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Children who have lost a parent to HIV/AIDS, known as AIDS orphans, face multiple stressors affecting their health and development. Family economic empowerment (FEE) interventions have the potential to improve these outcomes and mitigate the risks they face. We present efficacy and cost-effectiveness analyses of the Bridges study, a savings-led FEE intervention among AIDS-orphaned adolescents in Uganda at four-year follow-up. Intent-to-treat analyses using multilevel models compared the effects of two savings-led treatment arms: Bridges (1:1 matched incentive) and BridgesPLUS (2:1 matched incentive) to a usual care control group on the following outcomes: self-rated health, sexual health, and mental health functioning. Total per-participant costs for each arm were calculated using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to calculate incremental cost-effectiveness ratios (ICERs). Among 1,383 participants, 55% were female, 20% were double orphans. Mean age was 12 years at baseline. At 48-months, BridgesPLUS significantly improved self-rated health, (0.25, 95% CI 0.06, 0.43), HIV knowledge (0.21, 95% CI 0.01, 0.41), self-concept (0.26, 95% CI 0.09, 0.44), and self-efficacy (0.26, 95% CI 0.09, 0.43) and lowered hopelessness (-0.28, 95% CI -0.43, -0.12); whereas Bridges improved self-rated health (0.26, 95% CI 0.08, 0.43) and HIV knowledge (0.22, 95% CI 0.05, 0.39). ICERs ranged from $224 for hopelessness to $298 for HIV knowledge per 0.2 standard deviation change. Most intervention effects were sustained in both treatment arms at two years post-intervention. Higher matching incentives yielded a significant and lasting effect on a greater number of outcomes among adolescents compared to lower matching incentives at a similar incremental cost per unit effect. These findings contribute to the evidence supporting the incorporation of FEE interventions within national social protection frameworks.

Background In this paper, we argue for Gender as a Sociocultural Variable (GASV) as a complement to Sex as a Biological Variable (SABV). Sex (biology) and gender (sociocultural behaviors and attitudes) interact to influence health and disease processes across the lifespan—which is currently playing out in the COVID-19 pandemic. This study develops a gender assessment tool—the Stanford Gender-Related Variables for Health Research—for use in clinical and population research, including large-scale health surveys involving diverse Western populations. While analyzing sex as a biological variable is widely mandated, gender as a sociocultural variable is not, largely because the field lacks quantitative tools for analyzing the influence of gender on health outcomes. Methods We conducted a comprehensive review of English-language measures of gender from 1975 to 2015 to identify variables across three domains: gender norms, gender-related traits, and gender relations. This yielded 11 variables tested with 44 items in three US cross-sectional survey populations: two internet-based ( N = 2051; N = 2135) and a patient-research registry ( N = 489), conducted between May 2017 and January 2018. Results Exploratory and confirmatory factor analyses reduced 11 constructs to 7 gender-related variables: caregiver strain, work strain, independence, risk-taking, emotional intelligence, social support, and discrimination. Regression analyses, adjusted for age, ethnicity, income, education, sex assigned at birth, and self-reported gender identity, identified associations between these gender-related variables and self-rated general health, physical and mental health, and health-risk behaviors. Conclusion Our new instrument represents an important step toward developing more comprehensive and precise survey-based measures of gender in relation to health. Our questionnaire is designed to shed light on how specific gender-related behaviors and attitudes contribute to health and disease processes, irrespective of—or in addition to—biological sex and self-reported gender identity. Use of these gender-related variables in experimental studies, such as clinical trials, may also help us understand if gender factors play an important role as treatment-effect modifiers and would thus need to be further considered in treatment decision-making.

While there is a large body of research demonstrating that having an abortion is not associated with adverse mental health outcomes, less research has examined which factors may contribute to elevated levels of mental health symptoms at the time of abortion seeking. This study aims to develop and validate a new tool to measure dimensions of psychosocial burden experienced by people seeking abortion in the United States. To develop scale items, we reviewed the literature including existing measures of stress and anxiety and conducted interviews with experts in abortion care and with patients seeking abortion. Thirty-five items were administered to 784 people seeking abortion at four facilities located in three U.S. states. We used exploratory factor analysis (EFA) to reduce items and identify key domains of psychosocial burden. We assessed the predictive validity of the overall scale and each sub-scale, by assessing their associations with validated measures of perceived stress, anxiety, and depression using multivariable linear regression models. Factor analyses revealed a 12-item factor solution measuring psychosocial burden seeking abortion, with four subdomains: structural challenges, pregnancy decision-making, lack of autonomy, and others’ reactions to the pregnancy. The alpha reliability coefficients were acceptable for the overall scale (α = 0.83) and each subscale (ranging from α = 0.82–0.85). In adjusted analyses, the overall scale was significantly associated with stress, anxiety and depression; each subscale was also significantly associated with each mental health outcome. This new scale offers a practical tool for providers and researchers to empirically document the factors associated with people’s psychological well-being at the time of seeking an abortion. Findings suggest that the same restrictions that claim to protect people from mental health harm may be increasing people’s psychosocial burden and contributing to adverse psychological outcomes at the time of seeking abortion.

The bidirectional associations between negative self-conscious emotions such as shame and guilt and substance use are poorly understood. Longitudinal research is needed to examine the causes, consequences, and moderators of negative self-conscious emotions in people who use substances. Using parallel process latent growth curve modeling, we assessed bidirectional associations between shame and guilt and substance use (i.e., number of days in the past 30 used stimulants, alcohol to intoxication, other substances, or injected drugs) as well as the moderating role of positive emotion. Emotions were assessed using the Differential Emotions Scale. The sample included 110 sexual minority cisgender men with biologically confirmed recent methamphetamine use, enrolled in a randomized controlled trial in San Francisco, CA. Participants self-reported emotions and recent substance use behaviors over six time points across 15 months. Higher initial levels of shame were associated with slower decreases in stimulant use over time (b = 0.23, p = .041) and guilt was positively associated with stimulant use over time (β = 0.85, p < .0001). Initial levels of guilt and alcohol use were positively related (b = 0.29, p = .040), but over time, they had a negative relationship (β = -0.99, p < .0001). Additionally, higher initial levels of other drug use were associated with slower decreases in shame over time (b = 0.02, p = .041). All results were independent of depression, highlighting the specific role of self-conscious emotions. Shame and guilt are barriers to reducing stimulant use, and expanded efforts are needed to mitigate the deleterious effects of these self-conscious emotions in recovery from a stimulant use disorder.

The rapid scale-up of HIV therapy across Africa has failed to adequately engage adolescents living with HIV (ALWHIV). Retention and viral suppression for this group (ALWHIV) is 50% lower than for adults. Indeed, on the African continent, HIV remains the single leading cause of mortality among adolescents. Strategies tailored to the unqiue developmental and social vulnerabilities of this group are urgently needed to enhance successful treatment. We carried out a five-year longitudinal cluster randomized trial (ClinicalTrials.gov ID: NCT01790373) with adolescents living with HIV (ALWHIV) ages 10 to 16 years clustered at health care clinics to test the effect of a family economic empowerment (EE) intervention on viral suppression in five districuts in Uganda. In total, 39 accredited health care clinics from study districts with existing procedures tailored to adolescent adherence were eligible to participate in the trial. We used data from 288 youth with detectable HIV viral loads (VL) at baseline (158 -intervention group from 20 clinics, 130 -non-intervention group from 19 clinics). The primary end point was undetectable plasma HIV RNA levels, defined as < 40 copies/ml. We used Kaplan-Meier (KM) analysis and Cox proportional hazard models to estimate intervention effects. The Kaplan-Meier (KM) analysis indicated that an incidence of undetectable VL (0.254) was significantly higher in the intervention condition compared to 0.173 (in non-intervention arm) translated into incidence rate ratio of 1.468 (CI: 1.064-2.038), p = 0.008. Cox regression results showed that along with the family-based EE intervention (adj. HR = 1.446, CI: 1.073-1.949, p = 0.015), higher number of medications per day had significant positive effects on the viral suppression (adj.HR = 1.852, CI: 1.275-2.690, p = 0.001). A family economic empowerment intervention improved treatment success for ALWHIV in Uganda. Analyses of cost effectiveness and scalability are needed to advance incorporation of this intervention into routine practice in low and middle-income countries.

Our ability to measure household-level food insecurity has revealed its critical role in a range of physical, psychosocial, and health outcomes. Currently, there is no analogous, standardized instrument for quantifying household-level water insecurity, which prevents us from understanding both its prevalence and consequences. Therefore, our objectives were to develop and validate a household water insecurity scale appropriate for use in our cohort in western Kenya. We used a range of qualitative techniques to develop a preliminary set of 29 household water insecurity questions and administered those questions at 15 and 18 months postpartum, concurrent with a suite of other survey modules. These data were complemented by data on quantity of water used and stored, and microbiological quality. Inter-item and item-total correlations were performed to reduce scale items to 20. Exploratory factor and parallel analyses were used to determine the latent factor structure; a unidimensional scale was hypothesized and tested using confirmatory factor and bifactor analyses, along with multiple statistical fit indices. Reliability was assessed using Cronbach's alpha and the coefficient of stability, which produced a coefficient alpha of 0.97 at 15 and 18 months postpartum and a coefficient of stability of 0.62. Predictive, convergent and discriminant validity of the final household water insecurity scale were supported based on relationships with food insecurity, perceived stress, per capita household water use, and time and money spent acquiring water. The resultant scale is a valid and reliable instrument. It can be used in this setting to test a range of hypotheses about the role of household water insecurity in numerous physical and psychosocial health outcomes, to identify the households most vulnerable to water insecurity, and to evaluate the effects of water-related interventions. To extend its applicability, we encourage efforts to develop a cross-culturally valid scale using robust qualitative and quantitative techniques.

Purpose – Trans women of color contend with multiple marginalizations; the purpose of this study is to examine associations between experiencing discriminatory (racist/transphobic) events and depression symptoms. It uses a categorical measure of combined discrimination, and examines a protective association of transgender identity on depression symptoms. Design/methodology/approach – Data from a subset of trans women of color participants in the Sheroes study were analyzed with linear and logistic regression. Associations of depression symptoms with racist and transphobic events, combined discrimination, coping self-efficacy, and transgender identity were assessed with odds ratios. Findings – Exposure to discriminatory events and combined discrimination positively associated with depression symptom odds. Increased transgender identity associated with increased coping self-efficacy, which negatively associated with depression symptom odds. Research limitations/implications – Cross-sectional study data prohibits inferring causality; results support conducting longitudinal research on discrimination's health effects, and research on transgender identity. Results also support operationalizing intersectionality in health research. The study's categorical approach to combined discrimination may be replicable in studies with hard to reach populations and small sample sizes. Practical implications – Health programs could pursue psychosocial interventions and anti-discrimination campaigns. Interventions might advocate increasing participants’ coping self-efficacy while providing space to explore and develop social identity. Social implications – There is a need for policy and health programs to center trans women of color concerns. Originality/value – This study examines combined discrimination and identity in relation to depression symptoms among trans women of color, an underserved population.

Lesbian, gay, bisexual, and transgender (LGBT) adolescents are at increased risk for substance use, relative to their heterosexual counterparts. Although previous research has demonstrated that experiences of anti-LGBT harassment, discrimination, and victimization may explain some of this disparity, little is known about the mechanisms whereby such mistreatment leads to substance abuse. This study aimed to examine whether mechanisms suggested by the Social Development Model might explain the links between school-based victimization and substance use in this population. Five hundred and four ethnically diverse LGBT adolescents ages 14–19 reported their experiences with school victimization, substance abuse, school bonding, and deviant peer group affiliation. Anti-LGBT victimization in school was associated with substance abuse, and although causality cannot be established, structural equation modeling confirmed that the data are consistent with a theoretical model in which this association was mediated by increased affiliation with deviant peers. Preventive interventions for LGBT adolescents must not only attempt to make schools safer for these youth, but also help keep them engaged in healthy peer groups when they are confronted with mistreatment in school.

Background People living with HIV (PLHIV) are highly impacted by food insecurity through pathways including poor adherence to antiretroviral therapy and inadequate nutrition. Limited evidence exists on whether economic empowerment interventions can improve food insecurity among PLHIV in sub-Saharan Africa. We evaluated the effectiveness of Mlambe , an economic empowerment and relationship-strengthening intervention, on food insecurity among couples living with HIV who drink alcohol in Malawi. Methods We analyzed data from 78 couples who participated in the Mlambe study, implemented in Zomba, Malawi. The study enrolled married couples living with HIV and unhealthy alcohol use (based on the AUDIT-C) from HIV care settings: an urban hospital, a rural private community, and a peri-urban health center. Couples were randomized into two groups: the Mlambe intervention or enhanced usual care (EUC). Mlambe intervention included incentivized savings accounts and sessions on financial literacy training and relationship skills over ten months. Study assessments occurred at baseline, 10- and 15-months. Food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS), which was categorized into four levels (food secure, mild, moderate, and severe food insecurity). We fit two-level, logistic mixed effects models testing the effect of Mlambe on severe food insecurity, given that most couples reported being food insecure. Results The mean age of participants at baseline was 43.4 years, with 78.2% reporting primary education. On average, couples had been married for 13.8 years. Over half (53.3%) reported unhealthy alcohol use, 91.6% were HIV-positive, and 57.1% experienced severe food insecurity. Couples in Mlambe intervention showed a significant reduction in severe food insecurity as compared to the EUC arm at the 15-month follow-up (OR = 0.81, 95% CI: 0.66, 0.99). No significant reductions were observed at 10 months, which immediately followed the intervention period. Conclusion Mlambe intervention demonstrated a significant reduction in severe food insecurity among HIV-positive couples with unhealthy alcohol use at 15-months. This pilot study provides evidence that integrated interventions targeting economic and relationship factors at household level have the potential to effectively reduce food insecurity in settings like Malawi. A full-scale efficacy study is needed to confirm findings with a larger sample and longer follow-up. Study clinical trial registration Mlambe was registered on ClinicalTrials.gov (NCT #04906616, 08/15/2019).

Cardiometabolic disorders (CMD) such as hypertension and diabetes are increasingly prevalent in sub-Saharan Africa, placing people living with HIV at risk for cardiovascular disease and threatening the success of HIV care. Spouses are often the primary caregivers for people living with CMD, and understanding patients’ and partners’ conceptions of CMD could inform care. We conducted semi-structured interviews with 25 couples having a partner living with HIV and either hypertension or diabetes. Couples were recruited from HIV clinics in Malawi and were interviewed on beliefs around symptoms, causation, prevention, and treatment for CMD. Data were analyzed at the individual and dyadic levels using framework analysis and Kleinman’s theory of explanatory models as a lens. On average, participants were 51 years old and married for 21 years. Approximately 57%, 14%, and 80% had hypertension, diabetes, and HIV. Couples endorsed a combination of biomedical explanatory models (beliefs around physical and mental health) and traditional explanatory models (beliefs around religion and natural remedies), although tended to emphasize the biomedical model. Half of couples believed stress was the main cause of hypertension. For diabetes, diet was believed to be a common cause. In terms of prevention, dietary changes and physical activity were most frequently mentioned. For disease management, medication adherence and diet modifications were emphasized, with some couples also supporting herbal remedies, stress reduction, and faith in God as strategies. Participants were generally more concerned about CMD than HIV due to poor access to CMD medications and beliefs that CMD could lead to sudden death. Within couples, partners often held many of the same beliefs but diverged around which etiological or preventive factors were most important (e.g., stress versus diet) and the best diet for CMD. Health education programs should involve primary partners to build knowledge of CMD and address overlap with HIV, and reinforce accurate information on lifestyle factors for the prevention and treatment of CMD.