Application of an egocentric social network approach to examine changes in social connections following treatment for anxiety and depression: A novel measurement tool for clinical trials research?

The epidemic of loneliness and social isolation has been recognized as a public health crisis warranting the same prioritization as other public health issues today, such as obesity, substance use disorders, and tobacco use. Social disconnection is particularly prevalent and disabling among individuals with anxiety and depression, yet it is inadequately evaluated and addressed in most clinical psychology treatment research. Studies generally employ global measures of perceived connectedness, loneliness, or relationship satisfaction, limiting understanding about elements of one's social network that may change with treatment. This study examined changes in the degree (number of people nominated) and quality of one's social network from pre-to post-treatment using an egocentric social network approach in 59 adults (mean age = 30.8 years, range = 18 to 54) with clinically elevated anxiety or depression who were randomized to a cognitive and behavioral positive valence treatment versus waitlist. Participants (egos) named people in their lives (alters) with whom they discussed important issues or spent free time. For each alter, participants rated how close they felt, how close they thought the alter felt to them, and how frequently they communicated. Linear regressions, which included treatment group as a predictor, revealed no group differences in changes in network degree, perceived alter feelings of closeness, or communication frequency, despite prior findings from this sample indicating larger increases in perceived global connectedness in the treatment group. Unexpectedly, the control group reported a greater increase in perceived closeness to alters. Post-hoc analyses revealed this was explained by the treatment group identifying more distal social ties (e.g., extended family, colleagues, roommates) as alters following treatment - an outcome positively associated with global improvements in connectedness. This proof-of-concept study suggests egocentric social network surveys may provide unique information on treatment-related changes in social functioning. Suggestions are provided for adaptations to facilitate application of social network surveys to mental health treatment research.

Amplification of Positivity Treatment for Anxiety and Depression: A Randomized Experimental Therapeutics Trial Targeting Social Reward Sensitivity to Enhance Social Connectedness.

BACKGROUND: Social disconnection is common and causes significant impairment in anxiety and depressive disorders, and it does not respond sufficiently to available treatments. The positive valence system supports social bond formation and maintenance but is often hyporesponsive in people with anxiety or depression. We conducted an experimental therapeutics trial to test the hypothesis that targeting positive valence processes through cognitive and behavioral strategies would enhance responsivity to social rewards, a core mechanism underlying social connectedness. METHODS: Sixty-eight adults who endorsed clinically elevated anxiety and/or depression with social impairment were randomized 1:1:1 to 5 (n = 23) or 10 (n = 22) sessions of amplification of positivity (AMP) treatment or waitlist (n = 23). Pre- to posttreatment change in striatal activity (primary outcome) during social reward anticipation was measured using functional magnetic resonance imaging, and reactivity to a social affiliation task (secondary) and self-reported social connectedness (exploratory) were examined. Primary analyses compared AMP (doses combined) versus waitlist. A second aim was to compare the effects of different doses. RESULTS: AMP engaged the hypothesized treatment target, leading to greater striatal activation during anticipation of social rewards versus waitlist (d = 1.01 [95% CI = 0.42-1.61]; largest striatal volume). AMP yielded larger improvements in positive affect and approach behavior during the affiliation task (but not other outcomes) and social connectedness. Larger striatal and social connectedness increases were observed for 5-session versus 10-session AMP (d range = 0.08-1.03). CONCLUSIONS: Teaching people with anxiety or depression strategies to increase positive thoughts, behaviors, and emotions enhances activity in brain regions that govern social reward processing and promotes social connectedness. Social reward sensitivity may be a transdiagnostic target for remediating social disconnection.

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.

Characterizing Nigerien men's social networks and their influence on family planning-related attitudes and behaviors.

This work uses data from a family planning (FP) program evaluation and social network study among men married to adolescent girls (ages 13-19) in Dosso, Niger to explore who influences their FP and through which social mechanisms. We asked men (N = 237) to nominate and describe their perceptions of key social contacts (alters). We sought to interview the most influential alter (N = 157 interviewed alters), asking them about their own FP-related attitudes and behaviors. Men primarily nominated male friends as alters. We found that men participating in the program were more likely to perceive alters to hold attitudes supportive of gender equitable FP decisions (AOR: 4.36, 95% CI: 1.83, 10.35) and FP use (AOR: 4.22, 95% CI: 1.72, 10.35). Alters' attitudes supporting FP were related to those of the men who nominated them (1-unit increase in alters' attitudes score related to a 0.48 unit increase in men's attitudes; 95% CI: 0.32, 0.63). Men who perceived their alters would support gender equitable FP decisions were more likely to have ever used FP methods (AOR: 10.43, 95% CI: 2.50, 43.58) as were those who perceived their alters would support their own FP use (AOR: 12.76, 95% CI: 2.55, 63.81). Men who perceived their alters would support gender equitable FP decisions were more likely to report spousal communication (AOR: 8.71, 95% CI: 3.06, 24.83), as were those who perceived that alters would support their own FP use (AOR: 9.06, 95% CI: 3.01, 27.26). Alters' and men's behaviors (contraceptive use and spousal communication) were not associated. These results demonstrate that perceived approval from network members may be critical to FP-related attitudes and behaviors. However, since FP promotion programs may affect perception and/or composition of social networks, future research should include larger sample sizes and longitudinal data to understand the effect of changing norms on social relationships.

Associations of attitudes and social norms with experiences of intimate partner violence among married adolescents and their husbands in rural Niger: a dyadic cross-sectional study.

BACKGROUND: Prior cross-sectional research suggests that both men's and women's attitudes towards intimate partner violence (IPV) are predictive of women's IPV experience, although this can vary greatly by context. In general, women who have experienced IPV are likely to report attitudes accepting of it. Men who perpetrate IPV may also report attitudes accepting of it, although some research has found that there is not always an association. Studies that investigate these dynamics often conflate attitudes with social norms, or use attitudes as a proxy for social norms, given that valid measures on social norms are usually lacking. Here we conduct a secondary data analysis to ask how are men's and women's IPV-related attitudes associated with women's reports of IPV and how are men's and women's perceived social norms associated with women's reports of IPV. METHODS: Dyadic data were collected from a representative sample of married adolescent girls and their husbands in 48 rural villages of the Dosso region of Niger (N = 1010). Assessments included logistic regression analyses of husbands' and wives' reports of individual attitudes towards IPV, and social norms based on husbands' and wives' perceptions of their communities' beliefs related to gender roles and acceptability of IPV. RESULTS: Eight percent of women in this sample reported IPV. We found that, consistent with other research, wives who have reported IPV are more likely to report attitudes in support of IPV, while for husbands whose wives report IPV, that relationship is insignificant. On the other hand, husbands who report that people in their community believe there are times when a woman deserves to be beaten are more likely to have perpetrated IPV, while for wives there is no association between the community norm and IPV reporting. Finally, wives who report that people in their community hold inequitable gender norms in general are more likely to have experienced IPV, while for husbands, community gender norms are not predictive of whether their wives have reported IPV. CONCLUSIONS: Our results are evidence that IPV prevention interventions focused solely on individual attitudes may be insufficient. Targeting and assessment of social norms are likely critical to advancing understanding and prevention of IPV.

Through our own eyes and voices: The experiences of those "left-behind" in rural, indigenous migrant-sending communities in western Guatemala.

Migration from Central America to the United States has become a strategy to escape economic poverty, exclusionary state policies and violence for people of Mayan descent. Under the principles Community Based Participatory Research, we explored the health concerns of Indigenous Mayans in rural migrant-sending communities of Guatemala using their own visual images and narratives through a Social Constructivist lens. Half of households in the study region have at least one member emigrated to the United States, making many "transnational families." Focus groups and photographs and narratives from 20 Photovoice participants, aged 16-65, revealed significant health challenges related to conditions of poverty. Drivers of immigration to the United States included lack of access to healthcare, lack of economic opportunity, and an inability to pay for children's education. Health implications of living in communities "left-behind" to immigration centered around changes in societal structure and values. Mental health challenges, sadness and loss were experienced by both children and adults left behind. An increase in substance use as a coping mechanism is described as increasingly common, and parental absence leaves aging grandparents raising children with less guidance and supervision. Lack of economic opportunity and parental supervision has left young adults vulnerable to the influence of cartel gangs that are well-established in this region. Findings from this study provide insight into challenges driving immigration, and the health impacts faced by rural, Indigenous communities left behind to international immigration. Results may inform research and interventions addressing disparities and strategies to cope with economic and health challenges.

Association of Physician Referrals with Timely Cancer Care Using Tumor Registry and Claims Data.

More Americans are being screened for and more are surviving colorectal cancer due to advanced treatments and better quality of care; however, these benefits are not equitably distributed among diverse or older populations. Differential care delivery outcomes are driven by multiple factors, including access to timely treatment that comes from high-quality care coordination. Providers help ensure such coordinated care, which includes timely referrals to specialists. Variation in referrals between providers can also result in differences in treatment plans and outcomes. Patients who are more often referred between the same diagnosing and treating providers may benefit from more timely care compared to those who are not. Our objective is to examine patterns of referral, or patient-sharing networks (PSNs), and our outcome, treatment delay of 30-days (yes/no). We hypothesize that if a patient is in a PSN they will have lower odds of a 30-day treatment initiation delay. Our observational population-based analysis using the National Cancer Institute (NCI)-linked tumor registry and Medicare claims database includes records for 27,689 patients diagnosed with colorectal cancer from 2001 to 2013, and treated with either chemotherapy, radiotherapy, or surgery. We modeled the adjusted odds of a delay and found 17.04% of patients experienced a 30-day delay in initial treatment. Factors that increased odds of a delay were lack of membership in a PSN (adjusted odds ratio [AOR]: 2.20; 95% confidence interval [CI]: 1.71-2.84), racial/ethnic minority status, and having multiple comorbidities. Provider characteristics significantly associated with greater odds of a delay were if dyads were not in the same facility (AOR: 1.95; 95% CI: 1.81-2.10), if providers were different genders, most notably male (diagnosing) and female (treating) [AOR: 1.23; 95% CI: 1.08-1.40, p = 0.0015]. PSNs appear to be associated with reduced of a care delay. The associations observed in our study address the demand for developing multilevel interventions to improve the delivery and coordination of high-quality of care for older cancer patients.

The teamwork structure, process, and context of a paediatric cardiac surgery team in Mongolia: A mixed-methods approach.

INTRODUCTION: Effective teamwork in paediatric cardiac surgery is known to improve team performance and surgical outcomes. However, teamwork in low- and middle-income countries (LMICs), including Mongolia, is understudied. We examined multiple dimensions of teamwork to inform a team-based training programme to strengthen paediatric cardiac surgical care in Mongolia. METHODS: We used a mixed-methods approach, combining social network analysis and in-depth interviews with medical staff, to explore the structure, process, quality, and context of teamwork at a single medical centre. We conceptualised the team's structure based on communication frequency among the members (n = 24) and explored the process, quality, and context of teamwork via in-depth interviews with select medical staff (n = 9). RESULTS: The team structure was highly dense and decentralised, but the intensive care unit nurses showed high betweenness-centrality. In the quality and process domain of teamwork, we did not find a regular joint decision-making process, leading to the absence of common goals among the team members. Although role assignment among the medical staff was explicit, those strictly defined roles hindered active communication about patient information and responsibility-sharing. Most interviewees did not agree with the organisational policies that limited discussions among team members; therefore, medical staff continued to share training and work experiences with each other, leading to strong and trustworthy relationships. CONCLUSION: The findings of this study underscore the importance of well-structured and goal-oriented communication between medical staff, as well as the management of the quality of collaboration within a team to increase teamwork effectiveness in paediatric cardiac surgery teams in LMICs.

Associations between spousal gender equity and recent unintended pregnancy among married adolescent girls and their husbands in rural Niger.

This study in rural Niger examines if gender equity attitudes of married adolescent girls and their husbands are associated with recent unintended pregnancy (UIP) and ever-use of family planning (FP). Logistic regression models were used to calculate adjusted associations between husbands' and wives' equity (jointly and separately) and the two outcomes. UIP was less likely to be reported by adolescent girls with equitable husbands, controlling for wife's equity (adjusted odds ratio/aOR: 0.57, 95% confidence interval/CI: 0.41-0.80), and was more likely to be reported by equitable wives (aOR: 2.26, CI: 1.59-3.24). In stratified analyses, wife's equity was associated with a nearly three-fold likelihood of UIP in couples with inequitable husbands (aOR: 2.79, CI: 1.58-5.05). Ever having used FP was not associated with husbands' or wives' gender equity. Interventions targeting reproductive health outcomes for married adolescent girls should focus on spousal equity attitudes - improving wives' equity might be ineffective if husbands remain inequitable.

Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data.

BACKGROUND: Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis. METHODS: We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised. FINDINGS: Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras. INTERPRETATION: Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health.

Social network and social normative characteristics of married female adolescents in Dosso, Niger: Associations with modern contraceptive use.

In this study we analysed the social networks of a sample of married adolescent girls (ages 13-19 years) residing in Dosso, Niger (N = 322); data were collected for evaluation of a family planning (FP) intervention. Participants were asked to name individuals important in their lives (alters) using three name generating questions as part of a larger survey on reproductive health, social norms, and FP. One alter per girl was then recruited to be separately interviewed (N = 250). This provided us with two separate datasets: one with data from each respondent regarding each person that they nominated, and one with the interviewed alters matched with the respondent who nominated them. We found that married adolescent girls who were nulliparous were more likely to have no alters and that those in the intervention had the most alters. Alters of treatment participants were more likely to have used FP. Respondents were more likely to have used FP when their sisters or in-laws had, but there was no correlation with use by friends. Our results provide evidence of diffusion of the FP program to those close to intervention participants. Future research should study these dynamics, crucial to understanding intervention costing, impact, and normative change.

Women's business? A social network study of the influence of men on decision-making regarding female genital mutilation/cutting in Senegal.

There exist two dominant but conflicting views on the role of men in the perpetuation female genital mutilation/cutting (FGM/C). One paints men as culprits, with FGM/C viewed as a manifestation of patriarchal oppression of women. An alternative portrays men as relatively uninvolved in a practice described as 'women's business'. These two perspectives lead to divergent predictions: if FGM/C underpins patriarchal structures, men should be expected to be ardent supporters of FGM/C as it bolsters their power and status; if FGM/C is a women's affair, men should have little involvement. We test these predictions using data from a mixed-method study of norms and social networks in two regions of Senegal. Data show that men comprise 50% of core network members, although they exert influence in different ways in each study site. In South Senegal excision is upheld by men, as well as older women, through a constellation of norms that define FGM/C as prerequisite to marriage and social inclusion. In Central Senegal these gender norms have eroded, opening possibilities for abandonment of FGM/C, and men, particularly fathers, at times successfully advocate this change. This suggests that men can play an important role in ending FGM/C, and should be involved in intervention efforts.

Mapping the patchwork: Exploring the subnational heterogeneity of child marriage in India.

Despite dramatic reductions in child marriage over the past decade, more than one in four girls in India still marry before reaching age 18. This practice is driven by a complex interplay of social and normative beliefs and values that are inadequately represented in national- or even state-level analyses of the drivers of child marriage. A geographic lens was employed to assess variations in child marriage prevalence across Indian districts, identify hot and cold spots, and quantify spatial dependence and heterogeneity in factors associated with district levels of child marriage. Data were derived from the 2015-16 National Family Health Survey and the 2011 India Census, and represent 636 districts in total. Analyses included global Moran's I, LISAs, spatial Durbin regression and geographically weighted regression. This study finds wide inter- and intra-state heterogeneity in levels of child marriage across India. District levels of child marriage were strongly influenced by geographic characteristics, and even more so by the geographic characteristics of neighboring districts. Districts with higher levels of female mobile phone access and newspaper use had lower levels of child marriage. These relationships, however, were all subject to substantial local spatial heterogeneity. The results indicate that characteristics of neighboring districts, as well as characteristics of a district itself, are important in explaining levels of child marriage, and that those relationships are not constant across India. Child marriage reduction programs that are targeted within specific administrative boundaries may thus be undermined by geographic delineations that do not necessarily reflect the independent and interdependent characteristics of the communities who live therein. The geographic, social and normative characteristics of local communities are key considerations in future child marriage programs and policies.

Associations of spousal communication with contraceptive method use among adolescent wives and their husbands in Niger.

OBJECTIVES: This study aims to examine associations between spousal communication about contraception and ever use of modern contraception, overt modern contraceptive use (with husband's knowledge), and covert modern contraceptive use (without husband's knowledge) among adolescent wives and their husbands in Niger. STUDY DESIGN: Cross-sectional data, from the Reaching Married Adolescents Study, were collected from randomly selected adolescent wives (ages 13-19 years) and their husbands from 48 randomly selected villages in rural Niger (N = 1,020 couples). Logistic regression models assessed associations of couples' reports of spousal communication about contraception with wives' reports of contraception (overall, overt, and covert). RESULTS: About one-fourth of adolescent wives and one-fifth of husbands reported spousal communication about contraception. Results showed couples' reports of spousal communication about contraception were positively associated with ever use of modern contraception. Couples' reports of spousal communication about contraception were negatively associated with covert modern contraceptive use compared to overt use. Wives' reports of spousal communication were marginally associated with covert use compared to no use but husbands' reports were not. CONCLUSION: Among a sample of couples in Niger, spousal communication about contraception was positively associated with modern contraceptive use (compared to no use) and negatively with covert use (compared to overt use) but wives' and husbands' reports showed differential associations with covert use compared to no use. Since there is little understanding of couple communication surrounding covert contraceptive use decisions, research should focus on characterizing content and context of couple communication particularly in cases of disagreement over fertility decisions.

Associations between village-level norms on marital age and marital choice outcomes among adolescent wives in rural Niger.

Social norms, the often unspoken rules that dictate behavior, are increasingly understood to play a role in child, early and forced marriage (CEFM) practices, but are less frequently examined in quantitative research on CEFM. No research on this topic has focused on Niger, despite the country having the highest prevalence of child marriage in the world. This study examines the associations of community and individual-level norms on marital age and marital choice with the outcomes of girls' age at marriage and choice in marriage. We used data from a family planning evaluation trial conducted in three districts within the Dosso region of Niger. Survey data were collected from adolescent wives and their husbands (N = 582) on demographics, normative beliefs regarding girls' age at marriage and marital choice, and among wives, age at marriage and engagement in marital choice. We developed our community-level norm variables by using the aggregate data from husbands' and wives' norms and wives' CEFM experiences. Using crude and adjusted regression models, we assessed the associations between our norms variables and our CEFM outcomes. In this context of very high prevalence of CEFM, we found that village-level norms related to marital choice, particularly the norms of men, are associated with younger age of girls at marriage. We also found that younger age of girls at marriage is positively associated with lower likelihood of their engagement in marital choice. Further, we find that village-level norms related to a later age of marriage and support for marital choice, as well as adolescent wives' perceptions of community norms related to a higher age of marriage, are associated with higher odds of a wife having had marital choice. These findings suggest the value of community level social norms change on CEFM in Niger, and the importance of focusing on child marriage and girls' marital choice simultaneously given their interconnection.

Spatial analysis of individual- and village-level sociodemographic characteristics associated with age at marriage among married adolescents in rural Niger.

BACKGROUND: Niger has the highest prevalence of child marriage in the world. While child marriage in Niger is clearly normative in the sense that it is commonly practiced, the social and contextual factors that contribute to it are still unclear. METHODS: Here, we tested the importance of village-level factors as predictors of young age at marriage for a group of married adolescent girls (N = 1031) in the Dosso district of rural Niger, using multi-level and geographic analyses. We aggregated significant individual level factors to determine whether, independent of a girl's own sociodemographic characteristics, the impact of each factor is associated at the village level. Finally, we tested for spatial dependence and heterogeneity in examining whether the village-level associations we find with age at marriage differ geographically. RESULTS: The mean age of marriage for girls in our study was 14.20 years (SD 1.8). Our statistical results are consistent with other literature suggesting that education is associated with delayed marriage, even among adolescent girls. Younger ages at marriage are also associated with a greater age difference between spouses and with a greater likelihood of women being engaged in agricultural work. Consistent with results at the individual level, at the village level we found that the proportion of girls who do agricultural work and the mean age difference between spouses were both predictive of a lower age at marriage for individual girls. Finally, mapping age at marriage at the village level revealed that there is geographical variation in age at marriage, with a cluster of hot spots in the Hausa-dominated eastern area where age at marriage is particularly low and a cluster of cold spots in the Zarma-dominated western areas where age at marriage is relatively high. CONCLUSIONS: Our findings suggest that large-scale approaches to eliminating child marriage in these communities may be less successful if they do not take into consideration geographically and socially determined contextual factors at the village level.

Social normative and social network factors associated with adolescent pregnancy: a cross-sectional study of 176 villages in rural Honduras.

BACKGROUND: Adolescent pregnancy and childbirth are common throughout Central America. While gendered beliefs promoting motherhood are a known risk factor, their association with adolescent childbirth within the social networks of Central American communities is unknown. METHODS: This was a cross-sectional study looking at adolescent childbirth amongst women ages 15-20 years (N = 2990) in rural Honduras, using reproductive health data on all individuals ≥15 years of age (N = 24 937 of 31 300 population) including social network contacts, all of whom were interviewed as part of the study. The outcome, adolescent childbirth, was defined as having had a child < age 20 years. Predictors included whether a woman's social contact had an adolescent childbirth and the social contact's reported perception of community support for adolescent childbirth. RESULTS: While girls who identified a father in the village as a social contact had a lower likelihood of adolescent childbirth regardless of whether or not they reported being in a partnership, this finding did not hold for girls who identified mothers. There was an association between a social contact's report of norms supporting adolescent childbirth and a girl's risk of adolescent childbirth; however, village-level aggregate norms attenuated that relationship. Independent significant associations were found between a girl's risk of adolescent childbirth and both a social contact's adolescent childbirth and the village proportion of women who had had an adolescent childbirth. The association between social contacts' adolescent childbirth and a girl's risk of adolescent childbirth across relationships was more robust for stronger relationships and when the social contact was closer in age to the girl. CONCLUSIONS: If, as this evidence suggests, a strong driver of adolescent childbirth is the frequency of the occurrence of adolescent childbirth both within the greater community and within a girl's proximal social network, the challenge for intervention strategies is to encourage norms that prevent adolescent childbirth without stigmatising those who have had an adolescent childbirth. Programmatic efforts to counter prevailing norms that limit a woman's role to motherhood, and that support and encourage strong norms for girls' education may play an important role in addressing this situation.

Why context matters for social norms interventions: The case of child marriage in Cameroon.

Child marriage is a global health and human rights issue. In Cameroon, 30% of women are married before age 18 but little research exists on the drivers of child marriage in the country. This qualitative study contributes to understanding the role of social norms in sustaining child marriage in Far-North and East Cameroon. Participants in the study (N = 80) included women and men from four, ethnically different, rural communities (two in the Far-North, two in the East). Methods for data collection included 16 semi-structured focus groups, in which we investigated the system of social norms sustaining child marriage in these communities. We asked participants about typical age at marriage for girls (local practices) and whether they believed that age to be appropriate (their attitudes). We found the relation between practices and attitudes to be different in each community. We discuss the implications of these different relations for social norms interventions, enriching existing theoretical explanations. Evidence emerging from our findings suggest that effective social norms interventions should be embedded within cultural understandings of the relations between people's attitudes and practices.

Gender Norms and Weight Control Behaviors in U.S. Adolescents: A Prospective Cohort Study (1994-2002).

PURPOSE: The aim of this article was to determine the relationship between gender norms and weight control behaviors in U.S. adolescents. METHODS: We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health (N = 9,861), at baseline in 1994-1995 (ages 11-18 years, Wave I), 1-year follow-up (ages 12-19 years, Wave II), and 7-year follow-up (ages 18-26 years, Wave III). The primary exposure variable was a measure of one's gender normativity based on the degree to which males and females behave in ways that are similar to the behaviors of their same-gender peers. The outcome variable was an individual's weight control attempts (trying to lose or gain weight) and behaviors (dieting, fasting/skipping meals, vomiting, or weight-loss pills/laxatives/diuretics to lose weight or ate different/more foods than usual or taking supplements to gain weight). RESULTS: In logistic regression analyses controlling for potential confounders, a higher baseline individual gender normativity score (higher femininity in females and higher masculinity in males) was associated with weight loss attempts (ß = .10; p = .01) and weight loss behaviors (ß = .18; p < .001) in girls but was associated with weight gain attempts (ß = .18; p < .001) and behaviors (ß = .16; p < .001) in boys at 1-year follow-up. Higher individual gender normativity score was protective of weight loss attempts (ß = -.15; p < .001) and weight loss behaviors (ß = -.17; p < .001) in males but not females at 7-year follow-up. Loess plots provided visualizations of significant relationships. CONCLUSIONS: Gender norms may reinforce a thinner body ideal for girls but a larger ideal for boys.

Knowledge, attitudes, and practices related to family planning and gender equity among husbands of adolescent girls in Niger.

Despite having the highest fertility rate in the world, research on Niger men and family planning (FP) is limited. We collected survey data collected in the Dosso region of Niger in 2016 from 1136 men who are the husbands of adolescent girls. We report descriptive statistics, bivariate and multivariable logistic regression on three dichotomous outcomes: (a) knowledge of modern contraceptives, (b) beliefs that only husbands should make FP decisions, and (c) current FP use. About 56% had ever heard of the pill, 6% had ever heard of an intrauterine device, and 45% had ever heard of an injectable. In our multivariable analyses, we found: a man knowing at least one modern method was significantly associated with his age, wife's education level, gender ideology, and wife's say in healthcare decisions; men's belief that men alone should make FP decisions was associated with husband's Quranic education, gender ideology, and attitudes towards violence against women; men's reports of adolescent wives' current family planning use was associated with men's Quranic education, women's involvement in her own healthcare decisions, and belief that men alone should decide about family planning. Finding suggests that interventions should target aim to reduce gender inequities to increase family planning utilisation.