Exploring barriers to using modern contraceptives and accessing safe abortion care in women who terminated unintended pregnancies in Southern Ethiopia.

BACKGROUND: Unsafe abortion is a major medical and public health problem in Ethiopia and contributes significantly to abortion-related morbidity and mortality in the country. We explored women's experiences with modern contraceptives and identified barriers to accessing safe abortion care and other sexual and reproductive health services. METHODS: We recruited participants from six health clinics and a public hospital in southern Ethiopia. We conducted one-on-one interviews with 34 women aged 18-49 years who sought abortion care within the past twelve months of the study. Interviews were recorded, transcribed verbatim, translated to English, and imported into Dedoose software. We analysed the data using a directed content analysis. RESULTS: Our findings show prevailing belief among participants that contraceptives caused infertility, abnormalities in subsequent pregnancies, and other side effects. Some of the women suggested that medical or unsafe abortions were a better alternative to using modern contraceptives for terminating unplanned pregnancies. Barriers to accessing safe abortion care included costs of services, lack of privacy, and fear of judgment from providers. Women who had negative experiences with providers were more likely to seek unsafe abortion the second time around. CONCLUSION: Providers need to address women's concerns about using modern contraceptives, educate their clients about the best ways to prevent unwanted pregnancies, and provide non-judgemental services. In addition, comprehensive counselling services that include contraceptive counselling should be made available to women before, during, and after abortion care. Finally, providers should strive to be facilitators of, not barriers to, safe abortion care.

The Field Epidemiology Training Program's Contribution to Essential Public Health Functions in Seven National Public Health Institutes.

Objective: This study explores how Field Epidemiology Training Programs (FETP) whose National Public Health Institutes (NPHI) are supported by U.S. Centers for Disease Control and Prevention (CDC) have contributed to strengthening essential public health functions. Methods: We conducted 96 semi-structured interviews with public health experts including NPHI staff, non-NPHI government staff, and staff from non-governmental and international organizations in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda, and Zambia. We managed data using MAXQDA and employed direct content analysis to derive themes. Results: Three overarching themes emerged in relation to FETPs' role within the NPHIs' public health functions. These themes included contribution to improving country surveillance systems, role in providing leadership in outbreak responses, and strengthening countries' and the NPHIs' surveillance workforce capacity. Participants also shared challenges around FETPs' implementation and suggestions for improvement. Conclusion: The results demonstrate the value of FETPs in strengthening public health systems through building workforce capacity and improving surveillance systems. By identifying the successes of FETPs in contributing to essential public health functions, our findings might inform current and future FETP implementation and its integration into NPHIs.

Evaluation of Ethiopia's field epidemiology training program - frontline: perspectives of implementing partners.

BACKGROUND: Field Epidemiology Training Program (FETP) has been adopted as an epidemiology and response capacity building strategy worldwide. FETP-Frontline was introduced in Ethiopia in 2017 as a three-month in-service training. In this study, we evaluated implementing partners' perspectives with the aim of understanding program effectiveness and identifying challenges and recommendations for improvement. METHODS: A qualitative cross-sectional design was utilized to evaluate Ethiopia's FETP-Frontline. Using a descriptive phenomenological approach, qualitative data were collected from FETP-Frontline implementing partners, including regional, zonal, and district health offices across Ethiopia. We collected data through in-person key informant interviews, using semi-structured questionnaires. Thematic analysis was conducted, assisted with MAXQDA, while ensuring interrater reliability by using the consistent application of theme categorization. The major themes that emerged were program effectiveness, knowledge and skills differences between trained and untrained officers, program challenges, and recommended actions for improvement. Ethical approval was obtained from the Ethiopian Public Health Institute. Informed written consent was obtained from all participants, and confidentiality of the data was maintained throughout. RESULTS: A total of 41 interviews were conducted with key informants from FETP-Frontline implementing partners. The regional and zonal level experts and mentors had a Master of Public Health (MPH), whereas district health managers were Bachelor of Science (BSc) holders. Majority of the respondents reflected a positive perception towards FETP-Frontline. Regional and zonal officers as well as mentors mentioned that there were observable performance differences between trained and untrained district surveillance officers. They also identified various challenges including lack of resources for transportation, budget constraints for field projects, inadequate mentorship, high staff turnover, limited number of staff at the district level, lack of continued support from stakeholders, and the need for refresher training for FETP-Frontline graduates. CONCLUSIONS: Implementing partners reflected a positive perception towards FETP-Frontline in Ethiopia. In addition to scaling-up the program to reach all districts to achieve the International Health Regulation 2005 goals, the program also needs to consider addressing immediate challenges, primarily lack of resources and poor mentorship. Continued monitoring of the program, refresher training, and career path development could improve retention of the trained workforce.

Benefits and challenges of consolidating public health functions into a National Public Health Institute: a policy analysis

National Public Health Institutes (NPHIs) around the world vary in composition. Consolidated organizational models can bring together critical functions such as disease surveillance, emergency preparedness and response, public health research, workforce development and laboratory diagnosis within a single focal point. This can lead to enhanced coordination and management of resources and enable more efficient and effective public health operations. We explored stakeholders' perceptions about the benefits and challenges of consolidating public health functions in an NPHI in seven countries where the US Centers for Disease Control and Prevention has supported NPHI establishment and strengthening. From August 2019 through January 2020, we interviewed a total of 96 stakeholders, including NPHI staff (N = 43), non-NPHI government staff (N = 29) and non-governmental and international organization staff (N = 24) in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. We conducted a policy analysis using Tea Collins's health policy analysis framework to assess various possible options for coordinating public health functions and their likely effectiveness. The findings can be used by policymakers as they consider public health infrastructure. We found that consolidating functions in an NPHI, to the extent politically and organizationally feasible, promotes efficiency, flexibility and coordination, as well as supports data-driven health recommendations to government decision makers. Countries pursuing NPHI establishment can weigh the potential challenges and benefits of consolidating functions when determining which public health functions will comprise the NPHI, including clarity of role, access to resources, influence over decisions and political viability.

Benefits and challenges of consolidating public health functions into a National Public Health Institute: a policy analysis.

National Public Health Institutes (NPHIs) around the world vary in composition. Consolidated organizational models can bring together critical functions such as disease surveillance, emergency preparedness and response, public health research, workforce development and laboratory diagnosis within a single focal point. This can lead to enhanced coordination and management of resources and enable more efficient and effective public health operations. We explored stakeholders' perceptions about the benefits and challenges of consolidating public health functions in an NPHI in seven countries where the US Centers for Disease Control and Prevention has supported NPHI establishment and strengthening. From August 2019 through January 2020, we interviewed a total of 96 stakeholders, including NPHI staff (N = 43), non-NPHI government staff (N = 29) and non-governmental and international organization staff (N = 24) in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. We conducted a policy analysis using Tea Collins's health policy analysis framework to assess various possible options for coordinating public health functions and their likely effectiveness. The findings can be used by policymakers as they consider public health infrastructure. We found that consolidating functions in an NPHI, to the extent politically and organizationally feasible, promotes efficiency, flexibility and coordination, as well as supports data-driven health recommendations to government decision makers. Countries pursuing NPHI establishment can weigh the potential challenges and benefits of consolidating functions when determining which public health functions will comprise the NPHI, including clarity of role, access to resources, influence over decisions and political viability.

Becoming Secondary Survivors: Exploring the Effects of Conflict-Related Sexual Violence on the Health and Well-Being of Families in Northern Uganda.

The enduring consequences of conflict-related sexual violence (CRSV) and its catastrophic effects on the health and well-being of survivors has been well documented. However, there is a dearth of evidence on the impact of CRSV on families of survivors who care for them. The aim of this study was to explore the ripple effects of CRSV on families of survivors living in three post-conflict districts in northern Uganda: Gulu, Lira, and Pader. We present emerging themes from qualitative interviews with 22 family members including parents, siblings, and partners. Interviews were recorded, transcribed verbatim, translated to English, and imported into MAXQDA Analytics Pro 12. We used a modified approach to grounded theory to analyze the data. Our findings show that family members faced multiple challenges as a result of their indirect exposure to survivors that were abducted by the Lord's Resistance Army. These included negative impacts on their relationship with the survivor, secondary traumatic stress, stigma, and challenges with caring for children born in captivity. Participants also shared coping mechanisms they used to mitigate psychological distress, including focusing on their faith, seeking support from social connections, and memory repression. The interviews revealed that most female participants did not seek formal care because they feared stigma and did not think it would be available for individuals not directly affected by sexual violence. Our findings point to the importance of moving beyond a narrow focus on the impact of CRSV on survivors and health care workers to a broader view of understanding the effects on families, and designing interventions that address their needs. Integrating care for families and other informal caregivers might mitigate secondary trauma, and ensure individuals are emotionally protected and equipped to care for survivors.

A comparative cross-sectional evaluation of the Field Epidemiology Training Program-Frontline in Ethiopia.

BACKGROUND: The Field Epidemiology Training Program (FETP)-Frontline is a three-month in-service training aimed at improving surveillance officers' capacity to collect, analyze, and interpret surveillance data, and respond to health emergencies. We evaluated the effectiveness of the FETP-Frontline which was introduced in Ethiopia in 2016. METHODS: We conducted a comparative, randomized cross-sectional study to assess surveillance-related knowledge, skills, and performance among trained and untrained officers using a structured questionnaire and observation checklist. We compared the knowledge, skills, and performance scores of trained and untrained officers using the Fisher's Exact test, chi-square test, and t-test at p-value < 0.05 for statistical significance. RESULTS: We conducted the study among 74 trained and 76 untrained surveillance officers. About three-quarters of all participants were male, and the average age was 34 (± 8.6) years. Completeness and timeliness of surveillance reports were significantly higher among trained than untrained surveillance officers. The trained officers were more likely to have produced epidemiologic bulletins (55% vs 33%), conducted active surveillance six months before the survey (88% vs 72%), provided surveillance training (88% vs 65%), conducted strengths, weakness, opportunities, and threats (SWOT) analysis (55% vs 17%), and utilized Microsoft Excel to manage surveillance data (87% vs 47%). We also observed improved surveillance officers' perceived skills and knowledge, and the availability and quality of surveillance formats and reports among the trained group. CONCLUSIONS: FETP-Frontline trained surveillance officers demonstrated better knowledge, skills, and performance in most surveillance activities compared to the untrained officers. FETP-Frontline can address competency gaps among district surveillance officers in Ethiopia and other countries. Scaling up the program to cover unreached districts can enable achieving the human resource development core capacity requirement of the International Health Regulations 2005.

Qualitative evaluation of enabling factors and barriers to the success and sustainability of national public health institutes in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia.

OBJECTIVES: The success of National Public Health Institutes (NPHIs) in low-income and middle-income countries (LMICs) is critical to countries' ability to deliver public health services to their populations and effectively respond to public health emergencies. However, empirical data are limited on factors that promote or are barriers to the sustainability of NPHIs. This evaluation explored stakeholders' perceptions about enabling factors and barriers to the success and sustainability of NPHIs in seven countries where the U.S. Centers for Disease Control and Prevention (CDC) has supported NPHI development and strengthening. DESIGN: Qualitative study. SETTING: Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. PARTICIPANTS: NPHI staff, non-NPHI government staff, and non-governmental and international organisation staff. METHODS: We conducted semistructured, in-person interviews at a location chosen by the participants in the seven countries. We analysed data using a directed content analysis approach. RESULTS: We interviewed 43 NPHI staff, 29 non-NPHI government staff and 24 staff from non-governmental and international organisations. Participants identified five enabling factors critical to the success and sustainability of NPHIs: (1) strong leadership, (2) financial autonomy, (3) political commitment and country ownership, (4) strengthening capacity of NPHI staff and (5) forming strategic partnerships. Three themes emerged related to major barriers or threats to the sustainability of NPHIs: (1) reliance on partner funding to maintain key activities, (2) changes in NPHI leadership and (3) staff attrition and turnover. CONCLUSIONS: Our findings contribute to the scant literature on sustainability of NPHIs in LMICs by identifying essential components of sustainability and types of support needed from various stakeholders. Integrating these components into each step of NPHI development and ensuring sufficient support will be critical to strengthening public health systems and safeguarding their continuity. Our findings offer potential approaches for country leadership to direct efforts to strengthen and sustain NPHIs.

The enduring consequences of conflict-related sexual violence: a qualitative study of women survivors in northern Uganda.

BACKGROUND: One in three women in northern Uganda report having suffered from conflict-related sexual violence (CRSV), including forced marriage and rape. Research on the long-term effects of CRSV on the health and social well-being of survivors is scant, but crucial to informing policy and improving programs tailored to conflict-affected communities. Understanding women's perceptions of and experiences with CRSV, especially related to the persistent health and social challenges they continue to face, is critical for developing effective and targeted interventions. METHODS: We worked with a local, survivor-led organization to recruit participants purposively from three post-conflict districts in northern Uganda: Gulu, Lira, and Pader. Women who had experienced CRSV and who were 18 years of age or older were eligible to participate. We asked participants open-ended questions about their experience with CRSV, including how it continues to affect their health and social well-being, any impact it had on their relationships, and if they faced barriers to accessing services. We transcribed, translated, and uploaded interview responses to the qualitative data analysis software MAXQDA and analyzed data thematically using a modified approach to grounded theory. RESULTS: We conducted 30 interviews between October 2016 and March 2017. All participants reported experiencing forced marriage, rape, or forced pregnancy. Over two-thirds of participants said they continued to face physical and psychological issues, including untreated sexually transmitted infections, anxiety, and depression. Almost half of the women faced challenges with maintaining links with family members, stigma related to their experiences during abduction that also extended to their children born in captivity, and difficulty with accessing and affording health care. Barriers to seeking care included fear of disclosure and being unable to find services. Women identified peer-support from other survivors as a key coping mechanism. CONCLUSIONS: Women survivors continue to face multifaceted health and social problems in the post-conflict period. Most health-related programs that were set up at the end of the war in northern Uganda are no longer available. Increasing access to care, particularly services tailored to treating chronic reproductive health issues and mental health, is paramount for women survivors in northern Uganda and other conflict-affected regions.

Psychometric Properties of a Scale on Judgmental Communication with Peers About Sex Among YMSM and Their Close Friends in Lebanon.

We are not aware of any validated sexual health communication scales for use with young men who have sex with men (YMSM). We used data from an HIV prevention study in Lebanon with 226 YMSM aged 18-29 to assess the psychometric characteristics of our scale, Judgmental Communication with Peers about Sex (JCPS). The construct validity of the JCPS scale was supported by it being negatively correlated with general social support, percentage of alters perceived to be supportive, and the percentage of peers who are perceived to use condoms. The scale was positively correlated with gay-related discrimination, feeling part of the gay community, and gay social integration. These findings reflect a reliable, valid measure to assess judgmental sexual health communication between YMSM.

Stakeholders' assessment of US Centers for Disease Control and Prevention's contributions to the development of National Public Health Institutes in seven countries.

National Public Health Institutes (NPHIs) can strengthen countries' public health capacities to prevent, detect, and respond to public health emergencies. This qualitative evaluation assessed the role of the US Centers for Disease Control and Prevention (CDC) in NPHI development and strengthening of public health functions. We interviewed NPHI staff (N = 43), non-NPHI government staff (N = 29), and non-governmental organization staff (N = 24) in seven countries where CDC has supported NPHI development: Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda, and Zambia. Participants identified four areas of support that were the most important: workforce capacity building, technical assistance for key public health functions, identifying institutional gaps and priorities, and funding to support countries' priorities. Participants underscored the need for capacity building directed toward country-driven priorities during planning and implementation. Continued support for NPHI development from CDC and other partners is vital to building stronger public health systems, improving population health, and strengthening global health security.

Multisectoral cost analysis of a human and livestock anthrax outbreak in Songwe Region, Tanzania (December 2018-January 2019), using a novel Outbreak Costing Tool.

OBJECTIVES: We applied a novel Outbreak Costing Tool (OCT), developed by the US Centers for Disease Control and Prevention (CDC), to estimate the costs of investigating and responding to an anthrax outbreak in Tanzania. We also evaluated the OCT's overall utility in its application to a multisectoral outbreak response. METHODS: We collected data on direct costs associated with a human and animal anthrax outbreak in Songwe Region (December 2018 to January 2019) using structured questionnaires from key-informants. We performed a cost analysis by entering direct costs data into the OCT, grouped into seven cost categories: labor, office, travel and transport, communication, laboratory support, medical countermeasures, and consultancies. RESULTS: The total cost for investigating and responding to this outbreak was estimated at 102,232 United States dollars (USD), with travel and transport identified as the highest cost category (62,536 USD) and communication and consultancies as the lowest, with no expenditure, for the combined human and animal health sectors. CONCLUSIONS: Multisectoral investigation and response may become complex due to coordination challenges, thus allowing escalation of public health impacts. A standardized framework for collecting and analysing cost data is vital to understanding the nature of outbreaks, in anticipatory planning, in outbreak investigation and in reducing time to intervention. Pre-emptive use of the OCT will also reduce overall and specific (response period) intervention costs for the disease. Additional aggregation of the costs by government ministries, departments and tiers will improve the use of the tool to enhance sectoral budget planning for disease outbreaks in a multisectoral response.

The Enriched Life Scale (ELS): Development, exploratory factor analysis, and preliminary construct validity for U.S. military veteran and civilian samples.

The U.S. military veteran serving nonprofit, Team Red, White & Blue (RWB), defined an "enriched life" as having physical, mental, and emotional health; supportive relationships; and a sense of purpose. Until now, no corresponding measure of an "enriched life" existed for the purposes of clinical assessment and research. The primary objective of this study was to explore the psychometric properties of the Enriched Life Scale (ELS) in veteran and civilian samples. Our secondary objective was to examine differences in ELS scores in subgroups of veterans who had combat deployments and service-related injuries. Veteran thought leaders working with social scientists developed the ELS and implemented exploratory factor analysis to determine the underlying dimensions of the "enriched life" construct. One thousand one hundred and eighty-seven veterans and 598 civilians participated in the study. This article describes the development of the ELS, reliability, exploratory factor analysis, and preliminary construct validity. The final ELS had 40 items and consisted of five constructs that were labeled "Genuine Relationships"; "Sense of Purpose"; "Engaged Citizenship"; "Mental Health"; and "Physical Health." Measures had high internal consistency (α = 0.82-0.94). Civilians scored higher than veterans on every ELS item, subscales, and total score, with small to large effect size differences noted between groups. In the veteran subsample, individuals with combat experience scored lower on every ELS subscale than those without combat experience (small effect sizes), as did veterans with service-related injuries in comparison to those without them (small to large effect sizes). This article establishes preliminary psychometric properties of the ELS-a promising instrument to measure an enriched life. Further study is currently underway to establish confirmatory factor analyses and explore extending its usage to diverse military and civilian samples.

Confirmatory Factor Analysis of the Enriched Life Scale Among US Military Veterans.

The Enriched Life Scale (ELS) is a 40-item measure developed by the military veteran service organization, Team Red, White & Blue (RWB), to systematically capture and quantify the lived experiences of military veterans transitioning to civilian life. As Team RWB's mission is to "enrich veterans' lives," veterans who conceived of and co-developed the ELS as a psychometric instrument defined what an "enriched life" would entail. Exploratory factor analysis (EFA) of the ELS revealed a five-factor structure capturing the domains of: physical health, mental health, genuine relationships, sense of purpose, and engaged citizenship. The goal of the current study was to use confirmatory factor analysis to validate the factor structure of the ELS in a sample of veterans not affiliated with Team RWB. We also sought to explore convergent validity with the Military to Civilian Questionnaire, a measure of military to civilian reintegration challenges. Five hundred and twenty-nine veterans participated in the study. We estimated three models, one-factor, four-factor, and five-factor model via maximum likelihood estimation with robust Huber-White standard errors. The five-factor model showed the best fit to the data (RMSEA = 0.05, CFI = 0.90, TLI = 0.90, SRMR = 0.06). Additionally, the five-factor model demonstrated convergent and discriminant validity, as well as internal consistency reliability (genuine relationships, α = 0.90; sense of purpose, α = 0.93; engaged citizenship, α = 0.89; mental health, α = 0.88; and physical health, α = 0.78). Overall, the ELS is a valid and reliable measure of veteran enrichment and could potentially be used in conjunction with diagnostic instruments that capture strain-related transition challenges (to include mental health disorders) to capture post-military service wellbeing.

Benefits and Challenges of Safer-Conception Counseling for HIV Serodiscordant Couples in Uganda.

CONTEXT: Safer-conception counseling may help people living with HIV to reduce the risk of transmission to partners and children. However, such counseling is rarely offered or evaluated in low-income countries. METHODS: In 2014-2015, in-depth qualitative interviews were conducted at a Ugandan HIV clinic with 42 HIV-positive clients and 16 uninfected partners who had participated in a safer-conception counseling intervention for serodiscordant couples seeking to have a child. Participants attended up to six monthly counseling sessions in which they received instruction and ongoing support in using the safer-conception method they selected. Content analysis of interview transcripts was used to identify themes related to the benefits and challenges of safer-conception counseling. RESULTS: Almost two-thirds of participants felt that safer-conception counseling was an empowering experience that enabled them to make informed choices regarding childbearing, learn how to conceive safely and understand how to stay healthy while trying to conceive. Timed unprotected intercourse was the most frequently used safer-conception method. Seven couples had successful pregnancies, and no uninfected partners seroconverted. Participants' primary concerns and challenges regarding counseling and method use were issues with manual self-insemination, difficulty with engaging partners and fear of HIV infection. CONCLUSIONS: Counseling can help HIV-infected individuals make informed choices about childbearing and safer-conception methods; however, a controlled clinical trial is needed to determine whether clients use such methods correctly and to assess rates of pregnancy and transmission. Policymakers need to consider including safer-conception counseling as part of routine HIV care.

Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda.

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.

Stakeholder Experiences in a Stepped Collaborative Care Study Within U.S. Army Clinics.

OBJECTIVE: This article examines stakeholder experiences with integrating treatment for posttraumatic stress disorder (PTSD) and depression within primary care clinics in the U.S. Army, the use-of-care facilitation to improve treatment, and the specific therapeutic tools used within the Stepped Treatment Enhanced PTSD Services Using Primary Care study. METHODS: We conducted a series of qualitative interviews with health care providers, care facilitators, and patients within the context of a large randomized controlled trial being conducted across 18 Army primary care clinics at 6 military installations. RESULTS: Most of stakeholders' concerns clustered around the need to improve collaborative care tools and care facilitators and providers' comfort and abilities to treat behavioral health issues in the primary care setting. CONCLUSIONS: Although stakeholders generally recognize the value of collaborative care in overcoming barriers to care, their perspectives about the utility of different tools varied. The extent to which collaborative care mechanisms are well understood, navigated, and implemented by providers, care facilitators, and patients is critical to the success of the model. Improving the design of the web-based therapy tools, increasing the frequency of team meetings and case presentations, and expanding training for primary care providers on screening and treatment for PTSD and depression and the collaborative care model's structure, processes, and offerings may improve stakeholder perceptions and usage of collaborative care.

Who Are the Men Caring for Maltreated Youth? Male Primary Caregivers in the Child Welfare System.

The goal of this study is to better understand the characteristics of men who act as primary caregivers of maltreated children. We examined differences between male primary caregivers (fathers) for youth involved in the child welfare system and female primary caregivers (mothers). We conducted secondary data analyses of the National Survey of Child and Adolescent Well-Being-II baseline data. Overall, primary caregiving fathers and mothers were more similar than different, though a few differences were revealed. Compared to mothers, fathers tended to be older and were more likely to be employed, with a higher household income and older children. Fathers and mothers did not differ in terms of depression or parenting behavior, but there was evidence that mothers have more problems with drug use compared to fathers. Compared to fathers, mothers reported higher levels of internalizing and externalizing problems in their children. Children with male primary caregivers were more likely to have experienced physical abuse but less likely to have experienced emotional abuse or witnessed domestic violence than children with female primary caregivers. These findings may help to inform researchers, practitioners, and policy makers on how to address the needs of male caregivers and their children.

Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System.

OBJECTIVE: Over the past decade, there has been growing recognition of the mental health consequences associated with deployment and service by military service personnel. This study examined potential barriers to mental health care faced by members of the military in accessing needed services. METHODS: This qualitative study of stakeholders was conducted across six large military installations, encompassing 18 Army primary care clinics, within the context of a large randomized controlled trial. Stakeholders included patients recruited for the study (N=38), health care providers working within site clinics (N=31), and the care managers employed to implement the intervention protocol (N=7). RESULTS: Issues raised across stakeholder groups fell into two main categories: structural factors associated with the Army medical system and institutional attitudes and cultural issues across the U.S. military. Structural issues included concerns about the existing capacity of the system, for example, the number of providers available to address the population's needs and the constraints on clinic hours and scheduling practices. The institutional attitude and cultural issues fell into two main areas: attitudes and perceptions by the leadership and the concern that those attitudes could have negative career repercussions for those who access care. CONCLUSIONS: Although there have been significant efforts to improve access to mental health care, stakeholders within the military health system still perceive significant barriers to care. Efforts to ensure adequate and timely access to high-quality mental health care for service members will need to appropriately respond to capacity constraints and organizational and institutional culture.

Multi-level Correlates of Safer Conception Methods Awareness and Attitudes Among Ugandan HIV Clients with Fertility Intentions.

Many people living with HIV desire childbearing, but low cost safer conception methods (SCM) such as timed unprotected intercourse (TUI) and manual self-insemination (MSI) are rarely used. We examined awareness and attitudes towards SCM, and the correlates of these constructs among 400 HIV clients with fertility intentions in Uganda. Measures included awareness, self-efficacy, and motivation regarding SCM, as well as demographics, health management, partner and provider characteristics. Just over half knew that MSI (53%) and TUI (51%) reduced transmission risk during conception, and 15% knew of sperm washing and pre-exposure prophylaxis. In separate regression models for SCM awareness, motivation, and self-efficacy, nearly all independent correlates were related to the partner, including perceived willingness to use SCM, knowledge of respondent's HIV status, HIV-seropositivity, marriage and equality in decision making within the relationship. These findings suggest the importance of partners in promoting SCM use and partner inclusion in safer conception counselling.