Browsing by Subject "Sub Saharan Africa studies"

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.

Objective: The prevalence of cognitive impairment in HIV-positive patients is estimated to be 39% in Uganda [1]. Despite the high prevalence of impairment, routine HIV management in Uganda does not include neuropsychological assessment. The objective of this study was to compare performance on the gold standard neuropsychological exam and on the CogState computerized exam. We hypothesized that there would be a high degree of correlation between performance on the two exams.

Methods: This cross-sectional survey was conducted from August to October 2011. Each participant completed the standard neuropsychological exam, which consisted of 10 tasks across 7 cognitive ability domains. Patients also completed CogState, which consisted of 4 tasks using playing cards. Performance for each exam was standardized using normative data from HIV seronegative controls to produce z-scores. The primary outcome measures were average z-scores of performance for each exam.

Results: Out of 181 patients tested, 130 (72%) were classified as impaired on the gold standard neuropsychological exam, while 104 (57%) were classified as impaired on CogState. The sensitivity of CogState compared to the gold standard was 65% (95% CI = 56% - 73%) and the specificity was 63% (95% CI = 48% - 73%). The Pearson's correlation of cumulative performance between the exams is 0.552, which is significant at the 0.01 level. Finally, those patients with normal cognition performed the best on CogState, while those with the most severe impairment performed the worst.

Conclusions: Our findings suggest that CogState is a feasible and useful tool to screen for and monitor impairment in HIV-positive patients, especially in resource-limited settings. Future studies are needed to examine how individual performance on CogState changes over time.

Abstract

Introduction: Due to Tanzania’s rising population and shortage of physicians, there has been an emphasis on the expansion of medical schools in the past two decades, both in number and class size. In order to teach a growing student body, faculty adopted e-learning (electronic learning) systems to distribute materials and educate students. At Kilimanjaro Christian Medical University College (KCMUCo) faculty adopted the e-learning system called Learning Management Content System (LCMS+) in 2011. LCMS+ allowed students to access and download course materials during the year; but the association between the downloaded course materials and final grade was unknown. This study aimed to analyze the association between the downloaded materials and final grade in a course between 2011 and 2016.

Methods: To determine the association between downloaded materials and grade, a retrospective analysis study studied first- and second-year medical students in seven courses from 2011-2016 at KCMUCo. The study initially measured the frequency of downloaded course material (i.e. powerpoints, readings, assignments, course outlines and discussion board posts) from LCMS+ per first and second-year student. The final course grades were then obtained. A linear regression was used to assess the association between (1) downloads and grade and (2) sociodemographic variables and grade.

Results: Of the 1,527 students and 5,205 student-course-years studied, there was a weak or null association between downloaded materials and grade for each year and for different types of downloaded material. The distributions of the grades were approximately normal from 2011-2014 and in 2014-2016 there was a left shift of grade distribution. Additionally the female sex and post-service history were associated with slightly lower grades in some of the student years.

Conclusion: This study demonstrated there was no strong association between the number of downloads and grade. There was also no association between the type of downloaded material and grade and the number of materials did not increase the longer the e-learning system was at KCMUCo. More research on how e-learning systems can benefit students is required and may lead to better training for future generations of health care providers.

Background: Over 1.7 billion children and adolescents around the world lack access to safe and affordable surgical care, mostly in low- and middle-income countries (LMICs), where children and adolescents can account for up to half of a country’s population. Yet, the burden of surgical needs for children in Tanzania is still poorly defined. The aim of this study is to assess the epidemiology and outcomes of pediatric surgical procedures performed over one year at the Kilimanjaro Christian Medical Centre, Moshi, Tanzania.Methods: We reviewed the medical and surgical records of all children (< 16 years of age) who underwent surgery between January 1st, 2022 and December 31st, 2022 at the Kilimanjaro Christian Medical Centre. Descriptive statistics were used to assess demographic and clinical characteristics. Geospatial mapping tools were used to visualize the distribution of the patient’s district of origin. Results: We collected data on 2031 children, 59.8% (n = 1215) of whom were male, and more than half were between 1 and 5 years old (58.6%, [n = 1191]). In terms of procedure type, half of the procedures were tonsillectomies/adenoidectomies (51.1%), followed by laparotomies (3.4%), and ventriculoperitoneal shunts (3.2%). We identified 33 deaths prior to discharge. Children from uninsured families and those under one year old were more likely to have traveled longer, visited another health facility, and required an emergency procedure compared to children from insured families and other age groups. Conclusion: Being a child who is under one year old and from an uninsured family is associated with more urgent procedures and poorer outcomes, highlighting disparities in access to surgery for children in Northern Tanzania. Resource mobilization to provide financial protection for families who seek surgical care and health system strengthening at lower-level hospitals are crucial to addressing inequitable and unaffordable access to surgical care and improving health outcomes for children across Tanzania.

BACKGROUND: This study describes the prehospital transport of traumatic brain injury (TBI) patients and its impact on TBI outcome to inform quality improvement for the existing trauma system. Data was collected over 4 months at a major referral hospital in Moshi,Tanzania.

METHODS: Patient demographics, mechanism of injury, injury severity (Glasgow Coma Score), and vitals were recorded on presentation to the Casualty Department. Prehospital factors recorded include time, distance and cost. Multivariable regression analyses evaluated the effect of prehospital factors on unfavourable patient TBI outcome, in-hospital factors and demographics were controlled for. Unfavorable outcome was defined as Glasgow Outcome Score<5 on discharge or death.

RESULTS: Road traffic injuries were the most common mechanism of injury (67.1%). The majority of patients were referred from other facilities in and around the region (62.3%), with 23% from the local public hospital There was no evidence of prehospital care available in this region. Average prehospital duration was more than 1 hour, a third of this was spent in prehospital transit for a majority of the patients. A minority used Ambulances. Predictors of unfavourable outcome (GOS<5) were: prehospital time greater than 60 minutes, multiple physical transfers during the prehospital course and being referred from another hospital.

CONCLUSION: The lack of prehospital care calls for further research into prehospital interventions for this setting. Further analysis should be conducted with a larger sample size to increase accuracy of the findings.

As health systems continue to implement task shifting models to overcome health access barriers and inequity, it is critical to understand the experiences of lay individuals in these new roles. This is particularly true for lay counselors who provide mental health services. This study sought to understand lay counselor experiences through the lens of identity, stress, motivation, burnout, and self-efficacy. Semi-structured interviews and focus group discussions were conducted with three groups of lay counselors with varying levels of counseling experience from a family therapy program in Eldoret, Kenya. Using thematic analysis, emergent themes were explored to characterize counselor experiences and inform task shifting implementation improvements. Such research provides crucial insight so that future interventions can improve support of lay providers.

Background: Cancer is grossly underreported and underdiagnosed in Africa, as only an estimated 57% of childhood cancers are diagnosed and survival rates for children with cancer are very low; an estimated 20% of children survive cancer in Africa. Several factors can lead to delays in treatment and discontinuing treatment such as lack of knowledge about cancer and negative beliefs or stigma about cancer. The research objective of this paper is to explore the types of stigmas faced by pediatric cancer patients and their families to inform interventions to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.Methods: The study took place at Bugando Medical Centre (BMC) in Mwanza, Tanzania. The study sample included more than 300 patients who had completed treatment for pediatric cancer at Bugando Cancer Centre. This qualitative study was conducted using structured focus group discussions (FGD) and in-depth interviews (IDI) with patients and caregivers. Data was transcribed and translated into English and NVivo12 was used for qualitative data analysis and coding through an inductive and deductive approach. Results: The main themes of stigma found in both the FGDs and IDIs were severity of condition, avoidance, financial discrimination, beliefs about causes of cancer and stigma due to physical changes. These themes were found among all age groups and were experienced by both caregivers and patients. Conclusions: The results and data gathered from this study illustrate that cancer stigma is still an issue faced by pediatric cancer patients and their families. It also illustrates that, although some aspects of stigma have been described and addressed in the literature through adult stigma studies, there are aspects of stigma for pediatric cancer patients specifically that should be addressed. The data gathered here can be used to develop interventions targeted towards cancer stigma for pediatric populations, to reduce cancer stigma and increase survival rates of pediatric cancer patients in Tanzania.

Background: Globally, traumatic brain injury (TBI) accounts for the highest burden of deaths and disabilities globally. Studies suggest a complex relationship between injury, mental health, and alcohol. Though hazardous alcohol use and TBI exert heavy burdens in Tanzania, their interaction with mental health is largely unknown. This study aims to explore the mental health and alcohol use profiles of TBI patients in a low-income country.

Methods: Secondary data analysis of a registry of adults (≥ 18) with TBI of any severity presenting to the Kilimanjaro Christian Medical Center Emergency Department (ED) within 24 hours of injury. Patient data were collected at ED arrival and at three months follow-up. Variables included measures of functional independence, psychiatric health, quality of life, and alcohol use. Hazardous alcohol use was defined as an Alcohol Use Disorder Identification Test (AUDIT) score greater than seven. We conducted a latent profile analysis (LPA) to determine pre-injury mental health profiles of patients and logistic regression to assess association of patient profile with hazardous drinking at three months after injury.

Results: Of 190 participants, 51 (26.8%) were hazardous drinkers. The majority of the sample was male (83.7%) and the median age was 29.5 years. The LPA model with the strongest fitness revealed five profiles of mental health and drinking patterns. The “Poor Mental Health Drinkers” (9.4%) profile had worse quality of life and higher depression and hazardous drinking scores. The “Disabled Non-drinkers” (11.4%) profile had worse motor functional independence and low hazardous drinking scores. The “Non-drinkers” (53.5%) had good quality of life, little to no depression, good functional independence and low hazardous drinking scores. The “Drinkers” were similar to the “Non-drinkers” profile, except with high hazardous drinking scores. Predictors of hazardous drinking three months post-injury included disability and being a hazardous drinker before injury.

Conclusions: This study provides insight into the possible mental health and drinking pattern profiles for TBI patients. The categorization of patients may help in resource allocation of alcohol interventions for those who are at the highest risk for hazardous alcohol use. Limitations included recall bias for pre-injury information.

Alcohol Use Disorder (AUD) and Major Depressive Disorder (MDD) account for millions of deaths and disabilities each year with many theories on the interaction between the two disorders. Tanzania has a high rate of harmful alcohol use, depression, and alcohol-related injuries. To address the growing burden, a nurse-led Brief Negotiational Intervention (BNI) was implemented in the Kilimanjaro Christian Medical Centre Emergency Department in 2020. Three-month outcomes from this study have shown that AUDIT scores are not significantly reduced by the intervention. Thus, this study aims to explore the relationship and potential mediating effects of depression within the context of the BNI at KCMC ED. For quantitative aims, we used secondary data from the PRACT 6-month outcomes. We compared demographic characteristics between AUDIT/PHQ-9 categories using median, IQR, Kruskal-Wallis, and Fisher’s Exact Test. We then specified two cross-sectional structural equation models at 3 and 6 months to explore depression as a mediator between BNI and AUDIT scores. For our qualitative aim, we conducted 15 semi-structured interviews and analyzed data using a thematic coding approach. Out of our 282 participants, demographic characteristics differed between AUDIT/PHQ-9 groups on gender and education. Additionally, depression does not mediate the relationship between BNI and AUDIT scores at 3 or 6 months. However, BNI is reducing AUDIT and PHQ-9 scores at 6 months. Our qualitative data highlights the association between AUD and MDD and explores the importance of social communities for both disorders. More research is needed to determine the temporality between AUD and MDD in this context. Yet, this study has provided evidence that an alcohol-based BNI has provided benefits for AUD and MDD. Thus, it’s imperative to capitalize on this unintended intervention effect and modify the intervention to include a mental health component.

Background: Perinatal depression in low- and middle-income countries (LMICs) is common and associated with many negative outcomes. Although effective interventions exist, many cases in LMICs remain untreated due to a lack of human resources. Task-sharing approaches such as Thinking Healthy program were proved to be feasible to expand access to treatment in LMICs but were facing certain barriers to scale up. In this study, we adapted Thinking Healthy Program to the artificial intelligence system called Tess (named Zuri in Kenya) to provide automated psychological support for perinatal women in Kenya. The objective was to gather preliminary data on feasibility, acceptability, and perceived impacts of the automated psychological support on perinatal women in Kenya.

Methods: Women were recruited from two public hospitals in Kiambu County, Kenya. After enrollment, each woman was matched to another new participant with similar maternity status and was randomly assigned to have a 1-week or 2-week baseline period. We prompted participants to rate their mood every 3 days throughout the study. We also reviewed system logs and conducted in-depth interviews to determine feasibility, acceptability, and perceived impacts of the intervention.

Results: 647 women were invited to participate; 86 of them completed the SMS screening and 41 of them enrolled in the study. Among all the enrolled participants, 27 of them (65.9%) sent at least one message to Zuri and 31 (75.6%) of them submitted at least three ratings. 14 women (34.1%) engaged with Zuri beyond registration. Free chats were a big part of the participants’ interactions with Zuri. During free chats, the most common intervention module was mindfulness-based meditation, and the most common rapport-building module was discussion about the women’s passion. Most interviewees expressed positive attitudes towards Zuri. They also reported some positive changes in their life after using Zuri.

Conclusion: The preliminary data showed that Zuri was feasible, acceptable, and had some perceived impacts among a sample of pregnant women and new mothers in Kenya. Automated psychological support is still in its infancy, but it has great potential to close the large treatment gap that exists in many LMICs.

Background: In sub-Saharan Africa, epilepsy is ranked 14th for the highest disability burden. In Uganda, specifically, epilepsy has risen from 14th in 2007 to 10th for the highest burden of disability in 2017. Despite the significant disease burden of epilepsy in Uganda, there have been no national prevalence studies. Our first aim is to understand the overall epilepsy prevalence in Uganda. Additionally, we want to understand the impact that demographic and socio-economic factors have on epilepsy prevalence and whether these factors varied in their impact geographically.

Methods: Three hundred and thirty EAs were selected for this study, stratifications included urban/rural and the 10 sub-regions delineated in the DHS. In each EA, we randomly selected 30 households out of 100 (on average). All members of the household that consented, or assented, to be part of the study were included. We used a 13-item survey, broken into two levels, to screen for epilepsy and collected a variety of demographic and socio-economic factors from each participant. These factors were mapped to determine the impact, and significance, that each factor had on the geographic distribution of epilepsy prevalence in Uganda.

Results: The groups who had the highest epilepsy prevalence were under 35 years of age, had less than a primary level of education, lived in rural areas, had less than five household members, had access to a mobile phone and had less than two combined assets. The vast majority of positive screened participants were Christian and made less than 20,000 UGX a week.

Conclusions: From this study, we can see areas within Uganda where some geographic, demographic, and socio-economic factors have possibly played a role in epilepsy prevalence, as defined by our first screen. We can begin to understand these patterns and explore them further to determine the true nature of these factors and their relationship with epilepsy. There are current policy changes that could greatly improve access to care, stigma, and prevent further epilepsy cases by improving infrastructure in key areas.

Background Globally, it is estimated that 11% of all disability adjusted life years lost result from conditions requiring surgical intervention. Efforts to estimate burden at country-specific levels have been recommended to plan surgical delivery platforms. However, existing analyses of hospital records are not representative of population-level needs. Therefore, we piloted a population-level epidemiologic survey in a large, peri-urban District of Uganda. The exercise would inform implementation of the eventual nation-wide survey of Uganda.

Methods A 2-stage cluster sampling design was used to sample fifty five (55) households. In each household, up to 2 individual respondents were recruited. Village Health Team (VHT) members served as enumerators and used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument to acquire self-reported data on existing surgical conditions and surgical history. A head/representative of household was asked about household deaths within the previous 12-months. Descriptive statistics, weighted adjustments, and regression modeling were used to analyze results.

Results Six of 96 individual respondents (6.25%) reported an existing surgical condition. The lifetime prevalence of surgical conditions was 26.0% (25 of 96 individuals), reporting 33 total surgical conditions. The most commonly reported problems were wound related (54.5% - 18 of 33). The most common anatomic regions affected were face/head/neck, extremities, and abdomen. Injuries were responsible for 51.5% of reported surgical conditions. Two of three household deaths involved proximate causes that were surgically treatable. For all met and unmet need, 80% (20 of 25 individuals) were treated or need treatment at a District Hospital or lower level facility.

Prevalence of existing surgical conditions was used in this pilot to compute a nation-wide study sample size of 4,750. The pilot study cost USD 25/respondent and averaged 36 minutes per household. Major revisions in deployment of the nation-wide survey included: hiring enumerators who lived in the EAs, random household sampling, shift in data collection equipment, and improving breath and depth of data acquired by the SOSAS instrument.

Conclusion The prevalence of existing surgical conditions in Wakiso District was within range of previous pilot studies deploying the same SOSAS instrument, albeit not from Uganda. A large proportion of individuals have surgical problems that can be treated at District Hospital or lower level facilities. The pilot study was feasible and necessary to inform deployment of the nation-wide survey.

Background: Despite CDC advisories, many pregnant women in Northern Tanzania consume alcohol. The WHO SAFER initiative calls for tailored interventions to target alcohol use during pregnancy in Moshi, Tanzania. Addressing this issue involves understanding the complex alcohol use patterns among pregnant women. Yet, data on pregnant female subgroups and their associated drinking habits in Moshi are lacking, Methods: This cross-sectional study uses secondary data from pregnant women enrolled from Kilimanjaro Christian Medical Centre's (KCMC’s) Reproductive Health Center (RHC) and Emergency Department (ED). Structured survey questionnaires assess sociodemographic and psychological traits, and alcohol consumption patterns. Basic summary statistics were used to compare pregnant women who consumed alcohol with those who did not. Latent class analysis (LCA) identified distinct subgroups among enrolled pregnant women based on sociodemographic and psychological attributes. Associations between latent classes and alcohol use patterns were evaluated using logistic odds regression (LOR). Results: No significant associations were found between latent groups of pregnant women and alcohol use patterns such as drinking quantity, frequency, or AUD status. Differences in individual sociodemographic and psychological traits between pregnant women who consume alcohol and those who do not were non-significant, except for age. Conclusions: Understanding variations in alcohol use among unique subgroups of pregnant women is essential for the development of targeted interventions to alleviate the burden of alcohol use during pregnancy. LCA identified unique subgroups, yet the study's limited sample size warrants caution. Future efforts should consider the interplay of cultural norms, societal stigma, and personal attitudes toward prenatal alcohol consumption, going beyond traditional sociodemographic factors. Addressing drinking habits among young women is also crucial, as these behaviors may persist into pregnancy.

Background: Sickle cell disease (SCD) is a debilitating genetic blood disorder that seriously impacts the quality of life of affected individuals and their families. With 85% of cases occurring in sub-Saharan Africa, it is essential to identify the barriers and facilitators of optimal outcomes for people with SCD in this setting. This study focuses on understanding the relationship between support systems and disease outcomes for SCD patients and their families in Cameroon and South Africa.

Methods: This mixed-methods study utilizes surveys and semi-structured interviews to assess the experiences of 29 SCD patients and 28 caregivers of people with SCD across three cities in two African countries: Cape Town, South Africa; Yaoundé, Cameroon; and Limbe, Cameroon.

Results: Patients in Cameroon had less treatment options, a higher frequency of pain crises, and a higher incidence of malaria than patients in South Africa. Social support networks in Cameroon consisted of both family and friends and provided emotional, financial, and physical assistance during pain crises and hospital admissions. In South Africa, patients relied on a strong medical support system and social support primarily from close family members; they were also diagnosed later in life than those in Cameroon.

Conclusions: The strength of medical support systems influences the reliance of SCD patients and their caregivers on social support systems. In Cameroon the health care system does not adequately address all factors of SCD treatment and social networks of family and friends are used to complement the care received. In South Africa, strong medical and social support systems positively affect SCD disease burden for patients and their caregivers. SCD awareness campaigns are necessary to reduce the incidence of SCD and create stronger social support networks through increased community understanding and decreased stigma.