Search

Objectives. To analyze abortion incidence in Indiana concurrent with changes in abortion-related laws. Methods. Using publicly available data, we created a timeline of abortion-related laws in Indiana, calculated abortion rates by geography, and described changes in abortion occurrence coincident with changes in abortion-related laws between 2010 and 2019. Results. Between 2010 and 2019, Indiana’s legislature passed 14 abortion-restricting laws, and 4 of 10 abortion-providing clinics closed. The Indiana abortion rate decreased from 7.8 abortions per 1000 women aged 15 to 44 years in 2010 to 5.9 in 2019. At all time points, the abortion rate was 58% to 71% of the Midwestern rate and 48% to 55% of the national rate. By 2019, nearly 1 in 3 (29%) Indiana residents who obtained abortion care did so outside the state. Conclusions. Access to abortion in Indiana over the past decade was low, required increases in interstate travel to obtain care, and co-occurred with the passage of numerous abortion restrictions. Public Health Implications. These findings preview unequal abortion access and increases in interstate travel as state-level restrictions and bans go into effect across the country. (Am J Public Health. 2023;113(4):429–437. https://doi.org/10.2105/AJPH.2022.307196 )

The number of women using long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and implants-is increasing and 14% of contraceptive users in the United States adopt LARC. We examined correlates of LARC never-use in a population-based survey of reproductive-aged women in Ohio.We analyzed data from the 2018-19 Ohio Survey of Women. We examined the prevalence of LARC never-use and reasons for never-use among ever users of contraception (N = 2388). Using Poisson regression to generate prevalence ratios (PRs), we examined associations between selected correlates (demographic factors, healthcare access/quality measures, and religious/political views) and LARC never-use.Most Ohio women (74%) had never used LARC. Commonly reported reasons for not using an IUD or an implant were preferring a different method (46% and 45%, respectively), not wanting an object inside their body (45% and 43%), side effect concerns (39% and 33%), insertion/removal concerns (31% and 25%), and unfamiliarity (13% and 20%). Conservative political views (PR: 1.12, 95% confidence interval [CI]: 1.04-1.22), pro-life affiliation (PR: 1.11, 95% CI: 1.02-1.20), placing high importance on religion in daily life (PR: 1.15, 95% CI: 1.06-1.26), and being non-Hispanic white as compared to non-Hispanic Black (PR: 1.20, 95% CI: 1.02-1.41) were significantly associated with LARC never-use. Findings were generally similar for models analyzing IUD and implant never-use separately.Among ever-users of contraception, LARC never-use was associated with having conservative political views, being religious, and having a pro-life affiliation. Except for race/ethnicity, demographic and healthcare measures were not associated with LARC never-use among women in Ohio.

The increased rate of twinning has pointed out newer challenges in clinical practices related to gestational complications, intrauterine growth restriction, perinatal mortality, and comorbidities. As a twin pregnancy progresses, the increased demand for oxygen supply can easily disrupt the redox homeostasis balance and further impose a greater challenge for the developing fetuses. A substantial birth-weight difference acts as an indicator of a deficit in oxygenation or blood flow to one of the fetuses, which might be related to a low bioavailable nitric oxide level. Therefore, in this study, we focused on networks involved in the adjustment of oxygen supply, like the activation of inducible and endothelial nitric oxide synthase (NOS3) along with free radical and lipid peroxide formation in mature twin pairs with high birth-weight differences. The selected parameters were followed by immunofluorescence staining, fluorescence-activated cell sorting analysis, and biochemical measurements in the umbilical cord vessels and fetal red blood cells. Based on our data set, it is clear that the lower-weight siblings are markedly exposed to persistent intrauterine hypoxic conditions, which are connected to a decreased level in NOS3 activation. Furthermore, the increased level of peroxynitrite aggravates lipid peroxidation and induces morphological and functional damage and loss in redox homeostasis.

Background: We assessed the relationship between depressive symptoms and perceived COVID-19 risk in the next month. Methods: This analysis used survey data collected during a July 2020 cross-sectional study using a household-based probability sampling design. A total of 615 noninstitutionalized, English- and/or Spanish-speaking adults in Ohio were included. Depressive symptoms screening occurred using the Patient Health Questionnaire-2 (PHQ-2). We applied survey weights so that presented analyses represent the adult population in Ohio. We performed log-risk regression modeling (generalized linear model with binomial distribution and log link) to estimate unadjusted and covariate-adjusted prevalence ratios examining the association between screening positive for depressive symptoms and perceived risk of COVID-19 in the next month. Results: The study population was majority female (59.1%) and White (90.3%). The mean age was 55.9 years (standard deviation (SD)=17.3). About 1 in 20 (4.6%) screened positive for depressive symptoms. A positive depressive symptoms screen was not significantly associated with perceived risk of COVID-19 in the next month (prevalence ratio [PR]=0.75; 95% confidence interval [CI]=0.25–2.24). After confounder adjustment, the adjusted prevalence ratio (aPR) was nearly unchanged (aPR=0.78; 95% CI=0.24–2.55). Conclusion: As depression is often associated with anxiety and pessimism toward the future, the lack of association between depressive symptoms screening and perception of COVID-19 risk in the next month is surprising. Social withdrawal, which is also associated with depression, may have concealed any increased perceived COVID-19 risk, as depressed individuals who remained socially isolated may have had lower perceived COVID-19 risk.

Antiviral drug discovery and its developmental processes happen to be the need of the hour. The break-out burden of complications and mortality caused by viruses like Influenza, Ebola, MERS, SARS and presently, the subtype SARS-CoV-2 are randomly growing in an exponential arc. Under such critical circumstances, there occurs an urgent paradigm shift in the research domain where antimalarial drugs like Hydoxychloroquine were given as a prophylactic treatment to improve the condition of the patients affected by the SARS-CoV-2-COVID-19 disease. For the use of emergency purposes in this global pandemic, a ground breaking development has taken place in vaccine therapy with mRNA-based technologies by pharma giants like Pfizer- BioNTech, Moderna Inc. and AstraZeneca Plc. All three newly launched successful mRNA vaccines, like Comirnaty, mRNA-1273 and AZD1222, in their late-phase clinical trials showed an effective rate up to ~ 95%. Many alternative approaches use translational medicines and artificial intelligence tools to mitigate clinical morbidities within a given timeframe. Hence in this particular book chapter, we tried to highlight the pros and cons of all the possible antiviral drug interventions and strategies that have been implemented from the past till the present to combat several epidemics and global pandemics. At present, the occurrence of the COVID-19 pandemic imposed a greater threat and unprecedented challenge in the antiviral drug discovery platform that needs to be focused on in detail.

The American Sexually Transmitted Diseases Association has, for several years, been conducting a cross-sector workshop to bring together a variety of stakeholders to develop ideas for collaboratively improving the sexually transmitted infection control efforts in the United States. In this summary, we share the content of discussions and ideas of the fourth annual workshop for future research and potential changes to practice with a focus on diagnostic capacity.

Purpose To estimate the prevalence of current and past COVID-19 in Ohio adults. Methods We used stratified, probability-proportionate-to-size cluster sampling. During July 2020, we enrolled 727 randomly-sampled adult English- and Spanish-speaking participants through a household survey. Participants provided nasopharyngeal swabs and blood samples to detect current and past COVID-19. We used Bayesian latent class models with multilevel regression and poststratification to calculate the adjusted prevalence of current and past COVID-19. We accounted for the potential effects of non-ignorable non-response bias. Results The estimated statewide prevalence of current COVID-19 was 0.9% (95% credible interval: 0.1%-2.0%), corresponding to ∼85,000 prevalent infections (95% credible interval: 6,300-177,000) in Ohio adults during the study period. The estimated statewide prevalence of past COVID-19 was 1.3% (95% credible interval: 0.2%-2.7%), corresponding to ∼118,000 Ohio adults (95% credible interval: 22,000-240,000). Estimates did not change meaningfully due to non-response bias. Conclusions Total COVID-19 cases in Ohio in July 2020 were approximately 3.5 times as high as diagnosed cases. The lack of broad COVID-19 screening in the United States early in the pandemic resulted in a paucity of population-representative prevalence data, limiting the ability to measure the effects of statewide control efforts.

Most studies investigating abortion attitudes use nationally representative data, leaving a need for studies of variation within a state. This study investigates abortion opinion among women in Ohio, a state with restrictive abortion policies, as well as how individual-level characteristics are associated with abortion opinions. Data comes from the Ohio Survey of Women, which was administered from October 2018 to June 2019 to women aged 18–44 years in Ohio (n = 2529; analytic n = 2356). From six questions capturing abortion opinion, we developed a composite measure indicating whether respondents felt “supportive,” “unsupportive,” or “mixed” toward abortion. We examined correlates of abortion opinions using multinomial logistic regression, with “mixed” as the reference category. We applied survey weights in all analyses so that the results are representative of our population as a whole (Ohio women aged 18–44). Fifty-three percent of respondents were supportive of abortion, with 30% offering mixed views and 17% being unsupportive. Most sociodemographic variables were inconsistent in their significance. Independents (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.30–0.65) and Democrats (OR: 0.23, CI: 0.14–0.39) were significantly less likely to be unsupportive versus mixed than Republicans. Democrats (OR: 0.4.54, CI: 3.17–6.79) were more likely to be supportive than mixed compared to Republicans, as were those with some other political affiliation (OR: 3.38, CI: 1.89–6.04). Compared to those who never attend religious services, those who attend once per week or more were significantly more likely to be unsupportive than mixed (OR: 3.54, CI: 2.04–6.13), and less likely to be supportive than mixed (OR: 0.33, CI: 0.19–0.55). Additionally, Protestants (OR: 0.62, CI: 0.39–0.97), other Christians (OR: 0.33, CI: 0.39–0.57), and those of other denominations (OR: 0.47, CI: 0.24–0.93) were less likely than those unaffiliated with a religious denomination to be supportive than mixed. Knowing someone who had an abortion or having had one oneself increased odds of being supportive over mixed (OR: 2.16, CI: 1.64–2.84), while being from rural Appalachia decreased odds of being supportive (OR: 0.70, CI: 0.50–0.97). Black respondents were more likely to feel mixed compared to white respondents, having lower odds of being both unsupportive (OR: 0.23, CI: 0.10–0.55) and supportive (OR: 0.55, CI: 0.34–0.91) than mixed. Overall, a majority of women of reproductive age in Ohio were supportive of abortion, with political affiliation and religious service attendance correlating with abortion opinion. The relatively high amount of support for abortion in Ohio highlights an inconsistency between opinion and Ohio’s restrictive legislative landscape.

Objectives We sought to quantify the prevalence of ever attendance at a crisis pregnancy center (CPC) among adult, reproductive-age women in Ohio and identify demographic factors associated with ever attendance. Study Design We analyzed data from the Ohio Survey of Women, a survey of adult, reproductive-age women (N = 2529) conducted in 2018 to 2019. We calculated unadjusted and adjusted prevalence ratios (PRs) to evaluate the possible associations between demographic factors and ever CPC attendance. Analyses used statistical weights to be population-representative. Results Analyses are based on women reporting ever (n = 291) or never CPC attendance (n = 2151). Prevalence of ever CPC attendance was 13.5%. Ever CPC attendance was higher among women of Black, non-Hispanic race/ethnicity (adjusted PR, 2.1; 95% confidence interval [CI], 1.4–3.2) and currently in the lowest socioeconomic status (SES) stratum (defined as less than a college degree and annual household income less than $75,000) (aPR, 1.6; 95% CI, 1.1–2.3) compared to those of other race/ethnicity and in the highest SES stratum. Conclusions Disparities exist among adult women in Ohio regarding their ever use of CPCs. Because CPCs typically are not medical facilities and may provide inaccurate information, future studies should evaluate a wider range of correlates of recent CPC attendance. Implications Findings from a population-based survey of adult, reproductive-age women in Ohio indicate that ever attendance to a CPC for pregnancy-related care is not rare, and this attendance is higher among Black/non-Hispanic women and those of low SES compared to other women.

The maternal physiological state during pregnancy have an excess demand for oxygen supply which can easily disrupt the redox homeostasis balance. There is a change in the maternal haemodynamic profile with an increased cardiac output, reduced systemic vascular resistance and blood pressure (de Haas et al., 2017). In response to this high oxygen demand red blood cell (RBC) mass level steadily increases by 20-30% from 8 to 10 weeks of the gestational period till the end of pregnancy (Foley, 2018). In connection to that, there are increasing evidences of enhanced oxidative insults during intrauterine development leading to severe abnormalities or pathological states like spontaneous miscarriage, preterm delivery, preeclampsia, ectopic pregnancy, intrauterine growth restriction (IUGR), placental abruption, perinatal death etc. Moreover, in cases of multiple/twin pregnancy there is an additional stress with the greater risks of miscarriage, anaemia, preterm delivery, gestational hypertensive disorders, IUGR, diabetes operative delivery and related postnatal and neonatal illnesses. Modern usage of in-vitro fertilization (IVF) therapies led to higher incidence of multiple pregnancies. There have been relevant data on the increasing foetal, neonatal and perinatal mortality rate of 3-6 times in twin and 5-15 times in other multiple pregnancies with comparison to the singleton pregnancies. During pregnancy, the connection between the mother and the foetus is provided by the placenta and the umbilical cord. The umbilical cord vascular system is the sole pathway of oxygen and nutrient transport to the foetus from the placenta. Therefore, the major obstetric complications are directly or indirectly connected to the placental or umbilical cord disorders causing intrauterine hypoxia and/or impaired blood flow to the developing foetus. The major part of umbilical cord lacks innervations and hence the vascular tone is mainly regulated by nitric oxide (NO), i.e. derived from the endothelial nitric oxide synthase (NOS3). The NO being a potent vasoactive agent causes vasodilation and increases the rate of perfusion, nutrient and oxygen supply. Usually intensive prenatal care and surveillances are done in high risk cases like multiple/twin pregnancy by the advanced non-invasive biomedical devices. The usage of high performance equipment like Blood oxygen level-dependent–magnetic resonance imaging was utilized to study changes in the placental oxygenation status in human pregnancies. It can also assess the placental perfusion and oxygen transport. Similarly, ultrasound and Doppler flow measuring techniques not only can visualize the umbilical cord but simultaneously can assess the foetal blood flow parameters through the umbilical cord vessels. These approaches can easily detect any abnormalities in the umbilical cord circulation, but lacks to highlight the underlying molecular mechanisms behind any kind of impaired functionality in the foetal vascular system that can highly influence the in-utero development. Further on this topic we elaborated in details.

Background The importance of the neuronal microenvironment has been recently highlighted in gut region-specific diabetic enteric neuropathy. Regionally distinct thickening of endothelial basement membrane (BM) of intestinal capillaries supplying the myenteric ganglia coincide with neuronal damage in different intestinal segments. Accelerated synthesis of matrix molecules and reduced degradation of matrix components may also contribute to the imbalance of extracellular matrix dynamics resulting in BM thickening. Among the matrix degrading proteinases, matrix metalloproteinase 9 (MMP9) and its tissue inhibitor (TIMP1) are essential in regulating extracellular matrix remodelling. Aim To evaluate the intestinal segment-specific effects of diabetes and insulin replacement on ganglionic BM thickness, MMP9 and TIMP1 expression. Methods Ten weeks after the onset of hyperglycaemia gut segments were taken from the duodenum and ileum of streptozotocin-induced diabetic, insulin-treated diabetic and sex- and age-matched control rats. The thickness of BM surrounding myenteric ganglia was measured by electron microscopic morphometry. Whole-mount preparations of myenteric plexus were prepared from the different gut regions for MMP9/TIMP1 double-labelling fluorescent immunohistochemistry. Post-embedding immunogold electron microscopy was applied on ultrathin sections to evaluate the MMP9 and TIMP1 expression in myenteric ganglia and their microenvironment from different gut segments and conditions. The MMP9 and TIMP1 messenger ribonucleic acid (mRNA) level was measured by quantitative polymerase chain reaction. Results Ten weeks after the onset of hyperglycaemia, the ganglionic BM was significantly thickened in the diabetic ileum, while it remained intact in the duodenum. The immediate insulin treatment prevented the diabetes-related thickening of the BM surrounding the ileal myenteric ganglia. Quantification of particle density showed an increasing tendency for MMP9 and a decreasing tendency for TIMP1 from the proximal to the distal small intestine under control conditions. In the diabetic ileum, the number of MMP9-indicating gold particles decreased in myenteric ganglia, endothelial cells of capillaries and intestinal smooth muscle cells, however, it remained unchanged in all duodenal compartments. The MMP9/TIMP1 ratio was also decreased in ileal ganglia only. However, a marked segment-specific induction was revealed in MMP9 and TIMP1 at the mRNA levels. Conclusion These findings support that the regional decrease in MMP9 expression in myenteric ganglia and their microenvironment may contribute to extracellular matrix accumulation, resulting in a region-specific thickening of ganglionic BM.

Objectives We describe the prevalence and correlates of nonuse of preferred contraceptive method among women 18-44 years of age in Ohio using contraception. Study Design The population-representative Ohio Survey of Women had 2529 participants in 2018–2019, with a response rate of 33.5%. We examined prevalence of preferred method nonuse, reasons for nonuse, and satisfaction with current method among current contraception users (n = 1390). We evaluated associations between demographic and healthcare factors and preferred method nonuse. Results About 25% of women reported not using their preferred contraceptive method. The most common barrier to obtaining preferred method was affordability (13%). Those not using their preferred method identified long-acting methods (49%), oral contraception (33%), or condoms (21%) as their preferred methods. The proportion using their preferred method was highest among intrauterine device (IUD) users (86%) and lowest among emergency contraception users (64%). About 16% of women using permanent contraception reported it was not their preferred method. Having the lowest socioeconomic status (versus highest) (prevalence ratio [PR]: 1.47, 95% CI: 1.11–1.96), Hispanic ethnicity (versus non-Hispanic white) (PR: 1.83, 95% CI: 1.15–2.90), reporting poor provider satisfaction related to contraceptive care (PR: 2.33, 95% CI: 1.02–5.29), and not having a yearly women's checkup (PR: 1.31, 95% CI: 1.01–1.68) were significantly associated with nonuse of preferred method. Compared to preferred-method nonusers, higher proportions of preferred-method users reported consistent contraceptive use (89% vs. 73%, p Conclusions Affordability and poor provider satisfaction related to contraceptive care were associated with nonuse of preferred contraceptive method. Those using their preferred method reported more consistent use. Implications Cost is an important barrier for women in obtaining their preferred contraceptive methods. Low quality birth control care may also be a barrier to preferred-method use. Removal of cost barriers and improvement in contraceptive counseling strategies may increase access to preferred contraceptive methods.

Since March 2021, the Ohio legislature has been actively considering laws that would ban abortion if the United States Supreme Court overturns the Roe v. Wade decision that legalized abortion nationally in 1973.We used a national database of publicly advertised abortion facilities to calculate driving distances for Ohioans before and after the activation of proposed abortion bans. Using a legal analysis of abortion laws following the overturn of Roe, we determined which states surrounding Ohio would continue providing abortion care. We calculated distances from each Ohio county centroid to the nearest open abortion facility in three scenarios: (1) as of February 2022, (2) the best-case post-Roe scenario (two of the five surrounding states continue to offer abortion care), and (3) worst-case post-Roe scenario (no surrounding states continue to offer abortion care). We calculated population-weighted distances using county-level data about women aged 15-44 years from the 2019 American Community Survey.In February 2022, all Ohio county centroids were at most 99 miles from an abortion facility (median = 50 miles). The best-case post-Roe scenario shows 62 of Ohio's 88 counties to be 115-279 miles away from the nearest facility (median = 146). The worst-case shows 85 counties to be 191-339 miles away from the nearest facility (median = 264). The current average population-weighted driving distance from county centroid to the nearest facility is 26 miles; the post-Roe scenarios would increase this to 157 miles (best-case) or 269 miles (worst-case).Ohio's proposed abortion bans would substantially increase travel distances to abortion care, impacting over 2.2 million reproductive-aged Ohioans.

Individuals with autism spectrum disorder are more likely than typically developing individuals to experience a range of gastrointestinal abnormalities, including chronic diarrhea, constipation, food sensitivities, and abdominal pain. These gastrointestinal symptoms have been associated with higher levels of irritability and aggressive behavior, but less is known about their relationship with core autism spectrum disorder symptoms. We investigated the relationship between autism spectrum disorder and gastrointestinal symptom severity while accounting for three associated behavioral symptom domains (Irritability, Aggressiveness, and Specific Fears), in a sample of 176 children (140 males and 36 females) ages 2–7 years old with autism spectrum disorder. Most participants had at least one reported gastrointestinal symptom (93.2%) and had more than one gastrointestinal symptom (88.1%). After accounting for each associated behavioral symptom domain, repetitive behaviors and stereotypies were positively associated with gastrointestinal symptom severity. Social and communication difficulties were not significantly associated with gastrointestinal symptom severity after accounting for associated behavioral symptoms. Our findings replicate a previously described association between irritability and aggression and gastrointestinal symptoms. Furthermore, gastrointestinal symptom severity is associated with repetitive behaviors, a subset of core autism spectrum disorder symptoms. This suggests that gastrointestinal symptoms may exacerbate repetitive behaviors, or vice versa, independent from other associated behavioral symptoms. Lay Abstract Individuals with autism spectrum disorder are more likely than typically developing individuals to experience a range of gastrointestinal abnormalities, including chronic diarrhea, constipation, food sensitivities, and abdominal pain. These gastrointestinal symptoms have been associated with higher levels of irritability and aggressive behavior, but less is known about their relationship with core autism spectrum disorder symptoms. We investigated the relationship between autism spectrum disorder symptom severity and gastrointestinal symptoms while accounting for three associated behavioral symptom domains (Irritability, Aggressiveness, and Specific Fears), in a sample of 176 children (140 males and 36 females) ages 2–7 years old with autism spectrum disorder. A large majority (93.2%) of the sample had at least one reported gastrointestinal symptom, and most (88.1%) participants had more than one gastrointestinal symptom. Various types of gastrointestinal symptoms were reported; the most common symptoms reported were constipation, food limits, gas/bloating, and stomach pain. After accounting for each associated behavioral symptom domain, repetitive behaviors and stereotypies were significantly associated with gastrointestinal symptom severity. Increased severity of autism spectrum disorder symptoms was correlated with increased gastrointestinal symptom severity. Social and communication difficulties were not significantly associated with gastrointestinal symptom severity after accounting for associated behavioral symptoms. Our findings replicate a previously described association between irritability and aggression and gastrointestinal symptoms. Furthermore, we found that repetitive behaviors, but not social or communication symptoms, are associated with gastrointestinal symptom severity, even after accounting for associated behavioral symptoms. This suggests that gastrointestinal symptoms may exacerbate repetitive behaviors, or vice versa, independent from other associated behavioral symptoms.

Objectives. To examine abortion utilization in Ohio from 2010 to 2018, a period when more than 15 abortion-related laws became effective. Methods. We evaluated changes in abortion rates and ratios examining gestation, geographic distribution, and abortion method in Ohio from 2010 to 2018. We used data from Ohio’s Office of Vital Statistics, the Centers for Disease Control and Prevention’s Abortion Surveillance Reports, the American Community Survey, and Ohio’s Public Health Data Warehouse. Results. During 2010 through 2018, abortion rates declined similarly in Ohio, the Midwest, and the United States. In Ohio, the proportion of early first trimester abortions decreased; the proportion of abortions increased in nearly every later gestation category. Abortion ratios decreased sharply in most rural counties. When clinics closed, abortion ratios dropped in nearby counties. Conclusions. More Ohioans had abortions later in the first trimester, compared with national patterns, suggesting delays to care. Steeper decreases in abortion ratios in rural versus urban counties suggest geographic inequity in abortion access. Public Health Implications. Policies restricting abortion access in Ohio co-occur with delays to care and increasing geographic inequities. Restrictive policies do not improve reproductive health.

The HerpeSelect 2 ELISA IgG test for herpes simplex virus type 2 (HSV-2) infection is widely used, convenient, and inexpensive. However, it has been shown to have lower specificity among populations in Sub-Saharan Africa compared with HSV-2 tests regarded as criterion standards.In 2016, we collected blood and survey data from 248 women participating in a community-based cohort study in rural Malawi (the Umoyo wa Thanzi project). Using multinomial logistic regression accounting for village-level clustering, we examined unadjusted associations between select demographic and sexual risk factors and HSV-2 serostatus. Because increasing the index value cutpoint for a positive result improves specificity, we coded HSV-2 serostatus in 2 ways: the manufacturer's recommended cutpoints (0.9, negative; 0.9-1.1, indeterminate;1.1, positive) and modified cutpoints with improved specificity (0.9, negative; 0.9-3.5, indeterminate;3.5, positive). We aimed to investigate whether associations between select risk factors and HSV-2 serostatus varied under the 2 approaches.The prevalence of HSV-2 in this sample was 67% under the manufacturer's cutpoint and 22% under the modified cutpoint. Under both cutpoints, age, household size, number of marriages, and number of pregnancies were associated with HSV-2-positive serostatus. Using modified cutpoints, current bacterial vaginosis (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.35-7.47), partner concurrency (OR, 4.88; 95% CI, 2.54-9.37) and unsure about partner concurrency (OR, 1.91; 95% CI, 1.08-3.38) were associated with HSV-2 seropositivity. Household size, education, and marital status were the only variables significantly associated with indeterminate HSV-2 serostatus using the modified cutpoints.HSV-2-focused interventions informed by identifying individuals likely to have or acquire HSV-2 must be aware that different target populations may emerge depending on which cutpoints are adopted.

The relationship between housing instability and reproductive healthcare is understudied. We examined the association between housing insecurity and access and utilization of general healthcare, contraceptive healthcare, and abortion care.Using data from a population-representative survey of adult reproductive-age Ohio women (N = 2,529), we assessed housing insecurity (not paying rent/mortgage on time in the past year). We examined associations between housing insecurity and the following outcomes: (1) not being able to access general healthcare in the past year; (2) experiencing delays or difficulties in accessing contraceptive healthcare in the past year; and (3) ever having an abortion. We used unadjusted and adjusted logistic regression models. We selected confounders a priori and included age, socioeconomic status, and healthcare status.Overall, 10.6% of Ohio women of adult reproductive age experienced housing insecurity. Approximately 27.5% of respondents were not able to access general healthcare and 10.4% experienced delays or difficulties in accessing contraceptive care. Compared to housing-secure respondents, housing-insecure women were less able to access general healthcare (adjusted odds ratio [aOR]:2.16; 95% confidence interval [CI]:1.45-3.23) and more likely to experience delays or difficulties when accessing contraceptive care (aOR:1.74; 95% CI:1.00-3.04). Insecure housing was not statistically associated with ever having an abortion (aOR:1.76; 95% CI:0.93-3.34).In this study, recent housing insecurity was associated with poorer access to general and contraceptive healthcare. Studies utilizing multidimensional measures of housing insecurity and other material insecurity measures are needed to further explore the relationship between material insecurity and access to general and contraceptive care.

In twin/multiple pregnancy, siblings experience an adverse intrauterine environment which forms the major etiological factor leading to pathological conditions. The status of the developing fetus is highly determined by the nitric oxide (NO) level, that facilitates vasodilation which in turn modulates the oxygen and nutrition supply. As the umbilical cord (UC) lacks innervation, activation of the endothelial nitric oxide synthase (NOS3) is fundamental to maintain adequate NO production. Recent ground breaking fact showed that under stress conditions, circulating red blood cells (RBCs) can actively produces NO as a “rescue mechanism”. Therefore, this study majorly focused on the molecular mechanisms that affected the redox environment by altering NOS3 activation - both in the UC arteries and vein endothelium and RBCs - that have impacts on developmental parameters, like birth weight. In connection to that, we pursued the communication efficiency between the vessels' endothelium and the circulating RBCs in demand of bioavailable NO. Our results indicated that twinning itself at stage 33–35 weeks, does not reduce the NOS3 level and its phosphorylation status in the cord vessels. However, RBC-NOS3 activation is highly upregulated during this period - providing additional evidence for the active regulatory role of fetal RBCs in the rate of blood flow - and this functional activity highly correlates with the birth weight of the fetuses. Detailed analysis on NOS3 signalling at different time points of gestation could establish a benchmark in understanding of the pathophysiological mechanisms involved in the process of developing neonatal vascular diseases.

Purpose To examine the association between sexual minority status and the prevalence of emotional distress and substance use among a nationally-representative sample of youth who reported sexual violence victimization. Methods Data were from the 2017 National Youth Risk Behavior Survey, a biennial school-based survey. We restricted the sample to youth who reported any past-year sexual violence victimization. We estimated prevalence ratios using modified Poisson regression with robust error variance to examine associations of sexual minority status with depressive symptomology, suicidality, and substance use. Results Among the 1364 (9.7%) students who experienced sexual violence, 78% were girls. Relative to heterosexual youth, sexual minority youth had higher prevalence estimates for the emotional distress outcomes and marijuana use. Sexual minority status was associated with depressive symptomology (adjusted prevalence ratio [aPR] 1.33, 95% confidence interval 1.22–1.44), suicidal ideation (aPR: 1.91, 1.66–2.20), medically treated suicide attempt (aPR: 2.74, 1.53–4.93), and past 30-day marijuana use (aPR: 1.29, 1.06–1.57). Conclusions Among youth who experience sexual violence, sexual minorities may experience more emotional distress and substance use outcomes than heterosexuals. Rape crisis programs and other tertiary interventions should attend to the unique needs of sexual minorities who have been sexually victimized.

Objectives We aimed to characterize the combined impact of federal, state, and institutional policies on barriers to expanding medication and telemedicine abortion care delivery during the COVID-19 pandemic in the abortion-restrictive states of Ohio, Kentucky, and West Virginia. Study Design We analyzed 4 state policies, 2 COVID-related state executive orders, and clinic-level survey data on medication abortion provision from fourteen abortion facilities in Ohio, Kentucky, and West Virginia from December 2019 to December 2020. We calculated the percent of medication abortions provided at these facilities during the study period by state, to assess changes in medication abortion use during the pandemic. Results We ascertained that COVID-19-executive orders in Ohio and West Virginia that limited procedural abortion in Spring 2020 coincided with an increase in the overall number and proportion of medication abortions in this region, peaking at 1613 medication abortions (70%) in April 2020. Ohio and West Virginia, which had executive orders limiting procedural abortion, saw relatively greater increases in April compared to Kentucky. Despite temporary lifting of the mifepristone REMS, prepandemic regulations banning telemedicine abortion in Kentucky and West Virginia and requiring in-person clinic visits for medication abortion distribution in Ohio limited clinics’ ability to adapt to offer medication abortion by mail. Conclusions Our findings illustrate how restrictive medication and telemedicine abortion policies in Ohio, Kentucky, and West Virginia created additional obstacles for patients seeking medication abortion during the pandemic. Permanently lifting federal regulations on in-clinic distribution of mifepristone would only advantage abortion seekers in states without restrictive telehealth and medication abortion policies. State policies that limit access to comprehensive abortion services should be central in larger efforts toward dismantling barriers that impinge upon reproductive autonomy. Implication Statement We find that abolishing the REMS on mifepristone would not be enough to expand access to patients in abortion-restrictive states with telemedicine and medication abortion laws. While the REMS is a barrier, it represents one of several hindrances to the expansion of telemedicine abortion distribution across the United States.

Background: In the United States, pregnant people seeking an abortion often travel in order to access care. Abortion access is often more limited for people who live in states with few abortion facilities and restrictive abortion legislation. Methods: We computed state-specific abortion rate (number of abortions per thousand women ages 15-44) with CDC 2018 Abortion Surveillance data and Census data. We calculated percentage of abortion patients leaving their state of residence for abortion care for each state using the CDC’s 2018 Abortion Surveillance data. We categorized percent leaving by policy restrictiveness using NARAL’s classification of restrictiveness of state abortion laws. We categorized percent leaving by “facility density” (number of abortion facilities per million women ages 15-44), calculated using Census data and ANSIRH’s Abortion Facility Database. We created a map of percent leaving by state and a scatterplot of percent leaving against facility density. Thirty-nine states with high quality data are included in our analysis. Findings: In 2018, an average of 8% of US patients left their state of residence for abortion care. Percent leaving varied widely by state: 59% left South Carolina, 53% South Dakota, 46% Mississippi, and 42% Kentucky, while 5% or fewer of patients left from 16 of the states we evaluated. States with more restrictive laws averaged 9% of patients leaving, while states with less restrictive or more protective laws averaged 4% of patients leaving. States in the bottom quartile for facility density averaged 32% leaving, while states in the top quartile averaged 2% leaving. Interpretation: Many patients travel across state lines for abortion care. Restrictive state-level abortion policy and facility scarcity may play a role in patients leaving their state of residence. Funding: This study was supported by a philanthropic foundation that makes grants anonymously. Funding: This study was supported by a philanthropic foundation that makes grants anonymously. The Declaration of Interest: The authors have no conflicts of interest to report.

Background Legislative and judicial procedures related to banning abortion after 6 weeks of gestation in Ohio occurred from November 2018 to July 2019. These activities could have increased the belief that abortion has become illegal even though the 6-week abortion ban has never been in effect to date. Objective We sought to determine the prevalence and correlates of holding the belief that abortion is illegal in Ohio and to evaluate whether this belief increased over the time in which the 6-week abortion ban was introduced, passed twice, and then blocked in Ohio. Study Design We analyzed data from the first wave of the Ohio Survey of Women, a population-based survey of adult, reproductive-aged Ohioan women conducted from October 2018 to June 2019. During each of the 8 survey months, a median of 240 women (range, 70–761) completed the survey, including the survey question “Based on what you know or have heard, is it legal to get an abortion in your state?” We used multivariable logistic regression to assess the prevalence and correlates of believing that abortion is illegal in the state of Ohio. In addition, we used multinomial logistic regression to evaluate whether this belief increased over the interval during which women completed the survey, which roughly corresponded to the interval marked by legislative and judicial activities surrounding the 6-week abortion ban. Results Most of the 2359 participants understood that abortion is legal in the state of Ohio (64.0%) with the remainder believing it to be illegal (9.8%) or being unsure (26.2%). Correlates of believing abortion to be illegal included younger age, lower socioeconomic status, never married or married status, and black, non-Hispanic race and ethnicity. Being unsure about legality did not change over time; however, the proportion of women who believed that abortion is illegal increased from the first month (4.5%) to the last month (15.9%) of the study period. Each additional study month was associated with a 17% increase in the odds of believing abortion to be illegal, in both unadjusted and adjusted models (odds ratio, 1.17; 95% confidence interval, 1.08–1.27). Conclusion Attempts to restrict abortion access could contribute to women mistakenly believing that abortion is illegal despite it being unsuccessful.

Intrauterine hypoxic condition increases the generation of reactive oxygen species and fetal oxidative stress. Multiple pregnancy always bears an additional oxidative stress condition with severe complications, such as prematurity, structural abnormalities, delayed development and low birthweight. The umbilical cord (UC) vessels, along with circulating fetal red blood cells (RBCs), highly determine the oxygenation status of fetus and regulate the feto-placental circulation. As UC lacks innervation, the activation of the endothelial nitric oxide synthase (NOS3) is fundamental for proper NO production. Therefore, we aimed to study the NOS3 activation pathways along with damages to macromolecules in the endothelium of UC vessels and RBCs of mature non-discordant twins, in connection to major differences in their birth weight. We provide evidence that, under severe hypoxic conditions such as twin pregnancy, the NOS3-related NO production pathways are altered both in UC vessels and RBCs, moreover, the extent of changes is highly birthweight-specific. Furthermore, macromolecular damages are prominent in the RBCs and arteries compared to the vein, with a similar increase in the Arginase1 level, which is believed to play a role in NOS3 functionality, resulting in endothelial dysfunctionality, which might have relevance to the major etiologies of cardiovascular diseases in later life.

Objective The objective of the study was to characterize and compare the attitudes, beliefs, and perceptions about epilepsy across community and patient cohorts in Uganda. Methods This was a descriptive study utilizing two samples: a randomly selected, national survey community sample and a hospital-based patient sample of people with epilepsy (PWE) and their caregivers attending clinic settings in Kampala and Mbarara, Uganda for epilepsy care. Both samples were surveyed about their beliefs about epilepsy, its treatment, and people who have the illness. Multivariate linear regression was used to examine group differences and variables associated with specific beliefs. Results Among the 15,818 community survey participants who participated in this study, 435 study participants reported symptoms suggestive of recurrent seizures, and all 626 subjects in the hospital-based sample had confirmed epilepsy. Results revealed significant differences across groups in their endorsement of epilepsy as a contagion; 37% of people in the community unaffected by epilepsy, and 39% of people with suspected epilepsy who did not seek care believed that epilepsy was contagious by touch, in contrast to 8% of PWE or their caregivers attending regular hospital-based care. Higher educational attainment and income, and seeking regular hospital-based medical care were associated with less endorsement of epilepsy as a contagion, while age, education, income, area of residence, and presence of seizure symptoms, were significant predictors of support or belief in the basic rights of PWE. Study participants within the community who screened negative for seizures placed the most restrictions on rights for PWE. To varying degrees, the samples all endorsed the effectiveness of allopathic, traditional, and religious providers, and the use of pharmaceutical drugs, traditional rituals and herbs, and prayer. Conclusions People with epilepsy who are attending biomedical care for routine epilepsy care think differently about epilepsy, its treatment, and the rights of those with the disease than the general population. Within the community setting, more erroneous beliefs and negative attitudes about epilepsy and PWE persist, and they not only contribute to stigma but also interfere with the patients' health-seeking behavior. Further confounding the care of PWE, the pluralistic healthcare system in Uganda is evident in endorsements spanning biomedical, traditional, and religious treatment methods. Focused awareness campaigns utilizing local epilepsy societies are needed to promote epilepsy health literacy, to favorably impact acceptance and opportunities for PWE in Uganda, and to facilitate efficient uptake of biomedical care. This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"

Background NSAIDs are the most common class of painkillers and anti-inflammatory agents. They also show other functions like chemoprevention and chemosuppression for which they act at the protein but not at the genome level since they are mostly anions at physiological pH, which prohibit their approach to the poly-anionic DNA. Complexing the drugs with bioactive metal obliterate their negative charge and allow them to bind to the DNA, thereby, opening the possibility of genome level interaction. To test this hypothesis, we present the interaction of a traditional NSAID, Piroxicam and its copper complex with core histone and chromatin. Methods Spectroscopy, DLS, and SEM studies were applied to see the effect of the interaction on the structure of histone/chromatin. This was coupled with MTT assay, immunoblot analysis, confocal microscopy, micro array analysis and qRT-PCR. Results The interaction of Piroxicam and its copper complex with histone/chromatin results in structural alterations. Such structural alterations can have different biological manifestations, but to test our hypothesis, we have focused only on the accompanied modulations at the epigenomic/genomic level. The complex, showed alteration of key epigenetic signatures implicated in transcription in the global context, although Piroxicam caused no significant changes. We have correlated such alterations caused by the complex with the changes in global gene expression and validated the candidate gene expression alterations. Conclusion and general significance Our results provide the proof of concept that DNA binding ability of the copper complexes of a traditional NSAID, opens up the possibility of modulations at the epigenomic/genomic level.

Women are born with millions of primordial follicles which gradually decrease with increasing age and this irreversible supply of follicles completely exhausts at menopause. The fertility capacity of women diminishes in parallel with aging. The mechanisms for reproductive aging are not fully understood. We have observed a decline in Brca1 mediated DNA repair in aging rat primordial follicles. To further understand the age-related molecular changes, we performed microarray gene expression analysis using total RNA extracted from immature (18 to 20 day old) and aged (400 to 450 day old) rat primordial follicles. The results of current microarray study revealed that there were 1,011 (>1.5 fold, p

Background The Focus HerpeSelect 2 ELISA IgG Test, used to diagnose herpes simplex virus type 2 (HSV-2) infection, is inexpensive, convenient, and widely used. However, past studies document poor specificity of this test in African populations. Increasing the index value cutpoint for a positive result improves specificity, but no studies to our knowledge have examined whether the correlates of HSV-2 infection change when the cutpoint for positivity changes. We investigated whether associations between select demographic and sexual risk factors and HSV-2 serostatus varied when the cutpoint for positivity was increased. Methods We sampled women (n=218) from the Umoyo wa Thanzi project, an ongoing community-based cohort study in rural Malawi. Using multinomial logistic regression and accounting for village-level clustering, we examined unadjusted and adjusted associations between select risk factors and HSV-2 serostatus. HSV-2 serostatus was coded in two ways: the manufacturer’s recommended cutpoints ( 1.1=positive), and modified cutpoints ( 3.5=positive). Results We assessed associations between HSV-2 serostatus and age, bacterial vaginosis (BV), and partner concurrency under each set of cutpoints. Measures of effect were weaker using the manufacturer’s cutpoints compared to the modified cutpoints. Age was not significantly correlated with positive vs. negative serostatus using the manufacturer’s cutpoint (relative risk ratio (RRR)=1.03, 95% CI: 0.97–1.09), but the association strengthened using the modified cutpoint (RRR=1.09, 95% CI: 1.01–1.17). Using the manufacturer’s cutpoint, the RRR for BV was 1.73 (95% CI: 0.71–4.19) vs. RRR=2.70 (95% CI: 0.94–7.79) for the modified cutpoint. For partner concurrency, the RRR using the manufacturer’s cutpoint was 1.47 (95% CI: 0.71–3.07), vs. RRR=3.45 (95% CI: 1.12–10.57) for the modified threshold. Conclusion Changing the test cutpoints affected observed associations with previously-identified HSV-2 risk factors. HSV-2 prevention interventions informed by correlates of HSV-2 infection must be aware that different target populations may emerge depending on which cutpoints are adopted. Disclosure No significant relationships.

An understanding of the basic pathophysiological mechanisms of neonatal diseases necessitates detailed knowledge about the wide range of complications in the circulating fetal RBCs. Recent publications on adult red blood cells (RBCs) provide evidence that RBCs carry an active nitric oxide synthase (NOS3) enzyme and contribute to vascular functioning and integrity via their active nitric oxide synthesis. The aim of this study was to determine the effect of maternal smoking on the phenotypical appearance and functionality of fetal RBCs, based on morphological and molecular studies. We looked for possible links between vascular dysfunction and NOS3 expression and activation and its regulation by arginase (ARG1). Significant morphological and functional differences were found between fetal RBCs isolated from the arterial cord blood of neonates born to nonsmoking (RBC-NS,n=62) and heavy-smoking (RBC-S,n=51) mothers. Morphological variations were quantified by Advanced Cell Classifier, microscopy-based intelligent analysis software. To investigate the relevance of the newly suggested “erythrocrine” function in fetal RBCs, we measured the levels of NOS3 and its phosphorylation in parallel with the level of ARG1, as one of the major influencers of NOS3 dimerization, by fluorescence-activated cell sorting. Fetal RBCs, even the “healthy-looking” biconcave-shaped type, exhibited impaired NOS3 activation in the RBC-S population, which was paralleled with elevated ARG1 level, thus suggesting an increased redox burden. Our molecular data indicate that maternal smoking can exert marked effects on the circulating fetal RBCs, which could have a consequence on the outcome of in utero development. We hypothesize that any endothelial dysfunction altering NO production/bioavailability can be sensed by circulating fetal RBCs. Hence, we are putting forward the idea that neonatal RBC could serve as a real-time sensor for not only monitoring RBC-linked anomalies but also predicting the overall status of the vascular microenvironment.

Effective prophylactic strategy against the current epidemic of sexually transmitted HIV-1 infection requires understanding of the innate gatekeeping mechanisms at the genital mucosa. Surfactant protein D (SP-D), a member of the collectin family of proteins naturally present in the vaginal tract, is a potential HIV-1 entry inhibitor at the cellular level. Human EpiVaginal tissues compartmentalized in culture inserts were apically exposed to HIV-1 and/or a recombinant fragment of human SP-D (rfhSP-D) and viral passage was assessed in the basal chamber containing mononuclear leukocytes. To map the gene signature facilitating or resisting the transepithelial viral transfer, microarray analysis of the HIV-1 challenged EpiVaginal tissues was performed in the absence or presence of rfhSP-D. Mucosal biocompatibility of rfhSP-D was assessed ex vivo and in the standard rabbit vaginal irritation model. The passage of virus through the EpiVaginal tissues toward the underlying target cells was associated with a global epithelial gene signature including differential regulation of genes primarily involved in inflammation, tight junctions and cytoskeletal framework. RfhSP-D significantly inhibited HIV-1 transfer across the vaginal tissues and was associated with a significant reversal of virus induced epithelial gene signature. Pro-inflammatory NF-κB and mTOR transcripts were significantly downregulated, while expression of the tight junctions and cytoskeletal genes was upheld. In the absence of virus, rfhSP-D directly interacted with the EpiVaginal tissues and upregulated expression of genes related to structural stability of the cell and epithelial integrity. There was no increment in the viral acquisition by the PBMCs present in basal chambers wherein, the EpiVaginal tissues in apical chambers were treated with rfhSP-D. The effective concentrations of rfhSP-D had no effect on lactobacilli, epithelial barrier integrity and were safe on repeated applications onto the rabbit vaginal mucosa. This pre-clinical safety data, coupled with its efficacy of restricting viral passage via reversal of virus-induced gene expression of the vaginal barrier, make a strong argument for clinical trials of rfhSP-D as a topical anti-HIV microbicide. The authors thank HIV Research Trust, UK for providing scholarship to Hrishikesh Pandit and Brigham and Women’s Hospital (BWH) for permitting to visit and work in Fichorova lab. The work was partly supported by Medical Innovation Fund (Project no. 2011-16850) of Indian Council of Medical Research (ICMR), New Delhi, India. We are grateful to Director, NIRRH for providing financial support as the Institutional Grant and all the Institutional facilities for experimentation (Accession no. 618). The authors thank HIV Research Trust, UK for providing scholarship to Hrishikesh Pandit to work at the Fichorova's Laboratory. This study was partly supported by Medical Innovation Fund (Project no. 2011-16850) of Indian Council of Medical Research (ICMR), New Delhi, India. We are grateful to Director, NIRRH for providing financial support via the Institutional Grant and the Institutional facilities (Accession no. 618).

Objective This study sets out to describe the current demographics of people with epilepsy (PWE) attending hospital-based care in Uganda and the epilepsy treatment practices within three of the largest Ugandan public referral hospitals. Methods In a six-month prospective cohort study, 626 children and adults attending epilepsy clinics at Mulago National Referral Hospital, Butabika National Referral Mental Hospital and Mbarara Regional Referral Hospital were enrolled. Using a study questionnaire, data were collected at baseline and at 3 weeks, 3 months, and 6 months following enrollment. Specific data surrounding individual patient demographics, clinical characteristics and severity of epilepsy, and treatment of epilepsy with antiepileptic drugs (AEDs) were collected. Results Female patients totaled to 50.8%, with a nearly equal gender distribution at each hospital. There was no statistical difference in gender or age between sites. The majority of PWE had completed primary school, with less than 15% of patients completing more than a secondary education. Seizure severity was high, with most patients having multiple seizures per week at the initial onset of epilepsy, and greater than 90% of patients reporting a loss of consciousness with seizures. The majority of patients (54.95%) also reported a developmental or learning delay. Most patients were on 1 AED (46.01%) or 2 AEDs (36.90%), with carbamazepine being the most frequently prescribed AED. There was a trend towards improved seizure severity over the follow-up period, as assessed by the corresponding Personal Impact of Epilepsy Scale (PIES) subscale. Conclusions People with epilepsy attending hospital-based care in Uganda tend to have severe forms of epilepsy requiring management with AEDs. Current hospital-based practices show a positive trend for seizure burden and quality of life of PWE in Uganda. Further interventions to improve overall access to biomedical care are required to continue to advance the management of PWE across all communities. This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"

Objective Epilepsy is a disease that is stigmatized globally. Several studies have introduced sensitization efforts to reduce stigma towards people with epilepsy (PWE) in various settings. Although sensitization efforts have shown some evidence of improved attitudes towards epilepsy, progress has been limited. This systematized literature review summarizes the existing literature concerning interventions that reduce stigma towards PWE. By conducting an overview of existing interventions, we aimed to consolidate knowledge and outcomes of existing efforts as well as highlight gaps and directions for future interventions. Methods We searched MEDLINE (via PubMed) and Embase for English-language studies published between January 1, 1970 and November 15, 2017 that focused on stigma reduction strategies for PWE in any global setting. Studies were included if they described a stigma reduction intervention for epilepsy. Studies were excluded if they were reviews, editorials, conference proceedings, abstracts, or did not discuss a stigma reduction intervention. We thematically grouped studies based on type(s) of intervention(s) addressed and summarized interventions, outcome measures, and results for each study included in the review. Results Of the 1975 initial citations, 32 studies met our inclusion criteria. Interventions clustered into four broad categories including public awareness interventions, policy-based interventions, school-based interventions, and interventions that targeted PWE themselves as well as their caregivers and peers. Efficacy of these interventions as reported by the authors was mixed. Many studies did not use validated outcome measures to assess stigma. Conclusions Although intervention efforts have been made towards epilepsy stigma reduction at many levels, stigma towards and discrimination against PWE prevail worldwide. About 75% of the studies included in this review were conducted in high-income countries (HICs) despite the disproportional need in low- and middle-income countries (LMICs). Furthermore, robust outcome measures to assess efficacy in stigma reduction for interventions are lacking, calling into question the validity of reported outcomes for both positive and null findings. Therefore, more work is needed in both developing effective stigma reduction strategies, especially in LMICs, and validating tools to measure their efficacy. This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"

Epilepsy is a global public health concern, with the majority of cases occurring in lower- and middle-income countries where the treatment gap remains formidable. In this study, we simultaneously explore how beliefs about epilepsy causation, perceived barriers to care, seizure disorder characteristics, and demographics influence the initial choice of healthcare for epilepsy and its impact on attaining biomedical care (BMC).This study utilized the baseline sample (n = 626) from a prospective cohort study of people with epilepsy (PWE) attending three public hospitals in Uganda (Mulago National Referral Hospital, Butabika National Referral Mental Hospital, and Mbarara Regional Referral Hospital) for epilepsy care. Patient and household demographics, clinical seizure disorder characteristics, and sociocultural questionnaires were administered. Logistic regression and principal component analyses (PCA) were conducted to examine associations with the choice of primary seizure treatment.The sample was 49% female, and 24% lived in rural settings. A biomedical health facility was the first point of care for 355 (56.7%) participants, while 229 (36.6%) first sought care from a traditional healer and 42 (6.7%) from a pastoral healer. Preliminary inspection of candidate predictors using relaxed criteria for significance (p 0.20) identified several factors potentially associated with a greater odds of seeking BMC first. Demographic predictors included older caredriver (decision-maker for the participant) age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: [0.99, 1.02], p-value: 0.09), greater caredriver education level (OR = 1.21, 95% CI: [1.07, 1.37], p-value = 0.003), and lower ratio of sick to healthy family members (OR = 0.77 [0.56, 1.05], P = 0.097). For clinical predictors, none of the proposed predictors associated significantly with seeking BMC first. Self-report causation predictors associated with a greater odds of seeking BMC first included higher belief in biological causes of epilepsy (OR = 1.31 [0.92, 1.88], P = 0.133) and lower belief in socio-spiritual causes of epilepsy (OR = 0.68 [0.56, 0.84], P 0.001). In the multivariate model, only higher caredriver education (OR = 1.19 [1.04, 1.36], P = 0.009) and lower belief in socio-spiritual causes of epilepsy (OR = 0.69 [0.56, 0.86], P 0.01) remained as predictors of seeking BMC first. Additionally, PCA revealed a pattern which included high income with low beliefs in nonbiological causes of epilepsy as being associated with seeking BMC first (OR = 1.32 [1.12, 1.55], p = 0.001). Despite reaching some form of care faster, individuals seeking care from traditional or pastoral healers experienced a significant delay to eventual BMC (P 0.001), with an average delay of more than two years (traditional healer: 2.53 years [1.98, 3.24]; pastoral care: 2.18 [1.21, 3.91]).Coupled with low economic and educational status, belief in spiritual causation of epilepsy is a dominant determinant of opting for traditional or pastoral healing over BMC, regardless of concurrent belief in biological etiologies. There is a prolonged delay to eventual BMC for PWE who begin their treatment seeking with nonallopathic providers, and although nonallopathic healers provide PWE with benefits not provided by BMC, this notable delay likely prevents earlier administration of evidence-based care with known efficacy. Based on these findings, initiatives to increase public awareness of neurobiological causes of epilepsy and effectiveness of biomedical drug treatments may be effective in preventing delays to care, as would programs designed to facilitate cooperation and referral among traditional, faith-based, and biomedical providers. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Purpose We sought to address the construct validity and reliability of the Personal Impact of Epilepsy Scale (PIES), an epilepsy-specific quality-of-life measure, in patients with epilepsy in Uganda. We also sought to assess the applicability of the scale across three languages: English, Luganda, and Runyankole. Methods Patients with epilepsy (N = 626) were recruited at the time of care seeking from Mulago National Referral Hospital (MNRH), Butabika National Referral Mental Hospital (BNRMH), and Mbarara Regional Referral Hospital (MRRH), and were given the English, Runyankole, and Luganda versions of the PIES as a part of a larger interview. Reliability, internal consistency specifically, was assessed using three parameters: Cronbach's alpha, McDonald's Omega, and composite reliability. Construct validity (internal structure) was evaluated with principal component analysis (PCA) for three factors, as well as confirmatory factor analysis (CFA) for a three-factor structure of the scale. We also assessed correlations between the three PIES subscales and the seizure severity question in the Liverpool Seizure Severity Scale (LSSS) and reported seizure frequency. Results The three-factor model of the PIES had adequate reliability, with Cronbach's Alpha, McDonald's Omega, and composite reliability values over 0.7, except for the Cronbach's Alpha and McDonald's Omega values for the second factor, which was slightly lower than 0.7 in the full sample as well as when stratified by study language. The PCA and CFA models for the scale demonstrated adequate fit with the Tucker–Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA), with TLI and CFI values above 0.9 and RMSEA values less than 0.08. However, the model demonstrated inadequate fit with the Chi-square indicator, which yielded a significant p-value. Individual factor loadings ranged from 0.50 to 0.95 in the full sample, 0.45 to 0.98 in the English sample, and 0.45 to 0.93 in the Luganda sample. Finally, the three PIES subscales aligned with reported seizure frequency and the seizure severity question from the LSSS. Conclusions This study presents the first Luganda and Runyankole versions of the PIES, and the first validation of this scale in English and Luganda with patients with epilepsy in Uganda. The PIES was found to have acceptable psychometric properties for reliability and validity parameters. Thus, the scale is recommended for use and for further investigation in patients with epilepsy in Uganda. This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda”

Objective Epilepsy, a neurological disorder with effective biomedical treatment, remains largely untreated in Uganda. Potential reasons for this treatment gap (TG) include limited access to trained providers and clinics, social stigmata of seizures, cultural beliefs, or lack of public understanding of epilepsy as a treatable condition. The current study aimed to formally evaluate barriers faced by people with epilepsy (PWE) in Uganda when seeking biomedical care. Methods In a cross-sectional study, 435 participants drawn from a community prevalence study were enrolled. We included participants reporting a history of recurrent seizures suggestive of epilepsy, who completed a survey about barriers to obtaining care for their symptoms. Principal axis factor analysis (PFA) using a promax rotation was conducted for data reduction. Frequencies of barrier factors were compared across those who did not seek care for epilepsy (n = 228), those who sought care from biomedical facilities (n = 166), and those who sought care from a traditional or pastoral healer (n = 41). Results The PFA yielded a five-factor solution: 1) logistical and actual costs; 2) treatment effectiveness; 3) influence of the opinion of others; 4) doctors' care; and 5) contextual factors impacting decision-making. Variables related to logistical and actual costs were most endorsed. Comparison of groups by care sought did not reveal a difference in endorsement of factors, with the exception that those who sought biomedical care were more likely to endorse factors related to doctors' care compared with those that sought care from traditional or pastoral healers (P = .005). Conclusions People with repetitive seizures in Uganda report several barriers to obtaining biomedical care in Uganda, with those related to practical and actual costs endorsed the most. It is imperative that interventions developed to reduce the TG in Uganda consider these practical issues to improve access to effective epilepsy care. This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda

Objective Epilepsy is one of the most prevalent, treatable neurological diseases globally. In sub-Saharan Africa, people with epilepsy (PWE) frequently seek treatment from traditional or pastoral healers, who are more accessible than biomedical care providers. This often contributes to the substantial time delay in obtaining adequate biomedical care for these patients. In Uganda, the few biomedical providers who can treat epilepsy cannot meet the great need for epilepsy care. Additionally, patients are often hesitant to seek biomedical care, often preferring the easily accessible and trusted sociocultural treatment options. This study sought to elucidate the barriers to biomedical care for PWE as well as identify potential solutions to overcome these barriers from various stakeholder perspectives. Methods This study used qualitative research methods. Semistructured interviews and focus group discussions were conducted with four major stakeholder groups: PWE or family members of PWE, neurologists and psychiatrists, traditional healers, and pastoral healers. All interviews and focus group discussions that were in English were audio recorded and transcribed verbatim. Those that were not in English were translated live and audio recorded. A translator later translated the non-English portion of audio recording to ensure proper interpretation. Two independent coders coded the dataset and conducted an inter-rater reliability (IRR) assessment to ensure reliable coding of the data. Thematic analysis was then performed to discern themes from the data and compare nuances between each of the study design groups. Results Participants discussed several different causes of epilepsy ranging from spiritual to biological causes, often incorporating elements of both. Commonly endorsed spiritual causes of epilepsy included witchcraft and ancestral spirits. Commonly endorsed biological causes included genetics, fever, malaria, and brain injury. For patients and families, beliefs about the cause of epilepsy often played a role in whom they chose to seek treatment from. Three major barriers to biomedical care were discussed: practical barriers, medical infrastructure barriers, and barriers related to stigma. Practical barriers related to issues such as transportation, cost of medical care, and distance to the nearest healthcare facility. Under medical infrastructure, drug stock-outs and lack of access to antiepileptic drugs (AEDs) were the most consistent problems stated among patients. Stigma was heavily discussed and brought up by nearly every participant. Additionally, three significant solutions to improving epilepsy care in Uganda were highlighted by participants: collaboration among treatment providers, community sensitization efforts to address stigma, and building medical infrastructure. Within building infrastructure, all participant types, except traditional healers, proposed the development of an epilepsy clinic designed to specifically treat epilepsy. Conclusions Based on these findings, there are four critical interventions that should be considered for improving epilepsy care in Uganda: the creation of dedicated epilepsy clinics, infrastructure strengthening to address medication stock-outs, community outreach programs for sensitization, and collaboration between biomedical providers and traditional healers. This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda”