Mary C Smith Fawzi

• ScD
• Professor (Assistant) at Harvard Medical School

Healthy Options is a psychosocial support group intervention facilitated by community-based health workers (CBHWs) to reduce symptoms of depression in perinatal women living with HIV in Tanzania. The objective of this study was to determine incremental cost-effectiveness of Healthy Options intervention in comparison to enhanced usual care for depre...

Background More than 80% of cervical cancer cases diagnosed globally are in low-income and middle-income countries. In sub-Saharan Africa, where treatment facilities are widely unavailable, it is a leading cause of cancer deaths in women. Human papillomavirus (HPV) vaccination, which is known to prevent almost 90% of cases of cervical cancer, has l...

Background Lesotho is one of the 30 countries with the highest tuberculosis incidence rates in the world, estimated at 650 per 100,000 population. Tuberculosis case detection is extremely low, particularly with the rapid spread of COVID-19, dropping from an estimated 51% in 2020 to 33% in 2021. The aim of this study is to understand the barriers to...

Background Perinatal women living with HIV (PWLH) have a greater risk of depression compared to other women; however, there are limited specialized mental health services available to them. We aimed to determine whether a stepped-care intervention facilitated by trained lay providers can improve mental health outcomes postpartum for PWLH. Methods...

In Tanzania, limited mental health service availability and structural flaws in child protection reporting and justice processes lead to significant underreporting of child victimization. A better understanding of help-seeking behaviors for trauma-affected youth and sociocultural barriers to help-seeking will inform screening, triage, and intervent...

Background We assessed the feasibility of implementing psychological counseling services (PCS) for mothers of children with autism spectrum disorders (ASD) integrated within special education settings in urban Bangladesh. Method In two special education schools for ASD in Dhaka City, trained female psychologists screened mothers using the Patient...

Lesotho has one of the highest tuberculosis (TB) incidence rates in the world, estimated at 654/100,000 population. However, TB detection remains low, with only 51% of people with TB being diagnosed and treated. The aim of this study was to evaluate implementation of TB screening and identify drivers of suboptimal TB screening in Lesotho. We used a...

HIV-related stigma represents a potent risk factor for a range of poor health outcomes, including mental health symptoms, treatment non-adherence, and substance use. Understanding the role of HIV-related stigma in promoting healthcare outcomes is critical for vulnerable populations, such as pregnant women living with HIV, in contexts with continued...

Background: Uterine fibroids, the most common cause of gynecologic surgery, have a reported cumulative incidence of 59% among Black women in the U.S. Uterine fibroids negatively impact the quality of women's lives. No study has been found in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk fa...

Limited information is available on the association between depression and viral suppression among people living with HIV (PLH) in sub-Saharan Africa. We conducted a prospective cohort study of 3996 adults initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania. Log-binomial models were used to assess the association between depression a...

Background Healthy Options (HO) is a psychosocial support group intervention facilitated by community-based health workers (CBHWs) to treat depression in perinatal women living with HIV in Tanzania. The objective of this study was to determine incremental cost-effectiveness of HO in treating perinatal depression in HIV positive women in comparison...

Background Decades of political and economic instability have taken a significant toll on health outcomes among children in Iraq. In a health system with optimal resources, five-year rates of survival for childhood cancer would exceed 80%; however, a study in Iraq demonstrated a much lower survival rate of 50%, reflecting a disrupted health care in...

The NAMWEZA intervention was implemented, using a ten-session group format, to build skills targeting psychosocial vulnerabilities and enhancing HIV prevention among people living with HIV (PLH) and their social networks. The overall goal of this intervention is to improve psychological wellbeing and reduce HIV risk behaviours. These analyses aim t...

Objectives: We aim to describe the social network members of participants of a behavioural intervention, and examine how the effects of the intervention may spillover among network members. Design: Secondary analysis of a step-wedge randomised controlled trial. Setting: Change agents (CAs) were recruited from waiting rooms of HIV treatment fac...

The aim of the study is to compare sociodemographic characteristics, psychosocial factors, HIV knowledge and risk behaviors of people living with HIV (PLH) and their social network members (NMs) to inform HIV prevention programs that engage PLH as prevention educators in their communities. We compared baseline characteristics of PLH enrolled in an...

Intimate partner violence (IPV) exacts a heavy burden on women, resulting in poor health outcomes. This study had the following aims: (1) estimate the prevalence of IPV post-disclosure of HIV status among pregnant women living with HIV and depression; and (2) evaluate risk and protective factors for IPV post-disclosure. Participants were women acce...

Background Uterine fibroids, the most common cause of gynecologic surgery, have a reported lifetime cumulative incidence of 59% among Black women in the U.S. Uterine fibroids increase mortality, morbidity, and negatively impact the quality of women’s lives. To our knowledge, no study has been published in the literature about fibroids in Haiti. We...

Background Uterine fibroids, the most common cause of gynecologic surgery, have a reported cumulative incidence of 59% among Black women in the U.S. Uterine fibroids negatively impact the quality of women’s lives. No study has been found in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk fact...

Background Uterine fibroids, the most common cause of gynecologic surgery, have a reported cumulative incidence of 59% among Black women in the U.S. Uterine fibroids negatively impact the quality of women’s lives. No study has been found in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk fact...

Background: The Zanmi Lasante Depression Symptom Inventory (ZLDSI) is a screening tool for major depression used in 12 primary care clinics in Haiti's Central Plateau. Although previously validated in a clinic-based sample, the present study is the first to evaluate the validity and clinical utility of the ZLDSI for depression screening in a schoo...

Background: Despite the need for mental health surveillance in humanitarian emergencies, there is a lack of validated instruments. This study evaluated a sequential screening process for major depressive disorder (MDD) using the two- and eight-item Patient Health Questionnaires (PHQ-2 and PHQ-8, respectively). Methods: This study analyzed data c...

Background: Hope or hopefulness enhances coping and improves quality of life in persons with chronic or incurable illnesses. Lack of hope is associated with depression and anxiety, which impact negatively on quality of life. In Tanzania, where HIV prevalence is high, the rates of depression and anxiety are over four times higher among people livin...

Background: Perinatal women accessing prevention of mother-to-child transmission of HIV (PMTCT) services are at an increased risk of depression; however, in Tanzania there is limited access to services provided by mental health professionals. This paper presents a protocol and baseline characteristics for a study evaluating a psychosocial support...

Background: Rwanda has made substantial economic progress over the past two decades. However, evidence suggests that malnutrition among children remains high in spite of this progress. This study aims to examine trends and potential risk factors associated with childhood stunting from 2000 to 2015 in Rwanda. Methods: Data for this study come fro...

Objective This study aimed to determine the burden of depression, suicidal ideation and suicidal behaviour amongst adolescents at sites in six sub‐Saharan African countries and examine associated risk and protective factors. Methods Household‐based cross‐sectional study involving male and female adolescents ages 10‐19 years. A total of 7,662 adole...

Objective To determine the magnitude of relationships of early life factors with child development in low/middle-income countries (LMICs). Design Meta-analyses of standardised mean differences (SMDs) estimated from published and unpublished data. Data sources We searched Medline, bibliographies of key articles and reviews, and grey literature to...

Introduction NAMWEZA is a novel intervention that focuses on preventing HIV and promoting sexual and reproductive health and rights by addressing underlying factors related to vulnerability of acquiring HIV, such as depression, intimate partner violence (IPV) and stigma. The goal of the study was to evaluate the effect of the NAMWEZA intervention o...

Although a number of HIV prevention programs have been implemented, such as mass media campaigns, high rates of unprotected and concurrent sexual partnerships, as well as low uptake HIV testing and limited HIV knowledge, persist in Tanzania. We examined the effect and predicting factors of HIV prevention communication among people living with HIV (...

The article “Postpartum depression and child growth in Tanzania: A Cohort Study” (Holm‐Larsen et al, BJOG xxxx) extends growing literature documenting a link between postpartum depression (PPD) in mothers and child nutritional indicators during first years of life in lower‐ and middle‐income countries (LMICs) (Surkan et al Bull WHO 2011;287:607–615...

Background Major depression has a significant impact on years lived with disability (YLD) globally. In resource-limited countries, depression may accompany daily challenges of economic security that people face, hence there is a critical need to develop depression screening tools at primary levels of health care. The overall goal of the study is to...

Introduction The first 1000 days of life is a period of great potential and vulnerability. In particular, physical growth of children can be affected by the lack of access to basic needs as well as psychosocial factors, such as maternal depression. The objectives of the present study are to: (1) quantify the burden of childhood stunting in low/midd...

The association between earthquakes and youth post-traumatic stress disorder (PTSD) has been well described, but little is known about the relationship between other stressful life events (SLEs) and PTSD among earthquake-affected youth. This study examines a variety of SLEs, including earthquake, and their association with PTSD among school-going H...

Abstract Background Psychosocial factors have been linked with loss to follow-up (LTFU) and clinical outcomes among people living with HIV (PLH), however little is known about the effect of psychosocial support on LTFU among PLH in treatment and care. The purpose of this study was to explore the effect of NAMWEZA (“Yes, together we can”) friends’ p...

The aims of this study were to describe how people living with HIV (PLWH) perceive hope and illustrate implications for HIV care and treatment. This is a qualitative study done to explore perceptions and meanings of hope among PLWH attending care and treatment clinics in Dar es Salaam, Tanzania. In all, 10 focus group discussions and 9 in-depth int...

Background The mental health treatment gap for youth in low- and middle-income countries (LMICs) is substantial; strategies for redress are urgently needed to mitigate the serious health and social consequences of untreated mental illness in youth. Aims To estimate the burden of major depressive episode (MDE) and posttraumatic stress disorder (PTS...

Background Task-sharing with teachers to promote youth mental health is a promising but underdeveloped strategy in improving care access in low-income countries. Aims To assess feasibility, acceptability and utility of the teacher accompaniment phase of a school-based Teacher-Accompagnateur Pilot Study (TAPS) in Haiti. Methods We assigned student...

Objective: The objective of the study was to assess the relationship of depression at antiretroviral therapy (ART) initiation with mortality and clinical outcomes among Tanzanian women living with HIV. Design: We conducted a prospective cohort study of 1,487 women who initiated ART in Dar es Salaam, Tanzania. Methods: Symptoms of depression an...

Objective: The objective of the study was to assess the relationship of depression at antiretroviral therapy (ART) initiation with mortality and clinical outcomes among Tanzanian women living with HIV. Design: We conducted a prospective cohort study of 1487 women who initiated ART in Dar es Salaam, Tanzania. Methods: Symptoms of depression and anxi...

Background Stunting affects one-third of children under 5 y old in developing countries, and 14% of childhood deaths are attributable to it. A large number of risk factors for stunting have been identified in epidemiological studies. However, the relative contribution of these risk factors to stunting has not been examined across countries. We esti...

Forest plot of observational studies comparing growth of HIV-infected children under 2 y of age who did not receive HAART versus HIV-exposed uninfected children. (TIF)

Methods used to identify sources of evidence on effect sizes. (DOCX)

Description of conversion of stunting prevalence among children under 5 y to stunting prevalence among children age 2 y. (DOCX)

Country profiles showing country-specific results for all risk factors. (DOCX)

Data availability statement. (XLSX)

The 137 included developing countries. By sub-region (A) and by region (B). (TIF)

Population attributable fraction of stunting attributable to the selected risk factor clusters by country. (A) Maternal nutrition and infection. (B) Teenage motherhood and short birth intervals. (C) FGR and preterm birth. (D) Child nutrition and infection. (E) Environmental factors. (TIF)

(DOC)

Prevalence data inputs (in percent, with 95% confidence intervals in parentheses where available) for exposure to untreated HIV, unimproved water and sanitation, maternal anemia, maternal underweight, maternal malaria, and standard deviations (in centimeters, with 95% confidence intervals) of maternal height. (XLSX)

Ratios of stunting and mean height-for-age z-score among children age 2 y compared to children under age 5 y from 104 and 102 surveys, respectively, from the WHO Global Database on Child Growth and Malnutrition. (DOCX)

Population attributable fraction and number of stunting cases by region attributable to the childhood nutrition and infection cluster of risk factors, based on differing assumptions about the proportion of zinc deficiency that is mediated through diarrhea (95% confidence intervals in parentheses). (DOCX)

Ranking of risk factors within each country with respect to the attributable number of stunting cases. The leading risk factor is ranked one and colored bright red, and the risk factor with the smallest number of attributable cases is ranked 16 and colored dark green. Risk factors are ordered with respect to their global impact on stunting, and cou...

Description of height-for-age z-score to stunting prevalence crosswalk. (DOCX)

Grant proposal methods. (DOCX)

Scatter plot and regression line to model prevalence of stunting (height-for-age z-score less than −2) from height-for-age z-scores using survey data from the WHO Global Database on Child Growth and Malnutrition. (TIF)

Categories of level of evidence on causal effects of risk factors on stunting. (DOCX)

Systematic review of HAART and childhood growth. (DOCX)

Background and objectives: In Rwanda, significant progress has been made in advancing access to antiretroviral therapy (ART) among youth. As availability of ART increases, adherence is critical for preventing poor clinical outcomes and transmission of HIV. The goals of the study are to (1) describe ART adherence and mental health problems among yo...

[This corrects the article DOI: 10.1371/journal.pone.0157042.].

Background: The growth of >300 million children <5 y old was mildly, moderately, or severely stunted worldwide in 2010. However, national estimates of the human capital and financial losses due to growth faltering in early childhood are not available. Objective: We quantified the economic cost of growth faltering in developing countries. Design...

Objective To determine the impact of intimate partner violence against women on children’s growth and nutritional status in low- and middle-income countries. Methods We pooled records from 42 demographic and health surveys in 29 countries. Data on maternal lifetime exposure to physical or sexual violence by an intimate partner, socioeconomic and d...

Background Depression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term. Methods A validation...

Background Suicide is a leading cause of death for young people. Children living in sub-Saharan Africa, where HIV rates are disproportionately high, may be at increased risk.AimsTo identify predictors, including HIV status, of suicidal ideation and behaviour in Rwandan children aged 10-17.Method Matched case-control study of 683 HIV-positive, HIV-a...

Antenatal and post-natal depression has demonstrated a significant burden in sub-Saharan Africa, with rates ranging from 10% to 35%. However, perinatal women living with HIV in Tanzania have reported an even greater prevalence of depression (43–45%). The primary goal of this study was to examine the relationship between maternal depression and infa...

Background: The global HIV/AIDS response has advanced in addressing the health and well-being of HIV-positive children. Although attention has been paid to children orphaned by parental AIDS, children who live with HIV-positive caregivers have received less attention. This study compares mental health problems and risk and protective factors in HI...

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing...

Background: Children infected with and affected by HIV are at increased risk of mental health problems, which has implications for risk behavior, educational attainment and provision of healthcare services. Methods: A case-control design was used to assess the prevalence of mental health problems among N= 680 children aged 10-17 who are (a) HIV-inf...

Global health has increasingly been gaining recognition as a distinct field in recent years. However, most introductory-level courses in epidemiology rely on examples primarily from the U.S. and Europe. In 2009, a joint program of Harvard Medical School and the Harvard School of Public Health was initiated to offer an intensive summer session on ad...

Abstract The objective of the study was to assess the effectiveness of group counseling, using a problem-solving therapy approach, on reducing depressive symptoms and increasing prenatal disclosure rates of HIV status among HIV-positive pregnant women living in Dar es Salaam, Tanzania. A randomized controlled trial was performed comparing a six-wee...

More than 390 000 children are newly infected with HIV each year, only 28 per cent of whom benefit from early infant diagnosis (EID). Rwanda's Ministry of Health identified several major challenges hindering EID scale-up in care of HIV-positive infants. It found poor counseling and follow-up by caregivers of HIV-exposed infants, lack of coordinatio...

Purpose: To examine the role of caregiver mental health and risk and protective factors in influencing levels of internalizing and externalizing emotional and behavioral symptoms over time among a sample of refugee adolescents. Methods: Prospective study of 153 Kunama refugee adolescents receiving an emergency education intervention while living i...

There is considerable research around the morbidity and mortality related to noncommunicable diseases (NCDs), particularly cardiovascular disease and diabetes, among people living with HIV/AIDS (PLWHA) in resource-richer settings. Less is known about the burden and appropriate management of NCDs, particularly 'other' NCDs including cancer, renal, p...

We studied the effect of antiretroviral therapy (ART) on the quality of life (QOL) of Cubans with HIV/AIDS. We conducted a cross-sectional study including administration of the Medical Outcomes Study-HIV Health Survey Questionnaire to a representative sample of the 1592 Cubans receiving ART in 2004. For univariate analyses, we compared mean HIV sca...

Progress towards the first Millennium Development Goal (MDG1) to end poverty and hunger has lagged behind attainment of other MDGs due to chronic poverty and worldwide inequity in access to adequate health care, food, clean water, and sanitation. Despite ongoing challenges, Rwanda has experienced economic progress and the expansion of the national...

Although India is poised to meet its Millennium Development Goal for providing access to safe drinking water, there remains a worrying discrepancy in access between urban and rural areas. In 2006, 96% of the urban population versus 86% of the rural population obtained their drinking water from an improved water source. To increase access to potable...

While delivering innovative care for over 17 million children living with and affected by HIV/AIDS is a priority for today's global health community, most of these children's health needs remain unmet. Concerns about funding, implementation, and transparency continue to obstruct quality care for all. This paper discusses why services supported by m...

Background: Considerable debate on the benefits and challenges of poverty reduction strategies, such as cash-transfers and microfinancing initiatives, and their impact on health status, continues. The FXB-Village Network is a unique model that integrates immediate provision of basic needs (e.g. access to potable water, adequate housing, etc.) with...

ABSTRACT: Partners In Health (PIH) works with the Ministry of Health to provide comprehensive health services in Haiti. Between 1994 and 2009, PIH recommended exclusive formula feeding in the prevention of mother-to-child transmission (PMTCT) of HIV program and provided support to implement this strategy. We conducted this study to assess HIV-free...

Background Of the 12 million global adult syphilis infections occurring globally each year, syphilis disproportionately affects women in low-income countries. WHO estimates about 80% of syphilis positive pregnancies go untreated, often in Latin America and Africa. Economic and socio-structural characteristics may explain some of the vulnerability f...

In 2000, all 191 United Nations member states agreed to work toward the achievement of a set of health and development goals by 2015. The achievement of these eight goals, the Millennium Development goals (MDGs) is highly dependent on improving the status of women, who play a key role in health and education in families and communities around the w...

Depression during pregnancy may negatively influence social functioning, birth outcomes and postnatal mental health. A cross-sectional analysis of the baseline survey of a prospective study was undertaken with an objective of determining the prevalence and socio-demographic factors associated with depressive morbidity during pregnancy in a Tanzania...

Several studies show depression is common during pregnancy. However, there is limited information in Tanzania on the magnitude of perceived distress during pregnancy and meanings ascribed to such distress. A descriptive survey collected data using unstructured interviews from 12 traditional practitioners and 10 peri-urban women with previous pregna...

In many settings worldwide, HIV-positive individuals have experienced a significant level of stigma and discrimination. This discrimination may also impact other family members affected by the disease, including children. The aim of our study was to identify factors associated with stigma and/or discrimination among HIV-affected youth and their HIV...

Younsook Lim and colleagues describe the Rwanda Learning Collaborative on Child Health, which aimed to improve and extend the impact of prevention of mother-to-child transmission of HIV/AIDS.

Prevention of mother to child transmission (PMTCT) programmes have traditionally been narrow in scope, targeting biomedical interventions during the perinatal period, rather than considering HIV as a family disease. This limited focus restricts programmes' effectiveness, and the opportunity to broaden prevention measures has largely been overlooked...

The goals of this study were to (1) estimate the prevalence of HIV infection among women accessing services at a women's health center in rural Haiti and (2) to identify economic risk factors for HIV infection in this population. Women who accessed healthcare services at this center between June 1999 and December 2002 were recruited to participate....

The study is an analysis of baseline data from a pilot psychosocial support intervention for HIV-affected youth and their caregivers in Haiti. Six sites in Haiti's Central Department affiliated with Partners In Health/Zanmi Lasante (PIH/ZL) and the Haitian Ministry of Health were included. Participants were recruited from a list of HIV-positive pat...

Previous studies of Haitian immigrant and refugee youth have emphasized "externalizing" behaviors, such as substance use, high risk sexual behavior, and delinquency, with very little information available on "internalizing" symptoms, such as depression and anxiety. Analyzing stressors and "internalizing" symptoms offers a more balanced picture of t...

Objectives: The aims of the study were to: 1) describe the burden of psychiatric symptoms and degree of psychosocial functioning among HIV-affected youth and their parents/caregivers in central Haiti; and 2) examine the association between depressive symptoms in parents/caregivers and psychosocial outcomes among HIV-affected youth. Methods: Basel...

Background: In high HIV burden settings such as Haiti, youth affected by HIV/AIDS must cope with a multitude of stressors. HIV-affected youth have been shown to have an increased risk of depression and problem behaviors, which may lead to engagement in HIV risk behaviors. Objectives: The aims of our study were: to estimate the prevalence of inter...

Background: Families affected by the stressors of chronic poverty and HIV may be at risk of child abuse if not offered adequate counseling and support. The abuse that results can lead to further isolation and despair for both parent and child. Methods: The TALC (Teens and Adults Learning to Communicate) curriculum, developed for HIV+ mothers and...

Several years ago, the RFK Memorial Center for Human Rights, Center for Human Rights and Global Justice at NYU School of Law, Partners In Health and Zanmi Lasante began a unique collaboration to investigate the role of the United States in blocking loans to Haiti from the Inter-American Development Bank (IDB) which were slated to improve water and...

In June 2008 the RFK Memorial Center for Human Rights, Center for Human Rights and Global Justice at NYU School of Law, Partners In Health and Zanmi Lasante, released a report titled: Woch nan Soley: The Denial of the Right to Water in Haiti. This report documents interference by the United States resulting in the delay of loans from the Inter-Amer...