INTRODUCTION: As part of a laboratory strengthening program in Malawi to achieve and maintain International Organization for Standardization (ISO) 15189 accreditation, we intended to mentor selected HIV molecular laboratories to achieve this accreditation. Due to the COVID-19 pandemic, mentorship pivoted to a hybrid model using an Internet-based approach and on-site mentorships. We describe the implementation of this strategy, successes, and challenges. METHODS: We conducted weekly, 1-hour virtual mentorship sessions for the 5 initial laboratories (cohort 1) selected based on their Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) performance score of 3 or more stars. Laboratories presented updates and supporting documents electronically, and trainings were conducted virtually. In September 2020, when travel restrictions were relaxed, we initiated hybrid mentorships and audits for cohort 1 laboratories. The same hybrid approach was used to mentor 4 additional laboratories in cohort 2. We performed descriptive analysis, and the Wilcoxon signed-rank test was used to compare the training pre-and post-test scores. RESULTS: Between March 2020 and May 2023, the team completed a total of 54 virtual mentorship sessions and 20 on-site visits across 9 laboratories. Overall, the team conducted 8 training sessions for 35 laboratory quality officers. Median score improvement (pre-test vs. post-test scores) was observed across individual trainings and across cohorts (P<.01). At the end of cohort 1, 4 of 5 (80%) laboratories were accredited. One laboratory that did not reach accreditation joined cohort 2. At the end of the mentoring period, all 5 cohort 2 laboratories were accredited. CONCLUSIONS: We demonstrated that using a hybrid mentorship model for accreditation was a successful strategy during the COVID-19 pandemic. For the first time in Malawi, this strategy resulted in accrediting 9 of the 10 HIV molecular laboratories in 3 years at a reduced cost. Continuous mentorship is key in the maintenance of accreditation.

From Malawi's HIV case surveillance, we report clinical characteristics and outcomes of 4461 children living with HIV on antiretroviral treatment aged <5 years from January to December, 2022. Among the 4% of children living with HIV who died, 43% were asymptomatic, 35% had advanced or severe symptoms at the time of HIV diagnosis and 50% died within 6 months of receiving an HIV diagnosis.

Few studies have investigated tobacco use among people with disabilities living in low- and middle-income countries (LMICs). We aimed to examine current tobacco use among men and women with disabilities using Demographic and Health Survey (DHS) data from 9 LMICs. We considered a respondent currently use tobacco products if they reported current use of any combustible/smoked tobacco products or smokeless tobacco products. We performed secondary analyses of DHS data from 2016-2021 collected in Haiti, Mali, Mauritania, Nigeria, Pakistan, Rwanda, South Africa, Timor-Leste, and Uganda. We examined marginal effects in logistic regression to calculate the adjusted prevalence and adjusted prevalence differences of tobacco use by disability status, controlling for selected sociodemographic characteristics. The adjusted prevalence of current use of tobacco products among women with a moderate/severe disability, mild disability, and no disability varied across countries, with medians of 1.9% (range = 0.1% [Mali] to 11.3% [Pakistan]), 3.2% (range = 0.9% [Nigeria] to 13.3% [South Africa]), and 2.3% (range = 0.5% [Nigeria] to 8.9% [South Africa]), respectively. For men with moderate/severe disability, the median adjusted prevalence for current use of tobacco products was 18.8% (range = 8.9% [Rwanda] to 55.0% [Timor-Leste]). The median prevalences of current use of tobacco products for men with mild disability and no disability were similar to those with moderate/severe disability, at 16.5% and 15.9%, respectively. Current tobacco product use among people with disabilities varied for countries included in our study; however, with few exceptions, current tobacco product use was similar across disability status groups. Additional research is warranted to determine whether our findings extend beyond the nine countries assessed here. It is important to consider the needs of people with disabilities in tobacco prevention, control, and cessation efforts so that this substantial population can benefit equitably from such programs, interventions, or policies.

Purpose: The pathways by which adverse childhood experiences (ACEs) are associated with early marriage and early pregnancy are poorly understood. Early marriage and early pregnancy may be risk factors for adulthood intimate partner violence (IPV). The aim of this study was to assess the relationships among ACEs, early marriage, early pregnancy, and IPV among women in Honduras. Method: We used weighted data from 1,436 women aged 18–24 years from the nationally representative 2017 Honduras Violence Against Children and Youth Survey. We used path analysis to estimate relationships and accounted for sample design, non-response, and within-country clustering. Results: We found that ACEs had differential relationships with outcomes of interest. For example, witnessing violence in the community was directly associated with increased probability of early pregnancy (10 percentage points (PP); 95% CI: 0.04, 0.15) and IPV (6 PP; 95% CI: 0.01, 0.10), while emotional violence was not directly or indirectly associated with any outcome. Early marriage and early pregnancy had no direct or indirect effect on IPV, but the total effect of early marriage on IPV was significant. Conclusions: Understanding the relationship between ACEs, early marriage, early pregnancy, and IPV may help inform prevention efforts. For example, programs aiming to reduce early pregnancy may consider addressing sexual violence experienced in childhood. © 2023, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

The implementation of several tobacco control policies in the Philippines may have contributed to a decrease in secondhand smoke (SHS) exposure. We examined changes in SHS exposure at work and in public places between 2009 and 2015 among adults aged ≥15 years and interpreted these results within the tobacco policy landscape in the Philippines. We analyzed the Philippines Global Adult Tobacco Survey 2009 and 2015 data. We examined marginal effects in logistic regression to get the adjusted prevalence of SHS exposure at five work and public places, controlling for selected characteristics. We calculated adjusted prevalence ratios and adjusted prevalence differences between 2009 and 2015. Adjusted prevalence of SHS exposure decreased from 2009 to 2015 by 19% (5.7 percentage points) at work, 45% (11.2 percentage points) in government buildings, 48% (3.2 percentage points) in healthcare facilities, 29% (8.2 percentage points) in restaurants, and 33% (19.9 percentage points) on public transportation. Although the prevalence of SHS exposure at work and in public places decreased significantly between 2009 and 2015, a substantial proportion of adults remain exposed to SHS. This study highlights the importance of continued implementation, enforcement, monitoring, and evaluation of tobacco control and prevention measures in the Philippines.

There has been increasing national attention to the issue of racial disparities in pregnancy-related deaths. Federal legislation can support approaches at multiple levels of intervention to improve maternal health. As part of the CDC Policy Academy, a team of CDC staff completed a policy analysis to determine the approaches addressed in federal legislation to reduce racial disparities in pregnancy-related deaths. We analyzed federal maternal mortality legislation introduced January 2017 through December 2021. Common approaches addressed by the legislation were categorized into themes and reviewed for their alignment with approaches identified in clinical and public health literature to reduce pregnancy-related deaths, with an emphasis on social determinants of health (SDOH) approaches and reducing racial disparities. Thirty-seven unduplicated bills addressed pregnancy-related deaths, including 27 House or Senate bills that were introduced but not passed, 6 resolutions highlighting the maternal health crisis, 2 bills that passed the House only, and 2 bills enacted into law (Preventing Maternal Deaths Act of 2018 and Protecting Moms Who Served Act). The most common themes mentioned in federal legislation were improving maternal health care, addressing health inequities and SDOH, enhancing data, and promoting women's health. Legislation focused on health inequities and SDOH emphasized implicit bias training and improving SDOH, including racism and other social factors. The reviewed federal legislation reflected common clinical and public health approaches to prevent pregnancy-related deaths, including a significant focus on reducing bias and improving SDOH to address racial disparities.

BACKGROUND: Mental health problems ranging from depression to more severe acts such as self-harm or suicidal behaviours are a serious problem among adolescents and young adults. Exposure to violence during the life of young people can increase mental health issues for youth. This study examines the relationship between exposure to violence and mental health issues among youth using a nationally representative study in Malawi. METHODS: We analysed data from the nationally representative Violence Against Children Survey from Malawi (2013) to quantify the association between exposures to violence (physical, sexual and emotional) and their relationship with mental distress, self-harm behaviours and suicidal ideation and attempts among youth aged 13-24 years. We evaluated the association of exposures to violence against children with reported mental health conditions among women and men. We used ordinal logistic regression models with appropriate survey weights to assess exposures to violence and the three outcomes of interest. RESULTS: Children and youth aged 13-24 years exposed to violence in childhood reported higher levels of adverse mental health effects, including mental distress, self-harm behaviours and suicidal ideation and attempts. The odds of reporting these outcomes increased as the number of violence types increased. CONCLUSIONS: Understanding the risks based on different combinations of exposures to violence in Malawi can help identify populations at higher risk and optimise violence prevention strategies.

Country-specific estimates of tobacco use among people living with HIV (PLWH) are lacking for much of sub-Saharan Africa. We aim to evaluate the association between the HIV status and tobacco product use status, frequency, and intensity, using nationally representative data from Zambia. We analyzed data from the 2018 Demographic and Health Survey conducted in Zambia among women aged 15-49 years and men aged 15-59 years. We performed logistic regression to assess the associations of HIV status, selected sociodemographic, and other characteristics with indicators of tobacco use (i.e., status, frequency, and intensity). Among women, 14.3% tested positive for HIV and 2.7% reported current smoking or tobacco use; women living with HIV were more likely to report currently smoking or using tobacco than women living without HIV (4.4% vs. 2.4%; aPR: 1.46). Among men, 8.4% tested positive for HIV and 19.5% reported current smoking; men living with HIV were more likely than men living without HIV to report current smoking (27.8% vs. 18.7%; aPR: 1.22). Several sociodemographic characteristics were associated with tobacco use, including age, residence (urban/rural), education level, employment status, and wealth index. The frequency and intensity of smoking among men who currently smoked did not differ by HIV status. Tobacco use was more likely in PLWH than those without HIV in Zambia. Our findings highlight the need to encourage and support tobacco cessation among PLWH, possibly by offering cessation services at existing intersections with health care or integrating cessation support into mHealth and other alternative models of care. Copyright © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

INTRODUCTION: Tobacco is the leading cause of preventable death in the world. Identification of factors associated with quit attempts and successful quitting can help strengthen tobacco cessation programs. In Ethiopia, no prior study of such factors exists. Our aim was to identify factors associated with quit attempts and successful quitting among adults who smoke tobacco in Ethiopia. METHODS: We used the Ethiopian 2016 Global Adult Tobacco Survey (GATS) data (n=10150). GATS is a nationally representative household survey that collects data on sociodemographic and tobacco-related characteristics. We calculated prevalence of reported past 12 months quit attempts and successful quitting and performed logistic regression to obtain prevalence ratios with 95% confidence intervals. A p<0.05 was considered statistically significant. RESULTS: Overall 42.0% of people who smoked tobacco made a quit attempt. Men were more likely (APR=3.9; 95% CI: 1.4-10.7) to make a quit attempt compared to women but were less likely to successfully quit (APR=0.6; 95% CI: 0.3-0.9). Those aware of the health harms of tobacco were 2.5 (95% CI: 1.1-5.5) and 3.9 (95% CI: 1.8-8.5) times as likely to make a quit attempt and successfully quit, respectively, than those unaware. Receiving healthcare provider advice to quit was not associated with quit attempts. CONCLUSIONS: More than 4 in 10 people smoking tobacco in Ethiopia are making attempts to quit. Receipt of healthcare provider advice to quit is not yet associated with quit attempts in Ethiopia; however, awareness of the health harms of tobacco is a powerful predictor of quit attempt and success in quitting. Improved access to cessation support and expanded awareness of the health harms of tobacco are urgently needed to enhance both quit attempts and success across Ethiopia.

INTRODUCTION: Noticing health warnings on cigarette packages has been associated with thinking about quitting. This study examined sociodemographic characteristics associated with awareness of health warnings on cigarette packages and thinking about quitting because of health warning labels among adults who currently smoked tobacco. METHODS: We analyzed data from the 2017 Zambia WHO STEPS survey (STEPwise approach to surveillance) for noncommunicable disease risk factors. Descriptive analyses and logistic regression were performed to assess the association of select sociodemographic characteristics with awareness of health warnings and thinking about quitting because of health warnings. RESULTS: Adults who currently smoked tobacco who were aged 30-44 years, of Chewa ethnicity, or with a formal education, were more likely to be aware of health warnings than those aged 18-29 years (adjusted prevalence ratio, APR=1.26; 95% CI: 1.02-1.54), of Bemba ethnicity (APR=1.43; 95% CI: 1.17-1.74), or with no formal education (APR: 2.61-5.95). Among all adults who currently smoked, those of Chewa ethnicity (APR=1.55; 95% CI: 1.03-2.35), or with a formal education (APR:1.80-4.38), were more likely to report thinking about quitting because of health warnings than those who were of Bemba ethnicity or with less than primary school education level. Women who currently smoked were 49% less likely (APR=0.51; 95% CI: 0.23-0.84) to report thinking about quitting than men. Among a subset of adults who currently smoked who were aware of health warning labels, no sociodemographic characteristics were significantly associated with thinking about quitting in unadjusted or adjusted models. CONCLUSIONS: Sociodemographic characteristics such as sex, ethnicity, and education level were significantly associated with awareness of cigarette health warnings. Among cigarette smokers aware of health warnings, no sociodemographic differences in thinking about quitting were found. Tobacco control campaigns may need to target people of ethnicities with the highest smoking prevalence in the country.

We aimed to assess Centers for Disease Control and Prevention (CDC) data systems on the extent of data collection on sex, sexual orientation, and gender identity as well as on age and race/ethnicity. Between March and September 2019, we searched 11 federal websites to identify CDC-supported or -led U.S. data systems active between 2015 and 2018. We searched the systems' website, documentation, and publications for evidence of data collection on sex, sexual orientation, gender identity, age, and race/ethnicity. We categorized each system by type (disease notification, periodic prevalence survey, registry/vital record, or multiple sources). We provide descriptive statistics of characteristics of the identified systems. Most (94.1%) systems we assessed collected data on sex. All systems collected data on age, and approximately 80% collected data on race/ethnicity. Only 17.7% collected data on sexual orientation and 5.9% on gender identity. Periodic prevalence surveys were the most common system type for collecting all the variables we assessed. While most U.S. public health data and monitoring systems collect data disaggregated by sex, age, and race/ethnicity, far fewer do so for sexual orientation or gender identity. Standards and examples exist to aid efforts to collect and report these vitally important data. Additionally important is increasing accessibility and appropriately tailored dissemination of reports of these data to public health professionals and other collaborators.

OBJECTIVE: Research on adverse childhood experiences (ACEs) and use of modern contraception is limited in Honduras. The government has made substantial gains in promoting modern contraception. Young adults experience high rates of violence. The aim of this study was to assess the relationship between ACEs and contraceptive behaviors among young women and men. METHODS: We used data from 810 women and 753 men aged 18-24 years from the 2017 Honduras Violence against Children Survey, a cross-sectional, nationally representative household survey of childhood adversity. We assessed associations between ACEs and three contraceptive use outcomes: use versus nonuse of modern contraceptives; use of methods requiring medium/high or low programmatic support among current contraceptive users; and frequent versus infrequent condom use. FINDINGS: Exposure to physical or emotional abuse and witnessing violence in the home was not significantly associated with the three contraceptive use outcomes for men or women. Sexual abuse and parental separation reduced odds of contraceptive use among women (Odds Ratio (OR) < 0.60) but not among men. In contrast, orphan status increased odds of modern contraception use among men (OR 1.93) and frequent condom use among women (OR 2.22). CONCLUSION: The inconsistent direction and magnitude of associations between ACEs and modern contraceptive use among young men and women suggests divergent relationships between ACEs and sexual and reproductive health behaviors. Results may highlight the strength of norms around contraceptive use and/or widespread access to community-based family planning programs and comprehensive sexuality education, irrespective of exposure to ACEs in Honduras.

BACKGROUND: Research from high-income countries shows that witnessing intimate partner violence (IPV) between caregivers is experienced by up to a third of all children and is related to poor mental health outcomes. Much less is known about the burden of witnessing IPV in low- and middle-income countries. OBJECTIVES: This study seeks to explore the magnitude of witnessing IPV between caregivers, its association with other types of violence and the relationship between witnessing IPV in the past and current mental distress. PARTICIPANTS AND SETTING: Representative data from the Violence against Children Surveys (VACS) from Cambodia (N = 2373), Malawi (N = 2147) and Nigeria (N = 4098) are employed. METHODS: Logistic regression was applied to assess the association between witnessing IPV in childhood and mental distress in adulthood. RESULTS: Between 22.4 % and 34.3 % of participants witnessed IPV between their caregivers during childhood. Respondents who witnessed IPV had higher odds of mental distress, compared to those who did not witness IPV in Cambodia (OR 2.73 [2.02, 3.72] for females, OR 2.38 [1.67, 3.41] for males) and Malawi (OR 2.48 [1.43, 4.28] for females, OR 1.66 [1.11, 2.48] for males). In Nigeria only male respondents who witnessed IPV had higher odds of mental distress (OR 2.12 [1.60, 2.80]), but females had no significant association (OR 0.91 [0.68, 1.20]). CONCLUSIONS: The findings highlight the association of negative mental health consequences faced by children living in households with intimate partner violence for selected low- and middle-income countries. Children's exposure to IPV should be considered when providing support to survivors of IPV. Special considerations should be made to provide culturally and resource-appropriate support.

The purpose of this study was to assess whether the endorsement of inequitable gender norms about intimate partner violence against women (IPVAW) and sexual behavior was associated with intimate partner violence (IPV) victimization, IPV perpetration, and sexual risk behavior. Nigerian youth aged 13-24 (n = 4,203) participated in the nationally representative, cross-sectional Nigeria Violence Against Children Survey (VACS) in 2014. Inequitable gender norms about IPVAW were assessed using six items from the Demographic and Health Surveys (DHS), and inequitable gender norms about sexual behavior were assessed using four items adapted from the Gender-Equitable Men (GEM) scale. The number of inequitable gender norms endorsed was summed and associations with having been a victim or perpetrator of IPV and sexual risk behaviors were assessed using logistic regression. Endorsing 3 or more inequitable gender norms about either IPVAW or sexual behavior were both associated with increased odds of IPV victimization, perpetration, and sexual risk behaviors, after adjustment for demographic characteristics, witnessing violence in childhood, and having been a victim of other forms of childhood violence. Demonstrating that endorsement of inequitable gender norms about sexual behavior was associated with violence and that inequitable gender norms about IPVAW were associated with sexual risk behaviors further highlights potential linkages between violence and HIV.

This study aims to quantify the prevalence of forced sex, pressured sex, and related pregnancy among adolescent girls and young women in five low- and middle-income countries. Nationally representative, cross-sectional household surveys were conducted in Haiti, Malawi, Nigeria, Zambia, and Uganda among girls and young women aged 13 to 24 years. A stratified three-stage cluster sample design was used. Respondents were interviewed to assess prevalence of sexual violence, pregnancy related to the first or most recent experience of forced or pressured sex, relationship to perpetrator, mean age at sexual debut, mean age at pregnancy related to forced or pressured sex, and prevalence of forced/coerced sexual debut. Frequencies, weighted percentages, and weighted means are presented. The lifetime prevalence of forced or pressured sex ranged from 10.4% to 18.0%. Among these adolescent girls and young women, the percentage who experienced pregnancy related to their first or most recent experience of forced or pressured sex ranged from 13.2% to 36.6%. In three countries, the most common perpetrator associated with the first pregnancy related to forced or pressured sex was a current or previous intimate partner. Mean age at pregnancy related to forced or pressured sex was similar to mean age at sexual debut in all countries. Preventing sexual violence against girls and young women will prevent a significant proportion of adverse effects on health, including unintended pregnancy. Implementation of strategies to prevent and respond to sexual violence against adolescent girls and young women is urgently needed.

BACKGROUND: Globally, over 1 billion children are victims of violence against children annually. Studies examining the health consequences of childhood violence have mostly focused on childhood physical violence (PV) and sexual violence (SV). Recent evidence suggests that childhood emotional violence (EV) may also be deleterious to the health and wellbeing of victims. OBJECTIVE: This study examines the independent association between EV and some health conditions, risk taking behaviors, and violence perpetration among Nigerian young adults ages 18-24 years. PARTICIPANTS AND SETTING: Data from 2014 Nigeria Violence Against Children Survey (n = 4,203), a nationally representative cross-sectional survey of individuals ages 13-24 were used. METHODS: Childhood EV was defined as EV victimization before age 18 perpetrated by a parent, adult caregiver or other adult relative. Logistic regression analyses assessed the association between EV in childhood and mental distress in the past 30 days, ever self-harm behaviors and history of sexually transmitted infections; risk behaviors such as having multiple sex partners in the past 12 months; and ever violence perpetration. RESULTS: After controlling for study covariates, EV in childhood was associated with mental distress in both males and females, and self-harm behaviors in females; excessive alcohol use and infrequent condom use in males, and multiple sexual partners in females; and PV perpetration in males and SV perpetration in females. CONCLUSION: EV in childhood is associated with some health conditions, risk taking behaviors, and violence perpetration. Implementing programs that address all forms of violence in childhood, including EV may benefit children.

INTRODUCTION: Coerced and forced sexual initiation (FSI) can have detrimental effects on children and youth. Understanding health outcomes that are associated with experiences of FSI is important for developing appropriate strategies for prevention and treatment of FSI and its consequences. METHODS: The Violence Against Children Surveys were conducted in Nigeria, Uganda, and Zambia in 2014 and 2015. We examined the prevalence of FSI and its consequences (sexual high-risk behaviors, violence experiences, mental health outcomes, and sexually transmitted infections (STI)) associated with FSI among youth aged 13-24 years in three countries in sub-Saharan Africa. RESULTS: Over one in ten youth aged 13-24 years who had ever had sex experienced FSI in Nigeria, Uganda, and Zambia. In multivariable logistic regression, FSI was significantly associated with infrequent condom use (OR=1.4, 95%CI=1.1-2.1), recent experiences of sexual violence (OR=1.6, 95%CI: 1.1-2.3), physical violence (OR=2.2, 95%CI: 1.6-3.0), and emotional violence (OR=2.0, 95%CI: 1.3-2.9), moderate/serious mental distress (OR=1.5, 95%CI: 1.1-2.0), hurting oneself (OR=2.0, 95%CI: 1.3-3.1), and thoughts of suicide (OR=1.5, 95%CI: 1.1-2.3), after controlling for demographic characteristics. FSI was not statistically associated with engaging in transactional sex, having multiple sex partners, or having a STI. CONCLUSION: FSI is associated with infrequent condom use, recent experiences of violence and mental health outcomes among youth in sub-Saharan Africa, which may increase the risk for HIV and other consequences. Developing strategies for prevention is important for reducing the prevalence of FSI and its effects on children and youth.

Children's exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

INTRODUCTION: Globally 1 billion children are exposed to violence every year. The Violence Against Children Surveys (VACS) are nationally representative surveys of males and females ages 13-24 that are intended to measure the burden of sexual, physical and emotional violence experienced in childhood, adolescence and young adulthood. It is important to document the methodological approach and design of the VACS to better understand the national estimates that are produced in each country, which are used to drive violence prevention efforts. METHODS: This study describes the surveys' target population, sampling design, statistical considerations, data collection process, priority violence indicators and data dissemination. RESULTS: Twenty-four national household surveys have been completed or are being planned in countries across Africa, Asia, the Caribbean, Central and South America, and Eastern Europe. The sample sizes range from 891 to 7912 among females (72%-98% response rate) and 803-2717 among males (66%-98% response rate). Two face-to-face interviews are conducted: a Household and an Individual Questionnaire. A standard set of core priority indicators are generated for each country that range from prevalence of different types of violence, contexts, risk and protective factors, and health consequences. Results are disseminated through various platforms to expand the reach and impact of the survey results. CONCLUSION: Data obtained through VACS can inform development and implementation of effective prevention strategies and improve health service provision for all who experience violence. VACS serves as a standardised tool to inform and drive prevention through high-quality, comprehensive data.

Adverse childhood experiences (ACEs) exhibit a dose-response association with poor health outcomes in adulthood, including HIV. In this analysis, we explored the relationship between ACEs and HIV sexual risk-taking behaviors among young adults in Malawi. We analyzed responses from sexually active 19- to 24-year-old males and females ( n = 610) participating in the Malawi Violence Against Children Survey. We tested the association between respondents' exposure to six ACEs (having experienced emotional, physical, or sexual violence; witnessing intimate partner violence or an attack in the community; one or both parents died) and infrequent condom use in the past year and multiple sexual partners in the past year. We used logistic regression to test the association between ACEs and these sexual risk-taking behaviors. A majority (82%) of respondents reported at least 1 ACE, and 29% reported 3+ ACEs. We found positive unadjusted associations between the number of ACEs (1-2 and 3+ vs. none) and both outcomes. In adjusted models, we found positive associations between the number of ACEs and infrequent condom use (adjusted odds ratio [aOR]: 2.7, 95% confidence interval [CI]: [1.0, 7.8]; aOR: 3.7, CI: [1.3, 11.1]). Among young adults in Malawi, exposure to ACEs is positively associated, in a dose-response fashion, with engaging in some sexual risk-taking behaviors. HIV prevention efforts in Malawi may benefit from prioritizing programs and policies aimed at preventing and responding to violence against children.

Objective: The epidemiology of violence against children is likely to differ substantially by sex and age of the victim and the perpetrator. Thus far, investment in effective prevention strategies has been hindered by lack of clarity in the burden of childhood violence across these dimensions. We produced the first age-specific and sex-specific prevalence estimates by perpetrator type for physical, sexual and emotional violence against children globally. Design: We used random effects meta-regression to estimate prevalence. Estimates were adjusted for relevant quality covariates, variation in definitions of violence and weighted by region-specific, age-specific and sex-specific population data to ensure estimates reflect country population structures. Data sources: Secondary data from 600 population or school-based representative datasets and 43 publications obtained via systematic literature review, representing 13 830 estimates from 171 countries. Eligibility criteria for selecting studies: Estimates for recent violence against children aged 0-19 were included. Results: The most common perpetrators of physical and emotional violence for both boys and girls across a range of ages are household members, with prevalence often surpassing 50%, followed by student peers. Children reported experiencing more emotional than physical violence from both household members and students. The most common perpetrators of sexual violence against girls aged 15-19 years are intimate partners; however, few data on other perpetrators of sexual violence against children are systematically collected internationally. Few age-specific and sex-specific data are available on violence perpetration by schoolteachers; however, existing data indicate high prevalence of physical violence from teachers towards students. Data from other authority figures, strangers, siblings and other adults are limited, as are data on neglect of children. Conclusions: Without further investment in data generation on violence exposure from multiple perpetrators for boys and girls of all ages, progress towards Sustainable Development Goals 4, 5 and 16 may be slow. Despite data gaps, evidence shows violence from household members, peers in school and for girls, from intimate partners, should be prioritised for prevention. Trial registration number: PROSPERO 2015: CRD42015024315.

INTRODUCTION: Sexual violence (SV) against children is a global health and human rights issue that can have short and long-term consequences for health and wellbeing. Disclosing SV increases the likelihood that children can access health and protective services and receive psychosocial support. Research in high-income countries has found that child SV survivors are more likely to disclose when they are girls/women, experience fewer SV events, and experience SV perpetrated by a stranger. No studies have examined correlates of SV disclosure in Kenya. OBJECTIVE: The objective of this research was to assess the correlates of disclosing SV among Kenyan youth ages 13-24 who reported an SV experience before age 18. METHODS: In 2010, the Kenya Ministry of Gender, Children and Social Development, the U.S. Centers for Disease Control and Prevention's (CDC) Division of Violence Prevention, the UNICEF Kenya Country Office, and the Kenya National Bureau of Statistics (KNBS) conducted a national survey of violence against children. These data were used to conduct weighted logistic regression analyses to determine which factors were correlated with reporting SV disclosure. RESULTS: Among the 27.8% of girls/women and 14.5% of boys/men who reported SV before age 18, 44.6% of girls/women and 28.2% of boys/men reported to have disclosed the experience. In weighted logistic regression analysis, the odds of disclosure were lower among survivors who were boys/men and among survivors who reported more SV events, and higher when any perpetrator was a family member. CONCLUSION: More context-specific research on SV disclosure among young people is needed globally.

Understanding factors that are associated with disclosure of sexual violence (SV) is important for the delivery of health services as well as developing strategies for prevention and response. The Violence Against Children Surveys were conducted in Malawi and Nigeria. We examined the prevalence of SV, help-seeking behaviors, and factors associated with disclosure among girls and young women aged 13 to 24. The self-reported prevalence of SV was similar in Nigeria (26%) and Malawi (27%). Among females who experienced SV, approximately one third (37%) in Nigeria and one half (55%) in Malawi ever disclosed their experience of SV. Females in Nigeria were significantly more likely to disclose to their parents (31.8%) than females in Malawi (9.5%). The most common reason for nondisclosure in Nigeria was not feeling a need or desire to tell anyone (34.9%) and in Malawi was embarrassment (29.3%). Very close relationships with one or both parents were significantly associated with disclosure among Nigerian females (odds ratio [OR] = 5.5, 95% confidence interval [CI] = [2.1, 14.6]) but were inversely associated with disclosure among Malawian females (OR = 0.05, 95% CI = [0.01, 0.33]). Reasons for nondisclosure of SV and factors associated with disclosure among females differ in the African nations studied. The stigma associated with shame of SV may prevent females from disclosing and thus receiving necessary support and health, social, and other services. This study demonstrates a need to reduce barriers for disclosure to improve the delivery of health, social, and other response services across African nations, as well as to develop culturally appropriate strategies for its response.

This study examines exposure to multiple forms of violence among Malawian children and youth and their association with mental health outcomes. The Malawi Violence Against Children and Young Women Survey was conducted among a nationally representative sample of males and females aged 13 to 24 years ( n = 2,162) in Malawi in 2013. The experience of sexual, physical, and emotional violence prior to age 18 and during the past 12 months and associated health outcomes were ascertained using a comprehensive interview. Latent factors of sexual violence, physical violence, and emotional violence as well as psychological distress were constructed. We examined whether the experience of violence was related to psychological distress after controlling for age and gender. Violence exposure prior to age 18 (early life) and during the past 12 months (proximal) were valid indicators for a latent factor representing overall lifetime violence exposure. Females were more likely to experience sexual violence, whereas males were more likely to experience physical violence. Experience of any type of violence decreased with age whereas experience of psychological distress increased with age. Current psychological distress was directly associated with exposure to sexual and emotional violence recently or during childhood. Exposure to multiple forms of violence during lifetime was related to two to seven folds higher odds of experiencing psychological distress compared with those who had never experienced violence. Future intervention strategies should address three forms of violence against children simultaneously in light of the associated adverse mental health outcomes.

More than 1 billion children - half the children in the world - are victims of violence every year. As part of the Post-2015 sustainable development agenda, the UN has issued a global call-to-action: to eliminate violence against children. Essential to preventing violence against children is guidance to countries on using the best available evidence to address this problem. THRIVES provides this evidence. It represents a framework of complementary strategies that, taken together, have potential to achieve and sustain efforts to prevent violence against children. These strategies, which span health, social services, education, and justice sectors, include Training in parenting, Household economic strengthening, Reduced violence through legislative protection, Improved services, Values and norms that protect children, Education and life skills, and Surveillance and evaluation. For each THRIVES area, we review evidence for effectiveness and identify programmatic or policy examples. This framework will facilitate commitments to effective, sustainable, and scalable action.

BACKGROUND: Under most circumstances, the lifetime experience of sexual violence (SV) among girls and young women would likely increase with age. However, the empirical data from a retrospective study may not necessarily conform to this belief. METHODS: Data from a nationally representative sample of females aged 13-24 years in Malawi in 2013 (n=1029) were analyzed. SV was defined as unwanted touching or attempted, pressured, or physically forced sex. The distribution of four types of SV among victims was compared between younger (13-18 years) and older (19-24 years) age groups. The strength of association between SV exposure and health outcomes was examined by age group. RESULTS: The risk of experiencing SV during their lifetime was three times greater for younger than that for older age females (Hazard ratio=3.32). Among females who had experienced SV, older age females were more likely to report forced or pressured sex (41.2%) as their initial SV experience than younger age females (17.8%). The strength of association between the SV exposure and health outcomes did not differ by age group. CONCLUSIONS: The self-report lifetime and childhood victimization to sexual violence may not necessarily higher among older than that among younger females. The current risk of exposure to sexual violence seems to influence the recall of lifetime and childhood victimization to a great extent. In order to make the field aware of this phenomenon, prevalence estimates from all three time frames (lifetime, childhood, and during the past 12 months) should be reported separately by age group.

BACKGROUND AND OBJECTIVE: Globally, little evidence exists on sexual violence against boys. We sought to produce the first internationally comparable estimates of the magnitude, characteristics, risk factors, and consequences of sexual violence against boys in 3 diverse countries. METHODS: We conducted nationally representative, multistage cluster Violence Against Children Surveys in Haiti, Kenya, and Cambodia among males aged 13 to 24 years. Differences between countries for boys experiencing sexual violence (including sexual touching, attempted sex, and forced/coerced sex) before age 18 years were examined by using chi(2) and logistic regression analyses. RESULTS: In Haiti, Kenya, and Cambodia, respectively, 1459, 1456, and 1255 males completed surveys. The prevalence of experiencing any form of sexual violence ranged from 23.1% (95% confidence Interval [CI]: 20.0-26.2) in Haiti to 14.8% (95% CI: 12.0-17.7) in Kenya, and 5.6% (95% CI: 4.0-7.2) in Cambodia. The largest share of perpetrators in Haiti, Kenya, and Cambodia, respectively, were friends/neighbors (64.7%), romantic partners (37.2%), and relatives (37.0%). Most episodes occurred inside perpetrators' or victims' homes in Haiti (60.4%), contrasted with outside the home in Kenya (65.3%) and Cambodia (52.1%). The most common time period for violence in Haiti, Kenya, and Cambodia was the afternoon (55.0%), evening (41.3%), and morning (38.2%), respectively. Adverse health effects associated with violence were common, including increased odds of transactional sex, alcohol abuse, sexually transmitted infections, anxiety/depression, suicidal ideation/attempts, and violent gender attitudes. CONCLUSIONS: Differences were noted between countries in the prevalence, characteristics, and risk factors of sexual violence, yet associations with adverse health effects were pervasive. Prevention strategies tailored to individual locales are needed.

OBJECTIVE: To describe the Violence Against Children Surveys (VACS). The survey is a national, household survey that systematically measures the prevalence, nature and consequences of sexual, physical and emotional violence against children. DESIGN: This report provides information about the history, implementation, ethical protections, utility, results, limitations, and future directions of the VACS work. RESULTS: The study has been implemented in 11 countries in Africa, Asia and the Caribbean, providing each of these countries with baseline data and momentum to address violence against children as a public health and human rights priority. These data are novel in each country, and VACS is well poised to contribute to an existing surveillance system or be used as the basis of a periodic surveillance system. CONCLUSIONS: Without ongoing surveillance to assess prevalence and the impact of policy, prevention and response programming, violence will likely continue to be overlooked as the linchpin public health crisis that it is, globally and in individual countries.

CONTEXT: Evidence confirms associations between childhood violence and major causes of mortality in adulthood. A synthesis of data on past-year prevalence of violence against children will help advance the United Nations' call to end all violence against children. OBJECTIVES: Investigators systematically reviewed population-based surveys on the prevalence of past-year violence against children and synthesized the best available evidence to generate minimum regional and global estimates. DATA SOURCES: We searched Medline, PubMed, Global Health, NBASE, CINAHL, and the World Wide Web for reports of representative surveys estimating prevalences of violence against children. STUDY SELECTION: Two investigators independently assessed surveys against inclusion criteria and rated those included on indicators of quality. DATA EXTRACTION: Investigators extracted data on past-year prevalences of violent victimization by country, age group, and type (physical, sexual, emotional, or multiple types). We used a triangulation approach which synthesized data to generate minimum regional prevalences, derived from population-weighted averages of the country-specific prevalences. RESULTS: Thirty-eight reports provided quality data for 96 countries on past-year prevalences of violence against children. Base case estimates showed a minimum of 50% or more of children in Asia, Africa, and Northern America experienced past-year violence, and that globally over half of all children-1 billion children, ages 2-17 years-experienced such violence. LIMITATIONS: Due to variations in timing and types of violence reported, triangulation could only be used to generate minimum prevalence estimates. CONCLUSIONS: Expanded population-based surveillance of violence against children is essential to target prevention and drive the urgent investment in action endorsed in the United Nations 2030 Sustainable Development Agenda.

Sexual violence against children is a significant global public health problem, yet limited studies exist from low-resource settings. In Haiti we conducted the country's first, nationally representative survey focused on childhood violence to help inform the development of a national action plan for violence against children. The Haiti Violence Against Children Survey was a household-level, multistage, cluster survey among youth age 13-24. In this analysis we sought to determine whether sexual violence sentinel events (unwanted sexual touching or unwanted attempted sex) were predictive of later unwanted, completed, penetrative sex in Haiti. We also sought to explore characteristics of sentinel events and help-seeking behavior among Haitian children. Multivariable logistic regression was used to test associations between sentinel events and later unwanted, completed, penetrative sex. Overall, 1,457 females reported on experiences of sexual violence occurring in childhood (before age 18). A sentinel event occurred in 40.4% of females who experienced subsequent unwanted completed sex. Females experiencing a sentinel event were approximately two and a half times more likely to experience later unwanted completed sex (adjusted odds ratio=2.40, p=.004) compared to individuals who did not experience a sentinel event. The mean lag time from first sentinel event to first unwanted completed sex was 2.3 years. Only half (54.6%) of children experiencing a sentinel event told someone about their experience of sexual violence. Among children, sentinel events occur frequently before later acts of completed unwanted sex and may represent a useful point of intervention. Reporting of sexual violence by children in Haiti is low and can be improved to better act on sentinel events.