Browsing by Department "Global Health"

Background: Global aging poses various challenges for both developing and developed countries. The proportion of older adults in developed countries is currently much higher than in developing countries. Health authorities are now confronting increasing public health problems, including a growing burden of oral diseases among older people. Although the percentage of older adults who have retained their natural teeth has increased steadily during the past decades, the number of natural teeth might still contribute vastly to older people’s quality of life. As little research has been conducted in the Southeast Asia area, this study aims to 1) investigate the association of number of natural teeth and oral pain with oral health-related quality of life; 2) discover ethnic disparities in regards to number of natural teeth and oral health-related quality of life; and 3) examine factors related to number of natural teeth retained among elderly Singaporeans.

Methods: The study was carried out in a dental clinic conducting a questionnaire survey on patients who visited the clinic. Geriatric Oral Health Assessment Index (GOHAI) was used and the GOHAI total score (ranged from 12 - 60) was measured to describe participants’ oral health-related quality of life from three perspectives: physical, social, and mental health components. Participants’ dental records were linked to the questionnaire survey and data on their dental parameters were also collected. Linear regression analysis was conducted as the main method towards all the three study aims, whereas logistic regression analysis was performed as supplementary evidence especially for Aim 1. Non-parametric statistical tests were also used in cased of normality assumption requirements throughout the analytical process.

Results: The mean GOHAI total score of the study subjects was 47.72 (SD = 7.45). The mean number of natural teeth was 18.27 (SD = 8.15). A positive association between number of natural teeth and GOHAI total score was found by the linear regression analysis (Coefficient = 0.20, 95%CI: 0.17, 0.44) and a Spearman correlation test (rho=0.22, P < 0.01). A negative association between oral pain and GOHAI total score was detected by the linear regression (Coefficient = -5.88, 95%CI: -7.86, -3.91) and a Spearman correlation test (rho = -0.40, p < 0.001) as well. In terms of factors associated with number of natural teeth, older people with more number natural teeth were found to be associated with younger age, higher educational level, and flossing at least once a day. Ethnic disparities were observed with Malays exhibited the lowest number of natural teeth and GOHAI total score, compared to Chinese and Indians.

Conclusions: The oral health-related quality of life of the investigated population was generally fair. Ethnic disparities existed in oral health-related quality of life and number of natural teeth among older adults in Singapore that Malays had adverse oral health status compared to Chinese and Indians. With more number of natural teeth retained and less oral pain, a person was more likely to have better oral health-related quality of life. Flossing at least once a day might contribute to the retention of more natural teeth.

Background: Church-based health promotion programs have been shown to be effective in improving health outcomes, but rarely do they approach wellness from a holistic standpoint. This is a missed opportunity for fuller integration within congregations. This study sought to assess and evaluate the feasibility of a holistic multi-site church-based health promotion program, through engagement, acceptability, and preliminary behavior change outcomes. Methods: This study utilized a concurrent mixed-methods approach in order to evaluate the “Congregational Wellness Challenge” (CWC), a pilot initiative that encouraged behavior change in three areas of holistic wellness: body, spirit, and soul, over six weeks. Participants were asked to complete one activity from each of the three categories every day for forty days, and congregations were encouraged to support those participating in the challenge. This study utilized a pre-post one-group design. Participants were surveyed at baseline and at six weeks about their health behaviors and opinions of the programs, as well as recording their behaviors on activity logs. Seventeen semi-structured in-depth interviews were conducted eight weeks post-challenge. Results: The 39 participants in the study completed 64.2% of the activities during the challenge. There was a significant increase in several of the body health variables. The number of people reporting 30 minutes of physical activity about once a week, two or three times a week or every day, compared to (no times a week?) nearly doubled, from 43.5% to 82.6% (p=0.012). Vegetable and fruit intake also significantly increased, from 52.2% of people reporting eating at least 5 servings of vegetables and fruits daily to 100% of respondents (p=0.001). Frequency of reading for pleasure significantly increased, as did Scripture meditation, bible study, and singing to the Lord. Qualitative results indicated an overall acceptability of the program. Participants had a variety of motivations for joining, and gave valuable feedback on the importance of recording their activities. Conclusion: The CWC pilot initiative was feasible in a wide variety of churches, and future research should focus on the effectiveness of holistic wellness programs and improving implementation practices.

Background: An estimated 2.6 million children under 15 years are living with HIV. Children often begin antiretroviral therapy (ART) without learning why they are sick or the purpose of their medication. The objective of this study was to estimate the prevalence of pediatric HIV disclosure in two districts in rural Zimbabwe, characterize the process of disclosure, and begin investigating the predictors and consequences of disclosure.

Methods: This was a cross-sectional survey of 372 primary caregivers of HIV-positive children between the ages of 9 and 15 years living in Bikita and Zaka districts and receiving ART or pre-ART from a network of 21 eligible clinics. Surveys were administered individually in Shona by trained Zimbabwean enumerators. Disclosure was referred to if a child knows he or she has a health condition called HIV. Full disclosure was defined as a caregiver's report that the child knows he or she has an illness called HIV, how he or she acquired the illness, and can pass the infection to someone else. The prevalence of disclosure was estimated for the overall sample, by district, and by clinic. Characteristics of the process of disclosure as well as predictors and consequences of disclosure were identified for the overall sample.

Results: The overall prevalence of disclosure in the sample is 66.9 percent (95% CI 62.0 to 71.5%). Disclosure rates are similar across districts: 64.1 percent in Bikita (56.5 to 71.7%) and 69.0 percent in Zaka (62.8 to 75.2%). Across the 21 study clinics, disclosure rates ranged from 47.8 to 85.7 percent. Among the children who know that they are HIV-positive, 69.9 percent know how they were infected (63.9 to 75.2%) and 48.6 percent know that they could pass the infection to someone else (42.5 to 54.8%). The average child learned about his or her illness at age 10.0 (SD=1.9). In the majority of cases, the caregiver informed the child directly (58.6%) and 28.5 percent of children learned of their status from a health worker. Most caregivers who have disclosed to their child reported that their overall disclosure experience was positive (81.5%), with 76.7 percent having improved their adherence to medication following disclosure. Predictors of disclosure were identified as follows: caregivers’ high level of self-efficacy to disclose (p<0.05); HIV-positive caregivers’ high level of HIV-related shame (p<0.001); HIV-positive caregivers’ high level of awareness of their own HIV symptoms and implications of HIV on their health and future (p<0.05); caregivers’ assessment that their child has cognitive skills and is emotionally mature (p<0.10); higher levels of child’s formal education (p<0.05); and caregivers who are not currently married or living with someone else (p<0.01). The following were not predictors of disclosure: caregivers’ assessment of benefits of disclosure outweighing the risks of disclosure, perception of HIV-related stigma and/or discrimination, access to health care, quality of health care, child or caregiver gender, or socioeconomic status did not appear to influence the caregivers’ decision to disclose to their child.

Conclusions: Caregivers who are taking care of children between the ages of 9 and 15 need proper support and assistance from health workers for pediatric HIV disclosure. More efforts are needed to encourage and assist caregivers to inform their child about his or her HIV status. In the future, helpful disclosure support interventions would address caregivers’ HIV-related shame, improve the psychosocial wellbeing of the caregivers, educate caregivers about HIV and HIV treatment, and help them improve parent-child communication, all of which may allow caregivers to increase their overall self-efficacy and therefore facilitate a successful, age-appropriate disclosure process for both the caregivers and their children.

Introduction: Extensive studies on tickborne pathogens (TBPs) have been conducted in developed nations, relatively less has been done in developing nations leaving a large gap of knowledge. Mongolia, a country built upon nomadic culture and pastoralism is an ideal system to study TBPs as the population is at an increased risk due to increased time spent outside herding livestock. Discoveries of TBPs in Mongolia include Babesia spp., Anaplasma spp., Borrelia spp., Rickettsia spp. and tick-borne encephalitis virus. While research has focused on TBPs in humans and ticks in Mongolia, little research has assessed animal reservoirs, specifically small mammal species, as reservoirs for TBPs. This project aimed to 1) identify the role of small mammal species in the ecology of TBPs in Mongolia, specifically Rickettsia spp., Anaplasma spp., and Borrelia spp. using serological and molecular analysis and 2) identify risk factors associated with the prevalence of TBPs in small mammal populations in Mongolia.

Methods: From June to July 2016, rodents were live-trapped, and whole blood, serum and ear biopsy samples were collected. Sixty-four rodents were trapped in three aimags (provinces) in northern Mongolia. Whole blood samples were tested by PCR to detect the presence of Rickettsia spp., Anaplasma spp., and Borrelia spp.. In addition, ear biopsy samples were tested by PCR to detect the presence of Borrelia spp.. All rodents were serologically tested for antibodies to Anaplasma phagocytophilum and Rickettsia rickettsii. A multivariate model was used to assess risk factors for the presence of tickborne pathogens. Risk factors examined included species and sex of animal, location and presence of ticks.

Results: 56.0%, 39.0% and 0.0% of animals were positive by PCR for Borrelia spp., Rickettsia spp. and Anaplasma spp., respectively. 41.9% and 24.2% of animals were seropositive for A. phagocytophilum and Rickettsia rickettsii, respectively. Risk factors found to be important predictors of Borrelia spp. molecular detection included small mammal capture in Tov aimag (OR, 4.1; 95% CI, 1.00 – 16.80), male small mammals (OR, 3.07; 95% CI, 0.99 – 9.51) and ground squirrel species type (OR, 3.24; 95% CI, 0.90 – 11.70). The risk factor found to be an important predictor of Rickettsia spp. molecular detection was Mongolian gerbil species type (OR, 246.5; 95% CI, 20.77 – 2925.88). Presence of ticks on small mammals (OR, 4.62; 95% CI, 0.92 – 23.24) was an important risk factor for A. phagocytophilum antibody detection. No risk factors were identified as being important predictors of antibody detection of R. Rickettsii.

Conclusion: The results of this study provide considerable evidence of TBPs circulating in small mammal populations in Northern Mongolia. Further information on TBPs in ticks, humans, livestock and wildlife reservoirs will be important to address public health interventions for TBPs in Mongolia in the future.

Background: Plasmodium falciparum has developed resistance against artemisinin and partner drugs that have been widely used globally as artemisinin-based combination therapies (ACT). Such resistance, poses the greatest challenge to the prospect of malaria elimination in the Greater Mekong Subregion (GMS). Genetic polymorphisms in P. falciparum that confer resistance to the drugs that are part of two most commonly used ACT in the GMS, artemisinin-lumefantrine (AL) and dihydroartemisisnin-piperaquine (DP). Single point mutations in Kelch propeller domain of falciparum chromosome 13 (K13) for artemisinin resistance, and copy number variations of plasmepsin 2/3 are associated with piperaquine resistance, and Pfmdr-1 for mefloquine and lumefantrine resistance. Although the efficacy is high for ACTs in Myanmar, molecular markers of resistance to either of the drugs in ACT can still be present and may indicate that the drugs will be at risk in the near future. Therefore, this study aimed to detect genetic polymorphisms in K13, Pfmdr-1, and plasmepsin 2 (Pfpm-2) that mediate ACT treatment outcomes in Myanmar. Methods: The current study uses a cross-sectional study design and retrospective analysis of laboratory samples collected in previous therapeutic efficacy studies (TES) conducted during 2014 to 2018 in nine sentinel malaria endemic remote townships in Myanmar. The ACTs used in these TES were artemether-lumefantrine, dihydroartemisinin-piperaquine, and pyronaridine-artesunate. 176 samples were randomly selected out of 651 samples from nine TES sites because of the time constraint. K13 genotyping was done by Sanger sequencing, and the copy numbers of Pfpm-2 and Pfmdr-1 were quantified by real-time polymerase chain reaction. Results: Among 176 randomly selected pre-treatment parasites, we observed non- synonymous mutation in the K13 gene in 25% (42/169; 95% CI: 18.3, 31.4). Overall, 23% (39/169; 95% CI: 16.7, 29.4) of infections harbored a K13 mutation that has been validated as associated with artemisinin resistance. Among these, 58.9% (23/39) encoded the F446I substitution. The prevalence of parasites harboring the C580Y mutation that is the most closely associated with artemisinin resistance was 6.5% (11/169; 95% CI: 2.8, 10.2), and was present in 4 out of 9 study sites. Only 1 sample 0.6% (1/172; 95% CI: 0, 1.7) harbored more than one copy of Pfpm-2; this parasite also contained the K13 C580Y mutation conferring artemisinin resistance. No parasites harbored more than one copy of Pfmdr-1. Conclusion: Consistent with the high efficacy of ACTs in Myanmar, there were little evidence of resistance to artemisinin or partner drugs by analysis of molecular markers. However, there was remarkable amount of K13 molecular markers (C580Y, F446I, R561H) seen in this study. These observed K13 markers have already been confirmed and validated by WHO. This finding may be a warning sign of developing artemisinin resistance which may, in turn, have an effect on the malaria elimination process in Myanmar. Emergence of drug resistant malaria in GMS threatens the malaria elimination effort in the region as well as globally. Continued monitoring of artemisinin and its partner drugs resistance is needed to prevent the spread of drug resistant malaria.

Mental illness is prevalent worldwide in all cultures with varying manifestations. Its socioeconomic impact cannot be underestimated. Mental health accounts for as much as 14 percent of the global disease burden (Prince, et al. 2007) and depression is ranked as the fourth leading contributor to the global disease burden. Nevertheless, mental health remains largely ignored worldwide, especially in developing nations.

This cross-sectional study, examines depression in two rural districts in Ghana, West Africa. Ghana, like many African nations, consists of many ethnic groups, with lineage networks that dictate personal and public behaviors. Ghana is unique in that approximately half of the population belongs to the Akan, matrilineal clan. The study hypothesized that by examining two clan groups (the Akan and Ga-Adangbe) that differed in lineage a statistically significant difference in rates of depression would be ascertained.

Upon receipt of ethical board approval from the Duke University Institutional Review Board in Durham, NC and Noguchi Memorial Institute for Medical Research Institutional Review Board in Ghana, researchers using the Depression Anxiety Stress Scales Short form (DASS-21) in a geographically randomly selected sample to measure depression as well as anxiety and stress among the participants and a demographic survey, researchers compared the prevalence of depression between the matrilineal Akan clan and patrilineal Ga-Adangbe clan. Data was analyzed using STATA 11.0.

The results indicate a rejection of the null hypothesis. There is a statistically significant difference in depression score between the women in the Ga-Adangbe clan and Akan clan. This study reports high co-morbidity of anxiety and stress with depression. Further research should expand to include other tribes in Ghana and other mental illnesses.

Introduction: Traumatic brain injury (TBI) accounts for the majority of Uganda’s neurosurgical disease burden, but invasive intracranial pressure (ICP) monitoring is infrequently used. Noninvasive monitoring through tools like pupillometry could change the care of TBI patients in such a setting. Given the novelty of noninvasive monitoring in Uganda, this study sought to assess the feasibility of pupillometry for noninvasive ICP monitoring for TBI patients. Methods: Healthcare workers in Kampala, Uganda received education on pupillometry, practiced using the device on healthy volunteers, and completed interviews focused on pupillometry and its potential implementation. Qualitative analysis of the interviews assessed pupillometry acceptability and feasibility. Quantitative analysis assessed learning time, time to obtain a measurement, and accuracy of measurements during training. Results: Twenty-two providers completed the study. Participants described how pupillometry would add value to the care of patients with TBI during examination, delivering interventions, and monitoring. Reported concerns included the cost, understanding, and maintenance needs of the pupillometer. Participants also discussed potential challenges with using pupillometry, including limited accessibility and availability as well as challenges with documentation. They suggested offering continued education and providing technical support as strategies to support successful implementation. During training, average time to learn was 13.6 minutes (IQR 3.8) and average time to obtain a measurement was 51.1 seconds (IQR 14.2). Paired t tests to evaluate accuracy after training showed no statistically significant difference in the comparison measurements. Conclusion: Pupillometry would be feasible to use for noninvasive ICP monitoring for TBI patients in Uganda, as long as concerns about the device could be addressed and implementation barriers overcome.

Abstract

Background: An estimated 80% of patients with epilepsy reside in LMICs, where surgical options for treating medication refractory epilepsy (MRE) may not be readily available. This study assesses the need for an epilepsy surgery program in Uganda and evaluates the current capacity for implementing such a program at the nation’s largest hospital, the Mulago National Referral Hospital (MNRH).

Methods: Medical records of 183 adult patients receiving care for epilepsy at the Bosa Psychiatric Clinic between January and April 2021 were retrospectively reviewed to determine patterns of medical management of epilepsy. 13 clinicians across Psychiatry, Neurology, and Neurosurgery were interviewed; these interviews were analyzed thematically to address the subjects of need and capacity for epilepsy surgery at MNRH. 41 patients and 63 caregivers were surveyed on their perceptions and attitudes toward surgery as a potential treatment for epilepsy.

Results: Nearly half (49%) of patients receiving care at the Bosa Clinic had been treated on two or more anti-epileptic drugs (AEDs) over the course of their disease, with Carbamazepine, Sodium Valproate, and Phenytoin being the most commonly prescribed medications. Only few patients had records of prior brain imaging (8.2%) and EEG (21%) in their medical charts, and no patient had prior referral for surgical evaluation. The interviewed clinicians noted that there is a need for an epilepsy surgery program to augment the current medical practice. They identified infrastructure, cost, further specialized training, and public perception as factors to address in implementing a sustainable epilepsy surgery program locally. 53.3% of patients and 58.5% of caregivers would consider epilepsy surgery only after they had tried 5 or more AEDs without resolution of seizures, citing complications and cost as deterrents.

Conclusions: Both clinical records and clinician interviews demonstrated a need for a surgical option for treating idiopathic epilepsy among Ugandans with medication refractory epilepsy. Investigative modalities such as EEG, CT, and MRI are locally accessible for preliminary evaluation of surgical candidacy. A future pilot program could serve as a platform for training personnel to sustain an epilepsy surgery program at MNRH, and patients and caregivers would subscribe to surgical treatment if a local program is affordable and has a low complication rate.

Background: In Kenya, approximately 14.5% of children and youth meet criteria for a mental disorder. Despite this high burden, research is very limited related to mental health problems this population. Research is needed on the measurement of child mental health problems and on the risk and protective factors associated with these conditions.

Objectives: (1) Evaluate a set of survey items, chosen from both standardized measures and locally developed items, to identify those that that best differentiate between children with and without mental health problems. (2) Identify and explore important individual- and family-level influences on child mental health.

Methods: Individual surveys and semi-structured interviews were administered to members (1-2 caregivers, 1 child age 8-17) of 22 families living in Eldoret, Kenya. We evaluated differences in survey item endorsement between children with and without mental health problems to identify the best performing items. We used mixed-methods analysis of semi-structured interview transcripts and associated rating scores to explore differences between children with and without mental health problems on a variety of family-level variables.

Results: Following an extensive cultural adaptation process, fourteen of 26 survey items were successful in differentiating between children with and without mental health problems. Successful survey items were all drawn from standardized measures; no locally developed items were successful. All family-level variables (e.g., overall family functioning, couples’ relationship quality, parent-child relationship quality, and caregiver mental health) were strongly associated with child mental health outcomes, evidenced by large effect sizes ranging from 0.86 to 4.16. Subsequent qualitative analysis identified specific components of these variables likely contributing to the large numerical differences in scores.

Conclusions: The results of this study both suggest that standardized measures are appropriate for use in this population and highlight the importance of cultural adaptation before implementing standardized assessment tools. Additionally, the results indicate that the family environment is a promising target for interventions aiming to reduce mental health problems in Kenyan children.

Background: Reports from the first monkeypox (MPX) active surveillance program in the Democratic Republic of Congo (DRC) in the 1980s determined that the disease was not of epidemic potential, with R0<1. However, during an active surveillance period from 2005-2007, researchers found a 20-fold increase during the last 30 years. The purpose of this study was to analyze the contact data from 2005-07 and compare characteristics to those of the 1980s, and toassess the change in R0 of MPX. Methods: Contact tracing information and samples from active lesions were collected. Samples were screened by PCR and positive cases were ranked by generation and grouped into chains of transmission according to date of rash onset, contact tracing, and location. R0 was determined using calculations provided in the 1980s study and chain size distribution was compared. Results: Of 1407 suspected cases of MPX investigated in 2005-07, 287 provided contact information with an average of 6.22 (range, 1-20) contacts each. Among the 703 positive cases, 408 distinct chains of transmission were identified. Average chain size was 1.75 cases (range, 1-12), with the longest reaching six generations. The crude secondary attack rate (AR) was 0.092, with an effective R0 of 0.576. Discussion: Contact characteristics and types of contacts differed from those of the 1980s program. This analysis found a higher crude secondary attack rate and effective R0. This could be the result of a higher proportion of unvaccinated contacts, or that the virus is better able to transmit between humans with a more limited amount of contact.

Background: The uptake of evidence-based secondary preventative therapy among patients with myocardial infarction (MI) patients is low in northern Tanzania, and short-term mortality is high. The aim of this study was to describe current patterns of inpatient and discharge care among hospitalized patients with MI to identify opportunities for improvement.

Methods: Adult patients (18 years old) participants with acute MI were consecutively enrolled in the emergency department of a tertiary care hospital in Moshi, Tanzania, from February 2022 through January 2023. A standardized questionnaire collecing demographic and health data was administered to participants at enrollment. During hospitalization, research assistants administered a standardized questionnaire to participants on a daily basis to collect information about symptom progression and counselling received. Information about inpatient testing and treatment were obtained directly from electronic medical records. At time of discharge, a discharge survey was administered to participants to collect information about discharge counseling and post-discharge plans for appointments and medications. Discharge prescriptions were collected directly from the medical record. Thirty days after enrollment, a follow-up survey was administered via telephone to participants to assess symptom status, medication use, and appointment attendance.

Results: Of the 73 participants with MI, 21 (29%) died during their initial hospitalization. During the hospital stay: 39 (53%) participants received aspirin, 29 (40%) received clopidogrel, 28 (38%) received dual antiplatelet therapy, 25 (34%) received a beta-blocker, and 36 (49%) received a statin. Fourty-three (59%) participants reported being informed of their diagnosis during their hospitalization, and 21 (29%) reported receiving dietary counselling. Of 9 participants who reported ongoing tobacco use, 2 (22%) reported receiving smoking cessation counseling. Of the 52 participants who survived to hospital discharge, 36 (69%) were given a follow-up appointment, 18 (35%) were prescribed aspirin, 23 (44%) were prescribed clopidogrel, 14 (27%) were prescribed dual antiplatelet therapy, 15 (29%) were prescribed a beta-blocker, and 21 (40%) were prescribed a statin. Four (5%) participants died between discharge and follow-up, resulting in an overall thirty-day mortality rate of 34%. Of the 48 participants surviving to 30 days, 14 (29%) were rehospitalized, 35 (73%) reported ongoing chest pain or dyspnea, 2 (4%) reported taking aspirin, and 4 (8%) reported taking clopidogrel.

Conclusions: There are multiple opportunities to improve uptake of evidence-based MI care during the inpatient and discharge phases of care. Further study is needed to address barriers to enhance the quality of MI care and reduce MI-associated mortality.

Background: South African adolescents living with HIV (ALWH) experience elevated risk for poor HIV-related outcomes due to challenges associated with HIV disease management. While previous research suggests that social support may mitigate poor HIV-related outcomes, we know little about the specific types of family social support that help ALWH achieve better health outcomes or how this support might be better facilitated. This study aimed to address this gap by characterizing the types of social support provided by family members to assist ALWH in their HIV care management.Methods: We conducted fifty-nine in-depth, semi-structured interviews with ALWH (n=20), their caregivers (n=19), and community stakeholders (n=20) in Cape Town, South Africa. Using deductive and then inductive thematic methods, we triangulated data from these three groups in NVivo to qualitatively analyze family social support. Results: We identified four types of family social support: instrumental support, appraisal support, emotional support, and informational support. Families provided crucial instrumental support through treatment reminders and attending clinic appointments with ALWH. Families also acted as strong sources of appraisal support to help ALWH reflect upon the importance of medication adherence by promoting future orientation and HIV normalization. Similarly, families facilitated adherence through emotional support, such as motivating ALWH and demonstrating interest in their health. Lastly, families offered informational assistance to educate adolescents about managing HIV treatment challenges, such as side effects. Conclusion: In characterizing family social support, our findings highlight sources of struggle and possible solutions to the challenges that ALWH face in their HIV care. Our results suggest that ALWH and providers rely heavily on families to distribute these four types of support in HIV care, emphasizing the importance of exploring how to better facilitate and replicate this support. Understanding these types of social support is a crucial step to identifying potential gaps in care and possible intervention strategies. As such, future research should inquire about the efficacy of incorporating these types of social support into interventions to assist ALWH in their HIV care management.

Background: The prevalence of childhood obesity in the US is high; this includes young children living in low-income households. Many of these children are served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Digital interventions that target caregivers enrolled in WIC show potential for childhood obesity prevention. This study aims to describe 1) the formative research for developing a pilot digital intervention focused on improving diet quality and increasing redemption of WIC-approved foods, and 2) the challenges faced in developing the intervention due to the COVID-19 pandemic. Methods: In-depth interviews were conducted with 13 WIC caregivers. Interviews were recorded and transcribed. Transcripts were coded using structural themes, and analyzed using NVivo 12. A data reduction table was created afterwards and inter-coder reliability was achieved. Results: Fourteen themes clustered into four domains. The first domain centered on how caregivers perceived healthy eating. Definitions for healthy and unhealthy eating depended on the source of nutrition information and contributed to practices of healthy eating. The second domain described the caregiver’s purchasing of WIC-approved foods. Fruits, vegetables, milk, cheese, and eggs were the most purchased foods, while yogurt and peanut butter were the least purchased foods. The biggest facilitator to purchasing WIC-approved foods was taste preferences, and the biggest barrier was picky eating. The third domain described WIC’s helpfulness in healthy eating promotion; caregivers believed in the latter and provided suggestions for WIC to help them further. The last domain described the text messaging preferences. It showed that WIC caregivers believed that a text messaging program would help them eat healthier. They preferred receiving text messages weekly, in the morning, and receiving recipes and tips. The COVID-19 pandemic affected implementation of the intervention through disrupting contact with stakeholders, the recruitment process, and the completion of surveys used for intervention feasibility analysis. Conclusions: Future studies should consider utilizing and documenting formative research to guide intervention development. Comprehensive protocols for contacting stakeholders, recruitment, and follow up are important proactive tools during implementation.

Background: Autism Spectrum Disorder (ASD) is a major global health challenge as the majority of individuals with ASD live in low- and middle-income countries (LMICs) and receive little to no services or support from health or social care systems. Despite this global crisis, the development and validation of ASD interventions has almost exclusively occurred in high-income countries, leaving many unanswered questions regarding what contextual factors would need to be considered to ensure the effectiveness of interventions in LMICs. This study sought to conduct explorative research on the contextual adaptation of a caregiver-mediated early ASD intervention for use in a low-resource setting in South Africa.

Methods: Participants included 22 caregivers of children with autism, including mothers (n=16), fathers (n=4), and grandmothers (n=2). Four focus groups discussions were conducted in Cape Town, South Africa with caregivers and lasted between 1.5-3.5 hours in length. Data was recorded, translated, and transcribed by research personnel. Data was then coded for emerging themes and analyzed using the NVivo qualitative data analysis software package.

Results: Nine contextual factors were reported to be important for the adaptation process including culture, language, location of treatment, cost of treatment, type of service provider, familial needs, length of treatment, support, and parenting practices. One contextual factor, evidence-based treatment, was reported to be both important and not important for adaptation by caregivers. The contextual factor of stigma was identified as an emerging theme and a specifically relevant challenge when developing an ASD intervention for use in a South African context.

Conclusions: Eleven contextual factors were discussed in detail by caregivers and examples were given regarding the challenges, sources, and preferences related to the contextual adaptation of a parent-mediated early ASD intervention in South Africa. Caregivers reported a preference for an affordable, in-home, individualized early ASD intervention, where they have an active voice in shaping treatment goals. Distrust of community-based nurses and health workers to deliver an early ASD intervention and challenges associated with ASD-based stigma were two unanticipated findings from this data set. Implications for practice and further research are discussed.

In sub-Saharan Africa, women are burdened with gendered tasks of cooking and fuel gathering, leading to time poverty, gender inequality, unhappiness, physical health issues due to unclean cooking methods, and broader social implications including employment limitations and adverse effects on household food security. This scenario underscores an urgent need to scrutinize and reveal the existing patterns of time use, especially for women. By applying pairwise correlation and ordinary least squares regression analyses, this study assesses the consistency across three distinct time use methods and delves into potential causes for any observed discrepancies especially for time use on fuel preparation and acquisition, as well as cooking. Data sourced from primary cooks across four Sub-Saharan African countries indicate that: (a) there is significant difference in time use that is recorded across time use methods; and (b) individual and household characteristics, and specific behaviours related to cooking and fuel activities, partially account for the observed time gaps in both cooking activities and fuel preparation and collection. This research contributes to the field by: 1) highlighting the challenges in achieving consistent time measurements, underscoring the variations that different methods can produce; and 2) providing insights on the influence of individual and household factors, as well as cooking and fuel-related behaviours, on the perception and reporting of time use. These findings suggest directions for developing more reliable and valid methods for time use research, especially for interventions aimed at reducing the burden of uncompensated work on women in sub-Saharan Africa.

Background: Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a common sleep disorder that affects millions of adults worldwide, with higher prevalence reported in Asia compared to Western countries. If left untreated, OSAHS can lead to serious health complications such as high blood pressure, heart disease, stroke, and diabetes. While polysomnography (PSG) is considered the gold standard of sleep testing, it may not be suitable for all OSAHS patients due to its cost and invasiveness. In recent years, the development of mobile applications has provided a convenient and accessible tool for screening and diagnosis of OSAHS. This study aimed to evaluate the efficacy of the Dr. Being app, a snoring analysis software for smartphones, in screening Chinese adults for OSAHS. The findings of this study will provide insights into the potential of mobile health technologies in improving the detection and management of OSAHS in China.Methods: In this prospective study conducted between December 2021 to December 2022, 50 patients were recruited from the sleep center of Shanghai Sixth People's Hospital. The study participants had a mean age of 49.7±17.4 years, with a male predominance of 70%, and a mean body mass index of 28.2±5.0 kg/m². Each participant underwent monitoring throughout the night using both the Dr. Being app and polysomnography (PSG). The Dr. Being app's automatic analysis generated relevant indicators, which were then compared with the results obtained from PSG interpreted by sleep professionals according to recommended guidelines. The study aimed to evaluate the concordance between the apnea-hypopnea index (AHI) obtained by the Dr. Being app and PSG results. Furthermore, the researchers assessed the sensitivity and specificity of the Dr. Being app in diagnosing OSAHS, which could provide valuable insights into the effectiveness of smartphone apps in sleep testing. Results: This study's findings suggest that there were significant differences between the total sleep time (TST) and apnea-hypopnea index (AHI) measured by the Dr. Being app and PSG. Specifically, the TST measured by the Dr. Being app was found to be significantly higher than PSG, while PSG had a slightly higher AHI measurement than the Dr. Being app. Despite these differences, the Bland-Altman consistency test showed that the AHI measurements obtained from both methods were statistically consistent, indicating that the Dr. Being app can provide accurate measurements of AHI, which is a crucial indicator of OSAHS severity. Furthermore, the study assessed the sensitivity and specificity of the Dr. Being app in diagnosing OSAHS at different AHI thresholds. The results indicated that the app had high sensitivity and specificity for OSAHS diagnosis at an AHI threshold of 5/h and moderate sensitivity and specificity at an AHI threshold of 15/h. However, the sensitivity decreased while the specificity increased as the AHI threshold increased to 30/h. Overall, these findings suggest that the Dr. Being app could be a valuable tool for OSAHS screening and diagnosis, particularly in resource-limited areas. Conclusion: These findings highlight the usefulness of the Dr. Being app in the screening and diagnosis of OSAHS, particularly in resource-limited areas where access to PSG may be limited. The app's high sensitivity in detecting early OSAHS index indicates its potential as a valuable tool for both clinicians and patients. With its ability to provide accurate measurements of mild AHI, the Dr. Being app could aid in the early detection of this condition. Overall, the Dr. Being app could serve as a valuable supplement to traditional sleep testing methods, potentially improving the accessibility and affordability of OSAHS diagnosis and management.

Background: Healthcare systems such as that of Rwanda face barriers in terms of infrastructural, financial, human, and technical resources. The value-based care framework offers an approach to examining health delivery systems facing resource-constraints and to highlight areas for greater progression towards maximizing impact on health outcomes given resource limitations. Methods: A qualitative approach was used to explore One Family Health’s care delivery model and its challenges and successes using value-based care as an underlying analytic framework. Primary data in the form of 8 qualitative semi-structured interviews were combined with secondary data from 14 previously conducted semi-structured interviews. Thematic analysis was applied to analyze the data. Results: Successes indicate OFH contribution to expanding access to care in Rwanda and challenges of the OFH health post model point to financing model and its relation to Rwanda’s recent financing changes. Quality of service delivery at the OFH health post approximately indicate strengths in patient-centeredness and equity and weaknesses in safety and efficiency. An anecdotal exploration of health outcomes suggest that individual patients improve as a result of visiting the health post and that the health post contributes to community wellbeing particularly in terms of health education and reducing the burden on health centers. Barring a small and biased sample, OFH nurses seem to be satisfied with the health post model, though their experience could be improved with routine training and increased supervision. Insights in integration and alignment in the context of the public-private partnership were also discussed. Conclusions: The One Family Health qualitative case study utilizing the value-based care framework offers several lessons for One Family Health, Rwanda Ministry of Health as it continues to contract with private sector entrepreneurs, and for further research that involves the application of the value-based care framework. These lessons include aligning its financial model with the aims of government financing initiatives, providing infrastructural and financial supports, and routine monitoring of health outcomes centered on patients as well as provider satisfaction and support.

Background: Harsh parenting behaviors are some of the most commonly used discipline practices parents use in the United States but are often difficult to measure. Self-report instruments are the most used method of assessing parenting behaviors, but likely result in response biases due to their methodological shortcomings. This study aimed to provide a viable alternative to traditional self-report surveys used to evaluate parenting practices with lower social desirability and lower literacy requirements. Our primary objectives were to adapt the Harsh Discipline Preference Discrete Choice Experiment (HDP-DCE), a picture-based measure originally developed for Liberia, for use with an American population, and evaluate its psychometric evidence of reliability and validity. Methods: We first adapted items through an iterative process of collecting feedback from 97 parents and 10 experts through focus groups and surveys to generate clear and acceptable images to elicit preferences for discipline strategies. We then administered the measure to 439 parents to explore the internal structure of the measure and evaluate multiple indicators of reliability and validity. Results: An exploratory factor analysis resulted in three potential factor-solutions, with the three-factor solution explaining the most variance and being the most theoretically sound. Analyses also demonstrated that the HDP-DCE has excellent internal consistency, good test-retest reliability, as well as good convergent and discriminant validity. Given these results the HDP-DCE could be a useful alternative or complement to traditional self-report tools in research and clinical work.

Background: The Cataldo Cancer Stigma Scale (CASS) was developed to measure patient experienced and perceived stigma and was further modified for use in the pediatric patient population. This study aimed to adapt and translate a Swahili version of the CASS for use in the Tanzanian pediatric patient population to measure cancer stigma and identify the types of stigma pediatric cancer patients face. Methods: Approximately 40 items were extracted from two prior developmental and validation studies of the CASS that assessed stigma in adult patients and non-patient cohorts. The survey items, developed initially in English, underwent translation into Swahili, back-translated, reconciled, and screened for duplications. The translated items were refined using concurrent cognitive interviewing. Results: After three rounds of cognitive interviews with 15 respondents, comprehension of the survey questions was assessed and improved with all items reaching at least 80% comprehension. Additional reviews included grammar and specific Swahili word selection changes to clarify the question’s meaning. Duplications or repetition of sentences were also considered to remove questions from the survey. The final survey comprised 25 survey items with 7 stigma sub-categories. Conclusions: This study sheds light on the complex nature of cancer-related stigma in pediatric patients. For future purposes, research is needed to validate the CASS survey with a larger sample of the population, including a comparison stigma assessment to establish validity.

Background

Melioidosis is a neglected tropical disease that is highly prevalent in Southeast Asia. Misdiagnoses are common as the presenting symptoms are similar to other diseases including upper respiratory infections. When not treated with antibiotics, the disease can lead to severe morbidity or death. Current diagnostics in low- and middle-income countries are often not sensitive nor rapid. Point-of-care rapid diagnostic tests (POC-RDTs) are a potential solution. Few studies have compared the accuracy of POC-RDTs and molecular assays against blood culture. The goal of this study was to conduct such comparisons in detecting Burkholderia pseudomallei infections among infection-suspected patients in Kapit, Sarawak, Malaysia.

Methods

We used an informed consent process as approved by two institutional review boards. In this cross-sectional study, we engaged patients meeting a melioidosis-like case definition that included classical symptoms such as prolonged fever with joint pain and/or abscess. We studied the patients routinely collected clinical specimens with a POC-RDT (Active Melioidosis DetectTM) and a molecular assay compared with the B. pseudomallei bacterial culture for isolation of the bacterial organism.

Results

One hundred patients aged 6 months - 79 years from Kapit Hospital were enrolled in the study from June 12, 2018 to January 8, 2019. Of the 100 sera, 97 urine, and 16 bodily fluid samples (total n= 213) tested with the RDT, 23 samples gave positive results (7 sera, 15 urine, and 1 bodily fluids). Compared to the molecular assay, the POC-RDT had a sensitivity of 40% (95% CI, 5%- 85%), specificity of 94% (95% CI, 87% - 98%), and an accuracy of 90% (95 CI, 82% - 95%) for sera; and a sensitivity of 80% (95% CI, 28%- 99%),a specificity of 65% (95% CI, 55% - 75%), and an accuracy of 87% (95 CI, 77% - 94%) for urine; and a sensitivity of 80% (95% CI, 28%- 99%), a specificity of 65% (95% CI, 55% - 75%), and an accuracy of 81% (95 CI, 54% - 96%) for other bodily fluids. Additionally, when compared to the bacterial culture results, the POC-RDT showed a sensitivity of 38% (95% CI, 9%- 76%), specificity of 95% (95% CI, 88% - 99%), and an accuracy of 90% (95 CI, 82% - 95%) for sera; a sensitivity of 88% (95% CI, 47%- 100%), a specificity of 88% (95% CI, 77% - 95%), and an accuracy of 94% (95 CI, 84% - 98%) for urine; and a sensitivity of 25% (95% CI, 1%- 81%), a specificity of 100% (95% CI, 74% - 100%), and an accuracy of 81% (95 CI, 54% - 96%) for other bodily fluids.

Conclusion

While study enrollment will continue, data from the first 100 participants, suggests the POC-RDT had poor sensitivity, good accuracy, and high specificity in detecting B. pseudomallei infection. Thus far, the POC-RDT assay seems to work better on urine specimens. Due to low sensitivity, the study data do not support recommending POC-RDT strips as a single diagnostic method. However, as the POC-RDT had high specificity when the test is positive it seems appropriate for clinicians to assume the patient is infected and to prescribe specific antimicrobial therapy. While more participant data are needed, it seems likely that the POC-RDT could be useful in helping physicians to begin treatment early with the high specificity that the POC-RDT has exhibited. If paired with an RDT with high sensitivity, this POC-RDT would add a great value to infection management.