BACKGROUND:Electronic health record (EHR) outcome ascertainment may introduce challenges if measurements are inconsistently or infrequently captured. OBJECTIVE:To evaluate the effects of the "Balance" intervention on EHR-derived secondary/exploratory outcomes and assess outcome frequency, timing, and variability. METHODS:Balance was a 2-arm, 12-month pragmatic randomized trial of a digital weight gain prevention intervention (N = 443). Cardiometabolic outcomes (eg, blood pressure, hemoglobin A1c, triglycerides, and total cholesterol) were extracted from the EHR and analyzed using linear mixed models. RESULTS:The intervention arm (n = 223) had lower systolic (-3.4 mm Hg, 95% confidence interval [CI]: -6.7 to -0.2) and diastolic blood pressure (-2.4 mm Hg, 95% CI: -4.3 to -0.6) at 6 months. Effects attenuated by 12 and 24 months. Other outcomes showed no significant differences. Blood pressure was measured 11.9 times per participant, 4.2 months apart. Other outcomes were measured 12 to 17.4 months apart. Variability averaged 1.0 standardized units. CONCLUSIONS:Trials using EHR data should account for data variability and sparsity in trial planning, implementation, and analysis.

Adolescents in lower-resource countries face a high burden of eye health problems. This study in Tanzania aimed to 1) estimate the prevalence of distance vision impairment among young adolescents, 2) describe academic performance by distance visual acuity status, and 3) examine facilitators and barriers to school-facilitated vision screenings and receiving eye care. Participants (primary school students in Standard 7) in the intervention arm of the Vijana Tambua Afya, translated as 'Youth Health Check', clinical trial (n = 509) attended school-facilitated, clinic-based health check-ups that included distance vision screening (presenting acuity). Data included adolescent surveys, medical record extraction, and Primary School Leaving Examination scores. Semi-structured interviews with parents and focus groups with school and clinic staff were conducted. Analyses included descriptive statistics and qualitative thematic analysis. Overall, based on their worse eye, 6.9% of students had mildly reduced vision and 4.3% had impaired vision on screening. 71.9% of students with mildly reduced or impaired vision scored a C or lower on the PSLE compared to 59.9% with normal vision. Less than 10% of students referred received follow-up care. School-based vision screenings were deemed largely successful by clinicians and teachers, but there were challenges related to follow-up care including referral linkages, households' financial barriers to vision care, and insufficient parental knowledge on the importance of timely pediatric eye care. Given the prevalence of visual impairment and its potential link to academic performance, governments should consider requiring school-based distance vision screenings. Further research on screening implementation strategies and strengthening follow-up care is needed.

Oral diseases are among the most common non-communicable diseases and adolescence represents an important time for intervention. The epidemiology of oral health is not well understood in low-resource settings. This study estimates the prevalence and correlates of oral pain and quality of life among adolescents in Tanzania. Baseline, cross-sectional data from a large randomized controlled trial of 1095 adolescents were analyzed. The primary outcome was self-reported oral pain in the past month. Regression models were conducted to assess the relationships between the prevalence of oral pain and sociodemographic characteristics and oral-health related behaviors. A chi-square test was used to explore associations between the experience of oral pain and quality of life measures from the EQ-5D-5 L instrument. The prevalence of oral pain was 13% (95% CI: 11.0, 15.9). No associations were observed between oral pain and most sociodemographic or behavioral factors. One association was found between perceived competence and reported oral pain in both the unadjusted (Prevalence ratio (PR): 1.20 95% CI: 1.04, 1.40) and adjusted models, (PR: 1.26, 95% CI: 1.07, 1.50). Analyses also showed associations with imprecise estimates between oral pain and district, maternal occupation, paternal occupation, and household hunger. A positive association was observed between reported oral pain and anxiety/depression and pain/discomfort measured on the EQ-5D-5 L quality of life instrument. This study contributes to the growing body of literature on the prevalence of oral pain among in-school adolescents. Findings support the need for population-based interventions to support good oral health among all adolescents.

Adolescents are disproportionately vulnerable to unintended pregnancies and delayed HIV treatment in low-resource settings. Tanzanian policies support adolescent access to contraception and HIV testing and counseling (HTC) without parental consent if needed; however, parent/guardian disapproval could lead to unmet service needs. This qualitative study explores factors that influence caregivers' attitudes towards adolescents accessing these services independently. VITAA is a cluster RCT testing a school-clinic partnership to provide adolescent health check-ups in Tanzania. Semi-structured interviews (n = 42) were conducted with a purposeful sample of parents/guardians (74% women) of VITAA participants. The extended theory of planned behavior for parent-for-child health behaviors informed thematic analysis. Many parents/guardians expressed hesitancy about adolescents accessing services independently. Contraception concerns included community norms about adolescents being too young for sex and fears that access to contraception decreases parents' behavioral control over adolescents. Conversely, many caregivers endorsed positive attitudes towards HTC, but they had worries about adolescents receiving positive test results alone. Parent/guardian attitudes shape adolescents' health-seeking behaviors and Tanzanian parents and guardians are hesitant about adolescents' independent service use for diverse reasons, including its potential relationship with sexual debut. Tailored communication interventions could encourage caregivers' support for adolescent service access to meet community goals for healthy adolescents.Trial registration: ClinicalTrials.gov identifier: NCT05306938..

As low-resource settings move to address the treatment and social service gap for people living with schizophrenia (PLWS), person-centered and recovery-oriented interventions should monitor impacts on empowerment. This study explores empowerment and associated factors among PLWS in Tanzania. This study uses endline data from the Culturally Adapted Family Psychoeducation for Adults with Psychotic Disorders in Tanzania (KUPAA) pilot trial. Participants included 66 dyads of PLWS and caregivers recruited from two tertiary-level hospitals. The main outcome variable of interest was empowerment (Rogers 28-item Empowerment Scale), and the main exposure variable was Participation in Society (Domain 6 of the WHO Disability Assessment Schedule, WHODAS 2.0). Key psychosocial correlates of interest included hopefulness, general self-efficacy, internalized stigma, and family functioning. Bivariate and multivariable analyses were used to explore variable relationships. There were 21 women and 40 men with a mean age of 32 years. Bivariate analyses revealed greater participation in society (p < 0.0003) was correlated with greater empowerment, higher hopefulness (p < 0.0001) and higher self-efficacy (p < 0.0001). Lower empowerment was correlated with higher self-stigma (p < 0.0001) and worse family functioning (p < .001). Multivariable models indicated more participation in society was associated with higher empowerment, but when hope, self-efficacy, internalized stigma, and/or family functioning were added to the models, those factors were more strongly correlated with empowerment than participation in society. Empowerment is increasingly being recognized as an important outcome of psychosocial interventions. Understanding empowerment and its possible effects on recovery-centered outcomes is important when thinking of future interventions for PLWS in low-resource settings. Future recovery-oriented interventions and research should both consider including empowerment measurement among PLWS and incorporate their lived experiences in psychosocial treatment programming.

Background. Despite a high burden of sepsis in Sub-Saharan Africa, clinical data for adolescent and adult sepsis in this setting are limited. We sought to describe clinical characteristics, management, and outcomes in adolescents and adults with sepsis in northern Tanzania. We also assessed for clinical associations with in-hospital mortality. Methods. We conducted a prospective observational cohort study at Kilimanjaro Christian Medical Centre in Moshi, Tanzania, 2019-2020. Data were collected on demographics, clinical characteristics, and management primarily from hours 0-6 after arrival at the emergency department. We calculated bivariable risk ratios (RRs) for associations between demographic and clinical factors and in-hospital death. A multivariable-adjusted analysis was performed for associations between antimicrobial and intravenous fluid administration and in-hospital death. Results. Of 86 participants with sepsis, 25 (29.1%) died in the hospital. Baseline characteristics associated with in-hospital mortality included inability to drink unassisted (RR, 3.15; 95% CI, 1.58-6.30), altered mentation (RR, 3.94; 95% CI, 2.12-7.33), quick Sequential Organ Failure Assessment (qSOFA) score >= 2 (RR, 2.86; 95% CI, 1.42-5.72), and Universal Vital Assessment score >= 5 (RR, 6.33; 95% CI, 2.36-17.02). Twenty-nine (33.7%) received an antimicrobial by hour 6. HIV antibody testing was performed for 4 (4.7%) participants by hour 6. On multivariable analysis, neither antimicrobial administration nor intravenous fluids >1L by hour 6 was associated with in-hospital mortality. Conclusions. Sepsis at our center in northern Tanzania carried a high risk of in-hospital mortality. Further research is needed to establish the highest-yield interventions suited to the unique characteristics of sepsis in Sub-Saharan Africa.

OBJECTIVES:The majority of childhood hearing loss is from preventable ear infections, and rural regions, such as Alaska, home to Alaska Native peoples, are disproportionately affected. The underlying mechanisms for otitis media-related hearing loss are not yet well understood; however, if left untreated, hearing loss has well-known lifelong consequences. A better understanding of the link between ear infections and genetic (Carnitine Palmitoyltransferase 1A [ CPT1A ] Arctic variant), environmental, and nutritional factors for rural Alaska Native children is necessary to establish effective interventions for early detection and management of otitis media-related hearing loss. DESIGN:This prospective cohort study enrolled Alaska Native children 1 to 4 years of age across 16 communities in Northwest Alaska during the Coronavirus disease pandemic (2021 to 2022). Delays in enrollment required study design changes to maximize recruitment. Participants received an ear and hearing assessment upon enrollment, and caregivers completed questionnaires assessing nutritional and environmental factors. A comprehensive chart review from birth to 6 months following enrollment was conducted to capture ear and hearing health history. Analysis used modified Poisson regression to assess relationships between household environmental, nutritional, and genetic factors and ear- and hearing-related outcomes. An exploratory subgroup analysis was performed to evaluate potential modification of associations by CPT1A status. RESULTS:A total of 245 children were enrolled in the study, and 236 were included in the final analytic sample. The mean age was 3 years (interquartile range: 2 to 4), and 49.6% of enrolled children were female. The prevalence of otitis media-related hearing loss was 34.8%, and 51.3% had visits for otitis media in the first year of life. The majority (72.5%) of enrolled children were fed breastmilk, 52.3% were homozygous for CPT1A Arctic variant, 22.6% lacked access to indoor plumbing, 5.9% had exposure to wood burning smoke, and 59% had at least one person in the home who smoked. There was some evidence that children who were homozygous for CPT1A had a higher prevalence (21%) of otitis media-related hearing loss (prevalence ratio [PR] = 1.21, 95% confidence interval [CI]: 0.78 to 1.86) compared with those not homozygous for CPT1A . Children who had any breastmilk had a 43% lower relative probability (PR = 0.59, 95% CI: 0.39 to 0.90) of otitis media-related hearing loss. There was little evidence of associations between otitis media-related hearing loss and indoor plumbing (PR = 0.92, 95% CI: 0.62 to 1.36) or the number of people living in the home (PR = 1.01, 0.92 to 1.11). There was a negative association between otitis media-related hearing loss and the presence of anyone who smoked (PR = 0.77, 95% CI: 0.58 to 1.01), the number of people who smoked (PR = 0.83, 95% CI: 0.75 to 0.93), and the ratio of persons who smoke to total adults in the home (PR = 0.64, 95% CI: 0.44 to 0.93). CONCLUSIONS:This study attempted to characterize environmental, nutritional, and genetic factors in rural Alaska Native peoples of Northwest Alaska; however, results are inconclusive, and careful consideration for how the Coronavirus disease pandemic may have affected healthcare behavior and potentially introduced bias in the sample is prudent. There continues to be a need for prospective research to characterize factors influencing otitis media-related hearing loss so that children at the highest risk can be identified early and receive preventive care.

OBJECTIVE:To characterize the relationship between risk factors and otitis media in a rural Alaska Native population ages 1 to 4 yr. DESIGN:This prospective cohort study was a substudy to an analysis of hearing loss determinants in Alaska Native children. This study enrolled Alaska Native children ages 1 to 4 yr from 16 communities in the Bering Strait region of northwest Alaska between October 2021 and August 2022. The aim was to characterize the relationship between environmental, genetic, and dietary risk factors and otitis media in this population, including exposure to household running water, smoke from a wood-burning stove, cigarette smoke, number of people in the household, breastfeeding, and homozygosity for the carnitine palmitoyltransferase 1 (CPT1A) arctic variant, a genetic factor in arctic populations associated with increased risk for respiratory infections. At enrollment and 6-mo follow-up, a parental questionnaire was used to assess environmental risk factors, and ear and hearing status was evaluated through audiometric screening, including tympanometry and otoscopy. A comprehensive chart review was performed to extract data from health care visits containing ICD-10 codes for otitis media. Descriptive statistics were used to summarize demographic data, and logistic regression models were used to identify associations between risk factors and otitis media incidence. RESULTS:There were 245 children enrolled in the study, and the final analytic sample consisted of 236 Alaska Native children ages 1 to 4 yr. The median age was 3.0 yr, and females made up 50% of the sample. Regarding heritage, 63% were Iñupiaq, 29% were Yupik, and 22% were St. Lawrence Island/Siberian Yupik. Geographically, 73% were from villages in the Norton Sound catchment area, and the remaining 27% were from the regional center of Nome. Of the children in the study, 53% were homozygous for the CPT1A arctic variant gene. Among the key risk factors identified, 72% of children had a history of being breastfed, 23% lacked household running water, and 6% were exposed to wood smoke. The mean number of people in the household was 6.2, and the mean number of people who currently smoked tobacco in the household was 1.1. The mean ratio of people who smoked tobacco to adults in the household was 0.4. During the 6-mo study period, 53% of children were diagnosed with one or more episodes of otitis media. CPT1A arctic variant homozygosity showed a trend toward a positive association with 6-mo cumulative odds of otitis media and moderating the effect of other risk factors on the odds of otitis media incidence. CONCLUSION:Otitis media is common in this population of rural Alaska Native children. CPT1A arctic variant homozygosity increased both the odds of otitis media incidence and the effect of all studied risk factors on otitis media incidence. Results should be interpreted cautiously, as the coronavirus disease 2019 pandemic negatively affected enrollment and likely affected the incidence of otitis media. Further prospective research is needed to better understand these relationships.

PURPOSE:KUPAA is a culturally adapted version of Family Psychoeducation (FPE) that has shown to be beneficial to people living with schizophrenia-spectrum disorders (PLWS), who may experience limitations across multiple functional domains. Family Psychoeducation can lead to improvement in functional outcomes that align with recovery goals; however, the mechanisms of action are unclear. The current study objective is to identify mechanisms by which the KUPAA intervention reduces disability and improves quality of life among care-seeking PLWS in Tanzania. METHODS:This clinical trial was conducted at Muhimbili National Hospital and Mbeya Zonal Referral Hospital and included a total of 66 dyads composed of PLWS ages 18-50 years and their caregivers. A causal mediation framework employing the g-formula was used to estimate the indirect effects of the KUPAA intervention on disability and quality of life, through the mediated pathways of hopefulness, self-stigma and generalized self-efficacy. RESULT:A greater decrease in mean disability score and increase in quality of life score was observed among KUPAA participants, compared to controls. We found that generalized self-efficacy mediates 33% of the effect of KUPAA on quality of life and generalized self-efficacy and hope each mediate 36% of the effect of KUPAA on disability. CONCLUSION:Results provide preliminary support for the hypothesis that KUPAA can reduce disability and improve quality life by reducing stigma, increasing hope and strengthening self-efficacy. Future psychosocial programs for PLWS should consider tailoring their interventions to focus on reducing stigma, increasing hope and fostering self-efficacy.

BACKGROUND:There is a treatment gap for those living with severe mental illnesses in low- and middle-income countries, yet not enough is known about those who are currently accessing clinical services. A better understanding of potentially modifiable factors associated with functioning and quality of life will help inform policies and programming.AIMS:To describe the functioning and quality of life for a psychiatric treatment-engaged population living with psychotic disorders in two urban areas of Tanzania, and to explore their respective correlates.METHODS:This study analyzed cross-sectional data from 66 individuals enrolled in the Kuwezeshana Kupata Uzima (KUPAA) pilot clinical trial who had a diagnosis of schizophrenia or schizoaffective disorder, recent relapse, and who were receiving outpatient treatment. Baseline functioning (WHO Disability Assessment Schedule 2.0) and quality of life (WHO Quality of Life BREF scale) were measured. Univariable and multivariable regression analyses were conducted to determine correlates of functioning and quality of life.RESULTS:Adjusted analyses indicated that higher disability was associated with higher food insecurity, more symptomatology, more self-stigma, less instrumental support, less hope, lower self-efficacy, and/or lower levels of family functioning. Higher quality of life was associated with higher levels of self-efficacy, more hopefulness, more instrumental support, less self-stigma, and better family functioning.CONCLUSIONS:Identification of factors associated with disability and quality of life can help clinicians and policymakers, as well as consumers of mental health services, to better co-design and target psychosocial interventions to optimize their impact in low-resource settings.TRIAL REGISTRATION:Trial registration: ClinicalTrials.gov # NCT04013932, July 10, 2019.

Rationale: Data on risk factors for chronic hypoxemia in low- and middle-income countries are lacking. Objectives: We aimed to quantify the association between potential risk factors and chronic hypoxemia among adults hospitalized in Kenya. Methods: A hospital-based, case-control study was conducted at Moi Teaching and Referral Hospital in Eldoret, Kenya. Adult inpatients were screened on admission and enrolled in a 1:2 case-to-control ratio. Cases were patients with chronic hypoxemia, defined as resting oxygen saturation as measured by pulse oximetry (SpO2) ⩽ 88% on admission and either 1-month postdischarge SpO2 ⩽ 88% or, if they died before follow-up, documented SpO2 ⩽ 88% in the 6 months before enrollment. Control subjects were randomly selected, stratified by sex, among nonhypoxemic inpatients. Data were collected using questionnaires and structured chart review. Regression was used to assess the associations between chronic hypoxemia and age, sex, smoking status, biomass fuel use, elevation, and self-reported history of tuberculosis and human immunodeficiency virus diagnosis. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Results: We enrolled 108 chronically hypoxemic cases and 240 nonhypoxemic control subjects into our Chronic Hypoxemia among Kenyan Adults (CHAKA) cohort. In multivariable analysis, compared with control subjects, chronically hypoxemic cases had significantly higher odds of older age (OR, 1.2 per 5-year increase [95% CI, 1.1-1.3]), female sex (OR, 3.6 [95% CI, 1.8-7.2]), current or former tobacco use (OR, 4.7 [95% CI, 2.3-9.6]), and prior tuberculosis (OR, 11.8 [95% CI, 4.7-29.6]) but no increase in the odds of human immunodeficiency virus diagnosis and biomass fuel use. Conclusions: These findings highlight the potential impact of prior tuberculosis on chronic lung disease in Kenya and the need for further studies on posttuberculosis lung disease.

BackgroundThe prevalence of obesity and its associated comorbidities continue to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care. ObjectiveThis study aims to evaluate the effectiveness of Balance, a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within federally qualified community health centers. MethodsBalance was a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a BMI of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of federally qualified community health centers in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and documented in the electronic health record. We compared the percentage of ≤3% weight gain in each arm at 24 months after randomization—our primary outcome—using individual empirical best linear unbiased predictors from the linear mixed-effects model. We used individual empirical best linear unbiased predictors from participants with at least 1 electronic health record weight documented within a 6-month window centered on the 24-month time point. ResultsWe randomized 443 participants, of which 223 (50.3%) participants were allocated to the intervention arm. At baseline, participants had a mean BMI of 32.6 kg/m2. Most participants were Latino or Hispanic (n=200, 45.1%) or non–Latino or Hispanic White (n=115, 26%). In total, 53% (n=235) of participants had at least 1 visit with weight measured in the primary time window. The intervention group had a higher proportion with ≤3% weight gain at 6 months (risk ratio=1.12, 95% CI 0.94-1.28; risk difference=9.5, 95% CI –4.5 to 16.4 percentage points). This difference attenuated to the null by 24 months (risk ratio=1.00, 95% CI 0.82-1.20; risk difference=0.2, 95% CI –12.1 to 11.0 percentage points). ConclusionsIn adults with overweight or obesity receiving primary care at a community health center, we did not find long-term evidence to support the dissemination of a digital health intervention for weight gain prevention. Trial RegistrationClinicalTrials.gov NCT03003403; https://clinicaltrials.gov/study/NCT03003403 International Registered Report Identifier (IRRID)RR2-10.1186/s12889-019-6926-7

Abstract Background We describe antibacterial use in light of microbiology data and treatment guidelines for common febrile syndromes in Moshi, Tanzania. Methods We compared data from 2 hospital-based prospective cohort studies, cohort 1 (2011–2014) and cohort 2 (2016–2019), that enrolled febrile children and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures. Participants with bloodstream infection (BSI) were categorized as receiving effective or ineffective therapy based upon antimicrobial susceptibility interpretations. Antibacterials prescribed for treatment of pneumonia, urinary tract infection (UTI), or presumed sepsis were compared with World Health Organization and Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe antibacterial use. Results Among participants, 430 of 1043 (41.2%) and 501 of 1132 (44.3%) reported antibacterial use prior to admission in cohorts 1 and 2, respectively. During admission, 930 of 1043 (89.2%) received antibacterials in cohort 1 and 1060 of 1132 (93.6%) in cohort 2. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between cohorts (P ≤ .002 for each). BSI was detected in 38 (3.6%) participants in cohort 1 and 47 (4.2%) in cohort 2. Of 85 participants with BSI, 81 (95.3%) had complete data and 52 (64.2%) were prescribed effective antibacterials. Guideline-consistent therapy in cohort 1 and cohort 2 was as follows: pneumonia, 87.4% and 56.8%; UTI, 87.6% and 69.0%; sepsis, 84.4% and 61.2% (P ≤ .001 for each). Conclusions Receipt of antibacterials for febrile illness was common. While guideline-consistent prescribing increased over time, more than one-third of participants with BSI received ineffective antibacterials.

Objectives: Childhood hearing loss has well-known lifelong consequences. Certain rural populations are at higher risk for infection-related hearing loss. For Alaska Native children, historical data on hearing loss prevalence suggest a higher burden of infection-related hearing loss, but updated prevalence data are urgently needed in this high-risk population. Design: Hearing data were collected as part of two school-based cluster-randomized trials in 15 communities in rural northwest Alaska over two academic years (2017–2019). All enrolled children from preschool to 12th grade were eligible. Pure-tone thresholds were obtained using standard audiometry and conditioned play when indicated. The analysis included the first available audiometric assessment for each child (n = 1634 participants, 3 to 21 years), except for the high-frequency analysis, which was limited to year 2 when higher frequencies were collected. Multiple imputation was used to quantify the prevalence of hearing loss in younger children, where missing data were more frequent due to the need for behavioral responses. Hearing loss in either ear was evaluated using both the former World Health Organization (WHO) definition (pure-tone average [PTA] > 25 dB) and the new WHO definition (PTA ≥ 20 dB), which was published after the study. Analyses with the new definition were limited to children 7 years and older due to incomplete data obtained on younger children at lower thresholds. Results: The overall prevalence of hearing loss (PTA > 25 dB; 0.5, 1, 2, 4 kHz) was 10.5% (95% confidence interval [CI], 8.9 to 12.1). Hearing loss was predominately mild (PTA >25 to 40 dB; 8.9%, 95% CI, 7.4 to 10.5). The prevalence of unilateral hearing loss was 7.7% (95% CI, 6.3 to 9.0). Conductive hearing loss (air-bone gap of ≥ 10 dB) was the most common hearing loss type (9.1%, 95% CI, 7.6 to 10.7). Stratified by age, hearing loss (PTA >25 dB) was more common in children 3 to 6 years (14.9%, 95% CI, 11.4 to 18.5) compared to children 7 years and older (8.7%, 95% CI, 7.1 to 10.4). In children 7 years and older, the new WHO definition increased the prevalence of hearing loss to 23.4% (95% CI, 21.0 to 25.8) compared to the former definition (8.7%, 95% CI, 7.1 to 10.4). Middle ear disease prevalence was 17.6% (95% CI, 15.7 to 19.4) and was higher in younger children (23.6%, 95% CI, 19.7 to 27.6) compared to older children (15.2%, 95% CI, 13.2 to 17.3). High-frequency hearing loss (4, 6, 8kHz) was present in 20.5% (95% CI, 18.4 to 22.7 [PTA >25 dB]) of all children and 22.8% (95% CI, 20.3 to 25.3 [PTA >25 dB]) and 29.7% (95% CI, 27.0 to 32.4 [PTA ≥ 20 dB]) of children 7 years and older (limited to year 2). Conclusions: This analysis represents the first prevalence study on childhood hearing loss in Alaska in over 60 years and is the largest cohort with hearing data ever collected in rural Alaska. Our results highlight that hearing loss continues to be common in rural Alaska Native children, with middle ear disease more prevalent in younger children and high-frequency hearing loss more prevalent with increasing age. Prevention efforts may benefit from managing hearing loss type by age. Lastly, continued research is needed on the impact of the new WHO definition of hearing loss on field studies.

Objectives: Determine the prevalence of airway disease (e.g., asthma, airflow obstruction, and eosinophilic airway inflammation) in Kenya, as well as related correlates of airway disease and health-related quality of life. Methods: A three-stage, cluster-randomized cross-sectional study in Uasin Gishu County, Kenya was conducted. Individuals 12 years and older completed questionnaires (including St. George's Respiratory Questionnaire for COPD, SGRQ-C), spirometry, and fractional exhaled nitric oxide (FeNO) testing. Prevalence ratios with 95% confidence intervals (CIs) were calculated. Multivariable models were used to assess correlates of airflow obstruction and high FeNO. Results: Three hundred ninety-two participants completed questionnaires, 369 completed FeNO testing, and 305 completed spirometry. Mean age was 37.5 years; 64% were women. The prevalence of asthma, airflow obstruction on spirometry, and eosinophilic airway inflammation was 21.7%, 12.3% and 15.7% respectively in the population. Women had significantly higher SGRQ-C scores compared to men (15.0 vs. 7.7). Wheezing or whistling in the last year and SGRQ-C scores were strongly associated with FeNO levels >50 ppb after adjusting for age, gender, BMI, and tobacco use. Conclusion: Airway disease is a significant health problem in Kenya affecting a young population who lack a significant tobacco use history.

While access to basic emergency obstetric and newborn care is necessary to reduce maternal and neonatal morbidity in low- and middle-income countries, data on the timeliness and quality of care at lower-level facilities is limited. This study examines timeliness of labor and delivery interventions and maternal and neonatal health status following deliveries in Uganda. Women were recruited from 6 rural, private facilities in the greater Masaka area, Uganda on admission to the labor ward. Research assistants directly observed timeliness and quality of care from admission through discharge. Research assistants also abstracted medical chart information. All 6 facilities received training from LifeNet International on quality-of-care interventions for maternal and newborn health. 321 participants were directly observed during delivery, and 304 participants were followed at 28 days postpartum. Labor and delivery processes were overall timely and reflect international guidance on labor interventions. Maternal and neonatal health was good at discharge (90.6 What does this study add? Labor and delivery processes were largely timely at private facilities. However, characteristics associated with poor health on discharge are different than those associated with poor health one month postpartum and illustrate the complex factors influencing outcomes during this time.

OBJECTIVE:Global medical oxygen security is limited by knowledge gaps in hypoxaemia burden and oxygen access in low-income and middle-income countries. We examined the prevalence and phenotypic trajectories of hypoxaemia among hospitalised adults in Kenya, with a focus on chronic hypoxaemia.DESIGN:Single-centre, prospective cohort study.SETTING:National tertiary referral hospital in Eldoret, Kenya between September 2019 and April 2022.PARTICIPANTS:Adults (age ≥18 years) admitted to general medicine wards.PRIMARY AND SECONDARY OUTCOME MEASURES:Our primary outcome was proportion of patients who were hypoxaemic (oxygen saturation, SpO2 ≤88%) on admission. Secondary outcomes were proportion of patients with hypoxaemia on admission who had hypoxaemia resolution, hospital discharge, transfer, or death among those with unresolved hypoxaemia or chronic hypoxaemia. Patients remaining hypoxaemic for ≤3 days after admission were enrolled into an additional cohort to determine chronic hypoxaemia. Chronic hypoxaemia was defined as an SpO2 ≤ 88% at either 1-month post-discharge follow-up or, for patients who died prior to follow-up, a documented SpO2 ≤88% during a previous hospital discharge or outpatient visit within the last 6 months.RESULTS:We screened 4104 patients (48.5% female, mean age 49.4±19.4 years), of whom 23.8% were hypoxaemic on admission. Hypoxaemic patients were significantly older and more predominantly female than normoxaemic patients. Among those hypoxaemic on admission, 33.9% had resolution of their hypoxaemia as inpatients, 55.6% had unresolved hypoxaemia (31.0% died before hospital discharge, 13.3% were alive on discharge and 11.4% were transferred) and 10.4% were lost to follow-up. The prevalence of chronic hypoxaemia was 2.1% in the total screened population, representing 8.8% of patients who were hypoxaemic on admission. Chronic hypoxaemia was determined at 1-month post-discharge among 59/86 patients and based on prior documentation among 27/86 patients.CONCLUSION:Hypoxaemia is highly prevalent among adults admitted to a general medicine ward at a national referral hospital in Kenya. Nearly 1 in 11 patients who are hypoxaemic on admission are chronically hypoxaemic.

Objective: Childhood hearing loss has well-known, lifelong consequences. Infection-related hearing loss disproportionately affects underserved communities yet can be prevented with early identification and treatment. This study evaluates the utility of machine learning in automating tympanogram classifications of the middle ear to facilitate layperson-guided tympanometry in resource-constrained communities. Design: Diagnostic performance of a hybrid deep learning model for classifying narrow-band tympanometry tracings was evaluated. Using 10-fold cross-validation, a machine learning model was trained and evaluated on 4810 pairs of tympanometry tracings acquired by an audiologist and layperson. The model was trained to classify tracings into types A (normal), B (effusion or perforation), and C (retraction), with the audiologist interpretation serving as reference standard. Tympanometry data were collected from 1635 children from October 10, 2017, to March 28, 2019, from two previous cluster-randomized hearing screening trials (NCT03309553, NCT03662256). Participants were school-aged children from an underserved population in rural Alaska with a high prevalence of infection-related hearing loss. Two-level classification performance statistics were calculated by treating type A as pass and types B and C as refer. Results: For layperson-acquired data, the machine-learning model achieved a sensitivity of 95.2% (93.3, 97.1), specificity of 92.3% (91.5, 93.1), and area under curve of 0.968 (0.955, 0.978). The model’s sensitivity was greater than that of the tympanometer’s built-in classifier [79.2% (75.5, 82.8)] and a decision tree based on clinically recommended normative values [56.9% (52.4, 61.3)]. For audiologist-acquired data, the model achieved a higher AUC of 0.987 (0.980, 0.993), had an equivalent sensitivity of 95.2 (93.3, 97.1), and a higher specificity of 97.7 (97.3, 98.2). Conclusions: Machine learning can detect middle ear disease with comparable performance to an audiologist using tympanograms acquired either by an audiologist or a layperson. Automated classification enables the use of layperson-guided tympanometry in hearing screening programs in rural and underserved communities, where early detection of treatable pathology in children is crucial to prevent the lifelong adverse effects of childhood hearing loss.

BACKGROUND:Adolescents and young adults with HIV repeatedly demonstrate low rates of antiretroviral therapy (ART) adherence as well as low rates of viral suppression. Digital health interventions are a promising way to engage adolescents and young adults with HIV to support ART adherence. However, few digital health interventions have been developed and tested with adolescents and young adults in countries like South Africa, where the HIV burden among adolescents and young adults is greatest. Masakhane Siphucule Impilo Yethu (MASI; Xhosa for "Let's empower each other and improve our health") is a comprehensive ART adherence-supporting app for South African adolescents and young adults with HIV. It was culturally adapted using the HealthMpowerment platform.OBJECTIVE:The aim of this paper is to describe the protocol for a pilot randomized controlled trial examining the feasibility, acceptability, and preliminary efficacy of MASI on self-reported ART adherence and social support.METHODS:We will enroll 50 adolescents and young adults with HIV ages 15-21 years. Participants will be recruited from public ART clinics linked to a large government-funded teaching hospital in Cape Town, South Africa. Participants will be randomized 1:1 into either the intervention arm receiving a full version of MASI or the control arm receiving an information-only version of the app (n=25 per arm). Participants will be asked to engage with MASI daily for 6 months. All participants will complete baseline and follow-up assessments at 3 and 6 months.RESULTS:Study screening began in May 2022 and the first participant was enrolled on June 21, 2022. As of June 12, 2023, 81 participants have completed screeners, and 36 eligible participants have been enrolled in the pilot randomized controlled trial. Recruitment is anticipated to last through August 31, 2023, with study activities anticipated through February 29, 2024.CONCLUSIONS:There is an urgent need for innovative interventions to improve ART adherence among adolescents and young adults in settings like South Africa. If found to be feasible and acceptable, MASI could be implemented with adolescents and young adults with HIV in other parts of the country.TRIAL REGISTRATION:ClinicalTrials.gov NCT04661878; https://clinicaltrials.gov/ct2/show/study/NCT04661878.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/47137.

Objectives:Diagnostic accuracy was evaluated for various screening tools, including mobile health (mHealth) pure-tone screening, tympanometry, distortion product otoacoustic emissions (DPOAE), and inclusion of high frequencies to determine the most accurate screening protocol for identifying children with hearing loss in rural Alaska where the prevalence of middle ear disease is high. Design:Hearing screening data were collected as part of two cluster randomized trials conducted in 15 communities in rural northwest Alaska. All children enrolled in school from preschool to 12th grade were eligible. Analysis was limited to data collected 2018 to 2019 (n = 1449), when both trials were running and measurement of high frequencies were included in the protocols. Analyses included estimates of diagnostic accuracy for each screening tool, as well as exploring performance by age and grade. Multiple imputation was used to assess diagnostic accuracy in younger children, where missing data were more prevalent due to requirements for conditioned responses. The audiometric reference standard included otoscopy, tympanometry, and high frequencies to ensure detection of infection-related and noise-induced hearing loss. Results:Both the mHealth pure-tone screen and DPOAE screen performed better when tympanometry was added to the protocol (increase in sensitivity of 19.9%, 95% Confidence Interval (CI): 15.9 to 24.1 for mHealth screen, 17.9%, 95% CI: 14.0 to 21.8 for high-frequency mHealth screen, and 10.4%, 95% CI: 7.5 to 13.9 for DPOAE). The addition of 6 kHz to the mHealth pure-tone screen provided an 8.7 percentage point improvement in sensitivity (95% CI: 6.5 to 11.3). Completeness of data for both the reference standard and the mHealth screening tool differed substantially by age, due to difficulty with behavioral testing in young children. By age 7, children were able to complete behavioral testing, and data indicated that high-frequency mHealth pure-tone screen with tympanometry was the superior tool for children 7 years and older. For children 3 to 6 years of age, DPOAE plus tympanometry performed the best, both for complete data and multiply imputed data, which better approximates accuracy for children with missing data. Conclusions:This study directly evaluated pure-tone, DPOAE, and tympanometry tools as part of school hearing screening in rural Alaskan children (3 to 18+ years). Results from this study indicate that tympanometry is a key component in the hearing screening protocol, particularly in environments with higher prevalence of infection-related hearing loss. DPOAE is the preferred hearing screening tool when evaluating children younger than 7 years of age (below 2nd grade in the United States) due to the frequency of missing data with behavioral testing in this age group. For children 7 years and older, the addition of high frequencies to pure-tone screening increased the accuracy of screening, likely due to improved identification of hearing loss from noise exposure. The lack of a consistent reference standard in the literature makes comparing across studies challenging. In our study with a reference standard inclusive of otoscopy, tympanometry, and high frequencies, less than ideal sensitivities were found even for the most sensitive screening protocols, suggesting more investigation is necessary to ensure screening programs are appropriately identifying noise- and infection-related hearing loss in rural, low-resource settings.