Browsing by Author "Walmer, David K"

Introduction: Cervical cancer is one of the leading causes of death for women in Haiti. The purpose of this study was to evaluate the feasibility of HPV self-sampling using CareHPV™ and subsequent treatment with cryotherapy in urban and rural areas of Haiti. CareHPV™ is a vaginal self-sample HPV testing kit used to detect 14 types of high-risk HPV and cryotherapy is a form of treatment that freezes precancerous lesions with CO2 or nitrous oxide. Methods: The study took place in Port-au-Prince and three rural communities within the suburban commune of Leogane. Screening took place at clinics, community centers, and churches. Participants were given consent forms to sign, as well as a demographic questionnaire and an acceptability survey. If their HPV test result was positive, they were called up to three times to go the community clinic for treatment. The number of women that returned for treatment following a positive HPV test result were compared in the urban and rural communities with a chi square test of association and a prevalence rate ratio. Acceptability was measured quantitatively on the Likert Scale. Results: Feasibility was defined as 80% acceptability and 80% treatment uptake. Other factors related to feasibility such as screening numbers and geographical barriers were discussed. Eighty percent acceptability was reached in both rural and urban communities. Eighty percent treatment uptake was only reached in the rural communities, with a treatment uptake of 83.3%. Eighty percent treatment uptake was not reached in the urban communities, with a treatment uptake of 42.1%. The prevalence rate ratio of 1.98 indicates that rural participants were found to be nearly twice as likely to return for treatment than urban participants. The chi square test of association shows that this difference in treatment uptake is significant with an estimated p-value of 0.01 at an alpha of 0.05. Further research is needed to investigate the reasons for higher loss to follow-up for treatment in urban communities to further efforts to establish a national HPV screening program in Haiti.

Background: The incidence and mortality rates of cervical cancer in Haiti are among the highest in the world, yet the screening coverage rate is among the lowest. Efforts to ameliorate this problem using cytology-based programs have fallen short due to geographic, socioeconomic, cultural, and infrastructural barriers to access. A prevention strategy based on vaginal, self-screening for high-risk (HR) HPV in communities may increase coverage by avoiding or diminishing these impediments. This study examined the diagnostic performance of self-screening when compared to clinician screening in two clinics in Port-au-Prince.

Methods: 1836 women participated in a cross-sectional study in which each underwent vaginal and cervical screening for HR HPV, and HIV rapid testing. HR HPV positive women returned for follow-up testing with colposcopy and biopsy. Data analysis explored the concomitant tests' comparative performance using percent agreements with Kappa statistics, test positivity, and the ability to detect various levels of biopsy-confirmed cervical intraepithelial neoplasia. Age-related prevalence rates were also determined. Statistical associations were measured using Chi-Square, Fisher's Exact, and McNemar's Tests.

Results: Overall concomitant test agreement was strong (91.39%, K=0.73), but varied with statistical significance by age in the youngest and oldest quartiles. Women between 42 and 48 years old demonstrated the highest concordance (93.45%, K=0.70). Vaginal test positivity was uniformly higher than cervical test positivity among participants of all ages. Vaginal samples identified 84.46% of HR HPV cases that cervical samples identified, and more than 90% of all high-grade disease. However, clinician screening accurately detected several more clinically relevant cases of disease (≥ CIN I) (56) than self-screening (53).

Conclusion: Strong test agreement indicated that vaginal screening produced comparable results to clinician screening, and age-related statistics may be able to inform test algorithms in the future. With plans to establish pathology labs in Leogane and Port-au-Prince that employ local talent and utilize the relatively affordable CareHPV Assay (QIAGEN), self-screening may be a diagnostically sound and financially feasible cervical cancer prevention strategy in Haiti.

AbstractAbstractAbstractAbstract Abstract

Spacing the inter-pregnancy interval to more than two years reduces maternal and neonatal morbidity and mortality. Modern contraceptive use can reduce maternal morbidity and mortality by contributing to birth spacing and reducing the total fertility rate. This study is designed to understand the factors associated with appropriate birth spacing and the barriers to modern contraceptive use in Leogane, Haiti. A cross sectional survey of 552 reproductive age women in Leogane proper was performed from June to July of 2011. Univariate, multivariate, and logisitic regressions were used to analyze the data. The results demonstrate the importance of education, employment status, contraceptive use and stable relationships in influencing appropriate birth spacing. Women who spaced their births tended to have less complications compared to women who did not, however this difference was not statistically significant. Barriers to contraceptive use were cultural factors such as religion, and low socioeconomic status. However, contraceptive use was positively influenced by education and partner acceptance of contraceptives. These findings indicate that family programs focused on educating women and their partners on the benefits of contraception and birth spacing would be successful in Leogane, Haiti.

Uncontrolled birth spacing is associated with higher rates of maternal and neonatal morbidity and mortality in low resource countries. The use of modern contraception (MC) is a strategy that proven to be successful to control birth spacing in the United States but is frequently unsuccessful in Haiti.

This study is intended to investigate women's health beliefs about MC in Leogane, Haiti. The Extended Health Belief Model from behavioral science is employed as a framework for data collection on three domains: perceived threats of unintended pregnancy, perceived barriers of contraception use, and modifying factors. In depth interviews of 16 reproductive age women conducted from June to July 2012 were transcribed and translated for analysis in QSR Nvivo. Seven themes are identified from the conversations. The results demonstrated that all the 16 women interviewed perceive unintended pregnancy as a threat that may potentially affecting women's life. Their perceptions of barriers during MC seeking include the fear of side effects and financial unaffordability. Modifying factors influencing their contraception use consist of competing traditional contraception methods, peer advice/experience, and religion. These findings suggest that future health education program should focus on contraception side effects knowledge spreading and replacing traditional methods with modern contraception through peer education and unmet family planning needs will be accommodated in Leogane, Haiti.

Background: Exclusive breastfeeding for the first 6 months of life reduces infant mortality and morbidity. A systematic review concluded that when an infant’s grandmother had a positive attitude towards breastfeeding, the mothers were 1.6 to 12.4 times more likely to exclusively breastfeed or refrain from early complimentary feeding. Evidence shows that mothers are not the sole decision makers when deciding whether to exclusively breastfeed or not. Despite widespread knowledge that grandmothers have the potential to influence a mothers exclusive breastfeeding decision, most breastfeeding education programs are only targeted towards mothers. In this study, we aim to investigate the impact of a formal antenatal breastfeeding education program on the acceptance and attitudes towards exclusive breastfeeding among mothers and grandmothers in rural Haiti. Methods: A convenience sample of pregnant women (16 years of age and older), who were attending the Carmelle Voltaire Women’s Clinic in Fondwa, Haiti between June-July of 2017, participated in a breastfeeding education program and completed a 17-item Infant Exclusive Breastfeeding Attitudes Questionnaire together with the infant’s grandmother. Data was collected at baseline, post-intervention, and one week after the intervention. Results: The Infant Exclusive Breastfeeding Attitudes Questionnaire was completed by 25 expectant mothers, and 10 maternal grandmothers. The Family member with the greatest influence on expectant mother’s breastfeeding practices according to expectant mothers, were maternal grandmothers. The formal antenatal breastfeeding education program had a positive impact on expectant mothers and grandmothers breastfeeding attitudes. Conclusion: This finding suggests that targeting grandmothers through breastfeeding promotion programs may be an effective means of increasing exclusive breastfeeding rates in rural Haiti.

Contraceptive prevalence in Haiti remains low despite extensive foreign aid targeted at improving family planning. [1] Earlier studies have found that peer-informed learning have been successful in promoting sexual and reproductive health. [2-5] This pilot project was implemented as a three-month, community-based, educational intervention to assess the impact of peer education in increasing contraceptive knowledge among women in Fondwa, Haiti. Research investigators conducted contraceptive information trainings to pre-identified female leaders of existing women’s groups in Fondwa, who were recruited as peer educators (n=4). Later, these female leaders shared the knowledge from the training with the test participants in the women’s group (n=23) through an information session. Structured surveys measuring knowledge of contraceptives were conducted with all participants before the intervention began, at the end of the intervention, and four weeks after the intervention. The surveys measured general contraceptive knowledge, knowledge about eight selected types of modern contraceptives and contraceptive preferences and attitudes. Only test participants showed significant improvement in their general contraceptive knowledge score (p<0.001), but both test participants and peer educators showed significant improvement in overall knowledge scores for identifying the types and uses of modern contraceptive methods. Assessment for knowledge retention remained significantly higher four weeks after the intervention than prior to the intervention. Therefore, a one-time, three-hour peer-based educational intervention using existing social structures is effective, and might be valuable in a population with minimal access to education and little to no knowledge about contraceptives.

Background: Haiti has the highest maternal mortality rate in the Latin American and Caribbean region. Despite the fact that Haiti has received twice as much family planning assistance as any other country in the western hemisphere, the unmet need for contraception remains particularly high. Our hypothesis is that unsuccessful efforts of family planning programs may be related to a misconstrued understanding of the complex role of gender in relationships and community in Haiti. This manuscript is one of four parts of a study that intends to examine some of these issues with a particular focus on the influence of uptake and adherence to long acting contraceptive (LAC) methods.

Methods: We conducted a three-month community-based qualitative assessment through 20 in-depth interviews in Fondwa, Haiti. Participants were divided into 4 groups of five: female users, female non-users, men and key community stakeholders.

Results: Based on the qualitative interviews, we found that main barriers included lack of access to family planning education and services and concerns regarding side effects and health risks, especially related to menstrual disruption and fears of infertility. Women have a constant pressure to remain fertile and bear children, due not only to social but also economic needs. As relationships are conceived as means for economic provision, the likelihood of uptake of irreversible methods (vasectomy and tubal ligation) was restricted by loss of fertility. Consequently, the discourse of family planning, though self-recognized in their favor, assumes women can afford not to bear children. This assumption should be questioned given the complexities of the other social determinants at play, all which affect the reproductive decisions made by Haitians.

Conclusions: Overall, our study indicated awareness surrounding contraception in the Haitian Fondwa community. Combining the substantial impact of birth spacing with the elevated yet unmet need for contraceptives in the area, it is necessary to address the intricacies of gender issues in order to implement successful programing. In Haiti not being able to bear a child poses a threat to economic and social survival, possibly explaining a dimension of the low uptake of LACs in the region, even when made available. For this reason, we believe IUDs (Intrauterine Devices) provide a suitable alternative, allowing the couple to comprehend all of the factors involved in decision making, thus decreasing the imbalances of power and knowledge prior to considering an irreversible alternative.

The development of HPV vaccines has generated a great deal of hope that the burden of cervical cancer may be eliminated over the next several decades. However, this enthusiasm may be premature if the genotypes associated with high-grade cervical dysplasia and cancer in other countries does not match the select HPV genotypes that were targeted by current vaccines. The objective of this study was to document the profile of high-risk HPV genotypes that are associated with moderate and high-grade dysplasia in a subset of women living in Port-au-Prince and Leogane, Haiti. Preliminary data collected around the world and by Family Health Ministries in Haiti suggest that the high-grade disease seen in many communities may have a different spectrum than the US and Europe. The cross-sectional study was conducted in two medical clinics situated in the cities of Port-au-Prince and Leogane, Haiti. Genotype-specific distribution from cervical samples collected from 269 women was correlated with corresponding cytopathology results. Genotypes associated with HSIL or invasive cancer were HPV-16 (POR 6.8; 95% CI 2.62-17.86), HPV-18 (POR 4.3; 95% CI 1.46-12.40), HPV-35 (POR 4.3; 95% CI 1.63-11.33), and HPV-58 (POR 7.9; 95% CI 1.95-32.00). HPV-58 appeared to have a higher oncogenic potential than HPV-16 and HPV-18. There was a difference in the HPV genotypic profile found in cervical disease in this Haitian population compared to the United States and Europe. It may be less cost-effective to introduce existing HPV prophylactic vaccines to Haiti; resources may be better spent treating existing disease until more appropriate vaccines are developed.

Objective: Approximately 85% of rural Haitian births happen at home, attended by family members or traditional birth attendants (TBAs). Our primary research question is: Are the TBAs in this study willing and/able to learn and retain the material in the education program, and integrate this material into their practice? Secondarily, we are interested in obtaining information toward answering the following two questions: 1. Are these TBAs interested in going on to become skilled birth attendants or working in conjunction with healthcare service providers at a future Fondwa health center, even if they do not become skilled birth attendants? 2. Does the education model that is utilized in this research allow us to measure short and long term changes in the TBA's abilities, as demonstrated by TBA feedback, test scores and observations of TBAs at deliveries?

Methods: This study implemented and assessed a pilot four-week TBA education program. Each TBA took a pre-test before beginning the program and a post-test after completing the program, as well as post-tests at six weeks and six months. Results for learning and retention between the four tests were analyzed in STATA using a Paired t-test. Effects of age, training method, literacy, numeracy and sex on learning and retention were analyzed in STATA using One-way ANOVA. The study also used group interviews and surveys with TBAs and community members to examine birth practices and to begin compiling baseline data for evaluation of the impact of the program. Associations between variables on the community surveys were analyzed using Chi-squared and Fisher's exact tests.

Results: Out of a total of 493 questions asked on the four tests (29 questions on each of 17 tests), 12.4% were answered correctly on the pretest, 65.1% on the first post test, 58.6% on the 6-week test, and 59.4% on the 6-month post-test. Analysis showed statistical significance for the learning increase between the pretest and the initial post-test (p = 0.0000) and for retention between the initial post-test and the 6-week post-test (p = 0.0086), but statistical insignificance between the 6-week post-test and the 6-month post-test (p = 0.6864). The influences of age, training method, literacy, numeracy and sex on learning and retention were not statistically significant. The influence of these variables on total (all four combined) test scores was significant for number literacy only (p=0.0214). The program design received unanimously positive feedback from the TBAs. The TBAs are interested in becoming skilled birth attendants (SBAs) or collaborating with SBAs.

Conclusion: The TBAs were willing and able to learn and retain the material in the education program, as demonstrated in a classroom setting. However, the critical question of how well they integrate this into their practice remains unanswered. The education model allows us to measure changes in abilities as measured by test scores, but the model does not successfully measure abilities as measured by observations at deliveries. We attended births (one) by invitation only. The education program would benefit from a preceptor component.