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Monzon R, Ornelas-Dorian C, Eucker SA, Rising K, O'Laughlin KN, Pauley A, Kean E, Geyer R, Lara Chavez C, Shughart L, Arreguin MI, Silverman E, Rodriguez RM. An evaluation of COVID-19 vaccine messaging platforms in the emergency department. Acad Emerg Med 2024. [PMID: 38706110 DOI: 10.1111/acem.14933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Rene Monzon
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | | | - Stephanie A Eucker
- Department of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - Kristin Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kelli N O'Laughlin
- Department of Emergency Medicine and Global Health, University of Washington, Seattle, Washington, USA
| | - Alena Pauley
- Department of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - Efrat Kean
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rachel Geyer
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Cecilia Lara Chavez
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Lindsey Shughart
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mireya I Arreguin
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Emily Silverman
- Department of Medicine, University of California, San Francisco, California, USA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, California, USA
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Klabbers RE, Hughes A, Dank M, O'Laughlin KN, Rogers M, Stoklosa H. Human trafficking risk factors, health impacts, and opportunities for intervention in Uganda: a qualitative analysis. Glob Health Res Policy 2023; 8:52. [PMID: 38072964 PMCID: PMC10712038 DOI: 10.1186/s41256-023-00332-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Human trafficking is a global public health issue that is associated with serious short- and long-term morbidity. To address and prevent human trafficking, vulnerabilities to human trafficking and forces sustaining it need to be better understood among specific subpopulations. We aimed to explore risk and protective factors for human trafficking, the health impact of exploitation, and barriers and facilitators of seeking help throughout the human trafficking trajectory among forced labor and sex trafficking victims in Kampala, Uganda. METHODS Between March and November 2020, in-depth, semi-structured qualitative interviews were conducted with 108 victims of forced labor and sex trafficking who had completed a human trafficking survey conducted by the Uganda Youth Development Link (UYDEL). Participants who experienced various forms of exploitation were purposively invited for qualitative interviews and a convenience sample was interviewed. Interviews explored personal history, trafficking recruitment, experiences of exploitation and abuse, and experiences seeking help. Interviews were analyzed using a combination of deductive and inductive thematic analysis. Themes and subthemes were organized using an adapted conceptual framework of human trafficking. RESULTS Poverty and an abusive home life, frequently triggered by the death of a caretaker, underpinned vulnerability to human trafficking recruitment. Limited education, lack of social support, and survival needs pushed victims into exploitative situations. Victims of human trafficking were systematically exploited and exposed to dangerous working conditions. Victims suffered from sexually transmitted diseases, incontinence, traumatic fistulae, musculoskeletal injuries, and mental health symptoms. Lack of awareness of resources, fear of negative consequences, restrictions on movement, and dependence on the trafficker and exploitation income prevented victims from seeking help. The police and healthcare workers were the few professionals that they interacted with, but these interactions were oftentimes negative experiences. CONCLUSIONS To address and prevent human trafficking, localized interventions are needed at all stages of the human trafficking trajectory. Health impacts of human trafficking are severe. As some of the few professionals trafficking victims interact with, police and healthcare workers are important targets for anti-trafficking training. Improved understanding of human trafficking drivers and barriers and facilitators to seeking help can inform the design of necessary interventions.
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Affiliation(s)
- Robin E Klabbers
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | - Meredith Dank
- Marron Institute of Urban Management, New York, NY, USA
| | - Kelli N O'Laughlin
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Hanni Stoklosa
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- HEAL Trafficking, Long Beach, CA, USA
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Bridi L, Albahsahli B, Bencheikh N, Baker DA, Godino JG, O'Laughlin KN, Al-Rousan T. Barriers and facilitators to self-measured blood pressure monitoring among US-resettled Arab refugees with hypertension: a qualitative study. BMC Prim Care 2023; 24:256. [PMID: 38036967 PMCID: PMC10687832 DOI: 10.1186/s12875-023-02215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Minoritized communities including refugees are at an increased risk of poorly controlled hypertension. Evidence indicates that self-measured blood pressure monitoring (SMBP) is an effective method to improve blood pressure control in patients with hypertension. However, it has not been studied among refugee populations. The objective of this study is to examine barriers and facilitators to SMBP among Arab refugees resettled in the United States (US) with diagnosed hypertension. METHODS A total of 109 participants were recruited through a Federally Qualified Health Center system that is a major provider of healthcare to refugees in San Diego, California. Participants completed a questionnaire and were interviewed using in-depth, semi-structured interviews. Interviews were transcribed and translated, and data were coded using inductive thematic analysis and organized based on the theory of care-seeking behavior. RESULTS Several barriers to engaging in effective SMBP monitoring were identified. Clinical and sociodemographic barriers included reliance on public monitors and poor hypertension literacy. Psychosocial barriers of affect, norms, and habits included fear and anxiety from hypertension, cultural stigma of illness, and conditional SMBP with symptoms, respectively. Utility psychosocial barriers included lack of SMBP prioritization in treatment and perceived inaccuracy of home monitors. Family members' support with home monitoring served as an important facilitator to SMBP. CONCLUSIONS There are several barriers to effective SMBP among the US-resettled Arab refugee population that may reflect unique cultural and care-seeking behaviors. Tailored public health and clinical interventions are needed to support refugee patients and providers to improve hypertension self-management behaviors for this unique population.
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Affiliation(s)
- Lana Bridi
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Behnan Albahsahli
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA, USA
| | - Nissma Bencheikh
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Dania Abu Baker
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA, USA
- School of Social Work, San Diego State University, San Diego, CA, USA
| | - Job G Godino
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA, USA
- Laura Rodriguez Research Institute, Family Health Centers of San Diego, San Diego, CA, USA
| | - Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA, USA
| | - Tala Al-Rousan
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA, USA.
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Molina MF, Nichol G, Eucker SA, Addo N, Rising K, Arreguin M, Morse D, Pauley A, Chavez CL, O'Laughlin KN, Duber H, Rodriguez RM. COVID-19 Booster Vaccine Hesitancy in the Emergency Department. Ann Emerg Med 2023; 82:509-516. [PMID: 37178104 PMCID: PMC10181915 DOI: 10.1016/j.annemergmed.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVE Little is known about COVID-19 booster vaccine hesitancy. We sought to determine the uptake of booster vaccines, as well as the prevalence of and reasons for booster hesitancy in emergency department (ED) patients. METHODS We performed a cross-sectional survey study of adult patients at 5 safety-net hospital EDs in 4 US cities from mid-January to mid-July 2022. Participants were fluent in English or Spanish and had received at least one COVID-19 vaccine. We assessed the following parameters: (1) the prevalence of nonboosted status and reasons for not getting a booster; (2) the prevalence of booster vaccine hesitancy and reasons for hesitancy; and (3) the association of hesitancy with demographic variables. RESULTS Of 802 participants, 373 (47%) were women, 478 (60%) were non-White, 182 (23%) lacked primary care, 110 (14%) primarily spoke Spanish, and 370 (46%) were publicly insured. Of the 771 participants who completed their primary series, 316 (41%) had not received a booster vaccine; the primary reason for nonreceipt was lack of opportunity (38%). Of the nonboosted participants, 179 (57%) expressed hesitancy, citing need for more information (25%), concerns about side effects (24%), and the belief that a booster was unnecessary after the initial series (20%). In the multivariable analysis, Asian participants were less likely to be booster hesitant than White participants (adjusted odds ratio [aOR] 0.21, 95% confidence interval [CI] 0.05 to 0.93), non-English-speaking participants were more likely to be booster hesitant than English-speaking participants (aOR 2.35, 95% CI 1.49 to 3.71), and Republican participants were more likely to be booster hesitant than Democrat participants (aOR 6.07, 95% CI 4.21 to 8.75). CONCLUSION Of almost half of this urban ED population who had not received a COVID-19 booster vaccine, more than one third stated that lack of opportunity to receive one was the primary reason. Furthermore, more than half of the nonboosted participants were booster hesitant, with many expressing concerns or a desire for more information that may be addressed with booster vaccine education.
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Affiliation(s)
- Melanie F Molina
- Department of Emergency Medicine, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
| | - Graham Nichol
- Division of General Internal Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, Harborview Medical Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | | | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Kristin Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Mireya Arreguin
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Dana Morse
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Alena Pauley
- Department of Emergency Medicine, Duke University, Durham, NC
| | - Cecilia L Chavez
- Department of Emergency Medicine, University of California, San Francisco, CA
| | | | - Herbie Duber
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA.
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Klabbers RE, Muwonge TR, Ajidiru S, Borthakur S, Mujugira A, Sharma M, Vinck P, Pham P, Celum C, Parkes-Ratanshi R, O'Laughlin KN. Understanding the barriers and facilitators of COVID-19 risk mitigation strategy adoption and COVID-19 vaccination in refugee settlements in Uganda: a qualitative study. BMC Public Health 2023; 23:1401. [PMID: 37474936 PMCID: PMC10360310 DOI: 10.1186/s12889-023-16320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 07/16/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Perspectives on COVID-19 risk and the willingness and ability of persons living in refugee settlements to adopt COVID-19 prevention strategies have not been rigorously evaluated. The realities of living conditions in Ugandan refugee settlements may limit the extent to which refugees can uptake strategies to mitigate COVID-19 risk. METHODS In-depth qualitative interviews were conducted between April 2021 and April 2022 to assess COVID-19 knowledge, risk perception, prevention strategy adoption including COVID-19 vaccination, and COVID-19 impact on living conditions in refugee settlements in Uganda. Interview participants included 28 purposively selected refugees who called into "Dial-COVID", a free telephone COVID-19 information collection and dissemination platform that was advertised in refugee settlements by community health workers. Interviews were analyzed using a combination of deductive and inductive content analysis. Emerging themes were mapped onto the Theoretical Domains Framework to identify domains influencing prevention behavior. Results were synthesized to provide intervention and policy recommendations for risk mitigation in refugee settlements for COVID-19 and future infectious disease outbreaks. RESULTS The COVID-19 pandemic detrimentally impacted economic and food security as well as social interactions in refugee settlements. Youth were considered especially impacted, and participants reported incidents of child marriage and teenage pregnancy following school closures. Participants displayed general knowledge of COVID-19 and expressed willingness to protect themselves and others from contracting COVID-19. Risk mitigation strategy uptake including COVID-19 vaccination was influenced by COVID-19 knowledge, emotions surrounding COVID-19, the environmental context and resources, personal goals, beliefs about the consequences of (non)adoption, social influences, and behavior reinforcement. Resource constraints, housing conditions, and competing survival needs challenged the adoption of prevention strategies and compliance decreased over time. CONCLUSIONS Contextual challenges impact the feasibility of COVID-19 risk mitigation strategy uptake in refugee settlements. Pre-existing hardships in this setting were amplified by the COVID-19 pandemic and related lockdowns. Targeted dispelling of myths, alignment of information across communication mediums, supporting survival needs and leveraging of respected role models are strategies that may hold potential to mitigate risk of infectious diseases in this setting. REGISTRATION DETAILS World Pandemic Research Network - 490,652.
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Affiliation(s)
- Robin E Klabbers
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | - Scovia Ajidiru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Patrick Vinck
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA
| | - Phuong Pham
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rosalind Parkes-Ratanshi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Kelli N O'Laughlin
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Omam LA, Jarman E, O'Laughlin KN, Parkes-Ratanshi R. Primary healthcare delivery models in African conflict-affected settings: a systematic review. Confl Health 2023; 17:34. [PMID: 37454133 DOI: 10.1186/s13031-023-00533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/12/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND In conflict-affected settings, access to primary healthcare for displaced populations is constrained by multiple challenges. These include geographical, cultural, communication, logistical and financial barriers, as well as risks posed to health workers and the population by insecurity. Different models of care are used to provide primary healthcare to affected communities. However, there is a paucity of evidence on how these models are selected and implemented by organisations working in conflict and displacement-affected settings. Our aim was to explore the different primary healthcare delivery models used in conflict-affected settings to understand gaps in existing healthcare delivery models. METHODS We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews. We searched six databases for manuscripts published from January 1992 to December 2020. Publications were included if they reported primary healthcare models of care in conflict-affected settings of Africa. Data was analyzed descriptively and thematically using tables, charts and text. RESULTS Forty-eight primary research articles were included for analysis from which thirty-three were rated as "high" quality. The results showed that the models of care in place in these conflict-affected settings include health facility-based, community-based, mobile clinics, outreach and home visits. Primary healthcare for internally displaced persons and refugees is provided by a wide range of actors including national and international organisations. A range of services is offered, most commonly nutrition, mental health and sexual/reproductive health. Some organisations offer vertical (stand-alone) services, while others use an integrated service delivery model. Multiple cadres of healthcare workers provide services, frequently lay healthcare workers such as Community Health Workers. CONCLUSION Understanding the different modalities of primary healthcare delivery in conflict-affected settings is important to identify existing practices and gaps in service delivery. Service delivery using community health workers in conflict-affected settings is a low-cost primary care delivery strategy that may help optimize contributions of existing personnel through task shifting.
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Affiliation(s)
- Lundi-Anne Omam
- Department of Public Health and Primary Care, University of Cambridge, Cambridgeshire, UK.
- Department of Psychiatry, University of Cambridge, Cambridgeshire, UK.
| | | | - Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, USA
| | - Rosalind Parkes-Ratanshi
- Department of Psychiatry, University of Cambridge, Cambridgeshire, UK
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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Rodriguez RM, Nichol G, Eucker SA, Chang AM, O'Laughlin KN, Pauley A, Rising KL, Eswaran V, Morse D, Li C, Patel A, Duber HC, Arreguin M, Shughart L, Glidden D, Butler J, Kemball R, Chan V, Lara-Chavez C, Guth A, Olarewaju I, Morse SC, Patel A, Schaeffer K, Grau D, Arab A, Tupetz A, Walker E, Watts P, Shughart H, Yan B, Finkelstein S, Chen H, Daniels N, White J, Sarafian J, Howard L, Alali L, Agun G, Chan EA, Covington A, Klasson C. Effect of COVID-19 Vaccine Messaging Platforms in Emergency Departments on Vaccine Acceptance and Uptake: A Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:115-123. [PMID: 36574256 PMCID: PMC9856883 DOI: 10.1001/jamainternmed.2022.5909] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Large segments of the US population's primary health care access occurs in emergency departments (EDs). These groups have disproportionately high COVID-19 vaccine hesitancy and lower vaccine uptake. OBJECTIVE To determine whether provision of COVID-19 vaccine messaging platforms in EDs increases COVID-19 vaccine acceptance and uptake in unvaccinated patients. DESIGN, SETTING, AND PARTICIPANTS This prospective cluster randomized clinical trial was conducted at 7 hospital EDs in 4 US cities from December 6, 2021, to July 28, 2022. Noncritically ill adult patients who had not previously received COVID-19 vaccines were enrolled. INTERVENTIONS A 3-pronged COVID-19 vaccine messaging platform (an English- or Spanish-language 4-minute video; a 1-page informational flyer; and a brief, scripted message from an ED physician or nurse) was delivered during patient waiting times. MAIN OUTCOMES AND MEASURES The 2 primary outcomes were (1) COVID-19 vaccine acceptance, assessed by survey responses in the ED, and (2) receipt of a COVID-19 vaccine within 30 days, ascertained by ED confirmation of vaccination, electronic health record review, and telephone follow-up. RESULTS Of the 496 participants enrolled (221 during intervention weeks and 275 during control weeks), the median (IQR) age was 39 (30-54) years, 205 (41.3%) were female, 193 (38.9%) were African American, 97 (19.6%) were Latinx, and 218 (44.0%) lacked primary care physicians. More intervention group participants, compared with control participants, stated that they would accept the vaccine in the ED (57 [25.8%] vs 33 [12.0%]; adjusted difference, 11.9 [95% CI, 4.5-19.3] percentage points; number needed to treat [NNT], 8 [95% CI, 5-22]). More intervention group participants than control participants received a COVID-19 vaccine within 30 days of their ED visit (44 [20.0%] vs 24 [8.7%]; adjusted difference, 7.9 [95% CI, 1.7-14.1] percentage points; NNT, 13 [95% CI, 7-60]). The intervention group had greater outcome effect sizes than the control group in participants who lacked a primary care physician (acceptance, 38 of 101 [37.6%] vs 16 of 117 [13.7%] [P for interaction = .004]; uptake, 31 of 101 [30.7%] vs 11 of 117 [9.4%] [P for interaction = .006]), as well as in Latinx persons (acceptance, 23 of 52 [44.2%] vs 5 of 48 [10.4%] [P for interaction = .004]; uptake, 22 of 52 [42.3%] vs 4 of 48 [8.3%] [P for interaction < .001]). CONCLUSIONS AND RELEVANCE Results of this cluster randomized clinical trial showed that with low NNT, implementation of COVID-19 vaccine messaging platforms in EDs leads to greater vaccine acceptance and uptake in unvaccinated ED patients. Broad implementation in EDs could lead to greater COVID-19 vaccine delivery to underserved populations whose primary health care access occurs in EDs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05142332.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco
| | - Graham Nichol
- Center for Prehospital Emergency Care, Division of General Internal Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Stephanie A Eucker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anna Marie Chang
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Alena Pauley
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vidya Eswaran
- Department of Emergency Medicine, University of California, San Francisco
| | - Dana Morse
- Department of Emergency Medicine, University of Washington, Seattle
| | - Cindy Li
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ashini Patel
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Herbie C Duber
- Department of Emergency Medicine, University of Washington, Seattle
| | - Mireya Arreguin
- Department of Emergency Medicine, University of California, San Francisco
| | - Lindsey Shughart
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dave Glidden
- Department of Epidemiology & Biostatistics, University of California, San Francisco
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Klabbers RE, Ashaba S, Stern J, Faustin Z, Tsai AC, Kasozi J, Kambugu A, Ventevogel P, Bassett IV, O'Laughlin KN. Mental disorders and lack of social support among refugees and Ugandan nationals screening for HIV at health centers in Nakivale refugee settlement in southwestern Uganda. Journal of Global Health Reports 2022; 6. [PMID: 37168525 PMCID: PMC10168545 DOI: 10.29392/001c.39600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Exposure to potentially traumatic events and daily stressors in humanitarian settings puts refugees and asylum seekers (henceforth collectively referred to as refugees) at increased risk for mental disorders. Little is known about how mental disorder prevalence compares between refugees and national populations who live in the same settings and are exposed to many of the same daily challenges. We aimed to compare the proportions of refugees and Ugandan nationals screening positive for mental disorders in a Ugandan refugee settlement to inform targeted health interventions. Given displacement’s disruptive effect on social networks and the importance of social support for mental health, we also aimed to assess social support. Methods Refugees and Ugandan nationals voluntarily testing for HIV at health centers in Nakivale Refugee Settlement were screened for post-traumatic stress disorder (PTSD CheckList-6 – Civilian Version [PCL-6]), depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (General Anxiety Disorder-7 [GAD-7]), and lack of social support (Brief Social Support Scale [BS6]). The association between refugee versus Ugandan national status and the four outcomes was assessed using log-binomial regression. Results Screening surveys were completed by 5,513 participants, including 3,622 refugees and 1,891 Ugandan nationals. A positive screen for PTSD, depression, anxiety and lack of social support was found for 2,388 (44%), 1,337 (25%), 1,241 (23%) and 631 (12%) participants, respectively. Refugee status was associated with a higher prevalence of a positive screen for PTSD (prevalence ratio (PR)=1.15; 95% confidence interval (CI)=1.08-1.23), depression (PR=1.22; 95% CI=1.11-1.36), anxiety (PR=1.28; 95% CI=1.14-1.42), and lack of social support (PR=1.50; 95% CI=1.27-1.78). When adjusted for the other outcomes, the higher prevalence of a positive screen for PTSD, anxiety and lack of social support for refugees remained statistically significant. Conclusions Elevated symptoms of mental disorders are found among refugees and Ugandan nationals testing for HIV in Nakivale Refugee Settlement. The significant association between refugee status and PTSD, anxiety and lack of social support symptoms highlights the distinct needs of this population. To determine the prevalence of mental disorders in these populations, comprehensive assessment, including psychological and neuropsychological testing, is needed.
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Affiliation(s)
- Robin E. Klabbers
- University of Washington, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | | | - Joshua Stern
- University of Washington, Seattle, Washington, USA
| | | | - Alexander C. Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julius Kasozi
- United Nations High Commissioner for Refugees, Kampala, Uganda
| | - Andrew Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter Ventevogel
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Ingrid V. Bassett
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kelli N. O'Laughlin
- University of Washington, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
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9
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Klabbers RE, Muwonge TR, Ayikobua E, Izizinga D, Bassett IV, Kambugu A, Tsai AC, Ravicz M, Klabbers G, O'Laughlin KN. Understanding the role of interpersonal violence in assisted partner notification for HIV: a mixed-methods study in refugee settlements in West Nile Uganda. J Glob Health 2021; 10:020440. [PMID: 33312504 PMCID: PMC7719270 DOI: 10.7189/jogh.10.020440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Assisted partner notification (APN) for HIV was introduced in refugee settlements in West Nile Uganda in 2018 to facilitate testing of sexual partners. While APN is an effective strategy recommended by the World Health Organization, its safety has not been evaluated in a refugee settlement context in which participants have high prior exposure to interpersonal violence. The extent to which interpersonal violence influences APN utilization and the frequency with which post-APN interpersonal violence occurs remains unknown. Methods To explore the relationship between APN and interpersonal violence, a cross-sectional mixed-methods study was conducted at 11 health centers in or near refugee settlements serving refugee and national populations in West Nile Uganda. Routinely collected index client and sexual partner data were extracted from APN registers and semi-structured interviews were conducted with health workers. Results Through APN, 1126 partners of 882 distinct index clients were identified. For 8% (75/958) of partners, index clients reported a history of intimate partner violence (IPV). For 20% (226/1126) of partners, index clients were screened for post-APN IPV; 8 cases were reported of which 88% (7/8) concerned partners with whom index clients reported prior history of IPV. In qualitative interviews (N = 32), health workers reported HIV disclosure-related physical, sexual and psychological violence and deprivation or neglect. Incidents of disclosure-related violence against health workers and dependents of index clients were also reported. Fear of disclosure-related violence was identified as a major barrier to APN that prevents index clients from listing sexual partners. Conclusions Incidents of interpersonal violence have been reported following HIV-disclosure and fear of interpersonal violence strongly influences APN participation. Addressing HIV perception and stigma may contribute to APN uptake and program safety. Prospective research on interpersonal violence involving index clients and sexual partners in refugee settlements is needed to facilitate safe engagement in APN for this vulnerable population.
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Affiliation(s)
- Robin E Klabbers
- Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Timothy R Muwonge
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Ayikobua
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diego Izizinga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ingrid V Bassett
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Miranda Ravicz
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gonnie Klabbers
- Department of Health, Ethics and Society, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, Washington, USA
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10
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Kubiak RW, Sveum EM, Faustin Z, Muwonge T, Zaidi HA, Kambugu A, Masereka S, Kasozi J, Bassett IV, O'Laughlin KN. Prevalence and risk factors for hypertension and diabetes among those screened in a refugee settlement in Uganda. Confl Health 2021; 15:53. [PMID: 34225741 PMCID: PMC8256510 DOI: 10.1186/s13031-021-00388-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/18/2021] [Indexed: 12/25/2022] Open
Abstract
Background Diabetes and hypertension are increasingly prevalent in low and middle income countries, but they are not well documented in refugee settlements in these settings. We sought to estimate the prevalence and associated characteristics of diabetes and hypertension among adults presenting for clinic-based HIV testing in Nakivale Refugee Settlement in Uganda. Methods HIV-negative adults presenting to outpatient clinics for HIV testing at three health centers in Nakivale Refugee Settlement were enrolled from January 2019 through January 2020. Multi-lingual research assistants administered questionnaires aloud to ascertain medical history and sociodemographic information. The research assistants used standardized procedures to measure participants’ blood pressure to detect hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg), and conduct a point-of-care blood glucose test for diabetes (random blood glucose ≥11.1 mmol/L with self-reported frequent urination or thirst, or fasting blood glucose ≥7.0 mmol/L regardless of symptoms), as per Uganda Ministry of Health guidelines. We used χ-square or Fisher’s exact test to test for differences in disease prevalence by refugee status and log-binomial or Poisson regression models to estimate associations of immigration status and country of origin, respectively, with hypertension and diabetes while controlling for age, sex, education level, and body mass index. Results Among 2127 participants, 1379 (65%) were refugees or asylum seekers and 748 (35%) were Ugandan nationals. Overall, 32 participants met criteria for diabetes (1.5%, 95% CI 1.1–2.1%) and the period prevalence was 2.3% (95% CI 1.7–3.0). There were 1067 (50%, 95% CI 48.0–52.2%) who met the criteria for pre-hypertension and 189 (9%, 95% CI 7.7–10.1%) for hypertension. These proportions did not vary by immigration status or country of origin in univariate tests or multivariable regression models. Conclusions Hypertension was common and diabetes was uncommon among those screened in a Ugandan refugee settlement. Routine blood pressure screening should be considered in this setting. Additional research could develop diabetes screening criteria to help identify at risk individuals in this limited resource setting.
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Affiliation(s)
- Rachel W Kubiak
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Elinor M Sveum
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Timothy Muwonge
- Infectious Diseases Institute, Makerere Univesity, Kampala, Uganda
| | | | - Andrew Kambugu
- Infectious Diseases Institute, Makerere Univesity, Kampala, Uganda
| | | | - Julius Kasozi
- United Nations High Commissioner for Refugees, Kampala, Uganda
| | - Ingrid V Bassett
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelli N O'Laughlin
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA. .,Department of Global Health, University of Washington, Seattle, WA, USA.
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11
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O'Laughlin KN, Greenwald K, Rahman SK, Faustin ZM, Ashaba S, Tsai AC, Ware NC, Kambugu A, Bassett IV. A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study. AIDS Behav 2021; 25:1729-1736. [PMID: 33263892 PMCID: PMC8081685 DOI: 10.1007/s10461-020-03102-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/21/2022]
Abstract
The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.
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Affiliation(s)
- Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Kelsy Greenwald
- Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA
| | | | | | | | - Alexander C Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Norma C Ware
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Kambugu
- Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Ingrid V Bassett
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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12
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Rodriguez RM, Torres JR, Chang AM, Haggins AN, Eucker SA, O'Laughlin KN, Anderson E, Miller DG, Wilkerson RG, Caldwell M, Lim SC, Raja AS, Baumann BM, Graterol J, Eswaran V, Chinnock B. The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study. Ann Emerg Med 2021; 78:502-510. [PMID: 34272104 PMCID: PMC8165082 DOI: 10.1016/j.annemergmed.2021.05.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/09/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022]
Abstract
Study objective Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care. Methods This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt. Results Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED. Conclusion ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA.
| | - Jesus R Torres
- Department of Emergency Medicine, Olive View UCLA Medical Center-University of California Los Angeles School of Medicine, Los Angeles, CA
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Stephanie A Eucker
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, NC
| | - Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Daniel G Miller
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD
| | - Martina Caldwell
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Stephen C Lim
- Section of Emergency Medicine, University Medical Center New Orleans, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Joseph Graterol
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Vidya Eswaran
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Brian Chinnock
- Department of Emergency Medicine, University of California San Francisco Fresno, Fresno, CA
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13
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O'Laughlin KN, Xu A, Greenwald KE, Kasozi J, Parker RA, Bustamante N, Parmar P, Faustin ZM, Walensky RP, Bassett IV. A cohort study to assess a communication intervention to improve linkage to HIV care in Nakivale Refugee Settlement, Uganda. Glob Public Health 2020; 16:1848-1855. [PMID: 33222633 DOI: 10.1080/17441692.2020.1847310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Communication interventions to enhance linkage to HIV care have been successful in sub-Saharan Africa but have not been assessed among refugees. Refugees and Ugandan nationals participating in HIV testing in Nakivale Refugee Settlement were offered weekly phone call and short message service (SMS) reminders. We assessed linkage to care and predictors of linkage within 90 days of testing, comparing Intervention participants to those unwilling or ineligible to participate (Non-Intervention). Of 208 individuals diagnosed with HIV, 101 (49%) participated in the intervention. No difference existed between Intervention and Non-intervention groups in linkage to care (73 [72%] vs. 76 [71%], p = 0.88). Excluding those who linked prior to receipt of intervention, the intervention improved linkage (69 [68%] vs. 50 [47%], p = 0.002). Participants were more likely to link if they were older (aOR 2.39 [1.31, 4.37], p = 0.005) or Ugandan nationals (aOR 3.76 [1.12, 12.66], p = 0.033). Although the communication intervention did not significantly improve linkage to HIV care, the linkage was improved when excluding those with same-day linkage. Excluding participants without a phone was a significant limitation; these data are meant to inform more rigorous designs moving forward. Innovative methods to improve linkage to HIV care for this vulnerable population are urgently needed.
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Affiliation(s)
- Kelli N O'Laughlin
- Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Julius Kasozi
- United Nations High Commissioner for Refugees, Representation in Uganda, Kampala, Uganda
| | - Robert A Parker
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nirma Bustamante
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Parveen Parmar
- Division of Global Emergency Medicine, Department of Emergency Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Rochelle P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Brigham & Women's Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ingrid V Bassett
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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14
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Chai PR, Carreiro S, Chapman BP, Boyer EW, O'Laughlin KN. Federal Funding in Emergency Medicine: Demographics and Perspectives of Awardees. West J Emerg Med 2020; 21:304-312. [PMID: 32191187 PMCID: PMC7081857 DOI: 10.5811/westjem.2019.12.45249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/08/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency physicians face multiple challenges to obtaining federal funding. The objective of this investigation was to describe the demographics of federally-funded emergency physicians and identify key challenges in obtaining funding. METHODS We conducted a retrospective database search of the National Institutes of Health (NIH) Research Portfolio Online Reporting Tool (NIH RePORTER) to collect data regarding the distribution and characteristics of federally-funded grants awarded to emergency medicine (EM) principal investigators between 2010-2017. An electronic survey was then administered to the identified investigators to obtain additional demographic data, and information regarding their career paths, research environment, and perceived barriers to obtaining federal funding. RESULTS We identified 219, corresponding to 51 unique, mentored career development awardees and 105 independent investigators. Sixty-two percent of investigators responded to the electronic survey. Awardees were predominantly White males, although a larger portion of the mentored awardee group was female. Greater than half of respondents reported their mentor to be outside of the field of EM. The most common awarding institution was the National Heart Lung and Blood Institute. Respondents identified barriers in finding adequate mentorship, time to gather preliminary data, and the quality of administrative support. CONCLUSION The last five years have showed a trend toward increasing grants awarded to EM investigators; however, we identified several barriers to funding. Initiatives geared toward support and mentorship of junior faculty, particularly to females, minorities, and those in less heavily funded areas of the country are warranted.
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Affiliation(s)
- Peter R Chai
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts.,The Fenway Institute, Boston, Massachusetts.,Massachusetts Institute of Technology, The Koch Institute for Integrated Cancer Research, Cambridge, Massachusetts
| | - Stephanie Carreiro
- University of Massachusetts Medical Center, Department of Emergency Medicine, Division of Medical Toxicology, Worcester, Massachusetts
| | - Brittany P Chapman
- University of Massachusetts Medical Center, Department of Emergency Medicine, Division of Medical Toxicology, Worcester, Massachusetts
| | - Edward W Boyer
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts.,The Fenway Institute, Boston, Massachusetts
| | - Kelli N O'Laughlin
- University of Washington, Department of Emergency Medicine, Seattle, Washington.,University of Washington, Department of Global Health, Seattle, Washington
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15
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O'Laughlin KN, Rouhani SA, Kasozi J, Greenwald KE, Perkons NR, Faustin ZM, Bassett IV, Ware NC. A qualitative approach to understand antiretroviral therapy (ART) adherence for refugees living in Nakivale Refugee Settlement in Uganda. Confl Health 2018; 12:7. [PMID: 29545828 PMCID: PMC5846232 DOI: 10.1186/s13031-018-0145-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/12/2018] [Indexed: 01/24/2023] Open
Abstract
Background Refugees living with HIV in sub-Saharan Africa suffer unique hardships that may increase their vulnerability to interruptions in antiretroviral therapy (ART). Methods To investigate refugees’ experiences adhering to ART, we conducted inperson interviews with refugees on ART (n = 73) and HIV clinic staff (n = 4) in Nakivale Refugee Settlement in southwest Uganda from March to July 2011. Three analysts used a conventional content analysis approach to evaluate these data. Results Refugees described profound motivation to adhere to ART and employed adherence strategies to facilitate success despite the austere setting. However, refugees spoke of specific hardships living in Nakivale that served as barriers to ART adherence, including difficulty accessing clinic when ill, food insecurity, drug stockouts, and violence and unrest in the settlement. For some refugees, need for ART inextricably linked them to the HIV clinic and prevented them from transitioning permanently away from the settlement. Conclusions By learning about refugees’ experiences we can design informed interventions to enhance ART adherence, thus minimizing morbidity and mortality, preventing transmission of HIV, and supporting refugees’ abilities to move freely toward repatriation, resettlement or integration in their host country.
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Affiliation(s)
- Kelli N O'Laughlin
- 1Division of International Emergency Medicine and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,2Medical Practice Evaluation Center, Department of Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Shada A Rouhani
- 1Division of International Emergency Medicine and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Julius Kasozi
- United Nations High Commissioner for Refugees, P.O. Box 3813, Kampala, Uganda
| | - Kelsy E Greenwald
- 3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA.,11Harvard Affiliated Emergency Medicine Residency, 75 Francis Street, Boston, MA 02115 USA
| | | | | | - Ingrid V Bassett
- 2Medical Practice Evaluation Center, Department of Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA.,7Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA.,8Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 0213 USA
| | - Norma C Ware
- 9Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,10Department of Global Health & Social Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
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16
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O'Laughlin KN, Kasozi J, Rabideau DJ, Parker RA, Mulogo E, Faustin ZM, Greenwald KE, Doraiswamy S, Walensky RP, Bassett IV. The cascade of HIV care among refugees and nationals in Nakivale Refugee Settlement in Uganda. HIV Med 2017; 18:513-518. [PMID: 28070923 DOI: 10.1111/hiv.12476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Refugees living in Uganda come from HIV-endemic countries, and many remain in refugee settlements for over a decade. Our objective was to evaluate the HIV care cascade in Nakivale Refugee Settlement and to assess correlates of linkage to care. METHODS We prospectively enrolled individuals accessing clinic-based HIV testing in Nakivale Refugee Settlement from March 2013 to July 2014. Newly HIV-diagnosed clients were followed for 3 months post-diagnosis. Clients underwent a baseline survey. The following outcomes were obtained from HIV clinic registers in Nakivale: clinic attendance ('linkage to HIV care'), CD4 testing, antiretroviral therapy (ART) eligibility, and ART initiation within 90 days of testing. Descriptive data were reported as frequency with 95% confidence interval (CI) or median with interquartile range (IQR). The impact of baseline variables on linkage to care was assessed with logistic regression models. RESULTS Of 6850 adult clients tested for HIV, 276 (4%; CI: 3-5%) were diagnosed with HIV infection, 148 (54%; CI: 47-60%) of those were linked to HIV care, 54 (20%; CI: 15-25%) had a CD4 test, 22 (8%; CI: 5-12%) were eligible for ART, and 17 (6%; CI: 3-10%) initiated ART. The proportions of refugees and nationals at each step of the cascade were similar. We identified no significant predictors of linkage to care. CONCLUSIONS Less than a quarter of newly HIV-diagnosed clients completed ART assessment, considerably lower than in other reports from sub-Saharan Africa. Understanding which factors hinder linkage to and engagement in care in the settlement will be important to inform interventions specific for this environment.
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Affiliation(s)
- K N O'Laughlin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard Humanitarian Initiative, Cambridge, MA, USA
| | - J Kasozi
- Representation in Uganda, United Nations High Commissioner for Refugees, Kampala, Uganda
| | - D J Rabideau
- Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA
| | - R A Parker
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - E Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Z M Faustin
- Kasese Campus, Bugema University, Kampala, Uganda
| | | | - S Doraiswamy
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - R P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - I V Bassett
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Boston, Massachusetts, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
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17
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O'Laughlin KN, Rabideau DJ, Kasozi J, Parker RA, Bustamante ND, Faustin ZM, Greenwald KE, Walensky RP, Bassett IV. Predictors of HIV infection: a prospective HIV screening study in a Ugandan refugee settlement. BMC Infect Dis 2016; 16:695. [PMID: 27881099 PMCID: PMC5120554 DOI: 10.1186/s12879-016-2021-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 11/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The instability faced by refugees may place them at increased risk of exposure to HIV infection. Nakivale Refugee Settlement in southwestern Uganda hosts 68,000 refugees from 11 countries, many with high HIV prevalence. We implemented an HIV screening program in Nakivale and examined factors associated with new HIV diagnosis. METHODS From March 2013-November 2014, we offered free HIV screening to all clients in the Nakivale Health Center while they waited for their outpatient clinic visit. Clients included refugees and Ugandan nationals accessing services in the settlement. Prior to receiving the HIV test result, participants were surveyed to obtain demographic information including gender, marital status, travel time to reach clinic, refugee status, and history of prior HIV testing. We compared variables for HIV-infected and non-infected clients using Pearson's chi-square test, and used multivariable binomial regression models to identify predictors of HIV infection. RESULTS During the HIV screening intervention period, 330 (4%) of 7766 individuals tested were identified as HIV-infected. Refugees were one quarter as likely as Ugandan nationals to be HIV-infected (aRR 0.27 [0.21, 0.34], p < 0.0001). Additionally, being female (aRR 1.43 [1.14, 1.80], p = 0.002) and traveling more than 1 h to the clinic (aRR 1.39 [1.11, 1.74], p = 0.003) increased the likelihood of being HIV-infected. Compared to individuals who were married or in a stable relationship, being divorced/separated/widowed increased the risk of being HIV-infected (aRR 2.41 [1.88, 3.08], p < 0.0001), while being single reduced the risk (aRR 0.60 [0.41, 0.86], p < 0.0001). Having been previously tested for HIV (aRR 0.59 [0.47, 0.74], p < 0.0001) also lowered the likelihood of being HIV-infected. CONCLUSIONS In an HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk of having HIV than refugees. The high HIV prevalence among clients seeking outpatient care, including Ugandan nationals and refugees, warrants enhanced HIV screening services in Nakivale and in the surrounding region. Findings from this research may be relevant for other refugee settlements in Sub-Saharan Africa hosting populations with similar demographics, including the 9 other refugee settlements in Uganda.
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Affiliation(s)
- Kelli N O'Laughlin
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA. .,Harvard Humanitarian Initiative, Cambridge, MA, USA.
| | - Dustin J Rabideau
- MGH Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
| | - Julius Kasozi
- United Nations High Commissioner for Refugees, Representation in Uganda, PO Box 3813, Kampala, Uganda
| | - Robert A Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,MGH Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nirma D Bustamante
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Brigham & Women's Hospital, Boston, MA, USA
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114-2698, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
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18
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Rouhani SA, O'Laughlin KN, Faustin ZM, Tsai AC, Kasozi J, Ware NC. The role of social support on HIV testing and treatment adherence: A qualitative study of HIV-infected refugees in southwestern Uganda. Glob Public Health 2016; 12:1051-1064. [PMID: 26783835 DOI: 10.1080/17441692.2015.1132472] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment.
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Affiliation(s)
- Shada A Rouhani
- a Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA.,b Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
| | - Kelli N O'Laughlin
- a Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA.,b Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA.,c Medical Practice Evaluation Center , Massachusetts General Hospital , Boston , MA , USA
| | | | - Alexander C Tsai
- e Massachusetts General Hospital (MGH) , MGH Global Health , Boston , MA , USA.,f Harvard Center for Population and Development Studies , Cambridge , MA , USA
| | - Julius Kasozi
- g United Nations High Commissioner for Refugees , Kampala , Uganda
| | - Norma C Ware
- h Department of Global Health and Social Medicine , Harvard Medical School , Boston , MA , USA
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19
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O'Laughlin KN, Rouhani SA, Faustin ZM, Ware NC. Testing experiences of HIV positive refugees in Nakivale Refugee Settlement in Uganda: informing interventions to encourage priority shifting. Confl Health 2013; 7:2. [PMID: 23409807 PMCID: PMC3645965 DOI: 10.1186/1752-1505-7-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/10/2013] [Indexed: 11/10/2022] Open
Abstract
Background Recent initiatives by international health and humanitarian aid organizations have focused increased attention on making HIV testing services more widely available to vulnerable populations. To realize potential health benefits from new services, they must be utilized. This research addresses the question of how utilization of testing services might be encouraged and increased for refugees displaced by conflict, to make better use of existing resources. Methods Open-ended interviews were conducted with HIV-infected refugees (N=73) who had tested for HIV and with HIV clinic staff (N=4) in Nakivale Refugee Settlement in southwest Uganda. Interviews focused on accessibility of HIV/AIDS-related testing and care and perspectives on how to improve utilization of testing services. Data collection took place at the Nakivale HIV/AIDS Clinic from March to July of 2011. An inductive approach to data analysis was used to identify factors related to utilization. Results In general, interviewees report focusing daily effort on tasks aimed at meeting survival needs. HIV testing is not prioritized over these responsibilities. Under some circumstances, however, HIV testing occurs. This happens when: (a) circumstances realign to trigger a temporary shift in priorities away from daily survival-related tasks; (b) survival needs are temporarily met; and/or (c) conditions shift to alleviate barriers to HIV testing. Conclusion HIV testing services provided for refugees must be not just available, but also utilized. Understanding what makes HIV testing possible for refugees who have tested can inform interventions to increase testing in this population. Intervening by encouraging priority shifts toward HIV testing, by helping ensure survival needs are met, and by eliminating barriers to testing, may result in refugees making better use of existing testing services.
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Affiliation(s)
- Kelli N O'Laughlin
- Brigham & Women's Hospital, 75 Francis Street, Boston, Massachusetts, 02115, USA.
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