Syrian refugee young adults as community mental health workers implementing problem management plus: Protocol for a pilot randomized controlled trial to measure the mechanisms of effect on their own wellbeing, stress and coping.

This pilot randomized controlled trial protocol aims to (1) assess the impact on the wellbeing of Syrian refugee young adults (18-24 years) of being a community mental health worker (CMHW) implementing WHO's evidence-based psychosocial intervention - Problem Management Plus (PM+) - with adults in their community, and (2) identify the mechanisms associated with the outcomes of enhanced wellbeing and coping, and reduced stress among these CMHWs. Over 108 million people have been forcibly displaced as of the end of 2022. Mental health consequences of these displacements are significant, yet human resources for health are not sufficient to meet the needs. A large proportion of refugee populations are youth and young adults (YA). Evidence indicates their engagement in supporting their communities leads to their own enhanced wellbeing and that of their community. This trial trains Syrian refugees to serve their communities as CMHW (n=19) or tutors (n=19) and compare wellbeing, stress and coping outcomes between these two groups and a control group (n = 40). We will also assess 7 mechanisms as potential pathways for the interventions to influence outcomes. Surveys will assess outcomes and mechanisms, hair samples will measure stress cortisol. The primary analysis will use a Bayesian Hierarchical Model approach to model the trajectories of the mechanisms and primary study endpoints over time for individuals in each of the arms. Our results will elucidate critical mechanisms in which engagement of young adults to support their community enhances their own wellbeing. Trial registration: National Institutes of Mental Health, NCT05265611, Registered prospectively in 2021. Lebanon clinical trials registry #: LBCTR2023015206, Registered in 2023.

E-cigarettes in college: Associations between mental health and e-cigarette use with other substances.

INTRODUCTION: College students are a priority population for substance use prevention, and other studies have reported associations between mental health and e-cigarette use. This study described the association of mental health to e-cigarette and other substance use (ECIG+ use) among US college students. METHODS: We used Fall 2018 and Spring 2019 National College Health Assessment data among undergraduate students aged 18-24 years (n=55654) at 138 institutions. We characterized substance use patterns and used multinomial regression to model adjusted odds of past 30-day ECIG use type [no substance use (reference); sole e-cigarette use; e-cigarette use and other substance use (ECIG+ use); no e-cigarette use but other substance use] by mental health characteristics, past 12-month diagnosis/treatment and psychological distress, individual characteristics, and college characteristics. RESULTS: Alcohol was the most prevalent substance (58%) used, followed by cannabis (23%) and e-cigarettes (15%). Nearly all (95%) students who used e-cigarettes reported using another substance. Adjusted odds of ECIG+ use (vs no substance use) were higher among students with past 12-month mental health diagnosis/treatment (AOR=1.5; 95% CI: 1.4-1.6) and higher psychological distress (AOR=1.1; 95% CI: 1.1-1.2). Other characteristics significantly associated with ECIG+ use included gender identity, sexual orientation, race and ethnicity, self-rated health, year in school, cumulative grade average, fraternity/sorority membership, and current residence. CONCLUSIONS: Most students who used e-cigarettes also reported other substance use, and this pattern of use was associated with poorer mental health outcomes than no substance use. Clarifying the relationship between mental health and ECIG+ use may enhance health interventions for college students.

Parenting a High and Growing Population of Youth in the Arab Region: A Scoping Review for an Evidence-Informed Research Agenda.

The Arab region is experiencing the largest youth cohort in its history. Parental influence is a clear factor in the well-being of this demographic. This scoping review serves as the first consolidated synthesis of existing research on parenting in the Arab world, aimed at identifying research gaps and informing future research agendas. Searches of 18 databases resulted in 4,758 records (1995-2018) in all languages. Using Arksey and O'Malley's methodological framework, eligible studies (n = 152) underwent duplicate data abstraction. An evidence gap map was developed using 3i.e.'s platform. Studies were mostly published in English (88%), and lead authors' affiliations were mostly from Arab institutions. Included studies were mostly cross-sectional (89%), quantitative (96%), conducted in a school/university (83%), and surveyed children and adolescents (70%). Most studies (79%) examined parenting influences on youth outcomes. Fewer examined parenting measurement (30%) or evaluated interventions (1%). Mental health and school performance were the most commonly investigated outcomes. The evidence gap map allows researchers who study youth in the Arab world to efficiently and visually delineate the gaps and strategically prioritize research needs. Future studies should employ robust mixed methods study designs, focus on evaluation and psychometric research, engage youth in the research process and explore a more diverse set of outcomes.

The "dirty work" of last responders: Occupational stigma risk and protective factors.

Last responders constitute an occupational category that includes all those who are involved in the postmortem care of deceased persons and their families. The work of last responders is often considered "dirty work" and, as a result, stigmatized. Last responders are aware of this stigma, and stigma consciousness has been associated with negative health outcomes. Despite the wide acknowledgment of stigma among last responders, specific risk, or protective factors for experiencing stigma have not been investigated. This paper aims to identify determinants of stigma among last responders in the United States. The data for this study were obtained from a national cross-sectional survey of last responders. The survey included a measure of stigma and multiple sociodemographic characteristics. A hurdle model was used to assess the association between the characteristics of last responders and their perceived stigma. Respondents were predominantly male (55.1%), White non-Hispanic (90.2%), and employed full-time (96%). Seventy-seven percent reported having experienced at least one form of occupation-related stigma. There was no significant association between the experience of stigma and any socio-demographic variables. The experience of stigma is nearly ubiquitous among last responders->75% of last responders in the sample experienced at least one form of stigma. Another aspect of its ubiquitous nature is the lack of evidence that stigma was experienced differentially across sex, race/ethnicity, employment type, and length of years as a last responder. Interventions are needed to decrease stigma among last responders and to support last responders in managing the consequences of the stigma they experience.

Community and Organizational Readiness to Adopt a Physical Activity Intervention in Micropolitan Settings.

BACKGROUND: Assessing community and organizational readiness is key to successfully implementing programs. The purpose of this study was to assess the baseline readiness of micropolitan communities to adopt an evidence-based physical activity (PA) intervention by exploring three dimensions: (1) attitudes and current efforts toward prevention, (2) community and organizational climate that facilitates (or impedes) change, and (3) capacity to implement change. METHOD: Data were collected from community leaders in 14 communities through an online survey in June 2021 (n = 149). Data were analyzed in aggregate using descriptive statistics for multiple-choice responses and content analysis for open ended responses. One-way repeated analyses of variance were used to compare mean score differences. RESULTS: In reference to their attitudes prior to the pandemic, respondents said that addressing PA was "somewhat a priority" in their professional positions (M = 2.01, SD = 0.94), their organizations (M = 2.08, SD = 0.91), and their communities (M = 2.28, SD = 0.88). Current PA efforts included statewide initiatives, community sponsored events/clubs, and youth sports leagues. The community climate included both PA facilitators (mainly outdoor PA resources) and barriers (cost, lack of social services, and an unsupportive PA environment). Individual-level capacity (M = 2.94; SD = 1.21) to adopt a PA program was regarded lower than the community's capacity (M = 3.95; SD = 0.82), and perceptions of capacity at the community level improved even more if technical assistance (M = 3.96; SD = 0.84) or financial support (M = 4.12; SD = 0.80) were provided. CONCLUSION: Readiness varied by dimension, suggesting the need for tailored implementation supports including technical assistance and financial support.

Ignored and distressed: a cross-sectional study of the impact of COVID-19 on last responders.

BACKGROUND: Last responders constitute an occupational category that includes all those that are involved in the postmortem care of deceased persons and their families. Last responders are exposed to several categories of work-related stressors that affect their health and well-being. COVID-19 exacerbated these stressors. Research to understand the consequences of COVID-19 on the health and wellbeing of last responders is nascent. This study aimed to assess COVID-19 related stress, coping and wellbeing among last responders in the United States. METHODS: We conducted a national cross-sectional survey of last responders in July through September of 2020. The survey measured wellbeing, stress, coping, and stigma; COVID-19 experiences, and socio-demographics. A ridge regression model was fit for the outcome variables. RESULTS: Analysis was conducted on 366 respondents from 43 states. Respondents were male (55.4%), age 50 + (57.4%), and White non-Hispanic (90.3%); 54% reported moderate-high stress and 41% endorsed mild-severe anxiety. Seventy-seven percent had experienced at least one form of stigma related to their occupation. Variables associated with higher perceived stress and anxiety included gender (female), shorter length of employment, perceiving a higher impact from COVID-19 on everyday life, and increased perceived stigma. CONCLUSIONS: Last responders are a critical part of the health care system. Throughout this pandemic, last responders have been frequently ignored and not prioritized for protection and support. Interventions to support last responders cope with stress, and to decrease anxiety are urgently needed. There is also a critical need to challenge community stigma towards last responders.

Conceptual framework for systemic capacity strengthening for health policy and systems research.

Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening.

Integrating user experience evaluation in the development of a web-based Community Engagement Toolkit.

Current advances in technology have allowed programs to become more innovative and provide web-based services and products for their participants. This requires evaluators to expand their evaluation repertoire to continue to provide useful and actionable information. Our study illustrates the application of user experience evaluation as part of the formative evaluation of the Community Engagement Toolkit (CETK), developed by the Network of the National Library of Medicine. The CETK is a website containing resources that help library staff deliver health-literacy programming more effectively. The overarching objective of the evaluation was to obtain in-depth feedback from potential users about the website design and content in order to make the toolkit user friendly and useful. We used an online video conferencing software to conduct contextual observations and interviews with geographically dispersed participants. Findings from the evaluation study indicated an overall favorable review of the toolkit's interface and navigation, but relatively less favorable review of content relevance and broad appeal for the participants. Feedback from the participants was used to inform the development of the toolkit to increase the likelihood of its use and value for intended users.

Does knowing about the long-term health effects of alcohol matter? Evidence from a university sample in Lebanon.

BACKGROUND: Research linking awareness of health effects of alcohol and harmful alcohol drinking status is limited. AIMS: To investigate the association between awareness of long-term alcohol effects and alcohol use disorders. METHODS: University students aged 18-25 years (n = 1155) completed a self-filled survey. Participants were asked if they knew that alcohol causes: (1) problems in the liver; (2) cancers of the mouth, throat, oesophagus and breast; (3) damage to the heart; and (4) weakening of the immune system. Multinomial regression analyses were conducted to assess the association between awareness of long-term alcohol effects and alcohol drinking status, including Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) alcohol use disorders. RESULTS: One third (32.8%) were past-year drinkers and 18% screened positive for DSM-5 alcohol use disorders. Compared to past-year drinkers with no alcohol use disorders, non-past-year ever drinkers were twice as likely to know about the link between alcohol and cancers of the mouth, throat, oesophagus and breast. Past-year drinkers with an alcohol use disorders were less likely to know about this association. Non-past-year ever drinkers (vs past-year drinkers with no alcohol use disorders) were also 2.6 times more likely to know the alcohol liver risks. CONCLUSIONS: There is a strong inverse relationship between awareness of the effects of alcohol and harmful consumption among young people, providing preliminary support for the protective nature of knowledge on alcohol drinking status. Efforts to increase public awareness of the long-term health effects of alcohol may be useful in reducing alcohol-related harm.

'When I smoked it, it was like a slap in the face but it felt really good': exploring determinants of midwakh use among young adults in Lebanon.

BACKGROUND: Dokha ('dizziness' in English) is a type of alternative tobacco product (ATP) increasing in popularity in the Arab world; and smoked in a pipe called a midwakh. Midwakh use is common among nationals in the United Arab Emirates (UAE); yet, evidence indicates its spread among expats in the UAE as well as beyond the UAE. Research on midwakh use is nascent, and no qualitative research has been published. This paper explored the context and determinants of midwakh use among young adults in Lebanon using qualitative methods. METHODS: We conducted four focus group discussions with 18 midwakh ever smokers aged 18-25 years in Lebanon. Discussions were recorded, transcribed and thematically analysed using the Pragmatics, Attraction, Communication, Expectations framework. RESULTS: 'Pragmatics' was evident in participants' comments about availability of a supply of dokha. For 'attraction', participants described why they prefer midwakh smoking and compared it to other ATPs. Regarding communication, participants shared terms used to describe their use of midwakh (eg, 'buzz'/taking a hit). Participants also described expectations from smoking midwakh, including stress relief. CONCLUSION: Midwakh smoking is appealing to young adults due to factors such as the 'buzz', perceived harm reduction, stress relief and its ability to satisfy nicotine craving with small amounts of tobacco. As a result, despite experiencing negative effects on first use, young adults choose to continue to use midwakh, and find it hard to quit. These results have implications for prevention and control of midwakh smoking among young adults. Framework Convention on Tobacco Control guidance documents to address ATPs are critically needed to prevent the global spread of yet another tobacco product.

"I Like to Try My Hardest to Keep My Small Family Together": Housing as a Key Resource for Academic Success of Pregnant and Parenting College-Aged Students.

Pregnant and/or parenting students (PPS) face unique challenges to attending college. The prevalence of housing insecurity may be higher among college PPS. Adding to the limited research in this area, our study explores how housing could be a barrier to attending and maintaining academic success in college for PPS. We partnered with a Midwestern community college (CC) to conduct the study, which consisted of (1) an environmental scan of in-state collegiate housing programs available to PPS, (2) an online survey among PPS attending the partner CC, and (3) key informant interviews with providers at agencies serving PPS and high school PPS planning to attend college. Eight of the 18 institutions we identified from our environmental scan offered family housing. Populations most often addressed were married students (56%), families (39%), and single parents (28%). Out of 22 responses from our online survey, about a third of PPS disagreed or strongly disagreed that they felt satisfied with housing support provided by the partnering CC and that housing options offered were family friendly. PPS perceived affordability, proximity to campus and to their children's school, on-site day care, and amenities as important aspects of housing. Key informant participants (n = 9 interviews) described social support, PPS-specific housing, and access to services as important to college attendance. Community college efforts to meet the needs of PPS must consider the unique barriers PPS face to finding affordable and stable housing. Collaborating with local agencies that offer services for PPS is one approach to ensuring their academic success.

Attitudes and practices of public health academics towards research funding from for-profit organizations: cross-sectional survey.

OBJECTIVES: The growing trend of for-profit organization (FPO)-funded university research is concerning because resultant potential conflicts of interest might lead to biases in methods, results, and interpretation. For public health academic programmes, receiving funds from FPOs whose products have negative health implications may be particularly problematic. METHODS: A cross-sectional survey assessed attitudes and practices of public health academics towards accepting funding from FPOs. The sampling frame included universities in five world regions offering a graduate degree in public health; 166 academics responded. Descriptive, bivariate, and logistic regression analyses were conducted. RESULTS: Over half of respondents were in favour of accepting funding from FPOs; attitudes differed by world region and gender but not by rank, contract status, % salary offset required, primary identity, or exposure to an ethics course. In the last 5 years, almost 20% of respondents had received funding from a FPO. Sixty per cent of respondents agreed that there was potential for bias in seven aspects of the research process, when funds were from FPOs. CONCLUSIONS: Globally, public health academics should increase dialogue around the potential harms of research and practice funded by FPOs.

Implementing Community-Based Participatory Research with Communities Affected by Humanitarian Crises: The Potential to Recalibrate Equity and Power in Vulnerable Contexts.

Worldwide, over 70.8 million people are forcibly displaced from their homes as a result of persecution, conflict, violence, or human rights violation. In humanitarian crises, protection and the provision of basic needs are often prioritized. Research may be seen as opportunistic. However, without documenting and researching humanitarian responses, knowledge is not shared and does not accumulate, limiting the application of evidence-based interventions where they are most needed. Research in humanitarian crises is complex, both ethically and methodologically. Community-engaged research, and specifically community-based participatory research (CBPR), can address some of the challenges of research in these settings. Using case studies of research we have conducted with communities affected by humanitarian crises, we highlight challenges and opportunities of the application of the ten core principles of CBPR in humanitarian settings. Despite some challenges and barriers, CBPR is a highly effective approach to use when engaging these populations in research. We argue that the application of CBPR in these settings has the potential to recalibrate the scales of equity and power among vulnerable populations.

'Most at risk' for COVID19? The imperative to expand the definition from biological to social factors for equity.

First recognized in December 2019, the Coronavirus Disease 2019 (COVID19) was declared a global pandemic by the World Health Organization on March 11, 2020. To date, the most utilized definition of 'most at risk' for COVID19 morbidity and mortality has focused on biological susceptibility to the virus. This paper argues that this dominant biomedical definition has neglected the 'fundamental social causes' of disease, constraining the effectiveness of prevention and mitigation measures; and exacerbating COVID19 morbidity and mortality for population groups living in marginalizing circumstances. It is clear - even at this early stage of the pandemic - that inequitable social conditions lead to both more infections and worse outcomes. Expanding the definition of 'most at risk' to include social factors is critical to implementing equitable interventions and saving lives. Prioritizing populations with social conditions is necessary for more effective control of the epidemic in its next phase; and should become standard in the planning for, and prevention and mitigation of all health conditions. Reversing disparities and health inequities is only possible through an expansion of our 'most-at-risk' definition to also include social factors.

The impact of DSM classification changes on the prevalence of alcohol use disorder and 'diagnostic orphans' in Lebanese college youth: Implications for epidemiological research, health practice, and policy.

BACKGROUND: Studies comparing prevalence of alcohol use disorder (AUD) using DSM-IV and DSM-5 diagnostic criteria in college students are limited. This study examines changes in AUD prevalence estimates using DSM-IV versus DSM-5 and characterizes the profile of DSM-5 "diagnostic orphans." METHODS AND FINDINGS: A college student sample (n = 1,155; mean age: 21 ±1.97) selected conveniently from six large private and public universities in Greater Beirut, Lebanon completed an anonymous survey in May 2016. The study response rate was 83.1%. Data on DSM-IV and DSM-5 AUD criteria were gathered from 582 past-year drinkers, of which 377 (65%) were screened to have DSM-IV abuse/dependence, and 203 (35%) to have any DSM-5 AUD (58% mild, 21% moderate, and 21% severe). Overall percent agreement between measures was 68% (kappa = 0.41). One hundred and ninety-one students met one DSM-5 AUD criterion only (i.e. "diagnostic orphans," herein DOs), of which the majority (82%) endorsed "hazardous use." Compared to past-year drinkers with zero-endorsed DSM-5 criteria, DOs were more likely to be aged 21 or above [OR = 1.57(1.21-2.03)], less likely to perceive their socioeconomic status (SES) as poorer vs. same as others [OR = 0.17(0.07-0.43)], more likely to drink 1-2 times/week vs. ≤3 times per month [OR = 2.24(1.44-3.49)], and more likely to report past-year cigarette smoking [OR = 2.16(1.10-4.24)]. When compared to past-year drinkers with DSM-5 AUD, DOs were more likely to be pursuing a graduate or medical degree (vs. undergraduate degree) [2.06 (1.09-3.89)], and to be living with parents most of the time vs. not [OR = 2.68(1.14-6.31)]. DOs (versus drinkers with AUD) were less likely to drink at a high frequency (3-4 times /week or more vs.≤3 times per month) [OR = 0.15(0.05-0.48)], and to report past-year waterpipe smoking [OR = 0.54(0.34-0.85)], but more likely to report past-year marijuana use [1.89(1.10-3.23)]. The findings are subject to recall bias and under-reporting and the study could not infer causality because temporality of associations cannot be established in a cross-sectional study design. CONCLUSIONS: DSM-IV abuse/dependence prevalence rate was higher than DSM-5 AUD prevalence mainly due to the high percentage of students who engaged in "hazardous use". The DO screen might capture a young person in transition between non-drinking/occasional drinking to drinking frequently/developing an AUD. The prevention, identification, and management of DOs may be critical components of a national alcohol harm-reduction policy.

Bullying Victimization and Use of Substances in High School: Does Religiosity Moderate the Association?

Alcohol, tobacco and other drug use continue to pose serious public health concerns among youth. Bullying victimization has been identified as a risk factor and religiosity a protective factor for adolescent substance use. No previous research has examined the potential moderating role of religiosity. We explore the association between bullying victimization and substance use in adolescents with low and high levels of religiosity. A cross-sectional survey was conducted with a representative sample of high school students in greater Beirut. Binary and multinomial logistic models were used, adjusting for demographics, and stratified by level of religiosity. Of the 986 students responding to the survey, 65% were females; 48% had experienced some form of bullying; and 52% self-rated as low in religiosity. Between 10 and 30% were current users of alcohol or tobacco. Students of lower religiosity levels who had been bullied were more likely to use substances than those who self-rated as high religiosity. Religiosity may be a potential moderator of the association between being bullied and substance use, but the exact mechanisms and underlying reasons need further investigation.