Leveraging Community Health Workers and a Responsive Digital Health System to Improve Vaccination Coverage and Timeliness in Resource-Limited Settings: Protocol for a Cluster Randomized Type 1 Effectiveness-Implementation Hybrid Study.

BACKGROUND: Tanzania is 1 of 20 countries where the majority of unvaccinated and undervaccinated children reside. Prior research identified substantial rural-urban disparities in the coverage and timeliness of childhood vaccinations in Tanzania, with children in rural settings being more likely to receive delayed or no vaccinations. Further research is necessary to identify effective and scalable interventions that can bridge rural-urban gaps in childhood vaccination while accounting for multifaceted barriers to vaccination. OBJECTIVE: This protocol describes a type 1 effectiveness-implementation hybrid study to evaluate Chanjo Kwa Wakati (timely vaccination in Kiswahili), a community-based digital health intervention to improve vaccination timeliness. The intervention combines human resources (community health workers), low-cost digital strategies (electronic communication, digital case management, and task automation), a vaccination knowledge intervention, and insights from behavioral economics (reminders and incentives) to promote timely childhood vaccinations. METHODS: The study will be conducted in 2 predominantly rural regions in Tanzania with large numbers of unvaccinated or undervaccinated children: Shinyanga and Mwanza. Forty rural health facilities and their catchment areas (clusters) will be randomized to an early or delayed onset study arm. From each cluster, 3 cohorts of mother-child dyads (1 retrospective cohort and 2 prospective cohorts) will be enrolled in the study. The timeliness and coverage of all vaccinations recommended during the first year of life will be observed for 1200 children (n=600, 50% intervention group children and n=600, 50% nonintervention group children). The primary effectiveness outcome will be the timeliness of the third dose of the pentavalent vaccine (Penta3). Quantitative surveys, vaccination records, study logs, fidelity checklists, and qualitative interviews with mothers and key informants will inform the 5 constructs of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. The results will be used to develop an implementation blueprint to guide future adaptations and scale-up of Chanjo Kwa Wakati. RESULTS: The study was funded in August 2022. Data collection is expected to last from February 2024 to July 2027. CONCLUSIONS: This study will address the lack of rigorous evidence on the effectiveness of community-based digital health interventions for promoting vaccination coverage and timeliness among children from sub-Saharan Africa and identify potential implementation strategies to facilitate the deployment of vaccination promotion interventions in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT06024317; https://www.clinicaltrials.gov/study/NCT06024317. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52523.

Timeliness of Delivery Care and Maternal and Neonatal Health Outcomes in Private Facilities in Masaka Area, Uganda: A Quasi-Experimental Study.

OBJECTIVES: While access to basic emergency obstetric and newborn care is necessary to reduce maternal and neonatal morbidity in low- and middle-income countries, data on the timeliness and quality of care at lower-level facilities is limited. This study examines timeliness of labor and delivery interventions and maternal and neonatal health status following deliveries in Uganda. METHODS: Women were recruited from 6 rural, private facilities in the greater Masaka area, Uganda on admission to the labor ward. Research assistants directly observed timeliness and quality of care from admission through discharge. Research assistants also abstracted medical chart information. All 6 facilities received training from LifeNet International on quality-of-care interventions for maternal and newborn health. RESULTS: 321 participants were directly observed during delivery, and 304 participants were followed at 28 days postpartum. Labor and delivery processes were overall timely and reflect international guidance on labor interventions. Maternal and neonatal health was good at discharge (90.6% and 88.8%) and 28 days postpartum (93.1% and 87.5%). However, there was no association between health at discharge and at 28 days for mothers or neonates (p = 0.67, p = 1.0, respectively). Demographic characteristics associated with maternal and neonatal health on discharge were different than those associated with maternal and neonatal health at 28 days. CONCLUSIONS FOR PRACTICE: Evidence on timeliness and quality of care can help inform strategies to further decrease maternal and neonatal morbidity. Additional focus is needed to retain patients in care to identify those developing poor health after delivery.

Hopefulness among individuals living with schizophrenia and their caregivers in Tanzania: an actor-partner interdependence model.

BACKGROUND: Hopefulness is a positive orientation or state of mind that can aid in the recovery and treatment of mental illness, as it can have significant impacts on clinical and psychosocial outcomes. As resource-constrained settings work to implement recovery-oriented care, there is a need to better understand hopefulness among people living with schizophrenia (PLWS) and caregivers in their extended family networks. This study seeks to examine the dyadic relationship of hopefulness and its associated correlates among PLWS attending outpatient psychiatric clinics and their caregivers in Tanzania. METHODS: This study utilized baseline and immediate post-intervention data collected as part of a randomized controlled trial testing a culturally tailored model of Family Psychoeducation, KUPAA, in Tanzania. The Herth Hope Index was used to measure hopefulness among PLWS (n = 33) and their caregivers (n = 33) at baseline and immediate post-intervention. Univariable and multivariable regression models were conducted to determine correlates of hopefulness at baseline, while the Actor-Partner Interdependence Model (APIM) was employed to examine the longitudinal, dyadic relationship of hopefulness among and between PLWS and their caregivers. RESULTS: Better family functioning was associated with higher levels of hopefulness in PLWS and their caregivers. Lower levels of stigma, lower symptom severity, and lower disability were associated with higher levels of hopefulness in PLWS. For PLWS and their caregivers, actor effects from the APIM model were less than one (PLWS, [Formula: see text]; caregivers, [Formula: see text]), indicating stability (within each person) in hopefulness over time. Regarding partner effects, a caregiver's baseline hopefulness had a positive effect on the hopefulness of their PLWS at follow-up ([Formula: see text]). This indicates that higher caregiver hope at time 0 is associated with higher levels of hope in PLWS at time 1. Baseline hopefulness levels for PLWS had a negative effect on caregivers' hopefulness at follow-up ([Formula: see text]). This suggests that higher hopefulness among PLWS at baseline is associated with lower levels of hope in caregivers at follow-up. CONCLUSION: Hopefulness is important to consider in family or caregiver-based treatments for PLWS because caregiver hopefulness may influence improvements in hopefulness among PLWS over time. Future studies should further explore the longitudinal dyadic relationship of hopefulness for these populations, as hope is a non-pharmacological and modifiable mechanism of change that is underutilized in care and treatment plans for PLWS globally. TRIAL REGISTRATION: Clinical Trials #NCT04013932, July 10, 2019.

Prevalence of self-reported diabetes risk factors and integration of diabetes screening and referral at two urban HIV care and treatment clinics in Zambia.

People living with HIV (PLWH) on antiretroviral therapy (ART) are living longer and are at risk of HIV co-morbidities including non-communicable diseases (NCDs), particularly in low-resource settings. However, the evidence base for effectively integrating HIV and NCD care is limited. The Chronic Health Care (CHC) checklist, designed to screen for multiple NCDs including a 6-item diabetes self-report screener, was implemented at two PEPFAR-supported HIV clinics in Kabwe and Kitwe, Zambia. Study objectives were to describe the HIV care and treatment population and their self-reported diabetes-related symptoms, and to evaluate provider-initiated screening and referral post-training on the CHC checklist. This cross-sectional study enrolled 435 adults receiving combination ART services. Clinic exit interviews revealed 46% self-reported at least one potential symptom, and 6% self-reported three or more symptoms to the study team, indicating risk for diabetes and need for further diagnostic testing. In comparison, only 8% of all participants reported being appropriately screened for diabetes by their health provider, with less than 1% referred for further testing. This missed opportunity for screening and referral indicates that HIV-NCD integration efforts need more fully resourced and multi-pronged approaches in order to ensure that PLWH who are already accessing ART receive the comprehensive, holistic care they need.

Beyond coverage: Rural-urban disparities in the timeliness of childhood vaccinations in Tanzania.

BACKGROUND: Timely vaccination maximizes efficacy for preventing infectious diseases. In the absence of national vaccination registries, representative sample survey data hold vital information on vaccination coverage and timeliness. This study characterizes vaccination coverage and timeliness in Tanzania and provides an analytic template to inform contextually relevant interventions and evaluate immunization programs. METHODS: Cross-sectional data on 6,092 children under age 3 from the 2015-16 Tanzania Demographic and Health Survey were used to examine coverage and timeliness for 14 vaccine doses recommended in the first year of life. The Kaplan-Meier method was used to model time to vaccination. Cox proportional hazard models were used to examine factors associated with timely vaccination. RESULTS: Substantial rural-urban disparities in vaccination coverage and timeliness were observed for all vaccines. Across 14 recommended doses, documented coverage ranged from 52 % to 79 %. Median vaccination delays lasted up to 35 days; gaps were larger among rural than urban children and for later doses in vaccine series. Among rural children, median delays exceeded 35 days for the 3rd doses of the polio, pentavalent, and pneumococcal vaccines. Median delays among urban children were < 21 days for all doses. Among rural and urban children, lower maternal education and delivery at home were associated with increased risk of delayed vaccination. In rural settings, less household wealth and greater distance to a health facility were also associated with increased risk of delayed vaccination. DISCUSSION: This study highlights persistent gaps in uptake and timeliness of childhood vaccinations in Tanzania and substantial rural-urban disparities. While the results provide an informative situation assessment and outline strategies for identifying unvaccinated children, a national electronic registry is critical for comprehensive assessments of the performance of vaccination programs. The timeliness measure employed in this study-the amount of time children are un- or undervaccinated-may serve as a sensitive performance metric for these programs.

The Health Innovation Impact Checklist: a tool to improve the development and reporting of impact models for global health innovations.

Donor financing is increasingly relying on performance-based measures that demonstrate impact. As new technologies and interventions enter the innovation space to address global health challenges, innovators often need to model their potential impact prior to obtaining solid effectiveness data. Diverse stakeholders rely on impact modeling data to make key funding and scaling decisions. With a lack of standardized methodology to model impact and various stakeholders using different modeling strategies, we propose that a universal innovation impact checklist be used to aid in transparent and aligned modeling efforts. This article describes a new Health Innovation Impact Checklist (HIIC) - a tool developed while evaluating the impact of health innovations funded under the Saving Lives at Birth (SL@B) program. SL@B, a global health Grand Challenge initiative, funded 116 unique maternal and newborn health innovations, four of which were selected for cost-effectiveness analyses (CEAs) within our evaluation. A key data source needed to complete a CEA was the lives saved estimate. HIIC was developed to help validate draft impact models from the SL@B donors and our own team's additional modeling efforts, to ensure the inclusion of standardized elements and to pressure test assumptions for modeling impact. This article describes the core components of HIIC including its strengths and limitations. It also serves as an open call for further reviewing and tailoring of this checklist for applicability across global efforts to model the impact of health innovations.

Perceived burden and family functioning among informal caregivers of individuals living with schizophrenia in Tanzania: a cross-sectional study.

BACKGROUND: Globally, families play a critical role in providing care and support for persons living with schizophrenia. It is important to identify potentially modifiable factors that influence perceived caregiver burden in order to properly address the needs of caregivers. This is especially relevant in low-resource settings where psychiatric services are scarce and interventions could be most effective if targeted to both the individual living with schizophrenia and their caregiver. This study examines correlates of perceived burden among informal caregivers of individuals with schizophrenia in Tanzania, in particular, the association between burden and caregiver-reported family functioning. METHODS: This study used baseline data from an individually randomized controlled trial with 65 pairs of individuals with schizophrenia and their informal caregivers in Dar es Salaam and Mbeya, Tanzania. Caregiver burden was measured using the Burden Assessment Scale. Univariable and multivariable regression analyses were performed to determine the relationship between caregiver burden and family functioning and to explore other correlates of burden. RESULTS: Sixty-three percent of caregivers reported experiencing high burden as a result of caring for a relative with schizophrenia. Multivariable regression analyses revealed that poor family functioning and the caregiver being employed were associated with high caregiver burden, while higher levels of hopefulness in the caregiver was associated with low caregiver burden. CONCLUSION: Caregivers who were employed, reported poor family functioning, and/or had low levels of hopefulness were more likely to perceive high caregiver burden. Future interventions aiming to reduce caregiver burden may benefit from improving family functioning and nurturing hope among caregivers of individuals living with schizophrenia. Policies and programs should be cognizant of the needs of caregivers that work in addition to providing care for a relative with schizophrenia in order to better support them.

Implementation challenges to patient safety in Guatemala: a mixed methods evaluation.

BACKGROUND: Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala. METHODS: We used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation. RESULTS: We found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions. CONCLUSION: Implementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

The impact of a maternal mental health intervention on intimate partner violence in Northern Ghana and the mediating roles of social support and couple communication: secondary analysis of a cluster randomized controlled trial.

BACKGROUNDS: Diverse intervention efforts are implemented to address intimate partner violence (IPV) against women. Via a syndemics theory lens and emerging empirical evidence, mental health interventions demonstrate promise to partially ameliorate IPV. However, the mechanisms of change underlying many IPV interventions are not well understood. These gaps impede our efforts to strengthen or integrate effective components into the current mental health resources, especially in low- and middle-income countries (LMICs). This study aims to examine the impact of a maternal mental health intervention called Integrated Mothers and Babies Course & Early Childhood Development (iMBC/ECD) on IPV and whether social support and/or couple communication mediates the intervention effects among women in rural, Northern Ghana. METHODS: The current study is a secondary data analysis of a cluster randomized controlled trial. IPV was measured at baseline and 8 months post-intervention (~ 19 months post-baseline). At baseline, 84.8% of the women enrolled in the study (n = 374) reported some type of IPV in the past 12 months. Logistic regression models and multiple mediation analyses were used to address the study aims. RESULTS: iMBC/ECD did not reduce IPV in the intervention group compared to the control group. Social support and couple communication did not mediate the intervention effects on IPV as indicated by the indirect effects of the multiple mediation models. However, increase in social support reduced women's odds of experiencing emotional violence by 7%, odds ratio (OR) = 0.93, p = 0.007; b = - 0.07, 95% confidence interval (CI) = (- 0.13, - 0.02), and improvement in couple communication demonstrated promise in reducing women's odds of experiencing controlling behaviors by 7%, OR = 0.93, p = 0.07; b = - 0.07, CI = (- 0.14, 0.005), though the improvements were not due to the intervention. CONCLUSION: This maternal mental health intervention did not reduce IPV; however, the findings extend our knowledge about the impact of such interventions on IPV and the potential mechanisms of change via social support and couple communication. Future research evaluating the impact of mental health interventions on IPV and mechanisms of change is essential for the development of effective interventions. Future programs addressing IPV in LMICs should consider risk factors beyond relationship level (e.g. poverty and gender inequity). TRIAL REGISTRATION: ClinicalTrials.gov # NCT03665246 , Registered on August 20th, 2018.

Correlates of early stimulation activities among mothers of children under age two in Siaya County, Kenya: Maternal mental health and other maternal, child, and household factors.

RATIONALE: The first two to three years of life are critical for early child development (ECD), which affects later life trajectories in health, development, and earning potential. Global calls for early stimulation activities to support optimal development among young children are increasing and there is a need to better understand the factors associated with maternal engagement in early stimulation activities, particularly maternal mental health. OBJECTIVE: This study examined important factors associated with early stimulation activities performed by mothers of children ages 0-2 in rural Kenya. METHODS: Baseline cohort data from an evaluation of an integrated maternal mental health and an ECD intervention included 374 interviews with mothers of children under 24 months. Descriptive and multivariable analyses were performed. RESULTS: Maternal mental health was not associated with maternal early stimulation activities. Having worked in the past week was associated with more frequent early stimulation activities. At the child level, female sex was associated with more frequent early stimulation activities but prematurity at birth was associated with less frequent early stimulation activities. At the household level, ownership of children's toys and books was associated with more frequent early stimulation activities. CONCLUSIONS: This study indicates that both mothers and families could benefit from availability of ECD-friendly resources such as homemade toys and children's books (particularly for low-income families), and tailored messaging to support early stimulation activities for both girl and boy children and for those prematurely-born. Local governments and community-based programs can aim to both raise awareness about the importance of early childhood development and educate caregivers on specific age-appropriate early stimulation activities that promote optimal growth. Future research should also explore the reciprocal and temporal relationships between maternal mental health and early stimulation activities to inform and elucidate their potential synergistic impact on ECD.

The Effects of Antenatal Depression and Women's Perception of Having Poor Health on Maternal Health Service Utilization in Northern Ghana.

OBJECTIVES: To examine the effects of antenatal depression and women's perceived health during the antenatal period on maternal health service utilization in rural northern Ghana; including how the effect of antenatal depression on service use might be modified by women's perceived health. METHODS: Probable antenatal depression was assessed using the Patient Health Questionnaire (PHQ-9). Linear regression was used for the outcome of number of antenatal care (ANC) visits, and logistic regression was used for the outcomes of facility delivery, postnatal care (PNC) within 7 days and completion of continuum of care. Continuum of care was defined as having had four or more ANC visits, delivered at a health facility and had PNC visit within 7 days. RESULTS: Antenatal depression had very small or no association with maternal health service utilization. Women with self-perceived fair or poor health were significantly less likely to use PNC within 7 days and less likely to complete the continuum of care. As for effect modification, we found that for women with probable moderate or severe antenatal depression (a score of 10 or greater), those with perceived fair or poor health used fewer ANC visits and were less likely to use PNC within 7 days than those with perceived excellent, very good or good health. CONCLUSIONS: Women experiencing moderate or severe antenatal depression and/or who self-perceive as having poor health should be identified and targeted for additional support to access and utilize maternal health services.

Improving global maternal and newborn survival via innovation: Stakeholder perspectives on the Saving Lives at Birth Grand Challenge.

The Saving Lives at Birth (SL@B) funding partners joined in 2011 to source, support, and scale maternal and newborn health (MNH) innovations to improve maternal and newborn survival by focusing on the 24 hours around the time of birth. A multi-methods, retrospective portfolio evaluation was conducted to determine SL@B's impact. Forty semi-structured, key informant interviews (KIIs) were conducted with experts in global MNH based in low- and middle-income and in high-income countries to assess the SL@B program. KIIs were conducted with global MNH technical experts, innovators, government officials in low- and middle-income countries, donors, private investors, and implementing partners to include the full spectrum of voices involved in identifying and scaling innovations. Data were analyzed using thematic analysis. Stakeholders believe the SL@B program has been successful in changing the way maternal and newborn health programs are delivered with a focus on doing things differently through innovation. The open approach to sourcing innovation was seen as positive to the extent that it brought more interdisciplinary stakeholders to think about the problem of maternal and newborn survival. However, a demand-driven approach that aims to source innovations that address MNH priority needs and takes into account the needs of end users (e.g. individuals and governments) was suggested as a strategy for ensuring that more innovations go to scale.

Impact evaluation of a maternal and neonatal health training intervention in private Ugandan facilities.

Global and country-specific targets for reductions in maternal and neonatal mortality in low-resource settings will not be achieved without improvements in the quality of care for optimal facility-based obstetric and newborn care. This global call includes the private sector, which is increasingly serving low-resource pregnant women. The primary aim of this study was to estimate the impact of a clinical and management-training programme delivered by a non-governmental organization [LifeNet International] that partners with clinics on adherence to global standards of clinical quality during labour and delivery in rural Uganda. The secondary aim included describing the effect of the LifeNet training on pre-discharge neonatal and maternal mortality. The LifeNet programme delivered maternal and neonatal clinical trainings over a 10-month period in 2017-18. Direct clinical observations of obstetric deliveries were conducted at baseline (n = 263 pre-intervention) and endline (n = 321 post-intervention) for six faith-based, not-for-profit primary healthcare facilities in the greater Masaka area of Uganda. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum haemorrhage and neonatal resuscitation). Data were supplemented by daily facility-based assessments of infrastructure during the study periods. Results showed positive and clinically meaningful increases in observed handwashing, observed delayed cord clamping, partograph use documentation and observed 1- and/or 5-minute APGAR assessments (rapid scoring system for assessing clinical status of newborn), in particular, between baseline and endline. High-quality intrapartum facility-based care is critical for reducing maternal and early neonatal mortality, and this evaluation of the LifeNet intervention indicates that their clinical training programme improved the practice of quality maternal and neonatal healthcare at all six primary care clinics in Uganda, at least over a relatively short-term period. However, for several of these quality indicators, the adherence rates, although improved, were still far from 100% and could benefit from further improvement via refresher trainings and/or a closer examination of the barriers to adherence.

Effect of a lay counselor-delivered integrated maternal mental health and early childhood development group-based intervention in Northern Ghana: a cluster-randomized controlled trial.

BACKGROUND: Caregiver mental health is linked to early childhood development, yet more robust evidence of community-based interventions to prevent maternal depression and optimize socio-emotional development of young children is needed. Objectives of this cluster-randomized controlled trial (cRCT), based in Northern Ghana, are to assess the impact of the lay counselor-delivered, group-based Integrated Mothers and Babies Course and Early Childhood Development (iMBC/ECD) program on (1) the mental health of mothers of children under age 2; and (2) the socio-emotional development of their children. METHODS: This cRCT randomized 32 women's groups - 16 received iMBC/ECD content (intervention) and 16 received general health education content (control). Surveys were administered at baseline, immediate post-intervention, and 8-month post-intervention. The primary outcome was maternal depression [Patient Health Questionnaire (PHQ-9)], and the secondary outcome was child's socio-emotional development [Ages and Stages Questionnaire: Social Emotional (ASQ:SE-2)]. Qualitative interviews with 33 stakeholders were also conducted. RESULTS: In total, 374 participants were enrolled at baseline while pregnant with the index child, 19% endorsing moderate/severe depression. Of these, 266 (71.1%) completed the 8-month post-intervention survey (~19 months post-baseline). There were no significant effects of iMBC/ECD on PHQ-9 and ASQ:SE-2 scores. However, results favored the intervention arm in most cases. iMBC participants were highly satisfied with the program but qualitative feedback from stakeholders indicated some implementation challenges. CONCLUSIONS: This real-world evaluation had null findings; however, post-intervention depression levels were very low in both arms (3%). Future research should examine the potential impact of women's groups on postpartum mental health more broadly with varying content.

Effect of a lay counselor delivered integrated maternal mental health and early childhood development group-based intervention in Siaya County, Kenya: A quasi-experimental longitudinal study.

BACKGROUND: Maternal mental health is linked to early childhood development; yet there is a gap in evidence-based interventions for low-resource settings. This study estimates the impact of 'Integrated Mothers and Babies Course and Early Childhood Development' (iMBC/ECD), a cognitive-behavioral, group-based intervention, on maternal depression and early childhood social-emotional development in Siaya County, Kenya. METHODS: This quasi-experimental study enrolled 417 pregnant women and mothers of children under age 2 across two sub-counties in Siaya County. The intervention area had 193 women in 23 groups implementing iMBC/ECD and the control area had 224 women in 30 groups exposed to ECD only content. Mother/index child dyads were followed for two years. To estimate the causal treatment effect from the non-randomized design, we implemented the propensity score weighting method with inverse probability weights. RESULTS: At baseline, 10.2% of participants endorsed moderate/severe depressive symptoms. At 14-months post-intervention, 7.4% endorsed moderate/severe depression. Overall, iMBC/ECD intervention did not have a significant impact on reducing maternal depression or improving children's social and emotional development. However, sub-group analyses revealed that iMBC/ECD was associated with lowered depressive symptoms among women with no/low education, four or more children and/or no experience of intimate partner violence in the past year. Women with high program attendance (more than half of 14 sessions) also experienced consistently fewer depressive symptoms compared to those with lower attendance. LIMITATIONS: Non-randomized study, sub-group analyses are exploratory. CONCLUSIONS: The iMBC/ECD program may have the potential to improve maternal mental health and early child development for more targeted vulnerable populations.

Medical record bias in documentation of obstetric and neonatal clinical quality of care indicators in Uganda.

OBJECTIVE: To achieve a high quality of care (QoC), accurate measurements are needed. This study evaluated the validity of QoC data from the medical records for childbirth deliveries and assessed whether medical records can be used to evaluate the efficacy of interventions to improve QoC. STUDY DESIGN AND SETTING: This study was part of a larger study of QoC training program in Uganda. Study data were collected in two phases: (1) validation data from 321 direct observations of deliveries paired with the corresponding medical records; (2) surveillance data from 1,146 medical records of deliveries. Sensitivity, specificity, and predictive values were used to measure the validity of the medical record from the validation data. Quantitative bias analysis was conducted to evaluate QoC program efficacy in the surveillance data using prevalence ratio and odds ratio. RESULTS: On average, sensitivity (84%) of the medical record was higher than the specificity (34%) across 11 QoC indicators, showing a higher validity in identifying the performed procedure. For 5 out of 11 indicators, bias-corrected odds ratios and prevalence ratios deviated significantly from uncorrected estimates. CONCLUSION: The medical records demonstrated poor validity in measuring QoC compared with direct observation. Using the medical record to assess QoC program efficacy should be interpreted carefully.

Common mental disorders and intimate partner violence against pregnant women living with HIV in Cameroon: a cross-sectional analysis.

BACKGROUND: Women living with HIV are at increased risk of poor mental health and intimate partner violence (IPV). Mental health disorders have been consistently associated with suboptimal HIV-related outcomes. Little is known about the prevalence or correlates of mental health disorders among pregnant women living with HIV in sub-Saharan Africa. METHODS: This study assessed the prevalence of probable common mental disorders (CMD), i.e., depressive or anxiety disorders, and the relationship between probable CMD and recent IPV among pregnant women living with HIV in Cameroon. The sample included 230 pregnant women living with HIV aged > 18 enrolled in care at 10 HIV clinics in Cameroon. Probable CMD was assessed with the WHO Self Reporting Questionnaire (SRQ-20). Multivariable logistic regression was conducted to assess the relationship between IPV and probable CMD. RESULTS: Almost half (42%) of participants had probable CMD using a 7/8 cut-off of the SRQ-20. Emotional, physical, and sexual IPV were reported by 44, 37, and 31% of respondents, respectively. In multivariable regression analyses, all forms of IPV assessed were significantly associated with greater odds of probable CMD. CONCLUSIONS: Pregnant women living with HIV in Cameroon had a high prevalence of probable CMD and IPV. Screening and services to address IPV and mental health are urgently needed for this population. Integrated interventions to both prevent and screen and address IPV and probable CMD should be developed, implemented, and evaluated.

The syndemic effects of mental ill health, household hunger, and intimate partner violence on adherence to antiretroviral therapy among pregnant women living with HIV in Yaoundé, Cameroon.

BACKGROUND: This research advances understanding of interrelationships among three barriers to adherence to antiretroviral therapy (ART) among pregnant women living with HIV (WLWH) in Cameroon: probable common mental disorders (CMD), intimate partner violence (IPV), and hunger. METHODS: The sample included 220 pregnant WLWH in Cameroon. Multivariable modified Poisson regression was conducted to assess the relationship between IPV, hunger, and CMD on ART adherence. RESULTS: Almost half (44%) of participants recently missed/mistimed an ART dose. Probable CMD was associated with greater risk of missed/mistimed ART dose (aRR 1.5 [95% CI 1.1, 1.9]). Hunger was associated with greater risk of missed/mistimed ART dose among those who reported IPV (aRR 1.9 [95% CI 1.2, 2.8]), but not among those who did not (aRR 0.8 [95% CI 0.2, 2.3]). CONCLUSION: Suboptimal ART adherence, CMD, and IPV were common among pregnant WLWH in Cameroon. Pregnant WLWH experiencing IPV and hunger may be especially vulnerable to suboptimal ART adherence.

Prevalence and correlates of maternal early stimulation behaviors during pregnancy in northern Ghana: a cross-sectional survey.

BACKGROUND: Per UNICEF's Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana. METHODS: This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis. RESULTS: About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors. CONCLUSION: Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development. TRIAL REGISTRATION: Clinical Trials # NCT03665246 , August 29, 2018.