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

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

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

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

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

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