Publications by authors named "Mary Jane Rotheram-Borus"

242 Publications

Using Machine Learning to Predict Young People's Internet Health and Social Service Information Seeking.

Prev Sci 2021 May 11. Epub 2021 May 11.

University of California, UCLA Center for Community Health, 10920 Wilshire Blvd Suite 350, Los AngelesLos Angeles, CA, 90024, USA.

Machine learning creates new opportunities to design digital health interventions for youth at risk for acquiring HIV (YARH), capitalizing on YARH's health information seeking on the internet. To date, researchers have focused on descriptive analyses that associate individual factors with health-seeking behaviors, without estimating of the strength of these predictive models. We developed predictive models by applying machine learning methods (i.e., elastic net and lasso regression models) to YARH's self-reports of internet use. The YARH were aged 14-24 years old (N = 1287) from Los Angeles and New Orleans. Models were fit to three binary indicators of YARH's lifetime internet searches for general health, sexual and reproductive health (SRH), and social service information. YARH responses regarding internet health information seeking were fed into machine learning models with potential predictor variables based on findings from previous research, including sociodemographic characteristics, sexual and gender minority identity, healthcare access and engagement, sexual behavior, substance use, and mental health. About half of the YARH reported seeking general health and SRH information and 26% sought social service information. Areas under the ROC curve (≥ .75) indicated strong predictive models and results were consistent with the existing literature. For example, higher education and sexual minority identification was associated with seeking general health, SRH, and social service information. New findings also emerged. Cisgender identity versus transgender and non-binary identities was associated with lower odds of general health, SRH, and social service information seeking. Experiencing intimate partner violence was associated with higher odds of seeking general health, SRH, and social service information. Findings demonstrate the ability to develop predictive models to inform targeted health information dissemination strategies but underscore the need to better understand health disparities that can be operationalized as predictors in machine learning algorithms.
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http://dx.doi.org/10.1007/s11121-021-01255-2DOI Listing
May 2021

Designing Evidence-Based Preventive Interventions That Reach More People, Faster, and with More Impact in Global Contexts.

Annu Rev Clin Psychol 2021 05;17:551-575

Department of Psychiatry, University of California, Los Angeles, California 90024, USA; email:

This article demonstrates the substantial similarities globally among preventive, evidence-based interventions (EBIs) designed to address HIV by providing four examples: an HIV family-focused intervention, the Community Popular Opinion Leader intervention, a South African maternal/child health program, and an EBI for sex workers in India. Each identified the key problems in the target population, utilized well-established social cognitive theories, created processes for engaging the target population, set standards for staff accountability, and included routine data collection to facilitate iterative program improvements over time. Building EBIs based on these common, robust features is an alternative design strategy to replication with fidelity. These components provide a road map for researchers, especially those using new technologies, and for local providers seeking to deliver EBIs that match their clients' and communities' needs. Technology platforms and community organizations may serve as resources for designers of the next generation of EBIs, offering an alternative to repeatedly validating the same interventions and replicating them with fidelity.
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http://dx.doi.org/10.1146/annurev-clinpsy-081219-120453DOI Listing
May 2021

Associations between caregiver mental health and young children's behaviour in a rural Kenyan sample.

Glob Health Action 2021 01;14(1):1861909

Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa.

: Research shows that caregiver mental health problems have direct, significant effects on child behaviour. While these risks are amplified in low-resource settings, limited evidence exists from these places, especially sub-Saharan Africa. : We measured associations between caregiver mental health and child behaviour in a rural Kenyan sample, hypothesizing that higher rates of caregiver mental health would be associated with increased child behavioural problems. We also sought to provide an overview of caregiver mental health symptoms in our sample. : Cross-sectional data were collected from caregivers of children ages 4-5 years old enrolled in a community-based early child development programme in western Kenya. 465 caregivers were recruited and assessed at baseline, and answered questions about child behaviour, mental health symptoms (depression, anxiety, stress), and help-seeking. A multivariate linear regression model was used to assess significance of each mental health factor. : Caregiver anxiety ( = 0.01) and parenting stress ( < 0.001) were significantly associated with child behavioural problems. 245 caregivers (52.9%) had high levels of symptoms of depression, anxiety, or both; furthermore, 101 caregivers (21.7%) scored above the cut-off for both of these scales. A high proportion of our sample (60.6%) reported seeking some formal or informal psychosocial support services; however, less than one-third of these caregivers were symptomatic (30.9%). : Anxiety and stress were associated with poorer child behavioural outcomes. Our sample reflected a higher prevalence of caregiving adults with mental health symptomology than previous estimates from Kenya, with few high-symptom caregivers seeking support. We discuss further implications for programming and health services delivery.
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http://dx.doi.org/10.1080/16549716.2020.1861909DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801103PMC
January 2021

Research Priorities to End the Adolescent HIV Epidemic in the United States: Viewpoint.

JMIR Res Protoc 2021 Jan 4;10(1):e22279. Epub 2021 Jan 4.

Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.

Youth represent 21% of new HIV diagnoses in the United States. Gay, bisexual, and transgender (GBT) youth, particularly those from communities of color, and youth who are homeless, incarcerated, in institutional settings, or engaging in transactional sex are most greatly impacted. Compared with adults, youth have lower levels of HIV serostatus awareness, uptake of antiretroviral therapy (ART), and adherence. Widespread availability of ART has revolutionized prevention and treatment for both youth at high risk for HIV acquisition and youth living with HIV, increasing the need to integrate behavioral interventions with biomedical strategies. The investigators of the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) completed a research prioritization process in 2019, focusing on research gaps to be addressed to effectively control HIV spread among American youth. The investigators prioritized research in the following areas: (1) innovative interventions for youth to increase screening, uptake, engagement, and retention in HIV prevention (eg, pre-exposure prophylaxis) and treatment services; (2) structural changes in health systems to facilitate routine delivery of HIV services; (3) biomedical strategies to increase ART impact, prevent HIV transmission, and cure HIV; (4) mobile technologies to reduce implementation costs and increase acceptability of HIV interventions; and (5) data-informed policies to reduce HIV-related disparities and increase support and services for GBT youth and youth living with HIV. ATN's research priorities provide a roadmap for addressing the HIV epidemic among youth. To reach this goal, researchers, policy makers, and health care providers must work together to develop, test, and disseminate novel biobehavioral interventions for youth.
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http://dx.doi.org/10.2196/22279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813632PMC
January 2021

Optimizing screening for anorectal, pharyngeal, and urogenital C. trachomatis and N. gonorrhoeae infections in at risk adolescents and young adults in New Orleans, Louisiana and Los Angeles, California, USA.

Clin Infect Dis 2020 Dec 10. Epub 2020 Dec 10.

Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA.

Background: Public health organizations have inconsistent recommendations for screening adolescents and young adults for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) infections. Guidelines suggest different combinations of anorectal, pharyngeal, and urogenital testing based on age, sex, and sexual activity. Further evaluation of how identity and behaviors impact the anatomic distribution of C. trachomatis and N. gonorrhoeae infection is needed to optimize future screening practices.

Methods: We assessed the positivity of C. trachomatis and N. gonorrhoeae infections at different anatomic sites in a cohort of at-risk sexually active adolescents and young adults between 12-24 years old in New Orleans, Louisiana and Los Angeles, California. Participants were tested for C. trachomatis and N. gonorrhoeae at three sites (anorectum, pharynx, and urethral/cervix) every four months using self-collected swabs. We stratified anatomic distributions of infection into four gender and sexual behavior categories: (i) cisgender men who have sex with men and transgender women (MSMTW), (ii) cis-heterosexual males, (iii) cis-heterosexual females, and (iv) gender minorities assigned female at birth.

Results: While three-site testing detected all infections, two-site (anorectum and urethra/cervix) testing identified 92-100% of C. trachomatis or N. gonorrhoeae infections in participants assigned female at birth and cis-heterosexual males. For MSMTW, two site anorectal and pharyngeal testing versus single site anorectal testing increased the proportion of individuals with either infection from 74 to 93%.

Conclusion: Sexual behavioral and gender identity factors may influence detection of C. trachomatis and N. gonorrhoeae infections at specific anatomic testing sites. Testing guidelines should incorporate sexual behavior and gender identity.
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http://dx.doi.org/10.1093/cid/ciaa1838DOI Listing
December 2020

Not Remembering History, Dooms Us to Repeat It: Using the Lessons of the Global HIV Response to Address COVID-19.

AIDS Behav 2020 Dec 29;24(12):3288-3290. Epub 2020 Oct 29.

Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa.

High income countries (HIC) have set the initial global policy responses to COVID-19. Yet, low and middle income countries (LIMIC) face very different challenges than HIC. In LMIC, there is a far greater emphasis on community solutions; families live in far more dense communities, making shelter-in-place mandates questionable; and strengthening existing health systems is more important than novel services. LMIC have far fewer economic resources. Most distressing, the successful economic commitments that HIC made to help stop HIV in LMIC have not yet been imitated, or even initiated-this support is needed now to fight COVID-19.
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http://dx.doi.org/10.1007/s10461-020-03066-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595707PMC
December 2020

Community health worker home visiting in deeply rural South Africa: 12-month outcomes.

Glob Public Health 2020 Oct 22:1-14. Epub 2020 Oct 22.

Department of Psychiatry & Biobehavioural Sciences, Semel Institute, University of California, Los Angeles, CA, USA.

Home visiting by community health workers (CHW) improves child outcomes in efficacy trials, there is however limited evidence of impact evaluating CHW programmes when operating outside of a research project. A CHW programme, previously demonstrated efficacious in a peri-urban township, was evaluated in a deeply rural context in a non-randomised comparative cohort study. Two non-contiguous, rural areas in the Eastern Cape of South Africa of about equal size and density were identified and 1469 mother-infant pairs were recruited over 33 months. In one area, CHWs conducted perinatal home visits (intervention group). Mothers in the comparison group received standard clinic care. Maternal and child outcomes were compared between the groups at one year. Mothers in the intervention group had significantly fewer depressive symptoms than mothers in the comparison group. Children of intervention mothers attained a higher proportion of their developmental milestones, compared to children in the comparison group. There were no other significant differences between mothers and children in the two groups. It is important to establish key parameters for implementing efficacious CHW programmes, especially as the numbers of CHWs are rapidly increased and are becoming critical components of task-shifting strategies of health departments in low and middle income countries (LMIC).
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http://dx.doi.org/10.1080/17441692.2020.1833960DOI Listing
October 2020

Identifying fetal alcohol spectrum disorder among South African children at aged 1 and 5 years.

Drug Alcohol Depend 2020 12 30;217:108266. Epub 2020 Aug 30.

Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Cape Town, South Africa; School of Nursing and Midwifery, Queens University, Belfast, UK.

Background: Fetal Alcohol Spectrum Disorders (FASD) are a global health concern. Early intervention mitigates deficits, yet early diagnosis remains challenging. We examined whether children can be screened and meet diagnoses for FASD at 1.5 years compared to 5 years post-birth.

Methods: A population cohort of pregnant women in 24 neighborhoods (N = 1258) was recruited and 84.5 %-96 % were reassessed at two weeks post-birth, 0.5 years, 1.5 years, 3 years, and 5 years later. A two-step process was followed to diagnose FASD; first, a paraprofessional screened the children and then a physician evaluated the child. We evaluated FASD symptoms at 1.5 vs. 5 years. We also examined maternal differences in children receiving a positive FASD screening (n = 160) with those who received a negative FASD screening.

Results: Screening positive for FASD more than doubled from 1.5 years to 5 years (from 6.8 % to 14.8 %). About one quarter of children who screened positive and were evaluated by a physician, were diagnosed as having a FASD. However, half did not complete the 2nd stage screening. Compared to mothers of children with a negative FASD screening, mothers of children with a positive FASD screening were less likely to have a high school education and more likely to have lower incomes, have experienced interpersonal partner violence, and have a depressed mood. Mothers of children who did not follow up for a 2nd stage physician evaluation were more like to live in informal housing compared to those who followed-up (81.3 % vs. 62.5 %, p = 0.014).

Conclusions: We found that children can be screened and diagnosed for FASD at 1.5 and 5 years. As FASD characteristics develop over time, repeated screenings are necessary to identify all affected children and launch preventive interventions. Referrals for children to see a physician to confirm diagnosis and link children to care remains a challenge. Integration with the primary healthcare system might mitigate some of those difficulties.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736512PMC
December 2020

Utilizing Principles of Private Enterprise to Improve Maternal and Child Health Programs.

Int J MCH AIDS 2020 20;9(2):252-256. Epub 2020 Jul 20.

Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Cape Town, South Africa.

High quality maternal and child health (MCH) programs are needed to meet the global Sustainable Development Goals 1, 2, 3, and 10. Yet, the vast majority of MCH programs are small, lack capacity and personnel, and are judged based on their relationships with funders, rather than their performance in the field. Adopting principles common among private enterprise could have a significant impact on shifting MCH to focus on implementing larger, higher quality programs and to routinely evaluate MCH as meeting/not meeting their primary mission. For example, focusing on recruiting personnel who have excellent social skills and are pragmatic problem-solvers reflects a principle of . Similar principles such as Matters and are guideposts that can improve the quality of MCH programs over time. This commentary outlines criteria which could both guide MCH organizational development and funders' evaluations of MCH.
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http://dx.doi.org/10.21106/ijma.384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376832PMC
July 2020

Intimate Partner Violence and Food Insecurity Predict Early Behavior Problems Among South African Children over 5-years Post-Birth.

Child Psychiatry Hum Dev 2021 06;52(3):409-419

Global Centre for Children and Families, Department of Psychiatry and Biobehavioral Sciences, Semel Institute, The University of California, 10920 Wilshire Blvd., Los Angeles, USA.

Households experiencing intimate partner violence (IPV) and food insecurity are at high risk of lifelong physical and behavioral difficulties. Longitudinal data from a perinatal home-visiting cluster-randomized controlled intervention trial in South Africa townships were used to examine the relationships between household settings and mothers' histories of risk and children's behavior problems at 3 and 5 years of age. IPV, food insecurity, maternal depressed mood, and geriatric pregnancy (at age of 35 or older) were consistently associated with children's internalizing and externalizing behavior problems. Aggressive behavior was more prevalent among 3- and 5-year olds boys, and was associated with maternal alcohol use. The effects of these factors on child behavior were more prominent than maternal HIV status. There is a continuing need to reduce IPV and household food insecurity, as well as supporting older, depressed, alcohol using mothers in order to address children's behavioral needs.
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http://dx.doi.org/10.1007/s10578-020-01025-1DOI Listing
June 2021

Corrigendum to "Perinatal maternal depression in rural South Africa: Child outcomes over the first two years". Journal of Affective Disorders, 247 (2019) 168-174.

J Affect Disord 2020 Sep 16;274:1223. Epub 2020 Jun 16.

Department of Psychiatry & Biobehavioral Sciences, Semel Institute, University of California, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA.

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http://dx.doi.org/10.1016/j.jad.2020.06.001DOI Listing
September 2020

Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life.

BMC Health Serv Res 2020 Jun 29;20(1):594. Epub 2020 Jun 29.

Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California, 10920 Wilshire Blvd., Suite 350, Los Angeles, California, 90024, USA.

Background: More than 50% of Africa's population lives in rural areas, which have few professional health workers. South Africa has adopted task shifting health care to Community Health Workers (CHWs) to achieve the Sustainable Development Goals, but little is known about CHWs' efficacy in rural areas.

Methods: In this longitudinal prospective cohort study, almost all mothers giving birth (N = 470) in the Zithulele Hospital catchment area of the OR Tambo District were recruited and repeatedly assessed for 2 years after birth with 84.7-96% follow-up rates. During the cohort assessment we found that some mothers had received standard antenatal and HIV care (SC) (n = 313 mothers), while others had received SC, supplemented with home-visiting by CHWs before and after birth (HV) (n = 157 mothers, 37 CHWs). These visits were unrelated to the cohort study. Multiple linear and logistic regressions evaluated maternal comorbidities, maternal caretaking, and child development outcomes over time.

Results: Compared to mothers receiving SC, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. Mothers in both groups were equally likely to secure the child grant, and infant growth and achievement of developmental milestones were similar over the first 2 years of life.

Conclusion: CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed. The South African Government is planning broad implementation of CHW programmes, and this study examines a comprehensive, home-visiting model in a rural region.
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http://dx.doi.org/10.1186/s12913-020-05436-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325027PMC
June 2020

Emerging Opportunities Provided by Technology to Advance Research in Child Health Globally.

Glob Pediatr Health 2020 17;7:2333794X20917570. Epub 2020 May 17.

Stellenbosch University, Stellenbosch, Western Cape, South Africa.

Current approaches to longitudinal assessment of children's developmental and psychological well-being, as mandated in the United Nations Sustainable Development Goals, are expensive and time consuming. Substantive understanding of global progress toward these goals will require a suite of new robust, cost-effective research tools designed to assess key developmental processes in diverse settings. While first steps have been taken toward this end through efforts such as the National Institutes of Health's Toolbox, experience-near approaches including naturalistic observation have remained too costly and time consuming to scale to the population level. This perspective presents 4 emerging technologies with high potential for advancing the field of child health and development research, namely (1) affective computing, (2) ubiquitous computing, (3) eye tracking, and (4) machine learning. By drawing attention of scientists, policy makers, investors/funders, and the media to the applications and potential risks of these emerging opportunities, we hope to inspire a fresh wave of innovation and new solutions to the global challenges faced by children and their families.
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http://dx.doi.org/10.1177/2333794X20917570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235657PMC
May 2020

South African mothers' immediate and 5-year retrospective reports of drinking alcohol during pregnancy.

PLoS One 2020 16;15(4):e0231518. Epub 2020 Apr 16.

Global Center for Children and Families, University of California Los Angeles, Los Angeles, California, United States of America.

Prenatal alcohol-drinking is often measured with self-report, but it is unclear whether mothers give more accurate answers when asked while pregnant or some time after their pregnancy. There is also the question of whether to measure drinking in a dichotomous or continuous fashion. We sought to examine how the timing and scale of self-reports affected the content of reports. From a sample of 576 black mothers around Cape Town, South Africa, we compared prenatal reports of prenatal drinking with 5-year retrospective reports, and dichotomous metrics (drinking or abstinent) with continuous metrics (fluid ounces of absolute alcohol drunk per day). Amounts increased over the 5-year period, whereas dichotomous measures found mothers less likely to report drinking later. All four measures were weakly associated with birth weight, birth height, child head circumference soon after birth, and child intelligence at age 5. Furthermore, neither reporting time nor the scale of measurement were consistently related to the strengths of these associations. Our results point to problems with self-report, particularly with this population, but we recommend post-birth continuous measures as the best of the group for their flexibility and their consistency with previous research.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231518PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162489PMC
July 2020

Community-based Implementation of Centers for Disease Control and Prevention's Recommended Screening for Sexually Transmitted Infections Among Youth at High Risk for HIV Infection in Los Angeles and New Orleans.

Sex Transm Dis 2020 07;47(7):481-483

From the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.

We examined whether the implementation of the Centers for Disease Control and Prevention's recommended screening of Chlamydia trachomatis/Neisseria gonorrhoeae with proactive follow-up among high-risk youth recruited from community and clinic settings reduced future C. trachomatis/N. gonorrhoeae diagnoses. After the Centers for Disease Control and Prevention's recommendations demonstrated a 41% decline in sexually transmitted infections; 3 tests in 1 year resulted in a 10% decline.
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http://dx.doi.org/10.1097/OLQ.0000000000001171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371266PMC
July 2020

Who can we reach and who can we keep? Predictors of intervention engagement and adherence in a cluster randomized controlled trial in South Africa.

BMC Public Health 2020 Feb 27;20(1):275. Epub 2020 Feb 27.

Department of Psychiatry & Biobehavioral Sciences, Semel Institute, University of California Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, California, 90024, USA.

Background: Engaging and retaining young men in community-based interventions is highly challenging. The purpose of this study was to investigate the individual factors that predict intervention engagement and adherence in a sample of at-risk South African men.

Methods: Baseline data were collected as a part of a cluster randomised control trial (RCT) situated in Khayelitsha and Mfuleni, two peri-urban settlements situated on the outskirts of Cape Town, South Africa. Neighbourhoods were randomised to one of three intervention conditions. We performed univariate descriptive statistics to report neighbourhood and individual socio-demographic factors, and ran multivariate models, adjusting for entry of study, to determine if high adherence and consistency of engagement with the intervention were associated with socio-behavioural demographics and risk behaviours, such as hazardous substance use, gangsterism, and criminal activity.

Results: Total of 729 men were on average 22.5 years old (SD 2.8), with a mean of 10 years of education. More than half of the sample were single (94%), lived with their parents (66%) and had an income below ~$30 (52%). The overall mean of adherence is 0.41 (SD 0.24) and mean of consistency of engagement is 0.61 (SD 0.30). Our data indicated that completing more years of education, living with parents, and having higher socioeconomic status were significantly associated with higher rates of engagement and adherence. Men with a history of gang membership demonstrated higher levels of adherence and consistent engagement with the intervention, compared with other men who were recruited to the intervention. Crucially, our data show that young men with a history of substance use, and young men who report symptoms of depression and high levels of perceived stress are equally likely as other young men to adhere to the intervention and attend intervention sessions consistently.

Conclusion: Our results may contribute to a better understanding of young men's patterns of engagement and adherence to public health interventions. The results may have important implications for policy and practice, as they may be useful in planning more effective interventions and could potentially be used to predict which young men can be reached through community-based interventions.

Trial Registration: ClinicalTrials.gov registration, NCT02358226. Prospectively registered 24 November 2014.
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http://dx.doi.org/10.1186/s12889-020-8357-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045524PMC
February 2020

Editorial Perspective: Stop describing and start fixing - the promise of longitudinal intervention cohorts.

J Child Psychol Psychiatry 2020 12 19;61(12):1388-1390. Epub 2020 Feb 19.

Department of Psychiatry, Semel Institute, University of California, Los Angeles, CA, USA.

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http://dx.doi.org/10.1111/jcpp.13213DOI Listing
December 2020

Crystal Clear with Active Visualization: Understanding Medication Adherence Among Youth Living with HIV.

AIDS Behav 2020 Apr;24(4):1207-1211

Department of Psychiatry & Biobehavioral Sciences, Semel Institute, University of California Los Angeles, 10920, Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA.

Adherence to antiretroviral therapy (ART) among youth remains low. We piloted an adapted active visualization device that demonstrates how ART works in the body. Youth living with HIV were randomized to: (1) standard care (n = 14) or the (2) adapted active visualization intervention (n = 14) and 71% of the sample (n = 19) were re-assessed on viral load, adherence behaviors, and illness perceptions 2.5 months later. Intervention youth had lower viral loads, reported less difficulty in adhering to ART, and more motivation and control over their HIV than standard care at follow-up. Active visualization may be an acceptable tool to address ART adherence among youth.
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http://dx.doi.org/10.1007/s10461-019-02721-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085439PMC
April 2020

A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa.

AIDS Patient Care STDS 2019 11;33(11):466-472

Department of Psychiatry, University of California Los Angeles, Los Angeles, California.

The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% ( = 110) were lost to follow-up, 7.7% ( = 68) transferred out of the region, 10.2% ( = 90) left the program and came back at a later date, and 4.0% ( = 35) died. Of the on-treatment population, 82.9% ( = 480/579) had VL testing within 7 months and 92.6% ( = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested ( = 457/536), or 78.9% ( = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.
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http://dx.doi.org/10.1089/apc.2019.0055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6839417PMC
November 2019

Maternal and child health outcomes in rural South African mothers living with and without HIV.

AIDS Care 2020 04 22;32(4):452-461. Epub 2019 Oct 22.

Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California at Los Angeles, Los Angeles, CA, USA.

In the era of widespread antiretroviral therapy (ART), consequences of being HIV-exposed is unclear for children, especially in rural communities. A population sample of consecutive births (470/493) in the Eastern Cape of South Africa (SA) were recruited and reassessed at five points over the first 24 months. Maternal and child outcomes between mothers living with and without HIV were assessed using multiple linear and logistic regressions. At birth, 28% of the sample was mothers living with HIV and five additional mothers seroconverted. All mothers living with HIV reported taking ART. The rate of depressed mood and IPV was similar across serostatus. However, mothers living with HIV significantly decreased their alcohol use after learning about their pregnancy and were more likely to exclusively breastfeed when compared to mothers without HIV. Despite maternal HIV status, children had similar growth across the first 24 months of life. Future work is needed to assess if these developmental trajectories will persist.
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http://dx.doi.org/10.1080/09540121.2019.1679706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047533PMC
April 2020

Associations between violence, criminality, and cognitive control deficits among young men living in low resource communities in South Africa.

Aggress Behav 2020 01 14;46(1):5-15. Epub 2019 Oct 14.

Department of Psychiatry & Biobehavioral Sciences, Semel Institute, University of California Los Angeles, Los Angeles, California.

Despite empirical support for "Self-control theory" in criminology, there is controversy about how self-control should be operationalized. Working within the framework of "self-control theory," we investigated if violence and criminal behaviors are associated with nine distinct dimensions of cognitive control in a community sample of young men (n = 654) living in peri-urban townships in South Africa. Cognitive control was assessed using the Behavior Rating Inventory of Executive Function. Multivariate statistical analysis was used, to identify associations between violence and criminality, and deaggregated measures of nine distinct components of cognitive control. Fifteen percent of the sample reported recent violence, 27% had been in physical fights with family/friends in the preceding 6 months, 10% reported being arrested, 4% reported forced sexual contact, and 26% reported intimate partner violence (IPV). Controlling for substance use and sociodemographic variables, contact with the criminal justice system and violence were associated with deficits in all domains of cognitive control. Forced sexual contact was associated with behavioral dysregulation. IPV was associated with behavior dysregulation and executive control dysfunction. Future studies might utilize deaggregated measures of self-control to provide further insight into links between particular components of cognitive control and various forms of offending and violence.
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http://dx.doi.org/10.1002/ab.21867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205326PMC
January 2020

Sexually Transmitted Infection Positivity Among Adolescents With or at High-Risk for Human Immunodeficiency Virus Infection in Los Angeles and New Orleans.

Sex Transm Dis 2019 11;46(11):737-742

From the Division of Infectious Diseases.

Background: Gay, bisexual, and transgender youth and homeless youth are at high risk for sexually transmitted infections (STIs). However, little recent data exist describing STI positivity by anatomical site among those groups. We determined the positivity of Chlamydia trachomatis (CT) infection, Neisseria gonorrhoeae (NG) infection, and syphilis antibody reactivity among lesbian, gay, bisexual, transgender, and homeless youth.

Methods: We recruited 1,264 adolescents with high risk behavior aged 12 to 24 years from homeless shelters, lesbian, gay, bisexual, and transgender organizations, community health centers, and using social media and online dating apps in Los Angeles, California and New Orleans, Louisiana from May 2017 to February 2019. Participants received point-of-care pharyngeal, rectal, and urethral/vaginal CT and NG testing and syphilis antibody testing. We calculated STI positivity by anatomical site and compared positivity by participant subgroups based on human immunodeficiency virus (HIV) status, sex assigned at birth, and gender identity.

Results: CT and NG positivity and syphilis antibody reactivity was higher among HIV-infected adolescent men who have sex with men (MSM) than HIV-uninfected adolescent MSM (40.2% vs. 19%, P < 0.05), particularly CT or NG rectal infection (28% vs. 12.3%, P < 0.05). Of participants with positive CT or NG infections, 65% had extragenital-only infections, 20% had both extragenital and urogenital infections, and 15% had urogenital-only infections.

Conclusions: Sexually transmitted infection positivity was high, particularly among transgender women and MSM. The high proportion of rectal and pharyngeal infections highlights the importance of both urogenital and extragenital STI screening. More accessible STI testing is necessary for high-risk adolescent populations.
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http://dx.doi.org/10.1097/OLQ.0000000000001056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812613PMC
November 2019

Associations between young children's exposure to household violence and behavioural problems: Evidence from a rural Kenyan sample.

Glob Public Health 2020 02 19;15(2):173-184. Epub 2019 Aug 19.

Department of Global Health, Faculty of Medicine and Health Sciences, Institute for Life Course Health Research, Stellenbosch University, South Africa.

Little is known about how young children in low- and middle-income countries (LMICs) experience violence in their homes, and how different types of household violence may affect child development. This study reports on levels of exposure to household violence and associations with child behavioural outcomes in preschool-aged children in western Kenya. A sample of 465 caregivers, whose children ( = 497) attended early learning centres supported by an international NGO, were enrolled in the study. Caregivers reported on exposure to intimate partner violence (IPV), household discipline practices, attitudes about gender roles, and child behavioural outcomes. Multivariable analysis showed significant predictive effects of IPV (regression coefficient = 1.35, SE = 0.54,  = 0.01) and harsh psychological child discipline (regression coefficient = 0.74, SE = 0.22,  = 0.001), but not physical discipline (regression coefficient = 0.42, SE = 0.24,  = 0.08), on worse child behavioural problems. These findings indicate that child exposure to violence in different forms is highly prevalent, and associated with poorer outcomes in young children. Community-based programmes focused on parenting and early child development are well-positioned to address household violence in LMIC settings, but must be supported to provide a broader understanding of violence and its immediate and long-term consequences.
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http://dx.doi.org/10.1080/17441692.2019.1656274DOI Listing
February 2020

Alcohol, But Not Depression or IPV, Reduces HIV Adherence Among South African Mothers Living with HIV Over 5 Years.

AIDS Behav 2019 Dec;23(12):3247-3256

Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Francie van Zijl Drive, Cape Town, 7505, South Africa.

Alcohol, depression, and intimate partner violence (IPV) are endemic in sub-Saharan Africa. This article examines whether and how these conditions affect mothers living with HIV (MLH), compared to mothers without HIV (MWOH). In particular, we assess the influence of these comorbidities on engagement in HIV care and adherence to antiretroviral therapies (ARV) among MLH. Data on maternal HIV care are typically based on clinic samples, with substantial loss to follow-up. This study fills that gap by including all mothers in specified areas. A cohort study examines MLH in Cape Town, South Africa recruited in pregnancy and followed repeatedly for 5 years, compared to MWOH. Almost all (98%) pregnant women in 12 neighborhoods (N = 594) were recruited in pregnancy. Mothers and children were reassessed five times over 5 years with high retention rates at each of the six assessments, from 98.7% at 2 weeks to 82.8% at 5 years post-birth. MLH's uptake and adherence to HIV care was evaluated over time associated with maternal comorbidities of alcohol use, depressed mood, and IPV using mixed effects logistic regression. MLH have fewer resources (income, food, education) and are more likely to face challenges from alcohol, depression, and having seropositive partners over time than MWOH. Only 22.6% of MLH were consistently engaged in HIV care from 6 months to 5 years post-birth. At 5 years, 86.7% self-reported engaged in HIV care, 76.9% were receiving ARVs and 87% of those on ARV reported consistent ARV adherence. However, data on viral suppression are unavailable. Alcohol use, but not depressed mood or IPV, was significantly related to reduced uptake of HIV care and adherence to ARV over time. Adherence to lifelong ARV by MLH requires a combination of structural and behaviorally-focused interventions. Alcohol abuse is not typically addressed in low and middle-income countries, but is critical to support MLH.
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http://dx.doi.org/10.1007/s10461-019-02617-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854305PMC
December 2019

Maternal HIV does not affect resiliency among uninfected/HIV exposed South African children from birth to 5 years of age.

AIDS 2019 06;33 Suppl 1:S5-S16

Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.

Objective: Examine resiliency among a South African population cohort of children of mothers living with HIV (MLH) and mothers without HIV (MWOH) in low-income townships over the first 5 years of life.

Design: A cluster randomized controlled intervention trial evaluating child resiliency and the effects of home visiting in township neighborhoods from pregnancy through 5 years postbirth.

Methods: The population of pregnant women in 24 matched neighborhoods were recruited and randomized by neighborhood to a standard care condition (n = 594) or a paraprofessional home visiting intervention condition (n = 644). Mothers and children were assessed at 2 weeks, 6, 18, 36, and 60 months postbirth (92-84% follow-up; 10.2% mortality). Resilient children were identified based on consistently meeting global standards for growth, cognitive functioning, and behavior. Maternal HIV status (n = 354 MLH; n = 723 mothers without HIV MWOH), intervention condition, maternal risks, caretaking, sociodemographic characteristics, and neighborhood were examined as predictors of child resiliency over time using analysis of variance, chi-square analyses, and Fisher's exact tests, where appropriate.

Results: None of HIV-seropositive children (n = 17) were resilient; 19% of 345 HIV-exposed but uninfected children of MLH were resilient, a rate very similar to the 16% among MWOH. Resiliency was significantly associated with lower income, food security, not having a live-in partner, and the absence of maternal risk (i.e., not being depressed, using alcohol, or being a victim of intimate partner violence). Being randomized to a home visiting intervention, maternal breastfeeding for at least 3 months and attending a preschool crèche were also unrelated to resiliency. Although matched pairs of neighborhoods had similar rates of resilient children, resiliency varied significantly by neighborhood with rates ranging from 9.5 to 27%.

Conclusion: We set a new standard to define resiliency, as consistently recommended by theoreticians. Although seropositive children are not resilient, uninfected children of MLH are as resilient as their peers of MWOH. Typical protective factors (e.g., home visiting, breastfeeding, preschool) were unrelated to resiliency over the first 5 years of life.

Trial Registration: ClinicalTrials.gov registration #NCT00996528.
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http://dx.doi.org/10.1097/QAD.0000000000002176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6870979PMC
June 2019

HIV, children, and obesity: too soon for conclusions?

Lancet Child Adolesc Health 2019 07;3(7):e9

Global Center for Children and Families and Semel Institute, Department of Psychiatry, University of California, Los Angeles, CA, USA.

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http://dx.doi.org/10.1016/S2352-4642(19)30152-XDOI Listing
July 2019

The Experiences of Young Men, Their Families, and Their Coaches Following a Soccer and Vocational Training Intervention to Prevent HIV and Drug Abuse in South Africa.

AIDS Educ Prev 2019 06;31(3):224-236

Department of Family Medicine, University of California Los Angeles.

Young men in South Africa are at high-risk for HIV, substance abuse, and gender-based violence. This article presents qualitative results from a pilot study testing soccer leagues and vocational training to engage young-adult township men to deliver preventive interventions, including rapid HIV and alcohol/drug testing, shifting attitudes toward gender-based violence, and promoting other prosocial behaviors. Three groups participated in focus groups and in-depth interviews on experiences with the program: (1) a subset of 15 participants, (2) 15 family members, and (3) five intervention coaches. Results suggest that participants first reduced substance use on tournament days and then gradually reduced to practice days and beyond. Families suggested that "keeping young men occupied" and encouragement of prosocial behaviors was critical to risk reduction and led to increased community respect for the men. Coaches noted that behavioral and attitudinal changes were incremental and slow. The use of incentives was problematic and more research is needed to understand how incentives can be used in interventions of this nature.
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http://dx.doi.org/10.1521/aeap.2019.31.3.224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192051PMC
June 2019

The association of maternal alcohol use and paraprofessional home visiting with children's health: A randomized controlled trial.

J Consult Clin Psychol 2019 Jun;87(6):551-562

Department of Psychology, Stellenbosch University.

Objective: This study examines the effect of a home visiting intervention on maternal alcohol use, problematic drinking, and the association of home visiting and alcohol use on children's behavioral, cognitive, and health outcomes at 5 time points over 5 years.

Method: We analyzed 5,099 observations of 1,236 mothers and their children from pregnancy to 5 years postbirth, within a longitudinal cluster-randomized trial evaluating the effect of a home visiting intervention on mothers in Cape Town, South Africa. Paraprofessional home visitors coached mothers on coping with multiple risk factors, including a brief, 1-visit intervention on alcohol prevention in pregnancy. We assessed changes in maternal drinking over time in relation to the intervention, and then examined the impact of these drinking patterns on child outcomes over five years.

Results: Drinking increased over the 5 years postbirth, but it was significantly lower in the intervention condition. Compared with abstinence, mothers' problematic drinking was associated with decreased child weight (-0.21 z-units) at all assessments, increased child aggressive behavior (3 to 7 additional symptoms), and decreased child performance on an executive functioning measure (the silly sounds task; odds ratio = .34) at 3 and 5 years. The intervention's effect was associated with increased child aggression (0.25 to 0.75 of 1 additional symptom), but the intervention appeared to decrease the effect of problem drinking on children's aggressive acts and executive functioning.

Conclusion: These findings support the need for sustained interventions to reduce alcohol use, especially for mothers who exhibit problematic drinking. Maternal drinking influences children's health and development over time. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6775769PMC
June 2019

Home Visiting and Antenatal Depression Affect the Quality of Mother and Child Interactions in South Africa.

J Am Acad Child Adolesc Psychiatry 2019 12 26;58(12):1165-1174. Epub 2019 Mar 26.

Institute for Life Course Health Research, Stellenbosch University, Stellenbosch, South Africa; School of Nursing and Midwifery, Queens University, Belfast, UK.

Objective: To examine whether maternal depressed mood at birth moderated the protective effect of a home-visiting intervention on the quality of caregiving for children growing up in a low- and middle-income country.

Method: Almost all pregnant mothers in 24 Cape Town neighborhoods were recruited into a cluster randomized controlled trial matched by neighborhoods to the Philani home-visiting condition (HVC) or the standard care condition (SC). At 3 years after birth, the quality of mother-child interactions between HVC and SC mothers with and without antenatal depressed mood was assessed in a representative subset by rating videotaped observations of mother-child interactions on 10 dimensions of caregiving.

Results: As predicted, maternal depressed mood at birth moderated the effect of the HVC on the quality of mother-child interactions. Among nondepressed mothers, mothers and their children in the HVC scored significantly higher on 5 of the 10 dimensions of the maternal-child interaction scale than mothers in the SC: mothers exhibited more maternal sensitivity, talked more, had more harmonious interactions, and had children who paid more attention and exhibited more positive affect. However, being in the HVC did not significantly affect the mother-child interaction scores among mothers with depressed mood. Among HVC children, those with mothers with depressed mood showed significantly less positive affect and talked less with their mothers than children with nondepressed mothers. SC children with mothers with depressed mood were more responsive and paid attention to their mothers than children with nondepressed mothers.

Conclusion: Home visiting resulted in a better quality of caregiving for mothers without depressive symptoms. Future interventions need to specifically target maternal depression and positive mother-child interactions.

Clinical Trial Registration Information: Mentor Mothers: A Sustainable Family Intervention in South African Townships; https://clinicaltrials.gov; NCT00972699; Philani Home-based Nutrition Intervention Program; https://clinicaltrials.gov; NCT00995592.
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http://dx.doi.org/10.1016/j.jaac.2019.03.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316421PMC
December 2019

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months.

Soc Psychiatry Psychiatr Epidemiol 2019 Sep 25;54(9):1111-1123. Epub 2019 Feb 25.

Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Building B, 46 Sawkins Road, Rondebosch, Cape Town, Western Cape, 7700, South Africa.

Purpose: Latent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed.

Methods: This is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes.

Results: Four trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories.

Conclusions: Severe depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.
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http://dx.doi.org/10.1007/s00127-019-01665-2DOI Listing
September 2019