Abigail M. Hatcher

Background: Healthcare worker (HCW) HIV-related stigma can reduce participation in HIV prevention services in Malawi, including HIV index testing. However, evidence on interventions to reduce HCW stigma and improve client experiences of care in index testing settings remains limited. We evaluated HCW stigmatizing attitudes and also assessed anticipated stigma and perceptions of respectful care among both people living with HIV (index clients) and their sexual partners (contact clients) in index testing settings. Methods: We conducted a cluster randomized controlled trial across 33 clusters providing index case testing in southeastern Malawi. All HCWs received standard, in-person training. Enhanced cluster HCWs additionally received the blended learning training package consisting of tablet-based modules and in-person sessions incorporating stigma-reduction content. HCW stigmatizing attitudes were evaluated one-month (wave 1) and one-year post-training (wave 2). A subset of index and contact clients completed anticipated stigma and respectful care scales at exit interviews. Scales ranged from 0–3 (HCW stigma), 0–1 (anticipated stigma), and 1–5 (respectful care), with higher scores reflecting more stigma or respectful care. Generalized estimating equations with an identity link and gamma distribution estimated adjusted mean differences between arms. Results: We enrolled 305 HCWs, 341 index clients, and 194 contact clients. Overall stigma levels were low and respectful care ratings were high across arms. Mean HCW stigma scores were 0.8 (wave 1) and 0.7 (wave 2); adjusted mean differences between arms were −0.1 (p = 0.3) at wave 1 and 0.0 (p = 1.0) at wave 2. Index and contact client anticipated stigma means were both 0.1; adjusted mean differences between arms were 0.0 (p = 0.9) for index and 0.0 (p = 0.7) for contact clients. Respectful care means were 4.0 for index and 4.2 for contact clients; adjusted mean differences between arms were 0.0 (p = 0.9) for index and −0.1 (p = 0.3) for contact clients. Conclusions: The enhanced training package did not improve HCW or client stigma-related outcomes. Further research is needed to reduce HCW and client stigma and improve respectful care.

Background: Measuring intimate partner violence (IPV) remains a challenge in health research due to the wide range of available measures, with each designed for different purposes, populations, and types of violence. Selecting the most appropriate IPV measure requires careful alignment with a study's overall goals while balancing conceptual, ethical, and pragmatic considerations. Objectives: To introduce a decision‐making framework to guide researchers in selecting IPV measures for use in health‐focused research. Methods: A targeted review was completed to identify all published systematic reviews focused on IPV measures. Using a consensus‐driven approach, systematic reviews were appraised to determine the criteria and characteristics most commonly used to categorize and evaluate measures. A set of commonly recurring measurement characteristics was identified across reviews, including shared challenges in IPV measurement. Results: We identified six domains characterizing variation across IPV measures, including: purpose, populations, types of violence, time frame, context, and data collection methods. Some reviews considered additional characteristics including psychometric evidence and cultural relevance. Others discussed practical considerations, such as language availability and respondent burden. Based on these findings, we developed a decision‐making framework and accompanying checklist designed to support researchers in evaluating the fit and appropriateness between available IPV measures and the specific aims, populations, and contextual considerations of their studies. Conclusions: Structured guidance that draws on the broader IPV field can support intentional and transparent decision‐making, improving the quality and fit of IPV measurement. Clinical Relevance: The proposed framework, along with the IPV measure checklist, supports both researchers and clinicians in selecting the strongest IPV measure for their study. By offering structured guidance on navigating the wide variety of available IPV measures, this framework supports more consistent, interpretable, and methodologically rigorous IPV measurement.

Adverse childhood experiences and intergenerational trauma are associated with a variety of negative health outcomes and are particularly prevalent among people of color and those living in rural communities. The social accelerator model offers a novel means of assisting organizations in scaling up their initiatives and increasing their impact. This study investigates the lessons learned from adapting the social accelerator model to address community-level trauma and build resilience in a rural setting. We conducted qualitative interviews with program staff and the initial cohort of participants of the Resilient Leaders Initiative: a trauma-informed social accelerator designed for public institutions in Edgecombe County, North Carolina. Participating community organizations included a local high school, church, and courthouse. In-depth interviews (n = 23) explored strengths, challenges, and perceived outcomes of the program and were thematically analyzed. The program’s deep community ties generated strong relationships among the cohort and created a safe space for participants to address trauma. Those interviewed identified the virtual program’s flexible structure as a key strength, but also reported experiencing confusion around roles, outcomes, and program language. A shared passion for building community resilience among participants and staff served as a key motivator throughout the program. Findings indicate that a flexible environment, strong interpersonal relationships, and deep community roots are essential to facilitating the creation of trauma-informed solutions among community organizations via the social accelerator model.

Background: Persistent hypertension is common after preeclampsia and is causally tied to later cardiovascular risks. This study examined whether being HIV-infected and on antiretroviral therapy (ART) is associated with persistent postpartum hypertension among women diagnosed with preeclampsia. Methods: We conducted a six-month prospective cohort study at Kanyama and Women and Newborn hospitals from January 01, 2022, to June 30, 2023, among 190 women diagnosed with preeclampsia (59 HIV-positive, 131 HIV-negative). Sociodemographic and clinical characteristics were collected at delivery, six weeks, three months and six months after giving birth. Persistent hypertension was diagnosed if a participant presented with elevated blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg and/or taking medication for hypertension at the study visit. We used a generalized estimating equation to describe the relationship between treated HIV and persistent hypertension six months following delivery. Results: We retained 136 participants (71.6%) to six months postpartum, at a median age of 30 years. Overall, persistent hypertension at six weeks, three months, and six months postpartum was common (37.4%, 17.1% and 16.9%, respectively). Six-week postpartum prevalence was higher in the HIV group than HIV-negative group (54.6% vs 28.8%, p<0.001), with no measurable difference at three months (24.3% vs 13.2%, p = 0.145) or six months (18.2% vs 16.3%, p = 0.787). Multivariable analysis demonstrates higher odds (adjusted odds ratio [aOR] = 1.68, 95% CI: 1.09–2.60) of persistent hypertension among the HIV+treatment group than HIV-negative counterparts after accounting for age, body mass index and time since delivery. Conclusion: We demonstrate an elevated risk of persistent hypertension among postpartum women with comorbid preeclampsia and treated HIV. Peripartum patients in HIV-endemic settings may benefit from timely detection of hypertension and treatment interventions to improve health outcomes.

Sexual and gender minority (SGM) adults in South Africa face high levels of violence and poor mental health outcomes. Interventions to prevent these negative health implications are hampered by a lack of representative data among this population. This study aims to quantify the associations between three forms of violent victimization and depressive symptoms in a sub-sample of SGM drawn from a population-based cross-sectional study in Gauteng, South Africa. Data come from the sixth Quality of Life survey conducted in South Africa’s Gauteng province. Brief screeners assessed childhood sexual abuse (CSA), past-year intimate partner violence (IPV), non-partner violence, and depressive symptoms. Three survey-weighted logistic regression analyses were fit to model associations between elevated depressive symptoms and CSA, past-year IPV, and past-year non-partner violence, controlling for socio-demographics (age, race, sex, area of residence, education, socioeconomic status, and recent employment). N = 1,328 SGM respondents were included. Over 40% ( n = 537) reported depressive symptoms, while 17% ( n = 222) reported CSA, 5% ( n = 67) reported IPV, and 16% ( n = 208) reported non-partner violence. CSA and non-partner violence were associated with significantly higher odds of reporting depressive symptoms (aOR: 1.51, 95% CI [1.03, 2.23]; aOR: 1.84, [1.24, 2.73], respectively). IPV was not associated with elevated depressive symptoms (aOR: 1.17, [0.64, 2.16]). In all models, employment in the past 7 days was associated with significantly lower odds of reporting depressive symptoms. Recent and childhood violence is a major burden that is associated with elevated symptoms of depression among SGM in urban South Africa. Community-tailored interventions and policy-related advocacy related to employment and violence prevention may alleviate depressive symptoms in SGM adults in Gauteng.

Background: South Africa has among the highest rates of intimate partner violence (IPV) globally, with young women at heightened risk due to inequitable gender roles, limited relationship skills, and inadequate social support. Despite an urgent need for violence prevention in low- and middle-income settings, most efficacious approaches are time-intensive and costly to deliver. Digital, interactive chatbots may help young women navigate safer relationships and develop healthier gender beliefs and skills Methods: Young women (18–24 years old) across South Africa were recruited via Facebook for participation in an individually randomised controlled trial (n = 19,643) during the period of June 2021-September 2021. Users were randomly allocated, using a pipeline algorithm, to one of four trial arms: Pure Control (PC) had no user engagement outside of study measures; Attention Treatment (T0) provided didactic information about sexual health through a text-based chatbot; Gamified Treatment (T1) was a behaviourally-informed gamified text-based chatbot; Narrative Treatment (T2) was a behaviourally-informed drama delivered through pre-recorded voice notes. All chatbots were delivered in WhatsApp, through which users were invited to complete brief “quizzes” comprising adapted versions of validated scales. Primary outcomes were short-form adaptations of scales for gender attitudes (Gender Relations Scale) and past-month IPV (WHO Multi-country Study Instrument). Secondary outcomes were identification of unhealthy relationship behaviours (Intimate Partner Violence Attitudes Scale) and brief screener for depressive symptoms (Patient Health Questionnaire). A direct chat link to a trained counsellor was a safety measure (accessed by 4.5% of the sample). We estimated treatment effects using ordinary least squares and heteroskedasticity robust standard errors Findings: The trial retained 11,630 (59.2%) to the primary endpoint of gender attitudes. Compared to control, all treatments led to moderate and significant changes in attitudes towards greater gender equity (Cohen’s D = 0.10, 0.29, 0.20 for T0, T1, and T2, respectively). The gamified chatbot (T1) had modest but significant effects on IPV: 56% of young women reported past-month IPV, compared to 62% among those without treatment (marginal effects = -0.07, 95%CI = -0.09to-0.05). The narrative treatment (T2) had no effect on IPV exposure. T1 increased identification of unhealthy relationship behaviours at a moderate and significant level (Cohen’s D = 0.25). Neither T1 nor T2 had a measurable effect on depressive symptoms as measured by the brief screener. Interpretation: A behaviourally-informed, gamified chatbot increased gender equitable attitudes and was protective for IPV exposure among young women in South Africa. These effects, while modest in magnitude, could represent a meaningful impact given potential to scale the low-cost intervention.

Depressive symptoms are a major burden of disease globally and is associated with violence and poverty. However, much of the research linking these conditions is from resource-rich settings and among smaller, clinical samples. Secondary data from a household survey in Gauteng Province of South Africa examines the cross-sectional association between adult women’s elevated depressive symptoms and markers of violence. Using tablet computers, participants self-completed interview modules to screen for depressive symptoms (Patient Health Questionnaire 2-item screener), childhood exposure to physical and sexual abuse (Childhood Trauma Questionnaire 4-item index), as well as past-year exposure to sexual or intimate partner violence (SIPV; WHO Multicountry Study instrument 4-item index). Socio-economic status, food security, education, and income were self-reported. Representative data at the ward level allows for modeling of results using survey commands and mixed-level modeling. Of the 7,276 adult women participating in the household survey, 42.1% reported elevated depressive symptoms. A total of 63.9% reported childhood violence exposure and 5.3% had past-year SIPV. Multi-level modeling suggests that violence is a strong predictor of depressive symptoms. Childhood abuse alone increases the odds of high depressive symptomology, after controlling for individual-level markers of poverty and neighborhood of residence (aOR 1.31, 95%, CI 1.17–1.37). Combined exposure to childhood abuse and past-year SIPV increased odds of reporting elevated depressive symptoms (aOR 2.05, 95%, CI 1.54–2.71). Ward characteristics account for 6% of the variance in depressive symptoms, over and above the contributions of household food security and socio-economic status. Exposure to violence in childhood and past-year SIPV were associated with depressive symptoms among women. These associations persist after controlling for socio-economic markers and latent neighborhood characteristics, which also had significant association with elevated depressive symptoms. These data suggest that efforts to reduce the burden of depressive symptoms may benefit from approaches that prevent violence against women and children.

Background: South Africa has among the highest rates of intimate partner violence (IPV) globally, with young women at heightened risk due to inequitable gender roles, limited relationship skills, and inadequate social support. Despite an urgent need for violence prevention in low- and middle-income settings, most efficacious approaches are time-intensive and costly to deliver. Digital, interactive chatbots may help young women navigate safer relationships and develop healthier gender beliefs and skills. Methods: Young women (18-24 years old) across South Africa were recruited via Facebook for participation in an individually randomised controlled trial (n=19,643) during the period of June 2021-September 2021. Users were randomly allocated, using a pipeline algorithm, to one of four trial arms: Pure Control (PC) had no user engagement outside of study measures; Attention Treatment (T0) provided didactic information about sexual health through a text-based chatbot; Gamified Treatment (T1) was a behaviorally-informed gamified text-based chatbot; Narrative Treatment (T2) was a behaviorally-informed drama delivered through pre-recorded voice notes. All chatbots were delivered in WhatsApp, through which users were invited to complete brief “quizzes” comprising adapted versions of validated scales. A direct chat link to a trained counsellor was a safety measure (accessed by 4·5% of the sample). Primary outcomes were adapted validated scales of gender beliefs and past-month IPV. Secondary outcomes were identification of unhealthy relationship behaviors and depressive symptoms. We estimated treatment effects using ordinary least squares and heteroskedasticity robust standard errors.Findings: Compared to control, all treatments were effective in improving gender beliefs (Cohen’s D=0·10, 0·29, 0·20 for T0, T1, and T2, respectively). The gamified chatbot (T1) had small but significant effects on IPV: 56% of young women reported past-month IPV, compared to 62% among those without treatment (marginal effects=-0·07, 95%CI=-0·09to-0·05). The narrative treatment (T2) had no effect on IPV exposure. T1 significantly increased identification of unhealthy relationship behaviors (Cohen’s D=0·25). Neither T1 nor T2 had a measurable effect on mental health, nor did either treatment arm cause mental distress.Interpretation: A behaviorally-informed, gamified chatbot increased gender equitable beliefs and skills and was protective for IPV exposure among young women in South Africa. These effects, while modest in magnitude, could represent a meaningful impact given potential to scale the low-cost intervention.

Violence against women and girls (VAWG) is a global human rights and public health concern. Food insecurity is a sign of severe poverty, and likely to heighten women’s vulnerability to VAWG and men’s perpetration of it. However, the extent of the association and the multiple pathways between food insecurity and VAWG are not well understood. We systematically assessed peer reviewed quantitative and qualitative literature to explore this in low- and middle-income countries. Fixed effects meta-analysis was used to synthesize quantitative evidence. Qualitative data was analyzed using thematic analysis. From a search of 732 titles, we identified 23 quantitative and 19 qualitative or mixed-methods peer-reviewed manuscripts. In a meta-analysis of 21 cross-sectional studies with 20,378 participants, food insecurity was associated with doubled odds of reported VAWG (odds ratio [OR] = 2.38, 95% confidence interval [CI] = 1.82–3.10). This finding was consistent for both women’s experience or male perpetration of VAWG. Qualitative and mixed-methods papers offered insight that underlying conditions of inequitable gender norms, economic deprivation, and social isolation frame both food insecurity and VAWG. Food insecurity may trigger survival behaviors due to household stress and lack of meeting expected gender roles, which leads to VAWG. VAWG exposure may lead to food insecurity if women are more impoverished after leaving a violent household. Potential protective factors include financial stability, the involvement of men in VAWG programming, transformation of gender norms, and supporting women to develop new networks and social ties. Strong evidence exists for a relationship between food security and VAWG. Future funding should target causal directions and preventive options through longitudinal and interventional research. Strategies to ensure households have access to sufficient food and safe relationships are urgently needed to prevent VAWG.