Prevalence and associated factors of common mental disorders among internally displaced people by armed conflict in Cabo Delgado, Mozambique: a cross-sectional community-based study.

Background: Humanitarian emergencies are a major global health challenge with the potential to have a profound impact on people's mental and psychological health. Displacement is a traumatic event that disrupts families and affects physical and psychological health at all ages. A person may endure or witness a traumatic incident, such as being exposed to war, and, as a result, develop post-traumatic stress disorder (PTSD). There is a lack of information about post-traumatic stress disorder, depression, and anxiety disorder in low and middle-income countries in humanitarian emergency contexts such as Mozambique. This study aimed to assess the prevalence of PTSD, depression, and anxiety, and associated factors among armed conflict survivors in Cabo Delgado, north region of Mozambique in 2023. Methods: A community-based cross-sectional study was conducted between January and April 2023 among 750 participants, who were selected by convenience. A face-to-face interview used the Primary Care Post-Traumatic Stress Disorder Checklist (PC-PTSD-5) to evaluate PTSD, the Generalized Anxiety Disorder Scale (GAD-7) to evaluate anxiety and the Patient Health Questionnaire - Mozambique (PHQ-9 MZ) to evaluate depression. The association between PTSD and demographic and psychosocial characteristics was analyzed using bivariate and multivariable binary logistic regression. We used a 5% significance level. Results: The three mental disorders assessed were highly prevalent in our sample with 74.3% PTSD, 63.8% depression, and 40.0% anxiety. The chance of developing PTSD was higher in females (AOR = 2.30, 95% CI 1.50-3.51), in patients with depression symptoms (AOR = 8.27, 95% CI = 4.97-13.74) and anxiety symptoms (AOR = 1.45, 95% CI = 0.84-2.50). Conclusion: This study reported that the prevalence of PTSD, depression, and anxiety were high. Patients having depressive symptoms, anxiety symptoms, and being female are more at risk of developing PTSD. There is a need to integrate screening for common mental disorders in the context of humanitarian emergencies and its adapted integration of psychosocial interventions.

Correction: Access to health services for men who have sex with men and transgender women in Beira, Mozambique: A qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0228307.].

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health.

BACKGROUND: Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its mechanisms of action. METHODS: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor's recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects. RESULTS: Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process. CONCLUSIONS: Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Prevalence and associated factors of common mental disorders in primary care settings in Sofala Province, Mozambique.

BACKGROUND: In Mozambique, the prevalence of common mental illness in primary care is not well established. AIMS: This study aimed to assess the prevalence of, and associated factors for, common mental illness in patients accessing primary care services in three Ministry of Health clinics in Mozambique. METHOD: Adult patients were recruited from the waiting rooms of prenatal, postpartum and general out-patient consultations. A mental health professional administered a diagnostic interview to examine prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence. Generalised linear mixed models were used to examine the odds of each disorder and sociodemographic associations. RESULTS: Of 502 patients interviewed, 74.1% were female (n = 372) and the average age was 27.8 years (s.d. = 7.4). Of all participants, 23.9% (n = 120) met diagnostic criteria for at least one common mental disorder; 8.6% were positive for MDD (n = 43), 13.3% were positive for GAD (n = 67), 4.8% were positive for PTSD (n = 24) and 4.0% were positive for any substance misuse or dependence (n = 20). Patients attending prenatal or postpartum consultations had significantly lower odds of any common mental disorder than patients attending out-patient primary care. Age was negatively associated with MDD, but positively associated with substance misuse or dependence. CONCLUSIONS: Over 20% of patients attending primary care in Mozambique may have common mental disorders. A specific focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence would provide a targeted response to high-risk demographics.

Demonstration project of a lay counselor delivered trans-diagnostic mental health intervention for newly diagnosed HIV patients in Mozambique.

ABSTRACTCommon mental disorders (CMDs) are associated with poor HIV outcomes in low- and middle-income countries. The present study implemented a psychological therapy delivered in routine HIV care and examined its effects on HIV outcomes in Mozambique. The Common Elements Treatment Approach (CETA) was integrated into routine HIV care in Sofala, Mozambique for all newly-diagnosed HIV+ patients with CMD symptoms. HIV treatment initiation and retention were compared to overall facility averages (those enrolled in CETA + those not enrolled). Of 250 patients screened, 59% (n = 148 met the criteria for CETA enrollment, and 92.6 (n = 137) enrolled in CETA. After four CETA visits, CMD symptoms decreased >50% and suicidal ideation decreased 100%. Patients enrolling in CETA had an antiretroviral therapy initiation rate of 97.1%, one-month retention of 69.2%, and three-month retention of 82.4%. Patients in the comparison group had one-month retention of 66.0% and three-month retention of 68.0%. CETA may be a promising approach to reduce symptoms of CMDs and improve HIV care cascade outcomes in areas with high HIV prevalence.

Community Health Workers' Knowledge, Attitudes, and Practices towards Epilepsy in Sofala, Central Mozambique.

BACKGROUND: Epilepsy is the most common neurological disease in the world, affecting 50 million people, with the majority living in low- and middle-income countries (LMICs). A major focus of epilepsy treatment in LMICs has been task-sharing the identification and care for epilepsy by community health workers (CHWs). The present study aimed to assess the knowledge, attitudes, and practices (KAPs) of CHWs towards epilepsy in Mozambique. METHODS: One hundred and thirty-five CHWs completed a questionnaire that included socio-demographic characteristics and 44-items divided into six subscales pertaining to KAPs towards epilepsy (QKAP-EPI) across nine districts of Sofala, Mozambique. The internal consistency was examined to evaluate the reliability of the instrument (QKAP-EPI). The association between sociodemographic variables and QKAP-EPI subscales was examined using linear regression models. RESULTS: The internal consistency was moderate for two subscales (causes of epilepsy, α = 0.65; medical treatment, α = 0.694), acceptable for cultural treatment (α = 0.797) and excellent for 2 subscales (safety and risks, α = 0.926; negative attitudes, α = 0.904). Overall, CHWs demonstrated accurate epilepsy knowledge (medical treatment: mean = 1.63, SD = 0.28; safety/risks: mean = 1.62, SD = 0.59). However, CHWs reported inaccurate epilepsy knowledge of the causes, negative attitudes, as well as culturally specific treatments for epilepsy, such as: "if a person with epilepsy burns when set on fire they cannot be treated". Knowledge about how to manage epileptic seizures varied across the different emergency care practices, from the accurate belief that it is not advisable to place objects in the individual's mouth during an epileptic seizure, to the wrong perception of the need to hold the person in seizures to control seizures. Heterogeneity in the level of epilepsy knowledge was observed among CHWs, when considering epilepsy according to the local names as treatable ("Dzumba") and other forms as untreatable ("Nzwiti"). CONCLUSION: CHWs knowledge of medical treatment and epilepsy safety/risks were adequate. However, information on the causes of epilepsy, stigmatizing attitudes, cultural treatment, and some knowledge of epileptic seizure management were low. These areas of poor knowledge should be the focus of educating CHWs in increasing their ability to provide quality care for patients with epilepsy in Mozambique.

Toward 90-90-90 Goals for Global Mental Health.

This Viewpoint discusses the adoption of 90-90-90 goals for global mental health, specifically targeting neurologic and substance use disorders, to prioritize mental health quality improvement within existing health services and destigmatize these conditions to promote treatment.

Prevalence and correlates of suicidal behavior in primary care settings in Mozambique.

BACKGROUND: This study assessed the prevalence of suicidal behavior and associated risk factors in public primary health care in Mozambique. METHODS: The Mini International Neuropsychiatric Interview was used to evaluate suicidal behavior among 502 adults attending three Primary Health Care (PHC) settings. RESULTS: In the past month, 13% (n = 63) of PHC attendees expressed suicidal ideation, 8% (n = 40) had made a suicide plan, 4% (n = 20) had made a suicide attempt, and 5% (n = 25) reported a lifetime suicide attempt. Females had 2.8-fold increased odds of suicide plan (95% CI: 1.5, 5.5) and 3.3-fold increased odds of suicide attempt in the past month (95% CI: 1.2, 9.1). Each 10-year increase in age was associated with 0.61-fold the odds of suicide plan (95% CI: 0.38, 0.98) and 0.09-fold the odds of suicide attempt (95% CI: 0.01, 0.69) in the past month. People living with HIV (PLWHA) had 2.2-fold increased adjusted odds of past month suicide attempt (CI: 1.1, 4.1). CONCLUSION: Suicidal behaviors are common among adults attending PHC clinics in Mozambique. Screening and linkage to effective preventive interventions are urgently needed in PHC settings. Females, younger individuals, and PLWHA are at elevated risk for suicidal behavior in PHC.

Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial.

BACKGROUND: Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique. METHODS: Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels. DISCUSSION: This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs. TRIAL REGISTRATION: ClinicalTrials.gov; NCT05103033 ; 11/2/2021.

Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: scoping review and expert consultation.

BACKGROUND: Lay Health Workers (LHW) are important providers of community mental health services and help mitigate access and treatment gaps in Africa. However, there is a paucity of knowledge about the role and performance of these workers, as well as about the extent to which the interventions delivered are culturally adapted to the African context. AIMS: This scoping review aimed to explore the content and aspects concerning the cultural adaptation and sustainability of psychological interventions delivered by LHW to people with mental disorders in Africa. METHODS: We conducted a scoping review of the peer-reviewed literature published from January 2000 to December 2018 to identify psychological interventions delivered by LHW for people with mental disorders in Africa. We systematically searched PubMed, Google scholar and Hinari to select relevant publications. The articles were evaluated for risk of bias according to study design with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools. Expert consultation was performed according to Arksey & O'Malley framework and cultural adaptation analysis was performed according to Bernal framework. RESULTS: Out of 14,549 retrieved records, we identified ten peer-reviewed articles conducted in Zimbabwe, Uganda, South Africa and Zambia describing four distinct interventions. Six were randomized controlled trials; none addressed implementation outcomes. Group-based interpersonal therapy (n = 5), trauma-focused cognitive behaviour therapy (n = 1), problem solving therapy (n = 3) and narrative exposure therapy (n = 1) emerged as psychological interventions delivered by LHW for people with depression, anxiety, trauma and suicidal behavior. Psychological interventions delivered by LHW in Africa were all culturally adapted to meet the competence of LHW. All the interventions were associated with symptom improvement, but the quality of this evidence varied widely with study design. CONCLUSION: Task-shifting psychological interventions delivered by LHW after appropriate cultural adaptation show promise for addressing unmet mental health care needs in Africa. More effectiveness and implementation evidence is needed, especially with regard to psychological interventions delivered by LHW for adolescence, older people and those with severe mental disorders and suicidal behaviors.

Integrating a Transdiagnostic Psychological Intervention Into Routine HIV Care: A Mixed-Methods Evaluation of the Common Elements Treatment Approach in Mozambique.

INTRODUCTION: We integrated a transdiagnostic psychological intervention (Common Elements Treatment Approach [CETA]) into routine HIV care in Sofala, Mozambique. This task-shared program screens and treats newly diagnosed HIV+ patients with comorbid mental health symptoms. METHODS: A mixed-methods evaluation included demographics, intake screening scores, mental health symptoms, and barriers/facilitators to implementation examined through interviews. Multilevel models were used to analyze factors associated with symptom improvement and loss to follow-up (LTFU). RESULTS: From March 2019 to June 2020, 820 individuals were screened for CETA treatment; 382 (46.6%) showed clinically significant mental health symptoms and attended 1484 CETA sessions. Of CETA patients, 71.5% (n = 273/382) had general mental distress, 7.3% (n = 28) had alcohol abuse/dependence, 12.0% (n = 46) had suicidal ideation, and 3.7% (n = 14) had other violent ideation; 66.2% (n = 253) had experienced at least 1 traumatic event at intake. Mental health symptoms decreased by 74.1% (17.0 to 4.4) after 5 CETA sessions, and 37.4% of patients (n = 143) achieved a ≥50% symptom reduction from intake. LTFU was 29.1% (n = 111), but 59.5% of LTFU patients (n = 66) achieved a ≥50% symptom reduction before LTFU. Facilitators for CETA implementation included readiness for change given the unaddressed burden of mental illness. Barriers included complexity of the intervention and stigma. CONCLUSIONS: Approximately 45% of newly diagnosed HIV+ individuals in Mozambique have clinically significant mental health symptoms at diagnosis. Integrating CETA into routine HIV platforms has in-context feasibility. Future implementation studies can optimize strategies for patient retention and scale-up.

Psychometric Validation of a Combined Assessment for Anxiety and Depression in Primary Care in Mozambique (CAD-MZ).

This study sought to validate a combined assessment for major depression and generalized anxiety, administered by health providers in a primary care setting in Mozambique. Patients attending a primary care visit (N = 502) were enrolled in the study and completed the Patient Health Questionniare-9, the Generalized Anxiety Disorder-7, and six items identified in a global systematic qualitative review of depression that were not captured in existing measures (e.g., social isolation, "thinking too much," and "heart problems"). A separate trained mental health provider conducted the Mini International Neuropsychiatric Interview 5.0, adapted for Mozambique, to establish clinical diagnoses. Item response theory, factor analysis, and receiver operating characteristics were all used to identify the best screening items. Eight items were identified for the final screener: four items from the Patient Health Questionniare-9, two from the Generalized Anxiety Disorder-7, and two from the global depression literature. A cut-score of 7 was found to consistently increase the diagnostic likelihood of having a particular disorder. Overall, findings indicate good clinical utility of the screener in primary care in Mozambique.

Validity and item response theory properties of the Alcohol Use Disorders Identification Test for primary care alcohol use screening in Mozambique (AUDIT-MZ).

BACKGROUND: No validated tools exist to screen for substance use or dependence in Mozambique. The aim of this study was to validate the Alcohol Use Disorder Identification Test (AUDIT) for use in primary care settings in Mozambique. METHODS: The study administered a final adapted Mozambican 10-item AUDIT (AUDIT-10-MZ) to 502 individuals from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary health care clinics in Sofala Province, Mozambique. The study evaluated the AUDIT-10-MZ against the MINI 5.0-MZ as a gold standard diagnostic tool. RESULTS: Using the MINI 5.0-MZ, 16 (3.2%) of the sample tested positive for alcohol dependence and 3 (0.6%) tested positive for harmful alcohol use. The full AUDIT-10-MZ had acceptable internal consistency (α = 0.74); however, the shorter AUDIT-C-MZ had a higher alpha value than the full AUDIT screener (α = 0.79). The AUDIT-10-MZ performed well for screening in primary care, achieving areas under the receiver operating characteristic curves (AUROCs) of 0.94 (95% CI: 0.91, 0.96) for alcohol dependence. The AUDIT-C-MZ also performed well with an AUROC of 0.88 (95% CI: 0.80, 0.96) for alcohol dependence. Using a cut-off of ≥6, the AUDIT-10-MZ achieved a sensitivity of 68.8% and specificity of 92.0% for screening for alcohol dependence; a cut-off of ≥3 for the AUDIT-C-MZ achieved a sensitivity of 56.3% and specificity of 90.7%. CONCLUSIONS: Both the AUDIT-10-MZ and AUDIT-C-MZ are valid instruments for screening for alcohol dependence in Mozambique. The AUDIT-C-MZ performed particularly well and providers could use it as a brief screener in primary care settings. Optimal cut-points will depend on weighing false positives and false negatives but could be employed at ≥ 6 or ≥ 7 for the AUDIT-10-MZ and at ≥ 2 or ≥ 3 for the AUDIT-C-MZ. Future implementation research is needed to examine how best to integrate screening for substance use or dependence in primary care settings in Mozambique and other similar LMICs.

Optimizing treatment cascades for mental healthcare in Mozambique: preliminary effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH).

Substantial investments are being made to scale-up access to mental healthcare in low- and middle-income countries, but less attention has been paid to quality and performance of nascent public-sector mental healthcare systems. This study tested the initial effectiveness of an implementation strategy to optimize routine outpatient mental healthcare cascade performance in Mozambique [the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH)]. This study employed a pre-post design from September 2018 to August 2019 across four Ministry of Health clinics among 810 patients and 3234 outpatient mental health visits. Effectiveness outcomes evaluated progression through the care cascade, including: (1) initial diagnosis and medication selection; (2) enrolling in follow-up care; (3) returning after initial consultation within 60 days; (4) returning for follow-up visits on time; (5) returning for follow-up visits adherent to medication and (6) achieving function improvement. Clustered generalized linear models evaluated odds of completing cascade steps pre- vs post-intervention. Facilities prioritized improvements focused on the follow-up cascade, with 62.5% (10 of 16) monthly system modifications targeting medication adherence. At baseline, only 4.2% of patient visits achieved function improvement; during the 6 months of SAIA-MH implementation, this improved to 13.1% of patient visits. Multilevel logistic regression found increased odds of returning on time and adherent [aOR = 1.53, 95% CI (1.21, 1.94), P = 0.0004] and returning on time, adherent and with function improvement [aOR = 3.68, 95% CI (2.57, 5.44), P < 0.0001] after SAIA-MH implementation. No significant differences were observed regarding other cascade steps. The SAIA-MH implementation strategy shows promise for rapidly and significantly improving mental healthcare cascade outcomes, including the ultimate goal of patient function improvement. Given poor baseline mental healthcare cascade performance, there is an urgent need for evidence-based implementation strategies to optimize the performance of mental healthcare cascades in low- and middle-income countries.

Conhecimentos, Atitudes e Práticas dos Trabalhadores de Saúde em Moçambique sobre a COVID-19: estudo online rápido / Knowledge, Attitudes and Practices of Health Workers in in Mozambique about COVID-19: rapid online study

Os profissionais de saúde (PS), como profissionais da linha de frente, têm maior risco de infecção pela COVID-19. Foram adoptadas várias medidas para controlar a rápida propagação da epidemia da COVID-19 em Moçambique. A adesão dos (PS) a essas medidas é influenciada por seus conhecimentos, atitudes e práticas (CAP) em relação à COVID-19. Neste estudo, analisámos os CAP dos PS em relação à COVID-19 durante o primeiro mês da pandemia em Moçambique. Os PS, foram convidados a participar do estudo, através dos grupos de redes sociais. O questionário de conhecimento é composto por 13 questões referentes às características clínicas e prevenção da COVID-19. As atitudes e práticas em relação à COVID-19 foram avaliadas por meio de perguntas sobre a confiança no controle da COVID-19 e o uso de máscaras quando em locais públicos.Entre os respondentes da pesquisa (n = 431), 53,1% eram mulheres, 57,8% possuíam o grau de licenciatura. A taxa geral de respostas correctas do questionário de conhecimento foi de 87,2%. A maioria dos inquiridos (86,2%) tem confiança de que Moçambique vencerá a luta contra a COVID-19. A maioria dos PS (91,2%) usou máscara quando saiu de casa nos últimos dias. Em geral, os participantes da pesquisa possuem bons conhecimentos sobre a COVID-19 e atitudes positivas em relação à vitória na batalha contra a COVID-19. As acções de educação e treinamento em COVID-19 para profissionais de saúde devem ter em consideração factores como género, experiência de trabalho e nível de diferenciação profissional. No entanto, existem lacunas em aspectos de conhecimento e práticas que devem receber atenção especial pelas autoridades de saúde em futuras iniciativas de educação dos profissionais de saúde sobre a COVID-19.

Health Care Workers (HCW) as a frontline's professional has higher risk of infections and worst outcome by COVID-19. Measures have been adopted to control the rapid spread of the COVID-19 epidemic in Mozambique. HCW adherence to these measures is affected by their knowledge, attitudes, and practices (KAP) towards COVID-19. In this study, we investigated Mozambican HCW KAP towards COVID-19 during the first month of the pandemic in Mozambique. An online sample of Mozambican HCW was invited to participate via the HCW social media groups. The knowledge questionnaire consisted of 13 questions regarding the clinical characteristics and prevention of COVID-19. Attitudes and practices towards COVID-19 was assessed using questions on confidence in winning the battle against COVID-19 and wearing masks when going out in recent days. Among the survey respondents (n=431), 53.1 % were women, 57.8% held a bachelor degree. The overall correct rate of the knowledge questionnaire was 87.2%. The majority of the respondents (86.2%) had confidence that Mozambique can win the battle against COVID-19. Most HCW (91.2%) wore masks when going out in recent days. In general, HCW who participated in the survey have good knowledge about COVID-19, and positive attitudes towards victory in the battle against COVID-19. Education and training actions on COVID-19 for HCW should take into account factors such as gender, work experience and level of professional differentiation. However, there are gaps in aspects of knowledge and practices that should be given special attention by health authorities in future initiatives to raise awareness and education for health professionals

Validity and item response theory properties of the Patient Health Questionnaire-9 for primary care depression screening in Mozambique (PHQ-9-MZ).

BACKGROUND: Depression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique. METHODS: The PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 502 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool. RESULTS: The majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach's alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%. CONCLUSIONS: The PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.

Access to health services for men who have sex with men and transgender women in Beira, Mozambique: A qualitative study.

OBJECTIVES: HIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Médecins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM- and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care. METHODS: In-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF's programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework. RESULTS: Nine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement, including social media. Interviewees reported experiencing stigma and discrimination because of their gender or sexual identity. HIV-related stigma and health-care setting discrimination, including gossip and breach of confidentiality, were also reported. Although the presence of the peer-educators and their outreach activities were appreciated, they had limited visibility and an over-focus on health and HIV. The face-to-face networks of MSM and transgender women were small and fragmented. Virtual networks such as Facebook were mainly used for flirting, dating and informal communication. Most interviewees were at ease using social media and would consider it as a means of engaging with health messaging. CONCLUSIONS: MSM and transgender women have challenges in accessing health services due to being stigmatised because of their gender identity and their sexual behaviour, and often experience stigma at home, in health-care facilities and in their communities. Peer-driven models of engagement were appreciated but have limitations. There is an untapped potential for further expansion and engagement with face-to-face and virtual platforms to reach MSM and transgender women in settings with a high HIV burden, and to provide them with essential information about HIV and their health.

Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms.

BACKGROUND: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. METHODS: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. RESULTS: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. DISCUSSION: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.