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Older displaced persons often receive limited attention from aid organizations, policy-makers and service providers in countries of resettlement. The objective of this study is to identify the relationship between experiencing traumatic events and stressors prior to resettlement, current resettlement stressors, social support, and mental health of older Bhutanese with a refugee life experience.Study participants were 190 older Bhutanese with a refugee life experience living in a metropolitan area in New England (US) and Ontario (Canada). We used structural equation modeling to determine the association between traumatic and stressful events in Bhutan and Nepal, current resettlement stressors, and symptoms of anxiety and depression, as measured by the GAD-7 and PHQ-9. We assessed the role of social support as an effect modifier in the relationship between these variables.Surviving torture was associated with anxiety (Both past traumas and current resettlement stressors contribute to the current psychosocial functioning of older Bhutanese with a refugee life experience. Based on our findings, social support is critical in promoting mental health in this population.

Background During the 2014–15 Ebola Virus Disease (EVD) epidemic, thousands of people in Sierra Leone were infected with the devastating virus and survived. Years after the epidemic was declared over, stigma toward EVD survivors and others affected by the virus is still a major concern, but little is known about the factors that influence stigma toward survivors. This study examines how key personal and ecological factors predicted EVD-related stigma at the height of the 2014–2015 epidemic in Sierra Leone, and the personal and ecological factors that shaped changes in stigma over time. Methods Using three waves of survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines factors associated with self-reported personal stigma toward Ebola survivors (11 items, α = 0.77) among 1008 adults (74.6% retention rate) from 63 census enumeration areas of the Western Rural and Western Urban districts of Sierra Leone. Participants were randomly sampled at the height of the EVD epidemic and followed up as the epidemic was waning and once the epidemic had been declared over by the WHO. Three-level mixed effects models were fit using Stata 16 SE to examine cross-sectional associations as well as predictors of longitudinal changes in stigma toward EVD survivors. Results At the height of the EVD epidemic, female sex, household wealth, post-traumatic stress, EVD-related fear and perceived infection risk are a few of the factors which predicted higher levels of stigma toward survivors. On average, stigma toward EVD survivors decreased significantly as the epidemic declined in Sierra Leone, but female sex, EVD fear, and risk perceptions predicted a slower rate of change. Conclusion This study identified key individual and psychosocial characteristics which may predict higher levels of stigma toward infectious disease survivors. Future studies should pursue a better understanding of how personal characteristics and perceptions, including psychosocial distress, fear, and perceived infection risk serve as pathways for stigma in communities affected by infectious disease.

Countering violent radicalization is a priority in many countries, prompting research that assesses attitudes and beliefs about violent radicalization in the general population. The majority of violent radicalization assessments have been developed among specific populations, with limited investigation into the generalizability and cross-cultural applicability of measurement tools. A transcultural investigation raises questions about the implicit assumptions and norms that inform instrument development. This research examined the psychometric properties of the Sympathy for Violent Radicalization Scale (SyfoR), a measure developed for use with Pakistani and Bangladeshi immigrant groups in the UK, in two convenience samples of youth and young adults in North America and Western Europe. We investigated the factor structure, reliability, and construct validity of adapted versions of the SyfoR among convenience samples of youth and young adults living in Belgium (N = 2014) and in Quebec, Canada (N = 1364) via online surveys administered to students engaged in secondary and post-secondary education. Results indicate that, in both samples, a reduced, 8-item version of the SyfoR has a 3-factor structure with good model fit statistics using confirmatory factor analysis and good internal consistency reliability. More studies are needed to assess the appropriateness of the SyfoR for use in diverse contexts and among diverse populations. The potential usefulness and harmfulness of measures of violent radicalization should balance the benefits of obtaining local data with the risks associated with pathologizing social dissent. ispartof: TRANSCULTURAL PSYCHIATRY vol:58 issue:5 pages:669-682 ispartof: location:England status: published

This article describes the incorporation of an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), into a youth entrepreneurship training program in Sierra Leone. A collaborative team approach (CTA) was used as the implementation strategy to address the human resource shortage and related challenges associated with capacity and access to care.A cluster randomized quasi-experimental pilot trial (N=175) was conducted in one rural district of Sierra Leone. Pilot data assessed implementation feasibility and clinical effectiveness when using a CTA. A larger hybrid type-2 effectiveness-implementation cluster randomized trial is underway (N=1,151) in three rural districts. Findings on feasibility and fidelity, barriers and facilitators influencing the integration of the YRI into the entrepreneurship program, and clinical effectiveness of the YRI are of interest.Findings from the pilot study indicated that the YRI can be implemented within a youth entrepreneurship program and provide mental health benefits to youths at high risk of emotion dysregulation and interpersonal deficits. Pilot findings informed the ongoing, larger hybrid type-2 trial to understand barriers and facilitators of the CTA and clinical effectiveness of the YRI within youth employment programming.In fragile postconflict settings, innovative approaches are needed to address the mental health treatment gap. Findings from this study will support efforts by the government of Sierra Leone and its partners to address human resource challenges and increase access to evidence-based mental health services.

Background Former child soldiers are at elevated risk for mental health problems (e.g., traumatic stress, emotion dysregulation, and internalizing and externalizing problems). To examine which groups of former child soldiers are more likely to have difficulties with emotion regulation, interpersonal relationships, and mental health postconflict, we explored patterns of war trauma exposure and their effects on subsequent mental health problems among former child soldiers in Sierra Leone. Methods Participants were 415 (23.86% female) Sierra Leonean former child soldiers participating in a 15-year, four-wave longitudinal study. At T1 (2002), 282 former child soldiers (aged 10-17) were recruited. T2 (2004) included 186 participants from T1 and an additional cohort of self-reintegrated former child soldiers (NT2 = 132). T3 (2008) and T4 (2016/2017) participants were youth enrolled in previous waves (NT3 = 315; NT4 = 364). Latent profile analysis (LPA) was used to classify participants based on the first-time reports of eight forms of war exposure (separation and loss of assets, parental loss, loss of loved ones, witnessing violence, victimization, perpetrating violence, noncombat activities, and deprivation). ANOVA examined whether patterns of war exposure were associated with sociodemographic characteristics and mental health outcomes between T1 and T4. Results LPA identified two profiles: higher exposure versus lower exposure, using cumulative scores of eight forms of war-related trauma exposure. The 'higher war exposure' group comprised 226 (54.5%) former child soldiers and the 'lower war exposure' group included 189 (45.5%). Significantly higher levels of violence-related and combat experiences characterized the group exposed to more traumatic events. The 'higher war exposure' group reported more PTSD symptoms at T2, more hyperarousal symptoms across all waves, and more difficulties in emotion regulation at T4. Conclusions Former child soldiers exposed to higher levels of war-related traumatic events and loss should be prioritized for mental health services immediately postconflict and as they transition into adulthood.

Early child development (ECD) programs are increasingly combined with targeted cash transfers for poor households to break intergenerational poverty. However, few evidence-based, scalable, and sustainable ECD programs that complement cash transfer programs exist in in low- and-middle-income countries. We conducted a cluster-randomized pilot study to assess whether Sugira Muryango, a strengths-based home-visiting intervention to promote child development and prevent violence among children aged 6–36 months, could be delivered by community-based lay workers to poor families participating in Rwanda’s cash-for-work Vision Umurenge Program (VUP). Data collection occurred among 38 families at baseline, endline, and 6 months after the intervention and included child-level (child engagement, caretaking, and health and development), caregiver-level (family unity and mental health) and household-level (water and sanitation practices and family conflict) outcomes. We compared trajectories of Sugira Muryango families vs. families receiving the cash transfer only over time using mixed-effect models. Sugira Muryango children experienced significantly greater ECD engagement than children in control families and marginally significant reductions in exposure to violent disciplinary methods. Sugira Muryango caregivers reported greater shared decision-making between parents and marginally significant improvements in family unity and anxiety. Conflict within intervention households halved between baseline and follow-up. Satisfaction was high. This randomized pilot demonstrates that Sugira Muryango can be delivered by community-based lay workers, improves access to nurturing care and stimulation among children living in poverty, and may reduce intra-family conflict. A large-scale effectiveness study is underway to assess the intervention’s impact on child development and health outcomes.

Purpose We report on the extent of sexual harassment among residents and examine its relationship to specialty and program year and effects. Methods Using the C–Change Resident Survey, we surveyed residents in 34 internal medicine, pediatrics, and general surgery programs in 14 academic medical centers (AMCs). A total of 1708 residents completed the survey (70% response-rate); 51% (n = 879) were women. Respondents reported unwanted sexual comments, attention, or advances by a superior or colleagues within the last 2 years. Measures of vitality and ethical or moral distress were included in the surveys. Results Rates of sexual harassment reported by women differed across the 34 programs, with an interquartile range of 0%-11%. Residents in pediatrics had the lowest frequencies of sexual harassment (mean 2%, 95% confidence interval [CI] 0%, 4%). Residents in internal medicine had higher rates of sexual harassment (mean 7%, 95% CI 1%, 25%). Residents in surgery had the highest rates (mean 12%, 95% CI 2%, 33%). Sexual harassment was associated with lower levels of vitality and higher ethical or moral distress (both, P Conclusions Sexual harassment is more common for women residents in Internal Medicine and Surgery programs. The adverse effects of sexual harassment on female residents detracts from an institution’s professional workforce.

IntroductionFamilies living in extreme poverty require interventions to support early-childhood development (ECD) due to broad risks. This longitudinal cluster randomised trial examines the effectiveness of Sugira Muryango (SM), a home-visiting intervention linked to Rwanda’s social protection system to promote ECD and reduce violence compared with usual care (UC).MethodsFamilies with children aged 6–36 months were recruited in 284 geographical clusters across three districts. Cluster-level randomisation (allocated 1:1 SM:UC) was used to prevent diffusion. SM was hypothesised to improve child development, reduce violence and increase father engagement. Developmental outcomes were assessed using the Ages and Stages Questionnaire (ASQ-3) and the Malawi Development Assessment Tool (MDAT) and anthropometric assessments of growth. Violence was assessed using questions from UNICEF Multiple Indicators Cluster Survey (MICS) and Rwanda Demographic and Health Surveys (DHS). Father engagement was assessed using the Home Observation for Measurement of the Environment. Blinded enumerators conducted interviews and developmental assessments.ResultsA total of 541 SM families and 508 UC families were enrolled and included in the analyses. Study attrition (2.0% children; 9.6% caregivers) was addressed by hot deck imputation. Children in SM families improved more on gross motor (d=0.162, 95% CI 0.065 to 0.260), communication (d=0.081, 95% CI 0.005 to 0.156), problem solving (d=0.101, 95% CI 0.002 to 0.179) and personal-social development (d=0.096, 95% CI −0.015 to 0.177) on the ASQ-3. SM families showed increased father engagement (OR=1.592, 95% CI 1.069 to 2.368), decreased harsh discipline (incidence rate ratio, IRR=0.741, 95% CI 0.657 to 0.835) and intimate partner violence (IRR=0.616, 95% CI:0.458 to 0.828). There were no intervention-related improvements on MDAT or child growth.ConclusionSocial protection programmes provide a means to deliver ECD intervention.Trial registration numberNCT02510313.

Background Sugira Muryango is a father-engaged early child development and violence-prevention home-visiting programme delivered by trained lay workers. This cluster-randomised trial evaluates whether families living in extreme poverty (Ubudehe 1, the poorest category in the Government of Rwanda’s wealth ranking) who receive Sugira Muryango in combination with a government-provided social protection programme demonstrate greater responsive, positive caregiving, nutrition, care seeking, hygiene, and father involvement compared with control families receiving usual care (UC). Methods Using detailed maps, we grouped closely spaced villages into 284 geographic clusters stratified by the type of social protection programmes operating in the village clusters; 198 clusters met all enrolment criteria. Sugira Muryango was delivered to n = 541 families in 100 treatment clusters with children aged 6–36 months living in extreme poverty. We assessed changes in outcomes in intervention and n = 508 UC control families using structured surveys and observation. Analyses were intent to treat using mixed models to accommodate clustering. Results Families receiving Sugira Muryango improved on core outcomes of parent-child relationships assessed using the Home Observation for Measurement of the Environment (Cohen’s d = 0.87, 95% CI: 0.74, 0.99) and the Observation of Mother-Child Interaction (Cohen’s d = 0.29, 95% CI: 0.17, 0.41). We also saw reductions in harsh discipline on items from the UNICEF MICS (OR = 0.30: 95% CI: 0.19, 0.47) and in violent victimisation of female caregivers by their partners (OR = 0.49, 95% CI: 0.24, 1.00) compared with UC. Moreover, children in families receiving SM had a 0.45 higher increase in food groups consumed in the past 24 h (Cohen’s d = 0.35, 95% CI: 0.22, 0.47), increased care seeking for diarrhoea (OR = 4.43, 95% CI: 1.95, 10.10) and fever (OR = 3.28, 95% CI: 1.82, 5.89), and improved hygiene behaviours such as proper treatment of water (OR = 3.39, 95% CI: 2.16, 5.30) compared with UC. Finally, Sugira Muryango was associated with decreased caregiver depression and anxiety (OR = 0.58, 95% CI: 0.38, 0.88). Conclusions Sugira Muryango led to improvements in caregiver behaviours linked to child development and health as well as reductions in violence. Trial registration ClinicalTrials.gov number NCT02510313.

To clarify our understanding of how the culture of residency training influences the well-being of residents, this study reports on the vitality of residents at 34 programs across the United States and identifies characteristics of the programs, institutions and residents that are associated with high resident vitality.In 2014 to 2015, residents nationally were surveyed using the validated C - Change Resident Survey. The survey assessed residents' vitality and 12 other dimensions that characterize residents' perspectives of the culture of the residency training programs: Self-efficacy, Institutional/program support, Relationships/inclusion/trust, Values alignment, Ethical/moral distress, Respect, Leadership aspirations, Mentoring, Work-life integration, Gender equity, Racial/ethnic minority equity, and self-assessed Competencies. Multilevel models were used to assess vitality within and across programs, and examine predictors including resident, program, and institution characteristics.Two thousand four hundred and fifty-two residents from 11 General Surgery, 12 Internal Medicine, and 11 Pediatrics programs at 14 U.S. academic health systems.One thousand seven hundred and eight residents responded (70% response rate). The mean Vitality score was 3.6 (range 1-5, where values of 4-5 represent high Vitality). There was wide variation among the 34 programs in the percent of residents who had high Vitality scores, ranging from 17% to 71%. However, the average Vitality scores within specialty (Surgery, Medicine, and Pediatrics) were not significantly different. The strongest predictors of Vitality were Work-life integration, Relationships/inclusion/trust, Institutional/program support, Res?pect, Values alignment, and Ethical/moral distress, which together accounted for 50% of vitality variance. Individual demographics accounted for just 3% of variance.Vitality is an essential component of resident well-being, and within each specialty there are programs that have excelled in promoting a culture of high vitality. Our findings suggest that we should test interventions to enhance resident vitality by focusing greater attention on providing institutional support, aligning individual and institutional values, integrating work and personal life, and facilitating relationships, inclusiveness and trust.

Engineers and policymakers have expressed concern that too few students enter the engineering pipeline. This has led to many efforts to engage students in engineering in after-school programs, summer programs, and more recently, in school curricula. The expectation is that, through these efforts, greater numbers of more demographically diverse children will become aware of engineering as a possible career option, and some will decide to pursue it, thereby increasing and diversifying the population pursuing engineering careers. This expectation makes the assumption that students will become more interested in and form more positive attitudes towards engineering as they encounter it in formal and informal settings. To measure this assumption, we have developed an Engineering Interest and Attitudes (EIA) survey, drawing from earlier surveys used to measure student interest in and attitudes toward science. We show that the subscales developed from EFA and CFA are reliable, and considerable evidence is present for the validity of use of EIA for measuring young students’ engineering interests and attitudes. We also present evidence that EIA can be used by researchers and curriculum developers with students ages 8-11 to measure change in student interests and attitudes towards the goal of evaluating engineering activities, programs, and curricula.

A practical instrument is needed to reliably measure the clinical learning environment and professionalism for residents. To develop and present evidence of validity of an instrument to assess the culture of residency programs and the clinical learning environment. During 2014–2015, we surveyed residents using the C - Change Resident Survey to assess residents’ perceptions of the culture in their programs. Residents in all years of training in 34 programs in internal medicine, pediatrics, and general surgery in 14 geographically diverse public and private academic health systems. The C - Change Resident Survey assessed residents’ perceptions of 13 dimensions of the culture: Vitality, Self-Efficacy, Institutional Support, Relationships/Inclusion, Values Alignment, Ethical/Moral Distress, Respect, Mentoring, Work–Life Integration, Gender Equity, Racial/Ethnic Minority Equity, and self-assessed Competencies. We measured the internal reliability of each of the 13 dimensions and evaluated response process, content validity, and construct-related evidence validity by assessing relationships predicted by our conceptual model and prior research. We also assessed whether the measurements were sensitive to differences in specialty and across institutions. A total of 1708 residents completed the survey [internal medicine: n = 956, pediatrics: n = 411, general surgery: n = 311 (51% women; 16% underrepresented in medicine minority)], with a response rate of 70% (range across programs, 51–87%). Internal consistency of each dimension was high (Cronbach α: 0.73–0.90). The instrument was able to detect significant differences in the learning environment across programs and sites. Evidence of validity was supported by a good response process and the demonstration of several relationships predicted by our conceptual model. The C - Change Resident Survey assesses the clinical learning environment for residents, and we encourage further study of validity in different contexts. Results could be used to facilitate and monitor improvements in the clinical learning environment and resident well-being.

Background: Sugira Muryango ​ (SM) is an early child development and violence-prevention home-visiting program delivered by trained lay workers. This cluster-randomised trial evaluates whether families living in extreme poverty who receive SM in combination with government-provided social protection demonstrate greater responsive and positive caregiving, nutrition, care seeking, hygiene, and father involvement compared with control families receiving usual care (UC).Methods: Sugira Muryango (SM) was delivered to families with children aged 6–36 months living in extreme poverty. We assessed changes in outcomes in intervention and UC control families using structured surveys and observation. Analyses were intent to treat using mixed models.Results: Families receiving SM improved significantly on responsive caregiving using the Home Observation for Measurement of the Environment (Cohen’s d= 0.78; p< 0.001) and the Observation of Mother-Child Interaction (Cohen’s d= 0.29; p< 0.001) and showed decreased violent discipline (OR:0.34: 95% CI: 0.22, 0.51) compared with UC. Children in families receiving SM also had a 0.44 higher increase in food groups consumed in the past 24 hours (Cohen’s d= 0.34, p< 0.001), increased care seeking for diarrhoea (OR=2.2, 95% CI: 1.5, 3.1) and fever (OR: 3.3, 95% CI: 2.3, 4.8), and improved hygiene behaviours such as proper treatment of water (OR: 3.6; 95% CI: 2.4, 5.5) compared with UC. SM was also associated with a decreased intimate partner violence (OR=0.67, 95% CI: 0.33, 1.3) and caregiver depression and anxiety (OR=0.9, 95% 0.58, 1.4).Conclusions: Sugira Muryango led to improvements in family functioning and caregiver behaviours linked to child development and health.

Objective To investigate the associations of war and postconflict factors with mental health among Sierra Leone’s former child soldiers as adults. Method In 2002, we recruited former child soldiers from lists of soldiers (aged 10–17 years) served by Disarmament, Demobilization, Reintegration centers and from a random door-to-door sample in 5 districts of Sierra Leone. In 2004, self-reintegrated child soldiers were recruited in an additional district. At 2016/2017, 323 of the sample of 491 former child soldiers were reassessed. Subjects reported on war exposures and postconflict stigma, family support, community support, anxiety/depression, and posttraumatic stress symptoms. Results Of the subjects, 72% were male, with a mean age of 28 years. In all, 26% reported killing or injuring others; 67% reported being victims of life-threatening violence; 45% of female subjects and 5% of male subjects reported being raped; and 32% reported death of a parent. In 2016/2017 (wave 4), 47% exceeded the threshold for anxiety/depression, and 28% exceeded the likely posttraumatic stress disorder threshold. Latent class growth analysis yielded 3 trajectory groups based on changes in stigma and family/community acceptance; “Improving Social Integration” (n = 77) fared nearly as well as the “Socially Protected” (n = 213). The “Socially Vulnerable” group (n = 33) had increased risk of anxiety/depression above the clinical threshold and possible PTSD, and were around 3 times more likely to attempt suicide. Conclusion Former child soldiers had elevated rates of mental health problems. Postconflict risk and protective factors related to outcomes long after the end of conflict. Targeted social inclusion and family interventions could benefit the long-term mental health of former child soldiers.

Purpose There are disparities in mental health of refugee youth compared with the general U.S. population. We conducted a pilot feasibility and acceptability trial of the home-visiting Family Strengthening Intervention for refugees (FSI-R) using a community-based participatory research approach. The FSI-R aims to promote youth mental health and family relationships. We hypothesized that FSI-R families would have better psychosocial outcomes and family functioning postintervention compared with care-as-usual (CAU) families. We hypothesized that FSI-R would be feasible to implement and accepted by communities. Methods A total of 40 Somali Bantu (n = 103 children, 58.40% female; n = 43 caregivers, 79.00% female) and 40 Bhutanese (n = 49 children, 55.30% female; n = 62 caregivers, 54.00% female) families were randomized to receive FSI-R or CAU. Refugee research assistants conducted psychosocial assessments pre- and post-intervention, and home visitors delivered the preventive intervention. Multilevel modeling assessed the effects of FSI-R. Feasibility was measured from retention, and acceptability was measured from satisfaction surveys. Results The retention rate of 82.50% indicates high feasibility, and high reports of satisfaction (81.50%) indicate community acceptance. Across communities, FSI-R children reported reduced traumatic stress reactions, and caregivers reported fewer child depression symptoms compared with CAU families (β = −.42; p = .03; β = −.34; p = .001). Bhutanese FSI-R children reported reduced family arguing (β = −1.32; p = .04) and showed fewer depression symptoms and conduct problems by parent report (β = −9.20; p = .04; β = −.92; p = .01) compared with CAU. There were no significant differences by group on other measures. Conclusions A family-based home-visiting preventive intervention can be feasible and acceptable and has promise for promoting mental health and family functioning among refugees.

This study explored how coping with war-related traumatic events in Sierra Leone impacted mental health outcomes among 529 youth (aged 10–17 at baseline; 25% female) using longitudinal data from three time points (Time 1 in 2002, Time 2 in 2004, and Time 3 in 2008). We examined two types of coping items (approach and avoidance); used multiple regression models to test their relations with long-term mental health outcomes (internalizing behaviors, externalizing behaviors, adaptive/prosocial behaviors, and posttraumatic stress symptoms); and used mediation analyses to test whether coping explained the relation between previous war exposures (being raped, death of parent(s), or killing/injuring someone during the war) and those outcomes. We found that avoidance coping items were associated with lower internalizing and posttraumatic stress behaviors at Time 3, and provided some evidence of mediating the relation between death of parent(s) during the war and the two outcomes mentioned above. Approach coping was associated with higher Time 3 adaptive/prosocial behaviors, whereas avoidance coping was associated with lower Time 3 adaptive/prosocial behaviors. Avoidance coping may be a protective factor against mental illness, whereas approach coping may be a promotive factor for adaptive/prosocial behaviors in war-affected societies. This study has important implications for designing and implementing mental health interventions for youth in postconflict settings.

INTRODUCTION Despite the well-recognized benefits of mentoring in academic medicine, there is a lack of clarity regarding what constitutes effective mentoring. We developed a tool to assess mentoring activities experienced by faculty and evaluated evidence for its validity. METHODS The National Initiative on Gender, Culture, and Leadership in Medicine-"C-Change"-previously developed the C-Change Faculty Survey to assess the culture of academic medicine. After intensive review, we added six items representing six components of mentoring to the survey-receiving help with career and personal goals, learning skills, sponsorship, and resources. We tested the items in four academic health centers during 2013 to 2014. We estimated reliability of the new items and tested the correlation of the new items with a mentoring composite variable representing faculty mentoring experiences as positive, neutral, or inadequate and with other C-Change dimensions of culture. RESULTS Among the 1520 responding faculty (response rate 61-63%), there was a positive association between each of the six mentoring activities and satisfaction with both the amount and quality of mentoring received. There was no difference by sex. Cronbach α coefficients ranged from 0.89 to 0.95 across subgroups of faculty (by sex, race, and principal roles). The mentoring responses were associated most closely with dimensions of Institutional Support (r = 0.58, P < .001), Institutional Change Efforts for Faculty Support (r = 0.52, P < .001), Values Alignment (r = 0.58, P < .001), Self-efficacy (r = 0.43; P < .001), and Relationships/Inclusion/Trust (r = 0.41; P < .001). DISCUSSION Data demonstrated that the Mentoring scale is a valid instrument to assess mentoring. Survey results could facilitate mentoring program development and evaluation.

HIV-affected families report higher rates of harmful alcohol use, intimate partner violence (IPV) and family conflict, which can have detrimental effects on children. Few evidence-based interventions exist to address these complex issues in Sub-Saharan Africa. This mixed methods study explores the potential of a family-based intervention to reduce IPV, family conflict and problems related to alcohol use to promote child mental health and family functioning within HIV-affected families in post-genocide Rwanda. A family home-visiting, evidence-based intervention designed to identify and enhance resilience and communication in families to promote mental health in children was adapted and developed for use in this context for families affected by caregiver HIV in Rwanda. The intervention was adapted and developed through a series of pilot study phases prior to being tested in open and randomized controlled trials (RCTs) in Rwanda for families affected by caregiver HIV. Quantitative and qualitative data from the RCT are explored here using a mixed methods approach to integrate findings. Reductions in alcohol use and IPV among caregivers are supported by qualitative reports of improved family functioning, lower levels of violence and problem drinking as well as improved child mental health, among the intervention group. This mixed methods analysis supports the potential of family-based interventions to reduce adverse caregiver behaviors as a major mechanism for improving child well-being. Further studies to examine these mechanisms in well-powered trials are needed to extend the evidence-base on the promise of family-based intervention for use in low- and middle-income countries.

Anaerobic digestion for biogas production forms one of the fundamental building blocks of the Bioeconomy, and a research programme has been underway in Northern Ireland, which culminated in the publication of a Biogas Research Action Plan 2020 in 2014. One important element of this programme was the identification of the need for an evidence base for the potential Bioresource feedstocks. We report on the outputs of the Quantification of Feedstocks for Anaerobic Digestion research, which has identified the organic feedstocks available for biogas production on a regional basis and categorised these: organic (biodegradable) fraction of municipal solid waste (OFMSW), sewage sludge, organic industrial and commercial wastes, and manure from livestock, food wastes and energy crops. The research further quantified the biogas and energy potential of these feedstocks and possible reductions in Greenhouse Gas (GHG) emissions. The limitations of the research are acknowledged and opportunities to address these and build on and extend the research are identified, including the extension of the research to include feedstocks for other Bioeconomy processes and the application and further development of the biorefinery concept.

A pre-post design with 6–13-month follow-up assessed the feasibility and acceptability of a home-visiting intervention to promote early childhood development, improve parenting and shared decision-making, and reduce violence in impoverished Rwandan households. Twenty vulnerable families with a child 36-months or younger enrolled in Sugira Muryango. Measures of parenting, home environment, family-violence, decision-making, and health-status were administered at pre/post and follow-up. Families reported high satisfaction post-intervention. OMCI scores improved for 4.8% of mother-child dyads at post-intervention and 19.0% at follow-up, while 9.5% of dyads showed declines at both times. HOME Inventory scores improved for 9.5% and 14.3% of dyads at post-intervention and follow-up respectively and declined for 4.8% and 0.0%. Indicators for equal decision-making and child dietary-diversity improved at post-intervention and follow-up. Fewer mothers believed physical punishment was necessary at follow-up. Sugira Muryango shows promise for improving parenting, beliefs about harsh punishment, child nutritional status, and shared decision-making among vulnerable families.

Faculty with high vitality are essential to the missions of academic health centers (AHCs). Because little is known about how to measure or enhance faculty vitality, the authors assessed current faculty vitality and identified its predictors.In a stratified random sample of 26 nationally representative U.S. AHCs, the authors surveyed 4,578 full-time faculty during 2007-2009. The validated survey measured detailed faculty perceptions of their professional experiences and organizational culture. Vitality was measured with a previously evaluated five-item scale.Of the faculty invited, 2,381 (52%) responded, with 2,218 eligible for analysis. Respondents included 512 (23%) underrepresented in medicine minority (URMM) faculty and 1,172 (53%) women. In a multivariable model including individual- and AHC-level factors, the strongest predictors of vitality were faculty members' perceptions of four dimensions of AHC culture: Relationships/inclusion, Values alignment, Work-life integration, and Institutional support (all P.001). Weaker predictors were faculty age, institution type (public/private), and the AHC's National Institutes of Health funding rank (all P ≤ .03). Half of the respondents scored high on vitality, whereas 25% had low, or suboptimal, scores. Holding perceptions of culture constant, neither female nor URMM faculty had vitality scores that were different on average from male or nonminority faculty.A large percentage of faculty lack the vitality essential to meeting the AHC missions of discovery, education, and patient care. Enhancing faculty vitality, and AHC resilience, requires more attention to strengthening relationships, improving the misalignment between faculty and institutional values, and improving work-life integration.

Trauma from witnessing events such as bombings and killings as well as direct victimization or participation in violence has been associated with psychosocial distress and poor mental health among war-exposed children and adolescents. This study examines the relationship between caregiver mental health and child internalizing (anxiety and depression) symptoms over a 4-year period in postconflict Sierra Leone.The sample included 118 adolescent Sierra Leonean youth (73% male; mean age = 16.5 years at Time 1) and their caregivers (40% male; mean age = 39.0 at Time 1). To measure depression and anxiety symptoms, the Hopkins Symptom Checklist-25 was used with adults and the Oxford Measure of Psychosocial Adjustment - previously validated for use with children and adolescents in the region - was used to assess youth. A multivariate hierarchical linear model (HLM) for studying change within dyads was implemented to study covariation in internalizing symptoms among caregivers and youth over time; these models also included covariates at the individual, family and community levels. The relationship of caregiver mental health to child's internalizing was tested in a latent variable extension of the HLM.The latent variable extension estimated that a one standard deviation (SD) change in caregiver anxiety/depression was associated with a .43 SD change in youth internalizing (p.01) over the 4-year period. Family acceptance was negatively related to youth internalizing (p.001), while community stigma was positively associated (p.001).The findings highlight an important interplay between caregiver and child mental health within the postconflict setting and the need for psychosocial interventions to extend beyond the individual to account for family dynamics.

Mental health problems are linked to violence exposures such as witnessing or participating in war-related activities. Of particular concern is whether such exposure perpetuates risk of violent behavior. Externalizing problems have received limited attention in research on war-affected youth. Three waves of data (2002–2008) from a prospective longitudinal study in Sierra Leone were used to examine externalizing trajectories in 529 war-affected youth (average age 14.9 at baseline; 25% female). Of four groups, the largest represented a trajectory designated as ‘stable,’ with relatively low levels of externalizing at baseline declining slightly across the time points. Compared to the stable group, the probability of being classified in the ‘deteriorators’ group was greater among those who reported having injured/killed another person during the war and with a history of family abuse and neglect reported at T3. Membership in the ‘improvers’ group was more likely for those with higher family support and was also associated with reporting injuring/killing others during the war. A minority indicated sustained, heightened symptom levels, which was also associated with family abuse and neglect following the war. Our findings demonstrate that both traumatic war experiences and post-war experiences play vital roles in shaping adolescents' trajectories of externalizing over time.

OBJECTIVE: To evaluate sustained improvements 6 months after a 40-session, in-school computer attention training intervention using neurofeedback or cognitive training (CT) administered to 7- to 11-year-olds with attention-deficit/hyperactivity disorder (ADHD). METHODS: One hundred four children were randomly assigned to receive neurofeedback, CT, or a control condition and were evaluated 6 months postintervention. A 3-point growth model assessed change over time across the conditions on the Conners 3–Parent Assessment Report (Conners 3-P), the Behavior Rating Inventory of Executive Function Parent Form (BRIEF), and a systematic double-blinded classroom observation (Behavioral Observation of Students in Schools). Analysis of variance assessed community-initiated changes in stimulant medication. RESULTS: Parent response rates were 90% at the 6-month follow-up. Six months postintervention, neurofeedback participants maintained significant gains on Conners 3-P (Inattention effect size [ES] = 0.34, Executive Functioning ES = 0.25, Hyperactivity/Impulsivity ES = 0.23) and BRIEF subscales including the Global Executive Composite (ES = 0.31), which remained significantly greater than gains found among children in CT and control conditions. Children in the CT condition showed delayed improvement over immediate postintervention ratings only on Conners 3-P Executive Functioning (ES = 0.18) and 2 BRIEF subscales. At the 6-month follow-up, neurofeedback participants maintained the same stimulant medication dosage, whereas participants in both CT and control conditions showed statistically and clinically significant increases (9 mg [P = .002] and 13 mg [P < .001], respectively). CONCLUSIONS: Neurofeedback participants made more prompt and greater improvements in ADHD symptoms, which were sustained at the 6-month follow-up, than did CT participants or those in the control group. This finding suggests that neurofeedback is a promising attention training treatment for children with ADHD.

To evaluate the efficacy of 2 computer attention training systems administered in school for children with attention-deficit hyperactivity disorder (ADHD).Children in second and fourth grade with a diagnosis of ADHD (n = 104) were randomly assigned to neurofeedback (NF) (n = 34), cognitive training (CT) (n = 34), or control (n = 36) conditions. A 2-point growth model assessed change from pre-post intervention on parent reports (Conners 3-Parent [Conners 3-P]; Behavior Rating Inventory of Executive Function [BRIEF] rating scale), teacher reports (Swanson, Kotkin, Agler, M-Flynn and Pelham scale [SKAMP]; Conners 3-Teacher [Conners 3-T]), and systematic classroom observations (Behavioral Observation of Students in Schools [BOSS]). Paired t tests and an analysis of covariance assessed change in medication.Children who received NF showed significant improvement compared with those in the control condition on the Conners 3-P Attention, Executive Functioning and Global Index, on all BRIEF summary indices, and on BOSS motor/verbal off-task behavior. Children who received CT showed no improvement compared to the control condition. Children in the NF condition showed significant improvements compared to those in the CT condition on Conners 3-P Executive Functioning, all BRIEF summary indices, SKAMP Attention, and Conners 3-T Inattention subscales. Stimulant medication dosage in methylphenidate equivalencies significantly increased for children in the CT (8.54 mg) and control (7.05 mg) conditions but not for those in the NF condition (0.29 mg).Neurofeedback made greater improvements in ADHD symptoms compared to both the control and CT conditions. Thus, NF is a promising attention training treatment intervention for children with ADHD.

A diverse medical school faculty is critical to preparing physicians to provide quality care to an increasingly diverse nation. The authors sought to compare experiences of underrepresented in medicine minority (URMM) faculty with those of non-URMM faculty in a nationally representative sample of medical schools.In 2007-2009, the authors surveyed a stratified random sample of 4,578 MD and PhD full-time faculty from 26 U.S. medical schools. Multiple regression models were used to test for differences between URMM and other faculty on 12 dimensions of academic culture. Weights were used to adjust for oversampling of URMM and female faculty.The response rate was 52%, or 2,381 faculty. The analytic sample was 2,218 faculty: 512 (23%) were URMM, and 1,172 (53%) were female, mean age 49 years. Compared with non-URMM faculty, URMM faculty endorsed higher leadership aspirations but reported lower perceptions of relationships/inclusion, gave their institutions lower scores on URMM equity and institutional efforts to improve diversity, and more frequently engaged in disparities research. Twenty-two percent (115) had experienced racial/ethnic discrimination. For both values alignment and institutional change for diversity, URMM faculty at two institutions with high proportions (over 50%) of URMM faculty rated these characteristics significantly higher than their counterparts at traditional institutions.Encouragingly, for most aspects of academic medicine, the experiences of URMM and non-URMM faculty are similar, but the differences raise important concerns. The combination of higher leadership aspirations with lower feelings of inclusion and relationships might lead to discouragement with academic medicine.

Observational measures can add objective data to both research and clinical evaluations of children’s behavior in the classroom. However, they pose challenges for training and attaining high levels of interrater reliability between observers. The Behavioral Observation of Students in Schools (BOSS) is a commonly used school-based observation instrument that is well adapted to measure symptoms of attention deficit/hyperactivity disorder (ADHD) in the classroom setting. Reliable use of the BOSS for clinical or research purposes requires training to reach reliable standards (kappa ≥ 0.80). The current study conducted training observations in one suburban and one urban elementary school in the Greater Boston area. To enhance interrater reliability and reduce training time, supplemental guidelines, including 30 additional rules to follow, were developed over two consecutive school years. The complete protocol was then used for training in the third school year. To reach sufficient interrater reliability (kappa ≥ 0.80) during training, 45 training observations were required in the first year while, in the third year, only 17 observations were required. High interrater reliability was sustained after training across all three school years, accumulating a total of 1,001 post-training observations. It is estimated that clinicians or researchers following this proposed protocol, who are naive to the BOSS, will require approximately 30 training observations to reach proficient reliability. We believe this protocol will make the BOSS more accessible for clinical and research usage, and the procedures used to obtain high interrater reliability using the BOSS are broadly applicable to a variety of observational measures.

Background Children affected by HIV are at risk for poor mental health. We conducted a pilot randomized controlled trial (RCT) of the Family Strengthening Intervention (FSI-HIV), a family home-visiting intervention to promote mental health and improve parent–child relationships in families with caregivers living with HIV, hypothesizing that child and family outcomes would be superior to usual care social work services. Methods Eighty two families (N = 170 children, 48.24% female; N = 123 caregivers, 68.29% female) with at least one HIV-positive caregiver (n = 103, 83.74%) and school-aged child (ages 7–17) (HIV+ n = 21, 12.35%) were randomized to receive FSI-HIV or treatment-as-usual (TAU). Local research assistants blind to treatment conducted assessments of child mental health, parenting practices, and family functioning at baseline, post-intervention, and 3-month follow-up. Multilevel modeling assessed effects of FSI-HIV on outcomes across three time points. Trial Registration: NCT01509573, ‘Pilot Feasibility Trial of the Family Strengthening Intervention in Rwanda (FSI-HIV-R).' https://clinicaltrials.gov/ct2/show/;NCT01509573?term=Pilot+Feasibility+Trial+of+the+Family+Strengthening+Intervention+in+Rwanda+%28FSI-HIV-R%29&rank=1. Results At 3-month follow-up, children in FSI-HIV showed fewer symptoms of depression compared to TAU by both self-report (β = −.246; p = .009) and parent report (β = −.174; p = .035) but there were no significant differences by group on conduct problems, functional impairment, family connectedness, or parenting. Conclusions Family-based prevention has promise for reducing depression symptoms in children affected by HIV. Future trials should examine the effects of FSI-HIV over time in trials powered to examine treatment mediators.

Three waves of data from a prospective longitudinal study in Sierra Leone were used to examine internalizing trajectories in 529 war-affected youth (ages 10-17 at baseline; 25% female). Latent class growth analyses identified four trajectories: a large majority of youth maintained lower levels of internalizing problems (41.4%) or significantly improved over time (47.6%) despite very limited access to care; but smaller proportions continued to report severe difficulties six years post-war (4.5%) or their symptoms worsened (6.4%). Continued internalizing problems were associated with loss of a caregiver, family abuse and neglect, and community stigma. Despite the comparative resilience of most war-affected youth in the face of extreme adversity, there remains a compelling need for interventions that address family- and community-level stressors.

The potential capacity of children to confront the HIV/AIDS pandemic is rarely considered. Interventions to address the impact of the pandemic on children and adolescents commonly target only their vulnerabilities. We evaluated the Young Citizens Program, an adolescent-centered health promotion curriculum designed to increase self- and collective efficacy through public education and community mobilization across a municipality in the Kilimanjaro Region of Tanzania. The theoretical framework for the program integrates aspects of human capability, communicative action, social ecology and social cognition. The design consists of a cluster randomized-controlled trial (CRCT). Fifteen pairs of matched geopolitically defined neighborhoods of roughly 2000–4000 residents were randomly allocated to treatment and control arms. Within each neighborhood cluster, 24 randomly selected adolescents, ages 9–14, deliberated on topics of social ecology, citizenship, community health and HIV/AIDS competence. Building on their acquired understanding and confidence, they dramatized the scientific basis and social context of HIV infection, testing and treatment in their communities over a 28-week period. The curriculum comprised 5 modules: Group Formation, Understanding our Community, Health and our Community, Making Assessments and Taking Action in our Community and Inter-Acting in our Community. Adolescent participants and adult residents representative of their neighborhoods were surveyed before and after the intervention; data were analyzed using multilevel modeling. In treatment neighborhoods, adolescents increased their deliberative and communicative efficacy and adults showed higher collective efficacy for children. Following the CRCT assessments, the control group received the same curriculum. In the Kilimanjaro Region, the Young Citizens Program is becoming recognized as a structural, health promotion approach through which adolescent self-efficacy and child collective efficacy are generated in the context of civil society and local government.

Energized and productive faculty are critical to academic medicine, yet studies indicate a lack of advancement and senior roles for women.Using measures of key aspects of the culture of academic medicine, this study sought to identify similarity and dissimilarity between perceptions of the culture by male and female faculty.The C - Change Faculty Survey was used to collect data on perceptions of organizational culture.A stratified random sample of 4,578 full-time faculty at 26 nationally representative US medical colleges (response rate 52 %). 1,271 (53 %) of respondents were female.Factor analysis assisted in the creation of scales assessing dimensions of the culture, which served as the key outcomes. Regression analysis identified gender differences while controlling for other demographic characteristics.Compared with men, female faculty reported a lower sense of belonging and relationships within the workplace (T = -3.30, p 0.01). Self-efficacy for career advancement was lower in women (T = -4.73, p 0.001). Women perceived lower gender equity (T = -19.82, p 0.001), and were less likely to believe their institutions were making changes to address diversity goals (T = -9.70, p 0.001). Women were less likely than men to perceive their institution as family-friendly (T = -4.06, p 0.001), and women reported less congruence between their own values and those of their institutions (T = -2.06, p 0.05). Women and men did not differ significantly on levels of engagement, leadership aspirations, feelings of ethical/moral distress, perception of institutional commitment to faculty advancement, or perception of institutional change efforts to improve support for faculty.Faculty men and women are equally engaged in their work and share similar leadership aspirations. However, medical schools have failed to create and sustain an environment where women feel fully accepted and supported to succeed; how can we ensure that medical schools are fully using the talent pool of a third of its faculty?

Vital, productive faculty are critical to academic medicine, yet studies indicate high dissatisfaction and attrition. The authors sought to identify key personal and cultural factors associated with intentions to leave one's institution and/or academic medicine.From 2007 through early 2009, the authors surveyed a stratified random sample of 4,578 full-time faculty from 26 representative U.S. medical schools. The survey asked about advancement, engagement, relationships, diversity and equity, leadership, institutional values and practices, and work-life integration. A two-level, multinomial logit model was used to predict leaving intentions.A total of 2,381 faculty responded (52%); 1,994 provided complete data for analysis. Of these, 1,062 (53%) were female and 475 (24%) were underrepresented minorities in medicine. Faculty valued their work, but 273 (14%) had seriously considered leaving their own institution during the prior year and 421 (21%) had considered leaving academic medicine altogether because of dissatisfaction; an additional 109 (5%) cited personal/family issues and 49 (2%) retirement as reasons to leave. Negative perceptions of the culture-unrelatedness, feeling moral distress at work, and lack of engagement-were associated with leaving for dissatisfaction. Other significant predictors were perceptions of values incongruence, low institutional support, and low self-efficacy. Institutional characteristics and personal variables (e.g., gender) were not predictive.Findings suggest that academic medicine does not support relatedness and a moral culture for many faculty. If these issues are not addressed, academic health centers may find themselves with dissatisfied faculty looking to go elsewhere.

Based on the Conservation of Resources theory, we used data from the National Survey of Midlife Development in the United States (MIDUS I, 1995–1996; N=1779) to estimate by covariance structure analysis the direct and indirect effects of work and family demands, resources, and support on psychological distress. In a new application of the theory, we estimated six within-role mediational pathways linking work-related predictors to psychological distress through work interfering with family (WIF) and family-related predictors to psychological distress through family interfering with work (FIW). Finally, in a departure from previous work–family research, we estimated six cross-role mediational pathways linking work-related predictors to psychological distress through FIW and family-related predictors to psychological distress through WIF. Ten of the 12 hypothesized mediational effects were significant and another was marginally significant, supporting the mediational role of work–family conflict within Conse...

This is the first prospective study to investigate psychosocial adjustment in male and female former child soldiers (ages 10–18; n = 156, 12% female). The study began in Sierra Leone in 2002 and was designed to examine both risk and protective factors in psychosocial adjustment. Over the 2-year period of follow-up, youth who had wounded or killed others during the war demonstrated increases in hostility. Youth who survived rape not only had higher levels of anxiety and hostility but also demonstrated greater confidence and prosocial attitudes at follow-up. Of the potential protective resources examined, improved community acceptance was associated with reduced depression at follow-up and improved confidence and prosocial attitudes regardless of levels of violence exposure. Retention in school was also associated with greater prosocial attitudes.

Objective To investigate the longitudinal course of internalizing and externalizing problems and adaptive/prosocial behaviors among Sierra Leonean former child soldiers and whether postconflict factors contribute to adverse or resilient mental health outcomes. Method Male and female former child soldiers (N = 260, aged 10 to 17 years at baseline) were recruited from the roster of an non-governmental organization (NGO)-run Interim Care Center in Kono District and interviewed in 2002, 2004, and 2008. The retention rate was 69%. Linear growth models were used to investigate trends related to war and postconflict experiences. Results The long-term mental health of former child soldiers was associated with war experiences and postconflict risk factors, which were partly mitigated by postconflict protective factors. Increases in externalizing behavior were associated with killing/injuring others during the war and postconflict stigma, whereas increased community acceptance was associated with decreases in externalizing problems ( b = −1.09). High baseline levels of internalizing problems were associated with being raped, whereas increases were associated with younger involvement in armed groups and social and economic hardships. Improvements in internalizing problems were associated with higher levels of community acceptance and increases in community acceptance ( b = −0.86). Decreases in adaptive/prosocial behaviors were associated with killing/injuring others during the war and postconflict stigma, but partially mitigated by social support, being in school and increased community acceptance ( b = 1.93). Conclusions Psychosocial interventions for former child soldiers may be more e ffective if they account for postconflict factors in addition to war exposures. Youth with accumulated risk factors, lack of protective factors, and persistent distress should be identified. Sustainable services to promote community acceptance, reduce stigma, and expand social supports and educational access are recommended.

This paper describes the WFD Consulting multi-organization database and the methodology used by the five quantitative studies in this special issue to examine workplace flexibility (Hill & Civian, 2008). The database includes 72,161 responses representing 312,459 employees from 25 US organizations in five industries gathered from 1996 to 2006. These studies have an average response rate of 45%. First, an overview of the research questions is presented. Next, definitions and psychometric properties of several commonly used measures and indexes are explained. After this, analytic strategies for hierarchical linear modeling including handling of missing data, protocols for model building, and accommodating clustered data structures are described. Finally, the strengths and limitations of using this kind of dataset for academic research are discussed.

This study examines the relationship of perceived workplace flexibility and supportive work–life policies to employee engagement and expectations to remain with the organization (expected retention). It also explores the association of formal and occasional (informal) use of flexibility with these outcomes. Data are from a multi-organization database created by WFD Consulting of studies conducted between 1996 and 2006. Results revealed that perceived flexibility and supportive work–life policies were related to greater employee engagement and longer than expected retention. Employee engagement fully mediated the relationship between perceived flexibility and expected retention and partially mediated the relationship between supportive work–life policies and expected retention. Both formal and occasional use of flexibility were positively associated with perceived flexibility, employee engagement, and expected retention. These analyses provide evidence that workplace flexibility may enhance employee engage...

This study explores how the reported use and perceived value of five workplace flexibility options differ by gender and life stage. It also examines the relationship of perceived workplace flexibility, gender, and life stages to family-to-work conflict and stress and burnout. Data are from a multi-company database created by WFD Consulting containing the results of studies conducted in multiple organizations between 1996 and 2006. Results revealed a curvilinear relationship in differences between men and women in the use of workplace flexibility options over the life course. Hierarchical linear modeling (HLM) revealed that perceived flexibility consistently predicted less family-to-work conflict and less stress and burnout. Gender (being female) was also modestly associated with greater family-to-work conflict and greater stress and burnout. The addition of life stage variables significantly increased the proportion of the variance explained in family-to-work conflict and stress and burnout. The addition ...

A community-based cluster randomized control trial in a medium-sized municipality in Tanzania was designed to increase local competence to control HIV/AIDS through actions initiated by children and adolescents aged 10 to 14 years. Representative groups from the 15 treatment communities reached mutual understanding about their objectives as health agents, prioritized their actions, and skillfully applied community drama (“skits”) to impart knowledge about the social realities and the microbiology of HIV/AIDS. In independently conducted surveys of neighborhood residents, differences were found between adults who did and did not witness the skits in their beliefs about the efficacy of children as HIV/AIDS primary change agents.

Investigating the effects of social context (e.g., neighborhood or school context) on the timing of behaviors (such as cigarette use initiation) requires both multi-level modeling and eventhistory analysis, and often requires the construction of a retrospective person-period data set from cross-sectional data. In this article we describe procedures for constructing such a data set and discuss modeling strategies for estimating multi-level discrete-time event history models. We show that the estimation of two-level discrete-time models involves three distinct modeling assumptions (the assumptions that individual- and neighborhood-level covariates have the same effect at all time points and the assumption that the baseline logithazard curves in each neighborhood are parallel) and discuss methods of relaxing and empirically testing each of these assumptions. Estimation can be simplified in some cases if we additionally assume that the shape of the baseline logit-hazard curve in each neighborhood can be approximated by a simple functional form. The methods described here are applicable to a wide variety of questions where the dependent variable of interest is either onset or cessation. Here we apply these methods to the analysis of cigarette use initiation in a sample of 1,979 11- to 18-year-olds drawn from 79 neighborhoods of Chicago. We find that the racial composition of a neighborhood accounts for roughly half of the difference in age of smoking initiation between Black and White teenagers. Specifically, we find that living in a neighborhood with a large percentage of Black residents is associated with a lower hazard of adolescent cigarette use initiation than is living in neighborhoods with few Black residents.