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BACKGROUND: Nodding syndrome is a poorly understood neurological disorder that predominantly occurs in Africa. We hypothesised that nodding syndrome is a neuroinflammatory disorder, induced by antibodies to Onchocerca volvulus or its Wolbachia symbiont, cross-reacting with host neuronal proteins (HNPs), and that doxycycline can be used as treatment. METHODS: In this randomised, double-blind, placebo-controlled, phase 2 trial, we recruited participants from districts affected by nodding syndrome in northern Uganda. We included children and adolescents aged 8-18 years with nodding syndrome, as defined by WHO consensus criteria. Participants were randomly assigned (1:1) to receive either 100 mg doxycycline daily or placebo for 6 weeks via a computer-generated schedule stratified by skin microscopy results, and all parties were masked to group assignment. Diagnoses of O volvulus and antibodies to HNPs were made using luciferase immunoprecipitation system assays and immunohistochemistry. The primary outcome was change in the proportion with antibodies to HNPs, assessed at 24 months. All participants were included in safety analyses, and surviving participants (those with samples at 24 months) were included in primary analyses. Secondary outcomes were: change in concentrations of antibodies to HNPs at 24 months compared with baseline; proportion of participants testing positive for antibodies to O volvulus-specific proteins and concentrations of Ov16 or OVOC3261 antibodies at 24 months compared with baseline; change in seizure burden, proportion achieving seizure freedom, and the proportions with interictal epileptiform discharges on the diagnostic EEG; overall quality of life; disease severity at 24 months; and incidence of all-cause adverse events, serious adverse events, and seizure-related mortality by 24 months. This trial is registered with ClinicalTrials.gov, NCT02850913. FINDINGS: Between Sept 1, 2016, and Aug 31, 2018, 329 children and adolescents were screened, of whom 240 were included in the study. 140 (58%) participants were boys and 100 (42%) were girls. 120 (50%) participants were allocated to receive doxycycline and 120 (50%) to receive placebo. At recruitment, the median duration of symptoms was 9 years (IQR 6-10); 232 (97%) participants had O volvulus-specific antibodies and 157 (65%) had autoantibodies to HNPs. The most common plasma autoantibodies were to human protein deglycase DJ-1 (85 [35%] participants) and leiomodin-1 (77 [32%] participants) and, in cerebrospinal fluid (CSF), to human DJ-1 (27 [11%] participants) and leiomodin-1 (14 [6%] participants). On immunohistochemistry, 46 (19%) participants had CSF autoantibodies to HNPs, including leiomodin-1 (26 [11%]), γ-aminobutyric acid B receptors (two [<1%]), CASPR2 (one [<1%]), or unknown targets (28 [12%]). At 24 months, 161 (72%) of 225 participants had antibodies to HNPs compared with 157 (65%) of 240 at baseline. 6 weeks of doxycycline did not affect the concentration of autoantibodies to HNPs, seizure control, disease severity, or quality of life at the 24-month follow-up but substantially decreased Ov16 antibody concentrations; the median plasma signal-to-noise Ov16 ratio was 16·4 (95% CI 6·4-38·4), compared with 27·9 (8·2-65·8; p=0·033) for placebo. 14 (6%) participants died and, other than one traffic death, all deaths were seizure-related. Acute seizure-related hospitalisations (rate ratio [RR] 0·43 [95% CI 0·20-0·94], p=0·028) and deaths (RR 0·46 [0·24-0·89], p=0·028) were significantly lower in the doxycycline group. At 24 months, 96 (84%) of 114 participants who received doxycycline tested positive for antibodies to Ov16, compared with 97 (87%) of 111 on placebo (p=0·50), and 74 (65%) participants on doxycycline tested positive for antibodies to OVOC3261, compared with 57 (51%) on placebo (p=0·039). Doxycycline was safe; there was no difference in the incidence of grade 3-5 adverse events across the two groups. INTERPRETATION: Nodding syndrome is strongly associated with O volvulus and the pathogenesis is probably mediated through an O volvulus induced autoantibody response to multiple proteins. Although it did not reverse disease symptoms, doxycycline or another prophylactic antibiotic could be considered as adjunct therapy to antiseizure medication, as it might reduce fatal complications from acute seizures and status epilepticus induced by febrile infections. FUNDING: Medical Research Council (UK). TRANSLATION: For the Luo translation of the abstract see Supplementary Materials section.
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Doxiciclina , Síndrome del Cabeceo , Humanos , Niño , Adolescente , Femenino , Masculino , Doxiciclina/uso terapéutico , Síndrome del Cabeceo/tratamiento farmacológico , Método Doble Ciego , Uganda , Resultado del Tratamiento , Antibacterianos/uso terapéutico , Onchocerca volvulus/efectos de los fármacosRESUMEN
OBJECTIVES: To determine the association between body mass index (BMI) and chronic hypertension (CHTN) one-year postpartum following pregnancies complicated by hypertensive disorders of pregnancy (HDP). STUDY DESIGN: A retrospective cohort study of patients with HDP (gestational hypertension or preeclampsia) in a single Midwestern academic center from 2014 to 2018. The primary outcome was CHTN at one-year postpartum, defined as systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg or taking antihypertensive medication at one-year postpartum. The primary exposure variable was BMI at one-year postpartum, categorized as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25-<30 kg/m2), and obese (≥30 kg/m2) and as continuous BMI variable. Descriptive statistics and adjusted logistic regression analysis were performed. RESULTS: Out of 596 patients with HDP included in this analysis, 275 (46.1 %) had CHTN one-year postpartum. Mean one-year postpartum BMI was 27.9 ± 5.2 kg/m2. Prevalence of CHTN at one-year postpartum was higher in obese (38.1 %) and overweight (30.0 %) groups compared to the normal weight group (29.9 %), p < 0.001. In multivariate logistic regression, obesity at one-year postpartum, compared to normal, was associated with 73 % higher likelihood of CHTN following HDP (adjusted OR 1.73, 95 % CI 1.06-2.84). With BMI as a continuous variable, each unit increase in BMI one-year postpartum was associated with 6 % higher likelihood of CHTN (adjusted OR 1.06, 95 % CI 1.02-1.15). CONCLUSIONS: Obesity at one-year postpartum following HDP was associated with a higher risk of CHTN compared with normal BMI. Weight is a modifiable risk factor that should be targeted in postpartum interventions to reduce cardiovascular disease following HDP.
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Hipertensión Inducida en el Embarazo , Preeclampsia , Embarazo , Femenino , Humanos , Sobrepeso , Índice de Masa Corporal , Estudios Retrospectivos , Obesidad/complicaciones , Obesidad/epidemiología , Periodo Posparto , Factores de RiesgoRESUMEN
BACKGROUND: Poor physical access to health facilities could increase the likelihood of undetected intimate partner violence (IPV) during pregnancy. We aimed to determine sub-regional differences and associations between spatial accessibility to health facilities and IPV among pregnant women in Uganda. METHOD: Weighted cross-sectional analyses were conducted using merged 2016 Uganda Demographic and Health Survey and 2014 Uganda Bureau of Statistics health facility datasets. Our study population were 986 women who self-reported being currently pregnant and responded to IPV items. Outcome was spatial accessibility computed as the near point linear distance [< 5 km (optimal) vs. ≥ 5 km (low)] between women's enumeration area and health facility according to government reference cutoffs. Primary independent variable (any IPV) was defined as exposure to at least one of physical, emotional, and sexual IPV forms. Logistic regression models were sequentially adjusted for covariates in blocks based on Andersen's behavioral model of healthcare utilization. Covariates included predisposing (maternal age, parity, residence, partner controlling behavior), enabling (wealth index, occupation, education, economic empowerment, ANC visit frequency), and need (wanted current pregnancy, difficulty getting treatment money, afraid of partner, and accepted partner abuse) factors. RESULTS: Respondents' mean age was 26.1 years with ± 9.4 standard deviations (SD), mean number of ANC visits was 3.8 (± 1.5 SD) and 492/986 (49.9%) pregnant women experienced IPV. Median spatial accessibility to the nearest health facility was 4.1 km with interquartile range (IQR) from 0.2 to 329.1 km. Southwestern, and Teso subregions had the highest average percentage of pregnant women experiencing IPV (63.8-66.6%) while Karamoja subregion had the highest median spatial accessibility (7.0 to 9.3 km). In the adjusted analysis, pregnant women exposed to IPV had significantly higher odds of low spatial accessibility to nearest health facilities when compared to pregnant women without IPV exposure after controlling for enabling factors in Model 2 (aOR 1.6; 95%CI 1.2, 2.3) and need factors in Model 3 (aOR 1.5; 95%CI 1.1, 3.8). CONCLUSIONS: Spatial accessibility to health facilities were significantly lower among pregnant women with IPV exposure when compared to those no IPV exposure. Improving proximity to the nearest health facilities with ANC presents an opportunity to intervene among pregnant women experiencing IPV. Focused response and prevention interventions for violence against pregnant women should target enabling and need factors.
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Violencia de Pareja , Mujeres Embarazadas , Embarazo , Femenino , Humanos , Adulto , Mujeres Embarazadas/psicología , Estudios Transversales , Uganda , Violencia de Pareja/psicología , Instituciones de Salud , Factores de Riesgo , Parejas Sexuales/psicología , PrevalenciaRESUMEN
BACKGROUND: Intimate partner violence (IPV) remains a pervasive form of gender-based violence (GBV) that is largely undisclosed, especially among women seeking healthcare services in Uganda. Prioritizing survivor needs may improve IPV disclosure. This study explores healthcare worker experiences from provider-patient interactions with survivors seeking antenatal care services (ANC) in Uganda. METHODS: In-depth interviews were conducted among twenty-eight experienced healthcare providers in a rural and an urban-based ANC clinic in Eastern and Central Uganda. Providers were asked what they viewed as the needs and fears of women identified as having experienced any form of IPV. Iterative, inductive/deductive thematic analysis was conducted to discover themes regarding perceived needs, fears, and normalizing violence experienced by IPV survivors. RESULTS: According to healthcare providers, IPV survivors are unaware of available support services, and have need for support services. Providers reported that some survivors were afraid of the consequences of IPV disclosure namely, community stigma, worries about personal and their children's safety, retaliatory abuse, fear of losing their marriage, and partners' financial support. Women survivors also blamed themselves for IPV. Contextual factors underlying survivor concerns included the socio-economic environment that 'normalizes' violence, namely, some cultural norms condoning violence, and survivors' unawareness of their human rights due to self-blame and shame for abuse. CONCLUSIONS: We underscore a need to empower IPV survivors by prioritizing their needs. Results highlight opportunities to create a responsive healthcare environment that fosters IPV disclosure while addressing survivors' immediate medical and psychosocial needs, and safety concerns. Our findings will inform GBV prevention and response strategies that integrate survivor-centered approaches in Uganda.
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Violencia de Pareja , Sobrevivientes , Niño , Femenino , Humanos , Embarazo , Instituciones de Atención Ambulatoria , Violencia de Pareja/psicología , Atención Prenatal , Sobrevivientes/psicología , Violencia , Personal de Salud , Investigación CualitativaRESUMEN
BACKGROUND: Optimal utilization of antenatal care (ANC) services improves positive pregnancy experiences and birth outcomes. However, paucity of evidence exists on which factors should be targeted to increase ANC utilization among women experiencing intimate partner violence (IPV) in Uganda. OBJECTIVE: To determine the independent association between IPV exposure and ANC utilization as well as the predictors of ANC utilization informed by Andersen's Behavioral Model of Healthcare Utilization. METHODS: We analyzed 2016 Uganda Demographic and Health Survey data that included a sample of 1,768 women with children aged 12 to 18 months and responded to both ANC utilization and IPV items. Our outcome was ANC utilization, a count variable assessed as the number of ANC visits in the last 12 months preceding the survey. The key independent variable was exposure to any IPV form defined as self-report of having experienced physical, sexual and/or emotional IPV. Covariates were grouped into predisposing (age, formal education, religion, problem paying treatment costs), enabling (women's autonomy, mass media exposure), need (unintended pregnancy, parity, history of pregnancy termination), and healthcare system/environmental factors (rural/urban residence, spatial accessibility to health facility). Poisson regression models tested the independent association between IPV and ANC utilization, and the predictors of ANC utilization after controlling for potential confounders. RESULTS: Mean number of ANC visits (ANC utilization) was 3.71 visits with standard deviation (SD) of ± 1.5 respectively. Overall, 60.8% of our sample reported experiencing any form of IPV. Any IPV exposure was associated with lower number of ANC visits (3.64, SD ± 1.41) when compared to women without IPV exposure (3.82, SD ± 1.64) at p = 0.013. In the adjusted models, any IPV exposure was negatively associated with ANC utilization when compared to women with no IPV exposure after controlling for enabling factors (Coef. -0.03; 95%CI -0.06,-0.01), and healthcare system/environmental factors (Coef. -0.06; 95%CI -0.11,-0.04). Predictors of ANC utilization were higher education (Coef. 0.27; 95%CI 0.15,0.39) compared with no education, high autonomy (Coef. 0.12; 95%CI 0.02,0.23) compared to low autonomy, and partial media exposure (Coef. 0.06; 95%CI 0.01,0.12) compared to low media exposure. CONCLUSION: Addressing enabling and healthcare system/environmental factors may increase ANC utilization among Ugandan women experiencing IPV. Prevention and response interventions for IPV should include strategies to increase girls' higher education completion rates, improve women's financial autonomy, and mass media exposure to improve ANC utilization in similar populations in Uganda.
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Violencia de Pareja , Atención Prenatal , Niño , Femenino , Embarazo , Humanos , Uganda , Aceptación de la Atención de Salud , Encuestas y Cuestionarios , Embarazo no PlaneadoRESUMEN
BACKGROUND: No-show appointments pose a significant challenge for healthcare providers, particularly in rural areas. In this study, we developed an evidence-based predictive model for patient no-shows at the Marshfield Clinic Health System (MCHS) rural provider network in Wisconsin, with the aim of improving overbooking approaches in outpatient settings and reducing the negative impact of no-shows in our underserved rural patient populations. METHODS: Retrospective data (2021) were obtained from the MCHS scheduling system, which included 1,260,083 total appointments from 263,464 patients, as well as their demographic, appointment, and insurance information. We used descriptive statistics to associate variables with show or no-show status, logistic regression, and random forests utilized, and eXtreme Gradient Boosting (XGBoost) was chosen to develop the final model, determine cut-offs, and evaluate performance. We also used the model to predict future no-shows for appointments from 2022 and onwards. RESULTS: The no-show rate was 6.0% in both the train and test datasets. The train and test datasets both yielded 5.98. Appointments scheduled further in advance (> 60 days of lead time) had a higher (7.7%) no-show rate. Appointments for patients aged 21-30 had the highest no-show rate (11.8%), and those for patients over 60 years of age had the lowest (2.9%). The model predictions yielded an Area Under Curve (AUC) of 0.84 for the train set and 0.83 for the test set. With the cut-off set to 0.4, the sensitivity was 0.71 and the positive predictive value was 0.18. Model results were used to recommend 1 overbook for every 6 at-risk appointments per provider per day. CONCLUSIONS: Our findings demonstrate the feasibility of developing a predictive model based on administrative data from a predominantly rural healthcare system. Our new model distinguished between show and no-show appointments with high performance, and 1 overbook was advised for every 6 at-risk appointments. This data-driven approach to mitigating the impact of no-shows increases treatment availability in rural areas by overbooking appointment slots on days with an elevated risk of no-shows.
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Instituciones de Atención Ambulatoria , Pacientes Ambulatorios , Humanos , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Personal de Salud , Atención a la SaludRESUMEN
OBJECTIVE: To determine the association between lifetime exposure to discrimination and unplanned healthcare utilization in pregnant persons. METHODS: This was a prospective cohort study of pregnant persons receiving care from 2021 to 2022. Primary data was collected from participants on sociodemographic factors and on Perceived Ethnic Discrimination Questionnaire (PED-Q), a validated 17-item scale measuring perceived lifetime interpersonal racial and ethnic discrimination in four domains: work/school, social exclusion, stigmatization, and threat. The primary outcome was unplanned healthcare utilization, defined as unplanned labor and delivery admissions, triage, Emergency Department, or urgent care visits. Bivariate and multivariate analyses were done to examine the association between lifetime exposure to discrimination and unplanned healthcare utilization. RESULTS: A total of 289 completed the PED-Q and were included in the analysis. Of these, 123 (42.6%) had unplanned healthcare utilization. Mean (SD) of lifetime racial and ethnic discrimination was significantly higher in people with unplanned healthcare utilization compared to those with planned healthcare utilization [1.67 (0.63) vs 1.48 (0.45), p = 0.003]. Univariate analysis showed that lifetime racial and ethnic discrimination was significantly associated with unplanned healthcare utilization (OR 1.96, 95% CI 0.23-3.11). Significant associations were found between unplanned healthcare utilization and maternal age (p = 0.04), insurance type (p = 0.01), married status (p < 0.001), education (p = 0.013), household income (p = 0.001), and chronic hypertension (p = 0.004). After controlling for potential confounding factors, self-reported lifetime racial and ethnic discrimination remained significantly associated with higher odds of unplanned healthcare utilization (aOR 1.78, CI 95% 1.01-3.11). CONCLUSION: We found that a higher level of self-reported lifetime racial and ethnic discrimination was associated with increased unplanned healthcare utilization during pregnancy.
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BACKGROUND: Firearm fatalities are a major public health concern, claiming the lives of 40,000 Americans each year. While firearm fatalities have pervasive effects, it is unclear how social determinants of health (SDOH) such as residential racial segregation, income inequality, and community resilience impact firearm fatalities. This study investigates the relationships between these SDOH and the likelihood of firearm fatalities. METHODS: County-level SDOH data from the Agency for Health Care Research and Quality for 2019 were analyzed, covering 72 Wisconsin counties. The dependent variable was the number of firearm fatalities in each county, used as a continuous variable. The independent variable was residential racial segregation (Dissimilarity Index), defined as the degree to which non-White and White residents were distributed across counties, ranging from 0 (complete integration) to 100 (complete segregation), and higher values indicate greater residential segregation (categorized as low, moderate, and high). Covariates were income inequality ranging from zero (perfect equality) to one (perfect inequality) categorized as low, moderate, and high, community resilience risk factors (low, moderate, and high risks), and rural-urban classifications. Descriptive/summary statistics, unadjusted and adjusted negative binomial regression adjusting for population weight, were performed using STATA/MPv.17.0; P-values ≤ 0.05 were considered statistically significant. ArcMap was used for Geographic Information System analysis. RESULTS: In 2019, there were 802 firearm fatalities. The adjusted model demonstrates that the risk of firearm fatalities was higher in areas with high residential racial segregation compared to low-segregated areas (IRR.:1.26, 95% CI:1.04-1.52) and higher in areas with high-income inequality compared to areas with low-income inequality (IRR.:1.18, 95% CI:1.00-1.40). Compared to areas with low-risk community resilience, the risk of firearm fatalities was higher in areas with moderate (IRR.:0.61, 95% CI:0.48-0.78), and in areas with high risk (IRR.:0.53, 95% CI:0.41-0.68). GIS analysis demonstrated that areas with high racial segregation also have high rates of firearm fatalities. CONCLUSION: Areas with high residential racial segregation have a high rate of firearm fatalities. With high income inequality and low community resilience, the likelihood of firearm fatalities increases.
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BACKGROUND AND OBJECTIVE: Nodding syndrome (NS) is a unique childhood-onset epileptic disorder that occurs predominantly in several regions of sub-Saharan Africa. The disease has been associated with Onchocerca volvulus (Ov)-induced immune responses and possible cross-reactivity with host proteins. The aim of this study was to compare structural changes in the brain on MRI between NS and other forms of onchocerciasis-associated epilepsies (OAEs) and to relate structural changes to the Ov-induced immune responses and level of disability. METHODS: Thirty-nine children with NS and 14 age-matched participants with other forms of OAE from an endemic region in Uganda underwent detailed clinical examination, serologic evaluation (including Ov-associated antibodies to Ov-16 and Hu-leiomodin-1) and quantitative volumetric analysis of brain MRIs (1.5 T scanner) using Neuroreader, a cloud-based software. RESULTS: Cerebral and cerebellar atrophy were the predominant features in both NS and OAE. On quantitative volumetric analysis, participants with NS had larger ventricular volumes compared with participants with OAE, indicative of increased global cortical atrophy (pcorr = 0.036). Among children with NS, severe disability correlated with higher degree of atrophy in the gray matter volume (pcorr = 0.009) and cerebellar volume (pcorr = 0.009). NS cases had lower anti-Ov-16 IgG signal-to-noise ratios than the OAE cases (p < 0.01), but no difference in the levels of the Hu-leiomodin-1 antibodies (p = 0.64). The levels of Ov-associated antibodies did not relate to the degree of cerebral or cerebellar atrophy in either NS or OAE cases. DISCUSSION: This is the first study to show that cerebral and cerebellar atrophy correlated with the severity of NS disability, providing an imaging marker for these endemic epileptic disorders that until now have remained poorly characterized. Both NS and OAE have cerebral and cerebellar atrophy, and the levels of Ov-associated antibodies do not seem to be related to the structural changes on MRI.
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Epilepsia , Síndrome del Cabeceo , Onchocerca volvulus , Oncocercosis , Niño , Animales , Humanos , Síndrome del Cabeceo/complicaciones , Síndrome del Cabeceo/epidemiología , Oncocercosis/complicaciones , Oncocercosis/epidemiología , Anticuerpos AntinuclearesRESUMEN
OBJECTIVE: To compare contraception use between women with and without pregestational diabetes. METHODS: Cross-sectional data on women aged 18-44 years from 2011 to 2017 National Survey of Family Growth (NSFG) was analysed. Maternal diabetes was defined as the presence of pre-gestational type 1 or type 2 diabetes. Bivariate and multiple logistic regression analyses were run to evaluate the association between the use of contraception and by contraception type: permanent, long-acting reversible contraception (LARC), other hormonal method, other non-hormonal method, and none, and maternal diabetes status, controlling for relevant covariates. RESULTS: Among the total study sample of 28,454, 1344 (4.7%) had pregestational diabetes. Unadjusted analysis showed women with a history of pregestational diabetes were more likely to use permanent contraception following pregnancy (58.0% vs. 38.7%, p < 0.001) or no contraception (27.2% vs. 24.5%, p < 0.001), but less likely to use LARC (3.4% vs. 11.7%, p < 0.001), other hormonal contraception (4.1% vs. 8.9%, p < 0.001), or other non-hormonal contraception (7.2% vs. 16.4%, p < 0.001). In adjusted analyses, permanent (aOR 1.62, 95% CI 0.72-2.26) remained significant, however the differences were no longer statistically significant: LARC (aOR 0.34, 95% CI 0.12-1.00); other hormonal (aOR 0.61, 95% CI 0.27-1.35); other non-hormonal (aOR 0.59, 95% CI 0.25-1.43); and None (aOR 1.11, 95% CI 0.65-1.89). CONCLUSION: In this analysis, we found that women with pregestational diabetes were more likely to use permanent contraception methods compared to women without pregestational diabetes; however over a quarter of women with pregestational diabetes did not use contraception between pregnancies.
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Diabetes Mellitus Tipo 2 , Anticoncepción Reversible de Larga Duración , Anticoncepción/métodos , Conducta Anticonceptiva , Estudios Transversales , Femenino , Humanos , EmbarazoRESUMEN
Background: The global burden of cervical cancer is concentrated in low-and middle-income countries (LMICs), with the greatest burden in Africa. Targeting limited resources to populations with the greatest need to maximize impact is essential. The objectives of this study were to geocode cervical cancer data from a population-based cancer registry in Kampala, Uganda, to create high-resolution disease maps for cervical cancer prevention and control planning, and to share lessons learned to optimize efforts in other low-resource settings. Methods: Kampala Cancer Registry records for cervical cancer diagnoses between 2008 and 2015 were updated to include geographies of residence at diagnosis. Population data by age and sex for 2014 was obtained from the Uganda Bureau of Statistics. Indirectly age-standardized incidence ratios were calculated for sub-counties and estimated continuously across the study area using parish level data. Results: Overall, among 1873 records, 89.6% included a valid sub-county and 89.2% included a valid parish name. Maps revealed specific areas of high cervical cancer incidence in the region, with significant variation within sub-counties, highlighting the importance of high-resolution spatial detail. Conclusions: Population-based cancer registry data and geospatial mapping can be used in low-resource settings to support cancer prevention and control efforts, and to create the potential for research examining geographic factors that influence cancer outcomes. It is essential to support LMIC cancer registries to maximize the benefits from the use of limited cancer control resources.
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Neoplasias del Cuello Uterino , Femenino , Humanos , Incidencia , Pobreza , Análisis Espacial , Uganda/epidemiología , Neoplasias del Cuello Uterino/epidemiología , Neoplasias del Cuello Uterino/prevención & controlRESUMEN
BACKGROUND: Uganda clinical guidelines recommend routine screening of pregnant women for intimate partner violence (IPV) during antenatal care (ANC). Healthcare providers play a critical role in identifying IPV during pregnancy in ANC clinics. This study explored facilitators and barriers for IPV screening during pregnancy (perinatal IPV screening) by ANC-based healthcare workers in Uganda. METHODS: We conducted qualitative in-depth interviews among twenty-eight purposively selected healthcare providers in one rural and an urban-based ANC health center in Eastern and Central Uganda respectively. Barriers and facilitators to IPV screening during ANC were identified iteratively using inductive-deductive thematic analysis. RESULTS: Participants had provided ANC services for a median (IQR) duration of 4.0 (0.1-19) years. Out of 28 healthcare providers, 11 routinely screened women attending ANC clinics for IPV and 10 had received IPV-related training. Barriers to routine IPV screening included limited staffing and space resources, lack of comprehensive gender-based violence (GBV) training and provider unawareness of the extent of IPV during pregnancy. Facilitators were availability of GBV protocols and providers who were aware of IPV (or GBV) tools tended to use them to routinely screen for IPV. Healthcare workers reported the need to establish patient trust and a safe ANC clinic environment for disclosure to occur. ANC clinicians suggested creation of opportunities for triage-level screening and modification of patients' ANC cards used to document women's medical history. Some providers expressed concerns of safety or retaliatory abuse if perpetrating partners were to see reported abuse. CONCLUSIONS: Our findings can inform efforts to strengthen GBV interventions focused on increasing routine perinatal IPV screening by ANC-based clinicians. Implementation of initiatives to increase routine perinatal IPV screening should focus on task sharing, increasing comprehensive IPV training opportunities, including raising awareness of IPV severity, trauma-informed care and building trusting patient-physician relationships.
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Violencia de Pareja , Atención Prenatal , Femenino , Humanos , Violencia de Pareja/prevención & control , Tamizaje Masivo , Embarazo , Mujeres Embarazadas , Atención Prenatal/métodos , UgandaRESUMEN
Cases of coronavirus disease 2019 (COVID-19) detected, and COVID-19 associated mortality increased since the first case was confirmed in Uganda. While adherence to WHO-recommended measures to disrupt COVID-19 transmission has since been implemented, it has been reported to be sub-optimal. An increase in intimate partner violence (IPV) cases was linked to enforcement of COVID-19 lockdowns and other preventive measures especially in informal settings of Kampala. We determined the association between adherence to COVID-19 preventive measures and intimate partner violence among women dwelling in informal settings in Kampala, Uganda. Between July and October 2020, we conducted a three-month prospective cohort study of 148 women living in informal settlements of Kampala during the COVID-19 lockdown and easing of restrictive measures. Participants were surveyed at baseline, at 3-weeks and 6-weeks (endline). The dependent variable was adherence to COVID-19 preventive measures (remained adherent vs poorly adherent) between baseline and endline surveys. This composite outcome variable was computed from implementing all four variables: social distancing, wearing face masks, frequent hand washing and use of hand sanitizers at baseline and endline surveys. The key independent variable was IPV measured as experiencing at least one form of physical, emotional, or sexual IPV. Covariates were age, education, marital status, household size, occupation, and having problems getting food. Adjusted logistic regression analyses tested the independent association between adherence to COVID-19 preventive measures and intimate partner violence. Among 148 respondents, the mean age (SD) was 32.9 (9.3) years, 58.1% were exposed to at least one form of IPV, and 78.2% had problems getting food. Overall, 10.1% were poorly adherent to COVID-19 preventive measures during the first COVID-19 wave. After controlling for potential confounders, remaining adherent to COVID-19 preventive measures were more likely to experience intimate partner violence when compared to women who were poorly adherent to COVID-19 preventive measures during the first COVID-19 wave in Uganda [OR 3.87 95%CI (1.09, 13.79)]. Proportions of women in informal settlements of Kampala experiencing at least one form of IPV during the first COVID-19 wave is substantial. Remaining adherent to preventive measures for COVID-19 transmission may increase IPV exposure risk among women living in informal settlements in Kampala. Contextualizing COVID-19 interventions to the needs of marginalized and vulnerable women and girls in informal settings of Kampala is warranted. Processes to integrated violence prevention and response strategies into the Uganda COVID-19 prevention strategy are underscored.
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In 2019, Sierra Leone declared national emergency over rape and other forms of sexual violence (SV), hence diverting resources from other issues to tackle SV. However, little is known about nationwide risk/protective factors for SV, and this has been a source of critique for the new policy. To fill this gap in knowledge, we investigated the factors for SV toward women using a nationally representative sample. We analyzed the 2013 Demographic and Health Survey (DHS) data, including 16,658 women, aged 15-49 years. The outcome was current SV, defined as being physically forced to have sexual intercourse within the last 12 months. We examined respondent's background, sexual activities, and experience of domestic violence (DV). Logistic regression analyses were performed using STATA/SE v.15.1, accounting for survey design and sample weights. Values of p less than .05 were considered statistically significant. ArcMap was used to demonstrate geographic distribution of SV cases. We found that about 258 (6.3%) women reported SV. In adjusted analysis, women in the north (than south; 2.88, 95% CI = [1.44, 5.75]) and women circumcised between the ages of 1 and 14 (1.67, 95% CI = [1.10, 2.54]) reported higher risk of SV, respectively. Women who had sex more than 25 times per year were 6.9 times more likely to report SV, compared with those with 1 to 24 times (6.91, 95% CI = [1.48, 32.19]). The odds of SV were 6 times higher among women who reported experiencing recent physical violence (5.86, 95% CI = [2.49, 13.80]) or history of SV (6.34, 95% CI = [2.57, 15.65]). In conclusion, this study adds to the literature by providing information on major factors associated with SV toward women in Sierra Leone using a nationally representative sample. Women in the north (Tonkolili), circumcised between the ages of 1 and 14, had sex more than 25 times per year, reported physical violence (12 months before the survey) and SV (ever forced to have sex) reported higher risk for current SV. While more research is needed, these findings will help inform the current emergency operations against SV in Sierra Leone.
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Delitos Sexuales , Conducta Sexual , Adolescente , Niño , Preescolar , Estudios Transversales , Femenino , Humanos , Lactante , Prevalencia , Sierra Leona/epidemiologíaRESUMEN
BACKGROUND/OBJECTIVE: Existing studies have shown that pregestational diabetes is a significant risk factor for adverse birth outcomes. However, it is unclear, whether pregestational diabetes and neonatal birthweight that is appropriate for the gestational age (AGA), a proxy for overall adequate glycemic control, is associated with higher infant mortality. To address this controversy, this study investigated the relationship between pregestational diabetes and infant mortality in appropriate-for-gestational age infants in the United States. METHODS: Data from the National Vital Statistics System-Linked Birth-Infant Death dataset, including 6,962,028 live births between 2011 and 2013 were analyzed. The study was conducted in the US and data were analyzed in Milwaukee, Wisconsin. The outcome was mortality among AGA newborns, defined as annual deaths per 1000 live births with birthweights between the 10th and 90th percentiles for gestational age delivering at ≥37 weeks. The exposure was pregestational diabetes. Covariates were maternal demographics, behavioral/clinical, and infant factors. Logistic regression was used with p values <.05 considered statistically significant. RESULTS: A total of 6,962,028 live births met inclusion criteria. Of these, a total of 11,711 (1.0%) term AGA birthweight infants died before their first birthday. About 35,689 (0.5%) mothers were diagnosed with pregestational diabetes prior to pregnancy with 0.3% of infants whose mothers had diabetes dying in their first year of life. In the unadjusted model, pregestational diabetes had a significant association with increased odds of mortality in term AGA infants (OR: 1.9, 95% CI: 1.6 - 2.3). AGA mortality remained significantly higher for women with pregestational diabetes compared to controls, after adjusting for maternal demographics (OR: 1.9, 95% CI: 1.6-2.3), behavioral/clinical characteristics (OR: 1.6, 95% CI: 1.3-2.0), and infant factors (OR: 1.3, 95% CI: 1.1-1.6). CONCLUSIONS: In term pregnancies, pregestational diabetes was significantly associated with 30% higher mortality among AGA birthweight infants. Our study is innovative in its focus on AGA infants that overall is associated with good maternal glycemic control during pregnancy and in theory should confer a risk for infant mortality that is similar to pregnancies not complicated by pregestational diabetes. Despite this, we still found that even term AGA infants have higher risk of mortality in the setting of maternal pregestational diabetes. Implications of our findings underscore the importance of close antepartum surveillance and optimization of glycemic control preconception, identification of treatment targets, and health policies to reduce infant mortality. The results from this study may assist other researchers and clinicians understand how best to target future interventions to reduce term infant mortality and the burden of pregestational diabetes in the United States.
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Diabetes Gestacional , Recién Nacido Pequeño para la Edad Gestacional , Lactante , Embarazo , Recién Nacido , Femenino , Estados Unidos/epidemiología , Humanos , Peso al Nacer , Edad Gestacional , Mortalidad InfantilRESUMEN
Epidemiological studies suggest a link between onchocerciasis and various forms of epilepsy, including nodding syndrome (NS). The aetiopathology of onchocerciasis associated epilepsy remains unknown. This case-control study investigated potential risk factors that may lead to NS and other forms of non-nodding epilepsy (OFE) in northern Uganda. We consecutively recruited 154 persons with NS (aged between 8 and 20 years), and age-frequency matched them with 154 with OFE and 154 healthy community controls. Participants' socio-demography, medical, family, and migration histories were recorded. We tested participants for O. volvulus serum antibodies. The 154 controls were used for both OFE and NS separately to determine associations. We recruited 462 people with a median age of 15 years (IQR 14, 17); 260 (56.4%) were males. Independent risk factors associated with the development of NS were the presence of O. volvulus antibodies [aOR 8.79, 95% CI (4.15-18.65), p-value < 0.001] and preterm birth [aOR 2.54, 95% CI (1.02-6.33), p-value = 0.046]. Risk factors for developing OFE were the presence of O. volvulus antibodies [aOR 8.83, 95% CI (4.48-17.86), p-value < 0.001] and being born in the period before migration to IDP camps [aOR 4.28, 95% CI (1.20-15.15), p-value = 0.024]. In conclusion, O. volvulus seropositivity was a risk factor to develop NS and OFE; premature birth was a potential co-factor. Living in IDP camps was not a risk factor for developing NS or OFE.
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Globally, epilepsy is the most common chronic neurological disorder. The incidence in sub-Saharan Africa is 2-3 times higher than that in high income countries. Infection by Onchocerca volvulus may be an underlying risk factor for the high burden and based upon epidemiological associations, has been proposed to cause a group of disorders-Onchocerca associated epilepsies (OAE) like nodding syndrome (NS). To improve our understanding of the disease spectrum, we described the clinical, electroencephalographic (EEG) and magnetic resonance imaging (MRI) features of children with epilepsy and sero-positive for Onchocerca volvulus (possible OAEs other than nodding syndrome). Twenty-nine children and adolescents with non-nodding syndrome OAE in northern Uganda were enrolled. A diagnosis of OAE was made in patients with epilepsy and seizure onset after age 3 years, no reported exposure to perinatal severe febrile illness or traumatic brain injury, no syndromic epilepsy diagnosis and a positive Ov-16 ELISA test. Detailed clinical evaluation including psychiatric, diagnostic EEG, a diagnostic brain MRI (in 10 patients) and laboratory testing were performed. Twenty participants (69%) were male. The mean age was 15.9 (standard deviation [SD] 1.9) years while the mean age at seizure onset was 9.8 (SD 2.9) years. All reported normal early childhood development. The most common clinical presentation was a tonic-clonic seizure. The median number of seizures was 2 (IQR 1-4) in the previous month. No specific musculoskeletal changes, or cranial nerve palsies were reported, neither were any vision, hearing and speech difficulties observed. The interictal EEG was abnormal in the majority with slow wave background activity in 52% (15/29) while 41% (12/29) had focal epileptiform activity. The brain MRI showed mild to moderate cerebellar atrophy and varying degrees of atrophy of the frontal, parietal and occipital lobes. The clinical spectrum of epilepsies associated with Onchocerca may be broader than previously described. In addition, focal onset tonic-clonic seizures, cortical and cerebellar atrophy may be important brain imaging and clinical features.
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OBJECTIVE: Nodding syndrome is a poorly understood epileptic encephalopathy characterized by a unique seizure type-head nodding-and associated with Onchocerca volvulus infection. We hypothesized that altered immune activation in the cerebrospinal fluid (CSF) and plasma of children with nodding syndrome may yield insights into the pathophysiology and progression of this seizure disorder. METHOD: We conducted a case-control study of 154 children (8 years or older) with long-standing nodding syndrome and 154 healthy age-matched community controls in 3 districts of northern Uganda affected by nodding syndrome. Control CSF samples were obtained from Ugandan children in remission from hematological malignancy during routine follow-up. Markers of immune activation and inflammation (cytokines and chemokines) and complement activation (C5a) were measured in plasma and CSF using ELISA or Multiplex Luminex assays. O volvulus infection was assessed by serology for anti-OV-16 IgG levels. RESULTS: The mean (SD) age of the population was 15.1 (SD: 1.9) years, and the mean duration of nodding syndrome from diagnosis to enrollment was 8.3 (SD: 2.7) years. The majority with nodding syndrome had been exposed to O volvulus (147/154 (95.4%)) compared with community children (86/154 (55.8%)), with an OR of 17.04 (95% CI: 7.33, 45.58), P < .001. C5a was elevated in CSF of children with nodding syndrome compared to controls (P < .0001). The levels of other CSF markers tested were comparable between cases and controls after adjusting for multiple comparisons. Children with nodding syndrome had lower plasma levels of IL-10, APRIL, CCL5 (RANTES), CCL2, CXCL13, and MMP-9 compared with community controls (P < .05 for all; multiple comparisons). Plasma CRP was elevated in children with nodding syndrome compared to community children and correlated with disease severity. SIGNIFICANCE: Nodding syndrome is associated with exposure to O. volvulus. Compared to controls, children with long-standing symptoms of nodding syndrome show evidence of complement activation in CSF and altered immune activation in plasma.
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Síndrome del Cabeceo , Onchocerca volvulus , Adolescente , Animales , Estudios de Casos y Controles , Niño , Activación de Complemento , Humanos , Síndrome del Cabeceo/epidemiología , Uganda/epidemiologíaRESUMEN
BACKGROUND: We aimed to examine age and gender differences in the relationship between depression and quality of life among United States adults. METHODS: Medical Expenditure Panel Survey data for 2008 to 2016 on 227,663 adults were analyzed. The dependent variable, quality of life, included physical component summary scores and mental component summary scores from the Short Form Health Survey. The key independent variable, depression, was measured using the two-item Patient Health Questionnaire. General linear regression models examined the relationship between quality of life and depression. Models were adjusted for individual and environmental characteristics, symptom status, functional and biological status, and health perceptions and were stratified by gender and age. RESULTS: In adjusted models, mental component summary scores were significantly lower among those with depression compared with those without depression (ß = -0.39; 95% confidence interval [CI], 0.38 to -1.16) and lower among women compared with men (ß = -0.10; 95% CI, 0.10 to -1.31). Models stratified by gender and age found women with depression ages 40 to 64 (ß = -0.07; 95% CI, 0.07 to -0.20) and 65 or older (ß = -0.08; 95% CI, 0.08 to -0.24) had significantly lower physical component summary scores compared with those without depression. Among men with depression, those ages 18 to 39 (ß = -0.03; 95% CI, 0.03 to -0.10) and 40 to 64 (ß = -0.09, 95% CI, 0.08 to -0.26) had lower physical component summary scores compared with those without depression. Women and men of all ages with depression had significantly lower mental component summary scores compared with those without depression. CONCLUSIONS: Public health interventions and clinical approaches to address depression in women and men should target functional status in men and perceptions of health in women.
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Depresión , Calidad de Vida , Adolescente , Adulto , Estudios Transversales , Depresión/epidemiología , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Factores Sexuales , Encuestas y Cuestionarios , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVE: To analyze the association between racial bias and postpartum depression among women in Wisconsin. METHODS: Analyzed the Wisconsin Pregnancy Risk Assessment Monitoring System with a weighted sample of 125,581 women/mothers who delivered a live birth in 2016-2017. The outcome was self-reported postpartum depression. The independent variable was racial bias exposure. Survey-weighted logistic regression analyses were performed adjusting for confounders in 6 models-socioeconomic position, psychosocial factors, health risk behaviors, health care access, stress/obesity, and disease condition. All analyses were completed using STATA accounting for complex survey design and sample weights. RESULTS: In this sample, 6.6% of women/mothers experienced racial bias and 11.5% had postpartum depression. In unadjusted analysis, the odds of postpartum depression were higher for women who experienced racial bias than those who did not (OR 2.15; 95% CI, 1.35-3.41). Non-Hispanic Black women had higher odds for racial bias exposure than other racial/ethnic groups (OR 6.01; 95% CI, 1.69-21.41). However, the relationship between racial bias and postpartum depression was not significant after adjusting for socioeconomic position (OR 1.17; 95% CI, 0.69-1.97), psychosocial factors (OR 1.07; 95% CI, 0.63-1.81), health risk behaviors (OR 0.90; 95% CI, 0.55-1.49], health care access (OR 1.01; 95% CI, 0.60-1.70), stress/obesity (OR 0.73; 95% CI, 0.41-1.30), and disease/morbidity (OR 0.85; 95% CI, 0.46-1.57). DISCUSSION/CONCLUSION: Racial bias was associated with significantly increased risk of postpartum depression. Black women had higher odds for racial bias exposure than other groups. The relationship between racial bias and postpartum depression was not significant after adjusting for confounders, suggesting that social determinants potentially influenced this relationship. These findings should inform screening and health education interventions to minimize racism and poor maternal health outcomes.