While SARS-CoV-2 vaccines have shown strong efficacy, their suboptimal uptake combined with the continued emergence of new viral variants raises concerns about the ongoing and future public health impact of COVID-19. We investigated viral and host factors, including vaccination status, that were associated with SARS-CoV-2 disease severity in a setting with low vaccination rates. We analyzed clinical and demographic data from 1,957 individuals in the state of Georgia, USA, coupled with viral genome sequencing from 1,185 samples. We found no difference in disease severity between individuals infected with Delta and Omicron variants among the participants in this study, after controlling for other factors, and we found no specific mutations associated with disease severity. Compared to those who were unvaccinated, vaccinated individuals experienced less severe SARS-CoV-2 disease, and the effect was similar for both variants. Vaccination within 270 days before infection was associated with decreased odds of moderate and severe outcomes, with the strongest association observed at 91–270 days post-vaccination. Older age and underlying health conditions, especially immunosuppression and renal disease, were associated with increased disease severity. Overall, this study provides insights into the impact of vaccination status, variants/mutations, and clinical factors on disease severity in SARS-CoV-2 infection when vaccination rates are low. Understanding these associations will help refine and reinforce messaging around the crucial importance of vaccination in mitigating the severity of SARS-CoV-2 disease.

Introduction Under Sustainable Development Goal 5, prevalence of intimate partner violence (IPV) is a globally reportable indicator. There is a lack of consensus on how to measure and report psychological IPV, affecting prevalence estimates and cross-country comparability. We examine similarities and differences in the patterning of women's experiences of psychological abuse in low- and middle-income countries (LMICs) to inform common cut points. Methods Data include 13,452 ever-partnered women from six LMICs participating in the WHO multi-country study on women's health and domestic violence against women and 306,101 from 47 LMICs participating in the Demographic and Health Surveys. A confirmatory latent class analysis (LCA) approach was applied to identify the optimal class structure using the 3 DHS and 4 WHO psychological IPV items, assessed the impact of physical and sexual IPV on class structure, and tested class generalizability across countries. We validated the three-class solution by regressing the classes on physical IPV, sexual IPV, controlling behaviors, and injury due to domestic violence. We used item response theory (IRT) methods to assess item-level characteristics of the items. Results Analysis confirmed the three-class structure in most countries. Addition of physical and sexual IPV did not change overall class structure or improve discrimination or homogeneity of the items. The three-class structure was invariant within most WHO-classified regions. Operationalized classes informed by the LCA resulted in prevalences of roughly 90% low-to-no class, 7% moderate-intensity class, and 3% high-intensity class. Classes showed convergent validity with all outcomes tested. IRT analysis revealed good discriminations but substantial information overlaps over a narrow range of the latent psychological violence construct. Conclusions This study confirms the three-class pattern but suggests some differences across countries. and regions. We suggest cut points distinguishing violent from non-violent acts and demarcating levels of severity for future study. Findings offer evidence-based guidance to rectify challenges.

Women comprise two-thirds of the global-health (GH) workforce but are underrepresented in leadership. GH departments are platforms to advance gender equality in GH leadership. Using a survey of graduates from one GH department, we compared women's and men's post-training career agency and GH employment and assessed whether gender gaps in training accounted for gender gaps in career outcomes. Master-of-Public-Health (MPH) and mid-career-fellow alumni since 2010 received a 31-question online survey. Forty-four per cent of MPH alum and 24% of fellows responded. Using logistic regression, we tested gender gaps in training satisfaction, career agency, and GH employment, unadjusted and adjusted for training received. Women (N = 293) reported lower satisfaction with training (M7.6 vs 8.2) and career agency (leadership ability: M6.3 vs 7.4) than men (N = 60). Women more often than men acquired methods-related skills (95% vs 78%), employment recommendations (42% vs 18%), and group membership. Men more often than women acquired leadership training (43% vs 23%), award recommendations (53% vs 17%), and conference support (65% vs 35%). Women and men had similar odds of GH employment. Accounting for confounders and gender-gaps in training eliminated gender gaps in five of six career-agency outcomes. Panel studies of women's and men's career trajectories in GH are needed.

Background: Intimate partner violence (IPV) is highly prevalent in the United States and impacts the physical and mental health and social well-being of those who experience it. Healthcare settings are important intervention points for IPV screening and referral, yet there is a wide range of implementation of IPV protocols in healthcare settings in the U.S., and the evidence of the usefulness of IPV screening is mixed. This process evaluation investigates the facilitators and barriers to implementing Coordinated Care for IPV Survivors through the M Health Community Network (“M Health Network”), an intervention that aimed to standardize IPV screening and referral in a multi-specialty clinic and surgery center (CSC). Two validated IPV screens were introduced and mandated to be done by rooming staff at least once every 3 months with all clinic patients regardless of gender; the Humiliation Afraid Rape Kick (HARK) for presence of IPV and the shortened Danger Assessment (DA-5) for lethality of IPV. Upon a positive screen, the patient was offered immediate informational resources and, if willing, was referred to a social worker for care coordination with a community organization. Methods: Semi-structured, individual and group process interviews with clinic managers and clinic staff at 8 CSC clinics (N = 24) were undertaken at 3,12, and 27 months after intervention start. Semi-structured interviews were undertaken with the research team (N = 3) post-implementation. A Consolidated Framework for Implementation Research (CFIR) codebook was used to code data in two rounds. After each round, thick description was used to write detailed and contextual descriptions of each code. Facilitators and barriers to implementation were identified during the second round of thick description. Results: Facilitators to implementation were clinic staff support, dedication, and flexibility and research team engagement. Barriers were lack of prioritization, loss of intervention champions, lack of knowledge about intervention protocol and resources, staff and patient discomfort discussing IPV, and operational issues with screen technology. Conclusions: The IPV protocol was implemented, but faced common barriers. CFIR is a complex, but comprehensive, tool to guide process evaluation for IPV screening and referral interventions in health systems in the U.S.

Objective The current study investigated mediators between childhood/adolescent adversities (e.g., dating violence, maltreatment, homelessness, and parental death), low socioeconomic status (SES) during adolescence, and cardiovascular disease (CVD) risk in young adulthood. The purpose of these analyses was to understand whether SES during adolescence and childhood/adolescent adversities affect CVD risk through similar pathways, including maternal relationship quality, health behaviors, financial stress, medical/dental care, educational attainment, sleep problems, and depressive symptoms. Methods Using the National Longitudinal Study of Adolescent to Adult Health (N = 14,493), which has followed US adolescents (Wave 1; M = 15.9 years) through early adulthood (Wave 4; M = 28.9 years), associations were examined between childhood/adolescent adversity and SES to 30-year CVD risk in young adulthood. The outcome was a Framingham-based prediction model of CVD risk that included age, sex, body mass index, smoking, systolic blood pressure, diabetes, and antihypertensive medication use at Wave 4. Path analysis was used to examine paths through the adolescent maternal relationship to young adult mediators of CVD risk. Results Childhood/adolescent adversity significantly predicted greater adult CVD risk through the following pathways: maternal relationship, health behaviors, financial stress, lack of medical/dental care, and educational attainment; but not through depressive symptoms or sleep problems. Lower SES during adolescence significantly predicted greater adult CVD risk through the following pathways: health behaviors, financial stress, lack of medical/dental care, and educational attainment, but not maternal relationship, depressive symptoms, or sleep problems. Conclusions Childhood/adolescent adversities and SES affected CVD risk in young adulthood through both similar and unique pathways that may inform interventions.

To date, there are numerous normative change programs for AYSRH in the field and going to scale [1]. Many of these are doing so, however, with scant evidence of the desired normative change outcomes, resulting largely from the fact that social norms' measurement has lagged behind [2,3]. As programs are developed to shift social norms to improve adolescent and youth sexual and reproductive health (AYSRH) outcomes, rigorous but practical approaches are needed to identify the social norms that are influencing behaviors, measure changes in social norms, and understand how these changes impact behavioral outcomes.

Existing data suggest that there are distinct patterns (or classes) of intimate partner violence (IPV) experience that depart from dichotomous categorizations used to monitor progress toward Sustainable Development Goal 5.2. Less is known about the patterning of IPV in non-Western settings. This study estimates distinct classes of IPV experience in Nepal and examines potential community-level variability in these classes and in the association between IPV class and depressive symptoms. This study used data collected in 2016 from a random sample of Nepalese married women of reproductive age (N = 1440) living in 72 communities in three districts (Nawalparasi, Chitwan, and Kapilvastu). We used fixed effects and random effects latent class models of 2 through 6 classes. We fit a negative binomial regression model adjusted for relevant confounders to examine the relationship of the latent IPV classes with depressive symptoms. A four-class model was the best fitting. It included a “low exposure” class (77.36% of the sample) characterized by a low probability of experiencing any form of IPV, a “sexual violence” class (9.03% of the sample) characterized by a high probability of experiencing a form of sexual violence, a “moderate violence” class (6.60% of the sample) characterized by modest probabilities of experiencing less severe emotional and physical IPV, and a “systematic violence” class (7.01% of the sample) characterized by a high probability of being exposed to all forms of IPV. Adding random effects did not improve model fit, suggesting no community-level variations in classes. Relative to membership in the low exposure class, membership in all other classes was associated with a higher count of depressive symptoms. Those in the systematic class had a mean weighted symptom count 2.29 times that of the low exposure group. Classes of IPV exposure must be identified to ensure that surveillance and programming are attuned to women's experiences of violence.

Introduction Emerging research has linked women's sanitation and menstrual hygiene experiences with increased vulnerability to violence outside the home. Few studies, however, have investigated the relationship between menstruation and violence perpetrated by family members. This type of violence may be linked specifically to restrictions placed on women during menstruation, which are common in some regions of Nepal owing to shared power differentials that disfavour women, and societal norms that stigmatise menstruation. Objective To record the prevalence of menstrual restrictions experienced by married women and examine potential associations between intimate partner violence (IPV) in the past year and menstrual restrictions imposed by husbands and/or in-laws among women in three districts of Nepal: Nawalparasi, Kapilvastu and Chitwan. Methods Baseline data from a larger randomised control trial aiming to reduce IPV in three districts of the Terai region of Nepal (n=1800) were used to assess the prevalence of menstrual restrictions and the association with IPV. Results Nearlythree out of four women (72.3%) reported experiencing high menstrual restriction, or two or more types of menstrual restriction. When controlling for demographic variables and IPV, no type of IPV was associated with high menstrual restrictions. Conclusion The experience of menstrual restriction was widespread in this sample of women in Nepal. Future research should seek to identify how best to capture menstrual stigma and deviations around such norms. The global health and development community should prioritise integration with existing water and sanitation programmes to reduce stigma and ensure the well-being of menstruating women and girls. Trial registration number NCT02942433.

Background: Intimate partner violence (IPV) is a significant public health issue that affects one in three women globally and a similarly large number of women in Nepal. Although important policy and programmatic steps have been taken to address violence against women in Nepal over the past decade, there is still a gap on IPV research in Nepal, particularly with regard to social norms. Methods: This mixed-methods study used in-depth interviews with women and their husbands as well as baseline survey data from a cluster randomized trial testing a primary prevention intervention for IPV to examine the prevalence and risk factors for IPV. Baseline survey data included 1800 women from Nawalparasi, Chitwan, and Kapilvastu districts in Nepal. Multivariate regression was used to identify risk and protective factors for exposure to physical and / or sexual IPV in the prior 12 months. Case-based analysis was used to analyze one of 18 pairs of in-depth interviews to examine risk and protective factors within marriages. Results: Of 1800 eligible participants, 455 (25.28%) were exposed to IPV. In multivariate analyses, low caste, wife employment, income stress, poor marital communication, quarrelling, husband drunkenness, exposure to IPV as a child, in-law violence, and gender inequitable normative expectations were associated with IPV. The selected case interview represented common themes identified in the analysis including the wife's exposure to violence as a child, husband alcohol use, and marital quarrelling. Conclusions: Gender inequitable norms in the community and the intergenerational transmission of attitudes and behaviors supportive of IPV are important to address in intervention measures.

Background Violence against women and girls (VAWG) is a human-rights violation with adverse long-term and inter-generational consequences. Redefining VAWG as legally unacceptable is one strategy for social change. The co-occurrence of national laws against VAWG is understudied, and tools to monitor the national legal environment are lacking. We developed the Laws on Violence against Women and Girls Index (LoVI) to measure global progress to develop comprehensive national legislation against child marriage, sexual harassment, domestic violence, and marital rape. Methods Using data from 2016 and 2018 for 189 countries from the World Bank Women, Business, and the Law database, we used factor analysis to assess the dimensionality of the LoVI. We examined the distribution of the LoVI across countries and regions, and the relationship of national rankings on the LoVI with those for other indicators from the United Nations, Demographic and Health Surveys, and World Factbook. Results A single LoVI factor showed good model fit in the factor analysis. National LoVI rankings were positively associated with gender equality in human development and economic rights-related rankings and negatively associated with rates of justifying wife beating and of lifetime and prior-year physical and/or sexual IPV. The LoVI was not associated with national indicators for human development and income inequality. Conclusion The LoVI is a concise, coherent, validated index to monitor the progress of nations on adopting comprehensive legislation to advance 2030 Sustainable Development Goal 5, to eliminate VAWG.