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Mental health disorders in pregnant women living with HIV are associated with poor maternal and child outcomes, and undermine the global goals of prevention of mother-to-child transmission of HIV (PMTCT). This study aimed to determine prevalence of depression and anxiety and identify factors associated with these common mental health disorders among HIV-infeced pregnant women in Tanzania. We enrolled 200 pregnant women living with HIV from antenatal care clinics in the Kilimanjaro region. Women were eligible if they were in the second or third trimester of pregnancy and had been in PMTCT care for a minimum of one month. Data were collected via interviewer administered surveys. Participants self reported depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and anxiety symptoms (Brief Symptom Index, BSI). Multivariate logistic regression models examined factors associated with depression, anxiety, and comorbid depression and anxiety. 25.0% of women met screening criteria for depression (EPDS ≥10). Depression was significantly associated with being single (aOR = 4.2, 95% CI = 1.1-15.5), food insecurity (aOR = 2.4, 95% CI = 1.0-6.4), and HIV shame (aOR = 1.2, 95% CI = 1.1-1.3). 23.5% of participants met screening criteria for anxiety (BSI ≥1.01). Anxiety was associated with being single (aOR = 3.6, 95%CI = 1.1-11.1), HIV shame (aOR = 1.1, 95% CI = 1.1-1.2) and lifetime experience of violence (aOR = 2.3, 95% CI = 1.0-5.1). 17.8% of the sample met screening criteria for both depression and anxiety. Comorbid depression and anxiety was associated with being single (aOR = 4.5, 95%CI = 1.0-19.1), HIV shame (aOR = 1.2, 95%CI = 1.1-1.3) and lifetime experience of violence (aOR = 3.4, 95% CI = 1.2-9.6). Depression and anxiety symptomatology was common in this sample of pregnant women living with HIV, with a sizable number screening positive for comorbid depression and anxiety. In order to successfully engage women in PMTCT care and support their well-being, strategies to screen for mental health disorders and support women with mental illnesses are needed.

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

Hypertension, a leading risk for cardiovascular mortality, is an important co-morbidity among people living with HIV (PLHIV). In Tanzania, hypertension prevalence among PLHIV approaches 20 to 30%. However, most patients are unaware of their diagnosis and are not receiving treatment. Understanding the barriers to hypertension care is a critical first step in developing interventions to improve cardiovascular outcomes among PLHIV in Tanzania and similar settings. Between September 1st and November 26th, 2018 thirteen semi structured in-depth interviews were conducted with hypertensive patients engaged in HIV care in two HIV clinics located in government health facilities in northern Tanzania. Interviews were audio-recorded, translated into English, transcribed and thematically coded using NVivo. Data analysis was conducted using applied thematic analysis. Participants had a median age of 54 (IQR 41-65) years. Of the 13 participants, eight stated they had used antihypertensive medication previously, but only one participant described current use of antihypertensive therapy. All participants were currently using antiretroviral therapy. The data revealed a range of themes including limited hypertension knowledge. Universally, all participants believed that \"thinking too much\", i.e. stress, was the major contributor to hypertension and that by \"reducing thoughts\", one may control hypertension. Additional emerging themes included a perceived overlap between hypertension and HIV, delays in hypertension diagnosis and linkage to care, challenges with provider communication and counseling, reluctance towards antihypertensive medication, lack of integration of hypertension and HIV care, and additional structural barriers to hypertension care. Participants described multiple, intersecting challenges related to hypertension management. Barriers specific to PLHIV included siloed care, HIV-related stigma, and burden from multiple medical conditions. Multifaceted strategies that seek to address structural barriers, hypertension education, psychosocial stressors and stigma, and that are integrated within HIV care are urgently needed to improve cardiovascular outcomes among PLHIV in sub-Saharan Africa.

ObjectiveTo describe the lived experience of patients undergoing diagnosis and treatment of placenta accreta spectrum (PAS).DesignQualitative study of semi-structured interviews. A content analysis was used to analyse interview data using a consistent set of codes to designate data segments that contain similar material. Codes were analysed and grouped based on thematic similarities. Thematic results were systematically reviewed, verified and audited to address trustworthiness and rigour of the data and analysis.SettingA single PAS programme in Utah, USA, from 2017 to 2020.ParticipantsPatients with PAS during the study period were eligible. Those experiencing fetal demise or termination were excluded. Of 25 patients contacted at random, 17 agreed to participate in interviews. Those included were predominantly non-Hispanic white, highly parous, with average age of 34.7 years.ResultsThe lived experiences of patients with PAS emerged across the time continuum from diagnosis, pregnancy, birth, to postpartum care and recovery. Themes common across the care continuum were: the emotional burden of diagnosis and management; fear and uncertainty related to health outcomes; and lack of autonomy and medical helplessness related to medical decision-making. Many patients experienced birth-related trauma, mourned the loss of future fertility and were dissatisfied with the lack of options for treatment for this serious pregnancy complication.ConclusionsPatients undergoing diagnosis and treatment for PAS often experienced care that conflicted with their goals for pregnancy and birth. Clinical care for PAS would benefit from interventions aiming to engage patients and providers in shared decision-making and systems designed to address the social, psychological and emotional needs of patients with PAS.

Despite the broad success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs, HIV care engagement during the pregnancy and postpartum periods is suboptimal. This study explored the perspectives of women who experienced challenges engaging in PMTCT care, in order to better understand factors that contribute to poor retention and to identify opportunities to improve PMTCT services. We conducted in-depth interviews with 12 postpartum women to discuss their experiences with PMTCT care. We used data from a larger longitudinal cohort study conducted in five PMTCT clinics in Moshi, Tanzania to identify women with indicators of poor care engagement (i.e., medication non-adherence, inconsistent clinic attendance, or high viral load). Women who met one of these criteria were contacted by telephone and invited to complete an interview. Data were analyzed using applied thematic analysis. We observed a common pathway that fear of stigma contributed to a lack of HIV disclosure and reduced social support for seeking HIV care. Women commonly distrusted the results of their initial HIV test and reported medication side effects after care initiation. Women also reported barriers in the health system, including difficult-to-navigate clinic transfer policies and a lack of privacy and confidentiality in service provision. When asked how care might be improved, women felt that improved counseling and follow-up, affirming patient-provider interactions, and peer treatment supporters would have a positive effect on care engagement. In order to improve the impact of PMTCT programs, there is a need to implement active tracking and follow-up of patients, targeting individuals with evidence of poor care engagement. Tailored supportive intervention approaches may help patients to cope with both the perceived and actual impacts of HIV stigma, including navigating disclosures to loved ones and accessing social support. Fostering HIV acceptance is likely to facilitate commitment to long-term treatment.

Background Effective follow-up care plays a critical role in enhancing breast cancer outcomes, as diagnosing breast cancer in earlier stages can improve mortality and ease treatment burden. Individuals with unmet social needs face greater barriers in completing their follow-up care (e.g., additional imaging, biopsies, and surgery). They are two times less likely to complete follow-up appointments. When patients do not complete follow-up appointments, they are at higher risk of detecting breast cancer at a later stage. We aim to examine how a social needs intervention via community navigation may (1) address patients’ social needs, and (2) improve the completion of recommended medical care following an abnormal mammography. Methods This is a single-center randomized controlled trial taking place in the Intermountain West. We plan to enroll 1,450 participants throughout the study. Women with abnormal mammography results will be invited to complete a validated, 10-item social needs screening assessment in English or Spanish. Eligible patients will be at least 18 years of age, speak English or Spanish, and indicate at least one social need. Participants will be randomized to passive or active social needs categories. Those in the active group will be called by 211 United Way services (211), a service which connects callers to community resources. The passive group will not receive a call from 211. Instead, they will be provided with information to contact 211 independently if they choose to. Primary outcomes are: (1) change in social needs, and (2) follow-up of abnormal mammography results, and will be assessed through follow-up surveys and chart reviews. Interviews and focus group discussions will explore how social needs influence patients’ adherence to recommended follow-up after an abnormal mammography result, and the role of community service navigation assistance in that follow-up. Discussion This study utilizes a 10-item social needs assessment and community navigation services to address social needs that prevent women from receiving timely follow-up after an abnormal mammogram screening. Our goal is to improve breast cancer follow-up outcomes for women with social needs. Trial registration The study was pre-registered at ClinicalTrials.gov on March 12, 2024, under identifier NCT06305312.

Background Systemic lupus erythematosus (SLE) is a life-threatening, chronic, autoimmune disease requiring long term subspecialty care due to its complex and chronic nature. Childhood-onset SLE (cSLE) is more severe than adult-onset, and the cSLE population in South Africa has been reported to have an even higher risk than patients elsewhere. Therefore, it is critical to promptly diagnose, treat, and manage cSLE. In this paper, we aim to describe and evaluate barriers and enablers of appropriate long-term care of cSLE South Africa from the perspective of caregivers (parents or family members). Methods Caregivers ( n  = 22) were recruited through pediatric and adult rheumatology clinics. Individuals were eligible if they cared for youth ( ≤  19 years) who were diagnosed with cSLE and satisfied at least four of the eleven ACR SLE classification criteria. Individual in-depth, semi-structured interviews were conducted between January 2014 and December 2014, and explored barriers to and facilitators of ongoing chronic care for cSLE. Data were analyzed using applied thematic analysis. Results Four barriers to chronic care engagement and retention were identified: knowledge gap, financial burdens, social stigma of SLE, and complexity of the South African medical system. Additionally, we found three facilitators: patient and caregiver education, robust support system for the caregiver, and financial support for the caregiver and patient. Conclusion These findings highlight multiple, intersecting barriers to routine longitudinal care for cSLE in South Africa and suggest there might be a group of diagnosed children who don’t receive follow-up care and are subject to loss to follow-up. cSLE requires ongoing treatment and care; thus, the different barriers may interact and compound over time with each follow-up visit. South African cSLE patients are at high risk for poor outcomes. South African care teams should work to overcome these barriers and place attention on the facilitators to improve care retention for these patients and create a model for other less resourced settings.

Background Despite a high prevalence of human papillomavirus (HPV) and cervical cancer in low and middle-income countries, stigma remains an issue. Addressing HPV and cervical cancer stigma could significantly improve health outcomes for these conditions. The objective of this study was to identify the manifestations of stigma and their potential impacts on health-seeking behavior. Methods Twenty-six in-depth interviews were conducted with women living with HIV, HIV-negative women, community health volunteers, and health care providers in Kisumu, Kenya in 2019. The interviews were designed to draw out existing attitudes or experiences related to stigma within the community. We conducted a thematic analysis of the interviews to identify internalized, anticipated, and discriminatory attitudes. Results Within internalized attitudes, a prominent observed theme was a fear of death associated with a positive HPV test. This stemmed from a lack of understanding of differences between HPV and cervical cancer and posed a significant barrier for women deciding to seek screening or to continue with treatment. Discriminatory attitudes of community members, including assumptions of promiscuity, infidelity, or HIV status, were perceived to prevent women from accessing screening and treatment opportunities. The interviews also exhibited a limited awareness of HPV in this region, which may have contributed to a lack of enacted stigma towards people living with HPV or cervical cancer. Conclusion Stigma has the potential to lead to decreased screening and treatment uptake through its drivers. This includes a decreased perception of personal risk due to a lack of knowledge, which results in increased HPV-risk behaviors. Future research must focus on creating and integrating stigma-reducing interventions, primarily to encourage women to seek out primary and secondary preventative measures.

Background Antimicrobial resistance has been named as one of the top ten threats to public health in the world. Hospital-based antimicrobial stewardship programs (ASPs) can help reduce antimicrobial resistance. The purpose of this study was to determine perceived barriers to the development and implementation of ASPs in tertiary care centers in three low- and middle-income countries (LMICs). Methods Interviews were conducted with 45 physicians at tertiary care hospitals in Sri Lanka (n = 22), Kenya (12), and Tanzania (11). Interviews assessed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics that inform antimicrobial use, receptiveness to ASPs, and perceived barriers to implementing ASPs. Two independent reviewers coded the interviews using principles of applied thematic analysis, and comparisons of themes were made across the three sites. Results Barriers to improving antimicrobial prescribing included prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to changing current practices regarding antimicrobial prescribing, and limited diagnostic capabilities. The most frequent of these barriers in all three locations was limited drug availability. Many physicians in all three sites had not heard of ASPs before the interviews. Improved education was a suggested component of ASPs at all three sites. The creation of guidelines was also recommended, without prompting, by interviewees at all three sites. Although most participants felt microbiological results were helpful in tailoring antibiotic courses, some expressed distrust of laboratory culture results. Biomarkers like erythrocyte sedimentation rate and c-reactive protein were not felt to be specific enough to guide antimicrobial therapy. Despite limited or no prior knowledge of ASPs, most interviewees were receptive to implementing protocols that would include documentation and consultation with ASPs regarding antimicrobial prescribing. Conclusions Our study highlighted several important barriers to implementing ASPs that were shared between three tertiary care centers in LMICs. Improving drug availability, enhancing availability of and trust in microbiologic data, creating local guidelines, and providing education to physicians regarding antimicrobial prescribing are important steps that could be taken by ASPs in these facilities.

Introduction Antenatal depression in low-and middle-income countries is under-diagnosed and leads to poorer outcomes in the pregnancy and postpartum periods. The aim of this study was to quantify depressive symptoms among pregnant women in Moshi, Tanzania, and identify factors associated with probable depression. Methods Between March and December 2019, we enrolled 1039 pregnant women attending their first antenatal care appointment at two government health facilities to complete an audio computer-assisted self-interview. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS), with a score > 13 indicating probable depression. A log-binomial regression model was used to identify factors associated with probable antenatal depression. Results A total of 11.5% (119/1033) met criteria for probable depression. Depression was more common among women who were not married (16.5% vs. 7.9%, PrR = 1.5, 95% CI 1.0, 2.1) and women who reported a lifetime history of violence (22.6% vs. 5.3%, PrR = 3.3, 95% CI 2.2, 5.0). Depression was less common among women who reported more partner-specific support (PrR = 0.92, 95% CI 0.87, 0.96). Conclusions Screening pregnant women for depressive symptoms is an essential component of evidence-based maternity care and should be accompanied by appropriate support and resources. Women who are not married, have limited support from a partner, or have experienced violence are especially vulnerable to depressive symptomatology during pregnancy.