Browsing by Author "Lesosky, Maia Rose"

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    Open Access
    Assessing and addressing missed opportunities for vaccination in Cape Town through a collaborative quality improvement approach
    (2024) Nnaji, Chukwudi; Lesosky, Maia Rose; Myer Benjamin
    Background: While significant investments and efforts have been made to promote universal access to immunisation services in South Africa, current evidence shows substantial coverage gaps across the country. Missed opportunities for vaccination (MOV) have been recognised as a major contributor to sub-optimal immunisation coverage globally. The overall aim of the research and its component studies was to assess and address MOV in primary health care (PHC) settings in Cape Town. To achieve this overarching goal, the research sought to address five specific objectives. It started with quantitative and qualitative assessments of the magnitude and multi-dimensional factors associated with MOV among children aged 0-23 months attending PHC facilities in the Cape Town Metro Health District. The goal of that formative assessment was to help inform the design, implementation and evaluation of contextually appropriate quality improvement interventions targeted at reducing MOV in participating PHC facilities. In addition, the research sought to contribute important evidence on the feasibility, effectiveness and sustainability of quality improvement interventions in addressing MOV in PHC contexts. Study rationale, supporting literature and specific objectives are described in detail in Chapters 1-2. Methods: The research used a mixed-methods approach, incorporating data from both quantitative and theory-informed qualitative studies. To address the five specific objectives, the research had five component studies. The first study involved a quantitative assessment of the magnitude of MOV and associated factors (Chapter 3), consolidated with two qualitative studies to provide deeper understanding and contextualisation of the first study's quantitative findings from the perspectives of caregivers and health workers (Chapter 4). These were followed by a non-randomised controlled study to evaluate the effectiveness of the package of quality improvement strategies implemented in participating health facilities (Chapter 5) and a post-intervention mixed-methods evaluation of the factors facilitating or hindering the successful implementation of quality improvement interventions (Chapter 6). Study design, methodological considerations and conceptual underpinnings are described in detail in various study chapters (Chapters 3-6). Strengths and limitations of each study design are also discussed in their respective chapters, as are their implications for further research. Results: The first component study (reported and discussed in detail in Chapter 3) involved a quantitative study that aimed to assess the prevalence and determinants of MOV in PHC settings in Cape Town. It found a prevalence of 14% and identified individual and health system factors associated with MOV. The second study (reported and discussed in Chapter 4) used a qualitative design (focus group discussions with caregivers) to explore the factors that may influence MOV among children in the study setting. Similarly, the third study (reported also in Chapter 4) employed another qualitative design (in-depth interviews) to explore the factors that may influence MOV from the perspectives of healthcare workers. Both qualitative studies provided important contextual insights that complemented and enhanced understanding of the findings from the quantitative MOV assessment. In the fourth component study (reported and discussed in Chapter 5), findings from the quantitative and qualitative baseline assessments were used to design and evaluate a package of facility-level quality improvement interventions. From the evaluation using a non-randomised controlled design, we found that implementing contextually appropriate quality improvement strategies was feasible and effective at reducing MOV occurrence in participating PHC facilities. In the final study, we used a mixed-methods evaluation design to conduct a post-implementation evaluation of the quality improvement intervention. From that, we were able to identify the quality improvement implementation facilitators and barriers and how they influenced participants' experiences and perceptions of implementation outcomes, the understanding of which is important for informing the adaptation and sustainability of future MOV-targeted quality improvement strategies. Conclusion Overall, the research has demonstrated that there was a substantial burden of MOV among children in Cape Town. It has also provided some scientifically robust evidence on the feasibility, effectiveness and adaptability of a facility-level quality improvement intervention for addressing MOV in primary health care contexts in Cape Town and similar contexts. Implications of study findings for policy, practice and further research have been discussed with specific recommendations in various study chapters (Chapters 3-6) and consolidated in the integrated discussion in the final chapter (Chapter 7).
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    Clustering of longitudinal viral loads in the Western Cape
    (2020) Arua, Eke Nnanna; Lesosky, Maia Rose; Myer, Landon
    Introduction: Routine viral load (VL) monitoring is important for assessing the effectiveness of ART in South Africa. There is little information however, on how the longitudinal VL patterns change for subgroups of persons living with HIV (PLHIV) who have experienced at least one elevated VL. We investigated the possible longitudinal VL patterns that may exist among this unique population. Methods: This mini-dissertation offers three components; a research protocol (Section A), a literature review (Section B) and a journal ready manuscript (Section C). We examined HIV VL data for the Western Cape from 2008 to 2018, taken from the National Health Laboratory Services (NHLS). Using< 1000 copies/mL as a threshold for viral suppression, we identified 109092 individuals who had at least one instance of an elevated VL. A nonparametric (KML-Shape) and a model-based (LCMM) clustering technique were used to identify latent subgroups of longitudinal VL trajectories among these individuals. Results: Both the KML-Shape and LCMM clustering techniques identified five latent viral load trajectory subgroups. KML-Shape found majority of individuals' trajectories belonged to clusters that had a decreasing longitudinal VL trend (76.6% of individuals), while LCMM found a smaller proportion of individuals' trajectories belonged to clusters that had a decreasing longitudinal trend (52.5% of individuals). Most of the trajectory subgroups identified had long periods of low-level viremia. Conclusion: Although majority of individuals belonged to clusters that had downward trends, further research is needed to better understand factors contributing to membership of clusters that did not have a downward longitudinal trend. Understanding these factors may help in the development of targeted HIV prevention programs for these individuals.
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    Prevalence and risk factors associated with alcohol consumption in pregnant Ugandan women
    (2022) Tshabalala, Phumzile Kimberly Pretty; Lesosky, Maia Rose
    Introduction: Foetal alcohol syndrome disorder (FASD) is caused by alcohol consumption during pregnancy. Foetal alcohol syndrome (FAS) is a lifelong condition that results in reduced quality of life. We examined the prevalence and risk factors associated with alcohol consumption in a population of pregnant Ugandan women. Methods: This mini dissertation comprises of two sections: a research protocol (Section A) and a manuscript (Section B). We made use of data previously collected (2018) for the "IMPALA” study and focused our research on alcohol consumption during pregnancy. This study consisted of 566 eligible study participants between the ages of 15-46. Univariable and multivariable logistic regression methods were used to identify risk factors associated with alcohol consumption among study participants. Results: Our study population consisted mainly of married women who work as farmers, living in rural areas. We found that 14% of the study participants consumed alcohol while pregnant. Both the univariable and multivariable regression found that age, residential area, married polygamously and married monogamously were significantly (p-value < 0.05) associated with alcohol consumption amongst study participants. Number of children and being a farmer were significantly associated in the univariable regression model only, the pattern of association was similar in the multivariable regression model. Conclusion: The prevalence of alcohol consumption in pregnancy was found to be 14% with age, residential area, number of children and working as a farmer being identified as the risk factors for alcohol consumption. Our conclusion is that alcohol consumption in this population was similar to that reported in other studies.
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    The quality and variation of spirometry reads for testing lung function in children in sub Saharan Africa
    (2019) Maduna, Dumsile Nontokozo; Lesosky, Maia Rose
    Background: Lung function assessments have become the cornerstone of understanding the ever-increasing burden of non-communicable respiratory conditions worldwide. The introduction of pulmonary function testing (PFT) has made maximal expiratory flow/volume (MEFV) measurements the basis of lung function assessments and spirometry the most widely used diagnostic tool for lung function testing. The effectiveness of spirometry to distinguish between normal and abnormal lung function has been realised in adults; however, there is an observed history of misinterpretation in children. The quality of measurements remains a major concern in children and good quality measurements are critical in the diagnosis of any health condition as well as understanding the burden of abnormal lung function in children in low and middleincome countries (LMICs). Objective: This study describes the quality and variation of spirometry reads for evaluating lung function in children in a Malawian population. Methods: This study was conducted according to a protocol developed and granted ethical approval by the Faculty of Health Sciences Human Research Ethics Committee, University of Cape Town (HREC REF 669/2018). The protocol describes the parent study data collection, project analysis plans and ethical and other considerations. Current literature on lung function using spirometry was systematically reviewed and synthesised. The literature review included primary studies and review articles that included spirometry measurement in children from settings in Africa and other low- and middle- income countries. The descriptive study involves secondary analysis of data contributed by the Children Lung Health study, a cross-sectional survey conducted in Malawi. Spirometry measurements from 802 healthy children aged 6-8 years, inexperienced in performing MEFV manoeuvres, are evaluated. Data in the primary study were collected by means of a structured questionnaire which included items on socio-demographic characteristics and spirometry was performed according to the American Thoracic Society and European Respiratory Society (ATS/ERS) guidelines using an Easy on-PC spirometer in the participant‘s home. The ATS/ERS standards for adults and the modified recommendations for children were applied to evaluate quality. Descriptive statistics were used to describe the quality of spirometry indices and univariable logistic regression to identify and describe variables that are predictors of quality. Results: The findings of the study were that many children (34%) failed to reach the complete ATS/ERS quality standards. The end-of-test criteria (forced expiratory time) was the most difficult to meet for children and if this is not met (i.e. exhalation is not complete), the forced vital capacity (FVC) will be underestimated leading to it being misinterpreted. More than 30% of the children failed to meet the repeatability criteria when the relative differences for FVC and forced expiratory volume in the first second (FEV1) was used, yet they are the most appropriate in paediatric practice as compared to absolute differences. Young children were more likely to produce poor quality spirometry as compared to older children. Conclusion: Young children may perform acceptable spirometry according to the modified ATS/ERS recommendations; however, the quality remains suboptimal. Further modification of the already lowered quality standards, seems to be the viable option, but the implications of this clinically has not been evaluated. Other alternatives need to be explored for this group.
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    The Role of Streptococcus Pneumoniae Carriage on Wasting Among Vaccinated Gambian Infants: A Longitudinal Analysis of a Birth Cohort
    (2022) Zwane, Phindi; Lesosky, Maia Rose
    Wasting remains a serious public health problem, affecting 45 million children under five years old worldwide. A comprehensive understanding of the factors associated with child wasting is needed to inform interventions aimed at reducing and preventing wasting. Some studies have suggested that asymptomatic colonization of bacterial agents such as Streptococcus Pneumoniae (pneumococcus) may have negative impacts on child growth and nutritional status. The aim this study is to investigate the determinants of wasting and to assess the effect of pneumococcus carriage on wasting in children under the age of 2 years. The rationale, aim and objectives of the current study, along with the methodology, data analysis plan and ethical considerations are outlined in the protocol presented in Part A. Part B presents a manuscript that outlines and discusses the findings of the study. This study was a secondary analysis of data collected from 120 infants recruited at birth and followed up at regular intervals for two years. The data was collected in Rural Gambia between March 2013 and September 2015 as part of the Vaccination and Paediatric Microbiome Project. Nutritional status was classified using weight-for-length (WLZ), length-for-age (LAZ) and weight-forage (WAZ) z-scores for wasting, stunting and underweight respectively. Regression methods were used to evaluate the factors associated with both wasting, as a binary indicator, and weight-for-length z-scores among children aged 6-24 months. Over the two years of follow-up, 66.7% (80/120) of children had at least one episode of wasting with 36.3% (29/80) experiencing repeated episodes. About 47.5% (57/120) became stunted and 41.7% (50/120) became underweight. Nearly all the children (97.5%) became pneumococcus carriers at least once in the two years of follow up, with 50% of children becoming carriers within the first month of life. A small proportion of the children (15.8%) were born carriers. Carriage was lowest in the dry season but began to increase in the wet season until February, where it peaked. The median duration of carriage was 269.1 days (IQR: 70-508 days) Child age, mother's age at delivery, inflammation at birth, having at least one episode of wasting in the first six months of life, reporting a recent illness, and being observed in the rainy season had significant effects on WLZ scores in both the adjusted and unadjusted models. Pneumococcus carriage only had a significant association with WLZ scores in the adjusted model [RR: -0.18 (95% CI: -0.35 – - 0.01)], while low birthweight only had a significant association in the unadjusted model [RR: -0.78 (95% CI: -1.49 – -0.07)]. Mother's age at birth, inflammation at birth and reporting a recent illness was significantly associated with wasting as a binary indicator in both the adjusted and unadjusted models. Being observed in the rainy season decreased the odds of wasting, although, this association was only significant in the adjusted model [OR: 0.28 (95% CI: 0.10 – 0.75)]. Pneumococcus carriers had lower odds of wasting in the unadjusted model [OR: 0.29 (95% CI: -0.35 – 0.93)] and higher odds of wasting in the adjusted model [OR: 1.62 (95% CI: 0.70 – 3.74)]. Neither association was statistically significant. This study found low birthweight, early episodes of wasting, inflammation at birth and recent illness to be associated with wasting in children between the ages of 6-24 months. Targeting maternal nutrition during pregnancy, neonatal care and infant feeding practises may help reduce wasting among children between 6-24 months of age by reducing low birthweight, undernutrition, illness, and inflammation in early infancy. Further research is needed to understand the role of pneumococcus on child undernutrition.