Clea Sarnquist, DrPH, MPH

All Publications

• Reduced Risk of SARS-CoV-2 Infection Among Household Contacts with Recent Vaccination and Past COVID-19 Infection: Results from Two Multi-Site Case-Ascertained Household Transmission Studies. American journal of epidemiology Rolfes, M. A., Talbot, H. K., Morrissey, K. G., Stockwell, M. S., Maldonado, Y., McLean, H. Q., Lutrick, K., Bowman, N. M., Rao, S., Izurieta, H. S., Zhu, Y., Chappell, J., Battan-Wraith, S., Merrill, L. S., McClaren, S., Sano, E., Petrie, J. G., Biddle, J., Johnson, S., Salvatore, P., Smith-Jeffcoat, S. E., Asturias, E. J., Lin, J. T., Ellingson, K. D., Belongia, E. A., Olivo, V., Mellis, A. M., Grijalva, C. G. 2024

  Abstract

  Households are a primary setting for transmission of SARS-CoV-2. We examined the role of prior SARS-CoV-2 immunity on the risk of infection in household close contacts. Households in the United States with an individual who tested positive for SARS-CoV-2 during September 2021-May 2023 were enrolled if the index case's illness began ≤6 days prior. Household members had daily self-collected nasal swabs tested by RT-PCR for SARS-CoV-2. The effects of prior SARS-CoV-2 immunity (vaccination, prior infection, or hybrid immunity) on SARS-CoV-2 infection risk among household contacts were assessed by robust, clustered multivariable Poisson regression. Of 1,532 contacts (905 households), 8% had immunity from prior infection alone, 51% from vaccination alone, 29% hybrid immunity, and 11% had no prior immunity. Sixty percent of contacts tested SARS-CoV-2-positive during follow-up. The adjusted risk of SARS-CoV-2 infection was lowest among contacts with vaccination and prior infection (aRR: 0.81, 95% CI: 0.70, 0.93, compared with contacts with no prior immunity) and was lowest when the last immunizing event occurred ≤6 months before COVID-19 affected the household (aRR: 0.69, 95% CI: 0.57, 0.83). In high-transmission settings like households, immunity from COVID-19 vaccination and prior infection was synergistic in protecting household contacts from SARS-CoV-2 infection.

  View details for DOI 10.1093/aje/kwae334

  View details for PubMedID 39218430

• Acceptability and feasibility of implementing the Enhanced Assess, Acknowledge, Act (EAAA) sexual assault prevention intervention on a U.S. university campus: Themes from qualitative interviews and written reflections. Journal of American college health : J of ACH Behl, R., Umunna, I., Edem, B., Mphamba, D., Baiocchi, M., Sarnquist, C. 2024: 1-8

  Abstract

  Objectives: Assess the acceptability of and self-reported behavioral change from participation in a sexual assault prevention intervention on a U.S. university campus. Participants: Thirty-one undergraduate students who identified as women and opted-in to participating in both the intervention and research. Methods: In-depth interviews and written reflections were collected. Analysis was thematic with three investigators coding and reaching consensus. Results: The EAAA program was well-liked by most participants, with positive behavior changes reported. Five key themes reflecting strengths of EAAA were identified, including improved verbal communication, reduced sexual assault myths, empowerment, recognizing and responding to danger cues, and learning about healthy sexuality. Three key themes reflecting challenges were identified, including time commitment, use of outdated program materials, and a single gender focus. Conclusions: EAAA translates well, with a few adaptations, to a residential campus environment in the U.S. Research is needed to assess program effectiveness in reducing sexual assault.

  View details for DOI 10.1080/07448481.2024.2351411

  View details for PubMedID 38754093

• A Review of Evidence-Based Dating Violence Prevention Programs With Behavioral Change Outcomes for Adolescents and Young Adults. Trauma, violence & abuse Chawla, S. A., Solomon, J., Sarnquist, C. 2024: 15248380241246779

  Abstract

  Adolescent dating violence (DV) is not only a social but also a public health problem, necessitating the development and scale-up of prevention strategies. We conducted a review of the literature to identify adolescent and young adult DV prevention programs that have shown promising behavioral outcomes. The literature search covered articles published from 1996 to 2022 and indexed in Medline, Cochrane, Scopus, PsycINFO, and Embase. The review focused on programs implemented and evaluated in the United States or Canada that included intervention and comparison groups, a baseline assessment, and at least one post-assessment conducted after the intervention exposure. Promising behavioral outcomes were defined as positive, statistically significant differences between intervention and comparison groups with respect to DV perpetration or victimization or bystander behavior in relation to DV. A total of 118 articles were screened by abstract and read in-depth. Eighteen programs that met the inclusion criteria were identified. Of these programs, one showed reductions in DV victimization, six showed reductions in DV perpetration, and nine showed behavioral reductions in both violence perpetration and victimization. The review highlighted that while multiple programs have demonstrated efficacy in preventing or reducing intimate partner violence in North American youth populations, more robust research on the replication of these programs outside researcher-controlled environments is needed. Furthermore, issues with program inclusivity, such as with sex and gender-minority individuals, should be considered in future intervention development and replication research.

  View details for DOI 10.1177/15248380241246779

  View details for PubMedID 38671574

• Sexual Assault Among Young Adolescents in Informal Settlements in Nairobi, Kenya: Findings from the IMPower and SOS Cluster-Randomized Controlled Trial. Prevention science : the official journal of the Society for Prevention Research Sarnquist, C., Friedberg, R., Rosenman, E. T., Amuyunzu-Nyamongo, M., Nyairo, G., Baiocchi, M. 2023

  Abstract

  Sexual assault is a global threat to adolescent health, but empowerment self-defense (ESD) interventions have shown promise for prevention. This study evaluated the joint implementation of a girls' ESD program and a concurrent boys' program, implemented via a cluster-randomized controlled trial in informal settlements of Nairobi, Kenya, from January 2016 to October 2018. Schools were randomized to the 12-h intervention or 2-h standard of care. Students were randomly sampled to complete surveys at baseline and again at 24 months post-intervention. A total of 3263 girls, ages 10-14, who completed both baseline and follow-up surveys were analyzed; weights were adjusted for dropout. At follow-up, 5.9% (n = 194/3263) of girls reported having been raped in the prior 12 months. Odds of reporting rape were not significantly different in the intervention versus SOC group (OR: 1.21; 95% CI (0.40, 5.21), p = 0.63). Secondary outcomes, social self-efficacy (OR: 1.08; 95% CI (0.95, 1.22), p = 0.22), emotional self-efficacy (OR 1.07; 95% CI (0.89, 1.29), p = 0.49), and academic self-efficacy (OR: 0.90; 95% CI (0.82, 1.00), p = 0.06) were not significantly different. Exploratory analyses of boys' victimization and perpetration are reported. This study improved on previous ESD studies in this setting with longitudinal follow-up of individuals and independent data collection. This study did not show an effect of the intervention on self-reported rape; findings should be interpreted cautiously due to limitations. Sexual assault rates are high in this young population, underscoring a dire need to implement and rigorously test sexual assault prevention interventions in this setting. The trial was registered with Clinical Trials.gov # NCT02771132. Version 3.1 registered on May 2017, first participant enrolled January 2017.

  View details for DOI 10.1007/s11121-023-01595-1

  View details for PubMedID 37966676

  View details for PubMedCentralID 6553848

• Symptoms, viral loads, and rebound among COVID-19 outpatients treated with nirmatrelvir/ritonavir compared to propensity score matched untreated individuals. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Smith-Jeffcoat, S. E., Biddle, J. E., Talbot, H. K., Morrisey, K. G., Stockwell, M. S., Maldonado, Y., McLean, H. Q., Ellingson, K. D., Bowman, N. M., Asturias, E., Mellis, A. M., Johnson, S., Kirking, H. L., Rolfes, M. A., Olivo, V., Merrill, L., Battan-Wraith, S., Sano, E., McLaren, S. H., Vargas, C. Y., Goodman, S., Sarnquist, C. C., Govindaranjan, P., Petrie, J. G., Belongia, E. A., Ledezma, K., Pryor, K., Lutrick, K., Bullock, A., Yang, A., Haehnel, Q., Rao, S., Zhu, Y., Schmitz, J., Hart, K., Grijalva, C. G., Salvatore, P. P. 2023

  Abstract

  Nirmatrelvir/ritonavir (N/R) reduces severe outcomes among patients with COVID-19; however, rebound after treatment has been reported. We compared symptom and viral dynamics in community-based individuals with COVID-19 who completed N/R and similar untreated individuals.We identified symptomatic participants who tested SARS-CoV-2 positive and were N/R eligible from a COVID-19 household transmission study: index cases from ambulatory settings and their households were enrolled, collecting daily symptoms, medication use, and respiratory specimens for quantitative PCR for 10 days, March 2022-May 2023. Participants who completed N/R (treated) were propensity score matched to untreated participants. We compared symptom rebound, viral load (VL) rebound, average daily symptoms, and average daily VL by treatment status measured after N/R completion or, if untreated, seven days after symptom onset.Treated (n=130) and untreated participants (n=241) had similar baseline characteristics. After treatment completion, treated participants had greater occurrence of symptom rebound (32% vs 20%; p=0.009) and VL rebound (27% vs 7%; p<0.001). Average daily symptoms were lower among treated participants compared to untreated participants without symptom rebound (1.0 vs 1.6; p<0.01), but not statistically lower with symptom rebound (3.0 vs 3.4; p=0.5). Treated participants had lower average daily VLs without VL rebound (0.9 vs 2.6; p<0.01), but not statistically lower with VL rebound (4.8 vs 5.1; p=0.7).Individuals who completed N/R experienced fewer symptoms and lower VL but were more likely to have rebound compared to untreated individuals. Providers should still prescribe N/R, when indicated, and communicate possible increased rebound risk to patients.

  View details for DOI 10.1093/cid/ciad696

  View details for PubMedID 37963102

• Variation in rates of sexual assault crisis counsellor usage during forensic examination in California: an observational study. BMJ open Serenska, A., Sarnquist, C. C., Darmstadt, G. L. 2023; 13 (10): e072635

  Abstract

  A critical asset to post-assault care of survivors is support from sexual assault crisis counsellors (SACCs). We sought to elucidate variation in implementation between California counties in SACC accompaniment during Sexual Assault Forensic Examination (SAFE).SACC attendance data from 2019 was obtained from the California Governor's Office of Emergency Services (CalOES). To assess SACC attendance rates during SAFEs, we requested SAFE quantity data from sheriffs and public health departments, the State Forensic Bureau, and the California Department of Justice (DOJ), but all requests were unanswered or denied. We also sought SAFE data from District Attorneys (DAs) in each county, and received responses from Marin and Contra Costa Counties. To estimate numbers of SAFEs per county, we gathered crime statistics from the Federal Bureau of Investigation's (FBI's) Uniform Crime Reporting Program and OpenJustice, a transparency initiative by the California DOJ. For each data source, we compared SACC attendance to SAFE quantities and incidences of sexual assault statewide.At the state level, data on SACC attendance per CalOES and DOJ archival data on sexual assault were used to approximate relative rates of SACC accompaniment at SAFEs; 83% (30 of 36) of counties had values <50%. The joint sexual assault crisis centre for Contra Costa and Marin Counties reported that 140 SACCs were dispatched in 2019, while DAs in Contra Costa and Marin reported completion of 87 SAFEs in 2019, for a calculated SACC accompaniment rate of 161%. Proxy data sourced from FBI and DOJ crime statistics displayed significant inconsistencies, and DOJ data was internally inconsistent.SACC accompaniment at SAFEs appears to be low in most California counties, however, limited data accessibility and data discrepancies and inaccuracies (e.g., rates over 100%) prevented reliable determination of SACC accompaniment rates during SAFEs. Substantial improvements in data accuracy and transparency are needed to ensure survivors' adequate access to resources.

  View details for DOI 10.1136/bmjopen-2023-072635

  View details for PubMedID 37865414

• Understanding ART Adherence among Adolescent Girls and Young Women in Western Kenya: A Cross-Sectional Study of Barriers and Facilitators. International journal of environmental research and public health Altamirano, J., Odero, I. A., Omollo, M., Awuonda, E., Ondeng'e, K., Kang, J. L., Behl, R., Ndivo, R., Baiocchi, M., Barsosio, H. C., Sarnquist, C. C. 2023; 20 (20)

  Abstract

  BACKGROUND: HIV remains a leading cause of death for adolescent girls and young women (AGYW) in sub-Saharan Africa. This population has a high incidence of HIV and other comorbidities, such as experiencing violence, and low antiretroviral therapy (ART) adherence. To reach global HIV goals, data are needed on the specific adherence barriers for AGYW living with HIV, so interventions can be targeted effectively.METHODS: Cross-sectional data were collected at urban and rural health facilities in and around Kisumu County, western Kenya, from January to June 2022, from AGYW 15-24 years of age who were living with HIV. Surveys included questions on intimate partner violence, mental health issues, food security, and orphanhood. Adherence was categorized using viral load testing where available and the Center for Adherence Support Evaluation (CASE) adherence index otherwise. Logistic regression was used to assess associations between potential explanatory variables and adherence.FINDINGS: In total, 309 AGYW participated. AGYW with experiences of emotional violence (Odds Ratio [OR] = 1.94, 95% Confidence Interval [CI] = 1.03-3.66), moderate or severe depression (OR = 3.19, 95% CI = 1.47-6.94), and/or substance use (OR = 2.71, 95% CI = 1.24-5.92) had significantly higher odds of poor adherence when compared to AGYW without these respective experiences. Physical and sexual violence, food insecurity, and orphanhood were not associated with poor adherence in this cohort.INTERPRETATION: Elucidating the risk factors associated with poor adherence among AGYW living with HIV allows us to identify potential targets for future interventions to improve ART adherence and HIV care outcomes. Mental health and violence prevention interventions, including combination interventions, may prove to be promising approaches.

  View details for DOI 10.3390/ijerph20206922

  View details for PubMedID 37887660

• Mental health and gender-based violence: An exploration of depression, PTSD, and anxiety among adolescents in Kenyan informal settlements participating in an empowerment intervention. PloS one Friedberg, R., Baiocchi, M., Rosenman, E., Amuyunzu-Nyamongo, M., Nyairo, G., Sarnquist, C. 2023; 18 (3): e0281800

  Abstract

  This study examines the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) among adolescents attending schools in several informal settlements of Nairobi, Kenya. Primary aims were estimating prevalence of these mental health conditions, understanding their relationship to gender-based violence (GBV), and assessing changes in response to an empowerment intervention.Mental health measures were added to the final data collection point of a two-year randomized controlled trial (RCT) evaluating an empowerment self-defense intervention. Statistical models evaluated how past sexual violence, access to money to pay for a needed hospital visit, alcohol use, and self-efficacy affect both mental health outcomes as well as how the intervention affected female students' mental health.Population prevalence of mental health conditions for combined male and female adolescents was estimated as: PTSD 12.2% (95% confidence interval 10.5-15.4), depression 9.2% (95% confidence interval 6.6-10.1) and anxiety 17.6% (95% confidence interval 11.2% - 18.7%). Female students who reported rape before and during the study-period reported significantly higher incidence of all mental health outcomes than the study population. No significant differences in outcomes were found between female students in the intervention and standard-of-care (SOC) groups. Prior rape and low ability to pay for a needed hospital visit were associated with higher prevalence of mental health conditions. The female students whose log-PTSD scores were most lowered by the intervention (effects between -0.23 and -0.07) were characterized by high ability to pay for a hospital visit, low agreement with gender normative statements, larger homes, and lower academic self-efficacy.These data illustrate a need for research and interventions related to (1) mental health conditions among the young urban poor in low-income settings, and (2) sexual violence as a driver of poor mental health, leading to a myriad of negative long-term outcomes.

  View details for DOI 10.1371/journal.pone.0281800

  View details for PubMedID 36989329

• Qualitative perspectives on COVID-19, interpersonal violence, and interventions to improve well-being from adolescent girls and young women in Kisumu, Kenya. Frontiers in reproductive health Reed, R. E., Omollo, M., Odero, I., Awuonda, E., Ochere, P., Ondeng'e, K., Kang, J. L., Altamirano, J., Barsosio, H. C., Sarnquist, C. 2023; 5: 1236588

  Abstract

  Introduction: Adolescent girls and young women (AGYW) face a high burden of gender-based violence (GBV) worldwide. The COVID-19 pandemic and associated policies led to global increases in GBV, decreased access to resources, and disruptions of pathways to care. We aimed to understand the effects of COVID-19 on AGYW affected by GBV in Kisumu, Kenya, as well as to identify possible interventions to mitigate those effects.Methods: Focus group discussions (FGDs) were conducted with AGYW aged 15-25 with a history of exposure to GBV. AGYW were split into age-matched groups; aged 15-19 for younger groups and 19-25 for older groups. Discussions focused on how COVID-19 affected experiences of GBV, access to care services, economic and social outcomes, and opportunities for interventions to mitigate negative impacts of COVID-19 and violence.Results: Five FGDs with 46 AGYW were completed in June-September 2021. AGYW described increases in all types of GBV, particularly sexual abuse and intimate partner violence. Early marriage and subsistence transactional sex also increased. AGYW described violence as both a cause and effect of poor economic, social and health consequences related to the pandemic. Notably, AGYW emphasized stress, lack of mental health support and increased substance use as risk factors for violence, and discussed the deleterious mental health effects of violence-particularly in the wake of disruption of mental health services. COVID-19 disrupted referrals to violence-related services, and reduced access to both medical services and psychosocial services. AGYW believed that interventions focused on improving mental health as well as economic empowerment would be the most feasible and acceptable in mitigating the negative effects of COVID-19 and related exacerbations in violence.Discussion: AGYW reported increases in almost all forms of GBV during the pandemic, with related exacerbation in mental health. Concurrently, AGYW endorsed decreased access to care services. As there is no evidence that violence and mental health challenges will quickly resolve, there is an urgent need to identify and implement interventions to mitigate these negative effects.

  View details for DOI 10.3389/frph.2023.1236588

  View details for PubMedID 38107484

• Youth voices from an informal settlement of Nairobi, Kenya: Engaging adolescent perspectives on violence to inform prevention. Global public health Mphamba, D., Solomon, F. R., Nyairo, G., Kim, C. J., Krishnamoorthi, M., Edem, B., Amuyunzu-Nyamongo, M., Kang, J., Baiocchi, M., Sarnquist, C. C. 2022: 1-14

  Abstract

  We examined the experiences of violence and self-reported behavioural and community changes as a result of participation in a sexual assault prevention intervention in an informal settlement in Nairobi, Kenya. We conducted longitudinal qualitative in-depth interviews with 20 adolescent girls and 11 adolescent boys at baseline, 12, and 24 months. Analysis was thematic with two investigators coding and reaching consensus about the themes. Participants' ages ranged from 10 to 13 at baseline; girls' mean age was 11.9, boys' mean age was 11.6. Participants reported experiencing high levels of violence at all stages of the study. Most reported feeling more empowered to protect themselves and others from sexual assault because of the intervention. While participants had mixed responses about change in sexual assault incidence, most perceived an improvement in inter-gender relationships after the intervention. Participants at midline and endline cited acquaintances and friends as potential perpetrators of sexual violence more often than at baseline and were more open to reporting violent incidents. The very young adolescents in this setting perceived that this sexual assault prevention intervention led to improvements in gender relations, adolescent girls' empowerment and, recognition of harmful rape myths.Trial registration: ClinicalTrials.gov identifier: NCT02771132.

  View details for DOI 10.1080/17441692.2022.2076895

  View details for PubMedID 35579915

• Rebuilding child health in South Kivu, Democratic Republic of Congo (DRC): evaluating the Asili social enterprise program. Conflict and health Behl, R., Ali, S., Altamirano, J., Leno, A., Maldonado, Y., Sarnquist, C. 2022; 16 (1): 21

  Abstract

  The Democratic Republic of Congo (DRC) has a long history of conflict and ongoing local instability; the eastern provinces, including South Kivu, have been especially affected. Health systems and livelihoods have been undermined, contributing to massive inequities in access to health services and high rates of internal displacement. Asili, an innovative social enterprise program, aimed to provide essential community services and improve the health of under-five children in two South Kivu communities, Mudaka and Panzi, via provision of small-format, franchisable health clinics and clean water services.We evaluated utilization and acceptance of Asili services in two study sites, Mudaka and Panzi. Data collected included questions on housing conditions, food security, and at follow up, Asili membership and use, satisfaction with services, and recommendations for improvement. Structured pre- and post-interviews with primary caregivers of families with under-five children were the primary source of data with additional community input collected through focus group discussions.At baseline, we enrolled 843 households in Mudaka and 890 in Panzi. Market segmentation analysis illuminated service usage patterns, showing Asili services were well received overall in both Mudaka and Panzi. Families reporting higher levels of proxy measures of socioeconomic status (SES), such as electricity, land ownership, and education, were more likely to use Asili services, findings that were further supported by focus group discussions among community members.Rebuilding health infrastructure in post-conflict settings, especially those that continue to be conflict-affected and very low SES, is a challenging prospect. Focus group results for this study highlighted the positive community response to Asili, while also underscoring challenges related to cost of services. Programs may need, in particular, to have different levels of costs for different SES groups. Additionally, longer follow-up periods and increased stability may be needed to assess the potential of social enterprise interventions such as Asili to improve health outcomes, especially in children.Institutional Review Board approval for this study was obtained at Stanford University (IRB 35216) and the University of Kinshasa, DRC. Further, this study has been registered on Clinicaltrials.gov (record NCT03536286), retrospectively registered as of 4/23/2018.

  View details for DOI 10.1186/s13031-022-00454-0

  View details for PubMedID 35526031

• A Novel Model for Generating Creative, Community-Responsive Interventions to Reduce Gender-Based Violence on College Campuses. International journal of environmental research and public health Graham, S., Zha, C. C., King, A. C., Banchoff, A. W., Sarnquist, C., Dauber, M., Baiocchi, M. 2021; 18 (15)

  Abstract

  Currently, the most successful prevention interventions against sexual violence (SV) on United States college campuses target modifications at the individual and interpersonal levels. Community-level interventions have been under-developed for college campuses. To address this gap, we employ a citizen science model for understanding campus community factors affecting SV risk. The model, called Our Voice, starts by engaging groups of college students to collect data in their own communities, identifying factors they view as increasing the risk of SV. In facilitated meetings, participants then review and analyze their collective data and use it to generate actionable community-level solutions and advocate for them with local decision-makers. We share findings from a first-generation study of the Our Voice model applied to SV prevention on one college campus, and include recommendations for further research.

  View details for DOI 10.3390/ijerph18157933

  View details for PubMedID 34360224

• The Effect of Combining Business Training, Microfinance, and Support Group Participation on Economic Status and Intimate Partner Violence in an Unplanned Settlement of Nairobi, Kenya JOURNAL OF INTERPERSONAL VIOLENCE Sarnquist, C. C., Ouma, L., Lang'at, N., Lubanga, C., Sinclair, J., Baiocchi, M. T., Cornfield, D. N. 2021; 36 (7-8): 3903–21

  View details for DOI 10.1177/0886260518779067

  View details for Web of Science ID 000630100900065

• Empirical Insights for Improving Sexual Assault Prevention: Evidence From Baseline Data for a Cluster-Randomized Trial of IMPower and Sources of Strength. Violence against women Rosenman, E., Sarnquist, C., Friedberg, R., Amuyunzu-Nyamongo, M., Oguda, G., Otieno, D., Baiocchi, M. 2019: 1077801219886380

  Abstract

  The empirical science of measuring and preventing sexual assault is in its infancy, especially when considering adolescents in developing nations. We analyze pre-intervention data collected in a two-arm cluster-randomized controlled trial of a classroom-based sexual assault prevention program deployed to Class 6 students around Nairobi, Kenya. We estimate that 7.2% of girls were raped in the prior 12 months. We identify school- and individual-level risk factors for rape. We isolate, as much as possible, variation in probability of rape attributable to a subset of these risk factors. We discuss statistical challenges and solutions in each of these domains.

  View details for DOI 10.1177/1077801219886380

  View details for PubMedID 31766987

• A protocol for a cluster-randomized controlled trial testing an empowerment intervention to prevent sexual assault in upper primary school adolescents in the informal settlements of Nairobi, Kenya. BMC public health Sarnquist, C. n., Kang, J. L., Amuyunzu-Nyamongo, M. n., Oguda, G. n., Otieno, D. n., Mboya, B. n., Omondi, N. n., Kipkirui, D. n., Baiocchi, M. n. 2019; 19 (1): 834

  Abstract

  Sexual violence against adolescents is prevalent worldwide and results in significant physical and mental injuries as well as loss of economic and personal potential. Urban informal settlements such as those around Nairobi, Kenya have been shown to have especially high incidences of violence. Research has shown that empowerment interventions for female adolescents can reduce sexual assault. However, these interventions have had limited testing in urban informal settlements, with young adolescents, or in coordination with complementary programs for male adolescents.This study was a two-arm, parallel, cluster-randomized trial testing a combination of a previously-tested girls' intervention, IMPower, and a newly revised boys' intervention, Source of Strength. Clusters were defined as schools within the informal settlements; participants were adolescent girls and boys in class 6, generally between the ages of 10-14 at baseline. Data collection began in January 2016 and continued through December 2018. The primary outcome was the change in incidence of self-reported sexual assault among girls from baseline, compared to a life skills standard of care intervention. Secondary outcomes included experiences of physical and emotional violence, as well as determining the effects of the intervention on self-efficacy, self-esteem, and gender attitudes and beliefs, and how those effects led to changes in experience of sexual assault. For the primary outcome and several of the secondary outcomes, we used an intention to treat estimand.This was the first randomized controlled trial with longitudinal follow-up of an empowerment self-defense approach to violence prevention for adolescents in informal settlements. The large size and rigorous design supported analysis to understand multiple subgroup experiences in the hypothesized reduction in sexual assault. The study was also unique in its focus on young (10-14 years of age) adolescents and in engaging both boys and girls in separate but coordinated curriculums. The focus on a highly vulnerable and understudied population will make it a significant contribution to the literature on violence prevention.Clinical Trials.gov # NCT02771132 . Version 3.1 registered May 2017, first participant enrolled January 2017. Retrospectively registered.

  View details for DOI 10.1186/s12889-019-7154-x

  View details for PubMedID 31248392

• Prevalence and risk factors for sexual assault among class 6 female students in unplanned settlements of Nairobi, Kenya: Baseline analysis from the IMPower & Sources of Strength cluster randomized controlled trial. PloS one Baiocchi, M. n., Friedberg, R. n., Rosenman, E. n., Amuyunzu-Nyamongo, M. n., Oguda, G. n., Otieno, D. n., Sarnquist, C. n. 2019; 14 (6): e0213359

  Abstract

  Gender-based violence (GBV) is a crucial global health problem among all age groups, including adolescents. This study describes incidences of GBV, as well as factors associated with sexual assault, among female adolescents in class six living in urban informal settlements in Nairobi, Kenya.Study participants were interviewed using a structured survey instrument focusing on experiences of GBV, including emotional, physical, and sexual violence, and corresponding perpetrators, as well as gender attitudes, alcohol use, self-efficacy, and previous sexual experiences. Summary statistics and clustered bootstrap confidence intervals were calculated for social behaviors and violence rates. Stepwise logistic regression identified variables associated with an adolescent's experience of sexual assault.In this population 7·2% of adolescent girls reported being raped in the prior twelve months, with 11·1% of these rape victims reporting over five experiences. Among the 21·3% who report having had a boyfriend, 38·1% reported emotional, physical, and/or sexual intimate partner violence (IPV). Boyfriends were identified most often as perpetrators, accounting for 46·3% of reported lifetime rapes. Previous experience of physical (p = <0·001) or emotional (p<0·001) IPV and home violence (p<0·001) were risk factors for being raped, while high self-efficacy (p<0·001) was a protective factor.Sexual assault and GBV are major challenges in this highly-disadvantaged population. Novel prevention efforts are needed for this age group, as prevention is often targeted at older adolescents. Prevention efforts should focus on assaults by perpetrators known to adolescents, especially boyfriends, and may need to account for the adolescents' previous experience of, and exposure to, violence.

  View details for DOI 10.1371/journal.pone.0213359

  View details for PubMedID 31170151

• Protocol Paper: Oral Poliovirus Vaccine Transmissibility in Communities After Cessation of Routine Oral Poliovirus Vaccine Immunization CLINICAL INFECTIOUS DISEASES Sarnquist, C., Holubar, M., Garcia-Garcia, L., Ferreyra-Reyes, L., Delgado-Sanchez, G., Pablo Cruz-Hervert, L., Montero-Campos, R., Altamirano, J., Purington, N., Boyle, S., Modlin, J., Ferreira-Guerrero, E., Canizales-Quintero, S., Diaz Ortega, J., Desai, M., Maldonado, Y. A. 2018; 67: S115–S120

  View details for DOI 10.1093/cid/ciy606

  View details for Web of Science ID 000450051800016

• Spatial Analyses of Oral Polio Vaccine Transmission in an Community Vaccinated With Inactivated Polio Vaccine CLINICAL INFECTIOUS DISEASES Jarvis, C., Altamirano, J., Sarnquist, C., Edmunds, W., Maldonado, Y. 2018; 67: S18–S25

  View details for DOI 10.1093/cid/ciy622

  View details for Web of Science ID 000450051800003

• Assessing the Risk of Vaccine-derived Outbreaks After Reintroduction of Oral Poliovirus Vaccine in Postcessation Settings CLINICAL INFECTIOUS DISEASES Fu, R., Altamirano, J., Sarnquist, C. C., Maldonado, Y. A., Andrews, J. R. 2018; 67: S26–S34

  View details for DOI 10.1093/cid/ciy605

  View details for Web of Science ID 000450051800004

• Validation of a High-throughput, Multiplex, Real-time Qualitative Polymerase Chain Reaction Assay for the Detection of Sabin Oral Polio Vaccine in Environmental Samples CLINICAL INFECTIOUS DISEASES Altamirano, J., Leary, S., van Hoorebeke, C., Sarnquist, C., Behl, R., Garcia-Garcia, L., Ferreyra-Reyes, L., Huang, C., Sommer, M., Maldonado, Y. 2018; 67: S98–S102

  View details for DOI 10.1093/cid/ciy639

  View details for Web of Science ID 000450051800013

• OPV Vaccination and Shedding Patterns in Mexican and US Children CLINICAL INFECTIOUS DISEASES Altamirano, J., Sarnquist, C., Behl, R., Garcia-Garcia, L., Ferreyra-Reyes, L., Leary, S., Maldonado, Y. 2018; 67: S85–S89

  View details for DOI 10.1093/cid/ciy636

  View details for Web of Science ID 000450051800011

• Characterization of Household and Community Shedding and Transmission of Oral Polio Vaccine in Mexican Communities With Varying Vaccination Coverage CLINICAL INFECTIOUS DISEASES Altamirano, J., Purington, N., Behl, R., Sarnquist, C., Holubar, M., Garcia-Garcia, L., Ferreyra-Reyes, L., Montero-Campos, R., Pablo Cruz-Hervert, L., Boyle, S., Modlin, J., van Hoorebeke, C., Leary, S., Huang, C., Sommer, M., Ferreira-Guerrero, E., Delgado-Sanchez, G., Canizales-Quintero, S., Diaz Ortega, J., Desai, M., Maldonado, Y. A. 2018; 67: S4–S17

  View details for DOI 10.1093/cid/ciy650

  View details for Web of Science ID 000450051800002

• Protocol Paper: Oral Poliovirus Vaccine Transmissibility in Communities After Cessation of Routine Oral Poliovirus Vaccine Immunization. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Sarnquist, C., Holubar, M., Garcia-Garcia, L., Ferreyra-Reyes, L., Delgado-Sanchez, G., Cruz-Hervert, L. P., Montero-Campos, R., Altamirano, J., Purington, N., Boyle, S., Modlin, J., Ferreira-Guerrero, E., Canizales-Quintero, S., Diaz Ortega, J. L., Desai, M., Maldonado, Y. A. 2018; 67 (suppl_1): S115–S120

  Abstract

  Background: We aimed to elucidate household and community-level shedding and transmission of trivalent oral polio vaccine (tOPV) in communities with inactivated polio vaccine (IPV) routine immunization after tOPV is administered during a national health week (NHW).Methods: We conducted a 3-arm, randomized trial with data collected at baseline through 10 weeks post-NHW in households with at least 1 child <5 years old in 3 semi-rural communities in Orizaba, Mexico. Selected communities were geographically isolated but socio-demographically similar. Each community was assigned an oral polio vaccine (OPV) immunization rate: 10, 30, or 70% of participating households. From 2653 households in the 3 communities, ~150 households per community were selected, for 466 in total. Households were randomized as vaccinated or unvaccinated, with only 1 child under 5 in the vaccinated household receiving OPV during the February 2015 NHW. No other community members received OPV during this NHW. Stool samples were collected up to 10 weeks post-vaccination for all members of the 466 study households and were analyzed for the presence of OPV serotypes using a multiplex polymerase chain reaction assay.Results: We will report on the factors associated with, and incidence and duration of, household and community shedding and transmission of OPV. The secondary outcomes will characterize temporal and geospatial OPV serotype shedding patterns.Conclusions: The current global polio eradication plan relies on transitioning away from OPV to IPV. This study contributes to understanding patterns of OPV shedding and transmission dynamics in communities with primary IPV immunity, in order to optimize the reduction of OPV transmission.

  View details for PubMedID 30376084

• Spatial Analyses of Oral Polio Vaccine Transmission in an Community Vaccinated With Inactivated Polio Vaccine. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Jarvis, C. I., Altamirano, J., Sarnquist, C., Edmunds, W. J., Maldonado, Y. 2018; 67 (suppl_1): S18–S25

  Abstract

  Background: Understanding the spatial dynamics of oral polio vaccine (OPV) transmission will improve resource targeting. Mexico provides a natural laboratory, as it uses inactivated polio vaccine routinely as well as OPV bi-annually.Methods: Using geospatial maps, we measured the distance and density of OPV vaccinees' shedding in the areas nearest to unvaccinated households in 3 Mexican villages. Comparison of transmission to unvaccinated households utilized a mixed effects logistic regression with random effects for household and time, adjusted for age, gender, area, and running water.Results: The median distance from an unvaccinated household to its nearest OPV-shedding household was 85 meters (interquartile range, 46-145) and the median number of vaccinees shedding OPV within 200 m was 3 (2-6). Transmission to unvaccinated households occurred by day 1. There was no association (odds ratio [OR] 1.04; 95% credible interval [CrI] 0.92-1.16) between the distance from OPV shedding and the odds of transmission. The number of OPV vaccinees shedding within 200 m came close to a significant association with unvaccinated transmission (OR 0.93; CrI 0.84-1.01), but this was not the case for households 100 or 500 m apart. Results were consistent across the 3 villages.Conclusions: Geospatial analysis did not predict community transmission from vaccinated to unvaccinated households, because OPV use resulted in rapid, low transmission levels. This finding supports the global cessation of OPV.

  View details for PubMedID 30376089

• Characterization of Household and Community Shedding and Transmission of Oral Polio Vaccine in Mexican Communities With Varying Vaccination Coverage. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Altamirano, J., Purington, N., Behl, R., Sarnquist, C., Holubar, M., Garcia-Garcia, L., Ferreyra-Reyes, L., Montero-Campos, R., Cruz-Hervert, L. P., Boyle, S., Modlin, J., van Hoorebeke, C., Leary, S., Huang, C., Sommer, M., Ferreira-Guerrero, E., Delgado-Sanchez, G., Canizales-Quintero, S., Diaz Ortega, J. L., Desai, M., Maldonado, Y. A. 2018; 67 (suppl_1): S4–S17

  Abstract

  Background: The World Health Assembly 2012 Polio Eradication and Endgame Strategic Plan calls for the eventual cessation of all oral polio vaccines (OPVs), to be replaced with inactivated polio vaccine (IPV); however, IPV induces less robust mucosal immunity than OPV. This study characterized household and community OPV shedding and transmission after OPV vaccination within primarily IPV-vaccinated communities.Methods: Households in 3 IPV-vaccinated Mexican communities were randomized to receive 3 levels of OPV vaccination coverage (70%, 30%, or 10%). Ten stool samples were collected from all household members over 71 days. Analysis compared vaccinated subjects, household contacts of vaccinated subjects, and subjects in unvaccinated households. Logistic and Cox regression models were fitted to characterize transmission of OPV by coverage and household vaccination status.Results: Among 148 vaccinated children, 380 household contacts, and 1124 unvaccinated community contacts, 78%, 18%, and 7%, respectively, shed OPV. Community and household contacts showed no differences in transmission (odds ratio [OR], 0.67; 95% confidence interval [CI], .37-1.20), in shedding trajectory (OR, 0.61; 95% CI, .35-1.07), or in time to shedding (hazard ratio, 0.68; 95% CI, .39-1.19). Transmission began as quickly as 1 day after vaccination and persisted as long as 71 days after vaccination. Transmission within unvaccinated households differed significantly across vaccination coverage communities, with the 70% community experiencing the most transmissions (15%), and the 10% community experiencing the least (4%). These trends persisted over time and in the time to first shedding analyses.Conclusions: Transmission did not differ between household contacts of vaccinees and unvaccinated households. Understanding poliovirus transmission dynamics is important for postcertification control.

  View details for PubMedID 30376097

• Validation of a High-throughput, Multiplex, Real-time Qualitative Polymerase Chain Reaction Assay for the Detection of Sabin Oral Polio Vaccine in Environmental Samples. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Altamirano, J., Leary, S., van Hoorebeke, C., Sarnquist, C., Behl, R., Garcia-Garcia, L., Ferreyra-Reyes, L., Huang, C., Sommer, M., Maldonado, Y. 2018; 67 (suppl_1): S98–S102

  Abstract

  Background: Currently, the primary mechanism for poliovirus detection is acute flaccid paralysis (AFP) surveillance, with environmental sampling serving as a complement. However, as AFP cases drop, environmental surveillance will become increasingly critical for poliovirus detection. Mexico provides a natural environment to study oral polio vaccine (OPV) transmission, as it provides routine injected polio vaccine immunization and biannual OPV campaigns in February and May.Methods: As part of a study of OPV transmission in which 155 children were vaccinated with OPV, monthly sewage samples were collected from rivers leading from 3 indigenous Mexican villages (Capoluca, Campo Grande, and Tuxpanguillo) from February to May 2015. Samples were also collected from October 2015 to October 2017, during which time there were standard OPV campaigns. Samples were analyzed for the presence of OPV serotypes, using a real-time qualitative polymerase chain reaction assay capable of detecting as few as 9, 12, and 10 copies/100 L of viral ribonucleic acid for OPV serotypes 1, 2, and 3 (OPV-1, -2, and -3), respectively. Included here are 54 samples, taken up to November 2016.Results: Of the 54 samples, 13 (24%) were positive for OPV. After the vaccination of 155 children in February 2015, OPV was found 2 months after vaccination. After unrestricted OPV administration in February 2016, OPV was detected in sewage up to 8 months after vaccination. OPV-3 was found in 11 of the 13 positive samples (85%), OPV-2 was found in 3 positive samples (23%), and OPV-1 was found in 1 sample (8%).Conclusions: OPV can be detected even when small amounts of the vaccine are introduced into a community, as shown by OPV-positive sewage samples even when only 155 children were vaccinated. When OPV vaccination was unrestricted, sewage samples were positive up to 8 months after vaccination, implying community OPV circulation for at least 8 months. OPV-3 was the serotype most found in these samples, indicating prolonged transmission of OPV-3 when compared to the other serotypes. Future work could compare the phylogenetic variance of OPV isolates from sewage after OPV vaccinations.

  View details for PubMedID 30376093

• OPV Vaccination and Shedding Patterns in Mexican and US Children. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Altamirano, J., Sarnquist, C., Behl, R., Garcia-Garcia, L., Ferreyra-Reyes, L., Leary, S., Maldonado, Y. 2018; 67 (suppl_1): S85–S89

  Abstract

  Background: As wild poliovirus is eradicated and countries switch from oral poliovirus vaccine (OPV) to inactivated poliovirus vaccine (IPV) per World Health Organization recommendations, preventing circulation of vaccine-derived poliovirus (cVDPV) is a top priority. Currently, the impact of prior poliovirus vaccination on OPV shedding is not fully understood.Methods: Stool samples from 2 populations were tested for OPV to assess shedding patterns. 505 samples from 43 US children vaccinated with OPV were collected over 42 days post-vaccination. 1,379 samples from 148 Mexican children vaccinated with OPV were collected over 71 days post-vaccination. Prior vaccination history was recorded for both groups.Results: Seventeen (40%) of the US children had never received poliovirus vaccination while the Mexican children had received at least 2 doses of IPV and 116 (78%) had OPV exposure. In total, 84% of US children and 78% of Mexican children shed OPV (P = .44, Fisher exact test), with a mean shedding duration of 17.4 days for US children and 9.3 days for Mexican children (P < .0001, Wilcoxon-Mann Whitney test).Conclusions: Prior vaccination did not affect the likelihood of shedding, as the US and Mexico cohorts had similar shedding proportions. However, prior vaccination affected shedding duration as the Mexican children, who were largely OPV exposed and all of whom had at least 2 IPV vaccinations, shed OPV for half as long as the US cohort. Since different countries maintain different poliovirus vaccination schedules, it is likely that duration of shedding of OPV varies in populations around the world.

  View details for PubMedID 30376085

• The Effect of Combining Business Training, Microfinance, and Support Group Participation on Economic Status and Intimate Partner Violence in an Unplanned Settlement of Nairobi, Kenya. Journal of interpersonal violence Sarnquist, C. C., Ouma, L., Lang'at, N., Lubanga, C., Sinclair, J., Baiocchi, M. T., Cornfield, D. N. 2018: 886260518779067

  Abstract

  Intimate partner violence (IPV) has myriad negative health and economic consequences for women and families. We hypothesized that empowering women through a combination of formal business training, microfinance, and IPV support groups would decrease IPV and improve women's economic status. The study included adult female survivors of severe IPV. Women living in Korogocho received the intervention and women in Dandora served as a standard of care (SOC) group, but received the intervention at the end of the follow-up period. Women in the intervention groups ( n = 82, SOC group, n = 81) received 8 weeks of business training, assistance creating a business plan, a small initial loan (about US$60), and weekly business and social support meetings. The two primary outcome measures included change in: (a) average daily profit margin, and (b) incidence of severe IPV. Exploratory analysis also looked at incidence of violence against children and women's self-efficacy. Average daily profit margin in the intervention group increased by 351 Kenyan Shillings (about US$3.5) daily (95% CI = [172, 485]). IPV directed against participating women decreased from a baseline of 2.1 to 0.26 incidents, a difference of 1.84 incidents (95% CI = [1.32, 2.36]). Violence against children in the household in the prior 3 months decreased from 1.1 to 0.55 incidents, a difference of 0.55 incidents (95% CI = [0.16, 1.03]). Finally, the intervention appears to have increased self-efficacy scores by 0.42 points (95% CIs 0.13, 0.71). In a low-resource urban environment, employing three complementary interventions resulted in higher daily profit margins and lower IPV in the intervention compared with the SOC group. These data support the notion that employing multiple interventions concomitantly might possess synergistic, beneficial effects, and hold promise to address profound poverty and interrupt the devastating cycle of IPV.

  View details for PubMedID 29862883

• Associations between women's perceptions of gender relations and self-esteem and self-efficacy in a former conflict zone: baseline findings in South Kivu, DR Congo Sarnquist, C., Behl, R., Talib, A., Altamirano, J., Jerome, B., Inungu, J., Maldonado, Y. ELSEVIER SCI LTD. 2018: S5

  View details for Web of Science ID 000437672000005

• Assessing the Risk of Vaccine-derived Outbreaks After Reintroduction of Oral Poliovirus Vaccine in Postcessation Settings. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Fu, R. n., Altamirano, J. n., Sarnquist, C. C., Maldonado, Y. A., Andrews, J. R. 2018; 67 (suppl_1): S26–S34

  Abstract

  The Polio Eradication and Endgame Strategic Plan 2013-2018 calls for the gradual withdrawal of oral poliovirus vaccine (OPV) from routine immunization. We aimed to quantify the transmission potential of Sabin strains from OPV when it is reintroduced, accidentally or deliberately, in a community vaccinated with inactivated poliovirus vaccine alone.We built an individual-based stochastic epidemiological model that allows independent spread of 3 Sabin serotypes and differential transmission rates within versus between households. Model parameters were estimated by fitting to data from a prospective cohort in Mexico. We calculated the effective reproductive number for the Mexico cohort and simulated scenarios of Sabin strain resurgence under postcessation conditions, projecting the risk of prolonged circulation, which could lead to circulating vaccine-derived poliovirus (cVDPV).The estimated effective reproductive number for naturally infected individuals was about 1 for Sabin 2 and Sabin 3 (OPV2 and OPV3) in a postcessation setting. Most transmission events occurred between households. We estimated the probability of circulation for >9 months to be (1) <1% for all 3 serotypes when 90% of children <5 years of age were vaccinated in a hypothetical outbreak control campaign; (2) 45% and 24% for Sabin 2 and Sabin 3, respectively, when vaccine coverage dropped to 10%; (3) 37% and 8% for Sabin 2 and Sabin 3, respectively, when a single active shedder appeared in a community.Critical factors determining the risk of cVDPV emergence are the scale at which OPV is reintroduced and the between-household transmission rate for poliovirus, with intermediate values posing the greatest risk.

  View details for PubMedID 30376087

• Assessing the individual risk of fecal poliovirus shedding among vaccinated and non-vaccinated subjects following national health weeks in Mexico PLOS ONE Ferreyra-Reyes, L., Pablo Cruz-Hervert, L., Troy, S. B., Huang, C., Sarnquist, C., Delgado-Sanchez, G., Canizales-Quintero, S., Holubar, M., Ferreira-Guerrero, E., Montero-Campos, R., Rodriguez-Alvarez, M., Mongua-Rodriguez, N., Maldonado, Y., Garcia-Garcia, L. 2017; 12 (10): e0185594

  Abstract

  Mexico introduced inactivated polio vaccine (IPV) into its routine immunization (RI) schedule in 2007 but continued to give trivalent oral polio vaccine (tOPV) twice a year during national health weeks (NHW) through 2015.To evaluate individual variables associated with poliovirus (PV) shedding among children with IPV-induced immunity after vaccination with tOPV and their household contacts.We recruited 72 children (both genders, ≤30 months, vaccinated with at least two doses of IPV) and 144 household contacts (both genders, 2 per household, children and adults) between 08/2010 and 09/2010 in Orizaba, Veracruz. Three NHW took place (one before and two after enrollment). We collected fecal samples monthly for 12 months, and tested 2500 samples for polioviruses types 1, 2 and 3 with three serotype-specific singleplex real-time RT-PCR (rRT-PCR) assays. In order to increase the specificity for OPV virus, all positive and 112 negative samples were also processed with a two-step, OPV serotype-specific multiplex rRT-PCR.We estimated adjusted hazard ratios (HR) and 95% CI using Cox proportional hazards regression for recurrent events models accounting for individual clustering to assess the association of individual variables with the shedding of any poliovirus for all participants and stratifying according to whether the participant had received tOPV in the month of sample collection.216 participants were included. Of the 2500 collected samples, using the singleplex rRT-PCR assay, PV was detected in 5.7% (n = 142); PV1 in 1.2% (n = 29), PV2 in 4.1% (n = 103), and PV3 in 1.9% (n = 48). Of the 256 samples processed by multiplex rRT-PCR, PV was detected in 106 (PV1 in 16.41% (n = 42), PV2 in 21.09% (n = 54), and PV3 in 23.05% (n = 59). Both using singleplex and multiplex assays, shedding of OPV among non-vaccinated children and subjects older than 5 years of age living in the same household was associated with shedding of PV2 by a household contact. All models were adjusted by sex, age, IPV vaccination and OPV shedding by the same individual during the previous month of sample collection.Our results provide important evidence regarding the circulation of poliovirus in a mixed vaccination context (IPV+OPV) which mimics the "transitional phase" that occurs when countries use both vaccines simultaneously. Shedding of OPV2 by household contacts was most likely the source of infection of non-vaccinated children and subjects older than 5 years of age living in the same household.

  View details for PubMedID 29023555

• Evidence That Classroom-Based Behavioral Interventions Reduce Pregnancy-Related School Dropout Among Nairobi Adolescents HEALTH EDUCATION & BEHAVIOR Sarnquist, C., Sinclair, J., Mboya, B. O., Langat, N., Paiva, L., Halpern-Felsher, B., Golden, N. H., Maldonado, Y. A., Baiocchi, M. T. 2017; 44 (2): 297-303

  Abstract

  Purpose To evaluate the effect of behavioral, empowerment-focused interventions on the incidence of pregnancy-related school dropout among girls in Nairobi's informal settlements. Method Retrospective data on pregnancy-related school dropout from two cohorts were analyzed using a matched-pairs quasi-experimental design. The primary outcome was the change in the number of school dropouts due to pregnancy from 1 year before to 1 year after the interventions. Results Annual incidence of school dropout due to pregnancy decreased by 46% in the intervention schools (from 3.9% at baseline to 2.1% at follow-up), whereas the comparison schools remained essentially unchanged (p < .029). Sensitivity analysis shows that the findings are robust to small levels of unobserved bias. Conclusions Results suggest that these behavioral interventions significantly reduced the number of school dropouts due to pregnancy. As there are limited promising studies on behavioral interventions that decrease adolescent pregnancy in low-income settings, this intervention may be an important addition to this toolkit.

  View details for DOI 10.1177/1090198116657777

  View details for Web of Science ID 000398072000012

• Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting. PLoS neglected tropical diseases Haque, F., Ball, R. L., Khatun, S., Ahmed, M., Kache, S., Chisti, M. J., Sarker, S. A., Maples, S. D., Pieri, D., Vardhan Korrapati, T., Sarnquist, C., Federspiel, N., Rahman, M. W., Andrews, J. R., Rahman, M., Nelson, E. J. 2017; 11 (1)

  Abstract

  The emergence of mobile technology offers new opportunities to improve clinical guideline adherence in resource-limited settings. We conducted a clinical pilot study in rural Bangladesh to evaluate the impact of a smartphone adaptation of the World Health Organization (WHO) diarrheal disease management guidelines, including a modality for age-based weight estimation. Software development was guided by end-user input and evaluated in a resource-limited district and sub-district hospital during the fall 2015 cholera season; both hospitals lacked scales which necessitated weight estimation. The study consisted of a 6 week pre-intervention and 6 week intervention period with a 10-day post-discharge follow-up. Standard of care was maintained throughout the study with the exception that admitting clinicians used the tool during the intervention. Inclusion criteria were patients two months of age and older with uncomplicated diarrheal disease. The primary outcome was adherence to guidelines for prescriptions of intravenous (IV) fluids, antibiotics and zinc. A total of 841 patients were enrolled (325 pre-intervention; 516 intervention). During the intervention, the proportion of prescriptions for IV fluids decreased at the district and sub-district hospitals (both p < 0.001) with risk ratios (RRs) of 0.5 and 0.2, respectively. However, when IV fluids were prescribed, the volume better adhered to recommendations. The proportion of prescriptions for the recommended antibiotic azithromycin increased (p < 0.001 district; p = 0.035 sub-district) with RRs of 6.9 (district) and 1.6 (sub-district) while prescriptions for other antibiotics decreased; zinc adherence increased. Limitations included an absence of a concurrent control group and no independent dehydration assessment during the pre-intervention. Despite limitations, opportunities were identified to improve clinical care, including better assessment, weight estimation, and fluid/ antibiotic selection. These findings demonstrate that a smartphone-based tool can improve guideline adherence. This study should serve as a catalyst for a randomized controlled trial to expand on the findings and address limitations.

  View details for DOI 10.1371/journal.pntd.0005290

  View details for PubMedID 28103233

• A Behavior-Based Intervention That Prevents Sexual Assault: the Results of a Matched-Pairs, Cluster-Randomized Study in Nairobi, Kenya. Prevention science Baiocchi, M., Omondi, B., Langat, N., Boothroyd, D. B., Sinclair, J., Pavia, L., Mulinge, M., Githua, O., Golden, N. H., Sarnquist, C. 2016: -?

  Abstract

  The study's design was a cluster-randomized, matched-pairs, parallel trial of a behavior-based sexual assault prevention intervention in the informal settlements.The participants were primary school girls aged 10-16. Classroom-based interventions for girls and boys were delivered by instructors from the same settlements, at the same time, over six 2-h sessions. The girls' program had components of empowerment, gender relations, and self-defense. The boys' program promotes healthy gender norms. The control arm of the study received a health and hygiene curriculum. The primary outcome was the rate of sexual assault in the prior 12 months at the cluster level (school level). Secondary outcomes included the generalized self-efficacy scale, the distribution of number of times victims were sexually assaulted in the prior period, skills used, disclosure rates, and distribution of perpetrators. Difference-in-differences estimates are reported with bootstrapped confidence intervals.Fourteen schools with 3147 girls from the intervention group and 14 schools with 2539 girls from the control group were included in the analysis. We estimate a 3.7 % decrease, p = 0.03 and 95 % CI = (0.4, 8.0), in risk of sexual assault in the intervention group due to the intervention (initially 7.3 % at baseline). We estimate an increase in mean generalized self-efficacy score of 0.19 (baseline average 3.1, on a 1-4 scale), p = 0.0004 and 95 % CI = (0.08, 0.39).This innovative intervention that combined parallel training for young adolescent girls and boys in school settings showed significant reduction in the rate of sexual assault among girls in this population.

  View details for PubMedID 27562036

• Evidence That Classroom-Based Behavioral Interventions Reduce Pregnancy-Related School Dropout Among Nairobi Adolescents. Health education & behavior Sarnquist, C., Sinclair, J., Omondi Mboya, B., Langat, N., Paiva, L., Halpern-Felsher, B., Golden, N. H., Maldonado, Y. A., Baiocchi, M. T. 2016

  Abstract

  Purpose To evaluate the effect of behavioral, empowerment-focused interventions on the incidence of pregnancy-related school dropout among girls in Nairobi's informal settlements. Method Retrospective data on pregnancy-related school dropout from two cohorts were analyzed using a matched-pairs quasi-experimental design. The primary outcome was the change in the number of school dropouts due to pregnancy from 1 year before to 1 year after the interventions. Results Annual incidence of school dropout due to pregnancy decreased by 46% in the intervention schools (from 3.9% at baseline to 2.1% at follow-up), whereas the comparison schools remained essentially unchanged (p < .029). Sensitivity analysis shows that the findings are robust to small levels of unobserved bias. Conclusions Results suggest that these behavioral interventions significantly reduced the number of school dropouts due to pregnancy. As there are limited promising studies on behavioral interventions that decrease adolescent pregnancy in low-income settings, this intervention may be an important addition to this toolkit.

  View details for PubMedID 27486178

• Community circulation patterns of oral polio vaccine serotypes 1, 2, and 3 after mexican national immunization weeks. journal of infectious diseases Troy, S. B., Ferreyra-Reyes, L., Huang, C., Sarnquist, C., Canizales-Quintero, S., Nelson, C., Báez-Saldaña, R., Holubar, M., Ferreira-Guerrero, E., García-García, L., Maldonado, Y. A. 2014; 209 (11): 1693-1699

  Abstract

  Background. With wild poliovirus nearing eradication, preventing circulating vaccine-derived poliovirus (cVDPV) by understanding oral polio vaccine (OPV) community circulation is increasingly important. Mexico, where OPV is given only during biannual national immunization weeks (NIWs) but where children receive inactivated polio vaccine (IPV) as part of their primary regimen, provides a natural setting to study OPV community circulation. Methods. In total, 216 children and household contacts in Veracruz, Mexico, were enrolled, and monthly stool samples and questionnaires collected for 1 year; 2501 stool samples underwent RNA extraction, reverse transcription, and real-time polymerase chain reaction (PCR) to detect OPV serotypes 1, 2, and 3. Results. OPV was detected up to 7 months after an NIW, but not at 8 months. In total, 35% of samples collected from children vaccinated the prior month, but only 4% of other samples, contained OPV. Although each serotype was detected in similar proportions among OPV strains shed as a result of direct vaccination, 87% of OPV acquired through community spread was serotype 2 (P < .0001). Conclusions. Serotype 2 circulates longer and is transmitted more readily than serotypes 1 or 3 after NIWs in a Mexican community primarily vaccinated with IPV. This may be part of the reason why most isolated cVDPV has been serotype 2.

  View details for DOI 10.1093/infdis/jit831

  View details for PubMedID 24367038

  View details for PubMedCentralID PMC4017366

• Rape prevention through empowerment of adolescent girls. Pediatrics Sarnquist, C., Omondi, B., Sinclair, J., Gitau, C., Paiva, L., Mulinge, M., Cornfield, D. N., Maldonado, Y. 2014; 133 (5): e1226-32

  Abstract

  Sexual assault is a major cause of injury, unplanned pregnancy, HIV infection, and mental health problems worldwide. In parts of sub-Saharan Africa, sexual assault has reached epidemic proportions. This study evaluated the efficacy of an empowerment and self-defense intervention for adolescent girls to decrease the incidence of sexual assault and harassment in Nairobi's large informal settlements.A prospective cohort of 1978 adolescents from 4 neighborhoods near Nairobi were taught empowerment, deescalation, and self-defense skills in six 2-hour sessions. The standard-of-care (SOC) group (n = 428) received a life skills class. Self-reported, anonymous survey data were collected at baseline and 10.5 months after intervention.Annual sexual assault rates decreased from 17.9/100 person-years at baseline to 11.1 at follow-up (rate ratio = 1.61; 95% confidence interval [CI], 1.26-1.86; P < .001); there was no significant change in the SOC group (14.3 to 14.0, rate ratio = 1.02; 95% CI, 0.67-1.57, P = .92). Sexual assault disclosure in the intervention group increased from 56% to 75% (P = .006), compared with a constant incidence of disclosure (53%) in the SOC group. The majority (52.3%) of adolescents in the intervention group reported using skills learned to stop an assault.This intervention decreased sexual assault rates among adolescent girls in Kenya. The intervention was also associated with an increase in the disclosure of assaults, thereby enabling survivors to seek care and support and possibly leading to the identification and prosecution of perpetrators. This model should be adaptable to other settings both in Africa and globally.

  View details for DOI 10.1542/peds.2013-3414

  View details for PubMedID 24733880

• Integrating family planning and prevention of mother to child HIV transmission in Zimbabwe. Contraception Sarnquist, C. C., Moyo, P., Stranix-Chibanda, L., Chipato, T., Kang, J. L., Maldonado, Y. A. 2014; 89 (3): 209-214

  Abstract

  The objective was to integrate enhanced family planning (FP) and prevention of mother-to-child HIV transmission services in order to help HIV-positive Zimbabwean women achieve their desired family size and spacing as well as to maximize maternal and child health.HIV-positive pregnant women were enrolled into a standard-of-care (SOC, n=33) or intervention (n=65) cohort, based on study entry date, and followed for 3 months postpartum. The intervention cohort received education sessions aimed at increasing FP use and negotiation power. Both groups received care from nurses with enhanced FP training. Outcomes included FP use, FP knowledge and HIV disclosure, and were assessed with Fisher's Exact Tests, binomial tests and t tests.The intervention cohort reported increased control over condom use (p=.002), increased knowledge about IUDs (p=.002), increased relationship power (p=.01) and increased likelihood of disclosing their HIV status to a partner (p=.04) and having that partner disclose to them (p=.04) when compared to the SOC cohort. Long-acting reversible contraception (LARC) use in both groups increased from ~2% at baseline to >80% at 3 months postpartum (p<.001).FP and sexual negotiation skills and knowledge, as well as HIV disclosure, increased significantly in the intervention cohort. LARC uptake increased significantly in both the intervention and SOC cohorts, likely because both groups received care from nurses with enhanced FP training. Successful service integration models are needed to maximize health outcomes in resource-constrained environments; this intervention is such a model that should be replicable in other settings in sub-Saharan Africa and beyond.This study provides a rigorously evaluated intervention to integrate FP education into ante- and postnatal care for HIV-positive women and also to train providers on FP. Results suggest that this intervention had significant effects on contraception use and communication with sexual partners. This intervention should be adaptable to other areas.

  View details for DOI 10.1016/j.contraception.2013.11.003

  View details for PubMedID 24332254

• Antiretroviral therapy adherence and predictors to adherence in Albania: a cross-sectional study. Journal of infection in developing countries Morrison, S. D., Rashidi, V., Sarnquist, C., Banushi, V. H., Hole, M. K., Barbhaiya, N. J., Gashi, V. H., Osterberg, L., Maldonado, Y., Harxhi, A. 2014; 8 (7): 853-862

  Abstract

  The possibility of an HIV/AIDS epidemic in southeastern Europe (SEE) is not improbable. Thus, an understanding of the current issues surrounding HIV/AIDS care, specifically antiretroviral therapy (ART) adherence, in countries within SEE is critical. This study was conducted to determine the ART adherence characteristics of Albania's HIV-positive population.This cross-sectional study reports initial demographic and adherence characteristics of patients receiving HIV/AIDS treatment in Albania. Retrospective review of pharmacy medications dispensed supplemented reported adherence behavior. Further, an adherence index was utilized to explore adherence more thoroughly.Patient-reported adherence and pharmacy review showed adherence levels of 98.9±4.4% and 97.7±4.7%, respectively. Assessment by adherence index revealed an index level of 91.7±6.7. Factors associated with a score of < 95 on the adherence index were: being partnered (OR = 0.29, 95% CI = 0.09 - 0.98), history of depression (OR = 0.24, 95% CI = 0.08 - 0.76), increased number of barriers to care (OR = 0.80, 95% CI = 0.66 - 0.97), and increased number of current social and medical needs (OR = 0.72, 95% CI = 0.58 - 0.91).Interventions aimed at reducing barriers to care, addressing current medical and social needs, and treating mental health issues may help improve adherence to ART in patients with HIV/AIDS in Albania. With little known about HIV/AIDS in SEE, this study provides guidance on how SEE countries can help prevent a possible rise in the prevalence of HIV given the close link of ART adherence and spread of HIV.

  View details for DOI 10.3855/jidc.3563

  View details for PubMedID 25022295

• Factors Influencing Women's Decision to Seek Antenatal Care in the ANDES of Peru MATERNAL AND CHILD HEALTH JOURNAL Ayala, L. S., Blumenthal, P. D., Sarnquist, C. C. 2013; 17 (6): 1112-1118

  Abstract

  This qualitative study aimed to assess factors influencing pregnant women's decision to seek or avoid antenatal care (ANC) in the Andes of Peru. Open-ended, semi-structured interviews were conducted with 24 women utilizing ANC (+) and 10 women avoiding ANC (-). Interviews were translated to English from Quechua and Spanish, transcribed, and analyzed using grounded theory. Factors influencing ANC- women included: expecting criticism for having additional children; long ANC wait time and inconvenient hours of operation; and masculine gender of health workers. For ANC+ women, motivating factors included: maximizing positive health outcomes; past negative maternity experiences; pressure from family members; and avoidance of rumored fines or fees associated with ANC non-attendance and in-hospital deliveries, respectively. Both ANC+ and ANC- women were fearful and embarrassed about possible criticism for having additional children and the gender of the health workers, yet they weighed these factors differently. To better understand how rural women make decisions about ANC attendance, it is important to consider the value they place on the factors influencing their decision, and their emotional assessment of such issues.

  View details for DOI 10.1007/s10995-012-1113-9

  View details for Web of Science ID 000321785300017

  View details for PubMedID 22956365

• Reproductive Health and Family Planning Needs Among HIV-Infected Women in Sub-Saharan Africa CURRENT HIV RESEARCH Sarnquist, C. C., Rahangdale, L., Maldonado, Y. 2013; 11 (2): 160-168

  Abstract

  Review key topics and recent literature regarding reproductive health and family planning needs for HIV-infected women in Sub-Saharan Africa.Electronic searches performed in PubMed, JSTOR, and Web of Science; identified articles reviewed for inclusion.Most HIV-infected women in Sub-Saharan Africa bear children, and access to antiretroviral therapy may increase childbearing desires and/or fertility, resulting in greater need for contraception. Most contraceptive options can be safely and effectively used by HIV-infected women. Unmet need for contraception is high in this population, with 66- 92% of women reporting not wanting another child (now or ever), but only 20-43% using contraception. During pregnancy and delivery, HIV-infected women need access to prevention of mother-to-child transmission (PMTCT) services, a skilled birth attendant, and quality post-partum care to prevent HIV infection in the infant and maximize maternal health. Providers may lack resources as well as appropriate training and support to provide such services to women with HIV. Innovations in biomedical and behavioral interventions may improve reproductive healthcare for HIV-infected women, but in Sub-Saharan Africa, models of integrating HIV and PMTCT services with family planning and reproductive health services will be important to improve reproductive outcomes.HIV-infected women in Sub-Saharan Africa have myriad needs related to reproductive health, including access to high-quality family planning information and options, high-quality pregnancy care, and trained providers. Integrated services that help prevent unintended pregnancy and optimize maternal and infant health before, during and after pregnancy will both maximize limited resources as well as provide improved reproductive outcomes.

  View details for PubMedID 23432491

• Communicating About Vaccines and Vaccine Safety: What Are Medical Residents Learning and What Do They Want to Learn? JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE Sarnquist, C., Sawyer, M., Calvin, K., Mason, W., Blumberg, D., Luther, J., Maldonado, Y. 2013; 19 (1): 40-46

  Abstract

  Physicians spend significant amounts of time discussing vaccine safety concerns with patients and parents. This study aimed to better understand the educational needs of US residents regarding vaccine safety communication, primarily by quantifying the vaccine safety communication training that residents currently receive and elucidating residents' preferences around education about vaccines and vaccine safety communication.A mixed-methods needs assessment consisting of focus groups and a survey.A convenience sample of 303 medical residents in pediatrics, family medicine, and internal medicine from across the United States participated in an online, anonymous survey from March through June 2010. In addition, 9 focus groups with 47 resident participants were held. MAIN OUTCOME MEASURES/RESULTS: The sample included residents in pediatrics (239, 80.2%), internal or family medicine (30, 10.1%), and dual medicine-pediatrics (29, 9.7%); 20.6% of the residents reported "not learning" about vaccine safety communication in their residency programs. Preferred learning methods, which were also the most commonly used methods, included didactic lectures and role-modeling/cases. Electronic teaching method were not only less desired but also very rarely utilized. More than 95% of residents reported thinking that vaccine safety communication would be very or somewhat important in their careers.Improving education on vaccine safety communication within US residency programs, as well as offering self-learning opportunities, can better prepare physicians for their careers.

  View details for DOI 10.1097/PHH.0b013e3182495776

  View details for PubMedID 23169402

• Cultural adaptation of a survey to assess medical providers' knowledge of and attitudes towards HIV/AIDS in Albania. PloS one Morrison, S. D., Rashidi, V., Banushi, V. H., Barbhaiya, N. J., Gashi, V. H., Sarnquist, C., Maldonado, Y., Harxhi, A. 2013; 8 (3): e59816

  Abstract

  Though the HIV/AIDS epidemic in Southeastern Europe is one of low reported prevalence, numerous studies have described the pervasiveness of medical providers' lack of knowledge of HIV/AIDS in the Balkans. This study sought to culturally adapt an instrument to assess medical providers' knowledge of and attitudes towards HIV/AIDS in Albania. Cultural adaptation was completed through development of a survey from previously validated instruments, translation of the survey into Albanian, blinded back translation, expert committee review of the draft instrument, focus group pre-testing with community- and University Hospital Center of Tirana-based physicians and nurses, and test-retest reliability testing. Blinded back translation of the instrument supported the initial translation with slight changes to the idiomatic and conceptual equivalences. Focus group pre-testing generally supported the instrument, yet some experiential and idiomatic changes were implemented. Based on unweighted kappa and/or prevalence adjusted bias adjusted kappa (PABAK), 20 of the 43 questions were deemed statistically significant at kappa and/or PABAK ≥0.5, while 12 others did not cross zero on the 95% confidence interval for kappa, indicating their probable significance. Subsequently, an instrument to assess medical providers' knowledge of and attitudes toward HIV/AIDS for an Albanian population was developed which can be expanded within Albania and potentially to other countries within the Balkans, which have an Albanian-speaking population.

  View details for DOI 10.1371/journal.pone.0059816

  View details for PubMedID 23544101

  View details for PubMedCentralID PMC3609723

• Cultural adaptation of a survey to assess medical providers' knowledge of and attitudes towards HIV/AIDS in Albania. PloS one Morrison, S. D., Rashidi, V., Banushi, V. H., Barbhaiya, N. J., Gashi, V. H., Sarnquist, C., Maldonado, Y., Harxhi, A. 2013; 8 (3)

  Abstract

  Though the HIV/AIDS epidemic in Southeastern Europe is one of low reported prevalence, numerous studies have described the pervasiveness of medical providers' lack of knowledge of HIV/AIDS in the Balkans. This study sought to culturally adapt an instrument to assess medical providers' knowledge of and attitudes towards HIV/AIDS in Albania. Cultural adaptation was completed through development of a survey from previously validated instruments, translation of the survey into Albanian, blinded back translation, expert committee review of the draft instrument, focus group pre-testing with community- and University Hospital Center of Tirana-based physicians and nurses, and test-retest reliability testing. Blinded back translation of the instrument supported the initial translation with slight changes to the idiomatic and conceptual equivalences. Focus group pre-testing generally supported the instrument, yet some experiential and idiomatic changes were implemented. Based on unweighted kappa and/or prevalence adjusted bias adjusted kappa (PABAK), 20 of the 43 questions were deemed statistically significant at kappa and/or PABAK ≥0.5, while 12 others did not cross zero on the 95% confidence interval for kappa, indicating their probable significance. Subsequently, an instrument to assess medical providers' knowledge of and attitudes toward HIV/AIDS for an Albanian population was developed which can be expanded within Albania and potentially to other countries within the Balkans, which have an Albanian-speaking population.

  View details for DOI 10.1371/journal.pone.0059816

  View details for PubMedID 23544101

  View details for PubMedCentralID PMC3609723

• Staphylococcal infections in children, California, USA, 1985-2009. Emerging infectious diseases Gutierrez, K., Halpern, M. S., Sarnquist, C., Soni, S., Arroyo, A. C., Maldonado, Y. 2013; 19 (1): 10-20

  Abstract

  We conducted a retrospective, observational, population-based study to investigate the effect of staphylococcal infections on the hospitalization of children in California during 1985-2009. Hospitalized children with staphylococcal infections were identified through the California Office of Statewide Health Planning and Development discharge database. Infections were categorized as community onset, community onset health care-associated, or hospital onset. Infection incidence was calculated relative to all children and to those hospitalized in acute-care facilities. A total of 140,265 records were analyzed. Overall incidence increased from 49/100,000 population in 1985 to a peak of 83/100,000 in 2006 and dropped to 73/100,000 in 2009. Staphylococcal infections were associated with longer hospital stays and higher risk for death relative to all-cause hospitalizations of children. The number of methicillin-resistant Staphylococcus aureus infections increased, and the number of methicillin-susceptible S. aureus infections remained unchanged. Children <3 years of age, Blacks, and those without private insurance were at higher risk for hospitalization.

  View details for DOI 10.3201/eid1901.111740

  View details for PubMedID 23260060

• Levels of self-reported depression and anxiety among HIV-positive patients in Albania: a cross-sectional study CROATIAN MEDICAL JOURNAL Morrison, S. D., Banushi, V. H., Sarnquist, C., Gashi, V. H., Osterberg, L., Maldonado, Y., Harxhi, A. 2011; 52 (5): 622-628

  Abstract

  To gain an initial perspective of mental health issues facing the Human Immunodeficiency Virus (HIV)-positive population at the University Hospital Center of Tirana (UHCT) HIV/AIDS Ambulatory Clinic.From June-August 2009, we conducted semi-structured interviews with 79 patients (93% response rate) at the UHCT HIV/AIDS Ambulatory Clinic. The interviews assessed patient-reported histories of mental health diagnoses, patients' demographics, and current emotional health status.The percentage of patients who reported a history of diagnosis of depression or anxiety was high - 62.3% and 82.3%, respectively. Factors associated with a history of depression included having been diagnosed with anxiety (P<0.001), having a higher number of barriers to care (P<0.001), having a higher number of current medical and social needs (P<0.001), or having not obtained antiretroviral therapy (ART) abroad (P=0.004). Factors associated with a history of anxiety included having been on first-line ART (P=0.008), having been diagnosed with HIV for shorter periods of time (P=0.043), having been diagnosed with depression (P<0.001), having a higher number of current medical and social needs (P=0.035), or having not obtained ART abroad (P=0.003).Mental health problems are widespread among the known HIV-positive patient population in Albania. The high prevalences of anxiety and depression and of dual diagnoses of these conditions suggest the need for more mental health care for HIV-positive patients in Albania.

  View details for DOI 10.3325/cmj.2011.52.622

  View details for PubMedID 21990080

• BARRIERS TO CARE AND CURRENT MEDICAL AND SOCIAL NEEDS OF HIV-POSITIVE PATIENTS IN ALBANIA CENTRAL EUROPEAN JOURNAL OF PUBLIC HEALTH Morrison, S. D., Banushi, V. H., Sarnquist, C., Gashi, V. H., Osterberg, L., Maldonado, Y., Harxhi, A. 2011; 19 (2): 91-97

  Abstract

  As HIV/AIDS prevalence rises in Eastern Europe, assessment of local epidemics in the bordering Central European region, especially South Eastern Europe, is vital in order to meet treatment and prevention needs. Understanding current medical and social needs and barriers to care experienced by HIV-positive patients in these regions may provide insight into how to best respond to the local epidemics, increase patients' access to treatment, and reduce loss to follow-up.This study assesses the patient characteristics, barriers to care, and current medical and social needs of HIV-positive patients in Albania. Semi-structured interviews were used in this cross-sectional study.We interviewed 79 of 85 patients (93% response rate) followed at the University Hospital Center of Tirana (UHCT) HIV/AIDS Ambulatory Clinic, which represented the majority of patients under HIV care in Albania during 2009.The local HIV epidemic seems to be comprised mainly of heterosexual men who have spent an average of 3.6 years abroad. The vast majority of patients under care at UHCT HIV/AIDS Ambulatory Clinic had experienced barriers to care associated with social stigma (97.4%), lack of knowledge of HIV medical care (76.6%), and medical provider's lack of knowledge of HIV (70.9%). Social needs of the patients were also overwhelmingly unmet (90.0-95.7%).In addressing HIV/AIDS in Albania, it will be crucial to educate the healthcare sector in ways to identify and address barriers to care and current medical and social needs of HIV-positive patients.

  View details for PubMedID 21739899

• Rural HIV-infected women's access to medical care: ongoing needs in California AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Sarnquist, C. C., Soni, S., Hwang, H., Topol, B. B., Mutima, S., Maldonado, Y. A. 2011; 23 (7): 792-796

  Abstract

  HIV-infected women living in rural areas often have considerably less access to care than their urban and suburban counterparts. In much of the USA, little is known about HIV care among rural populations. This study elucidated barriers to care for rural women in California. Methods included retrospective structured interviews conducted with 64 women living in rural areas and receiving HIV care at 11 California healthcare facilities. Facilities were randomly sampled and all HIV-infected female patients seeking care at those facilities during a specified time period were eligible. The most commonly cited barriers to accessing care included physical health problems that prevented travel to care (32.8%), lack of transportation (31.2%), and lack of ability to navigate the healthcare system (25.0%). Being divorced/separated/widowed (compared to being either married or single) was associated with reporting physical health as a barrier to care (p=0.03); being unemployed (p=0.003) or having to travel 31-90 minutes (p=0.007, compared to less than 31 or greater than 90) were both associated with transportation as a barrier; and speaking English rather than Spanish was associated with reporting "difficulty navigating the system" (p=0.04). Twenty-nine women (45.3%) reported difficulty in traveling to appointments. Overall, 24 (37.5%) women missed an HIV medical appointment in the previous 12-month period, primarily due to their physical health and transportation limitations. Physical health and transportation problems were both the major barriers to accessing health services and the primary reasons for missing HIV care appointments among this population of HIV-infected women living in rural areas. Providing transportation programs and/or mobile clinics, as well as providing support for patients with physical limitations, may be essential to improving access to HIV care in rural areas.

  View details for DOI 10.1080/09540121.2010.516345

  View details for PubMedID 21287418

• How Racial and Ethnic Groupings May Mask Disparities: The Importance of Separating Pacific Islanders From Asians in Prenatal Care Data MATERNAL AND CHILD HEALTH JOURNAL Sarnquist, C. C., Grieb, E. M., Maldonado, Y. A. 2010; 14 (4): 635-641

  Abstract

  To understand racial/ethnic differences in prenatal care receipt among Pacific Islanders and Asians, who are often combined into a single A/PI category.Retrospective, population-based data were collected by the Vital Statistics branch of the California Department of Health Services. Approximately 2.6 million records of all live California births with a birth certificate in 2000-2004 were included. Analysis focused on prenatal care receipt and population characteristics associated with lack of adequate prenatal care, especially among Asian and Pacific Islander groups.Pacific Islanders (n = 11,962) were the most likely, compared to any other racial/ethnic group, to have inadequate prenatal care (OR = 2.9, 95% CIs 2.8-3.1), even when controlling for factors known to affect care receipt, specifically maternal age, educational attainment, parity, insurance, geographical region of residence, and maternal place of birth. In contrast, Asian women (n = 295,741) received care closer to that of the White reference group (OR = 1.5, 95% CIs 1.5-1.5). Among Pacific Islanders, Samoans (OR = 3.0, 95% CIs 2.7-3.4) were at particular risk of inadequate care compared to other PI sub-groups.Pacific Islander women received less adequate prenatal care than women of other racial/ethnic groups. The common practice of combining Asians and Pacific Islanders into a single A/PI category may mask needs in the Pacific Islander community. Therefore, in order to continue to reduce health disparities, it may be necessary to collect separate data on these two distinct populations in order to be able to appropriately direct programs and resources.

  View details for DOI 10.1007/s10995-009-0494-x

  View details for PubMedID 19582560

• Frequency of Cervical Cancer and Breast Cancer Screening in HIV-Infected Women in a County-Based HIV Clinic in the Western United States JOURNAL OF WOMENS HEALTH Rahangdale, L., Sarnquist, C., Yavari, A., Blumenthal, P., Israelski, D. 2010; 19 (4): 709-712

  Abstract

  Women's primary-care services are frequently dispensed to HIV-infected women through HIV specialty clinics. Our objective was to evaluate cervical cancer and breast cancer screening practices in a county-based HIV clinic in San Mateo, California.This was a retrospective cohort study of medical records of HIV-infected women obtaining HIV care at this site.Between January 1, 2002 and December 31, 2006, 69 women were documented to have at least 12 months of medical care at the clinic. Median followup time was 51 months. Over 253 person-years of followup, there were 656 pap smears performed per 1,000 person-years; 77.9% of women had at least one Pap smear during the study time period. A total of 59.5% (47/79) of normal pap smears had a followup pap smear within 18 months; 62.0% of abnormal pap smears had a followup pap smear within 12 months. A CD4 count of less than 200 cells/mm(3) was associated with not receiving a pap smear in multivariable analysis. Mammogram screening was performed on 64.7% of women aged 40 or older.Based on the results of this study, the majority of HIV-infected women at this clinic received cervical and breast cancer screening at some point during their care. Only two-thirds of abnormal pap smear results had followup pap smear screening within a year. With the increased risk of cervical cancer in HIV-infected women, efforts should be made to promote cervical cancer screening, particularly in high-risk women.

  View details for DOI 10.1089/jwh.2009.1412

  View details for Web of Science ID 000277030400009

  View details for PubMedID 20201703

  View details for PubMedCentralID PMC2867552

• Prenatal Screening for Infectious Diseases: An Analysis of Disparities and Adherence to Policy in California 134th Annual Meeting of the American-Public-Health-Association Sheikh, L. A., Sarnquist, C., Grieb, E. M., Sullivan, B., Maldonado, Y. A. SPRINGER/PLENUM PUBLISHERS. 2009: 260–67

  Abstract

  Prenatal infectious diseases are a major cause of mortality and morbidity among newborns, but many are preventable with proper maternal screening and treatment. METHODS; Adherence to prenatal infectious disease screening guidelines and demographic factors that influence adherence were determined utilizing existing data on 1837 live births from 1999-2003.We found higher rates of testing for syphilis (94.54%), rubella (92.69%) and hepatitis B (94.23%) than for HIV (73.82%) and GBS (69.05%). Adherence to testing guidelines varied by both disease and maternal factors. Lack of insurance, geographic location, inadequate prenatal care and incarceration were the main maternal factors associated with lack of testing.Disease screening rates may be improved by reducing socioeconomic barriers to prenatal testing, supporting access to insurance, eliminating provider biases and providing adequate prenatal care.

  View details for DOI 10.1007/s10995-008-0341-5

  View details for PubMedID 18446431

• Increased Uptake of HIV Testing With the Integration of Nurse-Initiated HIV Testing Into Routine Prenatal Care JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Cohan, D., Sarnquist, C., Gomez, E., Feakins, C., Maldonado, Y., Zetola, N. 2008; 49 (5): 571-573

  View details for Web of Science ID 000261219000020

  View details for PubMedID 19202463

• Patient acceptance of and satisfaction with rapid HIV testing in a labor and delivery setting JOURNAL OF WOMENS HEALTH Rahangdale, L., Sarnquist, C., Maldonado, Y., Cohan, D. 2008; 17 (3): 465-471

  Abstract

  To evaluate women's acceptance of and satisfaction with rapid human immunodeficiency virus (HIV) testing in a labor and delivery (L&D) setting.We conducted a cross-sectional survey of pregnant women who underwent counseling for rapid HIV testing in an L&D unit at a university-affiliated urban hospital from April 1, 2005, to July 15, 2006. Medical chart abstractions were performed for all 158 eligible women, and a convenience sample of 46 women also completed a survey evaluating their satisfaction using a validated decisional conflict scale.Uptake of rapid HIV testing was 98.1% (155 of 158). Overall, 89.1% of the 46 surveyed women reported feeling satisfied with their testing experience, and 82.6% of women reported no decisional conflict in making decisions for rapid testing; 9% of women reported decisional conflict. The median decisional conflict score on a scale of 0-100 was 5 (mean 11.6, SD 16). In addition, most women reported feeling certain about their decision to test (87.0%), feeling informed about testing (76.1%), having high levels of clarity about their values regarding testing (76.1%), and feeling supported in their decision-making process (76.1%).In this study population, there was a high level of acceptance and satisfaction with rapid HIV testing in the L&D setting. Rapid HIV testing is a vital component of perinatal HIV transmission prevention, as well as being an opportunity for women, some of whom have little contact with the healthcare system, to learn their HIV status.

  View details for DOI 10.1089/jwh.2007.0545

  View details for PubMedID 18373491

• Rapid HIV testing on Labor and delivery - Lessons from the field JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Rahangdale, L., Sarnquist, C., Feakins, C., Nassos, P., Haller, B., Cohan, D. 2007; 46 (3): 376-378

  View details for Web of Science ID 000250607500023

  View details for PubMedID 18090304

• The effectiveness of state and national policy on the implementation of perinatal HIV prevention interventions AMERICAN JOURNAL OF PUBLIC HEALTH Sarnquist, C. C., Cunningham, S. D., Sullivan, B., Maldonado, Y. 2007; 97 (6): 1041-1046

  Abstract

  The 1994 and 1995 US Public Health Service Guidelines regarding HIV testing and treatment for pregnant women and the resulting 1995 California law mandating an HIV test and treatment offer to every pregnant woman aim to reduce perinatal HIV transmission. However, the effectiveness of such policies after implementation is often unclear. We analyzed the association between these policies and offers of HIV tests and treatment to HIV-infected women in California.Data from active, population-based surveillance of 496 HIV-infected women and their infants, collected from 1987 to 2002, were analyzed to compare rates of offers of HIV tests and treatment before and after 1996.We found significant increases in offers of HIV tests (P<.001) and offers of treatment (P<.001) when we compared women who delivered between 1987 and 1995 with those who delivered between 1996 and 2002. Receipt of prenatal care was the major predictor of both test and treatment offer. A significant shift in reported HIV risk factors was also evident between the 2 groups.Our findings of increased offers of HIV tests and treatment to HIV-infected pregnant women suggest that the national guidelines and the 1996 California law improved health care for these women, which may lessen the risk of perinatal HIV transmission.

  View details for DOI 10.2105/AJPH.2005.072371

  View details for PubMedID 17463383

• A comparison of perinatal HIV prevention opportunities for Hispanic and non-Hispanic women in California AIDS EDUCATION AND PREVENTION Kropp, R. Y., Sarnquist, C. C., Montgomery, E. T., Ruiz, J. D., Maldonado, Y. A. 2006; 18 (5): 430-443

  Abstract

  Using a semi-structured survey and convenience sample of pregnant/recently delivered Hispanic (n = 453) and non-Hispanic (n = 904) women in four California counties, this study compared rates of timely prenatal care (PNC) initiation, HIV test counseling, test offering, and test acceptance in PNC between Hispanic and non-Hispanic women. Hispanic women were less likely to report timely PNC initiation (69.3% vs. 80.4%, p < .0001), receiving test offer (69.5% vs. 76.7%, p = .002), and ever having been tested (77.3% vs. 87.9%, p < .0001) than non-Hispanic women. Hispanic women were more likely to report not knowing where to go (p = .04) and having no insurance (p < .001), transportation (p = .001), and child care (p = .007) as reasons for late PNC start. Both Hispanic and non-Hispanic women most commonly accepted a test offer for their health/health of their baby; Hispanic women were more likely to accept based on doctor/nurse recommendation (80.1% vs. 62.7%, p < .001). A quarter of Hispanic and non-Hispanic women reported they didn't feel they had a choice or that test was done automatically. Efforts to improve perinatal HIV prevention opportunities for all women in California are required. Furthermore, Hispanic women may have disparities in receipt of prenatal care and HIV test offer that need additional attention.

  View details for Web of Science ID 000241078100005

  View details for PubMedID 17067254