Browsing by Author "Watt, Melissa H"

Background: The Western Cape Province of South Africa has one of the highest documented rates of FASD globally. In order to establish FASD prevention interventions that can effectively reach women in this high-risk population, it is important to understand the attitudes that women hold towards alcohol use during pregnancy and examine reasons why positive attitudes may not necessarily translate to behavior in this setting. Study aims: The aims of this secondary analysis were to: describe the attitudes towards alcohol use during pregnancy, compare attitudes with alcohol use behaviors during past pregnancies, and build a logistic regression model to examine predictors of harmful attitudes toward alcohol use during pregnancy. These quantitative aims then set the stage for a qualitative exploration of reasons for harmful behaviors, in spite of attitudes that would support drinking cessation during pregnancy. Methods: This study is based on cross-sectional data from 200 women who were recruited from alcohol-serving venues in a single township in Cape Town, South Africa. A sub-set of 24 was selected to participate in-depth qualitative interviews. Measures of interest included: demographics, attitudes about alcohol use during pregnancy, history of abuse, depression, current drinking behavior, drinking during past pregnancy, and pregnancy intentions and attitudes. Quantitative analysis was conducted in three steps. First, descriptive statistics were used to describe the sample. Second, drinking behaviors in past pregnancies and attitudes toward alcohol use during pregnancy were examined separately and then together in order to describe any potential attitude/behavior gap in this population. Third, logistic regression models were built to examine predictors of attitudes toward alcohol use during pregnancy. Interviews were reviewed and coded for emergent themes under categories that were identified a priori: knowledge about risks of alcohol use during pregnancy, contributors to alcohol use during pregnancy, and contributors to resiliency against alcohol use during pregnancy. Results: The sample of 200 women ranged in age from 18 to 43, were all of Coloured (mixed-race) ancestry, and most had not completed secondary school. Most were not intending to become pregnant and most reported a history of abuse. Though approximately 83% (n=164) of women with a history of pregnancy did not report having harmful attitudes toward alcohol use during pregnancy, more than half of these women (n=84, 51.2%) still reported alcohol use during a previous pregnancy. This discrepancy revealed the existence of a stark attitude-behavior gap in which the holding of harmful attitudes toward alcohol use during pregnancy is not entirely predictive of alcohol use during pregnancy. The strongest predictors of holding harmful attitudes were a history of abuse (AOR=3.33, 95% CI 1.06-10.50) and drinking during a previous pregnancy (AOR=6.87, 95% CI 1.79-26.33). Qualitative data analysis revealed several factors that contributed to alcohol use during pregnancy: 1) Having an unplanned pregnancy; 2) Drinking because of stress or to cope; 3) History of abuse or trauma; 4) Reliance on the venue space for solace; 5) Recreation; and 6) Feelings of invincibility. Conclusions: These data further define the existence of an attitude-behavior gap in this population and highlight that in this setting, having non-harmful attitudes might not be enough to elicit healthy behavior. This points to a need for identification and implementation of policies or interventions that go beyond education to build intrinsic motivation to refrain from alcohol use during pregnancy.

Background: Early detection and early intervention for autism spectrum disorder (ASD) is critical because it can reduce the severity of core ASD symptoms, and result in significant long-term improvements in language acquisition, social skills, cognitive abilities, and adaptive behaviors. Involving caregivers in the delivery of early ASD intervention is becoming increasingly important, particularly in low-resource settings, due to limited access to specialist ASD services. Currently, there is no published research on early ASD intervention in South Africa or sub-Saharan Africa (SSA). In addition, there are no published descriptions of caregiver-child joint activity routines, in which early intervention techniques can be embedded, or perceptions of the acceptability of a caregiver coaching approach.

Study Aims: This study aimed to elicit qualitative descriptions of caregiver-child joint activity routines in order to understand how the Early Start Denver Model (ESDM), an evidence-based early ASD intervention, could fit in a low resource South African setting. It also aimed to gauge the acceptability of a caregiver coaching intervention from South African caregivers of young children with ASD who received two taster sessions of caregiver coaching.

Methods: Participants were recruited from the Western Cape Education Department autism waiting list through convenience sampling. Four focus group discussions were conducted with 22 caregivers of young children with ASD, which gathered data on caregiver-child joint activity routines. Four additional families were recruited to participate in two caregiver coaching sessions each. Four in-depth interviews were subsequently conducted with the six caregivers from these families, which gathered data on joint activity routines and acceptability of a caregiver coaching intervention. Data were analyzed through a qualitative content analysis approach, which used a combination of inductive and deductive methods to determine the salient themes and subthemes within the data.

Results: Caregiver descriptions of joint activity routines aligned with ESDM themes of object-based play, sensory social routines, and family routines. In object-based play caregivers reported engaging in turn-taking with their children, teaching skills across developmental domains, embracing child-directed activities, and managing challenges related to play in resource limited settings. In sensory social routines, caregivers described physical play, an awareness of the child’s affect and engagement, increased child expressive communication, and willingness of the child to engage with different play partners. In family routines, caregivers reported child participation in meals and bath time. Caregivers reported that a caregiver coaching approach was acceptable and that they had acquired a variety of skills, including strategies to enhance their child’s social communication. Caregivers preferred receiving coaching in their homes as opposed to in a clinic setting; however, limitations in physical space and financial resources were important considerations.

Conclusion: Training caregiver coaches and non-specialist workers narrows the treatment gap by providing access to children in need of early ASD intervention. This is essential, because of the scarcity of psychologists and psychiatrists working in mental health in low and middle-income countries (LMIC). Descriptions from South African caregivers of caregiver-child joint activity routines and acceptability of the caregiver coaching approach contextualize the caregiver coaching intervention. These data will inform the adaptation and piloting of an early ASD intervention within a low-resource South African setting.

Background: Obstetric fistula is the development of a necrosis between the bladder and the vagina and/or the bladder and the rectum as a result of prolonged obstructed labor, resulting in urinary or fecal incontinence. In Tanzania surgical repair for obstetric fistula is provided freely by the government but it is estimated that there are over 25,000 women living with an untreated fistula. These women experience high degrees of psycho-social stresses exacerbated by the stigma surrounding their condition. There is a dire need to explore stigma within this population in order to better understand its impact, as stigma affects both treatment seeking behavior as well as long term recovery of those who access surgical repair.

Study Aims: This study aims to understand the experiences of stigma among women with obstetric fistulas by examining both internalized and enacted stigma, and by identifying pertinent correlates of internalized stigma.

Methods: This mixed-methods study utilized both quantitative and qualitative data collected in two related studies at a single hospital in Moshi, Tanzania. All study participants were women receiving surgical repair for an obstetric fistula. In the quantitative portion, cross-sectional survey data were collected from 52 patients. The primary outcome was fistula-related stigma, measured using an adaptation of the HASI-P stigma scale, which included constructs of both internalized and enacted stigma. In the qualitative portion, 45 patients participated in a semi-structured in-depth interview, which explored topics such as stressors caused by the fistula, coping mechanisms, and available support. The transcripts were analyzed using analytic memos and an iterative process of thematic coding using the framework of content analysis.

Results: Expressions of internalized stigma were common in the sample, with a median score of 2.1 on a scale of 0 – 3. Internalized was significantly correlated with negative religious coping, social participation, impact of incontinence and enacted stigma. Qualitative analysis was consistent and demonstrated widespread themes of shame and embarrassment. Experiences of enacted stigma were not as common (median score of 0), although some items, like those pertaining to mockery and blame, were endorsed by up to 25% of the study sample. Themes of anticipated stigma (isolation and non-disclosure due to the possibility of stigmatization) were also evident in the qualitative sample and may explain the low enacted stigma scores observed.

Conclusion: In this sample of women receiving surgical repair for an obstetric fistula, stigma was evident, with internalized stigma resulting in psychological impacts for patients. Experiences of both anticipated and enacted stigma were also observed. There is a need to explore interventions that would decrease stigma while also increasing support for these women, as stigma may be a barrier towards accessing surgical repair and reintegration following surgery.

Keywords: Tanzania, obstetric fistula, stigma, maternal health

Background: In 2013, Tanzania adopted the Option B+ protocol for prevention of mother-to-child-transmission (PMTCT) of HIV, whereby all HIV-positive pregnant women initiate lifetime antiretroviral therapy (ART). Option B+ holds great promise for improving women’s health and moving towards an “AIDS-free generation”. This study aimed to evaluate the implementation of Option B+ in selected sites in Kilimanjaro region of Tanzania using the Consolidated Framework for Implementation Research (CFIR). Methods: Data were obtained through semi-structured observations, review of clinic records, and key informant interviews (KIIs) with healthcare providers across the PMTCT care cascade. 35 hours of observation and 30 KIIs were conducted at three healthcare facilities from May 2017 to July 2017. Findings: The data revealed key themes in relation to CFIR domains. Considering the intervention characteristics, the protocol was adaptable as it was observed in three healthcare facilities with different staffing and flows of care. Considering the outer setting, providers noted that stigma and lack of partner involvement were key patient-level factors hampered implementation. Interconnectedness of facilities helping implementation, but poor referral systems existed. The maladies of the underlying health system hindered optimal implementation. Considering the individual (provider) characteristics, knowledge about the protocol varied depending on training and level of experience. There was consensus that Option B+ was effective in preventing vertical HIV transmission. However, considering the process of implementation, fidelity of implementation varied across clinics and over time, determined by providers present, clinic set-up, time of day and patient volume. As observed, the burden of record keeping appeared to hamper focused provider-patient interactions. Discussion: Future success in implementation of the Option B+ protocol in Tanzania requires additional training of providers on the guidelines, including counseling and patient-centered care. Community education focusing on stigma reduction and uptake of HIV testing among men will provide a more supportive implementation context. Implementation activities extending beyond the clinical setting, including home-based care, are needed. Electronic medical records may decrease the burden of redundant documentation, help track women lost to follow-up at the clinic level and improve the quality of care.

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Background: Family planning provides women, men, and adolescents the ability to prevent or postpone childbearing. Family planning is a cost-effective strategy for reducing high-risk pregnancies, unsafe abortions, and allowing for birth spacing. This study was conducted in rural Ghana with three goals: 1) to estimate the prevalence of modern family planning use and unmet need for modern contraceptives, 2) to identify factors associated with unmet need for modern family planning, and 3) to understand women’s experiences and behaviors related to modern family planning use. Methods: This explanatory mixed-methods study collected 281 household surveys and 33 in-depth interviews of women 18-49 years old from the Amansie West District of Ghana. Measures of interest included: demographics, pregnancy history, pregnancy status, pregnancy intentions and attitudes, knowledge and perceived availability of modern contraceptives, modern contraceptive use, perception or partner’s attitude toward family planning, depression, autonomy, partner communication, freedom from coercion and partner support. Unmet need was defined as women of fertility age, that reported not having a hysterectomy, who were not currently pregnant, were sexually active in the last three months, did not wish to become pregnant in the next few months and were not using a modern family planning method. Met need was defined as women of fertility age, that reported not having a hysterectomy, were not currently pregnant, were sexually active in the last 3 months, did not wish to become pregnant in the next few months and were using a modern family planning method. Descriptive statistics were used to describe the demographic characteristics and family planning use. Cronbach’s alpha test was performed to measure the internal consistency of the measures described previously. Two-sample t-tests were used to test for significant differences between the met need and unmet need for modern contraceptives populations for continuous variables. Categorical variables were tested for statistically significant differences using a chi-squared test. The interviews explored community and individual perspectives of family planning, barriers to use, experiences with family planning use, and reasons for using or not using family planning. Results: The prevalence of met need and unmet need for modern family planning use were found to be 14.9% and 33.1%, respectively. About half (52%) of the sample were found to have no current or near future need for family planning. No factors were found to be significantly different in comparing those with a met need and unmet for modern family planning. A fear of side effects was the most reported barrier to modern family planning use, 31.7% (n=89). Qualitative interviews found a fear of side effects to stem from rumors concerning consequences that occur when a woman is unable to menstruation, experienced by many women using modern contraceptives. Conclusion: This study highlights the discrepancy between the knowledge of modern family planning and perceived availability that may account for unmet need for modern family planning. Furthermore, the data illustrated the impact of rumors and misconceptions on the use of family planning and revealed that many of the predicted barriers to family planning use may no longer be as relevant.

Abstract

Background: Autism spectrum disorder (ASD), a lifelong neurodevelopmental disorder, is recognized by the World Health Organization as a growing global public health concern (World Health Organization, 2013) and may represent some of the greatest burden of disease in children and adolescents. Although currently there is no known cure for ASD, different levels of recovery are still observed in patients. Early detection and intervention with evidence-based treatment models such as the Early Start Denver Model (ESDM) can improve intellectual ability and adaptive behaviors, and decrease symptom severity and challenging behaviors (Dawson et al, 2010; Rogers et al, 2012; Estes et al., 2015). In addition, early intervention with models such as ESDM can decrease long term costs associated with special education services, sheltered employment and supported living (Cidav et al., 2017). In South Africa a small start has been made on caregiver coaching early autism intervention, where caregivers are taught strategies to enhance their child’s social communication attempts (Franz et al., 2017; Guler et al., 2017). But important question remains as to whether non-specialists can deliver an early autism intervention at fidelity and in doing so impact child social communication and social engagement. Fidelity of intervention delivery is the degree to which programs are implemented as intended by program developers and is important because it is a potential moderator of the effect of the intervention on targeted health outcomes (Carroll et al., 2007; Brownson, Colditz, & Proctor, 2012).

Study Aims: The long-term goal of the study is to advance our understanding of the efficacy of caregiver coaching early autism interventions delivered by non-specialists in low resource settings. The overall aims of this South African study are tracking changes in fidelity of caregiver and non-specialist intervention implementation measured using established ESDM fidelity scales of (a) caregiver implementation of ESDM, and (b) non-specialist caregiver

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coaching techniques during 12 weeks of 1 hour per week P-ESDM coaching in 6 caregiver-child dyads.

Method: The overall study design is a hybrid type 1 effectiveness design. There are twelve 60-minute sessions in total, one hour per week, and all sessions will be video recorded. Each session of non-specialist coaching and caregiver child interaction will be coded at each of the 12 sessions for fidelity of caregiver implementation of ESDM strategies and coaching skills. The data analysis process aims to track changes in the fidelity of caregiver implementation of ESDM and the fidelity of non-specialist caregiver coaching techniques during each of the 12 week of 1 hour per week P-ESDM coaching in 2 caregiver-child dyads. The display fidelity scores visually across session time points, a similar approach used by Vismara (Vismara, Colombi, & Rogers, 2009). In addition, modifications are made to the original plan to adapt local situations to make the intervention more fit to local settings and such modifications are documented using Wiltsey-Stirman framework.

Results: The adaptation process is documented by the Wiltsey-Stirman framework by five categories of modifications on who made the adaptations, what is modified, level of delivery, context of modification and the nature of modification. The fidelity score for each caregiver and coach fidelity rating items are listed and the average fidelity scores for all intervention sessions are also calculated. The worst performing rating items on Caregiver Fidelity Scale are ABC format, joint activity structure and elaboration, quality of dyadic engagement, instructional techniques and application. The worst performing rating items on Coaching Fidelity Scale are greeting and check-in, conversational and reciprocal, reflective, coaching activity 2 and collaborative. There is no significant increasing or decreasing trend of caregiver and coach performances based on average fidelity scores across twelve sessions and

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there are no strong correlation observed between coaching fidelity scores and caregiver fidelity scores.

Conclusion: Training non-specialists and including them as a part of ASD treatment can help to reduce the resources gap by providing accessible and affordable early ASD intervention in lower-resourced settings. Culturally-sensitive adaptations made to the original intervention program are also needed to make the treatment reach its full capacity in a multi-cultural and multi-lingual community like South Africa. There are only two pairs of caregiver, child and non- specialist dyads participated in this pre-pilot study and such lack of sufficient data serves as a major limitation of this study. In subsequent researches, more caregivers and non-specialists shall participate in the study to help with building more systematic adaptation process and generalize the process of reaching intervention fidelity in lower-resourced settings like South Africa. And these types of interventions have the potential to be scaled up in community settings globally and begin to address the needs of young children and families impacted by autism.

Background: HIV-related stigma is a barrier to the success of programs targeting the prevention and treatment of HIV. In Sub Saharan Africa, where the HIV epidemic is concentrated, men play a critical role in defining and shaping social constructs, including HIV stigma. This study aimed to describe HIV stigmatizing attitudes, to identify factors associated with stigmatizing attitudes, and to explore the broader context of HIV stigmatizing attitudes among men in Tanzania. Methods: This mixed-method study recruited 489 men from antenatal clinics of two public primary health care facilities in Moshi municipality, Tanzania. Participants completed a structured survey using audio computer assisted self-interviewing technology; a subset of 16 men completed in-depth interviews. HIV stigmatizing attitudes were examined using a modified version of the Personal Stigma Scale, and logistic regression models identified associating factors. Qualitative data were analyzed using applied thematic analysis. Results: The majority (72%, n=356) of participants endorsed at least one of the stigmatizing attitudes; the most common attitude endorsed was a perception of HIV is a punishment for bad behavior (37%, n=180). In a multivariable logistic analysis, men with only primary education were twice as likely as those with secondary or high to hold high stigmatizing attitudes (OR=2.05, 95% CI 1.39, 3.04). Qualitative analysis revealed that masculine identity intensified the vulnerability of men towards HIV stigma, while HIV testing experience spurred behavior change to reduce HIV risk behavior. Conclusions: HIV stigmatizing attitudes are prevalent among men. Comprehensive community-based stigma reduction programs to provide a supportive environment for men are crucial to increase uptake of HIV testing and treatment services.

Background: Hypertension, a leading risk for cardiovascular mortality, is an important co-morbidity among people living with HIV (PLWH). Understanding the epidemiologic patterns of hypertension and barriers to hypertension care is a critical first step in developing interventions to improve cardiovascular outcomes among PLWH in sub-Saharan Africa (SSA). Methods: Semi-structured in-depth interviews were conducted with 13 hypertensive patients engaged in HIV care in northern Tanzania. Patients attending a single HIV clinic in Moshi, Tanzania were screened consecutively for hypertension. Hypertension was defined as having at least one of the following: 1) a self-reported diagnosis of hypertension, 2) a single blood pressure measurement > 160 mmHg systolic or > 100 mmHg diastolic, or 3) two measurements at separate visits, obtained at least one week apart of > 140 mmHg systolic or > 90 mmHg diastolic. All screened participants completed a short demographic survey. Participants who met criteria for hypertension were invited to complete a knowledge, attitudes and practices survey that included questions about previous hypertension history. Results: The data revealed a range of themes including poor understanding of hypertension causes, limited hypertension knowledge, perceived overlap and comparisons between hypertension and HIV, delays in hypertension diagnosis and linkage to care, shortcomings of provider communication and counseling, reluctance to use antihypertensive medication, lack of integration of hypertension and HIV care, and multiple barriers to hypertension care. Over an 8-week period, 555 patients were screened for hypertension. Hypertension prevalence was 19.6% (20.3% among women and 16.8% among men). The median age of patients with hypertension was 50 (IQR 43 – 57 years), compared to 42 (IQR 35 – 49 years) years for normotensive patients. Older age (OR 1.07, 95% CI 1.04 – 1.09, p<0.001) and higher body mass index (BMI) (OR 1.13, 95% CI 1.09 – 1.18, p<0.001) were independently associated with hypertension. Among the 91 patients with hypertension who completed additional questions about their hypertension history, 44 (48%) reported having a prior blood pressure check, 32 (35%) were previously aware of their hypertension diagnosis, and only 21 (23%) reported ever taking antihypertensive drugs. Of the 10 patients (11%) reporting current antihypertensive use, none had a controlled blood pressure. Conclusions: Participants described multiple, intersecting challenges related to hypertension management. Hypertension prevalence among patients engaged in HIV care was high. Despite a high burden of disease, the rates of screening, awareness, treatment and control were unacceptably low. Multifaceted strategies that address barriers to care along the hypertension care continuum and that are integrated within HIV care are urgently needed to improve cardiovascular outcomes among PLWH in SSA.

The needs of South African men with HIV are often overlooked in providing healthcare for people living with HIV/AIDS, leading to unique needs and experiences for men seeking HIV/AIDS healthcare. Compounding this phenomenon are norms of masculinity guiding these men's behaviors as they navigate health and healthcare systems. The aim of this study is to provide new insight on which components of masculinity interplay with healthcare access in South Africa. The study took place at one primary health care clinic in a peri-urban township in rural KwaZulu-Natal, South Africa. In-depth individual interviews were conducted with 21 HIV-positive men recruited from the clinic. Direct observations of the HIV clinic waiting area were also conducted. Data was analyzed using a grounded theory-informed memo-writing approach. Participants expressed a range of ways in which masculine ideals and identity both promoted and inhibited their willingness and ability to engage in HIV care. Notions of masculinity and social identity were often directly tied to behaviors influencing care engagement. Such engagement fostered the reshaping of identity around a novel sense of clinic advocacy in the face of HIV. Our findings suggested that masculinities are complex, and are subject to changes and reprioritization in the context of HIV. Interventions focusing on reframing hegemonic masculinities and initiating treatment early may have success in bringing more men to the clinic.

Background: Many health providers worldwide stigmatize people living with mental illness, creating a barrier to providing quality mental health services. Interventions aiming to reduce stigma during medical school have utilized education and contact-based methods to improve student attitudes towards mental illness. However, the effectiveness of these methods has never before been compared in medical schools in low-income countries. The aim of this study was to evaluate a video featuring a mental health service user with depression in a randomized controlled pilot trial among medical students in Nepal. Methods: In a three-armed randomized controlled pilot trial, participants were randomized to one of three conditions: a didactic video lecture based on the mental health Gap Action Programme Implementation Guide (mhGAP-IG) depression module, a service user testimonial video about living with depression, and a condition with no video presentation. Participants were 94 second and third year medical students in Nepal. All of the measures were collected post-intervention. The primary outcome was explicit attitudes measured on the Social Distance Scale (SDS). Additional outcomes were implicit attitudes on two Implicit Association Tests (IAT), diagnostic accuracy, treatment knowledge, and symptom knowledge. Results: Both the didactic lesson (SDS mean score, M = 33.32; standard deviation, SD = 9.57) and the service user videos (M= 30.13; SD= 9.16) had lower explicit stigma after the video presentations compared to the control (M= 39.10; SD= 11.14) (F2,91= 6.37, p= 0.003, R2= 0.12), but there was no difference between the two intervention conditions (F1,61= 1.55, p= 0.23, R2= 0.02). There were no significant differences on implicit associations (IAT d score), depression diagnosis, treatment knowledge, and symptom knowledge. Conclusions: Prerecorded videos (whether didactic or service user testimonials) are scalable learning tools that have potential to reduce explicit stigma among medical students in low resources settings. Additional research is necessary to explore the differences between both didactic education and service user testimonial interventions, as well as the potential outcomes when the videos are combined. A full scale randomized controlled trial will be conducted based on these findings.

Clinical Trials Registration: CTRN NCT03231761

Background: Limpopo Province has the highest rates of intimate partner violence (IPV) in South Africa, with data suggesting that over half of women experience IPV in their lifetimes. However, data among young, university-attending women in this province is lacking. This study aimed to estimate the prevalence of IPV victimization among university women and examine factors associated with IPV history. The study also aimed to explore how university women recognize IPV, suggest ways victims seek help, and identify a victim’s coping strategies using qualitative methods.

Methods: This study utilized a mixed methods approach and was conducted at the University of Venda (UNIVEN), a rural-based university in Vhembe district. Convenience sampling was used to recruit female participants who were currently enrolled at the university, aged 18 to 31 years, and currently in a relationship or in a relationship within the past year. 113 females were enrolled in the study. After obtaining written informed consent, we conducted a self-administered cross-sectional survey. IPV was measured using the Revised Conflict Tactics Scale (CTS2), which assessed for both past year and lifetime IPV experiences. To explore the association between IPV and other factors, other measures included an alcohol use screening tool (AUDIT-C) and a measure assessing attitudes toward gender roles. Descriptive statistics and Fisher’s exact tests were performed to assess the relationship between potential risk factors and IPV. Logistic regression analyses examined the associations between exposure variables and lifetime IPV victimization. Short explanatory model interviews (SEMI) examining women’s perceptions of IPV-related issues using a custom vignette were administered directly following the survey. The interviews were recorded and later analyzed using thematic analysis.

Results: 92.23% of participants reported being victims of any form of IPV in their lifetime. Psychological aggression (82.52%) was the most prevalent type of lifetime violence, followed by sexual coercion (73.79%), physical assault (37.86%), and injury (15.53%). The joint frequency distribution of IPV victimization by subscale reveals that 9.71% of participants reported being victims of all four forms of IPV at least once in their lifetime, while most respondents reported experiencing two types of IPV (35.9%). Compared to having no sexual partners in the past year, having two or more sexual partners was significantly associated with higher odds of being a lifetime victim of sexual coercion (p = 0.031; OR: 4.41; 95% CI 1.14 - 17.02). Study findings support an increased odds of lifetime IPV (p = 0.030; OR: 7.04; 95% CI 1.21 – 40.97) and physical assault (p = 0.010; OR: 3.77; 95% CI 1.37 – 10.40) for participants who personally knew an IPV victim at UNIVEN compared to women who did not personally know a victim. Participants who disagreed or strongly disagreed that IPV should be viewed as a crime were 11.37 times more likely to be victims of lifetime sexual coercion than those who agreed (p = 0.027; OR: 11.37; 95% CI 1.32 - 97.82). The SEMI revealed most women recognized IPV in the vignette, and the recommended help-seeking behaviors included seeking informal and formal help, leaving the relationship, and changing behavior.

Conclusions: IPV prevalence among the study sample was reported nearly universally. Number of sexual partners, personally knowing a victim of IPV at the university, and attitudes toward gender roles were significantly associated with having a history of IPV. University commitment and multi-sectoral collaboration at all levels are critical for the provision of resources, services, and violence prevention efforts. Future research is needed to inform evidence-based interventions that will reduce victimization by addressing risk factors, under-reporting, and barriers to seeking help.

Background: Autism spectrum disorder (ASD) is a major public health challenge worldwide. Early intensive intervention services have been shown to reduce core ASD symptomatology, but there are many barriers to implementing these services in low resource settings. Training caregivers to deliver intensive early ASD intervention may help to overcome many of the implementation barriers, but there is limited research about the feasibility of delivering a caregiver-mediated early ASD intervention in low resource settings and the compatibility of such interventions with existing platforms of care. Study Aims: This study explored key stakeholder perspectives on the feasibility of implementing early ASD intervention services in the Western Cape Province of South Africa. Methods: Eight in-depth interviews with District and Provincial representatives from the Department of Health, the Department of Education, the Department of Social Development, and two non-governmental organizations were conducted. Results: Stakeholders identified 20 current policies relevant to ASD in South Africa, future directions for ASD policy, and perceived barriers to ASD early intervention services. All participants reported a strong desire for early intervention services and identified key potential facilitators to early intervention. Conclusion: Caregiver mediated early ASD intervention may address barriers to ASD services in the Western. This study identified perceived barriers to such interventions as well as facilitators to delivering a caregiver mediated intervention. Adaptions of caregiver-mediated early ASD interventions in the Western Cape must be affordable, simplified to be delivered by paraprofessionals, and adapted to include local cultural components such as language.

Background: By facilitating access to prevention and care services, HIV serostatus disclosure has been associated with improved physical health, psychological well-being, and improved health behaviors for people living with HIV/AIDS (PLWHA). Disclosure to sexual partners, in particular, can help prevent the forward transmission of HIV. Disclosure can increase social support but can also lead to negative social outcomes including stigma and discrimination. Thus, disclosing HIV status to friends, family, and sexual partners is a complex psychosocial challenge that PLWHA face, particularly adolescents and youth who have an increased lifespan due to current effective treatment protocols.

Objectives: This study had three objectives: 1) to determine gender-related differences in the rate and patterns of HIV serostatus disclosure to family, friends and sexual partners among HIV-positive youth in Haiti; 2) to identify gender-specific relational and psychosocial predictors of HIV disclosure to sexual partner; and 3) to qualitatively explore and describe motivations and experiences related to HIV disclosure in this population.

Methods: A cross-sectional study was conducted in a random sample of 680 sexually active HIV-positive young adults (18-29 years) from six clinics in Port-au-Prince, Haiti. Socio-demographic, health, sexual and reproductive history, sexual behavior, psychosocial and disclosure data were collected using a pre-tested interviewer-administered structured questionnaire. Rates and patterns of HIV serostatus were described, and factors associated with disclosure to all sexual partners in the past 3 months were analyzed using hierarchical logistic regression models, separately by gender. Qualitative data was collected through individual in-depth interviews with a purposefully selected sample of 12 young adult participants to explore whom they chose to disclose to, how they disclosed to these individuals, and how these individuals reacted. Content analysis allowed for the description of motivations and experiences related to HIV disclosure in this population.

Results: Slightly over half (56%) of participants had told at least one person about their HIV status. Female respondents were more likely than male respondents to have disclosed to family or friends. Male youth were more likely to disclose their status for the first time to sexual partners (35%), while female youth were more likely to choose their mother as their first confidant (51%). Overall, 33% of participants reported having disclosed their HIV status to all their sexual partners from the last 3 months, with no significant difference across genders. For both genders, older age and being unaware of partners' HIV status were significantly associated with lower odds of HIV serostatus disclosure. Additionally for young males, disclosure stigma was negatively associated with disclosure while HIV acceptance and personalized stigma were significant predictors of disclosure. Female youth who were single, had casual or multiple partners, and experienced greater personalized stigma were less likely to disclose, whereas the availability of social support was positively associated with disclosure to all sexual partners. While disclosure to sexual partners was motivated primarily by a desire to encourage partners to test for HIV and increase condom use, or by a sense of moral responsibility, important contextual differences emerged in qualitative analysis with regards to barriers to disclosure, particularly fear of stigma and fear of partner's reaction.

Conclusion: Rates of HIV serostatus disclosure to family, friends and sexual partners were low among this population of HIV-positive youth in Port-au-Prince. Context-specific gender-sensitive interventions are needed to increase social support, reduce HIV-related stigma, and assist youth living with HIV in making effective decisions on disclosure that will ultimately improve their well-being and quality of life. Further research is necessary to better understand the process and outcomes of HIV serostatus disclosure to sexual partners, as well as the relationship between HIV serostatus disclosure and sexual risk behaviors in this young HIV-positive population.

Gold has been one of the most important minerals in human history and has played an integral role in the economies of and societies of many cultures, particularly in the West African nation of Ghana. While legal gold mining is one of the prominent industries, illegal Artisanal Small-Scale gold mining, referred to as galamsey, has seen an increase in activity as the price of gold has increased while people’s economic situations remain precarious; unfortunately, the result of this practice have led to substantial negative effects, such as water body contamination, loss of arable land, and increased exposure to toxic chemicals such as Mercury & acid threatening communities’ health. The purpose of this study was to qualitatively examine individuals’ perceptions of the drivers that led to galamsey, and their perceptions of its impact regarding health, environment, and society .The study was conducted in the Ashanti Region and consisted of recorded In-Depth interviews with 20 participants representing individuals affected by Galamsey including miners, teachers, and health workers. The data were then analyzed using a thematic analysis approach using Nvivo software. Results showed that the drivers of galamsey were overwhelmingly economic ones; individuals often worked in galamsey due to necessity, as the scarcity of other forms of employment did not provide sufficient income to sustain themselves or their families, even if they agreed with the premise of galamsey’s negative effects. While there has been substantial efforts to reduce galamsey utilizing law enforcement, future policy directions may also include rectifying the economic circumstances that drive individuals to engage in galamsey in order to eliminate the issue at the source.

Background

Postpartum hemorrhage is the most significant contributor to maternal mortality globally, claiming 140,000 lives annually. Postpartum hemorrhage is a leading cause of maternal death in South Africa, with the literature indicating that 80 percent of the postpartum hemorrhage deaths in South Africa are avoidable. Ghana, as of 2010, witnesses 2700 maternal deaths annually, primarily because of poor quality of care in health facilities and services being difficult to access. As per WHO recommendations, uterotonics are integral to treating postpartum hemorrhage as soon as it is diagnosed. In case of persistent bleeding or limited availability of uterotonics, the uterine balloon tamponade (UBT) can be used as a second line of defense. If both these measures are unable to counter the bleeding, providers must perform surgical interventions. Literature on the UBT, as one tool in the protocol to address postpartum hemorrhage, has shown it to have success rates ranging from 60 to 100 percent. Despite the potential to lower the number of postpartum hemorrhage deaths in South Africa and Ghana, the UBT has not been incorporated widely in South Africa and Ghana. The aim of this study is to describe the barriers involved with integrating the UBT into South Africa and Ghana’s health systems to address postpartum hemorrhage.

Methods

The study took place in multiple sites in South Africa (Cape Town, Johannesburg, Durban and Mpumalanga) and in Accra, Ghana. South Africa and Ghana were selected because postpartum hemorrhage contributes greatly to their maternal mortality numbers and there is potential in both countries to lower those rates through greater use of the UBT. A total of 25 participants were interviewed through purposive sampling, snowball sampling and participant referrals, and included various categories of stakeholders integral to the integration process of a medical device. Individual in-depth interviews were used for data collection, with interview questions being tailored to each stakeholder category. The focus of the interviews was on the protocol used to counter postpartum hemorrhage, the frequency with which the UBT is used as part of the protocol, and the process of integrating it into the South Africa and Ghana’s health systems. The data collected were coded using NVivo and analyzed using content analysis.

Results

The barriers to integration of the uterine balloon tamponade to address postpartum hemorrhage in South Africa and Ghana were evident on the political, economic and health delivery levels. The results indicated that the barriers to integration in South Africa included the low recognition of postpartum hemorrhage as a problem, the lack of clarity surrounding the role of the Medicines Control Council as a regulatory body for medical devices, and low awareness of the UBT as an intervention to control postpartum hemorrhage. The barriers in Ghana were the cash constraints experienced by the Ghana Health Services to fund medical devices, a heavy reliance on donors for funding, and the lack of consistent knowledge on processes involving clinical trials for new medical devices in Ghana.

Conclusion

Existing literature on methods to counter postpartum hemorrhage to reduce maternal mortality has focused on and emphasized the efficacy of the UBT. Despite overwhelming evidence supporting the use of the UBT, many health systems across the world, particularly low-income countries, do not have access to the device owing to numerous barriers in integrating the device into obstetric care. This study illustrates the need to focus on incorporating the UBT into health systems for greater availability to health workers and its use as standard of care. Ultimately, this study can be used as a stepping-stone for more research on this subject, providing evidence to influence policymakers to integrate the UBT into their protocols for postpartum hemorrhage response.