REAPing the benefits: development and use of a structured evaluation framework to codify learning resources for Global Health professionals

BACKGROUND

The learning opportunities for global health professionals have expanded rapidly in recent years. The diverse array of learners and wide range in course quality underscore the need for an improved course vetting process to better match learners with appropriate learning opportunities.

METHODS

We developed a framework to assess overall course quality by determining performance across four defined domains Relevance, Engagement, Access, and Pedagogy (REAP). We applied this framework across a learning catalogue developed for participants enrolled in the Sustaining Technical and Analytic Resources (STAR) project, a global health leadership training program.

RESULTS

The STAR learning activities database included a total of 382 courses, workshops, and web-based resources which fulfilled 531 competencies across three levels: core, content, and skill.

RELEVANCE

The majority of activities were at an understanding or practicing level across all competency domains (486/531, 91.5%). Engagement: Many activities lacked any peer engagement (202/531, 38.0%) and had limited to no faculty engagement (260/531, 49.0%). Access: The plurality of courses across competencies were offered on demand (227/531, 42.7%) and were highly flexible in pace (240/531, 45.2%). Pedagogy: Of the activities that included an assessment, most matched activity learning objectives (217/531, 40.9%).

CONCLUSIONS

Through applying REAP to the STAR project learning catalogue, we found many online activities lacked meaningful engagement with faculty and peers. Further development of structured online activities providing learners with flexibility in access, a range of levels of advancement for content, and opportunities to engage and apply learning are needed for the field of global health.

Calibrating a chief complaint list for low resource settings: a methodologic case study

BACKGROUND

The chief or presenting complaint is the reason for seeking health care, often in the patient's own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs.

METHODS

This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list.

RESULTS

Overall, 3537 patients' chief complaints were reviewed, of which 640 were identified as 'potential mismatches.' When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. "Pain" was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list.

CONCLUSIONS

This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

The relationship between mindfulness, depression, anxiety, and quality of life in individuals with schizophrenia spectrum disorders

Introduction

Mindfulness-based interventions have received growing attention over the last years for the treatment of various mental disorders, including schizophrenia spectrum disorders (SSD), demonstrating their transdiagnostic validity. However, no study has examined the relationship of probable mechanisms underlying the therapeutic effects of mindfulness in SSD.

Objectives

The current study examines the relationship between mindfulness, depression, anxiety, and quality of life in individuals with SSD through quantitative measures.

Methods

A total of 83 participants with SSD were recruited at the in- and outpatient facility of the Charité – Universitätsmedizin Berlin in Germany. Participants completed the Southampton Mindfulness Questionnaire, Comprehensive Inventory for Mindful Experiences, and Freiburger Mindfulness Inventory, the Depression, Anxiety, Stress Scale, and the World Health Organization Quality of Life Questionnaire. PROCESS analysis examined the relationship between mindfulness and quality of life and the mediating role of depression and anxiety.

Results

Indicated a significant positive association between mindfulness and physical health, psychological and environmental quality of life. Depression and anxiety were found to mediate this relationship, with higher depression and anxiety scores being related to lower mindfulness and quality of life. In this relationship, however, depression was found to be the stronger predictor.

Conclusions

The findings of this study provide insight into the mechanisms of mindfulness. Initial evidence for the transdiagnostic and process-based clinical relevance of MBIs for SSD has been found and future studies can further explore the role of mindfulness for central therapeutic processes of change by employing longitudinal designs.

Disclosure

No significant relationships.

Mindfulness-based group therapy for inpatients with schizophrenia spectrum disorders – feasibility, acceptability, and preliminary outcomes of a rater-blinded randomized controlled trial

Introduction

The therapeutic effectiveness of mindfulness-based interventions (MBIs) has been shown for various mental disorders. However, for schizophrenia spectrum disorders (SSD), only a few trials have been conducted, mostly in outpatient settings.

Objectives

This study aimed to investigate feasibility, acceptability, and preliminary effectiveness of a four-week mindfulness-based group therapy (MBGT) for in-patients with SSD.

Methods

A pre-registered randomized controlled trial (RCT) was conducted at the in-patient ward for SSD. All measures were employed at baseline, post-intervention (4-weeks), and follow-up (12-weeks). The primary outcome was ‘mindfulness’. Secondary outcomes were rater-blinded positive- and negative symptoms, depression, social functioning, as well as self-rated mindfulness, depression, anxiety, psychological flexibility, quality of life, and medication regime.

Results

N=40 participants were randomized into either four-week treatment-as-usual (TAU; n=19) or MBGT+TAU (n = 21). Protocol adherence was 95.2%, and the retention rate to treatments was 95%. ANCOVA analysis revealed significant improvements in the MBGT+TAU compared to TAU for the primary outcome and negative symptoms. Exploratory analyses showed medium-to-large intervention effects on secondary outcomes mindfulness, positive, negative, and depressive symptoms, psychological flexibility, quality of life, and social functioning for MBGT+TAU and small-to-moderate changes on positive symptoms and social functioning for TAU. No serious adverse effects were reported.

Conclusions

This study supports the feasibility and acceptability of MBGT for in-patients with SSD, including high protocol adherence and retention rates. A proof of concept of the MBIs and corresponding improvements on various clinical and process parameters warrant a fully powered RCT to determine effectiveness, cost-efficiency, and longitudinal outcomes of MBGT for SSD.

Disclosure

No significant relationships.

Yoga-based group therapy for in-patients with schizophrenia spectrum disorders – a qualitative approach

Introduction

Yoga may pose a promising complementary therapy in the multimodal treatment of schizophrenia spectrum disorders (SSD). However, to date, no studies have qualitatively examined the patients’ experience of practising Yoga.

Objectives

This qualitative study aimed to assess the mechanisms and processes of Yoga-based group therapy (YBGT) for in-patients with SSD by exploring their subjective experiences.

Methods

Twenty-five semi-structured interviews were conducted with in-patients with SSD after they participated in a YBGT session. Interviews were transcribed, coded by two independent researchers, and analysed using an inductive thematic approach. The research team collaboratively discussed emerging categories to reduce redundancy and form meaningful themes and subthemes.

Results

The analysis revealed seven main themes. YBGT was perceived as feasible and focusing on individual adaptation, captured by the theme ‘inclusivity’. Nevertheless, participants encountered ‘challenges’; thus, physical limitations need to be considered. While practising together, participants experienced ‘interconnectedness’ and developed a ‘mindful stance’ as they accepted their limitations and adapted exercises with self-compassion. Following the flow of asanas required physical persistence, which ultimately led many participants to experience ‘confidence’ and ‘relaxation’. YBGT affected ‘symptom representation’ as heightened awareness led participants to notice impeding as well as improved symptoms.

Conclusions

YBGT seemed to have various promising effects on in-patients with SSD. Future research should examine to what extent these effects can be sustained and how the mindful approach during YBGT can be transferred to areas outside the Yoga class. Furthermore, a randomised-controlled trial could investigate the effectiveness of a manualised YBGT.

Disclosure

No significant relationships.

Introducing a psychiatric genetic cohort of schizophrenia patients and controls from Vietnam

Introduction

Genome-wide association studies (GWAS) have successfully revealed genetic risk variants for schizophrenia (SCZ). However, the vast majority of GWAS largely comprise European samples. As a result, the derived polygenic risk scores (PRS) show decreased predictive power when applied to non-European populations.

Objectives

A long-term scientific cooperation between the Charité Universitätsmedizin Berlin and the Hanoi Medical University aims to address this limitation by recruiting a large genetic cohort of comprehensively phenotyped schizophrenia patients and controls in Vietnam.

Methods

A pilot study was conducted at the Department of Psychiatry of the Medical University Hanoi in 2017. Data collection encompassed i) genome-wide SNP genotyping of 200 schizophrenia patients and 200 control subjects ii) structured interviews to assess symptom severity (PANSS), iii) clinical parameters (e.g. duration of illness, medication) and demography.

Results

SCZ-PRS of the pilot sample (N=400) were generated using different training data sets: i) European, ii) East-Asian and iii) mixed GWAS summary statistics from the Psychiatric Genomics Consortium’s latest discovery sample. Most variance explained was observed using a mixed discovery sample (R²liability=0.053, p=3.11*10^-8, Pd <0.5), followed by PRS based on the East-Asian summary statistics (R²liability=0.0503, p=6.78*10^-8, Pd <1) and the European sample (R²liability=0.0363, p = 4.26*10^-6, Pd <0.01).

Conclusions

With this pilot project we established an efficient recruitment, genotyping and data analysis pipeline. Our results corroborate previous findings indicating that transferability of PRS across populations depends on the ancestral composition of the initial discovery dataset. We therefore aim to expand data collection efforts in the future in order to improve risk prediction across diverse populations.

Disclosure

No significant relationships.

Feasibility of implementing same-day antiretroviral therapy initiation during routine care in Ekurhuleni District, South Africa: Retention and viral load suppression

Background

Same-day initiation (SDI) of antiretroviral therapy (ART) has been advocated as an approach to increase linkage to care and overall ART initiation. Clinical trials have demonstrated impressive benefits. However, questions regarding patient preparedness and retention in care remain for routine implementation of this approach.

Objectives

In this study, we sought to describe SDI of ART during routine care delivery and compare time to ART initiation on longitudinal care outcomes.

Method

We performed a retrospective chart review of 100 consecutive individuals, newly diagnosed with HIV, from 10 health facilities across Ekurhuleni, from January to July 2017. Records were reviewed for a period of 1 year post-diagnosis. Abstracted data included demographics, time to ART initiation, clinic visits and laboratory test results (including viral load testing).

Results

A total of 993 patient records were reviewed, of which 826 were included in the analysis. The majority of patients (752, 91%) had ART initiation recorded, of which 654 (79%) had ART initiated within 30 days, and 224 (27%) had SDI. Uptake of SDI of ART was higher among women (36% vs. 10.4%; p < 0.001) and in younger patients (33.7% in those < 29 years; p < 0.01). Retention in care at 6 months was achieved in 477 (58%) patients. Of those with 6-month viral loads, 350/430 (73%) had a viral load < 400 c/m. Retention in care and viral suppression were similar among those with SDI of ART and later ART initiation.

Conclusion

Same-day initiation of ART was successfully delivered with similar retention and viral load outcomes as subsequent initiation, providing re-assurance for scale-up of this strategy in routine care.

The impact of HIV knowledge and attitudes on HIV testing acceptance among patients in an emergency department in the Eastern Cape, South Africa

BACKGROUND

Transmission of HIV in South Africa continues to be high due to a large proportion of individuals living with undiagnosed HIV. Uptake of HIV testing is influenced by a multitude of factors including the patient's knowledge and beliefs about HIV.

METHODS

This study sought to quantify the impact of knowledge and attitudes on HIV testing acceptance in an emergency department by co-administering a validated HIV knowledge and attitudes survey to patients who were subsequently offered HIV testing.

RESULTS

During the study period 223 patients were interviewed and offered HIV testing. Individuals reporting more negative overall attitudes (p = 0.006), higher levels of stigma to HIV testing (p < 0.001), and individuals who believed their test was confidential (p < 0.001) were more likely to accept an HIV test.

CONCLUSIONS

Interventions focused on improving patient perceptions around testing confidentiality will likely have the greatest impact on testing acceptance in the emergency department.

Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments

BACKGROUND

The Eastern Cape province of South Africa has one of the highest burdens of HIV in the world. Emergency Departments (EDs) can serve as optimal clinical sites for the identification of new HIV infections and entry into care. We sought to determine the current burden of HIV disease among ED patients in the Eastern Cape.

METHODS

We conducted a prospective cross-sectional observational study in the EDs of three Hospitals in the Eastern Cape province of South Africa from June 2017 to July 2018. All adult, non-critical patients presenting to the ED were systematically approached and offered a Point-Of-Care (POC) HIV test in accordance with South African guidelines. All HIV-positive individuals had their blood tested for the presence of antiretroviral therapy (ART) and the presence of viral suppression (≤ 1000 copies/ml). HIV incidence was estimated using a multi-assay algorithm, validated for a subtype C epidemic.

FINDINGS

Of the 2901 patients for whom HIV status was determined (either known HIV-positive or underwent POC HIV testing), 811 (28.0%) were HIV positive, of which 234 (28.9%) were newly diagnosed. HIV prevalence was higher in Mthatha [34% (388/1134) at Mthatha Regional Hospital and 28% (142/512) at Nelson Mandela Academic Hospital], compared to Port Elizabeth [22% (281/1255) at Livingstone Hospital]. HIV incidence was estimated at 4.5/100 person-years (95% CI: 2.4, 6.50) for women and 1.5 (CI 0.5, 2.5) for men. Of all HIV positive individuals tested for ART (585), 54% (316/585) tested positive for the presence of ARTs, and for all HIV positive participants with viral load data (609), 49% (299/609) were found to be virally suppressed.

INTERPRETATION

Our study not only observed a high prevalence and incidence of HIV among ED patients but also highlights significant attrition along the HIV care cascade for HIV positive individuals. Furthermore, despite developing an optimal testing environment, we were only able to enrol a small sub-set of the ED population. Given the high HIV prevalence and high attrition in the ED population, HIV services in the ED should also develop strategies that can accommodate large testing volumes and ART initiation.

Socioeconomic status amplifies genetic effects in middle childhood in a large German twin sample

The Scarr-Rowe hypothesis predicts that the heritability of cognitive abilities is higher in more privileged socioeconomic conditions, meaning that genetic potential can be more fully expressed in environments characterized by high socioeconomic status (SES) compared to low SES. This gene × SES interaction, however, has been replicated mostly in the United States, but not in other Western nations like the United Kingdom. In the current study, we tested the interaction between childhood SES and the heritability of cognitive ability in 3,074 German twin pairs comprising three age cohorts at different developmental stages (mean ages of 11, 17, and 23 years). Higher SES was associated with significantly higher mean cognitive ability scores in the two younger cohorts, with reduced variances at higher SES levels. Results further support the Scarr-Rowe hypothesis in middle childhood, and to some degree in adolescence, but not in adulthood. This indicates that the role of family SES as a moderator of the heritability of cognitive ability changes as children grow older. Moreover, children's shared experiences appear to be explain more variance in cognitive ability at the lower end of the SES distribution in middle childhood and adolescence.

Effect of fetal hemodynamics on growth in fetuses with single ventricle or transposition of the great arteries

OBJECTIVES

As birth weight is a critical predictor of outcome in neonates with congenital heart defect (CHD), the common problem of poor fetal growth in this population is clinically important. However, it is not well understood and the impact of fetal hemodynamics on fetal growth and birth weight in those with CHD has not been assessed. In this study, we sought to evaluate the association between combined cardiac output (CCO) and fetal middle cerebral artery (MCA) and umbilical artery (UA) pulsatility indices (PIs) and fetal growth in different subgroups of CHD, and to study the effects of fetal hemodynamics on late gestational weight gain. We hypothesized that fetuses with CHD will have lower CCO and be smaller at birth.

METHODS

This was a retrospective review of fetal echocardiograms from 67 fetuses diagnosed with hypoplastic left heart syndrome (HLHS, n = 30), non-HLHS single ventricle (SV) (n = 20) or dextrotransposition of the great arteries (d-TGA, n = 17), compared with normal controls (n = 42). CCO was calculated using valvar area, velocity-time integral and heart rate and indexed to estimated fetal weight. MCA- and UA-PI were calculated using systolic, diastolic and mean velocities. Fetal biometry was recorded. Regression models were used to study trends in CCO, MCA- and UA-PI and fetal biometry over gestational age. To evaluate fetal weight gain in late gestation, Z-scores of estimated fetal weight at 30 weeks and birth weight were compared. Regression analysis was used to determine the associations of CCO, indexed CCO and MCA- and UA-PI at 30 weeks with birth weight, length and head circumference Z-scores, in addition to weight gain late in gestation. The gestational age of 30 weeks was chosen based on previous studies that found evidence of poor weight gain in fetuses with CHD in late gestation, starting at around that time.

RESULTS

CCO increased with gestation in all four groups but the rate was slower in fetuses with HLHS and in those with SV. MCA-PI was lower in fetuses with HLHS compared with in those with non-HLHS-SV throughout gestation, suggesting different cerebral blood distribution. At the end of gestation, rate of fetal weight gain slowed in those with HLHS and in those with SV (similar to CCO curves), and head circumference growth rate slowed in all groups but controls. CCO, indexed CCO and MCA- and UA-PI did not correlate with any of the birth measurements or with weight gain late in gestation in fetuses with CHD.

CONCLUSIONS

We found no associations of CCO or MCA- and UA-PI with late gestational weight gain or biometry at birth in fetuses with CHD. This does not support fetal hemodynamics as the primary driver of suboptimal fetal growth in fetuses with SV. Future research could further explain genetic and placental abnormalities that may affect fetal growth in those with CHD. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Factors Associated With End-of-Life Planning in Huntington Disease

OBJECTIVE

Knowledge of one's gene status for adult onset conditions provides opportunity to make advance end-of-life (EOL) plans. The purposes of these analyses were to (1) determine the prevalence of EOL plans, including advance directives (ADs) among persons across 3 stages of Huntington disease (HD) and (2) examine factors associated with having ADs in this sample.

METHODS

Data are from 503 participants in the HD Quality of Life study. Participants completed an online health-related quality-of-life survey that included questions regarding EOL planning and self-reported HD symptoms. Frequencies were calculated for EOL planning by the HD stage. Bivariate analysis and logistic regression were used to identify variables associated with having ADs.

RESULTS

A total of 38.2% of participants stated they had ADs and fewer than half had other EOL plans. Being older, increased HD stage, more years of education, lower anxiety, more swallowing symptoms, and higher meaning and purpose were associated with having ADs.

CONCLUSION

The prevalence of ADs in our sample is comparable to the general US population, but surprisingly low, considering the severity and long disease course of HD.

PRACTICE IMPLICATIONS

Health-care providers should develop specific interventions early in the disease process to increase ADs in this population.

Acculturation strategies and severity of depression among Vietnamese migrants

Aims

Migration with its long-term changes and the resulting task to adjust to the new environment has been associated with an increased risk for mental health problems. This study aims to gain further insight on the relationship between the fours acculturations strategies (integration, assimilation, separation, marginalization) and severity of depression.

Methods

A total of n = 79 first generation Vietnamese outpatients from a psychiatric outpatient clinic for Vietnamese migrants in Germany were investigated regarding self-reported depressive symptoms (patient health questionnaire-9) and acculturation (Stephenson multigroup acculturation scale; SMAS).

Results

Patients with an integration acculturation strategy reported lower severity of depression compared to marginalized patients, who reported the highest severity of depression.

Conclusion

The results implicate that the integration of both the mainstream society and the ethnic society might serve as a resource, whereas the rejection of both societies might increase the risk of depression.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Differences in symptom expression between Vietnamese and German patients utilizing a psychiatric outpatient service using the PHQ

Objective

Despite a large body of work on somatic symptom presentation among people of Asian descent, research has shown heterogeneous results. Examining symptom presentation in clinically and ethnically well-characterized populations constitutes a first step towards better understanding differing patterns symptom of presentation. This is the first larger study aiming to compare Vietnamese and German psychiatric outpatients regarding symptom presentation.

Methods

110 Vietnamese and 109 German patients seeking psychiatric treatment at two outpatient clinic services in Berlin were asked to complete the patient health questionnaire (PHQ). Comparisons of Vietnamese and German patients were conducted using independent t-tests. The somatic symptom module (PHQ-15), the depression module (PHQ-9) and the original PHQ-modules examining anxiety and psychosocial stress levels were compared for both groups using multivariate analysis. Categorical variables were evaluated using Chi2 analysis. Crohnbach's alpha was calculated separately for both groups and all PHQ modules.

Results

Vietnamese patients endorsed significantly higher levels of somatic symptoms overall and on individual somatic items, such as pain-related disturbancies. Yet, German and Vietnamese patients did not differ in terms of depression severity. Vietnamese patients with fewer German language skills showed a significantly higher tendency for somatization. While German patients showed higher total scores on the anxiety- and stress-modules of the PHQ, this difference was not statistically significant. Vietnamese and German patients showed comparable Crohnbach's alpha for all subscales.

Conclusion

As data was collected from both groups upon the first visit to an outpatient clinic, the symptoms reported could be reflective of culture related symptom awareness when feeling discomfort in the context of mental illness.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Relationship between migration-stressors and self-reported symptoms of depression in an outpatient sample of Vietnamese migrants in Germany

Introduction

Vietnamese migrants under the influence of migration-related stressors (MRS) represent a vulnerable group within the mental health care system in Germany.

Aims

First study examining the relationship between the quantity of experienced MRS and the severity of self-reported symptoms of depression in a Vietnamese outpatient-sample.

Methods

137 first-generation Vietnamese migrants diagnosed with depression were asked to complete the BDI-II and 24 questions about stressful experiences related to the migration process. Linear regression models was performed to examine the influence of the MRS-quantity on BDI-II total score and on BDI-II subscales (Buckley et al., 2001).

Results

A higher number of experienced MRS was found to be related to a higher BDI-II total score, as well as to a higher score on the cognitive subscale in particular. Regarding the cognitive depression-dimension the BDI-II items pessimism, past failure, guilt feelings, punishment feelings and suicidal thoughts were positively related to the MRS-quantity.

Discussion and conclusion

A dose-response-relationship was found, with a higher number of MRS being related to a higher severity level of self-reported depressiveness as well as to a higher level of cognitive depression-symptoms in particular. The increase in suicidal ideations in the light of MRS-exposure is in line with findings from other migrant populations. Therapeutic interventions may focus (more) on depressive cognitions as a result of recurring MRS-experiences. Special attention should be placed on suicidal thoughts being boosted by MRS.

Disclosure of interest

The authors have not supplied their declaration of competing interest.