Background: In Colombia, internal violence, displacement, COVID-19, suicide, and climate crises threaten the survival of younger adults, many of whom are parents. Such premature mortality increases orphanhood risks. Evidence-based psychosocial support for surviving caregivers has potential to mitigate adverse impacts of orphanhood for bereaved children in crisis settings. Here, we adapted the Hope Group program from war-affected Ukraine to post-COVID-19 Colombia Parenting with Hope, and evaluated the effectiveness of psychosocial and parenting support delivered via home visits on improvements in caregiver mental health, violence against children, parenting practices, and child behavioral issues. Methods: Participants (n=220) included surviving caregivers co-residing with children experiencing death of a parent or caregiver in the previous 12-36 months. Next-of-kin caregivers were identified through vital statistics data, death certificate annexes, radio/social media, schools, COVID-19 laboratories, and referrals. We used pre-post and quasi-experimental approaches to evaluate the effectiveness of Parenting with Hope. For both analysis types, we constructed Bayesian models to estimate mean change and percent change following completion of the 8-session program. Results: Both pre-post and quasi-experimental findings showed significant improvements across all mental health, violence prevention, parenting, and child outcomes. Pre-post results showed caregiver depression/anxiety ratings decreased by 91.2% (95% posterior credible interval (CrI) -93.7, -87.6), and hopefulness increased by 43.8% (95% CrI 34.5, 54.8) and self-care, by 139.5% (95% CrI 107.5, 178.1). Each component measure of parenting practices (nonviolent discipline, positive parenting, parental monitoring, and parental involvement) improved significantly. By endline, violence against children had decreased by 63.9% (95% CrI -71.1, -54.4), and child externalizing and internalizing behaviors, by 74.4% (95% CrI, -78.0%, -70.3%). Pre-post and quasi-experimental findings showed equivalence. Conclusion: This study generalizes evidence for effectiveness of Parenting with Hope in crisis settings to surviving Colombian caregivers, on improved mental health, parenting practices, and reduced violence against children and child behavioral issues. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Financial support for conducting this intervention was provided by the Moderna Charitable Foundation. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Imperial College London Ethics Committee and University of Sucre Ethics Committee approved this study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Children affected by orphanhood of any cause may benefit from assessment and referral to appropriate services. Timely and accurate data can guide policy. We leveraged new data sources expanding previous reports on national COVID-19-associated orphanhood to estimate national and sub-national numbers of children newly affected by death of parents and co-residing elderly caregivers due to all-causes and to COVID-19-associated causes in 2020-2021 in Brazil. We estimated that 1,300,000 (95% uncertainty interval 1,190,000, 1,430,000) children in Brazil experienced loss of one or multiple parents and/or co-residing caregivers 60+. 673,000 (652,000, 690,000) children were estimated to have lost one or both parents, of which 149,000 (144,000, 154,000) were COVID-19-associated; 635,000 (534,000, 758,000) children were estimated to have lost a co-residing grandparent or other kin, of which 135,000 (85,900, 199,000) were COVID-19-associated. Orphanhood estimates varied across states. The highest all-cause rate of parental orphanhood was in Roraima, at 17.5 (95% uncertainty interval 15.6, 20.6) per 1000 children, and the lowest was in Santa Catarina, at 9.5 (8.7, 10.4) per 1000 children. COVID-19-associated orphanhood was also unevenly distributed, with Mato Grosso experiencing the greatest rate, at 4.4 (3.9, 5.3) per 1000 children, while Pará experienced the lowest rate of 1.4 (1.2, 1.8) per 1000 children. We compared our estimates with administrative data for COVID-19-associated orphanhood (from Brazil’s civil registry offices and manually reviewed death certificates in Campinas) and found that a similar demographic distribution of orphanhood. However, our estimates suggested that administrative sources undercount orphanhood, suggesting that approximately 32% and 56% of total orphanhood was captured in the two datasets, respectively. Our findings highlight the extent of orphanhood in Brazil and the large inequalities between states. Our comparisons with administrative data both validate our model and suggest that strengthening vital registration systems can put children at the center of public health responses globally. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement N.S. acknowledges support from the Oxford-Radcliffe Scholarship from University College, Oxford, the EPSRC CDT in Modern Statistics and Statistical Machine Learning (Imperial College London and University of Oxford), A. Maslov for studentship support, EPSRC EP/V002910/2, and US Centers for Disease Control and Prevention and World Health Organization, “Building Global Public Health Capacity to Link Real-Time Modelling Data on COVID-19-associated Orphanhood and Caregiver Deaths to Inform Prevention, Preparedness and Protection from COVID-19 consequences,” 2023 (CDC/WHO grant). H.T.J.U. acknowledges funding from the Moderna Charity Foundation. A.B. acknowledges funding from EPSRC EP/X038440/1. E.S. acknowledges funding from EPSRC EP/V002910/2 and support from the AI2050 program at Schmidt Sciences (Grant [G-22-64476]). A.V.R.A and O.R. acknowledge funding from the Moderna Charity Foundation. L.C. acknowledges funding from the European Research Council (#771468). L.B. acknowledges CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)), Grant (312475/2022-5) and Fapesp (Fundação de Amparo à Pesquisa do Estado de São Paulo (Fapesp)), Grant (2021/08772-9). S.F. acknowledges funding from CDC/WHO grant and EPSRC EP/V002910/2. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: N/A I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable All code and data (where we are able to provide directly) required to reproduce these results are available at https://github.com/MLGlobalHealth/BrazilOrphanhood. Where we are unable to provide original data, instructions are provided in this repository on how to obtain the data.

Deaths of parents and grandparent caregivers threaten child well-being owing to losses of care, financial support, safety and family stability, but are relatively unrecognized as a public health crisis. Here we used cause-specific vital statistics death registrations in a modeling approach to estimate the full magnitude of orphanhood incidence and prevalence among US children aged 0-17 years between 2000 and 2021 by cause, child age, race and ethnicity, sex of deceased parent and state, and also accounted for grandparent caregiver loss using population survey data. In 2021, we estimate that 2.91 million children (4.2% of children) had in their lifetime experienced prevalent orphanhood and caregiver death combined, with incidence increasing by 49.5% and prevalence by 7.9% since 2000. Populations disproportionately affected by orphanhood included 5.2% of all adolescents; 6.4% and 4.7%, respectively, of non-Hispanic American Indian or Alaska Native, and non-Hispanic Black children; and children in southern and eastern states. In 2021, drug overdose was the leading cause of orphanhood among non-Hispanic white children, but not among minoritized subgroups. Effective policies and programs to support nearly three million bereaved children are needed to reduce the acute and long-term negative effects of orphanhood.

Importance: Deaths of parents and grandparent caregivers linked to social and health crises threaten child wellbeing due to losses of nurturance, financial support, physical safety, family stability, and care. Little is known about the full burden of all-causes and leading cause-specific orphanhood and caregiver death beyond estimates from select causes. Objective : To estimate 2000-2021 prevalence and incidence trends of all-cause orphanhood and caregiver death among children <18, by cause, age, race/ethnicity, and state. Data Sources : National Center for Health Statistics (NCHS) birth, death, race/ethnicity, and population data to estimate fertility rates and identify causes of death; 1983-1998 ICD-9 causes-of-death harmonized to ICD-10 classifications; 1999-2021 ICD-10 causes-of-death; CDC WONDER for state-specific estimates; and American Community Survey for grandparent population estimates. Data extraction and synthesis : We extracted U.S. population-level death, birth, population size, race, and ethnicity data from NCHS and attributed to each deceased individual the average number of children left behind according to subgroup-specific fertility rates in the previous 0-17 years. We examined prevalence and incidence of orphanhood by leading causes-of-death, including COVID-19, the leading 5 causes-of-death for 1983-2021, and additional leading causes for ages 15-44. We extended these to obtain state-level outcome estimates. Main outcome measures : National incidence and prevalence of orphanhood and caregiver death from 2000-2021, with orphanhood by year, parental cause-of-death and sex, child age, race/ethnicity, and state. Results: From 2000-2021, orphanhood and custodial/co-residing grandparent caregiver loss annual incidence and prevalence trends increased 49.2% and 8.3%, respectively. By 2021, 2.9 million children (4% of all children) had experienced prevalent orphanhood and caregiver death. Populations disproportionately affected by orphanhood included 5.0% of all adolescents; 6.5%, 4.8%, and 3.9% respectively of non-Hispanic American Indian/Alaska Native, non-Hispanic Black, and non-Hispanic White children; and children in New Mexico and Southern and Eastern States. Parental death due to drug overdose during 2020-2021 surpassed COVID-19 as the leading cause of incident and prevalent orphanhood during the COVID-19 pandemic. Conclusions and Relevance: Policies, programs, and practices aimed at orphanhood prevention, identification, and linkage to services and support of nearly 3 million bereaved children are needed, foremost prioritizing rapidly increasing overdose-linked orphanhood.

Abstract Background In 2021, more than two-thirds of the world’s children lived in a conflict-affected country. In 2022, 13 million Ukrainians were forced to flee their homes after Russia’s full-scale invasion. Hope Groups are a 12-session psychosocial, mental health, and parenting support intervention designed to strengthen parents, caregivers, and children affected by war and crisis. The primary objective of this study is to evaluate the effectiveness of Hope Groups among Ukrainians affected by war, compared to a wait-list control group. This protocol describes a promising decentralized intervention delivery model and an innovative research design, which estimates the causal effect of Hope Groups while prioritizing prompt delivery of beneficial services to war-affected participants. Methods This protocol describes a pragmatic cluster randomized controlled trial (RCT) among Ukrainians externally displaced, internally displaced within Ukraine, and living at home in war-affected areas. This study consists of 90 clusters with 4–7 participants per cluster, totaling approximately n = 450 participants. Intervention clusters will receive 12-session Hope Groups led by peer facilitators, and control clusters will be wait-listed to receive the intervention after the RCT concludes. Clusters will be matched on the facilitator performing recruitment and intervention delivery. Primary outcomes are caregiver mental health, violence against children, and positive parenting practices. Secondary outcomes include prevention of violence against women and caregiver and child well-being. Outcomes will be based on caregiver report and collected at baseline and endline (1-week post-intervention). Follow-up data will be collected among the intervention group at 6–8 weeks post-intervention, with aims for quasi-experimental follow-ups after 6 and 12 months, pending war circumstances and funding. Analyses will utilize matching techniques, Bayesian interim analyses, and multi-level modeling to estimate the causal effect of Hope Groups in comparison to wait-list controls. Discussion This study is the first known randomized trial of a psychosocial, mental health, and parenting intervention among Ukrainians affected by war. If results demonstrate effectiveness, Hope Groups hold the potential to be adapted and scaled to other populations affected by war and crisis worldwide. Additionally, methodologies described in this protocol could be utilized in crisis-setting research to simultaneously prioritize the estimation of causal effects and prompt delivery of beneficial interventions to crisis-affected populations. Trial registration This trial was registered on Open Science Framework on November 9, 2023. Registration: OSF.IO/UVJ67.

Background:Nearly one in six children lived in war zones in 2023. Evidence-based psychosocial and parenting support has potential to mitigate negative impacts for parents and children co-exposed to war and displacement, especially in relation to mental health and harsh parenting reactions. In the current war in Ukraine, local mental health experts co-created and evaluated, with global experts, the effectiveness of psychosocial and parenting support groups, called 'Hope Groups' on improvements in mental health, positive parenting, and violence against children. This paper aimed to assess the effectiveness of psychosocial and parenting support groups, called 'Hope Groups,' on improvements in caregiver mental health, positive parenting, and prevention of violence against children, for families affected by the war in Ukraine, using a pre/post study design. Methods:Participants (n = 577) included Ukrainian caregivers, 66% (381) of whom were parents and co-residing caregivers of children ages 0-17, while the remaining 34% were non-resident informal caregivers. Internally displaced, externally displaced, and those living at-home in war-torn regions were invited to groups by trained Ukrainian peer facilitators. Using a pre-post design, we compared individual level frequency measures at three time-points - baseline, midline, and endline, to assess changes in 4 mental health, and 9 parenting and child health outcomes. We analyzed these outcomes using paired t-tests to compare outcomes at baseline-to-midline (after 4-sessions) and baseline-to-endline (after 10-sessions), which estimated the mean changes in days per week and associated percent change, during the respective periods; we quantified uncertainties using bias-corrected and accelerated (BCa) bootstrapping with 95% uncertainty ranges for baseline-midline and baseline-endline estimates. We used this same approach for stratified analyses to assess potential effect modification by displacement status and facilitator type. We further used linear models to adjust for age and sex. Findings:Compared to baseline, every mental health, parenting, and child health outcome improved significantly at midline and endline. Mental health ratings showed endline reductions in depressive symptoms of 56.8% (95% CI: -59.0,-54.3; -1.8 days/week), and increases in hopefulness, coping with grief, and self-care, ranging from 62.0% (95% CI: 53.6,71.3; 2.2 days/week) to 77.0% (95% CI: 66.3,88.3; 2.2 days/week). Significant improvements in parenting and child health outcomes included monitoring children, reinforcing positive behavior, supporting child development, protecting child, nonviolent discipline, and child verbalizing emotions. By endline, emotional violence, physical violence, and child despondency had dropped by 57.7% (95% CI: -63.0%,-51.9; -1.3 days/week), 64.0% (95% CI: -79.0,-39.5; -0.22 days/week), and 51.9% (95% CI: -45.1,-57.9; -1.2 days/week), respectively. Outcomes stratified by displacement status remained significant across all groups, as did those according to facilitator type (lay versus professional). Interpretation:This study demonstrates preliminary evidence, using a brief survey and pre-post design as is appropriate for acute and early protracted emergency settings, of the feasibility and effectiveness of Hope Groups for war-affected Ukrainian caregivers, on improved mental health, positive parenting, and reduced violence against children.

BACKGROUND:In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood). METHODS:We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020-April 30, 2021, to include the new period of May 1-Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0-4 years, 5-9 years, and 10-17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates. FINDINGS:The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90·0% (95% CrI 89·7-90·4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100-2 987 000) to 5 200 300 (3 619 400-5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100-497 900) children aged 0-4 years, 736 800 (726 900-746 500) children aged 5-9 years, and 2 146 700 (2 120 900-2 174 200) children aged 10-17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76·5% (95% CrI 76·3-76·7) of children were paternal orphans, whereas 23·5% (23·3-23·7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood. INTERPRETATION:Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5·0 million COVID-19 deaths meant that 5·2 million children lost a parent or caregiver. Our data on children's ages and circumstances should support pandemic response planning for children globally. FUNDING:UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

The new WHO estimates for COVID-19 excess deaths allow us to generate supdated and more accurate models of COVID-19 associated orphanhood and caregiver loss. Using methodology established in prior studies, we combine age-specific fertility and excess death estimates from January 2020 to May 2022. We find 10.4 million children have lost a parent or caregiver due to COVID-associated excess deaths, and 7.5 million children have experienced COVID-associated orphanhood. Without supportive intervention, caregiver loss can bring severe risks of poverty, school dropout, sexual exploitation, and mental health distress. It is essential that evidence-based care for these children is integrated into all national response plans as a caring action to protect children from immediate and long-term harms of COVID-19.

This study assesses estimates of new orphanhood based on excess deaths to provide a comprehensive measure of the COVID-19 pandemic’s long-term impact on orphanhood and caregiver loss.

Background: The global COVID-19 pandemic and response has focused on prevention, detection, and response. Beyond morbidity and mortality of those infected, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, delayed development, and institutionalization. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation.Methods: We use mortality and fertility data to model rates of COVID-19-associated orphanhood and caregiver deaths for 18 countries in Africa, Asia, Europe, and the Americas, and extrapolate global estimates of COVID-associated deaths of parents and grandparent caregivers.Results: We estimate that globally, >1 million children were orphaned or lost a caregiver due to COVID-19-associated deaths during March–December 2020. Countries with higher rates of caregiver deaths included Peru, South Africa, Mexico, Russian Federation, Colombia, Brazil, Islamic Republic of Iran, Argentina, U.S.A., and Spain (range, 1·1–9·8/1000). For most countries, numbers of children orphaned were greater than deaths among those aged 15–44 years; 2–5 times more children had deceased fathers than deceased mothers.Conclusions: Orphanhood and caregiver deaths are a shadow pandemic resulting from COVID-19-associated deaths: we find that over one million children worldwide have lost a parent or caregiver in just ten months. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families nurture children bereft of caregivers and promote their recovery. Strengthening family-based care can help ensure that institutionalization of these children is avoided. These data demonstrate the need for an additional pillar of our response: prevent, detect, respond, and care for children.Funding: UK Research and Innovation (Global Challenges Research Fund (GCR), Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, U.S. National Institutes of Health, Imperial College.Declaration of Interests: Dr. Donnelly reports grants from UK Medical Research Council and grants from NIHR during the conduct of the study. Dr. Cluver reports grants from UK Research and Innovation (UKRI) Global Challenges Research Fund, during the conduct of the study. All other authors report nothing to disclose.Ethics: We used modeled aggregate data and publicly available de-identified survey metadata.

BACKGROUND:The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation.METHODS:We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60-84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection-fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers.FINDINGS:Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000-1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000-1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15-50 years. Between two and five times more children had deceased fathers than deceased mothers.INTERPRETATION:Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children.FUNDING:UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Background: In the past six months, proliferation of new variants, updated mortality data, and vaccine access disparities have increased estimates of children experiencing COVID-19-associated orphanhood. To inform responses, we modelled increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death; and cumulative orphanhood age-group distribution and circumstance (maternal/paternal). Methods: We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths between May 1 — October 31, 2021, for 21 countries. Using yearly fertility contributions, we grouped children by age (0-4, 5-9, 10-17), maternal/paternal orphanhood, and modelled global and regional extrapolations. Findings: The number of children affected by COVID-19-associated orphanhood and caregiver death increased 90% from April 30 to October 31, 2021: from 2,700,000 [95% CrI 1,976,000-2,987,000] to 5,200,000 [95% CrI 3,751,000-5,826,000]. From April 30, 2020 - October 31, 2021, 490,000 [95% CrI 321,400-573,400] children ages 0-4, 737,000 [95% CrI 485,700-865,800] children 5-9, and 2,144,000 [95% CrI 1,418,800-2,553,900] children 10-17 experienced COVID-associated parental death. In each age-group/region, paternal orphanhood prevalence exceeded maternal orphanhood for children 0-4, 11.5% vs. 3.1%, children 5-9, 17.1% vs. 4.8%, and children 10-17, 48% vs. 15.6% respectively.Interpretation: Our findings show that numbers of children affected by COVID-associated orphanhood increased by 90% in 6 months compared to the first 14 months of the pandemic with 5.0 million COVID-19 deaths and 5.2 million children having lost a parent or caregiver over the entire 20-month period. We provide data on children’s ages and circumstances, to support response planning for children globally. Funding Information: UK Research and Innovation (Global Challenges Research Fund (GCR), Engineering and Physical Sciences Research Council, Medical Research Council), Oak Foundation, UK National Institute for Health Research, U.S. National Institutes of Health, Imperial College.Declaration of Interests: Dr. Donnelly reports grants from UK Medical Research Council and grants from NIHR during the conduct of the study. Dr. Cluver reports grants from UK Research and Innovation (UKRI) Global Challenges Research Fund, during the conduct of the study. All other authors report nothing to disclose.

Background: Most COVID-19 deaths occur among adults, not children, and attention has focused on mitigating COVID-19 burden among adults. However, a tragic consequence of adult deaths is that high numbers of children might lose their parents and caregivers to COVID-19-associated deaths. Methods: We quantified COVID-19-associated caregiver loss and orphanhood in the US and for each state using fertility and excess and COVID-19 mortality data. We assessed burden and rates of COVID-19-associated orphanhood and deaths of custodial and co-residing grandparents, overall and by race/ethnicity. We further examined variations in COVID-19-associated orphanhood by race/ethnicity for each state. Results: We found that from April 1, 2020 through June 30, 2021, over 140,000 children in the US experienced the death of a parent or grandparent caregiver. The risk of such loss was 1.1 to 4.5 times higher among children of racial and ethnic minorities, compared to Non-Hispanic White children. The highest burden of COVID-19-associated death of parents and caregivers occurred in Southern border states for Hispanic children, Southeastern states for Black children, and in states with tribal areas for American Indian/Alaska Native populations. Conclusions: We found substantial disparities in distributions of COVID-19-associated death of parents and caregivers across racial and ethnic groups. Children losing caregivers to COVID-19 need care and safe, stable, and nurturing families with economic support, quality childcare and evidence-based parenting support programs. There is an urgent need to mount an evidence-based comprehensive response focused on those children at greatest risk, in the states most affected.

Community violence is a prevalent form of interpersonal violence in South Africa for children living in low-income areas. Trauma arising from violence exposure is of concern in contexts where access to treatment is often unattainable. As simultaneous multisectoral strategies show higher potential to counter interpersonal violence than single interventions, the World Health Organization with partners created INSPIRE. INSPIRE takes an integrated approach coordinated across formal and informal settings of civil and private society. Responding to research paucity on methods that counter community violence in LMIC settings, this study employed a cross-sectional correlational design consisting of a sample of 2,477 children aged 10 to 17 years from the Young Carers 2009-2010 study conducted in a low-income, HIV-endemic province of South Africa highly affected by community violence. Multiple logistic regressions assessed individual and dose associations between four INSPIRE-based violence prevention strategies-positive parenting, basic necessities, formal social support, and school structural support-and direct and indirect community violence outcomes. Three strategies had significant associations with community violence outcomes: necessities (direct p < .001; adjusted odds ratio [AOR] = .57; indirect p < .01; AOR = .62), formal support (direct p < .05; AOR = .83; indirect p < .05; AOR = .73), and school support (direct p < .001; AOR = .53; indirect p < .001; AOR = .49). Combined interventions in direct and indirect community violence analyses demonstrated that children reporting a higher number of strategies were less likely to have experienced community violence. This outcome extends the results of longitudinal studies in South Africa highlighting social protection with care as a means to overcome structural deprivation strains, thereby reducing the likelihood of children's exposure to community violence. Moreover, these findings uphold the INSPIRE model as an effective cross-sectoral approach to prevent and reduce the community violence that children experience.

This study, a secondary analysis of the HPTN 068 randomized control trial, aimed to quantify the association of father and male presence with HIV incidence and first pregnancy among 2533 school-going adolescent girls and young women (AGYW) in rural South Africa participating in the trial between March 2011 and April 2017. Participants' ages ranged from 13-20 years at study enrollment and 17-25 at the post-intervention visit. HIV and pregnancy incidence rates were calculated for each level of the exposure variables using Poisson regression, adjusted for age using restricted quadratic spline variables, and, in the case of pregnancy, also adjusted for whether the household received a social grant. Our study found that AGYW whose fathers were deceased and adult males were absent from the household were most at risk for incidence of first pregnancy and HIV (pregnancy: aIRR = 1.30, Wald 95% CI 1.05, 1.61, Wald chi-square p = 0.016; HIV: aIRR = 1.27, Wald 95% CI 0.84, 1.91, Wald chi-square p = 0.263) as compared to AGYW whose biological fathers resided with them. For AGYW whose fathers were deceased, having other adult males present as household members seemed to attenuate the incidence (pregnancy: aIRR = 0.92, Wald 95% CI 0.74, 1.15, Wald chi-square p = 0.462; HIV: aIRR = 0.90, Wald 95% CI 0.58, 1.39, Wald chi-square p = 0.623) such that it was similar, and therefore not statistically significantly different, to AGYW whose fathers were present in the household.

Purpose: Youth suicide clusters may be exacerbated by suicide contagion-the spread of suicidal behaviors. Factors promoting suicide contagion are poorly understood, particularly in the advent of social media. Using cross-sectional data from an ongoing youth suicide cluster in Ohio, this study examines associations between suicide cluster-related social media and suicidal behaviors. Methods: We surveyed 7thto 12th-grade students in northeastern Ohio during a 2017-2018 suicide cluster to assess the prevalence of suicidal ideation (SI), suicide attempts (SAs), and associations with potential contagion-promoting factors such as suicide cluster-related social media, vigils, memorials, news articles, and watching the Netflix series 13 Reasons Why before or during the cluster. Generalized estimating equations examined associations between potential contagion promoting factors and SI/SA, adjusting for nonmodifiable risk factors. Subgroup analyses examined whether associations between cluster-related factors and SI/SA during the cluster varied by previous history of SI/SA. Results: Among participating students, 9.0% (876/9,733) reported SI and 4.9% attempted suicide (481/9,733) during the suicide cluster. Among students who posted suicide cluster-related content to social media, 22.9% (267/1,167) reported SI and 15.0% (175/1,167) attempted suicide during the suicide cluster. Posting suicide cluster-related content was associated with both SI (adjusted odds ratio 1.7, 95% confidence interval 1.4-2.0) and SA during the cluster (adjusted odds ratio 1.7, 95% confidence interval 1.2-2.5). In subgroup analyses, seeing suicide cluster-related posts was uniquely associated with increased odds of SI and SA during the cluster among students with no previous history of SI/SA. Conclusions: Exposure to suicide cluster-related social media is associated with both SI and SA during a suicide cluster. Suicide interventions could benefit from efforts to mitigate potential negative effects of social media and promote prevention messages. Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

Coronavirus disease 2019 (COVID-19) is changing family life. The United Nations Educational, Scientific and Cultural Organization estimates 1·38 billion children are out of school or child care, without access to group activities, team sports, or playgrounds. Parents and caregivers are attempting to work remotely or unable to work, while caring for children, with no clarity on how long the situation will last. For many people, just keeping children busy and safe at home is a daunting prospect. For those living in low-income and crowded households, these challenges are exacerbated. This has serious implications. Evidence shows that violence and vulnerability increase for children during periods of school closures associated with health emergencies.1Rothe D Gallinetti J Lagaay M Campbell L Ebola: beyond the health emergency. Plan International, Monrovia, Liberia2015Google Scholar Rates of reported child abuse rise during school closures. Parents and children are living with increased stress, media hype, and fear, all challenging our capacity for tolerance and long-term thinking. For many, the economic impact of the crisis increases parenting stress, abuse, and violence against children. But times of hardship can also allow for creative opportunity: to build stronger relationships with our children and adolescents. WHO, UNICEF, the Global Partnership to End Violence Against Children, the United States Agency for International Development USAID, the US Centers for Disease Control and Prevention (CDC), Parenting for Lifelong Health, and the UK Research and Innovation Global Challenges Research Fund Accelerating Achievement for Africa's Adolescents Hub are collaborating to provide openaccess online parenting resources during COVID-19. These resources focus on concrete tips to build positive relationships, divert and manage bad behaviour, and manage parenting stress. They are shared through social media, and they are accessible on non-smartphones through the Internet of Good Things. A team of international volunteers are producing translations in 55 languages. Importantly, these parenting resources are based on robust evidence from randomised controlled trials in low-income and middle-income countries.2Cluver L Meinck F Steinert J et al.Parenting for Lifelong Health: a pragmatic cluster randomised controlled trial of a non-commercialised parenting programme for adolescents and their families in South Africa.BMJ Global Health. 2018; 3e000539Crossref Scopus (125) Google Scholar, 3Ward CL Wessels IM Lachman JM et al.Parenting for Lifelong Health for Young Children: a randomized controlled trial of a parenting program in South Africa to prevent harsh parenting and child conduct problems.J Child Psychol Psychiatry. 2020; 61: 503-512Crossref PubMed Scopus (75) Google Scholar, 4Vally Z Murray L Tomlinson M Cooper PJ The impact of dialogic book-sharing training on infant language and attention: a randomized controlled trial in a deprived South African community.J Child Psychol Psychiatry. 2015; 56: 865-873Crossref PubMed Scopus (96) Google Scholar COVID-19 is not the first virus to threaten humanity, and it will not be the last. We need to utilise effective strategies to strengthen families to respond, care, and protect a future for the world's children.5Clark H Coll-Seck AM Banerjee A et al.A future for the world's children? A WHO-UNICEF-Lancet Commission.Lancet. 2020; 395: 605-658Summary Full Text Full Text PDF PubMed Scopus (524) Google Scholar For WHO's information on parenting in the time of COVID-19 see https://www.who.int/emergencies/diseases/novelcoronavirus-2019/advice-forpublic/healthy-parentingFor UNICEF's tips for parenting during the COVID-19 outbreak see https://www.unicef.org/coronavirus/covid-19-parentingtipsFor Parenting for Lifelong Health's COVID-19 resources see https://www.covid19parenting.com/For CDC's guidance for schools see https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html For WHO's information on parenting in the time of COVID-19 see https://www.who.int/emergencies/diseases/novelcoronavirus-2019/advice-forpublic/healthy-parenting For UNICEF's tips for parenting during the COVID-19 outbreak see https://www.unicef.org/coronavirus/covid-19-parentingtips For Parenting for Lifelong Health's COVID-19 resources see https://www.covid19parenting.com/ For CDC's guidance for schools see https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html This online publication has been corrected. The corrected version first appeared at thelancet.com on April 9, 2020 This online publication has been corrected. The corrected version first appeared at thelancet.com on April 9, 2020 We declare no competing interests Department of ErrorCluver L, Lachman JM, Sherr L, et al. Parenting in a time of COVID-19. Lancet 2020; 395: e64—In this Correspondence, Gretchen Bachman's affiliation should have been "Department of Orphans and Vulnerable Children, United States Agency for International Development, Washington, DC, USA". This correction has been made to the online version as of April 9, 2020. Full-Text PDF

Objectives To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents. Study design A cross-sectional survey was administered to 10 546 seventh-to twelfth-grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30-day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions to determine the proportion of adolescents' recent opioid misuse attributable to ACEs. Results Nearly 1 in 50 adolescents reported opioid misuse within 30 days (1.9%); approximately 60% of youth experienced >= 1 ACE; 10.2% experienced >= 5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (aOR 1.9, 95% CI, 0.9-3.9), 2 ACEs (aOR, 3.8; 95% CI, 1.9-7.9), 3 ACEs (aOR, 3.7; 95% CI, 2.2-6.5), 4 ACEs (aOR, 5.8; 95% CI, 3.1-11.2), and >= 5 ACEs (aOR, 15.3; 95% CI, 8.8-26.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing >= 1 ACE was 71.6% (95% CI, 59.8-83.5). Conclusions There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. More than 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.

Objective To describe associations between childhood violence and forced sexual initiation in young Malawian females. Study design We analyzed data from 595 women and girls who were 13-24 years old who ever had sex and participated in Malawi's 2013 Violence Against Children Survey, a nationally representative household survey. We estimated the overall prevalence of forced sexual initiation and identified subgroups with highest prevalences. Using logistic regression, we examined childhood violence and other independent predictors of forced sexual initiation. Results The overall prevalence of forced sexual initiation was 38.9% among Malawian girls and young women who ever had sex. More than one-half of those aged 13-17 years at time of survey (52.0%), unmarried (64.6%), or experiencing emotional violence in childhood (56.9%) reported forced sexual initiation. After adjustment, independent predictors of forced sexual initiation included being unmarried (aOR, 3.54; 95% CI, 1.22-10.27) and any emotional violence (aOR, 2.47; 95% CI, 1.45-4.24). Those experiencing emotional violence alone (aOR, 3.04; 95% CI: 1.01-9.12), emotional violence in combination with physical or nonpenetrative sexual violence (aOR, 2.50; 95% CI, 1.23-5.09), and emotional violence in combination with physical and nonpenetrative sexual violence (aOR, 2.61; 95% CI, 1.20-5.67) had an increased independent odds of forced sexual initiation. Conclusions Experiences of forced sexual initiation are common among Malawian females. Emotional violence is strongly associated with forced sexual initiation, alone and in combination with other forms of childhood violence. The relationship between emotional violence and forced sexual initiation highlights the importance of comprehensive strategies to prevent childhood violence.