Thoughts of self-harm in adolescents: Relationship with violence in the Dominican Republic(2024).
Badger K, Baez Caraballo P, Gibbs A, Messina L, Halpern M, Amesty S (2024) Thoughts of self-harm in adolescents: Relationship with violence in the Dominican Republic.PLOS Global Public Health, 4(1), e0002711. doi:10.1371/journal.pgph.0002711.
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Violence against adolescents is a pressing health problem with long-term implications for future physical and mental well-being, such as thoughts of self-harm, which have been associated with suicidal ideation and completion. However, much of the research has been conducted only in high-income countries. This study aimed to examine the correlation between violence against adolescents and self-harm thoughts in La Romana, Dominican Republic (DR). Cross-sectional survey data was collected at a community-based clinic from participants aged 13–20. Participants were recruited through the clinic’s adolescent program and peer referral, and verbal consent was obtained. A survey solicited information about each participant’s demographics, experiences with violence, and thoughts of harm to self or others. The survey was completed by 49 adolescents. The mean age was 16.78 (SD 2.34); 65% were female. We performed t-tests and Fisher’s exact to investigate the relationship between demographics, reported violence experiences and having self-harm thoughts. About half (45%) had experienced physical violence, 76% had experienced emotional violence, and 12% had experienced sexual violence. The most common perpetrators of physical and emotional violence were classmates (12% and 24%), and the most common perpetrator of sexual violence was an ex-partner (4.1%). Ten participants (20.4%) had thought about harming themselves. Self-harm thoughts were significantly associated with being female (p = 0.025), employed (p = 0.05), and a higher number of experiences of physical (0.029) and sexual violence (p = 0.023). The results of this study suggest a high prevalence of both violence and self-harm thoughts in adolescents in the DR. Interventions that address physical and sexual violence against adolescents may be particularly important. Particular attention should also be paid to screening for self-harm thoughts in female-identifying adolescents. Further research is needed to better understand the relationship between violence and self-harm thoughts in adolescents in the DR.

 

Reaching “covidianidad”: A qualitative study of the impact of the COVID-19 pandemic on the perceived mental health of health care workers in the Dominican Republic (2023).Báez Caraballo P, Schriger S, Escober J, Acevedo A, García Alejandro A, Halpern M, et al. (2023) Reaching “covidianidad”: A qualitative study of the impact of the COVID-19 pandemic on the perceived mental health of health care workers in the
Dominican Republic. PLOS Global Public Health. doi:10.1371/journal.pgph.0002652.
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We aimed to explore how the COVID-19 pandemic affected the lives of healthcare workers (HCWs) in the Dominican Republic. We also aimed to identify the types of resources that HCWs felt were needed to support their mental health. We used purposive and convenience sampling in four health centers in the eastern Dominican Republic to recruit 28 HCWs (doctors, nurses, psychologists, and community health workers) between April 2021 and August 2021. Through semi-structured interviews, we elicited HCWs experiences during the pandemic and how they felt these experiences impacted their mental health. Interview transcripts were analyzed using an inductive/deductive thematic approach. Main stressors experienced during the pandemic by HCWs and their sequelae included anxiety due to misinformation and uncertainty, fear of the disease, the robustness of pandemic-related changes they faced in their work and daily life, and COVID-19’s economic impact. HCWs reflected on protective factors that transformed their acute sense of crisis felt at the beginning of the pandemic into what HCWs referred to as “covidianidad [everyday COVID]”, a situation that became manageable through mechanisms including social support, professional motivation, positive work environment and resilience. Lastly, HCWs identified stigmatization of and limited access to mental health services as challenges to supporting their mental health. While Dominican HCWs were vulnerable to the challenges posed by COVID-19 in sustaining their mental health, for many, the situation became manageable through the evolution of “covidianidad.” Further research and interventions are needed to reduce stigmatization of mental health services and foment a positive environment for HCWs’ mental health, to promote resiliency to future challenges.

 

Impact of an STI Diagnosis on People Living With HIV in La Romana, Dominican Republic: A Cross-Sectional, Qualitative, Descriptive Study, J Assoc Nurses AIDS Care 2023. Sanabria G, Stonbraker S, Bateman M, Halrpern M, Amesty S.
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The objective of this study was to explore how receiving a sexually transmitted infection (STI) diagnosis affects subsequent STI knowledge and sexual risk behavior among key populations in La Romana, Dominican Republic (DR) who participated in a parent study 12 to 24 months before the current study. Nine participants, with a mean age of 37 years (range 20-54 years) and a female majority (89%), who were recruited from the parent study completed in-depth interviews, questionnaires assessing STI knowledge, and received STI testing. Interviews were analyzed using qualitative descriptive methodology and questionnaire data, comparing individual’s responses between the parent and current studies. Participants reported safer sexual behaviors after original STI diagnosis, such as more frequent condom use. Questionnaires showed improvement in STI knowledge between the parent and current studies. Three participants had an STI reinfection. Findings warrant further exploration into more comprehensive and targeted STI treatment methods for key populations in the DR.

 

High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic.2023
Amesty S, Perez-Figueroa R, Stonbraker S, Halpern M, Donastorg Y, Perez-Mencia M, Lantigua F, Soriano L, Baez-Caraballo P, Gilbert J, Buccini F, Sharp J, Hernandez B, Gelfond J, Cardwell E, Nicholas C, Egan KA, Gomes A, Van Dyke E, Nicholas SW, Grodman M, Taylor BS, et al. (2023). High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic. Therapeutic Advances in Infectious Disease. doi:10.1177/20499361231193561.
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High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic. Background: Sexually transmitted infections (STIs) are a major health issue, exacerbated by limited financial and infrastructural resources in developing countries. Methods: Prevalence of STIs was assessed in two urban centers of the Dominican Republic (DR) among populations at high risk for STIs: pregnant youth, men who have sex with men (MSM), trans women (TG), batey residents, female sex workers, and people living with human immunodeficiency virus (HIV). We conducted a cross-sectional survey and biological specimen collection to screen for Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma genitalium, Trichomonas vaginalis (trichomoniasis), Treponema pallidum (syphilis), HIV, hepatitis B and C, and human papillomavirus (HPV) among at-risk populations between 2015 and 2018. Ureaplasma urealyticum testing was also conducted even though it is not considered a STI. A non-probability community sample was recruited. Descriptive statistics examined the prevalence of STIs by population. Results: A total of 1991 subjects participated in the study. The median age was 26years (range: 18–65). Most participants were female (65.3%), heterosexual (76.7%), and were not partnered (55.7%). Most of the participants reported unprotected vaginal sex in the last 6months (54%); among MSM and TG almost half of the participants reported unprotected anal sex in the last 6months and 17.6% reported drug use in the last 6months. Almost half of the participants (49%) tested positive for one or more STIs. The most prevalent STI was Chlamydia trachomatis (12.8%), and human papillomavirus (11.9%). Among transgender women, 65.3% tested positive for an STI, 64.8% of female sex workers tested positive for an STI, and 53.8% of pregnant adolescents tested positive for an STI. Conclusion: There is a high prevalence of STIs among key and under resourced populations in the DR. Our findings highlight the need to conduct further research to optimize prevention and care strategies for structurally vulnerable and under resourced populations in the DR.

 

Mixed method evaluation of a clinic waiting room–based health education program in the Dominican Republic(2023).S Cohen, M Halpern, S Stonbraker, Health Education Research, Volume 38, Issue 2, April 2023, Pages 177–191,Mixed method evaluation of a clinical waiting room-based health education program in the Dominican Republic. Health Education Research. doi:https://doi.org/10.1093/her/cyad001.
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Waiting rooms provide an ideal location to disseminate health information. In this mixed-methods study, we evaluated waiting room–based health education talks at two clinics in the Dominican Republic and explored recommendations for implementing this intervention in similar settings. The talks addressed noncommunicable diseases, sexually transmitted infections, family planning and gender-based violence. We conducted pre- and posttests to assess attendees’ change in knowledge and conducted semi-structured interviews with a subset of them. We conducted a semi-structured focus group with educators. Analyses included Wilcox Signed Rank Tests and McNemar tests for pre- and posttests, conventional content analysis for individual interviews and transcript coding for the focus group. Patient participants were 69.3% female aged 39.6 years (SD = 13.5) on average at one clinic (n = 127) and 100% female aged 17.4 (SD = 1.3) on average at the second clinic (n = 24). Focus group participants (n = 5) had 4.8 years (SD = 3.3) of health educator experience on average. Pre- and posttests showed significant improvement (P < 0.05) across all talks. Qualitative interviews emphasized engaging, clear and brief content delivery with visual aids. The focus group highlighted the importance of patient-centered design with culturally concordant delivery and identified implementation challenges. Findings demonstrate that waiting room–based education talks improve knowledge and provide suggestions for similar interventions.

 

The impact of expedited third semester viral load testing on the proportion of vaginal deliveries in HIV-positive pregnant women in the Dominican Republic 2022. Nimalendran R, Egan KA, Dyke EV, Amesty S, Halpern M, Hod E, Lerebours L, Nicholas SW, Spitalnik S, Whittier S, Stotler B. (2022). The impact of expedited third trimester viral load testing on the proportion of vaginal deliveries in HIV-positive pregnant women in the Dominican Republic. Integrative Gynecology and Obstetrics Journal. doi:10.31038/IGOJ.2022523

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Objective: Advances in HIV treatment have led to a significant decrease in vertical transmission. Lack of adequate viral load testing capabilities inhibited the ability to follow national and international guidelines for obstetric care in the Dominican Republic (DR). The objective of this study was to determine if expedited third trimester viral load testing in HIV-positive pregnant women led to an increase in vaginal deliveries at a clinic in the DR, thus demonstrating the ability to follow national guidelines for obstetric delivery of HIV-positive women on antiretroviral therapy (ART).
Study Design: This study enrolled pregnant HIV-positive patients at a clinic in the DR October 2014-July 2015. Viral load testing was performed 34-36-weeks gestation and results were available within 48 hours. Demographic information, clinical factors, and obstetric outcomes were collected and compared to patients in a retrospective cohort, who delivered January 2012-December 2012 when expedited viral load testing was unavailable.
Results: Of the 20 women in the study, 17 (85%) had viral loads <1000 and seven women (35%) delivered vaginally. In the comparison retrospective cohort, of 41 women, three women (7%) had vaginal deliveries. Comparing the two groups, there was a statistically significant increase in vaginal deliveries from 7% to 35% (p=0.02) after expedited viral load testing was made available. All infants born in the study were HIV-negative.
Conclusion: The study with expedited viral load testing available had an increased number of vaginal deliveries of HIV-positive women on ART. The majority of these patients were on ART with HIV viral loads.

Power and respect in global health research collaboration: Perspectives from research partners in the United States and the Dominican Republic(2023). Green C, Scharf J, Jiménez‐Bautista A, Halpern M. (2023). Power and respect in global health research collaboration: Perspectives from research partners in the United States and the Dominican Republic. Developing World Bioethics, 1–10 Journal Title TBD.
doi:10.1111/dewb.12384.
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Research partnerships between institutions in the Global North and institutions in the Global South have many potential benefits, including sharing of knowledge and resources. However, such partnerships are traditionally exploitative to varying degrees. In order to promote equity in South-North research partnerships, it is necessary to learn from the experiences of researchers collaborating internationally. This study analyzed transcripts from eleven semi-structured qualitative interviews with researchers working at Clínica de Familia La Romana, an institution in the Dominican Republic with decades of experience with research and research partnerships with institutions from the Global North. The findings of this study suggest that respect for resources invested in research, as well as for the researchers and institutions themselves, are vital components to a successful global health research partnership. These findings have implications for individual research partnerships, as well as the policies of journals and institutions providing funding that affect these partnerships.

 

Use of Multiple Methods to Measure Adherence to Antiretroviral Treatment in La Romana, Dominican Republic Rev Panam Salud Publica 2022. Báez P, Tiburcio A, Alba N, Mateo F, Grullon E, Cordero S, Fernández A, Reinoso J, Cruz D, Gómez K, Vargas N, Saint-Hilaire C, Abreu OL, Acosta G, Halpern M, Stonbraker S, et al. (2022). Medición de adherencia a antirretrovirales con métodos múltiples en La Romana, República Dominicana. Revista Panamericana de Salud Pública. doi:https://doi.org/10.26633/RPSP.2022.207.
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Objective:To develop a tool that measures levels of adherence to antiretroviral treatment (ART) in resour ce-poor settings, based on a combination of four methods for measuring adherence. Methods. Retrospective review of 500 medical records of people living with HIV, randomly selected from October 2017 to January 2020. Adherence to ART was measured by combining four measurement methods (coverage of prescribed ART, ART picked up at pharmacies, viral load, and self-reported adherence). Chi squared tests were performed with p<0.05 for statistically significant differences and logistic binary regression to identify the probability of optimal and suboptimal adherence. Spearman tests were performed for correlation of categories, and Cronbach’s alpha was used to measure the internal consistency of the tool. Results. We obtained 497 adherence scores. Of these, 307 (61.8%) users qualified as adherent, 141 (28.4%) as semi-adherent, and 49 (9.8%) as non-adherent. A higher probability of optimal adherence was found in groups aged 60 years and older (odds ratio [OR]: 1.6; CI95%: 0.8–3.5), with no difference between men and women (OR: 0.9; CI95%: 0.7–1.4). Spearman’s test reported a relationship (r = 0.8) between viral load levels and final score, and Cronbach’s alpha yielded modest internal consistency (α = 0.7). Conclusions. A tool was developed to measure adherence to ART in a resource-poor environment. The tool shows modest levels of internal consistency and a strong correlation between viral load and adherence.

If the give their mind to HIV, the don’t last long”: An explanatory model of HIV infection in a limited-resource setting informs person-centered care 2022.Stonbraker S, Sanabria G, Cunto-Amesty S, Alcantara C, Abraido-Lanza AF, Rowell-Cunsolo T, Halpern M, Bakken S, Schnall R, George M. (2022). “If they give mind to HIV, they don’t last as long”: An explanatory model of HIV infection in a limited-resource setting informs Persons-Centered care. Global Qualitative Nursing Research, doi:https://doi.org/10.1177/23333936221097112
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Explanatory models describe individuals’ perceptions of their illness experiences, which can guide culturally relevant care. We constructed an explanatory model of the experience of living with human immunodeficiency virus (HIV) in the Dominican Republic. Following qualitative descriptive methodology, we conducted interviews in Spanish using a semi-structured interview guide developed using Kleinman’s explanatory model framework. Two bilingual researchers coded interview transcripts following conventional content analysis. We used deductive codes from Kleinman’s framework and inductive codes external to the framework to construct the codebook. We arranged codes by shared meaning into categories and constructed themes that reflected shared findings from inductive categories and deductive codes. Twenty-six persons living with HIV participated. They provided rich descriptions of their experiences represented by four cross-cutting themes, which informed the explanatory model. By incorporating this in-depth understanding of patients’ illness experiences into care delivery, nurses can cultivate culturally meaningful and trusting patient-centered partnerships that improve health.

HIV pre-exposure prophylaxis: assessment of acceptability among members of HIV serodiscordant/serostatus unknown couples. International Journal of STD & AIDS, Vol 0(0) 1-7, 2022. Bracho-Sanchez E, Stonbraker S, Halpern M, Wood S, Lowenthal E. (2022). HIV pre-exposure prophylaxis: assessment of acceptability among members of HIV serodiscordant/serostatus unknown couples. International Journal of STD &amp; AIDS. doi:10.1177/09564624221097753.
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Background: Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection but is not yet widely available in resource-limited settings such as the Dominican Republic. We aimed to ascertain PrEP acceptability among people living with HIV in the Dominican Republic who are part of HIV serodiscordant partnerships and understand relationships between PrEP acceptability, HIV stigma, and intimate partner violence.
Methods: A cross-sectional survey of people in care for HIV infection included acceptability-related questions and assessments of HIV stigma and intimate partner violence. We also explored the expected impact of PrEP on HIV disclosure rates and fertility intentions.
Results: Of the 100 participants, 74% had been in their current partnership for >1 year; 38% had not disclosed to their partner; 29% reported condomless sex, and 23% reported sex with multiple partners. PrEP was highly acceptable with 84% of participants saying they were “very likely” to offer PrEP to their partner if available and 21% stating it would allow them to have more children. Of those who had not disclosed to their partner, 71% stated PrEP would help them do so. No relationship was found between PrEP acceptability, HIV stigma, and intimate partner violence. However, higher than expected rates of PrEP acceptability limited the power of these analyses. 
Conclusion: Pre-exposure prophylaxis was considered to be highly acceptable among people living with HIV in the Dominican Republic who are part of serodiscordant partnerships.

High prevalence of rectal chlamydia among pregnant adolescents in La Romana, Dominican Republic warrants extragenital STI testing. International Journal of STD & AIDS, Vol 0(0) 1-7, 2021. Bancalari P, Nicholas C, Halpern M, Stonbraker S, Taylor B, Soriano L, Ljubicic D, Amesty S. (2021). High prevalence of rectal chlamydia among pregnant adolescents in La Romana, Dominican Republic warrants extragenital STI testing. International Journal of STD &amp; AIDS. doi:10.1177/09564624211043082.
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To our knowledge, there are no studies estimating the prevalence of extragenital sexually transmitted infections (STIs) among pregnant adolescents in the Caribbean. This study sought to fill this gap by assessing the prevalence and correlates of oral, genital, and rectal chlamydia (CT) among a sample of pregnant adolescents in La Romana, Dominican Republic. Two hundred pregnant youths, aged 15–24 years, were recruited by systematic sampling during their first prenatal visit to a maternal care unit. A sociodemographic and behavioral questionnaire was administered and urine and oral/anal swabs were collected and tested for CT. Descriptive analyses and Fisher’s exact tests were performed. The prevalence of oral, genital, and rectal CT was 6%, 15%, and 23%, respectively, although less than 5% of participants reported ever engaging in receptive anal intercourse. This discrepancy could be explained by autoinoculation, concurrent transmission during sex, undertreatment of rectal CT, or underreporting of anal sex. Almost half of CT infections would have been missed if only genital samples were collected, as current protocol dictates. More research is needed to understand sexual behaviors and rectal STI risk factors among heterosexual adolescent women. STI screening procedures for pregnant and sexually active adolescents should include routine testing of extragenital sites.

Clinician use of HIV-related infographics during clinic visits in the Dominican Republic is Associated with Lower Viral Loads and other improvements in Health Outcomes. AIDS and Behavior, 2021.Stonbraker S, Liu J, Sanabria G, George M, Cuanto-Amesty S, Alcantara C, Abraído-Lanza A, Halpern M, Rowel-Cunsolo T, Bakken S, Schnall R. (2021). Clinician use of HIV-related infographics during clinic visits in the Dominican Republic is Associated with Lower Viral Loads and other improvements in Health Outcomes. AIDS and Behavior. doi:https://doi.org/10.1007/s10461-021-03331-8.
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We designed an infographic intervention to help clinicians provide health information to persons living with HIV. In this study, we assessed the extent to which our intervention may improve objectively and subjectively measured health outcomes (CD4 count, viral load, and engagement with clinician among others) when integrated into routine visits in the Dominican Republic. In this pretest–posttest study, we followed participants for 9 months at 3-month intervals. Physicians administered the intervention during participants’ first 3 visits. Outcome measures, selected using a conceptual model, were assessed at 4 time points. We assessed changes in outcomes over time with general linear regressions and Wilcoxon Signed-Rank tests. Participants (N = 50) were mostly female (56%) and had been living with HIV for a mean of 6.3 years (SD = 6.1). All outcomes, except CD4 count, demonstrated statistically significant improvements by study end. This provides preliminary evidence our intervention may improve outcomes, but further testing is needed.

Barriers to HIV treatment adherence among adults living with HIV in the eastern Dominican Republic. International Journal of STD & AIDS. VOL0(0) 1-6, 2021. Bast E, Stonbraker S, Halpern M, Lowenthal E, Gross R. (2021). Barriers to HIV treatment adherence among adults living with HIV in the eastern Dominican Republic. International Journal of STD &amp; AIDS, 2021. doi:10.1177/09564624211014102.
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Despite access to nationally supplied antiretroviral treatment, viral load suppression rates remain suboptimal in the Dominican Republic. Counseling and support services are available but mainly targeted to those identified as having the most need. At Clínica de Familia La Romana (CFLR) in La Romana, all patients undergo a structured baseline interview including exploration of expected barriers to care. We conducted a retrospective cohort study of a random sample of patients at CFLR with treatment initiation between 1 January 2015 and 1 December 2017 to determine if self-identified barriers to HIV care predict viral load suppression. Viral load suppression occurred in 63% of the 203 patients evaluated. Lack of food (n = 19) was significantly associated with lack of viral suppression (OR 3.0, 95% CI 1.14–7.87). Nondisclosure of HIV status (n = 24) showed evidence for a protective effect (OR 0.33; 95% CI 0.11–1.0). Further steps should be taken to address food insecurity as well as to understand associated barriers to care among individuals with food insecurity.

Feasibility and acceptability of using information visualizations to improve HIV-related communication in a limited-resource setting: a short report. AIDS Care, 2021.Stonbraker S, Flynn G, George M, Cunto-Amesty S, Alcántara C, Abraído-Lanza A, Halpern M, Rowell-Cunsolo T, Bakken S, Schnall R. (2021). Feasibility and acceptability of using information visualizations to improve HIV-related communication in a limited-resource setting: a short report. AIDS Care. doi:https://doi.org/10.1080/09540121.2021.1883517.
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Infographics (visualizations that present information) can assist clinicians to offer health information to patients with low health literacy in an accessible format. In response, we developed an infographic intervention to enhance clinical, HIV-related communication. This study reports on its feasibility and acceptability at a clinical setting in the Dominican Republic. We conducted in-depth interviews with physicians who administered the intervention and patients who received it. We conducted audio-recorded interviews in Spanish using semi-structured interview guides. Recordings were professionally transcribed verbatim then analyzed using descriptive content analysis. Physician transcripts were deductively coded according to constructs of Bowen et al.’s feasibility framework and patient transcripts were inductively coded. Three physicians and 26 patients participated. Feasibility constructs endorsed by physicians indicated that infographics were easy to use, improved teaching, and could easily be incorporated into their workflow. Coding of patient transcripts identified four categories that indicated the intervention was acceptable and useful, offered feedback regarding effective clinical communication, and recommended improvements to infographics. Taken together, these data indicate our intervention was a feasible and acceptable way to provide clinical, HIV-related information and provide important recommendations for future visualization design as well as effective clinical communication with similar patient populations.

Digital Educational Support Groups Administered through WhatsApp Messenger Improve Health-Related Knowledge and Health Behaviors of New Adolescent Mothers in the Dominican Republic: A Multi-Method Study. Informatics. 2020; 7(4):51. Stonbraker S, Haight E, Lopez A, Guijosa L, Davison E, Bushley D, Aquino Peguero K, Araujo V, Messina L, Halpern M. (2020). Digital Educational Support Groups
Administered through WhatsApp Messenger Improve Health-Related Knowledge and Health Behaviors of New Adolescent Mothers in the Dominican Republic: A Multi-Method Study. Informatics. doi:https://doi.org/10.3390/informatics7040051.

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(1) Background: In limited-resource settings such as the Dominican Republic, many factors contribute to poor health outcomes experienced by adolescent mothers, including insufficient support and/or health knowledge. In response, we designed a digital educational support group, administered through WhatsApp Messenger, for new adolescent mothers. The purpose of this study was to assess if participation in this digital support group could improve health outcomes and health behaviors.

(2) Methods: Participants completed questionnaires with a health literacy screener, demographic items, knowledge questions, the Index of Autonomous Functioning, and five Patient Reported Outcomes Measurement Information System scales before and after the moderator-led intervention. Differences between pre- and post-intervention scores were calculated and perceptions of the intervention were explored through in-depth interviews analyzed with content analysis. Participants’ well-baby visit attendance and contraceptive use were compared to that of controls and a national sample.

(3) Results: Participants’ (N = 58) knowledge scores increased (p < 0.05). Participants were 6.58 times more likely to attend well-baby visits than controls (95% CI: 2.23–19.4) and their contraceptive use was higher than that of the national sample (p < 0.05). Participants indicated the intervention was enjoyable and beneficial.

(4) Conclusion: This adolescent-centered digital intervention is a promising method to improve health outcomes and health behaviors of young mothers in limited-resource settings.

Establishing content for a digital educational support group for new adolescent mothers in the Dominican Republic: a user-centered design. International Journal of Adolescent Medical Health, 2020. Stonbraker S, Haight E, Soriano L, Guijosa L, Davison E, Bushley D, Messina L, Halpern M, et al. (2020). Establishing content for a digital educational support group for new adolescent mothers in the Dominican Republic: a user-centered design. International Journal of Adolescent Medical Health. doi:10.1515/ijamh-2020-0054.

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Background
As digital interventions to improve health become widespread globally, it is critical to include target end-users in their design. This can help ensure interventions are maximally beneficial among intended populations.
Objectives
To generate the content of a digital educational support group, administered through WhatsApp, for new adolescent mothers and establish participants’ cellular access and WhatsApp use.
Participants
Adolescent mothers with new babies.
Methods
We completed a two-phase user-centered design process. In phase I design sessions, participants discussed their postpartum experiences and completed an activity to elucidate their health and wellbeing information needs. In phase II sessions, participants individually identified which health information topics were important to them, then all topics were prioritized as a group. Phase II participants also completed a brief survey on cell phone access and WhatsApp use.
Results
Phase I included 24 participants, 21 of whom completed phase II. Priority health and wellbeing information topics in the postpartum period were identified as: child growth and development, understanding your baby, common childhood illnesses, breastfeeding, childhood nutrition, family planning, and self-care. Of phase II participants, 45% had cellular phone access and none had a data plan. Cellular service was inconsistently obtained with data packages or Wi-Fi. 30% of participants had no experience using WhatsApp.
Conclusions
Participants identified numerous health information needs, which will serve as the content for our planned digital support group and provides valuable insight for health care providers globally. Less than half of participants had consistent cellular phone access, and none had reliable access to cellular service.

Factors related to subsequent adolescent pregnancy in the Dominican Republic. Journal of Adolescent and Family Health, 2020; 11(1).
Fay CJ, Fay KE, Messina LA, Halpern M, Stonbraker SB, et al. (2020). Factors related to subsequent adolescent pregnancy in the Dominican Republic. Journal of Adolescent and Family Health. https://scholar.utc.edu/jafh/vol11/iss1/8.

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Objectives: Adolescents with subsequent pregnancies in the Dominican Republic represent a significant but poorly understood population with little available data to inform health care services. The objective of this exploratory study was to begin to characterize this important cohort. Methods: A survey of demographic items and a sexual and obstetrical history was administered to 50 adolescents with subsequent pregnancies in La Romana, Dominican Republic. Results: Most participants were married (78%) and exclusively economically dependent on their partner (72%) and nearly half (48%) stopped attending school. Twelve percent reported having intended their current pregnancy. Conclusions: Adolescents with subsequent pregnancies were dependent on partners in the form of living conditions and marriage, economic dependence and unemployment, and lack of education.

Perceptions and Attitudes Toward Mobile Health in Development of an Exclusive Breastfeeding Tool: Focus Group Study With Caregivers and Health Promoters in the Dominican Republic. JMIR Pediatrics and Parenting, 2020; 3(2). Casilang CG, Stonbraker S, Japa I, Halpern M, Messina L, Steenhoff AP, Lowenthal ED, Fleisher L, et al. (2020). Perceptions and Attitudes Toward Mobile Health in Development of an Exclusive Breastfeeding Tool: Focus Group Study With Caregivers and Health Promoters in the Dominican Republic. JMIR Pediatrics and Parenting. doi:10.2196/20312.

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Background:
Despite growing interest in the use of technology to improve health outcomes in low- and middle-income countries (LMICs), local attitudes toward mobile health (mHealth) use in these settings are minimally understood. This is especially true in the Dominican Republic, where mHealth interventions are starting to emerge. This information is critical for developing effective mHealth interventions to address public health issues, such as low exclusive breastfeeding (EBF) rates, which can lead to poor outcomes. With an EBF rate of 5% in the first 6 months of life, the Dominican Republic has one of the lowest EBF rates worldwide.
Objective:
This study aims to describe the current use of information and communication technology (ICT) and to analyze the attitudes and perceptions related to using mHealth interventions among caregivers of children aged ≤5 years and health promoters in the Dominican Republic. Findings can inform mHealth strategies aimed at improving EBF in this, and other, LMICs.
Methods:
Participants were recruited from 3 outpatient sites: the Niños Primeros en Salud program at Centro de Salud Divina Providencia in Consuelo (rural setting) and Clínica de Familia La Romana and its program Módulo de Adolescentes Materno Infantil in La Romana (urban setting). Focus groups were conducted with caregivers and community health promoters to identify the use, attitudes, perceptions, and acceptability of mHealth as well as barriers to EBF. Discussions were conducted in Spanish, guided by semistructured interview guides. All sessions were audio-recorded and later transcribed. Thematic content analysis was conducted in Spanish by two bilingual researchers and was structured around a hybrid behavioral theory framework to identify salient themes.
Results:
All participants (N=35) reported having a mobile phone, and 29 (83%) participants had a smartphone. Sources for obtaining health information included the internet, physicians and clinic, family and friends, health promoters, and television. Barriers to mHealth use included the cost of internet service, privacy concerns, and perceived credibility of information sources. Participants indicated the desire for, and willingness to use, an mHealth intervention to support breastfeeding. The desired features of a possible mHealth intervention included offering diverse methods of information delivery such as images and video content, text messages, and person-to-person interaction as well as notifications for appointments, vaccines, and feeding schedules. Other important considerations were internet-free access and content that included maternal and child health self-management topics beyond breastfeeding.
Conclusions:
There is a high level of acceptance of ICT tools for breastfeeding promotion among caregivers in urban and rural areas of the Dominican Republic. As mHealth tools can contribute to increased breastfeeding self-efficacy, identifying desirable features of such a tool is necessary to create an effective intervention. Participants wanted to receive trusted and reliable information through various formats and were interested in information beyond breastfeeding.

Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study. Drug and Alcohol Dependence, April 2020. Pérez-Figueroa R, Mittal I, Halpern M, Pérez-Mencia M, Donastorg Y, Taylor BS, Amesty
S, et al. (2020). Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study. Drug andAlcohol Dependence. doi:10.1016/j.drugalcdep.2020.108039.

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Background
Evidence in different countries suggest an association between sex work and drug use. In the Dominican Republic an estimated 60,000–100,000 women work in the sex industry. However, little is known about their drug use behaviors.

Objective
To characterize the burden of drug use and examine correlates of these behaviors among female sex workers in the Dominican Republic.

Methods
Data for this analysis comes from a cross-sectional study among key populations at risk for HIV. A community sample of female sex workers (N = 389) was recruited using passive and active recruitment strategies. Participants completed a behavioral survey between 2015 and 2016. Logistic regression models were constructed to examine predictors of drug use.

Results
Protective factors against marijuana and crack or cocaine use included being heterosexual, having a higher level of education, regular employment, and fewer male sexual partners. Increased odds of crack or cocaine use were associated with incarceration, having slept in a place not meant for human habitation in the last six months, and having ever lived in a batey (a community around a sugar mill where workers and their families live). Participants that used marijuana were generally younger, while those that used crack or cocaine were older.

Conclusions
Our findings highlight characteristics of the social and economic environment that require further research to optimize prevention and care strategies for this population. Public health interventions are needed that address drug use, sexual risk-taking, and helping female sex workers and their families achieve a healthy life.