Predicting the drop out from the maternal, newborn and child healthcare continuum in three East African Community countries: application of machine learning models.

BACKGROUND: For optimal health, the maternal, newborn, and child healthcare (MNCH) continuum necessitates that the mother/child receive the full package of antenatal, intrapartum, and postnatal care. In sub-Saharan Africa, dropping out from the MNCH continuum remains a challenge. Using machine learning, the study sought to forecast the MNCH continuum drop out and determine important predictors in three East African Community (EAC) countries. METHODS: The study utilised Demographic Health Surveys data from the Democratic Republic of Congo (DRC) (2013/14), Kenya (2014) and Tanzania (2015/16). STATA 17 was used to perform the multivariate logistic regression. Python 3.0 was used to build five machine learning classification models namely the Logistic Regression, Random Forest, Decision Tree, Support Vector Machine and Artificial Neural Network. Performance of the models was assessed using Accuracy, Precision, Recall, Specificity, F1 score and area under the Receiver Operating Characteristics (AUROC). RESULTS: The prevalence of the drop out from the MNCH continuum was 91.0% in the DRC, 72.4% in Kenya and 93.6% in Tanzania. Living in the rural areas significantly increased the odds of dropping out from the MNCH continuum in the DRC (AOR:1.76;95%CI:1.30-2.38), Kenya (AOR:1.23;95%CI:1.03-1.47) and Tanzania (AOR:1.41;95%CI:1.01-1.97). Lower maternal education also conferred a significant increase in the DRC (AOR:2.16;95%CI:1.67-2.79), Kenya (AOR:1.56;95%CI:1.30-1.84) and Tanzania (AOR:1.70;95%CI:1.24-2.34). Non exposure to mass media also conferred a significant positive influence in the DRC (AOR:1.49;95%CI:1.15-1.95), Kenya (AOR:1.46;95%CI:1.19-1.80) and Tanzania (AOR:1.65;95%CI:1.13-2.40). The Random Forest exhibited superior predictive accuracy (Accuracy = 75.7%, Precision = 79.1%, Recall = 92.1%, Specificity = 51.6%, F1 score = 85.1%, AUROC = 70%). The top four predictors with the greatest influence were household wealth, place of residence, maternal education and exposure to mass media. CONCLUSIONS: The MNCH continuum dropout rate is very high in the EAC countries. Maternal education, place of residence, and mass media exposure were common contributing factors to the drop out from MNCH continuum. The Random Forest had the highest predictive accuracy. Household wealth, place of residence, maternal education and exposure to mass media were ranked among the top four features with significant influence. The findings of this study can be used to support evidence-based decisions in MNCH interventions and to develop web-based services to improve continuity of care retention.

Mediators of Ethnic Differences in Dropout Rates From a Randomized Controlled Treatment Trial Among Latinx and Non-Latinx White Primary Care Patients With Anxiety Disorders.

ABSTRACT: Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersen's Behavioral Model of Health Service Use (A behavioral model of families' use of health services. 1968; J Health Soc Behav. 1995; 36:1-10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

"I just keep quiet about it and act as if everything is alright" - The cascade from trauma to disengagement among adolescents living with HIV in western Kenya.

INTRODUCTION: There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement. METHODS: We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care. RESULTS: Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care. CONCLUSIONS: Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.

Pre-diagnostic drop out of presumptive TB patients and its associated factors at Bugembe Health Centre IV in Jinja, Uganda.

BACKGROUND: Drop out of presumptive TB individuals before making a final diagnosis poses a danger to the individual and their community. We aimed to determine the proportion of these presumptive TB drop outs and their associated factors in Bugembe Health Centre, Jinja, Uganda. METHODS: We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis.We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis. RESULT: Among the 216 registered presumptive TB patients who were less than 1% of patients visiting the outpatients' department, 40.7% dropped out before final diagnosis was made. Age and HIV status were significantly associated with pre-diagnostic drop out while gender and distance from the health center were not. CONCLUSION: A high risk to individuals and the community is posed by the significant proportion of presumptive TB patients dropping out before final diagnosis. Health systems managers need to consider interventions targeting young persons, male patients, HIV positive persons.

Incarceration as a Reason for US Alcohol and Drug Treatment Non-completion: a Multilevel Analysis of Racial/Ethnic and Sex Disparities.

Incarceration may be an overlooked reason for treatment non-completion experienced disproportionately by African Americans. This study utilized multilevel logistic regression to model treatment non-completion due to incarceration using the 2015-2016 Treatment Episode Dataset-Discharges. Among a sample restricted to treatment non-completers (n = 306,008), 5% terminated treatment because they became incarcerated (n = 13,082), which varied widely by demographics and by state. In Idaho, 46% of African Americans terminated treatment because they became incarcerated. Women had lower odds of treatment non-completion than men, and the effect of sex was strongest among African Americans (adjusted odds ratio [aOR] = 0.30, 95% confidence interval [95% CI] = 0.26-0.34). Among men, all racial/ethnic minority groups demonstrated significantly higher odds of treatment non-completion due to incarceration compared with Whites, and the strongest effect was among African Americans (aOR = 1.37, 95% CI = 1.29-1.44). Incarceration as a reason for treatment non-completion disproportionately affects African Americans and men and varies by state. Interventions targeting incarceration alternatives should be availed to racial/ethnic minorities already participating in treatment.

Retaining Hispanics: Lessons From the Hispanic Community Health Study/Study of Latinos.

We aimed to examine the retention of Hispanics/Latinos participating in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a prospective cohort study of 16,415 adults in 4 US cities who were enrolled between 2008 and 2011. We summarized retention strategies and examined contact, response, and participation rates over 5 years of annual follow-up interviews. We then evaluated motivations for participation and satisfaction with retention efforts among participants who completed a second in-person interview approximately 6 years after their baseline interview. Finally, we conducted logistic regression analyses estimating associations of demographic, health, and interview characteristics at study visit 1 (baseline) with participation, high motivation, and high satisfaction at visit 2. Across 5 years, the HCHS/SOL maintained contact, response, and participation rates over 80%. The most difficult Hispanic/Latino populations to retain included young, single, US-born males with less than a high school education. At visit 2, we found high rates of motivation and satisfaction. HCHS/SOL participants primarily sought to help their community and learn more about their health. High rates of retention of Hispanics/Latinos can be facilitated through the employment of bilingual/bicultural staff and the development of culturally tailored retention materials.

[Tuberculosis in indigenous children and adolescents in Brazil: factors associated with death and treatment dropout]. / Tuberculose entre crianças e adolescentes indígenas no Brasil: fatores associados ao óbito e ao abandono do tratamento.

The study aimed to describe clinical and sociodemographic characteristics, estimate incidence, and analyze factors associated with dropout and death during treatment of TB cases reported in indigenous children and adolescents in Brazil from 2006 to 2016. A historical case series was performed on incidence according to age bracket and major geographic region, and multinomial logistic regression was used to explain factors associated with treatment dropout and death. Of the 2,096 reported cases, 88.2% evolved to cure, 7.2% dropped out of treatment, and 4.6% evolved to death. There was a predominance of cases in boys 15-19 years of age and a higher proportion of deaths (55.7%) in children < 4 years. Considering indigenous children and adolescents with TB in Brazil as a whole, mean incidence was 49.1/100,000, ranging from 21.5/100,000 to 97.6/100,000 in the Northeast and Central, respectively. Cases with insufficient and irregular follow-up showed higher odds of dropout (OR = 11.1; 95%CI: 5.2-24.8/OR = 4.4; 95%CI: 1.9-10.3) and death (OR = 20.3; 95%CI: 4.9-84.9/OR = 5.1; 95%CI: 1.2-22.7). Cases in retreatment (OR = 2.4; 95%CI: 2.08-8.55) and with HIV coinfection (OR = 8.2; 95%CI: 2.2-30.9) were also associated with dropout. Extrapulmonary (OR = 1.8; 95%CI: 1.1-3.3) and mixed clinical forms (OR = 5.6; 95%CI: 2.8-11.4), age < 4 years (OR = 3.1; 95%CI: 1.5-6.4), and cases from the North (OR = 2.8; 95%CI: 1.1-7.1) and Central (OR = 2.8; 95%CI: 1.1-7.0) were associated with death. TB control in indigenous children and adolescents cannot be achieved without investments in research and development and without reducing social inequalities.

O objetivo deste estudo foi descrever características clínicas e sociodemográficas, estimar a incidência da tuberculose (TB), além de analisar fatores associados ao abandono e ao óbito na vigência do tratamento dos casos de TB notificados entre crianças e adolescentes indígenas, no Brasil, entre 2006-2016. Realizou-se análise da série histórica de incidência, segundo faixa etária e macrorregião e utilizou-se regressão logística multinomial para elucidar fatores associados ao abandono e ao óbito. Do total de 2.096 casos notificados, 88,2% tiveram cura, 7,2% abandonaram o tratamento e 4,6% evoluíram para óbito. Houve predomínio de casos em meninos de 15-19 anos e maior proporção de óbitos (55,7%) em < 4 anos. Considerando o conjunto de crianças e adolescentes indígenas com TB no Brasil, a incidência média foi 49,1/100 mil, variando de 21,5/100 mil a 97,6/100 mil nas regiões Nordeste e Centro-oeste, respectivamente. Os casos com acompanhamento insuficiente e regular tiveram maiores chances de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) e óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Os casos em retratamento (OR = 2,4; IC95%: 2,08-8,55) e com anti-HIV positivo (OR = 8,2; IC95%: 2,2-30,9) também mostraram-se associados ao abandono. As formas clínicas extrapulmonar (OR = 1,8; IC95%: 1,1-3,3) e mista (OR = 5,6; IC95%: 2,8-11,4), os casos em < 4 anos (OR = 3,1; IC95%: 1,5-6,4) e os casos provenientes das regiões Norte (OR = 2,8; IC95%: 1,1-7,1) e Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) mostraram-se associados ao óbito. Acreditamos que o controle da TB em crianças e adolescentes indígenas não poderá ser alcançado sem investimentos em pesquisa e desenvolvimento e sem a redução das desigualdades sociais.

El objetivo de este estudio fue describir características clínicas y sociodemográficas, estimar la incidencia de la tuberculosis (TB), además de analizar factores asociados al abandono y al óbito en la vigencia del tratamiento de los casos de TB, notificados entre niños y adolescentes indígenas, en Brasil entre 2006-2016. Se realizó un análisis de la serie histórica de incidencia, según la franja de edad y macrorregión y se utilizó la regresión logística multinomial para elucidar factores asociados al abandono y al óbito. Del total de 2.096 casos notificados, un 88,2% tuvieron cura, un 7,2% abandonaron el tratamiento y un 4,6% evolucionaron hacia óbito. Hubo un predominio de casos en chicos de 15-19 años y mayor proporción de óbitos (55,7%) en < 4 años. Considerando el conjunto de niños y adolescentes indígenas con TB en Brasil, la incidencia media fue 49,1/100.000, variando de 21,5/100.000 a 97,6/100.000 en las regiones Nordeste y Centro-oeste, respectivamente. Los casos con un seguimiento insuficiente y regular tuvieron mayores oportunidades de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) y óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Los casos de retorno al tratamiento (OR = 2,4; IC95%: 2,08-8,55) y con anti-VIH positivo (OR = 8,2; IC95%: 2,2-30,9) también se mostraron asociados al abandono. Las formas clínicas extrapulmonares (OR = 1,8; IC95%: 1,1-3,3) y mixta (OR = 5,6; IC95%: 2,8-11,4), los casos en < 4 años (OR = 3,1; IC95%: 1,5-6,4) y los casos procedentes de las regiones Norte (OR = 2,8; IC95%: 1,1-7,1) y Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) se mostraron asociados al óbito. Creemos que el control de la TB en niños y adolescentes indígenas no se podrá alcanzar sin inversiones en investigación y desarrollo y sin la reducción de las desigualdades sociales.

Tuberculose entre crianças e adolescentes indígenas no Brasil: fatores associados ao óbito e ao abandono do tratamento / Tuberculosis in indigenous children and adolescents in Brazil: factors associated with death and treatment dropout / Tuberculosis entre niños y adolescentes indígenas en Brasil: factores asociados al óbito y al abandono del tratamiento

Resumo: O objetivo deste estudo foi descrever características clínicas e sociodemográficas, estimar a incidência da tuberculose (TB), além de analisar fatores associados ao abandono e ao óbito na vigência do tratamento dos casos de TB notificados entre crianças e adolescentes indígenas, no Brasil, entre 2006-2016. Realizou-se análise da série histórica de incidência, segundo faixa etária e macrorregião e utilizou-se regressão logística multinomial para elucidar fatores associados ao abandono e ao óbito. Do total de 2.096 casos notificados, 88,2% tiveram cura, 7,2% abandonaram o tratamento e 4,6% evoluíram para óbito. Houve predomínio de casos em meninos de 15-19 anos e maior proporção de óbitos (55,7%) em < 4 anos. Considerando o conjunto de crianças e adolescentes indígenas com TB no Brasil, a incidência média foi 49,1/100 mil, variando de 21,5/100 mil a 97,6/100 mil nas regiões Nordeste e Centro-oeste, respectivamente. Os casos com acompanhamento insuficiente e regular tiveram maiores chances de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) e óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Os casos em retratamento (OR = 2,4; IC95%: 2,08-8,55) e com anti-HIV positivo (OR = 8,2; IC95%: 2,2-30,9) também mostraram-se associados ao abandono. As formas clínicas extrapulmonar (OR = 1,8; IC95%: 1,1-3,3) e mista (OR = 5,6; IC95%: 2,8-11,4), os casos em < 4 anos (OR = 3,1; IC95%: 1,5-6,4) e os casos provenientes das regiões Norte (OR = 2,8; IC95%: 1,1-7,1) e Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) mostraram-se associados ao óbito. Acreditamos que o controle da TB em crianças e adolescentes indígenas não poderá ser alcançado sem investimentos em pesquisa e desenvolvimento e sem a redução das desigualdades sociais.

Abstract: The study aimed to describe clinical and sociodemographic characteristics, estimate incidence, and analyze factors associated with dropout and death during treatment of TB cases reported in indigenous children and adolescents in Brazil from 2006 to 2016. A historical case series was performed on incidence according to age bracket and major geographic region, and multinomial logistic regression was used to explain factors associated with treatment dropout and death. Of the 2,096 reported cases, 88.2% evolved to cure, 7.2% dropped out of treatment, and 4.6% evolved to death. There was a predominance of cases in boys 15-19 years of age and a higher proportion of deaths (55.7%) in children < 4 years. Considering indigenous children and adolescents with TB in Brazil as a whole, mean incidence was 49.1/100,000, ranging from 21.5/100,000 to 97.6/100,000 in the Northeast and Central, respectively. Cases with insufficient and irregular follow-up showed higher odds of dropout (OR = 11.1; 95%CI: 5.2-24.8/OR = 4.4; 95%CI: 1.9-10.3) and death (OR = 20.3; 95%CI: 4.9-84.9/OR = 5.1; 95%CI: 1.2-22.7). Cases in retreatment (OR = 2.4; 95%CI: 2.08-8.55) and with HIV coinfection (OR = 8.2; 95%CI: 2.2-30.9) were also associated with dropout. Extrapulmonary (OR = 1.8; 95%CI: 1.1-3.3) and mixed clinical forms (OR = 5.6; 95%CI: 2.8-11.4), age < 4 years (OR = 3.1; 95%CI: 1.5-6.4), and cases from the North (OR = 2.8; 95%CI: 1.1-7.1) and Central (OR = 2.8; 95%CI: 1.1-7.0) were associated with death. TB control in indigenous children and adolescents cannot be achieved without investments in research and development and without reducing social inequalities.

Resumen: El objetivo de este estudio fue describir características clínicas y sociodemográficas, estimar la incidencia de la tuberculosis (TB), además de analizar factores asociados al abandono y al óbito en la vigencia del tratamiento de los casos de TB, notificados entre niños y adolescentes indígenas, en Brasil entre 2006-2016. Se realizó un análisis de la serie histórica de incidencia, según la franja de edad y macrorregión y se utilizó la regresión logística multinomial para elucidar factores asociados al abandono y al óbito. Del total de 2.096 casos notificados, un 88,2% tuvieron cura, un 7,2% abandonaron el tratamiento y un 4,6% evolucionaron hacia óbito. Hubo un predominio de casos en chicos de 15-19 años y mayor proporción de óbitos (55,7%) en < 4 años. Considerando el conjunto de niños y adolescentes indígenas con TB en Brasil, la incidencia media fue 49,1/100.000, variando de 21,5/100.000 a 97,6/100.000 en las regiones Nordeste y Centro-oeste, respectivamente. Los casos con un seguimiento insuficiente y regular tuvieron mayores oportunidades de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) y óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Los casos de retorno al tratamiento (OR = 2,4; IC95%: 2,08-8,55) y con anti-VIH positivo (OR = 8,2; IC95%: 2,2-30,9) también se mostraron asociados al abandono. Las formas clínicas extrapulmonares (OR = 1,8; IC95%: 1,1-3,3) y mixta (OR = 5,6; IC95%: 2,8-11,4), los casos en < 4 años (OR = 3,1; IC95%: 1,5-6,4) y los casos procedentes de las regiones Norte (OR = 2,8; IC95%: 1,1-7,1) y Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) se mostraron asociados al óbito. Creemos que el control de la TB en niños y adolescentes indígenas no se podrá alcanzar sin inversiones en investigación y desarrollo y sin la reducción de las desigualdades sociales.

Using Financial Incentives to Improve Rates of Viral Suppression and Engagement in Care of Patients Receiving HIV Care at 3 Health Clinics in Louisiana: The Health Models Program, 2013-2016.

OBJECTIVES: The Care and Prevention in the United States Demonstration Project aimed to reduce HIV/AIDS-related morbidity and mortality among racial/ethnic minority groups in 8 states. We evaluated Health Models, a pay-for-performance program piloted by the Louisiana Department of Health that used financial incentives to improve rates of engagement in HIV medical care and viral suppression among people with HIV. METHODS: We enrolled 2076 patients of 3 urban HIV specialty clinics in Louisiana in the Health Models pay-for-performance program on a rolling basis from September 2013 through September 2016 and gave patients cash incentives to attend HIV medical appointments, achieve or maintain viral suppression, and link to supportive services. We used laboratory data collected from Louisiana's HIV surveillance database to calculate rates of engagement in care and viral suppression during the first 24 months of enrollment. RESULTS: Of the 2076 patients who enrolled, 1400 (67.4%) were non-Hispanic black, 1480 (71.3%) were male, 1175 (56.6%) were men who have sex with men, and 1371 (66.0%) reported an annual income of <$15 000. At enrollment, 1456 (70.1%) patients were engaged in HIV care, and 1197 (57.7%) patients were virally suppressed. After 12 months of enrollment, 1474 of 1783 (82.7%) patients were virally suppressed. Of enrolled patients with at least 12 or 24 months of follow-up data, 1299 of 1317 (98.6%) patients were engaged in care during their first 12 months of enrollment, and 995 of 1033 (96.3%) patients were engaged in care between 12 and 24 months of enrollment. CONCLUSIONS: During the implementation of Health Models, enrolled patients had increases in rates of viral suppression and achieved rates of engagement in care and viral suppression that were higher than national levels; however, additional supportive services may be needed to further reduce socioeconomic disparities in the rates of viral suppression.

"Where It Falls Apart": Barriers to Retention in HIV Care in Latino Immigrants and Migrants.

Latino immigrants in the United States are disproportionately affected by HIV. Barriers to consistent attendance (retention) in HIV primary care constrain opportunities for HIV treatment success, but have not been specifically assessed in this population. We conducted semistructured interviews with 37 HIV-infected Latinos (aged ≥18 years and born in Puerto Rico or a Latin American Spanish-speaking country) and 14 HIV providers in metropolitan Boston (total n = 51). The Andersen Model of Healthcare Utilization informed a semistructured interview guide, which bilingual research staff used to explore barriers to HIV care. We used thematic analysis to explore the processes of retention in care. Six ubiquitous themes were perceived to influence HIV clinic attendance: (1) stigma as a barrier to HIV serostatus disclosure; (2) social support as a safety net during negative life circumstances; (3) unaddressed trauma and substance use leading to interruption in care; (4) a trusting relationship between patient and provider motivating HIV clinic attendance; (5) basic unmet needs competing with the perceived value of HIV care; and (6) religion providing a source of hope and optimism. Cultural subthemes were the centrality of family (familismo), masculinity (machismo), and trusting relationships (confianza). The timing of barriers was acute (e.g., eviction) and chronic (e.g., family conflict). These co-occurring and dynamic constellation of factors affected HIV primary care attendance over time. HIV-infected Latino immigrants and migrants experienced significant challenges that led to interruptions in HIV care. Anticipatory guidance to prepare for these setbacks may improve retention in HIV care in this population.

Mental Health Disparities, Treatment Engagement, and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review.

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.

Racial and Ethnic Variation in Perceptions of VA Mental Health Providers are Associated With Treatment Retention Among Veterans With PTSD.

BACKGROUND: Veterans with posttraumatic stress disorder (PTSD) who seek mental health care in the Veterans Health Administration frequently discontinue treatment prematurely. Early discontinuation of mental health treatment is more common among Veterans with PTSD who are of minority race or ethnicity. OBJECTIVES: To determine whether retention in individual therapy or pharmacotherapy among Veterans with PTSD are associated with patients' ratings of their mental health providers, and if those associations differ depending on Veteran race or ethnicity. RESEARCH DESIGN: Latino, African American, and white Veterans (n=2452) who participated in a prospective national cohort study of Veterans with PTSD at the beginning of an episode of care were surveyed immediately following Veterans' PTSD diagnoses and 6 months later. Pharmacy and mental health service utilization were abstracted from Veterans Health Administration administrative databases for 6 months postdiagnosis. Retention in treatments were modeled using logistic regression among Veterans who initiated individual therapy or pharmacotherapy. Demographics, treatment need, treatment-related beliefs, treatment process measures, and ratings of mental health providers were considered as predictors. RESULTS: Ratings of mental health providers, more than treatment beliefs, were associated with treatment retention. Among African American Veterans, retention in pharmacotherapy was reduced if the provider was perceived as not having helped manage medication side-effects (odds ratio, 0.36; confidence interval, 0.16-0.80). All Latino Veterans but one (99% or n=64) who rated their therapist as not caring discontinued individual psychotherapy. CONCLUSIONS: Ratings of mental health providers were associated with treatment retention. The salience of specific provider behaviors to treatment retention varied by Veteran race or ethnicity.

Sorafenib in Japanese Patients with Locally Advanced or Metastatic Medullary Thyroid Carcinoma and Anaplastic Thyroid Carcinoma.

BACKGROUND: Therapeutic options for treating advanced or metastatic medullary thyroid carcinoma (MTC) and anaplastic thyroid carcinoma (ATC) are still limited in Japan, even though vandetanib for MTC and lenvatinib for MTC and ATC have been approved. Sorafenib is an oral multikinase inhibitor approved for the treatment of patients with radioactive iodine-refractory differentiated thyroid cancer (DTC). An uncontrolled, open-label, multicenter, single-arm, Phase 2 clinical study was conducted to evaluate the safety and efficacy of sorafenib in Japanese patients with MTC and ATC. METHODS: Japanese patients with histologically confirmed ATC and locally advanced or metastatic MTC were enrolled from April to September 2014. The primary endpoint was to evaluate the safety of sorafenib. Treatment efficacy variables including progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), and maximum reduction in tumor size were evaluated as secondary endpoints. Patients received sorafenib 400 mg orally twice daily on a continuous basis and then continued treatment until the occurrence of disease progression, unacceptable toxicity, or withdrawal of consent. RESULTS: A total of 20 patients were screened, and 18 (8 with MTC and 10 with ATC) were enrolled. The most common drug-related adverse events were palmar-plantar erythrodysesthesia (72%), alopecia (56%), hypertension (56%), and diarrhea (44%). In the ATC patients, median PFS was 2.8 months [confidence interval 0.7-5.6], and median OS was 5.0 months [confidence interval 0.7-5.7]; ORR and DCR were 0% and 40%, respectively. In the MTC population, neither median PFS nor OS had been reached at the time of this analysis; ORR was 25% and DCR was 75%. CONCLUSIONS: The toxicities reported in this study were consistent with the known safety profile of sorafenib. Sorafenib seems to be effective in the treatment of advanced MTC but not ATC, and could be a new treatment option for locally advanced or metastatic MTC and radioactive iodine-refractory DTC.

Challenging Assumptions About African American Participation in Alzheimer Disease Trials.

OBJECTIVE: The authors investigated potential effects of increased African American participation in Alzheimer disease (AD) and mild cognitive impairment (MCI) clinical trials by examining differences in comorbid conditions and treatment outcome affecting trial design. METHODS: Using a meta-database of 18 studies from the Alzheimer's Disease Cooperative Study and the Alzheimer's Disease Neuroimaging Initiative, a cohort of 5,164 subjects were included for whom there were baseline demographic data and information on comorbid disorders, grouped by organ system. Meta-analysis was used to compare prevalence of comorbidities, dropouts, and rates of change on the cognitive subscale of the Alzheimer's Disease Assessment Scale by race. Clinical trial scenarios similar to recent therapeutic trials were simulated to determine effects of increased African American participation on statistical power. RESULTS: Approximately 7% of AD, 4% of MCI, and 11% of normal participants were African American. African American subjects had higher prevalence of cardiovascular disorders (odds ratio: 2.10; 95% confidence interval [CI]: 1.71-2.57) and higher rate of dropouts (odds ratio: 1.60; 95% CI: 1.15-2.21) compared with whites but lower rates of other disorders. There were no significant differences in rate of progression (-0.862 points/year; 95% CI: -1.89 to 0.162) by race and little effect on power in simulated trials with sample sizes similar to current AD trial designs. CONCLUSION: Increasing African American participation in AD clinical trials will require adaptation of trial protocols to address comorbidities and dropouts. However, increased diversity is unlikely to negatively affect trial outcomes and should be encouraged to promote generalizability of trial results.

Frequency and outcomes of new patients with pulmonary tuberculosis in Hatay province after Syrian civil war.

OBJECTIVE: It is known that tuberculosis is frequently seen among refugees. Hatay province is one of the cities that substantially expose to migration of refugees after Syrian civil war. In this study, it was aimed to compare frequency of new pulmonary tuberculosis (PTB) cases and treatment success/cure rates between Turkish and Syrian patients. FINDINGS: The study included 211 patients with PTB (178 Turkish and 33 Syrian patients) registered to Hatay Tuberculosis Outpatient Clinic between 2010 and 2013. On the basis of years, number of PTB patients registered was 53 (Turkish/Syrian: 52/1) in 2010, 44 (44/0) in 2011, 41 (39/2) in 2012, and 73 (43/30) in 2013. There were no significant differences between Turkish and Syrian patients regarding age groups, gender, marital status, contact history, smear result, and drug sensitivity assays when treatment success was considered (p>0.05). Directly observed therapy (DOT) rate was higher in patients who achieved successful treatment (97.6% vs. 2.4%; p<0.001). Number of patients successfully treated was smaller among Syrian patients (63.6% vs. 88.8%; p<0.001). Leaving the treatment and/or transfer rates were higher among Syrian patients (30.3% vs. 3.9%; p<0.001). During the study period, drug-resistant tuberculosis was detected in one Syrian and 3 Turkish patients. CONCLUSIONS: Although PTB frequency has increased in Hatay province within prior 4 years, treatment success among local population is still within limits established by World Health Organization (WHO). However, the treatment goal could not be achieved when considered together with refugees. To improve treatment success in refugees, implementation of a new national tuberculosis is needed control program in this population.

Growth of Infants Fed Formula with Evolving Nutrition Composition: A Single-Arm Non-Inferiority Study.

The nutritional composition of human milk evolves over the course of lactation, to match the changing needs of infants. This single-arm, non-inferiority study evaluated growth against the WHO standards in the first year of life, in infants consecutively fed four age-based formulas with compositions tailored to infants' nutritional needs during the 1st, 2nd, 3rd-6th, and 7th-12th months of age. Healthy full-term formula-fed infants (n = 32) were enrolled at ≤14 days of age and exclusively fed study formulas from enrollment, to the age of four months. Powdered study formulas were provided in single-serving capsules that were reconstituted using a dedicated automated preparation system, to ensure precise, hygienic preparation. The primary outcome was the weight-for-age z-score (WAZ) at the age of four months (vs. non-inferiority margin of -0.5 SD). Mean (95% CI) z-scores for the WAZ (0.12 (-0.15, 0.39)), as well as for the length-for-age (0.05 (-0.19, 0.30)), weight-for-length (0.16 (-0.16, 0.48)), BMI-for-age (0.11 (-0.20, 0.43)), and head circumferencefor-age (0.41 (0.16, 0.65)) at the age of four months, were non-inferior. Throughout the study, anthropometric z-scores tracked closely against the WHO standards (within ±1 SD). In sum, a fourstage, age-based infant formula system with nutritional compositions tailored to infants' evolving needs, supports healthy growth consistent with WHO standards, for the first year of life.

The association between ethnicity, socioeconomic status and compliance to pediatric weight-management interventions - A systematic review.

BACKGROUND: High dropout rates and low compliance to pediatric weight-management programs have been reported. Socioeconomic status (SES) and ethnicity have been suggested as potentially important determinants of dropout and non-compliance. This review aims to assess the association between SES, ethnicity and study- and intervention dropout and non-compliance among participants in pediatric weight-management programs. METHODS: PubMed, Embase, MEDLINE, Scopus, Cochrane, Web-of-Science and Google Scholar were searched for eligible studies up to March 2014. Included were randomised controlled trials (RCT), controlled clinical trials and cohort studies evaluating pediatric weight-management programs. Studies had to report dropout or non-compliance to the study or intervention with regard to ethnicity or SES. Associations between SES and ethnicity and dropout and non-compliance were analysed descriptively. RESULTS: Fourteen RCTs and 16 cohort studies were included, studying 7264 children and adolescents, aged 2-20 years. Twenty-four studies presented data on dropout or non-compliance regarding ethnicity and 26 studies presented data regarding SES. Black participants showed higher dropout rates in weight-management interventions (range 65-67%) than White participants (range 22-27%), and low family income was associated with lower compliance to weight-management interventions. CONCLUSIONS: Black ethnicity and low family income seemed to be associated with higher dropout and lower compliance to pediatric weight-management interventions. Future qualitative studies may be needed to assess underlying reasons for increased dropout and non-compliance in these sub-populations.

Residential and outpatient treatment completion for substance use disorders in the U.S.: Moderation analysis by demographics and drug of choice.

BACKGROUND: This study investigates the impact of residential versus outpatient treatment setting on treatment completion, and how this impact might vary by demographic characteristics and drug of choice, using a national sample of publicly funded substance abuse programs in the United States. METHODS: This is a retrospective analysis using data extracted from the 2011 Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS-D). A total of 318,924 cases were analyzed using logistic regression, fixed-effects logistic regression, and moderated fixed-effects logistic regression. RESULTS: Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment. The effect of residential treatment on treatment completion was not significantly moderated by gender, but it was for age, drug of choice, and race/ethnicity. Residential compared to outpatient treatment increased the likelihood of completion to a greater degree for older clients, Whites, and opioid abusers, as compared to younger clients, non-Whites, and alcohol and other substance users, respectively. CONCLUSION: We speculate that for opioid abusers, as compared to abusers of other drugs, residential treatment settings provide greater protection from environmental and social triggers that may lead to relapse and non-completion of treatment. Greater use of residential treatment should be explored for opioid users in particular.

Examining Minority Attrition Among Women in Longitudinal Trauma Research.

Research suggests that racial and ethnic minorities are more likely to attrit from longitudinal trauma studies than non-Hispanic Whites. Yet, little is known about how the loss of minority participants influences longitudinal findings as well as internal and external validity of study findings. Thus, the present study examined the effects of race/ethnicity on attrition in a longitudinal trauma study of women (minority = 223, non-Hispanic White or majority = 459) exposed to a campus shooting. Survival analyses were used to compare the attrition rates of minority participants to majority participants and assess the extent to which race/ethnicity, among other variables, predicted attrition. Minority participants were more likely to attrit than majority participants, hazard ratio (HR) = 0.69, 95% CI [0.48, 0.99], even after adjusting for study variables. A main effect was also found for age, HR = 1.06, 95% CI [1.01, 1.12]. Race/ethnicity did not interact with other study variables to influence attrition. The findings underscored the importance of assessing the effects of attrition on longitudinal findings and external validity.

Immigrants' Pathways to Outpatient Mental Health: Are there Differences with the Native Population?

A poor use of mental health services has been described in immigrants. We compared the sociodemographic, clinical and treatment features of immigrants and natives attending a Community Mental Health Centre (CMHC). 191 immigrants and 191 randomly selected natives applying to the Borgomanero CMHC between 1 January 2003 and 31 August 2013 were compared. Our sample consisted mainly of the so-called "economic" immigrant. Adjustment disorders and reaction to stress were the most frequent diagnoses; in most cases symptoms onset occurred after migration. Although treatment features overlapped in the two groups (duration, number of contacts), immigrants showed a higher frequency of treatment dropout. While it is necessary to improve access to mental health services for immigrants, for the "economic" immigrant it may be more important to focus on establishing a therapeutic relationship that can be experienced as reliable and trustworthy. The finding of similar pathways to access the CMHC in natives and immigrants is encouraging.