Background Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10–24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA. Aims To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania. Method In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes. Results Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context. Conclusions Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.
BackgroundAdolescence is a critical time of development and nutritional status in adolescence influences both current and future adult health outcomes. However, data on adolescent nutritional status is limited in low-resource settings. Mid-upper arm circumference (MUAC) has the potential to offer a simple, low-resource alternative or supplement to body mass index (BMI) in assessing nutrition in adolescent populations.MethodsThis is secondary data analysis, from a cross-sectional pilot study, which analyses anthropometric data from a sample of young adolescents attending their last year of primary school in Pwani Region and Dar es Salaam Region, Tanzania (n = 154; 92 girls & 62 boys; mean age 13.2 years).ResultsThe majority of adolescents (75%) were of normal nutritional status defined by BMI. Significantly more males were stunted than females, while significantly more females were overweight than males. Among those identified as outside the normal nutrition ranges, there was inconsistency between MUAC and BMI cut-offs. Bivariate analyses indicate that BMI and MUAC show a positive correlation for both female and male participants, and the relationship between BMI and MUAC was more strongly correlated among adolescent females.ConclusionsFurther studies are needed with more nutritionally and demographically diverse populations to better understand the nutritional status of adolescents and the practical contribution of MUAC cut-offs to measure adolescent nutrition.
Background Chronic psychotic disorders (CPDs) occur worldwide and cause significant burden. Poor medication adherence is pervasive, but has not been well studied in sub-Saharan Africa. Aims This cross-sectional survey of 100 poorly adherent Tanzanian patients with CPD characterised clinical features associated with poor adherence. Method Descriptive statistics characterised demographic and clinical variables, including barriers to adherence, adherence behaviours and attitudes, and psychiatric symptoms. Measures included the Tablets Routine Questionnaire, Drug Attitudes Inventory, the Brief Psychiatric Rating Scale, the Clinical Global Impressions scale, the Alcohol Use Disorders Identification Test and Alcohol, Smoking and Substance Involvement Screening Test. The relationship between adherence and other clinical variables was evaluated. Results Mean age was 35.7 years (s.d. 8.8), 61% were male and 80% had schizophrenia, with a mean age at onset of 22.4 (s.d. 7.6) years. Mean proportion of missed CPD medication was 64%. One in ten had alcohol dependence. Most individuals had multiple adherence barriers. Most clinical variables were not significantly associated with the Tablets Routine Questionnaire; however, in-patients with CPD were more likely to have worse adherence (P ≤ 0.01), as were individuals with worse medication attitudes (Drug Attitudes Inventory, P < 0.01), higher CPD symptom severity levels (Brief Psychiatric Rating Scale, P < 0.001) and higher-risk use of alcohol (Alcohol Use Disorders Identification Test, P < 0.001). Conclusions Poorly adherent patients had multiple barriers to adherence, including poor attitudes toward medication and treatment, high illness acuity and substance use comorbidity. Treatments need to address adherence barriers, and consider family supports and challenges from an intergenerational perspective.
Background: The burden of chronic psychotic disorders (CPDs) in sub-Saharan Africa (SSA) is significant. Poorly medically adherent patients are more likely to have worse outcomes and require more resources. However, factors impacting effective treatment of CPD in this population are unclear.Aim: Examine the relationship between alcohol use and disease management and compare alcohol risk stratification between the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in poorly medication adherent Tanzanians with CPD.Setting: Muhimbili National Hospital and ambulatory clinics in Dar es Salaam, Tanzania.Methods: 100 Tanzanians with CPDs and suboptimal medication adherence were dichotomized into low and moderate-to-high risk alcohol use based on AUDIT scores and compared regarding medication attitudes, adherence and psychiatric symptoms. Patients completed the ASSIST for comparison to AUDIT risk stratification.Results: Moderate-to-high risk alcohol users had worse medication attitudes (p 0.01), medication adherence (previous week, p = 0.01; previous month, p 0.001), and psychiatric symptoms (p = 0.03). They were younger, predominately male and more likely to have a family history of alcohol abuse. A logistic regression analysis found age, gender and family history of abuse as significant predictors of hazardous alcohol use (p = 0.02, 0.02, 0.01, respectively). Risk stratification between AUDIT and ASSIST aligned in 85% of participants.Conclusion: Alcohol use is an important consideration in treating poorly adherent Tanzanians with CPD. The ASSIST was comparable to the AUDIT in stratifying risky alcohol use with the additional benefit of screening for other substances.
Chronic psychotic disorders (CPDs) occur worldwide and cause significant burden including reduced quality of life and functional impairment. Care for CPD includes psychosocial and pharmacologic interventions (i.e. antipsychotic drugs) and ongoing health monitoring. This is challenging in resource-limited settings where staff are sparse and/or undertrained. Importantly, mental health human resource needs predict continued deficits compounded by increasing disease burden. A U.S. team recently developed and tested a CPD treatment approach that combines the use of long-acting antipsychotic medication (LAI) with a brief and practical customized adherence enhancement behavioral intervention (CAE-L). This report describes the methodological details of an ongoing, first-ever refinement and preliminary testing of CAE-L in poorly adherent patients with CPD in Tanzania. Additional innovative elements include: 1) a manualized curriculum that targets specific barriers and facilitators to medication adherence in Tanzanians with CPD, and 2) targeting known, high-risk individuals with CPD (those who miss ≥20% of prescribed antipsychotic medication). The study procedures are intended to pave the way for implementing a large-scale intervention trial for CPD in the Tanzanian setting. An important component of this project is capacity building to help form the next generation of care providers. Visit exchanges modeled on a successful NIH-funded Medical Education Partnership Initiative (MEPI) template will also use the U.S. and Tanzanian teams to share expertise, problem-solve, and plan iterative refinements of project deliverables. Taken together, this project has potential to advance the care of people with CPD in Tanzania and has high generalizability to Sub-Saharan Africa and other lower-resource settings.
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