Psychosocial impacts of Baby Friendly Spaces for Rohingya refugee mothers in Bangladesh: A pragmatic cluster-randomized controlled trial.

Background: This study evaluated the effectiveness of Baby Friendly Spaces (BFS), a psychosocial support program for Rohingya refugee mothers of malnourished young children in Bangladesh. Because BFS was already being implemented, we examined the benefit of enhancing implementation supports. Methods: In matched pairs, 10 sites were randomized to provide BFS treatment as usual (BFS-TAU) or to receive enhanced implementation support (BFS-IE). 600 mothers were enrolled and reported on maternal distress, functional impairment, subjective well-being and coping at baseline and 8-week follow-up. Data were analyzed using multilevel linear regression models to account for clustering; sensitivity analyses adjusted for the small number of clusters. Results: Significant within-group improvements in BFSIE were observed for distres (-.48, p = .014), functional impairment (-.30, p = .002) and subjective well-being (.92, p = .011); improvements in BFS-TAU were smaller and not statistically significant. Between-group comparisons favored BFS-IE for distress (ß = -.30, p = .058) and well-being (ß = .58, p = .038). Sensitivity adjustments produced p-values above .05 for all between-group comparisons. Discussion: Feasible adjustments to implementation can improve program delivery to increase impact on maternal distress and well-being. Although results should be interpreted with caution, study design limitations are common in pragmatic, field-based research.

Psychosocial support interventions in the context of forced displacement: A systematic review and meta-analysis.

Background: Forced displacement is associated with elevated risk for poor psychosocial wellbeing, yet there remains a lack of clarity around the effectiveness of commonly implemented psychosocial support interventions focused on preventing disorder and promoting wellbeing. This study aimed to synthesize the literature on evaluations of psychosocial support interventions for populations affected by forced displacement. Methods: We searched for peer reviewed and gray literature in seven databases (PubMed, Embase, Global Health, CINAHL, SocIndex, PsychInfo, PILOTS), fifteen organizational websites, and via solicitation through multiple networks. Various study designs were included, with the criteria that they report an evaluation of a psychosocial intervention delivered to populations affected by forced displacement, and included quantitative or qualitative data on psychosocial outcomes. Records were screened independently by two reviewers at both title/abstract and full-text review; data was double-extracted and study quality assessed, with discrepancies resolved by consensus. Meta-analyses for seven outcomes were conducted on a subset of 33 studies. Results: We identified 162 reports. Over half (55%) used a single-group study design, with fewer using non-random (19%) or randomized (21%) comparisons. Study designs incorporating comparison conditions were less likely to report positive findings than single-group studies. In the meta-analyses, a moderately strong overall effect was found for psychosocial wellbeing (ES: -0.534, 95% CI: [-0.870, -0.197], p=.005); small effects on both internalizing (ES: -0.152, 95% CI: [-0.310, 0.005], p= .057) and externalizing (ES: -0.249, 95% CI: [-0.515, 0.016], p=.064) problems were promising but not conclusive. Subgroup analysis suggested differential impacts on internalizing problems for adults (improvement; ES: -0.289, 95% CI: [-0.435, -0.143], p=.001) and children (worsening; ES: 0.129, 95% CI: [.054, 0.204], p=.002). Other subgroup analyses showed little meaningful variation by context, population, or intervention characteristics. Conclusion: Pragmatic, field-driven program evaluations are dominated by single-group designs with significant risk of bias. Findings from controlled studies are promising but highlight a need for more rigorous research to support causal inference, align outcomes with theories of change, improve measurement of more positive or wellbeing-focused outcomes, examine subgroup differences, and report potentially negative impacts.

School-based MHPSS interventions in humanitarian contexts: a realist review.

OBJECTIVE: The aim of this review is to elucidate the characteristics of school-based mental health and psychosocial support (MHPSS) interventions in humanitarian contexts and the hypothesised mechanisms by which they influence well-being or learning outcomes. METHODS: We conducted a realist review and searched PubMed, Embase, Global Health, CINAHL, PsychInfo, PILOTS and grey literature through January 2022. Eligible studies included children age 6-12 years, were conducted in humanitarian contexts in low-income or middle-income countries, and focused on universal MPHSS prevention in an educational setting, using any study design. Data were extracted and analysed using narrative synthesis and realist analysis techniques to create 'context-mechanism-outcome' configurations that were iteratively developed to modify, refine and substantiate programme theories. RESULTS: Twenty-seven articles, representing 19 studies, were included in the review. We analysed data from 26 articles. Eleven evidenced-informed programme theories were developed at the levels of the child (n=4), teacher (n=3), caregiver (n=2), school environment (n=1) and school managers/administrators (n=1). At the child level, mechanisms related to strengthening coping skills, emotion regulation, interpersonal relationships led to improved psychosocial well-being or learning outcomes. At the teacher level, coping skills and the provision of support to students were linked to psychosocial well-being and learning outcomes. At the caregiver level, strengthening interpersonal bonds trigger improved psychosocial well-being, and at the school environment level, fostering feelings of security was linked to psychosocial well-being and learning outcomes. We did not find any evidence supporting the programme theory at the school managers/administrators level. We found limited evidence of positive impacts of the included interventions to support these programme theories. CONCLUSIONS: These programme theories are a promising start towards ensuring school-based MHPSS interventions in humanitarian contexts better address the well-being and learning needs of children. Future research is needed to support these programme theories and enhance the evidence base.

Efficacy of the Common Elements Treatment Approach (CETA) for Unhealthy Alcohol Use Among Adults with HIV in Zambia: Results from a Pilot Randomized Controlled Trial.

This randomized controlled trial tested the efficacy of a multi-session, evidence-based, lay counselor-delivered transdiagnostic therapy, the Common Elements Treatment Approach (CETA), in reducing unhealthy alcohol use and comorbidities among persons living with HIV (PLWH) in Zambia. Adult PLWH with (a) unhealthy alcohol use plus mental health or substance use comorbidities, or (b) severe unhealthy alcohol use were randomized to receive a single-session alcohol brief intervention (BI) alone or BI plus referral to CETA. Outcomes were measured at baseline and a 6-month follow-up and included Alcohol Use Disorders Identification Test (AUDIT) score (primary), depression and trauma symptoms, and other substance use (secondary). We enrolled 160 participants; 78 were randomized to BI alone and 82 to BI plus CETA. Due to COVID-19, the trial ended early before 36 participants completed. Statistically and clinically significant reductions in mean AUDIT score from baseline to 6-month follow-up were observed in both groups, however, participants assigned to BI plus CETA had significantly greater reductions compared to BI alone (- 3.2, 95% CI - 6.2 to - 0.1; Cohen's d: 0.48). The CETA effect size for AUDIT score increased in line with increasing mental health/substance use comorbidity (0 comorbidities d = 0.25; 1-2 comorbidities d = 0.36; 3+ comorbidities d = 1.6). Significant CETA treatment effects were observed for depression, trauma, and several other substances. BI plus referral to CETA was feasible and superior to BI alone for unhealthy alcohol use among adults with HIV, particularly among those with comorbidities. Findings support future effectiveness testing of CETA for HIV outcomes among PLWH with unhealthy alcohol use.Clinical Trials Number: NCT03966885.

The end of the trial: Perspectives on cognitive processing therapy from community-based providers in the Democratic Republic of Congo.

Despite calls forincreased mental health programming in low-resource and humanitarian contexts and effectiveness trials of psychotherapy in these settings, little research exists on the extent to which providers and recipients continue to practice skills learned during trials of these programs. To understand if and how providers continued to use mental health intervention skills without ongoing institutional support following the completion of randomized controlled trials (RCTs), we analyzed data from semistructured interviews with six of seven providers who participated in an RCT of cognitive processing therapy (CPT) in the Democratic Republic of Congo 7 years prior. Provider interviews revealed continued knowledge of and, in some cases, the practice of core CPT skills as well as efforts to keep meeting with women in the community and a strong desire to learn new skills. Although financial limitations sometimes prohibited providers from formally convening CPT groups with women in need, participants maintained knowledge and skill use. Providers also reported feeling more valued in their communities, and they continued providing services beyond the planned intervention period despite a lack of ongoing support. In addition, participants described a strong desire to continue psychosocial interventions for trauma and learn more about this type of intervention. Reframing the evaluation of psychological interventions as program development and maintaining a strong working relationship with community partners may allow for increased sustainability of mental health services beyond the end of academic research studies in low-resource contexts.

Reliability and validity of a perinatal depression screening instrument in rural Mali.

Background: In order to reduce the burden of perinatal depression in low- and middle-income countries, health systems must be able to identify and treat women suffering from depression. The objective of our study was to develop a locally valid and reliable screening instrument for use in identifying pregnant women and mothers of young children with a local depression syndrome, dusukasi, in rural Mali. Methods: We administered a locally adapted screening instrument containing items from the Edinburgh Postpartum Depression Scale (EPDS) and Hopkins Symptom Checklist (HSCL-25) to 180 pregnant women and mothers of children under age 2 in Sélingué, Mali to assess the instrument's psychometric properties and validity. Item Response Theory was used to develop an abbreviated version of the measure and the validity and psychometric properties of this shortened version were compared with the full-length scale. Results: The full 28-item scale exhibited a single factor structure with good internal consistency (Cronbach's alpha = 0.92). Women who self-identified as suffering from dusukasi (n = 87) in a known groups analysis to assess construct validity had significantly higher depression and anxiety symptom scores (p < 0.0001) and functional impairment scores (p < 0.0001) compared to women not reporting dusukasi (n = 93). The shortened 16-item scale performed as well as the full scale in identifying women with dusukasi. Conclusions: Construct validity of our adapted screening instrument was supported for identifying dusukasi in rural Malian women. Our methodology can be applied in other settings to develop similarly valid screening instruments for perinatal depression.

Measuring sexual violence stigma in humanitarian contexts: assessment of scale psychometric properties and validity with female sexual violence survivors from Somalia and Syria.

BACKGROUND: Valid measures of sexual violence stigma that can be readily incorporated into program monitoring and evaluation systems are needed to strengthen gender-based violence (GBV) services in humanitarian emergencies. This study sought to assess the psychometric properties, construct validity, and measurement invariance of sexual violence stigma scales among female Somali GBV survivors in Kenya and Syrian GBV survivors in Jordan to identify an abbreviated scale that could be used across humanitarian contexts. METHODS: We administered measures of sexual violence stigma to 209 female survivors of sexual violence aged 15 and older in Kenya and Jordan. Exploratory factor analysis was used to assess the underlying latent structure, and Item Response Theory was used to estimate item difficulty and discrimination parameters to guide efforts to shorten the scales. Differential item functioning (DIF) by site was assessed using Multiple Indicators, Multiple Causes models. Construct validity of the sexual violence stigma scales was assessed by estimating correlations with functional impairment, depression, and disability. RESULTS: The sexual violence stigma measure exhibited distinct factor structures among Somali and Syrian GBV survivors. Among Somali survivors, a two-factor model with separate felt (10 items) and enacted (4 items) stigma constructs was identified, with scales for both domains exhibiting good internal consistency (Cronbach's alpha = 0.93 and 0.88, respectively). In Jordan, a single factor solution was uncovered for a 15-item stigma scale with good internal consistency (alpha = 0.86). The shortened core sexual stigma scale consisting of the 4 items that did not exhibit DIF had a Cronbach's alpha of 0.82 in Kenya and 0.81 in Jordan. The felt stigma scale in Kenya, the full stigma scale in Jordan, and abbreviated core stigma scales in both countries were meaningfully correlated with depression, while correlations with functional impairment were weaker and inconsistent across scales. CONCLUSIONS: An abbreviated core set of invariant perceived and internalized sexual violence stigma items demonstrated evidence of construct validity in two diverse settings. The ability of this measure to be efficiently administered as a part of routine program monitoring and evaluation activities, with the potential addition of items from a measurement bank to improve contextual relevance, can facilitate improvements in the delivery and quality of gender-based violence programs in humanitarian emergencies.

Feasibility of implementing a culturally adapted Prolonged Grief Disorder scale in the mental healthcare system in Nepal.

BACKGROUND: Nepali widows have a high prevalence of mental disorders, including prolonged grief disorder (PGD). Despite the considerable needs that Nepali widows have for mental health services, resources for mental health in Nepal are limited, amplifying the importance of accurate screening and diagnosis. The objective of this study was to explore the feasibility of implementing a culturally adapted Prolonged Grief Scale (PG-12/17-N) and provide actionable recommendations for its implementation. METHODS: Twenty-five mental health service providers in Kathmandu and Chitwan, Nepal were interviewed using a semi-structured guide based on selected constructs from the Consolidated Framework for Implementation Research. Qualitative data were inductively and deductively coded and analyzed to identify prominent themes. RESULTS: Providers reported that the main advantages of the scale were the need to identify widows at risk, cultural relevance, easy language, and inclusion of detailed and specific symptoms. Perceived weaknesses included the complexity in response options and scoring, length, item redundancy, overlap with depression symptoms, and lack of somatic symptoms. Providers discussed the need for training, supervision, and a referral and detection system required to implement the scale in Nepal. Further development of a brief version of the scale as a routine screener may facilitate detection and referral to care. CONCLUSION: Based on the results showing need to address PGD in Nepali widows, further efforts are needed to increase awareness about PGD and develop evidence-supported treatments for PGD, after which screening could be made routine for widows.

Integrating Mental Health into Maternal Health Care in Rural Mali: A Qualitative Study.

INTRODUCTION: Common perinatal mental disorders are prevalent in low- and middle-income countries. The gap between the need for and availability of mental health services, also known as the mental health treatment gap, is particularly acute for women during the perinatal period in rural Mali. This qualitative study aimed to identify a feasible and acceptable integrated care approach for the provision of maternal mental health care in rural Mali to help narrow the treatment gap and increase access to care. METHODS: From April to June 2016, qualitative data were collected in the Sélingué health district and Bamako, Mali. In-depth interviews were conducted among women, community health workers, midwives, and mental health specialists. Focus group participants included community health workers, midwives, and an obstetric nurse. All data were inductively coded and analyzed using a thematic analysis approach. RESULTS: Women described several coping strategies to manage their distress, including visiting their parents; confiding in a friend, relative, or community health worker; and participating in women's association groups. Mental health-related stigma was described as being widespread in the community and among health providers. In response to the lack of mental health services, midwives and community health workers supported the feasibility and acceptability of the integration of mental health services into maternal health services. Midwives were discussed as being key providers to conduct mental health screenings and provide initial psychosocial care for women. DISCUSSION: Integrated maternal and mental health interventions are needed to narrow the gap between the need for and availability of mental health services in rural Mali. Findings from this study underscore the great need for mental health services for women in the perinatal period who reside in rural Mali and that it is both feasible and acceptable to integrate mental health screening and low-level psychosocial care into antenatal care, delivered by midwives.

Measurement of violence against women and disability: protocol for a scoping review.

INTRODUCTION: Violence against women is a serious threat to women's health and human rights globally. Disability has been associated with increased risk of exposure to different forms of violence, however, there are questions concerning how best to measure this association. Research on understanding the association between violence and disability among women has included incorporating short disability measures into violence against women prevalence surveys. The potential to improve understanding of interconnections between violence and disability by measuring violence within disability-focused research is underexplored. The scoping review described here focuses on three areas of measurement of violence against women and disability: (1) measurement of violence within the context of disability-focused research, (2) measurement in research focused on the intersection of disability and violence and (3) measurement of disability in the context of research focused on violence against women. Specifically, we aim to map definitions, measures and methodologies in these areas, globally. METHODS AND ANALYSIS: For our scoping review, we will conduct searches for quantitative studies of disability-focused research which use measures of violence against women, and measures of disability in research focused on violence against women, in 11 online databases. Two authors will independently review titles and abstracts retrieved through the search strategy. We will search for grey literature, search the websites of National Statistics Offices for all countries to identify any national or subnational disability research and consult with experts for input. Data extraction will be conducted independently by one author and reviewed by another author, and data will be analysed and synthesised using a thematic synthesis approach. ETHICS AND DISSEMINATION: Ethics approval was not sought as no primary data is being collected. Findings will be disseminated through a publication in a peer-reviewed journal, through coordinated dissemination to researchers, practitioners, data users and generators and through various working groups and networks on violence against women and disability.

Violence against older women: A systematic review of qualitative literature.

The majority of the existing evidence-base on violence against women focuses on women of reproductive age (15-49), and globally there is sparse evidence concerning patterns of and types of violence against women aged 50 and older. Improved understanding of differing patterns and dynamics of violence older women experienced is needed to ensure appropriate policy or programmatic responses. To address these gaps in the evidence, we conducted a systematic review of qualitative literature on violence against older women, including any form of violence against women, rather than adopting a specific theoretical framework on what types of violence or perpetrators should be included from the outset, and focusing specifically on qualitative studies, to explore the nature and dynamics of violence against older women from the perspective of women. Following pre-planned searches of 11 electronic databases, two authors screened all identified titles, abstracts and relevant full texts for inclusion in the review. We extracted data from 52 manuscripts identified for inclusion, and conducted quality assessment and thematic synthesis from the key findings of the included studies. Results indicated that the vast majority of included studies were conducted in high-income contexts, and did not contain adequate information on study setting and context. Thematic synthesis identified several central themes, including the intersection between ageing and perceptions of, experiences of and response to violence; the centrality of social and gender norms in shaping older women's experiences of violence; the cumulative physical and mental health impact of exposure to lifelong violence, and that specific barriers exist for older women accessing community supports and health services to address violence victimization. Our findings indicated that violence against older women is prevalent and has significant impacts on physical and mental well-being of older women. Implications for policy and programmatic response, as well as future research directions, are highlighted.

Common Elements Treatment Approach (CETA) for unhealthy alcohol use among persons with HIV in Zambia: Study protocol of the ZCAP randomized controlled trial.

AIMS: Prevalence of unhealthy alcohol use and co-occurring mental health problems is high among persons living with HIV (PLWH) in sub-Saharan Africa (SSA). Yet, there is a dearth of evidence-based treatment options that can address both unhealthy alcohol use and comorbidities in SSA HIV care settings. Recent studies testing single-session alcohol brief interventions (BIs) among PLWH in SSA have suggested that more robust treatments are needed. This paper describes the protocol of a pilot randomized controlled superiority trial that will test the effectiveness of an evidence-based transdiagnostic multi-session psychotherapy, the Common Elements Treatment Approach (CETA), compared to a control condition consisting of a single session brief alcohol intervention (BI) based on CETA, at reducing unhealthy alcohol use, mental health problems, and other substance use among PLWH in urban Zambia. METHODS: The study is a single-blind, parallel, individually randomized trial conducted in HIV treatment centers in Lusaka. 160 PLWH who meet criteria for unhealthy alcohol use + mental health or substance use comorbidities and/or have a more severe alcohol use disorder are eligible. Participants are randomized 1:1 to receive the single-session BI or CETA. Outcomes are assessed at baseline and a six-month follow-up and include unhealthy alcohol use, depression, trauma symptoms, and other substance use. CONCLUSIONS: The trial is a first step in establishing the effectiveness of CETA at reducing unhealthy alcohol use and comorbidities among PLWH in SSA. If effectiveness is demonstrated, a larger trial featuring long-term follow-ups and HIV treatment outcomes will be undertaken.

Characterising the relationship between migration and stigma affecting healthcare engagement among female sex workers in Lomé, Togo.

Migration in West Africa is common and complicates the sustained delivery of comprehensive HIV care programmes for those with specific vulnerabilities to HIV, including female sex workers (FSW). This study evaluated whether migration potentiates the burden of stigma affecting FSW in Lomé, Togo. Respondent driven sampling identified 354 FSW who completed HIV testing and a questionnaire. Multivariable logistic regression was used to identify factors associated with stigma among FSW. Among study participants, 76.3% (270/354) were migrants, with 30.2% (107/354) reporting stigma. Migrant FSW were less likely to report stigma (aOR 0.40; 95% CI:0.22-0.73). FSW who had an abortion (aOR 3.40; 95% CI:1.79-6.30) and were tested for a sexually transmitted infection (STI) or HIV (aOR 2.03; 95% CI:1.16-3.55) were more likely to report stigma. Among FSW, 59.8% (211/353) disclosed selling sex to a health worker. Disclosure was more common among FSW who had been tested for an STI or HIV (36.7%; 77/210), or both (55.7%; 117/210), and resulted in an attenuated but significant association between STI or HIV testing and stigma, indicating that disclosure partially mediated the relationship. These results highlight the need to mitigate healthcare-related stigma affecting FSW, while also considering decentralised HIV testing approaches, including HIV self-testing.

Violence against older women: a protocol for a systematic review of qualitative literature.

INTRODUCTION: There is sparse evidence globally concerning patterns of and types of violence against women aged 50 and older. Improved understanding of older women's experiences of violence, including types of violence, perpetrators and health impacts, is needed to address evident gaps in the literature, address requirements for monitoring and reporting on global sustainable development goal indicators, and inform policy and programming for preventing and responding to violence against older women. The aim of the systematic review is to identify, evaluate and synthesise qualitative studies from all countries, exploring violence against women aged 50 and above, identifying types and patterns of violence, perpetrators of violence and impacts of violence on various health outcomes for older women. METHODS AND ANALYSIS: A systematic search for qualitative studies of violence against older women will be conducted in the following databases: PubMed, PsycINFO, Embase, CINAHL, PILOTS, ERIC, Social Work Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, ProQuest Criminal Justice and Dissertations and Theses Global. Studies will be focused on violence against older women (aged 50 and above), using qualitative methodology, exploring women's experiences of any type of violence perpetrated by any type of perpetrator. Two authors will independently review titles and abstracts retrieved through the search strategy. Data extraction will be conducted independently by one author and quality assessment will be conducted by two authors, using an adapted version of the Critical Appraisal Skills Programme scale. Data will be analysed and synthesised using a thematic synthesis approach. ETHICS AND DISSEMINATION: Ethics approvals are not required as primary data are not being collected. Findings will be disseminated through a publication in a peer-reviewed journal and used to inform development of a module to measure violence against older women, for use in specialised violence against women surveys. PROSPERO REGISTRATION NUMBER: CRD42019119467.

Author Correction to: Dusukasi-The Heart That Cries: An Idiom of Mental Distress Among Perinatal Women in Rural Mali.

The original version of this article unfortunately contained a mistake in the author name.

Dusukasi-The Heart That Cries: An Idiom of Mental Distress Among Perinatal Women in Rural Mali.

Perinatal mental health problems such as depression and anxiety are prevalent in low and middle-income countries. In Mali, the lack of mental health care is compounded by few studies on mental health needs, including in the perinatal period. This paper examines the ways in which perinatal women experience and express mental distress in rural Mali. We describe a process, relying on several different qualitative research methods, to identify understandings of mental distress specific to the Malian context. Participants included perinatal women, maternal health providers, and community health workers in rural southwest Mali. Participants articulated several idioms of distress, including gèlèya (difficulties), tôôrô (pain, suffering), hamin (worries, concerns), and dusukasi (crying heart), that occur within a context of poverty, interpersonal conflict, and gender inequality. These idioms of distress were described as sharing many key features and operating on a continuum of severity that could progress over time, both within and across idioms. Our findings highlight the context dependent nature of experiences and expressions of distress among perinatal women in Mali.

Migration and Mental Health in Low- and Middle-Income Countries: A Systematic Review.

OBJECTIVE: Rural-to-urban migration within low- and middle-income countries (LMICs), and migration from one LMIC to another, are prevalent forms of international migration. Migration may be associated with adverse mental health outcomes. The aim of the current study is to systematically review the literature on migration and mental health between and within LMICs. METHODS: This systematic review of PubMed, PsycINFO, Embase, Web of Science, and PILOTS, identified 2,818 total records published between 1991 and 2016, with 139 of these assessed for eligibility. Two authors reviewed full text to assess if they met inclusion criteria, extracted data, and applied a quality assessment to all included studies. RESULTS: The search identified 37 articles that met the inclusion criteria, based on 28 separate studies. All studies apart from one were cross-sectional studies, and studies utilized a range of sampling methods. In all, 19 of these studies were conducted in China. Studies addressed a range of mental health outcomes, and variation in prevalence was reported. Research questions addressed determinants of mental health outcomes, including analysis of risk and protective factors, such as social, cultural, and economic determinants; migration-related risk factors; and substance use. CONCLUSIONS: Limitations in study design and methodological rigor of studies indicate a limited evidence base concerning migration and mental health in LMICs. Expansion of research to different regions, utilization of adapted and validated measurement instruments, and longitudinal research could significantly strengthen the evidence base.

System dynamics-based evaluation of interventions to promote appropriate waste disposal behaviors in low-income urban areas: A Baltimore case study.

Inappropriate waste disposal is a serious issue in many urban neighborhoods, exacerbating environmental, rodent, and public health problems. Governments all over the world have been developing interventions to reduce inappropriate waste disposal. A system dynamics model is proposed to quantify the impacts of interventions on residential waste related behavior. In contrast to other models of municipal solid waste management, the structure of our model is based on sociological and economic studies on how incentives and social norms interactively affect waste disposal behavior, and its parameterization is informed by field work. A case study of low-income urban neighborhoods in Baltimore, MD, USA is presented. The simulation results show the effects of individual interventions, and also identify positive interactions among some potential interventions, especially information and incentive-based policies, as well as their limitations. The model can help policy analysts identify the most promising intervention packages, and then field test those few, rather than having to pilot test all combinations. Sensitivity analyses demonstrate large uncertainties about behavioral responses to some interventions, showing where information from survey research and social experiments would improve policy making.

Breastfeeding versus formula-feeding and girls' pubertal development.

To examine the association of breastfeeding or its duration with timing of girls' pubertal onset, and the role of BMI as a mediator in these associations. A population of 1,237 socio-economically and ethnically diverse girls, ages 6-8 years, was recruited across three geographic locations (New York City, Cincinnati, and the San Francisco Bay Area) in a prospective study of predictors of pubertal maturation. Breastfeeding practices were assessed using self-administered questionnaire/interview with the primary caregiver. Girls were seen on at least annual basis to assess breast and pubic hair development. The association of breastfeeding with pubertal timing was estimated using parametric survival analysis while adjusting for body mass index, ethnicity, birth-weight, mother's education, mother's menarcheal age, and family income. Compared to formula fed girls, those who were mixed-fed or predominantly breastfed showed later onset of breast development [hazard ratios 0.90 (95 % CI 0.75, 1.09) and 0.74 (95 % CI 0.59, 0.94), respectively]. Duration of breastfeeding was also directly associated with age at onset of breast development (p trend = 0.008). Associations between breastfeeding and pubic hair onset were not significant. In stratified analysis, the association of breastfeeding and later breast onset was seen in Cincinnati girls only. The association between breast feeding and pubertal onset varied by study site. More research is needed about the environments within which breastfeeding takes place in order to better understand whether infant feeding practices are a potentially modifiable risk factor that may influence age at onset of breast development and subsequent risk for disease in adulthood.