Antenatal care coverage and early childhood mortality in Zimbabwe: new interpretations from nationally representative household surveys

Zimbabwe has implemented universal antenatal care (ANC) policies since 1980 that have significantly contributed to improvements in ANC access and early childhood mortality rates. However, Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), two of Zimbabwe's main sources of health data and evidence, often provide seemingly different estimates of ANC coverage and under-five mortality rates. This creates confusion that can result in disparate policies and practices, with potential negative impacts on mother and child health in Zimbabwe. We conducted a comparability analysis of multiple DHS and MICS datasets to enhance the understanding of point estimates, temporal changes, rural-urban differences and reliability of estimates of ANC coverage and neonatal, infant and under-five mortality rates (NMR, IMR and U5MR, separately) from 2009 to 2019 in Zimbabwe. Our two samples z-tests revealed that both DHS and MICS indicated significant increases in ANC coverage and declines in IMR and U5MR but only from 2009 to 2015. NMR neither increased nor declined from 2009 to 2019. Rural-urban differences were significant for ANC coverage (2009-15 only) but not for NMR, IMR and U5MR. We found that there is a need for more precise DHS and MICS estimates of urban ANC coverage and all estimates of NMR, IMR and U5MR, and that shorter recall periods provide more reliable estimates of ANC coverage in Zimbabwe. Our findings represent new interpretations and clearer insights into progress and gaps around ANC coverage and under-five mortality rates that can inform the development, implementation, monitoring and evaluation of policy and practice responses and further research in Zimbabwe.

The Increasing Prevalence of Children Home Alone in Ghana: The Importance of Considering Regional Inequalities

Research from industrialized settings has linked inadequate child supervision with various negative consequences. Nevertheless, empirical research in lower- and middle-income countries about correlates of inadequate child supervision has been scarce. The few studies that exist tended to focus on individual- and household-level factors, and reported associations that are not significant or in mixed directions depending on the context. Structural factors are left underexplored, but taking a more macro-level lens in settings with high regional disparities can hold the key to explaining increases in prevalence of inadequate child supervision. Exploring the evolution over time of child supervision practices can also enrich this explanation. We use data from two rounds of Ghana Multiple Indicator Cluster Surveys to examine factors associated with children left home alone, and employ regional analysis using strata-level mixed effects. We found that in Ghana, the prevalence of children left home alone without adult supervision increased by 8.5% between 2011 and 2018 - an increase of more than 500,000 children over seven years. Statistical analyses suggest that variation between regions likely are associated with the growth of inadequate child supervision in this country. Future research should pay closer attention to how structural conditions, proxied by regions, can serve as either barriers or facilitators to adequate child supervision practices, helping shed light on residual variance unexplained by individual- and household-level factors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12187-023-10038-w.

"Youth as accessories": Stakeholder Perspectives on Youth Participation in Mental Health Policymaking [Part II]

PURPOSE

To elicit stakeholder perspectives on the findings from our scoping review on youth participation in mental health policymaking, we conducted a global consultation with young people and adults directly involved in mental health policymaking.

METHOD

Forty-four stakeholders from 16 countries, including 15 young people, 9 policymakers and 20 facilitators of youth participation, took part in individual interviews and/or focus groups. They were asked about how the review findings contrasted with their own experiences in mental health policymaking. The transcribed data were thematically analyzed.

RESULTS

All participants viewed lived experience as valuable in identifying policy gaps. Youth pointed out that children and youth with disabilities, diverse sexual orientations, and/or gender identities were often excluded, and spoke about feelings of being an "accessory", illustrating a lack of power-sharing in a tokenized policymaking process. Adult participants' accounts highlighted the challenges inherent in policymaking such as the need for political knowledge and institutional time constraints. A range of cultural, socio-economic, and political barriers to youth participation, that were often context-specific, were identified.

CONCLUSIONS

The diverse perspectives of stakeholders extended the review results. Based on our findings, we recommend that adults and institutions: (1) recognize lived experience as expertise in shaping mental health policies; (2) include diverse groups; (3) reduce tokenistic relationships through the creation of safer spaces, adult feedback, co-production, and social accountability; and (4) adopt an intersectional approach to address cultural, socio-economic, and political barriers to participation. Methodologically, our work demonstrates why stakeholder consultations are an essential component of scoping reviews.

Participation of Children and Youth in Mental Health Policymaking: A Scoping Review [Part I]

Although youth participation is oft-acknowledged as underpinning mental health policy and service reform, little robust evidence exists about the participation of children and youth in mental health policymaking. A scoping review based on Arksey and O'Malley's framework was conducted to identify and synthesize available information on children and youth's participation in mental health policymaking. Published studies up to November 30, 2020 were searched in Medline (OVID), PsycINFO (OVID), Scopus, and Applied Social Sciences Index and Abstracts (PROQUEST). Further studies were identified through Google Scholar and a grey literature search was conducted using Google and targeted web searches from October to December, 2020. Three reviewers performed screening and data extraction relevant to the review objective, followed by an online consultation. From 2,981 records, 25 publications were included. A lack of diversity among the youth involved was found. Youth were often involved in situational analysis and policy design, but seldom in policy implementation and evaluation. Both the facilitators of and barriers to participation were multifaceted and interconnected. Despite a range of expected outcomes of participation for youth, adults, organizations, and communities, perceived and actual effects were neither substantially explored nor reported. Our recommendations for mental health policymaking highlight the inclusion of children and youth from diverse groups, and the creation of relational spaces that ensure safety, inclusiveness, and diversity. Identified future research directions are: the outcomes of youth participation in mental health policymaking, the role of adults, and more generally, how the mental health of children and youth shapes and is shaped by the policymaking process.

Pre-/Post- Assessment of a Sexual and Reproductive Health Training Program for Young People in Namibia

During the first COVID-19 lockdown in Namibia (March-September 2020), the Ministry of Health and Social Services reported there were an estimated 14,983 teenage pregnancies in 2020, an increase from the prior year’s estimated 13,552. The regions of Kavango East and West were particularly impacted. In response to these figures, the Ombetja Yehinga Organisation (OYO), a youth-focused Namibian non-governmental organization, facilitated an after-school intervention in 2021 to discuss key sexual and reproductive health knowledge. An identical questionnaire was administered at both pre- and post-test, in order to provide baseline information for assessing the effectiveness of a school-based intervention to promote safe sexual behaviours. A total of 18 schools in the regions of Kavango East and West participated in the intervention between May-September 2021, and 638 learners aged 13-25 were included in data analysis after completing both the pre- and post-tests. Prior to the intervention, knowledge on sexual and reproductive health, including safe sexual behaviours and accessing contraceptives was limited. Results obtained at post-test indicate there were significant increases in participants’ level of knowledge between pre- and post-test, suggesting that school-based interventions (such as the OYO program) may be effective in disseminating this crucial information to at-risk populations.

The Families First Program to Prevent Child Abuse: Results of a Cluster Randomized Controlled Trial in West Java, Indonesia

The Families First parenting program is a 10-week paraprofessional-administered adaptation of the Positive Discipline in Everyday Parenting program for West Java, Indonesia. It has not been tested in a randomized controlled trial. The objective was to evaluate the effects of Families First on physical and emotional punishment. We conducted a cluster randomized controlled trial and randomly assigned 20 rural and urban villages in West Java, Indonesia, to intervention or waitlist. Caregivers of children aged 0-7 years in intervention villages received Families First. Between 2017 and 2018, measurements were taken before randomization, immediately post-intervention, and 6 months post-intervention. Primary outcome was presence versus absence of caregiver-reported physical or emotional punishment immediately post-intervention. Intention-to-treat regression models accounted for clustering within villages and were run to compare between groups. Participants and study personnel could not be blinded. There were 374 caregivers in the 10 intervention villages and 362 in the 10 waitlist villages included in the trial and in outcome analyses. The intervention did not result in a lower proportion of intervention families using punishment immediately post-intervention (odds ratio [OR] for physical or emotional punishment immediately post intervention = 1.20 (95% CI 0.79-1.82). There were no significant differences for positive and involved parenting, setting limits, and opinion on discipline, but caregivers in the intervention group had significantly lower odds of using positive discipline (OR = 0.65 (95% CI 0.53-0.80). Families First did not prevent punishment in a setting with low levels of reported punishment but should be tested in a setting with higher levels or among people selected for risk or presence.

The role of individual-, family-, and school-level resilience in the subjective well-being of children exposed to violence in Namibia

BACKGROUND

Children exposed to violence are at risk of a range of adverse outcomes. Given the unique cultural and social context, understanding what fosters children's resilience in resource-limited areas such as sub-Saharan Africa, is vital.

OBJECTIVES

Using data from the International Survey of Children's Well-Being (ISCWeB), this paper explores individual-, family-, and school-level factors associated with positive outcomes for children who have experienced some form of violence in Khomas region, Namibia.

METHOD AND PARTICIPANTS

Using a cross-sectional survey design, the ISCWeB questionnaire, assessing cognitive, affective, and psychological dimensions of well-being, child protection factors and violence exposure was administered to 2124 Grade four and six children.

RESULTS

Our sample had a mean age of 11.2 years. Overall, 56.8 % of children reported at least one incident of violence from an adult caregiver at home and 86.0 % of children reported some form of peer violence at school. Materially deprived children experienced higher incidence of both family and peer violence. The quality of children's relationships at home (β = 0.17, p < 0.001), and school (β = 0.07, p < 0.001) emerged as important protective factors for children's well-being for both types of violence, suggesting that supportive family and school relationships may be more important to the subjective well-being of children who experienced violence than material wellbeing, violence severity, and individual child factors.

CONCLUSIONS

Providing positive social interaction and emotional security in contextually and culturally appropriate ways within children's proximal systems should be prioritized while challenging norms that support violence in Namibian families and schools.

How societal responses to COVID-19 could contribute to child neglect

BACKGROUND

The ecosystemic approach to children's needs demands a cohesive response from societies, communities, and families. During the COVID-19 pandemic, the choices societies made to protect their community members from the virus could have created contexts of child neglect. With the closure of services and institutions, societies were no longer available to help meet the needs of children.

OBJECTIVE

The purpose of this study is to examine parents' reports on the response their children received to their needs during the COVID-19 crisis.

METHODS

During the period of the spring 2020 lockdown, 414 parents in the province of Quebec, Canada, completed an online questionnaire about the impact of the crisis on the response their children received to their needs.

RESULTS

Compared to parents of younger children, parents of older children reported less fulfillment of their child's needs in three measured domains, namely cognitive and affective, security, and basic care needs.

CONCLUSION

These results are discussed in light of the policies and the resources societies have put in place during the crisis to help families meet the needs of their children. Societies must learn from this crisis to put children at the top of their priorities in the face of a societal crisis. Thoughtful discussions and energy must be given to ensure that, while facing a crisis, the developmental trajectories of children are not sacrificed.

Protocol for a cluster randomised controlled trial evaluating a parenting with home visitation programme to prevent physical and emotional abuse of children in Indonesia: the Families First Programme

INTRODUCTION

Every year, up to 1 billion children are victims of violence worldwide. Most child abuse takes place in the context of punishment. The Families First Programme, an adaptation of the Positive Discipline in Everyday Parenting Programme to the West Java context, is a parenting support programme anchored on children's rights that gives parents guidance on child development, parenting and positive discipline practices. This trial will evaluate the effectiveness of the Families First Programme compared with a waitlist control group.

METHODS AND ANALYSIS

This is a pragmatic, parallel-group, stratified, cluster-randomised controlled trial. Twenty rural and urban villages in the Cianjur District, Indonesia, involving 720 caregivers of children up to 7 years of age, will be randomised. Villages will receive either a parenting programme consisting of 10 group sessions and four home visits over 3 months and standard community health and social services or just the latter. After completion of the trial period, the programme will be offered to those in the delayed group. Outcome data will be collected before randomisation (baseline), immediately postintervention (3 months postrandomisation) and 6 months later (9 months postrandomisation). The primary outcome will be frequency of physical and emotional punishment as measured by a weighted sum from three self-report items. Primary outcome analysis will use Poisson regression with generalised estimating equations and assess the interaction between intervention and time over baseline and 3 and 9 months postrandomisation assessments. Concurrent process evaluation will be conducted to assess programme satisfaction and facilitators and barriers to the implementation of the programme generalisable to other settings.

ETHICS AND DISSEMINATION

Ethics approval was obtained from McGill University and Universitas Katolik Indonesia Atma Jaya. Results will be published in peer-reviewed journals and presented at scientific conferences and events for decision-makers, including in the participating communities.

TRIAL REGISTRATION NUMBER

NCT03374761.

Dataset and figures on time-series analysis of child restraint policy impact in Chile

The main objective of this data article is to present the data set which depicts the impact of child restraint legislation in Chile and its regions. The population of the study consisted of all car crashes records provided by the national police from 2002 to 2014, which included children aged 0–3. Auto Regressive Integrated Moving Average ARIMA and Poisson model were used to present the association between the dependent and independent variables of interest. When the data are analyzed, it will help to determine the degree of relationship and the strength of significance between child restraint legislation policies enacted in 2005 and 2007, and child occupant fatalities and injuries. The data are related to “Impact of child restraint policies on child occupant fatalities and injuries in Chile and its regions: An interrupted time-series study” (Nazif-Munoz et al., 2018).

Impact of child restraint policies on child occupant fatalities and injuries in Chile and its regions: An interrupted time-series study

OBJECTIVES

We assessed the effectiveness of the child restraint legislation (CRL) introduced in Chile in December 2005 and the National Decree enacted in February 2007, which regulated the technical characteristics of child restraint devices with the goal of reducing child occupant fatalities and severe injuries nationally and within Chile's regions.

METHODS

An interrupted time-series design was used to measure the effect of CRL and the National Decree on two dependent variables-number of child occupant deaths in traffic collisions and number of child occupants severely injured in traffic collisions per vehicle fleet from 2002 to 2014 (police data). Our analyses compared the incidence of these outcomes in the post-intervention period (2006 to 2014) with the period prior to these interventions (2002-2005) nationally and by region, controlling for several confounders.

RESULTS

Nationally, the child restraint policies were associated with a 39.3% (95% CI: 4.7; 73.9) reduction in child occupant fatalities, but no significant decrease was observed in child severe injuries. These interventions were associated with a 75.3% (95% CI: 15.6; 135.1) reduction in the rate of child occupant fatalities in the southern regions, and a 32.9% (95% CI: 1.1; 67.0) reduction in the rate of children severely injured in the northern regions.

CONCLUSION

In the short term, the CRL and the National Decree were associated with fewer child occupant fatalities, at the national level and in the southern regions, and severely injured child occupants in traffic collisions in Chile's northern regions. These results demonstrate a limited temporal and territorial impact. This suggests that to effectively protect vulnerable populations across all territories, efforts should be expanded more consistently and sustained over time.

Non-adult child supervision practices in Lao People's Democratic Republic

Researchers have paid little attention to non-adult child supervision and the prevalence and factors influencing this practice in low-income countries. A better understanding of this phenomenon is needed to inform the development and implementation of policies and interventions to enhance child supervision in those settings. This study explores the prevalence and factors associated with young children being home alone or under the care of another young child in Lao People's Democratic Republic. Using the 2011-2012 Lao Social Indicator Survey (N = 10,740 for the subsample of 'child was home alone' and N = 10,539 for the subsample of 'child cared by another child < 10 years of age'), multi-level Poisson regressions were performed to determine the number of days children under five years of age were home alone or under the care of another child younger than 10 years of age. Large discrepancies across provinces and between urban and rural populations within each province were found. Children living in rural areas were more than five times more likely to be unsupervised than children living in urban settings (incidence rate ratio, IRR 5.2; 95% CI: 1.8-15.2), and children living in rural areas were nearly twice more likely to be under the care of another child than children living in urban settings (IRR 1.9; 95% CI: 1.3-2.8). Age was also a common factor in explaining variation in both dependent variables. Policies aimed at facilitating adequate child care and supervision should consider rurality to increase children's protection.

Protecting only white children: the impact of child restraint legislation in Brazil

Background

In 2010, Brazil introduced child restraint legislation (CRL). We assessed the effectiveness of CRL in reducing child (aged 0–8 years) injuries and fatalities by race. We performed an evaluation study with an interrupted time–series design.

Methods

We measured the effect of CRL on two outcomes—number of child deaths and number of child injured in traffic collisions per child population, stratified by race, from 2008 to 2014. We controlled for time, unemployment rate and oil consumption (barrels/day in thousands).

Results

The CRL was associated with a 3% reduction in the rate of child injuries among whites (incidence rate ratio (IRR): 0.97; 95% CI: 0.96–0.99), but no reduction in child injuries among non-whites (IRR: 0.99; 95% CI: 0.99–1.00). In the first month after the implementation of Brazil’s CRL we observed a 39% reduction in all child fatalities (IRR: 0.61; 95% CI: 0.44–0.84), including a 52% reduction among whites (IRR: 0.48; 95% CI: 0.33–0.68), but no reduction in non-white fatalities (IRR: 0.87; 95% CI: 0.55–1.37).

Conclusions

Our results support the hypothesis that socially advantaged populations were more likely to consistently adopt and employ restraint devices following the reform. Countries should also consider complementary policies that facilitate an equitable distribution of safety devices that reach vulnerable populations.

Mental health among adolescents living with HIV in Namibia: the role of poverty, orphanhood and social support

The mental health needs of children and adolescents living with HIV (ALHIV) in Namibia are poorly understood, despite the dramatic improvement in their survival. ALHIV in resource poor contexts face particular risk factors, such as poverty, orphanhood, and poor social support. This study examines the mental health of ALHIV in Namibia, and the factors that contribute to mental health problems. A case-control design assessed emotional and behavioural symptoms of distress, risk and protective factors among adolescents aged 12-18 years. Case participants were 99 HIV-positive adolescents. Case controls were 159 adolescents from the same community who were not known to be HIV seropositive at the time of the study. Control group participants were selected from schools using a stratified random sampling. A larger proportion of HIV-positive adolescents were orphaned (62.6% vs. 20.8%, p < .001); the groups showed no differences in poverty factors. HIV-positive adolescents scored lower than the control group on total perceived social support (p < .05) and caregiver support (p < .05), but no differences in perceived friend support and support from a self-selected person were present. HIV-positive adolescents reported significantly more total emotional and behavioural difficulties (p = .027) and conduct problems (p = .025), even after controlling for socio-demographic factors. However, after controlling for the effects of orphanhood, group differences in mental health outcomes were no longer significant. Furthermore, mediation analysis suggested that social support completely mediated the relationship between HIV status and mental health (standardised pathway coefficients = .05, p = .021). Policies and programmes that aim to strengthen social support and take orphanhood status into consideration may improve the mental health of adolescents living with HIV.

Rien ne doit se faire pour eux sans eux : renforcer la participation des demandeurs d'asile, réfugiés et migrants sans statut et des organismes communautaires dans la recherche en santé

The number of vulnerable migrants in Canada is on the rise. While debates on immigration policies have been at the forefront, there has been little dialogue regarding the health and well-being of refugees, asylum-seekers and non-status migrants despite the significant health inequities that these populations face. In this context, health research that aims to understand migrants' realities, develop appropriate health and social services and policies, and empower these populations, is needed more than ever. Participatory action research (PAR) is one approach for conducting relevant and empowering research with migrants, however it remains underutilized due to inadequate funding, infrastructure and support. PAR addresses real-life challenges, emphasizes collaboration with communities, and involves all stakeholders, including community-based organizations, in the co-construction and implementation of practical solutions. In this commentary, we call for more research with and for migrants, particularly in the form of PAR, as well as for more targeted funding initiatives and research conditions (University, funding agencies) that foster and support this type of research.

Predictors of mental health problems in adolescents living with HIV in Namibia

BACKGROUND

Little research in sub-Saharan Africa has looked at factors that predict mental health problems in adolescents living with HIV (ALHIV). This study examines the psychological impact of HIV in adolescents in Namibia, including risk and protective factors associated with mental health.

METHODS

Ninety-nine fully disclosed ALHIV between the ages of 12 and 18 were interviewed at a State Hospital in Windhoek. A structured questionnaire assessed mental health, using the SDQ (Goodman, 1997), sociodemographic factors, poverty, social support, adherence and stigma.

RESULTS

Mean age was 14.3 years, 52.5% were female and most were healthy. Twelve percent scored in the clinical range for total mental health difficulties and 22% for emotional symptoms. Poverty was associated with more total mental health difficulties, t(96) = -2.63, p = .010, and more emotional symptoms, t(96) = -3.45, p = .001, whereas better social support was a protective factor, particularly caregiver support (r = -.337, p = .001). Adherence problems, HIV-related stigma and disclosing one's own HIV status to others were also associated with more total mental health difficulties. Poverty (β = -.231, p = .023) and stigma (β = .268, p = .009) were the best predictors for total mental health difficulties, whereas stigma (β = .314, p = .002) predicted emotional symptoms. Social support had a protective effect on peer problems (p = .001, β = -.349).

CONCLUSIONS

Several contextual factors associated with poorer mental health in ALHIV are identified.

Parenting for the promotion of adolescent mental health: a scoping review of programmes targeting ethnoculturally diverse families

A scoping review of the literature on parenting programmes that target the promotion of adolescent mental health was conducted to examine the quality of the studies and unique content of programmes for parents from ethnoculturally diverse communities. PsycINFO and Web of Science were searched in April, 2011 (for all publications prior to that date) and again in August, 2015 (for publications from April, 2011 to August, 2015) using specific keywords and inclusion criteria. A hand search was also conducted. Overall, 107 studies met inclusion criteria for final data extraction and included evaluations of interventions targeted at substance use, early/risky sexual activity and behavioural problems. Eighteen of the 107 studies described programmes targeting parents of adolescents from diverse ethnocultural communities; the quality of these 18 studies was assessed using a marginally modified version of the Downs and Black Checklist (Downs & Black 1998). Their average quality assessment score was 16 out of 28. In addition, two key themes reflected in successful interventions emerged: strengthening parent-adolescent relationship through communication, and importance of community engagement in designing and implementing the intervention. Findings indicate gaps in service delivery to parents of adolescents from ethnoculturally diverse communities; there are a limited number of studies on programmes targeting ethnoculturally diverse parents of adolescents, and the quality of studies that do exist is overall low. Given increasing diversity, more emphasis should be placed on developing and modifying programmes to meet the needs of ethnoculturally diverse communities. More rigorous, standardised efforts should be made to evaluate programmes that do exist.

Encouraging understanding or increasing prejudices: A cross-sectional survey of institutional influence on health personnel attitudes about refugee claimants' access to health care

Background

This paper investigates the personal, professional and institutional predictors of health institution personnel's attitudes regarding access to healthcare for refugee claimants in Canada.

Methods

In Montreal, the staff of five hospitals and two primary care centres (n = 1772) completed an online questionnaire documenting demographics, occupation, exposure to refugee claimant patients, and attitudes regarding healthcare access for refugee claimants. We used structural equations modeling to investigate the associations between professional and institutional factors with latent functions of positive and negative attitudes toward refugee's access to healthcare.

Results

Younger participants, social workers, participants from primary care centres, and from 1st migrant generation had the lowest scores of negative attitudes. Respondents who experienced contact with refugees had lower scores of negative attitudes (B = -14% standard deviation [SD]; 95% CI: -24, -4%). However, direct contact with refugees increased scores of negative attitudes in the institution with the most negative attitudes by 36% SD (95% CI: 1, 71%).

Interpretation

Findings suggest that institutions influence individuals’ attitudes about refugee claimants’ access to health care and that, in an institutional context of negative attitudes, contact with refugees may further confirm negative perceptions about this vulnerable group.

Growing healthy children and communities: Children's insights in Lao People's Democratic Republic

A diverse group of 103 children aged 7-11 years old living in family and residential care in rural and urban settings in two northern provinces in Lao People's Democratic Republic participated in group discussions using images and community mapping. Children's identified sources of risk and protection illustrate primary public health and protection concerns and resources. Young children worried about lack of hygiene, unintentional injuries, corporal punishment, and domestic violence. They also expressed concern about gambling and children sleeping in the streets, even if they had never seen any of the latter in their communities. In contrast, food and shelter; artistic, religious, and cultural practices; supportive interpersonal relationships; and schooling largely evoked feelings of safety and belonging. Images that prompted conflicting interpretations surfaced individual and contextual considerations that nuanced analysis. Researchers and decision-makers will benefit from using this developmentally appropriate, context-sensitive child-centred visual method to elicit young children's views of risk and protection. It may also serve as a tool for public health education. Involving young children in the initial selection of images would further enhance the efficiency of the method.

Knowledge of Healthcare Coverage for Refugee Claimants: Results from a Survey of Health Service Providers in Montreal

Following changes to the Interim Federal Health (IFH) program in Canada in 2012, this study investigates health service providers' knowledge of the healthcare coverage for refugee claimants living in Quebec. An online questionnaire was completed by 1,772 staff and physicians from five hospitals and two primary care centres in Montreal. Low levels of knowledge and significant associations between knowledge and occupational group, age, and contact with refugees were documented. Social workers, respondents aged 40-49 years, and those who reported previous contact with refugee claimants seeking healthcare were significantly more likely to have 2 or more correct responses. Rapid and multiple changes to the complex IFH policy have generated a high level of confusion among healthcare providers. Simplification of the system and a knowledge transfer strategy aimed at improving healthcare delivery for IFH patients are urgently needed, proposing easy avenues to access rapidly updated information and emphasizing ethical and clinical issues.

Research ethics in global mental health: advancing culturally responsive mental health research

Global mental health research is needed to inform effective and efficient services and policy interventions within and between countries. Ethical reflection should accompany all GMHR and human resource capacity endeavors to ensure high standards of respect for participants and communities and to raise public debate leading to changes in policies and regulations. The views and circumstances of ethno-cultural and disadvantaged communities in the Majority and Minority world need to be considered to enhance scientific merit, public awareness, and social justice. The same applies to people with vulnerabilities yet who are simultaneously capable, such as children and youth. The ethical principles of respect for persons or autonomy, beneficence/non-maleficence, justice, and relationality require careful contextualization for research involving human beings. Building on the work of Fisher and colleagues (2002), this article highlights some strategies to stimulate the ethical conduct of global mental health research and to guide decision-making for culturally responsible research, such as developing culturally sensitive informed consent and disclosure policies and procedures; paying special attention to socioeconomic, cultural, and environmental risks and benefits; and ensuring meaningful community and individual participation. Research and capacity-building partnerships, political will, and access to resources are needed to stimulate global mental health research and consolidate ethical practice.

Access to health care for undocumented migrant children and pregnant women: the paradox between values and attitudes of health care professionals

Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children's rights are needed to promote equitable practices and advocacy against regulations limiting services.

Supervisory neglect and risk of harm. Evidence from the Canadian Child Welfare System

OBJECTIVE

This study explores prevalence and characteristics associated with supervisory neglect and physical harm in children in the child welfare system in Canada.

METHODS

The sample included all substantiated primary maltreatment investigations in the 2008 Canadian Incidence Study of Reported Child Abuse and Neglect excluding cases where exposure to intimate partner violence was the sole reason for investigation (n=3,380). Bivariate tests were used to assess differences across types of maltreatments and to compare supervisory neglect cases with and without physical harm on factors related to child injury and supervision.

RESULTS

Supervisory neglect was the primary concern in an estimated 12,793 cases of substantiated maltreatment across Canada in 2008. Compared to other types of maltreatment, cases of supervisory neglect involved more overcrowded housing conditions and children who were younger and less likely to have any functioning issue. Injuries were noted in only 2% of cases supervisory neglect and half of these injuries were not severe enough to require medical treatment. Other physical health conditions were noted in 2% of supervisory neglect cases. Physical harm was noted most often for toddlers (1-2 years old) and adolescents (12-15 years old). Household and caregiver characteristics were not associated with greater rates of physical harm. In contrast, 7% of children with any risk factor suffered physical harm as a result of supervisory neglect mainly related to substance abuse, self-harming behavior, and multiple incidents of running from care.

CONCLUSIONS

Child risk factors are often present in cases of supervisory neglect with physical harm. Nonetheless, 96% of all cases of supervisory neglect substantiated by Canadian child welfare authorities do not involve physical harm. Clearer guidelines are needed for the assessment of supervisory neglect. Alternative response systems may be more suitable for low-risk cases.

"When it's just me at home, it hits me that I'm completely alone": an online survey of adolescents in self-care

The present study examined adolescents' experiences of loneliness and solitude in their responses to an online survey on self-care. Both quantitative (n = 272) and qualitative (n = 150) responses were coded for these feelings when home alone. Results indicate that adolescents experience the duality of aloneness, including both positive solitude and negative loneliness. Adolescents' responses range from embraced solitude and self-care to feelings of loneliness and rejection of time by themselves. Adolescents reporting loneliness were significantly less likely to enjoy being home alone during the day and at night (p < or = .001). Also, gender, age, and emotions such as fear, boredom, and separation anxiety are associated with loneliness among adolescents in self-care. Interventions to increase connectedness and combat loneliness during out-of-school hours are recommended.

Unintentional childhood injuries in sub-Saharan Africa: an overview of risk and protective factors

The rate of unintentional injuries for children in sub-Saharan Africa has reached 53.1 per 100,000, the highest for regions across all income levels. This paper reviews the relevant literature on the epidemiology of unintentional childhood injuries in the region, with an emphasis on the risk factors associated with it. Several demographic, socioeconomic, and environmental factors contributing to injuries in children have been documented for the main causes of injury. Despite the high burden, child injury prevention and control programs and policies are limited or non-existent in many countries in the region. Accurate data regarding these injuries across and within countries is incomplete. Population-based estimates and investigations into context-specific risk factors, safety attitudes, and behaviours are needed to inform the development of effective interventions.

The association of single and double orphanhood with symptoms of depression among children and adolescents in Namibia

Despite high orphanhood and HIV prevalence rates in Southern Africa, no research has focused on mental health among orphaned children in Namibia. This study examined the association of orphan status and depressive symptoms in children and adolescents in Namibia. A back-translated Rukwangali and Silozi version of the children's depression inventory (CDI) was administered to 157 students (grades 1-10) in three schools in Kavango and Caprivi regions. Logistic regression was used to assess the relationship between type of orphanhood (single and double) and scores > or = 19 on the CDI. Participants (Mage = 14.9 year, SD = 3.1; 80 females, 77 males) included 84 non-orphans, 50 single orphans, and 23 double orphans. The mean total score on the CDI for the whole sample was 13.2 (SD = 6.0, range = 2-33, median = 12.0). Using the standard cut-point of > or =19 on the CDI, 21.9% of single and double orphans and 11.9% of non-orphans exhibited depressive symptoms. Double orphans were significantly more likely to score > or = 19 on the CDI than non-orphans (odds ratio [OR] = 3.23, 95% confidence interval [CI] = 1.07-9.79, P = 0.037). Single orphans were also more likely to score at least 19 on the CDI, although this was not significant (OR = 1.62, 95% CI = 0.61-4.32, P = 0.331). The study provides evidence that orphanhood is associated with ill mental health and that high rates of psychological distress are present in approximately 1 in 6 children and adolescents in Namibia. Mental health assessments are needed to validate cut-points locally and measure levels of impairment among children and adolescents, particularly orphans. Given the small sample size and limited power of the study, it is important that future studies address the issue of mental health among orphans in Namibia to inform the development of concrete policies and services for this population.

Children home alone unsupervised: modeling parental decisions and associated factors in Botswana, Mexico, and Vietnam

OBJECTIVE

This paper examines different child care arrangements utilized by working families in countries undergoing major socio-economic transitions, with a focus on modeling parental decisions to leave children home alone.

METHOD

The study interviewed 537 working caregivers attending government health clinics in Botswana, Mexico, and Vietnam. Analyses involve descriptive statistics, content analysis, and ethnographic decision modeling.

RESULTS

In one-half of the families in Botswana, over one-third of the families in Mexico, and one-fifth of the families in Vietnam, children are left home alone on a regular or occasional basis. Moreover, 52% of families leaving children home alone relied on other children to help with child care. Parental unavailability and poor working conditions, limited support networks, inability to afford child care, neighborhood safety, and children's age are critical factors in parents' decisions to leave children home alone. Children also may remain home alone or without quality supervision when informal child care providers fail to provide care. Seldom their preferred choice, parents identified risks (e.g., increasing unintentional injuries, loneliness, and poor behavioral and developmental consequences) and benefits (e.g., strengthening child independence and sibling relations) of this arrangement.

CONCLUSIONS

Poverty, social integration, local norms, and child development frame parents' decisions of care. Insufficient societal support to working families frequently resulted in unsafe child care arrangements and limited parental involvement in child education and health care. Current, comprehensive data on this phenomenon are needed to inform social services and policies in countries undergoing major socio-economic transitions.

PRACTICE IMPLICATIONS

Existing attention to children home alone has mostly focused on the associated risks, injuries, and poor outcomes; consequently, this child care arrangement is often assessed as parental neglect. However, understanding why children are left home alone or under the supervision of another child is crucial to the development of suitable interventions. Findings from this study of parental decision-making in Botswana, Mexico, and Vietnam highlight the need to understand the etiology of each case to assess whether parents are seeking the best option among untenable choices, or if it is, indeed, a case of parental, caregiver, or societal neglect.