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Global Health Education Day is an exciting opportunity to draw together global health researchers, educators, and students. Led by Robert J. Havey, MD Institute for Global Health's Center for Global Health Education, this year's event included a poster session where students, trainees, and faculty members presented posters on projects relevant to global health. All posters can be enlarged by clicking the link underneath each image.
Vitamin D Deficiency Among Muslim Women: The Nexus of Religion, Science, and Health
Vitamin D deficiency is common worldwide, in fact, it is estimated that 1 billion people have low Vitamin D levels with the highest prevalence in the Middle East and specifically among Muslim women who wear concealing clothes. Girls who grew up in conservative Islamic countries tend to have vitamin D deficiency from a very young age. At the biochemical level, we know that hypovitaminosis D has a cascade of effects throughout the body impacting its physiology and contributing to chronic conditions. Furthermore, the literature supports that Vitamin D deficiency has an impact on diabetes, heart disease, certain cancers, depression, and bone disorders. It is important to denote that the Quran does not actually call for a hijab but rather for modesty, however, it is primordial to recognize the importance of maintaining the sanctity of religious and cultural beliefs and practices and make peace with the supporting evidence-based science as it relates to the health effects of the increased predisposition to vitamin D deficiency in this at-risk population. Understanding its effects allows for prioritizing interventions and policies that will have an impact on population health. It is important to routinely check Vitamin D levels in hijabis as this will elevate the quality of care and identify and manage hypovitaminosis in its early stages. Likewise, designing health education interventions focusing on lifestyle strategies, ranging from diet and supplementation to modifying how conservative Muslim women can gain sun exposure without compromising their modesty in the public eye. Importantly, is at the commercial level in identifying the feasibility of alterations in the textile industry so these are lighter, more colorful, temperature controlled, and water resistant. Lastly, the crucial role played by the Islamic community and its respective community-based organizations in supporting this surveillance and health initiative to help drive effective change to protect, promote, and restore the health of hijabis as it relates to Vitamin D deficiency and potential chronic conditions arising as a result.
Presenting author: AG Palladino-Davis
Poster 1
Piloting a Critical Care Curriculum in Mwanza, TZ
This project aims to develop and pilot a comprehensive critical care curriculum tailored for pediatric residents and medical students at Bugando Medical Center in Mwanza, Tanzania. The curriculum will consist of a three-day educational course integrating didactic lectures, simulation exercises, and hands-on skill sessions. The primary objective is to equip pediatric residents with the necessary knowledge, skills, and confidence to effectively manage critically ill pediatric patients within the rapidly expanding critical care section at Bugando Medical Center. Bugando Medical Center, located in Mwanza, Tanzania, serves as a vital healthcare hub for the Lake Victoria region, catering to a diverse patient population with varying medical needs. With the increasing demand for critical care services, there is a pressing need to ensure that healthcare professionals, particularly pediatric residents and medical students, are adequately trained to address the complex needs of critically ill children. The educational course will encompass a variety of teaching modalities to cater to different learning styles and preferences. Didactic lectures will cover essential topics such as pediatric resuscitation, mechanical ventilation, hemodynamic monitoring, and sepsis management, providing a solid theoretical foundation for participants. Simulation sessions will offer a hands-on, interactive learning experience, allowing participants to practice clinical scenarios in a controlled environment, thus enhancing their clinical decision-making skills and teamwork abilities. Additionally, skill stations will provide participants with the opportunity to master procedural skills relevant to critical care, such as airway management Throughout the three-day course, emphasis will be placed on active participation, peer collaboration, and reflective learning. Participants will engage in case-based discussions, debriefings, and feedback sessions to reinforce key concepts and address individual learning needs. Moreover, the curriculum will be continuously evaluated and refined based on participant feedback and observed outcomes to ensure its effectiveness and relevance. By the conclusion of the pilot program, it is anticipated that participants will demonstrate improved confidence, competence, and readiness to manage pediatric critical care cases independently. Ultimately, this initiative aims to strengthen the capacity of Bugando Medical Center in delivering high-quality critical care services to pediatric patients.
Presenting author: Ali Austermuehle
Poster 2
Smile Train: Barriers to Cleft Care Before, During, and After COVID19
Background: During the COVID-19 pandemic, elective procedures including cleft palate and/or lip repair were halted around the world. Smile Train, the largest cleft organization with partner hospitals across the world, is dedicated to providing discounted quality cleft care for all. This study investigated how barriers to cleft care changed before, during, and after the COVID-19 pandemic. Methods: We obtained surveys from all Smile Train Hospitals who completed the Barriers to Care Survey from 2018, 2020, and 2022. Responses were categorized by region: North Asia, Asia, Africa, and Americas & Europe. Barriers were categorized into themes including: lack of patient awareness, equipment, funds, operating room access, professionals, staff, supplies, and barriers in patient travel and health. Descriptive and statistical analyses were completed for differences. Results: 664 survey responses were collected in 2018, 571 in 2020, and 563 in 2022, most often answered by a surgeon. Across all regions, survey responses indicating patient awareness as a barrier to cleft care decreased between 2018 and 2022 (41.42% in 2018, 37.83% in 2020, and 27.71% in 2022, p-value 0.018). In contrast, the proportion of patient health as a barrier increased between 2018 and 2022 (34.94% in 2018, 40.98% in 2020, and 46.36% in 2022). In Africa, patient health was reported as an increased barrier during the time of COVID (37.58% in 2018, 48.74% in 2020) and remained a barrier in 2022 (45.31%). While patient awareness in the Americas & Europe improved (18.02% in 2018, 4.20% in 2022), lack of professionals was reported as more of a barrier since 2018 (9.01% in 2018, 17.65% in 2022). In Asia, the proportion of patient awareness improved (46.72% in 2018, 32.57% in 2022), while the proportion of patient health worsened (44.16% in 2018, 59% in 2022). In North Asia, barriers including patient awareness, lack of equipment, funds (p-value < 0.001), staff (p-value 0.042), and supplies decreased from 2018 to 2022. Conclusions: Patient awareness and health seem to have been most impacted by the pandemic; yet regional disparities exist. Notably, North Asia had the most improvement in reported barriers to care which may demonstrate solution creativity amidst a crisis and/or increased aid provided to this region during the pandemic compared to others.
Presenting author: Ariel Figueroa, MD
Poster 3
Training Paradigms: A Current Update to Plastic Surgery Training in sub-Saharan Africa
BACKGROUND: In Sub-Saharan Africa (SSA), there is a demonstrated burden of surgical disease that necessitates expanded plastic surgery training and infrastructure. Specifically, burns, skin graft procedures and congenital anomalies make up a large burden of disease in SSA countries. There has been no recent comprehensive comparison of the available training programs and regional disparities in training opportunities. METHODS: The websites of plastic and reconstructive surgery (PRS) training paradigms were reviewed, and information regarding program requirements and structure were obtained. To explore financial considerations, GDP information was collected from the World Bank website. RESULTS: Following 5 years of medical school and 1 year of internship, PRS trainees may either continue training via 2 years of general surgery training under COSECSA or CMSA, 4-5 years of general surgery training via MMed Surgery, or 2.5-3 years of general surgery under WACS, all followed by 3 years of plastic surgery training. COSECSA training regions serve 32.9% of the population of Africa, including 14 core countries, 5 affiliated countries, and 13 accredited PRS programs, where 14 PRS trainees graduated in 2022. WACS serves 29.6% of the population of Africa, includes 15 countries and 32 accredited programs (29 in Nigeria, 3 in Ghana), where 5 PRS trainees graduated in 2023. CMSA serves 4.3% of the population of Africa, with 9 training institutions in South Africa. Major examinations taken for certification in each include a pre-residency, general surgery assessment and a final examination at the end of residency. Both MMed and COSECSA trainees can sit for the certifying exam administered by COSECSA. However, COSECSA does not limit eligibility for the certifying exam to institutions which follow their guidelines. A comparison of the training paradigms is demonstrated in Table 1. Access to PRS training opportunities varies widely in the region, even amongst countries with similar GDPs. Nigeria has a GDP ($2065.7 US thousand) comparable to Ghana ($2363.3 US thousand), Kenya ($2081.8 US thousand), and Gabon ($8820.3 US thousand), but offered significantly more training programs than the latter countries. Ethiopia, a country with a much lower GDP ($925.1 US thousand), has the most number of graduates of the countries listed. CONCLUSION: PRS training prerequisites, curriculum, and structure of examinations are comparable across the SSA region. However, regional disparities exist regarding the number of available programs, number of graduates, and eligibility for examinations, despite countries having similar GDPs. Across paradigms, COSECSA has the smallest ratio of accredited programs per country despite serving the largest number of countries. This suggests the strong possibility of success for initiatives that would be directed towards standardizing the qualifications to practice PRS in SSA, and increasing opportunities for intra-regional training.
Presenting author: Hannah Soltani
Poster 4
Three-Year Experience at a Free Neurology Clinic Serving a Migrant Population
Introduction To address identified gaps in resident education in social determinants of health and a desire for greater engagement with underserved patient populations, a monthly resident-led free neurology clinic was established in 2021. We report our experience at the Community Health Centre (CHC) and outline patient's ethnicity, spoken languages, comorbidities, work up and treatment. Additionally, we evaluate the educational value for residents volunteering at the clinic. Methods Patient demographic data, presenting complaints, work up, diagnoses and treatment were collected for all patients seen from May 2021 to December 2023. A semi structured survey with short answers and Likert scale was used to evaluate residents' experience at the CHC. Residents were asked to rate how the clinic changed their understanding, reasoning skills and clinical decision making when treating patients of various sociocultural and economic backgrounds in a low-resource setting. Barriers to volunteering at the clinic were also explored through the survey. Results One hundred and fifty-two patients were seen over 32 months at the CHC, where patients' primary language was Spanish (61.5%), Polish (17.9%), Czech (7.7%), and English (7.7%). Of those who self-reported their ethnicity, 74.1% identified as Lantinx, 23.3% as Eastern European, 2.5% as other (African American, North African, Asian). The most common presentations were headache (48%), seizures (17.6%), paresthesia (6.4%), diplopia (4.8%), dizziness (4%), weakness (4%), stroke (3.2%), low back pain (2.4%), Parkinsonism or tremor (2.4%), falls (1.6%), venous sinus thrombosis (1.6%), and memory loss (1.6%). Eleven residents (42.3%) responded to the survey. Seven of these residents had previously volunteered at the CHC. The majority of those who had volunteered agreed that their volunteering experience enhanced their conceptualization of sociocultural issues in patient care (71%), and were exposed to ways social, cultural and economic factors impact the patient-physician relationship (100%). The largest barriers to attending the clinic were the day on which the clinic was held (Saturday), and transport to its location. Conclusions The free neurology clinic at CHC serves a largely migrant population, with the majority of patients speaking Spanish and identifying as Latinx. The clinic has increased residents' exposure to and understanding of health inequities and cultural competency. Given this positive impact on resident education, the monthly half-day clinic was moved from Saturdays to Wednesdays, to facilitate participation in the clinic. Additionally, transport costs will also be covered for the residents.
Presenting author: Dina Ghandour
Poster 5
Improving Surgical Safety: Developing and Sustaining Patient Safety Improvement Training Initiative in Rwanda
Background: Half of intraoperative complications are attributed to ineffective non-technical skills including teamwork and communication between members of the surgical teams. To improve surgical outcomes in Rwandan Hospitals, a Non-Technical Skills for Surgery (NOTSS) program addressing low- and middle-income countries was developed and implemented in Rwanda from 2016 to 2022. However, since the NOTSS training workshops are delivered by external trainers, there is a need to understand the context and strategies for sustaining NOTSS training in Rwandan hospitals. The aim of this study was to identify barriers and facilitators sustaining and scaling the NOTSS training program in Rwandan hospitals. Methods: We conducted a qualitative study to explore the perspectives of members of the surgical teams (surgeons, theater nurses, and anesthetists), and hospital leadership (clinical directors, and directors of quality assurance) on barriers and facilitators of implementation and sustainment of the NOTSS program. Interviews and focus groups were conducted in November 2023. The Consolidated Framework for Implementation Research (CFIR 2.0) was used for development of the interview guide. A member of the study team fluent in English and the local language conducted in-person interviews and focus groups. Interviews and focus groups were audio-recorded, and transcribed verbatim in Kinyarwanda, before being translated into English. The CFIR 2.0 codebook was used for deductive thematic analysis. Transcripts were coded by two members of the study team. Results were categorized into barriers and facilitators according to the domains of CFIR 2.0. Results: We conducted 11 interviews and 7 focus groups, with 46 participants (8 surgeons, 20 theater nurses, 5 anesthetists, and 13 hospital leaders), from 9 Rwandan hospitals where the NOTSS program was implemented. Facilitating themes including actors reporting that the non-technical skills training would help them enhance intraoperative patient safety (innovation). They also reported that NOTSS is aligned with the hospital accreditation standards set by the Ministry of Health (outer context). Barriers to sustaining and scaling the NOTSS training program included high staff turnover, insufficient equipment and workforce (inner context), staff willingness to learn, and a lack of NOTSS champions (individual characteristics). Other Facilitators for effective intraoperative non-technical skills included existing infrastructure for continuous capacity building, a hospital-based new employee orientation program, and an existing continuous quality improvement culture (Implementation process). (Table 1) Conclusion: These findings highlight the recognition of the continuous NOTSS training as an opportunity to improve intraoperative patient safety, and to help hospitals meet accreditation standards. Our next steps consist of identifying and training NOTSS champions who will sustain NOTSS training in the hospital by integrating NOTSS into new employees' orientation programs.
Presenting author: Egide Abahuje
Poster 6
Relationship between Salivary Immune Markers, CD4+count and HIV-Oral Lesions among Newly Diagnosed Adults with HIV in Southwest Nigeria
Background: An understanding of immunological changes in the oral cavity of persons with HIV is pivotal to predicting oral health status in such individuals. This study aimed to assess the correlation between salivary levels of sIgA, cytokines, CD4+ T cell counts and oral lesions among newly diagnosed adults with HIV before antiretroviral therapy (ART) initiation. Methods: The study was conducted among adults (>18 years) newly diagnosed with HIV who presented at antiretroviral clinics of two tertiary hospitals in Ibadan, Nigeria. Data documented were socio-demographics, oro-facial lesions, CD4+ count and saliva samples before ART initiation. Saliva assays of sIgA and cytokines were done using ELISA kits. CD4+ counts and saliva analytes were compared between those with and those without oral lesions using Mann-Whitney U test. SPSS version 25 was used for data analysis. Results: Seventy one participants were enrolled having 23(32.4%) males and 48(67.6%) females; mean age 38.8±SD 11.7 years. HIV- oral lesions seen among the study participants included pseudomembranous and erythematous candidiasis (43.2%), oral melanotic hyperpigmentation (4.5%) and a combination of candidiasis with OMH (11.4%). The mean CD4+ count for all study participants was 356.04 ±244.16 cells/mm3; being lower among those with oral lesions 330.16±282.28 cells/mm3 compared to those without oral lesions 388.29±238.92cells/mm3. Also, the participants had median (inter-quartile range) values of sIgA as 7.99pg/mL (6.14-9.01), IL-6 as 7.09pg/mL (5.93-8.33) and IFN-γ as 6.23pg/mL (5.27-7.60). Comparatively, higher median (IQR) values of IL-10, IL-1β and TNF-α were found to be 40.38pg/mL (32.61-45.61), 21.48pg/mL (16.68-26.68) and 20.21pg/mL (14.56-23.82) respectively. Mann-Whitney U test revealed higher mean rank values for sIgA, IL-1β, IL-6 and IFN-γ but IL-10 was lower among participants with oral lesions. Only TNF-α did not vary with the presence or absence of oral lesions. Conclusion: HIV- oral lesions were found to be associated with lowered CD4+ count as well as salivary cytokine dysregulation. Key words: Cytokines, saliva, HIV, antiretroviral treatment
Presenting author: Elizabeth Abe
Poster 7
Establishing an African Hepatitis B/HIV-HBV Clinical Research Network Across Africa
Background Chronic hepatitis B virus (HBV) is a global problem. An estimated 254 million people were living with chronic hepatitis B infection in 2024, with 1.2 million new infections each year with 65 million living in Africa1. The prevalence of HBV in Nigeria, Mali, and Tanzania are some of the highest at 5.2 – 9.5%2,3. Among persons with HIV, HBV prevalence ranges up to 22%4. HBV has been poorly characterized in the sub-Saharan Africa, particularly among persons with HIV which has similar modes of transmission and representation in international studies and clinical trials is limited. Methods The African Hepatitis B/HIV-HBV Co-infection Clinical Research Network (AHBCRN) consortium is a collaboration between Northwestern University, Jos University Teaching Hospital, Nigeria, College of Medicine, University of Lagos, Nigeria, University College Hospital, University of Ibadan, Nigeria, Muhimbili National Hospital, Dar es Salaam, Tanzania, University of Science of Technical and Technology De Bamako, Mali established in 2023 with funding from a Robert J. Havey, MD Institute for Global Health, Global Innovation Challenge Award and Project Award at Northwestern University, Feinberg School of Medicine to address key research gaps in Hepatitis B (HBV) and HIV/HBV co-infection in SSA. Specific aims of the consortium are to: Establish a multi-site longitudinal observational clinical cohort of adult HBV and HIV-HBV participants recruited from these five academic institutions in East and West Africa from which to conduct large-scale population based prospective studies of CHB and identify participants for future CHB therapeutic trials. Develop a repository of HBV biospecimens (e.g., serum, plasma, PBMCs) and clinical data obtained from enrolled adult HBV and HIV-HBV participants. Describe clinical, virological, and immunological characteristics in HBV and HIV-HBV study participants and compare differences in characteristics across these diverse populations at different disease stages and exposures to treatment. Results Since its official launch in Nigeria in December 2023, the consortium has received approval for and implemented research cohorts at four of the five sites. As of April 2024, 120 persons with HBV and 81 persons with HBV/HIV on and off antivirals have been enrolled. REDCap, hosted from College of Medicine, University of Ibadan, is used for clinical and laboratory data entry and database coordination across AHBCRN network sites. The team uses a Microsoft SharePoint site to save and distribute CRF templates, site-specific IRB protocols, and consents, IRB approval letters, meeting agendas and other research resources. The team meets every other week via zoom to discuss participant enrollment and challenges, new opportunities for funding, new collaborations and progress on the scientific agenda. Conclusion This new multisite cohort study of Hepatitis B with representation from five high HIV and HBV prevalence areas in SSA expected to generate data that will significantly advance our understanding and knowledge of HBV in these settings and fill critical gaps in HBV prevention and care that is currently hindering progress to global HBV elimination.
Presenting author: Elizabeth Christian
Poster 8
Differences Between Viral Suppression and Psychosocial Markers among Adolescents living with HIV: The Role of Self-Efficacy, Quality of Life, and antiretroviral knowledge in Dar es Salaam, Tanzania
Background In Tanzania, One of the three UNAIDS 95% targets for combatting HIV have been reached (providing ART). The 1st and 3rd targets have not (95% PL-HIV know their status, 95% achieving viral suppression [VLS]). National report indicates VLS among adolescents with HIV(AWHIV) is 56-73%. To address this gap, we examined the association between VLS and psychosocial indicators among AWHIV Methods We administered a culturally adapted battery of self-reported behaviour, environmental and self-efficacy measures to randomly selected 558 AWHIV aged 15-19 years on ART from 10 high volume facilities in Dar es Salaam from August 2022 to May 2023, in a cross-sectional study. Primary outcome (VLS) data was from facilities' databases. Total scores and single item indicators were entered as dependent variables into separate general linear models using dichotomous independent variable: VLS (< 50) vs. No VLS (>/=50). Ethical approval, signed informed consents were obtained before starting Results There were no significant differences between VLS groups on depression, social support, or stigma (p>.05). The VLS group reported significantly higher quality of life compared with No VLS group (F=10.3, p< .001), a difference which was small in magnitude (d=.34). Single item indicators of health self-efficacy ("I am confident I can take care of my health"), life goals/ambition ("I aim to be successful [example, finishing school, getting a job"), and ARV administration knowledge ("I know at what times I take my ARVs") all significantly differentiated VLS groups. The VLS group reported significantly higher healthcare self-efficacy (F=3.9, p< .05) and higher life goals/ambitions (F=4.7, p< .05) compared with the No VLS group. The magnitude of these differences was small (d's=.21). The No VLS group reported significantly higher ART administration knowledge (F=4.1, p< .05) compared with VLS group (d=.23). Interpretation Findings suggest that experiencing symptoms of depression and stigma, and perceiving social support occurs regardless of one's VLS status; however, having VLS is associated with higher reports of quality of life, albeit to small extent. Also, to small extent, healthcare self-efficacy and having life goals/ambitions may play some role in viral suppression, and people with No VLS may be more knowledgeable about their ARV medication regimen, which would be expected given the stressors of having No viral suppression
Presenting author: Hellen Neema Siril
Poster 9
Charting Rehabilitation Outcomes for Patients Engaging in Medical Tourism: A Retrospective Cohort Study
Purpose: Medical tourism, defined as the act of traveling internationally to obtain medical care, has become increasingly prevalent world-wide. Globally, it is estimated that 617 million individuals engage in medical tourism, and the industry is thought to account for $513 billion USD annually. Despite expectations that medical tourism will continue to grow,5 no studies to date have explored inbound medical tourism within inpatient rehabilitation facilities in the United States. The aim of this present study is to fill this literature gap and to address patient characteristics associated with medical tourism in an American inpatient rehabilitation facility. Specifically, our aim was to assess what demographic, medical, and rehabilitation characteristics are associated with patients participating in medical tourism in an American acute inpatient rehabilitation facility? What are the rehabilitation outcomes for such patients? We predicted that there will be an improvement in Functional Independence Measures (FIM) and quality improvement (QI) scores before and after a course of acute inpatient rehabilitation (AIR) for acute inpatient rehabilitation patients participating in medical tourism. Methods: This is a retrospective cohort study of a sample of 153 patients participating in a medical tourism program at an inpatient rehabilitation facility between 2018 and 2023. Primary outcomes included demographic features, including social and medical characteristics, and rehabilitation outcomes including change in functional independence score (FIM) between admission and discharge, length of stay, and discharge destination. Results: Patients participating in medical tourism were primarily men (n = 103, 67.3%), white (n =91, 100%), primarily non-Latino (n= 88, 96.7%) and on average (SD) 45.8 (17.2) years old. The majority in our sample spoke Arabic (n = 110, 71.9%) followed by English (n = 33, 21.6%). 109 (71.2%) patients required an interpreter during rehabilitation. 119 (91.5%) patients originated from the Middle East. The largest proportion of patients had primarily a diagnosis of stroke (n= 25, 28.4%) followed by Medically Complex (n= 24, 27.3%). Patients demonstrated improvement in FIM scores (average) including bathing (1.39, p < 0.005), toileting (1.76, p < 0.005), transfers (1.91, p < 0.005), and locomotion (2.05, p < 0.005). 25 (28.4%) of patients had previously undergone a course of acute inpatient rehabilitation. 117 (76.5%) patients ultimately discharged home after an average of 59.2 days (SD 51.9) of inpatient rehabilitation. Conclusions: Patients participating in medical tourism in this stand-alone inpatient rehabilitation facility represent a diverse patient population in terms primary diagnoses with the majority originating from the Middle East and speaking Arabic. Patients demonstrated important improvements in independence across admission with the majority of patients discharging home after variable length of stay.
Presenting author: Jessica Marone
Poster 10
Assessing the long-term impact of an HPV screening intervention on willingness to vaccinate: Evidence from rural Kenya
Despite its status as a preventable disease, cervical cancer is the leading cause of cancer deaths in women in Kenya1. In 2018, the World Health Organization Director-General called for the elimination of cervical cancer worldwide, a strategy that was formally adopted in August 2020 by the World Health Assembly. The WHO established “90-70-90” targets for vaccination, screening, and treatment by the year 2030, wherein 90% of girls under 15 receive the HPV vaccine; 70% of women are screened twice (before 35 and again by age 45); and 90% of women with pre-cancer and cervical cancer are treated and managed2. In 2019, Kenya’s Ministry of Health introduced an HPV vaccination schedule for 10-year-old girls, but uptake has been low (first dose: 33% of target population; second dose: 16% of target population)3. Understanding parents’ willingness to vaccinate and barriers to vaccination are crucial for meeting the WHO’s targets in Kenya. This research builds on a two-phase cluster-randomized trial conducted in 2016 to evaluate the effectiveness of a community-wide HPV screening intervention in promoting follow-up care in Migori County, Kenya4. Women in both the intervention and control groups received HPV and cervical cancer education and outreach from community health volunteers over a 2-week dedicated community health campaign. Following which, women in the intervention group received HPV screening in a centralized location within their village, and women in the control villages were screened at the local government health facility. A follow-up survey conducted in July 2022 was administered to 1,080 women living in these control and intervention villages to assess the long-term impacts of the RCT and the ways in which women were dealing with the ongoing COVID-19 pandemic. Drawing on these survey data, this project identifies: 1. Parental willingness to vaccinate their daughters against HPV; 2. Women’s willingness to vaccinate themselves against COVID-19; 3. Reasons for supporting or opposing HPV and COVID-19 vaccination; 4. How participation in the HPV screening intervention shaped those views; and 5. Factors associated with willingness to vaccinate. On a micro level, this research documents vaccine support and hesitancy in rural Kenya. On a macro level, these results are useful for policy makers who seek to know what programs may or may not work to increase vaccine uptake in low- and middle-income countries where the disease burden of cervical cancer remains high. Meeting the WHO’s “90-70-90” targets will require an in-depth understanding of what barriers to vaccination remain, in order to eliminate them.
Presenting author: Kelly Hunter
Poster 11
A mixed-data exploration of caregivers' perceptions of stigma experiences of children with TB in Cape Town, South Africa
Background: Tuberculosis (TB)-related stigma often stems from a fear of TB infection and contagiousness, unequal power dynamics between social groups, and an association of TB with socially undesirable traits. TB stigma can have a profound effect on accessing and adhering to treatment and on social and economic capital. Aim: This study aimed to better understand how caregivers of young children with TB experience and understand TB stigma. Methods: This study was conducted within a prospective observational TB diagnostic cohort study called UMOYA. Children aged 0-13 (median age 2 years) presenting with presumptive pulmonary TB were enrolled and followed up for 6 months. Stigma questionnaires adapted from the Stop TB Partnership and activity-based interviews were administered during TB treatment. Caregivers of children diagnosed with TB (both microbiologically confirmed and clinically diagnosed) were asked about different domains of stigma and stigma-influencing behavior. Results: In total, 56 caregivers of 62 children (Aged 0-6-years) with TB completed the questionnaire. Ten additional caregivers were interviewed. Most children (71.1%) had one known TB contact in the household. The questionnaire revealed that anticipated stigma was a common concern, with worries about gossiping or negative talk about their children (14.8%) and potential hurt feelings due to their TB diagnosis (14.5%). Internalized stigma by the child, as perceived by caregivers, was less common. Interview themes highlighted anticipated rejection, isolation, and links to HIV. Age and self-confidence were suggested as potential protective factors against stigma. Conclusion: Childhood TB has an impact on caregivers and their households. Other TB cases in the household may influence caregivers' perspectives. Further research on the pathways through which TB stigma impacts treatment behavior is needed. Deepening our understanding of stigma among young children is critical to improving outcomes and experiences for children and their families affected by TB in South Africa.
Presenting author: Lyra Johnson
Poster 12
Providers' perspectives on culturally-relevant sexual and reproductive healthcare for refugee women: A qualitative study
Introduction/Background: Refugee women have low utilization of and poor outcomes related to sexual and reproductive health services. Little research has explored U.S. providers' perceptions of culturally-relevant strategies that may help address women's barriers to sexual and reproductive healthcare. Goals/Hypotheses/Questions: What are culturally-relevant strategies for healthcare providers to deliver high-quality care that can address existing barriers and improve sexual and reproductive healthcare experiences and outcomes for refugee women in the United States? Our study aims to fill this literature gap. Methods/Strategies/Activities: We conducted in-depth, semi-structured interviews with 17 providers (e.g., physicians, nurse practitioners, registered nurses) serving refugee women in metropolitan Atlanta, Georgia. We used convenience and snowball sampling for recruitment. We inquired about providers' perceptions and experiences of 1) refugee women's cultural or religious barriers to sexual and reproductive healthcare, 2) their training in working with refugee women, and 3) culturally-relevant strategies to deliver sexual and reproductive healthcare and increase utilization among refugee women. Two coders analyzed the data using a qualitative thematic approach. Results/Findings/Lessons Learned: According to providers, cultural and religious barriers to sexual and reproductive healthcare among refugee women included hesitancy to ask questions and voice concerns, low priority of preventive care, gendered expectations, and preference for gender-concordant providers. Many providers reported a lack of or inadequate formal training in providing sexual and reproductive healthcare for refugee women. Some attributed this lack of training to the fact that the refugee crisis was not as visible and widespread during their training compared to recent years. Other providers noted that it was only through opting into volunteer opportunities that experience was gained. Regarding culturally-relevant strategies to deliver sexual and reproductive healthcare, providers emphasized: recognizing implicit biases and acknowledging structural racism, accepting autonomous decision-making while also building trust, tailoring care to patients' characteristics and cultural backgrounds, and collaborating with community partners to implement health education initiatives. Conclusions/Implications/Next Steps: Our research found gaps in providers' education and training to deliver culturally-relevant sexual and reproductive healthcare for refugee women. Current health education and delivery is seen as failing to meet the needs of minoritized communities. It is important to strike a balance between learning about cultural backgrounds versus stereotyping them. The refugee identity is not homogeneous and more training and preparedness on the part of providers is needed to provide high-quality care for refugee women. In addition, providers identified multiple important strategies that can facilitate the provision of high-quality, culturally-relevant sexual and reproductive healthcare and increase utilization among refugee women. A comprehensive approach of providers receiving formal education during medical training, proactively seeking out information about refugee women's healthcare needs, partnering with community members and experts, and listening to individual patients may be beneficial.
Presenting author: Marian Enders
Poster 13
Catastrophic Health Expenditures for Colorectal Cancer Care: A Retrospective Analysis of the First Private Cancer Center in Nigeria
Introduction: Nearly a billion people worldwide risk Financial Catastrophe (FC) due to out-of-pocket health expenditures (OOP), with low- and middle-income countries disproportionately impacted. This is especially true for Nigeria, where 50% of the 200 million population live in poverty and over 96% are uninsured. For cancer patients specifically, nearly 70% do not seek treatment following diagnosis, while between 77-95% of those that do risk FC. As the global burden of colorectal cancer (CRC) is on the rise, with nearly 2 million new cases and 1 million deaths yearly, this study aims to evaluate the cost of treating CRC at the first private cancer center in Nigeria. Methods: We queried the center's cancer registry for uninsured patients diagnosed with CRC between 2013-2023. Treatment costs were abstracted from bills in patient charts (adjusted to 2023 USD), as were demographic and clinical characteristics. As we did not have access to patient income or household expenditure, risk for FC was defined as OOP > 20% of Nigeria's 2023 per capita GDP ($467). As all patients were uninsured, all costs were defined as OOP. Descriptive statistics, including mean (SD) and count (proportion), measured total OOP, treatment-specific OOP, demographics, and clinical characteristics. Two-sided Student's t-tests were used to compare total OOP by stage, cancer site, and sex (α= 0.05). Results: 91 patients (59% female, median age 58, 69% colon, 24% rectum, 15% stage 3, 66% stage 4) were included. For those receiving treatment, the average combined chemotherapy OOP (n = 41) was $7,877 (SD = $12,235) and combined procedure OOP (n = 24) was $1,156 (SD = $441). The average total OOP for patients undergoing both procedures and adjuvant therapies (n = 23) was $39,333 (SD = $57,776), over 80 times the national GDP. Stage 3-4 patients spent $12,000 more on average than stages 1-2 (p < .01), and colon cancer care spent $9,500 more than rectal (p = .052). The overall mean total OOP was $11,956 (SD = $1105), with 67% risking financial catastrophe. Of those treated with chemotherapy and/or a procedure (n = 42), 100% risked FC. The greatest contributors to total cost were chemotherapy (30%) and other drugs (21%), while procedures accounted for 3%. Conclusion: Treatment costs for CRC are highly catastrophic. This is especially true for those that present in stages 3 or 4, which is the case for most CRC cancer patients in Nigeria. Without risk protection through insurance or financial navigation, CRC care increases the risk of poverty for nearly all patients who undergo treatment. To improve access to treatment and reduce mortality, innovative solutions that reduce the financial burden of cancer care are needed at all levels of the Nigerian health system.
Presenting author: Matt Caputo
Poster 14
Barriers to Complex Obstetrical Care in Rural Philippines
Introduction: In the rural areas of the Philippines, access to healthcare is limited. In regards to women's health, it is well known that access to healthcare greatly impacts maternal mortality. Reduction in maternal mortality defined as any death occurring during pregnancy, labor, delivery, or up to 6 weeks postpartum, remains a goal for the United Nations Millennium Development Goals. Northwestern Minimally Invasive Gynecology (MIGs) division helped establish the Salcedo Doctor's Hospital in Salcedo, Eastern Samar Philippines, a rural area of the Philippines. At Salcedo Doctor's Hospital patients receive both gynecological and obstetrical care. This year the MIGS division returned for a mission trip incorporating care from a maternal-fetal medicine physician to expand the scope of obstetrical care provided. The aims of this study were (1) To assess the prevalence of women who have limited prenatal care among women delivering at Salcedo Doctor's Hospital in Salcedo, and (2) To assess the rate of obstetrical complications among women delivering at Salcedo Doctor's Hospital in Salcedo. Methods: Data on access to prenatal care were collected during the two-week visit by a maternal-fetal medicine physician from Northwestern University. Data on obstetric complications were collected from Hospital delivery records. Descriptive statistics were used to summarize the findings. Results: During the two-week mission trip at Salcedo Doctor's Hospital 35 prenatal visits were conducted. On average 72% of patients met the criteria for limited prenatal care with less than 3 visits during their pregnancies. Similarly, approximately 74% had not received a routine ultrasonographic study during their pregnancies. Since its establishment, Salcedo Women's Hospital has delivered 51 infants. 76.5% were attended by midwives. All patients underwent uncomplicated spontaneous labor, and all deliveries occurred without postpartum hemorrhage or obstetrical complications. Conclusion: Despite limited access to comprehensive obstetrical care, all patients underwent uncomplicated spontaneous labor, and all deliveries occurred without postpartum hemorrhage or obstetrical complications. These obstetrical outcomes at this single clinical site highlight the pivotal role midwives serve as a bridge in the gap of comprehensive obstetrical care in low-resource countries.
Presenting author: Nkechinyelum Ogu
Poster 15
Risk of Financial Catastrophe for Breast Cancer Patients in Nigeria: A Retrospective Analysis
Introduction: Cancer imposes a significant financial burden on patients and healthcare systems, particularly in low/middle-income countries like Nigeria, where breast cancer (BC) is the most common cancer and has the highest mortality, accounting for 18% of all cancer deaths. Less than 10% of the population in Nigeria has some form of health insurance with most patients paying out of pocket (OOP) for healthcare, leading to significant financial strain. This study aims to investigate the financial burden of BC care at Lakeshore Cancer Center (LCC) in Nigeria and identify risk factors for financial catastrophe. Methods: LCC was queried for uninsured patients diagnosed with breast cancers between 2013-2023, linked to cost data through chart abstraction of billing data and adjusted to 2023 USD. All costs were out-of-pocket costs (OOP) as all patients were uninsured. Risk for financial catastrophe was defined as OOP exceeding 20% of Nigeria's 2023 per capita GDP ($467). Total OOP and risk for financial catastrophe were measured with descriptive statistics and stratified by clinical characteristics. Results: 346 BC patients (99% female, median age 47. 39% stage 4, 26% stage 3, 26% stage 1-2) were included. Only 103 patients (30%) completed treatment. 257 (74%) patients risked financial catastrophe, despite only 30% completing treatment. For patients that underwent treatment, the median cost was $4500USD. Patients with HER2+/HR+ disease exhibited the highest treatment costs (table). Among patients that underwent a surgery and adjuvant therapy (n = 105), the average OOP was $18468 with 100% risking financial catastrophe. The highest contributors to the cohort's total costs were chemotherapy (26%), drugs (18%), and immunotherapy (16%). Surgery contributed 7.3%. Discussion: Less than one-third of BC patients completed treatment, and the majority faced financial catastrophe, especially those with HER2+/HR+ disease and patients who underwent multiple treatment modalities or immunotherapy. Targeted financial assistance programs are essential to ensure equitable access to quality cancer care while minimizing the risk of financial catastrophe.
Presenting author: Norah Zaza
Poster 16
Identifying Barriers to Neonatal Respiratory Care in Sub-Saharan Africa: A Literature Review
INTRODUCTION: Neonatal mortality rates continue to be significant in resource-limited hospitals in Sub-Saharan Africa. In 2022, this region had the highest neonatal mortality rate, estimated by the WHO to be at approximately 27 deaths per 1000 live births. Approximately 73% of these deaths happened in the first week of life where neonates are most vulnerable. The first week of life includes targeting labor, thermal care, hygienic cord care, and respiratory care after birth. Interventions made in these aspects are likely to have the greatest impact on mortality. Access to respiratory care in this region for neonates is met with multiple barriers including staffing constraints, lack of appropriate medical equipment and lack of neonatal knowledge and skill sets. METHODS: A systematic search was conducted across multiple academic databases including PubMed and MEDLINE, using relevant keywords in various combinations with "Sub-Saharan Africa", "respiratory", "neonatal", "barriers". Peer-reviewed articles published within the last ten years were included in the review that directly addressed neonatal care barriers. Articles were reviewed for relevance and significant findings by this author. RESULTS: There were a limited number of articles dedicated to addressing respiratory care barriers specifically in neonatal care for the Sub-Saharan Africa region. A total of seven articles were reviewed addressing neonatal care barriers specifically. However, multiple articles discussed lack of staffing, cost and lack of medical equipment as well as lack of training in neonatal care generally as barriers to providing optimal respiratory outcomes. Two articles investigated use of a low cost CPAP used in Tanzania which was shown by staff interviews to have become essential for treating neonatal respiratory distress. This suggests a need for more testing of and integration of lower cost medical equipment alternatives in respiratory care in such countries. CONCLUSION: This literature review reveals a gap in knowledge and research into exact respiratory care barriers in various countries of Sub-Saharan Africa. Limited articles were found specifically addressing neonatal respiratory care barriers in NICU settings for this particular region, however broad neonatal care barriers mentioned including lack of adequate neonatal training of staff, limitation of equipment and cost associated. Further investigation needs to be done to identify specific barriers in providing training and acquiring equipment for neonatal respiratory support as well as finding low cost interventions and alternatives for positive pressure respiratory support in neonates.
Presenting author: Tanvi Batish
Poster 17
Addressing Global Anesthesia Provider Shortages with Simulation Training
The global burden of surgical disease has been receiving more attention in the last several decades, and the gap between the need for surgical care and access continues to grow. There are many barriers to expanding surgical care in low-income countries including access to equipment, medications, training, qualified providers, and funding. One of the underappreciated barriers is an adequate and well-trained anesthesia workforce. In many low-income countries, anesthesia care is provided by physicians without training in anesthesia, nurses, or technicians. One study found that over 30% of medical facilities in low-income countries had no full or part-time staff to provide anesthesia care (Hendel et al). In Kenya in 2010, there were a total of 120 anesthesiologists for a population of 32 million (Dubowitz et al). In Mozambique in 2016, there were 33 anesthesiologists for a population of 25 million, and to reach the same provider-population ratio as the U.S. the country would need around 5,200 additional providers. There is only 1 residency program in the country, with 4 spots per year, and the year prior to the publication they had 0 residents begin training (Lyon et al). Much of the anesthetic workforce in many low-income countries is made up of anesthesia technicians who undergo a shorter and less formalized education than physicians. Particularly in obstetric anesthesia care, increasing morbidity and mortality have been attributed to anesthetic complications, often due to a lack of skilled providers. Given the high percentage of anesthesia providers with a less structured education, simulation is a great technique to help improve the quality of care in low-income countries, particularly to prepare for acute situations. However, developing simulations for use in low-income countries comes with many challenges. Available medications and equipment can be vastly different from those used in high-income countries, and funding is not available to purchase technologically advanced simulation equipment. Developing a simulation curriculum can be done with careful coordination and planning with health care practitioners practicing in these areas. We designed a simulation to train anesthesia providers at a hospital in Kenya, with the goal of improving the management of post-partum hemorrhage.
Presenting author: Taylor Pruis
Poster 18
Influence of HIV status disclosure on depressive symptoms and quality of life among children in North-Eastern Tanzania
Background: Disclosure of HIV status among HIV-infected children is very important for their mental and psychosocial well-being. However, there is limited information on the effect of HIV disclosure on mental health and the quality of life in HIV-infected children in Tanzania. Objective: To investigate the effect of HIV disclosure and associated factors on depressive symptoms and health-related quality (HRQOL) of life in HIV-infected children aged 8 -14 years in Tanga region, Tanzania. Methods: A cross-sectional study was conducted from June to November 2023 in public HIV clinics in Tanga, Tanzania. Information on depressive symptoms, HRQOL, child HIV and sociodemographic factors were collected. Depressive symptoms and HRQOL were assessed by the Children Depression Inventory-II and KIDScreen-27 Scales respectively. Simple Linear and Multiple Linear regression were used to assess association between HRQOL scores, depression scores and child sociodemographic and HIV-related factors. All analyses were statistically significant at P < 0.05. Results: A total of 278 children (median age 12 years (IQR: 10–13) were recruited. The overall sum of HRQOL and depressive symptoms scores in this population was 28616 and 1942 respectively. The mean scores for HRQOL among disclosed and non-disclosed children were 103.2 ± 13.5 and 102.7 ±12.6 respectively. The mean scores for depressive symptoms among disclosed and non-disclosed children were 6.3 ± 5.2 and 7.6 ±6.9 respectively. A total of 131 (47.1%) received HIV disclosure and a greater proportion were disclosed at the age of 9 (n=26, 19.9%) and 10 (n=30, 22.9%) years. No significant difference was observed for HRQOL scores (Coefficient = 0.4, 95% CI: -2.6, 3.5, p=0.8) and for depressive symptoms scores (Coefficient = -1.3, 95% CI: = -2.7, 0.2, p=0.09) among disclosed and non-disclosed HIV infected children. After adjustment for other variables, it was observed that, for each unit increase in depression scores among children, their HRQOL scores decreased by 1.1 (Coefficient= -1.1, 95%CI:-1.3, -0.9, P< 0.0001). HRQOL scores were observed to increase with the increase in child age in years (Coefficient=-1.4, 95% CI: -2.7, -0.1. P=0.04). Children with poor antiretroviral treatment (ART) adherence were associated with lower HRQOL scores than those with good ART adherence (Coefficient= -4.2, 95% CI:-7.0, -1.5, p=0.03). Conclusion: HIV disclosure was not associated with differences in HRQOL or depressive symptoms. However, the findings could have been influenced with other unmeasured confoubders which could be explained in a longitudinal study.
Presenting author: Veneranda M. Bwana, MD, MSc, PhD
Poster 19
Highlighting the Challenges & Barriers to Understanding the Extent and Etiology of High Rates of Congenital Anomalies in Tanzania: A Literature Review
Congenital anomalies are the fifth leading cause of death in children under age 5 and those who survive often experience significant morbidity, presenting an especially severe burden on low- and middle-income countries (LMICs). The serious burden of congenital anomalies within LMICs highlights underlying socioeconomic and healthcare inequalities and requires prompt attention from both local and international organizations to help decrease child morbidity and mortality from this cause. Because limited literature exists investigating the prevalence of congenital anomalies within LMICs outside of hospital-based, single-center studies, it remains challenging to understand the true extent of these birth defects and their associated risk factors within Tanzania. This review aims to examine the current hypotheses within recent studies for the relatively high rates of congenital anomalies within Tanzania and highlight the barriers to understanding the full extent of congenital anomalies within the general population of Tanzania as well as their associated risk factors. Additionally, based on what is currently known from recent studies regarding the etiology of Tanzania’s congenital anomalies, this review will conclude with a summary of potential interventions to help improve birth outcomes and decrease child morbidity and mortality from this cause. Current hypotheses for high rates of CAs include low rates of preconceptional folic acid supplementation, exposure to environmental hazards, maternal chronic disease, and increasing birth order. All studies reviewed support that babies born to mothers who did not take folic acid supplementation were more likely to be diagnosed with congenital anomalies. Further recommendations focus on promoting universal antenatal folic acid supplementation and family planning, calling for a national registry of congenital anomalies to aid with mapping and understanding of environmental and geographic risk factors, and encouraging antenatal fetal surveillance for early detection of anomalies.
Presenting author: Yashna Naidu
Poster 20
Education and Training for Impact: Initial Outcomes from the Fogarty Funded Cardiovascular Research Training Program in Nigeria (CeRTIN) program
Background: The NIH-funded Cardiovascular Research Training in Nigeria (CeRTIN) program seeks to increase the research capacity of Nigerian researchers in cardiovascular research, clinical trials, and patient-centered outcomes research (PCOR) to improve cardiovascular care and outcomes. CeRTIN is a multi-year program modeled after the FIC strategy for research training and capacity building in LMIC, combining mentored short-, medium-, and long-term training opportunities. The partnership links three institutions: the University of Abuja, Northwestern University, and Washington University in St. Louis. Methods: Three short-term training activities were evaluated. Two in-person and one hybrid event covered core concepts of clinical trials, PCOR, implementation research, data analysis, and qualitative research techniques. The evaluation was guided by the Kirkpatrick framework. Participants completed pre- and post-activity surveys on REDCAP measuring differences in knowledge and confidence in core domains, intentions and evidence of knowledge application in the work environment. Open-ended, qualitative feedback captured learning insights, engagement, and overall session feedback. Findings: Among 49 workshop participants in 2021 and 40 in 2022, 29 (59.1%) and 34 (85.0%) completed the surveys, respectively. Among 76 symposium participants, 25 (32.9%) responded. Most had limited baseline knowledge and experience in cardiovascular clinical trials, implementation research, and PCOR. Respondents reported increased knowledge, particularly in clinical trial study design and implementation research, after the training activities. They reported that activities effectively achieved stated goals, aligning with their personal learning objectives. Most expressed a strong intention to apply their newly acquired skills to their current and future research. Qualitative analysis identified common motivations for program participation, including skill improvements, networking, collaborating with peers, and deepening knowledge in cardiovascular research and related fields. Respondents expressed high interest in future medium- and long-term training opportunities. Interpretation: The short-term training activities demonstrated self-reported benefits and improvement in knowledge, with some demonstration of application of knowledge gained. Activities identified an applicant pool for medium- and long-term research training, with future program activities likely to refine workshop content based on participant feedback. Findings underscore the importance of cross-institutional partnerships to culturally tailor research training to address the CVD burden in LMICs.
Presenting author: Yi Gao
Poster 21
Leveraging ecological momentary assessment to examine the within-subject association between physical activity and stress level and variability during pregnancy
Background Physical activity (PA) during pregnancy is linked to improved maternal mental health. However, the prevalence of PA during pregnancy is low: Only about 13% meet recommended activity targets (i.e., at least 150 minutes per week). Understanding the nuanced relationship between PA and maternal stress during pregnancy is crucial for developing effective interventions to promote PA among pregnant individuals. Existing studies have primarily focused on between-subject associations of PA and level of maternal stress (i.e., do those with overall higher levels of exercise have lower stress overall) and utilized retrospective survey measures, the latter of which is subject to high recall bias. Less is known about the within-subject association of PA and level of maternal stress (i.e., during the time that pregnant individuals exercise, do they experience lower levels of stress than their average) and if PA is related to stress stabilization/variability (i.e., do those with overall higher levels of exercise tend to have greater stress stability). Furthermore, although evidence suggests that negative mood regulation expectancies (NMRE; beliefs in one's ability to initiate behaviors to alleviate a negative mood) is related to stress, it is unclear if the within-subject association is moderated by NMRE. This study utilized ecological momentary assessment (EMA) data to examine these three research questions and shed light on the nuanced role of PA on maternal stress to promote PA during pregnancy. Method Data were from 99 participants in a randomized controlled trial (RCT) of prenatal stress reduction. Mean maternal and gestational ages at recruitment were 34.41 years (SD=4.86) and 11.50 weeks (SD=2.94); most participants identified as White (70%), non-Hispanic (87%), having earned a college degree or higher (95%), and married (84%). Participants answered EMAs up to 4 times a day between waking and bedtime. In each EMA occasion, participants reported in the past hour, whether they had exercised or done PA and their stress using the Perceived Stress Scale. NMRE was measured at baseline using the Negative Mood Regulation Scale. Mixed-effects location scale models were used, controlling for intervention status, day of the week, time of the day, baseline maternal age, income-to-needs ratio, baseline stress, and depression. Result Pregnant individuals experienced lower levels of stress than their average stress when they exercised (within-subject association between PA and the level of stress β=-.25, p< 0.001). The within-subject reduction in stress was moderated by participants' negative mood regulation expectancies (β=0.04, p< 0.001): Stress reduced more for those with weaker belief in mood regulation while less for those with stronger belief. Participants with overall higher levels of PA tended to have less within-person variance (variance ratio 0.88, p< 0.05), indicating higher within-person mood stabilization. Implications Practitioners working with pregnant individuals may be more effective in promoting PA when they are equipped with a deeper knowledge of personalized health benefits of PA in stress reduction and mood stabilization. Future research can aim to replicate the findings in larger community samples and pinpoint effective implementation strategies on how to communicate the benefits of PA and develop personalized strategies for improving wellness.
Presenting author: Yudong Zhang
Poster 22