Victoria Simms | University of Ulster (original) (raw)

Papers by Victoria Simms

Research paper thumbnail of Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial

The Lancet, 2015

Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, p... more Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, particularly in those with advanced disease. We assessed the effect of a short period of community support to supplement clinic-based services combined with serum cryptococcal antigen screening. We did an open-label, randomised controlled trial in six urban clinics in Dar es Salaam, Tanzania, and Lusaka, Zambia. From February, 2012, we enrolled eligible individuals with HIV infection (age ≥18 years, CD4 count of <200 cells per μL, ART naive) and randomly assigned them to either the standard clinic-based care supplemented with community support or standard clinic-based care alone, stratified by country and clinic, in permuted block sizes of ten. Clinic plus community support consisted of screening for serum cryptococcal antigen combined with antifungal therapy for patients testing antigen positive, weekly home visits for the first 4 weeks on ART by lay workers to provide support, and in Tanzania alone, re-screening for tuberculosis at 6-8 weeks after ART initiation. The primary endpoint was all-cause mortality at 12 months, analysed by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISCRTN 20410413. Between Feb 9, 2012, and Sept 30, 2013, 1001 patients were randomly assigned to clinic plus community support and 998 to standard care. 89 (9%) of 1001 participants in the clinic plus community support group did not receive their assigned intervention, and 11 (1%) of 998 participants in the standard care group received a home visit or a cryptococcal antigen screen rather than only standard care. At 12 months, 25 (2%) of 1001 participants in the clinic plus community support group and 24 (2%) of 998 participants in the standard care group had been lost to follow-up, and were censored at their last visit for the primary analysis. At 12 months, 134 (13%) of 1001 participants in the clinic plus community support group had died compared with 180 (18%) of 998 in the standard care group. Mortality was 28% (95% CI 10-43) lower in the clinic plus community support group than in standard care group (p=0·004). Screening and pre-emptive treatment for cryptococcal infection combined with a short initial period of adherence support after initiation of ART could substantially reduce mortality in HIV programmes in Africa. European and Developing Countries Clinical Trials Partnership.

Research paper thumbnail of A National Survey of Musculoskeletal Impairment in Rwanda: Prevalence, Causes and Service Implications

PLoS ONE, 2008

Background: Accurate information on the prevalence and causes of musculoskeletal impairment (MSI)... more Background: Accurate information on the prevalence and causes of musculoskeletal impairment (MSI) is lacking in low income countries. We present a new survey methodology that is based on sound epidemiological principles and is linked to the World Health Organisation's International Classification of Functioning.

Research paper thumbnail of Inattention in very preterm children: Implications for screening and detection

Children born very preterm (VP; &... more Children born very preterm (VP; <32 weeks) are at risk for attention deficit/hyperactivity disorders (ADHD). ADHD in VP children have a different clinical presentation to ADHD in the general population, and therefore VP children with difficulties may not come to the teacher's attention in school. We have assessed ADHD symptoms to determine whether VP children's difficulties may go undetected in the classroom. Parents and teachers of 117 VP and 77 term-born children completed the Strengths and Difficulties Questionnaire to assess hyperactivity/inattention, emotional, conduct and peer problems, and the Du Paul ADHD Rating Scale-IV to assess inattention and hyperactivity/impulsivity symptoms. Special Educational Needs (SEN) were assessed using teacher report. Group differences in outcomes were adjusted for socio-economic deprivation. Parents and teachers rated VP children with significantly higher mean Strengths and Difficulties Questionnaire hyperactivity/inattention scores, and parents rated them with more clinically significant hyperactivity/inattention difficulties than term-born controls (Relative Risk (RR) 4.0; 95% CI 1.4 to 11.4). Examining ADHD dimensions, parents and teachers rated VP children with significantly more inattention symptoms than controls, and parents rated them with more clinically significant inattention (RR 4.8; 95% CI 1.4 to 16.0); in contrast, there was no excess of hyperactivity/impulsivity. After excluding children with SEN, VP children still had significantly higher inattention scores than controls but there was no excess of hyperactivity/impulsivity. VP children are at greater risk for symptoms of inattention than hyperactivity/impulsivity. Inattention was significantly increased among VP children without identified SEN suggesting that these problems may be difficult to detect in school. Raising teachers' awareness of inattention problems may be advantageous in enabling them to identify VP children who may benefit from intervention.

Research paper thumbnail of Mathematics difficulties in extremely preterm children: evidence of a specific deficit in basic mathematics processing

Pediatric Research, 2012

Background: extremely preterm (eP, <26 wk gestation) children have been observed to have poor aca... more Background: extremely preterm (eP, <26 wk gestation) children have been observed to have poor academic achievement in comparison to their term-born peers, especially in mathematics. This study investigated potential underlying causes of this difficulty. Methods: a total of 219 eP participants were compared with 153 term-born control children at 11 y of age. all children were assessed by a psychologist on a battery of standardized cognitive tests and a number estimation test assessing children's numerical representations. results: eP children underperformed in all tests in comparison with the term controls (the majority of Ps < 0.001). Different underlying relationships between performance on the number estimation test and mathematical achievement were found in eP as compared with control children. That is, even after controlling for cognitive ability, a relationship between number representations and mathematical performance persisted for eP children only (eP: r = 0.346, n = 186, P < 0.001; control: r = 0.095, n = 146, P = 0.256). conclusion: Interventions for eP children may target improving children's numerical representations in order to subsequently remediate their mathematical skills.

Research paper thumbnail of Musculoskeletal Impairment of Traumatic Etiology in Rwanda: Prevalence, Causes, and Service Implications

World Journal of Surgery, 2011

Background The present study examines demographics, causes, and diagnoses of traumatic musculoske... more Background The present study examines demographics, causes, and diagnoses of traumatic musculoskeletal impairment (MSI) in Rwanda and identifies treatment barriers in order to describe the injury burden and inform service planning. Methods In all, 105 clusters were chosen by multistage stratified cluster random sampling with probability proportional to size. Eighty people from each cluster were identified for screening by a modified compact segment sampling method. A screening questionnaire was applied and suspected cases and 10% of suspected non-cases underwent standardized examination. A structured interview obtained a detailed history, and an algorithmic classification system allocated diagnosis. Results Of 8,368 enumerated subjects, 6,756 were screened. Of these, 111 were traumatic MSI cases, with 121 diagnoses, giving a prevalence of 1.64% (95% CI 1.35-1.98). Extrapolation to the Rwandan population estimates 68,716 traumatic MSI cases, mostly in people of working age. Most affected were hand/finger joints (23%), elbow (16%), shoulder region (9%), and knee joint (9%). Some 11% of impairments were severe, 47.7% were moderate, and 41.3% were mild. Most common diagnoses were fracture malunion (21.5%) and post-traumatic joint stiffness (20.7%). The number of treatments needed was 199, including physiotherapy (87.2%) and surgery (53.7%), but 43% (95% CI 34-53) received less treatment than required. Of those who were undertreated, 63% cited cost. Conclusions In Rwanda the prevalence of traumatic MSI of 1.64%, mostly in people of working age, makes usual activities difficult or impossible and is therefore a significant national burden. The results of the present study identify the need for immediate surgical intervention and physiotherapy, with cost as a treatment barrier. This study may direct aid providers toward subsidizing access to orthopedic care and thus reduce the impact of traumatic MSI.

Research paper thumbnail of Integrating public health research trials into health systems in Africa: individual or cluster randomisation?

Tropical Medicine & International Health, 2014

Research paper thumbnail of Prevalence of epilepsy in Rwanda: a national cross-sectional survey

Tropical Medicine & International Health, 2008

To estimate the prevalence of epilepsy in Rwanda, as part of a survey of musculoskeletal impairme... more To estimate the prevalence of epilepsy in Rwanda, as part of a survey of musculoskeletal impairment (MSI). Cross-sectional nationally representative survey. Clusters of 105 people were selected with probability proportional to size, using the 2002 national census as the sampling frame. Within each cluster, 80 people were selected through compact segment sampling. Physiotherapists examined all participants using a standard questionnaire to assess the presence of seizures through self-report, as well as aetiology, treatment needs and severity of the seizures. Health-related quality of life was assessed using the EuroQol generic health index (EQ5D). The response rate was 80.8%, with 6757 individuals screened. The estimated prevalence of epilepsy was 0.7% (95% confidence intervals 0.5-0.9%). A quarter (23%) of cases reported that onset of epilepsy was at birth, for 32% onset was between birth and age 5, 23% between ages 5 and 16, and 21% above the age of 16. In 4.3% of people with epilepsy, an accident during a seizure caused permanent MSI, as identified by a case history and physical examination. The majority of people with epilepsy (59.6%) had never received medical treatment for it. Epilepsy was associated with a significantly reduced quality of life. Epilepsy is a significant and neglected health problem in Rwanda at all ages. Investing in treatment for epilepsy would prevent some disability causing accidents from occurring.

Research paper thumbnail of Poverty and musculoskeletal impairment in Rwanda

Transactions of the Royal Society of Tropical Medicine and Hygiene, 2008

The recently adopted UN Convention on the Rights of Persons with Disabilities acknowledges the ne... more The recently adopted UN Convention on the Rights of Persons with Disabilities acknowledges the need to address social exclusion and poverty of persons with disabilities. However, policy makers, especially in low-income countries, often lack information about the socioeconomic situation of this vulnerable group of society. This study aimed to assess the association between poverty and musculoskeletal impairment (MSI) in Rwanda. A nationwide population-based matched case-control study was undertaken in Rwanda. Data were collected on education, literacy, employment, household expenditure and assets for 345 cases and 532 matched controls. Conditional logistic regression was performed, and the results indicated that adults with MSI in Rwanda are more likely to have no employment (odds ratio (OR)=3.3, 95% CI 2.1-5.2) while children with MSI are less likely to attend school (OR=0.4, 95% CI 0.2-0.9). Cases with MSI are disadvantaged vis-à-vis housing conditions and household size, potentially indicating crowding. However, cases with MSI were not poorer than controls in terms of assets or expenditure. These data suggest that increased efforts should be undertaken in Rwanda in order to ensure that children with disabilities are included in schools and that adults with disabilities can find appropriate employment opportunities.

Research paper thumbnail of Encouraging children to think counterfactually enhances blocking in a causal learning task

The Quarterly Journal of Experimental Psychology, 2013

According to a higher order reasoning account, inferential reasoning processes underpin the widel... more According to a higher order reasoning account, inferential reasoning processes underpin the widely observed cue competition effect of blocking in causal learning. The inference required for blocking has been described as modus tollens (if p then q, not q therefore not p). Young children are known to have difficulties with this type of inference, but research with adults suggests that this inference is easier if participants think counterfactually. In this study, 100 children (51 five-year-olds and 49 six- to seven-year-olds) were assigned to two types of pretraining groups. The counterfactual group observed demonstrations of cues paired with outcomes and answered questions about what the outcome would have been if the causal status of cues had been different, whereas the factual group answered factual questions about the same demonstrations. Children then completed a causal learning task. Counterfactual pretraining enhanced levels of blocking as well as modus tollens reasoning but only for the younger children. These findings provide new evidence for an important role for inferential reasoning in causal learning.

Research paper thumbnail of A Decade Later, How Much of Rwanda's Musculoskeletal Impairment Is Caused by the War in 1994 and by Related Violence?

PLoS ONE, 2009

Background: In 1994 there was a horrific genocide in Rwanda following years of tension, resulting... more Background: In 1994 there was a horrific genocide in Rwanda following years of tension, resulting in the murder of at least 800,000 people. Although many people were injured in addition to those killed, no attempt has been made to assess the lasting burden of physical injuries related to these events. The aim of this study was to estimate the current burden of musculoskeletal impairment (MSI) attributable to the 1994 war and related violence.

Research paper thumbnail of The Prevalence of Blinding Trachoma in Northern States of Sudan

PLoS Neglected Tropical Diseases, 2011

Background: Despite historical evidence of blinding trachoma, there have been no widespread conte... more Background: Despite historical evidence of blinding trachoma, there have been no widespread contemporary surveys of trachoma prevalence in the northern states of Sudan. We aimed to conduct district-level surveys in this vast region in order to map the extent of the problem and estimate the need for trachoma control interventions to eliminate blinding trachoma.

Research paper thumbnail of What Palliative Care-Related Problems Do Patients Experience at HIV Diagnosis? A Systematic Review of the Evidence

Journal of Pain and Symptom Management, 2011

Context. Palliative care is an essential element of HIV care throughout the disease trajectory, b... more Context. Palliative care is an essential element of HIV care throughout the disease trajectory, but there is a lack of information to guide clinical care at HIV diagnosis.

Research paper thumbnail of Multidimensional Problems Among Advanced Cancer Patients in Cuba: Awareness of Diagnosis Is Associated with Better Patient Status

Journal of Pain and Symptom Management, 2009

Cancer is one of the major causes of death in Cuba, and in current practice, patients are not usu... more Cancer is one of the major causes of death in Cuba, and in current practice, patients are not usually informed of their diagnosis. Palliative care is an emerging discipline in this country. Cuban cancer patients with advanced disease completed the Palliative Outcome Scale (POS), and the researcher elicited patients' knowledge of their condition and prognosis. The POS consists of 12 items that address the clinical, psychosocial, spiritual, family, and service delivery elements considered relevant to patients with advanced disease. Ten items are scored 0 (no problem) to 4 (worst problem), with one open-response question about the main problems experienced and one question about whether the questionnaire was completed with help or alone. Mann-Whitney tests were used to compare POS item scores by patient awareness. Of the 91 patients who participated in the study, 41% knew they had cancer and 9% were believed to be aware that they were dying. The most burdensome problems recorded on the POS were wasted time on appointments (70% of patients scored 3 or 4), pain (42%), patient anxiety (39%), and family anxiety (37%). Those patients who were aware of their diagnosis had statistically significantly better scores with respect to symptoms, patient anxiety, receiving information, and receiving support from family and friends. This study adds to knowledge about characteristics of terminal cancer patients in Cuba and the factors contributing to patient burden. It is the first study to explore the palliative care needs of Cuban patients with advanced cancer. An association has been demonstrated between patient knowledge and quality of life in Cuba, a setting where disclosure is contrary to current clinical practice.

Research paper thumbnail of Additivity pretraining and cue competition effects: Developmental evidence for a reasoning-based account of causal learning

Journal of Experimental Psychology: Animal Behavior Processes, 2012

The effect of additivity pretraining on blocking has been taken as evidence for a reasoning accou... more The effect of additivity pretraining on blocking has been taken as evidence for a reasoning account of human and animal causal learning. If inferential reasoning underpins this effect, then developmental differences in the magnitude of this effect in children would be expected. Experiment 1 examined cue competition effects in children's (4-to 5-year-olds and 6-to 7-year-olds) causal learning using a new paradigm analogous to the food allergy task used in studies of human adult causal learning. Blocking was stronger in the older than the younger children, and additivity pretraining only affected blocking in the older group. Unovershadowing was not affected by age or by pretraining. In experiment 2, levels of blocking were found to be correlated with the ability to answer questions that required children to reason about additivity. Our results support an inferential reasoning explanation of cue competition effects.

Research paper thumbnail of Blocking in children’s causal learning depends on working memory and reasoning abilities

Journal of Experimental Child Psychology, 2013

and sharing with colleagues.

Research paper thumbnail of Multi-centred mixed-methods PEPFAR HIV care & support public health evaluation: study protocol

BMC Public Health, 2010

Background: A public health response is essential to meet the multidimensional needs of patients ... more Background: A public health response is essential to meet the multidimensional needs of patients and families affected by HIV disease in sub-Saharan Africa. In order to appraise curret provision of HIV care and support in East Africa, and to provide evidence-based direction to future care programming, and Public Health Evaluation was commissioned by the PEPFAR programme of the US Government.

Research paper thumbnail of Musculoskeletal impairment survey in Rwanda: Design of survey tool, survey methodology, and results of the pilot study (a cross sectional survey)

BMC Musculoskeletal Disorders, 2007

Background: Musculoskeletal impairment (MSI) is an important cause of morbidity and mortality wor... more Background: Musculoskeletal impairment (MSI) is an important cause of morbidity and mortality worldwide, especially in developing countries. Prevalence studies for MSI in the developing world have used varying methodologies and are seldom directly comparable. This study aimed to develop a new tool to screen for and diagnose MSI and to pilot test the methodology for a national survey in Rwanda.

Research paper thumbnail of Mathematics difficulties in children born very preterm: current research and future directions

Archives of Disease in Childhood - Fetal and Neonatal Edition, 2013

Children born very preterm have poorer attainment in all school subjects, and a markedly greater ... more Children born very preterm have poorer attainment in all school subjects, and a markedly greater reliance on special educational support than their term-born peers. In particular, difficulties with mathematics are especially common and account for the vast majority of learning difficulties in this population. In this paper, we review research relating to the causes of mathematics learning difficulties in typically developing children, and the impact of very preterm birth on attainment in mathematics. Research is needed to understand the specific nature and origins of mathematics difficulties in very preterm children to target the development of effective intervention strategies.

Research paper thumbnail of The presence of CD4 counts for the management of HIV patients in East Africa: A multicentred study

AIDS Care, 2014

New WHO guidance stipulates six-monthly CD4 testing and treatment initiation at CD4 less than 350... more New WHO guidance stipulates six-monthly CD4 testing and treatment initiation at CD4 less than 350. This study aimed to determine the presence of CD4 results in patient records across five care facilities in Kenya, and to identify factors associated with the presence of CD4 count. This is a cross-sectional study of consecutive outpatients. Participants completed self-reported outcomes of demographics, and both physical and mental health dimensions of quality of life and function; charts were reviewed for a CD4 count in the previous 13 months; 548 patients participated. For those diagnosed during the 13-month study period, 7.1% of the sample had no CD4 result on record. For those diagnosed prior to the study, 8.7% had no result. Multivariate logistic regression revealed that 30 days post-HIV diagnosis, facility and antiretroviral therapy use were associated with the odds of having a CD4 result on file. At six months, poverty and prevalence of multidimensional problems were associated with lack of CD4 result. For those diagnosed prior to the observation period, education level was associated with more infrequent CD4 counts, and facility and number of dependants were associated with odds of a CD4 result within six months. Our data suggest inconsistencies in CD4 results availability within and between facilities. Implementation of new guidance will require a shift in practice.

Research paper thumbnail of Can palliative care integrated within HIV outpatient settings improve pain and symptom control in a low-income country? A prospective, longitudinal, controlled intervention evaluation

AIDS Care, 2013

A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatme... more A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatment. WHO policy indicates palliative care as essential throughout the disease course. This study aimed to determine whether palliative care delivered from within an existing HIV outpatient setting improves control of pain and symptoms compared to standard care. A prospective, longitudinal controlled design compared patient outcomes at an outpatient facility that introduced palliative care training to clinicians and stocked essential palliative care drugs, to outcomes of a cohort of patients at a similar HIV care facility with no palliative care, in Tanzania. Inclusion criteria were clinically significant pain or symptoms. Patients were followed from baseline fortnightly until week 10 using validated self-report outcome measures. For the primary pain outcome, the required sample size of 120 patients was recruited. Odds of reporting pain reduced significantly more at intervention site (OR=0.60, 95% CI 0.50-0.72) than at control (OR=0.85, 95% CI 0.80-0.90), p=0.001. For secondary outcomes, longitudinal analysis revealed significant difference in slope between intervention and control, respectively: Medical Outcomes Study-HIV (MOS-HIV) physical score 1.46 vs. 0.54, p=0.002; MOS-HIV mental health 1.13 vs. 0.26, p=0.006; and POS total score 0.84 vs. 0.18, p=0.001. Neither baseline CD4 nor antiretroviral therapy (ART) use was associated with outcome scores. These data are the first to report outcomes evaluating integrated HIV outpatient palliative care in the presence of ART. The data offer substantive evidence to underpin the existing WHO clinical guidance that states an essential role for palliative care alongside HIV treatment, regardless of prognosis.

Research paper thumbnail of Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial

The Lancet, 2015

Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, p... more Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, particularly in those with advanced disease. We assessed the effect of a short period of community support to supplement clinic-based services combined with serum cryptococcal antigen screening. We did an open-label, randomised controlled trial in six urban clinics in Dar es Salaam, Tanzania, and Lusaka, Zambia. From February, 2012, we enrolled eligible individuals with HIV infection (age ≥18 years, CD4 count of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;200 cells per μL, ART naive) and randomly assigned them to either the standard clinic-based care supplemented with community support or standard clinic-based care alone, stratified by country and clinic, in permuted block sizes of ten. Clinic plus community support consisted of screening for serum cryptococcal antigen combined with antifungal therapy for patients testing antigen positive, weekly home visits for the first 4 weeks on ART by lay workers to provide support, and in Tanzania alone, re-screening for tuberculosis at 6-8 weeks after ART initiation. The primary endpoint was all-cause mortality at 12 months, analysed by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISCRTN 20410413. Between Feb 9, 2012, and Sept 30, 2013, 1001 patients were randomly assigned to clinic plus community support and 998 to standard care. 89 (9%) of 1001 participants in the clinic plus community support group did not receive their assigned intervention, and 11 (1%) of 998 participants in the standard care group received a home visit or a cryptococcal antigen screen rather than only standard care. At 12 months, 25 (2%) of 1001 participants in the clinic plus community support group and 24 (2%) of 998 participants in the standard care group had been lost to follow-up, and were censored at their last visit for the primary analysis. At 12 months, 134 (13%) of 1001 participants in the clinic plus community support group had died compared with 180 (18%) of 998 in the standard care group. Mortality was 28% (95% CI 10-43) lower in the clinic plus community support group than in standard care group (p=0·004). Screening and pre-emptive treatment for cryptococcal infection combined with a short initial period of adherence support after initiation of ART could substantially reduce mortality in HIV programmes in Africa. European and Developing Countries Clinical Trials Partnership.

Research paper thumbnail of A National Survey of Musculoskeletal Impairment in Rwanda: Prevalence, Causes and Service Implications

PLoS ONE, 2008

Background: Accurate information on the prevalence and causes of musculoskeletal impairment (MSI)... more Background: Accurate information on the prevalence and causes of musculoskeletal impairment (MSI) is lacking in low income countries. We present a new survey methodology that is based on sound epidemiological principles and is linked to the World Health Organisation's International Classification of Functioning.

Research paper thumbnail of Inattention in very preterm children: Implications for screening and detection

Children born very preterm (VP; &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;... more Children born very preterm (VP; &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;32 weeks) are at risk for attention deficit/hyperactivity disorders (ADHD). ADHD in VP children have a different clinical presentation to ADHD in the general population, and therefore VP children with difficulties may not come to the teacher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s attention in school. We have assessed ADHD symptoms to determine whether VP children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s difficulties may go undetected in the classroom. Parents and teachers of 117 VP and 77 term-born children completed the Strengths and Difficulties Questionnaire to assess hyperactivity/inattention, emotional, conduct and peer problems, and the Du Paul ADHD Rating Scale-IV to assess inattention and hyperactivity/impulsivity symptoms. Special Educational Needs (SEN) were assessed using teacher report. Group differences in outcomes were adjusted for socio-economic deprivation. Parents and teachers rated VP children with significantly higher mean Strengths and Difficulties Questionnaire hyperactivity/inattention scores, and parents rated them with more clinically significant hyperactivity/inattention difficulties than term-born controls (Relative Risk (RR) 4.0; 95% CI 1.4 to 11.4). Examining ADHD dimensions, parents and teachers rated VP children with significantly more inattention symptoms than controls, and parents rated them with more clinically significant inattention (RR 4.8; 95% CI 1.4 to 16.0); in contrast, there was no excess of hyperactivity/impulsivity. After excluding children with SEN, VP children still had significantly higher inattention scores than controls but there was no excess of hyperactivity/impulsivity. VP children are at greater risk for symptoms of inattention than hyperactivity/impulsivity. Inattention was significantly increased among VP children without identified SEN suggesting that these problems may be difficult to detect in school. Raising teachers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; awareness of inattention problems may be advantageous in enabling them to identify VP children who may benefit from intervention.

Research paper thumbnail of Mathematics difficulties in extremely preterm children: evidence of a specific deficit in basic mathematics processing

Pediatric Research, 2012

Background: extremely preterm (eP, <26 wk gestation) children have been observed to have poor aca... more Background: extremely preterm (eP, <26 wk gestation) children have been observed to have poor academic achievement in comparison to their term-born peers, especially in mathematics. This study investigated potential underlying causes of this difficulty. Methods: a total of 219 eP participants were compared with 153 term-born control children at 11 y of age. all children were assessed by a psychologist on a battery of standardized cognitive tests and a number estimation test assessing children's numerical representations. results: eP children underperformed in all tests in comparison with the term controls (the majority of Ps < 0.001). Different underlying relationships between performance on the number estimation test and mathematical achievement were found in eP as compared with control children. That is, even after controlling for cognitive ability, a relationship between number representations and mathematical performance persisted for eP children only (eP: r = 0.346, n = 186, P < 0.001; control: r = 0.095, n = 146, P = 0.256). conclusion: Interventions for eP children may target improving children's numerical representations in order to subsequently remediate their mathematical skills.

Research paper thumbnail of Musculoskeletal Impairment of Traumatic Etiology in Rwanda: Prevalence, Causes, and Service Implications

World Journal of Surgery, 2011

Background The present study examines demographics, causes, and diagnoses of traumatic musculoske... more Background The present study examines demographics, causes, and diagnoses of traumatic musculoskeletal impairment (MSI) in Rwanda and identifies treatment barriers in order to describe the injury burden and inform service planning. Methods In all, 105 clusters were chosen by multistage stratified cluster random sampling with probability proportional to size. Eighty people from each cluster were identified for screening by a modified compact segment sampling method. A screening questionnaire was applied and suspected cases and 10% of suspected non-cases underwent standardized examination. A structured interview obtained a detailed history, and an algorithmic classification system allocated diagnosis. Results Of 8,368 enumerated subjects, 6,756 were screened. Of these, 111 were traumatic MSI cases, with 121 diagnoses, giving a prevalence of 1.64% (95% CI 1.35-1.98). Extrapolation to the Rwandan population estimates 68,716 traumatic MSI cases, mostly in people of working age. Most affected were hand/finger joints (23%), elbow (16%), shoulder region (9%), and knee joint (9%). Some 11% of impairments were severe, 47.7% were moderate, and 41.3% were mild. Most common diagnoses were fracture malunion (21.5%) and post-traumatic joint stiffness (20.7%). The number of treatments needed was 199, including physiotherapy (87.2%) and surgery (53.7%), but 43% (95% CI 34-53) received less treatment than required. Of those who were undertreated, 63% cited cost. Conclusions In Rwanda the prevalence of traumatic MSI of 1.64%, mostly in people of working age, makes usual activities difficult or impossible and is therefore a significant national burden. The results of the present study identify the need for immediate surgical intervention and physiotherapy, with cost as a treatment barrier. This study may direct aid providers toward subsidizing access to orthopedic care and thus reduce the impact of traumatic MSI.

Research paper thumbnail of Integrating public health research trials into health systems in Africa: individual or cluster randomisation?

Tropical Medicine & International Health, 2014

Research paper thumbnail of Prevalence of epilepsy in Rwanda: a national cross-sectional survey

Tropical Medicine & International Health, 2008

To estimate the prevalence of epilepsy in Rwanda, as part of a survey of musculoskeletal impairme... more To estimate the prevalence of epilepsy in Rwanda, as part of a survey of musculoskeletal impairment (MSI). Cross-sectional nationally representative survey. Clusters of 105 people were selected with probability proportional to size, using the 2002 national census as the sampling frame. Within each cluster, 80 people were selected through compact segment sampling. Physiotherapists examined all participants using a standard questionnaire to assess the presence of seizures through self-report, as well as aetiology, treatment needs and severity of the seizures. Health-related quality of life was assessed using the EuroQol generic health index (EQ5D). The response rate was 80.8%, with 6757 individuals screened. The estimated prevalence of epilepsy was 0.7% (95% confidence intervals 0.5-0.9%). A quarter (23%) of cases reported that onset of epilepsy was at birth, for 32% onset was between birth and age 5, 23% between ages 5 and 16, and 21% above the age of 16. In 4.3% of people with epilepsy, an accident during a seizure caused permanent MSI, as identified by a case history and physical examination. The majority of people with epilepsy (59.6%) had never received medical treatment for it. Epilepsy was associated with a significantly reduced quality of life. Epilepsy is a significant and neglected health problem in Rwanda at all ages. Investing in treatment for epilepsy would prevent some disability causing accidents from occurring.

Research paper thumbnail of Poverty and musculoskeletal impairment in Rwanda

Transactions of the Royal Society of Tropical Medicine and Hygiene, 2008

The recently adopted UN Convention on the Rights of Persons with Disabilities acknowledges the ne... more The recently adopted UN Convention on the Rights of Persons with Disabilities acknowledges the need to address social exclusion and poverty of persons with disabilities. However, policy makers, especially in low-income countries, often lack information about the socioeconomic situation of this vulnerable group of society. This study aimed to assess the association between poverty and musculoskeletal impairment (MSI) in Rwanda. A nationwide population-based matched case-control study was undertaken in Rwanda. Data were collected on education, literacy, employment, household expenditure and assets for 345 cases and 532 matched controls. Conditional logistic regression was performed, and the results indicated that adults with MSI in Rwanda are more likely to have no employment (odds ratio (OR)=3.3, 95% CI 2.1-5.2) while children with MSI are less likely to attend school (OR=0.4, 95% CI 0.2-0.9). Cases with MSI are disadvantaged vis-à-vis housing conditions and household size, potentially indicating crowding. However, cases with MSI were not poorer than controls in terms of assets or expenditure. These data suggest that increased efforts should be undertaken in Rwanda in order to ensure that children with disabilities are included in schools and that adults with disabilities can find appropriate employment opportunities.

Research paper thumbnail of Encouraging children to think counterfactually enhances blocking in a causal learning task

The Quarterly Journal of Experimental Psychology, 2013

According to a higher order reasoning account, inferential reasoning processes underpin the widel... more According to a higher order reasoning account, inferential reasoning processes underpin the widely observed cue competition effect of blocking in causal learning. The inference required for blocking has been described as modus tollens (if p then q, not q therefore not p). Young children are known to have difficulties with this type of inference, but research with adults suggests that this inference is easier if participants think counterfactually. In this study, 100 children (51 five-year-olds and 49 six- to seven-year-olds) were assigned to two types of pretraining groups. The counterfactual group observed demonstrations of cues paired with outcomes and answered questions about what the outcome would have been if the causal status of cues had been different, whereas the factual group answered factual questions about the same demonstrations. Children then completed a causal learning task. Counterfactual pretraining enhanced levels of blocking as well as modus tollens reasoning but only for the younger children. These findings provide new evidence for an important role for inferential reasoning in causal learning.

Research paper thumbnail of A Decade Later, How Much of Rwanda's Musculoskeletal Impairment Is Caused by the War in 1994 and by Related Violence?

PLoS ONE, 2009

Background: In 1994 there was a horrific genocide in Rwanda following years of tension, resulting... more Background: In 1994 there was a horrific genocide in Rwanda following years of tension, resulting in the murder of at least 800,000 people. Although many people were injured in addition to those killed, no attempt has been made to assess the lasting burden of physical injuries related to these events. The aim of this study was to estimate the current burden of musculoskeletal impairment (MSI) attributable to the 1994 war and related violence.

Research paper thumbnail of The Prevalence of Blinding Trachoma in Northern States of Sudan

PLoS Neglected Tropical Diseases, 2011

Background: Despite historical evidence of blinding trachoma, there have been no widespread conte... more Background: Despite historical evidence of blinding trachoma, there have been no widespread contemporary surveys of trachoma prevalence in the northern states of Sudan. We aimed to conduct district-level surveys in this vast region in order to map the extent of the problem and estimate the need for trachoma control interventions to eliminate blinding trachoma.

Research paper thumbnail of What Palliative Care-Related Problems Do Patients Experience at HIV Diagnosis? A Systematic Review of the Evidence

Journal of Pain and Symptom Management, 2011

Context. Palliative care is an essential element of HIV care throughout the disease trajectory, b... more Context. Palliative care is an essential element of HIV care throughout the disease trajectory, but there is a lack of information to guide clinical care at HIV diagnosis.

Research paper thumbnail of Multidimensional Problems Among Advanced Cancer Patients in Cuba: Awareness of Diagnosis Is Associated with Better Patient Status

Journal of Pain and Symptom Management, 2009

Cancer is one of the major causes of death in Cuba, and in current practice, patients are not usu... more Cancer is one of the major causes of death in Cuba, and in current practice, patients are not usually informed of their diagnosis. Palliative care is an emerging discipline in this country. Cuban cancer patients with advanced disease completed the Palliative Outcome Scale (POS), and the researcher elicited patients' knowledge of their condition and prognosis. The POS consists of 12 items that address the clinical, psychosocial, spiritual, family, and service delivery elements considered relevant to patients with advanced disease. Ten items are scored 0 (no problem) to 4 (worst problem), with one open-response question about the main problems experienced and one question about whether the questionnaire was completed with help or alone. Mann-Whitney tests were used to compare POS item scores by patient awareness. Of the 91 patients who participated in the study, 41% knew they had cancer and 9% were believed to be aware that they were dying. The most burdensome problems recorded on the POS were wasted time on appointments (70% of patients scored 3 or 4), pain (42%), patient anxiety (39%), and family anxiety (37%). Those patients who were aware of their diagnosis had statistically significantly better scores with respect to symptoms, patient anxiety, receiving information, and receiving support from family and friends. This study adds to knowledge about characteristics of terminal cancer patients in Cuba and the factors contributing to patient burden. It is the first study to explore the palliative care needs of Cuban patients with advanced cancer. An association has been demonstrated between patient knowledge and quality of life in Cuba, a setting where disclosure is contrary to current clinical practice.

Research paper thumbnail of Additivity pretraining and cue competition effects: Developmental evidence for a reasoning-based account of causal learning

Journal of Experimental Psychology: Animal Behavior Processes, 2012

The effect of additivity pretraining on blocking has been taken as evidence for a reasoning accou... more The effect of additivity pretraining on blocking has been taken as evidence for a reasoning account of human and animal causal learning. If inferential reasoning underpins this effect, then developmental differences in the magnitude of this effect in children would be expected. Experiment 1 examined cue competition effects in children's (4-to 5-year-olds and 6-to 7-year-olds) causal learning using a new paradigm analogous to the food allergy task used in studies of human adult causal learning. Blocking was stronger in the older than the younger children, and additivity pretraining only affected blocking in the older group. Unovershadowing was not affected by age or by pretraining. In experiment 2, levels of blocking were found to be correlated with the ability to answer questions that required children to reason about additivity. Our results support an inferential reasoning explanation of cue competition effects.

Research paper thumbnail of Blocking in children’s causal learning depends on working memory and reasoning abilities

Journal of Experimental Child Psychology, 2013

and sharing with colleagues.

Research paper thumbnail of Multi-centred mixed-methods PEPFAR HIV care & support public health evaluation: study protocol

BMC Public Health, 2010

Background: A public health response is essential to meet the multidimensional needs of patients ... more Background: A public health response is essential to meet the multidimensional needs of patients and families affected by HIV disease in sub-Saharan Africa. In order to appraise curret provision of HIV care and support in East Africa, and to provide evidence-based direction to future care programming, and Public Health Evaluation was commissioned by the PEPFAR programme of the US Government.

Research paper thumbnail of Musculoskeletal impairment survey in Rwanda: Design of survey tool, survey methodology, and results of the pilot study (a cross sectional survey)

BMC Musculoskeletal Disorders, 2007

Background: Musculoskeletal impairment (MSI) is an important cause of morbidity and mortality wor... more Background: Musculoskeletal impairment (MSI) is an important cause of morbidity and mortality worldwide, especially in developing countries. Prevalence studies for MSI in the developing world have used varying methodologies and are seldom directly comparable. This study aimed to develop a new tool to screen for and diagnose MSI and to pilot test the methodology for a national survey in Rwanda.

Research paper thumbnail of Mathematics difficulties in children born very preterm: current research and future directions

Archives of Disease in Childhood - Fetal and Neonatal Edition, 2013

Children born very preterm have poorer attainment in all school subjects, and a markedly greater ... more Children born very preterm have poorer attainment in all school subjects, and a markedly greater reliance on special educational support than their term-born peers. In particular, difficulties with mathematics are especially common and account for the vast majority of learning difficulties in this population. In this paper, we review research relating to the causes of mathematics learning difficulties in typically developing children, and the impact of very preterm birth on attainment in mathematics. Research is needed to understand the specific nature and origins of mathematics difficulties in very preterm children to target the development of effective intervention strategies.

Research paper thumbnail of The presence of CD4 counts for the management of HIV patients in East Africa: A multicentred study

AIDS Care, 2014

New WHO guidance stipulates six-monthly CD4 testing and treatment initiation at CD4 less than 350... more New WHO guidance stipulates six-monthly CD4 testing and treatment initiation at CD4 less than 350. This study aimed to determine the presence of CD4 results in patient records across five care facilities in Kenya, and to identify factors associated with the presence of CD4 count. This is a cross-sectional study of consecutive outpatients. Participants completed self-reported outcomes of demographics, and both physical and mental health dimensions of quality of life and function; charts were reviewed for a CD4 count in the previous 13 months; 548 patients participated. For those diagnosed during the 13-month study period, 7.1% of the sample had no CD4 result on record. For those diagnosed prior to the study, 8.7% had no result. Multivariate logistic regression revealed that 30 days post-HIV diagnosis, facility and antiretroviral therapy use were associated with the odds of having a CD4 result on file. At six months, poverty and prevalence of multidimensional problems were associated with lack of CD4 result. For those diagnosed prior to the observation period, education level was associated with more infrequent CD4 counts, and facility and number of dependants were associated with odds of a CD4 result within six months. Our data suggest inconsistencies in CD4 results availability within and between facilities. Implementation of new guidance will require a shift in practice.

Research paper thumbnail of Can palliative care integrated within HIV outpatient settings improve pain and symptom control in a low-income country? A prospective, longitudinal, controlled intervention evaluation

AIDS Care, 2013

A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatme... more A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatment. WHO policy indicates palliative care as essential throughout the disease course. This study aimed to determine whether palliative care delivered from within an existing HIV outpatient setting improves control of pain and symptoms compared to standard care. A prospective, longitudinal controlled design compared patient outcomes at an outpatient facility that introduced palliative care training to clinicians and stocked essential palliative care drugs, to outcomes of a cohort of patients at a similar HIV care facility with no palliative care, in Tanzania. Inclusion criteria were clinically significant pain or symptoms. Patients were followed from baseline fortnightly until week 10 using validated self-report outcome measures. For the primary pain outcome, the required sample size of 120 patients was recruited. Odds of reporting pain reduced significantly more at intervention site (OR=0.60, 95% CI 0.50-0.72) than at control (OR=0.85, 95% CI 0.80-0.90), p=0.001. For secondary outcomes, longitudinal analysis revealed significant difference in slope between intervention and control, respectively: Medical Outcomes Study-HIV (MOS-HIV) physical score 1.46 vs. 0.54, p=0.002; MOS-HIV mental health 1.13 vs. 0.26, p=0.006; and POS total score 0.84 vs. 0.18, p=0.001. Neither baseline CD4 nor antiretroviral therapy (ART) use was associated with outcome scores. These data are the first to report outcomes evaluating integrated HIV outpatient palliative care in the presence of ART. The data offer substantive evidence to underpin the existing WHO clinical guidance that states an essential role for palliative care alongside HIV treatment, regardless of prognosis.