflicting. Our objective was to examine the role of mediating risk factors, such as engagement in transactional sex work, to elucidate the relation between armed conflict and HIV infection., Methods: We used multistage sampling across three Northeastern Ugandan districts to randomly select 605 women aged 13 to 49 to answer cross-sectional surveys from January to May of 2016. We used multivariate logistic regression model with R 4.0.3 to examine if exposure to armed conflict has an indirect effect on reporting having an HIV-positive serostatus through engagement in transactional sex work. Age and district residence were included as covariates., Results: Exposure to armed conflict β = .16, SE = .04, p < .05, OR = 1.17, 95% [CI .08, .23] was significantly associated with reporting a HIV-positive serostatus. For each 1-unit increase in exposure to armed conflict (i.e., additional type of armed conflict exposure), there was a 17% increase in the odds of reporting a HIV-positive serostatus. Engagement in transactional sex work was not associated with reporting a HIV-positive serostatus β = .04, SE = .05, p = .37, 95% [CI - .051, .138]. We found district of residence, age, and interaction effects., Conclusions: Although exposure to armed was associated with reporting an HIV-positive serostatus, this relationship was not mediated by engagement in transactional sex. Further research is needed on risk factors that mediate this relationship. The likelihood of reporting a HIV-positive serostatus increased with each additional type of exposure to armed conflict. Thus, screening for exposure to multiple traumatic stressors should occur in HIV prevention settings. Healthcare services that are trauma-informed and consider mental distress would likely improve HIV outcomes., (© 2022. The Author(s).)

Background: Men's alcohol misuse does not occur in a vacuum but has a cascade of consequences for families and children, with ties to violence, poor parenting, and poor partner and child mental health. Despite the intersection of individual and interpersonal problems associated with men's alcohol use, studies exploring the impact of men's completion of alcohol misuse treatment on family and family member outcomes are scarce. Here we begin to explore this question., Methods: We conducted qualitative interviews (N = 13) with female partners and children (8-17 years) of men with problem drinking who completed individual treatment targeting alcohol misuse, depressed mood, and family-focused efforts in Eldoret, Kenya. Interviews and thematic content analysis were guided by ecological-transactional systems theory., Results: Findings highlighted positive perceived changes for men, families, women and children that interacted together in a bi-directional pathway. Partners and children described men's reduced drinking, reduced spending, increased family-focused effort (e.g., coming home early), as well as increased emotion regulation, and openness to and communication with family. These changes were tied to perceived improvements in the couple and father-child relationship, including improved trust and time together, which were tied to improvements in women and children's emotional well-being (e.g., hope). Concurrently, reports noted men's increased effort to share money earned with the family which alleviated financial stress and helped ensure basic needs were met. Results aligned with the ecological transactional systems frame, with individuals in the family, family relationships, and economic climate each dynamically shaping each other., Conclusions: Although larger studies are needed, results provide promising signals regarding the potential downstream effects of individual treatment on family systems and members, which may in turn help maintain men's changes in drinking., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Northeastern Uganda has suffered from protracted armed conflict and HIV/AIDS and has some of the highest rates of intimate partner violence (IPV) globally. Little is known about how exposure to conflict and HIV influence individuals' syndemic risk markers or those of their partners. We conducted a population-based study using multistage sampling across three districts in Northeastern Uganda. We randomly surveyed 605 women aged 13-49 years and estimated syndemic problems for currently partnered women (N = 561) who reported for their male partners. Syndemic problems were lower in the low-conflict district than the high-conflict district, p = .009. Conflict exposure was associated with couples' syndemic scores, respondent: β = 0.182, p < .001; partner: β = .181, p < .001. Problem scores were significantly higher among women whose partner was either HIV positive, p = .031, or had an unknown HIV status, p = .016, compared with those whose partner was HIV negative. The total effects of women's, β = .15, p = .034, and men's, β = .137, p = .038, armed conflict exposure on male-to-female IPV were significant. For male partners, there were significant total effects of having an unknown, β = .669, p < .001, or positive, β = 1.143, p < .001, HIV status on experiencing female-to-male IPV. These results suggest that syndemic problems and corresponding treatments should consider couple influences. Addressing mediating problems of mental distress and alcohol misuse may reduce the risk of male-to-female IPV. Providing couple-based HIV psychosocial interventions could reduce men's exposure to IPV., (© 2021 International Society for Traumatic Stress Studies.)

Background: Hazardous drinking imposes a major public health burden worldwide, especially in low-income countries such as Mozambique. Implementation of the Screening, Brief Intervention, Referral to Treatment (SBIRT) approach to address problem drinking is recommended. However, evidence regarding the best strategies to implement SBIRT at scale is needed., Methods: Guided by the Reach Effectiveness Adoption Implementation Maintenance model, the authors will conduct a 2-year, cluster-randomized, hybrid type-2 implementation-effectiveness trial in 12 districts in Mozambique evaluating implementation, clinical effectiveness, outcomes, and cost. Eight districts will be randomly assigned to a mobile application-based health SBIRT condition and four to SBIRT-Conventional Training and Supervision. Interventions will be delivered by clinic-based community health workers. The Consolidated Framework for Implementation Research will guide the authors' mixed-methods assessments throughout the study., Results: The study arm showing better cost-effectiveness will be scaled up in the other arms' districts. During this 12-month scale-up phase, Ministry of Health personnel will be charged with providing training, clinical activities, and supervision in all 12 districts without research team support. The SBIRT scale-up phase is critical to identify facilitators and barriers for tracking internal and external factors in clinics that continue using the superior arm and those that switch to it., Next Steps: In a multistep process with stakeholders from multiple sectors, outcomes and lessons learned from this study will inform the development of an implementation tool kit to guide SBIRT scale-up of community services addressing hazardous drinking in other low- and middle-income countries and low-resource settings in high-income countries.

Objective: Stepped mental health care requires a rapid method for nonspecialists to detect illness. This study aimed to develop and validate a brief instrument, the Mental Wellness Tool (mwTool), for identification and classification., Methods: Cross-sectional development and validation samples included adults at six health facilities in Mozambique. Mini International Neuropsychiatric Interview diagnoses were the criterion standard. Candidate items were from nine mental disorder and functioning assessments. Regression modeling and expert consultation determined best items for identifying any mental disorder and classifying positives into disorder categories (severe mental disorder, common mental disorder, substance use disorder, and suicide risk). For validation, sensitivity and specificity were calculated for any mental disorder (index and proxy respondents) and disorder categories (index)., Results: From the development sample (911 participants, mean±SD age=32.0±11 years, 63% female), 13 items were selected-three with 0.83 sensitivity (95% confidence interval [CI]=0.79-0.86) for any mental disorder and 10 additional items classifying participants with a specificity that ranged from 0.72 (severe mental disorder) to 0.90 (suicide risk). For validation (453 participants, age 31±11 years, 65% female), sensitivity for any mental disorder was 0.94 (95% CI=0.89-0.97) with index responses and 0.73 (95% CI=0.58-0.85) with family proxy responses. Specificity for categories ranged from 0.47 (severe mental disorder) to 0.93 (suicide risk). Removing one item increased severe mental disorder specificity to 0.63 (95% CI=0.58-0.68)., Conclusions: The mwTool performed well for identification of any mental disorder with index and proxy responses to three items and for classification into treatment categories with index responses to nine additional items.

Objective: To report the interim results from the training of providers inevidence-based psychotherapies (EBPs) and use of mobile applications., Design and Setting: The Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence (PRIDE) study is a cluster-randomised hybrid effectiveness-implementation trial comparing three delivery pathways for integrating comprehensive mental healthcare into primary care in Mozambique. Innovations include the use of EBPs and scaling-up of task-shifted mental health services using mobile applications., Main Outcome Measures: We examined EBP training attendance, certification, knowledge and intentions to deliver each component. We collected qualitative data through rapid ethnography and focus groups. We tracked the use of the mobile applications to investigate early reach of a valid screening tool (Electronic Mental Wellness Tool) and the roll out of the EBPs PARTICIPANTS: Psychiatric technicians and primary care providers trained in the EBPs., Results: PRIDE has trained 110 EBP providers, supervisors and trainers and will train 279 community health workers in upcoming months. The trainings improved knowledge about the EBPs and trainees indicated strong intentions to deliver the EBP core components. Trained providers began using the mobile applications and appear to identify cases and provide appropriate treatment., Conclusions: The future of EBPs requires implementation within existing systems of care with fidelity to their core evidence-based components. To sustainably address the vast mental health treatment gap globally, EBP implementation demands: expanding the mental health workforce by training existing human resources; sequential use of EBPs to comprehensively treat mental disorders and their comorbid presentations and leveraging digital screening and treatment applications., Competing Interests: Competing interests: MAO receives royalties from the Research Foundation for Mental Hygiene for the commercial use of the Columbia Suicide Severity Rating Scale and owns shares in Mantra, Inc. She serves as an advisor to Alkermes and Fundacion Jimenez Diaz (Madrid). Her family owns stock in Bristol Myers Squibb.MMW receives royalties from Multi-Health Systems Inc. for use of the Social Adjustment Scale-Self-Report (SAS-SR) as well as book royalties from Perseus Press, Oxford Press, and APA Publishing. Additionally, MMW has received research funding from the Brain and Behavior Foundation, Templeton Foundation and the Sackler Foundation., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The context of place matters for mental health. Employing a feminist framework, this study used key informant interviews and focus group discussions in May 2012 with 77 conflict-affected adults, children, and adolescents in Northeastern Uganda to understand the relation of place and the symbolic space of family to IPV survivors' mental wellbeing to shape intervention possibilities. Using Grounded Theory methods, narratives identified numerous negative mental health experiences, such as having a disturbed mind, associated with inhabiting a violent domestic space. Place-associated qualities interacted with the symbolic space of the family to impede women's ability to enhance the safety of their domestic space, discourage separation, and encourage reunification in the case of separation, all of which related to negative mental health experiences. Interventions should not assume that IPV survivors' exposure to violence has terminated and look beyond mental health as an individual outcome.

Background: Large data sets, also known as "big data", shared in health information exchanges (HIEs), can be used in novel ways to advance health, including among communities at risk for HIV infection. We examined values and opinions about the acceptability of using electronic healthcare predictive analytics (eHPA) to promote HIV prevention in men who have sex with men (MSM). Our aims were twofold: (I) to evaluate the perspectives of MSM with diverse race/ethnicity and age on the acceptability of predictive analytics to determine individual HIV risk and (II) to determine acceptability of having targeted prevention messaging based upon those risk estimates sent directly to the consumer. Method: Two of the authors facilitated 12 focus groups (n=57) with adult MSM without HIV, living in NYC. Groups were divided by ethnicity (Black, Latino, and White) and age (under 35 and 35 and over). Participants were recruited through HIV prevention sites, community-based organizations, social media, and Internet sites that serve these communities. Grounded theory methods were used to analyze the data with Dedoose., Results: We identified six main themes related to acceptability: (I) reach, relevance, and potential uptake of using predictive analytics to establish HIV risk and deliver targeted prevention messaging; (II) patient-provider communication; (III) public health and individual rights; (IV) perceptions of intervention effectiveness; (V) electronic health data security; and (VI) stigma. Within each thematic domain, MSM discussed concerns, benefits, and provided recommendations for implementation., Conclusions: MSM in this study were supportive of the use of "big data" and technology to reach marginalized populations and improve public health, yet expressed concerns about the relevance, effectiveness, and security eHPA. Efforts to advance eHPA for HIV prevention should address these concerns, especially among the most-at-risk communities of color. Development of eHPA for HIV prevention should involve targeted messaging that addresses specific concerns regarding eHPA security, accuracy, and relevance., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 mHealth. All rights reserved.)

As global mental health research and programming proliferate, research that prioritizes women's voices and examines marginalized women's mental health outcomes in relation to exposure to violence at community and relational levels of the socioecological model is needed. In a mixed methods, transnational study, we examined armed conflict exposure, intimate partner violence (IPV), and depressive symptoms among 605 women in Northeastern Uganda. We used analysis of variance to test between groups of women who had experienced no IPV or armed conflict, IPV only, armed conflict only, and both; and linear regression to predict depressive symptoms. We used rapid ethnographic methods with a subsample ( n = 21) to identify problem prioritization; and, to characterize women's mental health experiences, we conducted follow up in-depth interviews ( n = 15), which we analyzed with grounded theory methods. Thirty percent of the sample met the cut-off for probable major depressive disorder; women exposed to both IPV and armed conflict had significantly higher rates of depression than all other groups. While women attributed psychological symptoms primarily to IPV exposure, both past-year IPV and exposure to armed conflict were significantly associated with depressive symptoms. Women identified socioeconomic neglect as having the most impact and described three interrelated mental health experiences that contribute to thoughts of escape, including escape through suicide. Policy efforts should be interprofessional, and specialists should collaborate to advance multi-pronged interventions and gender-informed implementation strategies for women's wellbeing., Competing Interests: Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Research examining the interrelated drivers of household violence against women and violence against children is nascent, particularly in humanitarian settings. Gaps remain in understanding how relocation, displacement and ongoing insecurity affect families and may exacerbate household violence., Methods: Employing purposive sampling, we used photo elicitation methods to facilitate semi-structured, in-depth interviews with female and male adolescents and adults aged 13-75 ( n  = 73) in two districts in Colombia from May to August of 2017. Participants were displaced and/or residing in neighborhoods characterized by high levels of insecurity from armed groups., Results: Using inductive thematic analysis and situating the analysis within a feminist socioecological framework, we found several shared drivers of household violence. Intersections among drivers at all socioecological levels occurred among societal gender norms, substance use, attempts to regulate women's and children's behavior with violence, and daily stressors associated with numerous community problems. A central theme of relocation was of family compositions that were in continual flux and of family members confronted by economic insecurity and increased access to substances., Conclusions: Findings suggest interventions that systemically consider families' struggles with relocation and violence with multifaceted attention to socioecological intersections., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Gender-based violence (GBV) is a major public health problem that is exacerbated in armed conflict settings. While specialized guidelines exist for conducting research with GBV, guidance on disseminating findings from GBV research is scant. This paper describes ethical considerations of designing and disseminating research findings on GBV, armed conflict, and mental health (including alcohol misuse) in conflict-affected settings in Northeastern Uganda. Following completion of two research studies, we conducted a half-day dissemination meeting with local community professionals (n=21) aged 24 to 60. Attendees were divided into small groups and given a quiz-style questionnaire on research findings to prompt discussion. Two primary ethical tensions arose. One ethical consideration was how to disseminate research findings equitably at the participant level after having taken care to collect data using safe and unharmful methods. Another ethical issue concerned how to transparently share findings of widespread problems in a hopeful and contextualized way in order to facilitate community response. We recommend planning for dissemination a priori, engaging with partners at local levels, and grounding dissemination for action in evidence-based practices., Competing Interests: Competing interests: None declared.

Background: The South African National Mental Health Policy Framework and Strategic Plan 2013-2020 was adopted to address the country's substantial burden and inadequate treatment of mental illness. It outlines measures toward the goal of full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, we conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of four districts in South Africa., Methods: Forty clinics (ten per district) were purposively selected to represent both urban and rural locations. District-level program managers (DPMs) for mental health, tuberculosis, and maternal-child healthcare were qualitatively interviewed about district policy and procedures for management of mental illness and challenges in integrating mental health services into primary care. Clinic nurses and mental health practitioners (MHPs) completed a quantitative questionnaire to assess their engagement with stepped care for patients with mental illness. Qualitative and quantitative data were collected concurrently and compared to triangulate progress in implementation of integrated services., Results: A total of 59 nurses and 17 MHPs completed questionnaires, and nine DPMs were interviewed (total n = 85). DPMs indicated that nurses should screen for mental illness at every patient visit, although only 43 (73%) nurses reported conducting universal screening and 26 (44%) reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialized care. However, only 7 (41%) MHPs indicated that they diagnose mental illness and 14 (82%) offer any treatment for mental illness. Addressing challenges to current integration efforts, DPMs highlighted 1) insufficient funding and material resources, 2) poor coordination at the district administrative level, and 3) low mental health awareness in district administration and the general population., Conclusions: Though some progress has been made toward integration of mental health services into primary care settings, there is a substantial lack of training and clarity of roles for nurses and MHPs. To enhance implementation, increased efforts must be directed toward improving district-level administrative coordination, mental health awareness, and financial and material resources.

Although psychiatric disorders are classified as non-communicable diseases, we believe this classification is too rigid and limiting. We present evidence of the communicability of psychiatric disorders through three major pathways: infectious and ecological, familial, and sociocultural communicability. Successful strategies developed to control the spread of communicable infectious diseases are relevant to curtailing the communicability of psychiatric disorders, thereby reducing their burden. Current interventions and policies that conceptualise psychiatric illnesses as non-communicable mostly focus on the individual. By applying strategies from infectious disease and chronic illness prevention models within a socioecological framework, we posit a broad communicable chronic disease psychiatric illness control plan for effectively treating the patient with the psychiatric disorder (host) as early as possible, providing benefits to their family and the community, and preventing transmission to others., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Relations among and interactions between exposure to armed conflict, alcohol misuse, low socioeconomic status, gender (in)equitable decision-making, and intimate partner violence (IPV) represent serious global health concerns. Our objective was to determine extent of exposure to these variables and test pathways between these indicators of interest., Methods: We surveyed 605 women aged 13 to 49 who were randomly selected via multistage sampling across three districts in Northeastern Uganda in 2016. We used Mplus 7.4 to estimate a moderated structural equation model of indirect pathways between armed conflict and intimate partner violence for currently partnered women ( n  = 558) to evaluate the strength of the relationships between the latent factors and determine the goodness-of-fit of the proposed model with the population data., Results: Most respondents (88.8%) experienced conflict-related violence. The lifetime/ past 12 month prevalence of experiencing intimate partner violence was 65.3%/ 50.9% (psychological) and 59.9%/ 43.8% (physical). One-third (30.7%) of women's partners reportedly consumed alcohol daily. The relative fit of the structural model was superior (CFI = 0.989; TLI = 0.989). The absolute fit (RMSEA = 0.029) closely matched the population data. The partner and joint decision-making groups significantly differed on the indirect effect through partner alcohol use ( a 1 b 1  = 0.209 [0.017: 0.467])., Conclusions: This study demonstrates that male partner alcohol misuse is associated with exposure to armed conflict and intimate partner violence-a relationship moderated by healthcare decision-making. These findings encourage the extension of integrated alcohol misuse and intimate partner violence policy and emergency humanitarian programming to include exposure to armed conflict and gendered decision-making practices., Competing Interests: This study was approved by the Yale University (#1510016599) and Makerere University (#SHSREC REC: 2015–050) Institutional Review Boards. All participants gave verbal consent prior to completing surveys. Not applicable. The authors declare that they have no competing interests. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Purpose of Review: Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research., Recent Findings: Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.

The high prevalence of gender-based violence (GBV) in armed conflict has been documented in various national contexts, but less is known about the complex pathways that constitute the relation between the two. Employing a community-based collaborative approach, we constructed a community-informed socioecological conceptual model from a feminist perspective, detailing how armed conflict relates to GBV in a conflict-affected rural community in Northeastern Uganda. The research questions were as follows: (1) How does the community conceptualize GBV? and (2) How does armed conflict relate to GBV? Nine focus group discussions divided by gender, age, and profession and six key informant interviews were conducted. Participants' ages ranged from 9 to 80 years ( n =34 girls/women, n = 43 boys/men). Grounded theory was used in analysis. Participants conceptualized eight forms of and 22 interactive variables that contributed to GBV. Armed conflict affected physical violence/quarreling, sexual violence, early marriage, and land grabbing via a direct pathway and four indirect pathways initiated through looting of resources, militarization of the community, death of a parent(s) or husband, and sexual violence. The findings suggest that community, organizational, and policy-level interventions, which include attention to intersecting vulnerabilities for exposure to GBV in conflict-affected settings, should be prioritized. While tertiary psychological interventions with women and girls affected by GBV in these areas should not be eliminated, we suggest that policy makers and members of community and organizational efforts make systemic and structural changes. Online slides for instructors who want to use this article for teaching are available on PWQ 's website at http://journals.sagepub.com/page/pwq/suppl/index., Competing Interests: Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.