Modern Slavery: Violence, Coercion and Mental Health of Female and Male Trafficking Survivors in the Mekong Sub-region: Cambodia, Thailand, and Vietnam

Background: Human trafficking is a crime and a violation of fundamental human rights that affects 40.3 million people worldwide. The Asia Pacific region accounts for the largest number of forced laborers including children, adolescents, and adults of both sexes. Previous research has reported a high prevalence of poor mental health among trafficking survivors, but limited research has assessed the sex-specific associations of trafficking-related exposures on the mental health of survivors of trafficking across different trafficking sectors Methods: This dissertation uses data from the Study on Trafficking, Exploitation and Abuse in the Mekong Sub-region (STEAM). Aim 1 analyzes first the association of violence (sexual, physical, or both) and coercion (personal and family threats) with mental health symptoms (anxiety, depression, and PTSD) by sex. Aim 2 examines how the living, working, and legal and economic insecurity conditions during trafficking affect the mental health of trafficking survivors, female and male. Aim 3 describes patterns of violence and coercion using a latent class analysis approach, assessing the association of these latent classes with mental health. Results: For females, both physical and sexual violence were associated with higher levels of anxiety, PTSD, and depression, while for males, exposure to physical violence with threats made with weapons was strongly associated with PTSD. Coercion in females was particularly strongly related to anxiety and PTSD, especially among those receiving both personal and family threats. Deprived conditions during trafficking were strongly associated with poor mental health in both females and males, but sex-related differences were observed. While for females, living conditions were strongly associated with anxiety, PTSD, and depression, the association in males in each of the three outcomes more than doubled. Excessive working hours were associated with poor mental health in females and males. For men and boys working excessively was associated strongly with anxiety, depression, but particularly with PTSD symptoms. For females, there was a twofold increase in PTSD for those working excessively. Being in a detention center or jail in the country of exploitation was strongly associated with anxiety, PTSD, and depression in males. Two different patterns of violence and coercion were identified in females and in males. A twofold higher prevalence of anxiety and PTSD was found in females classified as being exposed to “severe sexual and physical violence and coercion” compared to females exposed to “sexual violence and coercion.” For males the associations for PTSD and depression were elevated among those who were exposed to the class of “severe physical violence and coercion” relative to the “personal coercion” class but the findings were not statistically significant. Conclusions: Measuring the human trafficking experience is complex as it occurs in diverse labor sectors beyond sexual exploitation and affects both females and males of all ages. The experience of violence and coercion is pervasive yet multidimensional and differs by sex with profound effects on the mental health of trafficked female and male survivors. Exploitation as embodied in the trafficking experience entails abuse, violence, and deprived living and working conditions with profound consequences for mental health. Implementation of public health approaches at all levels of the spectrum of prevention (primary, secondary, and tertiary) and acknowledging the social determinants of health as major structural forces are fundamentally important to prevent and address human trafficking.PHDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/145940/1/lisgle_1.pd

Depression and Posttraumatic Stress Disorder Among Women with Vulvodynia: Evidence from the Population-Based Woman to Woman Health Study

Background: Psychological disorders may affect the pain experience of women with vulvodynia, but evidence remains limited. The present study aimed to describe the magnitude of the association of depression and posttraumautic stress disorder (PTSD) with the presence of vulvodynia in a nonclinical population from southeastern Michigan. Methods: Baseline data from 1,795 women participating in the Woman to Woman Health Study, a multiethnic population-based study, was used for this analysis. Validated screening questionnaires were conducted to assess vulvodynia, depression, and PTSD. Modified Poisson regression models with a robust variance estimation were used to estimate prevalence ratios (PR) and their 95% confidence intervals (CI) for the association between vulvodynia status and two mental health conditions, depression and PTSD. Results: In the adjusted models, women who screened positive for depression had a 53% higher prevalence of having vulvodynia (PR=1.53; 95% CI: 1.12, 2.10) compared with women who screened negative for depression. Women who screened positive for PTSD had more than a two-fold increase in the prevalence of having vulvodynia (PR=2.37; 95% CI: 1.07, 5.25) compared with women who screened negative for PTSD. Conclusions: The increased prevalence of vulvodynia among those screening positive for depression or PTSD suggests that these disorders may contribute to the likelihood of reporting vulvodynia. Alternatively, vulvodynia, depression, and PTSD may have a common pathophysiological and risk profile. Prospective studies are needed to improve our understanding of the temporal relation between mental health conditions and vulvar pain.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140131/1/jwh.2014.5001.pd

Mental health, violence and psychological coercion among female and male trafficking survivors in the greater Mekong sub-region: a cross-sectional study

Abstract Background Human trafficking is a pervasive global crime with important public health implications that entail fundamental human rights violations in the form of severe exploitation, violence and coercion. Sex-specific associations between types of violence or coercion and mental illness in survivors of trafficking have not been established. Methods We conducted a cross-sectional study with 1015 female and male survivors of trafficking (adults, adolescents and children) who received post-trafficking assistance services in Cambodia, Thailand or Vietnam and had been exploited in various labor sectors. We assessed anxiety and depression with the Hopkins Symptoms Checklist (HSCL-25) and post-traumatic stress disorder (PTSD) symptoms with the Harvard Trauma Questionnaire (HTQ), and used validated questions from the World Health Organization International Study on Women’s Health and Domestic Violence to measure physical and sexual violence. Sex-specific modified Poisson regression models were estimated to obtain prevalence ratios (PRs) and their 95% confidence intervals (CI) for the association between violence (sexual, physical or both), coercion, and mental health conditions (anxiety, depression and PTSD). Results Adjusted models indicated that for females, experiencing both physical and sexual violence, compared to not being exposed to violence, was a strong predictor of symptoms of anxiety (PR = 2.08; 95% CI: 1.64–2.64), PTSD (PR = 1.55; 95% CI: 1.37–1.74), and depression (PR = 1.57; 95% CI: 1.33–1.85). Among males, experiencing physical violence with additional threats made with weapons, compared to not being exposed to violence, was associated with PTSD (PR = 1.59; 95% CI: 1.05–2.42) after adjustment. Coercion during the trafficking experience was strongly associated with anxiety, depression, and PTSD in both females and males. For females in particular, exposure to both personal and family threats was associated with a 96% elevated prevalence of PTSD (PR = 1.96; 95% CI: 1.32–2.91) and more than doubling of the prevalence of anxiety (PR = 2.11; 95% CI: 1.57–2.83). Conclusions The experiences of violence and coercion in female and male trafficking survivors differed and were associated with an elevated prevalence of anxiety, depression, and PTSD in both females and males. Mental health services must be an integral part of service provision, recovery and re-integration for trafficked females and males.https://deepblue.lib.umich.edu/bitstream/2027.42/146741/1/40359_2018_Article_269.pd

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Persistent organochlorine pollutants and menstrual cycle characteristics

An evolving body of evidence suggests an adverse relation between persistent organochlorine pollutants (POPs) and menstruation, though prospective longitudinal measurement of menses is limited and served as the impetus for study. We prospectively assessed the relation between a mixture of persistent organochlorine compounds and menstrual cycle length and duration of bleeding in a cohort of women attempting to become pregnant. Eighty-three (83%) women contributing 447 cycles for analysis provided a blood specimen for the quantification of 76 polychlorinated biphenyls and seven organochlorine pesticides, and completed daily diaries on menstruation until a human chorionic gonadotropin confirmed pregnancy or 12 menstrual cycles without conception. Gas chromatography with electron capture detection was used to quantify concentrations (ng g(−1) serum); enzymatic methods were used to quantify serum lipids (mg dL(−1)). A linear regression model with a mixture distribution was used to identify chemicals grouped by purported biologic activity that significantly affected menstrual cycle length and duration of bleeding adjusting for age at menarche and enrollment, body mass index, and cigarette smoking. A significant 3-d increase in cycle length was observed for women in the highest tertile of estrogenic PCB congeners relative to the lowest tertile (β = 3.20; 95% CI 0.36, 6.04). A significant reduction in bleeding (<1 d) was observed among women in the highest versus lowest tertile of aromatic fungicide exposure (γ = −0.15; 95% CI −0.29, −0.00). Select POPs were associated with changes in menstruation underscoring the importance of assessing chemical mixtures for female fecundity