Norms are fundamental to social life, but basic questions about how they are affected by social context remain. Specifically, how do normative constraints depend on the presence and status of observers, and how do such relational contingencies vary across cultures? Using data from more than 25,000 individuals across 90 societies, we test several hypotheses linking normative constraints on everyday behaviors (like arguing, laughing, cursing, kissing, and crying), to the presence and status of observers. We find that behaviors widely viewed as appropriate in private become more constrained in the presence of others (an observer effect), and even more so when those others are higher in status (a status effect). Both observer and status effects are culturally universal, but the observer effect shows more variation across cultures. In particular, we find that observer effects are larger in societies that emphasize individualizing moral foundations, that is, avoiding harm and unfairness to others, because these societies are more permissive of actions when others are not around. The relative stability of status effects across cultural contexts suggests a universal tendency to defer in social hierarchies. These findings shed light on the relational contingency of everyday norms and underscore the role of such norms in the maintenance of social order and reproduction of inequality.

The current study explores the perceived benefits and outcomes of communitydriven Early Childhood Development (ECD) initiatives for children, families, and communities in rural Malawi, Tanzania, and Zambia. This study is nested within a larger study on community-led ECD initiatives across these three countries. Using a descriptive qualitative design, the study addressed the question: What benefits of ECD programs are perceived by children, families, and communities within a holistic child development framework? In this study, we present findings on the benefits of ECD programs from the perspective of community-based organizations, local government stakeholders, and parents of children below the age of five in the three countries. Findings revealed that ECD programs broadly benefit children, parents, and communities. Specifically, we found that ECD programs support children’s cognitive, physical, language, and socioemotional development, improving school readiness and academic outcomes. They ease caregiving burdens, improve family well-being, and incorporate health and nutrition support. By facilitating parental employment, especially for women, and strengthening community capacity, ECD programs also foster economic inclusion and community socioeconomic development. In conclusion, this study shows “everyone wins” when we invest in the ECD programs because the benefits extend beyond children, offering substantial social and economic returns on investment.

Reporting sexual violence to the police is key to an integrated service provision and to ensuring justice is served. However, though sexual violence is endemic globally, reporting of sexual violence remains suboptimal. This study explored factors and barriers to timely reporting of sexual violence among survivors from the perspective of frontline service providers. We used a semi-structured interview guide to interview twelve frontline service providers working in One Stop Center across five districts of Zambia. The interviewed service providers were nurses, police, paralegals, clinical officers, and counselors. Thematic analysis revealed themes around social contracts, sociocultural issues, physical conditions, psychological state, lack of knowledge, socioeconomic factors, and systemic issues as barriers to sexual violence reporting. Systematic and targeted interventions aimed at addressing these factors are key to increasing the reporting of sexual violence. These interventions have the potential to not only increase reporting but also prevent would-be offenders of sexual violence.

BackgroundAlthough meta-analyses have demonstrated the value of parenting programs to promote child development in low- and middle-income countries, scaling them horizontally and vertically through the system has remained largely undocumented. This study examines the enablers and barriers to scaling parenting programs implemented by different organizations in four countries, namely Bhutan, Rwanda, Serbia, and Zambia.MethodAn independent research and learning organization collected multi-method data from three sources, toward the end of a four-year period, to identify enablers and barriers of scale. The sources and method included: in-depth semi-structured interviews with two members of the technical resource teams (n = 8); phone surveys with a random sample of providers who delivered the program to caregivers (n = 529) along with in-depth interviews with a smaller number of providers (n = 44); and in-depth semi-structured interviews with key government stakeholders (n = 57). Content analysis was conducted to identify interviewees’ comments that reflected enablers and barriers to scale.ResultsFindings are presented to address horizontal and vertical enablers and barriers in each of the four country programs. Regarding horizontal scale, the main enabler was an existing workforce who was quickly trained to deliver the program and who perceived a need within their communities. Expanding the reach of the programs also required advocacy to raise demand among community leaders and caregivers. Design features of the programs, such as curriculum, modality, and dosage, contributed to effective outcomes as a function of their adaptation to providers’ and caregivers’ experiences. The main enabler of vertical scale was adoption by the government, integration into the system, and engagement of multisectoral stakeholders. Based on final reflections of stakeholders, qualitative data were provided for eight indicators of successful scale: demand, reach, equity, and workforce (for horizontal scale); multisectorality, adoption, policy/finance, and integration (for vertical scale).ConclusionPlanning for scale needs to be done at the start by considering facilitative design features, selection of a workforce, and ownership by the government. Ongoing implementation research conducted with different stakeholders is needed to provide feedback for course-correction during the process of scale. Eight indicators can be used to evaluate the level of successful scale achieved by programs.

Background/Objectives: As an independent research group, we examined parent and child outcomes of three different parenting programs delivered at scale. The programs were implemented in Bhutan, Serbia and Zambia by different organizations. Methods: Mixed methods included a caregiver interview using the HOME Inventory, a direct child assessment using the Global Scales of Early Development (GSED) and focus group discussions with caregivers (FGD). Sampled mothers and children were randomly selected for the HOME/GSED: Bhutan n = 432, Serbia n = 636, Zambia n = 1024. Over 40 mothers and fathers of children under 3 years were purposively selected for FGD. Intention-to-treat and secondary regression analyses of attendees and non-attendees were conducted on the HOME and GSED; FGDs were subject to content analysis. Results: Parenting practices were found to be minimally (Bhutan) or modestly (Zambia) higher for caregivers who attended group sessions. Caregivers in Serbia who recalled receiving play messages had higher HOME scores. Child outcomes showed small (Bhutan) or no differences (Serbia, Zambia) associated with participation. Conclusions: Explanations focused on limits to program participation in scaled programs, the need for pilot evaluations to ensure that the program design is effective, and the need to monitor delivery quality and other implementation processes.

Two case studies of parenting programs for parents of children 0 to 36 months of age, developed and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and UNICEF Zambia, were conducted by an independent research group. The focus was on how program delivery and scale-up were revised on the basis of feedback from implementation research. Feedback on workforce delivery quality was based on observations of deliveries using a monitoring form, as well as survey and interview data collected from the workforce. In-depth interviews with the resource team during the fourth year of implementation revealed how the feedback was used to address horizontal and vertical scaling. Delivery quality was improved in some cases by revising the delivery manual, offering refresher courses, and instituting regular monitoring. Scaling challenges in Zambia included slow progress with regard to reaching families in the two districts, which they addressed by trialing group sessions, and stemming workforce attrition. The challenges in Bhutan were low attendance and reducing the workload of providers. Vertical scaling challenges for both countries concerned maintaining demand through continuous advocacy at community and government levels to sustain financing and to show effectiveness in outcomes.

Abstract The current study investigated the motives that underlie support for COVID-19 preventive behaviorsin a large, cross-cultural sample of 12,758 individuals from 34 countries. We hypothesized that the associations of empathic prosocial concern and fear of disease, with support towards preventive COVID-19 behaviors would be moderated by the individual-level and country-level trust in the government. Results suggest that the association between fear of disease and support for COVID-19 preventive behaviors was strongest when trust in the government was weak (both at individual and country-level). Conversely, the association with empathic prosocial concern was strongest when trust was high, but this moderation was only found at individual-level scores of governmental trust. We discuss how both fear and empathy motivations to support preventive COVID-19 behaviors may be shaped by socio-cultural context, and outline how the present findings may contribute to a better understanding of collective action during global crises.

EDITORIAL article Front. Psychol., 21 February 2023Sec. Cultural Psychology Volume 14 - 2023 | https://doi.org/10.3389/fpsyg.2023.1150387

BackgroundIn the quest to ensure that quality healthcare is provided to all citizens through building healthcare worker capacity and extending reach for expert services, Zambia's Ministry of Health (MoH) in collaboration with its partners PEPFAR through the CDC and HRSA, began to implement the Extension for Community Healthcare Outcomes (ECHO) tele-mentoring program across the country through the Health Workers for the 21st Century (HW21) Project and University Teaching Hospital HIV/AIDS Project (UTH-HAP). This ECHO tele-mentoring approach was deemed pivotal in helping to improve the human immunodeficiency virus (HIV) service delivery capacity of health care workers.MethodThe study used a mixed method, retrospective program evaluation to examine ECHO participants' performance in the management of HIV/AIDS patients in all the 10 provinces of Zambia.Case presentationA phenomenological design was applied in order to elicit common experiences of ECHO users through focus group discussions using semi-structured facilitation guides in four provinces (Eastern, Lusaka, Southern and Western) implementing ECHO tele-mentoring approach. These provinces were purposively selected for this study. From which, only participants that had a monthly frequency of ECHO attendance of ten (10) and above were selected. The participants were purposively selected based on the type of cadre as well as facility type so that the final sample consisted of Doctors, Nurses, Midwives, Clinical Officers, Medical Licentiates, Pharmacy and Laboratory Personnel. All sessions were audio recorded and transcribed by the data collectors. A thematic content analysis approach was adopted for analyzing content of the interview's transcripts.ResultsEnhanced knowledge and skills of participants on HIV/TB improved by 46/70 (65.7%) in all provinces, while 47/70 (67.1%) of the participants reported that ECHO improved their clinical practice. Further, 12/70 (17.1%) of participants in all provinces reported that presenter/presentation characteristics facilitated ECHO implementation and participation. While, 15/70(21.4%) of the participants reported that ownership of the program had contributed to ECHO implementation and participation. Coordination, another enabler accounted for 14/70 (20%). Inclusiveness was reported as a barrier by 16/70 (22.8%) of the participants while 6/70 (8.6%) of them reported attitudes as a barrier (8.6%) to ECHO participation. In addition, 34/70 (48.6%) reported poor connectivity as a barrier to ECHO implementation and participation while 8/70 (11.5%) of the participants reported that the lack of ownership of the ECHO program was a barrier. 22/70 (31.4%) reported that increased workload was also a barrier to the program's implementation.ConclusionConsistent with its logical pathway model, healthcare providers' participation in ECHO sessions and onsite mentorship contributed to improved knowledge on HIV/TB among health care providers and patient health outcomes. In addition, barriers to ECHO implementation were intrinsic to the program its self, such as coordination, presenter and presentation characteristics other barriers were extrinsic to the program such as poor connectivity, poor infrastructure in health facilities and negative attitudes towards ECHO. Improving on intrinsic factors and mitigating extrinsic factors may help improve ECHO outcomes and scale-up plans.

With the COVID-19 pandemic, behavioural scientists aimed to illuminate reasons why people comply with (or not) large-scale cooperative activities. Here we investigated the motives that underlie support for COVID-19 preventive behaviours in a sample of 12,758 individuals from 34 countries. We hypothesized that the associations of empathic prosocial concern and fear of disease with support towards preventive COVID-19 behaviours would be moderated by trust in the government. Results suggest that the association between fear of disease and support for COVID-19 preventive behaviours was strongest when trust in the government was weak (both at individual- and country-level). Conversely, the association with empathic prosocial concern was strongest when trust in the government was high, but this moderation was only found at individual-level scores of governmental trust. We discuss how motivations may be shaped by socio-cultural context, and outline how findings may contribute to a better understanding of collective action during global crises.

Objective This pilot study investigated the different roles Zambian guardians and older siblings play in stimulating children and how time spent engaging in child stimulating activities was associated with child stimulation. In this study, guardians were women who are primary caregivers of the children. Background A lot of research has been done on child stimulation but little is known of different roles caregivers, especially older siblings, play in child stimulation. Method Questionnaires were administered to caregivers (both older siblings and guardians) of children between 3 and 5 years of age and their older siblings above 7 years old. Results Results showed that despite the female guardians spending more time taking care of their children, older siblings were significantly more involved in child stimulating activities than the female guardians. Further data showed that guardians with more education were associated with increased child stimulation. However, socioeconomic status, age of guardians, and family size were not associated with child stimulation. Conclusion In poor communities, older siblings engage more in child stimulating activities than their guardians. Child stimulation interventions have often focused on parents (guardians) leaving out older siblings who may play a more critical role, especially in circumstance were parental care and availability are absent. Therefore, for child cognitive and socioemotional stimulation interventions to be more effective in poor communities, they should include siblings. More research is needed to understand the role of male guardians and the degree to which sibling stimulation predicts cognitive and socioemotional development.

Coronavirus Anxiety Scale (CAS) is a widely used measure that captures somatic symptoms of coronavirus-related anxiety. In a large-scale collaboration spanning 60 countries (Ntotal = 21,513), we examined the CAS's measurement invariance and assessed the convergent validity of CAS scores in relation to the fear of COVID-19 (FCV-19S) and the satisfaction with life (SWLS-3) scales. We utilized both conventional exact invariance tests and alignment procedures, with results revealing that the single-factor model fit the data well in almost all countries. Partial scalar invariance was supported in a subset of 56 countries. To ensure the robustness of results, given the unbalanced samples, we employed resampling techniques both with and without replacement and found the results were more stable in larger samples. The alignment procedure demonstrated a high degree of measurement invariance with 9% of the parameters exhibiting noninvariance. We also conducted simulations of alignment using the parameters estimated in the current model. Findings demonstrated reliability of the means but indicated challenges in estimating the latent variances. Strong positive correlations between CAS and FCV-19S estimated with all three different approaches were found in most countries. Correlations of CAS and SWLS-3 were weak and negative but significantly differed from zero in several countries. Overall, the study provided support for the measurement invariance of the CAS and offered evidence of its convergent validity while also highlighting issues with variance estimation. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

At the heart of the Sustainable Development Goals (SDG) is the vision to “leave no one behind, and to see that all children survive, thrive and transform. However, some categories of children may remain left behind owing to their disproportionate exposure to the risk of threats and deficit of attention to the social and ecological climate that characterizes the various systems in which they are found. This study is concerned with one major question: Despite diverse local and international instruments that favor full nurturance and development of children, what social forces play as threat to full nurturance care in the context of children living in Orphan homes? Nurturing care framework and Brofenbrener’s ecological system theory were adopted as the analytical frameworks. Research design was exploratory. Data were collected through sessions of in-depth-interview with orphanage managers, caregivers, and social workers on the socio-ecology drivers of threat to children living within the orphan home space and its implications for nurturance care across the various complex systems of the child’s environment. The study found various factors across the complex systems of child development – microsystem, mesosystem, exosystem, microsysm and lastly, chronosystem- which undermine caregivers’ delivery and increases children’s vulnerability and risk of missing out on effective nurturance care. These vulnerabilities are endemic realities of social, and bio-ecologcal space in which child development occurs. This study recommends specialized interventions and policy directives relevant for each identified threat. It also calls for a stronger political will in improving the conditions of this category of the children while within the orphan home space and ultimately, actions towards deinstitutionalization of children.

Age-appropriate and validated assessment tools should be routinely implemented in clinical practice to monitor and discuss overall psychosocial well-being and quality of life (QoL) of all youth with diabetes. A This should include the well-being of caregivers. B The interdisciplinary team should assess general family functioning (stress, conflict, cohesion, adaptability, parental psychopathology), and diabetes-related functioning (communication, parental involvement and support, roles and responsibilities for self-management behaviors) especially during periods of transition (e.g., at diagnosis, at start of a new treatment plan, adolescence) and when there may be cultural or family based difficulties in adjustment to diabetes. B Referral to mental health professional is recommended when necessary. E The biopsychosocial model proposes that understanding illness requires understanding the complex interactions between biology (e.g., genes, viruses), psychology (e.g., mood, behavior) and social factors (e.g., family, society).1 Treatments must include attention to all of these domains. Being diagnosed with diabetes in childhood or adolescence can interfere with the normative developmental changes and interact with psychological and social factors in youth and their families. Integrated, collaborative care is therefore necessary. Although routine psychosocial screening in pediatric diabetes clinics effectively identifies youth struggling with psychosocial problems and facilitates referrals to appropriate care resources, screening and referral alone are not sufficient to ensure care is actually received.2 Integrated care models ensure that youth with diabetes access mental health care.3-5 When screening programs are initiated, there also must be a process for appropriate referrals to address identified concerns. Here we review the main findings from studies on stress, resilience and coping, psychological and psychiatric problems, neurocognitive functioning, and integration of psychosocial assessments. We also discuss the importance of diabetes in context, including family dynamics, social support, and the diabetes team. Given the rapid technological advances in diabetes management, we review the psychological advantages and challenges of technology. We conclude this chapter with a review of psychological and behavioral interventions in children and adolescents with diabetes. Based on these research findings, recommendations for optimal psychological care are offered and detailed in the Executive Summary (Section 2). Childhood and adolescence are challenging developmental stages. Young children can get stressed navigating their social worlds, particularly family, school, and friendships.6 Adolescence is characterized by major physical, hormonal, and psychological changes; hence it has been described as a period of stress and storm. Chronic illnesses such as diabetes exacerbate stress in children and adolescents,7, 8 and it is uncommon for children and adolescents with diabetes not to report stress.7, 9 The relationship between stress and diabetes is suggested to be bidirectional; stress can increase the risk of T2D, and living with diabetes can also cause stress.10-13 Managing diabetes, family conflicts around diabetes management, and dealing with diabetes emotions are often a major source of stress.8 Adversities and pandemics such as COVID-19 also accentuate stress levels in persons already affected by diabetes-specific stress. For example, the perceived increased risk of death due to COVID-19 and breakdowns in the supply chain affecting access to insulin and other supplies has contributed to anxiety and stress in the family related to diabetes care and management.14 Stressors can be subjective and the interpretation and perception of stressors or the actual exposure to stress events vary depending on age, geography, and socioeconomic factors. In developing as well as in high-income countries, low income is a major stressor.15, 16 Race, ethnicity, and other sociodemographic factors are also associated with stress17, 18 and coping strategies.19 Assessment of stressors should therefore be part of person-centered care. Diabetes distress (also referred to diabetes-related or diabetes-specific distress) is an emotional response to living with and managing diabetes. One in three adolescents with T1D,9 one in three adolescents and young adults with T2D20 and up to 60% of emerging adults21 report elevated diabetes distress. Although longitudinal studies are scarce, diabetes distress also seems to persist over time.22 Diabetes distress is best viewed as an expected emotional response to diabetes and not as a co-morbid disorder. The constant demands of diabetes management, including the relentless treatment tasks and decision-making, are key contributors to diabetes distress, particularly as these constant efforts do not always lead to the expected outcomes. Diabetes distress may negatively impact engagement with treatment, and subsequent glucose outcomes.22 Although they can co-exist, diabetes distress differs conceptually from depression and requires a different care pathway.23 Diabetes burnout is a relatively new and not yet well-researched concept without a widely used psychometric scale. The term diabetes burnout relates to high levels of diabetes distress and/or depression that produce significant barriers to diabetes management and glycemic management.24 It is characterized by feelings of mental, emotional and physical exhaustion of living with diabetes, leading to a detachment from diabetes and ignoring self-management responsibilities.25 As a consequence, burnout may lead to an experience of detachment from self, support systems (e.g., years of not attending diabetes appointments) and is associated with lack of acceptance of the condition.24 The concept is mainly described in adults with diabetes (T1D and T2D), not in children, adolescents or parents/carers. The Diabetes Burnout Scale (DBS) measures diabetes burnout specifically and was recently validated in adults.26 Further investigation of this concept in youth with diabetes, particularly young adults and parents, is warranted. Diabetes Resilience is achievement of optimal diabetes outcomes (i.e., high engagement in self-management behaviors, and close to target glycemic outcomes) despite the numerous challenges inherent in having diabetes.27 Attention to protective skills and behaviors (i.e., strengths) that promote resilient outcomes can enhance understanding of adjustment to diabetes and have implications for clinical care. These strengths include confidence or self-efficacy to manage the demands of diabetes, seeking and receiving developmentally appropriate help and support from family and others, and adaptability to handle unpredictable diabetes-related challenges (e.g., effective problem-solving and coping).27-31 Children and families who use adaptive coping strategies such as problem-solving have a better QoL and family functioning, and report fewer depressive and anxiety symptoms.32-36 Maladaptive coping strategies such as avoidance are associated with more significant diabetes-specific distress and suboptimal diabetes management, including fewer glucose checks and less frequent self-care behaviors.15, 34 Evidence-based interventions for children with diabetes such as cognitive behavioral therapy and interventions that promote parental involvement, goal setting, and problem-solving9 and reduce family conflict37 may be helpful in promoting resilience and addressing stress. Interventions to relieve stress and enhance social support for parents/caregivers are also needed in clinical care.37, 38 Based on evidence from large, population-based cohort studies youth and young adults with T1D are about twice as likely to be diagnosed with a psychiatric disorder, especially eating, mood, anxiety and behavior disorders, as peers without diabetes.39-41 ADHD, personality disorders and substance use disorders (especially in males) are also more common.39 Multi-morbidities are common: 1 in 5 youth has two or more psychiatric diagnoses.39 Overall, psychiatric disorders are associated with abnormal self-management (e.g., insulin-manipulation) and lower QoL.42, 43 Children and adolescents with diabetes have increased rates of eating disorders (ED) and disordered eating behaviors (DEB) rates compared to peers without diabetes.44-47 These issues are especially magnified in older adolescents and young adults. Consequences of eating disorders and disordered eating include increased risk and frequency of DKA, accelerated development of vascular complications and mortality.48, 49 Even mild symptoms are relevant, as they impact self-management.50 Population cohort studies show 1%–10% of adolescents and young adults with T1D have an ED.39-41 Bulimia and “other specified feeding and eating disorders” are more common, but not anorexia nervosa.51 Longitudinal studies of youth with T1D reveal that ED behaviors and symptoms are likely to persist and become more severe in young adulthood.50, 52 ED in youth with diabetes are often associated with comorbid psychiatric disorders and sub-optimal glycemic management. Relationships between disordered eating and depression symptoms, anxiety symptoms and lower QoL in populations with T1D and T2D53 are bi-directional. Risk factors for eating disorders and disordered eating include female gender (related to societal pressure to be thin, pubertal changes), DKA, and hyperglycemia.54 DEBs such as dietary restriction and intentional insulin omission55 are more prevalent than eating disorders. In children with T1D, DEBs affect about 30%–50% of females and 10%–20% of males.51 In youth with T2D the prevalence of DEB has been found to be about 50%.53 Youth with T2D and DEB had a significantly higher BMI, lower insulin sensitivity, more depressive symptoms, and poorer QoL than those without DEB, with no differences between males and females.53 A maladaptive family environment (e.g., lack of family mealtime structure, parent–child relationship quality) together with parents' personal eating attitudes (e.g., weight/shape concerns) and habits (e.g., attempts at weight loss) and negative comments about their child's weight are important when it comes to DEB in their children.56 DEBs often go unnoticed as adolescents and young adults refrain from being open and providers do not always feel equipped to identify and talk about them.57, 58 What usually is symptomatic and raises the attention of HCPs is frequent hospital admissions associated with DKA. Given the high prevalence and serious consequences, this calls for routine monitoring and screening of eating behaviors. A stepped approach, starting with screening with more detailed assessment following positive screens could be considered to facilitate discussion in clinical practice.57 Initial elevation of depressive symptoms and anxiety at diagnosis is often a transitional normal adaptive response.59 Thereafter, symptoms of depression and anxiety increase once again with longer disease duration, corresponding with the children's experience of diabetes management and implications as being more difficult and upsetting. For a smaller group of children, psychological problems persist.59 Youth with T1D are at an increased risk of elevated self-reported depressive symptoms compared to peers with prevalence rates ranging from 17% to 63%, depending on population, study design and diagnostic tool.60-62 Core symptoms include low mood, no enjoyment and negative cognitions, although coexistent irritability or oppositional behavior may lead to missed diagnosis. Somatic symptoms such as fatigue and brain fog may overlap with T1D symptoms from hypo- or hyperglycemia. European population-based studies also show an increased risk of diagnosed mood disorders in youth with T1D, both in boys and girls.39-41 Females and youth with a history of depressive episodes are especially at an increased risk. Despite the increased risk of depression, population-based studies do not find an increased risk of suicide attempts in youth with T1D compared to peers.39, 40 Fewer studies have been conducted in youth with T2D. In the TODAY study the prevalence of elevated depressive symptoms in youth with T2D was 15%, comparable to the US population without diabetes.63 The SEARCH study did not report prevalence rates for T2D specifically, however males with T2D were reported to have an increased risk of elevated depressive symptoms compared to males with T1D.64 Recent studies in Canada and the US showed an increased risk of depressive disorders as well as attempted and completed suicides in youth with T2D compared to peers without diabetes.20, 65 Longitudinal studies show mixed results regarding fluctuations in depressive symptoms and glycemic changes. Within-person increases in depressive symptoms over 6 months were associated with concurrent declines in glycemic management.66 However, 3- to 5-year longitudinal studies in adolescents and young adults with T1D did not show significant within-person associations between fluctuations in depressive symptoms and glycemic management changes.67-69 Anxiety is characterized by a predominance of exaggerated fear or worry, dysfunctional coping behaviors (e.g., preoccupation or avoidance of feared situations or experiences, the use of safety behaviors to mitigate perceived threats) and adrenergic symptoms. Generalized anxiety is described as “free floating” with continual symptoms and no specific focus. There is substantial comorbidity between anxiety and depression. As a counter to chronic uncomfortable feelings of anxiety, a person will compensate by avoiding as many stressful experiences as possible. In the context of diabetes, behaviors could include not attending appointments, checking blood glucose levels or taking insulin. Studies of anxiety symptoms in children and adolescents with T1D are mixed. Although up to 32% may have elevated anxiety symptoms, this may not be higher compared to peers without diabetes.62, 70 However, children and young adults with T1D and youth with T2D are at an increased risk for diagnosed anxiety disorders compared to controls varying from 11% to 32%.40-43, 65, 71-73 The highest risk is for those with onset of diabetes between age 10 and 14 years and increasing risk with diabetes duration.39 Children with diabetes and anxiety disorders are at risk for suboptimal glycemic outcomes, more hospitalizations, suboptimal self-management, lower QoL, more depressive symptoms and higher family conflict than peers with diabetes without anxiety disorders.74, 75 More recent studies seem to show similar prevalence rates of depressive and anxiety symptoms and disorders as the general pediatric population, possibly reflecting the advances in diabetes treatment and awareness of mental health problems.73, 76 Nevertheless, about 1 in 7 young people with diabetes experience psychological problems, which tend to increase with diabetes duration and remain elevated in young adults with type 1 and T2D.68, 76, 77 The high prevalence and the possible detrimental impact of these psychological symptoms and disorders on diabetes self-management and QoL4, 66 indicates that ongoing monitoring and screening and integration of psychological support in the care for youth with diabetes is warranted. An approach is outlined below. There should also be easy access to consulting psychiatrists for cases involving severe psychopathology and the potential need for psychotropic medications. Growing evidence documents that children and adolescents with T1D are more at risk for pathophysiological brain changes78-84 and neurocognitive deficits (e.g., memory, learning, and executive functioning)82, 83, 85-90 than healthy peers. Although limited, research in youth T2D also shows deficits in memory and processing speed compared with youth without diabetes matched by obesity status.91-93 Intelligence quotient (IQ) scores of youth with diabetes are statistically significantly lower than those of their peers without T1D.82 However, IQ scores in youth with diabetes are typically well within the average range and the clinical impact might be minimal. In addition to lower IQ, youth with diabetes are at risk for specific neurocognitive deficits such as information processing difficulties (attention, memory, processing speed), learning disabilities and problems with executive functions.82, 90-93 Executive functions involve goal-oriented behavior and other key skills for self-management such as planning, problem-solving and organization. While executive function deficits can make diabetes self-management more difficult, in turn, these difficulties in self-management could lead to worsening glycemic outcomes,94-97 which may lead to a dysfunctional cycle of further brain injury and even greater neurocognitive function deficits.83 Additionally, worse executive functions are linked to lower QoL and mental health problems.98-100 Hypoglycemia, hyperglycemia and DKA, especially if recurrent, can impact school functioning and educational attainment via a combination of mechanisms including altered cognitive function and non-attendance for acute treatment.101 However, findings regarding the impact of T1D on academic performance in young people are mixed. Older studies reported young people with T1D have lower academic performance compared to their peers or siblings without T1D102, 103 while more recent studies have not found differences in academic performance compared to peers.104-107 There is some evidence that young people with optimal glycemic management perform better academically.104, 105, 107 Several illness-related risk factors contribute to the greater risk for these brain changes and neurocognitive deficits in youth with T1D. Early age of diabetes onset is a specific risk factor for decline in IQ over time and neurocognitive deficits.88, 108 Recent research suggests that high-time outside range (TIR), the percentage of time blood glucose levels are in the target range of 3.9–10 mmol/L (70–180 mg/dl), negatively impacts brain development in youth with T1D,84 as does DKA, particularly at the time of diagnosis, with a decline in IQ over time and/or neurocognitive deficits.109-111 Protective strategies have also been identified, such as improving child sleep, continued family support, reducing caregiver distress and use of diabetes technology.82, 95 Collectively, studies identified early disease onset, and factors experienced around onset (higher HbA1c, severe hypoglycemic events and DKA) as major contributors to initial cognitive decrements, and with no or limited decline in cognitive abilities if these are experienced later after diagnosis. It is hypothesized that these early disease factors provide an ‘initial strike’, after which the brain adapts to the new situation of fluctuating glucose levels.112 The SEARCH for Diabetes in Youth study found that acquired knowledge, obesity, and depression contribute to executive functioning in youth with T1D and T2D and that differences in executive functioning observed in youth with T2D compared with those with T1D are in part attributable to differences in these factors.93 Interdisciplinary diabetes teams should be aware of risk and protective factors for neurocognitive deficits in youth with all types of diabetes. Ideally, questionnaire- or performance-based measures of neurocognitive function should be available for assessment by a mental health specialist when youth with diabetes are at risk and when they show signs of neurocognitive deficits in dealing with their diabetes self-management tasks (e.g., planning, prioritizing). Given the critical role of self-management and psychosocial factors impacting diabetes outcomes and QoL, it is imperative that psychological assessment be integrated routinely into clinical diabetes care. Validated psychological questionnaires are instrumental for screening and assessment. Such measures can facilitate addressing relevant psychosocial needs in a dialog with the person with diabetes and their family as part of routine diabetes team consultations.113, 114 The use of these assessments is feasible and accepted by children and youth with diabetes, families and HCPs and helps focus the clinical encounter more on psychosocial factors, facilitate shared-decision making and drive care decisions instead of mainly focusing on outcomes such as HbA1c and TIR.4, 114, 115 Routine assessments have been shown to positively impact well-being and satisfaction with care in young people with diabetes,114, 116, 117 without direct impact on self-management and glycemic outcomes.113, 115 Choice of assessment tool depends on the purpose, age and literacy of the person with diabetes. Children from the age of 8 years onwards are generally able to complete self-report questionnaires. In younger children, often parent-proxy measures are used, although instruments enabling the assessment of how the child is doing are available.118-120 Generic questionnaires can be used across different populations and capture more common aspects of the person's life, allowing for comparison to normative populations. Diabetes-specific questionnaires tap into and are more sensitive to symptoms and problem areas experienced by young people with diabetes. Diabetes-specific measures should be considered for DEB assessment because generic measures might capture behaviors that are part of treatment (e.g., carbohydrate counting and calorie restriction), and adverse effects of treatment such as excessive hunger secondary to hypoglycemia. In addition, generic measures are not able to capture insulin restriction or omission to lose weight. Several standardized and validated measures are available for providers to monitor well-being and screen for psychological difficulties of young people with diabetes.113, 121, 122 Monitoring tools can track changes over time across a broad range of domains and become part of person-centered care when feedback is provided to the person with diabetes during a clinical consultation.123 An example is routine monitoring of HRQOL which facilitates discussion between youth with diabetes and clinicians regarding psychosocial concerns as well as the different domains of HRQOL and the impact on diabetes self-management and well-being.113, 115, 117 Screening tools can help identify problems that may have gone otherwise unnoticed. Often, the score is weighted based on norm scores. An example is screening for depressive symptoms, where a cut-off is used to screen for young people at risk for clinical depression.4, 124 Screening is especially of importance in adolescence and young adulthood as this is are critical developmental periods where most psychological problems first arise.125 Routine screening for psychological difficulties from 12 years onwards, at least once a year, is recommended. Comprehensive psychosocial screening is feasible and can efficiently detect potential mental health problems and other issues impacting diabetes management.4 Many instruments have been developed to monitor QoL and screen for psychological problems in adolescents.113, 121, 126, 127 Only a few instruments capture the specific developmental domains of young adults.128 Standardized and validated questionnaires for psychosocial monitoring, screening, and diagnosis can be used in a stepped approach with positive findings leading to further evaluation.4, 5 Starting with informal verbal inquiries for monitoring well-being and/or QoL, including mood and distress where positive responses can be probed with additional questions and/or use of standardized measures and finally by structured interviews for diagnosis. These formal diagnostic assessments and interviews should be conducted by a qualified mental health professional, familiar with the care of young people with diabetes and help guide the selection of most appropriate intervention. Mental health specialists should train members of the health care team in screening instrument use. Further, if formal assessments are used, there must be a process for appropriate referrals to mental health specialists to address identified concerns. Screening and referral alone are not sufficient to impact clinical and psychological outcomes, nor can they ensure referrals are done so that mental health care is actually received.2 Integrated care models are critical.3-5 Diabetes self-management is most effective in the context of collaborative interpersonal relationships.129, 130 This involves the family context, peers, and diabetes team. The Social Ecological Theory and the biopsychosocial model consider the social environment or “interpersonal context of illness” as key to understanding the development and behavior of youth with diabetes to improve their health outcomes.131, 132 The interactions between youth with diabetes and their environments are reciprocal, and an individual's characteristics interact uniquely with their environment, creating a developmental context that is specific to that individual. This view helps to explain the differing developmental trajectories and outcomes of individuals with the same diagnosis of diabetes.131 Parental well-being affects their children's outcomes. Levels of psychological distress among parents of children with diabetes are greater than parents of children without diabetes.133 Many parents report significant distress after their child's diabetes diagnosis and have difficulty coping with their child's diabetes management.32 Parental depression and anxiety symptoms are common in the months following diagnosis, as are symptoms of post-traumatic stress due to the new responsibilities134-137 with nearly one in five parents reporting distress up to 4 years after diagnosis.138 Parents of younger children report an all-encompassing impact due to constant worry and the perceived need for vigilance.139 Fear of hypoglycaemia in parents of younger children, and distress about caring for a child with diabetes, affect parental well-being and relationships. This could, in turn, affect parenting behavior and the child's glycemic management.17, 139-142 Greater social support is associated with less stress in parents of children with recent diagnosis of diabetes.143 Connecting with other parents caring for a child with T1D can provide valued emotional and practical support and diabetes technology use could also lessen some burdens.139 Literature on the specific impact of T2D in youth on parental well-being is scarce. Parental well-being and coping also impacts their child's physical and mental health. When parents have adjustment difficulties and are greatly stressed, studies indicate they also have less diabetes management self-efficacy and their children have more behavioral and psychological problems.144-148 Although most studies have been conducted in mothers, it is important to consider fathers as well since paternal psychological maladjustment predicted suboptimal glycemic management in children 5 years after diagnosis.149 Further, avoidant coping in fathers was related to increased parenting stress when they were more involved in diabetes management.150 Providing psychological support to parents is an important clinical need and helping parents can lead to more effective management of diabetes.151, 152 Parenting and family interventions can be instrumental here and will be discussed below in Section 10. Parent support, levels of parent involvement, family conflict, parenting style, and family/parent–child relationship quality are all associated with psychological health outcomes in youth with diabetes, with some associations varying by parent gender, child age and demographic factors.153 Continued parental involvement in diabetes care throughout adolescence and into young adulthood is beneficial154, 155 as premature transition of responsibility may be detrimental.156 This involves parental monitoring of child behavior, which has favorable effects on youth internalizing and externalizing symptoms.153 Especially close parental monitoring of self-management tasks requiring executive functioning skills like problem-solving and impulse control is warranted to prevent glycemic outcome declines.95 The way parents are involved in their child's management matters. Diabetes-specific family conflict negatively affects treatment plan, glycemic management as well as QoL and depressive and/or anxiety symptoms in young people.157 Over-involvement, or unsupportive behaviors (such as nagging), could have adverse effects.140, 158 Parenting styles are important in these family interactions. An authoritative and responsive style (i.e., clear levels of expectations for self-management and warmth and sensitivity) is associated with better self-management (e.g., checking blood glucose levels more frequently, making healthy food choices) and glycemic management, and less overweight (therefore perhaps preventive for T2D); conversely, more psychological control is associated with suboptimal outcomes.155, 159 The benefits of an authoritative parenting style transcend ethnicity, socioeconomic status, and household composition.159 Studies that explored relationship quality and child psychological health generally found that more cohesive family relationships were associated with lower youth externalizing symptoms. There may be a relationship between higher quality family relationships and lower internalizing in youth with T1D, especially for youth of color.153 In addition, a warm and accepting environment is associated with better physiologic and psychosocial outcomes.154, 158 Although most research on the social context of youth with diabetes has focused on the family environment, as children get older (particularly during adolescence) peer relationships become more important. Supportive friends can complement parents' involvement in psychological outcomes160, 161 with yout

Objectives Utilising coping strategies to reduce and manage the intensity of negative and distressing emotions caused by diabetes is essential. However, little is known about the use of coping strategies among people living with diabetes in Sub-Saharan African countries like Zambia. This study investigates coping strategies used by people with diabetes in Zambia and how these are associated with diabetes-specific emotional distress, depression and diabetes self-care. Methods Cross-sectional data from 157 people with diabetes aged between 12 and 68 years were collected. Of the 157, 59% were people with type 1 diabetes and 37% with type 2 diabetes. About 4% had missing information in their record but had either type 1 or type 2 diabetes. Coping styles were measured using the Brief Version of the Coping Orientation to Problems Experienced (Brief COPE), diabetes specific-distress using the Problem Areas in Diabetes, depression using the Major Depression Inventory and self-care using the Diabetes Self-Care scale. Results Data showed that adaptive coping strategies such as religious coping, acceptance among others, were the most frequently used coping strategies among Zambian individuals with diabetes. Maladaptive coping strategies e.g., self-blame and self-distraction were related to increased diabetes specific-distress and depression. Emotional support was related to better diabetes self-care, while self-blame was related to poor diabetes self-care. Conclusion There is need to help individuals with diabetes identify adaptive strategies that work best for them in order to improve their quality of life.

In 2017, the Lancet Diabetes & Endocrinology published a landmark Commission on diabetes in sub-Saharan Africa. 1 Atun R Davies JI Gale EAM et al. Diabetes in sub-Saharan Africa: from clinical care to health policy. Lancet Diabetes Endocrinol. 2017; 5: 622-667 Summary Full Text Full Text PDF PubMed Scopus (245) Google Scholar The Commission highlighted a wide range of issues related to the management of diabetes in the African continent. These issues included the scarcity of data on the true burden of diabetes and its related complications, challenges in the availability and affordability of medicines, a shortage of trained health-care workers, and generally ill-prepared health systems. The Commission 1 Atun R Davies JI Gale EAM et al. Diabetes in sub-Saharan Africa: from clinical care to health policy. Lancet Diabetes Endocrinol. 2017; 5: 622-667 Summary Full Text Full Text PDF PubMed Scopus (245) Google Scholar also set out to propose operational targets, which could serve as a milestone for African governments and organisations to use to meet the goals of the UN high-level meeting on non-communicable diseases (NCDs) and sustainable development goals (SDGs). The goal of the UN high-level meeting on NCDs is to reduce premature death from NCDs by 25% by 2025, which goes in tandem with the SDG Target 3.4 (to reduce premature death from NCDs by 30% by 2030).

The aim of this study was to investigate the main effect and moderating effect of intergroup behaviours on the relationship between daily life stressors and emotional symptoms. Data was collected from 628 school going adolescents using the Daily Life Stressor Scale, emotional symptom subscale of the Strengths and Difficulties Questionnaire and the Behaviours from Intergroup Affect and Stereotypes - Treatment scale. Data showed that emotional symptoms and daily life stressors were common especially among girls. Daily life stressors, active harm and passive facilitation predicted increased emotional symptoms. However, contrary to the study hypothesis, active and passive harm, and active and passive facilitation did not moderate the relationship between daily life stressors and emotional symptoms. School based interventions focusing on reducing academic and interpersonal related daily life stressors should be considered in order to reduce emotional symptoms and improved wellbeing among school going adolescents.

Severe hypoglycemia is a burdensome complication of diabetes mellitus that can induce fear of hypoglycemia and contribute to suboptimal glycemic control. The challenge is to achieve and maintain adequate glycemic control while avoiding episodes of severe hypoglycemia. The purpose of the study was to determine how common fear of hypoglycemia was in Zambian out-patients with diabetes and also to explore correlates of fear of hypoglycemia. One hundred fifty-seven individuals with types 1 and 2 diabetes participated in the study. Fear of Hypoglycemia Scale, Diabetes Self-Care Inventory, Problem Areas in Diabetes, and the Major Depression Inventory were completed. Multiple linear regression models were computed to assess the association between fear of hypoglycemia and psychological factors. About 19% [16.3% type 1 and 12.6% type 2] of individuals with diabetes based on item endorsement expressed fear of hypoglycemia especially among individuals with type 1 diabetes. After controlling for demographic variables, diabetes self-care (ß = 0.24, p < 0.05), and diabetes specific distress (ß = 0.41, p < 0.001) were associated with fear of hypoglycemia. Fear of hypoglycemia was common and was positively associated with diabetes specific emotional distress and diabetes self-care. Interventions to avert fear of hypoglycemia are needed while optimizing glycemic control through managing diabetes care and emotion distress in individuals with diabetes.

This study explored experiences of adolescents living with cancer, focusing on physical and psychosocial problems. Semi-structured interviews were carried out on 18 adolescents aged between 12 and 18 years. Transcripts were analyzed using thematic analysis. Results showed that the adolescents faced a lot of physical, psychological, and social problems due to cancer diagnosis, treatment, and care. In order to improve their well-being and quality of life, psychosocial interventions should be incorporated in biomedical interventions that adolescents with cancer receive. This study proposes cost-effective interventions that can be implemented in resource-restricted sub-Saharan countries like Zambia.

Over a million people are living with HIV in Zambia, representing similar to 13% of the country's population. To increase HIV prevention communication, a community-based communication training program, the Parent-Child and Couples Communication Workshop, was developed from pilot data and culturally tailored for dissemination in Zambia. Workshop trainees (N = 195) were 18 years of age or more and community educators and counselors in the Copperbelt and Southern Provinces of Zambia, e.g., peer educators, lay counselors, teachers, nurses, mentors and program officers, workshops (N = 16) were conducted. Satisfaction with the workshops, readiness to conduct a workshop and implementation were assessed. Overall, readiness to conduct workshops following training and satisfaction with the workshop was similarly high across Provinces. Following the initial training, more than half of workshop trainees conducted workshops in their own communities. Zambian community members were receptive to learning techniques to disseminate communication strategies that could prevent HIV transmission. The use of culturally appropriate strategies and a training of trainers approach for communication and prevention may have enhanced workshop dissemination in Zambian communities. Future research should explore the use of culturally congruent HIV prevention initiatives in the Zambian context.