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Salazar LJ, Srinivasan K, Heylen E, Ekstrand ML. Medication Adherence among Primary Care Patients with Common Mental Disorders and Chronic Medical Conditions in Rural India. Indian J Psychol Med 2023; 45:622-628. [PMID: 38545530 PMCID: PMC10964881 DOI: 10.1177/02537176231173869] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Background Only a few studies have explored the relationship between psychosocial factors and medication adherence in Indian patients with noncommunicable diseases (NCDs). We aimed to examine the association of psychosocial variables with medication adherence in people with NCDs and comorbid common mental disorders (CMDs) from primary care in rural southern India. Methods We performed a secondary analysis using baseline data from a randomized controlled trial in 49 primary care health centers in rural southern India (HOPE study). Participants were adults (≥30 years) with NCDs that included hypertension, diabetes, and/or ischemic heart disease, and comorbid depression or anxiety disorders. Medication adherence was assessed by asking participants if they had missed any prescribed NCD medication in the past month. Data were collected between May 2015 and November 2018. The association between psychosocial and demographic variables and medication nonadherence were assessed via logistic regression analyses. Results Of the 2486 participants enrolled, almost one-fifth (18.06%) reported missing medication. Male sex (OR = 1.74, 95% CI 1.37-2.22) and higher internalized mental illness stigma (OR = 1.46, 95% CI 1.07-2.00) were associated with higher odds of missing medication. Older age (OR = 0.40, 95% CI 0.26-0.60, for participants aged 64-75 years vs 30-44 years), reporting more social support (OR = 0.65, 95% CI 0.49-0.86), and higher satisfaction with health (OR = 0.74, 95% CI 0.61-0.89) were associated with lower odds of missing medication. Conclusions Greater internalized mental illness stigma and less social support are significantly associated with lower rates of medication adherence in patients with NCDs and comorbid CMDs in rural India.
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Affiliation(s)
- Luke Joshua Salazar
- Dept. of Psychiatry, St. John’s Medical College, Sarjapur Road, Bengaluru, Karnataka, India
| | - Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St. John’s Research Institute, Bengaluru, Karnataka, India
| | - Elsa Heylen
- Center for AIDS Prevention Studies, Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, California, United States
| | - Maria L. Ekstrand
- Division of Mental Health and Neurosciences, St. John’s Research Institute, Bengaluru, Karnataka, India
- Center for AIDS Prevention Studies, Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, California, United States
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Ruben JP, Ekstrand ML, Heylen E, Srinivasan K. Correlates for the severity of suicidal risk in participants with common mental disorders with comorbid chronic medical conditions in rural primary healthcare settings in India. Indian J Psychiatry 2023; 65:687-693. [PMID: 37485404 PMCID: PMC10358822 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_41_23] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/29/2023] [Accepted: 05/16/2023] [Indexed: 07/25/2023] Open
Abstract
Context Suicide is on the rise in low- and middle-income countries (LMICs), including India. There are limited studies assessing factors linked to the severity of suicidal risk in patients with depression and comorbid chronic medical disorders in primary healthcare (PHC) settings. Aim This study examines factors linked to suicidal risk among participants in a cluster randomized controlled trial of collaborative care intervention (Healthier Options through Empowerment (HOPE Study)). Settings and Design The setting was at 49 PHC in the rural Ramanagara District of Karnataka State in southern India. Study eligibility criteria included being ≥30 years with at least mild depression or generalized anxiety disorder and at least one medical condition (cardiovascular disorder or type 2 diabetes mellitus). Methods and Material The severity of suicidal risk at baseline was assessed using the Mini International Neuropsychiatric Interview (MINI), and other measures included the severity of depression (Patient Health Questionnaire-9-items (PHQ-9)), the severity of anxiety (Generalized Anxiety Disorder Scale-7-items (GAD-7)), disability, social support, quality of life, number of comorbid chronic medical illnesses, and body mass index (BMI). Statistical Analysis Used Chi-square tests and independent-samples t-tests were used to compare the demographic and clinical characteristics of the no-low and mod-high suicidal risk groups. Logistic regression analysis was used to identify correlates associated with the mod-high suicidal risk group. Results Mod-high suicidal risk was significantly positively associated with the severity of depression and disability and significantly negatively associated with social support. Conclusion The severity of depression, higher disability scores, and lower social support were found to be independent correlates of mod-high suicidal risk. Screening, managing depression, and facilitating social support for patients with chronic medical illness in PHC settings may reduce suicidal risk.
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Affiliation(s)
- Johnson-Pradeep Ruben
- Department of Psychiatry, St. John’s Medical College, Bengaluru, Karnataka, India
- Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s Medical College, Bengaluru, Karnataka, India
| | - Maria L. Ekstrand
- Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s Medical College, Bengaluru, Karnataka, India
- Division of Prevention Sciences, University of California, San Francisco, USA
| | - Elsa Heylen
- Division of Prevention Sciences, University of California, San Francisco, USA
| | - Krishnamachari Srinivasan
- Department of Psychiatry, St. John’s Medical College, Bengaluru, Karnataka, India
- Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s Medical College, Bengaluru, Karnataka, India
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Lodi S, Rossi SL, Bendiks S, Gnatienko N, Lloyd-Travaglini C, Vetrova M, Toussova O, Bushara N, Blokhina E, Krupitsky E, Ekstrand ML, Lioznov D, Samet JH, Lunze K. Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia. AIDS Behav 2023; 27:462-472. [PMID: 35916947 PMCID: PMC9892353 DOI: 10.1007/s10461-022-03781-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 06/30/2022] [Indexed: 02/04/2023]
Abstract
People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.
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Affiliation(s)
- Sara Lodi
- Boston University School of Public Health, Boston, MA, USA.
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA.
| | - Sarah L Rossi
- Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Sally Bendiks
- Department of Medicine, Boston Medical Center, Boston, MA, USA
| | | | | | - Marina Vetrova
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical University of Saint Petersburg, St. Petersburg, Russia
| | - Olga Toussova
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical University of Saint Petersburg, St. Petersburg, Russia
| | - Natalia Bushara
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical University of Saint Petersburg, St. Petersburg, Russia
| | - Elena Blokhina
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical University of Saint Petersburg, St. Petersburg, Russia
| | - Evgeny Krupitsky
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical University of Saint Petersburg, St. Petersburg, Russia
- Department of Addiction, Bekhterev National Medical Research Center for Psychiatry and Neurology, St. Petersburg, Russia
| | - Maria L Ekstrand
- Center for AIDS Prevention Studies, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore, India
| | - Dmitry Lioznov
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical University of Saint Petersburg, St. Petersburg, Russia
| | - Jeffrey H Samet
- Boston University School of Public Health, Boston, MA, USA
- Department of Medicine, Boston Medical Center, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
| | - Karsten Lunze
- Department of Medicine, Boston Medical Center, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
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Steward WT, Srinivasan K, Raj T, Heylen E, Nyblade L, Mazur A, Devadass D, Pereira M, Ekstrand ML. The Influence of Transmission-Based and Moral-Based HIV Stigma Beliefs on Intentions to Discriminate Among Ward Staff in South Indian Health Care Settings. AIDS Behav 2023; 27:189-197. [PMID: 35776252 PMCID: PMC9805471 DOI: 10.1007/s10461-022-03755-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: 06/09/2022] [Indexed: 01/24/2023]
Abstract
HIV stigma is comprised of several beliefs, including transmission fears and moral judgments against affected communities. We examined the relationships among HIV-related stigma beliefs, endorsement of coercive measures for people living with HIV (PLWH), and intentions to discriminate. We sought to understand to what degree the different stigma beliefs shape support for restrictive policies and discriminatory intentions. Data were drawn from the baseline assessment of DriSti, a cluster randomized controlled trial of an HIV stigma reduction intervention in Indian healthcare settings (NCT02101697). Participants completed measures assessing transmission fears and moral judgments of HIV, endorsement of coercive measures against PLWH (public disclosure of HIV status, refusal of healthcare services, marriage and family restrictions, required testing, and sharing of HIV information in a clinic), and intentions to discriminate against PLWH in professional and personal settings. We utilized multivariate regression modeling with backward elimination to identify the coercive measures and behavioral intentions most strongly associated with moral judgments. 1540 ward staff members completed the assessment. Participants had relatively high perceptions of transmission fears (M = 1.92, SD = 0.79) and moral judgments (M = 1.69, SD = 0.83); endorsed more intentions to discriminate in professional (M = 6.54, SD = 2.28) than personal settings (M = 2.07, SD = 1.49), and endorsed approximately half of all coercive measures (M = 9.47, SD = 2.68). After controlling for transmission fears, perceptions of stronger moral judgments against PLWH were significantly associated with higher endorsement of coercive measures related to refusing services (β = 0.10, t = 4.14, p < 0.001) and sharing patients' HIV status in clinics (β = 0.07, t = 3.04, p = 0.002), as well as with stronger behavioral intentions to discriminate in professional settings (β = 0.05, t = 2.20, p = 0.022). HIV stigma interventions for hospital-based ward staff in India need to focus on both transmission fears and moral judgments that underlie prejudicial beliefs. While the moral judgments are not technically related to risk in a hospital setting, our findings suggest that personnel will continue to discriminate in their professional work so long as these beliefs bear on their decisions and actions.
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Affiliation(s)
- Wayne T Steward
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Tony Raj
- St. Johns Research Institute, Bangalore, India
| | - Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura Nyblade
- International Development Group, Global Health Division, RTI International, DC, Washington, USA
| | - Amanda Mazur
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Maria L Ekstrand
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
- St. Johns Research Institute, Bangalore, India.
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94143, USA.
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Siddaiah A, Srinivasan K, Satyanarayana V, Ekstrand ML. Feasibility and preliminary efficacy of training health workers in detecting Priority Mental Health Conditions among adolescents in rural South India. Pilot Feasibility Stud 2022; 8:267. [PMID: 36587228 PMCID: PMC9805108 DOI: 10.1186/s40814-022-01215-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/29/2022] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Half of all mental disorders start during adolescence, before 14 years. In India, the current prevalence of mental disorders in 13-17 years age group was 7.3%. Many gaps persist in the mental healthcare delivery through the national mental health program, the low psychiatrist population ratio being one of them. Community health workers can play an essential role in providing mental healthcare in such resource-constrained settings. The World Health Organization mental health gap action program (WHO mhGAP) is a widely studied mental health tool that health workers can use to identify mental disorders. The study's aim was to test the preliminary efficacy of training healthcare workers (HCWs) in identifying mental health conditions among adolescents using modified WHO mhGAP modules. METHODS The feasibility study was carried out in two Primary Health Centers (PHCs) in rural Bengaluru. Study had two components: (1) training of HCWs on adolescent mental health and (2) detection of selected priority mental health conditions among adolescents by trained HCWs. HCWs were trained in five adolescent mental health conditions using a training manual and modified WHO mhGAP modules that excluded emergency presentations and management sections. Pre- and post-training assessments were carried out. A sample of 272 adolescents attending PHCs were assessed for any mental health condition by HCWs using mhGAP modules. A sub-sample of adolescents and all adolescents identified by HCWs with a mental health condition was interviewed by the investigator to validate the diagnosis. Qualitative interviews were carried out with participating HCWs to understand the acceptability of the intervention, acceptability, and barriers to training in identifying mental health conditions among adolescents RESULTS: A total of 23 HCWs underwent training. There was a significant increase in the mental health knowledge scores of HCWs post-training compared to baseline (p value <0.001). Out of 272 adolescents, 18 (6.8%) were detected to have any mental health condition by HCWs as per the modified WHO mhGAP modules. A sample of 72 adolescents consisting of all adolescents identified with a mental health condition by HCWs and a random sample of adolescents without any diagnosis were validated by the research investigator (AS). There was a good agreement between diagnosis by health workers and the research investigator with a Cohen's Kappa of 0.88. Four themes emerged from the qualitative analysis. CONCLUSIONS Training was effective in improving the knowledge of HCWs. There was a good agreement between trained HCWs and the investigator in detecting adolescent mental health conditions using modified mhGAP modules. The modified WHO mhGAP can thus be used by trained non-specialist HCWs to screen for adolescent mental health conditions in primary health centers.
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Affiliation(s)
- Archana Siddaiah
- grid.416432.60000 0004 1770 8558Community Health Department, St John’s Medical College Hospital, Sarjapur road, John Nagar, Kormangala, Bengaluru, 560034 India
| | - Krishnamachari Srinivasan
- grid.416432.60000 0004 1770 8558Department of Psychiatry, St John’s Medical College, Head, Division of Mental Health and Neurosciences, St John’s Research Institute, Bengaluru, 560034 India
| | - Veena Satyanarayana
- grid.416861.c0000 0001 1516 2246Department of Clinical Psychology, National Institute of Mental Health and Neuro Science, Bengaluru, 560034 India
| | - Maria L. Ekstrand
- grid.266102.10000 0001 2297 6811Department of Medicine, Division of Prevention Science, University of California, San Francisco, USA
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Inbaraj LR, Heylen E, Srinivasan K, Ekstrand ML. Is self-reported adherence a valid measure of glycaemic control among people living with diabetes in rural India? A cross-sectional analysis. Prim Care Diabetes 2022; 16:849-852. [PMID: 36336604 PMCID: PMC9675721 DOI: 10.1016/j.pcd.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Visual analogue scale (VAS) is one of the simplest to measure medication adherence. It has neither been widely used for Non communicable diseases (NCD) nor validated for in the Indian setting. We examined the validity of self-reported medication adherence measures in relation to HbA1C in a rural population with diabetes mellitus (DM). METHODS Participants with DM was administered VAS, Diabetes Self-Management Questionnaire (DMSQ) and assessed for missed pills. Descriptive statistics and logistic regression analysis were done. RESULTS We recruited 1347 participants and 84% of them reported being 100% adherent as per VAS and 83.8% stated that they did not miss any pills. However, 58.2% of participants who reported having 100% adherence had poor glycaemic control, as did 58.1% of those who did not miss any pills. None of the diabetic self-care measures was significantly associated with glycaemic control. CONCLUSION We found a lack of association between self-reported adherence measures and glycaemic control in participants with DM suggesting that self-reported adherence scales may not be valid in this population.
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Affiliation(s)
- Leeberk Raja Inbaraj
- Department of Community Health and Family Medicine, Bangalore Baptist Hospital, Bengaluru, India; Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chennai, India.
| | - Elsa Heylen
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, USA
| | - Krishnamachari Srinivasan
- Department of Psychiatry, St John's Medical College Hospital, Bengaluru, Karnataka, India; Division of Mental Health and Neurosciences, St. John's Research Institute, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
| | - Maria L Ekstrand
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, USA; Division of Mental Health and Neurosciences, St. John's Research Institute, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
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Devadass D, Fernandez R, Raj TD, Heylen E, Nyblade L, Srinivasan K, Ekstrand ML. Standard Precautions are for everyone: The role of HIV stigma and implications for nursing education in India. J Nurs Educ Pract 2022; 12:69-76. [PMID: 36579144 PMCID: PMC9793881 DOI: 10.5430/jnep.v12n12p69] [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] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and objective Standard Precautions (SP) are infection control procedures universally applicable to every patient. Though SP reduces disease transmission, their implementation is dependent on the knowledge and skills of healthcare workers (HCWs). Poor knowledge regarding the appropriate use of SP can cause fear among HCWs, leading to stigma and discrimination while treating people living with HIV (PLWH). Stigma and discrimination are known barriers for PLWH to access HIV care services. The aim of the study was to assess nursing student knowledge of SP, SP self-efficacy and SP perceived efficacy of nursing students, and (2) to assess the association between SP knowledge, perceived efficacy, and intention to utilize unwarranted precautions, like using double gloves while treating PLWH. Methods This paper analyzes baseline (non-randomized) data of a cluster randomized controlled trial amongst 1868 Indian nursing students. Data was collected using computer-administered structured questionnaire. The associations between the measures were done using multiple, logistic and poisson regression models. Results Although 97% nursing students could identify SP, only 35.5% understood that they need to be used with all patients. Awareness of the importance of using SP with all patients was positively associated with self-efficacy. Students performing high-risk tasks frequently were significantly more likely to be confident in their ability to correctly use SP, but also had higher intention to use unwarranted precautions. Conclusions Existing teaching and training programs for HCWs need to provide clear guidelines and emphasize on the correct use of SP with all patients. This will increase both skills and confidence in their abilities (self-efficacy).
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Affiliation(s)
- Dhinagaran Devadass
- Division of Medical Informatics, St. John’s Research Institute, St. John’s Medical College, Bengaluru, India,Correspondence: Dhinagaran Devadass; ; Address: Division of Medical Informatics, St. John’s Research Institute, St. John’s Medical College, Bengaluru, India
| | - Ryan Fernandez
- Division of Medical Informatics, St. John’s Research Institute, St. John’s Medical College, Bengaluru, India
| | - Tony D.S. Raj
- Division of Medical Informatics, St. John’s Research Institute, St. John’s Medical College, Bengaluru, India
| | - Elsa Heylen
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, USA
| | - Laura Nyblade
- Global Health Division, International Development Group, RTI International, USA
| | - Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s Medical College, Bengaluru, India
| | - Maria L. Ekstrand
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, USA,Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s Medical College, Bengaluru, India
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Srinivasan K, Heylen E, Johnson Pradeep R, Mony PK, Ekstrand ML. Collaborative care compared to enhanced standard treatment of depression with co-morbid medical conditions among patients from rural South India: a cluster randomized controlled trial (HOPE Study). BMC Psychiatry 2022; 22:394. [PMID: 35698087 PMCID: PMC9195442 DOI: 10.1186/s12888-022-04000-3] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Depression is common among primary care patients in LMIC but treatments are largely ineffective. In this cluster-randomized controlled trial, we tested whether depression outcomes are different among recipients of a collaborative care model compared to enhanced standard treatment in patients with co-morbid chronic medical conditions. METHODS We conducted a cluster randomized controlled trial among participants 30 years or older seeking care at 49 primary health centers (PHCs) in rural Karnataka, diagnosed with major depressive disorder, dysthymia, generalized anxiety disorder, or panic disorder on the MINI-International Neuropsychiatric Interview plus either hypertension, diabetes, or ischemic heart disease. From a list of all PHCs in the district, 24 PHCs were randomized a priori to deliver collaborative care and 25 PHCs enhanced standard treatment. The collaborative care model consisted of a clinic-based and a community-based component. Study assessment staff was blinded to treatment arm allocation. The primary outcome was the individual-level PHQ-9 score over time. RESULTS Between May 2015 and Nov 2018, 2486 participants were enrolled, 1264 in the control arm, and 1222 in the intervention arm. They were assessed at baseline, 3, 6 and 12 months. The mean PHQ-9 depression score was around 8.5 at baseline. At each follow-up PHQ-9 scores were significantly lower in the intervention (5.24, 4.81 and 4.22 at respective follow-ups) than in the control group (6.69, 6.13, 5.23, respectively). A significant time-by-treatment interaction (p < 0.001) in a multi-level model over all waves, nested within individuals who were nested within PHCs, confirmed that the decrease in depression score from baseline was larger for collaborative care than enhanced standard care throughout follow-up. CONCLUSIONS The collaborative care intervention resulted in significantly lower depression scores compared to enhanced standard care among participants with co-morbid physical conditions. The findings have potential implications for integrating mental health and chronic disease treatment in resource constrained settings. TRIAL REGISTRATION ClinicalTrials.gov NCT02310932 , registered on December 8, 2014, and Clinical Trials Registry India CTRI/2018/04/013001 , registered on April 4, 2018. Retrospectively registered.
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Affiliation(s)
- Krishnamachari Srinivasan
- grid.418280.70000 0004 1794 3160Division of Mental Health & Neurosciences, St John’s Research Institute, Bangalore, India ,grid.416432.60000 0004 1770 8558Department of Psychiatry, St John’s Medical College, Bangalore, India
| | - Elsa Heylen
- grid.266102.10000 0001 2297 6811Division of Prevention Sciences, University of California, San Francisco, USA
| | - R. Johnson Pradeep
- grid.416432.60000 0004 1770 8558Department of Psychiatry, St John’s Medical College, Bangalore, India
| | - Prem K. Mony
- grid.416432.60000 0004 1770 8558Division of Epidemiology and Community Health, St John’s Medical College & Research Institute, Bangalore, India
| | - Maria L. Ekstrand
- grid.418280.70000 0004 1794 3160Division of Mental Health & Neurosciences, St John’s Research Institute, Bangalore, India ,grid.266102.10000 0001 2297 6811Division of Prevention Sciences, University of California, San Francisco, USA
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Srinivasan K, Salazar LJ, Heylen E, Ekstrand ML. Elevated homocysteine and depression outcomes in patients with comorbid medical conditions in rural primary care. Int J Noncommun Dis 2022; 7:95-97. [PMID: 36483766 PMCID: PMC9728592] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
We examined the association of elevated concentration of total homocysteine (tHcy) with the severity of depression in patients diagnosed with depression and comorbid chronic medical conditions in rural primary care settings in Karnataka. Participants were included from the control arm of a cluster-randomized controlled trial designed to evaluate the effects of using a collaborative care model to integrate screening and treatment of primary health center patients. tHcy was assayed at baseline, and depression severity scores were assessed using the Patient Health Questionnaire (PHQ-9) 6 months later. There was no difference in the mean PHQ-9 score between those with (mean PHQ = 7.4) and without (mean PHQ = 7.6) elevated tHcy levels (P = 0.67).
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Affiliation(s)
- Krishnamachari Srinivasan
- Department of Psychiatry, St. John’s Medical College
- Division of Mental Health and Neurosciences, St. John’s Research Institute, Bengaluru, Karnataka, India
| | | | - Elsa Heylen
- Department of Medicine, Division of Prevention Sciences, University of California, San Francisco, California, USA
| | - Maria L. Ekstrand
- Division of Mental Health and Neurosciences, St. John’s Research Institute, Bengaluru, Karnataka, India
- Department of Medicine, Division of Prevention Sciences, University of California, San Francisco, California, USA
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Harding R, Salins N, Sharan K, Ekstrand ML. Health literacy in communication, decision-making and outcomes among cancer patients, their families and clinicians in India: A multicentre cross-sectional qualitative study. Psychooncology 2022; 31:532-540. [PMID: 34687573 PMCID: PMC10505478 DOI: 10.1002/pon.5838] [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: 07/02/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cancer patients in India prefer full information regarding diagnosis and prognosis, but evidence suggests poor insight. This study aimed to identify the role of health literacy among adult patients living with cancer, their families and health professionals in decision-making and treatment outcomes in India. METHODS This cross-sectional in-depth study recruited patients, families and clinicians from three centers. Inductive thematic analysis informed a novel conceptual model. RESULTS We recruited n = 34 cancer patients, n = 33 family members, n = 11 doctors and n = 14 nurses (N = 92). Principle emergent themes were the following: (1) Preferences and dynamics of diagnosis and prognosis disclosure, for example, the dominant preference was for families who held hope for cure to discourage disclosure; clinicians sometimes disclosed in line with perceived ability to pay for treatment. (2) Understanding of disease and its treatment options (etiology, potential trajectory, treatment options), for example, lay understandings of cancer etiology as contamination from outside the home, and reluctance of patients to ask questions of clinicians. (3) Priorities in decision-making, for example, not engaging patients due to fear of patient distress, patients initiated on anticancer treatments without knowledge or consent, pursuing futile treatments. (4) Anxieties over finances and outcomes (disclosure, decision-making, care pathways), for example, clinicians attempting to reduce families pursuing expensive and inappropriate treatment options with patients who have poor insight, catastrophic spending based on poor decisions. CONCLUSION The novel evidence-based health literacy model offers potential for feasible and acceptable intervention to support families in communication, disclosure and decision-making. This may improve patients' access to informed, appropriate care pathways.
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Affiliation(s)
- Richard Harding
- Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, Florence Nightingale School of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Krishna Sharan
- Department of Radiotherapy & Oncology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Maria L. Ekstrand
- Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA
- St John's Research Institute, St John's National Academy of Health Sciences, Bengaluru, Karnataka, India
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11
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Ekstrand ML, Heylen E, Pereira M, Chandy S, Srinivasan K. Anxiety and Worry About COVID-19 Infection are Associated with Less Confidence in Ability to Engage in Treatment: Results from a South India Cohort of People Living with HIV (PLWH). J Int Assoc Provid AIDS Care 2022; 21:23259582221080303. [PMID: 35229681 PMCID: PMC8891242 DOI: 10.1177/23259582221080303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maria L Ekstrand
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA, USA
- St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Elsa Heylen
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA, USA
| | - Matilda Pereira
- St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Sara Chandy
- St John's Medical College Hospital, Medicine, Bangalore, India
| | - Krishnamachari Srinivasan
- St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
- Department of Psychiatry, St John’s Medical College, Bangalore, India
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12
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Salazar LJ, Ekstrand ML, Selvam S, Heylen E, Pradeep JR, Srinivasan K. The effect of mental health training on the knowledge of common mental disorders among medical officers in primary health centres in rural Karnataka. J Family Med Prim Care 2022; 11:994-999. [PMID: 35495844 PMCID: PMC9051705 DOI: 10.4103/jfmpc.jfmpc_1353_21] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/07/2021] [Accepted: 10/16/2021] [Indexed: 11/06/2022] Open
Abstract
Background Deficits in knowledge regarding identification and treatment of common mental disorders (CMD) and stigmatizing attitudes towards CMDs exist among primary care physicians in India. Objectives We aimed to assess the gain in knowledge of CMDs among primary health centre (PHC) doctors, after they underwent training in the identification and treatment of CMDs, and to assess the relationship between the gain in knowledge and demographic variables. We also assessed attitudes towards depression among PHC doctors who underwent training. Methods We assessed knowledge of CMDs among 38 PHC doctors before and after training using a multiple-choice questionnaire (MCQ). The training session included didactic teaching and case-based discussions. Results The post-test mean score was significantly higher compared to the pre-test mean score (P < 0.0001), indicative of a significant mean gain in knowledge of CMDs among PHC doctors following training. Significant improvements were noted on the questions assessing identification of CMDs, knowledge of depressive symptoms and identification of panic attacks, post-training (all P < 0.05). Participants with lower pre-test scores had greater improvements in knowledge post-training. Around half of the PHC doctors endorsed negative attitudes towards depression. Conclusions We demonstrated the efficacy of a training programme for PHC doctors in improving their knowledge of CMDs. Stigmatizing attitudes towards depression were present among around half the PHC doctors even after the training. This has implications for the strategy of integrating mental healthcare into primary care, with the overall goal of reducing the treatment gap for CMDs.
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Affiliation(s)
| | - Maria L. Ekstrand
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, USA
- Division of Mental Health and Neurosciences, St. John’s Research Institute, Bengaluru, India
| | - Sumithra Selvam
- Division of Epidemiology and Biostatistics, St. John’s Research Institute, Bengaluru, India
| | - Elsa Heylen
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, USA
| | - Johnson R Pradeep
- Department of Psychiatry, St. John’s Medical College, Bengaluru, India
| | - Krishnamachari Srinivasan
- Department of Psychiatry, St. John’s Medical College, Bengaluru, India
- Division of Mental Health and Neurosciences, St. John’s Research Institute, Bengaluru, India
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13
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Fernandez R, Raj TDS, Heylen E, Nyblade L, Devadass D, Srinivasan K, Ekstrand ML. Awareness of the Use of Standard Precautions during Care of People Living with HIV by Ward Attendants in Indian Hospitals. Indian J Community Med 2022; 47:142-146. [PMID: 35368470 PMCID: PMC8971887 DOI: 10.4103/ijcm.ijcm_1339_21] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/12/2022] [Indexed: 11/04/2022] Open
Abstract
Context: Standard precautions (SP) are infection prevention practices universally used during patient care to lower infection transmission. Aims: The aim of the study was to (1) assess Indian ward attendants' (WAs) knowledge, perceived efficacy, and self-efficacy regarding SP and (2) examine correlates of SP self-efficacy and intent to use unnecessary precautions during care of people living with HIV. Subjects and Methods: Data are sourced from a face-to-face baseline survey of a stigma-reduction trial among 1859 WAs from Indian hospitals. Percentages were used to describe categorical variables means and standard deviations for continuous variables. Multiple regressions examined associations between measures. Results: WAs who had heard of SP had 44% higher odds of confidently using SP than those who had not heard of them. Those aware of universal SP use were 43% more likely to feel confident in using SP but also reported greater intent to use unnecessary precautions. Conclusions: Hospitals could implement SP training for WAs, as their knowledge of universal use was lacking.
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Affiliation(s)
- Ryan Fernandez
- Division of Medical Informatics, St. John's Research Institute, St. John's Medical College, Bengaluru, India
| | - Tony D S Raj
- Division of Medical Informatics, St. John's Research Institute, St. John's Medical College, Bengaluru, India
| | - Elsa Heylen
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA
| | - Laura Nyblade
- Global Health Division, International Development Group, RTI International, Washington, DC, USA
| | - Dhinagaran Devadass
- Division of Medical Informatics, St. John's Research Institute, St. John's Medical College, Bengaluru, India
| | - Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St. John's Research Institute, St. John's Medical College, Bengaluru, India
| | - Maria L Ekstrand
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA.,Division of Mental Health and Neurosciences, St. John's Research Institute, St. John's Medical College, Bengaluru, India
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14
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Carpenter CL, Kapur K, Ramakrishna P, Pamujula S, Yadav K, Giovanni JE, Julian O, Ekstrand ML, Sinha S, Nyamathi AM. Lean Mass Improvement from Nutrition Education and Protein Supplementation among Rural Indian Women Living with HIV/AIDS: Results from Cluster Randomized Factorial Trial at 18-Month Follow-Up. Nutrients 2021; 14:179. [PMID: 35011054 PMCID: PMC8746930 DOI: 10.3390/nu14010179] [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: 11/20/2021] [Revised: 12/24/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022] Open
Abstract
Loss of lean muscle mass impairs immunity and increases mortality risk among individuals with HIV/AIDS. We evaluated the relative contributions of protein supplementation and nutrition education on body composition among 600 women living with HIV/AIDS in rural Andhra Pradesh, India. We conducted a cluster randomized controlled 2 × 2 factorial trial lasting six months with follow up at twelve and eighteen months. Interventions occurred in the Nellore and Prakasam regions of Andhra Pradesh by trained village women, ASHA (Accredited Social Health Activists), and included: (1) the usual supportive care from ASHA (UC); (2) UC plus nutrition education (NE); (3) UC plus nutritional protein supplementation (NS); (4) combined UC plus NE plus NS. A Bioimpedance Analyzer Model 310e measured body composition. SAS 9.4 analyzed all data. Mixed models using repeated measures evaluated lean mass change from baseline as primary and fat weight and total weight as secondary outcomes. Lean mass change was significantly associated with NS (p = 0.0001), NE (p = 0.0001), and combined NS plus NE (p = 0.0001), with similar associations for secondary outcomes. Stronger associations for total weight were observed with greater ART adherence. Nutritional interventions may improve physiologic response to HIV. Significant increases in lean mass resulted from independent and combined protein supplementation and nutrition education.
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Affiliation(s)
| | | | | | - Suresh Pamujula
- People’s Health Society, Nellore 524137, India; (P.R.); (S.P.)
| | - Kartik Yadav
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA 92697, USA; (K.Y.); (A.M.N.)
| | - Jennifer E. Giovanni
- Center for Human Nutrition, University of California, Los Angeles, CA 90024, USA;
| | - Olivia Julian
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA;
| | - Maria L. Ekstrand
- Center for AIDS Prevention, Department of Medicine, University of California, San Francisco, CA 94158, USA;
| | - Sanjeev Sinha
- All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India;
| | - Adeline M. Nyamathi
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA 92697, USA; (K.Y.); (A.M.N.)
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15
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Ekstrand ML, Heylen E, Gandhi M, Steward WT, Pereira M, Srinivasan K. COVID-19 Vaccine Hesitancy Among PLWH in South India: Implications for Vaccination Campaigns. J Acquir Immune Defic Syndr 2021; 88:421-425. [PMID: 34757971 PMCID: PMC8575086 DOI: 10.1097/qai.0000000000002803] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The global effort to end the Severe Acute Respiratory Syndrome - Coronavirus 2 pandemic will depend on our ability to achieve a high uptake of the highly efficacious vaccines in all countries. India recently experienced an unprecedented transmission surge, likely fueled by a premature reopening, the highly transmissible delta variant, and low vaccination rates. Indian media have reported high degrees of vaccine hesitancy, which could interfere with efforts to prevent future surges, making it crucial to better understand the reasons for such reluctance in vulnerable populations, such as people living with HIV. METHODS We conducted telephone interviews with 438 people living with HIV who were participants in a longitudinal cohort, designed to examine and validate novel antiretroviral therapy ART adherence measures. Interviews were conducted in January and February 2021 and covered COVID-19-related questions on confidence in vaccine safety and efficacy, worries of vaccine side effects, trust in COVID-19 information from specific sources, and intent to get vaccinated. RESULTS Over one-third of participants (38.4%, n = 168) met our definition of "vaccine hesitant" by reporting being either unlikely to get vaccinated at all or wanting to wait. Vaccine hesitancy was associated with lack of confidence in vaccine safety, concerns about side effects and efficacy, and distrust in common sources of vaccine-related information. DISCUSSION These results highlight several challenges for vaccination efforts. Campaigns may benefit from using trusted sources, including antiretroviral therapy center staff, providing clear information about safety and efficacy and emphasizing the role of vaccines in preventing severe disease, hospitalizations and death, and the reduction of forward transmission to unvaccinated household members.
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Affiliation(s)
- Maria L. Ekstrand
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Division of Mental Health and Neurosciences, St John's Research Institute, Bangalore, India; and
| | - Elsa Heylen
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Monica Gandhi
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Wayne T. Steward
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Matilda Pereira
- Division of Mental Health and Neurosciences, St John's Research Institute, Bangalore, India; and
| | - Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St John's Research Institute, Bangalore, India; and
- Department of Psychiatry, St John's Medical College, Bangalore, India
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16
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Vetrova MV, Cheng DM, Bendiks S, Gnatienko N, Lloyd-Travaglini C, Jiang W, Luoma J, Blokhina E, Krupitsky E, Lioznov D, Ekstrand ML, Raj A, Samet JH, Lunze K. HIV and Substance Use Stigma, Intersectional Stigma and Healthcare Among HIV-Positive PWID in Russia. AIDS Behav 2021; 25:2815-2826. [PMID: 33506305 DOI: 10.1007/s10461-021-03172-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 01/16/2021] [Indexed: 01/01/2023]
Abstract
Little is known about the intersection of HIV stigma and substance use stigma. Using data from 188 HIV-positive people who inject drugs (PWID) in Russia, we examined the associations of these stigmas and their interaction with access and utilization of healthcare. While substance use stigma was significantly associated with poor access to care (AOR 2.31, 95%CI 1.50-3.57), HIV stigma was not. HIV stigma was associated with lower inpatient care utilization (AOR 0.32, 95%CI 0.14-0.65), while substance use stigma was not. We did not detect a significant interaction between the two forms of stigma for either of the primary outcomes. However, those with high levels of both substance use stigma and HIV stigma had higher odds of poor general access to healthcare (AOR 1.86, 95%CI 1.19-2.92), and lower odds of recent general outpatient (AOR 0.52, 95%CI 0.32-0.85) and any inpatient (AOR 0.48, 95%CI 0.22-0.99) care utilization compared to those with low levels of both types of stigma. Interventions addressing both substance use and HIV stigma in general healthcare settings might improve care in this HIV key population.
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Affiliation(s)
- Marina V Vetrova
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical, University of Saint Petersburg, 6-8 Lev Tolstoy Street, St. Petersburg, Russia, 197022.
- Boston Medical Center, Boston, USA.
| | | | | | | | | | - Wenqing Jiang
- School of Public Health, Boston University, Boston, USA
| | - Jason Luoma
- Portland Psychotherapy Clinic, Research, & Training Center, Portland, OR, USA
| | - Elena Blokhina
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical, University of Saint Petersburg, 6-8 Lev Tolstoy Street, St. Petersburg, Russia, 197022
| | - Evgeny Krupitsky
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical, University of Saint Petersburg, 6-8 Lev Tolstoy Street, St. Petersburg, Russia, 197022
- Department of Addiction, Bekhterev National Medical Research Center for Psychiatry and Neurology, Saint Petersburg, Russia
| | - Dmitry Lioznov
- Laboratory of Clinical Psychopharmacology of Addictions, First Pavlov State Medical, University of Saint Petersburg, 6-8 Lev Tolstoy Street, St. Petersburg, Russia, 197022
| | - Maria L Ekstrand
- Center for AIDS Prevention Studies, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore, India
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego, San Diego, CA, USA
| | - Jeffrey H Samet
- Boston Medical Center, Boston, USA
- School of Public Health, Boston University, Boston, USA
- School of Medicine, Boston University, Boston, USA
| | - Karsten Lunze
- Boston Medical Center, Boston, USA
- School of Medicine, Boston University, Boston, USA
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17
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Shin SS, Satyanarayana VA, Ekstrand ML, Carpenter CL, Wang Q, Yadav K, Ramakrishnan P, Pamujula S, Sinha S, Nyamathi AM. The Effect of Community-Based Nutritional Interventions on Children of Women Living With Human Immunodeficiency Virus in Rural India: A 2 × 2 Factorial Intervention Trial. Clin Infect Dis 2021; 71:1539-1546. [PMID: 31608373 DOI: 10.1093/cid/ciz1009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/08/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Malnutrition is a common clinical concern among children in low-income communities affected by human immunodeficiency virus (HIV). We examined the effect of a community-based nutritional intervention on anthropometric and clinical outcomes of children of women living with HIV in rural India. METHODS We assigned women living with HIV and their child (oldest 3-8 years) to 1 of 4 programs: (1) community-based HIV care program, (2) program 1 + nutrition education, (3) program 1 + food supplement, and (4) all elements of programs 1-3. Study data were collected at baseline and months 6, 12, and 18. We applied mixed-effects modeling with restricted maximum likelihood estimation to examine changes in weight (all children) and CD4+ T-cell counts (children with HIV only). RESULTS Overall, 600 mother-child pairs were enrolled (150/group) with 100% retention at follow-up visits. Approximately 20% of children were living with HIV. Children in program 4 had higher weight gain than those in programs 1, 2, and 3 at all time points (adjusted P < .001). We found a higher increase in CD4+ T cells across all time points among participants in programs 3 and 4 compared with program 1 (adjusted P < .001). Factorial analysis suggested a synergistic effect of combining nutrition education and food supplements for weight gain but not for increase in CD4+ T cells. CONCLUSIONS A combination of nutrition education and food supplements provided to women living with HIV significantly increased weight and CD4+ T cells, and such interventions can be integrated into HIV-care programs in low-income settings.
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Affiliation(s)
- Sanghyuk S Shin
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
| | - Veena A Satyanarayana
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Maria L Ekstrand
- University of California San Francisco, San Francisco, California, USA.,St John's Research Institute, Bangalore, India
| | - Catherine L Carpenter
- Department of Epidemiology, University of California Los Angeles, Los Angeles, California, USA.,UCLA Center for Human Nutrition, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Qiao Wang
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
| | - Kartik Yadav
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
| | - Padma Ramakrishnan
- Department of Medicine, All India Institute of Medical Sciences, Delhi, India
| | | | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences, Delhi, India
| | - Adeline M Nyamathi
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
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18
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Allam RR, Takamiya M, Pant R, Gandham S, Yeldandi VV, Thomas J, Ekstrand ML, Dworkin MS. Factors associated with non-adherence to antiretroviral therapy among female sex workers living with HIV in Hyderabad, India. Int J STD AIDS 2021; 31:735-746. [PMID: 32631214 DOI: 10.1177/0956462420920145] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We determined factors associated with non-adherence (consuming <90% of monthly antiretroviral therapy) among female sex workers (FSWs). An interviewer-administered questionnaire was used in a sample of 100 South Indian FSWs living with HIV. We examined demographics, food insecurity, side effects, stigma, alcohol/substance use and self-efficacy. Non-adherence was assessed by self-report, pill-count and combined measures. Prevalence ratios and 95% confidence intervals (CIs) were calculated at p-value <0.1. Thirty-seven percent (33/90) of FSWs were non-adherent by pill-count, 29% (28/95) by self-report and 52% (51/99) by the combined measure. Seventy-six percent (76/100) of FSWs reported experience of at least one form of food insecurity in the past six months. In the regression analysis, arrest in the past year was independently associated with the combined measure of non-adherence (crude prevalence ratios 1.7, 95% CI 1.0-2.8). A successful combination adherence intervention should consider several of the socio-behavioral factors identified in this study including arrest and food insecurity.
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Affiliation(s)
| | - Mayuko Takamiya
- University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | | | | | | | - Jaya Thomas
- Chaithanya Mahila Mandali, Secunderabad, India
| | - Maria L Ekstrand
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mark S Dworkin
- University of Illinois at Chicago School of Public Health, Chicago, IL, USA
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19
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Rimal P, Khadka S, Bogati B, Chaudhury J, Rawat LK, Bhat KC, Manandhar P, Citrin D, Maru D, Ekstrand ML, Swar SB, Aryal A, Kohrt B, Shrestha S, Acharya B. Cross-cultural adaptation of motivational interviewing for use in rural Nepal. BMC Psychol 2021; 9:52. [PMID: 33794990 PMCID: PMC8017825 DOI: 10.1186/s40359-021-00557-y] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person’s behaviors. Methods We developed, translated, field-tested, and adapted a Nepali MI training module with key informants to generate insights on adapting MI for the first time in this cultural setting. Key informants were five Nepali nurses who supervise community health workers. We used structured observation notes to describe challenges and experiences in cross-cultural adaptation. We conducted this study as part of a larger study on using MI to improve adherence to HIV treatment. Results Participants viewed MI as an effective intervention with the potential to assist patients poorly engaged in care. Regarding patient autonomy, they initially shared examples of family members unsuccessfully dictating patient behavior change. These discussions led to consensus that every time the family members restrict patient's autonomy, the patient complies temporarily but then resumes their unhealthy behavior. In addition, participants highlighted that even when a patient is motivated to change (e.g., return for follow-up), their family members may not “allow” it. Discussion led to suggestions that health workers may need to conduct MI separately with patients and family members to understand everyone’s motivations and align those with the patient’s needs. Conclusions MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient’s autonomy and their role as a member of a complex social fabric to facilitate behavior change.
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Affiliation(s)
| | | | | | | | | | | | | | - David Citrin
- Possible, New York, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Anthropology, University of Washington, Seattle, WA, USA.,Henry M. Jackson School of International Studies, University of Washington, Seattle, WA, USA
| | - Duncan Maru
- Possible, New York, USA.,Icahn School of Medicine At Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.,Department of Health Systems Design and Global Health, Icahn School of Medicine At Mount Sinai, New York, USA.,Department of Internal Medicine, Icahn School of Medicine At Mount Sinai, New York, NY, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria L Ekstrand
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Sikhar Bahadur Swar
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Psychiatry, Kathmandu Medical College, Kathmandu, Nepal
| | - Anu Aryal
- Nyaya Health Nepal, Kathmandu, Nepal
| | - Brandon Kohrt
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA
| | - Srijana Shrestha
- Possible, New York, USA.,Department of Psychology, Wheaton College, Norton, MA, USA
| | - Bibhav Acharya
- Possible, New York, USA.,Department of Psychiatry, University of California San Francisco, San Francisco, USA
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20
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Johnson Pradeep R, Ekstrand ML, Selvam S, Heylen E, Mony PK, Srinivasan K. Risk factors for severity of depression in participants with chronic medical conditions in rural primary health care settings in India. J Affect Disord Rep 2021; 3. [PMID: 33681860 PMCID: PMC7929528 DOI: 10.1016/j.jadr.2020.100071] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Depression and chronic medical disorders are strongly linked. There are limited studies addressing the correlates of the severity of depression in patients with co-morbid disorders in primary care settings. This study aimed to identify the socio-demographic and disease-specific risk factors associated with the severity of depression at baseline among patients participating in a randomized controlled trial (HOPE study). Methods Participants were part of a randomized controlled trial in 49 primary care health centers in rural India. We included adults (≥ 30 years) with at least mild Depression or Anxiety Disorder and at least one Cardiovascular disorder or Type 2 Diabetes mellitus. They were assessed for the severity of depression using the PHQ-9, severity of anxiety, social support, number of co-morbid chronic medical illnesses, anthropometric measurements, HbA1c, and lipid profile. Results Proportionately there were more women in the moderate category of depression than men. Ordinal logistic regression showed co-morbid anxiety and a lower level of education significantly increased the odds of more severe depression, while more social support was significantly negatively associated with depression severity in women. In men, anxiety was positively associated with greater depression severity; while reporting more social support was negatively associated with depression. Limitations This is a cross-sectional study and thus, no causal conclusions are possible. Conclusions Anxiety and poor social support in both genders and lower educational levels in women were associated with increased severity of depression. Early identification of risk factors and appropriate treatment at a primary care setting may help in reducing the morbidity and mortality associated with depression.
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Affiliation(s)
- R Johnson Pradeep
- Department of Psychiatry, St John's Medical College, Sarjapur Road, Bangalore, Karnataka 560034, India
| | - Maria L Ekstrand
- Division of Mental Health and Neurosciences, St. John's Research Institute, St John's Medical College, Sarjapur Road, Bangalore, Karnataka 560034, India.,Division of Prevention Sciences, University of California, San Francisco, United States
| | - Sumithra Selvam
- Division of Epidemiology & Population Health, St John's Research Institute, St John's Medical College, Sarjapur Road, Bangalore, Karnataka 560034, India
| | - Elsa Heylen
- Division of Prevention Sciences, University of California, San Francisco, United States
| | - Prem K Mony
- Division of Epidemiology & Population Health, St John's Research Institute, St John's Medical College, Sarjapur Road, Bangalore, Karnataka 560034, India
| | - Krishnamachari Srinivasan
- Department of Psychiatry, St John's Medical College, Sarjapur Road, Bangalore, Karnataka 560034, India.,Division of Mental Health and Neurosciences, St. John's Research Institute, St John's Medical College, Sarjapur Road, Bangalore, Karnataka 560034, India
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21
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Satyanarayana VA, Burroughs HR, Heylen E, Yadav K, Sinha S, Nyamathi A, Ekstrand ML. Mental health of women living with HIV and its impact on child development in Andhra Pradesh, India. Vulnerable Child Youth Stud 2021; 16:307-319. [PMID: 34956392 PMCID: PMC8697731 DOI: 10.1080/17450128.2021.1883785] [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] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 01/18/2021] [Indexed: 06/14/2023]
Abstract
Global literature examining the association between mental health of women living with HIV (WLWH) and child development is scarce. In this study, we examined the relationship between mothers' mental health and their children's social development outcomes 6 months later. Data for these analyses come from several waves of interviews of 600 WLWH in the South Indian state of Andhra Pradesh, India. These women were enrolled in a 2×2 factorial clinical trial designed to assess the impact of food supplementation and nutrition education, both in addition to ASHA support, on adherence to ART and improved health outcomes for the women and one of their children. They were assessed on food security, stigma, social support, quality of life, depressive symptoms and child development outcomes. Results of longitudinal GEE regression analysis indicate that mother's depressive symptoms were significantly negatively associated with child's social quotient 6 months later. These findings have important implications for targeted health interventions, integrating mental health, both for WLWH and their children in India.
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Affiliation(s)
- Veena A. Satyanarayana
- Department of Clinical Psychology, National Institute of
Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Hadley R. Burroughs
- Center for AIDS Prevention Studies, Department of Medicine,
University of California San Franscisco (UCSF), USA
| | - Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine,
University of California San Franscisco (UCSF), USA
| | - Kartik Yadav
- Sue & Bill Gross School of Nursing, University of
California Irvine, USA
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical
Sciences, India
| | - Adeline Nyamathi
- Sue & Bill Gross School of Nursing, University of
California Irvine, USA
| | - Maria L. Ekstrand
- Center for AIDS Prevention Studies, Department of Medicine,
University of California San Franscisco (UCSF), USA
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22
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Nyblade L, Srinivasan K, Raj T, Oga EA, Heylen E, Mazur A, Devadass D, Steward WT, Pereira M, Ekstrand ML. HIV Transmission Worry Predicts Discrimination Intentions Among Nursing Students and Ward Staff in India. AIDS Behav 2021; 25:389-396. [PMID: 32804318 PMCID: PMC7855682 DOI: 10.1007/s10461-020-03001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Health facility stigma impedes HIV care and treatment. Worry of contracting HIV while caring for people living with HIV is a key driver of health facility stigma, however evidence for this relationship is largely cross-sectional. This study evaluates this relationship longitudinally amongst nursing students and ward staff in India. Worry of contracting HIV and other known predictors of intent to discriminate were collected at baseline and 6 months in 916 nursing students and 747 ward staff. Using fixed effects regression models, we assessed the effect of key predictors on intent to discriminate over a 6-month period. Worry of contracting HIV predicted intent to discriminate for nursing students and ward staff in care situations with low and high-risk for bodily fluid exposure, confirming prior cross-sectional study results and underscoring the importance of addressing worry of contracting HIV as part of health facility HIV stigma-reduction interventions.
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Affiliation(s)
- Laura Nyblade
- Global Health Division, International Development Group, RTI International, 13th St., NW, Suite 750, Washington, DC, 20005, USA.
| | - Krishnamachari Srinivasan
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Tony Raj
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Emmanuel A Oga
- Center for Applied Public Health Research, RTI International, Rockville, MD, USA
| | - Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Amanda Mazur
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Dhinagaran Devadass
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Wayne T Steward
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Matilda Pereira
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Maria L Ekstrand
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
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23
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Srinivasan K, Heylen E, Raj T, Nyblade L, Devadass D, Pereira M, Ekstrand ML. Reduction in Stigma Drivers Partially Mediates the Effect of a Stigma Reduction Intervention Among Nursing Students in India: The DriSti Cluster Randomized Controlled Trial. J Acquir Immune Defic Syndr 2021; 86:182-190. [PMID: 33105394 PMCID: PMC7884286 DOI: 10.1097/qai.0000000000002543] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV stigma in health care settings acts as a significant barrier to health care. Stigma drivers among health professionals include transmission fears and misconceptions and pre-existing negative attitudes toward marginalized groups vulnerable to HIV. The DriSti intervention, consisted of 2 sessions with videos and interactive exercises on a computer tablet and one interactive face-to-face group session, mostly tablet administered, was designed to target key stigma drivers that included instrumental stigma, symbolic stigma, transmission misconceptions and blame to reduce HIV stigma, and discrimination among nursing students (NS) and ward staff and tested in a cluster randomized trial. SETTING This report focuses on second and third year NS recruited from a range of nursing schools that included private, nonprofit, and government-run nursing schools in south India. RESULTS Six hundred seventy-nine NS received intervention and 813 NS were in the wait-list control group. Twelve months outcome analyses showed significant reduction among intervention participants in endorsement of coercive policies (P < 0.001) and in the number of situations in which NS intended to discriminate against PLWH (P < 0.001). Mediation analysis revealed that the effects of intervention on endorsement of coercive policies and intent to discriminate against PLWH were partially mediated by reductions in key stigma drivers. CONCLUSIONS This brief scalable stigma reduction intervention targeting key stigma drivers fills a critical gap in identifying the mechanistic pathways that aid in stigma reduction among health professionals.
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Affiliation(s)
- Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St John's Research Institute and St. John's Medical College, Bangalore, India
| | - Elsa Heylen
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA
| | - Tony Raj
- Division of Medical Informatics, St John's Research Institute, and St. John's Medical College, Bangalore, India; and
| | - Laura Nyblade
- Global Health Division, International Development Group, RTI International, Washington, DC
| | - Dhinagaran Devadass
- Division of Medical Informatics, St John's Research Institute, and St. John's Medical College, Bangalore, India; and
| | - Matilda Pereira
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA
| | - Maria L Ekstrand
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA
- Division of Medical Informatics, St John's Research Institute, and St. John's Medical College, Bangalore, India; and
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24
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Lin CP, Boufkhed S, Pai AA, Namisango E, Luyirika E, Sleeman KE, Costantini M, Peruselli C, Higginson IJ, Ekstrand ML, Harding R, Salins N, Bhatnagar S. Preparedness and Capacity of Indian Palliative Care Services to Respond to the COVID-19 Pandemic: An Online Rapid Assessment Survey. Indian J Palliat Care 2021; 27:152-171. [PMID: 34035634 PMCID: PMC8121233 DOI: 10.4103/ijpc.ijpc_429_20] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND COVID-19 has been causing a high burden of suffering for patients and families. There is limited evidence on the preparedness of Indian palliative care services for the pandemic. AIM This study aimed to assess the preparedness and capacity of Indian palliative care services in response to the COVID-19 pandemic. METHODS A cross-sectional online survey was developed based on prior evidence and international health regulations. It was emailed to the Indian Palliative Care Association members and investigators' professional networks in India. One participant per palliative care service was requested. Descriptive analysis was used. RESULTS Representatives of 78 palliative care services completed the survey. Three in four services had COVID-19 case definition and adapted their protocols for infection control (75%). About half of the services (55%) reported concerns about achieving appropriate hand hygiene in the community. More than half of the services (59%) had capacity to train nonspecialists for symptom control and psychological support. About half of the services reported that they had plans to redeploy staff (56%) and resources (53%) in the case of outbreaks. Two-fifths of the services used paper records to store an updated contact list of staff (40%) and did not have designated focal contacts for information update (40%). Staff anxiety related to personal infection risk and family care was relatively high (median score = 7 on a 1-10 scale). CONCLUSION We recommend the following resource allocation to enable palliative care services to support the Indian health system in delivering essential care in this and future pandemics: (1) infection control, especially in the community; (2) training using existing clinical protocols to strengthen palliative care across the health system; and (3) redeployment plans.
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Affiliation(s)
- Cheng-Pei Lin
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King's College London, London, UK
- School of Nursing, Institute of Community Health Care, National Yang-Ming University, Taipei, Taiwan
| | - Sabah Boufkhed
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Asha Albuquerque Pai
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda
| | | | - Katherine E Sleeman
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | | | - Carlo Peruselli
- Società Italiana di Cure Palliative (Italian Society of Palliative Care), MI, Italy
| | - Irene J Higginson
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Maria L Ekstrand
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, USA
- St John's Research Institute, Bengaluru, Karnataka, India
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sushma Bhatnagar
- Department of Oncoanesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
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25
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Salem BE, Hudson AL, Yadav K, Lucas J, Toyama J, Chen S, Faucette M, Ekstrand ML, Nyamathi AM. Correlates of Posttraumatic Stress Symptoms among Formerly Incarcerated, Homeless Women. Issues Ment Health Nurs 2020; 41:713-722. [PMID: 32400227 PMCID: PMC8428553 DOI: 10.1080/01612840.2020.1720050] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Posttraumatic stress symptoms are a pressing issue among women experiencing incarceration and homelessness. Baseline data were collected among formerly incarcerated homeless women (N = 130) who were on average 38.9 (SD = 11.36, range 19-64) years of age and recruited into a pilot randomized control trial (RCT) intervention program. A logistic regression was used to assess correlates of PTSD symptoms. The majority of the sample self-reported witnessing violence (85%) and had moderate PTSD symptoms (M = 1.61, SD = 1.62, range: 0-4). No past month drug use (p = 0.006), higher anger scores (p = 0.002), greater emotional support (p = 0.009), and psychological frailty (p = 0.02) were significantly associated with higher odds of PTSD symptoms. Moreover, women who experienced minor family conflicts had lower odds of PTSD symptoms relative to those that had family conflicts most of the time (p = 0.02). Similarly, controlling for all other variables, women who had a higher positive social interaction score also had lower odds of PTSD symptoms (p = 0.006). These findings are a call to action for academicians, service providers, and health practitioners to develop an intervention which integrates comprehensive PTSD screening, and discussion of ways to build coping skills, relationships with family and social networks, and utilizes a trauma-informed approach during reentry.
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Affiliation(s)
- Benissa E Salem
- School of Nursing, University of California, Los Angeles, California, USA
| | - Angela L Hudson
- School of Nursing, Azusa Pacific University, Azusa, California, USA
| | - Kartik Yadav
- School of Nursing, University of California, Irvine, California, USA
| | - Jaemilyn Lucas
- School of Nursing, San Bernardino and College of the Desert, California State University, San Bernardino, California, USA
| | - Joy Toyama
- School of Nursing, University of California, Los Angeles, California, USA
| | - Stephanie Chen
- Los Angeles County Department of Health Services, Los Angeles, California, USA
| | - Mark Faucette
- Housing for Health/Office of Diversion and Reentry, Los Angeles County Department of Health Services, Los Angeles, California, USA
| | - Maria L Ekstrand
- San Francisco School of Medicine, University of California, San Francisco, California, USA
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26
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Heylen E, Chandy S, Shamsundar R, Nair S, Ravi Kumar BN, Ekstrand ML. Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India. AIDS Care 2020; 33:486-493. [PMID: 32172599 DOI: 10.1080/09540121.2020.1742862] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.
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Affiliation(s)
- Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sara Chandy
- Department of Medicine, St. John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Ranjani Shamsundar
- Department of Microbiology, St. John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Shoba Nair
- Department of Pain and Palliative Medicine, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - B N Ravi Kumar
- Karnataka State AIDS Prevention Society, Bangalore, India
| | - Maria L Ekstrand
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,St. John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
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27
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Ekstrand ML, Raj T, Heylen E, Nyblade L, Devdass D, Pereira M, Mazur A, Srinivasan K. Reducing HIV stigma among healthcare providers in India using a partly tablet-administered intervention: the DriSti trial. AIDS Care 2020; 32:14-22. [PMID: 32151146 DOI: 10.1080/09540121.2020.1739221] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV stigma has long been recognized as a significant barrier in the worldwide fight against HIV. Across cultures, stigma has been shown to cause psychological distress and act as a barrier to engagement in care. Health professionals can serve as a crucial source of HIV stigma, with drivers that include fears and transmission misconceptions and pre-existing negative attitudes towards marginalized groups. To increase their impact, stigma reduction interventions need to be scalable and sustainable as well as adaptable to different cultural contexts. The DriSti intervention was designed to meet these needs through an easily adaptable, mostly tablet-administered, interactive intervention delivered to ward staff (n = 1,557) and nursing students (n = 1,625) in 62 Indian institutions, using a cRCT design, with wait-list controls. Six-month outcome analyses, showed significant reductions in misconceptions (p < .001) and worry about acquiring HIV at work (p < .001). Intervention participants also reported significantly greater reductions in endorsement of coercive policies (p < .001) and in the number of situations in which they intended to discriminate against PLWH (p < .001) than control participants. This brief, scaleable intervention could be adapted for similar populations in the region, using different mHealth platforms and thus has important implications for current global stigma reduction initiatives and training curricula.
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Affiliation(s)
- Maria L Ekstrand
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA, USA.,Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Tony Raj
- Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Elsa Heylen
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA, USA
| | - Laura Nyblade
- Global Health Division, International Development Group, RTI International, USA
| | - Dhinagaran Devdass
- Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Matilda Pereira
- Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Amanda Mazur
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA, USA
| | - Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, Department of Psychiatry, St. John's Research Institute, Bangalore, India
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28
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Salem BE, Bustos Y, Shalita C, Kwon J, Ramakrishnan P, Yadav K, Ekstrand ML, Sinha S, Nyamathi AM. Chronic Disease Self-Management Challenges among Rural Women Living with HIV/AIDS in Prakasam, Andhra Pradesh, India: A Qualitative Study. J Int Assoc Provid AIDS Care 2019; 17:2325958218773768. [PMID: 29756550 PMCID: PMC6713225 DOI: 10.1177/2325958218773768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 12/03/2022] Open
Abstract
Rural women living with HIV/AIDS (WLHA) in India experience challenges self-managing HIV/AIDS in their rural communities. The purpose of this qualitative study was to explore factors influencing their care and antiretroviral treatment (ART) adherence. Themes that emerged from the qualitative focus groups among WLHA (N = 24) in rural Prakasam, Andhra Pradesh, India, included: (1) coming to know about HIV and other health conditions, (2) experiences being on ART, (3) challenges maintaining a nutritious diet, (4) factors affecting health care access and quality, and (5) seeking support for a better future. Chronic disease self-management in rural locales is challenging, given the number of barriers which rural women experience on a daily basis. These findings suggest a need for individual- and structural-level supports that will aid in assisting rural WLHA to self-manage HIV/AIDS as a chronic illness.
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Affiliation(s)
- Benissa E Salem
- 1 School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yvita Bustos
- 1 School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA.,2 Psychology Department, Loyola University, Chicago, IL, USA
| | - Chidyaonga Shalita
- 1 School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA.,3 Biology Department, Macalester College, Forest Lake, MN, USA
| | - Jordan Kwon
- 1 School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA.,4 School of Nursing, Azusa Pacific University, Montebello, CA, USA
| | | | - Kartik Yadav
- 6 School of Nursing, University of California, Irvine, Irvine, CA, USA
| | - Maria L Ekstrand
- 7 University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Sanjeev Sinha
- 8 All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
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29
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Chandy S, Heylen E, Ravikumar BN, Ekstrand ML. Examining engagement in care of women living with HIV in South India. Health Care Women Int 2019; 41:553-566. [PMID: 31242078 DOI: 10.1080/07399332.2019.1623799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
HIV seropositive adherence-challenged women, who reported being on ART for at least four months were interviewed. Data on healthcare history, anti-retroviral therapy, clinic visits, doctor communication, disclosure and fear of stigma were collected. Better engagement in care was significantly more likely among older women, ≥ 10 years of education, higher income, HIV status disclosure to family, with higher community stigma fears and fewer healthcare access barriers. To promote retention, women may be encouraged to consider disclosing their HIV serostatus to supportive household members. A variety of possible interventions to overcome the prevalent barriers to care are provided.
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Affiliation(s)
- Sara Chandy
- Department of Medicine, St. John's Medical College, Bangalore, India
| | - Elsa Heylen
- Department of Medicine, University of California, San Francisco, CA, USA
| | - B N Ravikumar
- Karnataka State AIDS Prevention Society, Bangalore, India
| | - Maria L Ekstrand
- Department of Medicine, University of California, San Francisco, CA, USA.,St. John's Research Institute, Bangalore, India
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30
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Wilkerson JM, Rhoton JM, Li D, Rawat S, Patankar P, Rosser BRS, Ekstrand ML. Information, Motivation, and Self-Efficacy Among Men Who Have Sex With Men and Transgender Women in the State of Maharashtra, India. Health Educ Behav 2019; 46:304-311. [PMID: 30205760 PMCID: PMC6734545 DOI: 10.1177/1090198118796880] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND India's National AIDS Control Programme calls for, among other things, targeted behavioral interventions that address determinants contributing to new infections among men who have sex with men (MSM) and hijras (transgender women). AIM To determine if the information-motivation-behavioral skills model was transferable to an Indian context. METHODS We recruited 442 MSM and 7 hijras into an online cross-sectional study that asked questions about condom use knowledge, motivation, self-efficacy, and sexual behavior. Structural equation modeling was used to test the overall information-motivation-behavioral skills structure. RESULTS Condom use and HIV risk knowledge did not significantly predict condom use self-efficacy or having condomless anal sex with more than one male partner in the past 3 months, and knowledge was not significantly correlated with attitudes toward barebacking. Despite this, the final structural model explained 14.4% of the variance in condom use self-efficacy and 20.0% of the variance in risky sexual behavior. Overall fit of the model was good: χ2(201, N = 447) = 445.002, p < .0001, root mean square error of approximation = .052, 90% CI [.046, .059], comparative fit index = .989, Tucker-Lewis Index = .987. CONCLUSION The public health response to India's HIV epidemic is currently different than in the West due to differences in medication access and public health infrastructure. As Indian MSM and hijras learn more about the effectiveness of viral suppression and hopefully have greater access to preexposure prophylaxis, researchers should monitor for changing attitudes toward condoms and be prepared to collaborate with the public health infrastructure in order to develop interventions that reinforce positive attitudes toward condom use.
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Affiliation(s)
- J. Michael Wilkerson
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas, USA
| | - Jayson M. Rhoton
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas, USA
| | - Dennis Li
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas, USA
| | | | | | - B. R. Simon Rosser
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Maria L. Ekstrand
- University of California San Francisco Center for AIDS Prevention Studies, San Francisco, California, USA
- St John’s Research Institute of St John’s National Academy of Health Sciences, Bengaluru, India
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31
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Salem BE, Brecht ML, Ekstrand ML, Faucette M, Nyamathi AM. Correlates of physical, psychological, and social frailty among formerly incarcerated, homeless women. Health Care Women Int 2019; 40:788-812. [PMID: 30901288 PMCID: PMC6755073 DOI: 10.1080/07399332.2019.1566333] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 01/13/2018] [Revised: 11/28/2018] [Accepted: 01/04/2019] [Indexed: 01/11/2023]
Abstract
Frailty is a deficit accumulation in physical, psychological and social domains. Correlates of frailty were explored among formerly incarcerated, homeless women (N = 130, Mage = 38.9). Significant correlates of physical frailty were age, years homeless, prior violence, witnessing less violence, drug dependence, PTSD symptoms and tangible support. Significant correlates of psychological frailty were age, years homeless, witnessed violence, jail time, divorced less, drug use/dependence, prison time, methamphetamine use, and bodily pain. Significant correlates of social frailty were drug use, emotional regulation, and daily alcohol use. Reentry interventions are needed for formerly incarcerated, homeless women who experience physical, psychological and social frailty.
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Affiliation(s)
- Benissa E Salem
- UCLA School of Nursing, University of California , Los Angeles , California , USA
| | - Mary-Lynn Brecht
- School of Nursing, University of California , Los Angeles , California , USA
| | - Maria L Ekstrand
- School of Medicine, University of California, San Francisco School of Medicine , San Francisco , California , USA
| | - Mark Faucette
- Los Angeles County Department of Health Services, Housing for Health/Office of Diversion and Reentry , Los Angeles , California , USA
| | - Adeline M Nyamathi
- School of Nursing, University of California Irvine , Irvine , California , USA
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Shin SS, Carpenter CL, Ekstrand ML, Wang Q, Grover S, Zetola NM, Yadav K, Sinha S, Nyamathi AM. Cervical cancer awareness and presence of abnormal cytology among HIV-infected women on antiretroviral therapy in rural Andhra Pradesh, India. Int J STD AIDS 2019; 30:586-595. [PMID: 30813859 DOI: 10.1177/0956462419825950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/16/2022]
Abstract
Cervical cancer is a leading cause of death among women in low- and middle-income countries, and women living with HIV are at high risk for cervical cancer. The objective of this study was to estimate the prevalence and correlates of cervical cancer and pre-cancer lesions and to examine cervical cancer knowledge among women living with HIV receiving antiretroviral therapy in rural Andhra Pradesh, India. We conducted cytology-based screening and administered a standardized questionnaire among 598 HIV-infected women. We found 5 (0.8%), 39 (6.5%), 29 (4.9%), and 4 (0.7%) had atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and squamous cervical carcinoma (SCC), respectively. In multivariable logistic regression analysis, ASCUS/LSIL was independently associated with age >16 years old at first sexual encounter and smokeless tobacco use. We found no factors associated with HSIL/SCC. In total, 101 women (16.9%) had heard of cervical cancer and 28 (27.7%) of them correctly identified HIV infection as a risk factor. In light of the high prevalence of pre-cancer lesions and low level of cervical cancer knowledge in our study population, focused interventions are needed to improve cervical cancer literacy and prevention among rural women living with HIV.
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Affiliation(s)
- Sanghyuk S Shin
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | | | - Maria L Ekstrand
- 3 Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA
| | - Qiao Wang
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | - Surbhi Grover
- 4 Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,5 Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Nicola M Zetola
- 4 Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,5 Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Kartik Yadav
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | - Sanjeev Sinha
- 6 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Adeline M Nyamathi
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
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Nyblade L, Stockton MA, Giger K, Bond V, Ekstrand ML, Lean RM, Mitchell EMH, Nelson LRE, Sapag JC, Siraprapasiri T, Turan J, Wouters E. Stigma in health facilities: why it matters and how we can change it. BMC Med 2019; 17:25. [PMID: 30764806 PMCID: PMC6376713 DOI: 10.1186/s12916-019-1256-2] [Citation(s) in RCA: 292] [Impact Index Per Article: 58.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 01/08/2019] [Indexed: 11/10/2022] Open
Abstract
Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge-both approaches and methods-regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development's Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.
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Affiliation(s)
- Laura Nyblade
- RTI International, 701 13th ST NW, Suite 750, Washington, DC, USA
| | - Melissa A. Stockton
- Epidemiology Department, UNC Gillings School of Global Public Health, 2103 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC 27599 USA
| | - Kayla Giger
- RTI International, 701 13th ST NW, Suite 750, Washington, DC, USA
| | - Virginia Bond
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- School of Medicine, Zambart, P.O. Box 50697, Lusaka, Zambia
| | - Maria L. Ekstrand
- Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158-2549 USA
- St John’s Research Institute, St John’s National Academy of Health Sciences, Bengaluru, India
| | - Roger Mc Lean
- Health Economics Unit, Centre for Health Economics, Faculty of Social Sciences, University of the West Indies, St. Augustine Campus, St. Augustine, Trinidad and Tobago
| | - Ellen M. H. Mitchell
- International Institute for Social Studies, Erasmus University, Kortenaerkade 12, 2518 AX The Hague, Netherlands
| | - La Ron E. Nelson
- University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642 USA
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, Toronto, M5T 1B8 Canada
| | - Jaime C. Sapag
- Departments of Public Health and Family Medicine, School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Clinical Public Health Division, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Office of Transformative Global Health, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Ontario, Canada
| | - Taweesap Siraprapasiri
- Department of Disease Control, Ministry of Public Health of the Government of Thailand, Tivanond Road, Nonthaburi, 11000 Thailand
| | - Janet Turan
- Department of Health Care Organization and Policy, Maternal and Child Health Concentration, School of Public Health, University of Alabama at Birmingham, Birmingham, USA
- Behavioral and Community Sciences Core, UAB Center for AIDS Research (CFAR), Birmingham, USA
| | - Edwin Wouters
- Centre for Longitudinal & Life Course Studies, University of Antwerp, Sint-Jacobstraat 2, B-2000 Antwerp, Belgium
- Centre for Health Systems Research & Development, University of the Free State, PO Box 399, Bloemfontein, 9300 South Africa
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Garfin DR, Shin SS, Ekstrand ML, Yadav K, Carpenter CL, Sinha S, Nyamathi AM. Depression, social support, and stigma as predictors of quality of life over time: results from an Asha-based HIV/AIDS intervention in India. AIDS Care 2019; 31:563-571. [PMID: 30714386 DOI: 10.1080/09540121.2018.1563281] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Quality of life (QOL) is associated with better outcomes in HIV/AIDS populations. We explored predictors of improved QOL over time in 600 Women Living with HIV/AIDS (WLH/A) in India [mean age = 34.31, SD = 6.97], enrolled in a nurse-led-Asha (Accredited Social Health Activist) intervention. Trained local interviewers ascertained self-report data at baseline and six-month follow-up (post-intervention). Latent Class Analysis (LCA) identified constellations of responses on psychosocial indicators (depression, social support, internalized stigma and stigma fears); their relationship with QOL over time was examined. We identified three classes: Class 1) Highest Social Resources/Lowest Depression; Class 2) Some Social Resources/Highest Depression; and Class 3) Lowest Social Resources/Higher Depression. At baseline, Class 3 reported the lowest QOL (M = 0.25, SD = 0.26); Class 1 reported the highest (M = 0.37, SD = 0.33). Class 2's QOL did not differ from Class 3's QOL, likely due to the potent effects of high depression. At six-month follow-up, all groups reported improved QOL; class membership no longer predicted variability (contrast between Class 2 and 1 = -0.05, 95% CI = -0.14, 0.04; contrast between Class 3 and 1 = 0.01, 95% CI = -0.03, 0.05; contrast between Class 3 and 2 = 0.07, 95% CI = -0.02, 0.16). Psychosocial indicators are important predictors of QOL; an Asha-supported approach may have broad applicability to improve QOL in WLH/A in India.
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Affiliation(s)
- Dana Rose Garfin
- a Sue & Bill Gross School of Nursing , University of California , Irvine , CA , USA
| | - Sanghyuk S Shin
- a Sue & Bill Gross School of Nursing , University of California , Irvine , CA , USA
| | | | - Kartik Yadav
- a Sue & Bill Gross School of Nursing , University of California , Irvine , CA , USA
| | - Catherine L Carpenter
- c UCLA Center for Human Nutrition , David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Sanjeev Sinha
- d Department of Medicine , All India Institute of Medical Sciences , New Delhi , India
| | - Adeline M Nyamathi
- a Sue & Bill Gross School of Nursing , University of California , Irvine , CA , USA
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Ekstrand ML, Heylen E, Mazur A, Steward WT, Carpenter C, Yadav K, Sinha S, Nyamathi A. The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India. AIDS Behav 2018; 22:3859-3868. [PMID: 29789984 DOI: 10.1007/s10461-018-2157-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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] [Indexed: 12/29/2022]
Abstract
HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N = 600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one's diagnosis a secret may make it more difficult to take one's medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.
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Affiliation(s)
- Maria L Ekstrand
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA.
- St John's Research Institute, Bangalore, India.
| | - Elsa Heylen
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | - Amanda Mazur
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | - Wayne T Steward
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | | | | | - Sanjeev Sinha
- All India Institute of Medical Sciences, New Delhi, India
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Shin SS, Carpenter CL, Ekstrand ML, Yadav K, Shah SV, Ramakrishnan P, Pamujula S, Sinha S, Nyamathi AM. Household Food Insecurity as Mediator of the Association Between Internalized Stigma and Opportunistic Infections. AIDS Behav 2018; 22:3897-3904. [PMID: 29934793 DOI: 10.1007/s10461-018-2193-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Internalized HIV stigma can affect health outcomes, but the mechanism underlying this relationship is poorly understood. We investigated the potential pathways for the association between internalized stigma and opportunistic infections (OIs) among women living with HIV in rural India. We conducted a cross-sectional study involving in-person interviews with 600 participants. We modeled two outcome variables, total number of OIs and fungal dermatoses, which was the most frequently reported OI. Causal mediation analysis was performed to estimate the total effect, direct effect, and indirect effect through mediators while controlling for confounders. Food insecurity was a strong mediator of the association between internalized stigma and the number of OIs (70% of the total effect) and fungal dermatoses (83% of the total effect), while the indirect effect of stigma through adherence was minimal for both outcomes. Household food insecurity may be an important mediator of the impact of HIV-related stigma on opportunistic infections.
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Nyamathi AM, Carpenter CL, Ekstrand ML, Yadav K, Garfin DR, Muniz LC, Kelley M, Sinha S. Randomized controlled trial of a community-based intervention on HIV and nutritional outcomes at 6 months among women living with HIV/AIDS in rural India. AIDS 2018; 32:2727-2737. [PMID: 30289802 PMCID: PMC6361536 DOI: 10.1097/qad.0000000000002016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the impact of nurse-led Asha (Accredited Social Health Activist)-support behavioral and nutritional intervention among women living with HIV/AIDS (WLH/A) in rural India. DESIGN Cluster randomized controlled trial. METHODS Sixteen Primary Health Centers serving WLH/A in Andhra Pradesh were grouped into four regional clusters that were randomly allocated into one of four arms. All four groups included Asha-support and consisted of: Asha-support only (control group); nutrition education; nutrition supplementation; and the combination of supplementation and education. Differences between baseline and 6-month follow-up for key physiological outcomes (BMI, CD4 cell count) were analyzed using factorial mixed models that accounted for geographic clustering. RESULTS At 6 months, all groups improved CD4 cell count: Asha only [mean difference score (D) = 343.97, standard deviation (SD) = 106.94], nutrition education (D = 356.15, SD = 0.69), nutrition supplement (D = 469.66, SD = 116.0), and nutrition supplement and education (D = 530.82, SD = 128.56). In multivariable models, Asha-support and nutrition, and Asha-support and nutrition supplement interventions demonstrated independent significant improvements in CD4 cell count; the interaction term was significant [estimate = 529.9; 95% confidence interval (CI) 512.0, 547.8; P = 0.006]. BMI also increased for all groups: Asha only (D = 0.95, SD = 0.82), Asha and nutrition education (D = 1.28, SD = 0.53), Asha and nutrition supplement (D = 2.38, SD = 0.60), nutrition supplement, and nutrition supplement and education (D = 2.72, SD = 0.84). Nutrition supplementation and nutrition education demonstrated independent effects on BMI; the interaction term was not significant (estimate = 0.27; 95% CI = 2.5, 2.7; P = 0.80). CONCLUSION Interventions supported by community workers were efficacious at improving physiological outcomes and may be beneficial at meeting critical healthcare needs of vulnerable WLH/A in India.
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Affiliation(s)
| | | | - Maria L Ekstrand
- University of California, San Francisco, San Francisco, California, USA
| | | | | | | | | | - Sanjeev Sinha
- All India Institute of Medical Sciences, Department of Medicine, AIIMS Campus, New Delhi, India
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Ekstrand ML, Bharat S, Srinivasan K. HIV stigma is a barrier to achieving 90-90-90 in India. Lancet HIV 2018; 5:e543-e545. [PMID: 30319116 DOI: 10.1016/s2352-3018(18)30246-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Maria L Ekstrand
- University of California San Francisco, San Francisco, CA 94158, USA; St. John's Research Institute, Bangalore, India.
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Srinivasan K, Mazur A, Mony PK, Whooley M, Ekstrand ML. Improving mental health through integration with primary care in rural Karnataka: study protocol of a cluster randomized control trial. BMC Fam Pract 2018; 19:158. [PMID: 30205830 PMCID: PMC6134696 DOI: 10.1186/s12875-018-0845-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/31/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND People who are diagnosed with both mental and chronic medical illness present unique challenges for the health care system. In resource-limited settings, such as rural India, people with depression and anxiety are often under-served, due to both stigma and lack of trained providers and resources. These challenges can lead to complications in the management of chronic disease as well as increased suffering for patients, families and communities. In this study, we evaluate the effects of integrating mental health and chronic disease treatment of patients in primary health care (PHC) settings using a collaborative care model to improve the screening, diagnosis and treatment of depression in rural India. METHODS This study is a multi-level randomized controlled trial among patients with depression or anxiety and co-morbid diabetes, or cardiovascular disease. Aim 1 examines whether patients screened at community health-fairs are more likely to be diagnosed and treated for these co-morbid conditions than patients screened after presenting at PHCs. Aim 2 evaluates the impact of collaborative care compared to usual care in a cluster RCT, randomizing at the level of the PHCs. Intervention arm PHC staff are trained in mental health diagnoses, treatment, and the collaborative care model. The intervention also involves community-based "Healthy Living groups" co-led by Ashas, using cognitive-behavioral strategies to promote healthy behaviors. The primary outcome is severity of common mental disorders, with secondary outcomes being diabetes and cardiovascular risk, staff knowledge and patient perceptions. DISCUSSION If effective, our results will contribute to the field in five ways: 1) expand on implementation research in low resource settings by examining how multiple chronic diseases can be treated using integrated low-cost, evidence-based strategies, 2) build the capacity of PHC staff to diagnose and treat mental illness within their existing clinic structure and strengthen referral linkages; 3) link community members to primary care through community-based health fairs and healthy living groups; 4) increase mental health awareness in the community and reduce mental health stigma; 5) demonstrate the potential for intervention scale-up and sustainability. TRIAL REGISTRATION http://Clinicaltrials.gov : NCT02310932 registered December 8, 2014 URL: https://clinicaltrials.gov/ct2/show/record/NCT02310932 ; Clinical Trials Registry India: CTRI/2018/04/013001 retrospectively registered on April 4, 2018.
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Affiliation(s)
- Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka India
- Department of Psychiatry, St John’s Medical College Hospital, Bangalore, Karnataka India
| | - Amanda Mazur
- Division of Prevention Sciences, University of California, San Francisco, USA
| | - Prem K. Mony
- Division of Epidemiology and Community Health, St. John’s Medical College and Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Mary Whooley
- Division of Cardiology, University of California, San Francisco, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA USA
| | - Maria L. Ekstrand
- Division of Mental Health and Neurosciences, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka India
- Division of Prevention Sciences, University of California, San Francisco, USA
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Heylen E, Shamban E, Steward WT, Krishnan G, Solomon R, Srikrishnan AK, Ekstrand ML. Alcohol Use and Experiences of Partner Violence Among Female Sex Workers in Coastal Andhra Pradesh, India. Violence Against Women 2018; 25:251-273. [PMID: 29953335 DOI: 10.1177/1077801218778384] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This cross-sectional study describes the prevalence and context of violence by sexual partners against female sex workers (FSWs, N = 589) in Andhra Pradesh and its association with alcohol use by FSWs and abusive partners. In all, 84% of FSWs reported alcohol use; 65% reported lifetime physical abuse by a sexual partner. Most abused women suffered abuse from multiple partners, often triggered by inebriation or FSW's defiance. In multivariate logistic regressions, frequency of FSW's alcohol use was associated with abuse by clients and primary partner, whereas partner's alcohol use was only significant for abuse by primary partner, not clients.
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Affiliation(s)
- Elsa Heylen
- 1 University of California, San Francisco, USA
| | | | | | | | | | - A K Srikrishnan
- 4 Y.R. Gaitonde Centre for AIDS Research and Education, Chennai, India
| | - Maria L Ekstrand
- 1 University of California, San Francisco, USA.,5 St. John's Research Institute, Bangalore, India
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Nyblade L, Srinivasan K, Mazur A, Raj T, Patil DS, Devadass D, Radhakrishna K, Ekstrand ML. HIV Stigma Reduction for Health Facility Staff: Development of a Blended- Learning Intervention. Front Public Health 2018; 6:165. [PMID: 29977887 PMCID: PMC6021510 DOI: 10.3389/fpubh.2018.00165] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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: 02/10/2018] [Accepted: 05/17/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction: The effect of stigma on health and health inequity is increasingly recognized. While many medical conditions trigger stigmatization, the negative effects of HIV stigma are particularly well documented. HIV stigma undermines access, uptake, and adherence to both HIV prevention and treatment. People living with HIV face stigma in all aspects of their daily lives; however, stigma in the health system is particularly detrimental. A key component for health facility stigma-reduction interventions is participatory training of staff, often through several days of in-person training. Though this approach shows promise, it is time intensive and poses challenges for busy health facilities. In response, the DriSti study has developed a brief blended-learning approach to stigma reduction in Karnataka State, India. This paper describes the process and final content of the intervention development. The intervention is currently being tested. Final evaluation results will be published upon study completion. Methods: Grounded in behavior change strategies based on social cognitive theory principles that stress the importance of combining interpersonal interactions with specific strategies that promote behavior change, we used a three-phase approach to intervention development: (1) content planning—review of existing participatory stigma-reduction training activities; (2) story boarding—script development and tablet content production; and (3) pilot testing of tablet and in-person session materials. Results: The final intervention curriculum consists of three sessions. Two initial self-administered tablet sessions focus on stigma awareness, attitudes, fears of HIV transmission, and use of standard precautions. The third small group session covers the same material but includes skill building through role-play and testimony by a person living with HIV. A study team member administers the tablet sessions, explains the process, and is present throughout to answer questions. Conclusion: This paper describes the theoretical underpinning and process of developing the blended-learning curriculum content, and practical lessons learned.The approach covers three key drivers of HIV stigma—stigma awareness, fear of HIV transmission, and attitudes. Developing video content for the self-directed learning is complex, requires a diverse set of people and skills, and presents unexpected opportunities for stigma reduction. Co-facilitation of the in-person session by someone living with HIV is a critical component.
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Affiliation(s)
- Laura Nyblade
- Global Health Division, International Development Group, RTI International, Washington, DC, United States
| | | | - Amanda Mazur
- Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, United States
| | - Tony Raj
- St. Johns Research Institute, Bangalore, India
| | | | | | | | - Maria L Ekstrand
- St. Johns Research Institute, Bangalore, India.,Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, United States
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Rawat S, Wilkerson JM, Lawler SM, Patankar P, Rosser BRS, Shukla K, Butame S, Ekstrand ML. Recommendations for the Development of a Mobile HIV Prevention Intervention for Men Who Have Sex With Men and Hijras in Mumbai: Qualitative Study. JMIR Public Health Surveill 2018; 4:e46. [PMID: 29724705 PMCID: PMC5958284 DOI: 10.2196/publichealth.9088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 02/17/2018] [Accepted: 03/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background As Internet and mobile phone use expands in India, there is an opportunity to develop mobile health (mHealth) interventions for marginalized populations, including men who have sex with men (MSM) and hijras (transgender women), hesitant to access traditional health care systems. Objective The purpose of this study was to determine if an mHealth intervention was acceptable to MSM and hijras living in Mumbai, and if so, what features would be useful in targeting the prevention of HIV acquisition and to increase the quality of life among persons living with HIV/AIDS. Methods Data from 4 focus groups with MSM and interviews with 4 hijras, 10 health service providers, and 8 mHealth developers were thematically analyzed. Results Once the need for an mHealth intervention was confirmed, comments about features were organized into 3 themes: content, interface, and retention. Content subthemes included providing sex education for younger community members, providing information about STIs, and providing information and social support for persons living with HIV. Interface subthemes included presenting content using pictures; using videos to present stories of role models; using push notifications for testing, appointment, and medication reminders; using geolocation to link to just-in-time services; and using telemedicine to increase access to health service providers and community services. The 5 retention subthemes included keeping it fun, using gaming mechanics, developing content in regional languages, protecting confidentiality, and linking to social networking apps. Conclusions These findings may help inform mHealth development in India.
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Affiliation(s)
| | - J Michael Wilkerson
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sylvia M Lawler
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States
| | | | - B R Simon Rosser
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Kanjani Shukla
- Minnesota Department of Health, Minneapolis, MN, United States
| | - Seyram Butame
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Maria L Ekstrand
- University of California San Francisco Center for AIDS Prevention Studies, San Francisco, CA, United States
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Wilkerson JM, Di Paola A, Rawat S, Patankar P, Rosser BRS, Ekstrand ML. Substance Use, Mental Health, HIV Testing, and Sexual Risk Behavior Among Men Who Have Sex With Men in the State of Maharashtra, India. AIDS Educ Prev 2018; 30:96-107. [PMID: 29688773 PMCID: PMC6214349 DOI: 10.1521/aeap.2018.30.2.96] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Among 433 men who have sex with men in Maharashtra, India who completed an online survey, 23% reported hazardous drinking, 12% illicit substance, and 9% polysubstance use. The overall prevalence of depression and intimate partner violence (IPV) were 58% and 56%, respectively. Participants engaging in hazardous drinking had more sexual partners and were less likely to be married to women. Participants reporting illicit substance use or polysubstance use were more likely to have been out, had more sexual partners, or experienced IPV. Those reporting illicit substance use were more likely to engage in condomless anal sex. Based on our findings, we suggest that public health interventions integrate HIV, substance use, and mental health services.
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Affiliation(s)
- J Michael Wilkerson
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas
| | - Angela Di Paola
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas
| | | | | | - B R Simon Rosser
- University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Maria L Ekstrand
- University of California San Francisco Center for AIDS Prevention Studies, San Francisco, California
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Abstract
This study was designed to examine the rates of HIV serostatus disclosure in a sample of HIV-infected children in the state of Karnataka in South India, their reactions to learning their HIV-positive status and the reasons for and barriers to disclosure from the point of view of their caregivers. We enrolled 233 HIV-infected children, aged 5-18 years and their caregivers between July 2011 and February 2013 at HIV clinics in three tertiary care centers. Caregiver interviews included information about demographic characteristics, medical history, type of disclosure to the child and other related factors, including disclosure barriers. Three quarters (n = 185) of the caregivers reported that there had been no disclosure to the child, 15.4% (n = 38) reported partial disclosure (e.g. telling the child he or she had a 'chronic illness') and only 9.7% (n = 24) reported full disclosure, at a mean age of 10.9 (SD: 2.5) years. Caregivers, who planned to disclose in the future, stated on average that 16 years would be the right age. Those who favored a later disclosure reported that they feared strong negative emotional reactions from the child (p = 0.03) and social isolation (p < 0.001) following disclosure. These results show that that the level of full disclosure is low among South Indian youth living with HIV, and that when disclosure occurs, it is most likely to be partial. The majority of children who learned their status had been informed by a health-care provider, possibly reflecting the difficulty for a caregiver of having this conversation. The caregivers reported multiple disadvantages of disclosure, mostly because of fears of stigma and discrimination. Despite some evidence from the literature that disclosure can have positive effects on a child's health, it is thus clear that we need to develop, implement and evaluate community-based stigma reduction programs to reduce the social barriers to disclosure.
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Affiliation(s)
- Maria L Ekstrand
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA 94158, USA,St John’s Research Institute, Bangalore, Karnataka 560034, India,Correspondence: Maria L. Ekstrand, Professor of Medicine, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158-2549, USA. Tel: (415) 476-6268. Fax: (415) 476-5348. E-mail <> or < >
| | - Elsa Heylen
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA 94158, USA
| | - Kayur Mehta
- Division of Pediatric Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - G N Sanjeeva
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bangalore, Karnataka 560029, India
| | - Anita Shet
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Steward WT, Satyanarayana VA, Heylen E, Srikrishnan AK, Vasudevan CK, Krishnan G, Solomon D, Ekstrand ML. Alcohol use, expectancies and HIV-related sexual risk: a cross-sectional survey of male migrant workers in South India. AIDS Care 2017; 30:656-662. [PMID: 29084445 DOI: 10.1080/09540121.2017.1394964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 01/16/2023]
Abstract
Male migrant workers (MMWs) in India are vulnerable to developing alcohol-related problems and engaging in unprotected sex, putting them at risk of HIV. Research has shown that alcohol-related expectancies mediate vulnerability to alcoholism. We examined which expectancies were associated with sexual risk and drinking. We surveyed 1085 heterosexual MMWs in two South Indian municipalities, assessing expectancies, sex under the influence, and unprotected sex with female sex workers (FSW) and casual female partners in the prior 30 days. Men more strongly endorsed positive than negative expectancies (t = 53.59, p < .01). In multivariate logistic regression, the expectancy of having more fun helped drive the combination of alcohol and unprotected sex with FSW partners (OR = 1.22, p < .05), whereas the expectancy of better sex helped drive a similar combination with casual partners (OR = 1.24, p < .01). Men concerned about alcohol-induced deficits were less likely to drink with FSW partners (OR = 0.81, p < .01), but more likely to have unprotected sex with them (OR = 1.78, p < .01). To reduce risk, MMWs would benefit from combination prevention approaches that use behavioral strategies to address drinking norms and awareness of risk, while using biomedical strategies to reduce viral transmission when risk does occur.
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Affiliation(s)
- Wayne T Steward
- a Center for AIDS Prevention Studies, Department of Medicine , University of California San Francisco , San Francisco , USA
| | - Veena A Satyanarayana
- b Department of Clinical Psychology , National Institute of Mental Health and Neuro Sciences (NIMHANS) , Bengaluru , India
| | - Elsa Heylen
- a Center for AIDS Prevention Studies, Department of Medicine , University of California San Francisco , San Francisco , USA
| | - Aylur K Srikrishnan
- c Y.R. Gaitonde Centre for AIDS Research and Education (YRGCARE) , Chennai , India
| | | | | | | | - Maria L Ekstrand
- a Center for AIDS Prevention Studies, Department of Medicine , University of California San Francisco , San Francisco , USA
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Li DH, Rawat S, Rhoton J, Patankar P, Ekstrand ML, Simon Rosser BR, Wilkerson JM. Harassment and Violence Among Men Who Have Sex with Men (MSM) and Hijras After Reinstatement of India's "Sodomy Law". Sex Res Social Policy 2017; 14:324-330. [PMID: 29552236 PMCID: PMC5851470 DOI: 10.1007/s13178-016-0270-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
On December 11, 2013, the Indian Supreme Court recriminalized non-peno-vaginal sex under Sec. 377 of the Indian Penal Code (IPC), overturning a 2009 ruling that deemed IPC Sec. 377 unconstitutional. Similar "sodomy laws" in other countries have been associated with increased violence, harassment, and other discrimination against men who have sex with men (MSM) and transgender women. However, few studies have looked at the effects of such a law in an Indian context. This study examined experiences of victimization among MSM and hijra/transgender women (MSM-H) in the State of Maharashtra using a mixed-method approach. Data came from a quantitative survey and qualitative focus groups and interviews from an HIV prevention study as well as qualitative media and case reports from a local MSM-H-serving community-based organization. MSM-H in Maharashtra reported experiencing a high frequency of harassment, violence, and extortion, particularly from male sex partners met online and police. IPC Sec. 377 was implicated across qualitative sources as creating a culture of protection for harassment against MSM-H by being used directly as a tool for harassment, hindering victims of harassment from seeking legal recourse, and adversely impacting HIV and healthcare services. The reinstated IPC Sec. 377 may directly and indirectly facilitate negative health outcomes among MSM-H. Health agencies and advocates should continue to monitor the impact of IPC Sec. 377, incorporate rights-based approaches to protect MSM-H identities while addressing their health and well-being, and explore avenues to initiate discussions with the government to work toward repealing the law.
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Affiliation(s)
- Dennis H Li
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Ave., Suite 2700, Chicago, IL 60611, USA
| | | | - Jayson Rhoton
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | | | - Maria L Ekstrand
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
| | - B R Simon Rosser
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - J Michael Wilkerson
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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Radhakrishna K, Dass D, Raj T, Rakesh D, Kishore R, Srinivasan K, Nyblade L, Ekstrand-Abueg M, Ekstrand ML. Development of a Novel Tablet-based Approach to Reduce HIV Stigma among Healthcare Staff in India. Perspect Health Inf Manag 2017; 14:1b. [PMID: 28566985 PMCID: PMC5430130] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Although stigma is considered to be one of the major barriers to reducing the AIDS epidemic in India, efforts to reduce stigma have not been sufficiently examined. In response, a partially computer-administered three-session stigma reduction intervention was developed and is currently being tested. This paper describes the technological design, development, implementation, and management of these in-person tablet-administered assessment and intervention sessions that are being used to evaluate the efficacy of this innovative stigma reduction intervention among nursing students and ward attendants in India.
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Affiliation(s)
| | | | - Tony Raj
- St. John's Research Institute in Bangalore, India
| | - Divya Rakesh
- St. John's Research Institute in Bangalore, India
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Navani-Vazirani S, Heylen E, Deardorff J, Srikrishnan AK, Vasudevan CK, Solomon D, Ekstrand ML. The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India. ACTA ACUST UNITED AC 2017; 4. [PMID: 29202126 DOI: 10.24966/acrs-7370/100008] [Citation(s) in RCA: 2] [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: 12/28/2022]
Abstract
Mobile phones remain a largely untapped resource in the ongoing challenge to address Female Sex Worker (FSW) health, including HIV prevention services, in India. An important step towards designing effective mobile phone-based initiatives for FSWs is clarifying the contextual influences of mobile phone solicitation on sexual risk behavior. In this paper, we extend previously identified associations between mobile phone solicitation and condom practices by examining whether this association is moderated by sex work pay and offer key considerations for future research and implementation. Specifically, we conducted an analysis among 589 Indian FSWs, where FSWs who did not use mobile phones to solicit clients had the lowest mean sex work pay (INR 394/ USD 6.54) compared to FSWs who used both mobile and traditional strategies (INR 563/ USD 9.34). Our analysis indicate low paid FSWs who used mobile phones concurrently with traditional strategies had 2.46 times higher odds of inconsistent condom use compared to low paid FSWs who did not use mobile phones for client solicitation. No such effect was identified among high paid FSWs. These findings also identified group level differences among FSWs reporting different mobile phone solicitation strategies, including violence, client condom use and HIV status. Our results indicate that low pay does moderate the association between mobile phone solicitation and condom practices, but only among a sub-set of low paid FSWs. These findings also demonstrate the utility of classification by different mobile phone solicitation strategies for accurate assessment of sexual risk among mobile phone soliciting FSWs. In turn, this paves the way for novel approaches to utilize mobile phones for FSW HIV prevention. We discuss one such example, a mobile phone-based rapid screening tool for acute HIV infection targeting Indian FSWs.
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Affiliation(s)
| | - E Heylen
- Center for AIDS Prevention, University of California, San Francisco, California, USA
| | - J Deardorff
- School of Public Health, University of California, Berkeley, USA
| | - A K Srikrishnan
- YR Gaitonde Centre for AIDS Research and Education (YRG CARE), Chennai, Tamil Nadu, India
| | - C K Vasudevan
- YR Gaitonde Centre for AIDS Research and Education (YRG CARE), Chennai, Tamil Nadu, India
| | - D Solomon
- SHADOWS, Chirala, Andhra Pradesh, India
| | - M L Ekstrand
- School of Public Health, University of California, Berkeley, USA.,Center for AIDS Prevention, University of California, San Francisco, California, USA.,St. John's Research Institute, Bangalore, Karnataka, India
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Ekstrand ML, Rawat S, Patankar P, Heylen E, Banu A, Rosser BRS, Wilkerson JM. Sexual identity and behavior in an online sample of Indian men who have sex with men. AIDS Care 2016; 29:905-913. [PMID: 28027656 DOI: 10.1080/09540121.2016.1271103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 10/20/2022]
Abstract
Indian men who have sex with men are disproportionately impacted by HIV. While prevention efforts to date have focused on men who visit drop-in centers or physical cruising sites, little is known about men who are meeting sexual partners on virtual platforms. This paper explores issues related to sexual identity and sexual behaviors in an online sample of men who identified as gay (n = 279) or bisexual (n = 123). There were significant differences in outedness between the two groups, with 48% of bisexually identified men reporting that they were out to "no one" and 82% stating that they present themselves as heterosexual to family and friends. Corresponding rates for gay-identified men were 15% and 41%, respectively (both p < .001). Twenty-nine percent of bisexually identified men reported being married, compared to only 3% of the gay-identified men (p < .001). Bisexually identified men were also more likely to report having exclusively insertive anal sex (49% vs 30% p < .001), while gay-identified men were more likely to report exclusively receptive anal sex (41% vs 13% p < .0001). Rates of unprotected anal sex (UAS) in the two groups were similar; however, married men were significantly more likely to report unprotected vaginal sex (76% vs 35%, p < .012). Positive attitudes toward UAS and lower self-efficacy were associated with sexual risk in both groups; however, substance use was associated with sexual risk only among bisexually identified men. These findings show that a large proportion of Indian bisexually identified men lead closeted lives, especially in their interactions with friends and family, with the vast majority presenting as heterosexual. The lower condom use with wives may be due to societal pressures to have children. The results suggest that bisexually identified men may benefit from targeted programs and non-directive, non-judgmental individual or couples counseling which emphasizes condom use with both male and female partners.
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Affiliation(s)
- Maria L Ekstrand
- a Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies , University of California , San Francisco , CA , USA.,b St John's Research Institute, St John's National Academy of Health Sciences , Bengaluru , India
| | | | | | - Elsa Heylen
- a Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies , University of California , San Francisco , CA , USA
| | - Asha Banu
- d The Tata Institute of Social Sciences , Mumbai , India
| | - B R Simon Rosser
- e Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - J Michael Wilkerson
- f School of Public Health , The University of Texas Health Sciences Center at Houston (UTHealth) Houston , TX , USA
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Mehta K, Ekstrand ML, Heylen E, Sanjeeva GN, Shet A. Perspectives on disclosure among children living with HIV in India. Child Youth Serv Rev 2016; 71:277-281. [PMID: 28479647 PMCID: PMC5416817 DOI: 10.1016/j.childyouth.2016.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Kayur Mehta
- Department of Pediatrics, St. John's Medical College Hospital, Bangalore, India
| | - Maria L Ekstrand
- Department of Medicine, University of California San Francisco, United States of America
- St. John's Research Institute, Bangalore, India
| | - Elsa Heylen
- Department of Medicine, University of California San Francisco, United States of America
| | - GN Sanjeeva
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bangalore, India
| | - Anita Shet
- Department of Pediatrics, St. John's Medical College Hospital, Bangalore, India
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