This study seeks to investigate the development of noun and predicate comprehension and production in isiZulu-speaking children between the ages of 25 and 36 months. It compares lexical comprehension and production in isiZulu, using an Italian developed and validated vocabulary assessment tool: The Picture Naming Game (PiNG) developed by Bello, Giannantoni, Pettenati, Stefanini and Caselli . The PiN Research on the emergence of early lexical comprehension and production is very important for both enhancing our understanding of language acquisition and diagnostic purposes. In the South African context, improving numeracy and literacy skills remains a huge challenge in the public education sector  and production in isiZulu-speaking children between the ages of 25 and 36 months. The study is part of an international research collaboration that aims to investigate speech and co-speech gesture production and comprehension development in children. It compares lexical comprehension and production of two romance languages, Italian and French, and two South African Bantu languages, isiZulu and Sesotho, using an Italian developed and validated vocabulary assessment tool. This paper presents the preliminary findings of the lexical development of isiZulu speakers.et al., We use words to communicate about everything related to our physical environment, including events, activities, people, objects, places, relations, properties, and states of being Clark, , p. 1. WIt is well documented that typically developing children are accurately able, by 3.5 years of age, to produce most of the basic morphosyntactic structures of their languages such as relative clauses, the passive construction and other complex forms , but it also has speakers in neighbouring countries. IsiZulu is highly mutually intelligible with other Nguni languages, such as isiNdebele, isiXhosa, and siSwati. In 2011, South Africans citing isiZulu as their home language numbered 11.5 million, or 22.7% of the population, the language that has the highest number of speakers  language with a high number (about 15) of noun classes, triggering the agreement of verbs, adjectives, and other elements. In other words, ‘nominal and verbal modifiers follow the noun and verb respectively, and grammatical morphology is prefixed to both nouns and verbs’ , we have not come across literature that documents the acquisition of verbs, adjectives, and adverbs or the noun and its morphology.Studies on South African Bantu languages are definitely increasing, but as yet there has been no study that has looked at simultaneous comprehension and production during lexical development.We focus on the lexical development of comprehension and the production of nouns and predicates from a speech perspective. Specifically, this article seeks to explore the lexical development of isiZulu using the adapted assessment tool with three main objectives. These are to:Test the effectiveness of the adaptation of a vocabulary tool to measure isiZulu comprehension and production development.Test the universal finding that both comprehension and production performance increase with age for a less-studied language, isiZulu.Present our findings on the comprehension and production of the linguistic categories of nouns and predicates.Early childhood development research shows a strong interdependence between vocabulary, phonology, and grammar in both typical and atypical populations  was specifically developed to assess lexicon production and comprehension in children between the ages of 19 and 37 months, involving the consideration of both nouns and predicates, and based on the Italian MB-CDI. Previous studies have shown that it is extremely relevant to investigate the relationship between vocabulary comprehension and production as well as between nouns and predicates, as these skills and their relationships are indicators of both the level of language development and conceptual organisation. In general, studies using the PiNG tool with Italian children proved that the comprehension subtests were easier than the production subtests, thus allowing for their administration in younger children and resulting in fewer errors. Similarly, children found the noun subtests easier than the predicates subtests. Therefore, lower variability was found in vocabulary comprehension compared with production, and in nouns compared with predicates for hearing children  of objects and tools, animals, food and clothing  and is used in evaluating the comprehension and production of nouns in the noun comprehension subtest (NC) and the noun production subtest (NP), respectively. The second set contains 22 images (20 test pictures and two pre-test pictures) showing actions, location adverbs, and/or adjectives  and is used to evaluate the comprehension and production of predicates in the PC subtest and the predicate production subtest (PP), respectively. The original PiNG test for Italian children was adapted from the Italian MB- CDI and the items had different levels of difficulty. It included items that were ‘easy’, ‘moderately easy’, and ‘difficult’, based on the Italian normative sample  and the set of predicates  was carried out in isiZulu by the researcher, who is a native speaker of isiZulu and a linguist, together with two isiZulu-speaking research assistants, who are also linguists. The translation was further tested in a pilot study of native Zulu adults for validation (see Stage 2).ngikhombise ogijimayo (show me the person that is running): this would not allow a speaker to select a different card in the task because the question requires the speaker to select a card with a person who is doing something, for example, running.Of particular interest in the international collaborative comparative study is the different language typology of romance languages that are analytic and Bantu languages that are agglutinative. In the initial adaptation, a conscious decision was made to adapt the protocol questions as closely as possible to the original Italian version, that is, questions were to be ‘neutral’ so as not to give a clue to the answer. For example, in the Italian version, the question would be translated to ‘show me running’, which does not provide any clue to the participant for the comprehension task and, therefore, the speaker cannot get a clue on the referent. A participant could choose any item he or she deemed fit. However, because of the Noun Class system, agreement concords, and morphosyntax structure of Bantu languages, the question must have the relevant noun class and subject concord, which may give a clue to the item. For instance, in isiZulu, a semantic translation for the above example would read Twenty two adults  participated in the Zulu adult pilot study. Participants were drawn from the pre-dominant isiZulu speakers of Kwa-Zulu Natal, the south-east region of South Africa. Participants were university students from various communities in the Kwa-Zulu Natal area, 60% of whom were from the Empangeni area. The other 40% were from surrounding areas: Pongola, Harrismith, Durban, Eshowe, and Pietermaritzburg. Applying a neutral questioning style did not work. Participants would reformulate the question or stop the interviewer to ask for more clarity. If the questions were amended, participants answered with no difficulty. The inclusion of the class prefixes did not affect the results but rather assisted the participant in understanding what was requested of him or her. This was indicated by the fact that once the correct class prefixes were used, the participants would indicate that they did not recognise an item, or they would give an answer if they did. With the neutral questions, the participant would simply halt the interview, seek clarification, and personally supply the class prefixes. When the interviewer asked why the participant reformulated the utterances, all participants stated that the ‘neutral’ utterances were grammatically correct, but ambiguous and confusing. It is interesting to note that all 22 participants corrected the utterances.Agreement between participants was 95% for the comprehension subset and 86% for the production subset. Four items under the NP subset produced either no responses or ‘I do not know’ answers, referring specifically to bidet, radiator, penguin, and seal. Under the PP, two predicate task words produced a low frequency of correct target words .From the adult pilot results, it became clear that the isiZulu version of PiNG needed further adaptation before the pilot study with children was initiated. The adults seldom produced words in isiZulu for ‘seal’ and ‘penguin’ and so these items were changed to ‘snail’ and ‘crocodile’, respectively. As both ‘radiator’ and ‘bidet’ are foreign cultural objects, these two items were replaced by ‘heater’ and ‘toilet’. Some pictures were specifically cultural, such as the picture of the ‘roof’, which was a European type of roof, but in order to allow a systematic comparison with other languages in the four-language project, some items were retained for future adaptation.After the changes to the above-mentioned picture items, a pilot study was conducted with 15 Zulu children. The group included five children aged 25 months (±1 month), five children aged 30 months (±1 month), and five children aged 36 months (±1 month). This was done in order to test the corresponding adaptation of PiNG on a small sample in case further adaptation was needed before going onto the main study. Participants were drawn from Kwa-Zulu Natal, the same area where the adult pilot study was conducted. Data was collected from the urban townships of Empangeni and Ngwelezane on the northern coast of Kwa-Zulu Natal. The principals and caregivers were very helpful in providing the researchers with the children’s clinic cards. These vaccination cards aided the researchers in selecting participants for the appropriate age cohorts. The files provided by the teachers also gave the researchers additional information, including, for example, whether a child had been born prematurely or had a learning disability and needed to be excluded from the selected participants.We worked with nine crèches to ensure that our three age groups were exact. Many crèches could not form part of our participant sample because those children were bilingual and would alternate between naming items in English and isiZulu. We finally chose two schools from the city centre of Empangeni and four schools in the Ngwelezane township. Administration of the PiNG tool began with a familiarisation phase that involved playing various card games, counting games, and naming games with the children. Researchers also played with the children in the school playgrounds on the swings and slides. Once the researchers felt that the children were comfortable enough, they asked the children to play a game with them in front of the camera.The main study for the isiZulu data was collected from Soweto in the Gauteng province. The move from KZN was purely logistical as the researchers were all Gauteng based. Monolingual isiZulu-speaking children were chosen with the help of their caregivers. Children’s vaccination cards were examined to exclude premature babies or those with any recorded pathologies. All crèches require clinic or vaccination cards in order to enrol the child. The caregivers also assisted in selecting children, who they said showed no language delays in comparison to their peers. All selected children had parental consent (see the Ethics section).Forty-nine children from four neighbouring crèches participated in the study. Nine children were excluded from the data sample for various reasons: some children did not complete the two tasks, some children were bilingual and code-switched regularly, some children spoke too softly for the camcorder to record sound, and one child was sleepy and had to go for a nap. For this study, 36 participants were chosen with 12 per age cohort in consideration of gender balance. There were a total of 19 females and 17 males across the different age cohorts .et al., et al., et al., The procedure of this study followed those of previous studies , if the child indicated  the photograph corresponding to the item indicated by the adult researcher, the answer was considered correct. If the child selected the no target photograph or did not respond at all, the response was coded as incorrect or no response, respectively. Similarly, in the production subtests, if the child produced the target lexical item, their response was coded as correct. If the child produced a non-target item or did not respond at all, their response was coded as incorrect or no response, respectively. For some photographs, more than one answer was accepted as correct; for instance, for the ‘diaper’ item, some children called it ilorri (a lorry) and itruck (a truck) for the truck item. Responses that had a semantic relationship to the item depicted were coded as NTS, no target, but semantically correct to measure if the concept was in place even though the production was not successful. Incorrect responses occurred where the production was not the target response nor semantically related, for instance, isidudu (motorbike) for ‘truck’.Synonymous items were considered to be correct synonyms, for instance Three trained native isiZulu-speaking research assistants and the researcher independently coded the verbal transcription, that is, orthographical transcription directly from the film footage. Two different research assistants, who are also trained linguists, coded the classification of the speech responses as well as those of gesture. Disagreements were resolved through discussion.After the annotation phase was completed, all data was exported to Excel for an ultimate verification  and statistical analysis.Ethical considerations guided the pilot study as well as the main study. All children who participated were recruited on a voluntary basis after their caregivers signed an informed consent form, which was provided in their language, and after they themselves agreed to participate at the start of the task (‘Nouns’ or ‘Predicates’). Parents or members of the crèche were welcomed in the room during the administration of the tool. The tasks were interrupted or ended if a child verbalised a desire to stop, or expressed discomfort by crying and/or withdrawing. Children’s identities were kept confidential, and data obtained from this project were not disclosed to any third party. The Wits HREC Non-Medical Ethics Committee granted ethical clearance for the study (protocol number H13/08/43).Children’s responses were analysed according to the coding criteria listed in the method section. For our first objective, we analysed the comprehension and production tasks across the three age groups to test whether the PiNG assessment tool was effective in detecting the development of comprehension and production in isiZulu. Our second objective overlapped our first, and so our first finding addresses both of our objectives.For the comprehension and production tasks, an analysis of variance, ANOVA, was run with the age group as the independent variable.The correct answers for the comprehension and production task items are illustrated in F[2.69] = 3.143, p < 0.05 for the comprehension task. Post-hoc Bonferroni analysis showed that the effect of age was significant at 0.05 among all age groups throughout the entire sample, but was not significant between the 25-month-old and the 30-month-old groups. Similarly, for the production task, there was a significant age effect across the whole sample at  than labelling the correct items for predicates  with post-hoc test Bonferroni confirming that there was a significant difference between the 36-month group and the 25-month group at p < 0.03. There was no significant difference between the 25-month and the 30-month groups, nor between the 30-month and the 36-month groups for the noun subtest. For the PC subtest, post-hoc Bonferroni test confirmed that age had no significant effect, although there was a developmental trend between the different age groups.The comprehension of the noun and predicate subtests was better performed than the production of noun and predicate subtests across the age groups. In F = 7.4, p < 0.002) than in the PP subtest  = 0.96, p < 0.393). Post-hoc Bonferroni tests confirmed that there was a significant difference between the 36-month group with both the 25-month group and 30-month group, at p < 0.003 and p < 0.02, respectively. For the PP subtest, the post-hoc Bonferroni test confirmed that age had no significant effect across the three age groups. The 36-month children had an equal chance of correctly labelling PP items as the children in the 25-month and 30-month groups, despite the developmental trend we observe in For the production of nouns and predicates, we noted a similar pattern in that children performed better at labelling the correct items in the NP subtest .The photograph of the mountain showed a rising mountain of the European Alps, a type of geographical feature that is not commonly seen in South Africa. It was interesting to note that the children had difficulty identifying ‘snail’ and ‘elephant’, but managed easily to identify the domestic animals such as ‘cow’. The ‘bib’ and ‘hammer’ were also not easily identified: the children gave answers that focused more on the baby who was wearing the ‘bib’ and did not respond at all to the ‘hammer’ or said, Under the PC subset, there were seven items that had less than 50% success; ‘walk’, ‘behind’, ‘close’, ‘full’, ‘outside’, ‘to embrace’, and ‘short’.uhamba kuphi , as the picture showed a young boy walking along the passage of a house. The smaller children would either focus on the clothes the child was wearing or on the distractor card, which showed a young boy playing with toys. This performance did not show a developmental trend, which meant the 36-month-old children also had a similar chance of not perceiving or identifying ‘the walking’ from this picture. The item ‘embrace’ also produced some interesting comments across the age groups, similar to ‘kiss’ found in the PP subtest. The older the children, the more they avoided discussing intimacy with responses like bayaganga (they are being naughty) or they would simply avoid looking at the picture and focus on other pictures. The adjectives ‘short’, ‘full’, ‘outside’, and ‘behind’ were very difficult items that showed a distinct developmental pattern with responses that were semantically related, so for ‘short’, a child would say yincane  referring to a short pencil in the picture, and yet the prompt was for them to point to the object, which does not necessitate a verbal response.Some of the responses for ‘walk’ were Overall, production items scored lower than comprehension items, as seen in izandla/into yezandla zikamama (hands or something for my mum’s hands). Glove sizes in South African shops start for children who are about 4 to 5 years of age, and mittens are not commonly found. The older children labelled the item ‘diaper’ correctly, compared with the young children who tended to call it ipenti (a panty).The 36-month-old group was more familiar with the leather gloves depicted in the picture with most children saying The ‘picture’ item was also more familiar to the 36-month-old group, even though most children across the age groups identified it as a TV, because the picture looked like a flat screen TV. The picture depicted a lone beach with a blue sky, the ocean, and a strip of sand. The picture also garnered ambiguous responses from the adults in the pilot study.itruck or ilori.The item ‘truck’ produced the semantically related ‘a car or a bus or a big car’. This item did not display any developmental trajectory, as 36-month-old children were equally likely to produce ‘car’ rather than the target word ibhayibheli (a bible) across age groups as well. The ‘beach’ item produced equally random responses, with children either focusing on the water in the photo or on the sky.The ‘book’ item mostly produced ikgokgo (a monster) or some onomatopoeia sounds illustrating that ‘this is a scary thing that will eat me’. A few children avoided even looking at the picture or quickly pushed the card to the researcher.The wild animals ‘lion’ and ‘crocodile’ produced very interesting responses such as indlu (house) or isihlahla (a tree). This picture did not reveal an age pattern because the responses were random. The item ‘flags’ was extremely difficult, with no child giving a correct response. Most responses were iAfrica (Africa) or yiduku (head scarf), and these semantically related responses increased with age.The ‘roof’ item depicted a European type roof and a portion of a house with trees surrounding it. Most responses were either In the PP subtest, the following seven items were difficult for the children: ‘to turn’, ‘empty’, ‘in front of’, ‘heavy’, ‘far’, ‘inside’, and ‘long’.bayadlala/bahleli (they are playing or they are sitting). This response did not reveal a developmental trajectory because the responses were random across all age groups.The item for ‘to turn’ depicted a group of children on a merry-go-round. Children’s responses included For the adjectives and adverbs ‘empty’, ‘in front of’, ‘far’, ‘inside’, and ‘long’, the responses did not show correct labelling across all ages. These items showed a developmental pattern when considered in the light of that the responses showed that the children acquired this concept with age.Interestingly enough, five of these items were in the same set at the PC subtest, which shows consistency in the production of these categories. All the children had difficulty perceiving the item ‘heavy’. This item depicted a young child carrying a brown torn box while grimacing. Children’s responses focused on the child or the box being torn.Our study begins with an Italian picture naming assessment tool being adapted to a Bantu language, isiZulu. The tool is designed to directly observe the lexical composition of vocabulary in two related tasks; comprehension and production. To our knowledge, most studies on isiZulu or related Bantu languages have either directly observed either comprehension or production, but never both at the same time. Several pilot studies in both adult and children populations enabled us to alter obvious elements of cultural bias. Although some other problematic items remained, we decided to preserve our initial goal by keeping as many items as necessary for our systematic comparison with two romance languages, Italian and French, as well as another South African Bantu language, Sesotho.et al., Certain items such as the picture of a ‘roof’ did not depict a ‘roof’ as seen by many South African children. Some items such as ‘to turn’, which depicted a merry-go-round produced unexpected results in that one would expect most children to have been exposed to a merry-go-round as these are commonly found in parks, but instead the children focused more on the people in the picture than on what they were doing. Despite the cultural differences that may have stemmed from the images of our stimulus, we note that our findings confirm what has been long documented in literature: that comprehension comes before production. In a related cross-linguistic comparison, Japanese children showed a lower lexical production compared with the Italian children (Pettenati et al. (et al. (In terms of development, our results show how age affects both comprehension and production: 36-month-old children performed better than 30-month-old children who in turn performed better than 25-month-old children. Our statistical analysis did not discern a significant difference between the 25-month-old group and the 30-month-old group for comprehension, but it detected a significant difference between the 36-month to the 25-month and 30-month groups in terms of production. This was not surprising as, in the first study by Bello et al. , it was  (et al.  found thIn terms of production, our findings showed an overall effect of age, which meant that production does indeed lag behind comprehension. Moreover, the larger number of culturally foreign pictures in the noun comprehension subtest suggests that it may be necessary to further adapt the assessment tool to more effectively evaluate the isiZulu lexicon.Children used a semantic description strategy to try and explain unfamiliar items, which shows that though they may have the concept, the lexical item is not ‘concrete’ enough for them to relate to their physical environment. If perception is difficult, it is harder to retrieve the semantic representation from the lexicon and, as such, retrieval will be impaired Harley, .The production of the noun category showed an age effect but the predicate category did not show a similar difference. The higher number of adverbs and adjectives in the PP subtest was difficult for all the age groups, which could explain the lack of a significant difference. Alternatively, if verbs are acquired earlier, it shows that the children have reached a plateau phase between the ages of 24 and 36 months. Further research on the vocabulary spurt in isiZulu would shed more light on this issue.The lack of a child inventory like the MacArthur Bates CDI for isiZulu and related languages is a disadvantage. We have no idea which items are acquired first, nor do we have the exact age of the vocabulary spurt in isiZulu. Future analysis should look at the gender effect. Although gender-related data is available in this study, it has not yet been analysed. It would be interesting to see whether girls have an advantage over boys, as has frequently been reported in western languages.Developing normative lexical data on Zulu-speaking children or those speaking other related Bantu languages is important for research for both acquisition and clinical purposes. Finding a standardised assessment tool that can be used for South African Bantu languages is an ongoing challenge. The PiNG assessment tool has proved to be robust and effective in directly assessing a child’s lexical vocabulary. For further research into isiZulu, the tool would need further adaptation by replacing some images with items of local content.The literature states that children begin with language comprehension and, when the motoric and cognitive apparatus develops, language production follows suit. This is a universal linguistic parameter. Children start with objects and events around their immediate environment and quickly learn people’s names, concrete objects around them, and familiar routines coming from their home environment. The first words will therefore largely depend on this input, and cultural as well as linguistic constraints may affect this development.This study shows that as children get older, comprehension and production improve. It would therefore be very important for researchers or speech therapists to factor input into their intervention therapies. Children will understand and talk more about what they know and what surrounds them. Some linguistic phenomena like adjectives and adverbs are complex and not yet acquired by the Zulu child at 36 months.


As proposed diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis has been approved and revised, the contents and changes are informed. Although disseminated intravascular coagulation (DIC) is a serious disease, there is no gold standard for its diagnosis, no single biomarker by which DIC can be clearly diagnosed, and no anticoagulants have been recommended for the treatment of DIC in worldwide . We reviFor this reason, the JSTH proposed a provisional draft of the DIC diagnostic criteria, which used the classifications of “hematopoietic disorder type” which omitted the platelet count score, “infectious type” which omitted the fibrinogen score, and “basic type” based on the underlying pathology , 3. An aAfter the drafting of the proposed criteria , severalIn conclusion, the JSTH diagnostic criteria for DIC have been revised and approved: Infectious-type DIC is now diagnosed based on a score of 5 points instead of 6 points.


We present an in-silico model of avascular poroelastic tumour growth coupled with a multiscale biphasic description of the tumour–host environment. The model is specified to in-vitro data, facilitating biophysically realistic simulations of tumour spheroid growth into a dense collagen hydrogel. We use the model to first confirm that passive mechanical remodelling of collagen fibres at the tumour boundary is driven by solid stress, and not fluid pressure. The model is then used to demonstrate the influence of collagen microstructure on peritumoural permeability and interstitial fluid flow. Our model suggests that at the tumour periphery, remodelling causes the peritumoural stroma to become more permeable in the circumferential than radial direction, and the interstitial fluid velocity is found to be dependent on initial collagen alignment. Finally we show that solid stresses are negatively correlated with peritumoural permeability, and positively correlated with interstitial fluid velocity. These results point to a heterogeneous, microstructure-dependent force environment at the tumour–peritumoural stroma interface. The importance of mechanics in cancerous growth, invasion and metastasis is well-established . I). I2]). Given the potentially correlated nature of these observations, it is instructive to build a reductionist mathematical model with which to isolate and test each component separately. In order to make such a model biologically relevant, it should be parametrised by measurable biophysical properties at multiple scales. This motivates the development of a multiscale, multiphase model that can be coupled with a model of tumour growth. A brief overview of pertinent models is given here; see e.g. , 9] for for9] foPioneering work by  investigTo our knowledge there exists no multiple length scale description of biphasic tumour growth. The model we present here uses the biphasic formulation proposed by  to extenHere we conduct simulations of in-vitro tumour spheroid growth into a collagen hydrogel to test that i) tumour growth causes passive microstructural remodelling; ii) collagen microstructure influences macroscale fluid flow; and iii) solid stress is correlated with tissue permeability and interstitial fluid flow. The paper is structured as follows: ‘Material and methods’ provides a description of multiscale tumour modelling and its numerical implementation, including a link to our open-source software; ‘Results’ presents the set of hypothesis tests using the proposed model; and ‘Discussion’ critiques the results and methods.T, embedded in a shell of peritumoural stroma, ΩP, with a boundary interface between the tumour and peritumoural stroma, ΓI, and an external boundary, ΓE. For simplification, spherical symmetry is assumed and only one eighth of the total domain is analysed; symmetry surfaces are collectively denoted by ΓS. The tumour is defined at the macroscopic scale only, while the peritumoural stroma (PTS) is treated as a multiscale material. As with our previous work V is the u′ is the directional derivative of the microscale displacement, Here z, and k is the fibre permeability, defined as k = (rT ⋅ c ⋅ r)−1, where r is the fibre direction cosine matrix (i.e. the mapping between the fibre and fluid frames) and c is the diagonalised fibre drag coefficient matrix. The diagonal components are set equal to expressions previously derived for parallel , , , to nameIt is worth noting the limitations of the current model, particularly with a view to its application to in-vivo tumour growth and patient-specific modelling . First, S1 FileHere we provide the finite element form of the coupled macro-micro conservation equations.(PDF)Click here for additional data file.S1 TableThis table lists the material parameters used in all simulations, unless stated otherwise in the text.(PDF)Click here for additional data file.


Most Malawian women who start ART under Option B+ are still in care three years later, a higher than average adherence rate for life-threatening chronic disease treatments, worldwide (50%). We asked 75 Malawian on ART their motivations for remaining in treatment, and what barriers they overcame. Focus groups and interviews included 75 women on ART for 6+ months, at 12 health facilities. Four main motivations for continuing ART emerged: 1) evidence that ART improved their own and their children’s health; 2) strong desire to be healthy and keep their children healthy; 3) treatment was socially supported; 4) HIV/ART counselling effectively showed benefits of ART and told women what to expect. Women surmounted the following barriers: 1) stigma; 2) health care system; 3) economic; 4) side effects. Women stayed on ART because they believed it works. Future interventions should focus on emphasizing ART’s effectiveness, along with other services they provide. In 2011, Malawi implemented an innovative policy (“Option B+”) to prevent mother-to-child transmission (PMTCT) by providing lifelong ART to all HIV-infected pregnant and breastfeeding women . In OptiIf we take a global perspective on long-term therapy for chronic life-threatening diseases, Malawi’s Option B+ adherence and retention rates are impressively high, and much higher than in some other countries that have adopted the program.  Most papEpidemiologists and public health experts who design and evaluate HIV treatment programs have studied the reasons for poor adherence to ART. Several systematic reviews highlight important individual-, interpersonal- and community-level, and health-system-level barriers to treatment uptake, retention in care, and adherence. On the individual-level, poor knowledge of HIV/ART ,16, psycWe visited 12 health care facilities across Malawi and conducted observations, semi-structured interviews (SSI), and focus group discussions (FGDs) with women retained on ART under Option B+ for a minimum of six months, to determine why they stayed on ART, and what barriers they had overcome to remain in treatment.This qualitative study was designed to complement our earlier quantitative studies on adherence and retention in Malawi’s Option B+ program ,5,6,24, We usually recruited participants at ART clinics, but some women were recruited from the ANC during routine antenatal visits. We included women aged 15 years or older who visited the facility and had remained on ART under Option B+ for at least 6 months. Health care workers (HCWs) helped us recruit our subjects by flagging patients who met our inclusion criteria and introduced us to them. We interviewed women and conducted FGDs until we reached data saturation . We conWe triangulated our data, supplementing SSIs and FGDs with field notes from ethnographic observations. Both SSIs and FGDs used open-ended questions designed to elicit stories about motivations and barriers from participants. The subject’s narrative progress was guided by the interviewer, who then encouraged participants to expand on specific topics raised in their stories. The central question, to which the interviewer was instructed to return throughout the interview, was why participants stayed on ART long-term, and what challenges they faced in so doing. In the second part of the interview, the interviewer kept participants on track by asking them more probing questions about factors they and other participants said helped motivate them and allowed them to stay on ART. NP conducted all individual interviews and led all focus groups. We could not hold FGDs at every site because sometimes not enough women attended the facility on the day we visited. Sometimes enough women attended, but since we could only hold the FGD after all women were finished with their appointments with the nurse, some of these women would not wait for others to finish. Our observations focused on infrastructure (the layout and size of rooms), number of clients and health care workers, waiting times, the privacy and confidentiality afforded clients, and client-healthcare worker interactions.We were aware that the level of privacy would change from facility to facility, and that we would need to be flexible and creative in our efforts to find or make comfortable spaces for participants to answer sensitive questions. Depending upon available facilities or weather, we held SSIs and FGDs in built environments, under a tree, or even in our vehicle if no more suitable place was available. Interviews were conducted in Chichewa, the local language, recorded on a Sony IC recorder, transcribed in Chichewa, and then translated into English by research assistants. NP, who is bilingual in Chichewa and English, vetted all translations for accuracy. Our researcher in the field (NP), accompanied our quantitative research team to health facilities, where she observed interactions and events in public areas of the hospital or clinic, and sometimes spoke casually to patients or HCWs in and around those areas. She took light notes while observing and followed those up with detailed field notes written in private. No confidential information was collected during the observations, and our field researcher kept no identifying records. Interviews were conducted between November 2014 and December 2015. We reviewed the literature, iteratively analyzed data, and reviewed ethnographic notes until late 2016.Our data analysis team consisted of a Malawian social scientist , and a Swiss-resident cultural studies scholar . NP had the responsibility of coding transcripts independently in Atlas.ti. KT coded some transcripts in Atlas.ti and was responsible for closely reading all transcripts to identify narrative patterns. We took an inductive approach, reading and rereading the transcripts to identify key concepts in both SSIs and FGDs. We searched for patterns across the transcripts and grouped them into themes. NP and KT met several times to discuss emerging categories and themes, and then to finalize categories after saturation was reached. Disagreements were resolved by consensus.We extracted data on characteristics of informants and mentioned barriers and facilitators from coded transcripts and generated quantitative datasets. We then used descriptive statistics to show characteristics of the informants who participated in FGDs and SSIs. We calculated proportions of informants who mentioned barriers and facilitators in FGDs and SSIs. We visualized patterns of barriers and facilitators that were mentioned in SSDs and FGDs in a matrix. The rows of the matrix represent barriers and facilitators, and the colons represent informants. Greyed boxes indicate that the informant mentioned a facilitator or barrier. Statistical analysis was done in Stata .We counted the barriers and facilitators mentioned in FGDs on the individual-level and not on the group-level. Participants often confirmed barriers and facilitators that were mentioned by someone else and we felt that it was not appropriate to count on group-level because views of individuals do not necessarily reflect the view of the whole group. We acknowledge that both approaches  have advantages and disadvantaged, but we felt that the former approach was more appropriate.Participation was voluntary; patients were free to withdraw at any time without penalty. At the end of the interview or discussion, participants were given money to cover their transport to and from the clinic. We told potential interviewees about the goals of our study, after informing them about confidentiality, risks, and advantages. We explained we would use the information they gave us to publish academic papers, and we would share the results with the Ministry of Health. We included only subjects who gave us informed written or verbal consent, which we recorded at the beginning of each interview. In the FGDs, we assigned numbers to participants, and asked that they use the numbers instead of their names to protect their anonymity. These recordings were de-identified. After our research assistants transcribed the sessions, the interviewer (NP) carefully went over the transcripts again to ensure no personally identifying information was included. No other researchers handled transcripts before they were de-identified.The study was approved in Malawi by the National Health Sciences Research Committee. In Switzerland, the Cantonal Ethics Committee of Bern waived the requirement for ethical approval for our study.NP observed at all facilities, for a minimum of 5 hours and wrote over 43,000 words of notes. Clinics always started with a health talk given by either expert client, a Health Surveillance Assistant (HSA) or nurse (student or otherwise), followed by HIV test and counseling, then antenatal care and ART. In addition to providing ANC, clinics offered services including family planning and cancer screening. Infrastructure was inadequate. In most clinics, there were not enough benches to seat all the clients. Some clinics did not have enough rooms to service their clients, and the rooms they had were often overcrowded and provided no privacy. NP noted that on most days the clinics had a large crowd of women and sometimes a few men who accompanied their wives. NP saw as many as 72 women attending ANC, and up to eight couples. Most of the clinics had a shortage of nurses. Sometimes one nurse handled the whole ANC clinic with the assistance of student nurses, expert clients and sometimes ward attendants (cleaners). Overcrowding and staff shortages meant women sometimes spent up to eight 8 hours at the facility.We invited 80 pregnant or breastfeeding patients on ART to participate in our study. Of these, we ultimately included 75: 1 woman refused to participate; 3 waited for a while and left before the FGD started. We excluded one woman who was ineligible for the study from all analyses because she started ART long before Option B+ was introduced. Of the 75 women, 19 participated in the SSIs, and 56 participated in the FGDs. The median number of women per FGD was 7 (IQR 3.5–10). We conducted SSIs with patients at 11 out of 12 sites, and FGDs at 7 out of 12 sites . Most inOf the women who participated in FGDs and SSIs, two-thirds came from rural areas and the rest from urban areas. Most of the women were Christian, and most were Ngoni, Lomwe, Chewa or Yao. More than 80% of the women were married; more than half had finished upper primary or secondary school. Their median age was 30 years (IQR 24–33). Most were either housewives or small business owners and had 3 children. Participants in our SSI were on ART for a median length of 12 months at the time of the interview (IQR: 6–30). For more details on the characteristics of women who participated in SSIs or FGDs, see Almost all women were aware that ART improved quality of life and likelihood of survival, for themselves and for their children. They shared their own experiences on ART, their observations of others, and the advice given to them by health providers or family members. As we coded the data, four major motivations for continuing ART emerged: 1) evidence they had collected from their own experience with ART or from observing others on ART, which convinced them that ART improved their own and their children’s health 35/75); 2) they had a strong desire to be healthy 40/75 and to keep their children healthy (34/75); 3) their treatment was socially supported (31/75); and, 4) HIV/ART counselling helped them understand the benefits of ART and what they could expect (36/75)  Many women (35/75) explained that they stayed on ART because they noted that they had less or no illness since they started.“… as for me I do not find any problems ever since I started… and I have never been sick up to coming to the hospital to be admitted.”32-year-old, FGD003After their children were born, most of these women were motivated to continue ART after their child’s HIV test was negative (27/75). They anxiously waited for all three post-partum HIV tests  to come out negative. Every negative result was proof that the drugs were effective.Because this child, her sibling taught me a lot till now. I got pregnant while still taking [ART]. Until her birth. After 6 months, I came again to get her tested for the first time. After one year and some months, I came again for her to be tested and the results were the same, she was HIV-negative. After 2 years and 2 months, I came for the last time, her blood was the same [HIV-negative]. For sure that is the goodness that I see.”33-year-old, SS1004Women also spoke of being inspired by evidence that ART had worked for some people they knew. They mentioned family members or friends who were on ART for some time and are healthy and doing well (13/75).“I am motivated… I have my aunt who was found HIV-positive. She had twins, a girl and a boy. They got sick and they went to the hospital and they were tested…. They found that the boy was HIV positive and yet the girl was HIV negative. Now my child is 1 year 6 months and that child is 12 years and still taking the medication together with my aunt… That is what motivates me that ah how is she staying and this small child… he has stayed all these years….”28 years old, SSI010Almost all women said that they took ART to protect their own health, and to protect their children from contracting the virus.“But also, I was sick and sometimes I would say ah! But now it’s not okay, but after I started receiving the drugs I found that I was well and strong, and I can walk with ease. So, since that time to now I am okay.”24- year old, FGD005“Yes, so that maybe the baby should be born well. HIV-negative right? If you stop, have you loved your child? …I continue, and we are continuing… really…”30-year old, SSI008Some women said they took ART to live long enough to see their children grow, because no one else could take care of their children if they died prematurely.“… I see nobody who will take care of my children. So at least when I am dying, if I am to die… That is if the world does not end while I am alive, I should see how my children’s future will turn out. That’s why am still taking the medicine daily.”30-year-old, SSI008The realization that their child’s health was in their hands motivated them to stay on ART even when they experienced side-effects.Most of the women we interviewed (65/75) said they had gone to ANC and were tested on their own. Almost every one of them went home and told their partner of the test result, most of them the same day. One waited a few days, but eventually told her partner. Only two women said they had not disclosed to their partners. Most women said their partners accepted the result and agreed to be tested.“When I came to start antenatal, they said I should come for testing, so after being tested I was found HIV positive. Then I went home and explained to my husband. I told him that we should go to hospital together for testing. I have already found out my status, am HIV positive. You should also go for testing and we went. He is also HIV positive”26-year-old, SSI003Some of the women said they received support from their partners even though their partners did not get their own HIV test.“He never came for the test. I would lie if I say he came. But he never went…. He just encourages me to be taking [ART] so that my child will be born without the virus.”33-year-old, SSI002Some women (10/75) went to ANC with their partner and were tested together. Those with discordant results (8/75) rarely had arguments with their partners or were insulted by them. Instead, their partners encouraged them to continue treatment.“Before they told us the results with my husband, they asked us a few questions. They asked him if I tested positive could he accept… can he continue being with me or not? He accepted that he would stay with me. They asked me as well. I said I would be with him still, so he accepted, and we are still together”29-year-old, FGD001Only once during our observation did we hear of a marriage dissolving after a discordant result on previous day. Most women spoke of being encouraged by their partners. Others mentioned that their partner would sometimes collect their medicine for them or remind them of their appointment dates.“Yes, my husband was receiving the medicines for me and bringing them to me.”24-year-old, SSI0012“No, he has never denied me and also that time he had the heart of reminding me about the ARVs.”29-year-old, FGD002Most women disclosed to and were encouraged by one or more family members (31/75) or partners (42/75). Usually, they chose to tell their mothers. Those who did not have a good enough relationship with their mothers disclosed to other family members, including sisters, uncles, and children. Very few women disclosed to their friends, but the few that did said these friends were also on ART. Those who disclosed to family, partner, or friends said they received encouragement to continue treatment, to take pills without skipping doses, and to keep their appointment dates.“When I went home, I told all my relatives, we gathered and discussed. So, people came, ‘don’t worry you shouldn’t be anxious. It’s better you listen to the counselling you receive from hospital’.”39 years old woman, SSI0019“… there was my friend whom I chatted with. I didn’t know that she already started taking ARVs. I explained to her and she said, ‘there is no problem, I will be your witness [guardian] just like your relative’”.36-year-old, FGD007Almost all the women were worried after being diagnosed with HIV. Some women were anxious about taking the drugs every day for the rest of their life. Others worried about infecting their unborn child. Some women worried that their partner would not respond well to the news they were HIV-positive. Many of these women’s fears were allayed by counseling. Most (36/75) appreciated the counselling they received from the health providers, on the very first day or thereafter. They felt that counseling helped them overcome these worries and helped them stay on ART.“I was stressed about ah! I will be taking ARVs every day. I was also worried about the unborn child, that the baby would be infected, and it would be difficult for me to take care of him. So, the nurse explained to me that ah! When you follow what we will tell you here, your child will what? Will be okay, mm hm!”.29-year-old, SSI002“… when I was diagnosed with HIV, when I went for counseling they said that, when you start taking the drugs it is not good to stop, the minute you stop taking the drugs your life is never okay …”22-year-old, FGD005Most women experienced drug side effects like dizziness, heart palpitations, numbness, nightmares, vomiting, a feeling of drunkenness, and extreme hunger. Women mentioned that HCWs helped them get through the side effects and observed that side effects diminished or disappeared, just as medical personnel had assured them.“… the people that were teaching us said that when one has just started taking ARVs, they said she can experience some kind of signs. Maybe if you take the drugs, maybe you feel dizzy, maybe the heart beats fast, or maybe people feel numb… they said so. When the ARVs have adapted, well, it all stops. And when I started taking them, it happened to me for a week then it stopped. Now I don’t have any problem. I saw that the hospital staff were saying the truth.”30 years old, FGD007“I should say, when I was 5 months pregnant, that is when I decided to go to the hospital. They asked me why were you not coming to get more ARVs all these months? I told them that I was scared to take the ARVs. It’s not like they are scary but why were you not taking the drugs? I told them that they are making me feel drunk. They are making you drunk? Eh! You should go and drink them continuously because the child you are going to have can be infected with HIV, and he cannot live long, and you cannot live long too. That is what forced me to start taking the ARVs as advised.”19-year-old, FGD002In some areas, women said that community health workers (CHWs) followed them at home. These follow-up visits focused on their adherence to the ARVs, and side-effects of the drugs. Most appreciated the encouragement they received from these CHWs.“Yes, I have accepted that they used to follow me… he used to give me very good counsel, and we used to chat very well, about how things are. He would even help me get the drugs, help me count them, and tell me how it is. When he came here, I would always find peace in my heart, because we were chatting very well.”29-year-old, FGD002All the women we interviewed mentioned barriers to retention–obstacles that they overcame either singly or repeatedly, to continue treatment. We divided these barriers into four groups: 1) social barriers; 2) health care barriers; 3) economic barriers; 4) side effects of medication. These are described in detail below and in Disclosure is an immediate and pressing issue for women diagnosed with HIV on Option B+, especially since HCWs ask women who test HIV positive to identify guardians who can support them in their treatment and bring those guardians to their next ART visit. All the women we interviewed had disclosed to a partner, family member or friend. Among the women we interviewed, disclosure to their partner often did not have the consequences they feared.“I went to the village, so I left the drugs… I took some and left some at home. So, when I left them like that, he found them when he was left in the house so when I came back that is when he was asking ‘what are these drugs for?’ So, I then told him that those drugs I was given at the hospital. Why he said? Then I started explaining that I was tested, and I am HIV positive. So that’s when he said alright. Why didn’t you tell me all this time? I said I was afraid. He said do not be afraid….”40-year-old, FGD005Some (12/75) of the women we interviewed had ongoing difficulties with their partners. Sometimes partners (5/75) denied they could be HIV-positive, accused their wife of bringing the infection into the house, and provided no support.“When I went home I explained it to my husband. My husband answered that ‘no, that means you are the one who went and contracted the infection,’ and so on….”28-year-old, FGD004Some women hid their clinic appointment from their spouse to avoid quarrelling about the infection. They mixed their clinic visit with some business they had in town, so they could give their spouse a different reason for being in the area.“A while back like I said I would say I am going and when I come back we would quarrel about many issues. He would say so many things. Then I saw that I should not be troubled. I would make it so that when I take my business, he will be saying ‘my wife has gone to do business’. Like now, I have left it with someone. Maybe I can meet him he would say ‘what is it?’ ‘Oh, I am coming from the market. I went to feed the child cornmeal pulp.’ After that we go our separate ways”36-year old, SSI009A few women we interviewed were stigmatized by partners, families, and community members, and dealt with abuse on a regular basis, ranging from verbal attacks to exclusion.“But when we are arguing at home, they say that ‘this one is already finished, she takes ARVs, and she is finished…. She wants to give us bad luck… she is running on foam.”32-year-old, FGD004“So, this other time we quarreled and my husband went outside, ‘oh, you dog, you are stupid, and you should live with your infection.’ Then I went into the house and started deliberating. I was alone and then I said ‘oh, my relatives here should know about this, I should not hide it from them.’ I explained it to my relatives. Then it happened that I have been taking the medication from that time up to now, but I dig and bury them, because when we quarrel he takes out the bottles and throws them outside. So, I felt that I was being embarrassed at the plot.”36-year old, SSI009Women talked about long waiting times at health facilities, which were usually very crowded. This forced them to leave home early, so they ensure they were near the front of the line for treatment. Some women said waiting times were longer because HCWs were overworked or distracted with activities unrelated to work, that clinics were short staffed, or that HCWs did not open on time. Some complained that certain HCWs practiced favoritism.“I have concerns… the number of nurses during children’s clinic…. that is what concerns me because you find that you have left some chores undone at home that aah! Maybe when I come back from the hospital I should tend to them and you find that you take forever here at the hospital, that means you won’t do those chores because you get home late, yes.”24-year-old, SSI0012“You find that some of the staff here take health passports of people outside and receive the drugs for them while you are just standing in line, you wonder what is happening, you hear eh! He is helping those people first maybe 2 people. That is quite worrying because some of us come here early in the morning we stay here all morning …”37-year-old, FGD005We also documented understaffing in our field notes:“…the nurse told me that she was the only one on duty doing the clinic. She was being helped by the student nurses. She explained that the department has four nurses. Two were out for workshops and one was doing cervical cancer screening in another room. She started complaining that the clinic has stalled because there is no one in the PMTCT room to do the testing.”“The nurse complained that the day has been hectic and long… She saw about 86 clients by the end of the clinic and the majority which she saw herself. She did the best she could to be fast, but it would have been better if there were at least 2 nurses in that room. She was also not able to spend so much time with each client that was initiated on ART.”There were women who reported abusive treatment from HCWs, including being yelled at. We also documented shouting and HCW frustration in our field notes, though it was infrequent in our presence.“Most of the women didn’t know their ages. The counsellor was getting frustrated with every little thing, if the woman didn’t answer quickly or didn’t know how far along she was. I could hear her frustration in her voice. She was somehow scolding the women every now and again… she complained that she was already tired”Women who missed their appointment dates or whose pill counts did not match medical expectations were sometimes denied drug refills or sent to the back of line and usually treated as if they didn’t understand the importance of ART. They often had to attend group counselling again, which made their day at the clinic longer.I: Weren’t you disappointed that you thought of stopping right away, with the way you have explained?] No, I wasn’t disappointed, I came because it’s my life not hers, I came.”“I don’t know what kind of mistake they made in the bottle. The ARVs run out before my next appointment to receive ARVs. When I came here and explained they took my card [ART medical file] and threw it outside saying, ‘You won’t receive ARVs. It means you were sharing them with your friends’. So, I just sat there and didn’t say anything.  by a long time they tell you to go for group counselling, it means you did not learn well. So, they also take the guardian that accompany us… they call him/ her again, on Thursdays, on Fridays, I think. We go for counselling together, with the aim that she should encourage me to come every day of my appointments. …”Two economic barriers stood between some of these women and continuous ART treatment, and the effort to overcome them was continuous. The first was transportation, a barrier for a quarter of the women we interviewed (19/75). The second, mentioned much less frequently, was food insecurity (6/75). Food insecurity is common throughout Malawi; in April 2015, the World Food Program conservatively estimated that over 2.85 million people were food insecure (about 16.5% of the population) . Food inMost of the women walked long distances to get to the hospital, if they did not have enough money to pay transport fees. Nineteen women mentioned walking for more than an hour to get to the facility. Those who did not have their own bicycles and were not dropped off by their partners did not regularly have money to pay for transport costs, though a minibus was available if they lived in urban areas, or a bicycle taxi in rural areas. Women went to health facilities far from their homes for different reasons. For most women, there was no closer health facility. One woman chose a far-away health facility because it was close to a market, and she combined the visit with a trip to the market for either business or shopping and used it as an excuse to keep her hospital visits a secret. Some women preferred attending the district hospitals  to attending local health centers.“Yes, it takes us time like that because we are coming from far. Because we leave our homes maybe before four, because our homes are very far. So, when we have no money for bicycle taxi they charge 500. When we have no money for transport we just know that we will wake up before four and so when we get here maybe 5 o’clock. So, to be here till now is something that worries us a lot, because the way it is the time has gone,”29-years-old woman, FGD002“I have come with my husband he dropped me by bike. He is gone… He has left me 200 Kwacha for me to use when going back it will not be enough, the other side I will walk”26-year-old woman, SSI003Sometimes, because of the distance women missed appointments, but they still visited the health facility before their pills ran out.“So, a person is coming from… maybe you are coming from all the way so for you to get here, on foot, you have no transport. Getting here becomes difficult. So, it can happen that maybe… you can miss the appointment day, thinking how am I going to travel? You become lazy, right?”36-years-old, FGD004The first 6 months after ART initiation and after giving birth, women are expected to come every month for their drug refills so that the HCWs can monitor their adherence and their baby’s health/growth. Thereafter, based on their adherence trend, women are given refills at 2- or 3-month intervals. Most women preferred the longer intervals over the monthly visits.“But previously we were at pains that we were coming every month, when the month ends. It’s better now the government considered us by giving us medicine for 3 months, we do rest.”30-years-old woman, SSI007Most women (43/75) said they had had side effects from ARVs in the first few weeks after they started treatment. Side effects included dizziness, numbness in the feet, heart palpitation, nightmares, a feeling of lightheadedness, and excessive hunger. A few women admitted they had stopped taking ARVs for a short period because of the side effects. The side effects frequently disappeared or diminished if women took their ARVs at night before bed, ate sufficiently, and continued their ARVs without fail for several weeks. The one complaint that persisted was hunger. Women (19/75) emphasized that eating sufficiently was necessary to prevent them from feeling weak or sick in the morning.“…the reason why I stopped taking medicine was one, food was a problem. In terms of food stuffs… It was difficult for me. When I eat, it was like I haven’t eaten any food, and my heart was like… Pounding…”22-year-old, SSI020We did check for differences between rural and urban sites and found women’s responses were more similar than different. The women at urban sites mentioned transport costs and long waiting times in health facilities much less often than women at rural sites. Women at urban sites talked more about fear of disclosure than women at rural sites.We found that Malawian women made the decision to remain on ART based on their own desires and priorities. They wanted to keep themselves and their children healthy, and they saw evidence that ART improved their health and the health of their children. Their treatment was socially supported by partners, family or friends. HIV counsellors helped them understand the importance of treatment and encouraged them to continue; they also explained the likelihood of side effects and told them how to cope with them. All the women we interviewed mentioned overcoming some barriers to treatment, most commonly side effects, social barriers (primarily related to disclosure and stigmatization), long wait times, and difficulty with transport. Most women had similar motivations, but there was wider variation in the barriers they described. Results were similar across SSIs and FGDs and matched our observations.We discuss our limitations first, and then place them in context. We interviewed women retained in care, and not those lost to follow-up (LTFU). We could not compare the presence or absence of motivations and barriers between women who continued and discontinued treatment. For example, we found women were motivated to stay on ART when they saw evidence it was effective, but we could not determine if the perception that treatment was ineffective caused women to drop out. We did, however, have access to other studies that considered the motivations and barriers faced by HIV-positive women who spent less than 6 months on ART, and by women LTFU.Zhou (2016) and Kim, et al. (2016), for example, interviewed a group of recently diagnosed women with HIV at health care facilities in Lilongwe ,30. ThouThe women we interviewed did not face insurmountable structural barriers to treatment, decided to stay on ART, and had the resources to carry through their decisions. Our study and Zhou’s also represent two different time points in women’s ART treatment. Unlike Flax et al., we did not include women lost to follow-up; otherwise, the pool we drew from was similar. Though findings about barriers to ART should not be generalized to women lost to follow up, Flax et al. did report that women lost to follow-up faced similar barriers, including side effects, costs, and poor treatment by health care workers .Our study was strengthened by our use of multiple data collection techniques: we gave women opportunities to share their experiences in either SSI or FGD), and we collected observational data that augmented the data we collected in interviews and group discussions. For example, we observed the challenges health care workers faced in providing women with privacy and keeping their data confidential, though women did not discuss this much in the interviews. Our results were also consistent across the three methods of qualitative data collection we used: SSIs, FGDs, and observational notes. The cross-sectional nature of our study prevented us from examining how women’s barriers and motivations shift over the course of lifelong ART, though we suspect they do. Younger women were underrepresented in our study, which may be explained by our quantitative team’s finding that women in the first 6 months of ART treatment are most vulnerable to LTFU, while women retained for over a year default at a much lower rate . Our stuMost women we interviewed explained that they continued treatment because they saw evidence that ART improved their own and their children’s health. Women who stayed in care agreed that ART reduced morbidity and increased energy for chores like farming. Their beliefs in the effectiveness of medication were based on their own experience of taking medication that reduced symptoms or caused side effects, and on observing other patients who started, continued or stopped the medicine. Our findings are in line with those of earlier studies on medication adherence of patients on long-term therapies for the chronically ill. When patients do not feel better after treatment, they take it as evidence the treatment is ineffective; patients also see drug side effects as evidence a drug is harmful ,32,33. IBecause most women in our study were in antenatal care, our finding that women were motivated to stay healthy to care for their children was not unexpected. Earlier studies found that women did not want to pass the virus to their child, either during or after pregnancy. ,29 We foAlmost all the women in our study disclosed to their partners and asked them for advice and support for ART, but in cases where they did not receive support, or even received negative feedback, the women we interviewed were not discouraged. They began ART because they believed it was best for them and their children, this aligns with Kim et al.’s finding that women seek their partner’s advice about whether they should continue ART, but then make their own decision.  We foundStudies and systematic reviews have already identified many potential individual-level, interpersonal-level, community-level, and health-system-level barriers to adherence to ART. Our data showed that frequently cited health-system barriers (except long waiting times and transportation problems) have generally been addressed by Option B+ policy. Our participants frequently mentioned drug side effects and food insecurity when we asked them what made it difficult to adhere to ART. Side effects may crucially shape beliefs about the effectiveness of a drug, especially among asymptomatic HIV patients who do not feel “better” when on ART. Side effects were very common among the women that we interviewed, a finding confirmed by other studies from Malawi, ,40 WomenSeveral targeted interventions designed to improve ART retention among pregnant or postpartum women have been or are currently being tested in sub-Saharan Africa.  These inSince hunger exacerbates side effects, and food insecurity is common in Malawi, Option B+ might be able to retain a higher number of food insecure women if interventions provide food supplements to those women who need them. Prescribing alternative first-line regimens (e.g. integrase inhibitors) might reduce other side effects. Since most of the women in our study said they found it helpful when HIV counselors warned them about side effects in advance, and advised them on the proper intervals and conditions for taking their medications, providing more and better counseling on ART and its side effects could raise the number of women who start and continue ART.Our own and other data demonstrate that, in the absence of insurmountable barriers, women’s perceptions of ART determine their treatment decisions. Future interventions should, along with whatever other services are provided, be aimed at directly changing those perceptions in ways that support the choice to continue ART.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S3 Text(DOCX)Click here for additional data file.


Background: Violence has important health effects. The results of exposure to physical violence include, but may not be limited to, death from suicide and homicide. The connection between the experience of assault and risk of death from causes other than homicide and suicide has rarely been examined.Methods: We analysed data from the first Izhevsk Family Study (IFS-1), a population-based case–control study of premature mortality in Russian men. Structural equation models were used to obtain odds ratios (ORs) for the association between the proxy report of physical attack in the previous year and mortality.Results: The estimate of the all-cause mortality OR for assault, after adjusting for alcohol use and socio-demographic confounders, was 1.96 . Strong cause-specific associations were found for external causes, but associations were also found for deaths from cardiovascular and alcohol-related deaths.Conclusions: We found that, in our population of working-aged Russian men, there was a strong association between physical assault and mortality from a wide range of causes. Other than direct effects of physical assault on mortality, residual confounding is an important possibility. The association between assault and mortality, particularly from cardiovascular and alcohol-related causes requires replication and further investigation. Key MessagesVery few epidemiological studies have assessed the relationship between physical assault and mortality from non-external causes.There was a strong association between all-cause mortality and proxy reports of physical assault in the last year in our population of working-aged Russian men.Alcohol and socio-demographic variables explained this association to some extent, but not completely.Assault may increase mortality from alcohol-related and cardiovascular causes but this requires further study.Violence disproportionately affects the vulnerable and has universal ethical, legal, economic and health consequences.In the decade following the collapse of the Soviet Union, there was an increase in reported crime in a number of post-Communist states.et al.Relatively consistent positive associations between assault and characteristics such as younger age, male gender, lower socio-economic position, single marital status and alcohol misuse have been found in crime surveys from Anglophone countries,,et al.Violence is associated with a range of adverse health effects.,,Even since the sharp decline in male life expectancy in Russia in the 1990s, and then the improvements seen since the mid-2000s, premature mortality has remained very high compared with that seen in European countries.We have used the opportunity afforded by a unique case–control study conducted in the city of Izhevsk in Russia 2003–05 to investigate these issues further. Whereas the mortality and alcohol-consumption patterns of Russian men are rather exceptional, as the literature is so sparse, this setting provides a good basis for investigating the links between assault and mortality, and the potential role of alcohol, which will be of general interest to researchers and policy-makers.n = 544) and a third to cardiovascular disease (n = 573). In this analysis, we use 1750 controls who were live men randomly selected from a 2002 population register and frequency-matched within 5-year age bands to cases notified for that month; in addition, we use an additional 250 controls who were recruited in 2006 using the same protocol as used for the initial case–control study. The reason for this was to increase the sample size for a planned follow-up study of the controls.We analysed data from the first Izhevsk Family Study (IFS-1), a population-based case–control study of premature mortality in Russian men. The study protocol is described in detail elsewhere.этот человек в течение последнего года?: ему были нанесены телесные повреждения любым способом’ . For the controls, interviews were obtained from both the control and a proxy for 1941 men, but, for the main analyses, the data reported by the controls have not been used. Proxy information from controls as well as cases was used, in order to minimize differential measurement error in case and control information. Previous analyses of the relationship between control and proxy responses found moderate agreement of measures of alcohol use and near perfect agreement for markers of socio-economic position.,Interviews of controls took place between 2003 and 2006. Trained interviewers obtained information about the lives and behaviours of cases and controls from proxy respondents living in the same household. Proxies were mainly wives, mothers or daughters. For the cases, proxy interviews occurred around 2 months after the death. Information was collected on socio-demographics, health behaviours, violence and physical health. The primary exposure in this study  was determined according to the proxy response to a question about whether the subject had been physically assaulted in the past year. The text of this question in Russian was ‘Жертвой каких из перечисленных ниже преступлений становился zapoi  and on the consumption of non-beverage alcohols. Non-beverage alcohols are manufactured ethanol-containing substances not intended for drinking. These dimensions of hazardous drinking behaviour have been shown previously to be strongly associated with mortality in this population.Alcohol use was considered a priori as an important confounder or common cause of the association between physical assault and mortality. Given the multi-dimensional nature of alcohol use and the generally poor reliability of obtaining accurate measurement of alcohol volume from proxy reports, we used a series of previously developed alternative measures aimed at identifying aspects of heavy drinking that would be readily observable by a proxy informant who lived in the same household as a study subject.IJE online). This measure has been previously described and published based on the present data.,zapoi in the past year . The drinking of surrogate or non-beverage alcohols was measured using a binary variable for use in the past 12 months.In the analysis, we used a measure of acute alcohol-related dysfunction in the form of a latent variable manifested by the frequencies of four types of alcohol-related behaviour: hangover, excessive drunkenness, sleeping in clothes because of drunkenness and failing personal or family obligations because of drinking alcohol . Socio-economic position was measured using an amenities index derived from whether the man’s household had a car and central heating categorized as neither, one or both.Maximum likelihood estimation was used to obtain odds ratios (ORs) for the association between physical attack and mortality estimated from structural equation models. Separate models were fitted including (i) age only, (ii) age and all potential confounders except alcohol use, (iii) age and alcohol use and (iv) all potential confounders. Models which adjusted for alcohol use also included a measurement component consisting of the latent variable acute alcohol-related dysfunction.Separate models were fitted for all-cause mortality and for specific causes, based on chapters of the ICD-10.,Model fit for the measurement model was assessed using the confirmatory fit analysis (CFI), the Tucker Lewis Index (TLI) and the Root Mean Square Error of Approximation (RMSEA). CFI and TLI values greater than 0.95 indicate good model fit, with a minimum of 0.90 indicating acceptable fit.The roles of smoking and socio-economic status as confounders of the association between physical assault and mortality were investigated further in supplementary analyses. Structural equation models were fitted to look at the association between smoking and mortality by specific causes and smoking and physical assault in controls after adjusting for all other potential confounders including alcohol use. The roles of socio-economic variables and smoking as confounders of the association between assault and mortality were assessed by fitting model (ii) as stated above but with and without adjustment separately for (i) smoking and (ii) socio-economic status.The adjusted population attributable fraction and corresponding confidence intervals were estimated according to formulae from Greenland.http://www.ifsmetadata.info.Oral consent was obtained from proxy informants. Ethical approval for the study was obtained from the committees of the Izhevsk Medical Academy and the London School of Hygiene and Tropical Medicine. Further information about the Izhevsk Family Study and information about how to apply for the data for research are available at The corresponding author had full access to all anonymized data in the study and had final responsibility for the decision to submit for publication.The study comprised 1750 cases and 2000 controls. Counts of observations and missing data by case–control status for each covariate are displayed in The associations of mortality by cause with assault are shown in The association with external causes was particularly strong, but also displayed substantial attenuation on adjusting for socio-demographic and alcohol covariates. Among external causes, after adjusting for full model covariates, mortality from transport injuries, suicide (including when combined with undetermined causes), homicide and deaths from undetermined cause showed good evidence of an association with the physical assault.Among non-external causes, good evidence for associations remained after adjustment for all potential confounding variables factors for circulatory disease only; after adjustment, people who had been assaulted were nearly two times more likely to die from circulatory disease compared with those who were not assaulted. Among specific circulatory causes, fully adjusted ORs for both alcoholic cardiomyopathy and cerebrovascular disease were more than 2. Assault remained associated with death from digestive causes after adjusting for socio-demographic variables, but this association became too imprecise upon addition of alcohol-related variables to the model, although the point estimate remained more than 2.There was a strong association between alcohol-related causes of death and physical assault with an odds ratio of 4.2 after adjustment for confounders other than alcohol. For individual causes, there was strong evidence of an association for alcoholic cardiomyopathy, alcoholic liver disease and alcohol poisoning. As expected, the strength of the association reduced on adjusting for alcohol use but there remained good evidence for an association between physical assault and all alcohol-related causes of death and for alcoholic cardiomyopathy even after adjustment for alcohol use.IJE online). Although smoking was a strong risk factor for mortality including mortality from external causes (IJE online), the strong association between smoking and physical assault displayed in IJE online). Leaving out adjustment for smoking from the models had only a small effect on effect estimates for the association between assault and mortality, and did not change our substantive conclusions (IJE online). The same was true for models with and without adjustment for socio-economic status (IJE online).The results of further investigation of the role of smoking and socio-economic status as confounders of the association between physical assault and mortality are shown in the The adjusted population attributable fraction for mortality related to assault was 8.69% .To our knowledge, this is the first study to investigate the link between physical assault and mortality. We found that, in our population of working-aged Russian men, there was a strong association between physical assault and mortality from a wide range of causes. These effects were only partially removed on adjustment for alcohol and socio-demographic factors. The largest effects were seen for external causes, followed by circulatory diseases, especially stroke. Nevertheless, the attenuation of effects seen on adjustment was substantial in many instances, as would be expected from the very strong associations seen in There are a number of potential explanations for our results. First, there could be a direct effect of assault on mortality. Although we found an association with homicide deaths as anticipated, associations were also found for suicides, alcohol-related causes and cardiovascular mortality, indicating that not all the mortality burden of assault is carried by direct injuries. The strong and persistent association with deaths from transport injuries is less easy to understand.zapoi and the ingestion of non-beverage alcohols. However, the fact that the associations with the aggregate of alcohol-related causes remained even after adjustment for alcohol use in the past year suggests that there might be residual confounding by alcohol use, despite the density of information on various dimensions of alcohol ingestion we obtained from proxies. From this point of view, the experience of physical assault may be an additional indicator, not captured through the detailed questions on level and pattern of drinking, of hazardous drinkers at a certain stage of their drinking careers who are at risk of harm, both through behaviour that may increase their risk of being assaulted and through damage to their health physically through the biological effects of alcohol. Alternatively, it could be that assault, severe psychosocial disturbance with heavy alcohol use and physical disease all result from behavioural/lifestyle aspects of poverty not adequately accounted for here, and that there is residual confounding through socio-economic circumstances. However, it is worth noting that adjustment for socio-economic variables measured in this study did not have a strong impact on the size of the effect estimates.Second, although the association between assault and all-cause premature male mortality is consistent with causal pathways, assaulted people are likely to have differed from the rest of the population in important ways. The measure of assault could be an indicator of violent, risky, hazardous lifestyles, which in turn could be associated with mortality. In particular, assault and premature male mortality might share a common root cause, such as alcohol or deprivation, which was not adequately accounted for in this study. For example, it could be that people who are heavy drinkers have a pattern of behaviour and interactions with others that simultaneously put them at increased risk of assault and of death from alcohol-related causes, as well as other causes such as stroke. Alcohol misuse was prevalent among subjects (65% of cases and 45% of controls had been excessively drunk in the past 12 months) and was a major potential confounder for this hypothesis. Considerable attention was given to measuring alcohol use in detail, by assessing markers of alcohol-related dysfunction as a latent variable, the frequency of A third explanation is that assault could lead to increased alcohol consumption and this could lead to death; the association of assault with deaths from alcohol-related causes is consistent with alcohol ingestion as a coping strategy following assault, given the information-processing changes that ensue.,,Lastly, assault could result in premature mortality via neuroendocrine stress pathways, or alterations in other behaviours that result in increased risk of premature death.Overall, our analyses are unable to discriminate between these possibilities; direct effects, indirect effects and the many confounding-related explanations could each account for the associations reported here. However, whereas the exact mechanism for this is unclear, we have identified the experience of physical assault as a marker of increased risk of mortality, which is of importance in itself, particularly in Russia—a country with high premature mortality.The design of the study necessarily meant that all data on the physical assault and potential confounding factors were collected from proxy respondents. Proxy information from controls as well as cases was used. In a previous analysis, very good agreement was found between control and control proxy data for socio-economic variables.This was primarily a complete records analysis. Like all analyses with missing data, mechanisms for missing data and the influence of these missing data on the results cannot be directly estimated. Although we adjusted for a range of important confounders, the possibility of residual confounding or confounding by unknown factors remains. Because of the need for proxy information on cases, the study population was restricted to cases and controls that resided with one or more household member. Plausibly, the effect of assault on mortality could be different by whether the person lives alone, limiting generalizability. The study was conducted between 2003 and 2006; however, given limited evidence on this association elsewhere in the literature, we consider the results interesting despite the fact that they relate to mortality over a decade ago when, in Russia, alcohol consumption was higher and mortality was also higher.This is the first time the proxy report of physical assault in the previous year has been used as an indicator in an epidemiological study and it is likely to include a wide range of levels of assault. Our results are not able e.g. to differentiate between being simply pushed and being stabbed. Assault was operationalized as dichotomous, limiting the evaluation of whether effects on mortality varied by assault characteristics, e.g. severity/number of assaults.Violence research involving unrestricted populations, rather than vulnerable groups, should form a larger part of public health landscape; increasing evidence points to its continued omission as an indicator of a structural inequality akin to the historic exclusion of socio-economic data in past epidemiologic research.IJE online.www.wellcome.ac.uk/Funding). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.This work was supported by the Wellcome Trust, grant numbers 067232 and 078557 (Conflict of interest: The authors have no conflicts of interest to declare.Supplementary FigureClick here for additional data file.Supplementary Table S1-S4Click here for additional data file.