Water, Sanitation, and Hygiene Infrastructure and Resources in Schools in Belize during the COVID-19 Pandemic, 2021-2023.

Access to water, sanitation, and hygiene (WASH) resources in schools is critical for disease prevention and control, especially during public health emergencies. In Belize, systematic, national data on WASH in schools are needed to inform public health decisions and interventions. From December 2021 to January 2022, a national survey was sent electronically to government and government-aided primary and secondary schools in Belize (N = 308) to gather information on WASH services. From the survey, 12 pilot schools were selected based on the highest self-reported need for WASH resources to participate in additional evaluation and intervention, which included environmental nudges, supplemental supply provision, and hand hygiene education. To understand how the progression of the COVID-19 pandemic may have influenced hand hygiene, facility assessments to evaluate access to hand hygiene resources were conducted in person when most schools reopened for face-to-face learning during the pandemic (March 2022) and 15 months later (June 2023). Among the schools participating in the national survey (N = 221), 55% reported times when water was not available at the schools. Almost 9 in 10 schools (89%) had a functional handwashing station, and 47% reported always having soap for handwashing. Between baseline and follow-up at the 12 pilot schools, we observed decreases in the proportion of functional handwashing access points (-11%), functional handwashing access points accessible for individuals with disabilities (-17%) and small children (-29%), and functional alcohol-based hand rub dispensers (-13%). Despite the ongoing COVID-19 pandemic, we observed gaps in WASH resources in schools in Belize during the onsite assessments at the pilot schools. Schools should be encouraged and provided with WASH resources to maintain vigilance for disease control measures.

Novel species of Triatoma (Hemiptera: Reduviidae) identified in a case of vectorial transmission of Chagas disease in northern Belize.

Chagas disease is a leading cause of non-ischemic cardiomyopathy in endemic regions of Central and South America. In Belize, Triatoma dimidiata sensu lato has been identified as the predominate taxon but vectorial transmission of Chagas disease is considered to be rare in the country. We recently identified an acute case of vector-borne Chagas disease in the northern region of Belize. Here we present a subsequent investigation of triatomines collected around the case-patient's home. We identified yet undescribed species, closely related to Triatoma huehuetenanguensis vector by molecular systematics methods occurring in the peridomestic environment. The identification of a T. cruzi-positive, novel species of Triatoma in Belize indicates an increased risk of transmission to humans in the region and warrants expanded surveillance and further investigation.

Manatees display diel trends in acoustic activity at two microhabitats in Belize.

Many marine mammals exhibit diel trends in vocal production, which can provide information on habitat use and behavioral activity. In Belize, Antillean manatees (Trichechus manatus manatus) commonly inhabit small depressions in the substrate or deep-water coves known as "resting holes". Determining if manatees exhibit diel temporal trends in their call production rate and call types between microhabitats can provide insights into their diurnal and nocturnal activity patterns. Here, we investigate the diel vocalization patterns of wild Antillean manatees in two adjacent resting holes off of St. George's Caye, Belize. Recordings of manatees were made using a bottom-mounted hydrophone located near a reef barrier reef for nine days in July of 2017 and ten days in January of 2018. To explore if and how manatee acoustic activity differs between sites, we compared the number of calls per hour, the number of manatee positive hours, the number of tonal and atonal sounds, and the number of boats detected across sites. A total of 370 hours of acoustic recordings were analyzed resulting in the detection of 3,262 calls. There were no significant differences in the number of manatee calls produced per hour between sites. The average number of calls produced by manatees decreased over the course of several days. The proportion of tonal calls decreased with hours after sunset and increased in boat presence. These results suggest manatees in this region may exhibit different diel activity patterns which appear to be influenced by the characteristics of the environment. These findings can support ongoing conservation and management efforts to safeguard species in Belize.

Plant medicine usage of people living with type 2 diabetes mellitus in Belize: A qualitative exploratory study.

BACKGROUND: Type 2 Diabetes Mellitus (T2DM) is a primary cause of death in Belize, a low-income country with the highest rates in Central and South America. As many people in Belize cannot consistently access biomedical treatment, a reality that was exacerbated by the COVID-19 pandemic, plant medicine usage is estimated to have increased in recent years. This exploratory study seeks to understand which plants are being used, patterns of usage, and the state of patient-provider communication around this phenomenon. METHODS: Implementing a Constructivist Grounded Theory qualitative design, the research team conducted 35 semi-structured interviews with adults living with T2DM, 25 informant discussions, and participant observation with field notes between February 2020 and September 2021. Data analysis followed systematized thematic coding procedures using Dedoose analytic software and iterative verification processes. RESULTS: The findings revealed that 85.7% of participants used plants in their T2DM self-management. There were three main usage patterns, namely, exclusive plant use (31.4%), complementary plant use (42.9%), and minimal plant use (11.4%), related to factors impacting pharmaceutical usage. Almost none of participants discussed their plant medicine usage with their health care providers. CONCLUSIONS: Plant species are outlined, as are patients' reasons for not disclosing usage to providers. There are implications for the advancement of understanding ethnobotanical medicine use for T2DM self-management and treatment in Belize and beyond.

Voices of those living with type 2 diabetes in Belize: barriers to care before and during the COVID-19 pandemic.

Belize has the highest national prevalence of type 2 diabetes (T2D) of Central and South America, and fifth direst in the world. T2D is the leading cause of death in Belize, a country facing burdens of increasing prevalence with few resources. Since March of 2020, the COVID-19 pandemic has exacerbated the difficulties of those living with T2D in Belize. To address T2D issues in Belize, our interdisciplinary research team explored the barriers to care and self-management for adult patients with T2D in Belize prior to and during the COVID-19 pandemic.Research relationships between Canadian (ARH) and Belizean (LE) authors have been ongoing since 2016. Together we used a qualitative Constructivist Grounded Theory design generating knowledge through 35 semi-structured patient interviews, 25 key informant discussions, and participant observation with field notes between February 2020 to September 2021. We used Dedoose analysis software for a systematized thematic coding process, as well as iterative verification activities. Findings revealed several barriers to care and self-management, including: 1) the tiered health and social care system with major gaps in coverage; 2) the unfulfilled demand for accurate health information and innovative dissemination methods; and 3) the compounding of loss of community supports, physical exercise, and health services due to COVID-19 restrictions. In the post-pandemic period, it is necessary to invest in physical, nutritional, economic, and psychosocial health through organized activities adaptable to changeable public health restrictions. Recommendations for activities include sending patients informational and motivational text messages, providing recipes with accessibly sourced T2D foods, televising educational workshops, making online tools more accessible, and mobilising community and peer support networks.

Qualitative study of in-kind incentives to improve healthcare quality in Belize: Is quality work better than wealth?

BACKGROUND: There is a sparsity of knowledge of the specific mechanisms through which financial and non-financial incentives impact the performance of health teams. This study aims to address this knowledge gap by examining an in-kind incentives program for healthcare teams implemented in three districts in Belize (2012-2022) as part of the Salud Mesoamerica Initiative, which aimed to improve healthcare quality. METHODS: We performed a qualitative study to understand the mechanisms through which the in-kind incentive program supported quality improvement in Belize. We conducted key informant interviews (April-June 2021) remotely on a sample of former and current healthcare workers from Belize's Ministry of Health and Wellness familiar with the program. We analyzed responses using qualitative content analysis. We used open coding to identify patterns and themes. RESULTS: We conducted eight key informant interviews from a pool of thirty potential informants. Our analysis of the interviews yielded a total of 11 major themes with 27 subthemes. Most informants reported that in-kind incentives were not the primary motivation for improving their performance, though they did acknowledge that incentives had increased their attention on the quality of care provided. Conversely, we found that quarterly measurements and supportive supervision by national level authorities offered an external validation mechanism and instilled frontline staff with a sense of shared responsibility towards improving their performance. The majority of informants conveyed positive opinions about the in-kind incentives program. CONCLUSIONS: Our study contributes to the understanding of how in-kind incentives can enhance performance. We found that in-kind incentives created extrinsic motivation, leading to an increased focus on quality. Standardized measurements and supportive supervision improved intrinsic motivation and formed a stronger commitment to quality of care. Rather than focusing on tangible incentives, explicitly incorporating standardized measurements and supportive supervision in the routine work of the Ministry of Health could have longer lasting effects on quality improvement.

The adoption of climate-smart agriculture to address wildfires in the Maya Golden Landscape of Belize: Smallholder farmers' perceptions.

Ecosystems around the globe are enduring wildfires with greater frequency, intensity, and severity and this trend is projected to continue as a result of climate change. Climate-smart agriculture (CSA) has been proposed as a strategy to prevent wildfires and mitigate climate change impacts; however, it remains poorly understood as a strategy to prevent wildfires. Therefore, the authors propose a multimethod approach that combines mapping of wildfire susceptibility and social surveys to identify priority areas, main factors influencing the adoption of CSA practices, barriers to their implementation, and the best CSA practices that can be implemented to mitigate wildfires in Belize's Maya Golden Landscape (MGL). Farmers ranked slash and mulch, crop diversification, and agroforestry as the main CSA practices that can be implemented to address wildfires caused by agriculture in the MGL. In order to reduce wildfire risk, these practices should, be implemented in agricultural areas near wildlands with high wildfire susceptibility and during the fire season (February-May), in the case of slash and mulch. However, socio-demographic and economic characteristics, together with a lack of training and extension services support, inadequate consultation by agencies, and limited financial resources, hinder the broader adoption of CSA practices in the MGL. Our research produced actionable and valuable information that can be used to design policies and programs to mitigate the impacts of climate change and wildfire risk in the MGL. This approach can also be used in other regions where wildfires are caused by agricultural practices to identify priority areas, barriers and suitable CSA practices that can be implemented to mitigate wildfires.

9000 years of change in coral community structure and accretion in Belize reefs, western Atlantic.

Tropical coral reefs, as prominent marine diversity hotspots, are in decline, and long-term studies help to improve understanding of the effects of global warming, sea-level rise, ocean acidification, deterioration of water quality, and disease. Here, we evaluated relative coral abundance and reef accretion rates over the past 9000 years in Belize barrier and atoll reefs, the largest reef system in the Atlantic Ocean. Acropora palmata and Orbicella spp. have been the most common corals. The abundance of competitive, fast-growing acroporids was constant over multi-millennial timescales. A decline in A. cervicornis abundance, however, and three centennial-scale gaps in A. palmata occurrence, suggest that the modern decline in acroporids was not unprecedented. Stress-tolerant corals predominate at the beginning of Holocene successions. Following the improvement of environmental conditions after inundation of the reef pedestal, their abundance has decreased. The abundance of weedy corals has increased during the Holocene underlining the importance of fecundity for the coral community. Reef-accretion rate, as calculated based on 76 new U-series age dates, has decreased over the Holocene and the mean value of 3.36 m kyr-1 is at the lower end of global reef growth compilations and predicted future rates of rise in sea level.

Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis.

PURPOSE: Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services. METHODS: Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model. RESULTS: We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening. CONCLUSION: Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.

Redescription of the mole crab Emerita portoricensis Schmitt, 1935 (Crustacea: Decapoda: Hippidae), based on Caribbean populations from Puerto Rico, Belize, Costa Rica, and Panama.

The mole crab Emerita portoricensis Schmitt, 1935 was originally described solely on the basis of few key characters that were not precisely defined, giving reason to question subsequent reports of its distribution. The present study, prompted by recent collections documenting coloration in life, undertakes a comprehensive redescription of the species based on specimens of varied sizes from Puerto Rico, Belize, Costa Rica, and Panama. Collections from the northern Caribbean that at first take appear to represent a northernmost record of E. brasiliensis Schmitt, 1935 or southernmost occurrence of E. talpoida (Say, 1817), may be assignable E. portoricensis as now recognized. Among western Atlantic species, E. portoricensis and E. benedicti have to date been considered to have the dactylus of the first pereopod terminally subacute or sharply pointed, which purportedly separates them from E. brasiliensis and E. talpoida, western Atlantic species in which this article is terminally rounded. However, in E. portoricensis this character varies with specimen size and the magnification at which the distal extreme of the dactylus is examined, being rounded to varying degrees in all but the largest specimens. Even in sexually mature specimens of less than maximum size, this rounded tip is armed by a minute corneous spine in E. portoricensis, although it is less prominent than the terminal spine on the consistently more acute dactylus of E. benedicti at all adult sizes. Also, the carapace color in live specimens of E. portoricensis, as documented for specimens collected in both Belize and Panama, differs from that of E. brasiliensis, E. talpoida, and E. benedicti by typically including longitudinal and diagonal dark bars of olive brown on the branchial regions and a light longitudinal bar marking the posterior quarter of the median line. Posterior to the cervical groove, fine rugae of the carapace that form broken transverse lines are at most little diminished across the mid-dorsal longitudinal line in E. portoricensis and E. benedicti, somewhat more broken in E. brasiliensis, and distinctly diminished to all but absent at the midline in E. talpoida. Previously reported BINs in the Barcode of Life database include sequenced specimens from Costa Rica herein accepted as E. portoricensis. We exclude populations from Brazil that have been mis-assigned to E. portoricensis.

Trends and factors associated with HIV testing among women aged 15-49 years in Belize: an analysis using the Multiple Indicator Cluster Survey 2006, 2011, and 2015-2016.

BACKGROUND: Belize has one of the highest human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome prevalence rates in Central America, with women of reproductive age being particularly vulnerable to HIV. Therefore, this study examined the factors associated with HIV testing among women of reproductive age in Belize and trends in HIV testing in 2006, 2011, and 2015-2016. METHODS: Cross-sectional data were analyzed using three Belize Multiple Indicator Cluster Surveys. The number of participants were 1,675, 4,096, and 4,699 women aged 15-49 years in 2006, 2011, and 2015-2016, respectively. We used variance-weighted least-squares regression to estimate annual changes. Multivariate logistic regression analysis was performed to evaluate the associated factors. Analyses were conducted using Stata version 15, and weights were applied for generalization to the population. RESULTS: HIV testing rates increased from 47.7% in 2006 to 66.5% in 2015, with an average annual change of 0.082 (95% confidence interval: 0.07-0.09). Logistic regression models showed that women aged 15-24 years were less likely to have been tested for HIV compared to women aged 25-34 years. Women from the Mayan ethnic group were less likely to have been tested than those from other ethnic groups. Compared to women who spoke Spanish, those who spoke English/Creole were more likely to have been tested for HIV; additionally, those who spoke minority languages were less likely to have been tested. Being married and having given birth were associated with increased odds of HIV testing. Living in rural areas and households with the poorest wealth indices were associated with decreased odds of being tested for HIV. Women with good HIV knowledge and accepting attitudes towards people living with HIV were more likely to be tested. CONCLUSIONS: From 2006 to 2015, HIV testing in women of reproductive age showed an increasing trend in Belize. We recommend interventions to expand HIV testing for women of reproductive age in Belize, particularly those aged 15-24 years, speaking minority languages, living in rural areas, and having a low socioeconomic status.

HEMATOLOGIC AND BIOCHEMICAL VALUES OF FREE-RANGING HAWKSBILL SEA TURTLES (ERETMOCHELYS IMBRICATA) IN GLOVER'S REEF, BELIZE.

Blood samples were obtained from the dorsal cervical sinus of free-ranging hawksbill sea turtles (Eretmochelys imbricata) collected at Glover's Reef Marine Reserve, 42 km east of the coast of Belize, for hematology and plasma biochemistry analysis. Unknown sex, subadult turtles (N = 32) were sampled in 2013 (n = 22) and 2017 (n = 10). To provide a more robust data set, parameters that did not have statistically significant differences were pooled and treated as a single population. Eleven hematologic parameters were evaluated; of these, five were pooled. Twenty-three plasma biochemical parameters were evaluated; of these, 15 were pooled. The PCV observed in this study (mean 33.44%) was double that observed in two studies of juvenile hawksbills in Dubai (means 17% and 16%), whereas the total WBC count was half that observed in immature and adult hawksbills sampled in the Galápagos (mean 2.91 × 103 versus 5.3 × 103/µl). Total protein and albumin were lower than regionally similar, adult female hawksbills in Brazil (means 3.36 versus 5.45 g/dl and 0.93 versus 2.11 g/dl, respectively). Globulins were higher (mean 2.43 versus 1.06 and 0.5 g/dl), driving the albumin:globulin ratio lower than that observed in two studies of juvenile hawksbills in Dubai (0.4:1 versus 1.1:1 and 1:1, respectively). These findings represent a geographically distinct population from previous reports, highlight the variability in blood parameters from disparate populations, and reaffirm the vital importance of considering a multitude of variables when interpreting reptilian blood values. The similarities in the majority of values observed in 2013 and 2017 provide confidence in the stability of these parameters in this population.

Cancer Demographics and Time-to-Care in Belize.

BACKGROUND: Belize is a middle-income Caribbean country with poorly described cancer epidemiology and no comprehensive cancer care capacity. In 2018, GO, Inc., a US-based NGO, partnered with the Ministry of Health and the national hospital in Belize City to create the first public oncology clinic in the country. Here, we report demographics from the clinic and describe time intervals to care milestones to allow for public health targeting of gaps. PATIENTS AND METHODS: Using paper charts and a mobile health platform, we performed a retrospective chart review at the Karl Heusner Memorial Hospital (KHMH) clinic from 2018 to 2022. RESULTS: During this time period, 465 patients with cancer presented to the clinic. Breast cancer (28%) and cervical cancer (12%) were most common. Most patients (68%) presented with stage 3 or 4 disease and were uninsured (78%) and unemployed (79%). Only 21% of patients ever started curative intent treatment. Median time from patient-reported symptoms to a biopsy or treatment was 130 and 189 days. For the most common cancer, breast, similar times were seen at 140 and 178 days. Time intervals at the clinic: <30 days from initial visit to biopsy (if not previously performed) and <30 days to starting chemotherapy. CONCLUSION: This study reports the first clinic-based cancer statistics for Belize. Many patients have months between symptom onset and treatment. In this setting, the clinic has built infrastructure allowing for minimal delays in care despite an underserved population. This further affirms the need for infrastructure investment and early detection programs to improve outcomes in Belize.

Diversity and distribution of orchid bees (Hymenoptera: Apidae, Euglossini) in Belize.

Background: Orchid bees are abundant and widespread in the Neotropics, where males are important pollinators of orchids they visit to collect fragrant chemicals later used to court females. Assemblages of orchid bees have been intensively surveyed in parts of Central America, but less so in Belize, where we studied them during the late-wet and early-dry seasons of 2015-2020. Methods: Using bottle-traps baited with chemicals known to attract a variety of orchid bee species, we conducted surveys at sites varying in latitude, historical annual precipitation, elevation, and the presence of nearby agricultural activities. Each sample during each survey period consisted of the same number of traps and the same set of chemical baits, their positions randomized along transects. Results: In 86 samples, we collected 24 species in four genera: Euglossa (16 species), Eulaema (3), Eufriesea (3), and Exaerete (2). During our most extensive sampling (December 2016-February 2017), species diversity was not correlated with latitude, precipitation, or elevation; species richness was correlated only with precipitation (positively). However, a canonical correspondence analysis indicated that species composition of assemblages varied across all three environmental gradients, with species like Eufriesea concava, Euglossa imperialis, and Euglossa viridissima most common in the drier north, and Euglossa ignita, Euglossa purpurea, and Eulaema meriana more so in the wetter southeast. Other species, such as Euglossa tridentata and Eulaema cingulata, were common throughout the area sampled. Mean species diversity was higher at sites with agricultural activities than at sites separated from agricultural areas. A Chao1 analysis suggests that other species should yet be found at our sites, a conclusion supported by records from adjacent countries, as well as the fact that we often added new species with repeated surveys of the same sites up through early 2020, and with the use of alternative baits. Additional species may be especially likely if sampling occurs outside of the months/seasons that we have sampled so far.

Coral Gardens Reef, Belize: An Acropora spp. refugium under threat in a warming world.

Live coral cover has declined precipitously on Caribbean reefs in recent decades. Acropora cervicornis coral has been particularly decimated, and few Western Atlantic Acropora spp. refugia remain. Coral Gardens, Belize, was identified in 2020 as a long-term refugium for this species. This study assesses changes in live A. cervicornis coral abundance over time at Coral Gardens to monitor the stability of A. cervicornis corals, and to explore potential threats to this important refugium. Live coral cover was documented annually from 2012-2019 along five permanent transects. In situ sea-surface temperature data were collected at Coral Gardens throughout the study period and compared with calibrated satellite data to calculate Maximum Monthly Mean (MMM) temperatures and Degree Heating Weeks (DHW). Data on bathymetry, sediment, substrate, herbivore abundance, and macroalgal abundance were collected in 2014 and 2019 to assess potential threats to Coral Gardens. Live coral cover declined at all five transect sites over the study period. The greatest loss of live coral occurred between 2016 and 2017, coincident with the earliest and highest maximum average temperatures recorded at the study site, and the passage of a hurricane in 2016. Structural storm damage was not observed at Coral Gardens, though live coral cover declined after the passage of the storm. Uranium-thorium (230Th) dating of 26 dead in situ fragments of A. cervicornis collected in 2015 from Coral Gardens revealed no correlation between coral mortality and tropical storms and hurricanes in the recent past. Our data suggest that several other common drivers for coral decline (i.e. herbivory, predation, sedimentation, pH) may likely be ruled out for Coral Gardens. At the end of the study period, Coral Gardens satisfied most criteria for refugium status. However, the early onset, higher mean, and longer duration of above-average temperatures, as well as intermittent temperature anomalies likely played a critical role in the stability of this refugium. We suggest that temperature stress in 2016 and perhaps 2015 may have increased coral tissue vulnerability at Coral Gardens to a passing hurricane, threatening the status of this unique refugium.

Burnout, mental health, physical symptoms, and coping behaviors in healthcare workers in Belize amidst COVID-19 pandemic: A nationwide cross-sectional study.

BACKGROUND: Healthcare workers are vulnerable to burnout, especially during the COVID-19 pandemic in the low resource settings. Belize is a small Central American developing country known for its chronic healthcare worker shortage and this is the first study to assess burnout prevalence and its associated factors among healthcare workers in Belize. AIM: To evaluate the prevalence of burnout and its associated factors in HCWs in Belize covering multiple domains (mental health, physical symptoms, and coping behaviors) during the COVID-19 pandemic. METHODS: A cross-sectional survey that was developed and validated by a panel of experts was delivered online to all the healthcare workers in Belize from September to November 2021. Burnout was assessed using Copenhagen Burnout Inventory. Depression and anxiety screening was carried out using the Patient Health Questionnaire - 2 (PHQ-2) and Generalized Anxiety Disorder 2-item (GAD-2). Burnout associated factors were estimated using logistic regression models. FINDINGS: Of the total of 263 participants, 27.76% had overall burnout: 56.65% had personal, 54.37% had work-related, and 19.39% had patient-related burnout. Burnout was positively associated with anxiety (OR: 3.14 [1.67, 5.92]), depression (OR: 4.45 [2.30, 8.61]), intentions of quitting their jobs (OR: 2.59 [1.49, 4.51]), health status worsening (OR: 2.21 [1.26, 3.87]), multiple physical symptom presentation (OR: 1.19, [1.10, 1.29]), and use of multiple maladaptive coping behaviors (OR: 1.66, [1.30, 2.12]). INTERPRETATION: Healthcare workers in Belize showed substantial levels of burnout which were significantly associated with using maladaptive coping behaviors, presenting multiple physical symptoms, quitting their jobs, health status worsening, and other mental health issues. These findings should be used to develop and implement programs such as regular health check-ups, health promotion awareness campaigns, and worker recruitment strategies which would improve the working conditions, quality of life, and psychological well-being of our healthcare workers.

Validation of the Kriol and Belizean English Adaptation of the Revised Children's Anxiety and Depression Scale for Use With Adolescents in Belize.

PURPOSE: To validate a culturally-adapted Kriol and Belizean English version of the Revised Children's Anxiety and Depression Scale (RCADS) through comparison with clinical diagnoses made using the Kiddie Schedule of Affective Disorders and Schizophrenia. METHODS: Participants comprised of 256 adolescents aged 10-14 years and 15-19 years, who completed the adapted RCADS (10 depression items, 12 anxiety items) in one-on-one interviews, followed by a diagnostic assessment using Kiddie Schedule of Affective Disorders and Schizophrenia administered by trained clinicians. Sensitivity, specificity, positive predictive value, negative predictive value, diagnostic odds ratios, area under the curve (AUC), and Youden's Index were calculated for RCADS cutoffs and scores on the total scale and anxiety and depression subscales. RESULTS: For adolescents aged 10-14 years (n = 161), the AUC was 0.72 for the full scale, 0.67 for anxiety subscale, and 0.76 for depression subscale. For adolescents aged 15-19 years (n = 95), the AUCs were 0.82, 0.77, and 0.83. Most depression items performed well in discriminating those with and without diagnoses. Separation anxiety items performed poorly. "Thoughts of death" were common even among adolescents not meeting diagnostic criteria. The RCADS depression subscale presented the strongest psychometric properties with adolescents aged 15-19 years (at cutoff of 13, sensitivity = 0.83, specificity = 0.77, positive predictive value = 0.47, negative predictive value = 0.95, odds ratio = 15.96). CONCLUSION: The adapted RCADS-22 had acceptable categorization for adolescents aged 10-14 years and excellent categorization for adolescents aged 15-19 years; therefore, the tool is recommended for use among the latter age group. Based on sensitivity and specificity values at different cutoffs, guidance is provided to select different thresholds to suit clinical, public health, or other uses to detect and quantify adolescent depression and anxiety in Belize.

Implications for Mental Health Promotion and Prevention Interventions: Findings From Adolescent Focus Group Discussions in Belize, Kazakhstan, and South Africa.

PURPOSE: This study aimed to understand 10- to 19-year-old adolescents' conceptions of mental health and well-being, and suggestions for appropriate interventions, in three low- and middle-income countries to inform the design of adolescent-responsive preventive and promotive mental health programming. METHODS: Ninety-one adolescents participated in focus group discussions in Belize, Kazakhstan, and South Africa. The discussions were recorded, transcribed, translated, and analyzed using thematic analysis. RESULTS: Adolescents were active contributors to the discussions and provided important information and solutions for improving adolescents' mental health from interpersonal skills training to interventions in schools and communities. Adolescents identified a need for social emotional skills development, particularly regarding interpersonal relationships and navigating peer pressure and bullying. Furthermore, the discussions highlighted the need for programming to be tailored to the local context regarding language, contextual challenges faced by adolescents, and choice of program facilitators. Adolescents valued supportive interactions with adults in their lives and recommended that programs should include teacher/parent training on interacting with adolescents. CONCLUSIONS: These findings highlight that adolescents are valuable partners in developing adolescent health interventions and show that social emotional skills are key components in such interventions. These programs should be culturally and locally appropriate and include components for teachers and parents.