Browsing by Author "Stewart, Kearsley"

AbstractBackground: With the bulk of global sickle cell disease (SCD) research primarily focusing on high-income/low-burden countries, countries such as Uganda continue to report the highest rates of SCD as a result of this inequity. Three out of four of those affected worldwide are born in sub-Saharan Africa (Macharia et al., 2018). The primary goals of the study are to address the current research gap in the acceptability and feasibility of SCD interventions among youth in Kalangala, Uganda by understanding 1) the efficacy of various education modalities to improve SCD knowledge among adolescents, 2) changes in health behaviors, self-perception, and family planning among adolescents after SCD education interventions, and 3) the impact of SCD-related stigma on willingness to access SCD screening, treatment, and knowledge. Youth stakeholders are the primary target population of this study. Youth stakeholders provide a unique perspective apart from their adult counterparts, as this demographic starts to consider the interconnectedness of individual health, family planning, and health access. Methods: Sixty-five stakeholders contributed to a total of 18 interviews (8 focus group discurssion; 10 in-depth interviews). The study incorporated an applied thematic analysis for all interviews to assess knowledge and perceptions of SCD, facilitators and barriers to SCD services, and outlooks on individual and family health. Results: Due to COVID-19 restrictions, this study was permitted to complete in-depth interviews and focus group discussions among youth. Analysis revealed that participants were not aware of the pathology of SCD, but were familiar with the social and health implications of having SCD. The most frequent facilitators and barriers included: access to SCD education; stigma; community engagement; and economic barriers. Conclusions: Findings from this study indicate potential areas for further engagment with youth stakeholders through health interventions that offer education in SCD pathology, and available services in order to mitigate the effects of SCD in a low-resource and vulnerable area. In addition, there is a need to address stigma and misconceptions in SCD, which requires a multi-sectoral and interdisciplinary approach that engages all community stakeholders. This study can inform future SCD interventions among youth members in Kalangala, Uganda.

Background: Adolescents and young people (AYP) living in Zimbabwe face an exceptionally high burden of HIV. Even with increased health intervention focusing on young people, engagement with sexual, reproductive healthcare remains low. AYP need increased attention to achieve the UNAIDS’ 95-95-95 goal for 2030. This study aims to assess the barriers and facilitators to sexual, reproductive healthcare access for adolescents and young people aged 16-24 in three districts in Zimbabwe. Methods: Seventy-five stakeholders, including AYP living with HIV, AYP with unknown or negative HIV status, family members of AYP, community gatekeepers, community- and facility-based healthcare workers, and community-based organization representatives contributed to in-depth interviews. We conducted thematic analysis on the interview summaries to assess knowledge and perceptions of sexual, reproductive health (SRH), barriers and facilitators to accessing SRH services, and challenges maintaining ART. Results: The stakeholder analysis revealed varied levels of knowledge and perceptions of SRH, and consensus about barriers and facilitators to accessing SRH services and challenges to maintaining ART. The most frequent challenges mentioned included stigma and logistical barriers, while the most frequent facilitators included a private and a youth-friendly environment. Conclusions: Based on the consensus among all stakeholders, findings from this study indicate an urgent need for youth-friendly sexual health interventions that offer a private and welcoming environment for AYP living in Zimbabwe. Additionally, this study contributes to existing literature supporting community-based sexual, reproductive healthcare interventions. This formative research can inform targeted future interventions addressing sexual, reproductive healthcare access for adolescents and young people in Zimbabwe.

Introduction: Sickle cell disease (SCD) is a genetically inherited recessive blood disorder that affects millions of people worldwide. The management of SCD should and can be considered a collaborative team effort, and requires the comprehensive and coordinated support of several medical professionals. The rising number of adults living with SCD creates a need for long term therapeutic and management strategies as well as a better understanding of the transition from pediatric to adult care. The research goal for this project is to compare the two systems that exist for treatment of adolescents with SCD in Jamaica and the United States by assessing differences and similarities in patients’ readiness for adult treatment and their understanding of SCD and its management. Methods: This study was conducted in the Sickle Cell Unit at the University of West Indies (UWI) hospital in Kingston, Jamaica. Eligibility for this study was defined as patients with SCD, between the ages of 13-19, seeking treatment at the health facility in the University of the West Indies, who have no acute illness at the time of study. After a verbal and written consent process during check-in, each participant completed a demographic survey, disease knowledge questionnaire, the ASH Transition Readiness Assessment Questionnaire, and had the opportunity to participate in in-depth interviews. Following data collection, results subsequently with similar previously completed surveys from patients at the Duke University Sickle Cell Center. Results: Gender and socioeconomic factors were not associated with differences in assessment scores in Jamaica. Total scores for disease knowledge questionnaires increased with age, however mean scores for the 17-19 age group were 62.17% lower than Duke University patients of the same age. Self-evaluation with the ASH Transition Readiness Assessment also showed an increase in scores with age, and significant increases in disease knowledge and appointments sections in both the 13-14 and 17-19 age groups, estimated by a p-value of 0.023 and 0.006, respectively. The results, however, were also generally lower than similar Transition Readiness Assessment measures at Duke. In-depth interviews revealed patient insight into disease knowledge, treatment involvement and experiences with doctors, family, and in the clinic. Answers align with both questionnaires used in this study.

Background: The WHO estimates that in 2010 there were over 10,000 road traffic injury related fatalities in Tanzania. Pedestrians accounted for a third of those fatalities. Education is essential to improving Tanzanians' road safety. Theatre has been used as a modality for education for many years, though most efficacy research focuses on professionally created and delivered theatre. The act of creating theatre is an inherently collaborative process, making it a good tool for participatory interventions that involve community members. Collaborative, theatre-based interventions have several benefits for global health projects: 1) they are relatively low-cost; 2) they incorporate community ideas encouraging stakeholder investment; and 3) they have potential to be self sustaining after development aid has stepped away. However, there are two main impediments to using collaborative theatre in global health interventions. First, there is little investigation on the efficacy of collaborative theatre to educate. Second, there are few guidelines to help drama-based programs take advantage of collaboration with amateur community members for health topics.

This study combined qualitative and quantitative methods to understand how participatory theatre with amateur community participants can convey health topics such as road and pedestrian safety in Tanzania. The study measured local primary students' pedestrian knowledge, evaluated theatrical performance as a method to teach pedestrian safety, and explored how community members could use drama techniques to become advocates for road traffic injury prevention. This project sought to adapt a replicable framework of applied theatre exercises to address health issues in a collaborative manner between community members and educators.

Hypothesis: Participatory theatre will increase pedestrian knowledge among primary students.

Methods: Young adult volunteers from Moshi, Tanzania participated in a month long workshop to create a performance to teach road and pedestrian safety. The workshop process was evaluated through qualitative methods, including journaling by the workshop facilitator, daily informal group discussions, and performance response cards from community leaders. At the end of the project, 17 open-ended surveys were administered in Kiswahili among the participants. A focus group with 8 participants was also conducted at the end of the project. A follow up focus group was conducted four months following the end of the project.

Workshop participants presented their play in Kiswahili to local primary schools. Knowledge assessment surveys were administered in Kiswahili to 439 primary school students. Pre and post knowledge assessment surveys were utilized to measure the impact that the community created play had on students' pedestrian knowledge.

Results: Primary school audiences showed statistical improvement between their pre and post survey scores. The average mean score improved from 71.40% of the pedestrian knowledge items correctly answered to 84.39% (P>

Refugees and asylum seeking children (Newcomers) enter the U.S.A. with little psychosocial support, despite having consistently higher rates of mental health problems. Art therapy has been seen as a potentially powerful intervention that can be implemented in high income countries with marginalized communities. Given art therapy’s un-centering of English, this mental health intervention is widely used within civil society but has not been rigorously evaluated. This study adds to the growing literature that examines the impact of art therapy interventions for Newcomer populations. We evaluated the impact of the North Carolina Art Therapy Institute’s (ATI) Newcomer’s Program, to inform further implementation of the Newcomer’s Program. In addition to the evaluation, we wanted to compare two forms of implementation, an intense weeklong “summer camp” program vs. a semester-long school-based program. This study used a mixed methods approach to assess the impact and value of the Art Therapy Institute’s (ATI) Newcomer’s Program in Durham, NC with Newcomers aged 4-14. The study, conducted in Fall 2018 in Durham, NC, compared two styles of implementation, a summer camp program (Number of youth = 31) and a school-based program (Number of youth =53). The number of hours of therapy remained consistent between programs (hours = 10.5) to allow us to compare. Qualitative data was collected after each implementation of the Newcomer’s Program with parents of refugee youth (N=2) and therapists (N=5). We found that the Newcomer’s Program had modest impact in reducing hyperactivity and inattention in both arms, and had statistically significant increase in prosocial behavior for the school-based program. Despite the modest impact observed, interviews with therapists and parents highlighted implementation challenges and non-quantifiable impact. This study has highlighted the need for further examination of the positive effects of art therapy interventions with Newcomer populations.

Background: Exclusive breastfeeding (EBF) in Kenya is on the rise, but there is still room for improvement. Current literature demonstrates that fathers have a positive influence on breastfeeding initiation, duration, and exclusivity. Yet there is a lack of information on paternal support in Kiambu County and Kenya, as a whole. This study aimed to explore fathers’ experiences with fatherhood, their perspectives and narratives on EBF, and the ways they support their partners through EBF for 6 months.

Methods: The study took place in three public, government hospitals in Kiambu County, Kenya. Two qualitative research methods were used to address the study aims: in-depth interviews and qualitative story completion. Data was analyzed using a rigorous process of applied thematic analysis.

Results: Fathers in this study described fatherhood as a challenging, but rewarding experience. Participants articulated positive sentiments towards EBF and had varying levels of knowledge on its benefits. Fathers described that they supported their partners by providing a nutritious diet and financial resources, helping with household chores, and facilitating childcare. Finally, the findings also illuminated evident gaps in paternal knowledge on EBF and the lack of father-centered information at public health facilities. Conclusions: This research established a baseline understanding of paternal support for a specific subgroup of fathers in Kiambu County, Kenya. Future research can further these findings by building a more representative, holistic picture of paternal support in Kenya. This will provide the necessary insights for designing context-specific educational interventions and programs targeting fathers in Kenya.

Background: Outbreaks of infectious diseases such as Ebola have dramatic economic impacts on affected nations due to significant direct costs and indirect costs, as well as increased expenditure by the government to meet the health and security crisis. Despite its dense population, Nigeria was able to contain the outbreak swiftly and was declared Ebola free on 13th October 2014. Although Nigeria’s Ebola containment success was multifaceted, the private sector played a key role in Nigeria’s fight against Ebola. An epidemic of a disease like Ebola, not only consumes health resources but also detrimentally disrupts trade and travel to impact both public and private sector resulting in the ‘fearonomic’ effect of the contagion. In this thesis, I have defined ‘fearonomics’ or the ‘fearonomic effects’ of a disease as the intangible and intangible economic effects of both informed and misinformed aversion behavior exhibited by individuals, organizations, or countries during an outbreak. During an infectious disease outbreak, there is a significant potential for public-private sector collaborations that can help offset some of the government’s cost of controlling the epidemic.

Objective: The main objective of this study is to understand the ‘fearonomics’ of Ebola in Nigeria and to evaluate the role of the key private sector stakeholders in Nigeria’s Ebola response.

Methods: This retrospective qualitative study was conducted in Nigeria and utilizes grounded theory to look across different economic sectors in Nigeria to understand the impact of Ebola on Nigeria’s private sector and how it dealt with the various challenges posed by the disease and its ‘fearonomic effects'.

Results: Due to swift containment of Ebola in Nigeria, the economic impact of the disease was limited especially in comparison to the other Ebola-infected countries such as Liberia, Sierra Leone, and Guinea. However, the 2014 Ebola outbreak had more than a just direct impact on the country’s economy and despite the swift containment, no economic sector was immune to the disease’s fearonomic impact. The potential scale of the fearonomic impact of a disease like Ebola was one of the key motivators for the private sector engagement in the Ebola response.

The private sector in Nigeria played an essential role in facilitating the country’s response to Ebola. The private sector not only provided in-cash donations but significant in-kind support to both the Federal and State governments during the outbreak. Swift establishment of an Ebola Emergency Operation Centre (EEOC) was essential to the country’s response and was greatly facilitated by the private sector, showcasing the crucial role of private sector in the initial phase of an outbreak. The private sector contributed to Nigeria’s fight against Ebola not only by donating material assets but by continuing operations and partaking in knowledge sharing and advocacy. Some sector such as the private health sector, telecom sector, financial sector, oil and gas sector played a unique role in orchestrating the Nigerian Ebola response and were among the first movers during the outbreak.

This paper utilizes the lessons from Nigeria’s containment of Ebola to highlight the potential of public-private partnerships in preparedness, response, and recovery during an outbreak.

Background: Youth living with HIV have worse health outcomes compared to adults or children. Few interventions have been developed engaging youth in their care to promote resilience. Peer-led education is one potential way to boost confidence and bolster resilience while also improving HIV knowledge of youth living with HIV (YLHIV). Peer youth leaders (PYL) can be effective educators because they are seen as trustworthy and relatable to their peers. PYL themselves may also benefit from increased resilience and empowerment after taking on leadership position at their monthly adolescent HIV clinic. This study evaluated the acceptability, feasibility, and effectiveness of using PYL to teach an HIV education. Methods: Seven HIV-infected youth were recruited based on their previous enrollment in a mental health intervention for HIV-infected youth. Those who demonstrated confidence, excellent adherence, and upstanding behavior were chosen to become PYL. PYLs were trained by a doctor, social worker, and previously trained group leaders of a mental health intervention to teach an HIV education curriculum adapted from the Baylor International Pediatric AIDS Initiative. Trainings occurred once a week for two to three hours in preparation for teaching at the monthly adolescent HIV clinic. Two PYLs taught one-hour lessons to youth during the monthly adolescent HIV clinic. Approximately 25 clinic attendees were asked to volunteer to complete pre/post knowledge assessments and provided feedback on the PYL model. Acceptability and feasibility of using PYL to deliver an HIV curriculum to YLHIV was evaluated through attendance records, fidelity checklists and feedback notes that were documented by trained group leaders who supervised PYL curriculum delivery. In depth interviews were conducted to evaluate change in fears, motivations, and resilience among PYL before and after assuming the leadership role. PYL resilience was measured using the Connor-Davidson Scale at baseline (prior to starting the teaching role) and 6 months after initiating training. Results: A PYL model of delivering an HIV curriculum was both feasible and acceptable as reported by youth attending monthly adolescent HIV clinic and PYL. Qualitative findings showed peer education created safe discussion spaces, reduced stress of participants, and enhanced beliefs of importance in maintaining good adherence. HIV knowledge was improved as measured by self-report, and improvement did not meet statistical significant (p =0.057). PYL leaders demonstrated trends toward improved resilience as measured by Connor-Davidson Resilience Scale and increased confidence, feelings of self-worth, sense of purpose, social support, and optimism and decreased internal stigma based on in-depth interviews. Conclusions: Results demonstrated the PYL model of teaching an HIV curriculum was feasible and acceptable. PYL had improved resilience as a result of taking on a leadership role at their monthly adolescent HIV clinic. Future evaluation of YLHIV retention in care and health outcomes as a result of participation in the PYL education should be explored.

Background Adolescents and young people face social, structural, and systems-level barriers which prevent them from accessing facility-based HIV testing, leading to delays in knowledge of HIV diagnosis and subsequent linkage to care. The World Health Organization (WHO) recommends oral mucosal transudate HIV self-testing to augment HIV testing services, and it may serve as an entry point for young people to engage with the HIV prevention and care cascade. However, presently young people across sub-Saharan Africa lack access to HIV self-test kits, which are available only at facility-based testing sites, through piloted distribution, or for purchase at prohibitive costs in private pharmacies. Youth-friendly distribution models for HIV self-testing are required. This study assessed 1) young people’s experiences of, and preferences for, campus-based HIV self-test distribution at tertiary level colleges in Zimbabwe; and 2) provider perceptions of the feasibility of scaled campus-based HIV self-test distribution across Zimbabwean tertiary schools.

Methods In depth interviews (n=26) and focus group discussions (n=4) were conducted with adolescents and young people (n=52), and key informant interviews (n=5) and focus group discussions (n=1) were conducted with nurses (n=14). Participants were recruited from nine universities and technical vocational colleges in Harare, Bindura, Masvingo, and Gweru, Zimbabwe. Data was recorded, transcribed, and coded for emergent themes using NVIVO 12 qualitative data analysis software package.

Results Overall, campus-based delivery of HIV self-tests was highly accepted by young people at tertiary level colleges. Participants reported enhanced feelings of privacy, confidentiality, autonomy, and empowerment with campus-based self-testing compared to facility-based self-testing. They found that the public nature of the campaign-style testing station generated a social acceptance of HIV testing amongst students on campus. Participants raised concerns about experiencing social coercion to test, lack of emotional support when testing alone, and adequate linkage to care systems. Participants agreed that campus-based HIV self-test distribution programs should be led by lay counselors, offer both on-site and off-site testing, provide links to prevention services including VMMC and PrEP, integrate comprehensive sexual and reproductive health education, and have continuous post-test counseling. Nurses cited limited human resources, clinic licensure, and low uptake of campus clinic services as factors affecting the feasibility of scaling campus-based HIVST distribution in tertiary schools across Zimbabwe.

Background: Low-income countries often face the challenge of being incapable to

prevent, treat, and manage diseases that are becoming increasingly prevalent over recent years.

An example of this is the rise of chronic kidney disease (CKD) primarily due to type 2 diabetes

in rural settings in India. Research concerning preventive CKD and diabetes care in India

therefore needs to be conducted. Mobile-health has shown to be an effective tool for

supplementing the efficiency and outreach of health care in low-income settings.

Methods: This study aimed to 1) understand current practices and preparedness of staff

related to CKD and diabetes management in rural settings in India 2) identify barriers and

facilitators for quality CKD management and care in rural settings 3) assess the perceived

usefulness and barriers to the mHealth mobile-clinical decision support system (mCDSS)

approach with respect to CKD in limited resource settings. Qualitative in-depth interviews were

conducted with 13 stakeholders comprised of health workers, government officials, and

patients with CKD and diabetes to accomplish these objectives. Thematic analysis of these

interviews yielded four primary themes.

Results: These themes consisted of 1) shortages of CKD and diabetes health services 2)

low awareness of CKD and diabetes 3) high familiarity with and suggestions for mobile-based

device use 4) supported use of Accredited Social Health Activists (ASHA)s for implementation

and utilization of a mobile-based device to manage CKD and diabetes in rural India. Generally,

stakeholders reported an insufficiency of health care services to combat CKD and diabetes, as

well as reportedly being in favor of a mobile-based device to mitigate this shortage.

Stakeholders also underscored the high plausibility of Accredited Social Health Activists

(ASHA)s successfully implementing and utilizing the device for CKD and diabetes services.

Conclusions: This analysis will inform creation and implementation of this device in

order to increase CKD and diabetes health care in rural settings in India. Specifically,

components of this device may be created to address opinions reported by stakeholders. For

example, an awareness component can be designed for this device to address the reported low

awareness for CKD and diabetes. Additionally, a referral system may be incorporated from

ASHA to physician to mitigate the high portion of CKD and diabetic patients undiagnosed.

Incorporating these components into this device may effectively address the input of

stakeholders and work towards increasing CKD and diabetes health care in rural India.

Social interactions with civil society are an essential component of the refugee experience, actively shaping humanitarian aid as well as policies towards refugee needs (Barnes, 2011; Van der Leun & Bouter, 2015). However, material needs are frequently depicted as the main endeavor for refugee support. This overlooks the moral components of the refugee experience, through the need for dignity (del Soto, 2008), mental health resources (Silove et al., 2017) and a sense of security (Eby et al., 2011) which are essential support structures if refugees are to, even temporarily, live in the new communities they join. Notably, current research on existing systems emphasizes material refugee provisions with little focus on mental health (Weine, 2011) or the cultural implications of integration (Esses et al., 2017). This thesis explores refugees’ perceptions of integration in host countries with an emphasis on the lack of support structures beyond material humanitarian response in Egypt and Jordan as a secondary data analysis project. It is based on 108 qualitative life-story interviews with Iraqi refugees conducted by the Kenan Refugee Project of Duke University between 2012 and 2019 primarily in Cairo, Egypt and Amman, Jordan. Through this analysis, I determined a pressing need for a temporary, informal integration process with much needed social support and mental health resources beyond the current legal standards in place. I further argue that the multi-dimensional, multi-disciplinary nature of refugee needs are frequently overlooked and underestimated and that a new approach beyond materialprovisions at the global decision-making table is long overdue for the dignity, human rights and quality of life refugees deserve across the globe.

Background: In 2016, 36.7 million people globally were living with HIV and approximately 70% knew their status. Novel HIV testing methods and strategies are needed to reach the first “90-90-90” target by 2020; that is 90% of people living with HIV know their status. Children and adolescents face additional barriers to HIV testing that stem from gaps in provider-initiated testing and counselling (PITC), parents’ concerns related to stigma and discrimination, and beliefs that children living with HIV cannot survive to adolescence. PITC barriers and the stigma and discrimination parents’ may face when seeking HIV testing and counselling (HTC) for their children could be reduced through a novel HIV testing strategy, which includes oral fluid tests (OFTs) and parents performing oral fluid HIV self-tests (O-HIVST) on their children. Therefore, the study aims of this thesis were: 1) to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of an OFT for HIV in children aged 2-18 using the standard point of care rapid diagnostic test (RDT) as a reference, 2) to explore parents’/guardians’ and older adolescent’s knowledge of, and attitudes about, OFTs and O-HIVST, 3) to explore parents’/guardians’ and older adolescent’s preferences when undergoing O-HIVST. No studies to our knowledge have examined the diagnostic accuracy of OFTs in children or the facilitators of O-HIVST performed by a parent or guardian on their children.

Methods: We conducted the study in two large urban hospitals in Harare, Zimbabwe. The sample included children and adolescents aged 2-18 whose HIV status was unknown. We performed an OFT, followed by a finger-prick RDT to validate the OFT results. In addition, we conducted in-depth interviews (IDIs) with parents/guardians of children aged 2-15 and older adolescents aged 16-18. Quantitative analysis included tabulating descriptive statistics and calculating sensitivity, specificity, PPV, and NPV of the OraQuick ADVANCE® Rapid HIV-1/2 Antibody Test. Thematic qualitative analysis was conducted on the IDIs.

Results: Preliminary sensitivity results of the OFT showed high sensitivity at 100% (95% CI 83.89, 100.00) and high specificity at 99.77% (95% CI 99.17, 99.97) compared to the finger-prick RDT. In addition, PPV was 91.30% (95% CI 71.96, 98.93), and NPV was 100% (95% CI 99.57, 100.00). Qualitative findings showed low knowledge of OFTs and O-HIVST among parents and adolescents. However, participants reported favorable attitudes towards performing O-HIVST on themselves and their children and also reported a preference for a wide range of uptake mechanisms when asked about O-HIVST. Participants expressed concern about O-HIVST but felt that counselling could reduce unfavorable reactions to positive O-HIVST results.

Conclusions: The preliminary analysis confirmed the OFT has high sensitivity, but a larger sample size is needed to obtain a more accurate estimate of OFT sensitivity. If future findings confirm our preliminary results, we recommend OFTs as a method to increase HIV testing and uptake among children. Participants’ low knowledge of OFTs and O-HIVST indicate sensitization is needed before scale up of this new method. We also recommend O-HIVST implementation include a variety of strategies to increase O-HIVST uptake among children and adolescents who may face barriers to traditional HTC.

Since 2005, China Global Fund AIDS programs have considered men who have sex with men (MSM) an "at-risk population" with priority and significance to receiving HIV testing. Community-based organizations (CBOs) have been involved in implementing the intervention programs, including free HIV testing, to MSM. This thesis explores the consequences of HIV testing as an intervention on local MSM's perceptions and relationships. Participant observation, in-depth interview and textual analysis were conducted during fieldwork research at a local CBO. It is argued that the complexities of everyday practices of public health programs at the community-level need to be emphasized in supervision. The success of China's HIV/AIDS intervention strategies is at stake: free HIV testing needs to be implemented as a benefit to testing receivers' health instead of as an obligation or commodity. In everyday practice, HIV testing is full of complexities and via HIV testing, interrelations among CDC system, local CBOs, and local MSM are reproduced and images and perceptions of free HIV testing are reconstructed. Moreover, receiving HIV testing was integrated into a new moral discourse of how to be a "good" MSM. It is recommended for local CBOs to cultivate their professionalization, and be aware of new stigmatization produced by free HIV testing. Meanwhile, a transition of local governmentality and supervision technologies is needed.