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Coaxum LA, Sakita FM, Mlangi JJ, Kweka GL, Tarimo TG, Temu GA, Kilonzo KG, Arthur D, Bettger JP, Thielman NM, Limkakeng AT, Hertz JT. Provider attitudes towards quality improvement for myocardial infarction care in northern Tanzania. PLOS Glob Public Health 2024; 4:e0003051. [PMID: 38574056 PMCID: PMC10994299 DOI: 10.1371/journal.pgph.0003051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 03/03/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Myocardial Infarction (MI) is a leading cause of death worldwide. In high income countries, quality improvement strategies have played an important role in increasing uptake of evidence-based MI care and improving MI outcomes. The incidence of MI in sub-Saharan Africa is rising, but uptake of evidence-based care in northern Tanzania is low. There are currently no published quality improvement interventions from the region. The objective of this study was to determine provider attitudes towards a planned quality improvement intervention for MI care in northern Tanzania. METHODS This study was conducted at a zonal referral hospital in northern Tanzania. A 41-question survey, informed by the Theoretical Framework for Acceptability, was developed by an interdisciplinary team from Tanzania and the United States. The survey, which explored provider attitudes towards MI care improvement, was administered to key provider stakeholders (physicians, nurses, and hospital administrators) using convenience sampling. RESULTS A total of 140 providers were enrolled, including 82 (58.6%) nurses, 56 (40.0%) physicians, and 2 (1.4%) hospital administrators. Most participants worked in the Emergency Department or inpatient medical ward. Providers were interested in participating in a quality improvement project to improve MI care at their facility, with 139 (99.3%) strongly agreeing or agreeing with this statement. All participants agreed or strongly agreed that improvements were needed to MI care pathways at their facility. Though their facility has an MI care protocol, only 88 (62.9%) providers were aware of it. When asked which intervention would be the single-most effective strategy to improve MI care, the two most common responses were provider training (n = 66, 47.1%) and patient education (n = 41, 29.3%). CONCLUSION Providers in northern Tanzania reported strongly positive attitudes towards quality improvement interventions for MI care. Locally-tailored interventions to improve MI should include provider training and patient education strategies.
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Affiliation(s)
- Lauren A. Coaxum
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Francis M. Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jerome J. Mlangi
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Godfrey L. Kweka
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tumsifu G. Tarimo
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gloria A. Temu
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Kajiru G. Kilonzo
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Arthur
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Janet P. Bettger
- Department of Health and Rehabilitation Sciences, Temple University, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
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Hertz JT, Sakita FM, Prattipati S, Coaxum L, Tarimo TG, Kweka GL, Mlangi JJ, Stark K, Thielman NM, Bosworth HB, Bettger JP. Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping. BMC Health Serv Res 2024; 24:393. [PMID: 38549108 PMCID: PMC10979618 DOI: 10.1186/s12913-024-10831-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/06/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa. METHODS Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies. RESULTS Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials. CONCLUSIONS Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | - Kristen Stark
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Janet P Bettger
- Duke Global Health Institute, Duke University School of Medicine, Durham, NC, USA
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Hertz JT, Stark K, Sakita FM, Mlangi JJ, Kweka GL, Prattipati S, Shayo F, Kaboigora V, Mtui J, Isack MN, Kindishe EM, Ngelengi DJ, Limkakeng AT, Thielman NM, Bloomfield GS, Bettger JP, Tarimo TG. Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention. Ann Glob Health 2024; 90:21. [PMID: 38495415 PMCID: PMC10941691 DOI: 10.5334/aogh.4361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
Background Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Objectives Co-design a quality improvement intervention for AMI care tailored to local contextual factors. Methods An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. Findings The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. Conclusion MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.
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Affiliation(s)
- Julian T. Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristen Stark
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Francis M. Sakita
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University, Moshi, Tanzania
| | | | | | | | - Frida Shayo
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Julius Mtui
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | | | | | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janet P. Bettger
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Madut DB, Manavalan P, Mtalo A, Peter T, Ostermann J, Njau B, Thielman NM. Predictors of prior HIV testing and acceptance of a community-based HIV test offer among male bar patrons in northern Tanzania. PLOS Glob Public Health 2024; 4:e0002946. [PMID: 38408037 PMCID: PMC10896543 DOI: 10.1371/journal.pgph.0002946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Abstract
Community-based HIV testing offers an alternative approach to encourage HIV testing among men in sub-Saharan Africa. In this study, we evaluated a community-based HIV testing strategy targeting male bar patrons in northern Tanzania to assess factors predictive of prior HIV testing and factors predictive of accepting a real-time HIV test offer. Participants completed a detailed survey and were offered HIV testing upon survey completion. Poisson regression was used to identify prevalence ratios for the association between potential predictors and prior HIV testing or real-time testing uptake. Of 359 participants analyzed, the median age was 41 (range 19-82) years, 257 (71.6%) reported a previous HIV test, and 321 (89.4%) accepted the real-time testing offer. Factors associated with previous testing for HIV (adjusted prevalence ratio [aPR], 95% CI) were wealth scores in the upper-middle quartile (1.25, 1.03-1.52) or upper quartile (1.35, 1.12-1.62) and HIV knowledge (1.04, 1.01-1.07). Factors that predicted real-time testing uptake were lower scores on the Gender-Equitable Men scale (0.99, 0.98-0.99), never testing for HIV (1.16, 1.03-1.31), and testing for HIV > 12 months prior (1.18, 1.06-1.31). We show that individual-level factors that influence the testing-seeking behaviors of men are not likely to impact their acceptance of an HIV offer.
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Affiliation(s)
- Deng B. Madut
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Preeti Manavalan
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Antipas Mtalo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Timothy Peter
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jan Ostermann
- Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina, United States of America
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M. Thielman
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
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Prattipati S, Tarimo TG, Kweka GL, Mlangi JJ, Samuel D, Sakita FM, Tupetz A, Bettger JP, Thielman NM, Temu G, Hertz JT. Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study. Int J STD AIDS 2024; 35:18-24. [PMID: 37703080 DOI: 10.1177/09564624231199507] [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: 09/14/2023]
Abstract
INTRODUCTION People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. METHODS In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. RESULTS 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. CONCLUSIONS PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.
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Affiliation(s)
| | | | | | | | | | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Anna Tupetz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Janet P Bettger
- Department of Health and Rehabilitation Sciences, Temple University College of Public Health, Philadelphia, PA, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gloria Temu
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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Lieber WC, Rahim FO, Lartey HSQ, Shah D, Mmbaga BT, Thielman NM, Hertz JT. Capacity building for infectious disease control in Sub-Saharan Africa. Pathog Glob Health 2023:1-3. [PMID: 37853767 DOI: 10.1080/20477724.2023.2272363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Affiliation(s)
| | - Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Henry S Q Lartey
- Department of Environmental Science, University of Cape Coast, Cape Coast, Ghana
| | - Devesh Shah
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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Smith CM, Daley LA, Lea C, Daniel K, Tweedy DS, Thielman NM, Staplefoote-Boynton BL, Aimone E, Gagliardi JP. Experiences of Black Adults Evaluated in a Locked Psychiatric Emergency Unit: A Qualitative Study. Psychiatr Serv 2023; 74:1063-1071. [PMID: 37042104 PMCID: PMC10732806 DOI: 10.1176/appi.ps.20220533] [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] [Indexed: 04/13/2023]
Abstract
OBJECTIVE Evidence shows that Black individuals have higher rates of coercive emergency psychiatric interventions than other racialized groups, yet no studies have elevated the voices of Black patients undergoing emergency psychiatric evaluation. This qualitative study sought to explore the experiences of Black individuals who had been evaluated in a locked psychiatric emergency unit (PEU). METHODS Electronic health records were used to identify and recruit adult patients (ages ≥18 years) who self-identified as Black and who had undergone evaluation in a locked PEU at a large academic medical center. In total, 11 semistructured, one-on-one interviews were conducted by telephone, exploring experiences during psychiatric evaluation. Transcripts were analyzed with thematic analysis. RESULTS Participants shared experiences of criminalization, stigma, and vulnerability before and during their evaluation. Although participants described insight into their desire and need for treatment and identified helpful aspects of the care they received, they noted a mismatch between their expectations of treatment and the treatment received. CONCLUSIONS This study reveals six major patient-identified themes that supplement a growing body of quantitative evidence demonstrating that racialized minority groups endure disproportionate rates of coercive interventions during emergency psychiatric evaluation. Interdisciplinary systemic changes are urgently needed to address structural barriers to equitable psychiatric care.
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Affiliation(s)
- Colin M Smith
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Lori-Ann Daley
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Chris Lea
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Keith Daniel
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Damon S Tweedy
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Nathan M Thielman
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - B Lynette Staplefoote-Boynton
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Elizabeth Aimone
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Jane P Gagliardi
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
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Navuluri N, Lagat DK, Birgen E, Kitur S, Kussin PS, Murdoch DM, Thielman NM, Parish A, Green CL, MacIntyre N, Egger JR, Wools-Kaloustian K, Que LG. Prevalence and phenotypic trajectories of hypoxaemia among hospitalised adults in Kenya: a single-centre, prospective cohort study. BMJ Open 2023; 13:e072111. [PMID: 37723111 PMCID: PMC10510888 DOI: 10.1136/bmjopen-2023-072111] [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: 01/24/2023] [Accepted: 08/25/2023] [Indexed: 09/20/2023] Open
Abstract
OBJECTIVE Global medical oxygen security is limited by knowledge gaps in hypoxaemia burden and oxygen access in low-income and middle-income countries. We examined the prevalence and phenotypic trajectories of hypoxaemia among hospitalised adults in Kenya, with a focus on chronic hypoxaemia. DESIGN Single-centre, prospective cohort study. SETTING National tertiary referral hospital in Eldoret, Kenya between September 2019 and April 2022. PARTICIPANTS Adults (age ≥18 years) admitted to general medicine wards. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary outcome was proportion of patients who were hypoxaemic (oxygen saturation, SpO2 ≤88%) on admission. Secondary outcomes were proportion of patients with hypoxaemia on admission who had hypoxaemia resolution, hospital discharge, transfer, or death among those with unresolved hypoxaemia or chronic hypoxaemia. Patients remaining hypoxaemic for ≤3 days after admission were enrolled into an additional cohort to determine chronic hypoxaemia. Chronic hypoxaemia was defined as an SpO2 ≤ 88% at either 1-month post-discharge follow-up or, for patients who died prior to follow-up, a documented SpO2 ≤88% during a previous hospital discharge or outpatient visit within the last 6 months. RESULTS We screened 4104 patients (48.5% female, mean age 49.4±19.4 years), of whom 23.8% were hypoxaemic on admission. Hypoxaemic patients were significantly older and more predominantly female than normoxaemic patients. Among those hypoxaemic on admission, 33.9% had resolution of their hypoxaemia as inpatients, 55.6% had unresolved hypoxaemia (31.0% died before hospital discharge, 13.3% were alive on discharge and 11.4% were transferred) and 10.4% were lost to follow-up. The prevalence of chronic hypoxaemia was 2.1% in the total screened population, representing 8.8% of patients who were hypoxaemic on admission. Chronic hypoxaemia was determined at 1-month post-discharge among 59/86 patients and based on prior documentation among 27/86 patients. CONCLUSION Hypoxaemia is highly prevalent among adults admitted to a general medicine ward at a national referral hospital in Kenya. Nearly 1 in 11 patients who are hypoxaemic on admission are chronically hypoxaemic.
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Affiliation(s)
- Neelima Navuluri
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - David K Lagat
- Department of Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Elcy Birgen
- Duke Global Health Institute, Durham, North Carolina, USA
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Sylvia Kitur
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Peter S Kussin
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David M Murdoch
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M Thielman
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Neil MacIntyre
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joseph R Egger
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Loretta G Que
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Sakita FM, O’Leary P, Prattipati S, Kessy MS, Kilonzo KG, Mmbaga BT, Rugakingira AA, Manavalan P, Thielman NM, Samuel D, Hertz JT. Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study. PLOS Glob Public Health 2023; 3:e0001929. [PMID: 37603550 PMCID: PMC10441788 DOI: 10.1371/journal.pgph.0001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/28/2023] [Indexed: 08/23/2023]
Abstract
Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.
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Affiliation(s)
| | - Paige O’Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | | | | | - Preeti Manavalan
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Dorothy Samuel
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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10
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Rahim FO, Jain B, Bloomfield GS, Jain P, Rugakingira A, Thielman NM, Sakita F, Hertz JT. A holistic framework to integrate HIV and cardiovascular disease care in sub-Saharan Africa. AIDS 2023; 37:1497-1502. [PMID: 37199570 DOI: 10.1097/qad.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, Massachusetts
- Stanford University School of Medicine, Stanford, California
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pankaj Jain
- Highmark Health, Pittsburgh
- Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | | | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Stanford University School of Medicine, Stanford, California
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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11
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Sakita FM, Prattipati S, Chick J, Samu LP, Maro AV, Coaxum L, Galson SW, Samuel D, Limkakeng AT, O'Leary PR, Kilonzo KG, Thielman NM, Temu G, Hertz JT. Six-month blood pressure and glucose control among HIV-infected adults with elevated blood pressure and hyperglycemia in northern Tanzania: A prospective observational study. PLoS One 2023; 18:e0285472. [PMID: 37155672 PMCID: PMC10166506 DOI: 10.1371/journal.pone.0285472] [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] [Received: 08/23/2022] [Accepted: 04/25/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND People with HIV in sub-Saharan Africa are increasingly developing age-related comorbidities. The purpose of this prospective observational study was to describe 6-month outcomes among Tanzanians with HIV and elevated blood pressure or hyperglycemia under current care pathways. METHODS Adults presenting for routine HIV care were enrolled and underwent blood pressure and blood glucose measurements. Participants with abnormal blood pressure or glucose were referred for further care, as per current guidelines. Participants' blood pressure and point-of-care glucose were re-evaluated during their 6-month follow-up visit. Elevated blood pressure was defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. Hyperglycemia was defined as fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl. An electrocardiogram was obtained at enrollment and at follow-up. Interim myocardial infarction and interim myocardial ischemia were defined as new pathologic Q waves and new T-wave inversions, respectively. RESULTS Of 500 participants, 155 had elevated blood pressure and 17 had hyperglycemia at enrolment. At 6-month follow-up, 7 (4.6%) of 155 participants with elevated blood pressure reported current use of an anti-hypertensive medication, 100 (66.2%) had persistent elevated blood pressure, 12 (7.9%) developed interim myocardial infarction, and 13 (8.6%) developed interim myocardial ischemia. Among 17 participants with hyperglycemia, 9 (56%) had persistent hyperglycemia at 6 months and 2 (12.5%) reported current use of an anti-hyperglycemic medication. CONCLUSIONS Interventions are needed to improve non-communicable disease care pathways among Tanzanians with HIV.
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Affiliation(s)
- Francis M Sakita
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Jordan Chick
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Linda P Samu
- Health Department, Moshi Municipal Council, Moshi, Tanzania
| | | | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sophie W Galson
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Alexander T Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Paige R O'Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Gloria Temu
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
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12
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Hertz JT, Prattipati S, Kweka GL, Mlangi JJ, Tarimo TG, Mmbaga BT, Thielman NM, Sakita FM, Rubach MP, Bloomfield GS, Manavalan P. Prevalence and predictors of uncontrolled hypertension, diabetes, and obesity among adults with HIV in northern Tanzania. Glob Public Health 2022; 17:3747-3759. [PMID: 35282776 PMCID: PMC9468185 DOI: 10.1080/17441692.2022.2049344] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/19/2022] [Indexed: 02/06/2023]
Abstract
HIV is associated with increased risk of cardiovascular disease, but there has been less study of cardiovascular comorbidities among people with HIV in sub-Saharan Africa. In a cross-sectional observational study, Tanzanian adults presenting for outpatient HIV care completed a questionnaire and underwent weight, height, blood pressure, and blood glucose measurement. Hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension. Uncontrolled hypertension was defined as measured blood pressure ≥140/90 mmHg. Diabetes was defined by fasting glucose ≥126 mg/dl, random glucose ≥200 mg/dl, or self-reported diabetes. Obesity was defined by body mass index ≥30 kg/m2. Multivariate logistic regression was performed to identify predictors of uncontrolled hypertension. Among 500 participants, 173 (34.6%) had hypertension, 21 (4.2%) had diabetes, and 99 (19.8%) were obese. Of those with hypertension, 116 (67.1%) were unaware of their hypertension, and 155 (89.6%) had uncontrolled hypertension. In multivariate analysis, uncontrolled hypertension was associated with older age (OR 1.07, 95% CI: 1.05-1.10, p < 0.001) and higher body mass index (OR 1.17, 95% CI: 1.11-1.22, p < 0.001). Interventions are needed to improve screening and treatment for hypertension, diabetes, and obesity among Tanzanians with HIV.
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Affiliation(s)
- Julian T Hertz
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
| | | | | | | | | | - Blandina T Mmbaga
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
| | - Francis M Sakita
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Matthew P Rubach
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
| | - Gerald S Bloomfield
- Duke University School of Medicine, Durham, NC
- Duke Global Health Institute, Durham, NC
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13
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Ostermann J, Njau B, Masaki M, Mtuy T, Itemba D, Hobbie A, Yelverton V, Moore S, Yamanis T, Thielman NM. Feasibility, Acceptability, and Potential Cost-Effectiveness of a Novel Mobile Phone Intervention to Promote Human Immunodeficiency Virus Testing Within Social Networks in Tanzania. Sex Transm Dis 2022; 49:778-781. [PMID: 35093981 PMCID: PMC9329485 DOI: 10.1097/olq.0000000000001611] [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: 11/26/2022]
Abstract
ABSTRACT Among 145 individuals surveyed in Tanzania, 42% indicated willingness to test for human immunodeficiency virus in response to a confidential, phone-based text message. On average, participants were likely to provide contact information for 1.5 members of their social networks, suggesting high feasibility and moderate acceptability of a novel mHealth human immunodeficiency virus testing intervention.
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Affiliation(s)
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Martha Masaki
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | | | - Amy Hobbie
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC
| | | | - Spencer Moore
- Department of Social Sciences, Wageningen University, Wageningen, The Netherlands
| | - Thespina Yamanis
- School of International Service, American University, Washington, DC
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14
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Ostermann J, Njau B, Hobbie AM, Mtuy TB, Masnick M, Brown DS, Mühlbacher AC, Thielman NM. Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report. AIDS Care 2022:1-9. [PMID: 36063533 PMCID: PMC9985668 DOI: 10.1080/09540121.2022.2119471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management, University of South Carolina, Columbia, SC,USA,South Carolina Smart State Center for Healthcare Quality, University of South Carolina, Columbia, SC, USA,Duke Global Health Institute, Duke University, Durham, NC, USA,Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amy M. Hobbie
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Tara B. Mtuy
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Derek S. Brown
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA,Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Axel C. Mühlbacher
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA,Institut Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany,Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA,Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA,Nathan M. Thielman, Duke University, Box 90519, Durham, NC 27708, Tel: +1 919 668 7173,
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15
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Manavalan P, Madut DB, Wanda L, Msasu A, Mmbaga BT, Thielman NM, Watt MH. A community health worker delivered intervention to address hypertension among adults engaged in HIV care in northern Tanzania: Outcomes from a pilot feasibility study. J Clin Hypertens (Greenwich) 2022; 24:1095-1104. [PMID: 35899325 PMCID: PMC9380132 DOI: 10.1111/jch.14518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/27/2022] [Accepted: 05/07/2022] [Indexed: 11/28/2022]
Abstract
Current care models are inadequate to address the dual epidemic of hypertension and HIV in sub‐Saharan Africa. We developed a community health worker (CHW)‐delivered educational intervention, integrated into existing HIV care to address hypertension in persons living with HIV. A detailed educational curriculum was created with five sessions: three in‐person clinic sessions and two telephone sessions. The intervention was piloted among hypertensive adults at one HIV clinic in northern Tanzania over a 4‐week period. Primary outcomes were feasibility, fidelity, and acceptability of the intervention. Secondary outcomes included hypertension care engagement and systolic and diastolic blood pressure (SBP and DBP). Among 16 eligible participants, 14 (64% women, median age of 54.5 years) were recruited into the study, and 13 (92.9%) completed all five intervention sessions. The intervention was delivered with 98.8% fidelity to the curriculum content. Hypertension care engagement improved following the intervention. At baseline, two (15.4%) participants had seen a doctor previously for hypertension, compared to 11 (84.6%) participants post‐intervention (P = .0027). No participant was using antihypertensives at baseline, compared to 10 (76.9%) post‐intervention (P = .0016). Pre‐intervention median SBP was 164 (IQR 152–170) mmHg, compared to post‐intervention SBP of 146 (IQR 134–154) mmHg (P = .0029). Pre‐intervention median DBP was 102 (IQR 86–109) mmHg, compared to post‐intervention DBP of 89 (IQR 86–98) mmHg (P = .0023). A CHW‐delivered educational intervention, integrated into existing HIV care, is feasible and holds promise in improving hypertension care engagement and reducing blood pressure. Further research is needed to evaluate the efficacy and scale‐up of our intervention.
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Affiliation(s)
- Preeti Manavalan
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida, USA.,Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Deng B Madut
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Lisa Wanda
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Ally Msasu
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Blandina T Mmbaga
- Duke Global Health Institute, Durham, North Carolina, USA.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Melissa H Watt
- Duke Global Health Institute, Durham, North Carolina, USA.,Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
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16
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Smith CM, Turner NA, Thielman NM, Tweedy DS, Egger J, Gagliardi JP. Association of Black Race With Physical and Chemical Restraint Use Among Patients Undergoing Emergency Psychiatric Evaluation. Psychiatr Serv 2022; 73:730-736. [PMID: 34932385 DOI: 10.1176/appi.ps.202100474] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [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] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Few studies have examined the disproportionate use of restraints for Black adults receiving emergency psychiatric care. This study sought to determine whether the odds of physical and chemical restraint use were higher for Black patients undergoing emergency psychiatric care compared with their White counterparts. METHODS This single-center retrospective cohort study examined 12,977 unique encounters of adults receiving an emergency psychiatric evaluation between January 1, 2014, and September 18, 2020, at a large academic medical center in Durham, North Carolina. Self-reported race categories were extracted from the electronic medical record. Primary outcomes were the presence of a behavioral physical restraint order or chemical restraint administration during the emergency department encounter. Covariates included age, sex, ethnicity, height, time of arrival, positive urine drug screen results, peak blood alcohol concentration, and diagnosis of a bipolar or psychotic disorder. RESULTS A total of 961 (7.4%) encounters involved physical restraint, and 2,047 (15.8%) involved chemical restraint. Models with and without a race covariate were compared by using quasi-likelihood information criterion scores; in each instance, the model with race performed better than the model without. Black patients were more likely to be physically (adjusted odds ratio [AOR]=1.35; 95% confidence interval [CI]=1.07-1.72) and chemically (AOR=1.33; 95% CI=1.15-1.55) restrained than White patients. CONCLUSIONS After analyses were adjusted for measured confounders, Black patients undergoing psychiatric evaluation were at higher odds of experiencing physical or chemical restraint compared with White patients, which is consistent with the growing body of evidence revealing racial disparities in psychiatric care.
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Affiliation(s)
- Colin M Smith
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Nicholas A Turner
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Nathan M Thielman
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Damon S Tweedy
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Joseph Egger
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
| | - Jane P Gagliardi
- Department of Medicine (Smith, Turner, Thielman, Gagliardi), Department of Psychiatry and Behavioral Sciences (Smith, Tweedy, Gagliardi), and Duke Global Health Institute (Thielman, Egger), Duke University School of Medicine, Durham, North Carolina
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17
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Hertz JT, Sakita FM, Kweka GL, Loring Z, Thielman NM, Temu G, Bartlett JA. Healthcare-seeking behaviour, barriers to care and predictors of symptom improvement among patients with cardiovascular disease in northern Tanzania. Int Health 2022; 14:373-380. [PMID: 31840178 PMCID: PMC9248051 DOI: 10.1093/inthealth/ihz095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Little is known about healthcare-seeking behaviour and barriers to care for cardiovascular disease (CVD) in sub-Saharan Africa. METHODS Emergency department patients in Tanzania with acute CVD were prospectively enrolled. Questionnaires were administered at enrollment and 30 d later. RESULTS Of 241 patients, 186 (77.2%) had visited another facility for the same illness episode (median symptom duration prior to presentation was 7 d) and 82 (34.0%) reported that they were initially unaware of the potential seriousness of their symptoms. Of the 208 (86.3%) patients completing follow-up, 16 (7.7%) had died, 38 (18.3%) had visited another facility for persistent symptoms, 99 (47.6%) felt they understood their diagnosis, 87 (41.8%) felt they understood their treatment and 11 (7.8%) could identify any of their medications. Predictors of 30 d survival with symptom improvement included medication compliance (p<0.001), understanding the diagnosis (p=0.007), understanding the treatment (p<0.001) and greater CVD knowledge (p=0.008). CONCLUSIONS Patients with CVD in Tanzania usually visit multiple facilities for the same illness episode, typically after prolonged delays. Only a minority understand their diagnosis and treatment, and such understanding is correlated with survival with symptom improvement. Patient-centred interventions are needed to improve the quality of cardiovascular care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Godfrey L Kweka
- Kilimanjaro Christian Research Institute, PO Box 2236, Moshi, Tanzania
| | - Zak Loring
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC 27701, USA
| | - Nathan M Thielman
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA
| | - Gloria Temu
- Department of Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - John A Bartlett
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA
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18
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Hertz JT, Sakita FM, Kweka GL, Tarimo TG, Goli S, Prattipati S, Bettger JP, Thielman NM, Bloomfield GS. One-Year Outcomes and Factors Associated With Mortality Following Acute Myocardial Infarction in Northern Tanzania. Circ Cardiovasc Qual Outcomes 2022; 15:e008528. [PMID: 35300504 PMCID: PMC9018510 DOI: 10.1161/circoutcomes.121.008528] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about long-term outcomes and uptake of secondary preventative therapies following acute myocardial infarction (AMI) in sub-Saharan Africa. METHODS Consecutive patients presenting with AMI (as defined by the Fourth Universal Definition of AMI Criteria) to a northern Tanzanian referral hospital were enrolled in this prospective observational study. Follow-up surveys assessing mortality, medication use, and rehospitalization were administered at 3, 6, 9, and 12 months following initial presentation, by telephone or in person. Multivariate logistic regression was performed to identify baseline clinical and sociodemographic factors associated with one-year mortality. RESULTS Of 152 enrolled patients with AMI, 5 were lost to one-year follow-up (96.7% retention rate). Mortality rates were 34.9% (53 of 152 participants) during the initial hospitalization, 48.7% (73 of 150 patients) at 3 months, 52.7% (78 of 148 patients) at 6 months, 55.4% (82 of 148 patients) at 9 months, and 59.9% (88 of 147 patients) at one year. Of 59 patients surviving to one-year follow-up, 43 (72.9%) reported persistent anginal symptoms, 5 (8.5%) were taking an antiplatelet, 8 (13.6%) were taking an antihypertensive, 30 (50.8%) had been rehospitalized, and 7 (11.9%) had ever undergone cardiac catheterization. On multivariate analysis, one-year mortality was associated with lack of secondary education (odds ratio, 0.26 [95% CI, 0.11-0.58]; P=0.001), lower body mass index (odds ratio, 0.90 [95% CI, 0.82-0.98]; P=0.015), and higher initial troponin (odds ratio, 1.30 [95% CI, 1.05-1.80]; P=0.052). CONCLUSIONS In northern Tanzania, AMI is associated with high all-cause one-year mortality and use of evidence-based secondary preventative therapies among AMI survivors is low. Interventions are needed to improve AMI care and outcomes.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine (J.T.H.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania (F.M.S.)
| | - Godfrey L Kweka
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
| | - Tumsifu G Tarimo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
| | - Sumana Goli
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Sainikitha Prattipati
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Janet P Bettger
- Department of Orthopaedic Surgery (J.P.B.), Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Washington, District of Colombia (J.P.B.)
| | - Nathan M Thielman
- Department of Internal Medicine (N.M.T.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Gerald S Bloomfield
- Division of Cardiology (G.S.B.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC (G.S.B.)
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19
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Gray CL, Whetten K, Daniels JL, Hudgens MG, Pettifor AE, Hobbie AM, Thielman NM, Dubie ME, Itemba D, Madan I, Vann V, Wasonga AI, Manongi R, Ostermann J, Whetten RA, Pence BW. Family Composition and Stability for Orphans: A Longitudinal Study of Well-Being in 5 Low- and Middle-Income Countries. Int J Public Health 2022; 66:1604057. [PMID: 34992514 PMCID: PMC8724025 DOI: 10.3389/ijph.2021.1604057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 11/25/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives: Many orphaned children in low- and middle-income countries live with family. Yet, their household composition and its stability are not well-characterized, nor is impact of stability on longer-term outcomes. Methods: We used the longitudinal, multi-country Positive Outcomes for Orphans cohort to describe adult family living with orphans. Stability was measured by changes in presence of six familial relations over time, and related to three outcomes: 1) incident abuse, 2) cognitive functioning, 3) emotional difficulties. Associations were estimated using generalized linear models fit with generalized estimating equations. For abuse, Poisson regression estimated risk ratios. For continuous scores of cognitive functioning and emotional difficulties, linear models estimated mean differences (MDs) with 95% confidence intervals. Results: Among 1,359 orphans, 53–61% reported living with their mother each year; 7–13% with father; nearly 60% reported ≥1 change in composition over follow-up. Compared to 0 changes, difficulties increased with 1 change [MD: 0.23 (−0.33, 0.79)], 2 changes [MD: 0.57 (0.00, 1.16)] and ≥3 changes [MD: 0.73 (0.18, 1.29)]. No associations were found with abuse or cognitive functioning. Conclusion: Orphan well-being may be improved through supports stabilizing household composition or targeting emotional resilience.
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Affiliation(s)
- Christine L Gray
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Kathryn Whetten
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States.,Sanford School of Public Policy, Duke University, Durham, NC, United States
| | - Julie L Daniels
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Audrey E Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amy M Hobbie
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Nathan M Thielman
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States.,Division of Infectious Diseases, Department of Medicine, School of Medicine, Duke University, Durham, NC, United States
| | | | | | - Ira Madan
- Sahara Centre for Residential Care and Rehabilitation, New Delhi, India
| | - Vanroth Vann
- Development for Cambodian Children, Battambang, Cambodia
| | | | | | - Jan Ostermann
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States.,Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Rachel A Whetten
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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20
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Prattipati S, Mlangi JJ, Tarimo TG, Kweka GL, Thielman NM, Bettger JP, Mmbaga BT, Sakita FM, Hertz JT. Knowledge, attitudes, and preventive practices regarding ischemic heart disease among HIV-positive individuals in northern Tanzania. Trop Med Int Health 2021; 26:1652-1658. [PMID: 34637597 PMCID: PMC11012094 DOI: 10.1111/tmi.13690] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe knowledge, attitudes, and practices (KAP) regarding ischemic heart disease (IHD) among adults with HIV in Tanzania. METHODS Adults presenting for routine HIV care at a clinic in northern Tanzania were consecutively enrolled and were administered a standardised KAP survey. For each participant, an IHD knowledge score was calculated by tallying correct answers to the IHD knowledge questions, with maximum score 10. Individual 5-year risk of cardiovascular event was calculated using the Harvard NHANES model. Associations between participant characteristics and IHD knowledge scores were assessed via Welch's t-test. RESULTS Among the 500 participants, the mean (SD) age was 45.3 (11.4) years and 139 (27.8%) were males. Most participants recognised high blood pressure (n = 313, 62.6%) as a risk factor for IHD, but fewer identified diabetes as a risk factor (n = 241, 48.2%), or knew that aspirin reduces the risk of a secondary cardiovascular event (n = 73, 14.6%). Higher IHD knowledge score was associated with post-primary education (mean 6.27 vs. 5.35, p = 0.001) and with >10% 5-year risk of cardiovascular event (mean 5.97 vs. 5.41, p = 0.045). Most participants believed there were things they could do to reduce their chances of having a heart attack (n = 361, 72.2%). While participants indicated that they adhered to their prescribed medications (n = 488, 97.6%), only 106 (21.2%) attended regular health check-ups. CONCLUSION Efforts are needed to improve gaps in IHD knowledge, and increase uptake of cardiovascular preventative practices among Tanzanian adults with HIV.
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Affiliation(s)
| | | | | | | | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Janet P Bettger
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Washington, District of Colombia, USA
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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21
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Manavalan P, Wanda L, Galson SW, Thielman NM, Mmbaga BT, Watt MH. Hypertension Care for People With HIV in Tanzania: Provider Perspectives and Opportunities for Improvement. J Int Assoc Provid AIDS Care 2021; 20:23259582211052399. [PMID: 34751055 PMCID: PMC8743911 DOI: 10.1177/23259582211052399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
One in three people with HIV (PWH) has hypertension. However, most hypertensive PWH in sub-Saharan Africa are unaware of their hypertension diagnosis and are not on treatment. To better understand barriers to hypertension care faced by PWH, we interviewed 15 medical providers who care for patients with HIV and hypertension in northern Tanzania. The data revealed barriers at the patient, provider, and system level and included: stress, depression, and HIV-related stigma; lack of hypertension knowledge; insufficient hypertension training; inefficient prescribing practices; challenges with counselling; capacity limitations in hypertension care; high costs of care; and lack of routine hypertension screening and follow-up. Opportunities for improvement focused on prioritizing resources and funding towards hypertension care. System-related challenges were the underlying cause of barriers at individual levels. Strategies that focus on strengthening capacity and utilize existing HIV platforms to promote hypertension care delivery are urgently needed to improve cardiovascular outcomes among PWH.
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Affiliation(s)
- Preeti Manavalan
- 3463University of Florida, Gainesville, FL, USA.,3065Division of Infectious Diseases at Duke Medical Centre, Durham, NC, USA.,199688Duke Global Health Institute, Durham, NC, USA
| | - Lisa Wanda
- 108095Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Sophie W Galson
- 3065Division of Infectious Diseases at Duke Medical Centre, Durham, NC, USA.,199688Duke Global Health Institute, Durham, NC, USA
| | - Nathan M Thielman
- 3065Division of Infectious Diseases at Duke Medical Centre, Durham, NC, USA.,199688Duke Global Health Institute, Durham, NC, USA
| | - Blandina T Mmbaga
- 199688Duke Global Health Institute, Durham, NC, USA.,108095Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,108094Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Melissa H Watt
- 199688Duke Global Health Institute, Durham, NC, USA.,University of Utah, Salt Lake City, UT, USA
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22
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Ostermann J, Flaherty BP, Brown DS, Njau B, Hobbie AM, Mtuy TB, Masnick M, Mühlbacher AC, Thielman NM. What factors influence HIV testing? Modeling preference heterogeneity using latent classes and class-independent random effects. J Choice Model 2021; 40:100305. [PMID: 35422879 PMCID: PMC9007550 DOI: 10.1016/j.jocm.2021.100305] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Efforts to eliminate the HIV epidemic will require increased HIV testing rates among high-risk populations. To inform the design of HIV testing interventions, a discrete choice experiment (DCE) with six policy-relevant attributes of HIV testing options elicited the testing preferences of 300 female barworkers and 440 male Kilimanjaro mountain porters in northern Tanzania. Surveys were administered between September 2017 and July 2018. Participants were asked to complete 12 choice tasks, each involving first- and second-best choices from 3 testing options. DCE responses were analyzed using a random effects latent class logit (RELCL) model, in which the latent classes summarize common participant preference profiles, and the random effects capture additional individual-level preference heterogeneity with respect to three attribute domains: (a) privacy and confidentiality (testing venue, pre-test counseling, partner notification); (b) invasiveness and perceived accuracy (method for obtaining the sample for the HIV test); and (c) accessibility and value (testing availability, additional services provided). The Bayesian Information Criterion indicated the best model fit for a model with 8 preference classes, with class sizes ranging from 6% to 19% of participants. Substantial preference heterogeneity was observed, both between and within latent classes, with 12 of 16 attribute levels having positive and negative coefficients across classes, and all three random effects contributing significantly to participants' choices. The findings may help identify combinations of testing options that match the distribution of HIV testing preferences among high-risk populations; the methods may be used to systematically design heterogeneity-focused interventions using stated preference methods.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management, University of South Carolina, 915 Greene Street, Columbia, SC, USA
- South Carolina Smart State Center for Healthcare Quality, University of South Carolina, Columbia, SC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Brian P. Flaherty
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Derek S. Brown
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amy M. Hobbie
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Tara B. Mtuy
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Axel C. Mühlbacher
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
- Institut Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
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23
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Goli S, Sakita FM, Kweka GL, Tarimo TG, Temu G, Thielman NM, Bettger JP, Bloomfield GS, Limkakeng AT, Hertz JT. Thirty-day outcomes and predictors of mortality following acute myocardial infarction in northern Tanzania: A prospective observational cohort study. Int J Cardiol 2021; 342:23-28. [PMID: 34364908 DOI: 10.1016/j.ijcard.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a rising burden of myocardial infarction (MI) within sub-Saharan Africa. Prospective studies of detailed MI outcomes in the region are lacking. METHODS Adult patients with confirmed MI from a prospective surveillance study in northern Tanzania were enrolled in a longitudinal cohort study after baseline health history, medication use, and sociodemographic data were obtained. Thirty days following hospital presentation, symptom status, rehospitalizations, medication use, and mortality were assessed via telephone or in-person interviews using a standardized follow-up questionnaire. Multivariate logistic regression was performed to identify baseline predictors of thirty-day mortality. RESULTS Thirty-day follow-up was achieved for 150 (98.7%) of 152 enrolled participants. Of these, 85 (56.7%) survived to thirty-day follow-up. Of the surviving participants, 71 (83.5%) reported persistent anginal symptoms, four (4.7%) reported taking aspirin regularly, seven (8.2%) were able to identify MI as the reason for their hospitalization, and 17 (20.0%) had unscheduled rehospitalizations. Self-reported history of diabetes at baseline (OR 0.32, 95% CI 0.10-0.89, p = 0.04), self-reported history of hypertension at baseline (OR 0.34, 95% CI 0.15-0.74, p = 0.01), and antiplatelet use at initial presentation (OR 0.19, 95% CI 0.04-0.65, p = 0.02) were all associated with lower odds of thirty-day mortality. CONCLUSIONS In northern Tanzania, thirty-day outcomes following acute MI are poor, and mortality is associated with self-awareness of comorbidities and medication usage. Further investigation is needed to develop interventions to improve care and outcomes of MI in Tanzania.
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Affiliation(s)
- Sumana Goli
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA.
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Godfrey L Kweka
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Tumsifu G Tarimo
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Gloria Temu
- Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Janet P Bettger
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Gerald S Bloomfield
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
| | | | - Julian T Hertz
- Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710, USA; Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710, USA
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24
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Hertz JT, Madut DB, Rubach MP, William G, Crump JA, Galson SW, Maro VP, Bloomfield GS, Limkakeng AT, Temu G, Thielman NM, Sakita FM. Incidence of Acute Myocardial Infarction in Northern Tanzania: A Modeling Approach Within a Prospective Observational Study. J Am Heart Assoc 2021; 10:e021004. [PMID: 34320841 PMCID: PMC8475708 DOI: 10.1161/jaha.121.021004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Rigorous incidence data for acute myocardial infarction (AMI) in sub‐Saharan Africa are lacking. Consequently, modeling studies based on limited data have suggested that the burden of AMI and AMI‐associated mortality in sub‐Saharan Africa is lower than in other world regions. Methods and Results We estimated the incidence of AMI in northern Tanzania in 2019 by integrating data from a prospective surveillance study (681 participants) and a community survey of healthcare‐seeking behavior (718 participants). In the surveillance study, adults presenting to an emergency department with chest pain or shortness of breath were screened for AMI with ECG and troponin testing. AMI was defined by the Fourth Universal Definition of AMI criteria. Mortality was assessed 30 days following enrollment via in‐person or telephone interviews. In the cluster‐based community survey, adults in northern Tanzania were asked where they would present for chest pain or shortness of breath. Multipliers were applied to account for AMI cases that would have been missed by our surveillance methods. The estimated annual incidence of AMI was 172 (207 among men and 139 among women) cases per 100 000 people. The age‐standardized annual incidence was 211 (263 among men and 170 among women) per 100 000 people. The estimated annual incidence of AMI‐associated mortality was 87 deaths per 100 000 people, and the age‐standardized annual incidence was 102 deaths per 100 000 people. Conclusions The incidence of AMI and AMI‐associated mortality in northern Tanzania is much higher than previously estimated and similar to that observed in high‐income countries.
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Affiliation(s)
- Julian T Hertz
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
| | | | - Matthew P Rubach
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
| | | | - John A Crump
- Otago Global Health Institute Dunedin New Zealand
| | | | | | - Gerald S Bloomfield
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
| | | | - Gloria Temu
- Kilimanjaro Christian Medical Centre Moshi Tanzania
| | - Nathan M Thielman
- Duke University School of Medicine Durham NC.,Duke Global Health Institute Durham NC
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25
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Madut DB, Manavalan P, Mtalo A, Peter TA, Ostermann J, Njau B, Thielman NM. Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons. AIDS Behav 2021; 25:2014-2022. [PMID: 33389376 DOI: 10.1007/s10461-020-03131-6] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.
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Affiliation(s)
- Deng B Madut
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Preeti Manavalan
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Antipas Mtalo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Department of Medicine, Duke University, 315 Trent Drive, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, USA
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26
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Navuluri N, Srour ML, Kussin PS, Murdoch DM, MacIntyre NR, Que LG, Thielman NM, McCollum ED. Oxygen delivery systems for adults in Sub-Saharan Africa: A scoping review. J Glob Health 2021; 11:04018. [PMID: 34026051 PMCID: PMC8109278 DOI: 10.7189/jogh.11.04018] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Respiratory diseases are the leading cause of death and disability worldwide. Oxygen is an essential medicine used to treat hypoxemia from respiratory diseases. However, the availability and utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described. We aim to identify and describe existing data around oxygen availability and provision for adults in sub-Saharan Africa, determine knowledge or research gaps, and make recommendations for future research and capacity building. Methods We systematically searched four databases for articles on April 22, 2020, for variations of keywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteria were studies that included adults and addressed hypoxemia assessment or outcome, oxygen delivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapy and outcomes. Results 35 studies representing 22 countries met inclusion criteria. Availability of oxygen delivery systems ranged from 42%-94% between facilities, with wide variability in the consistency of availability. There was also wide reported prevalence of hypoxemia, with most studies focusing on specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, and titrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the most cost-effective delivery system in areas where power is readily available. Conclusions There is a substantial need for building capacity for oxygen delivery throughout sub-Saharan Africa. Addressing this critical issue will require innovation and a multi-faceted approach of developing infrastructure, better equipping facilities, and health care worker training.
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Affiliation(s)
- Neelima Navuluri
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Maria L Srour
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter S Kussin
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - David M Murdoch
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Neil R MacIntyre
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Loretta G Que
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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27
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Ostermann J, Njau B, Hobbie A, Mtuy T, Masaki ML, Shayo A, van Zwetselaar M, Masnick M, Flaherty B, Brown DS, Mühlbacher AC, Thielman NM. Using discrete choice experiments to design interventions for heterogeneous preferences: protocol for a pragmatic randomised controlled trial of a preference-informed, heterogeneity-focused, HIV testing offer for high-risk populations. BMJ Open 2020; 10:e039313. [PMID: 33158826 PMCID: PMC7651730 DOI: 10.1136/bmjopen-2020-039313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Approximately one million undiagnosed persons living with HIV in Southern and Eastern Africa need to test for HIV. Novel approaches are necessary to identify HIV testing options that match the heterogeneous testing preferences of high-risk populations. This pragmatic randomised controlled trial (PRCT) will evaluate the efficacy of a preference-informed, heterogeneity-focused HIV counselling and testing (HCT) offer, for improving rates of HIV testing in two high-risk populations. METHODS AND ANALYSIS The study will be conducted in Moshi, Tanzania. The PRCT will randomise 600 female barworkers and 600 male Kilimanjaro mountain porters across three study arms. All participants will receive an HIV testing offer comprised of four preference-informed testing options, including one 'common' option-comprising features that are commonly available in the area and, on average, most preferred among study participants-and three options that are specific to the study arm. Options will be identified using mixed logit and latent class analyses of data from a discrete choice experiment (DCE). Participants in Arm 1 will be offered the common option and three 'targeted' options that are predicted to be more preferred than the common option and combine features widely available in the study area. Participants in Arm 2 will be offered the common option and three 'enhanced' options, which also include HCT features that are not yet widely available in the study area. Participants in Arm 3, an active control arm, will be offered the common option and three predicted 'less preferred' options. The primary outcome will be uptake of HIV testing. ETHICS AND DISSEMINATION Ethical approval was obtained from the Duke University Health System IRB, the University of South Carolina IRB, the Ethics Review Committee at Kilimanjaro Christian Medical University College, Tanzania's National Institute for Medical Research, and the Tanzania Food & Drugs Authority (now Tanzania Medicines & Medical Devices Authority). Findings will be published in peer-reviewed journals. The use of rigorous DCE methods for the preference-based design and tailoring of interventions could lead to novel policy options and implementation science approaches. TRIAL REGISTRATION NUMBER NCT02714140.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management, University of South Carolina, Columbia, South Carolina, USA
- South Carolina Smart State Center for Healthcare Quality, University of South Carolina, Carolina, South Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amy Hobbie
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
| | - Tara Mtuy
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aisa Shayo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Max Masnick
- Selway Labs, LLC, Barrington, Rhode Island, USA
| | - Brian Flaherty
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Axel C Mühlbacher
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
- Institut Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
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Madut DB, Park LP, Yao J, Reddy EA, Njau B, Ostermann J, Whetten K, Thielman NM. Predictors of mortality in treatment experienced HIV-infected patients in northern Tanzania. PLoS One 2020; 15:e0240293. [PMID: 33031434 PMCID: PMC7544106 DOI: 10.1371/journal.pone.0240293] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 09/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background While factors that drive early mortality among people living with HIV (PLWH) initiating antiretroviral therapy (ART) in sub-Saharan Africa (SSA) have been described, less is known about the predictors of long-term mortality for those with ART experience. Methods PLWH and on ART attending two HIV treatment clinics in Moshi, Tanzania were enrolled from 2008 through 2009 and followed for 3.5 years. Demographic, psychosocial, and clinical information were collected at enrollment. Plasma HIV RNA measurements were collected annually. Cause of death was adjudicated by two independent reviewers based on verbal autopsy information and medical records. Bivariable and multivariable analyses were conducted using Cox proportional hazard models to identify predictors of mortality. Results The analysis included 403 participants. The median (IQR) age in years was 42 (36–48) and 277 (68.7%) participants were female. The proportion of participants virologically suppressed during the 4 collection time points was 88.5%, 94.7%, 91.5%, and 94.5%. During follow-up, 24 participants died; the overall mortality rate was 1.8 deaths per 100 person-years. Of the deaths, 14 (58.3%) were suspected to be HIV/AIDS related. Predictors of mortality (adjusted hazard ratio, 95% confidence interval) were male sex (2.63, 1.01–6.83), secondary or higher education (7.70, 3.02–19.60), receiving care at the regional referral hospital in comparison to the larger zonal referral hospital (6.33, 1.93–20.76), and moderate to severe depression symptoms (6.35, 1.69–23.87). Conclusions As ART coverage continues to expand in SSA, HIV programs should recognize the need for interventions to promote HIV care engagement for men and the integration of mental health screening and treatment with HIV care. Facility-level barriers may contribute to challenges faced by PLWH as they progress through the HIV care continuum, and further understanding of these barriers is needed. The association of higher educational attainment with mortality merits further investigation.
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Affiliation(s)
- Deng B. Madut
- Department of Medicine, Duke University, Durham, NC, United States of America
- * E-mail:
| | - Lawrence P. Park
- Department of Medicine, Duke University, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Jia Yao
- Center for Health Policy and Inequalities Research, Durham, NC, United States of America
- Duke Sanford School of Public Policy, Duke University, Durham, NC, United States of America
| | - Elizabeth A. Reddy
- Division of Infectious Disease, SUNY Upstate Medical University, Syracuse, NY, United States of America
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Kathryn Whetten
- Duke Global Health Institute, Durham, NC, United States of America
- Center for Health Policy and Inequalities Research, Durham, NC, United States of America
- Duke Sanford School of Public Policy, Duke University, Durham, NC, United States of America
| | - Nathan M. Thielman
- Department of Medicine, Duke University, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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29
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Hertz JT, Sakita FM, Kweka GL, Bloomfield GS, Bartlett JA, Tarimo TG, Temu G, Bettger JP, Thielman NM. Effect of a Triage-Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre-Post Study. J Am Heart Assoc 2020; 9:e016501. [PMID: 32772764 PMCID: PMC7660831 DOI: 10.1161/jaha.120.016501] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/08/2020] [Indexed: 01/07/2023]
Abstract
Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub-Saharan Africa. Triage-based interventions have improved ACS diagnosis and management in high-income settings but have not been evaluated in sub-Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage-based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician-documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage-based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point-of-care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre-post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52-19.7; P<0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07-36.13; P<0.001). Conclusions Introduction of a triage-based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED-based interventions on ACS care and clinical end points in sub-Saharan Africa.
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Affiliation(s)
- Julian T. Hertz
- Department of SurgeryDuke University School of MedicineDurhamNC
- Duke Global Health InstituteDuke UniversityDurhamNC
| | - Francis M. Sakita
- Department of Emergency MedicineKilimanjaro Christian Medical CentreMoshiTanzania
- Kilimanjaro Christian Medical University CollegeMoshiTanzania
| | | | - Gerald S. Bloomfield
- Duke Global Health InstituteDuke UniversityDurhamNC
- Department of MedicineDuke University School of MedicineDurhamNC
| | - John A. Bartlett
- Duke Global Health InstituteDuke UniversityDurhamNC
- Kilimanjaro Christian Medical University CollegeMoshiTanzania
- Department of MedicineDuke University School of MedicineDurhamNC
| | | | - Gloria Temu
- Kilimanjaro Christian Medical University CollegeMoshiTanzania
- Department of MedicineKilimanjaro Christian Medical CentreMoshiTanzania
| | - Janet P. Bettger
- Duke Global Health InstituteDuke UniversityDurhamNC
- Department of Orthopaedic SurgeryDuke University School of MedicineDurhamNC
| | - Nathan M. Thielman
- Duke Global Health InstituteDuke UniversityDurhamNC
- Department of MedicineDuke University School of MedicineDurhamNC
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30
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Hertz JT, Sakita FM, Kweka GL, Limkakeng AT, Galson SW, Ye JJ, Tarimo TG, Temu G, Thielman NM, Bettger JP, Bartlett JA, Mmbaga BT, Bloomfield GS. Acute myocardial infarction under-diagnosis and mortality in a Tanzanian emergency department: A prospective observational study. Am Heart J 2020; 226:214-221. [PMID: 32619815 DOI: 10.1016/j.ahj.2020.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Growing evidence suggests that under-diagnosis of acute myocardial infarction (AMI) may be common in sub-Saharan Africa. Prospective studies of routine AMI screening among patients presenting to emergency departments in sub-Saharan Africa are lacking. Our objective was to determine the prevalence of AMI among patients in a Tanzanian emergency department. METHODS In a prospective observational study, consecutive adult patients presenting with chest pain or shortness of breath to a referral hospital emergency department in northern Tanzania were enrolled. Electrocardiogram (ECG) and troponin testing were performed for all participants to diagnose AMI types according to the Fourth Universal Definition. All ECGs were interpreted by two independent physician judges. ECGs suggesting ST-elevation myocardial infarction (STEMI) were further reviewed by additional judges. Mortality was assessed 30 days following enrollment. RESULTS Of 681 enrolled participants, 152 (22.3%) had AMI, including 61 STEMIs and 91 non-STEMIS (NSTEMIs). Of AMI patients, 91 (59.9%) were male, mean (SD) age was 61.2 (18.5) years, and mean (SD) duration of symptoms prior to presentation was 6.6 (12.2) days. In the emergency department, 35 (23.0%) AMI patients received aspirin and none received thrombolytics. Of 150 (98.7%) AMI patients completing 30-day follow-up, 65 (43.3%) had died. CONCLUSIONS In a northern Tanzanian emergency department, AMI is common, rarely treated with evidence-based therapies, and associated with high mortality. Interventions are needed to improve AMI diagnosis, care, and outcomes.
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31
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Manavalan P, Madut DB, Hertz JT, Thielman NM, Okeke NL, Mmbaga BT, Watt MH. Hypertension burden and challenges across the hypertension treatment cascade among adults enrolled in HIV care in northern Tanzania. J Clin Hypertens (Greenwich) 2020; 22:1518-1522. [PMID: 32652868 DOI: 10.1111/jch.13929] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/17/2020] [Accepted: 05/30/2020] [Indexed: 12/15/2022]
Abstract
Failure to address hypertension among people living with HIV (PLWH) may undermine the significant progress made toward reducing mortality among this high-risk population in sub-Saharan Africa (SSA). Here, the authors report hypertension prevalence, diagnosis, and treatment among patients enrolled in HIV care in Tanzania. Patients attending an HIV clinic were consecutively screened for hypertension. Hypertension was defined as follows: a single blood pressure measurement ≥160 mm Hg systolic or ≥100 mm Hg diastolic, two measurements at separate visits ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or self-reported hypertension diagnosis. The authors screened 555 patients, and 19.6% met hypertension criteria. Among a subset of 91 hypertensive participants, 44 (48.4%) reported previous blood pressure measurements, 32 (35.2%) were aware of diagnosis, 10 (11.0%) reported current antihypertensive use, and none had controlled blood pressure. Addressing barriers along the hypertension treatment cascade must be a top priority to improve cardiovascular outcomes among PLWH in SSA.
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Affiliation(s)
- Preeti Manavalan
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Deng B Madut
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Division of Emergency Medicine, Duke University, Durham, NC, USA
| | - Nathan M Thielman
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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32
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Ostermann J, Mühlbacher A, Brown DS, Regier DA, Hobbie A, Weinhold A, Alshareef N, Derrick C, Thielman NM. Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment. Value Health 2020; 23:851-861. [PMID: 32762986 DOI: 10.1016/j.jval.2020.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making. METHODS A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models. RESULTS Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics. CONCLUSION Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services, Policy and Management, University of South Carolina, Columbia, SC, USA
| | - Axel Mühlbacher
- Institute of Health Economics and Healthcare Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Dean A Regier
- Cancer Research Centre, University of British Columbia, Vancouver, BC, Canada
| | - Amy Hobbie
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Andrew Weinhold
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Noor Alshareef
- Department of Health Services, Policy and Management, University of South Carolina, Columbia, SC, USA
| | - Caroline Derrick
- Department of Medicine, University of South Carolina, Columbia, SC, USA
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Hertz JT, Sakita FM, Manavalan P, Madut DB, Thielman NM, Mmbaga BT, Staton CA, Galson SW. The Burden of Hypertension and Diabetes in an Emergency Department in Northern Tanzania. Ethn Dis 2019; 29:559-566. [PMID: 31641323 DOI: 10.18865/ed.29.4.559] [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: 11/18/2022] Open
Abstract
Introduction Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa. Methods A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL. Results Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic complications, the most common admission diagnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%). Conclusions The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hypertension and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hospitalizations highlights the urgent need for improvements in primary preventative care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC.,Duke Global Health Institute, Duke University, Durham, NC
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Deng B Madut
- Department of Medicine, Duke University, Durham, NC
| | | | - Blandina T Mmbaga
- Kilimanjaro Christian Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Catherine A Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC.,Duke Global Health Institute, Duke University, Durham, NC
| | - Sophie W Galson
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC
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Brown JF, Dye JM, Tozay S, Jeh-Mulbah G, Wohl DA, Fischer WA, Cunningham CK, Rowe K, Zacharias P, van Hasselt J, Norwood DA, Thielman NM, Zak SE, Hoover DL. Anti-Ebola Virus Antibody Levels in Convalescent Plasma and Viral Load After Plasma Infusion in Patients With Ebola Virus Disease. J Infect Dis 2019; 218:555-562. [PMID: 29659889 DOI: 10.1093/infdis/jiy199] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/03/2018] [Indexed: 11/14/2022] Open
Abstract
Background Ebola virus (EBOV) neutralizing antibody in plasma may reduce viral load following administration of plasma to patients with Ebola virus disease (EVD), but measurement of these antibodies is complex. Methods Anti-EBOV antibody was measured by 2 neutralization and 2 enzyme-linked immunosorbent assays (ELISAs) in convalescent plasma (ECP) from 100 EVD survivor donors in Liberia. Viral load was assessed repetitively in patients with EVD participating in a clinical trial of enhanced standard of care plus ECP. Results All 4 anti-EBOV assays were highly concordant for detection of EBOV antibody. Antibodies were not detected in plasma specimens obtained from 15 of 100 donors, including 7 with documented EBOV-positive reverse-transcription polymerase chain reaction during EVD. Viral load was reduced following each dose in the 2 clinical trial participants who received ECP with higher antibody levels but not in the 2 who received ECP with lower antibody levels. Conclusions Recovery from EVD can occur with absence of detectable anti-EBOV antibody several months after disease onset. ELISAs may be useful to select ECP donors or identify ECP units that contain neutralizing antibody. ECP with higher anti-EBOV antibody levels may have greater effect on EBOV load-an observation that requires further investigation. Clinical Trials Registration NCT02333578.
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Affiliation(s)
- Jerry F Brown
- Eternal Love Winning Africa Hospital, Paynesville, Liberia
| | - John M Dye
- US Army Medical Research Institute of Infectious Disease, Frederick, Maryland
| | - Sam Tozay
- Eternal Love Winning Africa Hospital, Paynesville, Liberia
| | | | - David A Wohl
- University of North Carolina School of Medicine, Chapel Hill
| | | | | | - Kathleen Rowe
- Blood Centers of America, West Warwick, Rhode Island
| | - Peter Zacharias
- Safe Blood for Africa Foundation, Washington, District of Columbia, Hinckley, Ohio
| | - James van Hasselt
- Safe Blood for Africa Foundation, Washington, District of Columbia, Hinckley, Ohio
| | - David A Norwood
- US Army Medical Research Institute of Infectious Disease, Frederick, Maryland
| | | | - Samantha E Zak
- US Army Medical Research Institute of Infectious Disease, Frederick, Maryland
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35
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Hertz JT, Sakita FM, Manavalan P, Mmbaga BT, Thielman NM, Staton CA. Knowledge, attitudes, and preventative practices regarding ischemic heart disease among emergency department patients in northern Tanzania. Public Health 2019; 175:60-67. [PMID: 31401252 DOI: 10.1016/j.puhe.2019.06.017] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/11/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The objective of this study is to increase understanding of knowledge, attitudes, and preventative practices regarding ischemic heart disease (IHD) in sub-Saharan Africa in order to develop patient-centered interventions to improve care and outcomes. STUDY DESIGN This is a prospective observational study. METHODS Adult patients presenting with chest pain or shortness of breath to an emergency department in northern Tanzania were enrolled. A questionnaire was adapted from existing knowledge attitude and practice surveys regarding cardiovascular disease and the WHO STEPS instrument. Individual five-year risk of cardiovascular event was determined by validated models based on age, sex, systolic blood pressure, body mass index, diabetes, and smoking status. An IHD knowledge score was calculated by giving one point for each correct response to the knowledge-related items, with a maximum score of 10. Associations between IHD knowledge and patient characteristics were assessed by Welch's t-test. RESULTS A total of 349 patients were enrolled, with median interquartile range (IQR) age 60 (45, 72) years. Of participants, 259 (74.2%) had hypertension, and 228 (65.3%) had greater than 10% five-year risk of cardiovascular event. The mean (SD) knowledge score was 4.8 (3.3). The majority of respondents (224, 64.2%) recognized obesity as a risk factor for heart attack, while a minority (34, 9.7%) knew that a daily aspirin could reduce the risk of cardiovascular event. Greater IHD knowledge was associated with younger age (P = 0.045) and higher levels of education (P < 0.001) but not higher risk of cardiovascular disease (P = 0.123). Most respondents expressed a willingness to diet to improve their health (322, 92.3%) and a preference for treatment from a physician rather than a traditional healer for a heart attack (321, 92.0%). A minority of patients reported exercising regularly (88, 25.2%) or seeing a doctor routinely for checkups (100, 28.7%). CONCLUSIONS High-risk emergency department patients in northern Tanzania have moderate knowledge regarding IHD but do not consistently engage in healthy preventive practices. Patient-centered interventions are needed to improve IHD knowledge and practices in high-risk populations.
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Affiliation(s)
- J T Hertz
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA; Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA.
| | - F M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania
| | - P Manavalan
- Department of Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - B T Mmbaga
- Kilimanjaro Christian Research Institute, Tumaini University, PO Box 3010, Moshi, Tanzania
| | - N M Thielman
- Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA
| | - C A Staton
- Division of Emergency Medicine, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA; Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA
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36
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Derrick CB, Ostermann J, Weissman SB, Hobbie A, Alshareef N, Weinhold A, Yelverton V, Thielman NM. Who Wants to Switch? Gauging Patient Interest in Novel Antiretroviral Therapies. Open Forum Infect Dis 2018; 5:ofy247. [PMID: 30364593 PMCID: PMC6197380 DOI: 10.1093/ofid/ofy247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Study participants were asked about their interest in switching to novel drug delivery systems that reduce the dosing frequency of antiretroviral regimens. Across a diverse, treatment-experienced cohort, we describe greatest interest in switching to an oral regimen taken once weekly, followed by injections taken every other month and twice-annual implants.
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Affiliation(s)
- Caroline B Derrick
- Department of Medicine, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Sharon B Weissman
- Department of Medicine, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Amy Hobbie
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Noor Alshareef
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Andrew Weinhold
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Valerie Yelverton
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Fachbereich Gesundheit, Pflege, Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
| | - Nathan M Thielman
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina.,Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
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Hussaini SMQ, Madut D, Tong BC, Pavlisko EN, Schell WA, Perfect JR, Thielman NM. Pulmonary blastomycosis presenting as primary lung cancer. BMC Infect Dis 2018; 18:336. [PMID: 30021526 PMCID: PMC6052517 DOI: 10.1186/s12879-018-3244-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 07/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blastomycosis is an endemic mycosis in North America that is caused by the dimorphic fungus Blastomyces dermatitidis. The illness is a systemic disease with a wide variety of pulmonary and extra-pulmonary manifestations. The initial presentation of blastomycosis may easily be mistaken for other infectious or non-infectious etiologies. CASE PRESENTATION We present the case of a 52-year-old African-American male and former smoker that presented to his primary care provider with a 2-week history of non-productive cough, night sweats and weight loss. Initially diagnosed with primary lung malignancy, the patient was subsequently found to have pulmonary blastomycosis mimicking lung cancer. The patient underwent a successful course of treatment with posaconazole. CONCLUSIONS Chronic blastomycosis can present with clinical and radiographic features indistinguishable from thoracic malignancies. There is no clinical syndrome specific for blastomycosis, thus a high degree of suspicion is required for early diagnosis. In this case report, we review recent evidence in radiographic features, diagnostic considerations and treatment of the disease.
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Affiliation(s)
- Syed Mohammed Qasim Hussaini
- Duke University School of Medicine, Durham, North Carolina, 27710, USA.,Duke-NUS Medical School, Singapore, 510568, Singapore
| | - Deng Madut
- Division of Infectious Diseases, Department of Medicine, Duke Global Health Institute, Duke University Medical Center, 310 Trent Drive, Durham, NC, 27710, USA
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, 27710, USA
| | | | - Wiley A Schell
- Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke Global Health Institute, Duke University Medical Center, 310 Trent Drive, Durham, NC, 27710, USA
| | - Nathan M Thielman
- Division of Infectious Diseases, Department of Medicine, Duke Global Health Institute, Duke University Medical Center, 310 Trent Drive, Durham, NC, 27710, USA.
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Krebs E, Gerardo CJ, Park LP, Nickenig Vissoci JR, Byiringiro JC, Byiringiro F, Rulisa S, Thielman NM, Staton CA. Erratum to "Mortality-Associated Characteristics of Patients with Traumatic Brain Injury at the University Teaching Hospital of Kigali, Rwanda" [World Neurosurgery 102 (2017) 571-582]. World Neurosurg 2017; 106:1047. [PMID: 28803734 DOI: 10.1016/j.wneu.2017.07.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Elizabeth Krebs
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Charles J Gerardo
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Lawrence P Park
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Division of Global Neurosurgery and Neurosciences, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Stephen Rulisa
- University Teaching Hospital of Kigali, Kigali, Rwanda; School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Division of Global Neurosurgery and Neurosciences, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Krebs E, Gerardo CJ, Park LP, Nickenig Vissoci JR, Byiringiro JC, Byiringiro F, Rulisa S, Thielman NM, Staton CA. Mortality-Associated Characteristics of Patients with Traumatic Brain Injury at the University Teaching Hospital of Kigali, Rwanda. World Neurosurg 2017; 102:571-582. [PMID: 28336445 PMCID: PMC5681277 DOI: 10.1016/j.wneu.2017.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 10/19/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with TBI in low and middle-income countries have worse outcomes than patients in high-income countries. We evaluated important clinical indicators associated with mortality for patients with TBI at University Teaching Hospital of Kigali, Kigali, Rwanda. METHODS A prospective consecutive sampling of patients with TBI presenting to University Teaching Hospital of Kigali Accident and Emergency Department was screened for inclusion criteria: reported head trauma, alteration in consciousness, headache, and visible head trauma. Exclusion criteria were age <10 years, >48 hours after injury, and repeat visit. Data were assessed for association with death using logistic regression. Significant variables were included in a multivariate logistic regression model and refined via backward elimination. RESULTS Between October 7, 2013, and April 6, 2014, 684 patients were enrolled; 14 (2%) were excluded because of incomplete data. Of patients, 81% were male with mean age of 31 years (range, 10-89 years; SD 11.8). Most patients (80%) had mild TBI (Glasgow Coma Scale [GCS] score 13-15); 10% had moderate (GCS score 9-12) and 10% had severe (GCS score 3-8) TBI. Multivariate logistic regression determined that GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were significantly associated with death. CONCLUSIONS GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were associated with mortality. These findings inform future research that may guide clinicians in prioritizing care for patients at highest risk of mortality.
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Affiliation(s)
- Elizabeth Krebs
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Charles J Gerardo
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Lawrence P Park
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Division of Global Neurosurgery and Neurosciences, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Stephen Rulisa
- University Teaching Hospital of Kigali, Kigali, Rwanda; School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Division of Global Neurosurgery and Neurosciences, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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O'Donnell JK, Gaynes BN, Cole SR, Edmonds A, Thielman NM, Quinlivan EB, Heine A, Modi R, Pence BW. Stressful and traumatic life events as disruptors to antiretroviral therapy adherence. AIDS Care 2017; 29:1378-1385. [PMID: 28351158 DOI: 10.1080/09540121.2017.1307919] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Stressful and traumatic life events (STLEs) are common among HIV-infected individuals and may affect health behaviors such as adherence to antiretroviral (ARV) therapy, with important implications for treatment outcomes. We examined the association between STLEs and ARV adherence among 289 US-based participants enrolled between 7/1/2010 and 9/1/2013 in a study of depression treatment for HIV-infected patients. Participants received monthly telephone calls to assess STLEs and pill count-based ARV adherence. Inverse probability of observation weighting was combined with multiple imputation to address missing data. Participants were mostly male (71%) and black (63%), with a median age of 45 years. Median monthly adherence was 96% (interquartile range (IQR): 85-100%). Participants experienced a mean of 2.48 STLEs (range: 0-14) in the previous month. The presence of ≥2 STLEs was associated with a mean change in adherence of -3.67% (95% confidence interval (CI): -7.12%, -0.21%) and decreased likelihood of achieving ≥95% adherence (risk ratio (95% CI) = 0.82 (0.71, 0.95)). For each additional STLE, the mean adherence change was -0.90% (95% CI: -1.79%, 0.00%). STLEs were associated with poorer ARV adherence, including decreased likelihood of adhering to ≥95% of ARV doses. This level of adherence has a critical role in regimen effectiveness and prevention of resistance.
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Affiliation(s)
- Julie K O'Donnell
- a Department of Epidemiology , Gillings School of Global Public Health, University of North Carolina , Chapel Hill , USA
| | - Bradley N Gaynes
- b Department of Psychiatry , University of North Carolina, School of Medicine , Chapel Hill , USA
| | - Stephen R Cole
- a Department of Epidemiology , Gillings School of Global Public Health, University of North Carolina , Chapel Hill , USA
| | - Andrew Edmonds
- a Department of Epidemiology , Gillings School of Global Public Health, University of North Carolina , Chapel Hill , USA
| | - Nathan M Thielman
- c Center for Health Policy , Duke Global Health Institute, Duke University , Durham , USA
| | - E Byrd Quinlivan
- d Institute for Global Health and Infectious Diseases , Center for AIDS Research, University of North Carolina , Chapel Hill , USA
| | - Amy Heine
- e Institute for Global Health and Infectious Diseases , University of North Carolina , Chapel Hill , USA
| | - Rhiddi Modi
- f Division of Infectious Diseases , University of Alabama, Birmingham School of Medicine , Birmingham , USA
| | - Brian W Pence
- a Department of Epidemiology , Gillings School of Global Public Health, University of North Carolina , Chapel Hill , USA
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Lewandowski LB, Watt MH, Schanberg LE, Thielman NM, Scott C. Missed opportunities for timely diagnosis of pediatric lupus in South Africa: a qualitative study. Pediatr Rheumatol Online J 2017; 15:14. [PMID: 28231857 PMCID: PMC5322669 DOI: 10.1186/s12969-017-0144-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 11/24/2016] [Accepted: 01/29/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Systemic Lupus Erythematosus (SLE) is a serious multisystem autoimmune disease, which is more aggressive in children and people of African descent. In South Africa, pediatric SLE (pSLE) patients are at high risk for severe disease. Similar to pSLE worldwide, South African children and adolescents with SLE require subspecialized medical care. The aim of this study is to describe the care-seeking experiences of families and examine factors that contribute to delays in the diagnosis of pSLE. Specifically, we sought to identify factors to inform interventions that support the timely referral and diagnosis of pediatric SLE patients in South Africa. METHODS In-depth, semi-structured interviews were conducted with 22 caregivers of pSLE patients recruited from two government hospitals in Cape Town, South Africa in 2014. Interviews were audio-recorded, transcribed, and analyzed for themes related to barriers to diagnosis. RESULTS Six themes were identified and classified as either caregiver or health system barriers to diagnosis. Caregiver barriers included lack of knowledge regarding SLE, financial difficulties, and the social stigma of SLE. Health system barriers were lack of trained staff, a complex medical system, and misdiagnosis. CONCLUSION Caregivers reported missed opportunities for diagnosing pSLE in their children. Raising public awareness may improve caregiver awareness and reduce stigma of pSLE. Improving family education at diagnosis holds potential to increase patient-physician trust and mitigate fear. Education modules for primary care providers at initial point of contact with the health care system may improve recognition of early pSLE and facilitate expedited referral to a specialist.
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Affiliation(s)
- Laura B. Lewandowski
- National Institute of Arthritis, Musculoskeletal, and Skin Diseases, NIH, DHHS, 9000 Rockville Pike, Building 10, 12 N248 Room 28, Bethesda, MD 20892-1102 USA ,0000 0004 1936 7961grid.26009.3dDuke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27710 USA ,0000000100241216grid.189509.cPediatric Rheumatology, Duke University Medical Center, 2301 Erwin Road, Durham, NC USA ,0000 0004 1937 1151grid.7836.aRed Cross War Memorial Children’s Hospital, University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, Western Cape South Africa
| | - Melissa H. Watt
- 0000 0004 1936 7961grid.26009.3dDuke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27710 USA
| | - Laura E. Schanberg
- 0000000100241216grid.189509.cPediatric Rheumatology, Duke University Medical Center, 2301 Erwin Road, Durham, NC USA
| | - Nathan M. Thielman
- 0000 0004 1936 7961grid.26009.3dDuke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27710 USA
| | - Christiaan Scott
- 0000 0004 1937 1151grid.7836.aRed Cross War Memorial Children’s Hospital, University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, Western Cape South Africa
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Gray CL, Pence BW, Messer LC, Ostermann J, Whetten RA, Thielman NM, O'Donnell K, Whetten K. Civic engagement among orphans and non-orphans in five low- and middle-income countries. Global Health 2016; 12:61. [PMID: 27729052 PMCID: PMC5057410 DOI: 10.1186/s12992-016-0202-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Communities and nations seeking to foster social responsibility in their youth are interested in understanding factors that predict and promote youth involvement in public activities. Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in resource-poor settings. Understanding whether and how OSC are engaged in civic activities is important for community and world leaders who need to provide care for OSC and ensure their involvement in sustainable development. METHODS The Positive Outcomes for Orphans study (POFO) is a multi-country, longitudinal cohort study of OSC randomly sampled from institution-based care and from family-based care, and of non-OSC sampled from the same study regions. Participants represent six sites in five low-and middle-income countries. We examined civic engagement activities and government trust among subjects > =16 years old at 90-month follow-up (approximately 7.5 years after baseline). We calculated prevalences and estimated the association between key demographic variables and prevalence of regular volunteer work using multivariable Poisson regression, with sampling weights to accounting for the complex sampling design. RESULTS Among the 1,281 POFO participants > =16 who were assessed at 90-month follow-up, 45 % participated in regular community service or volunteer work; two-thirds of those volunteers did so on a strictly voluntary basis. While government trust was fairly high, at approximately 70 % for each level of government, participation in voting was only 15 % among those who were > =18 years old. We did not observe significant associations between demographic characteristics and regular volunteer work, with the exception of large variation by study site. CONCLUSION As the world's leaders grapple with the many competing demands of global health, economic security, and governmental stability, the participation of today's youth in community and governance is essential for sustainability. This study provides a first step in understanding the degree to which OSC from different care settings across multiple low- and middle-income countries are engaged in their communities.
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Affiliation(s)
- Christine L Gray
- Department of Epidemiology, Gillings School of Global Public Health, CB #7435, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-7435, USA.
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, CB #7435, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-7435, USA.,Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA
| | - Lynne C Messer
- Department of Epidemiology, Gillings School of Global Public Health, CB #7435, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-7435, USA.,Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA.,School of Community Health, College of Urban and Public Affairs, Portland State University, PO Box 751, Portland, OR, 97207, USA
| | - Jan Ostermann
- Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA
| | - Rachel A Whetten
- Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA
| | - Nathan M Thielman
- Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA.,Department of Medicine, DUMC #3152, Division of Infectious Diseases and International Health, Duke University, Durham, NC, 27710, USA
| | - Karen O'Donnell
- Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA.,Center for Child and Family Health, Duke University, 411 West Chapel Hill Street, Suite 908, Durham, NC, USA
| | - Kathryn Whetten
- Center for Health Policy, Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, USA.,Terry Sanford Institute of Public Policy, Box 90239, Duke University, Box 90239, Durham, NC, 27708-0239, USA
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Landman KZ, Thielman NM, Mgonja A, Shao HJ, Itemba DK, Ndosi EM, Tribble AC, Shao JF, Bartlett JA, Crump JA. Antiretroviral Treatment Literacy Among HIV Voluntary Counseling and Testing Clients in Moshi, Tanzania, 2003 to 2005. ACTA ACUST UNITED AC 2016; 6:24-6. [PMID: 17329501 DOI: 10.1177/1545109706298479] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antiretroviral treatment literacy leads to greater HIV testing and treatment and antiretroviral treatment adherence. Among northern Tanzanian subjects, antiretroviral treatment awareness was only 17%. Factors associated with low antiretroviral treatment literacy included having exchanged money or gifts for sex, living in rural areas, having more than 2 children, and having a primary education only. Previous HIV testing was protective against low antiretroviral treatment literacy. These results support refocusing HIV education efforts and increasing synergy between HIV prevention and treatment programs.
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Affiliation(s)
- Keren Z Landman
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina 27710, USA
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Brown JF, Rowe K, Zacharias P, van Hasselt J, Dye JM, Wohl DA, Fischer WA, Cunningham CK, Thielman NM, Hoover DL. Apheresis for collection of Ebola convalescent plasma in Liberia. J Clin Apher 2016; 32:175-181. [PMID: 27393614 DOI: 10.1002/jca.21482] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 03/30/2016] [Revised: 05/23/2016] [Accepted: 06/05/2016] [Indexed: 11/06/2022]
Abstract
PURPOSE This report describes initiation of apheresis capability in Liberia, Africa to support a clinical trial of convalescent plasma therapy for Ebola Virus Disease. METHODS A bloodmobile was outfitted in the United States as a four-bed apheresis unit with capabilities including pathogen reduction, electronic blood establishment computer system, designated areas for donor counseling and laboratory testing, and onboard electrical power generation. After air transport to Liberia, the bloodmobile was positioned at ELWA Hospital, Monrovia, and connected to the hospital's power grid. Liberian staff were trained to conduct donor screening, which included questionnaire and onsite blood typing and transfusion transmitted infection (TTI) testing, and plasma collection and processing. RESULTS The bloodmobile was operational within 3 weeks after arrival of the advance team. Of 101 donors who passed the pre-screening questionnaire, 32 were deferred. Twenty-eight of ninty-nine tested survivors were deferred for positive transfusion transmitted infection (TTI) tests; twenty-one were positive for hepatitis B, hepatitis C, or human immunodeficiency virus. The majority of donors had type O blood; all but one were Rh positive. Forty-three survivors donated at least once; eighty-nine apheresis attempts resulted in eighty-one successful collections. CONCLUSIONS Apheresis capability was emergently established in Liberia to support an efficacy trial of Ebola Convalescent Plasma. Extensive cooperation among multinational team members, engineers, logisticians, and blood safety technical personnel at the operational site was required to surmount challenges to execution posed by logistical factors. The high proportion of positive TTI tests supported the use of a pathogen reduction system to enhance product safety. J. Clin. Apheresis 32:175-181, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jerry F Brown
- Eternal Love Winning Africa Hospital, Paynesville, Liberia
| | | | | | | | - John M Dye
- Division of Virology, United States Army Medical Research Institute of Infectious Disease, Frederick, MD
| | - David A Wohl
- University of North Carolina School of Medicine, Chapel Hill, NC
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Affiliation(s)
- Scott M Berry
- Berry Consultants, LLC, Austin, TX, USA University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Peter Dull
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | | | - Coleen K Cunningham
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Gray CL, Whetten K, Messer LC, Whetten RA, Ostermann J, O'Donnell K, Thielman NM, Pence BW. Potentially traumatic experiences and sexual health among orphaned and separated adolescents in five low- and middle-income countries. AIDS Care 2016; 28:857-65. [PMID: 26936018 PMCID: PMC4917905 DOI: 10.1080/09540121.2016.1147013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in sub-Saharan Africa and Asia. Over 153 million children worldwide have lost one or both parents, including 17 million orphaned by AIDS, and millions more have been separated from their parents. As younger orphans enter adolescence, their sexual health and HIV-related risk behaviors become key considerations for their overall health. Importantly, their high prevalence of exposure to potentially traumatic events (PTEs) may put OSC at additional risk for adverse sexual health outcomes. The Positive Outcomes for Orphans study followed OSC randomly sampled from institution-based care and from family-based care, as well as a convenience sample of non-OSC, at six sites in five low-and middle-income countries. This analysis focused on the 90-month follow-up, during which adolescents 16 and older were assessed for sexual health, including age at sexual debut, past-year sex, past-year condom use, and perceptions of condom use. We specifically examined the relationship between PTEs and sexual health outcomes. Of the 1258 OSC and 138 non-OSC assessed, 11% reported ever having sex. Approximately 6% of participants reported recent sex and 5% reported having recent unprotected sex. However, 70% of those who had recent sex reported that they did not use a condom every time, and perceptions of condom use tended to be unfavorable for protection against sexual risk behavior. Nearly all (90%) of participants reported experiencing at least one lifetime PTE. For those who experienced “any” PTE, we found increased prevalence of recent sex (PR = 1.39 [0.47, 4.07]) and of recent unprotected sex (PR = 3.47 [0.60, 19.91]). This study highlights the need for caregivers, program managers, and policymakers to promote condom use for sexually active OSC and identify interventions for trauma support services. Orphans living in family-based care may also be particularly vulnerable to early sexual debut and unprotected sexual activity.
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Affiliation(s)
- Christine L Gray
- a Department of Epidemiology, Gillings School of Global Public Health , University of North Carolina , Chapel Hill , NC , USA
| | - Kathryn Whetten
- b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA.,c Terry Sanford Institute of Public Policy, Duke University , Durham , NC , USA
| | - Lynne C Messer
- a Department of Epidemiology, Gillings School of Global Public Health , University of North Carolina , Chapel Hill , NC , USA.,b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA.,d College of Urban and Public Affairs , Portland State University , Portland , OR , USA
| | - Rachel A Whetten
- b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA
| | - Jan Ostermann
- b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA
| | - Karen O'Donnell
- b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA.,e Center for Child and Family Health , Duke University , Durham , NC , USA
| | - Nathan M Thielman
- b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA.,f Department of Medicine, Division of Infectious Diseases and International Health , Duke University , Durham , NC , USA
| | - Brian W Pence
- a Department of Epidemiology, Gillings School of Global Public Health , University of North Carolina , Chapel Hill , NC , USA.,b Center for Health Policy , Duke Global Health Institute, Duke University , Durham , NC , USA
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Ramadhani HO, Bartlett JA, Thielman NM, Pence BW, Kimani SM, Maro VP, Mwako MS, Masaki LJ, Mmbando CE, Minja MG, Lirhunde ES, Miller WC. The Effect of Switching to Second-Line Antiretroviral Therapy on the Risk of Opportunistic Infections Among Patients Infected With Human Immunodeficiency Virus in Northern Tanzania. Open Forum Infect Dis 2016; 3:ofw018. [PMID: 26949717 PMCID: PMC4776054 DOI: 10.1093/ofid/ofw018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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] [Received: 11/13/2015] [Accepted: 01/07/2016] [Indexed: 11/13/2022] Open
Abstract
Background. Due to the unintended potential misclassifications of the World Health Organization (WHO) immunological failure criteria in predicting virological failure, limited availability of treatment options, poor laboratory infrastructure, and healthcare providers' confidence in making switches, physicians delay switching patients to second-line antiretroviral therapy (ART). Evaluating whether timely switching and delayed switching are associated with the risk of opportunistic infections (OI) among patients with unrecognized treatment failure is critical to improve patient outcomes. Methods. A retrospective review of 637 adolescents and adults meeting WHO immunological failure criteria was conducted. Timely and delayed switching to second-line ART were defined when switching happened at <3 and ≥3 months, respectively, after failure diagnosis was made. Cox proportional hazard marginal structural models were used to assess the effect of switching to second-line ART on the risk of developing OI. Results. Of 637 patients meeting WHO immunological failure criteria, 396 (62.2%) switched to second-line ART. Of those switched, 230 (58.1%) were delayed. Switching to second-line ART reduced the risk of OI (adjusted hazards ratio [AHR], 0.4; 95% CI, .2-.6). Compared with patients who received timely switch after failure diagnosis was made, those who delayed switching were more likely to develop OI (AHR, 2.2; 95% CI, 1.1-4.3). Conclusion. Delayed switching to second-line ART after failure diagnosis may increase the risk of OI. Serial immunological assessment for switching patients to second-line ART is critical to improve their outcomes.
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Affiliation(s)
- Habib O Ramadhani
- Kilimanjaro Christian Medical Centre, Moshi; Tanzania; Department of Epidemiology, University of North Carolina, Chapel Hill
| | - John A Bartlett
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina
| | - Nathan M Thielman
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina
| | - Brian W Pence
- Department of Epidemiology , University of North Carolina , Chapel Hill
| | | | | | | | | | | | - Mary G Minja
- Kibosho Designated District Hospital , Moshi , Tanzania
| | | | - William C Miller
- Department of Epidemiology , University of North Carolina , Chapel Hill
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O'Donnell JK, Gaynes BN, Cole SR, Edmonds A, Thielman NM, Quinlivan EB, Shirey K, Heine AD, Modi R, Pence BW. Ongoing life stressors and suicidal ideation among HIV-infected adults with depression. J Affect Disord 2016; 190:322-328. [PMID: 26544615 PMCID: PMC4685465 DOI: 10.1016/j.jad.2015.09.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 06/09/2015] [Revised: 09/17/2015] [Accepted: 09/25/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Suicidal ideation is the most proximal risk factor for suicide and can indicate extreme psychological distress; identification of its predictors is important for possible intervention. Depression and stressful or traumatic life events (STLEs), which are more common among HIV-infected individuals than the general population, may serve as triggers for suicidal thoughts. METHODS A randomized controlled trial testing the effect of evidence-based decision support for depression treatment on antiretroviral adherence (the SLAM DUNC study) included monthly assessments of incident STLEs, and quarterly assessments of suicidal ideation (SI). We examined the association between STLEs and SI during up to one year of follow-up among 289 Southeastern US-based participants active in the study between 7/1/2011 and 4/1/2014, accounting for time-varying confounding by depressive severity with the use of marginal structural models. RESULTS Participants were mostly male (70%) and black (62%), with a median age of 45 years, and experienced a mean of 2.36 total STLEs (range: 0-12) and 0.48 severe STLEs (range: 0-3) per month. Every additional STLE was associated with an increase in SI prevalence of 7% (prevalence ratio (PR) (95% confidence interval (CI)): 1.07 (1.00, 1.14)), and every additional severe STLE with an increase in SI prevalence of 19% (RR (95% CI): 1.19 (1.00, 1.42)). LIMITATIONS There was a substantial amount of missing data and the exposures and outcomes were obtained via self-report; methods were tailored to address these potential limitations. CONCLUSIONS STLEs were associated with increased SI prevalence, which is an important risk factor for suicide attempts and completions.
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Affiliation(s)
- Julie K O'Donnell
- University of North Carolina at Chapel Hill, Department of Epidemiology, United States.
| | - Bradley N Gaynes
- University of North Carolina at Chapel Hill School of Medicine, Department of Psychiatry, United States
| | - Stephen R Cole
- University of North Carolina at Chapel Hill, Department of Epidemiology, United States
| | - Andrew Edmonds
- University of North Carolina at Chapel Hill, Department of Epidemiology, United States
| | - Nathan M Thielman
- Duke University, Center for Health Policy, Duke Global Health Institute, United States
| | - E Byrd Quinlivan
- University of North Carolina at Chapel Hill, Institute for Global Health, Infectious Diseases and Center for AIDS Research, United States
| | - Kristen Shirey
- Duke University School of Medicine, Department of Psychiatry, United States
| | - Amy D Heine
- University of North Carolina at Chapel Hill, Institute for Global Health and Infectious Diseases, United States
| | - Riddhi Modi
- University of Alabama at Birmingham, Division of Infectious Diseases, United States
| | - Brian W Pence
- University of North Carolina at Chapel Hill, Department of Epidemiology, United States
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Affiliation(s)
| | | | | | | | | | - James Russell
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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50
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Berry SM, Petzold EA, Dull P, Thielman NM, Cunningham CK, Corey GR, McClain MT, Hoover DL, Russell J, Griffiss JM, Woods CW. A response adaptive randomization platform trial for efficient evaluation of Ebola virus treatments: A model for pandemic response. Clin Trials 2016; 13:22-30. [PMID: 26768569 DOI: 10.1177/1740774515621721] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [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: 11/15/2022]
Abstract
The outbreak of Ebola virus disease in West Africa is the largest ever recorded. Numerous treatment alternatives for Ebola have been considered, including widely available repurposed drugs, but initiation of enrollment into clinical trials has been limited. The proposed trial is an adaptive platform design. Multiple agents and combinations will be investigated simultaneously. Additionally, new agents may enter the trial as they become available, and failing agents may be removed. In order to accommodate the many possible agents and combinations, a critical feature of this design is the use of response adaptive randomization to assign treatment regimens. As the trial progresses, the randomization ratio evolves to favor the arms that are performing better, making the design also suitable for all-cause pandemic preparedness planning. The study was approved by US and Sierra Leone ethics committees, and reviewed by the US Food and Drug Administration. Additionally, data management, drug supply lines, and local sites were prepared. However, in response to the declining epidemic seen in February 2015, the trial was not initiated. Sierra Leone remains ready to rapidly activate the protocol as an emergency response trial in the event of a resurgence of Ebola. (ClinicalTrials.gov Identifier: NCT02380625.) In summary, we have designed a single controlled trial capable of efficiently identifying highly effective or failing regimens among a rapidly evolving list of proposed therapeutic alternatives for Ebola virus disease and to treat the patients within the trial effectively based on accruing data. Provision of these regimens, if found safe and effective, would have a major impact on future epidemics by providing effective treatment options.
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Affiliation(s)
- Scott M Berry
- Berry Consultants LLC, Austin, TX, USA University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Peter Dull
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | | | | | - G Ralph Corey
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | | | | | | | - Christopher W Woods
- Duke Clinical Research Institute, Durham, NC, USA Duke Global Health Institute, Duke University, Durham, NC, USA Duke University School of Medicine, Durham, NC, USA
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