Prevalence of different variations of non-consented care during the childbirth process in Mexico by geographical regions: comparing ENDIREH survey data from 2016 to 2021.

INTRODUCTION: Non-consented care, a form of obstetric violence involving the lack of informed consent for procedures, is a common but little-understood phenomenon in the global public health arena. The aim of this secondary analysis was to measure the prevalence and assess change over time of non-consented care during childbirth in Mexico in 2016 and 2021, as well as to examine the association of sociodemographic, pregnancy-, and childbirth-factors with this type of violence. METHODS: We measured the prevalence of non-consented care and three of its variations, forced sterilization or contraception, forced cesarean section, and forced consent on paperwork, during childbirth in Mexico for 2016 (N = 24,036) and 2021 (N = 19,322) using data from Mexico's cross-sectional National Survey on the Dynamics of Household Relationships (ENDIREH). Weighted data were stratified by geographical regions. We performed adjusted logistic regression analyses to explore associations. RESULTS: The national prevalence of non-consented care and one of its variations, pressure to get a contraceptive method, increased from 2016 to 2021. A decrease in the prevalence was observed for forced contraception or sterilization without knowledge, forcing women to sign paperwork, and non-consented cesarean sections nationally and in most regions. Women between the ages of 26 and 35 years, married, cohabiting with partner, living in urban settings, who do not identify as Indigenous, and who received prenatal services or gave birth at the Mexican Institute of Social Security (IMSS) facilities experienced a higher prevalence of non-consented care. Being 26 years of age and older, living in a rural setting, experiencing stillbirths in the last five years, having a vaginal delivery, receiving prenatal services at IMSS, or delivering at a private facility were significantly associated with higher odds of reporting non-consented care. CONCLUSION: While a decrease in most of the variations of non-consented care was found, the overall prevalence of non-consented care and, in one of its variations, pressure to get contraceptives, increased at a national and regional level. Our findings suggest the need to enforce current laws and strengthen health systems, paying special attention to the geographical regions and populations that have experienced higher reported cases of this structural problem.

Using Responsive Feedback in Scaling a Gender Norms-Shifting Adolescent Sexual and Reproductive Health Intervention in the Democratic Republic of Congo.

PROGRAM DESCRIPTION: Growing Up GREAT! (GUG) is a sexual and reproductive health (SRH) program for adolescents aged 10-14 years in Kinshasa, Democratic Republic of the Congo (DRC). The multilevel program takes an ecological approach to foster community examination of gender inequitable norms and to increase adolescents' SRH knowledge, skills, and gender-equitable attitudes. GUG design, piloting, and scale-up were informed by a theory of change and responsive feedback mechanisms (RFMs) during piloting and scale-up. RESPONSIVE FEEDBACK MECHANISMS: The program engaged stakeholders via quarterly learning meetings to review monitoring data, evaluation results, and practice-based knowledge and to subsequently identify challenges and develop solutions. The program commissioned rapid research on specific intervention elements to improve implementation and documented scale-up learnings using the World Health Organization/ExpandNet framework. ACHIEVEMENTS: RFMs used in the pilot period allowed the program to address community concerns by intensifying orientation activities with parents and schools, shifting the calendar of activities to increase male engagement, and increasing facilitator training length to improve facilitation quality. Using RFMs during scale-up prompted further adaptations for program sustainability, including recommendations for task-shifting from NGO facilitators to community health workers. CONCLUSION: GUG used RFMs from pilot through scale-up to foster a learning culture among local partners, implementers at headquarters, and global research partners. Using responsive feedback (RF) enabled timely response to the evolving implementation context, resulting in strategic program adaptations that fostered increased community support of the project. Other successes due, at least in part, to this RF approach include incorporation of the program into DRC's national adolescent health strategy, and rapid response to the COVID-19 pandemic in educational strategies for program beneficiaries.

The pursuit of genetic gain in agricultural crops through the application of machine-learning to genomic prediction.

Current practice in agriculture applies genomic prediction to assist crop breeding in the analysis of genetic marker data. Genomic selection methods typically use linear mixed models, but using machine-learning may provide further potential for improved selection accuracy, or may provide additional information. Here we describe SelectML, an automated pipeline for testing and comparing the performance of a range of linear mixed model and machine-learning-based genomic selection methods. We demonstrate the use of SelectML on an in silico-generated marker dataset which simulated a randomly-sampled (mixed) and an unevenly-sampled (unbalanced) population, comparing the relative performance of various methods included in SelectML on the two datasets. Although machine-learning based methods performed similarly overall to linear mixed models, they performed worse on the mixed dataset and marginally better on the unbalanced dataset, being more affected than linear mixed models by the imposed sampling bias. SelectML can assist in the training, comparison, and selection of genomic selection models, and is available from https://github.com/darcyabjones/selectml.

Adolescent alcohol use: use of social network analysis and cross-classified multilevel modeling to examine peer group, school, and neighborhood-level influences.

Background: Neighborhood-, school-, and peer-contexts play an important role in adolescent alcohol use behaviors. Methodological advances permit simultaneous modeling of these contexts to understand their relative and joint importance. Few empirical studies include these contexts, and studies that do typically: examine each context separately; include contexts for the sole purpose of accounting for clustering in the data; or do not disaggregate by sex.Objectives: This study takes an eco-epidemiologic approach to examine the role of socio-contextual contributions to variance in adolescent alcohol use. The primary parameters of interest are therefore variance rather than beta parameters (i.e. random rather than fixed effects). Sex-stratified models are also used to understand how each context may matter differently for male and female adolescents.Method: Data come from the National Longitudinal Study of Adolescent to Adult Health (n = 8,534 females, n = 8,102 males). We conduct social network analysis and traditional and cross-classified multilevel models (CCMM) in the full and sex-disaggregated samples.Results: In final CCMM, peer groups, schools, and neighborhoods contributed 10.5%, 10.8%, and 0.4%, respectively, to total variation in adolescent alcohol use. Results do not differ widely by gender.Conclusions: Peer groups and schools emerge as more salient contributing contexts relative to neighborhoods in adolescent alcohol use for males and females. These findings have both methodological and practical implications. Multilevel modeling can model contexts simultaneously to prevent the overestimation of variance in youth alcohol use explained by each context. Primary prevention strategies addressing youth alcohol use should focus on schools and peer networks.

Balancing Quality, Intensity and Scalability: Results of a Multi-level Sexual and Reproductive Health Intervention for Very Young Adolescents in Kinshasa.

PURPOSE: In addition to the rapid physical and cognitive transformations very young adolescents (VYAs) experience between ages 10-14, gender and social norms internalized during this period have long-term implications as adolescents become sexually active. This age presents critical opportunities for early intervention to promote gender-equitable attitudes and norms for improved adolescent health. METHODS: In Kinshasa, DRC, Growing Up GREAT! implemented a scalable approach to engage in- and out-of-school VYAs, caregivers, schools, and communities. A quasi-experimental study evaluated the outcomes of sexual and reproductive health (SRH) knowledge, assets and agency, and gender-equitable attitudes and behaviors among VYA participants. Ongoing monitoring and qualitative studies provided insights into implementation challenges and contextual factors. RESULTS: Results show significant improvement in SRH knowledge and assets such as caregiver connectedness, communication, and body satisfaction among the intervention group. The intervention was also associated with significant improvements in gender-equitable attitudes related to adolescents' household responsibilities and decreased teasing and bullying. Intervention effects on awareness of SRH services, body satisfaction, chore-sharing, and bullying were stronger for out-of-school and younger VYAs, suggesting the intervention's potential to increase positive outcomes among vulnerable adolescents. The intervention did not shift key gender norm perceptions assessed. Implementation research suggests design decisions made to increase the intervention's scalability necessitated reductions in training and program dosing that may have affected results. DISCUSSION: Results affirm the potential of early intervention to increase SRH knowledge, assets and gender-equitable behaviors. They also highlight the need for more evidence on effective program approaches and segmentation for shifting VYA and SRH norms.

The Impacts of Two Gender-Transformative Interventions on Early Adolescent Gender Norms Perceptions: A Difference-in-Difference Analysis.

PURPOSE: Inequitable gender norms are widespread and can be harmful to the wellbeing of adolescents. This study estimates the effects of two gender-transformative interventions, Semangat Dunia Remaja or Teen Aspirations (SETARA) and Growing Up Great! (GUG!), on gender norms perceptions and attitudes among very young adolescents in poor urban settings in Bandar Lampung, Semarang, Denpasar (Indonesia), and Kinshasa (Democratic Republic of the Congo). METHODS: The study draws from the longitudinal Global Early Adolescent Study, using a quasi-experimental design to evaluate the interventions. Data collection took place between 2017 and 2020. Our analytical samples included 2,159 adolescents in Kinshasa and 3,335 in Indonesia. We conducted a difference-in-difference analysis using generalized estimation equations and generalized linear models, after stratification by site and sex. RESULTS: The interventions shifted a range of gender perceptions, although effects varied by program, city, and sex. SETARA shifted gender-normative perceptions related to traits, roles, and relations, while GUG! effects were more concentrated on attitudes toward chore sharing. SETARA was most effective in Semarang and Denpasar, but not in Bandar Lampung. In addition, both interventions were more consistently effective for girls than boys. DISCUSSION: Gender-transformative interventions can effectively promote gender equality in early adolescence, but effects are program-specific and context-specific. Our findings emphasize the importance of defined theories of change and consistent implementation in gender-transformative intervention.

Understanding How Gender Transformative Interventions Affect Adolescent Sexuality: A Cross-Cultural Perspective.

PURPOSE: Early adolescence is a critical period for developing healthy sexual and reproductive health (SRH) knowledge, attitudes, and behaviors. However, a gap exists in interventions targeting very young adolescents that encompass the multilevel influences impacting healthy sexuality. This examination of two SRH programs in Indonesia and the Democratic Republic of Congo will elucidate facilitators and barriers to improving young adolescent sexuality. METHODS: The Growing Up Great! (GUG) intervention in the Democratic Republic of Congo and Semangat Dunia Remaja or Teen Aspirations intervention in three districts in Indonesia were evaluated using the Global Early Adolescent Study survey. Adolescents were interviewed in 2017 and one year later in Kinshasa (n = 2,519). In Indonesia, baseline in 2018 was follow-up in 2020 in Bandar Lampung (n = 948), Denpasar (n = 1,156), and Semarang (n = 1,231). Outcomes included SRH knowledge and communication, awareness of SRH services, and attitudes about sexuality. Analysis followed a difference-in-difference approach to compare changes in each outcome over time between interventions and controls. RESULTS: Both interventions improved pregnancy and HIV knowledge, while Semangat Dunia Remaja or Teen Aspirations also improved SRH communication. Results differed by site in Indonesia, with Semarang, the site that adhered most closely to intervention design, observed the most improvements. Differential effects were also seen by gender, especially in Kinshasa where girls advanced in SRH communication and knowledge but not boys. Girls in Semarang shifted normative SRH attitudes, and boys in Denpasar improved knowledge. DISCUSSION: Interventions targeting very young adolescents can improve SRH knowledge, communication, and attitudes, though impact depends on context and implementation. Future programs should incorporate the community and environment influencing adolescent experiences with sexuality.

Clinical Outcomes Following Exercise Rehabilitation in People with Multimorbidity: A Systematic Review.

OBJECTIVE: To determine the effectiveness of exercise rehabilitation in people with multimorbidity. Exercise capacity was the primary outcome. Secondary outcomes were: health-related quality of life, activities of daily living, cardiometabolic outcomes, mental health outcomes, symptom scores, resource utilization, health behaviours, economic outcomes, and adverse events. DATA SOURCES: A search was conducted in MEDLINE, CINHAL, EMBASE, and Cochrane Central Register of Controlled Trials databases. STUDY SELECTION AND EXTRACTION: Randomized and non-randomized controlled trials and cohort studies of exercise rehabilitation vs any comparison in people with multimorbidity. DATA SYNTHESIS: Forty-four reports (38 studies) were included. Rehabilitation ranged from 8 weeks to 4 years, with 1-7 sessions of rehabilitation weekly. Exercise included aerobic and resistance, limb training, aquatic exercises and tai chi. Compared with usual care, exercise rehabilitation improved 6-min walk distance (weighted mean difference (WMD) 64 m, 95% CI 45-82) and peak oxygen consumption (WMD 2.74 mL/kg/min, 95% CI -3.32 to 8.79). Effects on cardiometabolic outcomes and health-related quality of life also favoured rehabilitation; however; few data were available for other secondary outcomes. CONCLUSION: In people with multimorbidity, exercise rehabilitation improved exercise capacity, health-related quality of life, and cardiometabolic outcomes.

Perceived Autonomy Support in Telerehabilitation by People With Chronic Respiratory Disease: A Mixed Methods Study.

BACKGROUND: Autonomy-supportive health environments can assist patients in achieving behavior change and can influence adherence positively. Telerehabilitation may increase access to rehabilitation services, but creating an autonomy-supportive environment may be challenging. RESEARCH QUESTION: To what degree does telerehabilitation provide an autonomy-supportive environment? What is the patient experience of an 8-week telerehabilitation program? STUDY DESIGN AND METHODS: Individuals undertaking telerehabilitation or center-based pulmonary rehabilitation within a larger randomized controlled equivalence trial completed the Health Care Climate Questionnaire (HCCQ; short form) to assess perceived autonomy support. Telerehabilitation participants were invited 1:1 to undertake semistructured interviews. Interviews were transcribed verbatim and coded thematically to identify major themes and subthemes. RESULTS: One hundred thirty-six participants (n = 69 telerehabilitation) completed the HCCQ and 30 telerehabilitation participants (42%) undertook interviews. HCCQ summary scores indicated that participants strongly agreed that the telerehabilitation environment was autonomy supportive, which was similar to center-based participants (HCCQ summary score, P = .6; individual HCCQ items, P ≥ .3). Telerehabilitation interview data supported quantitative findings identifying five major themes, with subthemes, as follows: (1) making it easier to participate in pulmonary rehabilitation, because telerehabilitation was convenient, saved time and money, and offered flexibility; (2) receiving support in a variety of ways, including opportunities for peer support and receiving an individualized program guided by expert staff; (3) internal and external motivation to exercise as a consequence of being in a supervised group, seeing results for effort, and being inspired by others; (4) achieving success through provision of equipment and processes to prepare and support operation of equipment and technology; and (5) after the rehabilitation program, continuing to exercise, but dealing with feelings of loss. INTERPRETATION: Telerehabilitation was perceived as an autonomy-supportive environment, in part by making it easier to undertake pulmonary rehabilitation. Support for behavior change, understanding, and motivation were derived from clinicians and patient-peers. The extent to which autonomy support translates into ongoing self-management and behavior change is not clear. TRIAL REGISTRY: Australian and New Zealand Clinical Trials Registry; No.: ACTRN12616000360415; URL: https://anzctr.org.au/.

The power of women's and men's Social Networks to catalyse normative and behavioural change: evaluation of an intervention addressing Unmet need for Family Planning in Benin.

BACKGROUND: In Benin, despite good knowledge and availability, modern contraceptive prevalence remains relatively low, and the unmet need for family planning is relatively high. This is partly due to insufficient attention to socio-normative barriers that influence need and method use. Applying social network theory, Tékponon Jikuagou (TJ) aims to reduce socio-normative barriers preventing modern contraceptive use in rural Benin. After community identification, TJ trains influential network actors who encourage critical dialogue about unmet need, family planning, gender, and other social norms within their networks, complemented by radio and services linkages. This paper evaluates TJ's effectiveness and how intervention components affect intermediate and primary FP outcomes. METHODS: We report findings from pre/post-intervention cross-sectional research with a comparison group conducted at baseline with 1,043 women and 1,030 men, and 14 months later at endline with 1,046 women and 1,045 men. Using sex-stratified models, we assessed balance across intervention and comparison groups on background characteristics using Pearson's chi-square tests of independence; performed bivariate tests of independence to assess differences between baseline to endline on intermediate outcomes and primary FP outcomes; used logistic regression to examine the effect of intervention components on intermediate and primary FP outcomes. RESULTS: Statistically significant improvements in primary outcomes: women's intentions to use modern contraception, achieve met need, and reduce perceived met need. The fourth primary outcome, actual use, showed substantial gains, although not statistically significant. Men's achievement of met FP need and reduced perceived met need were also statistically significant. Assessing intermediate outcomes at individual, couple, normative-network levels, TJ led to statistically significant increases in couple and network communication on fertility desires and family planning use and self-efficacy and confidence to access services. Both women and men showed significant shifts in the acceptability of discussing FP in public. Results for other indicators of norms change were inconsistent. CONCLUSIONS: An easy-to-implement, short-duration, gender-equitable social network intervention with a limited set of network actors, TJ effectively decreases social and normative barriers preventing women and men from seeking and using FP services. Results support the broader use of innovative social and behaviour change strategies that diffuse family planning ideas through social networks, diminish normative and communication barriers, and catalyse modern family planning use.

In many places with relatively low family planning use, insufficient program attention is paid to socio-normative barriers that influence need and method use. TJ catalyses women and men's social networks to spread new ideas and break communication and other social barriers that prevent women and men with unmet needs ­ people who wish to space their next birth but are not using effective family planning methods - from acting on their desires. A rigorous evaluation of the approach in rural Benin showed after only 14 months, TJ led to statistically significant improvements in intention to use contraception and met need. While showing substantial gains, women's use of contraception was not statistically significant.TJ increased women's and men's partner and network communication on fertility desires and family planning use and individual self-efficacy and confidence to act on intentions to address unmet need. The network influence on family planning use was equally significant. TJ led to new ideas within communities/social networks, including the perception that one's social networks approve of FP. Women and men who report that their network approves of FP were significantly more likely to discuss method use with their partners and seek services. TJ led to new perceptions that one's networks support FP.TJ represents an underused strategy for social and behaviour change. The social network approach encourages addressing the often-neglected social factors that stop women and men from acting on their desires to space births and use modern family planning methods.

Fostering gender equality and reproductive and sexual health among adolescents: results from a quasi-experimental study in Northern Uganda.

OBJECTIVE: To assess the impact of the Gender Roles, Equality and Transformations (GREAT) intervention: a narrative-based, resource-light, life-stage tailored intervention package designed to promote gender-equitable attitudes and behaviours, and improve sexual and reproductive health (SRH) and gender-based violence (GBV) outcomes among adolescents and their communities. DESIGN: Repeated cross-sectional evaluation study, using propensity score matching combined with difference-in-difference estimation. SETTING: Two postconflict communities in Lira and Amuru districts in Northern Uganda. PARTICIPANTS: Male and female unmarried adolescents (10-14 years, 15-19 years), married adolescents (15-19 years) and adults (over the age of 19 years) were selected using a stratified, two-stage cluster sample of primary and secondary schools and households (baseline: n=2464, endline: n=2449). PRIMARY OUTCOME MEASURES: Inequitable gender attitudes and behaviours; GBV; and SRH knowledge and behaviours. RESULTS: Statistically significant intervention effects were seen across all three outcomes-gender equity, GBV and SRH-among older and newly married adolescents and adults. Among older adolescents, intervention effects include shifts on: inequitable gender attitudes scale score: -4.2 points ((95% CI -7.1 to -1.4), p<0.05); Inequitable household roles scale score: -11.8 ((95% CI -15.6to -7.9), p<0.05); Inequitable attitudes towards GBV scale: -1.9 ((95% CI -5.0 to -0.2), p<0.05); per cent of boys who sexually assaulted a girl in past 3 months: -7.7 ((95% CI -13.1 to -2.3), p<0.05); inequitable SRH attitudes scale: -10.1 ((95% CI -12.9 to -7.3), p<0.05). Among married adolescents, intervention effects include shifts on: Inequitable household roles scale score: -6.5 ((95% CI -10.8 to -2.2), p<0.05); inequitable attitudes towards GBV scale: -4.7 ((95% CI -9.8 to -0.3), p<0.05); per cent who reacted violently to their partner: -15.7 ((95% CI -27.1 to -4.4), p<0.05); inequitable SRH attitudes scale: -12.9 ((95% CI -17.3 to -8.5), p<0.05). CONCLUSION: The GREAT intervention model demonstrates the promise of a resource-light, life-stage tailored programme that employs culturally appropriate, participatory and narrative-based techniques to advance gender equity and adolescent health. This type of programming contributes towards reductions in GBV and improved adolescent SRH outcomes.

Prevention of Sexual Violence in sport: A Socioecological Review.

Sexual violence in sport is prevalent and represents a serious public health concern. The social-ecological model for health promotion has been used successfully as a framework to identify individual-to-policy level factors aimed at health promotion or disease prevention. The purpose of this review was to examine both published and non-published (publicly available) SVP efforts conducted within the context of sport and make recommendations for future practice. Grey literature search methods were utilized to conduct a review of publicly available documents. This included (a) a comprehensive Google search using unique search terms that would identify SVP efforts within sport settings and (b) a review of the publicly accessible websites identified in the previous step. Following the grey literature search, and using the SVP practices identified in step one, we conducted a supplementary literature search using scientific publication search engines to identify whether the SVP practices identified in step one had associated peer-reviewed publications. Finally, we assessed various characteristics of each SVP practice including the target population, age range of intended participants, and whether the SVP had associated peer review publications. This led to the identification of 35 unique SVP practices: 25 (71%) SVP practices were assigned to the Intrapersonal level, 6 (17%) were assigned to the Interpersonal level, 9 (26%) were assigned to the Organizational level, 3 (9%) were assigned to the Community, and 2 (6%) were assigned to the Policy level. This review uncovered several important findings including a lack of multi-level SVP practices within sport, a lack of SVP practices that target children, minimal programming aimed at specifically preventing perpetration, the need to elevate policy level action, and a lack of peer-reviewed literature. Ultimately findings suggest that sport organizations ought to prioritize sexual violence prevention using national organizations for guidance.

Understanding the Roles of Sport and Alcohol Use in Adolescence on Physical and Sexual Intimate Partner Violence Perpetration in Young Adulthood: Findings From a Sex-Stratified Multilevel Analysis.

Adolescent peer groups shape beliefs that dictate behavioral norms, including intimate partner violence (IPV) perpetration behaviors, with lasting influence into adulthood. This study examines the role of sport engagement and alcohol use in adolescence on perpetration of physical and sexual IPV in young adulthood. A secondary data analysis was conducted with data from 3411 male and 4318 female participants in the National Longitudinal Study of Adolescent to Adult Health study. Sports and other school activity participation, as well as alcohol use, were measured in middle and high school students. Intimate partner violence perpetration was measured six years later with items from the revised Conflict Tactics Scales. Sex-stratified logistic cross-classified multilevel analyses indicate that, for males, participation in football in adolescence was associated with higher odds of IPV perpetration in young adulthood (aOR:1.26, p = .01). For males and females, non-engagement in any school activities in adolescence was associated with higher odds of IPV perpetration in young adulthood (male aOR: 1.52, p < .01; female aOR: 1.19, p = .04). Alcohol use in adolescence was also associated with higher odds of IPV perpetration in young adulthood for both males and females, even when low level drinking (1-2 drinks in the past 12 months) was reported (male aOR: 1.40, p < .01; female aOR: 1.38, p < .01). Random-effect estimates indicate small but significant contributions of adolescent peer, school, and neighborhood contexts on IPV perpetration in young adulthood for both boys and girls. These findings highlight that football engagement among boys, and alcohol use among boys and girls, are linked to longer-term risk for IPV perpetration, but engagement in other sports and school activities appear to serve as protective factors. These findings, taken with those regarding social context effects, suggest that positive social environment and networks in adolescence, inclusive of those offered in some sports, can be useful platforms for IPV prevention efforts.

Relationship between adolescent friendship networks and contraceptive use and unintended pregnancies in early adulthood in the United States.

OBJECTIVE: To examine the relationship between reproductive attitude of friends during adolescence, and unintended pregnancy outcomes and contraceptive non-use during early adulthood. STUDY DESIGN: We used longitudinal data from the National Longitudinal Study of Adolescent to Adult Health (n = 1866). Adolescent friendship network structures were constructed from the first wave of data to assess reproductive attitudes of friends, measured via 3 subscales: attitude toward contraceptive use, attitude toward sex in adolescence, and attitude toward pregnancy in adolescence. We then used multilevel logistic regression to examine the relationship of friends' reproductive attitudes in adolescence with unintended pregnancy and contraceptive non-use in adulthood. RESULTS: Around one-third of the sample experienced at least one unintended pregnancy, and 12% reported contraceptive non-use. Being friends with individuals who are not accepting of adolescent pregnancy reduced the likelihood of an unintended pregnancy in young adulthood (adjusted odds ratios [aOR]: 0.79; 95% CI: 0.67-0.94); this association varied by sex, being significant only for females (aOR:0.75; 95% CI: 0.58-0.96). Additionally, friends' acceptability of adolescent sex increased the odds of contraceptive use in later life. Individuals with friends who held negative attitude toward contraceptive use during adolescence were more likely to be non-users in later life (aOR:1.37; 95% CI: 1.03-1.81). CONCLUSIONS: Our results suggest a relationship between adolescent social networks and reproductive health outcomes in young adulthood, highlighting the importance of friendship networks for young individuals' reproductive well-being. IMPLICATIONS: Attitudes held by adolescent friends regarding contraceptive use, adolescent sex, and adolescent pregnancy have significant, and distinct associations with an individuals' later-life reproductive health outcomes. Future research should consider evaluation of social network-based sexual and reproductive health interventions aimed at adolescents.

Do gender-equitable attitudes translate to gender-equitable chore-sharing behavior? A sex-stratified longitudinal analysis among adolescents in Kinshasa.

Unpaid care work is disproportionately performed by women and girls, negatively impacting their ability to engage in educational, social, and economic opportunities. Despite calls to address these inequities, empirical evidence on interventions designed to shift gender attitudes is limited, especially within adolescent populations. To address this gap, we used longitudinal data to conduct difference-in-difference and logistic regression models to examine the impact of a norms-shifting intervention in Kinshasa on adolescent gender-equitable chore-sharing attitudes. As compared to controls, intervention participants were 2.3 times (p <0.001) more likely to hold gender-equitable attitudes towards chore-sharing at end line. Using baseline attitudes to predict end line behavior, we find that, as compared to adolescents with gender-inequitable attitudes, boys and girls who espoused equitable gender attitudes were 1.9 times (p <0.001) and 1.5 times (p=0.005), respectively, more likely to report gender-equitable chore-sharing behavior. Norms-shifting interventions should be prioritized among very young adolescents as a strategy to shift gender-inequitable attitudes.

Freedom of Movement and Adolescent Sexual Violence in India.

This study assesses associations between freedom of movement and sexual violence, both in marriage and outside of marriage, among a representative sample of adolescents in India. We analyzed data from girls aged 15 to 19 years (n = 9,593) taken from India's nationally representative National Family Health Survey 2015-2016. We defined freedom of movement using three items on whether girls could go unaccompanied to specified locations; we summated responses and categorized them as restricted, or unrestricted. We used multivariable regression to assess associations between restricted movement and nonmarital violence, and with marital sexual violence among ever-married girls. Results show that only 2% of girls reported nonmarital sexual violence, among married and unmarried girls; 6% of married girls reported marital sexual violence. Most girls (78%) reported some restriction in movement. Restricted movement was negatively associated with nonmarital sexual violence (adjusted odds ratio [AOR] = 0.52, 95% confidence interval [CI] = [0.31, 0.87], p = .01) but positively associated with marital sexual violence (AOR = 3.87, 95% CI = [1.82, 8.25], p < .001). Further analyses highlight that the observed association with nonmarital sexual violence was specific to urban and not rural girls. These findings reveal that approximately one in 30 adolescent girls in India has been a victim of sexual violence. Restricted movement is associated with lower risk for nonmarital sexual violence for urban adolescent girls, possibly due to lower exposure opportunity. Married girls with restricted movement have higher odds of marital sexual violence, possibly because these are both forms of control used by abusive husbands. Freedom of movement is a human right that should not place girls at greater risk for nonmarital violence or be used as a means of control by abusive spouses. Social change is needed to secure girls' safety in India.

Relative Risk of Intimate Partner Violence According to Access to Instrumental Social Support Among Pregnant Women in Eswatini Whose Partners Do and Do Not Drink Alcohol.

Intimate partner violence (IPV) affects one in three women around the world and is the tenth leading cause of death for women in Africa aged 15 to 29 years. Partner alcohol use, access to social support, and poverty all affect women's likelihood of experiencing violence. We sought to understand how partner alcohol use differentially affected the hypothesized association between a protective role of instrumental social support (in the form of food or financial loans) against IPV for a clinic-based sample of women in the Kingdom of Eswatini (formerly known as Swaziland). We use cross-sectional data from a parent study of women recruited from urban and rural antenatal clinics in Eswatini (n = 393) to calculate the association between experiencing IPV and perception of one's ability access to large cash loans, small cash loans, and food loans-both for the full sample and stratified by partner alcohol use. In fully adjusted models, the perception that one could access loans of food or money was associated with decreased relative risk of IPV for all women. These associations were modified by partner alcohol use. Access to instrumental support (loans of food or money) is associated with decreased risk of IPV, but this association varies according to the type of loan and whether or not a woman's partner drinks alcohol. Economic empowerment interventions to reduce IPV must be carefully tailored to ensure they are appropriate for a woman's specific individual, relationship, and community context.

Telerehabilitation for chronic respiratory disease: a randomised controlled equivalence trial.

RATIONALE: Pulmonary rehabilitation is an effective treatment for people with chronic respiratory disease but is delivered to <5% of eligible individuals. This study investigated whether home-based telerehabilitation was equivalent to centre-based pulmonary rehabilitation in people with chronic respiratory disease. METHODS: A multicentre randomised controlled trial with assessor blinding, powered for equivalence was undertaken. Individuals with a chronic respiratory disease referred to pulmonary rehabilitation at four participating sites (one rural) were eligible and randomised using concealed allocation to pulmonary rehabilitation or telerehabilitation. Both programmes were two times per week for 8 weeks. The primary outcome was change in Chronic Respiratory Disease Questionnaire Dyspnoea (CRQ-D) domain at end-rehabilitation, with a prespecified equivalence margin of 2.5 points. Follow-up was at 12 months. Secondary outcomes included exercise capacity, health-related quality of life, symptoms, self-efficacy and psychological well-being. RESULTS: 142 participants were randomised to pulmonary rehabilitation or telerehabilitation with 96% and 97% included in the intention-to-treat analysis, respectively. There were no significant differences between groups for any outcome at either time point. Both groups achieved meaningful improvement in dyspnoea and exercise capacity at end-rehabilitation. However, we were unable to confirm equivalence of telerehabilitation for the primary outcome ΔCRQ-D at end-rehabilitation (mean difference (MD) (95% CI) -1 point (-3 to 1)), and inferiority of telerehabilitation could not be excluded at either time point (12-month follow-up: MD -1 point (95% CI -4 to 1)). At end-rehabilitation, telerehabilitation demonstrated equivalence for 6-minute walk distance (MD -6 m, 95% CI -26 to 15) with possibly superiority of telerehabilitation at 12 months (MD 14 m, 95% CI -10 to 38). CONCLUSION: telerehabilitation may not be equivalent to centre-based pulmonary rehabilitation for all outcomes, but is safe and achieves clinically meaningful benefits. When centre-based pulmonary rehabilitation is not available, telerehabilitation may provide an alternative programme model. TRIAL REGISTRATION NUMBER: ACtelerehabilitationN12616000360415.

Community Participation by People with Chronic Obstructive Pulmonary Disease.

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV1: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all rs = 0.30, p < 0.05). Older age and more moderate-to-vigorous physical activity independently predicted greater community participation measured by CPI. Higher levels of depression symptoms were associated with less formal and informal community participation on ESS (rs = -0.25). More formal community participation on ESS was weakly (rs = 0.2-0.3) associated with older age, better lung function, exercise capacity and self-efficacy, and less breathlessness. Self-efficacy, exercise capacity, and age independently predicted formal community participation in individuals with COPD. Strategies to optimize self-efficacy and improve exercise capacity may be useful to enhance community participation in people with COPD.

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.