The associations of everyday and major discrimination exposure with violence and poor mental health outcomes during the COVID-19 pandemic.

Research on discrimination and risks for violence and mental health issues under the pandemic is notably absent. We examined the relative effects of perceived everyday discrimination (e.g., poorer service, disrespectful treatment in a typical week) and major experiences of race-based discrimination (e.g., racial/ethnic discrimination in housing or employment at any point in the lifetime) on experiences of violence and the PHQ-4 assessment of symptoms of depression and anxiety under the pandemic. We analyzed state-representative cross-sectional survey data from California adults (N = 2114) collected in March 2021. We conducted multivariate regression models adjusting for age, race/ethnicity, gender, sexual identity, income, and disability. One in four Californians (26.1%) experienced everyday discrimination in public spaces, due most often to race/ethnicity and gender. We found that everyday discrimination was significantly associated with past year physical violence (single form Adjusted Odds Ratio [AOR] 5.0, 95% CI 2.5-10.3; multiple forms AOR 2.6, 95% CI 1.1-5.8), past year sexual violence (multiple forms AOR 2.5, 95% CI 1.4-4.4), and mental health symptoms (e.g., severe symptoms, multiple forms AOR 3.3, 95% CI 1.6-6.7). Major experiences of race-based discrimination (reported by 10.0% of Californians) were associated with past year sexual violence (AOR 2.0, 95% CI 1.1-3.8) and severe mental health symptoms (AOR 2.7, 95% CI 1.2-6.2). Non-race-based major discrimination (reported by 23.9% of Californians) was also associated with violence and mental health outcomes Everyday discrimination, more than major experiences of discrimination, was associated with higher risk for violence and poor mental health outcomes during the pandemic. Non-race-based forms of major discrimination independently were also associated with these negative outcomes. Findings indicate that efforts to reduce and ultimately eliminate discrimination should be a focus of public health and COVID-19 rebuilding efforts.

Factors affecting delayed and non-receipt of healthcare during the COVID-19 pandemic for women in rural Maharashtra, India: Evidence from a cross-sectional study.

Background: Pathways to low healthcare utilisation under the COVID-19 pandemic are not well understood. This study aims to understand women's concerns about the health system's priorities and their increased burden of domestic responsibilities during COVID-19 as predictors of delayed or non-receipt of needed care for themselves or their children. Methods: We surveyed married women in rural Maharashtra, India (N = 1021) on their health and economic concerns between Feb 1 and March 26, 2021. This study period was when India emerged from the first wave of the pandemic, which had severely impacted the health systems, and before the second-even more devastating wave had started. We captured if women were concerned about access to non-COVID health services due to healthcare being directed solely to COVID-19) (exposure 1) and whether their domestic responsibilities increased during the pandemic (exposure 2). Our outcomes included women's reports on whether they delayed healthcare seeking (secondary outcome and mediator) and whether they received healthcare for themselves or their children when needed (primary outcome). We conducted adjusted regression models on our predictor variables with each outcome and assessed the mediation effects of delayed healthcare seeking for each of the exposure variables. Findings: We found that women who were concerned that healthcare was directed solely towards COVID-19 were more likely not to receive healthcare when needed (Adjusted Risk Ratio [ARR] = 1.49, 95% CI = 1.14, 1.95). We also found that women whose domestic care burden increased under the pandemic were more likely to delay healthcare seeking (ARR = 1.84, 95% CI = 1.05, 3.21). Delayed healthcare seeking mediated the associations between each of our exposure variables with our outcome variable, non-receipt of needed healthcare. Interpretation: Our findings suggested that women's perceptions of healthcare systems and their domestic labour burdens affected healthcare seeking during the pandemic in India, even before the second wave of COVID-19 incapacitated the health system. Support for women and health systems is needed to ensure healthcare uptake during crises. Funding: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA (grant numbers: R01HD084453- 01A1 and RO1HD61115); Department of Biotechnology, Government of India (grant #BT/IN/US/01/BD/2010); the EMERGE project (Bill and Melinda Gates Foundation Grants: OPP1163682 and INV018007; PI Anita Raj), and Bill and Melinda Gates Foundation Grant number INV-002967.

Spousal support and work performance during the COVID-19 pandemic among elected women representatives in rural Bihar, India: A cross-sectional, mixed-methods study.

Background: This study examines family support for professional work and domestic labour among Elected Women Representatives' (EWR) in rural Bihar, India, and associations of this support with EWRs' professional performance during the COVID-19 pandemic. Methods: We conducted a cross-sectional, mixed-method study, surveying 1338 EWRs and conducting in-depth interviews with 31 EWRs (Oct 14- Nov 6, 2020). Purposive sampling was used to select the participants. Our team has been working for more than a decade with EWRs across 10 districts in Bihar, providing them with capacity building and community interventions. All EWRs are part of our network, and around 2000 were reached out for the survey. Of these, 1338 consented to participate. Four survey participants from each district were randomly selected and invited for the in-depth interviews. Independent variables for our quantitative analysis included help from husband and other family members on a) EWR work and b) domestic work. Dependent variables, dichotomised as yes/no, assessed EWR workload, COVID-19 work, intervening on violence against women or child marriage, and belief EWRs can have impact. Separate multivariate logistic regression models assessed the hypothesised relationships. All models were adjusted for socio-demographic variables and indicators related to EWR's work experience and community perception or respect. Findings: Most women (76%; n = 1016 EWRs) received help from their husbands with EWR work while 39% reported husband help with domestic labour. Receipt of help from husband with domestic work was associated with increase in official work since the pandemic (aOR: 2.62; 95% CI: 1.84-3.71), arrangement of needed services during COVID-19 (aOR: 2.54; 95% CI:1.65-3.90), and self-belief regarding possibility of EWR impact (aOR: 3.49; 95% CI: 2.25-5.43). Husband's help with EWR work was related to increased odds for intervening to stop violence against women only (aOR: 2.18; 95% CI: 1.32-3.60). In-depth interviews with the selected 31 EWRs underscored an increase in their EWR work under COVID-19. The increase in EWR workload under the pandemic created time constrictions for EWR's domestic labour responsibilities, even as domestic labour responsibilities increased. Interpretation: Our study highlights the importance of husband's help and support in strengthening EWRs outcomes at work in India, with help in domestic work being related to a relatively wider range of outcomes that are indicative of EWR's performance, compared to husband's help with EWR work. These findings emphasize the need for building male responsibility for domestic labour, to improve women's professional performance and outcomes. Our study has few key limitations such as lack of causal interpretations due to reliance on cross-sectional research design, potential for social desirability bias in self-reported data, and absence of information related to changes in patterns of spousal and family support received by the EWRs as a result of the pandemic. Nonetheless, our findings are important, particularly for the context of Bihar, India, where appalling gender gaps still persist in all social and economic aspects of society. Funding: Bill & Melinda Gates Foundation: 2017, OPP1179246 and EMERGE COVID-19 (2019, OPP1163682); David & Lucile Packard Foundation: 2017- 66202.

COVID-19 burden, author affiliation and women's well-being: A bibliometric analysis of COVID-19 related publications including focus on low- and middle-income countries.

Background: Published literature documents tremendous gender inequities in the social, economic and health effects of the COVID-19 pandemic, but less evidence has come from low- and middle-income countries (LMICs) and even less from LMIC-based authors. We examine whether a) COVID-19 burden and b) LMIC-based authorship were associated with academic publications related to COVID-19 and women's well-being in LMICs. Methods: We reviewed academic articles on COVID-19 and women's well-being in LMICs published between February 2020 and May 2021 (n=1076 articles), using six electronic databases (PubMed, Web of Science, PsycInfo, EconLit, RePeC, NBER). Multilevel, mixed effects linear regressions assessed the relationships between each of our independent variables - a) COVID-19 burden (cases/100 population, deaths/100 population, deaths/cases) and b) author's country of primary affiliation, with publications related to COVID-19 and women's well-being, both overall and stratified by country income group. Findings: Eight-eight percent of articles had lead and/or senior authors affiliated with in-country institutions. Linear mixed effect models indicate that COVID-19 cases and case fatality ratios in a country were significantly and positively associated with the number of publications related to COVID-19 and women's well-being, though these relationships were significant only in upper-middle income group countries in stratified analyses. LMIC lead and senior authorship were also significantly and positively associated with our outcome, after adjusting for COVID-19 burden. Interpretation: While the majority of COVID-19 research examining women's well-being in LMICs in the first year and a half of the pandemic included country-affiliated author leadership, there were important gaps in representation. Findings highlight the importance of LMIC-based scholars to build local and gendered research in crises. Funding: Bill and Melinda Gates Foundation (INV-018007).

Gender differences in work attendance among health care workers in Northern Nigeria during the COVID-19 pandemic.

Background: The COVID-19 pandemic has resulted in the overwork of health care workers (HCWs) and greater household burdens for women. This study examines gender differences in HCWs' work attendance under COVID-19 and household burdens as a potential mediator of the gender difference in Northern Nigeria. Methods: From April to May 2021, we conducted a cross-sectional survey on work and household burdens with a convenience sample of male and female HCWs (N=334) across 16 facilities in the Gombe, Katsina, and Zamfara states in Northern Nigeria. We used a series of multilevel modified Poisson regression models to examine the associations between gender and HCW work attendance. We also tested the mediation effect of household burdens on this observed association. Findings: Only 2·10% of HCWs reported <5 days of work in a typical week; 35·33% worked 6-7 days a week (i.e., HCW overwork). Males were more likely than females to report HCW overwork (46·33% vs. 22·93%), and females were more likely than males to report an increase in household burden (59·24% vs. 40·68%). Adjusted regression models found that men were more likely than women to report HCW overwork (ARR: 1·76, 95% CI: 1·17-2·66). Increased household burdens mediated 9 percent of the total effect between gender and HCW work attendance. Interpretation: The COVID-19 pandemic in Northern Nigeria made female HCWs contend with the dual burdens of formal and informal care work. This contributes to lower attendance among female HCWs and overwork for their male counterparts. Funding: Bill and Melinda Gates Foundation Grant Numbers: OPP1163682 & INV018007.

Help seeking behavior by women experiencing intimate partner violence in india: A machine learning approach to identifying risk factors.

BACKGROUND: Despite the low prevalence of help-seeking behavior among victims of intimate partner violence (IPV) in India, quantitative evidence on risk factors, is limited. We use a previously validated exploratory approach, to examine correlates of help-seeking from anyone (e.g. family, friends, police, doctor etc.), as well as help-seeking from any formal sources. METHODS: We used data from a nationally-representative health survey conducted in 2015-16 in India, and included all variables in the dataset (~6000 variables) as independent variables. Two machine learning (ML) models were used- L-1, and L-2 regularized logistic regression models. The results from these models were qualitatively coded by researchers to identify broad themes associated with help-seeking behavior. This process of implementing ML models followed by qualitative coding was repeated until pre-specified criteria were met. RESULTS: Identified themes associated with help-seeking behavior included experience of injury from violence, husband's controlling behavior, husband's consumption of alcohol, and being currently separated from husband. Themes related to women's access to social and economic resources, such as women's employment, and receipt of maternal and reproductive health services were also noted to be related factors. We observed similarity in correlates for seeking help from anyone, vs from formal sources, with a greater focus on women being separated for help-seeking from formal sources. CONCLUSION: Findings highlight the need for community programs to reach out to women trapped in abusive relationships, as well as the importance of women's social and economic connectedness; future work should consider holistic interventions that integrate IPV screening and support services with women's health related services.

COVID-19-Related Financial Hardship, Job Loss, and Mental Health Symptoms: Findings from a Cross-Sectional Study in a Rural Agrarian Community in India.

Several countries, including India, imposed mandatory social distancing, quarantine, and lockdowns to stop the spread of the SARS-CoV-2 virus. Although these measures were effective in curbing the spread of the virus, prolonged social distancing, quarantine, and the resultant economic disruption led to an increase in financial stress and mental health concerns. Prior studies established a link between the first lockdown and an increase in mental health issues. However, few studies investigated the association between post-lockdown financial hardship, job loss, and mental health. In this study, we examined the association between COVID-19-related financial hardship, job loss, and mental health symptoms approximately nine months after the end of the first nationwide lockdown in India. Job loss was associated with higher reporting of mental health symptoms among men (aIRR = 1.16) while financial hardship was associated with poor mental health symptoms among women (aIRR = 1.29). Conversely, social support and government aid were associated with better mental health symptoms among women. Our findings highlight the need for financial assistance and job creation programs to aid families in the recovery process. There is also an urgent need for improving the availability and affordability of mental health services in rural areas.

Time from COVID-19 shutdown, gender-based violence exposure, and mental health outcomes among a state representative sample of California residents.

BACKGROUND: There is increasing evidence of the negative impact of the COVID-19 pandemic and resultant shutdowns on mental health. This issue may be of particular concern to those affected by intimate partner violence (IPV) and sexual violence. METHODS: We conducted a cross-sectional analysis using data from a California state-representative online survey conducted in the two weeks following the state stay-at-home order, enacted March 19, 2020 (unweighted N = 2081). We conducted a series of multivariate multinomial logistic regressions to assess the associations between a) time since stay-at-home order and b) partner and sexual violence exposure ever with our outcomes of interest: depression and/or anxiety symptoms in the past two weeks. Covariates included demographics and social support. FINDINGS: Nearly one in five (19•7%) respondents reported moderate or severe mental health symptoms in the past two weeks; 15•5% had a history of IPV and 10•1% had a history of sexual violence. In models adjusting for gender, partner and sexual violence history, and other demographics, time was significantly associated with greater mental health symptom severity, as were IPV and sexual violence. When we additionally adjusted for current social support, effects of time were lost and effects related to violence were slightly attenuated. INTERPRETATION: Time under shutdown is associated with higher odds of depression and anxiety symptoms, and may be worse for those with a history of IPV. However, those with greater social support appear to have better capacity to withstand the mental health impacts of the pandemic. Social support programs, inclusive of those available virtually, may offer an important opportunity to help address increased mental health concerns we are seeing under the pandemic. FUNDING: Blue Shield Foundation of California Grant RP-1907-137. Bill and Melinda Gates Foundation OPP1179208.