Associations between duration of first trimester intrauterine exposure to genocide against the Tutsi and health outcomes in adulthood.

OBJECTIVES: Hundreds of thousands of Rwandans were conceived during the 1994 genocide against the Tutsi, including thousands conceived by genocidal rape. We explore whether the duration of first trimester exposure to the genocide is associated with variation in adult mental health outcomes in individuals exposed to varying degrees of genocide-related stress in utero. MATERIALS AND METHODS: We recruited 30 Rwandans conceived via genocidal rape, 31 Rwandans conceived by genocide survivors not raped, and 30 individuals of Rwandan-descent who were conceived outside of Rwanda at the time of the genocide (control group). Individuals were age- and sex-matched across groups. Adult mental health was assessed through standardized questionnaires for vitality, anxiety, and depression. RESULTS: Among the genocide only group, a longer duration of first trimester prenatal exposure was associated with higher anxiety scores and lower vitality (both p < 0.010), and higher depression scores (p = 0.051). Duration of first trimester exposure was not associated with any measures of mental health among the genocidal rape or control group. DISCUSSION: Duration of exposure to genocide in the first trimester of gestation was associated with variation in adult mental health among the genocide only group. The lack of association between duration of first trimester exposure to genocide and adult mental health in the genocidal rape group may reflect the fact that stress associated with conception through rape persisted beyond the genocide period itself, encompassing all of gestation and likely beyond. Geopolitical and community interventions are needed in the context of extreme events during pregnancy to mitigate adverse intergenerational outcomes.

Toolkit article: Approaches to measuring social inequities in health in human biology research.

Across populations, human morbidity and mortality risks generally follow clear gradients, with socially-disadvantaged individuals and groups tending to have higher morbidity and mortality at all life stages relative to those more socially advantaged. Anthropologists specialize in understanding the proximate and ultimate factors that shape variation in human biological functioning and health and are therefore well-situated to explore the relationships between social position and health in diverse ecological and cultural contexts. While human biologists have developed sophisticated methods for assessing health using minimally-invasive methods, at a disciplinary level, we have room for conceptual and methodological improvement in how we frame, measure, and analyze the social inequities that might shape health inequities. This toolkit paper elaborates on some steps human biologists should take to enhance the quality of our research on health inequities. Specifically, we address: (1) how to frame unequal health outcomes (i.e., inequalities vs. disparities vs. inequities) and the importance of identifying our conceptual models of how these inequities emerge; (2) how to measure various axes of social inequities across diverse cultural contexts, and (3) approaches to community collaboration and dissemination. We end by discussing (4) future directions in human biology research of health inequities, including understanding the ultimate causes of sensitivity to social inequities and transitioning from research to action.

Feasibility and preliminary efficacy of acupuncture for angina in an underserved diverse population.

PURPOSE: Stable angina is ischemic chest pain on exertion or with emotional stress. Despite guideline-directed therapy, up to 30% of patients have suboptimal pain relief. The aims of this study were to: (1) determine the feasibility and acceptability of a randomized controlled trial (RCT) of acupuncture; and (2) evaluate preliminary efficacy of acupuncture with respect to reduction of pain and increased functional status and health-related quality of life (HRQoL). METHODS: Participants with stable angina for ⩾1 month received either a standardized acupuncture protocol, twice per week for 5 weeks, or an attention control protocol. Measures included the McGill Pain Questionnaire (average pain intensity (API), pain now) and the Seattle Angina Questionnaire-7 (functional status, symptoms, and HRQoL). Feasibility was defined as ⩾80% recruitment, ⩾75% retention following enrollment, and ⩾80% completion. Descriptive statistics and mixed-effects linear regression were used for analysis. RESULTS: The sample (n = 24) had a mean age of 59 ± 12 years, was predominantly female (63%), and represented minority groups (8% White, 52% Black, 33% Hispanic, and 8% Other). Feasibility was supported by 79% retention and 89% completion rates. The recruitment rate (68%) was slightly lower than expected. Acceptability scores were 87.9% for the acupuncture group and 51.7% for the control group. Outcomes were significantly better for the acupuncture versus control groups (API, b = -2.1 (1.1), p = 0.047; functional status, b = 27.6 (7.2), p < 0.001; and HRQoL, b = 38.8 (11.9), p = 0.001). CONCLUSIONS AND IMPLICATIONS: Acupuncture was feasible and acceptable in our diverse sample. We were slightly under the recruitment target of 80%, but participants who started the study had a high likelihood of completing it. Acupuncture shows promise for stable angina, but its effectiveness needs to be confirmed by a larger, adequately powered RCT. TRIAL REGISTRATION NUMBER: NCT02914834 (ClinicalTrials.gov).

Global Public Health Nursing.

BACKGROUND: An often under addressed and tragic legacy of genocide is the conception of children from rape. While the experience has been documented from their mothers' perspective, the perspectives and needs of individuals born of genocidal rape has been under-studied. METHODS: We conducted an integrative review of all peer-reviewed articles that reported on studies conducted among individuals born of genocidal rape published through 2020. We used an inductive process to identify and describe the themes from those studies. RESULTS: Twelve studies met the inclusion criteria. Ten articles reported on youth born of genocidal rape in Rwanda aged between 16 and 21 years, and two articles represented the perspective of adolescents in the former Yugoslavia aged 1416 years. Four themes were indentified: (1) birth origin stories associated with the crime of the father, (2) fractured sense of belonging to the victim-mother, perpetrator-father, their families, and the community at large, (3) intergenerational legacy of trauma and family identity, and (4) strategies to move forward including knowing the truth about one's origin, mental health, and peer support. CONCLUSION: These findings suggest that understanding increased risk of adverse health outcomes of youth born of genocidal rape could inform the design of evidence-based interventions for these and similar populations.

Associations between postpartum depression and assistance with household tasks and childcare during the COVID-19 pandemic: evidence from American mothers.

BACKGROUND: The early postpartum period is recognized cross-culturally as being important for recovery, with new parents receiving increased levels of community support. However, COVID-19-related lockdown measures may have disrupted these support systems, with possible implications for mental health. Here, we use a cross-sectional analysis among individuals who gave birth at different stages of the pandemic to test (i) if instrumental support access in the form of help with household tasks, newborn care, and care for older children has varied temporally across the pandemic, and (ii) whether access to these forms of instrumental support is associated with lower postpartum depression scores. METHODS: This study used data from the COVID-19 And Reproductive Effects (CARE) study, an online survey of pregnant persons in the United States. Participants completed postnatal surveys between April 30 - November 18, 2020 (n = 971). Logistic regression analysis tested whether birth timing during the pandemic was associated with odds of reported sustained instrumental support. Linear regression analyses assessed whether instrumental support was associated with lower depression scores as measured via the Edinburgh Postnatal Depression survey. RESULTS: Participants who gave birth later in the pandemic were more likely to report that the pandemic had not affected the help they received with household work and newborn care (p < 0.001), while access to childcare for older children appeared to vary non-linearly throughout the pandemic. Additionally, respondents who reported that the pandemic had not impacted their childcare access or help received around the house displayed significantly lower depression scores compared to participants who reported pandemic-related disruptions to these support types (p < 0.05). CONCLUSIONS: The maintenance of postpartum instrumental support during the pandemic appears to be associated with better maternal mental health. Healthcare providers should therefore consider disrupted support systems as a risk factor for postpartum depression and ask patients how the pandemic has affected support access. Policymakers seeking to improve parental wellbeing should design strategies that reduce disease transmission, while facilitating safe interactions within immediate social networks (e.g., through investment in COVID-19 testing and contact tracing). Cumulatively, postpartum instrumental support represents a potential tool to protect against depression, both during and after the COVID-19 pandemic.

Double Jeopardy: Young adult mental and physical health outcomes following conception via genocidal rape during the 1994 genocide against the Tutsi in Rwanda.

Rwandans conceived by rape during the 1994 genocide against the Tutsi have endured a violent beginning and a troubled childhood. Given compelling evidence of the influence of prenatal environments and adverse childhood experiences (ACEs) on future health, these individuals are at high risk of poor mental and physical health outcomes. The purpose of the study was to characterize mental and physical health outcomes in young adults who were exposed prenatally to maternal stress due to the genocide in general and those conceived by genocidal rape, and to determine whether ACEs compound these effects. Ninety-one 24-year-old Rwandans - 30 conceived by genocidal rape, 31 born of genocide survivors not raped, and a control group of 30 born of women with neither exposure - completed the Adverse Childhood Experiences International Questionnaire and measures of multiple physical and mental health characteristics. Data were collected from March 7 to April 6, 2019. Findings demonstrated that 1) individuals conceived during the genocide had poorer mental function (p = 0.002) and higher scores in post-traumatic stress disorder (PTSD), anxiety, depression, physical function, pain intensity, and sleep disturbance compared to young adults who were not exposed to genocide (all p < 0.033); 2) individuals conceived by genocidal rape reported more depression, PTSD, and pain interference compared to those prenatally exposed to maternal genocide stress only (all p < 0.008); and 3) among the group conceived via genocidal rape, the effects of prenatal exposures on depression, physical function, pain intensity and pain interference were exacerbated by ACEs (all p < 0.041). Being conceived during genocide, especially through genocidal rape, is associated with poor adult physical and mental health. The role of ACEs in exacerbating prenatal genocide exposure highlights opportunities for interventions to reduce these effects.

Acupuncture to Improve Symptoms for Stable Angina: Protocol for a Randomized Controlled Trial.

BACKGROUND: Acupuncture has demonstrated physiologic analgesic effects in Chinese patients with stable angina. One proposed mechanism of action for these analgesic effects is the downregulation of M1 macrophages, interleukin 1 beta, interleukin-6, interleukin-18, and tumor necrosis factor alpha. OBJECTIVE: This study aims to test a 10-session, 5-week acupuncture treatment protocol as a complementary therapy for symptoms of stable angina for American patients, who vary from Chinese patients in health care systems and other salient variables. METHODS: We are conducting a randomized controlled trial (RCT) of 69 adults (35 assigned to initial acupuncture and 34 to an attention control condition) with a medically confirmed diagnosis of stable angina, whose pain and associated symptoms have not been controlled to their satisfaction with guideline-directed medical management. Participants in the experimental group will receive a standardized traditional Chinese medicine point prescription. The attention control group will view non-pain-related health education videos over 5 weeks equal to the 10 hours of treatment for the acupuncture group. Participants will complete the McGill Pain Questionnaire and the Seattle Angina Questionnaire-7, as well as have inflammatory cytokines measured at baseline and study completion. The primary outcomes are anginal pain and quality of life. RESULTS: This study has been funded over 2 years by the National Institutes of Health, National Institute for Nursing Research. We are currently recruiting and expect to have initial results by December 2020. CONCLUSIONS: We will generate data on feasibility, acceptability, effect sizes, and protocol revisions for a future fully powered RCT of the protocol. Findings will help determine if patients with persistent ischemic symptoms experience a proinflammatory state and hyperalgesia caused by multiple neural and immune processes not always relieved with medication. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14705.

Building Nursing and Midwifery Capacity Through Rwanda's Human Resources for Health Program.

Global disparities in the quantity, distribution, and skills of health workers worldwide pose a threat to attainment of the Sustainable Development Goals by 2030 and deepens already existing global health inequities. Rwanda and other low-resource countries face a critical shortage of health professionals, particularly nurses and midwives. This article describes the Human Resources for Health (HRH) Program in Rwanda, a collaboration between the Ministry of Health of Rwanda and a U.S. consortium of academic institutions. The ultimate goal of the HRH Program is to strengthen health service delivery and to achieve health equity for the poor. The aim of this article is to highlight the HRH nursing and midwifery contributions to capacity building in academic and clinical educational programs throughout Rwanda. International academic partnerships need to align with the priorities of the host country, integrate the strengths of available resources, and encourage a collaborative environment of cultural humility and self-awareness for all participants.

Assessing the twinning model in the Rwandan Human Resources for Health Program: goal setting, satisfaction and perceived skill transfer.

BACKGROUND: Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model. METHODS: All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression. RESULTS: Most RF and USF reported setting goals with their twin (89% and 71%, respectively). Half of RF (52%) reported effective skill transfer compared to 10% of USF. Only 38% of RF and 28% of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect. CONCLUSIONS: Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce.

Association of sexual risk behaviour with previous HIV testing among voluntary HIV counselling and testing clients in Kigali, Rwanda.

With increased coverage of voluntary HIV counselling and testing (VCT) in Rwanda and a greater focus on repeat testing of key populations, it is important to understand whether the right clients are returning for repeat testing and if repeat testing is effective at reducing risk. We assessed the association between repeat testing and recent sexual risk behaviours among 1852 first time or repeat HIV testing clients in Kigali who had had sex, using data from a cross-sectional survey. Repeat testing was associated with being female, older and type of occupation. Multivariable analyses indicate that individuals who tested for HIV 1-2 times (aOR = 1.52, 95% CI: 1.08, 2.15) and 3+ times (aOR = 1.51, 95% CI: 1.06, 2.17) previously were more likely to report recent unprotected sex. Those with 3+ previous tests were more likely to have recently had multiple sexual partners (aOR = 2.19, 95% CI: 1.22, 3.92). However, a significant decrease in HIV prevalence is shown as individuals receive more HIV tests in their lifetime (p < 0.001). These findings show that individuals who report high-risk behaviours are returning for repeat tests. However, VCT may not be successful at addressing certain sexual risk behaviours. Therefore more intensive counselling or additional HIV prevention services may be needed.