Spatial Clustering in Temporal Trends of Female Genital Mutilation Risk: Leveraging Sparse Data in Ethiopia, Kenya, and Somalia.

Female genital mutilation (FGM) is a harmful practice rooted in gender inequality. Its elimination is part of national and international agendas including the Sustainable Development Goals of the United Nations. Understanding its geographical evolution is crucial for targeted programming. However, due to sparse data, it is challenging to establish international comparability and statistical reliability. Data on FGM is observed at different points in time and periodicity across countries and in contexts with varying age-risk patterns, all of which can be a source of inaccurate and biased estimates. We perform an exemplary analysis, drawing on survival and complex survey analysis in Ethiopia, Kenya, and Somalia. This novel approach addresses measurement challenges specific to FGM data and produces an internationally comparable indicator-the probability of not experiencing FGM by age 20. We pinpoint the onset of statistically significant FGM decline at the subnational level from cohorts born in the 1970s until the 1990s. In the same period, we observe no decline in FGM risk across regions clustered around international borders and increasing subnational inequalities within countries. Our methods thus provide crucial insights into the geographical pattern of temporal trends in FGM risk.

The effectiveness of post-discharge navigation added to an inpatient addiction consultation for patients with substance use disorder; a randomized controlled trial.

Background: It is unknown whether post-discharge navigation enhances the impact of hospital-initiated addiction care. This study tested the incremental benefit of telephonic linkage to a post-discharge navigator for patients who received an addiction consultation during hospitalization. Methods: A two-arm, randomized controlled trial of 395 hospitalized adults with substance use disorder who received an addiction consultation. The intervention group received post-discharge phone calls from a navigator to review the recommended treatment plan and address barriers to engagement on days 3, 7, 14, and 21. The primary outcome was days of alcohol or drug use in the past 30 assessed by Timeline Follow-back at 1 month. Results: Follow-up assessment completion rates were 46% at 1 month, and 41%, at 2 months. At baseline, intervention and control groups did not differ in substance use patterns; 45% reported primary alcohol use, 43% drugs, and 12% both. Heroin was the most common drug. At baseline, mean days of past 30-day alcohol or drug use were 13.6 in the intervention and 14.9 in the control group. The median number of navigation calls completed was 3 out of 4. At 1 month, both groups reported less use (decrease of 4.8 in intervention vs. 4.2 days in control group, p = 0.49). There were no differences between groups at 2 months. Compared to controls, participants who received all four calls had a greater decrease in use with a mean 8.6 days decrease from baseline (difference of 4.4 days, p = 0.0009). Conclusion: Post-discharge telephonic patient navigation did not further improve substance use outcomes following addiction consultation.

A Preliminary Investigation of Provider Attitudes Toward a Transdiagnostic Treatment: Outcomes from Training Workshops with the Unified Protocol.

Evidence-based psychological treatments (EBPTs) for common mental health conditions are efficacious but remain underutilized in clinical service settings. Novel transdiagnostic and modular approaches that treat several disorders simultaneously promise to address common barriers to the dissemination and implementation of traditional EBPTs. Despite the promise that transdiagnostic treatments hold, the claims that these interventions can be more easily disseminated and implemented have not been widely tested. The present study examined whether a transdiagnostic treatment, the Unified Protocol (UP), addresses some barriers to dissemination and implementation for clinicians. Exploratory aims of the current study were to examine the effects of a UP introductory training workshop on clinician attitudes and behaviors by: (1) evaluating UP knowledge and treatment delivery, (2) determining relationships between clinician characteristics and their knowledge acquisition, satisfaction with UP, and UP penetration, and (3) exploring clinicians' perceptions of the UP's characteristics utilizing mixed methods. Workshop participants showed a good understanding of UP treatment concepts following training, and over a third of survey respondents reported use of the intervention 6-months after training. Positive attitudes toward EBPTs and fewer years of clinical practice were associated with greater satisfaction with the UP. Clinicians held positive views of the UP's flexibility and relative advantage over standard EBPTs but held negative views toward the manual's design and packaging. Overall, our findings suggest that clinicians may view transdiagnostic treatments such as the UP favorably and may consider them appealing over standard EBPTs. However, barriers associated with traditional EBPTs may extend to transdiagnostic treatments like the UP.

Does a Sway-Based Mobile Application Predict Future Falls in People With Parkinson Disease?

OBJECTIVE: To determine whether Sway, a sway-based mobile application, predicts falls and to evaluate its discriminatory sensitivity and specificity relative to other clinical measures in identifying fallers in individuals with Parkinson disease (PD). DESIGN: Observational cross-sectional study. SETTING: Community. PARTICIPANTS: A convenience sample of subjects with idiopathic PD in Hoehn and Yahr levels I-III (N=59). INTERVENTIONS: Participants completed a balance assessment using Sway, the Movement Disorders Systems-Unified PD Rating Scale motor examination, Mini-BESTest, Activities-specific Balance Confidence (ABC) Scale, and reported 6-month fall history. Participants also reported falls for each of the following 6 months. Binomial logistic regression was used to identify significant predictors of future fall status. Cutoff scores, sensitivity, and specificity were based on receiver operating characteristic plots. MAIN OUTCOME MEASURES: Sway score. RESULTS: The most predictive logistic regression model included fall history, ABC Scale, and Sway (P<.001). This model explained 61% (Nagelkerke R2) of the variance in fall prediction and correctly classified 85% of fallers. However, only fall history and ABC Scale were statistically significant (P<.02). Participants were 32 times more likely to fall in the future if they fell in the past. The ABC Scale and Mini Balance Evaluation Systems Test (Mini-BESTest) demonstrated greater accuracy than Sway (area under the curve=0.76, 0.72, and 0.65, respectively). Cutoff scores to identify fallers were 85% for the ABC Scale and 21 of 28 for the Mini-BESTest. CONCLUSION: Sway did not improve the accuracy of predicting future fallers beyond common clinical measures and fall history.

Understanding why patients with substance use disorders leave the hospital against medical advice: A qualitative study.

BACKGROUND: Hospital discharges against medical advice (AMA) is associated with negative health outcomes and re-admissions. Patients with substance use disorders (SUD) are up to three times more likely to be discharged AMA as compared to those without SUD. Studies suggest that undertreated withdrawal and a perception of stigma may increase the risk, however, to date, there are no published qualitative studies exploring the specific reasons why patients with SUD leave prematurely. Methods: Semi-structured interviews with patients (n = 15) with SUD with documented AMA discharges from our hospital between 9/2017 and 9/2018. Maximum variation sampling was employed to display diversity across gender, race, age, and type of substance use disorder (alcohol vs opioids). Patients were interviewed until no new concepts emerged from additional interviews. Two coders separately coded all transcripts and reconciled code assignments. Results: Four core issues were identified as patients' reasons for leaving the hospital prematurely: undertreated withdrawal and ongoing craving to use drugs, uncontrolled acute and chronic pain, stigma and discrimination by hospital staff about their SUD, and hospital restrictions, including not being allowed to intermittently leave the hospital floor. For patients with histories of criminal involvement, being hospitalized reminded them of being incarcerated. Conclusion: These findings shed light on the reasons patients with SUD are discharged from the hospital AMA, an event that is associated with increased thirty-day mortality and hospital re-admission. AMA discharges represent missed opportunities for the health care system to engage with patients struggling with a SUD. Our findings support the need for inpatient addiction treatment, particularly for management of withdrawal and co-occurring pain, and the need to address health care provider associated stigma surrounding addiction.

Access to Health Care Services among Young People Exchanging Sex in Detroit.

Within the related epidemics of sex exchange, drug use, and poverty, access to health care is shaped by intersecting identities, policy, and infrastructure. This study uses a unique survey sample of young adults in Detroit, who are exchanging sex on the street, in strip clubs, and at after-hours parties and other social clubs. Factors predicting access to free or affordable health care services, such as venue, patterns of sexual exchange influence, drug use and access to transportation, were examined using multivariable logistic regression and qualitative comparative analysis. The most significant predictors of low access to health care services were unstable housing and lack of access to reliable transportation. In addition, working on the street was associated with decreased access to services. Coordinated policy and programming changes are needed to increase health care access to this group, including improved access to transportation, housing, and employment, and integration of health care services.

Criminal Justice Involvement among Young People Exchanging Sex in Detroit.

For young adult sex workers, the risk of arrest and incarceration are dramatically influenced by the venue of sex exchange and individual and neighborhood characteristics. Using a unique venue-based survey sample of young adults in Detroit who are exchanging sex, multivariable logistic regression models were used to identify associations with arrest and incarceration. Criminal justice involvement was normative, and risk was increased by working on the street venue, using drugs, lacking stable housing, juvenile arrest or incarceration, dropping out of school before age 18, and neighborhood characteristics. Several promising points of intervention could reduce criminal justice involvement for young adults exchanging sex.

Examining the relationship between psychological distress and adherence to anti-retroviral therapy among Ugandan adolescents living with HIV.

Psychological distress is common among adolescents living with HIV (ALHIV) worldwide, and has been associated with non-adherence to anti-retroviral therapy (ART), leading to poor virologic suppression, drug resistance, and increased risk for AIDS morbidity and mortality. However, only a few studies have explored the relationship between psychological distress and ART adherence among adolescents in sub-Saharan Africa. The paper examines the relationship between psychological distress and ART adherence, and effect of psychosocial resources on ART adherence. We conducted a cross-sectional survey of 464 ALHIV (aged 12-19; 53% female) seeking HIV care at a large HIV treatment center in Kampala, Uganda. ALHIV were recruited during routine clinic visits. Three self-reported binary adherence measures were utilized: missed pills in the past three days, non-adherence to the prescribed medical regimen, and self-rated adherence assessed using a visual analog scale. Psychological distress was measured as a continuous variable, and computed as the mean score on a locally developed and validated 25-item symptom checklist for Ugandan ALHIV. Psychosocial resources included spirituality, religiosity, optimism, social support, and coping strategies. After adjusting for respondents' socio-demographic characteristics and psychosocial resources, a unit increase in psychological distress was associated with increased odds of missing pills in past 3 days (Odds Ratio(OR) = 1.75; Confidence Interval (CI): 1.04-2.95), not following the prescribed regimen (OR = 1.63; CI: 1.08-2.46), and lower self-rated adherence (OR = 1.79; CI: 1.19-2.69). Psychosocial resources were associated with lower odds for non-adherence on all three self-report measures. There is a need to strengthen the psychosocial aspects of adolescent HIV care by developing interventions to identify and prevent psychological distress among Ugandan ALHIV.

Development of a psychosocial distress measure for Ugandan adolescents living with HIV.

Psychological distress among adolescents living with HIV (ALH) has been associated with risky behaviors including non-adherence to anti-retroviral therapy, leading to increased risk for AIDS morbidity and mortality. Efforts to establish the nature, prevalence, and impact of psychological distress among ALH in Uganda are hindered by the lack of culturally relevant assessment tools. The purpose of this study was to develop and test a measure for psychological distress for Ugandan ALH aged 12-19 years (N = 508; 53.1 % female). Using a mixed method approach, we developed and tested a 25-item checklist with six subscales-anhedonia, depressive-anxiety, isolation, suicidal ideation, sleep problems, and somatization. We found adequate reliability for the scale (α = 0.89), and a satisfactory measurement structure in our confirmatory factor analyses (RMSEA <1.0, and CFI and TLI >0.90). We discuss the potential use of this culturally sensitive scale to examine psychological distress among ALH in Uganda.

Gendered Patterns of Migration in Rural South Africa.

Gender is increasingly recognized as fundamental to understanding migration processes, causes and consequences. In South Africa, it is intrinsic to the social transformations fueling high levels of internal migration and complex forms of mobility. While female migration in Africa has often been characterized as less prevalent than male migration, and primarily related to marriage, in South Africa a feminization of internal migration is underway, fueled by women's increasing labor market participation. In this paper, we report sex differences in patterns, trends and determinants of internal migration based on data collected in a demographic surveillance system between 2001 and 2006 in rural KwaZulu-Natal. We show that women were somewhat more likely than men to undertake any migration, but sex differences in migration trends differed by migration flow, with women more likely to migrate into the area than men, and men more likely to out-migrate. Out-migration was suppressed by marriage particularly for women, but most women were not married; both men's and women's out-migrations were undertaken mainly for purposes of employment. Over half of female out-migrations (versus 35% of male out-migrations) were to nearby rural areas. The findings highlight the high mobility of this population and the extent to which gender is intimately related to the processes determining migration. We consider the implications of these findings for the measurement of migration and mobility, in particular for health and social policy and research among highly mobile populations in southern Africa.

The social legacy of AIDS: fertility aspirations among HIV-affected women in Uganda.

OBJECTIVES: We investigated the impact of HIV status on fertility desires in Uganda. METHODS: We surveyed 1594 women aged 18 to 49 years visiting outpatient services at Mbarara Regional Hospital, from May through August 2010. Of these, 59.7% were HIV-positive; 96.4% of HIV-positive women were using antiretroviral therapy (ART). We used logistic regression models to examine relationships between HIV status and fertility desires, marital status, household structure, educational attainment, and household income. RESULTS: Among married women, HIV-positive status was significantly associated with a lower likelihood of desiring more children (27.7% vs 56.4% of HIV-negative women; χ(2) = 39.97; P < .001). The difference remained highly significant net of age, parity, son parity, foster children, education, or household income. HIV-positive women were more likely to be poor, unmarried, single heads of household, in second marriages (if married), living with an HIV-positive spouse, and supporting foster children. CONCLUSIONS: We found a strong association between positive HIV status and lower fertility aspirations among married women in Uganda, irrespective of ART status. Although the increasing availability of ART is a tremendous public health achievement, women affected by HIV have numerous continuing social needs.

Incarceration and sexual risk: examining the relationship between men's involvement in the criminal justice system and risky sexual behavior.

In this study, we used data from Add Health Waves II and III to compare men who had been incarcerated to those who had not, and examined whether incarceration was associated with increased numbers of sexual partners and increased odds of concurrent partnerships. We used multivariate regression and propensity-score matching to compare sexual behavior of Wave III male respondents who had been incarcerated with those who had not, and compared sexual behavior at Wave II to identify differences in sexual behavior prior to incarceration. Incarceration was associated with an increased rate of lifetime sexual partnership, but this was attenuated by substance use. Criminal justice involvement was associated with increased odds of having partners who report concurrent partnerships, but no further increase was seen with incarceration. There were no significant sexual behavior differences prior to incarceration. These results suggest that the criminal justice system and substance use may interact to shape sexual behavior.

A novel look at racial health disparities: the interaction between social disadvantage and environmental health.

OBJECTIVES: We explored the notion that social disadvantage increases vulnerability to the health effects of environmental hazards. Specifically, we examined (1) whether race modifies the association between blood lead and blood pressure and (2) whether socioeconomic status (SES) plays a role in this modifying effect. METHODS: Using the National Health and Nutrition Examination Survey (2001-2008) and linear regression, we estimated the association between blood lead and blood pressure. Using interactions among race, SES, and lead, we estimated this association by levels of social disadvantage. RESULTS: Black men and women showed a 2.8 (P < .001) and 4.0 (P < .001) millimeters mercury increase in SBP, respectively, for each doubling of blood lead. White adults showed no association. This lead-SBP association exhibited by Blacks was primarily isolated to Blacks of low SES. For example, poor but not nonpoor Black men showed a 4.8 millimeters mercury (P < .001) increase in SBP for each doubling of blood lead. CONCLUSIONS: Our results suggest that social disadvantage exacerbates the deleterious health effects of lead. Our work provides evidence that social and environmental factors must be addressed together to eliminate health disparities.

Sex differences in HIV testing in Ghana, and policy implications.

HIV testing and counseling (HTC) is the primary gateway to all systems of AIDS-related care. This study describes sex differences in the use of HTC from data of the National AIDS/STI Control Program (NACP) over four years (2007-2010), across the 10 regions of Ghana. HTC data from NACP were from diagnostic centers (DCs), know your status campaigns (KYS) and prevention of mother-to-child transmission (PMTCT) sites across the country. Data highlight significantly greater use of HTC by females than males. From 2007 to 2010, females comprised 58.2% of all those using HIV testing at DCs and KYS, and this proportion rose to 75.9% when PMTCT data were included. The female: male testing ratio ranged from 6.2 in 2007 to 2.8 in 2010, suggesting a recent increase in male testing. The NACP data also indicate that females are more likely than males to test positive for HIV, suggesting either better catchment of HIV positive females, or potentially, a higher HIV epidemic among females than males. While the magnitude of the sex differences in testing varies by year and location, the data provide consistent evidence of lower male use of testing. Rigorous examination of HTC utilization rates, with closer attention to male use of testing, deserves closer policy attention.

Who is utilizing anti-retroviral therapy in Ghana: an analysis of ART service utilization.

INTRODUCTION: The global scale-up of antiretroviral therapy (ART) for HIV patients has led to concerns regarding inequities in utilization of ART services in resource-limited contexts. In this paper, we describe regional and sex differentials in the distribution of ART among adult HIV patients in Ghana. We highlight the need for interventions to address the gender-based and geographic inequities related to the utilization of ART services in Ghana. METHODS: We reviewed National AIDS/STIs Control Program's ART service provision records from January 2003 through December 2010, extracting data on adults aged 15+ who initiated ART in Ghana over a period of eight years. Data on the number of patients on treatment, year of enrollment, sex, and region were obtained and compared. RESULTS: The number of HIV patients receiving ART in Ghana increased more than 200-fold from 197 in 2003, to over 45,000 in 2010. However, for each of six continuous years (2005-2010) males comprised approximately one-third of adults newly enrolled on ART. As ART coverage has expanded in Ghana, the proportion of males receiving ART declined from 41.7% in 2004 to 30.1% in 2008 and to 27.6% in 2010. Also, there is disproportionate regional ART utilization across the country. Some regions report ART enrollment lower than their percent share of number of HIV infected persons in the country. CONCLUSIONS: Attention to the comparatively fewer males initiating ART, as well as disproportionate regional ART utilization is urgently needed. All forms of gender-based inequities in relation to HIV care must be addressed in order for Ghana to realize successful outcomes at the population level. Policy makers in Ghana and elsewhere need to understand how gender-based health inequities in relation to HIV care affect both men and women and begin to design appropriate interventions.

Prevalence of the metabolic syndrome in a rural population in Ghana.

BACKGROUND: The Metabolic syndrome (MS) which is a constellation of cardiometabolic risk factors including dyslipidaemia, hypertension, hyperglycaemia, central obesity, and endothelial dysfunction was hitherto relatively uncommon among Africans south of the Sahara. This study seeks to determine the prevalence of MS, its components and risk factors among a rural population in Ghana based on two popular international algorithms. METHODS: This was a cross-sectional survey of a rural population in Ghana conducted between November and December, 2007. Two hundred and twenty-eight (228) settler farmers, families and staff associated with the GOPDC Ltd, between the ages of 35 and 64 years, were randomly selected for the study; pregnant women were excluded. The prevalence of MS was estimated using the IDF and ATPIII criteria. RESULTS: The final subject pool included 102 males, and 104 females. The mean age of all subjects was 44.4 ± 6.9 years. The overall prevalence of MS by the IDF and ATPIII criteria were 35.9% and 15.0%, respectively, but there was an alarming female preponderance by both criteria {IDF: males = 15.7%, females =55.8%; ATPIII: males = 5.9%, females = 24.0%; sex differences p<0.001 for both criteria}. The most important determinants for IDF-defined MS were central obesity (55.3%), low High Density Lipoprotein (42.7%) and high Blood Pressure (39.5%). CONCLUSION: The triad of central obesity, high blood pressure and low HDL were most responsible for the syndrome in this rural population.

Key factors leading to reduced recruitment and retention of health professionals in remote areas of Ghana: a qualitative study and proposed policy solutions.

BACKGROUND: The ability of many countries to achieve national health goals such as the Millennium Development Goals remains hindered by inadequate and poorly distributed health personnel, including doctors. The distribution of doctors in Ghana is highly skewed, with a majority serving in two major metropolitan areas (Accra and Kumasi), and inadequate numbers in remote and rural districts. Recent policies increasing health worker salaries have reduced migration of doctors out of Ghana, but made little difference to distribution within the country. This qualitative study was undertaken to understand how practicing doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions. METHODS: In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors currently practicing in 3 regions (Greater Accra, Brong Ahafo, and Upper West); these 3 regions were chosen to represent progressively more remote distances from the capital of Accra. RESULTS AND DISCUSSION: All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. There was considerable stress placed on the need for rural doctors to have periodic contact with mentors through rural rotation of specialists, or remote learning centers, and reliable terms of appointment with fixed end-points. Also raised, but given less emphasis, were concerns about the adequacy of clinical equipment in remote facilities, and remote accommodations. CONCLUSIONS: In-depth discussions with doctors suggest that while salary is important, it is career development priorities that are keeping doctors in urban centers. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement.

For money or service?: a cross-sectional survey of preference for financial versus non-financial rural practice characteristics among Ghanaian medical students.

BACKGROUND: Health worker shortage and maldistribution are among the biggest threats to health systems in Africa. New medical graduates are prime targets for recruitment to deprived rural areas. However, little research has been done to determine the influence of workers' background and future plans on their preference for rural practice incentives and characteristics. The purpose of this study was to identify determinants of preference for rural job characteristics among fourth year medical students in Ghana. METHODS: We asked fourth-year Ghanaian medical students to rank the importance of rural practice attributes including salary, infrastructure, management style, and contract length in considering future jobs. We used bivariate and multivariate ordinal logistic regression to estimate the association between attribute valuation and students' socio-demographic background, educational experience, and future career plans. RESULTS: Of 310 eligible fourth year medical students, complete data was available for 302 students (97%). Students considering emigration ranked salary as more important than students not considering emigration, while students with rural living experience ranked salary as less important than those with no rural experience. Students willing to work in a rural area ranked infrastructure as more important than students who were unwilling, while female students ranked infrastructure as less important than male students. Students who were willing to work in a rural area ranked management style as a more important rural practice attribute than those who were unwilling to work in a rural area. Students studying in Kumasi ranked contract length as more important than those in Accra, while international students ranked contract length as less important than Ghanaian students. CONCLUSIONS: Interventions to improve rural practice conditions are likely to be more persuasive than salary incentives to Ghanaian medical students who are willing to work in rural environments a priori. Policy experiments should test the impact of these interventions on actual uptake by students upon graduation.

Willingness to work in rural areas and the role of intrinsic versus extrinsic professional motivations - a survey of medical students in Ghana.

BACKGROUND: Retaining health workers in rural areas is challenging for a number of reasons, ranging from personal preferences to difficult work conditions and low remuneration. This paper assesses the influence of intrinsic and extrinsic motivation on willingness to accept postings to deprived areas among medical students in Ghana. METHODS: A computer-based survey involving 302 fourth year medical students was conducted from May-August 2009. Logistic regression was used to assess the association between students' willingness to accept rural postings and their professional motivations, rural exposure and family parental professional and educational status (PPES). RESULTS: Over 85% of students were born in urban areas and 57% came from affluent backgrounds. Nearly two-thirds of students reported strong intrinsic motivation to study medicine. After controlling for demographic characteristics and rural exposure, motivational factors did not influence willingness to practice in rural areas. High family PPES was consistently associated with lower willingness to work in rural areas. CONCLUSIONS: Although most Ghanaian medical students are motivated to study medicine by the desire to help others, this does not translate into willingness to work in rural areas. Efforts should be made to build on intrinsic motivation during medical training and in designing rural postings, as well as favour lower PPES students for admission.