Browsing by Subject "Health sciences"

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.

This was a mixed-methods study aimed to comprehensively assess factors associated with mosquito control in Belmopan, Belize, in order to better inform stakeholders on the effectiveness of their efforts. A knowledge, attitudes, and perceptions (KAP) survey was employed within the four target communities of San Martin, Salvapan, Maya Mopan, and Las Flores. Additional epidemiological and entomological data was provided by relevant stakeholders. A total of 228 households were surveyed among the four target communities. Only 1/3 of respondents were able to demonstrate proficient knowledge. Knowledge was attained mostly through TV, Ministry of Health, hospital, and radio sources. Over 90% of respondents believed that mosquitos and the diseases they carry were a real issue for the community. Respondents living in Salvapan and Las Flores were more likely to have contracted Dengue Fever, Malaria, Chikungunya, or Zika than in other areas. Fan usage and regularly cleaning the yard were the two most employed practices for preventing mosquito bites and breeding. Approximately 85% of those surveyed viewed insecticide spraying to be effective. This assessment provides valuable insight into the needs of at- risk communities in regards to vector control. An increased focus on community outreach, education, and behavioral change can greatly impact the effectiveness of current vector control efforts. Stakeholders must work together and pool resources in order to effectively employ control interventions. Continued evaluation and community involvement is necessary to control mosquitos and prevent disease outbreaks.

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.

Behavioral symptoms of dementia cause considerable distress for persons with dementia and their caregivers and are related to adverse outcomes that have significant social and economic impact. Thus, behavioral symptoms represent one of the most challenging aspects of dementia care. Over the past three decades, research on behavioral symptoms of dementia has laid the foundation for development of non-pharmacological interventions by identifying underlying mechanisms of symptom development. However, the research has largely overlooked how the needs of military veterans may influence development and treatment of behavioral symptoms of dementia, including those needs associated with co-occurring dementia and posttraumatic stress disorder (PTSD). This dissertation aimed to develop knowledge related to behavioral symptoms of dementia among older veterans with and without PTSD by synthesizing current understanding of neurocognitive and psychiatric comorbidities of PTSD among veterans as well as explicating relationships among background factors, proximal factors, and behavioral symptoms of dementia among veterans living in residential care using the need-driven, dementia-compromised behavior (NDB) model.

This dissertation includes a systematic review in Chapter 2 that synthesized the patterns of neurocognitive and psychiatric comorbidities of PTSD in older veterans and revealed a substantial gap in the literature with regards to understanding manifestations and treatment of behavioral symptoms of dementia among older veterans with co-occurring dementia and PTSD. The primary study of this dissertation that encompasses Chapters 3 and 4 utilized an exploratory sequential mixed methods design using secondary data derived from the evaluation dataset of the STAR-VA training program. In Chapter 3, a qualitative study, as the first phase of the mixed methods study, analyzed text data that captured the interdisciplinary care team’s observation of behavioral symptoms of dementia and their circumstances for the subsample of 33 veterans from the STAR-VA dataset. This qualitative study described how behavioral symptoms of dementia are manifested among veterans with and without PTSD in the context of personal, interpersonal/social, and environmental factors that trigger the symptoms. Findings demonstrated that behavioral symptoms of dementia are heterogeneous, with distinct clusters of triggers that are multi-level, thereby warranting an interdisciplinary, multi-level approach to developing person-centered interventions. In addition, findings from this qualitative study informed the development of the second phase of the sequential mixed methods study in Chapter 4 that aimed to test hypothesized pathways between background factors, interpersonal triggers (proximal factors), and behavioral symptoms of rejection of care and aggression and to explore the moderating effect of PTSD on the hypothesized pathways. The mixed methods approach integrated quantitative data measured by standardized scales and text data for 315 veterans derived from the STAR-VA dataset. After converting text data into categorical variables, structural equation modeling (SEM) was performed to compare the patterns of relationships among background factors, interpersonal triggers, and behavioral symptoms of rejection of care and aggression between veterans with and without PTSD. The direct effect of interpersonal triggers and the indirect effect of background factors through interpersonal triggers on rejection of care and aggression emphasizes the importance of developing and implementing psychosocial interventions that improve interpersonal relationships. The multi-group SEM revealed that the full model was not moderated by PTSD. However, the differential direct and indirect effect of background factors and interpersonal triggers as a proximal factor on the behavioral outcomes between veterans with and without PTSD suggest potential different mechanisms of behavioral outcomes between veterans depending upon whether or not PTSD is present. Evidence for the PTSD-moderated mediating effect of interpersonal triggers on the relationship between depression and rejection of care was demonstrated, suggesting the need to develop targeted interventions for veterans with dementia and PTSD who have greater depressive symptoms.

The new knowledge generated from this dissertation helps to clarify complex patterns of associations among background factors such as PTSD and proximal factors and behavioral symptoms of dementia consistent with the NDB model, strengthening the foundation for development of novel approaches to designing and implementing person-centered care for veterans with co-occurring dementia and PTSD.

Effective patient care transitions require consideration of the patient’s social and clinical contexts, yet how these factors relate to the processes in care coordination remains poorly described. This dissertation aimed to describe provider networks and clinical care and social contexts involved during longitudinal care transitions across settings. The overall purpose of this dissertation is to uncover the longitudinal patterns of utilization and relational processes needed for effective care coordination in transitional care, so we can redesign interventions that focus on informational and relationship networks to improve interaction patterns and system performance for people living with heart failure (HF) as they undergo transitions across settings and over time. This dissertation was a retrospective exploratory study. Chapter 2 is an integrative review examining coordination processes in transitional care interventions for older adults with HF by integrating a social network analysis framework. We subsequently selected a cohort of patients aged 18 years or older (n = 1269) with an initial hospitalization for HF at Duke University Health System between January 1, 2016 and December 31, 2018 based on encounter, sociodemographic, and clinical data extracted from electronic health records (EHR). In Chapter 3, a latent growth trajectory analysis was used to identify distinct subgroups of patients based on the frequency of outpatient, as well as emergency department (ED) and inpatient encounters 1 year before and 1 year after the index hospitalization; multinomial logistic regression was then used to evaluate how outpatient utilization was related to acute care utilization. Based on findings (described in Chapter 3), we purposively sampled 11 patients from the Chapter 3 cohort for a second empirical study (described in Chapter 4) with a mixed-methods sequential explanatory design. These 11 patients had a full spectrum of experience in socioeconomic disadvantages based on three strata (race, insurance, and Area Deprivation Index), but they had similar levels of comorbidity and average severity of illness and displayed the same change in the severity of illness during the study period. We used quantitative and qualitative data available from clinical notes in the EHR, and integrated results from quantitative and qualitative analysis to better understand the social and clinical context and social structure essential for care coordination. High variability in transitional care is likely because care coordination processes are highly relational. The relational structure of transitional care interventions varied from triadic to complex network structures. Use of a network analysis framework helped to uncover relational structures and processes underlying transitional care to inform intervention development. Chapter 3 revealed that high heterogeneity exists in patients’ utilization patterns. A small subgroup of high users utilized a substantial amount of the resources. Patients with high outpatient utilization had more than 4 times the likelihood of also having high acute care utilization, and change in the severity of illness had the highest level of significance and strongest magnitude of effect on influencing high acute care utilization. Chapter 4 demonstrated the feasibility of using clinical notes and social network analysis (SNA) to assess the provider networks for patients with HF in care transitions. People who were experiencing more socioeconomic disadvantages and social instability were less likely to have densely connected provider teams and providers who were central and influential in the system network. Lacking consistent and reciprocal relationships with outpatient provider teams, especially primary care provider and cardiology teams, was precedent to poor care management and coordination. Turbulence in care transition can result from sources other than transitioning between settings. This dissertation demonstrated the (a) importance of understanding relational processes and structure during patients’ utilization of acute and outpatient care services and (b) potential to capture structural inequalities that may influence the efficiency of care coordination and health outcomes for patients with HF.

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: Hypertension and related complications are major contributors to deaths and disabilities in Nepal. We aim to explore existing work flows, needs and challenges to hypertension care coordination and assess feasibility of establishing a FCHV-based hypertension management program in Kavre, Nepal.

Design: We conducted 23 in depth-interviews and one focus group discussion that consists of nine patients with hypertension, six health workers, four health officials, and 12 FCHVs in two village development committees of Kavre district, Nepal. Applied thematic analysis was performed using NVivo 12.

Results: Health literacy related to hypertension was low. Delay in treatment initiation and lost to follow up were common patterns despite comply with antihypertensive medication. Underutilization of primary healthcare institutions, communication gap and lack of grass-roots level educational campaigns were identified as major health system-related barriers. Community pharmacies, monthly health camps and increasing governmental attention to NCDs were favorable for hypertension management. This study also showed FCHVs have the potential to promote hypertension educational, screening and referral in their catchments, with adequate training and proper motivation.

Conclusions: Barriers and facilitators identified in this study have implications for future hypertension management intervention design. We recommend grassroot level hypertension education and screening across the Nepal. FCHVs have the potential to take on these responsibilities, once they are empowered with appropriate training and motivated by proper incentives.

Keywords: hypertension management, barriers, facilitators, community health workers, female community health volunteers, Nepal, qualitative research

Background: The COVID-19 pandemic amplified disparities experienced by children in immigrant and refugee families (CIRF). The pandemic coincided with a recognition that proactively screening and addressing social risk drivers is an efficacious population health intervention. We used the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework to set up a program to screen for social risks drivers at a Federally Qualified Health Center (FQHC). The study sought to demonstrate to what extent the proactive outreach program would a) capture at-risk persons and b) facilitate linkage of identified persons to community resources. We sought to c) quantify social needs among CIRF and d) understand whether addressing social risk drivers would lead to caregivers perceiving an improvement in their child’s health. Lastly, we sought to e) elucidate the experiences with and preferences of families in regard to screening efforts. Methods: The study was conducted at the Lincoln Community Health Center in Durham, North Carolina. Eligible participants were ages 0-5, non-English speaking, and were seen at the clinic within the last 2 years. A care coordinator reached out to the guardians of eligible children for baseline screening. Participants with social needs received referral placement and navigation support. We looked at the number of baseline questionnaires completed, linkage rates and resolution of social needs as well as perceptions of SDOH screening and perceived changes in child’s health using descriptive and univariate statistics. Results: We attempted to contact 342 guardians; to date, we did not reach 85 (24.85%) participants and 21 (6.14%) have incomplete outreach. 212 (61.99%) participants were enrolled and completed baseline screening. Most participants had at least one social need. Of the 212 individuals enrolled, the 39 who completed the intervention (100%) indicated that the calls helped them to gain a better understanding of community resources. When asked who they would be most comfortable talking with about their social needs, the majority indicated a case manager in person (34, 89.5%) or over the phone (36, 94.74%). When asked about what characteristics were important to them when considering who they might speak with about their social needs, 36 (92.1%) selected language and 22 (57.9%) indicated that cultural affiliation was important. The impact of the intervention on the perception of child’s health was unable to be quantified due to a small sample size. Conclusion: Our findings illustrate the burden of social risk drivers experienced by CIRF and demonstrate the capacity of a proactive outreach SDOH screening program to meet the needs of CIRF served by a FQHC. It is our hope that this screening tool and proactive outreach program can be used as a model to better identify and address the social needs of CIRF and to thus enhance health outcomes and population health.

Adolescent girls are a vulnerable population disproportionately affected by HIV in high-prevalence settings such as sub-Saharan Africa. Despite the development of HIV prevention products and subsequent biomedical clinical trials to examine the efficacy and safety of the products, adolescent girls largely have been excluded from the clinical trials, thus delaying their potential access to these products. To further examine the challenges and opportunities for adolescent trial participation, this qualitative study explored and compared adolescents’ (15-17 years old) and young women’s (18-21 years old) perceptions of HIV risk, their perspectives on clinical trial participation, and their understanding of research trial concepts. Multiple in-depth interviews were conducted with 10 adolescent girls (age 15-17) and 11 young women (age 18-21) who were currently sexually active in Dar es Salaam, Tanzania. With similar socio-demographic characteristics and relationship patterns, adolescent girls were less certain about their own HIV risk compared to the young women who more readily recognized their risk. Regarding trial participation, participants in both groups largely did not have logistical concerns, rather they recognized benefits from trial participation, although they had a concern about the recommended condom use. In terms of research concepts, both the adolescent girls and the young women had a hard time understanding them, particularly the concept of placebos. More broadly, the adolescent girls believed they should be included in clinical trials and that they are able to provide informed consent without parental consent. Compared to the young women, adolescent girls had lower perceived HIV risk, similar understandings of research concepts, and higher acceptability of adolescent trial participation without parent consent (although they supported parental/guardian involvement). Even though adolescent girls seem to have potential acceptability and readiness to participate in clinical trials, meaningful modification may be required for the adolescent inclusion in such trials in order to enhance understanding of research concepts, minimize preventive misconceptions and improve the informed consent process to include parental inclusion if not consent.

In this dissertation, we present four novel contributions to the field of statistics with the shared goal of personalizing medicine to individual patients. These methods are developed to directly address problems in health care through two subfields of statistics: probabilistic machine learning and causal inference. These projects include improving predictions of adverse events after surgeries, or learning the effectiveness of treatments for specific subgroups and for individuals. We begin the dissertation in Chapter 1 with a discussion of personalized medicine, the use of electronic health record (EHR) data, and a brief discussion on learning heterogeneous treatment effects. In chapter 2, we present a novel algorithm, Predictive Hierarchical Clustering (PHC), for agglomerative hierarchical clustering of current procedural terminology (CPT) codes. Our predictive hierarchical clustering aims to cluster subgroups, not individual observations, found within our data, such that the clusters discovered result in optimal performance of a classification model, specifically for predicting surgical complications. In chapter 3, we develop a hierarchical infinite latent factor model (HIFM) to appropriately account for the covariance structure across subpopulations in data. We propose a novel Hierarchical Dirichlet Process shrinkage prior on the loadings matrix that flexibly captures the underlying structure of our data across subpopulations while sharing information to improve inference and prediction. We apply this work to the problem of predicting surgical complications using electronic health record data for geriatric patients at Duke University Health System (DUHS). The last chapters of the dissertation address personalized medicine from a causal perspective, where the goal is to understand how interventions affect individuals not full populations. In chapter 4, we address heterogeneous treatment effects across subgroups, where guidance for observational comparisons within subgroups is lacking as is a connection to classic design principles for propensity score (PS) analyses. We address these shortcomings by proposing a novel propensity score method for subgroup analysis (SGA) that seeks to balance existing strategies in an automatic and efficient way. With the use of overlap weights, we prove that an over-specified propensity model including interactions between subgroups and all covariates results in exact covariate balance within subgroups. This is paired with variable selection approaches to adjust for a possibly overspecified propensity score model. Finally, chapter 5 discusses our final contribution, a longitudinal matching algorithm aiming to predict individual treatment effects of a medication change for diabetes patients. This project aims to develop a novel and generalizable causal inference framework for learning heterogeneous treatment effects from Electronic Health Records (EHR) data. The key methodological innovation is to cast the sparse and irregularly-spaced EHR time series into functional data analysis in the design stage to adjust for confounding that changes over time. We conclude the dissertation and discuss future work in Section 6, outlining many directions for continued research on these topics.

Developing nations in Asia are posed to experience a significant increase in the population of older adults living in their respective societies. Over the coming decades, India, the second most populous country in the entire world, is poised to experience a significant increase in its elder population. India's population of adults 60 years of age or older is projected to increase from 8% to 19% of the countries total population by the year 2050. Figures predict that by mid-century, 323 million people in India will be aged 60 years or older, more than the total current U.S. population. As the demographic structure of India is making a dramatic shift, concerns regarding the health and wellbeing of the growing Indian elder population are emerging, as is the growing concern for social policy. In addition, Sri Lanka is the fastest aging nation in South Asia. Multiple factors, including an increase in the number of people considered to be the "oldest old" (80+ years of age), a decrease in the number of working age adults, and increases in disability amongst the elderly, could necessitate an increased need for institutionalization of elderly Sri Lankans into long-term care facilities.

This project aims to study aging in south Asia from two different perspectives. An analysis of existing data from Southern India was done to examine the attitudes and beliefs of Indian elders towards aging and support systems for the elderly. Mental health of Indian elders was assessed and logistic regression analysis was conducted to examine possible correlations between attitudes and beliefs of the elderly and elder mental health. In addition, a qualitative descriptive study of Sri Lankan elder homes was carried out in the southern district of Galle, Sri Lanka. A convenience sampling method was used to identify six elder homes located in the area, and visits were made to each of the homes. During the visits, elder home mangers were interviewed in order to gain general information on the functioning and history of the elder homes, as well as general information on the residents living at the facilities.

Results from the Kerala Aging Survey revealed that psychological distress was present for over one third of elders in Kerala. Rates of psychological distress were higher for women, the poor, and those with advanced age. Elder women appear to be especially vulnerable to psychological distress in old age. Elders believe that children are responsible for supporting parents in their old age; lack of satisfaction with support received from children was associated with the presence of psychological distress amongst elders. For the qualitative study on Sri Lankan elders homes, it was found that both familial and community support are significant factors in the long-term care of elderly Sri Lankans. Though many elder home residents had been diagnosed with a chronic NCD or disability, lack of familial support was consistently identified as the driving force necessitating the elderly to reside at the long-term care facilities. With little or no financial assistance from the government, the facilities themselves all relied heavily on donations from the community to function on a daily basis.

Background: The Kilimanjaro region has one of the highest rates of reported alcohol use per capita in Tanzania. Alcohol-related risky behaviors pose substantial threats to the health and well-being of alcohol users and people around them. This study sought to provide a better understanding of how risky behaviors are associated with alcohol use perceptions. Methods: This mixed method study took place in the Kilimanjaro Christian Medical Center. Quantitative data on alcohol use, the alcohol use disorder identification tool, alcohol-related consequences, and qualitative data on alcohol use perception and risky behaviors were collected from a hospital- and non-hospital-based sample in Moshi, Tanzania. Latent class analysis was applied to examine alcohol-related risky behaviors. Results: Three classes of risky behavior patterns were identified: “no risky behavior”, “moderate risky behaviors” and “high risky behaviors”. Membership of classes 3 was associated with the most alcohol use quantity and frequency. No association between classes and alcohol-stigma was found. Our qualitative results explored alcohol perceptions and risky behaviors and illustrated their possible associations. Conclusions: Although alcohol stigma may not associate the number of risky behaviors directly, our qualitative result helped us to understand how stigma associates with risky behaviors. This study may serve as a reference for designing and adjusting interventions for alcohol-related injury patients' needs; we can improve interventions by using our knowledge about misconception and stigma and the identified risky behaviors classes as a form of classification system.

Neurosurgical and neurological conditions account for a significant disease burden worldwide, with low- and middle-income countries bearing more than 90% of the burden. Uganda is a low-income nation with a high demand for neuro care services but limited access, especially in rural and remote areas. Mobile health clinics, which have proven to be effective in other specialties, could be adapted to provide neurological care in such regions. The objective of this research was to establish the feasibility, appropriateness, and usability of mobile neuro clinics for providing neurological care to people in Uganda's rural and remote communities. Participants who met the inclusion criteria were invited to participate in an education session. Following the education session, the participants participated in an interview session to evaluate the feasibility, appropriateness, and usability of mobile neuro clinics. The education and interview tools were developed using the Consolidated Framework for Implementation Research (CFIR). To weight provider views, a sentiment weighted scale was used, with total aggregate sentiment scores greater than 42 in each CFIR domain indicating high feasibility, acceptability, and usability. All the assessed CFIR domains scored above sentiment score of 49. The implementation process domain (167) received the best overall sentiment score, followed by the implementation climate structure (141), inner setting domain (102), innovation domain (59), and outer setting domain (55). According to the findings of the research, mobile neuro clinics are feasible, appropriate, and usable in Uganda. To achieve the best results, however, careful planning and integration involving stakeholders from conceptualization to execution are required.

Background: Teacher wellbeing is important because it impacts teachers’ ability to complete their work and also impacts student wellbeing. While published literature on teacher wellbeing has increased since the early 2000’s, a disproportionate amount of that work has been conducted in North America and Europe which has limited the generalizability of what is currently understand about teacher wellbeing. Additionally, contextual factors, such as gender, are thought to be potentially influential factors on teacher wellbeing but have yet to be extensively researched. This study aims to assess the relationship between gender and teacher wellbeing in Battambang, Cambodia and Bungoma, Kenya. Methods: Fifty-five teachers from Cambodia and Kenya, including both men and women, contributed to in-depth interviews. Thematic analysis was conducted on interview transcripts to assess gendered relationships and differential treatment, wellbeing facilitators, and participants’ responsibilities in addition to teaching. Additionally, demographic data was collected through surveys. Results: The thematic analysis revealed subtle differences in perceptions of treatment and relationships between participants who identified as men versus women, potential wellbeing facilitators for men and women, and insight into non-school roles and responsibilities for men and women teachers. Conclusions: Based on the nuances between men and women participants’ responses, findings from this study indicate that there may be an important relationship between gender and teacher wellbeing that is worth further researching. This study points to the need to further research in a few key areas including: (1) how do (if at all) gendered relationships and differential treatment make teachers feel/impact teacher wellbeing, and (2) how do (if at all) outside responsibilities in addition to teaching impact teacher stress, fatigue, burnout, and general wellbeing. Lastly, given that there were some differences in activities and opportunities that facilitate teacher wellbeing between men and women participants, this formative research can inform gender-specific interventions addressing teacher wellbeing in Cambodia and Kenya.

Purpose: GRID therapy (Spatially Fractionated RT) has the potential to amplify systemic anti-tumor immune effect. The optimal GRID design, radiation dosage and combination with immunotherapies are not well understood. In this work, we characterized two novel, high-resolution GRIDs of smaller width and spacing had been was previously employed at Duke University. By combining these GRIDs with anti-PD-1 immune checkpoint blockade, we investigated the efficacy of this combination therapy in a preclinical mouse model. This work has two main aims. First, to observe any anti-tumor response from GRID therapy that arises from sparing T cell lymphocytes in the valleys adjacent to high peak doses of radiation facilitating tumor antigen presentation. Second, to investigate the robustness and replicability of a previously published influential work (Markovsky et al., 2019) which demonstrated that hemi-irradiation can produce similar levels of tumor control as conventional radiation therapy [1]. This is one of the first studies we are aware of that combines mini-GRID treatment with immunotherapies. Methods: Prior to in vivo studies, two novel, high-resolution in-house mini-GRIDs were characterized using the Small Animal Radiation Research Platform (SARRP). To perform this characterization, the SARRP (225 kV,13 mAs) irradiated EBT3 film. Using the Epson 11000XL scanner, EBT3 films were scanned prior to and post irradiation. Median filters were applied to avoid artificially suppressing peak and valley dose distributions. A calibration curve was generated using irradiations of a known dosage to determine what dose was delivered to the high and low-dose regions of the GRIDs. From this, peak-to-valley dose ratios as well as output factors were be calculated. Then, two pilot studies were performed using SARRP to deliver RT to C57BL/6J mice with subcutaneous LLC1 (Lewis Lung Carcinoma) flank tumors. The first study tested the therapeutic efficacy of single dose radiation while the second investigated fractionated radiation utilizing the newer, high-resolution GRIDs. In the first study, mice were randomized to four groups: 15 Gy to an open 20 mm x 20 mm field (n=5), 15 Gy to a GRID with 1mm width and spacing (n=5), and 24 Gy to a GRID with 1mm width and spacing (n=5). For the second study, mice were randomized to four groups: an open 20 mm x 20 mm field (n=6), the same field irradiating only half the tumor (n=6) (following Markovsky et al., 2019), a GRID with 1 mm width and spacing (n=6) and a GRID with 254 µm width and spacing (n=7). For both in vivo studies, all mice in this study were treated with 200 μg of anti-PD-1 antibody prior to 15 Gy of RT (single AP field) on days 0, 3, and 6. Anti-PD-1 was then administered weekly until mice reached humane endpoint (>15 mm in any dimension or ulceration). Tumor growth was measured thrice weekly using digital calipers. Results: • Film Characterizations: The peak to valley dose ratios for the 254 µm and 152 µm GRIDS were 19.8 ± 0.7 and 9.37 ± 0.33 respectively. The output factors for these GRIDs were 0.62 ± 0.09 and 0.59 ± 0.03. • First in vivo Study: Tumor quadrupling times (days, ± SD) were: 8.94 ± 1.17 (open field, 15 Gy), 7.75 ± 0.91 (1mm GRID, 15 Gy) and 7.98 ± 1.08 (1mm GRID, 24 Gy). Mean survival times (days, ± SD) were: 16.00 ± 0.00 (open field, 15 Gy), 12.8 ± 1.09 (1mm GRID, 15 Gy and 24 Gy). None of these differences were statistically significant. The width of the valleys for the 254 µm GRID is 544 ± 33.94 µm and for the 152 µm GRID is 548 µm ± 31.57. Assuming a clinically that 100 cells with a diameter of 5µm represent a clinically relevant sample for irradiation, this is a sufficient area for irradiation. • Second in vivo Study: Tumor quadrupling times (days, ± SD) were: 12.8 ± 2.6 (open field), 8.4 ± 2.8 (hemi-irradiation), 9.7 ± 2.4 (1mm GRID), and 6.4 ± 4.4 (0.25 mm GRID). Mean survival times (days, ± SD) were: 14.2 ± 2.1 (open field), 12.2 ± 1.0 (hemi-irradiation), 11.3 ± 1.6 (1mm GRID), and 10.4 ± 2.2 (254 µm GRID). Compared to the open field, time to tumor quadrupling was lower in all groups, significantly so in the hemi-irradiated and 0.25 mm GRID groups (p<0.05). Both the hemi-irradiated and GRID groups showed significantly shorter mean survival times compared to conventional open-field treatment (p<0.05 for 1 mm GRID, p<0.01 for hemi-irradiation and 0.25 mm GRID). Conclusion: Two novel mini-GRIDs were successfully characterized using the SARRP for preclinical work, and sufficiently kept valley doses below 1.5 Gy for infiltrative T cell function [2] with peak doses greater than 15 Gy, thereby enabling tumor antigen presentation. However, neither single dose nor fractionated GRID therapy with anti-PD-1 improved tumor growth delay or survival in a preclinical LLC flank model. In contrast to published data with this model, hemi-irradiation worsened tumor control compared to conventional treatment. Our work, therefore, does support the conclusion drawn in the Markovsky paper that hem-irradiation provides comparable tumor control using hemi-irradiation to conventional treatment [1]. The development of new technologies such as FLASH radiotherapy may present new opportunities for future studies utilizing GRID therapy.

Background: Understanding the multifactorial causes of anemia on a population level is important for creating effective interventions that mitigate poor health outcomes associated with anemia, particularly in regions where these rates are highly elevated. This study aims to quantify the relative prevalence of iron deficiency anemia, anemia of inflammation, and micronutrient deficiency anemia within 2 – 11 year olds in Madre de Dios (MDD), Peru, where anemia rates are estimated to be between 40 and 50%. It further aims to assess varying risk factors for given etiologies by community type, particularly as many communities in this region experience varied exposure to gold-mining related methylmercury. Methods: Eight communities along the Madre de Dios River, within the Peruvian Amazon, were selected in order to screen 2 – 11 year olds for anemia. Those qualifying as anemic were invited to provide venous blood samples for iron level, inflammation, and nutrition biomarker analyses in order to differentiate between these anemia etiologies. Health history and household characteristics were gathered in survey format, and analyzed in relation to gathered biomarkers. Results: Overall anemia prevalence (18.5%) was significantly decreased from previous studies. 14.9% were iron deficient, 12.8% showed signs of inflammation, and 12.8% were Vitamin B12 deficient. Anemia prevalence varied significantly by sex. Risk factors for anemia did not vary significantly by community type, other than increased annual income in urban and mining communities, and a reduced likelihood for having been born prematurely within mining communities. Conclusions: Peru’s multi-sectoral approach to reducing anemia has shown promising results in MDD. Health determinant variations have proven largely insignificant for anemia outcomes within the screened communities.

The prevalence of hyperlipidemia, along with other non-communicable diseases, is on the rise in low- and middle-income countries. Given the resource-limited setting, a myriad of diagnostic challenges exist with traditional laboratory-based lipid tests, including mobility, timeliness, and laboratory infrastructure. Novel technology in the form of "point of care" devices seeks to overcome such barriers by providing immediate results without dependency on significant laboratory infrastructure. CardioChek PA (Polymer Technology Systems, Inc., Indianapolis, United States) is a point of care lipid measuring device and is readily available in Kenya. However, it has not been validated in this setting. In this study, I assess the accuracy of CardioChek PA with respect to standard laboratory-based testing, which is currently the gold standard.

In Webuye, Kenya, two blood samples were collected from 246 subjects to simultaneously measure the lipid levels via both CardioChek PA and the gold standard. All subjects were adults, and geographic stratified sampling methods were applied. Statistical analysis of the novel device's accuracy was based on percent bias, which is the standardized approach established by the National Cholesterol Education Program (NCEP) of the National Institute of Health (NIH). The NCEP suggests that percent bias be ≤±3% for low-density lipoprotein (LDL) cholesterol, ≤±5% for high-density lipoprotein (HDL) cholesterol, ≤±5% for total cholesterol (TC), and ≤±4% for triglycerides (TG). Misclassification rates and absolute percent bias were also analyzed.

This study found the CardioChek PA analyzer to be substantially inaccurate for LDL cholesterol (-25.9% bias), HDL cholesterol (-8.2% bias), and TC (-15.9% bias). For TG, the CardioChek PA performed well with a percent bias of 0.03%. However, the TG absolute percent bias (27.7%) and proportion of patients outside of the NCEP range (85%) reflected substantial inaccuracy of measurements. Moreover, those patients at higher risk of complications from hyperlipidemia were most likely to be misclassified into a lower risk category. Thus, we conclude that CardioChek PA is inaccurate and not suitable for our clinical setting. Furthermore, the findings highlight the need to validate new diagnostic tools in the appropriate setting prior to scale up regardless of its potential for novel utility.

Aims: Measurement of glycated hemoglobin (HbA1c) is an important indicator of glucose control over time. Point-of-care (POC) devices allow for rapid and convenient measurement of HbA1c, greatly facilitating diabetes care. We assessed two POC analyzers in the Peruvian Amazon where laboratory-based HbA1c testing is not available.

Methods: Venous blood samples were collected from 203 individuals from six different Amazonian communities with a wide range of HbA1c, 4.4-9.0% (25-75 mmol/mol). The results of the Afinion AS100 and the DCA Vantage POC analyzers were compared to a central laboratory using the Premier Hb9210 high-performance liquid chromatography (HPLC) method. Imprecision was assessed by performing 14 successive tests of a single blood sample.

Results: The correlation coefficient r for POC and HPLC results was 0.92 for the Afinion and 0.93 for the DCA Vantage. The Afinion generated higher HbA1c results than the HPLC (mean difference = +0.56% [+6 mmol/mol]; p < 0.001), as did the DCA Vantage (mean difference = +0.32% [4 mmol/mol]). The bias observed between POC and HPLC did not vary by HbA1c level for the DCA Vantage (p = 0.190), but it did for the Afinion (p < 0.001). Imprecision results were: CV = 1.75% for the Afinion, CV = 4.01% for the DCA Vantage. Sensitivity was 100% for both devices, specificity was 48.3% for the Afinion and 85.1% for the DCA Vantage, positive predictive value (PPV) was 14.4% for the Afinion and 34.9% for the DCA Vantage, and negative predictive value (NPV) for both devices was 100%. The area under the receiver operating characteristic (ROC) curve was 0.966 for the Afinion and 0.982 for the DCA Vantage. Agreement between HPLC and POC in classifying diabetes and prediabetes status was slight for the Afinion (Kappa = 0.12) and significantly different (McNemar’s statistic = 89; p < 0.001), and moderate for the DCA Vantage (Kappa = 0.45) and significantly different (McNemar’s statistic = 28; p < 0.001).

Conclusions: Despite significant variation of HbA1c results between the Afinion and DCA Vantage analyzers compared to HPLC, we conclude that both analyzers should be considered in health clinics in the Peruvian Amazon for therapeutic adjustments if healthcare workers are aware of the differences relative to testing in a clinical laboratory. However, imprecision and bias were not low enough to recommend either device for screening purposes, and the local prevalence of anemia and malaria may interfere with diagnostic determinations for a substantial portion of the population.

IntroductionSarcopenia, an age-associated disorder characterized by the loss of skeletal muscle mass and function, is becoming increasingly prevalent among older adults in China. High levels of family and social support have been reported to be associated with enhanced health outcomes among the elderly. However, the evidence regarding the protective impact of these factors on sarcopenia remains limited and controversial. Furthermore, only a limited number of studies have examined the prevalence of possible sarcopenia in China. The current study aimed to (1) estimate the prevalence of possible sarcopenia, (2) evaluate the perceived family functioning and social support, and (3) examine the associations between family functioning, social support, and sarcopenia.

MethodsCross-sectional data from 624 community-dwelling older participants aged 60 years and older in Suzhou, China were collected via structured interviews. Possible sarcopenias were defined in accordance with the criteria of the 2019 Asian Working Group for Sarcopenia. Family functioning was assessed using six positive items from the McMaster Family Assessment Device – General Functioning Subscale (GF6+). Social support was evaluated based on the Social Support Rating Scale (SSRS). Univariable and multivariable logistic regression was conducted to examine the association between family functioning, social support, and sarcopenia.

ResultsThe prevalence of possible sarcopenia was 10.58%. Females with sarcopenia were more likely to report depression (P<0.05). The mean scores of GF6+ and the total scores were 1.36 ± 0.61 and 32.96 ± 8.47, respectively. Female participants exhibited higher mean scores for GF6+ (P<0.05) and higher total scores for SSRS compared to male participants (P<0.05). No statistically significant associations between family functioning, social support, and sarcopenia were detected.

ConclusionOur study revealed sex differences in the perception of family functioning and social support among Chinese older adults. However, we did not find statistically significant associations between family functioning, social support, and sarcopenia. More research should be conducted in this novel field to facilitate the early screening and prevention of sarcopenia in China.