I n the 1980s, David Barker and colleagues (see Barker 1,2 and Barker et al 3,4) used hospital records from Hertfordshire, England, to link LBW to cardiovascular and respiratory disease later in life. They posited that certain adverse conditions in the womb can set the fetus on a pathway to lifelong ill health, a theory which became known as the fetal programming hypothesis. This groundbreaking work was a keystone in the foundation of the burgeoning field of life course epidemiology, which seeks to understand how determinants of health and disease interact across the span of a human life. 5,6 Although the idea that events in early life can shape the developing mind has been a cornerstone of psychiatry since Freud's time, using the life course approach to understand etiological frameworks in mental illness has only been

The Pakistan Lady Health Worker (LHW) program provides door-step reproductive health services in a context where patriarchal norms of seclusion constrain women's access to health care facilities. The program has not achieved optimal functioning, particularly in relation to raising levels of contraceptive use. One reason may be that the LHWs face the same mobility constraints that necessitated their appointment. Past research has documented the influence of gendered norms and extended family (biradari) relationships on rural women's mobility patterns. This study explores whether and how these socio-cultural factors also impact LHWs' home-visit rates. A mixed-method study was conducted across 21 villages in one district of Punjab in 2009-2010. Social mapping exercises with 21 LHWs were used to identify and survey 803 women of reproductive age. The survey data and maps were linked to visually delineate the LHWs' visitation patterns. In-depth interviews were conducted with 21 LHWs and 27 community members. Members of a LHW's biradari had two times higher odds of reporting a visit by their LHW and were twice as likely to be satisfied with their supply of contraceptives. Qualitative data showed that LHWs mobility led to a loss of status of women performing this role. Movement into space occupied by unrelated males was particularly shameful. Caste-based village hierarchies further discouraged visits beyond biradari boundaries. In response to these normative proscriptions, LHWs adopted strategies to reduce the amount of home visiting undertaken and to avoid visits to non-biradari homes. The findings suggest that LHW performance is constrained by both gender and biradari/caste-based hierarchies. Further, since LHWs tended to be poor and low caste, and at the same time preferentially visited co-members of their extended family who are likely to share similar socioeconomic circumstances, the program may be differentially providing health care services to poorer households, albeit through an unintended route.

Armed conflict disproportionately affects women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child and adolescent health and nutrition (abbreviated to women's and childern's health, i.e WCH in this paper) interventions in conflict-affected settings in Afghanistan,

Research CMAJBackground: Many people with depression experience repeated episodes. Previous research into the predictors of chronic depression has focused primarily on the clinical features of the disease; however, little is known about the broader spectrum of sociodemographic and health factors inherent in its development. Our aim was to identify factors associated with a long-term negative prognosis of depression. Methods:We included 585 people aged 16 years and older who participated in the 2000/01 cycle of the National Population Health Survey and who reported experiencing a major depressive episode in 2000/01. The primary outcome was the course of depression until 2006/07. We grouped individuals into trajectories of depression using growth trajectory models. We included demographic, mental and physical health factors as predictors in the multivariable regression model to compare people with different trajectories.Results: Participants fell into two main depression trajectories: those whose depression resolved and did not recur (44.7%) and those who experienced repeated episodes (55.3%). In the multivariable model, daily smoking (OR 2.68, 95% CI 1.54-4.67), low mastery (i.e., feeling that life circumstances are beyond one's control) (OR 1.10, 95% CI 1.03-1.18) and history of depression (OR 3.5, 95% CI 1.95-6.27) were significant predictors (p < 0.05) of repeated episodes of depression.Interpretation: People with major depression who were current smokers or had low levels of mastery were at an increased risk of repeated episodes of depression. Future studies are needed to confirm the predictive value of these variables and to evaluate their accuracy for diagnosis and as a guide to treatment. Abstract

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Objective: To investigate evidence of fetal programming in humans by studying whether adolescents born at high or low birth weights (LBW) are more likely to experience symptoms of depression and anxiety after experiencing stress. Method:The sample included 3732 members of a prospective Canadian cohort study assessed for symptoms of depression and anxiety at age 12 to 15 years (2006/2007), and had birth weight and gestational age (GA) data recorded in 1994/1995. Major stressful life events and chronic stressors were also reported throughout childhood. Results:After adjusting for acute and chronic stress, being born small for GA (SGA) (OR 1.50; 95% CI 1.08 to 2.08) or large (OR 1.31; 95% CI 0.99 to 1.72) for GA was associated with an increased risk of depression and anxiety in adolescence, compared with adolescents who were born at a weight appropriate for their GA. Most interactions between birth weight and stress were not significant; however, the relation between chronic stress and adolescent depression and anxiety was more pronounced in males who were born SGA (interaction P < 0.05). Conclusions:The link between birth weight and depression is complex and evidence of fetal programming is inconsistent; however, people born at LBW may be at an increased risk of depression in the face of chronic stress. W W WObjectif : Rechercher les données probantes de la programmation foetale chez les humains en étudiant si les adolescents dont le poids de naissance était élevé ou faible (PNF) sont plus susceptibles d'éprouver des symptômes de dépression et d'anxiété après avoir vécu du stress. Résultats : Après correction pour le stress aigu et chronique, être né petit pour l'AG (PAG) (RC 1,50; IC à 95 % 1,08 à 2,08) ou gros (RC 1,31; IC à 95 % 0,99 à 1,72) pour l'AG était associé à un risque accru de dépression et d'anxiété à l'adolescence, comparativement aux adolescents dont le poids de naissance était approprié pour leur AG. La plupart des interactions entre le poids de naissance et le stress n'étaient pas significatives; cependant, la relation entre le stress chronique et la dépression et l'anxiété adolescentes était plus prononcée chez les garçons nés PAG (interaction P < 0,05). Conclusions :Le lien entre le poids de naissance et la dépression est complexe et les données probantes d'une programmation foetale ne sont pas cohérentes; toutefois, les personnes nées à un PNF peuvent être à risque accru de dépression devant le stress chronique.

Background: Somalia has been ravaged by more than two decades of armed conflict causing immense damage to the country's infrastructure and mass displacement and suffering among its people. An influx of humanitarian actors has sought to provide basic services, including health services for women and children, throughout the conflict. This study aimed to better understand the humanitarian health response for women and children in Somalia since 2000. Methods: The study utilized a mixed-methods design. We collated intervention coverage data from publically available large-scale household surveys and we conducted 32 interviews with representatives from government, UN agencies, NGOs, and health facility staff. Qualitative data were analyzed using latent content analysis. Results: The available quantitative data on intervention coverage in Somalia are extremely limited, making it difficult to discern patterns or trends over time or by region. Underlying sociocultural and other contextual factors most strongly affecting the humanitarian health response for women and children included clan dynamics and female disempowerment. The most salient operational influences included the assessment of population needs, donors' priorities, and insufficient and inflexible funding. Key barriers to service delivery included chronic commodity and human resource shortages, poor infrastructure, and limited access to highly vulnerable populations, all against the backdrop of ongoing insecurity. Various strategies to mitigate these barriers were discussed. Incountry coordination of humanitarian health actors and their activities has improved over time, with federal and state-level ministries of health playing increasingly active roles. Conclusions: Emerging recommendations include further exploration of government partnerships with privatesector service providers to make services available throughout Somalia free of charge, with further research on innovative uses of technology to help reaches remote and inaccessible areas. To mitigate chronic skilled health worker shortages, more operational research is needed on the expanded use of community health workers. Persistent gaps in service provision across the continuum must be addressed, including for adolescents, for example. The is also a clear need for longer term development focus to enable the provision of health and nutrition services for women and children beyond those included in recurrent emergency response.

BackgroundOver 240 million children live in countries affected by conflict or fragility, and such settings are known to be linked to increased psychological distress and risk of mental disorders. While guidelines are in place, high-quality evidence to inform mental health and psychosocial support (MHPSS) interventions in conflict settings is lacking. This systematic review aimed to synthesise existing information on the delivery, coverage and effectiveness of MHPSS for conflict-affected women and children in low-income and middle-income countries (LMICs).MethodsWe searched Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Psychological Information Database (PsycINFO)databases for indexed literature published from January 1990 to March 2018. Grey literature was searched on the websites of 10 major humanitarian organisations. Eligible publications reported on an MHPSS intervention delivered to conflict-affected women or children in LMICs. We extracted and synthesised information on intervention delivery characteristics, including delivery site and personnel involved, as well as delivery barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data.ResultsThe search yielded 37 854 unique records, of which 157 were included in the review. Most publications were situated in Sub-Saharan Africa (n=65) and Middle East and North Africa (n=36), and many reported on observational research studies (n=57) or were non-research reports (n=53). Almost half described MHPSS interventions targeted at children and adolescents (n=68). Psychosocial support was the most frequently reported intervention delivered, followed by training interventions and screening for referral or treatment. Only 19 publications reported on MHPSS intervention coverage or effectiveness.DiscussionDespite the growing literature, more efforts are needed to further establish and better document MHPSS intervention research and practice in conflict settings. Multisectoral collaboration and better use of existing social support networks are encouraged to increase reach and sustainability of MHPSS interventions.PROSPERO registration numberCRD42019125221.