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Background: The University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) is a tool to assess the capacity of participants to consent in psychiatric research. However, little is known about the psychometric properties in low and middle-income countries. This study aimed to examine the psychometric properties of the UBACC. Methods: We examined the reliability, latent factor structure, and item response of the first attempt of the UBACC items in a sample of 32,208 adults (16,467 individuals with psychosis and 15,741 controls) in Ethiopia, Kenya, South Africa, and Uganda; exploring these properties in the full sample and stratified by country, diagnostic status, sex, and ethnolinguistic language groups. Results: Exploratory factor analysis (EFA) suggested a two-factor model for the overall sample. However, a three-factor model was more appropriate when examining the latent structure across country, language, and sex. Confirmatory factor analyses (CFA) revealed an adequately fitting three-factor model for the full sample and across country, sex, and language. A two-factor model, however, was more appropriate for English and Amharic languages. Across all groups, the internal consistency of the UBACC was low, indicating below-threshold reliability (Cronbach's α (95 % CI = 0.58 (0.57–0.59). Using a multidimensional item-response theory framework for the full sample revealed that UBACC item 8, measuring understanding of the benefits of study participation, was the most discriminating item. Many of the other items had below-threshold discriminating characteristics. Conclusion: EFA and CFA converged towards a two and three-dimensional structure for the UBACC, in line with the developers of the original scale. The differences in properties between populations and language groups, low internal consistency, and below-threshold item functioning suggest that investigations into the cultural and linguistic nuances are still warranted. Understanding the utility of consent tools, such as the UBACC, in underrepresented populations will be a part of the larger process which ensures that research participants are adequately protected.

Abstract Introduction The COVID-19 pandemic is still a public health concern in South Sudan having caused suffering since the first case of COVID-19 was introduced on 28th February 2020. COVAX vaccines have since been introduced using a number of strategies including fixed site, temporary mobile, hit and run in flooded and conflict affected areas. We aim to describe the 2 ICVOPT campaigns that were conducted to improve the uptake and document lessons learnt during the initial rollout of the COVID-19 vaccination programin South Sudan between February 2022 and June 2022 each lasting for 7-days. Methodology We conducted an operational cross-sectional descriptive epidemiological study of a series of the intensified COVID-19 vaccination Optimization (ICVOPT) campaigns from February 2022 to June 2022. Before the campaign, a bottom up micro-planning was conducted, validated by the County Health Departments (CHDs) and national MOH team. Each of the 2 campaigns lasted for 7 days targeting 30% of the eligible unvaccinated target population who were18 years and above. Each team consisted of 2 vaccinators, 2 recorders and 1 mobilizer. The teams employed both fixed site, temporary mobile, hit and run in flooded and conflict affected areas. The number of teams were calculated based on the daily workload per day (80 persons per team/day) for the duration of the campaigns. Results A total of 444,030 individuals were vaccinated with primary series COVID-19 vaccine (J&J) out of the targeted 635,030 persons. This represented 69.9% of target population in the selected 28 counties and 10 states of South Sudan in 7 days’ ICVOPT campaigns. More eligible persons were reached in 7 days campaigns than the 9 months of rollout of the COVID-19 vaccine prior to ICVOPT campaigns using the fixed site strategy at the health facility posts. Conclusion Intensified COVID-19 vaccination Optimization (ICVOPT) campaigns were vital and fast in scaling up vaccination coverages as compared to the fixed site vaccination strategies (2022 progress report on the Global Action Plan for Healthy Lives and Well-being for All Stronger collaboration for an equitable and resilient recovery towards the health-related Sustainable Development Goals, incentivizing collaboration, 2022) in complex humanitarian emergency settings and hard-to-reach areas of South Sudan.

BackgroundScalable PTSD screening strategies must be brief, accurate and capable of administration by a non-specialized workforce.MethodsWe used PTSD as determined by the structured clinical interview as our gold standard and considered predictors sets of (a) Posttraumatic Stress Checklist-5 (PCL-5), (b) Primary Care PTSD Screen for the DSM-5 (PC-PTSD) and, (c) PCL-5 and PC-PTSD questions to identify the optimal items for PTSD screening for public sector settings in Kenya. A logistic regression model using LASSO was fit by minimizing the average squared error in the validation data. Area under the receiver operating characteristic curve (AUROC) measured discrimination performance.ResultsPenalized regression analysis suggested a screening tool that sums the Likert scale values of two PCL-5 questions—intrusive thoughts of the stressful experience (#1) and insomnia (#21). This had an AUROC of 0.85 (using hold-out test data) for predicting PTSD as evaluated by the MINI, which outperformed the PC-PTSD. The AUROC was similar in subgroups defined by age, sex, and number of categories of trauma experienced (all AUROCs>0.83) except those with no trauma history- AUROC was 0.78.ConclusionIn some East African settings, a 2-item PTSD screening tool may outperform longer screeners and is easily scaled by a non-specialist workforce.

Background: The link between trauma exposure and psychotic disorders is well-established. Further, specific types of trauma may be associated with specific psychotic symptoms. Network analysis is an approach that can advance our understanding of the associations across trauma types and psychotic symptoms. Methods: We conducted a network analysis with data from 16,628 adult participants (mean age [standard deviation] = 36.3 years [11.5]; 55.8% males) with psychotic disorders in East Africa recruited between 2018 and 2023. We used the Life Events Checklist and the Mini International Neuropsychiatric Interview to determine whether specific trauma types experienced over the life course and specific psychotic symptoms were connected. We used an Ising model to estimate the network connections and bridge centrality statistics to identify nodes that may influence trauma types and psychotic symptoms. Results: The trauma type “exposure to a war zone” had the highest bridge strength, betweenness, and closeness. The psychotic symptom “odd or unusual beliefs” had the second highest bridge strength. Exposure to a war zone was directly connected to visual hallucinations, odd or unusual beliefs, passivity phenomena, and disorganized speech. Odd or unusual beliefs were directly connected to transportation accidents, physical assault, war, and witnessing sudden accidental death. Conclusion: Specific trauma types and psychotic symptoms may interact bidirectionally. Screening for psychotic symptoms in patients with war-related trauma and evaluating lifetime trauma in patients with odd or unusual beliefs in clinical care may be considered points of intervention to limit stimulating additional psychotic symptoms and trauma exposure. This work reaffirms the importance of trauma-informed care for patients with psychotic disorders.

Background Depression is common among adolescents living with HIV (ALHIV) and impacts their quality of life. However, it is not routinely detected and treated due to a lack of screening tools, coupled with large numbers of clients in the HIV clinics and limited staff. Enabling adolescents to do a self-assessment for depression on a tablet computer could possibly improve the detection of depression in this population. We set out to assess the detection and referral of depression among ALHIV in care in Uganda.Methods This was a quasi-experimental study design with a historical control at Baylor College of Medicine of Children’s Foundation. We conducted a retrospective chart review of 425 adolescents covering a 3-month period and documented the proportion screened for depression and referred to the clinic counsellors. From July to September 2022, eligible adolescents aged 10–19 years who had assented and consented self-assessed for depression using a Patient Health Questionnaire-Adolescent on a tablet computer-assisted self-interview (CASI). Adolescents who screened positive had a prompt on the tablet computers referring them to the counsellor for mental healthcare. We compared the proportions of participants screened for depression and referred to counsellors from clinic chart review and on the CASI using paired t-tests.Results Out of 425 medical records reviewed, 54% (231/425) were females and the median age was 15 years. Of the participants who self-assessed on the CASI, 52% (222/425) were males and the median age of all participants was 16 years. Self-assessment on the CASI increased the rate of detection of depression from 0% to 23.3%. Of those referred on the CASI, 15% accessed care at the referral point.Conclusion The use of CASI improves the rate of detection of depression among ALHIV; however, there is a need to address the barriers to effective referral for mental health services.

The Kessler Psychological Distress Scale (K10) has been widely used to screen psychological distress across many countries. However, its performance has not been extensively studied in Africa. The present study sought to evaluate and compare measurement properties of the K10 across four African countries: Ethiopia, Kenya, Uganda, and South Africa. Our hypothesis is that the measure will show equivalence across all.Data are drawn from a neuropsychiatric genetic study among adult participants (N = 9179) from general medical settings in Ethiopia (n = 1928), Kenya (n = 2556), Uganda (n = 2104), and South Africa (n = 2591). A unidimensional model with correlated errors was tested for equivalence across study countries using confirmatory factor analyses and the alignment optimization method. Results displayed 30 % noninvariance (i.e., variation) for both intercepts and factor loadings across all countries. Monte Carlo simulations showed a correlation of 0.998, a good replication of population values, indicating minimal noninvariance, or variation. Items “so nervous,” “lack of energy/effortful tasks,” and “tired” were consistently equivalent for intercepts and factor loadings, respectively. However, items “depressed” and “so depressed” consistently differed across study countries (R2 = 0) for intercepts and factor loadings for both items.The K10 scale likely functions equivalently across the four countries for most items, except “depressed” and “so depressed.” Differences in K10 items were more common in Kenya and Ethiopia, suggesting cultural context may influence the interpretation of some items and the potential need for cultural adaptations in these countries.

Abstract Background Psychotic disorders are common and contribute significantly to morbidity and mortality of people with psychiatric diseases. Therefore, early screening and detection may facilitate early intervention and reduce adverse outcomes. Screening tools that lay persons can administer are particularly beneficial in low resource settings. However, there is limited research evaluating the validity of psychosis screening instruments in Uganda. We aimed to assess the construct validity and psychometric properties of the Psychosis Screening Questionnaire (PSQ) in Uganda in a population with no history of a psychotic disorder. Methods The sample consisted of 2101 Ugandan adults participating as controls in a larger multi-country case-control study on psychiatric genetics who were recruited between February 2018 and March 2020. Participants were individuals seeking outpatient general medical care, caretakers of individuals seeking care, and staff or students recruited from five medical facilities that were age 18 years or older and able to provide consent. Individuals were excluded who had acute levels of alcohol or substance use, including being under inpatient hospitalization or acute medical care for one of these conditions. We used confirmatory factor analysis (CFA) and item response theory (IRT) to evaluate the factor structure and item properties of the PSQ. Results The overall prevalence screening positive for psychotic symptoms was 13.9% 95% CI (12.4,15.4). “Strange experiences” were the most endorsed symptoms 6.6% 95% CI (5.6,7.8). A unidimensional model seemed to be a good model or well-fitting based on fit indices including the root mean square error of approximation (RMSEA of 0.00), comparative fit index (CFI of 1.000), and Tucker-Lewis Index (TLI of 1.000). The most discriminating items along the latent construct of psychosis were items assessing thought disturbance followed by items assessing paranoia, with a parameter (discrimination) value of 2.53 and 2.40, respectively. Conclusion The PSQ works well in Uganda as an initial screening tool for moderate to high-level of psychotic symptoms.

Abstract Introduction The management of long-term physical conditions is a challenge worldwide, absorbing a majority resources despite the importance of acute care. The management of these conditions is done largely in primary care and so interventions to improve primary care could have an enormous impact. However, very little data exist on how to do this. Mental distress is frequently comorbid with long term physical conditions, and can impact on health behaviour and adherence, leading to poorer outcomes. DIALOG+ is a low-cost, patient-centred and solution-focused intervention, which is used in routine patient-clinician meetings and has been shown to improve outcomes in mental health care. The question arises as to whether it could also be used in primary care to improve the quality of life and mental health of patients with long-term physical conditions. This is particularly important for low- and middle-income countries with limited health care resources. Methods An exploratory non-controlled multi-site trial was conducted in Bosnia and Herzegovina, Colombia, and Uganda. Feasibility was determined by recruitment, retention, and session completion. Patient outcomes (quality of life, anxiety and depression symptoms, objective social situation) were assessed at baseline and after three approximately monthly DIALOG+ sessions. Results A total of 117 patients were enrolled in the study, 25 in Bosnia and Herzegovina, 32 in Colombia, and 60 in Uganda. In each country, more than 75% of anticipated participants were recruited, with retention rates over 90% and completion of the intervention exceeding 92%. Patients had significantly higher quality of life and fewer anxiety and depression symptoms at post-intervention follow-up, with moderate to large effect sizes. There were no significant improvements in objective social situation. Conclusion The findings from this exploratory trial suggest that DIALOG+ is feasible in primary care settings for patients with long-term physical conditions and may substantially improve patient outcomes. Future research may test implementation and effectiveness of DIALOG+ in randomized controlled trials in wider primary care settings in low- and middle-income countries. Trial registration All studies were registered prospectively within the ISRCTN Registry. ISRCTN17003451, 02/12/2020 (Bosnia and Herzegovina), ISRCTN14018729, 01/12/2020 (Colombia) and ISRCTN50335796, 02/12/2020 (Uganda).

Exposure to potentially traumatic events (PTE) is common and increases an individual's risk of developing post-traumatic stress disorder (PTSD) and other psychiatric disorders. PTEs can be screened with the Life Events Checklist for DSM 5 (LEC-5). However, the psychometric properties of the LEC-5 have never been assessed in Uganda. We aimed to estimate the prevalence of PTEs and evaluate the factor structure of the LEC-5 in a sample of N = 4,479 Ugandan adults between February 2018 -March 2020. We used the phenotyping data from a case-control study (NeuroGAP-Psychosis) in Uganda investigating the genetic and environmental risk factors for psychosis spectrum disorders with 4,479 participants (2,375 cases and 2,104 controls). Prevalence for PTEs was determined for all participants and by case-control status. The factor structure of the LEC-5 was assessed using an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA). The overall prevalence of exposure to one or more types of PTEs was 60.5%. Cases reported more frequency of exposure to PTEs than controls (64.2% vs 55.4%; p

Abstract Background Cervical cancer remains a public health problem worldwide, especially in sub-Saharan Africa. There are challenges in timely screening and diagnosis for early detection and intervention. Therefore, studies on cervical cancer and cervical intraepithelial neoplasia suggest the need for new diagnostic approaches including microRNA technology. Plasma/serum levels of microRNAs are elevated or reduced compared to the normal state and their diagnostic accuracy for detection of cervical neoplasms has not been rigorously assessed more so in low-resource settings such as Uganda. The aim of this systematic review was therefore to assess the diagnostic accuracy of serum microRNAs in detecting cervical cancer. Methods We will perform a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. We will search for all articles in MEDLINE/PubMed, Web of Science, Embase, and CINAHL, as well as grey literature from 2012 to 2022. Our outcomes will be sensitivity, specificity, negative predictive values, positive predictive values or area under the curve (Nagamitsu et al, Mol Clin Oncol 5:189-94, 2016) for each microRNA or microRNA panel. We will use the quality assessment of diagnostic accuracy studies (Whiting et al, Ann Intern Med 155:529-36, 2011) tool to assess the risk of bias of included studies. Our results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Diagnostic Test Accuracy studies (PRISMA-DTA). We will summarise studies in a flow chart and then describe them using a structured narrative synthesis. If possible, we shall use the Lehmann model bivariate approach for the meta analysis Use of the review results This systematic review will provide information on the relevance of microRNAs in cervical cancer. This information will help policy makers, planners and researchers in determining which particular microRNAs could be employed to screen or diagnose cancer of the cervix. Systematic review registration This protocol has been registered in PROSPERO under registration number CRD42022313275.

Abstract The World Health Organisation reports higher levels of bacterial resistance to cephalosporins and carbapenems of above 54%. The sufficient redox capabilities of Ficus thonningii phytochemicals for Ag+ reduction to Ag0 and ultimately aggregation to nucleation are exploited for the first time in attempting to enhance the antibacterial activity. Solution colour change to brown due to surface plasmon resonance phenomenon confirmed nanoparticle fabrication with a UV/Vis absorption peak at 426 nm. Fourier Transform Infrared spectra revealed functional groups (C=C at 1620–1680 cm−1; C=H at 1400–1600 cm−1 aromatics) for encapsulation, stabilisation, and reduction of the silver ion. The Dynamic Light Scattering technique verified F. thonningii encapsulated silver nanoparticles particle size of 57.84 nm with a negative zeta potential (−19.8 mV) as proof of stability. The surface, shape and topographical features were shown by Scanning Electron Microscopy as spherical orientations. An enhanced antimicrobial efficacy was displayed by the nanoparticles (inhibition zones of 26.1, 24.1 and 15.2 mm from 11.5, 10.6 and 6.5 mm) for Staphylococcus aureus, Streptococcus pyrogenes and Escherichia coli, respectively, compared to Flucloxacillin standard that was in the ranges of 21.5, 23.5 and 25.7 mm. The enhanced potency provides a basis for diversified approaches of generating novel drugs for treating bacterial infections.

Introduction: Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda. Methods: We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion. Results: There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [r(112) = 0.64, p

Abstract Introduction Cognitive impairment is common in first-episode psychosis patients and often associated with poor quality of life and functional impairment. However, most literature on this association is from high income countries and not low resource countries like Uganda. We aimed to determine the association between cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients. Methods At Butabika national psychiatric hospital of Uganda, we enrolled 94 first-episode psychosis patients aged 18–60 years with a confirmed first-episode of psychosis and no previous treatment with antipsychotic medication. Neuropsychological assessment was performed using the MATRICS consensus cognitive battery (MCCB). Quality of life and functional impairment were assessed using the brief version of the World Health Organisation Quality of Life scale (WHOQOL-BREF) and the MINI International Neuropsychiatric Inventory (MINI) respectively. Linear regression analyses determined the association between impairment in different cognitive domains with various quality of life and functional impairment domains while controlling for age, gender and level of education. Results High scores in the reasoning and problem solving cognitive domain were associated with better quality of life in the psychological domain of WHOQOL-BREF (p = 0.029). For functional impairment, high cognitive scores in the domains of speed of processing (p = 0.018), reasoning and problem solving (p = 0.015), working memory (p = 0.017) and visual learning and memory (p = 0.002) were associated with psychosis “having a greater impact on other members of the family” on the MINI. Higher scores in the social cognition domain were associated with “less aggressive and disruptive behaviour” (p = 0.003). Conclusion Cognitive impairment in Ugandan first-episode psychotic patients is associated with both poorer quality of life and functional impairment. Remediation of cognitive function may be a plausible intervention to improve outcomes in Ugandan first-episode psychosis patients.

Abstract Introduction Cardiovascular diseases (CVD) are the leading cause of mortality worldwide and are significantly associated with multiple comorbid disorders including mental disorders such as psychological distress (PD). At increased risk of PD are CVD patient sub-categories that not only require chronic therapy but also need follow up with continuous blood tests and dose adjustments (like the patients on warfarin). However, not much has been done to ascertain the burden of PD among patients on warfarin in Uganda. Objective To determine the prevalence and factors associated with PD among patients on anticoagulation with warfarin at the Uganda Heart Institute (UHI). Methods In this analytical cross-sectional study, 197 participants were sampled from adults on warfarin attending the Uganda Heart Institute (UHI) out patient clinic. The Self Reporting Questionnaire (SRQ-20), a tool with a total maximum score of 20 and cutoff for PD at ≥6 was used to determine the presence of PD among participants, and a socio-demographic questionnaire to document the socio-demographic characteristics of the subjects. Additional questions including the underlying CVD diagnosis, medications used (besides warfarin) and presence of chronic illnesess were also assessed. Bi-variable and multi-variabe logistic regression analysis techniques were used to examine the associations between the dependent and independent variables. Results The prevalence of PD was 32%. The unemployed participants were 4.5 times more likely to have PD (adjusted odds ratio [aOR]4.56, 95% confidence interval [CI]: 1.12–18.62, p = 0.04). Participants who had experienced social stressors were more likely to have PD (aOR: 11.38, CI: 3.60–36.04, p

BackgroundMental disorders are known to predict poverty, morbidity and mortality. In resource limited settings, low levels of mental health literacy (MHL) and high mental illness stigma (MIS) have been sighted as possible factors that may impede access to mental health care. However, little has been done to examine the association between mental disorders and these factors (MHL and MIS) in sub-Saharan Africa.MethodsWe assessed for the prevalence of major depressive disorders (MDD), substance use disorders (SUD), post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), documented MHL and MIS among 814 participants from 24 villages in central Uganda. We conducted regression analyses to examine the association between the prevalence of mental disorders, demographic factors as well as MIS and MHL.ResultsOver two thirds of the participants 581 (70%) were female. The mean age of the participants was 38 years (SD± 13.5). The prevalence of mental disorders ranged from 6.8-32%. Participants who were older were less likely to screen positive for GAD (OR 0.98; 0.96-0.99), female gender was protective against SUD (OR 0.46; 0.3-0.68) and those with MDD had lower education level (OR 0.23; 0.1-0.53). The mean MIS score was 11.3 (SD± 5.4) with a range of 6-30 and the mean MHL score was 21.7 (SD ±3.0) with a range of 10-30. MIS was negatively associated with GAD [β = -1.211 (-2.382 to -0.040)]. There no statistically significant association between MHL and a mental disorder.ConclusionThere was a high prevalence of mental disorders in the community that we studied. Adequate resources should be allocated to address this burden.

Abstract Background DIALOG+ is a resource-oriented and evidence-based intervention to improve quality of life and reduce mental distress. While it has been extensively studied in mental health care, there is little evidence for how to use it in primary care settings for patients with chronic physical conditions. Considering that DIALOG+ is used in existing routine patient-clinician meetings and is very low cost, it may have the potential to help large numbers of patients with chronic physical conditions, mental distress and poor quality of life who are treated in primary care. This is particularly relevant in low- and middle-income countries (LMICs) where resources for specialised services for such patients are scarce or non-existent. Methods An exploratory non-controlled trial will be conducted to primarily assess the feasibility and acceptability and, secondarily, outcomes of delivering DIALOG+ to patients with chronic physical conditions and poor quality of life in primary care settings in Bosnia and Herzegovina, Colombia and Uganda. Thirty patients in each country will receive DIALOG+ up to three times in monthly meetings over a 3-month period. Feasibility will be assessed by determining the extent to which the intervention is implemented as planned. Experiences will be captured in interviews and focus groups with care providers and participants to understand acceptability. Quality of life, symptoms of anxiety and depression, objective social situation and health status will be assessed at baseline and again after the three-session intervention. Discussion This study will inform our understanding of the extent to which DIALOG+ may be used in the routine care of patients with chronic physical conditions in different primary care settings. The findings of this exploratory trial can inform the design of future full randomised controlled trials of DIALOG+ in primary care settings in LMICs. Trial registration All studies were registered prospectively (on 02/12/2020 for Uganda and Bosnia and Herzegovina, and 01/12/2020 for Colombia) within the ISRCTN Registry. ISRCTN17003451 (Bosnia and Herzegovina), ISRCTN14018729 (Colombia) and ISRCTN50335796 (Uganda). Protocol version and date: v2.0; 28/07/2020 (Bosnia and Herzegovina), v0.3 02/08/2020 (Colombia) and v1.0, 05/11/2020 (Uganda).

Abstract Background Literature shows a high prevalence of psychological distress (PD) as well as common mental disorders (CMD) such as major depressive disorders (MDD), generalized anxiety disorders (GAD), post-traumatic stress disorders (PTSD), and substance misuse disorders (SUD) among people exposed to disasters and pandemics like the COVID-19. Moreover, CMD are associated with increased mortality (mainly through suicide) and morbidity (loss of productivity). A number of countries have made deliberate efforts to identify and manage CMD in light of COVID-19. However, low levels of mental health literacy (MHL) manifested by the individual’s unawareness of CMD symptoms, limited human and mental health infrastructure resources, and high levels of mental illness stigma (MIS) are barriers to integration of mental health care in general health care during pandemics and epidemics such as the COVID-19. Objectives For the proposed study, we will determine effectiveness of a psycho-education intervention delivered by village health team (VHT) members. Methods We will employ a cluster randomized trial design in 24 villages in central Uganda. We will collect baseline data to and document the prevalence of MHL, PD, MDD, PTSD, GAD, and SUD. We will distribute information education and communication materials (IEC) aimed at improving MHL to 420 adult individuals in the intervention arm (n = 12 villages). In the control arm (n = 12 villages), VHTs will distribute ministry of health COVID-19 information leaflets to 420 participants. Within 7 days of distributing the materials, research assistants will conduct a follow-up interview and assess for the same parameters (MHL, PD, MDD, PTSD, GAD, and SUD). We will use an intention to treat analysis to estimate the effectiveness of the psycho-education intervention. Discussion Findings from this research will guide policy and practice regarding the integration of mental health services in the community in the context of epidemic preparedness and response. Trial registration ClinicalTrials.gov NCT04616989 . Registered on 05 November 2020

Introduction: The MATRICS consensus cognitive battery (MCCB) is the gold standard for neuropsychological assessment in psychotic disorders but is rarely used in low resource settings. This study used the MCCB to determine the prevalence, profile and associations of various exposures with cognitive impairment in Ugandan first-episode psychosis patients. Methods: Patients and matched healthy controls were recruited at Butabika Hospital in Uganda. Clinical variables were first collated, and after the resolution of psychotic symptoms, a neuropsychological assessment of seven cognitive domains was performed using the MCCB. Cognitive impairment was defined as two standard deviations (SD) below the mean in one domain or 1SD below the mean in two domains. Descriptive statistics determined the prevalence and profile of impairment while regression models determined the association between various exposures with cognitive scores while controlling for age, sex and education. Results: Neuropsychological assessment with the MCCB found the burden of cognitive impairment in first-episode psychosis patients five times that of healthy controls. The visual learning and memory domain was most impaired in first-episode psychosis patients, while it was the working memory domain for the healthy controls. Increased age was associated with impairment in the domains of the speed of processing (p

Abstract Background An estimated 8–30 % of people living with HIV (PLWH) have depressive disorders (DD) in sub-Saharan Africa. Of these, the majority are untreated in most of HIV care services. There is evidence from low- and middle- income countries of the effectiveness of both psychological treatments and antidepressant medication for the treatment of DD among PLWH, but no evidence on how these can be integrated into routine HIV care. This protocol describes a cluster-randomised trial to evaluate the effectiveness and cost-effectiveness of the HIV + D model for the integration of a collaborative stepped care intervention for DD into routine HIV care, which we have developed and piloted in Uganda. Methods Forty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts will be randomly selected to participate in the trial. Each facility will recruit 10–30 eligible PLWH with DD and the total sample size will be 1200. The clusters will be randomised 1:1 to receive Enhanced Usual Care alone (EUC, i.e. HIV clinicians trained in Mental Health Gap Action Programme including guidelines on when and where to refer patients for psychiatric care) or EUC plus HIV + D (psychoeducation, Behavioural Activation, antidepressant medication and referral to a supervising mental health worker, delivered in a collaborative care stepwise approach). Eligibility criteria are PLWH attending the clinic, aged ≥ 18 years who screen positive on a depression screening questionnaire (Patient Health Questionnaire, PHQ-9 ≥ 10). The primary outcome is the mean depressive disorder symptom severity scores (assessed using the PHQ-9) at 3 months’ post-randomisation, with secondary mental health, disability, HIV and economic outcomes measured at 3 and 12 months. The cost-effectiveness of EUC with HIV + D will be assessed from both the health system and the societal perspectives by collecting health system, patient and productivity costs and mean DD severity scores at 3 months, additional to health and non-health related quality of life measures (EQ-5D-5 L and OxCAP-MH). Discussion The study findings will inform policy makers and practitioners on the cost-effectiveness of a stepped care approach to integrate depression management in routine care for PLWH in low-resource settings. Trial registration: ISRCTN, ISRCTN86760765. Registered 07 September 2017, https://doi.org/10.1186/ISRCTN86760765 .

Abstract Background Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Methods/design We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale –up. Discussion The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information – a critical gap for addressing a leading global cause of disability. Trial registration ClinicalTrials.gov NCT03466346, registered March 15, 2018.

Abstract Background About 20–40% of patients with diabetes mellitus (DM) suffer from depressive disorders (DD) during the course of their illness. Despite the high burden of DD among patients with DM, it is rarely identified and adequately treated at the majority of primary health care clinics in sub-Saharan Africa (SSA). The use of peer support to deliver components of mental health care have been suggested in resource constrained SSA, even though its acceptability have not been fully examined. Methods We conducted qualitative interviews (QI) to assess the perceptions of DM patients with an experience of suffering from a DD about the acceptability of delivering peer support to patients with comorbid DM and DD. We then trained them to deliver peer support to DM patients who were newly diagnosed with DD. We identified challenges and potential barriers to a successful implementation of peer support, and generated solutions to these barriers. Results Participants reported that for one to be a peer, they need to be mature in age, consistently attend the clinics/keep appointments, and not to be suffering from any active physical or co-morbid mental or substance abuse disorder. Participants anticipated that the major barrier to the delivery of peer support would be high attrition rates as a result of the difficulty by DM patients in accessing the health care facility due to financial constraints. A potential solution to this barrier was having peer support sessions coinciding with the return date to hospital. Peers reported that the content of the intervention should mainly be about the fact that DM was a chronic medical condition for which there was need to adhere to lifelong treatment. There was consensus that peer support would be acceptable to the patients. Conclusion Our study indicates that a peer support program is an acceptable means of delivering adjunct care to support treatment adherence and management, especially in settings where there are severe staff shortages and psycho-education may not be routinely delivered.

Introduction Untreated post-traumatic stress disorder (PTSD) results in considerable morbidity and higher risk of mortality. However, little is being done to treat PTSD in sub-Saharan Africa (SSA) settings where rates of PTSD are likely to be elevated due to mass exposure of the population to traumatic events. This systematic review aims to summarise available evidence on the efficacy of psychological therapies for PTSD in SSA.Methods and analysis A systematic search of the literature will be conducted in four electronic databases: PubMed, PsychInfo, EMBASE and Cochrane Register of Controlled Trials using keywords and synonyms related to ‘PTSD’, ‘psychological therapies’ and ‘SSA’. Studies will be included if they were conducted in SSA and used a randomised controlled trial design. Two researchers will screen the studies for eligibility to be included, and data on intervention types, population, comorbidities, comparison group intervention and PTSD outcomes will be extracted from those included. Risk of bias will be assessed using Cochrane risk-of-bias tool for randomised trials (version 2). Narrative synthesis of data will be conducted and pooled effect estimates calculated.Ethics and dissemination Ethical approval is not required as this is a protocol of a systematic review of available data. Findings will be disseminated to the scientific community through peer-reviewed publications and presentation at conferences.PROSPERO registration CRD42020181638.

Abstract Introduction Coronavirus disease 2019 (COVID‐19) has caused >3.5 million deaths worldwide and affected >160 million people. At least twice as many have been infected but remained asymptomatic or minimally symptomatic. COVID‐19 includes central nervous system manifestations mediated by inflammation and cerebrovascular, anoxic, and/or viral neurotoxicity mechanisms. More than one third of patients with COVID‐19 develop neurologic problems during the acute phase of the illness, including loss of sense of smell or taste, seizures, and stroke. Damage or functional changes to the brain may result in chronic sequelae. The risk of incident cognitive and neuropsychiatric complications appears independent from the severity of the original pulmonary illness. It behooves the scientific and medical community to attempt to understand the molecular and/or systemic factors linking COVID‐19 to neurologic illness, both short and long term. Methods This article describes what is known so far in terms of links among COVID‐19, the brain, neurological symptoms, and Alzheimer's disease (AD) and related dementias. We focus on risk factors and possible molecular, inflammatory, and viral mechanisms underlying neurological injury. We also provide a comprehensive description of the Alzheimer's Association Consortium on Chronic Neuropsychiatric Sequelae of SARS‐CoV‐2 infection (CNS SC2) harmonized methodology to address these questions using a worldwide network of researchers and institutions. Results Successful harmonization of designs and methods was achieved through a consensus process initially fragmented by specific interest groups (epidemiology, clinical assessments, cognitive evaluation, biomarkers, and neuroimaging). Conclusions from subcommittees were presented to the whole group and discussed extensively. Presently data collection is ongoing at 19 sites in 12 countries representing Asia, Africa, the Americas, and Europe. Discussion The Alzheimer's Association Global Consortium harmonized methodology is proposed as a model to study long‐term neurocognitive sequelae of SARS‐CoV‐2 infection. Key Points The following review describes what is known so far in terms of molecular and epidemiological links among COVID‐19, the brain, neurological symptoms, and AD and related dementias (ADRD) The primary objective of this large‐scale collaboration is to clarify the pathogenesis of ADRD and to advance our understanding of the impact of a neurotropic virus on the long‐term risk of cognitive decline and other CNS sequelae. No available evidence supports the notion that cognitive impairment after SARS‐CoV‐2 infection is a form of dementia (ADRD or otherwise). The longitudinal methodologies espoused by the consortium are intended to provide data to answer this question as clearly as possible controlling for possible confounders. Our specific hypothesis is that SARS‐CoV‐2 triggers ADRD‐like pathology following the extended olfactory cortical network (EOCN) in older individuals with specific genetic susceptibility. The proposed harmonization strategies and flexible study designs offer the possibility to include large samples of under‐represented racial and ethnic groups, creating a rich set of harmonized cohorts for future studies of the pathophysiology, determinants, long‐term consequences, and trends in cognitive aging, ADRD, and vascular disease. We provide a framework for current and future studies to be carried out within the Consortium. and offers a “green paper” to the research community with a very broad, global base of support, on tools suitable for low‐ and middle‐income countries aimed to compare and combine future longitudinal data on the topic. The Consortium proposes a combination of design and statistical methods as a means of approaching causal inference of the COVID‐19 neuropsychiatric sequelae. We expect that deep phenotyping of neuropsychiatric sequelae may provide a series of candidate syndromes with phenomenological and biological characterization that can be further explored. By generating high‐quality harmonized data across sites we aim to capture both descriptive and, where possible, causal associations.

BackgroundDepression is rarely screened for among People Living with Human Immunodeficiency Virus (PLHIV) although it is 2 to 3 times more prevalent among PLHIV than in the general population. In instances where depression is screened for using screening tools, it usually follows noticing depression risk factors. This practice of selectively screening for depression could be leaving some cases of depression unattended to. On the other hand, subjecting every client to screening tools (non-selective screening) offers every patient an opportunity to be managed for depression. However, this could require additional resources as compared to selective screening. We present and discuss results on whether non-selective and selective screening strategies differ in depression case detection, and in addition, we also present perceptions of the stake holders on the two screening strategies.MethodsThe study was conducted in Princess Diana Memorial Health Centre IV HIV clinic using a randomized controlled trial with a qualitative component. To determine whether there was a difference in depression case detection, consecutively sampled participants were randomly allocated to either non-selective or selective screening strategy. Participants allocated to selective screening were screened for depression using the patient health questionnaire (s) (PHQs) if they were at "crisis points". While those allocated to non-selective screening were screened regardless of whether the "crisis points" were noticed or not. The PHQ-2 and PHQ-9 were used in sequence. 326 PLHIV participated in the study. Outcomes of the MINI evaluation were analyzed for those with PHQ-9 scores of 10 or more to confirm major depressive disorder (MDD). Data was analyzed using the two sample Z-test for proportions with Stata 2013 software. To explore the perceptions of the stake holders, key informant interviews were performed with six stakeholders that experienced the study.ResultsCases of depression (PHQ-9 score ≥ 5) were more likely to be detected by the non-selective screening strategy 30.2% (49/162) compared to the selective screening strategy 19.5% (32/164) (difference in proportions 0.107, 95% confidence interval 0.014-0.200, Cohen's h = 0.25, P = 0.03). The stake holders thought it was important to screen for depression among PLHIV with preference to non-selective screening strategy.ConclusionEvidence from this data suggests that more cases of depression (PHQ-9 score ≥ 5) are likely to be detected with non-selective screening as opposed to selective screening.Trial registrationPACTR201802003141213 (name: comparison of routine versus selective screening for depression strategies among PLHIV attending Princess Diana Memorial Health Centre iv Soroti).

BackgroundPsychotic disorders contribute to significant morbidity and mortality partly due to the chronicity of the illness and high relapse rates. Delivering psycho-education messages about disease etiology, their signs and symptoms and the benefits of treatment adherence have been shown to improve clinical outcomes among individuals with psychoses. However, little has been done to examine the feasibility and efficacy of this intervention in low resourced settings.ObjectiveOur primary objective will be to determine the feasibility of recruiting and retaining patients with a first episode psychosis (FEP) and for the secondary objective, we will determine the preliminary efficacy of psycho-education on illness self-management, stigma, adherence to medications and symptom severity.HypothesisWe hypothesize that (i) we will recruit 70% of eligible participants and accrue a sample size of 80 over 20-weeks, retaining 80% of the sample size for 24 weeks, (ii) the intervention will lead to improvement in clinical outcomes (described above).MethodsWe will recruit 80 adult patients who have been diagnosed with a FEP, received antipsychotic medication at Butabika Hospital and reside within 21km from the Hospital. Trained village health team (VHTs) members will deliver 6 psycho-education sessions to 40 participants and their family members (intervention arm). Participants in the control arm (n = 40) will receive routine care. We will document how feasible it will be to recruit and retain participants over 24 weeks and document the preliminary efficacy of the intervention on illness self-management, stigma, adherence to medications and severity of symptoms.Data analysisWe will document the proportion of participants who consent and get recruited, the proportion of those who will get retained and reasons for drop out. We will conduct an intention to treat analysis comparing the groups at weeks 4, 12, 24 and assess the effect of the intervention on the clinical outcomes (described above). We will use the Bonferroni approach to correct for multiple comparisons.Trial registrationClinical trials.gov registration number: NCT04602585.

Spencer J Keene,1–3 Rachel E Jordan,1 Frits ME Franssen,3,4 Frank de Vries,2,5 James Martin,1 Alice Sitch,1,6 Alice Margaret Turner,1 Andrew P Dickens,1 David Fitzmaurice,7 Peymane Adab1 1Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; 2Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Center+, Maastricht, the Netherlands; 3Ciro, Horn, the Netherlands; 4Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Maastricht, The Netherlands; 5Utrecht Institute for Pharmaceutical Sciences Utrecht University, Utrecht, The Netherlands; 6NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; 7Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UKCorrespondence: Rachel E JordanInstitute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UKTel +44 0121 414 6775Email r.e.jordan@bham.ac.ukBackground: Reviews suggest that the ADO score is the most discriminatory prognostic score for predicting mortality among chronic obstructive pulmonary disease (COPD) patients, but a full evaluation and external validation within primary care settings is critical before implementation.Objectives: To validate the ADO score in prevalent and screen-detected primary care COPD cases at 3 years and at shorter time periods.Patients and methods: One thousand eight hundred and ninety-two COPD cases were recruited between 2012 and 2014 from 71 United Kingdom general practices as part of the Birmingham COPD Cohort study. Cases were either on the practice COPD register or screen-detected. We validated the ADO score for predicting 3-year mortality with 1-year and 2-year mortality as secondary endpoints using discrimination (area-under-the-curve (AUC)) and calibration plots.Results: One hundred and fifty-four deaths occurred within 3 years. The ADO score was discriminatory for predicting 3-year mortality (AUC= 0.74; 95% CI: 0.69–0.79). Similar performance was found for 1- (AUC= 0.73; 0.66–0.80) and 2-year mortality (0.72; 0.67–0.76). The ADO score showed reasonable calibration for predicting 3-year mortality (calibration slope 0.95; 0.70–1.19) but over-predicted in cases with higher predicted risks of mortality at 1 (0.79; 0.45–1.13) and 2-year (0.79; 0.57–1.01) mortality.Discussion: The ADO score showed promising discrimination in predicting 3-year mortality in a primary care population including screen-detected cases. It may need to be recalibrated if it is used to provide risk predictions for 1- or 2-year mortality since, in these time-periods, over-prediction was evident, especially in cases with higher predicted mortality risks.Keywords: pulmonary disease, chronic obstructive, mortality, prognosis, validation studies

Abstract Background Clinical practice guidelines (CPG) are developed based on a synthesis of evidence regarding the best options for the assessment, diagnosis and treatment of diseases and are recognized as essential quality improvement tools. However, despite growing availability of CPG, research evaluating their use for mental disorders in Uganda is lacking. For a successful implementation of CPG to be achieved, a number of considerations need to be put in place. Objective This study aimed to assess the feasibility and acceptability of the educational intervention that we developed towards improvement of the primary health care providers (PHCPs) uptake of the Uganda Clinical Guidelines (UCG) in integrating mental health services into PHC in Mbarara district, southwestern Uganda. Methods This was a descriptive cross-sectional qualitative study with a semi-structured in-depth interview guide. The educational intervention we were assessing had four components: (i) summarized UCG on common mental disorders; (ii) modified Health Management Information System (HMIS) registers to include mental health; (iii) clinician’s checklist outlining the steps to be followed; and iv) support supervision/training. Results Six themes emerged from the study while the components of the intervention formed the apriori subthemes. Key results based on the subthemes show: (i) summarized UCG: the participants liked the packaging stating that it eased their work, was time saving and user friendly; (ii) modified register: participants appreciated the modifications made to the register updating the existing record in the Health Management Information System (HMIS) registers to include mental health disorders; (iii) TRAINING and support supervision: the PHCPs attributed the success in using the summarized UCG to the training they received, and they further expressed the need to regularize the training in assessment for mental health and support by the mental health specialists. Conclusion Our study demonstrates that the use of summarized UCG, modified HMIS registers to include mental health, training and support supervision by mental health specialists in implementing the UCG in integrating mental health at PHC settings is feasible and acceptable by the PHCPs in Mbarara district, southwestern Uganda. Given the need for improved mental health care in Uganda, this intervention could be rigorously evaluated for effectiveness, scalability and generalizability.

Abstract Background Chloroquine, a previous highly efficacious, easy to use and affordable anti-malarial agent was withdrawn from malaria endemic regions due to high levels of resistance. This review collated evidence from published-reviewed articles to establish prevalence of Pfcrt 76T and Pfmdr-1 86Y alleles in malaria affected countries following official discontinuation of chloroquine use. Methods A review protocol was developed, registered in PROSPERO (#CRD42018083957) and published in a peer-reviewed journal. Article search was done in PubMed, Scopus, Lilacs/Vhl and Embase databases by two experienced librarians (AK, RS) for the period 1990-to-Febuary 2018. Mesh terms and Boolean operators (AND, OR) were used. Data extraction form was designed in Excel spread sheet 2007. Data extraction was done by three reviewers (NL, BB and MO), discrepancies were resolved by discussion. Random effects analysis was done in Open Meta Analyst software. Heterogeneity was established using I2-statistic. Results A total of 4721 citations were retrieved from article search (Pubmed = 361, Lilac/vhl = 28, Science Direct = 944, Scopus = 3388). Additional targeted search resulted in three (03) eligible articles. After removal of duplicates (n = 523) and screening, 38 articles were included in the final review. Average genotyping success rate was 63.6% (18,343/28,820) for Pfcrt K76T and 93.5% (16,232/17,365) for Pfmdr-1 86Y mutations. Prevalence of Pfcrt 76T was as follows; East Africa 48.9% (2528/5242), Southern Africa 18.6% (373/2163), West Africa 58.3% (3321/6608), Asia 80.2% (1951/2436). Prevalence of Pfmdr-1 86Y was; East Africa 32.4% (1447/5722), Southern Africa 36.1% (544/1640), West Africa 52.2% (1986/4200), Asia 46.4% (1276/2217). Over half, 52.6% (20/38) of included studies reported continued unofficial chloroquine use following policy change. Studies done in Madagascar and Kenya reported re-emergence of chloroquine sensitive parasites (IC50 95%). Conclusion The prevalence of chloroquine resistance alleles among Plasmodium falciparum parasites have steadily declined since discontinuation of chloroquine use. However, Pfcrt K76T and Pfmdr-1 N86Y mutations still persist at moderate frequencies in most malaria affected countries.

Abstract Background Efficacy of artemisinin (ART) agents, a critical element of current malaria control efforts is threatened by emergence and spread of resistance. Mutations in pfkelch13 gene associated with ART-resistance evolved in Southeast Asia (SEA). k13 mutations whose role in ART-resistance remains unknown, have subsequently emerged independently across all malaria-affected regions. The aim of this systematic review was to determine the prevalence and identify risk factors of Plasmodium falciparum k13 mutations in malaria-endemic countries. Methods An electronic search of studies from 2014 to date was done in MEDLINE via PubMED, SCOPUS, EMBASE and LILACS/VHL databases. Mesh terms and Boolean operators (AND, OR) were used. Two librarians independently conducted this search (RS and AK). The articles were screened for inclusion using a priori criteria set following PRISMA-P and STREGA guidelines. Three independent reviewers (NL, BB, and OM) extracted the data. Data analysis was performed in Open Meta Analyst software. Random effects analysis (DL) was used and heterogeneity established using I2-statistic. Results A total of 482 articles were retrieved from Pubmed = 302, Lilacs/Vhl = 50, Embase = 80, and Scopus = 37; Bibliography/other searches = 13, of which 374 did not meet the inclusion criteria. The aggregate prevalence of single nucleotide polymorphisms (SNPs) in pfkelch13 gene was 27.6% (3694/14,827) (95% CI 22.9%, 32.3%). Sub-group analysis showed that aggregate prevalence of non-synonymous SNPs in pfkelch13 gene was higher, 45.4% (95% CI 35.4%, 55.3%) in Southeast Asia as opposed to 7.6% (95% CI 5.6%, 9.5%) in the African region. A total of 165 independent k13 mutations were identified across malaria-affected regions globally. A total of 16 non-validated k13 mutations were associated with increased ART parasite clearance half-life (t1/2 > 5 h). The majority, 45.5% (75/165), of the mutations were reported in single P. falciparum parasite infections. Of the 165 k13-mutations, over half were reported as new alleles. Twenty (20) non-propeller mutations in the pfkelch13 gene were identified. Conclusion This review identified emergence of potential ART-resistance mediating k13 mutations in the African region. Diversity of mutations in pfkelch13 gene is highest in African region compared to SEA. Mutations outside the pfkelch13 propeller region associated with increased ART parasite clearance half-life occur in malaria-affected regions.

Abstract Background The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas. Purpose The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs). Methods This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC. Results Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care. Conclusion There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

Abstract Background Epilepsy is a neurological condition that is highly prevalent among children and adolescents with 80% of the victims living in low- and middle-income countries (LMIC). Epilepsy is associated with high levels of both perceived and enacted stigma, which vary geographically and greatly affects the victims’ quality of life and self-esteem. High rates of stigma are also a significant barrier to accessing medical care. Perceived and enacted epilepsy-related stigma is associated with various sociodemographic and clinical factors, which vary from place to place. Therefore, this review will determine the prevalence of stigma of epilepsy among children and adolescents and the associated factors worldwide. Methods We will search for literature in PubMed, EMBASE, PsycINFO, and CINAHL databases as well as grey literature. We will also search via Google Scholar to capture relevant literature that may not be in the searched databases. We will then screen reference lists of included studies for more studies. Studies that have documented the prevalence of epilepsy-related perceived or enacted stigma and the associated factors will be eligible for inclusion. Data will be extracted in duplicates using a pre-piloted tool consisting of study and participant characteristics as well as pre-determined factors associated with epilepsy. Heterogeneity will be assessed by a forest plot and quantified by I 2 statistic, and in case it is high, results will be reported as a narrative and it will further be explored by subgroup analysis. In case of homogeneity, meta-analysis will be done. Bias will be assessed using a critical appraisal tool developed for prevalence studies. The strength of evidence among the studies will be assessed using the GRADE approach. Discussion Findings from this review will document the burden of stigma of epilepsy and the common contributing factors, which will form the building blocks of interventions that address this health challenge. Systematic review registration PROSPERO CRD42017058957

Background: Childhood trauma is associated with mental health problems among adolescents living with HIV (ALHIV) in sub-Saharan Africa, but little is known about potential moderating factors. Methods: We enrolled 224 ALHIV aged 13–17 years and collected information on childhood trauma, major depressive disorder, and suicidality. We used modified multivariable Poisson regression to estimate the association between the mental health outcome variables and childhood trauma, and to assess for effect modification by social support. Results: Major depressive disorder had a statistically significant association with emotional abuse (adjusted relative risk [ARR] 2.57; 95% CI 1.31–5.04; P = 0.006) and physical abuse (ARR 2.16; 95% CI 1.19–3.89; P = 0.01). The estimated association between any abuse and major depressive disorder was statistically significant among those with a low level of social support (ARR 4.30; 95% CI 1.64–11.25; P = 0.003) but not among those with a high level of social support (ARR 1.30; 95% CI 0.57–2.98; P = 0.52). Suicidality also had a statistically significant association with emotional abuse (ARR 2.03; 95% CI 1.05–3.920; P = 0.03) and physical abuse (ARR 3.17; 95% CI 1.60–6.25.; P = 0.001), but no differences by social support were noted. Limitations: Corporal punishment is used widely in schools and homes as a form of discipline in Uganda; this cultural practice could have biased reporting about physical abuse. Conclusions: Childhood trauma is associated with poor mental health among ALHIV, but its effects may be moderated by social support. More research is needed to develop social support interventions for ALHIV with adverse childhood experiences for improved mental health outcomes.

Expansion of Antiretroviral Therapy (ART) programs in sub-Saharan Africa (SSA) has increased the number of people accessing treatment. However, the number of males accessing and being retained along the human immunodeficiency virus (HIV) care cascade is significantly below the UNAIDS target. Male gender has been associated with poor retention in HIV care programs, and little is known about strategies that reduce attrition of men in ART programs. This review aimed to summarize any studies on strategies to improve retention of heterosexual males in HIV care in SSA. An electronic search was conducted through Ovid® for three databases (MEDLINE®, Embase and Global Health). Studies reporting interventions aimed at improving retention among heterosexual men along the HIV care cascade were reviewed. The inclusion criteria included randomized-controlled trials (RCTs), prospective or retrospective cohort studies that studied adult males (≥15years of age), conducted in SSA and published between January 2005 and April 2019 with an update from 2019 to 2020. The search returned 1958 articles, and 14 studies from eight countries met the inclusion criteria were presented using the PRISMA guidelines. A narrative synthesis was conducted. Six studies explored community-based adherence support groups while three compared use of facility versus community-based delivery models. Three studies measured the effect of national identity cards, disclosure of HIV status, six-monthly clinic visits and distance from the health center. Four studies measured risk of attrition from care using hazard ratios ranging from 1.2-1.8, four studies documented attrition proportions at an average of 40.0% and two studies an average rate of attrition of 43.4/1000PYs. Most (62%) included studies were retrospective cohorts, subject to risk of allocation and outcome assessment bias. A pooled analysis was not performed because of heterogeneity of studies and outcome definitions. No studies have explored heterosexual male- centered interventions in HIV care. However, in included studies that explored retention in both males and females, there were high rates of attrition in males. More male-centered interventions need to be studied preferably in RCTs. Registry number: PROSPERO2020 CRD42020142923 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020142923.

Introduction: Several studies of neuropsychological measures have been undertaken in patients with psychotic disorders from low- and middle-income countries (LMICs). It is, however, unclear if the measures used in these studies are appropriate for cognitive screening in clinical settings. We undertook a systematic review to determine if measures investigated in research on psychotic disorders in LMICs meet the clinical utility criteria proposed by The Working Group on Screening and Assessment. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed. We determined if tests had been validated against a comprehensive test battery, the duration and scope of the tests, the personnel administering the tests, and the means of administration. Results: A total of 31 articles were included in the review, of which 11 were from Africa. The studies included 3254 participants with psychosis and 1331 controls. 3 studies reported on the validation of the test against a comprehensive cognitive battery. Assessments took 1 h or less to administer in 6/31 studies. The average number of cognitive domains assessed was four. Nonspecialized staff were used in only 3/31 studies, and most studies used pen and paper tests (17/31). Conclusion: Neuropsychological measures used in research on psychotic disorders in LMICs typically do not meet the Working Group on Screening and Assessment clinical utility criteria for cognitive screening. Measures that have been validated in high-income countries but not in LMICs that do meet these criteria, such as the Brief Assessment of Cognition in Schizophrenia, therefore deserve further study in LMIC settings.

IntroductionHospital based studies for psychotic disorders are scarce in low and middle income countries. This may impact on development of intervention programs.ObjectiveWe aimed to determine the burden of psychotic disorders among first treatment contact patients at the national psychiatric referral hospital in Uganda.MethodsA retrospective patient chart-file review was carried out in March 2019 for all patients presenting to the hospital for the first time in the previous year. Patients were categorised into those with and without psychotic disorders. We collected sociodemographic data on age, gender, occupation, level of education, ethnicity, religion and home district. We determined the one year prevalence of psychotic disorders among first treatment contact patients. Using logistic regression models, we also determined the association between psychotic disorders and various exposure variables among first treatment contact patients.ResultsIn 2018, 63% (95% CI: 60.2-65.1) of all first time contact patients had a psychosis related diagnosis. Among the patients with psychotic disorders, the median age was 29 years (IQR 24-36). Most of the patients were male (62.8%) and unemployed (63.1%). After adjusting for patients' residence, psychotic disorders were found to be more prevalent among the female gender [OR 1.58 (CI1.46-1.72)] and those of Pentecostal faith [OR 1.25 (CI 1.10-1.42)].ConclusionAmong first treatment contact patients in Uganda, there is a large burden of psychotic disorders. The burden was more prevalent among females as well as people of Pentecostal faith who seemed to use their church for faith-based healing. Incidence studies are warranted to determine if this phenomenon is replicated at illness onset.

Abstract Background Malaria control and prevention efforts continue to rely heavily on the use of medicines especially artemisinin agents. However, currently, the emergence of artemisinin resistance threatens this effort globally. The K13-gene polymorphisms associated with artemisinin resistance have been detected in Southeast Asia. In countries outside Southeast Asia, artemisinin resistance has not yet been confirmed. Methods/design The articles will be obtained from the search of MEDLINE via PubMed, Scopus, EMBASE, and LILACS/VHL databases. Mesh terms will be used in the article search. Boolean operators (“AND”, “OR”) will be used in the article search. Article search will be done independently by two librarians (RS and AK). The articles will be screened for inclusion using set criteria and following the PRISMA guidelines. Data extraction will be done by two independent reviewers (NL and BB), Kappa statistic will be calculated, and any discrepancies resolved by discussion. Heterogeneity in the articles will be established using I 2 statistic. Discussion This review will focus on establishing the K13-gene polymorphisms among Plasmodium falciparum parasites reported from previous studies in malaria-affected countries. Artemisinin resistance has not been widely reported among parasites in Africa and other malaria-endemic countries outside Southeast Asia. However, several studies on artemisinin resistance have reported different K13-gene polymorphisms from the validated mutations found in Southeast Asia. This study will collate evidence from previous studies on the commonly reported K13 -gene polymorphisms among P. falciparum parasites in malaria-affected countries. Systematic review registration PROSPERO CRD 42018084624

Abstract Background The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest—primary care providers (PCPs); Phenomenon of Interest—integration of mental health services into primary health care (PHC); Design—influenced robustness and analysis of the study; Evaluation—outcomes included subjective outcomes (views and attitudes); and Research type—qualitative, quantitative, and mixed methods studies. Methods Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory. Discussion We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted. Systematic review registration PROSPERO 2016 (Registration Number: CRD42016052000) and published in BMC Systematic Reviews August 2017.

Abstract Background Malaria remains one of the leading causes of morbidity and mortality in most low- and middle-income countries. Chloroquine is a previously cheap and effective antimalarial agent whose loss to resistance resulted in more than doubling of malaria-related mortality in malaria-endemic countries. Recently, chloroquine sensitivity is re-emerging among Plasmodium falciparum parasites which gives hope for malaria control and treatment efforts globally. The aim of the current review is to establish the prevalence of chloroquine resistance alleles among P. falciparum parasites in malaria-endemic areas after change in malaria treatment policy. Methods/design The articles will be obtained from search of MEDLINE via PubMed, SCOPUS, and EMBASE data bases. The Mesh terms will be used in article search. Boolean operators (“AND,” “OR”) will be used in article search. The article search will be done independently by two librarians. The PRISMA-P statement will be used to guide the conduct and reporting of the systematic review. STREGA guideline will be used in developing data abstraction form for the review. Data abstraction will be done by two independent reviewers, Kappa statistic will be calculated, and any discrepancies resolved by discussion. Data analysis will be done using STATA ver 13.0. The level of heterogeneity in the articles will be established by using the I 2-statistic. Publication bias will be assessed using funnel plot. Random effects analysis will be used. Discussion The review seeks to establish the extent of chloroquine resistance reversal in malaria-endemic countries. The evidence generated from this review will help guide policy makers on the potential re-emerging role of chloroquine in malaria treatment. Systematic review registration The systematic review protocol has been registered in PROSPERO with registration number CRD42018083957.

Martin R Miller,1 Shamil Haroon,1 Rachel E Jordan,1 Alice J Sitch,1 Andrew P Dickens,1 Alexandra Enocson,1 David A Fitzmaurice,2 Peymané Adab1 1Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK; 2Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK Background: Consensus on the definition of airflow obstruction to diagnose COPD remains unresolved.Methods: We undertook systematic case finding for COPD in primary care using the fixed ratio (FR) criterion (forced expiratory volume in 1 s/forced vital capacity [FEV1/FVC]

Sarah B Brien,1 Beth Stuart,1 Andrew P Dickens,2 Tony Kendrick,1 Rachel E Jordan,2 Paymane Adab,2 Mike Thomas1 1Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, 2Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Warwickshire, UK Purpose: Quality-of-life (QoL) scores in chronic obstructive pulmonary disease (COPD) have a weak relationship with physiologic impairment. We investigated factors associated with poor QoL, focusing on psychological measures potentially amenable to intervention.Patients and methods: We utilized a pre-existing Birmingham (UK) COPD cohort to assess factors associated with QoL impairment (COPD Assessment Test [CAT] scores). Univariate and multivariate regression models were constructed from three categories of variables: demographic, lung function/COPD-related symptoms, and psychosocial/behavioral factors.Results: Analyses were based on self-report questionnaire data from 735 participants. The multivariate model of variables independently associated with CAT included depression, dysfunctional breathing symptoms (Nijmegen score), and illness perception, in addition to COPD symptoms (wheeze, cough), exercise capacity, breathlessness, exacerbations, and deprivation; this model explained 72% of CAT score variation. In a dominance analysis assessing the relative contribution of variables, similar contributions were made by breathlessness (20.2%), illness perception (19.8%), dysfunctional breathing symptoms (17.5%), and depression (12.5%) with other variables contributing