Papers by Elizabeth Lowenthal
Principles and Practice of Pediatric Infectious Disease, 2008
Journal of the International AIDS Society, 2014
As adolescents living with HIV gain autonomy over their self-care and begin to engage in sexual r... more As adolescents living with HIV gain autonomy over their self-care and begin to engage in sexual relationships, their experiences of being informed about their HIV status and of telling others about their HIV status may affect their ability to cope with having the disease. In 2010, we conducted a qualitative study among adolescents aged 10-19 living with HIV in Zambia, and with their parents and health care providers. Through interviews and focus group discussions, we explored the disclosure of HIV status to adolescents living with HIV; adolescents' disclosure of their status to others; and the impact of both forms of disclosure on adolescents. Our study identified three main barriers to disclosure of HIV status: local norms that deter parents from communicating with their children about sexuality; fear of HIV stigma; and an underlying presumption that adolescents would not understand the consequences of a HIV diagnosis on their lives and relationships. With regard to adolescents...
Journal of Adolescent Health
AIDS and Behavior
Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) ne... more Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and ...
Journal of Global Health
Youth Lay Counsellors deserve comprehensive support not just supervision; of cases but also suppo... more Youth Lay Counsellors deserve comprehensive support not just supervision; of cases but also support that considers their mental emotional and economic health.
Table S1. Survey Risk and Protective Factor Items and Response Codes. Table S2. Factor Analysis F... more Table S1. Survey Risk and Protective Factor Items and Response Codes. Table S2. Factor Analysis Findings for Problem Behavior Theory Risk Factor Survey Items. Table S3. Factor Analysis Findings for Problem Behavior Theory Protective Factor Survey Items. (DOCX 48â kb)
Journal of Acquired Immune Deficiency Syndromes, 2016
Pill counts with calculated adherence percentages are used in many settings to monitor adherence,... more Pill counts with calculated adherence percentages are used in many settings to monitor adherence, but can be undermined by patients discarding pills to hide non-adherence. Pill counts suggesting that >100% of prescribed doses were taken can signal "pill dumping." We defined "overadherence" (OA) among a cohort of 300 HIV-infected adolescents as having >1/3 of pill counts with >100% adherence during a year of follow-up. Apparent over-adherence was more common in those with virologic failure than those with suppressed viral loads (33% vs 13%, chi 2 p=0.001). Pill count adherence repeatedly >100% may identify HIV-infected adolescents at increased risk of treatment failure.
International Journal of School Health, 2018
Background: Increased rates of alcohol and drugs abuse has been noted among secondary school stud... more Background: Increased rates of alcohol and drugs abuse has been noted among secondary school students in Botswana. Objectives: We conducted nine student focus groups to elicit motivations for substance use as well as risk and mitigating factors. Methods: Participants were purposely sampled from among 2,227 secondary school students surveyed regarding drug/alcohol use in secondary schools. Students were selected for focus group participation based on their scores on the alcohol use and dependency inventory tool (AUDIT) and self-reported risk factors for alcohol/drug use. Results: Students reported that alcohol/drugs are readily available at school and at home. A prominent theme among substance users was inadequate support from parents, who they describe as uncomfortable and unwilling to talk about common issues faced during adolescence, including alcohol/drug use. Conclusions: We identified opportunities to improve the current situation such as renewing efforts to restrict alcohol availability and focusing on parent-child communication interventions.
Community Mental Health Journal, 2021
When planning interventions for adolescents, adult interventions should not be used ‘as is’ in yo... more When planning interventions for adolescents, adult interventions should not be used ‘as is’ in youth settings. Stakeholder engagement can help understand the overall adolescent mental health ecosystem and adapt existing evidence-based interventions for the youth. To understand the overall mental health needs of adolescents in Botswana and the necessary adaptations required for an adolescent lay counselor based intervention in the country. We used the theory of change model and the nominal group technique in five stakeholder meetings. Meetings were held to discuss the mental health needs of youth in Botswana and identify priorities for a lay counsellor based intervention modelled after the Friendship Bench intervention, an existing mental health intervention for adults. The root causes of mental health problems among Botswana’s youth identified by stakeholders included limited mental health knowledge among the youth and the community, family problems, poor communication, low self-esteem, the rapid growth of technology, and biological/genetic predisposition. Structurally barriers included: mental illness-related stigma, lack of psychosocial support, incomplete follow up for health services, cultural beliefs about mental illness, and fragmented mental health services. The stakeholders envisage a program that could empower adolescents and youth counselors to address mental health concerns for a healthier community. The group identified and prioritized several key elements of an effective lay counselor intervention. A diverse group of community stakeholders can illustrate critical mental health needs and elements that countries could use to adapt and contextualize a lay counsellor based mental health intervention for new populations such as the youth.
African Journal of Health Professions Education, 2017
A registrar is a medical doctor undergoing training to become a specialist. Registrars frequently... more A registrar is a medical doctor undergoing training to become a specialist. Registrars frequently feel exhausted because of long working hours, overwhelmed by having a large body of clinical knowledge to master, stressed because of patients who depend on them for survival, financially burdened owing to an insufficient salary, and challenged with balancing the demands of professional and personal life. [1,2] Registrars often have tremendous responsibilities at work; yet, they have very little autonomy. According to the job demand-control-support model, employees who work in jobs with high demands, low control, and low social support experience the lowest level of psychological and physical wellbeing. [3] Therefore, registrars are at high risk of developing burnout. [4] Burnout has been defined as a three-dimensional syndrome that includes emotional exhaustion, depersonalisation and reduced personal accomplishment. [5] Emotional exhaustion is a depletion of emotional resources. Depersonalisation is a negative and cynical attitude towards others. Reduced personal accomplishment is a negative and dissatisfied evaluation of oneself. Unlike major depressive disorder, which affects all aspects of a person's life, burnout is a distinct work-related syndrome. [5] Globally, research has shown that burnout rates among doctors range from 25% to 76%. [1,4,6] Burnout has been correlated with various physical symptoms, including fatigue, insomnia, headaches and gastrointestinal distress. [1,4,5] Potential consequences of burnout include an increase in alcohol and drug use, a higher rate of depression, and an increased incidence of marital and family problems. [1,4,5] Doctors who are burnt out are more likely to self-report suboptimal patient care and medical errors. [6,7] Burnout often decreases empathy, compassion, and availability of doctors for their patients, which leads to lower patient satisfaction. [8] Overall, burnout can negatively impact a registrar's quality of life and the ability to provide sustainable, safe, and empathetic patient care, simultaneously weakening the morale of registrars in training programmes. [1,4,6,8] In resource-limited settings, work-related stresses are amplified compared with those of doctors working in resource-rich settings. [9,10] Registrars in resource-limited settings often work in overcrowded hospitals with inadequate medical supplies and equipment, have fewer mentoring and career-building opportunities, are paid less, and are faced with high patient mortality rates. In sub-Saharan Africa, HIV has added to the workload, with Background. Burnout during registrar training is high, especially in resource-limited settings where stressors are intensified. Burnout leads to decreased quality of life for doctors, poor job and patient satisfaction, and difficulty retaining doctors. Objectives. Primary: to measure burnout among registrars working at Princess Marina Hospital in Gaborone, Botswana. Secondary: to determine factors contributing to burnout and identify potential wellness interventions. Methods. The validated Maslach Burnout Inventory was used to measure the degree of emotional exhaustion, depersonalisation and personal accomplishment. Work-related difficulties and potential wellness interventions were explored through multiple-choice and open-ended questions. Results. Of 40 eligible registrars, 20 (50%) completed the survey. High levels of burnout were reported for emotional exhaustion in 65% (13/20), depersonalisation in 45% (9/20), and personal accomplishment in 35% (7/20) of registrars. A high degree of burnout was reported by 75% (15/20) of registrars in one or more domains. In the previous 7 days, registrars worked an average of 77 hours, took 1.5 overnight calls, slept 5.7 hours per night, and 53% (10/19) had ≥1 of their patients die. Five (25%) registrars considered leaving Botswana to work in another country, which correlated with those with the highest degree of burnout. The most common frustrations included insufficient salary and limited medical resources. Suggested interventions included improved mentorship and wellness lectures. Conclusions. There is a high degree of burnout, especially emotional exhaustion, among registrars. Encouragingly, most registrars have a desire to work in Botswana after training. Future research on improving registrar wellness in low-resource settings is urgently needed.
BMC Public Health, 2018
Background: Alcohol and illicit drug use has been recognized as a growing problem among adolescen... more Background: Alcohol and illicit drug use has been recognized as a growing problem among adolescents in Botswana. Little is known about factors affecting alcohol and drug use among Botswana's secondary school students. To aid the design and implementation of effective public health interventions, we sought to determine the prevalence of alcohol and drug use in secondary school students in urban and peri-urban areas of Botswana, and to evaluate risk and protective factors for substance use. Methods: We performed a 72-item cross-sectional survey of students in 17 public secondary schools in Gaborone, Lobatse, Molepolole and Mochudi, Botswana. The World Health Organization's (WHO) Alcohol Use Disorder Identification Test (AUDIT) was used to define hazardous drinking behavior. Using Jessor's Problem Behavior Theory (PBT) as our conceptual framework, we culturally-adapted items from previously validated tools to measure risk and protective factors for alcohol and drug use. Between-group differences of risk and protective factors were compared using univariate binomial and multinomial-ordinal logit analysis. Relative risks of alcohol and drug use by demographic, high risks and low protections were calculated. Multivariate ordinal-multinomial cumulative logit analysis, multivariate nominal-multinomial logit analysis, and binominal logit analysis were used to build models illustrating the relationship between risk and protective factors and student alcohol and illicit drug use. Clustered data was adjusted for in all analyses using Generalized Estimating Equations (GEE) methods. Results: Of the 1936 students surveyed, 816 (42.1%) reported alcohol use, and 434 (22.4%) met criteria for hazardous alcohol use. Illicit drug use was reported by 324 students (16.7%), with motokwane (marijuana) being the most commonly used drug. Risk factors more strongly associated with alcohol and drug use were reported alcohol availability, individual and social vulnerability factors, and poor peer modeling. Individual and social controls protections appear to mitigate risk of student alcohol and drug use. Conclusions: Alcohol and illicit drug use is prevalent among secondary school students in Botswana. Our data suggest that interventions that reduce the availability of alcohol and drugs and that build greater support networks for adolescents may be most helpful in decreasing alcohol and drug use among secondary school students in Botswana.
Journal of Child & Adolescent Mental Health, 2011
Objective-To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of ... more Objective-To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of psychosocial health, for screening HIV+ Batswana children. Method-Setswana versions of the parent and child PSC were administered to 509 HIV+ Batswana children (age 8-16) and their parents/guardians. Test properties were evaluated and cutoff scores were derived using receiver operating characteristic curve analysis. Scores on the parent-completed PSC and the child-completed PSC-Y were compared to parental and clinic staff reports of concern about the child's psychosocial health and to scores on the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. Results-The Setswana PSC has high internal consistency (Cronbach's alpha 0.87 for the parent-completed version). Comparing PSC scores to parental reports of concern and childreported depression symptoms, a cutoff score of 20 on the PSC and PSC-Y maximised the sensitivity and specificity. Conclusions-The PSC performed well in Setswana-speaking children and is a promising screening tool for paediatric psychosocial problems in busy clinical settings. Screening with the PSC may allow for early detection and treatment of psychosocial problems. This is likely to be of particular value for HIV+ children for whom HIV treatment non-adherence may result from untreated psychosocial dysfunction. Background Psychosocial dysfunction contributes greatly to morbidity among children and adolescents (Kelleher and Wolraich 1996, Prince et al. 2007). Most psychosocial problems are unrecognized and untreated, even among young people attending clinics for other healthcare
JAMA, 2013
ORE THAN 2 MILLION children worldwide are infected with human immunodeficiency virus (HIV), appro... more ORE THAN 2 MILLION children worldwide are infected with human immunodeficiency virus (HIV), approximately 90% of whom live in sub-Saharan Africa. 1,2 The scale-up of pediatric antiretroviral treatment in Africa has been lifesaving for children. 3,4 Critical review of long-term outcomes from the first children to receive HIV treatment in this region may help to guide treatment program improvements. The World Health Organization (WHO) recommends that children older than 3 years receive 1 of 2 nonnucleoside reverse transcriptase inhibitors (NNRTIs), nevirapine or efavirenz, and 2 drugs in the NRTI class. 5 Most countries favor nevirapinebased regimens for the majority of children due to perceived comparable effectiveness at lower cost. 6 Adult studies comparing efavirenz with nevirapine have shown mixed results. 6-9 However, a pooled analysis of 1688 patients in 7 randomized con
The Lancet Infectious Diseases, 2014
Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Sahara... more Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.
Introduction: Youth living with HIV (YLWH) experience higher rates of mental illness than their p... more Introduction: Youth living with HIV (YLWH) experience higher rates of mental illness than their peers. Holistic care for YLWH may involve adopting mental health screening programs into comprehensive HIV care to help identify and address mental health concerns in young people. We explored various contexts, procedures, and safety measures throughout the integration and maintenance of a mental health screening program for adolescents attending an HIV referral clinic in Gaborone, Botswana. Methods: Implementation goals included a safety goal of 100% appropriate referral rate for emergency cases, and a screening goal of 70% of the approximately 1100 adolescent and young adults who were clients of the clinic at least once in the one year review period. Frequent meetings with the behavioral health team and relevant clinic staff were conducted to determine when, where and how to screen the clients. Referral procedures and an emergency protocol for certain “red flag” behaviors was developed ...
BMJ Open
IntroductionNeurodevelopmental delays and cognitive impairments are common in youth living with H... more IntroductionNeurodevelopmental delays and cognitive impairments are common in youth living with HIV. Unfortunately, in resource-limited settings, where HIV infection impacts millions of children, cognitive and neurodevelopmental disorders commonly go undetected because of a lack of appropriate assessment instruments and local expertise. Here, we present a protocol to culturally adapt and validate the Penn Computerized Neurocognitive Battery (PennCNB) and examine its validity for detecting both advanced and subtle neurodevelopmental problems among school-aged children affected by HIV in resource-limited settings.Methods and analysisThis is a prospective, observational cohort study. The venue for this study is Gaborone, Botswana, a resource-limited setting with high rates of perinatal exposure to HIV and limited neurocognitive assessment tools and expertise. We aim to validate the PennCNB in this setting by culturally adapting and then administering the adapted version of the battery ...
International Journal of STD & AIDS
Despite access to nationally supplied antiretroviral treatment, viral load suppression rates rema... more Despite access to nationally supplied antiretroviral treatment, viral load suppression rates remain suboptimal in the Dominican Republic. Counseling and support services are available but mainly targeted to those identified as having the most need. At Clínica de Familia La Romana (CFLR) in La Romana, all patients undergo a structured baseline interview including exploration of expected barriers to care. We conducted a retrospective cohort study of a random sample of patients at CFLR with treatment initiation between 1 January 2015 and 1 December 2017 to determine if self-identified barriers to HIV care predict viral load suppression. Viral load suppression occurred in 63% of the 203 patients evaluated. Lack of food ( n = 19) was significantly associated with lack of viral suppression (OR 3.0, 95% CI 1.14–7.87). Nondisclosure of HIV status ( n = 24) showed evidence for a protective effect (OR 0.33; 95% CI 0.11–1.0). Further steps should be taken to address food insecurity as well as ...
Global Pediatric Health
Background. Parents’ beliefs about and engagement in reading aloud to young children and other po... more Background. Parents’ beliefs about and engagement in reading aloud to young children and other positive parenting practices have been associated with early childhood development (ECD) and later achievement. Aim. This exploratory study sought to assess parental attitudes and self-reported practices regarding ECD in a rural, low-income community in the Dominican Republic with many risk factors for ECD delays, including high rates of poverty, iron-deficiency anemia, and malnutrition. Methods. We used the Parent Reading Belief Inventory and open-ended questions to evaluate parental beliefs regarding reading, self-efficacy in promoting child development, current positive parenting practices, and parents’ concerns about the development of their 0- to 5-year-old children in Consuelo, Dominican Republic. We explored associations between demographic factors and strength of positive parenting beliefs and practices. Results. Overall participants had positive attitudes toward reading and their ...
BACKGROUND Despite growing interest in the use of technology to improve health outcomes and healt... more BACKGROUND Despite growing interest in the use of technology to improve health outcomes and health care delivery in low- and middle-income countries (LMIC), local attitudes towards mHealth use in these settings are minimally understood. This is especially true in the Dominican Republic, where attitudes toward mHealth have not been fully assessed. Yet, this information is critical for developing effective mHealth interventions to address public health problems, such as low rates of exclusive breastfeeding (EBF), which can lead to poor infant outcomes. With an EBF rate of 5% in the first 6 months of life, the Dominican Republic (DR) has one of the lowest EBF rates worldwide. OBJECTIVE This study aimed to describe the current use of information and communication technologies (ICT) and to analyze the attitudes and perceptions related to using cellular phones for mobile health (mHealth) interventions among caregivers of children ≤5 years old and health promoters in the DR. Findings can i...
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Papers by Elizabeth Lowenthal