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De Schacht C, Amorim G, Calvo L, Ntasis E, Van Rompaey S, Matsimbe J, Martinho S, Graves E, Sardella Alvim MF, Green A, Kassim H, Carlos IC, Wester CW, Audet CM. Time spent at health facility is a key driver of patient satisfaction, but did not influence retention to HIV care: A serial cross-sectional study in Mozambique. PLoS One 2024; 19:e0299282. [PMID: 38635537 PMCID: PMC11025808 DOI: 10.1371/journal.pone.0299282] [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: 05/03/2023] [Accepted: 02/07/2024] [Indexed: 04/20/2024] Open
Abstract
INTRODUCTION Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. METHODS Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. RESULTS Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]). CONCLUSIONS Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.
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Affiliation(s)
| | - Gustavo Amorim
- Department of Biostatistics, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
| | - Lázaro Calvo
- Friends in Global Health (FGH), Quelimane, Mozambique
| | | | | | | | | | - Erin Graves
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
| | | | - Ann Green
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
| | - Hidayat Kassim
- Provincial Health Directorate of Zambézia, Quelimane, Mozambique
- United Nations Funds for Development (UNFDP), Beira, Mozambique
| | - Inoque Carlos Carlos
- Operations Research Unit, Provincial Health Directorate of Zambézia, Quelimane, Mozambique
| | - C. William Wester
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, United States of America
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Graves E, Brooks HL, De Schacht C, Emílio A, Matino A, Aboobacar A, Audet CM. Healthcare Providers' Perspectives on a Novel Couple-Based HIV Treatment Intervention: A Qualitative Assessment of the Facilitators, Barriers, and Proposed Improvements to Implementation in Zambézia Province, Mozambique. AIDS Behav 2024; 28:1370-1383. [PMID: 38151664 DOI: 10.1007/s10461-023-04224-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/29/2023]
Abstract
Mozambique has one of the world's highest HIV/AIDS burdens. Despite significant investment in HIV care and treatment, pregnant and lactating women's retention in care remains suboptimal. One reason for poor maternal retention is lack of male partner support. We tested an interventional couple-based HIV care and treatment, including joint clinical appointments and couple-based educational and support sessions provided by a health counselor and peer educators, respectively. Healthcare providers delivering care for seroconcordant individuals were interviewed regarding their perspectives on facilitators and barriers to the couple-based intervention implementation. Analysis of interview responses was done using MAXQDA. Results pertaining to providers' perspectives on implementation and intervention characteristics were organized, interpreted, and contextualized using the Consolidated Framework for Implementation Research (CFIR 2.0), while providers' suggestions for improvements were coded and organized apart from CFIR. Providers felt the intervention was largely compatible with the local culture, and offered a significant advantage over standard individual-based care by facilitating patient follow-up and reducing wait times by prioritizing couples for services. They also believed it facilitated HIV treatment access through the provision of couple-based counseling that encouraged supportive behaviors towards retention. However, providers reported insufficient privacy to deliver couple-based care at some health facilities and concerns that women in difficult relationships may struggle to meaningfully participate. They suggested providing sessions in alternate clinic settings and offering a limited number of women-only visits. The facilitators and barriers described here contribute to informing the design and implementation of future couple-based interventions to improve HIV care for seroconcordant expectant couples.
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Affiliation(s)
- Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.
| | - Hannah L Brooks
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | | | | | | | - Arifo Aboobacar
- Provincial Health Directorate of Zambézia, Quelimane, Mozambique
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
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Gibas KM, Ahonkhai AA, Huang A, van Wyk C, Tsiga-Ahmed FI, Musa BM, Sani MU, Audet CM, Wester CW, Aliyu MH. The V-BRCH Project: Strengthening HIV Research Capacity in Nigeria through Intensive Workshops in Implementation Science and Grant Writing. Am J Trop Med Hyg 2024; 110:534-539. [PMID: 38350133 PMCID: PMC10919197 DOI: 10.4269/ajtmh.23-0711] [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: 10/13/2023] [Accepted: 11/20/2023] [Indexed: 02/15/2024] Open
Abstract
As persons with HIV live longer as the result of antiretroviral therapy, morbidity from HIV-associated noncommunicable diseases (NCDs) is increasing. The Vanderbilt-Nigeria Building Research Capacity in HIV and Noncommunicable Diseases program is a training platform created with the goal of training a cohort of successful Nigerian investigators to become leaders in HIV-associated NCD research. We describe survey findings from two week-long workshops in Kano, Nigeria, where trainees received instruction in implementation science and grant writing. Surveys assessed participants' self-perceived knowledge and confidence in topics taught during these workshops. Thirty-seven participants (all assistant professors) attended the implementation science workshop; 30 attended the grant-writing workshop. Response rates for the implementation science workshop were 89.2% for the preworkshop survey and 91.9% for the postworkshop survey. For the grant-writing workshop, these values were 88.2% and 85.3%, respectively. Improvement in participant knowledge and confidence was observed in every domain measured for both workshops. On average, a 101.4% increase in knowledge and a 118.0% increase in confidence was observed across measured domains among participants in the implementation science workshop. For the grant-writing workshop, there was a 68.8% increase in knowledge and a 70.3% increase in confidence observed. Participants rated the workshops and instructors as effective for both workshops. These workshops improved participants' knowledge and competence in implementation science and grant writing, and provide a model for training programs that aim to provide physician scientists with the skills needed to compete for independent funding, conduct locally relevant research, and disseminate research findings.
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Affiliation(s)
- Kevin M. Gibas
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Epidemiology & Infection Prevention, Rhode Island Hospital, Providence, Rhode Island
| | - Aima A. Ahonkhai
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander Huang
- Vanderbilt Institute for Global Health, Nashville, Tennessee
| | - Chelsea van Wyk
- Vanderbilt Institute for Global Health, Nashville, Tennessee
| | | | - Baba M. Musa
- Department of Medicine, Bayero University, Kano, Nigeria
| | | | | | | | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Nashville, Tennessee
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Audet CM, Seabi T, Oyekunle T, Hove J, Wagner RG. A individually randomized controlled trial comparing Healer-led vs. clinician- led training to improve personal protective equipment use among traditional healers in South Africa. PLOS Glob Public Health 2024; 4:e0002945. [PMID: 38394119 PMCID: PMC10889871 DOI: 10.1371/journal.pgph.0002945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
Like allopathic healthcare workers, healers are also exposed to patients' blood and body fluids. A widespread practice is the traditional "injection," in which the healer performs subcutaneous incisions to rub herbs directly into the bloodied skin, resulting in 1,500 blood exposures over their lifetime. We tested the impact of healer-led PPE training, staffed by trained traditional healers who reported using PPE during each risky clinical encounter vs. healthcare worker (HCW)-led PPE training sessions. We randomized 136 healers into one of the two study arms (67 in the healer-led group, 69 in the HCW-led group) and assessed the impact of trainer on PPE skills and use over a six-month period. All healers received one in-person day of didactic and practical training followed by three sessions at the healers' home. Participants were largely female (80%), averaged 51 years old, and practiced as a healer for an average of 17 years. Almost 44% either disclosed themselves as HIV+ or received a positive HIV test result at study initiation. Healers in the HCW arm showed equivalent PPE scores as those trained by traditional healers at baseline and at seven months. Healers in both arms self-reported high levels of glove use during"injections," with no statistical difference of use by study arm. When we assessed actual gloves and razor blades disposed of each month, a similar trend emerged. No one seroconverted during the study period. The need for PPE support among traditional healers cannot be ignored. Traditional healers can be trained to effectively disseminate PPE knowledge and skills to other traditional healers. With an estimated 200,000 traditional healers in South Africa, it is imperative that all of them have access to PPE training and supplies to prevent HIV, HCV, or HBV infections. Trial registration: ClinicalTrials.gov, NCT04440813. Registered 17 June 2020, https://clinicaltrials.gov/ct2/show/NCT04440813.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, United States of America
| | - Tshegofatso Seabi
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Taofik Oyekunle
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, United States of America
| | - Jennifer Hove
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ryan G. Wagner
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Sack DE, Seabi TM, Frisby MB, Diemer MA, Ndlovu GH, Wagner RG, Audet CM. Exploratory validation of relationship functioning and non-pregnant partner behavior scales in pregnant people living with HIV in Mpumalanga Province, South Africa. Glob Health Action 2023; 16:2210882. [PMID: 37171405 PMCID: PMC10184612 DOI: 10.1080/16549716.2023.2210882] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Partner engagement in antenatal care can improve care for pregnant people living with HIV. However, concerns about engaging unsupportive non-pregnant partners warrant further study to avoid engaging partners who pressure their pregnant partner to refuse testing or treatment and/or perpetuate intimate partner violence. We adapted established relationship functioning and partner behaviour questionnaires among pregnant people living with HIV initiating antenatal care in rural South Africa. We identified 13 previously validated psychometric scales with 255 items that assess relationship functioning and partner behaviour, but, to our knowledge, had not been used in Southern Africa. After item translation and cognitive interviewing with 30 pregnant people, we recruited an additional 208 pregnant people living with HIV receiving antenatal care. We conducted an exploratory factor analysis with maximum-likelihood extraction and oblique promax rotation with the 58 items and 10 scales that remained after translation and cognitive interviewing. We used parallel analysis, scree plots, and the Kaiser criterion to guide factor retention and assessed internal factor consistency via Cronbach's alpha. Of the 208 participants recruited, 197 (95%) answered each question and were included in the analysis. Exploratory factor analysis revealed 7 factors that assessed partner social support, sexual relationship power, emotional intimacy, threatened or enacted violence, sexual intimacy, violence in relationships, and partner engagement in pregnancy care via 37 items. Factor absolute Spearman correlations ranged from 0.012 to 0.518 and Cronbach's alpha ranged from 0.84 to 0.92. This preliminary analysis will guide further scale development. Future developments will also include relevant clinical outcomes to assess the predictive validity of the resulting measures. These steps will further refine these questions into a succinct screening tool to assess relationship functioning and partner behaviour. This screening tool may eventually guide the selection of partner-based interventions during pregnancy to improve outcomes for pregnant people and their partners.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tshegofatso M Seabi
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael B Frisby
- Department of Educational Policy Studies and the Research, Measurement, and Statistics Program, College of Education and Human Development, Georgia State University, Atlanta, GA, USA
| | | | - Godfrey H Ndlovu
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ryan G Wagner
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyn M Audet
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Brooks HL, Graves E, De Schacht C, Emílio A, Matino A, Aboobacar A, Audet CM. "If it weren't for this, we'd be sick" - Perspectives from participants of a couple-based HIV treatment and support program during prenatal and postpartum periods in Zambézia Province, Mozambique. J Acquir Immune Defic Syndr 2023:00126334-990000000-00336. [PMID: 38032747 DOI: 10.1097/qai.0000000000003351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Hannah L Brooks
- MSc, BSc; Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Nashville, TN, USA
| | - Erin Graves
- MPH, BSN; Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Nashville, TN, USA
| | | | - Almiro Emílio
- BSc; Friends in Global Health, Quelimane, Mozambique
| | - Ariano Matino
- BSc; Friends in Global Health, Quelimane, Mozambique
| | - Arifo Aboobacar
- BSc; Provincial Health Directorate of Zambézia, Quelimane, Mozambique
| | - Carolyn M Audet
- PhD, MSc; Vanderbilt University Medical Center, Institute for Global Health and Department of Health Policy, Nashville, TN, USA
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Sack DE, Matino A, Graves E, Emilio A, Shepherd BE, De Schacht C, Audet CM. Correlated depressive symptoms within seroconcordant, expectant partners living with HIV in Zambézia Province, Mozambique: a cross-sectional study. AIDS Care 2023; 35:1732-1740. [PMID: 36473205 PMCID: PMC10241982 DOI: 10.1080/09540121.2022.2151558] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A post hoc analysis assessed covariate-adjusted rank correlation between partner depressive symptoms. Females were younger than males (median 23 vs. 28 years) and more likely to report no education (20.7% vs. 7.9%). Approximately 10% screened positive for depression (PHQ-9 score ≥ 10). Partner depressive symptoms were predictive of higher participant PHQ-9 scores. A male partner PHQ-9 score of 10 (versus 5) increased the odds that the female partner would have a higher PHQ-9 score (adjusted odds ratio: 7.25, 95% Confidence Interval [CI]: 5.43-9.67). Partner PHQ-9 scores were highly correlated after covariate adjustment (Spearman's rho 0.65, 95% CI 0.57-0.72). Interventions aimed to reduce depressive symptoms and improve HIV-related outcomes during pregnancy should address both partners' depressive symptoms.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Bryan E Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
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Lewis JA, Bonnet K, Schlundt DG, Byerly S, Lindsell CJ, Henschke CI, Yankelevitz DF, York SJ, Hendler F, Dittus RS, Vogus TJ, Kripalani S, Moghanaki D, Audet CM, Roumie CL, Spalluto LB. Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study. Front Health Serv 2023; 3:1209720. [PMID: 37674596 PMCID: PMC10477991 DOI: 10.3389/frhs.2023.1209720] [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] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/04/2023] [Indexed: 09/08/2023]
Abstract
Introduction To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members. Methods Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation. Results A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior. Discussion Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.
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Affiliation(s)
- Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David G. Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susan Byerly
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
- Veterans Health Administration—Phoenix VA Health Care System, Radiology Service, Phoenix, AZ, United States
| | - David F. Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
| | - Sally J. York
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Fred Hendler
- Rex Robley VA Medical Center, Medicine Service, Louisville, KY, United States
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy J. Vogus
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, United States
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Drew Moghanaki
- Veterans Health Administration—Greater Los Angeles Veterans Affairs Medical Center, Radiation Oncology Service, Los Angeles, CA, United States
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Carolyn M. Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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Sack DE, Shepherd BE, Audet CM, De Schacht C, Samuels LR. Inverse Probability Weights for Quasicontinuous Ordinal Exposures With a Binary Outcome: Method Comparison and Case Study. Am J Epidemiol 2023; 192:1192-1206. [PMID: 37067471 PMCID: PMC10505412 DOI: 10.1093/aje/kwad085] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/23/2023] [Accepted: 04/07/2023] [Indexed: 04/18/2023] Open
Abstract
Inverse probability weighting (IPW), a well-established method of controlling for confounding in observational studies with binary exposures, has been extended to analyses with continuous exposures. Methods developed for continuous exposures may not apply when the exposure is quasicontinuous because of irregular exposure distributions that violate key assumptions. We used simulations and cluster-randomized clinical trial data to assess 4 approaches developed for continuous exposures-ordinary least squares (OLS), covariate balancing generalized propensity scores (CBGPS), nonparametric covariate balancing generalized propensity scores (npCBGPS), and quantile binning (QB)-and a novel method, a cumulative probability model (CPM), in quasicontinuous exposure settings. We compared IPW stability, covariate balance, bias, mean squared error, and standard error estimation across 3,000 simulations with 6 different quasicontinuous exposures, varying in skewness and granularity. In general, CBGPS and npCBGPS resulted in excellent covariate balance, and npCBGPS was the least biased but the most variable. The QB and CPM approaches had the lowest mean squared error, particularly with marginally skewed exposures. We then successfully applied the IPW approaches, together with missing-data techniques, to assess how session attendance (out of a possible 15) in a partners-based clustered intervention among pregnant couples living with human immunodeficiency virus in Mozambique (2017-2022) influenced postpartum contraceptive uptake.
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Affiliation(s)
- Daniel E Sack
- Correspondence to Dr. Daniel E. Sack, Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN 37203 (e-mail: )
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Audet CM, Sack DE, Ndlovu GH, Morkel C, Harris J, Wagner RG, Seabi TM. Women want male partner engagement in antenatal care services: A qualitative study of pregnant women from rural South Africa. PLoS One 2023; 18:e0283789. [PMID: 37011063 PMCID: PMC10069782 DOI: 10.1371/journal.pone.0283789] [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: 10/24/2022] [Accepted: 03/17/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION Evidence strongly shows that a supportive, involved male partner facilitates maternal HIV testing during pregnancy, increases maternal antiretroviral (ART) adherence and increases HIV-free infant survival. Partner engagement in antenatal care (ANC) is influential; however, the most effective strategy to engage male partners is currently unknown. Engaging pregnant women to understand whether male partner involvement is welcome in ANC, what this involvement entails and how best to invite their partner is an important first step in determining how best to engage male partners. METHODS We interviewed 36 pregnant women receiving ANC services at a district hospital in rural Mpumalanga, South Africa to assess the strengths and weaknesses of their current relationship, the type of partner support they receive, whether they would like their male partner to be involved in their ANC, and how best to invite their male partner to their appointments. We conducted a thematic analysis of the qualitative interviews using MAXQDA software. RESULTS Financial, emotional, and physical support were noted as important aspects of support currently provided by male partners, with most pregnant women wanting their partners to engage in ANC services during pregnancy. Preferred engagement strategies included participation in couple-based HIV testing and counseling, regular ANC appointment attendance, and delivery room presence. Women who reported a positive relationship with her partner were more likely to prefer inviting their partner without health facility assistance, while those who reported challenges in their relationship preferred assistance through a letter or community health worker. Pregnant women perceived regular business hours (due to their partner being employed and unable to take off work) and having a partner involved in multiple relationships as barriers in getting their partner to attend ANC services. DISCUSSION Rural South African women, even those in unsatisfactory relationships want their male partners to attend their ANC visits and birth. To make this possible, health facilities will have to tailor male partner engagement outreach strategies to the preferences and needs of the pregnant woman.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel E. Sack
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Godfrey H. Ndlovu
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Morkel
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jacob Harris
- Notre Dame University, Notre Dame, Indiana, United States of America
| | - Ryan G. Wagner
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tshegofatso M. Seabi
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sack DE, Emílio A, Graves E, Matino A, Paulo P, Aboobacar AU, De Schacht C, Audet CM. Attitudes and perceptions towards postpartum contraceptive use among seroconcordant partners with HIV in rural Mozambique: a qualitative study. Glob Health Res Policy 2023; 8:7. [PMID: 36918959 PMCID: PMC10014407 DOI: 10.1186/s41256-023-00292-4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/05/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Postpartum contraceptive uptake reduces short interpregnancy intervals, unintended pregnancies, and their negative sequalae: poor maternal and fetal outcomes. Healthy timing and spacing of pregnancy in people living with HIV (PLHIV) also allows time to achieve viral suppression to reduce parent-to-child HIV transmission. There is scant understanding about how couples-based interventions impact postpartum contraceptive uptake among PLHIV in sub-Saharan Africa. METHODS We interviewed 38 recently pregnant people and 26 of their partners enrolled in the intervention arm of the Homens para Saúde Mais (HoPS+) [Men for Health Plus] trial to assess their perceptions of, attitudes towards, and experiences with contraceptive use. Individuals in the HoPS+ intervention arm received joint-as opposed to individual-HIV-related services during pregnancy and postpartum periods, six counseling and skills sessions, and nine sessions with a peer support couple. Our thematic analysis of the 64 in-depth interviews generated 14 deductive codes and 3 inductive codes across themes within the Information, Motivation, and Behavior Model of health behavior change. RESULTS Participants reported accurate and inaccurate information about birth spacing and contraceptive methods. They described personal (health, economic, and religious) and social (gender norms, desired number of children) motivations for deciding whether to use contraceptives-with slightly different motivations among pregnant and non-pregnant partners. Finally, they explained the skills needed to overcome barriers to contraceptive use including how engagement in HoPS+ improved their shared decision-making skills and respect amongst partners-which facilitated postpartum contraceptive uptake. There were also several cases where non-pregnant partners unilaterally made family planning decisions despite disagreement from their partner. CONCLUSIONS These findings suggest that couples-based interventions during pregnancy and post-partum periods aimed at increasing postpartum contraceptive uptake must center pregnant partners' desires. Specifically, pregnant partners should be allowed to titrate the level of non-pregnant partner involvement in intervention activities to avoid potentially emboldening harmful gender-based intercouple decision-making dynamics.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.
| | | | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | | | - Paula Paulo
- Friends in Global Health, Quelimane, Mozambique
| | | | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
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Audet CM, Pettapiece-Phillips M, Kast K, White KD, Perkins JM, Marcovitz D. Implementation of a hospital-based intervention for MOUD initiation and referral to a Bridge Clinic for opioid use disorder. J Subst Use Addict Treat 2023; 146:208961. [PMID: 36880904 PMCID: PMC10018480 DOI: 10.1016/j.josat.2023.208961] [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: 05/09/2022] [Revised: 10/06/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Individuals struggling with opioid use disorder (OUD) utilize the adult emergency department (ED) and psychiatric emergency department at high rates. In 2019, Vanderbilt University Medical Center created a system for individuals identified in the emergency department with OUD to transition care to a Bridge Clinic for up to three months of comprehensive behavioral health treatment, alongside primary care, infectious diseases, and pain management, regardless of their insurance status. METHODS We conducted 20 interviews with patients enrolled in treatment in our Bridge Clinic and 13 providers in the psychiatric emergency department and emergency department. Our provider interviews focused on understanding experiences identifying people with OUD and referring them to care at the Bridge Clinic. Our patient interviews focused on understanding their experiences of care-seeking, the referral process, and their satisfaction with treatment at the Bridge Clinic. RESULTS Our analysis generated 3 major themes around patient identification, referral, and quality of care from providers and patients. The study found general agreement between both groups around the high quality of care delivered in the Bridge Clinic compared with OUD treatment at nearby treatment facilities, specifically because it offered a stigma-free environment for the delivery of medication for addiction therapy and psychosocial support. Providers highlighted the lack of a systematic strategy for identifying people with OUD in an ED setting. They also found the referral process cumbersome because it could not be done through EPIC and there were limited patient slots available. In contrast, patients reported a smooth and simple referral from the ED to the Bridge Clinic. CONCLUSIONS Creating a Bridge Clinic for comprehensive OUD treatment at a large university medical center has been challenging but has resulted in the creation of a comprehensive care system that prioritizes quality care. Funding to increase the number of patient slots available, coupled with an electronic system of patient referral, will increase the reach of the program to some of Nashville's most vulnerable constituents.
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Affiliation(s)
- Carolyn M Audet
- Department of Health Policy, Vanderbilt University, Nashville, TN 37203, USA.
| | | | - Kristopher Kast
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Katie D White
- Department Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Jessica M Perkins
- Department of Human and Organizational Development, Vanderbilt University, Nashville, TN 37203, USA.
| | - David Marcovitz
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Spalluto LB, Bonnet K, Sonubi C, Ernst LL, Wahab R, Reid SA, Agrawal P, Gregory K, Davis KM, Lewis JA, Berardi E, Hartsfield C, Selove R, Sanderson M, Schlundt D, Audet CM. Barriers to Implementation of Breast Cancer Risk Assessment: The Health Care Team Perspective. J Am Coll Radiol 2023; 20:342-351. [PMID: 36922108 PMCID: PMC10042588 DOI: 10.1016/j.jacr.2022.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/19/2022] [Accepted: 12/24/2022] [Indexed: 03/16/2023]
Abstract
PURPOSE To assess health care professionals' perceptions of barriers to the utilization of breast cancer risk assessment tools in the public health setting through a series of one-on-one interviews with health care team members. METHODS We conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with health care team members in the public health setting in the state of Tennessee between May 2020 and October 2020. An iterative inductive-deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual framework to depict influences of provider behavior in the utilization of breast cancer risk assessment. RESULTS A total of 24 interviews were completed, and a framework of influences of provider behavior in the utilization of breast cancer risk assessment was developed. Participants identified barriers to the utilization of breast cancer risk assessment (knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel); patient-level barriers as perceived by health care team members (psychological, economic, educational, and environmental); and strategies to increase the utilization of breast cancer risk assessment at the provider level (leadership buy-in, training, supportive policies, and incentives) and patient level (improved communication and better understanding of patients' perceived cancer risk and severity of cancer). CONCLUSIONS Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers as perceived by health care team members offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.
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Affiliation(s)
- Lucy B Spalluto
- Vice Chair of Health Equity, Associate Director of Diversity and Inclusion, Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; and Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee; RSNA Cochair, Health Equity Committee.
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Chiamaka Sonubi
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Laura L Ernst
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rifat Wahab
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio. https://twitter.com/RifatWahab
| | - Sonya A Reid
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, and Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pooja Agrawal
- University of Texas Medical Branch, John Sealy School of Medicine, Galveston, Texas
| | - Kris Gregory
- R. Ken Coit College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Katie M Davis
- Section Chief, Breast Imaging, Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer A Lewis
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; Co-director clinical lung screening program, Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee; and Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee; Rescue Lung Rescue Life Society Board Member
| | - Elizabeth Berardi
- Program Director, Tennessee Breast and Cervical Screening Program, Tennessee Department of Health, Nashville, Tennessee
| | - Crissy Hartsfield
- Clinical Programs Administrator, Division of Family Health and Wellness, Tennessee Department of Health, Nashville, Tennessee
| | - Rebecca Selove
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, and Director, Center for Prevention Research, Tennessee State University, Nashville, Tennessee
| | - Maureen Sanderson
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, and Department of Family and Community Medicine, Meharry Medical College, Nashville, Tennessee
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Associate Director of the Vanderbilt Center for Clinical Quality and Implementation Research and Associate Director of Research in Vanderbilt Institute for Global Health
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Spalluto LB, Bonnet K, Sonubi C, Reid SA, Lewis JA, Ernst LL, Davis KM, Wahab R, Agrawal P, D'Agostino C, Gregory K, Berardi E, Hartsfield C, Sanderson M, Selove R, Schlundt D, Audet CM. Black Women's Perspectives on Breast Cancer Risk Assessment. J Am Coll Radiol 2023; 20:314-323. [PMID: 36922105 PMCID: PMC10027374 DOI: 10.1016/j.jacr.2023.01.003] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/22/2022] [Accepted: 01/27/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE The aim of this study was to gather the perspectives of Black women on breast cancer risk assessment through a series of one-on-one interviews. METHODS The authors conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with Black women in Tennessee between September 2020 and November 2020. Guided by the Health Belief Model, qualitative analysis of interview data was performed in an iterative inductive and deductive approach and resulted in the development of a conceptual framework to depict influences on a woman's decision to engage with breast cancer risk assessment. RESULTS A total of 37 interviews were completed, and a framework of influences on a woman's decision to engage in breast cancer risk assessment was developed. Study participants identified several emerging themes regarding women's perspectives on breast cancer risk assessment and potential influences on women's decisions to engage with risk assessment. Much of women's decision context was based on risk appraisal (perceived severity of cancer and susceptibility of cancer), emotions (fear and trust), and perceived risks and benefits of having risk assessment. The decision was further influenced by modifiers such as communication, the risk assessment protocol, access to health care, knowledge, and health status. Perceived challenges to follow-up if identified as high risk also influenced women's decisions to pursue risk assessment. CONCLUSIONS Black women in this study identified several barriers to engagement with breast cancer risk assessment. Efforts to overcome these barriers and increase the use of breast cancer risk assessment can potentially serve as a catalyst to address existing breast cancer disparities. Continued work is needed to develop patient-centric strategies to overcome identified barriers.
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Affiliation(s)
- Lucy B Spalluto
- Vice Chair of Health Equity, Associate Director of Diversity and Inclusion, Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; and Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee; RSNA Cochair, Health Equity Committee.
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Chiamaka Sonubi
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sonya A Reid
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, and Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer A Lewis
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; Co-director clinical lung screening program, Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee; and Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee; Rescue Lung Rescue Life Society Board Member
| | - Laura L Ernst
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katie M Davis
- Section Chief, Breast Imaging, Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rifat Wahab
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio. https://twitter.com/%20RifatWahab
| | - Pooja Agrawal
- University of Texas Medical Branch, John Sealy School of Medicine, Galveston, Texas
| | - Chloe D'Agostino
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Kris Gregory
- R. Ken Coit College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Elizabeth Berardi
- Program Director, Tennessee Breast and Cervical Screening Program, Tennessee Department of Health, Nashville, Tennessee
| | - Crissy Hartsfield
- Clinical Programs Administrator, Division of Family Health and Wellness, Tennessee Department of Health, Nashville, Tennessee
| | - Maureen Sanderson
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, and Department of Family and Community Medicine, Meharry Medical College, Nashville, Tennessee
| | - Rebecca Selove
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, and Director, Center for Prevention Research, Tennessee State University, Nashville, Tennessee
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Associate Director of the Vanderbilt Center for Clinical Quality and Implementation Research and Associate Director of Research in Vanderbilt Institute for Global Health
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Audet CM, Seabi T, Ngobeni S, Berhanu RH, Wagner RG. Pulmonary tuberculosis vs. Tindzhaka and Mafularha: A mixed methods inquiry of traditional healers' perceptions of tuberculosis in rural South Africa. PLOS Glob Public Health 2023; 3:e0001611. [PMID: 37083848 PMCID: PMC10121049 DOI: 10.1371/journal.pgph.0001611] [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] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/20/2023] [Indexed: 04/22/2023]
Abstract
Although awareness of tuberculosis (TB) is high in South Africa, delays in TB testing or treatment persist. Even those with symptoms of TB often delay testing, with one study in Mpumalanga revealing a median allopathic care-seeking delay of four weeks. We sought to understand how traditional healers perceived TB symptoms among their patients, if they treated the disease, and what (if any) illnesses they defined as being traditional may have overlapping presentation with TB in South Africa. Nineteen traditional healers completed an in-depth interview (IDIs); 133 completed a quantitative survey about their treatment practices. IDIs focused on lung diseases treated, disease causation, treatment, and prognosis. Survey questions investigated diagnosis of lung ailments, including those treated by the allopathic health system and those by traditional healers. Traditional healers reported that they could differentiate between TB and traditional illnesses, like Tindzhaka and Mafularha, that presented with similar symptoms. Few (7.5%) believed they could treat TB, but the majority (72.9%) believed they could successfully treat Tindzhaka and Mafularha. Tindzhaka and Mafularha are interconnected illnesses that are reportedly caused by breaking social rules around death, sex and using the belongings of someone who recently passed away. Both, if not treated, are considered fatal. While we have no definitive data, traditional healers may be contributing to delays in the diagnosis and treatment for people with active TB by incorrectly diagnosing TB as Tindzhaka or Mafularha. Overcoming issues of trust and compensation, while respecting different forms of knowledge, are some of the challenges we face in successfully engaging with healers.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Tshegofatso Seabi
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sizzy Ngobeni
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Rebecca H Berhanu
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Ryan G Wagner
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Frisby MB, Diemer MA, Sack DE, Audet CM. Dyadic Validation of Relational Processes in Seroconcordant Mozambican Couples: Social Support, Physician Trust, and Stigma. AIDS Behav 2022; 26:4135-4143. [PMID: 35689708 PMCID: PMC9940156 DOI: 10.1007/s10461-022-03739-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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
Abstract
Psychometric instruments can quantify how people living with HIV experience three key barriers to antiretroviral therapy (ART) and retention: partner support, trust in medical professionals, and internalized HIV-related stigma. However, two challenges arise when using these instruments to measure and interpret relational processes among Mozambican couples, especially those participating in a couples intervention. First, relational measures have almost exclusively been developed and normed with Western, middle-class, and/or White adults. Second, traditional measurement approaches neglect the relational processes between partners. Using dyadic modeling, this paper demonstrates metric and scalar invariance for instruments measuring partner support (CFI = 0.964, TLI = 0.965, RMSEA = 0.034, SRMR = 0.052), trust in medical professionals (CFI = 0.978, TLI = 0.980, RMSEA = 0.033, SRMR = 0.039), and internalized HIV-related stigma (CFI = 0.960, TLI = 0.961, RMSEA = 0.050, SRMR = 0.060) within the novel context of seroconcordant HIV+ couples in Zambézia province.
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Affiliation(s)
| | | | - Daniel E Sack
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Carolyn M Audet
- Department of Health Policy and Institute for Global Health, Vanderbilt University, Nashville, TN, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in affiliation with the School of Public Health at University of the Witwatersrand, Johannesburg, South Africa
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Spencer HJJ, Katz S, Staub M, Audet CM, Banerjee R. A qualitative assessment of nonclinical drivers of pediatric outpatient antibiotic prescribing: The importance of continuity. Antimicrob Steward Healthc Epidemiol 2022; 2:e107. [PMID: 36483400 PMCID: PMC9726583 DOI: 10.1017/ash.2022.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Antibiotic overuse is common in outpatient pediatrics and varies across clinical setting and clinician type. We sought to identify social, behavioral, and environmental drivers of outpatient antibiotic prescribing for pediatric patients. METHODS We conducted semistructured interviews with physicians and advanced practice providers (APPs) across diverse outpatient settings including pediatric primary, urgent, and retail care. We used the grounded theory constant comparative method and a thematic approach to analysis. We developed a conceptual model, building on domains of continuity to map common themes and their relationships within the healthcare system. RESULTS We interviewed 55 physicians and APPs. Clinicians across all settings prioritized provision of guideline-concordant care but implemented these guidelines with varying degrees of success. The provision of guideline-concordant care was influenced by the patient-clinician relationship and patient or parent expectations (relational continuity); the clinician's access to patient clinical history (informational continuity); and the consistency of care delivered (management continuity). No difference in described themes was determined by setting or clinician type; however, clinicians in primary care described having more reliable relational and informational continuity. CONCLUSIONS Clinicians described the absence of long-term relationships (relational continuity) and lack of availability of prior clinical history (informational continuity) as factors that may influence outpatient antibiotic prescribing. Guideline-concordant outpatient antibiotic prescribing was facilitated by consistent practice across settings (management continuity) and the presence of relational and informational continuity, which are common only in primary care. Management continuity may be more modifiable than informational and relational continuity and thus a focus for outpatient stewardship programs.
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Affiliation(s)
- Hillary J. J. Spencer
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sophie Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Milner Staub
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn M. Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Audet CM, Pettapiece-Phillips M, Tian Y, Shepherd BE, Vermund SH, Salato J. "If it weren't for my traditional healer, I would be dead": Engaging traditional healers to support people living with HIV in rural Mozambique. PLoS One 2022; 17:e0270565. [PMID: 35763519 PMCID: PMC9239464 DOI: 10.1371/journal.pone.0270565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/02/2021] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Across rural sub-Saharan Africa, people living with HIV (PLHIV) commonly seek out treatment from traditional healers. We report on the clinical outcomes of a community health worker intervention adapted for traditional healers with insight into our results from qualitative interviews. We employed a pre-post intervention study design and used sequential mixed methods to assess the impact of a traditional healer support worker intervention in Zambézia province, Mozambique. After receiving a positive test result, 276 participants who were newly enrolled in HIV treatment and were interested in receiving home-based support from a traditional healer were recruited into the study. Those who enrolled from February 2016 to August 2016 received standard of care services, while those who enrolled from June 2017 to May 2018 received support from a traditional healer. We conducted interviews among healers and participants to gain insight into fidelity of study activities, barriers to support, and program improvement. Medication possession ratio at home (based on pharmacy pick-up dates) was not significantly different between pre- and post-intervention participants (0.80 in the pre-intervention group compared to 0.79 in the post-intervention group; p = 0.96). Participants reported receiving educational and psychosocial support from healers. Healers adapted their support protocol to initiate directly observed therapy among participants with poor adherence. Traditional healers can provide community-based psychosocial support, education, directly observed therapy, and disclosure assistance for PLHIV. Multiple factors may hinder patients' desire and ability to remain adherent to treatment, including poverty, confusion about medication side effects, and frustration with wait times at the health facility.
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Affiliation(s)
- Carolyn M. Audet
- Department of Health Policy, Vanderbilt University, Nashville, TN, United States of America
| | | | - Yuqi Tian
- Department of Biostatistics, Vanderbilt University, Nashville, TN, United States of America
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University, Nashville, TN, United States of America
| | - Sten H. Vermund
- School of Public Health, Yale University, New Haven, CT, United States of America
| | - Jose Salato
- Friends in Global Health, Quelimane, Mozambique
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Morris M, Okoth V, Prigmore HL, Ressler DJ, Mbeya J, Rogers A, Moon TD, Audet CM. The Prevalence of Interpersonal Violence (IPV) Against Women and its Associated Variables: An Exploratory Study in the Rongo Sub-County of Migori County, Kenya. J Interpers Violence 2022; 37:2083-2101. [PMID: 32627662 DOI: 10.1177/0886260520935484] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Interpersonal violence (IPV) within intimate partner relationships and gender-based violence remain major public health problems worldwide; 44.8% of Kenyan women have reported experiencing IPV beginning after the age of 15 years (National Bureau of Statistics Nairobi, Kenya, 2015). Combatting IPV and its sequelae is integral to promoting gender equality, a key target of the Sustainable Development Goals. We quantify the lifetime prevalence of IPV among women in two rural Kenyan communities, as well as factors associated with IPV in this area, such as educational attainment and severe depression. We conducted a cross-sectional population-based survey of households in the North and East Kamagambo wards of Migori County, Kenya in May 2018. A questionnaire regarding IPV was given to female respondents. Group-wise comparisons and multiple logistic regression analyses were performed to describe community prevalence and factors associated with IPV against women. A total of 873 women completed questions about IPV, representing a population estimate of 11,252 women in the study area. Lifetime IPV prevalence in the study area was 60.3%. Variables associated with IPV included involvement in a polygamous marriage (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: [1.13, 2.88]; p = .013), attaining six or fewer years of education (aOR: 1.84; 95% CI: [1.27, 2.66]; p = .001), and IPV exposure in girlhood (aOR: 1.59; 95% CI: [1.12, 2.28]; p = .011). IPV was independently associated with experience of emotional abuse (OR: 11.22; 95% CI: [7.02, 17.95]; p < .001) and severe depression (OR: 3.51; 95% CI: [1.03, 11.97]; p = .045). Violence against women is a public health emergency in Migori County, Kenya. Low educational attainment, IPV exposure in girlhood, and polygamy were significantly associated with experience of IPV. Our results provide hyper-local data necessary for targeted interventions and generalizable data with sampling methods for use by other implementing organizations in sub-Saharan Africa.
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Affiliation(s)
- Miller Morris
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | | | | | - Troy D Moon
- Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Jurinsky J, Perkins JM, Kakuhikire B, Nyakato VN, Baguma C, Rasmussen JD, Satinsky EN, Ahereza P, Kananura J, Audet CM, Bangsberg DR, Tsai AC. Ease of marital communication and depressive symptom severity among men and women in rural Uganda: cross-sectional, whole-population study. Soc Psychiatry Psychiatr Epidemiol 2022; 57:343-352. [PMID: 34355265 PMCID: PMC8792190 DOI: 10.1007/s00127-021-02135-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/22/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Depression is a major contributor to the global burden of disease. The extent to which marital communication may influence depression in contexts with little mental health support is unknown. METHODS We conducted a whole-population study of married adult residents of eight villages in a rural region of southwestern Uganda. Depression symptom severity was measured using a modified version of the Hopkins Symptom Checklist for Depression, with > 1.75 classified as a positive screen for probable depression. Respondents were asked to report about ease of marital communication ('never easy', 'easy once in a while', 'easy most of the time' or 'always easy'). Sex-stratified, multivariable Poisson regression models were fit to estimate the association between depression symptom severity and marital communication. RESULTS Among 492 female and 447 male participants (response rate = 96%), 23 women and 5 men reported communication as 'never easy' and 154 women and 72 men reported it as 'easy once in a while'. Reporting communication as 'never easy' was associated with an increased risk of probable depression among women (adjusted relative risk [ARR], 2.06; 95% confidence interval [CI], 1.08-3.93, p = 0.028) and among men (ARR, 7.10; 95% CI 1.70-29.56, p = 0.007). CONCLUSION In this whole-population study of married adults in rural Uganda, difficulty of marital communication was associated with depression symptom severity. Additional research is needed to assess whether communication training facilitated by local leaders or incorporated into couples-based services might be a novel pathway to address mental health burden.
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Affiliation(s)
| | - Jessica M. Perkins
- Peabody College, Vanderbilt University, Nashville, TN, USA,Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA,Corresponding author: Dr. Jessica M. Perkins, , Phone: (615) 875-3289, Fax: 615-343-2661
| | | | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Emily N. Satinsky
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
| | - Phionah Ahereza
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Justus Kananura
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA,University of Witwatersrand, Johannesburg, South Africa
| | - David R. Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda,Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, 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,Mongan Institute, Massachusetts General Hospital, Boston MA USA
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21
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Aliyu MH, Sani MU, Ingles DJ, Tsiga-Ahmed FI, Musa BM, Ahonkhai AA, Salihu HM, Audet CM, Wester CW. Building Research Capacity in HIV and Noncommunicable Diseases in Africa: A Mentorship and Leadership Workshop Report. J Contin Educ Health Prof 2022; 42:e106-e110. [PMID: 34459441 PMCID: PMC8876426 DOI: 10.1097/ceh.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Few structured mentoring programs target early-stage investigators in Africa, creating a gap in mentorship skills where HIV burden is greatest. We describe findings from a Nigeria-based workshop for early-career physician scientists to build mentoring and leadership capacity in HIV and noncommunicable disease research. METHODS Baseline surveys captured participant demographics, confidence in implementing mentoring competencies, and perceived importance of workshop training domains. The workshop included didactic presentations, small group activities, and interactive discussions. Daily surveys evaluated sessions, and postworkshop surveys solicited overall course impressions. RESULTS Of the 33 participants, most were male (n = 21, 63.6%) and from medicine, laboratory sciences, and surgical specialties. "Building mentees' confidence" and "setting mentees' research goals" were ranked as areas where participants most believed they needed training. Sessions were rated favorably across five areas. Greatest improvements in mean scores were for confidence in identifying personal temperament styles, describing mentoring and leadership theories/frameworks, and developing mentoring plans. Additional identified workshop strengths were content relevance, leadership case series, interactive nature, and collegial atmosphere. All respondents indicated learning something new/useful/helpful in each session. At 6-month postworkshop, most respondents (25 of 26, 96%) had replicated or plan to replicate parts of the workshop in their departments/institutions. DISCUSSION Effective mentoring training initiatives targeting future academic leaders have the potential to create skilled academicians who can impart mentoring skills and competencies to their mentees.
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22
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Aliyu MH, Iliyasu Z, Ingles DJ, Cassell HM, Lloyd WH, Ahonkhai AA, Abdu A, Audet CM, Wester CW. The V-RAMP Program: Building Research Administration and Management Capacity in Nigeria. J Glob Health Rep 2021; 5. [PMID: 34660911 DOI: 10.29392/001c.24355] [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: 11/08/2022] Open
Abstract
The increasing volume and complexity of research activities in Nigeria necessitates urgent measures to improve research infrastructure in grants administration and management. The Vanderbilt-Nigeria Research Administration and Management Training Program (V-RAMP) seeks to build infrastructure capacity in research administration and management and research ethics at a major teaching hospital in Nigeria. We will perform a mixed methods needs assessment of the administrative and management environment and develop an action plan to address infrastructure needs, prioritize processes, and guide program implementation. We will capacitate a newly established Office of Research Administration and improve the knowledge and skills of research administrators and grant managers via short term in-person trainings in Nashville, Tennessee and in Kano, Nigeria and through remote learning opportunities. We will enhance local administrative efficiency and performance of research ethics operations through training and mentoring of members and staff of the ethics review committee. Systematic processes to streamline protocols, including a REDCap protocol tracking database and standard operating procedures in the responsible conduct of research and rigor and reproducibility will also be developed. V-RAMP will enable the creation of a high-quality research administration environment that is knowledgeable, efficient, and compliant regarding the fiscal, management and ethical standards of sponsored research.
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Affiliation(s)
- Muktar H Aliyu
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, TN.,Department of Health Policy, Vanderbilt University Medical Center (VUMC), Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, TN
| | - Zubairu Iliyasu
- Department of Community Medicine, Bayero University & Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria
| | - Donna J Ingles
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, TN
| | - Holly M Cassell
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, TN
| | - Wendy H Lloyd
- Vanderbilt Coordinating Center, Vanderbilt University Medical Center (VUMC), Nashville, TN
| | - Aima A Ahonkhai
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, TN.,Division of Infectious Diseases, Vanderbilt University Medical Center (VUMC), Nashville, TN
| | - Aliyu Abdu
- Department of Medicine, Bayero University & Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, TN.,Department of Health Policy, Vanderbilt University Medical Center (VUMC), Nashville, TN.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C William Wester
- Vanderbilt Institute for Global Health (VIGH), Vanderbilt University Medical Center (VUMC), Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, TN.,Division of Infectious Diseases, Vanderbilt University Medical Center (VUMC), Nashville, TN
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23
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Sack DE, Wagner RG, Ohene-Kwofie D, Kabudula CW, Price J, Ginsburg C, Audet CM. Pregnancy-related healthcare utilisation in Agincourt, South Africa, 1993-2018: a longitudinal surveillance study of rural mothers. BMJ Glob Health 2021; 6:e006915. [PMID: 34620615 PMCID: PMC8499259 DOI: 10.1136/bmjgh-2021-006915] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/17/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Pregnancy-related health services, an important mediator of global health priorities, require robust health infrastructure. We described pregnancy-related healthcare utilisation among rural South African women from 1993 to 2018, a period of social, political and economic transition. METHODS We included participants enrolled in the Agincourt Health and Socio-Demographic Surveillance System in Mpumalanga Province, South Africa, a population-based longitudinal cohort, who reported pregnancy between 1993 and 2018. We assessed age, antenatal visits, years of education, pregnancy intention, nationality, residency status, previous pregnancies, prepregnancy and postpregnancy contraceptive use, and student status over the study period and modelled predictors of antenatal care utilisation (ordinal), skilled birth attendant presence (logistic) and delivery at a health facility (logistic). RESULTS Between 1993 and 2018, 51 355 pregnancies occurred. Median antenatal visits, skilled birth attendant presence and healthcare facility deliveries increased over time. Delivery in 2018 vs 2004 was associated with an increased likelihood of ≥1 additional antenatal visits (adjusted OR (aOR) 10.81, 95% CI 9.99 to 11.71), skilled birth attendant presence (aOR 4.58, 95% CI 3.70 to 5.67) and delivery at a health facility (aOR 3.78, 95% CI 3.15 to 4.54). Women of Mozambican origin were less likely to deliver with a skilled birth attendant (aOR 0.42, 95% CI 0.39 to 0.45) or at a health facility (aOR 0.43, 95% CI 0.41 to 0.46) versus South Africans. Temporary migrants reported fewer antenatal visits (aOR 0.35, 95% CI 0.33 to 0.38) but were more likely to deliver with a skilled birth attendant (aOR 1.91, 95% CI 1.66 to 2.2) or at a health facility (aOR 1.4, 95% CI 1.24 to 1.58) versus permanent residents. CONCLUSION Pregnancy-related healthcare utilisation and skilled birth attendant presence at delivery have increased steadily since 1993 in rural northeastern South Africa, aligning with health policy changes enacted during this time. However, mothers of Mozambican descent are still less likely to use free care, which requires further study and policy interventions.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan G Wagner
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Ohene-Kwofie
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Chodziwadziwa W Kabudula
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jessica Price
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carren Ginsburg
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyn M Audet
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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24
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Sack DE, De Schacht C, Paulo P, Graves E, Emílio AM, Matino A, Fonseca CL, Aboobacar AU, Van Rompaey S, Audet CM. Pre-exposure prophylaxis use among HIV serodiscordant couples: a qualitative study in Mozambique. Glob Health Action 2021; 14:1940764. [PMID: 34229580 PMCID: PMC8266225 DOI: 10.1080/16549716.2021.1940764] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) has the potential to reduce HIV transmission and stem the HIV epidemic. Unfortunately, PrEP uptake in rural sub-Saharan Africa has been slow and medication adherence has been suboptimal. Objective To explore the perspectives, attitudes, and experiences of HIV serodiscordant partners taking PrEP and develop a messaging campaign to improve PrEP uptake in rural Mozambique to reduce HIV transmission among serodiscordant partners. Methods In this qualitative study, we interviewed 20 people in serodiscordant relationships using PrEP at a rural health center in Zambézia province, Mozambique and employed inductive and deductive coding to elicit their perspectives, attitudes, and experiences related to learning their partner’s HIV status, barriers to PrEP uptake, obstacles to PrEP adherence, and decisions to disclose their PrEP use with family and friends using thematic analysis. Results Our analysis generated nine themes across various levels of the socioecological model. Participants reported a strong desire to stay in the discordant relationship and highlighted the importance of working together to ensure PrEP and antiretroviral therapy adherence, with the majority skeptical that adherence could be achieved without both partners’ support (individual and interpersonal). Although most participants were reticent about sharing their serodiscordant status with family and friends (individual and interpersonal), those who did found their family and friends supportive (interpersonal). Participants suggested increasing community health agent availability to help people navigate HIV prevention and treatment (organizational). We then created three oral stories, using themes from the interviews, with examples from various levels of the socioecological model that will be used to generate support for PrEP use among community members. Conclusions Our findings informed oral template stories that will be used to emphasize how couples can work together to improve PrEP uptake and reduce incident HIV infections in serodiscordant couples elsewhere in rural Mozambique.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Paula Paulo
- Friends in Global Health, Quelimane, Mozambique
| | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | | | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
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Ahonkhai AA, Aliyu MH, Audet CM, Bravo M, Simmons M, Claquin G, Memiah P, Fernando AN, Carlucci JG, Shepherd BE, Van Rompaey S, Yu Z, Gong W, Vermund SH, Wester CW. Poor retention and care-related sex disparities among youth living with HIV in rural Mozambique. PLoS One 2021; 16:e0250921. [PMID: 34019582 PMCID: PMC8139489 DOI: 10.1371/journal.pone.0250921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/20/2020] [Accepted: 04/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background There are few studies that characterize sex-related differences in HIV outcomes among adolescents and young adults (AYA) 15–24 years of age. Methods We conducted a retrospective cohort study among AYA who enrolled in a comprehensive HIV program in Mozambique between 2012–2016. We assessed patients by sex and pregnancy/lactation status, comparing time to combination antiretroviral therapy (ART) initiation using Cox proportional hazard models. We employed multivariable logistic regression to investigate pre- and post-ART retention. Patients were defined as ‘retained pre-ART’ if they attended at least 3 of 4 required visits or started ART in the 6 months after enrollment, and ‘retained post-ART’ if they had any ART pickup or clinical visit during the last 90 days of the one-year follow-up period. Results Of 47,702 patients in the cohort, 81% (n = 38,511) were female and 19% (n = 9,191) were male. Of the females, 57% (n = 21,770) were non-pregnant and non-lactating (NPNL) and 43% (n = 16,741) were pregnant or lactating (PL). PL (aHR 2.64, 95%CI:2.47–2.81) and NPNL females (aHR 1.36, 95%CI:1.30–1.42) were more likely to initiate ART than males. PL females had higher odds of pre-ART retention in care (aOR 3.56, 95%CI: 3.30–3.84), as did NPNL females (aOR 1.71, 95%CI: 1.62–1.81), compared to males. This was also true for retention post-ART initiation, with higher odds for both PL (aOR 1.78, 95%CI:1.63–1.94) and NPNL females (aOR 1.50, 95%CI:1.35–1.65) compared to males. Conclusions PL females were most likely to initiate ART and remain in care post-ART in this AYA cohort, likely reflecting expansion of Option B+. Despite pregnancy and policy driven factors, we observed important sex-related disparities in this cohort. NPNL females were more likely to initiate ART and be retained in care before and after ART initiation than males. These data suggest that young males need targeted interventions to improve these important care continuum outcomes.
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Affiliation(s)
- Aima A. Ahonkhai
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Friends in Global Health (FGH), Maputo, Mozambique
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Melynda Simmons
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Gael Claquin
- Friends in Global Health (FGH), Maputo, Mozambique
| | - Peter Memiah
- Division of Epidemiology and Prevention, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | | | - James G. Carlucci
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | | | - Zhihong Yu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Sten H. Vermund
- Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America
| | - C. William Wester
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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26
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Audet CM, Graves E, Emílio AM, Matino A, Paulo P, Aboobacar AM, Fonseca CL, Van Rompaey S, De Schacht C. Effect of a storytelling intervention on the retention of serodiscordant couples in ART/PrEP services at antenatal clinic in Namacurra province in Zambézia, Mozambique. Contemp Clin Trials Commun 2021; 22:100782. [PMID: 34095604 PMCID: PMC8167234 DOI: 10.1016/j.conctc.2021.100782] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 04/01/2021] [Accepted: 04/28/2021] [Indexed: 11/21/2022] Open
Abstract
Background Sub-Saharan Africa reported 550,000 new HIV infections among women in 2018. Pregnancy and the postpartum period are associated with an increased risk of HIV acquisition (adjusted risk ratio [RR]: 2.8 during pregnancy and 4.0 in postpartum period vs. non-pregnant or postpartum women, respectively). Acquisition of HIV during pregnancy and breastfeeding increases risk of mother to child transmission. We propose to test the impact of a peer-delivered oral storytelling intervention to increase retention in, and adherence to, pre-exposure prophylaxis (PrEP)/combination antiretroviral treatment (ART) among expectant couples. Design We propose a randomized controlled trial (RCT) (35 intervention and 35 control couples) at a health facility where 11% of expectant couples were in serodiscordant relationships in 2018. Couples randomized to the storytelling arm will be visited by a two community volunteers and who successfully adhered to PrEP/ART during a recent pregnancy. This expert couple will orate to participating couples three stories (at 1, 3 and 5 weeks after study enrollment) designed to empower, educate, and establish “ideal” interpersonal communication strategies within couples/families, and support adherence practices among participants. The primary outcome among HIV-uninfected women will be adherence to PrEP at 3 months. Conclusions PrEP among at-risk pregnant women must be implemented so that high levels of adherence and retention are achievable for them and their partners. We will test our storytelling intervention to identify an optimal strategy for PrEP education and family engagement in a region with high HIV prevalence. Our results will have an impact by effectively engaging serodiscordant couples in prevention/treatment during pregnancy and beyond.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.,Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN, 37203, USA
| | - Erin Graves
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | - Almiro M Emílio
- Friends in Global Health, Avenida dos Trabalhadores, 424, Quelimane, Mozambique
| | - Ariano Matino
- Friends in Global Health, Avenida dos Trabalhadores, 424, Quelimane, Mozambique
| | - Paula Paulo
- Friends in Global Health, Avenida dos Trabalhadores, 424, Quelimane, Mozambique
| | - Arifo M Aboobacar
- Provincial Health Directorate, Ministry of Health, Province of Zambézia, Quelimane, Mozambique
| | - Carlota L Fonseca
- Friends in Global Health, Avenida da Maguiguana, 32 R/C, Maputo, Mozambique
| | - Sara Van Rompaey
- Friends in Global Health, Avenida da Maguiguana, 32 R/C, Maputo, Mozambique
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Lewis JA, Spalluto LB, Henschke CI, Yankelevitz DF, Aguayo SM, Morales P, Avila R, Audet CM, Prusaczyk B, Lindsell CJ, Callaway-Lane C, Dittus RS, Vogus TJ, Massion PP, Limper HM, Kripalani S, Moghanaki D, Roumie CL. Protocol to evaluate an enterprise-wide initiative to increase access to lung cancer screening in the Veterans Health Administration. Clin Imaging 2021; 73:151-161. [PMID: 33422974 PMCID: PMC8479827 DOI: 10.1016/j.clinimag.2020.11.059] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/21/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The Veterans Affairs Partnership to increase Access to Lung Screening (VA-PALS) is an enterprise-wide initiative to implement lung cancer screening programs at VA medical centers (VAMCs). VA-PALS will be using implementation strategies that include program navigators to coordinate screening activities, trainings for navigators and radiologists, an open-source software management system, tools to standardize low-dose computed tomography image quality, and access to a support network. VAMCs can utilize strategies according to their local needs. In this protocol, we describe the planned program evaluation for the initial 10 VAMCs participating in VA-PALS. MATERIALS AND METHODS The implementation of programs will be evaluated using the Consolidated Framework for Implementation Research to ensure broad contextual guidance. Program evaluation measures have been developed using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Adaptations of screening processes will be assessed using the Framework for Reporting Adaptations and Modifications to Evidence Based Interventions. Measures collected will reflect the inner settings, estimate and describe the population reached, adoption by providers, implementation of the programs, report clinical outcomes and maintenance of programs. Analyses will include descriptive statistics and regression to evaluate predictors and assess implementation over time. DISCUSSION This theory-based protocol will evaluate the implementation of lung cancer screening programs across the Veterans Health Administration using scientific frameworks. The findings will inform plans to expand the VA-PALS initiative beyond the original sites and can guide implementation of lung cancer screening programs more broadly.
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Affiliation(s)
- Jennifer A Lewis
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America.
| | - Lucy B Spalluto
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America; Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America; Phoenix VA Health Care System, Phoenix, AZ, United States of America
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America; Phoenix VA Health Care System, Phoenix, AZ, United States of America
| | - Samuel M Aguayo
- Phoenix VA Health Care System, Phoenix, AZ, United States of America
| | | | - Rick Avila
- Paraxial LLC, Halfmoon, NY, United States of America
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Beth Prusaczyk
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Carol Callaway-Lane
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; VA Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States of America
| | - Robert S Dittus
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, United States of America
| | - Pierre P Massion
- Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America; VA Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States of America; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Heather M Limper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Drew Moghanaki
- Radiation Oncology, Atlanta VA Medical Center, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Christianne L Roumie
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Aliyu MH, Sani MU, Ingles DJ, Tsiga-Ahmed FI, Musa BM, Audet CM, Wester CW. The V-BRCH Project: building clinical trial research capacity for HIV and noncommunicable diseases in Nigeria. Health Res Policy Syst 2021; 19:32. [PMID: 33691722 PMCID: PMC7943703 DOI: 10.1186/s12961-020-00656-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 08/07/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
Antiretroviral therapy has turned HIV into a chronic condition, with morbidity from HIV-associated noncommunicable diseases (NCDs) becoming more common as HIV-infected individuals live longer. In Nigeria, the additional challenge of an under-capacitated health system highlights the need for skilled clinical investigators who can generate evidence to tackle the double burden of HIV and NCDs. The Vanderbilt-Nigeria Building Research Capacity in HIV and Non-communicable Diseases (V-BRCH) programme is a training platform to create a cohort of skilled Nigerian investigators with the capacity to lead independent clinical trial research focused on the intersection of HIV and NCDs. V-BRCH will solidify an atmosphere of continuous mentoring and skills acquisition for physician faculty at the Aminu Kano Teaching Hospital via short- and medium-term learning opportunities, paired mentoring arrangements, and mentored research projects. Trainees will attend an annual faculty enrichment programme in Nashville, in addition to on-site workshops in Nigeria on HIV-associated NCD epidemiology, clinical trials methodology, evidence synthesis, qualitative research methods, stakeholder engagement, knowledge translation, and grant writing. Research-oriented junior faculty will undergo focused training in clinical trials administration and regulatory oversight. Scholars will share best practices through mentoring panels, regular ‘Works in Progress’ meetings, and monthly career development seminars. Competitive seed grants will be provided to mentor–mentee teams to promote targeted in-country pilot studies focused on HIV-associated NCDs. For long-term training, physician scientists will be supported to undergo enhanced Master of Public Health (MPH) training at Bayero University in Nigeria and Master of Science in Clinical Investigation (MSCI) training at Vanderbilt. Short-term regional courses, staff development workshops, and MPH curriculum refinement will help to strengthen institutional capacity in HIV-associated NCD clinical trial research. V-BRCH will create a cohort of skilled Nigerian scientists who will be able to compete for independent funding and design and implement high quality research that will generate evidence to inform policy and practice and lead to improved outcomes for Nigerians impacted by HIV-associated NCDs.
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Affiliation(s)
- Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 725, Nashville, TN, 37203, United States of America. .,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States of America. .,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America.
| | - Mahmoud U Sani
- Department of Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Donna J Ingles
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 725, Nashville, TN, 37203, United States of America
| | - Fatimah I Tsiga-Ahmed
- Department of Community Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Baba M Musa
- Department of Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria.,Africa Center of Excellence for Population Health and Policy, Bayero University, Kano, Nigeria
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 725, Nashville, TN, 37203, United States of America.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - C William Wester
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 725, Nashville, TN, 37203, United States of America.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America.,Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Audet CM, Shepherd BE, Aliyu MH, Moshabela M, Pettapiece-Phillips MJ, Wagner RG. Healer-led vs. clinician-led training to improve personal protective equipment use among traditional healers in South Africa: a randomized controlled trial protocol. Glob Health Action 2021; 14:1898131. [PMID: 33797347 PMCID: PMC8023590 DOI: 10.1080/16549716.2021.1898131] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022] Open
Abstract
There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional 'injections', in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer's place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mosa Moshabela
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | | | - Ryan G. Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
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Sack DE, Frisby MB, Diemer MA, De Schacht C, Graves E, Kipp AM, Emílio A, Matino A, Barreto E, Van Rompaey S, Wallston KA, Audet CM. Interpersonal reactivity index adaptation among expectant seroconcordant couples with HIV in Zambézia Province, Mozambique. BMC Psychol 2020; 8:90. [PMID: 32859272 PMCID: PMC7456002 DOI: 10.1186/s40359-020-00442-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 01/16/2020] [Accepted: 07/15/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The ability to understand another's emotions and act appropriately, empathy, is an important mediator of relationship function and health intervention fidelity. We adapted the Interpersonal Reactivity Index (IRI) - an empathy scale - among seroconcordant expectant couples with HIV in the Homens para Saúde Mais (HoPS+) trial - a cluster randomized controlled trial assessing couple-based versus individual treatment on viral suppression - in Zambézia Province, Mozambique. METHODS Using baseline data from 1332 HoPS+ trial participants (666 couples), an exploratory factor analysis assessed culturally relevant questions from the IRI. Because empathy is interdependent among couples, we validated the results of the exploratory factor analysis using a dyadic confirmatory factor analysis (CFA) with dyadic measurement invariance testing. Finally, we assessed the relationship between scores on our final scale and basic demographic characteristics (sex, age, education, and depression) using t-tests. RESULTS We found two subscales: 1) a seven-item cognitive empathy subscale (Cronbach's alpha 0.78) and 2) a six-item affective empathy subscale (Cronbach's alpha 0.73). The dyadic CFA found acceptable model fit and metric invariance across partners (Comparative Fit Index (CFI) = 0.914, Tucker Lewis Index = 0.904, Root Mean Squared Error of Approximation = 0.056, ΔCFI = 0.011). We observed higher cognitive (p: 0.012) and affective (p: 0.049) empathy among males and higher cognitive (p: 0.031) and affective (p: 0.030) empathy among younger participants. More educated participants had higher affective empathy (p: 0.017) and depressed participants had higher cognitive empathy (p: < 0.001). This two-subscale, 13-item version of the IRI measures cognitive and affective empathy in HoPS+ trial participants and adults while accounting for the interdependent nature of empathy within partner dyads. CONCLUSIONS This scale will allow us to assess the interplay between empathy and other psychometric constructs (stigma, social support, etc.) in the HoPS+ trial and how each relates to retention in HIV, adherence to treatment, and prevention of maternal to child HIV transmission. Furthermore, this scale can be adapted for other sub-Saharan African populations, which will allow researchers to better assess HIV-related intervention efficacy. TRIAL REGISTRATION This study is within the context of the HoPS+ trial, registered at ClinicalTrials.gov as number NCT03149237 . Registered May 11, 2017.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.
| | | | | | | | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | | | | | | | | | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
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Audet CM, Clemens EM, Ngobeni S, Mkansi M, Sack DE, Wagner RG. Throwing the bones to diagnose HIV: Views of rural South African traditional healers on undertaking HIV counselling and testing. AIDS Care 2020; 33:1316-1320. [PMID: 32799661 DOI: 10.1080/09540121.2020.1808568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/29/2022]
Abstract
In 2018, nearly 800,000 HIV positive individuals in South Africa were unaware of their status. Traditional healers see patients who avoid health clinics, including those who refuse HIV testing. This manuscript details the results of a qualitative study to understand traditional healer perspectives on performing healer-initiated HIV counseling and testing HIV in rural South Africa. We conducted 30 structured in-depth interviews between April and June 2019 to elicit traditional healer attitudes towards partnering with local health services to perform HIV counseling and testing with their patients. Healers reported that while some patients are open about their HIV status, others lie about it due to stigma. This creates challenges with concurrent treatment, which healers believe leads to allopathic and/or traditional medication treatment failure. Most healers expressed both an interest and a willingness to perform HIV counseling and testing. Healers felt that by performing testing in the community, it would overcome issues related to HIV stigma, as well as a lack of confidentiality and trust with health care workers at the clinic. Trained traditional healers may be able to bridge the testing gap between "non-testers" and the allopathic health system, essentially "opening" thousands of new testing locations with little financial investment.
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Affiliation(s)
- Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, School of Medicine, Vanderbilt University, Nashville, USA
| | - Elise M Clemens
- Department of Health Policy, Vanderbilt University Medical Center, School of Medicine, Vanderbilt University, Nashville, USA
| | - Sizzy Ngobeni
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mevian Mkansi
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel E Sack
- Department of Health Policy, Vanderbilt University Medical Center, School of Medicine, Vanderbilt University, Nashville, USA
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Audet CM, Gobbo E, Sack DE, Clemens EM, Ngobeni S, Mkansi M, Aliyu MH, Wagner RG. Traditional healers use of personal protective equipment: a qualitative study in rural South Africa. BMC Health Serv Res 2020; 20:655. [PMID: 32669101 PMCID: PMC7362457 DOI: 10.1186/s12913-020-05515-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/07/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Traditional healers are frequently exposed to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) through the widespread practice of traditional "injections", in which the healer performs dozens of subcutaneous incisions using a razor blade to rub herbs directly into bloodied tissue. An average healer in Agincourt, a rural northeastern sub-district in Mpumalanga province, South Africa, experiences approximately 1500 occupational blood exposures over the course of their lifetime. Healers in Agincourt have an HIV prevalence of 30% compared to 19% in the general population, and healers who report exposure to patient blood have an adjusted 2.4-fold higher odds of being HIV-positive than those with no exposure. Although research on appropriate PPE use has been well documented for allopathic care providers, little is known about the practices of traditional healers. METHODS This qualitative study was conducted with 30 traditional healers who practice in the rural Bushbuckridge sub-district of Mpumalanga province, northeastern South Africa. We elicited traditional healer attitudes towards glove use during traditional treatments - including patient baths, injections, or other treatments that exposed healers to patient blood or open sores. RESULTS While 90% of healers reported using latex gloves during some treatments, the majority do not use them regularly. Most employ a combination of gloves, plastic shopping bags, bread bags, paper, and sticks to prevent blood exposure. Healers reported plastic bags slipping or breaking during procedures, exposing them to patient blood. Only three healers consistently used gloves, regardless of the cost. CONCLUSIONS Inadequate PPE use and high HIV prevalence make traditional healers particularly susceptible to contracting HIV in rural South Africa. Despite positive attitudes, consistent glove use remains low due to financial constraints and glove availability. Addressing issues of accessibility and cost of gloves for traditional healers could have a significant impact on the adherence to PPE and, in turn, reduce new HIV infections among this high-risk group.
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Affiliation(s)
- Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1200, Nashville, TN, 37203, USA.
| | - Elisa Gobbo
- Vanderbilt University, 2201 West End Ave, Nashville, TN, 37235, USA
| | - Daniel E Sack
- School of Medicine, Vanderbilt University, 1161 21st Ave S # D3300, Nashville, TN, 37232, USA
| | - Elise M Clemens
- School of Medicine, Vanderbilt University, 1161 21st Ave S # D3300, Nashville, TN, 37232, USA
| | - Sizzy Ngobeni
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
| | - Mevian Mkansi
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
| | - Muktar H Aliyu
- Department of Health Policy, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1200, Nashville, TN, 37203, USA
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
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Calder CL, O'Hara H, Tabatabai M, Maxwell CJ, Marryshow S, Ahonkhai AA, Audet CM, Wester CW, Aliyu MH. Adherence to Combination Antiretroviral Therapy among Pregnant Women Enrolled in a HIV Prevention Program in Rural North-central Nigeria. Int J MCH AIDS 2020; 9:81-92. [PMID: 32123632 PMCID: PMC7031888 DOI: 10.21106/ijma.327] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Adherence to combination antiretroviral therapy (ART) among pregnant women is essential to attaining the goal of eliminating mother-to-child HIV transmission. The objective of this study was to determine which factors affect adherence to ART among HIV-positive women enrolled in a large prevention of mother-to-child HIV transmission (PMTCT) trial in rural north-central Nigeria. METHODS The parent study included 372 HIV-positive pregnant women enrolled in a cluster-randomized control trial conducted at 12 health facilities in Nigeria between 2013 and 2015. This secondary analysis included HIV-positive women (and their infants) from the original trial with documented adherence data (n=210, 56.5%). The primary outcome was maternal adherence to ART, determined by self-report and based on the visual analogue scale (VAS) of a validated medication adherence tool. Participants with a VAS score of ≥ 95% were classified as adherent. We employed multivariate logistic regression to evaluate the predictors of maternal ART adherence in the study sample. RESULTS Approximately 61.0% of study participants (128/210) were adherent to ART. The majority of adherent participants (62.5%, 80/128) were enrolled in the trial intervention arm. The most common cited response for non-adherence was fear of status disclosure. Adherence to ART was associated with study arm (intervention arm vs. control arm, adjusted Odds Ratio (aOR) [95% CI]: 16.95 [5.30-54.23]), maternal ethnicity (Gwari vs. Other, aOR = 0.13 [0.05-0.38]), and partner HIV status (HIV-positive vs. unknown, aOR = 3.14 [1.22-8.07]). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Adherence to ART among a cohort of pregnant women enrolled in a PMTCT trial in rural North-Central Nigeria was associated with trial arm, maternal self-reported ethnicity, and partner's HIV status. Increased understanding of the interplay between these factors will enable the development of more targeted and effective interventions.
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Affiliation(s)
- Cedrina L Calder
- Meharry Medical College, School of Medicine, Department of Family and Community Medicine, Nashville, TN, USA
| | - Heather O'Hara
- Meharry Medical College, School of Medicine, Department of Family and Community Medicine, Nashville, TN, USA
| | - Mohammad Tabatabai
- Meharry Medical College, School of Graduate Studies and Research, Department of Biostatistics, Nashville, TN, USA
| | - Celia J Maxwell
- Howard University Hospital, Department of Medicine, Washington, DC, USA
| | - Salisha Marryshow
- Vanderbilt University Medical Center, Institute for Medicine and Public Health, Nashville, TN, USA
| | - Aima A Ahonkhai
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Department of Medicine, Nashville, TN, USA
| | - Carolyn M Audet
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Department of Health Policy, Nashville, TN, USA
| | - C William Wester
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Department of Medicine, Nashville, TN, USA
| | - Muktar H Aliyu
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Department of Health Policy, Nashville, TN, USA
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Spalluto LB, Thomas D, Beard KR, Campbell T, Audet CM, McBride Murry V, Shrubsole MJ, Barajas CP, Joosten YA, Dittus RS, Wilkins CH. A Community-Academic Partnership to Reduce Health Care Disparities in Diagnostic Imaging. J Am Coll Radiol 2019; 16:649-656. [PMID: 30947902 DOI: 10.1016/j.jacr.2018.12.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Lucy B Spalluto
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee and the Department of Radiological Sciences, Vanderbillt University Medical Center, Nashville, Tennessee.
| | - Debbie Thomas
- MidSouth Division of the American Cancer Society, Nashville, Tennessee
| | - Katina R Beard
- Matthew Walker Comprehensive Health Center, Nashville, Tennessee
| | - Thoris Campbell
- Metro Public Health Department, Tennessee Breast and Cervical Screening Program, Nashville, Tennessee
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Velma McBride Murry
- Department of Human and Organizational Development, Vanderbilt University, Nashville, Tennessee
| | - Martha J Shrubsole
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia P Barajas
- Office of Patient and Community Education, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Yvonne A Joosten
- Office for Community Engagement, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S Dittus
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee and the Department of Radiological Sciences, Vanderbillt University Medical Center, Nashville, Tennessee; Veterans Health Administration - Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee and the Department of Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee and Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Arriola-Vigo JA, Stovall JG, Moon TD, Audet CM, Diez-Canseco F. Perceptions of Community Involvement in the Peruvian Mental Health Reform Process Among Clinicians and Policy-Makers: A Qualitative Study. Int J Health Policy Manag 2019; 8:711-722. [PMID: 31779299 PMCID: PMC6885866 DOI: 10.15171/ijhpm.2019.68] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 09/17/2018] [Accepted: 08/03/2019] [Indexed: 11/25/2022] Open
Abstract
Background: The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation. Methods: A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care. Results: Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives. Conclusion: Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.
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Affiliation(s)
- Jose A Arriola-Vigo
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey G Stovall
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Troy D Moon
- Department of Pediatrics, Division of Infectious Diseases, and Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn M Audet
- Department of Health Policy, and Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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Bulsara SM, Wainberg ML, Audet CM, Newton-John TR. Retention in HIV Care in Australia: The Perspectives of Clinicians and Clients, and the Impact of Medical and Psychosocial Comorbidity. AIDS Patient Care STDS 2019; 33:415-424. [PMID: 31390222 DOI: 10.1089/apc.2019.0094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 01/01/2023] Open
Abstract
Significant advances in our understanding and treatment of HIV have led to improvements in the medical management of the illness, as HIV infection has evolved from an acute to a chronic illness. Increasing our understanding of the medical and/or psychosocial comorbidities, which can interact to determine "clinical complexity" and impact HIV management, will further strengthen this process. Retention in care is a critical step of the HIV Treatment Cascade, which facilitates effective management of these comorbidities and their impact on HIV medical management. This study sought to build on literature regarding medical and/or psychosocial comorbidity that impacts retention in care, and it often leads to clinically complex presentations, by gaining the perspectives of people living with HIV (PLHIV), and medical and allied health clinicians in the field in Sydney, Australia. A total of 16 clinicians (medical doctors, nurses, clinical psychologists, and social workers) and 14 clients participated in a series of focus groups; they were asked to comment on the perceived barriers to retention and the potential solutions to overcome these. The results indicated a significant degree of overlap between clinician and client perspectives, and they identified "service-specific factors," "logistic/practical factors," "medical/physical factors," and "psychosocial factors" as potential barriers to retention. Results are reviewed in the context of similarities and differences in perspectives between clinicians and PLHIV, and limitations regarding the generalizability of findings are discussed. The broader context of comorbidity and clinical complexity is also examined.
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Affiliation(s)
- Shiraze M. Bulsara
- Clinical Psychology, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
- The Albion Centre, Sydney, Australia
| | | | - Carolyn M. Audet
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Toby R.O. Newton-John
- Clinical Psychology, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
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Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. PLoS One 2019; 14:e0221809. [PMID: 31553735 PMCID: PMC6760763 DOI: 10.1371/journal.pone.0221809] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 01/11/2019] [Accepted: 08/15/2019] [Indexed: 01/10/2023] Open
Abstract
The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543-3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR's policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.
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Affiliation(s)
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
| | | | - Olujide O. Arije
- Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Melynda Simmons
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Kenneth A. Freedberg
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Aima A. Ahonkhai
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Aliyu MH, Sam-Agudu NA, Shenoi S, Goga AE, Ramraj T, Vermund SH, Audet CM. Increasing male engagement in the prevention of vertical transmission of HIV: what works in sub-Saharan Africa? BMJ 2019; 365:l1965. [PMID: 31171558 PMCID: PMC6598674 DOI: 10.1136/bmj.l1965] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Muktar Aliyu and colleagues discuss barriers, enablers, and research gaps in engaging male partners in prevention of vertical HIV transmission in sub-Saharan Africa
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Affiliation(s)
- Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, USA
| | - Nadia A Sam-Agudu
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
- Institute of Human Virology, Abuja, Nigeria
| | | | - Ameena E Goga
- South African Medical Research Council, Pretoria, South Africa
- Department of Paediatrics, University of Pretoria, South Africa
| | - Trisha Ramraj
- South African Medical Research Council, Pretoria, South Africa
| | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, USA
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Audet CM, Graves E, Barreto E, De Schacht C, Gong W, Shepherd BE, Aboobacar A, Gonzalez-Calvo L, Alvim MF, Aliyu MH, Kipp AM, Jordan H, Amico KR, Diemer M, Ciaranello A, Dugdale C, Vermund SH, Van Rompaey S. Partners-based HIV treatment for seroconcordant couples attending antenatal and postnatal care in rural Mozambique: A cluster randomized trial protocol. Contemp Clin Trials 2018; 71:63-69. [PMID: 29879469 PMCID: PMC6067957 DOI: 10.1016/j.cct.2018.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/26/2018] [Accepted: 05/31/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique. DESIGN We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services. CONCLUSIONS The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA.
| | - Erin Graves
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA
| | - Ezequiel Barreto
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Caroline De Schacht
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Wu Gong
- Vanderbilt University School of Medicine, Department of Biostatistics, 2525 West End Ave, Suite 11000, Nashville, TN 37203, USA
| | - Bryan E Shepherd
- Vanderbilt University School of Medicine, Department of Biostatistics, 2525 West End Ave, Suite 11000, Nashville, TN 37203, USA
| | | | - Lazaro Gonzalez-Calvo
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique; Vanderbilt University Medical Center, Department of Pediatrics, 2200 Children's Way, Nashville, TN 37232, USA
| | - Maria Fernanda Alvim
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Muktar H Aliyu
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA
| | - Aaron M Kipp
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Division of Epidemiology, Nashville, TN 37203, USA
| | - Heather Jordan
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA
| | - K Rivet Amico
- University of Michigan, Department of Health Behavior and Health Education, School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Matthew Diemer
- University of Michigan, Combined Program in Education and Psychology & Educational Studies, School of Education, Room 4120, Ann Arbor, MI 48109, USA
| | - Andrea Ciaranello
- Division of Infectious Diseases, 100 Cambridge St, Room 1670, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, 25 Shattuck St, Boston 02115, MA, USA
| | - Caitlin Dugdale
- Harvard Medical School, Harvard University, 25 Shattuck St, Boston 02115, MA, USA
| | - Sten H Vermund
- Yale School of Public Health, 60 College St., Suite 212, New Haven, CT, USA
| | - Sara Van Rompaey
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
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Oquendo MA, Duarte C, Gouveia L, Mari JJ, Mello MF, Audet CM, Pinsky I, Vermund SH, Mocumbi AO, Wainberg ML. Building capacity for global mental health research: challenges to balancing clinical and research training. Lancet Psychiatry 2018; 5:612-613. [PMID: 29628365 PMCID: PMC6402326 DOI: 10.1016/s2215-0366(18)30097-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 01/27/2018] [Accepted: 02/20/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Maria A Oquendo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Cristiane Duarte
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | | | - Jair J Mari
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Marcelo F Mello
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ilana Pinsky
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Ana O Mocumbi
- Instituto Nacional de Saúde, Maputo, Mozambique; Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Milton L Wainberg
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; New York State Psychiatric Institute, Columbia University, New York, NY, USA
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Audet CM, Wainberg ML, Oquendo MA, Yu Q, Blevins Peratikos M, Duarte CS, Martinho S, Green AF, Gonzalez-Calvo L, Moon TD. Depression among female heads-of-household in rural Mozambique: A cross-sectional population-based survey. J Affect Disord 2018; 227:48-55. [PMID: 29053975 PMCID: PMC5805617 DOI: 10.1016/j.jad.2017.10.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/22/2017] [Accepted: 10/04/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND An estimated 350 million people live with depression worldwide. In Mozambique, there are no national data quantifying the burden of mental illnesses. With the sixth highest suicide rate in the world, there is strong evidence of an unmet mental health need. We conducted a survey to measure the prevalence of depression among female heads of household and assess individual, social, and cultural risk factors associated with a positive depression screening. METHODS This survey was conducted across 14 rural districts in central Mozambique in 2014. We gathered information from 3543 female heads of household (100% response rate) on > 500 variables, including a depression screening tool (PHQ-8). Weighted percentages of survey responses are reported. RESULTS Among female heads of household, 14% screened positive for depression (PHQ-8 score ≥ 10). Our adjusted models show increased odds of depression per additional year of age (aOR: 1.02 [1.01, 1.04]; p = 0.002), additional year of education (aOR: 1.06 [1.02, 1.11]; p = 0.006), and additional kilometer from the nearest clinic (aOR: 1.05 [1.02, 1.07]; p = < 0.001). Experiencing food insecurity (aOR: 1.05 [1.02, 1.08]; p = 0.003) was associated with increased odds of depression. Being single (aOR: 0.42 [0.29, 0.60]) or divorced/widowed/separated (aOR: 0.57 [0.34, 0.98]; p < 0.001) vs. married was protective against depression, as was a perceived "sufficient" household income (aOR: 0.37 [0.19, 0.69]; p = 0.008). LIMITATIONS Social desirability bias may have led women to underreport feelings of depression. CONCLUSIONS The association of more education and marriage with increased odds of depression may reflect a frustration with limited opportunity for success experienced by some women in rural Mozambique.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health,Vanderbilt University Medical Center, Department of Health Policy,Friends in Global Health
| | | | | | - Qiongru Yu
- Vanderbilt University, Peabody Research Institute
| | | | | | | | - Ann F. Green
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health,Friends in Global Health
| | - Lazaro Gonzalez-Calvo
- Friends in Global Health,Vanderbilt University Medical Center, Department of Pediatrics
| | - Troy D. Moon
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health,Friends in Global Health,Vanderbilt University Medical Center, Department of Pediatrics
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Audet CM, Ngobeni S, Graves E, Wagner RG. Mixed methods inquiry into traditional healers' treatment of mental, neurological and substance abuse disorders in rural South Africa. PLoS One 2017; 12:e0188433. [PMID: 29261705 PMCID: PMC5736181 DOI: 10.1371/journal.pone.0188433] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 09/02/2016] [Accepted: 11/07/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Traditional healers are acceptable and highly accessible health practitioners throughout sub-Saharan Africa. Patients in South Africa often seek concurrent traditional and allopathic treatment leading to medical pluralism. METHODS & FINDINGS We studied the cause of five traditional illnesses known locally as "Mavabyi ya nhloko" (sickness of the head), by conducting 27 in-depth interviews and 133 surveys with a randomly selected sample of traditional healers living and working in rural, northeastern South Africa. These interviews were carried out to identify treatment practices of mental, neurological, and substance abuse (MNS) disorders. Participating healers were primarily female (77%), older in age (median: 58.0 years; interquartile range [IQR]: 50-67), had very little formal education (median: 3.7 years; IQR: 3.2-4.2), and had practiced traditional medicine for many years (median: 17 years; IQR: 9.5-30). Healers reported having the ability to successfully treat: seizure disorders (47%), patients who have lost touch with reality (47%), paralysis on one side of the body (59%), and substance abuse (21%). Female healers reported a lower odds of treating seizure disorders (Odds Ratio (OR):0.47), patients who had lost touch with reality (OR:0.26; p-value<0.05), paralysis of one side of the body (OR:0.36), and substance abuse (OR:0.36) versus males. Each additional year of education received was found to be associated with lower odds, ranging from 0.13-0.27, of treating these symptoms. Each additional patient seen by healers in the past week was associated with roughly 1.10 higher odds of treating seizure disorders, patients who have lost touch with reality, paralysis of one side of the body, and substance abuse. Healers charged a median of 500 South African Rand (~US$35) to treat substance abuse, 1000 Rand (~US$70) for seizure disorders or paralysis of one side of the body, and 1500 Rand (~US$105) for patients who have lost touch with reality. CONCLUSIONS While not all healers elect to treat MNS disorders, many continue to do so, delaying allopathic health services to acutely ill patients.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Sizzy Ngobeni
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Ryan G. Wagner
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
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Sarko KA, Blevins M, Ahonkhai AA, Audet CM, Moon TD, Gebi UI, Gana AM, Wester CW, Vermund SH, Aliyu MH. HIV status disclosure, facility-based delivery and postpartum retention of mothers in a prevention clinical trial in rural Nigeria. Int Health 2017; 9:243-251. [PMID: 28810669 DOI: 10.1093/inthealth/ihx023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 06/20/2017] [Indexed: 11/14/2022] Open
Abstract
Background Within the context of a cluster randomized prevention of mother-to-child HIV transmission (PMTCT) trial, we evaluated the impact of disclosure on selected PMTCT continuum of care measures. Methods In 12 rural matched-pair clinics randomly assigned to an intervention package versus standard-of-care, we enrolled 372 HIV-infected pregnant women from April 2013 to March 2014. This secondary analysis included 327 (87.9%) women with unknown HIV status or who were treatment naïve at presentation to antenatal care. We employed mixed effects logistic regression to estimate impact of disclosure on facility delivery and postpartum retention in HIV care at 6 and 12 weeks. Results Fully 86.5% (283/327) of women disclosed their HIV status to their partner, more in the trial intervention arm (OR 3.17, 95% CI 1.39-7.23). Adjusting for intervention arm, maternal age, education and employment, women who disclosed were more likely to deliver at a health facility (OR 2.73, 95%CI 1.11-6.72). Participants who disclosed also had a trend towards being retained in care at 6 and 12 weeks' postpartum (OR 2.72, 95% CI 0.79-9.41 and 2.46, 95% CI 0.70-8.63, respectively). Conclusions HIV status disclosure at 6 weeks' postpartum was positively associated with facility-based delivery, but not with early postpartum retention. Facilitating HIV status disclosure to partners can increase utilization of facility obstetric services.
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Affiliation(s)
- Kidane A Sarko
- Vanderbilt Institute for Global Health, Nashville, TN, USA
- Health Policy
| | | | - Aimalohi A Ahonkhai
- Vanderbilt Institute for Global Health, Nashville, TN, USA
- Medicine, Vanderbilt University Medical Center, TN, USA
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Nashville, TN, USA
- Health Policy
| | - Troy D Moon
- Vanderbilt Institute for Global Health, Nashville, TN, USA
- Pediatrics
| | - Usman I Gebi
- Health Policy
- Friends for Global Health Initiative in Nigeria, Abuja, Nigeria
| | | | - C William Wester
- Vanderbilt Institute for Global Health, Nashville, TN, USA
- Medicine, Vanderbilt University Medical Center, TN, USA
| | | | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Nashville, TN, USA
- Health Policy
- Medicine, Vanderbilt University Medical Center, TN, USA
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Audet CM, Ngobeni S, Wagner RG. Traditional healer treatment of HIV persists in the era of ART: a mixed methods study from rural South Africa. BMC Complement Altern Med 2017; 17:434. [PMID: 28854905 PMCID: PMC5577748 DOI: 10.1186/s12906-017-1934-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 08/18/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) substantially contributes to the burden of disease and health care provision in sub-Saharan Africa, where traditional healers play a major role in care, due to both their accessibility and acceptability. In rural, northeastern South Africa, people living with HIV often ping-pong between traditional healers and allopathic providers. METHODS We conducted 27 in-depth interviews and 133 surveys with a random sample of traditional healers living in Bushbuckridge, South Africa, where anti-retroviral therapy (ART) is publicly available, to learn: (1) healer perspectives about which HIV patients they choose to treat; (2) the type of treatment offered; (3) outcomes expected, and; (4) the cost of delivering treatment. RESULTS Healers were mostly female (77%), older (median: 58.0 years; interquartile range [IQR]: 50-67), with low levels of formal education (median: 3.7 years; IQR: 3.2-4.2). Thirty-nine healers (30%) reported being able to cure HIV in an adult patients whose (CD4) count was >350cells/mm3. If an HIV-infected patient preferred traditional treatment, healers differentiated two categories of known HIV-infected patients, CD4+ cell counts <350 or ≥350 cells/mm3. Patients with low CD4 counts were routinely referred back to the health facility. Healers who reported offering/performing a traditional cure for HIV had practiced for less time (mean = 16.9 vs. 22.8 years; p = 0.03), treated more patients (mean 8.7 vs. 4.8 per month; p = 0.03), and had lower levels of education (mean = 2.8 vs. 4.1 years; p = 0.017) when compared to healers who reported not treating HIV-infected patients. Healers charged a median of 92 USD to treat patients with HIV. CONCLUSION Traditional healers referred suspected HIV-infected patients to standard allopathic care, yet continued to treat HIV-infected patients with higher CD4 counts. A greater emphasis on patient education and healer engagement is warranted.
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Audet CM, Blevins M, Cherry CB, González-Calvo L, Green AF, Moon TD. Understanding intra-vaginal and labia minora elongation practices among women heads-of-households in Zambézia Province, Mozambique. Cult Health Sex 2017; 19:616-629. [PMID: 27921861 PMCID: PMC5460297 DOI: 10.1080/13691058.2016.1257739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Indexed: 06/06/2023]
Abstract
Intra-vaginal drying and tightening and labia minora elongation are commonly practised in some parts of southern Africa. We sought to capture data on these practices among women living in Zambézia province, Mozambique. Information was gathered from 3543 female heads of household on > 500 variables, including vaginal practices, in 2014. Women who planned to use intra-vaginal tightening substances had 1.84 times higher odds of ever receiving an HIV test (p < 0.001) and 1.40 times higher odds of at least one antenatal care visit attended during last pregnancy (p = 0.015). Women who had or planned to undergo labia minora elongation had 2.61 times higher odds of receiving an HIV test in the past (p < 0.001) and 1.60 times higher odds of attending at least one antenatal care visit during their last pregnancy (p < 0.001). There was little evidence for a relationship between self-reported HIV status and anticipated use of intra-vaginal tightening substances (p = 0.21). Current or anticipated participation in labia elongation showed a protective effect on HIV infection (p = 0.028). Given documented associations between intra-vaginal substance use, vaginal infections and HIV acquisition, understanding the prevalence of vaginal practices is an essential component to addressing the epidemic.
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Affiliation(s)
- Carolyn M Audet
- a Department of Health Policy , Vanderbilt University Medical Center , Nashville , USA
| | - Meridith Blevins
- b Department of Biostatistics , Vanderbilt University Medical Center , Nashville , USA
| | | | - Lazaro González-Calvo
- d Friends in Global Health , Impact and Project Evaluation Department , Quelimane , Mozambique
| | - Ann F Green
- c Institute for Global Health , Vanderbilt University Medical Center , Nashville , USA
| | - Troy D Moon
- e Department of Pediatrics , Vanderbilt University , Nashville , USA
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Audet CM, Salato J, Vermund SH, Amico KR. Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique. Implement Sci 2017. [PMID: 28407813 DOI: 10.1186/s13012-017-0582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Systematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system. METHODS Adaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients. RESULTS Traditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted. CONCLUSIONS Systematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers-an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA.
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - José Salato
- Friends in Global Health, Quelimane, Mozambique
- Friends in Global Health, Maputo, Mozambique
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Departments of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Audet CM, Salato J, Vermund SH, Amico KR. Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique. Implement Sci 2017; 12:50. [PMID: 28407813 PMCID: PMC5390357 DOI: 10.1186/s13012-017-0582-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 08/20/2016] [Accepted: 04/06/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Systematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system. METHODS Adaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients. RESULTS Traditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted. CONCLUSIONS Systematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers-an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA. .,Departments of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - José Salato
- Friends in Global Health, Quelimane, Mozambique.,Friends in Global Health, Maputo, Mozambique
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Departments of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Audet CM, Chire YM, Vaz LME, Bechtel R, Carlson-Bremer D, Wester CW, Amico KR, Gonzaléz-Calvo L. Barriers to Male Involvement in Antenatal Care in Rural Mozambique. Qual Health Res 2016; 26:1721-31. [PMID: 25854615 PMCID: PMC4598282 DOI: 10.1177/1049732315580302] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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] [Indexed: 05/08/2023]
Abstract
Low rates of antenatal care (ANC) service uptake limit the potential impact of mother-to-child HIV-prevention strategies. Zambézia province, Mozambique, has one of the lowest proportions of ANC uptake among pregnant women in the country, despite the availability of free services. We sought to identify factors influencing ANC service uptake (including HIV counseling and testing) through qualitative methods. In addition, we encouraged discussion about strategies to improve uptake of services. We conducted 14 focus groups to explore community views on these topics. Based on thematic coding of discourse, two main themes emerged: (a) gender inequality in decision making and responsibility for pregnancy and (b) community beliefs that uptake of ANC services, particularly, if supported by a male partner, reflects a woman's HIV-positive status. Interventions to promote ANC uptake must work to shift cultural norms through male partner participation. Potential strategies to promote male engagement in ANC services are discussed.
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Affiliation(s)
| | | | - Lara M E Vaz
- Vanderbilt University, Nashville, Tennessee, USA Friends in Global Health (FGH), Quelimane, Mozambique Save the Children, Washington, D.C., USA
| | - Ruth Bechtel
- Friends in Global Health (FGH), Quelimane, Mozambique
| | | | | | | | - Lázaro Gonzaléz-Calvo
- Vanderbilt University, Nashville, Tennessee, USA Friends in Global Health (FGH), Quelimane, Mozambique
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Audet CM, Salato J, Blevins M, Silva W, González-Calvo L, Vermund SH, Gaspar F. Occupational hazards of traditional healers: repeated unprotected blood exposures risk infectious disease transmission. Trop Med Int Health 2016; 21:1476-1480. [PMID: 27580349 DOI: 10.1111/tmi.12775] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 12/14/2022]
Abstract
OBJECTIVE Healers provide support for acute and chronic illnesses in rural Mozambique, such as socially acceptable traditional 'vaccinations' (subcutaneous cuts in the skin to rub herbs directly into the bloody lesion). We aimed to document the frequency of blood exposure by traditional practitioners in Mozambique. METHODS We conducted surveys with a simple random sample of 236 traditional healers in Zambézia province. Chi-square and Wilcoxon rank-sum tests were used to compare 'injection' behaviours across districts. RESULTS Healers treated a median of eight patients in the past month (IQR: 4-15). About 75% conducted 'injections'. These healers 'injected' a median of four patients (IQR: 1-8), used a new razor a median of three times (IQR: 1-8), and almost never used gloves. Lifetime blood exposures among those who provided 'injections' during treatments were estimated to be 1758 over a healer's career. CONCLUSION The majority of healers are exposed repeatedly to patient blood. Given the high prevalence of HIV, hepatitis B and C virus, and other blood-borne agents, specific healer practices are an occupational hazard and reuse of razors is risky for their clients.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Nashville, TN, USA. .,Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - José Salato
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Wilson Silva
- Vanderbilt Institute for Global Health, Nashville, TN, USA.,Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Lázaro González-Calvo
- Vanderbilt Institute for Global Health, Nashville, TN, USA.,Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
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Aliyu MH, Blevins M, Audet CM, Kalish M, Gebi UI, Onwujekwe O, Lindegren ML, Shepherd BE, Wester CW, Vermund SH. Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial. Lancet HIV 2016; 3:e202-11. [PMID: 27126487 DOI: 10.1016/s2352-3018(16)00018-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) and retention in care are essential for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to assess the effect of a family-focused, integrated PMTCT care package. METHODS In this parallel, cluster-randomised controlled trial, we pair-matched 12 primary and secondary level health-care facilities located in rural north-central Nigeria. Clinic pairs were randomly assigned to intervention or standard of care (control) by computer-generated sequence. HIV-infected women (and their infants) presenting for antenatal care or delivery were included if they had unknown HIV status at presentation (there was no age limit for the study, but the youngest participant was 16 years old); history of antiretroviral prophylaxis or treatment, but not receiving these at presentation; or known HIV status but had never received treatment. Standard of care included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The intervention package added task shifting, point-of-care CD4 testing, integrated mother and infant service provision, and male partner and community engagement. The primary outcomes were the proportion of eligible women who initiated ART and the proportion of women and their infants retained in care at 6 weeks and 12 weeks post partum (assessed by generalised linear mixed effects model with random effects for matched clinic pairs). The trial is registered with ClinicalTrials.gov, number NCT01805752. FINDINGS Between April 1, 2013, and March 31, 2014, we enrolled 369 eligible women (172 intervention, 197 control), similar across groups for marital status, duration of HIV diagnosis, and distance to facility. Median CD4 count was 424 cells per μL (IQR 268-606) in the intervention group and 314 cells per μL (245-406) in the control group (p<0·0001). Of the 369 women included in the study, 363 (98%) had WHO clinical stage 1 disease, 364 (99%) had high functional status, and 353 (96%) delivered vaginally. Mothers in the intervention group were more likely to initiate ART (166 [97%] vs 77 [39%]; adjusted relative risk 3·3, 95% CI 1·4-7·8). Mother and infant pairs in the intervention group were more likely to be retained in care at 6 weeks (125 [83%] of 150 vs 15 [9%] of 170; adjusted relative risk 9·1, 5·2-15·9) and 12 weeks (112 [75%] of 150 vs 11 [7%] of 168 pairs; 10·3, 5·4-19·7) post partum. INTERPRETATION This integrated, family-focused PMTCT service package improved maternal ART initiation and mother and infant retention in care. An effective approach to improve the quality of PMTCT service delivery will positively affect global goals for the elimination of mother-to-child HIV transmission. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development and US National Institutes of Health.
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Affiliation(s)
- Muktar H Aliyu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Meridith Blevins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Marcia Kalish
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Usman I Gebi
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN, USA; Friends in Global Health, Abuja, Nigeria
| | | | - Mary Lou Lindegren
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - C William Wester
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sten H Vermund
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
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