Mia Buono

People living with psychosis (PWLE) experience, anticipate, and internalize stigma. Over time, experienced and anticipated stigma can increase internalized stigma, negatively impacting health. However, predictors and outcomes of internalized stigma among PWLE and their caregivers remain unknown. We explore how stigma changes over time; the associations between hypothesized predictors and internalized stigma; and how internalized stigma influences mental health and functional outcomes. We analyzed data from a two-arm pilot randomized controlled trial comparing a community-based rehabilitation intervention to enhanced usual care in Blantyre, Malawi (NCT06080477). Sixty PWLE and 118 caregivers who met eligibility criteria completed interviewer-administered surveys at baseline, 6, and 12 months. Exploratory factor analysis (EFA) assessed the dimensionality of stigma scales. We used correlations and adjusted generalized estimating equations to examine associations between predictors and outcomes of internalized stigma. EFA supported single-factor structures with adequate internal consistency for most stigma scales. Among PWLE, mean internalized stigma, anticipated stigma, and experienced stigma decreased from baseline to 12 months in both arms. Stigma measures were generally comparable between arms except for family-enacted stigma, which was lower at 12 months among those receiving the intervention compared to usual care (mean difference = -0.97; -1.88, -0.05). At baseline, higher family-enacted stigma was moderately associated with higher internalized stigma scores (correlation coefficient = 0.34; 0.13, 0.53). Greater change in family-enacted stigma (regression coefficient = 0.24; 0.04, 0.43) and anticipated stigma (0.14; 0.02, 0.26) were weakly associated with greater change in internalized stigma. At baseline, internalized stigma was weakly associated with depressive (0.14; -0.08, 0.35) and anxiety symptoms (0.11; -0.08, 0.31). Over time, greater increases in internalized stigma were associated with higher anxiety (0.13; 0.01, 0.24). Caregivers’ internalized stigma decreased over 12 months, with no associated predictors. Anticipated, experienced, and internalized stigma are prevalent among PWLE in Malawi. Findings suggest the need to continue to explore the mechanisms between predictors and outcomes of internalized stigma.

Psychotic disorders are a leading cause of disability in Malawi. Community-based rehabilitation (CBR) interventions may improve quality of life (QOL) for people with lived experience of psychosis (PWLE) and their caregivers by addressing functional challenges and promoting empowerment and social reintegration. However, understanding how QOL may evolve over the course of participation in CBR in low-resource settings remains unknown. This analysis examined changes in QOL among PWLE and their caregivers participating in a CBR intervention in Malawi using a mixed-methods approach. We analyzed qualitative and quantitative data from the intervention arm of a two-arm pilot randomized controlled trial comparing a CBR intervention to enhanced usual care in Blantyre, Malawi (NCT06080477). Eligible participants were over 18, diagnosed with schizophrenia spectrum disorder, and had a caregiver willing to participate. Thirty PWLE and 58 caregivers completed interviewer-administered surveys at 6 and 12 months. In-depth qualitative interviews were conducted with a subsample of 12 PWLE and 14 caregivers between 6 and 9 months. Qualitative data were analyzed thematically. Quantitative data were summarized descriptively to assess changes in QOL, functioning, and functional outcomes over time. Qualitative findings highlighted improvements in QOL across multiple domains. PWLE described improvements in mental and physical health, increased independence, and social reintegration that contributed to better QOL. Caregivers reported improved mental health, reduced caregiving burden, and reintegrating into society improved QOL. Quantitative findings aligned with reported themes for PWLE. Mean QOL scores improved from 48.5 at baseline to 52.7 at 12 months. Mean psychosis severity scores decreased from 67.7 to 40.2. Functional outcomes such as employment, community engagement, and monthly income generation improved across the study period. CBR interventions are well-positioned to support psychosis management and improve overall QOL among PWLE and their family members in Malawi, supporting their broader implementation.

Background: Alcohol use contributes to over 3 million deaths annually. In Tanzania, there are no evidence-based culturally adapted interventions to address harmful alcohol use behaviors. Our hypothesis was that “ Punguza Pombe Kwa Afya Yako ” (PPKAY, Reduce Alcohol for your Health), a culturally adapted brief intervention with text-based boosters, is superior to usual care in reducing binge drinking at 3 months post discharge. Methods and findings: This manuscript reports. Stage 1 of our adaptive clinical trial which seeks to determine the effectiveness of the PPKAY+ booster to usual care; a subsequent stage will compare the PPKAY only to personalized and standard boosters. Adults who sought care for an acute injury at the Kilimanjaro Christian Medical Centre Emergency Department, self-disclosed alcohol use prior to the injury, scored ≥8 on the Alcohol Use Disorder Identification Test, and/or test positive by alcohol breathalyzer were offered enrollment. Participants were randomly assigned to PPKAY+ boosters (personalized or standard) or usual care at 1:1:1 allocation. Primary analyses followed the intention-to-treat principle. The PPKAY is a 15-min nurse delivered brief intervention using motivational interviewing techniques combined with a standardized or personalized text based reminder sent weekly to participants after hospital discharge and until 1 year post enrollment compared to a usual care arm. Follow-up was performed by blinded outcome assessors. Our pooled intervention arms PPKAY+ boosters were compared to usual care to determine the effectiveness of the intervention in reducing the number of binge drinking days, the trial’s primary outcome, in the previous 4 weeks at 3 months after discharge. A total of 1,484 patients were screened for eligibility between October 12th 2020, and on April 14th 2023. 448 patients met inclusion criteria and consented to participate. 148 were randomized to usual care, and 300 to the pooled intervention arm. Reasons for attrition included loss to follow-up ( n = 69), withdrawal ( n = 6), and deaths ( n = 4), with no differences between arms. Most participants were male (94%), from the Chagga tribe (59%) and had an average age of 36.4 years (SD 12.6) at baseline. At the 3-month follow-up, the intervention arm showed a notable reduction in mean predicted binge drinking days by 1.2 days (95% CI: [−2.3, −0.3]; p = 0.002) compared to the usual care group in a difference-in-differences analysis. Importantly, the self-reported nature of our primary outcome introduces the potential for social desirability bias, particularly in the absence of participant blinding, and should be considered a limitation when interpreting the findings. Conclusion: The reduction in binge drinking behavior at 3-month follow-up compared to usual care suggests our culturally adapted intervention is an effective alcohol intervention for patients acutely injured in Tanzania. According to the adaptive study design, the next phases of the trial will continue to compare the intervention arm with a paired down version without the text messages boosters. Trial registration number: ClinicalTrials.gov NCT04535011

Background:Alcohol use contributes to over 3 million deaths annually. In Tanzania, similar to other low- and middle-income countries, there are no evidence-based culturally adapted interventions to address harmful alcohol use behaviors. We aim to determine the effectiveness of a culturally adapted brief intervention, “Punguza Pombe Kwa Afya Yako/Reduce Alcohol for your Health”, with mobile health-based boosters in reducing alcohol use and consequences at 3 months after discharge for adult acute injury patients presenting for care. Methods:We are conducting a pragmatic adaptive randomized control trial with two distinct stages, of which we are reporting only Stage 1. Stage 1 is a superiority trial comparing a culturally adapted brief intervention with short-message-service (SMS) text boosters versus usual care. Participants eligible for enrollment are adult injury patients (≥18 years of age), who sought care for an acute injury (0.0 g/dL) by alcohol breathalyzer. For all stages, the primary outcome was the number of binge drinking days in the previous 4 weeks.Results: During the trial period, 448 patients met inclusion criteria and consented to participate in the study. Of these, 148 were randomized to usual care, and 300 were randomized to the intervention arms. At the 3-month follow-up, significant differences were observed between the intervention arm and the usual care group. In the primary outcome, the intervention arm showed a notable reduction in mean predicted binge drinking days by 2.03 days (95% CI: -3.53 to -0.86; p=0.0035). Additionally, significant reductions were seen in secondary outcomes for the intervention group: the mean predicted number of drinking days (reduction of 1 day; 95% CI: -2.71 to 0.82; p=0.0005), and the predicted mean difference in the number of drinks (-12.22 drinks; 95% CI: -29.5 to 3.32; p=0.0024). However, no significant differences were found between the two groups in terms of drinking-related consequences or depression.Discussion:When compared to the usual care arm, Punguza Pombe Kwa Afya Yako with text booster significantly reduces binge drinking days, binge drinking episodes, and mean number of drinks consumed. These reductions in alcohol use at 3-month follow-up suggest our culturally adapted intervention is effective for alcohol harm reduction in acute injury patients in Tanzania.

Globally, gender differences are well-documented in alcohol use behaviors and MDD, yet these remain understudied in Moshi, Tanzania. Understanding gender-specific nuances of these conditions is crucial for developing effective and culturally appropriate mental health treatments. This study aims to investigate gender differences in MDD, alcohol use, and other aspects of mental well-being among patients at Kilimanjaro Christian Medical Centre (KCMC). Six hundred and seventy-six patients presenting for care at the KCMC Emergency Department (ED) and Reproductive Health Centre (RHC) were enrolled between October 2021 and May 2022. Patients were selected through systematic random sampling and completed quantitative surveys, including the Alcohol Use Disorder Identification Test (AUDIT) and the Patient Health Questionnaire 9 (PHQ-9). Nineteen patients were purposively chosen from the study population for in-depth interviews (IDIs) exploring alcohol use, gender, and depression. ANOVA, chi-squared tests, adjusted log-binomial regressions, and a linear regression model were used to analyze quantitative data in RStudio. A grounded theory approach was used to analyze all IDIs in NVivo. Average [SD] PHQ-9 scores were 7.22 [5.07] for ED women, 4.91 [4.11] for RHC women, and 3.75 [4.38] among ED men. ED women held the highest prevalence of MDD (25%) compared to RHC women (11%) and ED men (7.9%) (p < 0.001). Depressive symptoms were associated with higher AUDIT scores for ED men (R2 = 0.11, p < 0.001). Qualitative analysis showed that while present for women, social support networks were notably absent for men, playing a role in alcohol use. For men, alcohol was described as a coping mechanism for stress. Intersectionality of gender, alcohol use, and depression is influenced by sociocultural and behavioral norms in Moshi. As such, multi-layered, gender-differentiated programming should be considered for the treatment of substance use and mental health conditions in this region.

Background: Rates of prenatal alcohol use in Sub-Saharan Africa (SSA) are increasing, despite regulatory bodies urging pregnant women to abstain from alcohol. Tanzania has minimal policies, interventions, and young female education addressing alcohol consumption during pregnancy (ACDP), leading to a considerable number of pregnancies being exposed to alcohol and consequent health consequences like fetal alcohol spectrum disorder (FASD). Research investigating the prevalence of ACDP in SSA —specifically in Tanzania— is abundant. In Tanzania, there is a limited understanding of alcohol use practices among pregnant women who consume alcohol (PWCA), as well as community knowledge, attitudes, and cultural beliefs related to ACDP. Methods: A total of 655 individuals were enrolled in this sequential, explanatory mixed-methods study using systematic random sampling between October 2021 and May 2022. Quantitative survey data from 533 female patients presenting for care at KCMC ED or RHC were analyzed to compare sociodemographic factors and alcohol use practices among pregnant, younger non-pregnant, and older non-pregnant women using descriptive frequencies in RStudio. Nineteen participants were purposively selected based on quantitative survey data for qualitative semi-structured IDIs exploring knowledge, attitudes, and cultural beliefs surrounding ACDP. A grounded theory approach was used to analyze in-depth interviews (IDIs) in NVivo. Results: A large percent of pregnant women reported alcohol consumption of at least once per week (42.2%). Older non-pregnant women had the highest rates of alcohol use per week (66.0%) and were more likely to believe alcohol use was acceptable during pregnancy. Younger non-pregnant women reported the highest weekly alcohol expenses and held the highest prevalence of harmful or hazardous drinking (HHD) (16.4%). Average [SD] AUDIT scores were 1.70 [3.28] for pregnant women, 2.94 [4.79] for younger non-pregnant women, and 2.51 [4.36] for older non-pregnant women. Older non-pregnant women exhibited the highest prevalence of depression (31.4%). Average [SD] PHQ-9 scores were 4.71 [3.12] for pregnant women, 5.85 [4.80] for younger non-pregnant women, and 7.29 [5.55] for older non-pregnant women. Qualitative analyses demonstrated that (1) cultural beliefs are intricately tied to perceived benefits of ACDP, (2) a history of alcohol use preceding pregnancy largely influences ACDP, and (3) community views of PWCA are negative. Significance: Our findings demonstrate a concerning trend of ACDP in Moshi, Tanzania. Cultural and community beliefs, along with limited knowledge of ACDP, among women of all ages appear to influence ACDP and community views of PWCA. Consequently, community-wide education initiatives and pre-pregnancy interventions highlighting the dangers of ACDP are necessary. Holistic support services may help curb alcohol use and improve birth experiences. Further research is needed to explore ACDP as a form of self-medication for depression, fear, anxiety, and pain in pregnant women in SSA.

Alcohol’s ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. In-depth interviews were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach. Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use encouraged for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men. Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context while treatment for men should be cognizant of the social pressures to drink. Strategies to address and/or mitigate these factors should be incorporated in subsequent care and interventions.

Background Unhealthy alcohol use negatively impacts many components of health and wellness, including mental health conditions like major depressive disorder (MDD). Globally, gender differences are common for both alcohol use behaviors and MDD, but these differences have not been studied within Moshi, Tanzania. To provide more effective and culturally appropriate mental health treatments, gender nuances around these conditions must be known. As such, this study aims to explore gender differences in MDD, alcohol use, and other aspects of mental well-being among patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. Methods Six hundred and seventy-six patients presenting for care at the KCMC Emergency Department (ED) and Reproductive Health Centre (RHC) were enrolled in this mixed-methods study between October 2021 and May 2022. Patients were selected through systematic random sampling and completed quantitative surveys including the Alcohol Use Disorder Identification Test (AUDIT) and the Patient Health Questionnaire 9 (PHQ-9). Nineteen patients were purposively chosen from the study population to participate in in-depth interviews (IDIs) exploring topics related to alcohol use, gender, and depression. Descriptive frequencies, univariate log-binomial regressions, and a linear regression model were used to analyze quantitative data, all of which were analyzed in RStudio. A grounded theory approach was used to analyze all IDIs in NVivo. Results Average [SD] PHQ-9 scores were 7.22 [5.07] for ED women, 4.91 [4.11] for RHC women, and 3.75 [4.38] among ED men. Similarly, ED women held the highest prevalence of MDD (25%) as compared to RHC women (11%) and ED men (7.9%) (pConclusion Intersectionality of gender, alcohol use, and depression is influenced by sociocultural and behavioral norms in Moshi. As such, multi-layered, gender-differentiated programming should be considered for the treatment of substance use and mental health conditions in this region.

Excessive alcohol use stands as a serious threat to individual and community well-being, having been linked to a wide array of physical, social, mental, and economic harms. Alcohol consumption differs by gender, a trend seen both globally and in Moshi, Tanzania, a region with especially high rates of intake and few resources for alcohol-related care. To develop effective gender-appropriate treatment interventions, differences in drinking behaviors between men and women must be better understood. Our study aims to identify and explore gender-based discrepancies in alcohol consumption among Kilimanjaro Christian Medical Center (KCMC) patients. A systematic random sampling of adult patients presenting to KCMC’s Emergency Department (ED) or Reproductive Health Center (RHC) was conducted from October 2021 until May 2022. Patients answered demographic and alcohol use-related questions and completed brief surveys, including the Alcohol Use Disorder Identification Test (AUDIT). Through purposeful sampling, 19 individuals also participated in in-depth interviews (IDIs) that focused on identifying gender differences in alcohol use. Quantitative data was analyzed in RStudio through descriptive frequencies, proportions, ANOVA, and Chi-squared tests, while IDIs were analyzed in Nvivo following a grounded theory approach. During the 8-month data collection timeline, 676 patients were enrolled. Men and women patients at KCMC’s ED and RHC were found to have significant differences in their alcohol use behaviors. For our quantitative data, this included lower average AUDIT scores among women (average [SD] AUDIT scores were 6.76 [8.16] among ED men, 3.07 [4.76] among ED women, and 1.86 [3.46] among RHC women). A subsequent IDI analysis revealed greater social restrictions around women’s drinking and more secretive alcohol use behaviors for where and when women would drink. For men, excess drinking was normalized within Moshi, tied to men’s social interactions with other men, and generally motivated by stress, social pressure, and despair over lack of opportunity. Significant gender differences in drinking behaviors were found, primarily influenced by sociocultural norms. These dissimilarities in alcohol use suggest that future alcohol-related programs should incorporate gender in their conceptualization and implementation.

Background Worldwide, alcohol is a leading risk factor for death and disability. Tanzania has particularly high rates of consumption and few resources dedicated to minimizing alcohol-related harm. Ongoing policy efforts are hampered by dynamic sociocultural, economic, and regulatory factors contributing to alcohol consumption. Through the voices of Kilimanjaro Christian Medical Center (KCMC) patients and a gender-focused lens, the goal of this project was to investigate community perceptions surrounding alcohol and the impact of its use in this region. Methods This was a mixed-methods study conducted at KCMC between October 2021 and May 2022. 678 adult (≥18 years old) Kiswahili-speaking patients who presented to KCMC’s Emergency Department (ED) or Reproductive Health Clinic (RHC) were enrolled through systematic random sampling to participate in quantitative surveys. Nineteen participants were selected for in-depth interviews (IDIs) through purposeful sampling. The impact and perceptions of alcohol use were measured through Drinkers’ Inventory of Consequences (DrInC) scores analyzed in R Studio through descriptive proportions, and IDI responses explored through a grounded theory approach utilizing both inductive and deductive coding methodologies. Results ED men were found to have the highest average [SD] DrInC scores (16.4 [19.6]), followed by ED women (9.11 [13.1]), and RHC women (5.47 [9.33]), with higher scores indicating greater perceived consequences. Participants noted alcohol has both perceived advantages and clear harms within their community. Increased conflict, long-term health outcomes, financial instability, stigma, and sexual assault were seen as negative consequences. Benefits were primarily identified for men and included upholding cultural practices, economic growth, and social unity. Physical and financial harm from alcohol impacted both genders, however, alcohol-related stigma and sexual assault were found to disproportionately affect women. Conclusion Our findings suggest that perceptions around drinking and alcohol’s social and physical consequences differ significantly by gender. To effectively minimize local alcohol-related harm, future alcohol-focused research and policy efforts should consider the distinct impacts alcohol has between genders.