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

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

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries.

INTRODUCTION: The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up. METHODS AND ANALYSIS: Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews. ETHICS AND DISSEMINATION: This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

2023 World Heart Federation guidelines for the echocardiographic diagnosis of rheumatic heart disease.

Rheumatic heart disease (RHD) is an important and preventable cause of morbidity and mortality among children and young adults in low-income and middle-income countries, as well as among certain at-risk populations living in high-income countries. The 2012 World Heart Federation echocardiographic criteria provided a standardized approach for the identification of RHD and facilitated an improvement in early case detection. The 2012 criteria were used to define disease burden in numerous epidemiological studies, but researchers and clinicians have since highlighted limitations that have prompted a revision. In this updated version of the guidelines, we incorporate evidence from a scoping review, an expert panel and end-user feedback and present an approach for active case finding for RHD, including the use of screening and confirmatory criteria. These guidelines also introduce a new stage-based classification for RHD to identify the risk of disease progression. They describe the latest evidence and recommendations on population-based echocardiographic active case finding and risk stratification. Secondary antibiotic prophylaxis, echocardiography equipment and task sharing for RHD active case finding are also discussed. These World Heart Federation 2023 guidelines provide a concise and updated resource for clinical and research applications in RHD-endemic regions.

Objectively measured medication adherence using assays for carvedilol and enalaprilat in patients with heart failure in Mozambique and Nigeria.

Background: Poor medication adherence leads to poor health outcomes and increased healthcare costs among patients with heart failure (HF). This study aimed to objectively assess medication adherence by measuring carvedilol and enalaprilat plasma concentrations among patients with HF. Methods: The present sub-study of the Safety, Tolerability, and Efficacy of Rapid Optimization, helped by NT-proBNP testing, of Heart Failure therapies (STRONG-HF) study involved adult patients with acute HF admitted in two Mozambican and two Nigerian hospitals who were not optimally treated with oral enalapril and carvedilol. Patients in the high-intensity arm of the STRONG-HF study, and those not meeting the biomarker criteria for persistent congestion, were included in the "frequent visit" (FV) arm. In the FV arm, blood for bioanalysis of plasma enalaprilat or/and carvedilol was drawn at the 2,6,12th week post-discharge. Patients in the usual care arm of STRONG-HF were included in the "standard visit" (SV) arm, which followed the usual local practice with blood sampling in week 12. Results: The study involved 113 (79 FV and 34 SV) participants with a mean age of 48.6 years and a mean left ventricular (LV) ejection fraction of 33.1%. Theenalaprilat below the lower level of quantification (LLOQ) was documented in 7.7%, 11.9%, and 15.6% of participants in FV during the 2,6 and 12th weeks. Carvedilol concentration below LLOQ was documented in 37%, 30%, and 44.4% of participants in the FV arm during the 2,6 and 12th weeks, respectively. For the SV arm, enalaprilat and carvedilol concentrations below LLOQ in the twelfth week were documented in 37.3% and 42.9% of patients, respectively. Conclusion: Up to a third of patients using enalapril and carvedilol did not take any medication during the 12 weeks of follow-up. Non adherence was more common in patients who had less follow up, emphasizing the importance of close follow up to adherence. No adherence was also more common in medications know to have more side effects such as carvedilol.

Access to Essential Medicines and Diagnostic Tests for Cardiovascular Diseases in Maputo City, Mozambique.

Background: To tackle the increasing burden of non-communicable diseases (NCDs) and reduce premature cardiovascular (CV) mortality by a third by the year 2030, countries must achieve 80% availability of affordable essential medicines (EMs) and technologies in all health facilities. Objectives: To evaluate access to EMs and diagnostics for CV diseases in Maputo City, Mozambique. Methods: Using a modified version of World Health Organization (WHO)/Health Action International (HAI) methodology, we collected data on availability and price of 14 WHO Core EMs and 35 CV EMs in all 6 public-sector hospitals, 6 private-sector hospitals, and 30 private-retail pharmacies. Data on 19 tests and 17 devices were collected from hospitals. Medicine prices were compared with international reference prices (IRPs). Medicines were considered unaffordable if the lowest paid worker had to spend more than one day's wage to purchase a monthly supply. Results: Mean availability of CV EMs was lower than that of WHO Core EMs in both public (hospitals: 20.7% vs. 52.6%) and private sectors (retail pharmacies: 21.5% vs. 59.8%; hospitals: 22.2% vs. 50.0%). Mean availability of CV diagnostic tests and devices was lower in public (55.6% and 58.3%, respectively) compared to private sector (89.5% and 91.7%, respectively). Across WHO Core and CV EMs, the median price of lowest priced generic (LPG) and most sold generic (MSG) versions were 4.43 and 3.20 times the IRP, respectively. Relative to the IRP, median price of CV medicines was higher than that of Core EMs (LPG: 4.51 vs. 2.93). The lowest paid worker would spend 14.0 to 17.8 days' wage monthly to undergo secondary prevention. Conclusion: Access to CV EMs is limited in Maputo City owing to low availability and poor affordability. Public-sector hospitals are not well equipped with essential CV diagnostics. This data could inform evidence-based policies for improving access to CV care in Mozambique.

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

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

A Multi-Site Study of Mental Disorders in the Mozambican Health Care System.

In Mozambique, human and financial resources for public mental health services are extremely limited. Understanding the mental health needs of those seeking healthcare can inform efficient targeting of mental health services. We examined if the frequency of mental disorders in a health facility varied based on the level of specialization of such facility, from primary care without mental health specialists (PrCMH -), to those with mental health specialists (PrCMH +) and tertiary care (TerC), where both inpatient and outpatient mental health services are available. Participants were adults (convenience sample) seeking health or mental health services at six facilities (2 PrCMH + , 3 PrCMH -, and 1 TerC) in the cities of Maputo and Nampula in Mozambique. Mental disorders were assessed by the MINI International Neuropsychiatric Interview (MINI) 4.0.0. We compared the sociodemographic characteristics and MINI diagnoses across the three types of health facilities. Multiple logistic regression models determined the likelihood that a person seeking services at each type of facility would have any mental disorder, common mental disorders (CMD), severe mental disorders (SMD), substance use disorders (SUD), and moderate-to-high suicide risk, adjusting for sociodemographic factors. Of the 612 total participants, 52.6% (n = 322) were positive for at least one mental disorder: 37.1% were positive for CMD, 28.9% for SMD, 13.2% for SUD, and 10.5% had suicide risk. Presence of any mental disorder was highest in TerC (62.5%) and lowest in PrCMH - (48.4%). Adjusting for sociodemographic covariates, participants in PrCMH + were significantly more likely to have SMD (OR 1.85, 95%CI 1.10-3.11) and SUD (OR 2.79, 95%CI 1.31-5.94) than participants in PrCMH -; participants in TerC were more likely to have CMD (OR 1.70, 95%CI 1.01-2.87) and SUD (OR 2.57, 95%CI 1.14-5.79) than in PrCMH -. Suicide risk was the only condition that did not differ across facility types. As anticipated, people with mental disorders were more likely to be cared for at facilities with mental health specialists. However, our study detected in this convenience sample a remarkably high frequency of mental disorders across different types of facilities within the Mozambican healthcare system. These results, if confirmed in representative samples, suggest a need to increase mental health services at the primary care level.

Emotional contagion behavior in a group of young girls in a secondary school in Maputo, Mozambique.

BACKGROUND: Emotional Contagion Behavior (ECB), the synchronized expression of emotional symptoms among members of a group, has been observed globally. In Mozambique, there have been numerous reports of ECB in recent years. Since 2010 several girls from a secondary school in Maputo City, Mozambique exhibited ECB which involved repeated fainting spells, sometimes including verbal aggression and threats to colleagues and teachers. We conducted a study to analyze sociodemographic and clinical characteristics associated with ECB. METHODS: This cross-sectional study included 154 females aged from 16 to 24 years old. We considered emotional contagion behavior as repeated fainting spells, sometimes including verbal aggression and threats to others (colleagues and teachers). Participants responded to a sociodemographic questionnaire, the Beck Anxiety Scale, and the revised Eysenck Personality Questionnaire (EPQ-R). Bivariate and multivariate logistic regression models analyzed sociodemographic and clinical characteristics associated with EBC. RESULTS: Among study participants, 57 presented ECB and 97 did not. The likelihood of ECB was higher among those with previous history of ECB (OR = 8.28, 95% CI [2.51, 27.30]; p ⩽ .001) and extroverted personality profile (OR = 1.15, 95% CI [1.01, 1.30]; p = .038). Having a romantic relationship was related to lower likelihood of having ECB (OR = 0.04, 95% CI [0.01, 0.19]; p = .001). CONCLUSIONS: These results suggest that ECB may repeat over time and be related to challenges pertaining to personality development, the presence of sexual life, and close relationships with peers faced by adolescent girls.

Does It Matter What Screener We Use? A Comparison of Ultra-brief PHQ-4 and E-mwTool-3 Screeners for Anxiety and Depression Among People With and Without HIV.

The burden of depression and anxiety disorders is high in sub-Saharan Africa, especially for people with HIV (PWH). The Patient Health Questionnaire-4 (PHQ-4) and Electronic Mental Wellness Tool-3 (E-mwTool-3) are ultra-brief screening tools for these disorders. We compared the performance of PHQ-4 and E-mwTool-3 for screening MINI-International Neuropsychiatric Interview diagnoses of depression and anxiety among a sample of individuals with and without HIV in two primary care clinics and one general hospital in Maputo City, Mozambique. Areas-under-the-curve (AUC) were calculated along with sensitivities and specificities at a range of cutoffs. For PWH, at a sum score cutoff of ≥ 1, sensitivities were strong: PHQ-4:Depression = 0.843; PHQ-4:Anxiety = 0.786; E-mwTool-3:Depression = 0.843; E-mwTool-3:Anxiety = 0.929. E-mwTool-3 performance was comparable to PHQ-4 among people with and without HIV.

Acute Rheumatic Fever and Rheumatic Heart Disease: Highlighting the Role of Group A Streptococcus in the Global Burden of Cardiovascular Disease.

Group A Streptococcus (GAS) causes superficial and invasive infections and immune mediated post-infectious sequalae (including acute rheumatic fever/rheumatic heart disease). Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are important determinants of global cardiovascular morbidity and mortality. ARF is a multiorgan inflammatory disease that is triggered by GAS infection that activates the innate immune system. In susceptible hosts the response against GAS elicits autoimmune reactions targeting the heart, joints, brain, skin, and subcutaneous tissue. Repeated episodes of ARF-undetected, subclinical, or diagnosed-may progressively lead to RHD, unless prevented by periodic administration of penicillin. The recently modified Duckett Jones criteria with stratification by population risk remains relevant for the diagnosis of ARF and includes subclinical carditis detected by echocardiography as a major criterion. Chronic RHD is defined by valve regurgitation and/or stenosis that presents with complications such as arrhythmias, systemic embolism, infective endocarditis, pulmonary hypertension, heart failure, and death. RHD predominantly affects children, adolescents, and young adults in LMICs. National programs with compulsory notification of ARF/RHD are needed to highlight the role of GAS in the global burden of cardiovascular disease and to allow prioritisation of these diseases aimed at reducing health inequalities and to achieve universal health coverage.

Pulmonary Hypertension in Children across Africa: The Silent Threat.

Pulmonary hypertension (PH) is a complex puzzle in Africa, especially among children who present with a cocktail of issues including recurrent pulmonary infections, unoperated congenital heart disease, and advanced rheumatic heart disease. Sickle cell anemia and neonatal complications of transiting from fetal circulation also contribute to the burden of pulmonary hypertension. Mortality from pulmonary arterial hypertension (PAH) remains high in Africa (18-21%), claiming sufferers in the first 6 months after diagnosis. Unfortunately, PH remains underreported in sub-Saharan Africa since many centers lack the capacity to diagnose and confirm it by the recommended gold standard, right heart catheterization. The unresolved burden of unoperated congenital heart lesions and rheumatic heart disease, among other preventable causes, stand out as major causes of PH in African children. This paper highlights pediatric PAH as a result of major gaps in care and illustrates the need for its prevention as well as for the promotion of research into the most important drivers, to prevent premature mortality in the continent.