Correlates for the severity of suicidal risk in participants with common mental disorders with comorbid chronic medical conditions in rural primary healthcare settings in India.

Context: Suicide is on the rise in low- and middle-income countries (LMICs), including India. There are limited studies assessing factors linked to the severity of suicidal risk in patients with depression and comorbid chronic medical disorders in primary healthcare (PHC) settings. Aim: This study examines factors linked to suicidal risk among participants in a cluster randomized controlled trial of collaborative care intervention (Healthier Options through Empowerment (HOPE Study)). Settings and Design: The setting was at 49 PHC in the rural Ramanagara District of Karnataka State in southern India. Study eligibility criteria included being ≥30 years with at least mild depression or generalized anxiety disorder and at least one medical condition (cardiovascular disorder or type 2 diabetes mellitus). Methods and Material: The severity of suicidal risk at baseline was assessed using the Mini International Neuropsychiatric Interview (MINI), and other measures included the severity of depression (Patient Health Questionnaire-9-items (PHQ-9)), the severity of anxiety (Generalized Anxiety Disorder Scale-7-items (GAD-7)), disability, social support, quality of life, number of comorbid chronic medical illnesses, and body mass index (BMI). Statistical Analysis Used: Chi-square tests and independent-samples t-tests were used to compare the demographic and clinical characteristics of the no-low and mod-high suicidal risk groups. Logistic regression analysis was used to identify correlates associated with the mod-high suicidal risk group. Results: Mod-high suicidal risk was significantly positively associated with the severity of depression and disability and significantly negatively associated with social support. Conclusion: The severity of depression, higher disability scores, and lower social support were found to be independent correlates of mod-high suicidal risk. Screening, managing depression, and facilitating social support for patients with chronic medical illness in PHC settings may reduce suicidal risk.

The Influence of Transmission-Based and Moral-Based HIV Stigma Beliefs on Intentions to Discriminate Among Ward Staff in South Indian Health Care Settings.

HIV stigma is comprised of several beliefs, including transmission fears and moral judgments against affected communities. We examined the relationships among HIV-related stigma beliefs, endorsement of coercive measures for people living with HIV (PLWH), and intentions to discriminate. We sought to understand to what degree the different stigma beliefs shape support for restrictive policies and discriminatory intentions. Data were drawn from the baseline assessment of DriSti, a cluster randomized controlled trial of an HIV stigma reduction intervention in Indian healthcare settings (NCT02101697). Participants completed measures assessing transmission fears and moral judgments of HIV, endorsement of coercive measures against PLWH (public disclosure of HIV status, refusal of healthcare services, marriage and family restrictions, required testing, and sharing of HIV information in a clinic), and intentions to discriminate against PLWH in professional and personal settings. We utilized multivariate regression modeling with backward elimination to identify the coercive measures and behavioral intentions most strongly associated with moral judgments. 1540 ward staff members completed the assessment. Participants had relatively high perceptions of transmission fears (M = 1.92, SD = 0.79) and moral judgments (M = 1.69, SD = 0.83); endorsed more intentions to discriminate in professional (M = 6.54, SD = 2.28) than personal settings (M = 2.07, SD = 1.49), and endorsed approximately half of all coercive measures (M = 9.47, SD = 2.68). After controlling for transmission fears, perceptions of stronger moral judgments against PLWH were significantly associated with higher endorsement of coercive measures related to refusing services (ß = 0.10, t = 4.14, p < 0.001) and sharing patients' HIV status in clinics (ß = 0.07, t = 3.04, p = 0.002), as well as with stronger behavioral intentions to discriminate in professional settings (ß = 0.05, t = 2.20, p = 0.022). HIV stigma interventions for hospital-based ward staff in India need to focus on both transmission fears and moral judgments that underlie prejudicial beliefs. While the moral judgments are not technically related to risk in a hospital setting, our findings suggest that personnel will continue to discriminate in their professional work so long as these beliefs bear on their decisions and actions.

Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia.

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

RESUMEN: Las personas infectadas por el VIH que se inyectan drogas a menudo experimentan manifestaciones de estigma relacionadas con el uso de sustancias y el propio VIH. En este estudio evaluamos los correlatos de estigma asociado al VIH (escala de estigma asociado al VIH de Berger), el estigma asociado al uso de sustancias ("Substance Abuse Self-stigma Scale") y el estigma interseccional del VIH y el uso de sustancias en una cohorte de personas infectadas por el VIH con antecedente de uso de drogas en San Petersburgo, Rusia. El estigma interseccional se definió como una puntuación superior a la mediana para ambas formas de estigma. De los 208 participantes, 56 (27%) tenían estigma interseccional. Los síntomas depresivos y la dependencia del alcohol se asociaron significativamente con una puntuación más alta de estigma relacionado con el VIH y las sustancias, pero no con el estigma interseccional. Las intervenciones individuales y comunitarias para reducir el impacto del estigma asociado al VIH y al uso de sustancias que afectan a las personas con VIH que se inyectan drogas deben tener en cuenta la salud mental y el uso nocivo de sustancias. Se necesitan estudios con datos longitudinales para comprender mejor los mecanismos que conducen al estigma interseccional.

Medication Adherence among Primary Care Patients with Common Mental Disorders and Chronic Medical Conditions in Rural India.

Background: Only a few studies have explored the relationship between psychosocial factors and medication adherence in Indian patients with noncommunicable diseases (NCDs). We aimed to examine the association of psychosocial variables with medication adherence in people with NCDs and comorbid common mental disorders (CMDs) from primary care in rural southern India. Methods: We performed a secondary analysis using baseline data from a randomized controlled trial in 49 primary care health centers in rural southern India (HOPE study). Participants were adults (≥30 years) with NCDs that included hypertension, diabetes, and/or ischemic heart disease, and comorbid depression or anxiety disorders. Medication adherence was assessed by asking participants if they had missed any prescribed NCD medication in the past month. Data were collected between May 2015 and November 2018. The association between psychosocial and demographic variables and medication nonadherence were assessed via logistic regression analyses. Results: Of the 2486 participants enrolled, almost one-fifth (18.06%) reported missing medication. Male sex (OR = 1.74, 95% CI 1.37-2.22) and higher internalized mental illness stigma (OR = 1.46, 95% CI 1.07-2.00) were associated with higher odds of missing medication. Older age (OR = 0.40, 95% CI 0.26-0.60, for participants aged 64-75 years vs 30-44 years), reporting more social support (OR = 0.65, 95% CI 0.49-0.86), and higher satisfaction with health (OR = 0.74, 95% CI 0.61-0.89) were associated with lower odds of missing medication. Conclusions: Greater internalized mental illness stigma and less social support are significantly associated with lower rates of medication adherence in patients with NCDs and comorbid CMDs in rural India.

Elevated homocysteine and depression outcomes in patients with comorbid medical conditions in rural primary care.

We examined the association of elevated concentration of total homocysteine (tHcy) with the severity of depression in patients diagnosed with depression and comorbid chronic medical conditions in rural primary care settings in Karnataka. Participants were included from the control arm of a cluster-randomized controlled trial designed to evaluate the effects of using a collaborative care model to integrate screening and treatment of primary health center patients. tHcy was assayed at baseline, and depression severity scores were assessed using the Patient Health Questionnaire (PHQ-9) 6 months later. There was no difference in the mean PHQ-9 score between those with (mean PHQ = 7.4) and without (mean PHQ = 7.6) elevated tHcy levels (P = 0.67).

Feasibility and preliminary efficacy of training health workers in detecting Priority Mental Health Conditions among adolescents in rural South India.

INTRODUCTION: Half of all mental disorders start during adolescence, before 14 years. In India, the current prevalence of mental disorders in 13-17 years age group was 7.3%. Many gaps persist in the mental healthcare delivery through the national mental health program, the low psychiatrist population ratio being one of them. Community health workers can play an essential role in providing mental healthcare in such resource-constrained settings. The World Health Organization mental health gap action program (WHO mhGAP) is a widely studied mental health tool that health workers can use to identify mental disorders. The study's aim was to test the preliminary efficacy of training healthcare workers (HCWs) in identifying mental health conditions among adolescents using modified WHO mhGAP modules. METHODS: The feasibility study was carried out in two Primary Health Centers (PHCs) in rural Bengaluru. Study had two components: (1) training of HCWs on adolescent mental health and (2) detection of selected priority mental health conditions among adolescents by trained HCWs. HCWs were trained in five adolescent mental health conditions using a training manual and modified WHO mhGAP modules that excluded emergency presentations and management sections. Pre- and post-training assessments were carried out. A sample of 272 adolescents attending PHCs were assessed for any mental health condition by HCWs using mhGAP modules. A sub-sample of adolescents and all adolescents identified by HCWs with a mental health condition was interviewed by the investigator to validate the diagnosis. Qualitative interviews were carried out with participating HCWs to understand the acceptability of the intervention, acceptability, and barriers to training in identifying mental health conditions among adolescents RESULTS: A total of 23 HCWs underwent training. There was a significant increase in the mental health knowledge scores of HCWs post-training compared to baseline (p value <0.001). Out of 272 adolescents, 18 (6.8%) were detected to have any mental health condition by HCWs as per the modified WHO mhGAP modules. A sample of 72 adolescents consisting of all adolescents identified with a mental health condition by HCWs and a random sample of adolescents without any diagnosis were validated by the research investigator (AS). There was a good agreement between diagnosis by health workers and the research investigator with a Cohen's Kappa of 0.88. Four themes emerged from the qualitative analysis. CONCLUSIONS: Training was effective in improving the knowledge of HCWs. There was a good agreement between trained HCWs and the investigator in detecting adolescent mental health conditions using modified mhGAP modules. The modified WHO mhGAP can thus be used by trained non-specialist HCWs to screen for adolescent mental health conditions in primary health centers.

Standard Precautions are for everyone: The role of HIV stigma and implications for nursing education in India.

Background and objective: Standard Precautions (SP) are infection control procedures universally applicable to every patient. Though SP reduces disease transmission, their implementation is dependent on the knowledge and skills of healthcare workers (HCWs). Poor knowledge regarding the appropriate use of SP can cause fear among HCWs, leading to stigma and discrimination while treating people living with HIV (PLWH). Stigma and discrimination are known barriers for PLWH to access HIV care services. The aim of the study was to assess nursing student knowledge of SP, SP self-efficacy and SP perceived efficacy of nursing students, and (2) to assess the association between SP knowledge, perceived efficacy, and intention to utilize unwarranted precautions, like using double gloves while treating PLWH. Methods: This paper analyzes baseline (non-randomized) data of a cluster randomized controlled trial amongst 1868 Indian nursing students. Data was collected using computer-administered structured questionnaire. The associations between the measures were done using multiple, logistic and poisson regression models. Results: Although 97% nursing students could identify SP, only 35.5% understood that they need to be used with all patients. Awareness of the importance of using SP with all patients was positively associated with self-efficacy. Students performing high-risk tasks frequently were significantly more likely to be confident in their ability to correctly use SP, but also had higher intention to use unwarranted precautions. Conclusions: Existing teaching and training programs for HCWs need to provide clear guidelines and emphasize on the correct use of SP with all patients. This will increase both skills and confidence in their abilities (self-efficacy).

Is self-reported adherence a valid measure of glycaemic control among people living with diabetes in rural India? A cross-sectional analysis.

BACKGROUND: Visual analogue scale (VAS) is one of the simplest to measure medication adherence. It has neither been widely used for Non communicable diseases (NCD) nor validated for in the Indian setting. We examined the validity of self-reported medication adherence measures in relation to HbA1C in a rural population with diabetes mellitus (DM). METHODS: Participants with DM was administered VAS, Diabetes Self-Management Questionnaire (DMSQ) and assessed for missed pills. Descriptive statistics and logistic regression analysis were done. RESULTS: We recruited 1347 participants and 84% of them reported being 100% adherent as per VAS and 83.8% stated that they did not miss any pills. However, 58.2% of participants who reported having 100% adherence had poor glycaemic control, as did 58.1% of those who did not miss any pills. None of the diabetic self-care measures was significantly associated with glycaemic control. CONCLUSION: We found a lack of association between self-reported adherence measures and glycaemic control in participants with DM suggesting that self-reported adherence scales may not be valid in this population.

Collaborative care compared to enhanced standard treatment of depression with co-morbid medical conditions among patients from rural South India: a cluster randomized controlled trial (HOPE Study).

BACKGROUND: Depression is common among primary care patients in LMIC but treatments are largely ineffective. In this cluster-randomized controlled trial, we tested whether depression outcomes are different among recipients of a collaborative care model compared to enhanced standard treatment in patients with co-morbid chronic medical conditions. METHODS: We conducted a cluster randomized controlled trial among participants 30 years or older seeking care at 49 primary health centers (PHCs) in rural Karnataka, diagnosed with major depressive disorder, dysthymia, generalized anxiety disorder, or panic disorder on the MINI-International Neuropsychiatric Interview plus either hypertension, diabetes, or ischemic heart disease. From a list of all PHCs in the district, 24 PHCs were randomized a priori to deliver collaborative care and 25 PHCs enhanced standard treatment. The collaborative care model consisted of a clinic-based and a community-based component. Study assessment staff was blinded to treatment arm allocation. The primary outcome was the individual-level PHQ-9 score over time. RESULTS: Between May 2015 and Nov 2018, 2486 participants were enrolled, 1264 in the control arm, and 1222 in the intervention arm. They were assessed at baseline, 3, 6 and 12 months. The mean PHQ-9 depression score was around 8.5 at baseline. At each follow-up PHQ-9 scores were significantly lower in the intervention (5.24, 4.81 and 4.22 at respective follow-ups) than in the control group (6.69, 6.13, 5.23, respectively). A significant time-by-treatment interaction (p < 0.001) in a multi-level model over all waves, nested within individuals who were nested within PHCs, confirmed that the decrease in depression score from baseline was larger for collaborative care than enhanced standard care throughout follow-up. CONCLUSIONS: The collaborative care intervention resulted in significantly lower depression scores compared to enhanced standard care among participants with co-morbid physical conditions. The findings have potential implications for integrating mental health and chronic disease treatment in resource constrained settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02310932 , registered on December 8, 2014, and Clinical Trials Registry India CTRI/2018/04/013001 , registered on April 4, 2018. Retrospectively registered.

The effect of mental health training on the knowledge of common mental disorders among medical officers in primary health centres in rural Karnataka.

Background: Deficits in knowledge regarding identification and treatment of common mental disorders (CMD) and stigmatizing attitudes towards CMDs exist among primary care physicians in India. Objectives: We aimed to assess the gain in knowledge of CMDs among primary health centre (PHC) doctors, after they underwent training in the identification and treatment of CMDs, and to assess the relationship between the gain in knowledge and demographic variables. We also assessed attitudes towards depression among PHC doctors who underwent training. Methods: We assessed knowledge of CMDs among 38 PHC doctors before and after training using a multiple-choice questionnaire (MCQ). The training session included didactic teaching and case-based discussions. Results: The post-test mean score was significantly higher compared to the pre-test mean score (P < 0.0001), indicative of a significant mean gain in knowledge of CMDs among PHC doctors following training. Significant improvements were noted on the questions assessing identification of CMDs, knowledge of depressive symptoms and identification of panic attacks, post-training (all P < 0.05). Participants with lower pre-test scores had greater improvements in knowledge post-training. Around half of the PHC doctors endorsed negative attitudes towards depression. Conclusions: We demonstrated the efficacy of a training programme for PHC doctors in improving their knowledge of CMDs. Stigmatizing attitudes towards depression were present among around half the PHC doctors even after the training. This has implications for the strategy of integrating mental healthcare into primary care, with the overall goal of reducing the treatment gap for CMDs.

Awareness of the Use of Standard Precautions during Care of People Living with HIV by Ward Attendants in Indian Hospitals.

Context: Standard precautions (SP) are infection prevention practices universally used during patient care to lower infection transmission. Aims: The aim of the study was to (1) assess Indian ward attendants' (WAs) knowledge, perceived efficacy, and self-efficacy regarding SP and (2) examine correlates of SP self-efficacy and intent to use unnecessary precautions during care of people living with HIV. Subjects and Methods: Data are sourced from a face-to-face baseline survey of a stigma-reduction trial among 1859 WAs from Indian hospitals. Percentages were used to describe categorical variables means and standard deviations for continuous variables. Multiple regressions examined associations between measures. Results: WAs who had heard of SP had 44% higher odds of confidently using SP than those who had not heard of them. Those aware of universal SP use were 43% more likely to feel confident in using SP but also reported greater intent to use unnecessary precautions. Conclusions: Hospitals could implement SP training for WAs, as their knowledge of universal use was lacking.

Association Between Maternal HIV Stigma Among South Indian Mothers Living with HIV and the CD4 Count of Children Living with HIV.

HIV stigma takes a multidimensional toll on a mother's ability to care for herself and subsequently may impact her ability to care for her child, particularly when mother and child are seroconcordant. A cross-sectional analysis was conducted to examine the association between maternal HIV stigma and child CD4 count in rural India. We assessed 108 mother-child dyads and found that a one-unit increase in community stigma fear decreased child CD4 count by 352 cells (95% CI = - 603, - 102), highlighting the need to develop a better understanding of the consequences of HIV-related stigma on the compounded burden of care in households where mother and child both live with HIV.

Health literacy in communication, decision-making and outcomes among cancer patients, their families and clinicians in India: A multicentre cross-sectional qualitative study.

OBJECTIVE: Cancer patients in India prefer full information regarding diagnosis and prognosis, but evidence suggests poor insight. This study aimed to identify the role of health literacy among adult patients living with cancer, their families and health professionals in decision-making and treatment outcomes in India. METHODS: This cross-sectional in-depth study recruited patients, families and clinicians from three centers. Inductive thematic analysis informed a novel conceptual model. RESULTS: We recruited n = 34 cancer patients, n = 33 family members, n = 11 doctors and n = 14 nurses (N = 92). Principle emergent themes were the following: (1) Preferences and dynamics of diagnosis and prognosis disclosure, for example, the dominant preference was for families who held hope for cure to discourage disclosure; clinicians sometimes disclosed in line with perceived ability to pay for treatment. (2) Understanding of disease and its treatment options (etiology, potential trajectory, treatment options), for example, lay understandings of cancer etiology as contamination from outside the home, and reluctance of patients to ask questions of clinicians. (3) Priorities in decision-making, for example, not engaging patients due to fear of patient distress, patients initiated on anticancer treatments without knowledge or consent, pursuing futile treatments. (4) Anxieties over finances and outcomes (disclosure, decision-making, care pathways), for example, clinicians attempting to reduce families pursuing expensive and inappropriate treatment options with patients who have poor insight, catastrophic spending based on poor decisions. CONCLUSION: The novel evidence-based health literacy model offers potential for feasible and acceptable intervention to support families in communication, disclosure and decision-making. This may improve patients' access to informed, appropriate care pathways.

Mental health of women living with HIV and its impact on child development in Andhra Pradesh, India.

Global literature examining the association between mental health of women living with HIV (WLWH) and child development is scarce. In this study, we examined the relationship between mothers' mental health and their children's social development outcomes 6 months later. Data for these analyses come from several waves of interviews of 600 WLWH in the South Indian state of Andhra Pradesh, India. These women were enrolled in a 2×2 factorial clinical trial designed to assess the impact of food supplementation and nutrition education, both in addition to ASHA support, on adherence to ART and improved health outcomes for the women and one of their children. They were assessed on food security, stigma, social support, quality of life, depressive symptoms and child development outcomes. Results of longitudinal GEE regression analysis indicate that mother's depressive symptoms were significantly negatively associated with child's social quotient 6 months later. These findings have important implications for targeted health interventions, integrating mental health, both for WLWH and their children in India.

COVID-19 Vaccine Hesitancy Among PLWH in South India: Implications for Vaccination Campaigns.

BACKGROUND: The global effort to end the Severe Acute Respiratory Syndrome - Coronavirus 2 pandemic will depend on our ability to achieve a high uptake of the highly efficacious vaccines in all countries. India recently experienced an unprecedented transmission surge, likely fueled by a premature reopening, the highly transmissible delta variant, and low vaccination rates. Indian media have reported high degrees of vaccine hesitancy, which could interfere with efforts to prevent future surges, making it crucial to better understand the reasons for such reluctance in vulnerable populations, such as people living with HIV. METHODS: We conducted telephone interviews with 438 people living with HIV who were participants in a longitudinal cohort, designed to examine and validate novel antiretroviral therapy ART adherence measures. Interviews were conducted in January and February 2021 and covered COVID-19-related questions on confidence in vaccine safety and efficacy, worries of vaccine side effects, trust in COVID-19 information from specific sources, and intent to get vaccinated. RESULTS: Over one-third of participants (38.4%, n = 168) met our definition of "vaccine hesitant" by reporting being either unlikely to get vaccinated at all or wanting to wait. Vaccine hesitancy was associated with lack of confidence in vaccine safety, concerns about side effects and efficacy, and distrust in common sources of vaccine-related information. DISCUSSION: These results highlight several challenges for vaccination efforts. Campaigns may benefit from using trusted sources, including antiretroviral therapy center staff, providing clear information about safety and efficacy and emphasizing the role of vaccines in preventing severe disease, hospitalizations and death, and the reduction of forward transmission to unvaccinated household members.

Preparedness and Capacity of Indian Palliative Care Services to Respond to the COVID-19 Pandemic: An Online Rapid Assessment Survey.

BACKGROUND: COVID-19 has been causing a high burden of suffering for patients and families. There is limited evidence on the preparedness of Indian palliative care services for the pandemic. AIM: This study aimed to assess the preparedness and capacity of Indian palliative care services in response to the COVID-19 pandemic. METHODS: A cross-sectional online survey was developed based on prior evidence and international health regulations. It was emailed to the Indian Palliative Care Association members and investigators' professional networks in India. One participant per palliative care service was requested. Descriptive analysis was used. RESULTS: Representatives of 78 palliative care services completed the survey. Three in four services had COVID-19 case definition and adapted their protocols for infection control (75%). About half of the services (55%) reported concerns about achieving appropriate hand hygiene in the community. More than half of the services (59%) had capacity to train nonspecialists for symptom control and psychological support. About half of the services reported that they had plans to redeploy staff (56%) and resources (53%) in the case of outbreaks. Two-fifths of the services used paper records to store an updated contact list of staff (40%) and did not have designated focal contacts for information update (40%). Staff anxiety related to personal infection risk and family care was relatively high (median score = 7 on a 1-10 scale). CONCLUSION: We recommend the following resource allocation to enable palliative care services to support the Indian health system in delivering essential care in this and future pandemics: (1) infection control, especially in the community; (2) training using existing clinical protocols to strengthen palliative care across the health system; and (3) redeployment plans.

Cross-cultural adaptation of motivational interviewing for use in rural Nepal.

BACKGROUND: Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person's behaviors. METHODS: We developed, translated, field-tested, and adapted a Nepali MI training module with key informants to generate insights on adapting MI for the first time in this cultural setting. Key informants were five Nepali nurses who supervise community health workers. We used structured observation notes to describe challenges and experiences in cross-cultural adaptation. We conducted this study as part of a larger study on using MI to improve adherence to HIV treatment. RESULTS: Participants viewed MI as an effective intervention with the potential to assist patients poorly engaged in care. Regarding patient autonomy, they initially shared examples of family members unsuccessfully dictating patient behavior change. These discussions led to consensus that every time the family members restrict patient's autonomy, the patient complies temporarily but then resumes their unhealthy behavior. In addition, participants highlighted that even when a patient is motivated to change (e.g., return for follow-up), their family members may not "allow" it. Discussion led to suggestions that health workers may need to conduct MI separately with patients and family members to understand everyone's motivations and align those with the patient's needs. CONCLUSIONS: MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient's autonomy and their role as a member of a complex social fabric to facilitate behavior change.

Risk factors for severity of depression in participants with chronic medical conditions in rural primary health care settings in India.

BACKGROUND: Depression and chronic medical disorders are strongly linked. There are limited studies addressing the correlates of the severity of depression in patients with co-morbid disorders in primary care settings. This study aimed to identify the socio-demographic and disease-specific risk factors associated with the severity of depression at baseline among patients participating in a randomized controlled trial (HOPE study). METHODS: Participants were part of a randomized controlled trial in 49 primary care health centers in rural India. We included adults (≥ 30 years) with at least mild Depression or Anxiety Disorder and at least one Cardiovascular disorder or Type 2 Diabetes mellitus. They were assessed for the severity of depression using the PHQ-9, severity of anxiety, social support, number of co-morbid chronic medical illnesses, anthropometric measurements, HbA1c, and lipid profile. RESULTS: Proportionately there were more women in the moderate category of depression than men. Ordinal logistic regression showed co-morbid anxiety and a lower level of education significantly increased the odds of more severe depression, while more social support was significantly negatively associated with depression severity in women. In men, anxiety was positively associated with greater depression severity; while reporting more social support was negatively associated with depression. LIMITATIONS: This is a cross-sectional study and thus, no causal conclusions are possible. CONCLUSIONS: Anxiety and poor social support in both genders and lower educational levels in women were associated with increased severity of depression. Early identification of risk factors and appropriate treatment at a primary care setting may help in reducing the morbidity and mortality associated with depression.

HIV and Substance Use Stigma, Intersectional Stigma and Healthcare Among HIV-Positive PWID in Russia.

Little is known about the intersection of HIV stigma and substance use stigma. Using data from 188 HIV-positive people who inject drugs (PWID) in Russia, we examined the associations of these stigmas and their interaction with access and utilization of healthcare. While substance use stigma was significantly associated with poor access to care (AOR 2.31, 95%CI 1.50-3.57), HIV stigma was not. HIV stigma was associated with lower inpatient care utilization (AOR 0.32, 95%CI 0.14-0.65), while substance use stigma was not. We did not detect a significant interaction between the two forms of stigma for either of the primary outcomes. However, those with high levels of both substance use stigma and HIV stigma had higher odds of poor general access to healthcare (AOR 1.86, 95%CI 1.19-2.92), and lower odds of recent general outpatient (AOR 0.52, 95%CI 0.32-0.85) and any inpatient (AOR 0.48, 95%CI 0.22-0.99) care utilization compared to those with low levels of both types of stigma. Interventions addressing both substance use and HIV stigma in general healthcare settings might improve care in this HIV key population.