A cross-cultural adaptation and validation of a scale to assess illness identity in adults living with a chronic illness in South Africa: a case of HIV.

The chronic illness trajectory and its outcomes are well explained by the concept of illness identity; the extent to which ill individuals have integrated their diagnosed chronic illness into their identity or sense of self. The capacity to measure illness identity in people living with HIV (PLHIV) is still relatively unexplored. However, this is potentially useful to help us understand how outcomes for PLHIV could be improved and sustained. This paper aims to explore the cross-cultural adaptation of a Belgian developed Illness Identity Questionnaire (IIQ) and validate the instrument using a sample of South African adults living with HIV. We followed a phased scale adaptation and validation process which included an investigation of conceptual, item, semantic and operational equivalence and also examined the psychometric properties of the IIQ. The concept of illness identity with its four factors; engulfment, rejection, acceptance and enrichment in PLHIV, was found to be relevant within this context. Five items from the original IIQ were excluded from the adapted IIQ due to either semantic insufficiency and/or inadequate measurement equivalence. The mode of administration of the IIQ was changed to accommodate current study participants. The original four factor 25-item model did not fit current data, however, a better contextualized, four-factor, 20-item model was identified and found valid in the current setting. The results showed adequate statistical fit; χ2/d.f. = 1.516, RMSEA = 0.076, SRMR = 0.0893, and CFI = 0.909. Convergent and discriminant validity were also tenable. The cross-cultural adaptation and validation of the IIQ was successful, resulting in the availability of an instrument capable of measuring illness identity in PLHIV in a high HIV prevalence and resource-constrained setting. This therefore addresses the paucity of information and expands on knowledge about illness identity.

From Physical Distancing to Social Loneliness among Gay Men and Other Men Having Sex with Men in Belgium: Examining the Disruption of the Social Network and Social Support Structures.

Since the start of the SARS-CoV-2 pandemic, levels of loneliness have increased among the general population and especially among sexual minorities, such as gay men and other men who have sex with men, who already experienced more problems with social isolation before the pandemic. We analyzed how the disruption of the social network and social support structures by containment measures impact loneliness among gay and other men having sex with men. Our sample consisted of gay and other men having sex with men who had in person communication with family as well as heterosexual friends and homosexual friends before the lockdown (N = 461). Multivariate regression analyses were performed with social provisions (social interaction and reliable alliance) and loneliness as dependent variables. A change from in-person communication with gay peers before the pandemic to remote-only or no communication with gay peers during the pandemic, mediated by change in social integration, was related to an increased feeling of loneliness during the pandemic compared with before the pandemic. There were some unexpected findings, which should be interpreted in the specific social context of the SARS-CoV-2 pandemic. On average, social integration and reliable alliance among MSM increased during the lockdown, even though in-person communication decreased and loneliness increased. Our results show it is critical to maintain a view of social support and social loneliness as lodged within larger social and cultural contexts that ultimately shape the mechanisms behind them.

Knowledge deficit and fear of COVID-19 among higher education students during the first wave of the pandemic and implications for public health: a multi-country cross-sectional survey.

BACKGROUND: Public health measures such as physical distancing and distance learning have been implemented during the COVID-19 pandemic. COVID-19 related knowledge deficit can increase fear that leads to negative mental health and COVID-19, especially among adolescents. Therefore, our study aimed to assess COVID-19 related knowledge deficit and its association with fear among higher education (HE) students during the first wave of COVID-19. METHODS: A cross-sectional survey, COVID-19 International Students Well-being Study (C-19 ISWS) was conducted in 133 Higher Education Institutions (HEIs) in 26 countries between April 27 and July 7, 2020. A stratified convenience sampling technique was used. Descriptive, bivariate, mixed-effect logistic regression analyses were conducted using R software. RESULTS: Out of 127,362 respondents, 72.1% were female, and 76.5% did not report a previous history of confirmed COVID-19. The majority of those without the previous infection 81,645 (83.7%) were from 21 European countries while the rest 15,850 (16.3%) were from 5 non-European countries. The most frequent correct response to COVID-19 related knowledge questions among respondents was having the virus without having symptoms (94.3%). Compared to participants with good knowledge, the odds of being afraid of acquiring SARS-COV-2 infection among those with poor knowledge was 1.05 (95%CI:1.03,1.08) and the odds of being afraid of contracting severe COVID-19 was 1.36 (95%CI:1.31,1.40). CONCLUSION: COVID-19 related knowledge was independently associated with both fear of acquiring SARS-COV-2 infection as well as contracting severe COVID-19. Our findings will serve as a basis for public health response for both the current and similar future pandemics by highlighting the need for addressing the COVID-19 knowledge deficit to fight the infodemic and prevent negative mental health outcomes.

Increased Anxiety and Depression Among Belgian Sexual Minority Groups During the First COVID-19 Lockdown-Results From an Online Survey.

The COVID-19 pandemic most likely had a negative impact on mental health. Sexual minorities are at higher risk for adverse mental outcomes such as depression, anxiety and suicidal ideation. Such mental health disparities may have exacerbated during the COVID-19 pandemic, due to restricted real-life social contact. The study aim was to examine changes in depression, anxiety and suicidal ideation among Belgian sexual minority adults between the periods before and during the first COVID-19 lockdown. We conducted an online survey, which was disseminated by community organizations throughout Belgium in April 2020. The questionnaire included two-item Generalized-Anxiety-Disorder (GAD-2) and Patient-Health-Questionnaire (PHQ-2) measures. To assess how such symptoms and other factors (e.g., loneliness) had changed, we asked to what extent these occurred before and since the lockdown. We included 965 fully completed questionnaires in the analysis. The proportions of participants screening positive for depression and anxiety were significantly higher during the lockdown than before the lockdown, based on their reported symptoms for these periods: 29.3%% vs. 13.5% (p < 0.001), and 37.1% vs. 25.7% (p < 0.001) respectively. Lonely and young participants were more likely to acquire depression. About one in five participants reported suicidal ideation. Our findings suggest that the COVID-19 pandemic has exacerbated already existing mental health disparities between sexual minority adults and the general population. These exacerbations may be the result of increased loneliness and social isolation. The results highlight the need for stimulating and strengthening social connectedness within the LGBTQI community during and in the aftermath of the COVID-19 pandemic, and the need for maintaining mental health services for such groups during pandemic restrictions.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave.

BACKGROUND: There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence. RESULTS: Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSIONS: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Substance Use among Belgian Higher Education Students before and during the First Wave of the COVID-19 Pandemic.

The COVID-19 pandemic prompted many countries to issue far-reaching policy measures that may have led to increased substance use. Higher education students may have been disproportionally affected due to the rearrangement of educational life and their susceptibility to psychosocial distress and substance use. The current study examined associations between pandemic-related stressors, psychosocial distress, and self-reported alcohol, tobacco, and cannabis use before and during the first wave of the pandemic. Data were collected in Belgium as part of the COVID-19 International Student Well-being Study (C19 ISWS) and analyzed using multinomial logistic regression analyses. The sample contained 18,346 higher education students aged 17 to 24 (75% women). Overall use of alcohol, tobacco, and cannabis as well as binge drinking decreased during the pandemic, perhaps due to limited social gatherings. Moving back to the parental home was associated with decreased substance use, while depressive symptoms were associated with increased substance use. Perceived threat and academic stress were associated with increased binge drinking among heavy bingers and increased tobacco use. Decreases among students who moved back to their parental home may be explained by increased informal social control. Increased substance use was associated with a number of stressors and psychosocial distress, which suggests that some students may have been self-medicating to manage their mental health amidst the pandemic. Public health policy concerning substance use may prove to be less effective if not tailored to particular subgroups within the student population.

Depressive symptoms in higher education students during the COVID-19 pandemic: the role of containment measures.

BACKGROUND: Students are a vulnerable group for the indirect impact of the COVID-19 pandemic, particularly their mental health. This paper examined the cross-national variation in students' depressive symptoms and whether this can be related to the various protective measures implemented in response to the initial stage of the COVID-19 outbreak. METHODS: Student data stem from the COVID-19 International Student Well-being Study, covering 26 countries during the first wave of the COVID-19 pandemic. Country-level data on government responses to the COVID-19 pandemic were retrieved from the Oxford COVID-19 Tracker. Multilevel analyses were performed to estimate the impact of the containment and economic support measures on students' depressive symptoms (n = 78 312). RESULTS: School and workplace closures, and stay-at-home restrictions were positively related to students' depressive symptoms during the COVID-19 pandemic, while none of the economic support measures significantly related to depressive symptoms. Countries' scores on the index of these containment measures explained 1.5% of the cross-national variation in students' depressive symptoms (5.3%). This containment index's effect was stable, even when controlling for the economic support index, students' characteristics, and countries' epidemiological context and economic conditions. CONCLUSIONS: Our findings raise concerns about the potential adverse effects of existing containment measures (especially the closure of schools and workplaces and stay-at-home restrictions) on students' mental health.

Abortion care in a pandemic: an analysis of the number and social profile of people requesting and receiving abortion care during the first COVID-19 lockdown (March 16 to June 14, 2020) in Flanders, Belgium.

BACKGROUND: The COVID-19 pandemic and the national COVID-19 measures might have increased potential barriers to abortion care and created new ones, especially for vulnerable groups. This study documents the impact of the pandemic and the lockdown measures on the profile of people going through the abortion process. METHODS: Using anonymized patient records from a Belgian abortion centre, we first compared the number of abortion requests and procedures during the first COVID-19 lockdown with the same months in the five preceding years. Next, we analysed the social profile of people requesting an abortion in those two time periods and looked at the number of long-acting reversible contraceptive devices (LARC) placed after curettage. RESULTS: The abortion centre saw a drop in the number of abortion requests during the lockdown. This difference was more pronounced for people in paid employment and people using (modern) contraception. People were also more likely to request an abortion earlier in their pregnancy. The drop in abortion procedures and LARC's placed after curettage was proportionate to the drop in abortion requests and did not differ according to clients' characteristics. CONCLUSION: Questions arose concerning the potential selectivity with which COVID-19 influenced the need for abortion care and accessibility to services. Although there was a general drop in abortion requests and procedures during the first COVID-19 lockdown in the studied abortion centre, our results suggest that the profile of people requesting and receiving an abortion did only slightly change during the lockdown, and did not affect vulnerable groups visibly harder.

Obstacles and opportunities: a qualitative study of the experiences of abortion centre staff with abortion care during the first COVID-19 lockdown in Flanders, Belgium.

The COVID-19 pandemic and corresponding measures impacted the organisation of services for abortion on request in Flanders, Belgium. This study describes abortion centre staff's perceptions of the influence of protective measures on abortion consultations and procedures, and aims to identify obstacles and opportunities that arose from this situation. Through the anonymised patient records of one Flemish abortion centre, we compared the number of requests and abortions during the first lockdown (16 March-14 June 2020) with the same period in the five preceding years. Using a phenomenological approach, we documented the procedures and conducted interviews (all inductively coded in Nvivo) with the centre's coordinator, seven psychosocial staff members and three doctors. Though fewer people requested and had an abortion, the pressure on the staff was high due to changed procedures. A substantial change was the substitution of telephone for in-person consultations, which the staff perceived as less suited for discussing worries, contraception counselling, and building trust. The centre remained accessible, but the staff perceived an influence on the emotional reactions of clients. Staff agreed that the lockdown did not negatively influence the abortion procedure itself. However, they felt a negative influence on the level of psychological support they could offer, especially in interactions with clients who were less certain of their choice and clients with whom there was no common language. When the lockdown was relaxed, a triage system was set up to ensure emotionally safe abortion care - as perceived by staff - for all clients.

The pandemic of online research in times of COVID-19.

The COVID-19 pandemic has led to an explosion of online research using rating scales. While this approach can be useful, two of the major challenges affecting the quality of this type of research include selection bias and the use of non-validated scales. Online research is prone to various forms of selection bias, including self-selection bias, non-response bias or only reaching specific subgroups. The use of rating scales requires contextually validated scales that meet psychometrical properties such as validity, reliability and-for cross-country comparisons-invariance across settings. We discuss options to prevent or tackle these challenges. Researchers, readers, editors and reviewers need to take a critical stance towards research using this type of methodology.

Disentangling depression in Belgian higher education students amidst the first COVID-19 lockdown (April-May 2020).

BACKGROUND: The surge of COVID-19 infections has prompted many countries to take unprecedented policy measures. In Belgium, the authorities implemented a nation-wide stay-at-home order for several months. Evidence of the mental health effect of such measures is scarce. A recent review by Brooks et al. has compiled a defined list of stressors affecting people's mental health under quarantine during previous epidemic settings. This study aims to test the association between these stressors and the mental health of students attending higher education during the stay-at-home order in Belgium. METHODS: In this cross-sectional study, 18,301 students from 13 higher education institutions (HEI) participated in an online survey between 26 April and 11 May 2020. We assessed the association between potential stressors and depressive symptoms severity scores and structural equation modeling was used to assess how stressors may mediate the association between duration of exposure and depressive symptoms severity. RESULTS: The stressors proposed by Brooks et al. were found to be associated with depressive symptoms severity. The stressors 'perceived academic stress', 'institutional dissatisfaction' and 'fear of being infected' were associated with substantially higher depressive symptoms severity scores. The association between duration of exposure and depressive symptoms severity was mediated by 'academic stress'. Being in a steady relationship and living together with others were both associated with a lower depressive symptoms severity. CONCLUSION: Findings underline the need for a student-centered approach and mental health prevention. Authorities and HEIs should consider whether and if so, how a stay-at-home order should be implemented.

The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium.

BACKGROUND: The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic. METHODS: A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. Twenty-one people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM). RESULTS: Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated. CONCLUSION: Our findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.

Reduced sexual contacts with non-steady partners and less PrEP use among MSM in Belgium during the first weeks of the COVID-19 lockdown: results of an online survey.

OBJECTIVES: To examine changes in the occurrence of physical sex with non-steady partners among men who have sex with men (MSM) in Belgium during the first weeks of the COVID-19 lockdown and associations with sociodemographic factors, sexual practices, drug, alcohol and pre-exposure prophylaxis (PrEP) use. A secondary objective was to explore changes in PrEP use and the need for PrEP follow-up. METHODS: A cross-sectional online survey. The questionnaire was available in Dutch, French and English, between April 10 and 27 (2020), and disseminated via sexual health and lesbian, gay, bisexual, trans, queer or intersex organisations throughout Belgium. Eligibility criteria included being 18 years or older, not being exclusively heterosexual and living or being born in Belgium. RESULTS: The sample included 694 MSM. Physical sex with non-steady partners decreased from 59.1% to 8.9% during the first weeks of the lockdown. Those who had sex with non-steady partners were significantly more likely to be HIV positive, to use PrEP or to have engaged in sexual practices such as group sex, chemsex and sex work before the lockdown, compared with their counterparts. Among those who used PrEP before the lockdown, 47.0% stopped using PrEP, 19.7% used event-driven PrEP and 33.3% used daily PrEP during the lockdown. Almost two-thirds of PrEP users had a PrEP care appointment in the weeks before the lockdown and a minority received follow-up elsewhere or online. Some PrEP users had concerns regarding their follow-up. CONCLUSIONS: MSM in our survey substantially reduced sexual contact with non-steady partners during the first weeks of the COVID-19 lockdown, suggesting that the risk for HIV and STI transmission in this period was low. We recommend ensuring access to sexual health services, such as HIV testing and follow-up for PrEP for the small group having multiple sex partners and engaging in sexual practices such as chemsex, or group sex, even in times of a pandemic threat.

The COVID-19 pandemic: diverse contexts; different epidemics-how and why?

It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability-by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere.