OpenUCT :: Browsing by Author "Levitt, Naomi"

Browsing by Author "Levitt, Naomi"

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Open Access
A qualitative study of the experiences of care and motivation for effective self-management among diabetic and hypertensive patients attending public sector primary health care services in South Africa
(2015-08-01) Murphy, Katherine; Chuma, Thandie; Mathews, Catherine; Steyn, Krisela; Levitt, Naomi
Background: Diabetes and hypertension constitute a significant and growing burden of disease in South Africa. Presently, few patients are achieving adequate levels of control. In an effort to improve outcomes, the Department of Health is proposing a shift to a patient-centred model of chronic care, which empowers patients to play an active role in self-management by enhancing their knowledge, motivation and skills. The aim of this study was to explore patients’ current experiences of chronic care, as well as their motivation and capacity for self-management and lifestyle change. Methods: The study involved 22 individual, qualitative interviews with a purposive sample of hypertensive and diabetic patients attending three public sector community health centres in Cape Town. Participants were a mix of Xhosa and Afrikaans speaking patients and were of low socio-economic status. Results: The concepts of relatedness, competency and autonomy from Self Determination Theory proved valuable in exploring patients’ perspectives on what a patient-centred model of care may mean and what they needed from their healthcare providers. Overall, the findings of this study indicate that patients experience multiple impediments to effective self-management and behaviour change, including poor health literacy, a lack of self-efficacy and perceived social support. With some exceptions, the majority of patients reported not having received adequate information; counselling or autonomy support from their healthcare providers. Their experiences suggests that the current approach to chronic care largely fails to meet patients’ motivation needs, leaving many of them feeling anxious about their state of health and frustrated with the quality of their care. Conclusions: In accordance with other similar studies, most of the hypertensive and diabetic patients interviewed for this study were found to be ill equipped to play an active and empowered role in self-care. It was clear that patients desire greater assistance and support from their healthcare providers. In order to enable healthcare providers in South Africa to adopt a more patient-centred approach and to better assist and motivate patients to become effective partners in their care, training, resources and tools are needed. In addition, providers need to be supported by policy and organisational change.
Open Access
Association of lopinavir concentrations with plasma lipid or glucose concentrations in HIV-infected South Africans: a cross sectional study
(BioMed Central Ltd, 2012) Sinxadi, Phumla; McIlleron, Helen; Dave, Joel; Smith, Peter; Levitt, Naomi; Maartens, Gary
BACKGROUND: Dyslipidaemia and dysglycaemia have been associated with exposure to ritonavir-boosted protease inhibitors. Lopinavir/ritonavir, the most commonly used protease inhibitor in resource-limited settings, often causes dyslipidaemia. There are contradictory data regarding the association between lopinavir concentrations and changes in lipids.AIM:To investigate associations between plasma lopinavir concentrations and lipid and glucose concentrations in HIV-infected South African adults. METHODS: Participants stable on lopinavir-based antiretroviral therapy were enrolled into a cross-sectional study. After an overnight fast, total cholesterol, triglycerides, and lopinavir concentrations were measured and an oral glucose tolerance test was performed. Regression analyses were used to determine associations between plasma lopinavir concentrations and fasting and 2 hour plasma glucose, fasting cholesterol, and triglycerides concentrations. RESULTS: There were 84 participants (72 women) with a median age of 36 years. The median blood pressure, body mass index and waist: hip ratio were 108/72 mmHg, 26 kg/m2 and 0.89 respectively. The median CD4 count was 478 cells/mm3. Median duration on lopinavir was 18.5 months. The median (interquartile range) lopinavir concentration was 8.0 (5.2 to 12.8) mug/mL. Regression analyses showed no significant association between lopinavir pre-dose concentrations and fasting cholesterol (beta-coefficient 0.04 (95% CI 0.07 to 0.00)), triglycerides (beta-coefficient 0.01 (95% CI 0.04 to 0.02)), fasting glucose (beta-coefficient 0.01 (95% CI 0.04 to 0.02)), or 2-hour glucose concentrations (beta-coefficient 0.02 (95% CI 0.09 to 0.06)). Lopinavir concentrations above the median were not associated with presence of dyslipidaemia or dysglycaemia. CONCLUSIONS: There was no association between lopinavir plasma concentrations and plasma lipid and glucose concentrations.
Open Access
Blood pressure variation and its association with outdoor temperature among adults with hypertension in a primary care setting in South Africa
(2018) Havyarimana, Enock; Bobrow, Kirsten; Levitt, Naomi
Rationale – There is limited evidence about the effect of climate on blood pressure management of people living with and cared for hypertension in Sub-Sahara Africa. We investigate the relationship between outdoor temperature and blood pressure in a primary care setting with limited control of indoor climate in Cape Town, South Africa. Method – The study uses blood pressure data from 2494 participants screened and enrolled for entry in the SMS-text Adherence (StAR) trial study. Participants’ data were matched with outdoor temperature and air quality data using the nearest hour of enrolment. Individuals were included in this study if they were recruited during the study’s screening period (June 2012 to November 2014) and the clinic’s operating hours (7h00 and 17h00). Result - 72% of participants enrolled for the trial were female and had a BMI of 31 kg/m2 . There was an inter-subject variation of blood pressure between participants enrolled in winter and spring. Those enrolled in winter (June – July) and in the morning (07h00-10h00) when temperatures were generally low, had a higher mean blood pressure compared to those enrolled during spring (September - November) and in the afternoons (≥13h00). Mean outdoor temperature during the trial period was 16.7°C (min: 3.7°C –max: 30.7°C) with lowest temperatures recorded in June. Both outdoor temperature and blood pressure were found to be associated with nitrogen dioxide (NO2) and sulphur dioxide and (SO2) and therefore may be confounded by them. In a multivariate analysis controlling for air pollution, humidity and several leading cardiovascular risk factors, it was observed that a 10°C increase in outdoor temperature was associated with 7.5mmHg (95% CI: 3, 82 - 11, 18) change in systolic blood pressure. This association is modified by age, BMI and the time of the day. Those 65 years and older, with a low BMI and those enrolled in the morning (7h00 – 10h00) had the greatest change in blood pressure due to outdoor temperature Conclusion –The study shows an inverse association between outdoor temperature and clinic-based blood pressure in a primary care setting in South Africa. Given the fact that clinic-based blood pressure measures are used to direct the management of hypertension, greater attention needs to be given to environmental factors which may affect it. This may become of greater clinical relevance with changes in the climate and extreme weather patterns, including extensive smog
Open Access
Cardiovascular risk factors in patients with Addison's disease: a comparative study of South African and Swedish patients
(Public Library of Science, 2014) Ross, Ian Louis; Bergthorsdottir, Ragnhildur; Levitt, Naomi; Dave, Joel Alex; Schatz, Desmond; Marais, David; Johannsson, Gudmundur
BACKGROUND: Patients with Addison's disease (AD) in Scandinavia have an increased risk for premature death due to cardiovascular disease (CVD). Serum lipids are important risk factors for CVD and vascular mortality. Replacement doses of hydrocortisone have historically been higher in Sweden than South Africa. The primary aim was to study the lipid profiles in a large group of patients with AD with the hypothesis that the lipid profile in patients in Sweden would be worse than in South Africa. METHODS: In a cross-sectional study, 110 patients with AD (55 from South Africa, 55 from Sweden) matched for age, gender, ethnicity and BMI were studied. Anthropometric measures, blood pressure, lipids, highly sensitive C-reactive protein (hs-CRP) and adiponectin were studied. RESULTS: All patients were Caucasian and the majority were women N = 36 (65.5%). Mean (standard deviation; SD) ages of the Swedish and South African patients were 52.9 (13.0) and 52.6 (14.4) years and BMI 25.3 (3.2) and 25.8 (4.1) kg/m 2 , respectively. The mean total daily hydrocortisone dose was greater in the Swedish patients than the South African patients, [33.0 (8.1) versus 24.3 (8.0) mg; p<0.0001]. South African patients had higher median (interquartilerange; IQR) triglycerides (TG) [1.59 (1.1-2.46) versus 0.96 (0.74-1.6) mmol/l; p<0.001], total cholesterol (TC) [6.02(1.50) versus 5.13 (0.87) mmol/l; p<0.001], LDL-C [4.43 (1.44) versus 2.75 (0.80) mmol/l; p<0.001] and median hs-CRP [2.15 (0.93-5.45) versus 0.99 (0.57-2.10) mg/L; p<0.003] and lower HDL-C [0.80 (0.40) versus 1.86 (0.46) mmol/l; p<0.001] than the Swedish patients. Approximately 20% of the patients in both cohorts had hypertension and diabetes mellitus. CONCLUSIONS: South African patients with AD have worse lipid profiles and higher hs-CRP compared to their matched Swedish patients, despite lower doses of hydrocortisone. It is uncertain at this time whether these are due to genetic or environmental factors.
Open Access
Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial
(BioMed Central, 2018-03-22) Fairall, Lara; Petersen, Inge; Zani, Babalwa; Folb, Naomi; Georgeu-Pepper, Daniella; Selohilwe, One; Petrus, Ruwayda; Mntambo, Ntokozo; Bhana, Arvin; Lombard, Carl; Bachmann, Max; Lund, Crick; Hanass-Hancock, Jill; Chisholm, Daniel; McCrone, Paul; Carmona, Sergio; Gaziano, Thomas; Levitt, Naomi; Kathree, Tasneem; Thornicroft, Graham
Background The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART. Methods The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively. Discussion The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings. Trial registration ClinicalTrials.gov ( NCT02407691 ) registered on 19 March 2015; Pan African Clinical Trials Registry ( 201504001078347 ) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) ( DOH-27-0515-5048 ) NHREC number 4048 issued on 21/04/2015.
Open Access
Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial
(BioMed Central, 2018-03-22) Petersen, Inge; Bhana, Arvin; Folb, Naomi; Thornicroft, Graham; Zani, Babalwa; Selohilwe, One; Petrus, Ruwayda; Mntambo, Ntokozo; Georgeu-Pepper, Daniella; Kathree, Tasneem; Lund, Crick; Lombard, Carl; Bachmann, Max; Gaziano, Thomas; Levitt, Naomi; Fairall, Lara
Background The high co-morbidity of mental disorders, particularly depression, with non-communicable diseases (NCDs) such as cardiovascular disease (CVD), is concerning given the rising burden of NCDs globally, and the role depression plays in confounding prevention and treatment of NCDs. The objective of this randomised control trial (RCT) is to determine the real-world effectiveness of strengthened depression identification and management on depression outcomes in hypertensive patients attending primary health care (PHC) facilities in South Africa (SA). Methods/design The study design is a pragmatic, two-arm, parallel-cluster RCT, the unit of randomisation being the clinics, with outcomes being measured for individual participants. The 20 largest eligible clinics from one district in the North West Province are enrolled in the trial. Equal numbers of hypertensive patients (n = 50) identified as having depression using the Patient Health Questionnaire (PHQ-9) are enrolled from each clinic, making up a total of 1000 participants with 500 in each arm. The nurse clinicians in the control facilities receive the standard training in Primary Care 101 (PC101), a clinical decision support tool for integrated chronic care that includes guidelines for hypertension and depression care. Referral pathways available include referrals to PHC physicians, clinical or counselling psychologists and outpatient psychiatric and psychological services. In the intervention clinics, this training is supplemented with strengthened training in the depression components of PC101 as well as training in clinical communication skills for nurse-led chronic care. Referral pathways are strengthened through the introduction of a facility-based behavioural health counsellor, trained to provide structured manualised counselling for depression and adherence counselling for all chronic conditions. The primary outcome is defined as at least 50% reduction in PHQ-9 score measured at 6 months. Discussion This trial should provide evidence of the real world effectiveness of strengtheneddepression identification and collaborative management on health outcomes of hypertensive patients withcomorbid depression attending PHC facilities in South Africa. Trial registration South African National Clinical Trial Register: SANCTR ( http://www.sanctr.gov.za/SAClinicalTrials ) (DOH-27-0916-5051). Registered on 9 April 2015. ClinicalTrials.gov : ID: NCT02425124 . Registered on 22 April 2015.
Open Access
Comparative assessment of absolute cardiovascular disease risk characterization from non-laboratory-based risk assessment in South African populations
(BioMed Central, 2013-07-24) Gaziano, Thomas A; Pandya, Ankur; Steyn, Krisela; Levitt, Naomi; Mollentze, Willie; Joubert, Gina; Walsh, Corinna M; Motala, Ayesha A; Kruger, Annamarie; Schutte, Aletta E; Naidoo, Datshana P; Prakaschandra, Dorcas R; Laubscher, Ria
Background: All rigorous primary cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk scores to identify high- and low-risk patients, but laboratory testing can be impractical in low- and middle-income countries. The purpose of this study was to compare the ranking performance of a simple, non-laboratory-based risk score to laboratory-based scores in various South African populations. Methods: We calculated and compared 10-year CVD (or coronary heart disease (CHD)) risk for 14,772 adults from thirteen cross-sectional South African populations (data collected from 1987 to 2009). Risk characterization performance for the non-laboratory-based score was assessed by comparing rankings of risk with six laboratory-based scores (three versions of Framingham risk, SCORE for high- and low-risk countries, and CUORE) using Spearman rank correlation and percent of population equivalently characterized as ‘high’ or ‘low’ risk. Total 10-year non-laboratory-based risk of CVD death was also calculated for a representative cross-section from the 1998 South African Demographic Health Survey (DHS, n = 9,379) to estimate the national burden of CVD mortality risk. Results: Spearman correlation coefficients for the non-laboratory-based score with the laboratory-based scores ranged from 0.88 to 0.986. Using conventional thresholds for CVD risk (10% to 20% 10-year CVD risk), 90% to 92% of men and 94% to 97% of women were equivalently characterized as ‘high’ or ‘low’ risk using the non-laboratory-based and Framingham (2008) CVD risk score. These results were robust across the six risk scores evaluated and the thirteen cross-sectional datasets, with few exceptions (lower agreement between the non-laboratory-based and Framingham (1991) CHD risk scores). Approximately 18% of adults in the DHS population were characterized as ‘high CVD risk’ (10-year CVD death risk >20%) using the non-laboratory-based score. Conclusions: We found a high level of correlation between a simple, non-laboratory-based CVD risk score and commonly-used laboratory-based risk scores. The burden of CVD mortality risk was high for men and women in South Africa. The policy and clinical implications are that fast, low-cost screening tools can lead to similar risk assessment results compared to time- and resource-intensive approaches. Until setting-specific cohort studies can derive and validate country-specific risk scores, non-laboratory-based CVD risk assessment could be an effective and efficient primary CVD screening approach in South Africa.
Open Access
Comparing dedicated and designated models of integrating mental health into chronic disease care: study protocol for a cluster randomized controlled trial
(BioMed Central, 2018-03-16) Myers, Bronwyn; Lund, Crick; Lombard, Carl; Joska, John; Levitt, Naomi; Butler, Christopher; Cleary, Susan; Naledi, Tracey; Milligan, Peter; Stein, Dan J; Sorsdahl, Katherine
Background In low- and middle-income countries (LMIC), it is uncertain whether a “dedicated” approach to integrating mental health care (wherein a community health worker (CHW) has the sole responsibility of delivering mental health care) or a “designated” approach (wherein a CHW provides this service in addition to usual responsibilities) is most effective and cost-effective. This study aims to compare the effectiveness and cost-effectiveness of these two models of service integration relative to treatment as usual (TAU) for improving mental health and chronic disease outcomes among patients with HIV or diabetes. Methods/Design This is a cluster randomised trial. We will randomise 24 primary health care facilities in the Western Cape Province of South Africa to one of three study arms. Within each cluster, we will recruit 25 patients from HIV and 25 from diabetes services for a total sample of 1200 participants. Eligible patients will be aged 18 years or older, take medication for HIV or diabetes, and screen positive on the Alcohol Use Disorder Identification Test for hazardous/harmful alcohol use or depression on the Centre for Epidemiology Scale on Depression. Participants recruited in clinics assigned to the designated or dedicated approach will receive three sessions of motivational interviewing and problem-solving therapy, while those recruited at TAU-assigned clinics will be referred for further assessment. Participants will complete an interviewer-administered questionnaire at baseline, and at 6 and 12 months post-enrolment to assess change in self-reported outcomes. At these end points, we will test HIV RNA viral load for participants with HIV and HbA1c levels for participants with diabetes. Primary outcomes are reductions in self-reported hazardous/harmful alcohol use and risk of depression. Secondary outcomes are improvements in adherence to chronic disease treatment, biomarkers of chronic disease outcomes, and health-related quality of life. Mixed-effect linear regression models will model the effect of the interventions on primary and secondary outcomes. The cost-effectiveness of each approach will be assessed using incremental cost-effectiveness ratios. Discussion Study findings will guide decision-making around how best to integrate mental health counselling into chronic disease care in a LMIC setting. Trial registration Pan African Clinical Trials Registry, Trial registration number: ACTR201610001825403 . Registered 17 October 2016.
Open Access
Differing patterns of overweight and obesity among black men and women in Cape Town: the CRIBSA study
(Public Library of Science, 2014) Peer, Nasheeta; Lombard, Carl; Steyn, Krisela; Gwebushe, Nomonde; Levitt, Naomi
Objectives To ascertain the prevalence and determinants of overweight/obesity in the 25-74-year-old urban black population of Cape Town and examine the changes between 1990 and 2008/09. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Data were collected by questionnaires, clinical measurements and biochemical analyses. Gender-specific linear regression models evaluated the associations with overweight/obesity. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%) in 2008/09. Mean body mass index (BMI) and waist circumference (WC) were 23.7 kg/m 2 (95% confidence interval (CI): 23.1-24.2) and 84.2 cm (95% CI: 82.8-85.6) in men, and 33.0 kg/m 2 (95% CI: 32.3-33.7) and 96.8 cm (95% CI: 95.5-98.1) in women. Prevalence of BMI ≥25 kg/m 2 and raised WC were 28.9% (95% CI: 24.1-34.3) and 20.1% (95% CI: 15.9-24.9) in men, and 82.8% (95% CI: 79.3-85.9) and 86.0% (95% CI: 82.9-88.6) in women. Among 25-64-year-olds, BMI ≥25 kg/m 2 decreased between 1990 (37.3%, 95% CI: 31.7-43.1) and 2008/09 (27.7%, 95% CI: 22.7-33.4) in men but increased from 72.7% (95% CI: 67.6-77.2) to 82.6% (95% CI: 78.8-85.8) in women. In the regression models for men and women, higher BMI was directly associated with increasing age, wealth, hypertension and diabetes but inversely related to daily smoking. Also significantly associated with rising BMI were raised low-density lipoprotein cholesterol and being employed compared to unemployed in men, and having >7 years of education in women. CONCLUSIONS: Overweight/obesity, particularly in urban black women, requires urgent action because of the associations with cardiovascular disease risk factors and their serious consequences.
Open Access
Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial
(BioMed Central Ltd, 2012) Mash, Bob; Levitt, Naomi; Steyn, Krisela; Zwarenstein, Merrick; Rollnick, Stephen
BACKGROUND: Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life. METHODS: Trial design: Pragmatic cluster randomized controlled trialParticipants: Type 2 diabetic patients attending 45 public sector community health centres in Cape TownInterventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.Objective: To evaluate the effectiveness of the group diabetes education programmeOutcomes: Primary outcomes: diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c. Secondary outcomes: self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of lifeRandomisation: Computer generated random numbersBlinding: Patients, health promoters and research assistants could not be blinded to the health centre's allocationNumbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.DISCUSSION:The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.TRIAL REGISTER:Pan African Clinical Trial Registry PACTR201205000380384
Open Access
Executive cognitive impairment detected by simple bedside testing is associated with poor glycaemic control in type 2 diabetes
(2007) de Wet, Hayley; Levitt, Naomi; Tipping, Brent
Aims. Cognitive impairment in people with type 2 diabetes is a barrier to successful disease management. We sought to determine whether impaired executive function as detected by a battery of simple bedside cognitive tests of executive function was associated with inadequate glycaemic control. Methods. People with type 2 diabetes attending a tertiary referral diabetic clinic who consented to participate in the study underwent a brief battery of cognitive testing (the Bedside Executive Screening Test) designed to detect executive function impairment. Glycaemic control was determined using blood glycated haemoglobin levels (HBA1c). Inadequate glycaemic control was defined as HBA1c ≥7%. Results. Executive function impairment was detected in 51 (52%) of the 98 study participants. The presence of executive function impairment was significantly associated with poor glycaemic control (HBA1c ≥7%) (odds ratio 4.9, 95% confidence interval 1.3 - 18.8, p=0.019). There were no significant differences between patients with and without executive function impairment with regard to age, target organ damage, patient reported adherence, and hypoglycaemic therapy. Patients with a lower level of education were more likely to demonstrate executive impairment when glycaemic control was poor (p=0.013). Conclusions. Executive function impairment is common in a population of people with difficult-to-manage type 2 diabetes. The presence of executive impairment is significantly associated with poor glycaemic control.
Open Access
Factors associated with excessive body fat in men and women: cross-sectional data from Black South Africans living in a rural community and an urban township
(Public Library of Science, 2015) Okop, Kufre Joseph; Levitt, Naomi; Puoane, Thandi
Objective To determine the factors associated with excessive body fat among black African men and women living in rural and urban communities of South Africa. METHODS: This is a cross-sectional analysis of data from the Prospective Urban and Rural Epidemiology (PURE) study, Cape Town, South Africa conducted in 2009/2010. The study sample included 1220 participants (77.2% women) aged 35-70 years, for whom anthropometric measurements were obtained and risk factors documented through face-to-face interviews using validated international PURE study protocols. Sex-specific logistic regression models were used to evaluate socio-demographic, lifestyle and psychological factors associated with three excessive body fat indicators, namely body mass index (BMI), waist circumference (WC) and body fat percent (BF%). RESULTS: The prevalence of excessive body fat based on BF%, WC and BMI cut-offs were 96.0%, 86.1%, and 81.6% for women respectively, and 62.2%, 25.9%, and 36.0% for men respectively. The significant odds of excessive body fat among the currently married compared to unmarried were 4.1 (95% CI: 1.3-12.5) for BF% and 1.9 (95% CI: 1.3-2.9) for BMI among women; and 4.9 (95% CI: 2.6-9.6), 3.2 (95% CI: 1.6-6.4) and 3.6 (95% CI: 1.9-6.8) for BF%, WC and BMI respectively among men. Age ≤50 years (compared to age >50 years) was inversely associated with excessive BF% in men and women, and less-than-a-college education was inversely associated with excessive BMI and WC in men. Tobacco smoking was inversely associated with all three excessive adiposity indicators in women but not in men. Unemployment, depression, and stress did not predict excessive body fat in men or women. CONCLUSION: The sex-differences in the socio-demographic and lifestyle factors associated with the high levels of excessive body fat in urban and rural women and men should be considered in packaging interventions to reduce obesity in these communities.
Open Access
Factors that influence patient empowerment in inpatient chronic care: Early implementation experience with a diabetes care intervention in South Africa
(2018) Abrahams, Nina; Gilson, Lucy; Levitt, Naomi
The burden of non-communicable diseases is growing rapidly globally and especially in low and middle-income countries. However, health systems around the world are not appropriately prepared for this increase in need for chronic care. Research suggests that health models that emphasise self-management and empowering patients to care actively for their disease are integral in non-communicable disease treatment as patients live with their disease well beyond contact with health services. Adherence and health-seeking behaviour literature suggest multiple factors within the lives of patients and within health systems that enhance or constrain patient empowerment interventions. However, in depth understanding of these factors are lacking in the South African context and especially in the inpatient setting as most research focuses on the role of primary care. This research used interviews with stakeholders in an upcoming inpatient diabetes intervention as a lens to qualitatively explore empowerment factors in further detail within the South African inpatient context. The study highlights multiple barriers to patient empowerment, namely the low socio-economic contexts of many South Africans who then struggle to access appropriate healthcare information and services and often have financial and emotional priorities that take precedence over their chronic illness. In addition, health services are bound by a shortage of resources and staff and ineffective communication systems which affects health professionals’ ability to implement patient empowerment strategies. It also highlights the unique barriers found in inpatient care as the hospital emphasises short-term acute treatment – losing potential engagement time with patients. The study suggests that patient and provider contexts make encouraging patient engagement in long term chronic care difficult. However, knowledge of these factors can be harnessed to improve chronic care interventions in low- and middle-income countries.
Open Access
Fasting substrate oxidation in relation to habitual dietary fat intake and insulin resistance in non-diabetic women: a case for metabolic flexibility?
(BioMed Central Ltd, 2013) Carstens, Madelaine; Goedecke, Julia; Dugas, Lara; Evans, Juliet; Kroff, Jacolene; Levitt, Naomi; Lambert, Estelle
BACKGROUND: Metabolic flexibility described as "the capacity of the body to match fuel oxidation to fuel availability" has been implicated in insulin resistance. We examined fasting substrate oxidation in relation to dietary macronutrient intake, and markers of insulin resistance in otherwise healthy women, with and without a family history of diabetes mellitus (FH DM). METHODS: We measured body composition (dual x-ray absorptiometry), visceral and subcutaneous adipose tissue area (VAT, SAT, using Computerised Tomography), fasting [glucose], [insulin], [free fatty acids], [blood lipids], insulin resistance (HOMA-IR), resting energy expenditure (REE), respiratory exchange ratio(RER) and self-reported physical activity in a convenience sample of 180 women (18-45 yrs). A food frequency questionnaire was used to assess energy intake (EI) and calculate the RER: Food Quotient (FQ) ratio. Only those with EI:REE (1.05 -2.28) were included (N=140). Insulin resistance was defined HOMA-IR (>1.95). RESULTS: The Insulin Resistant (IR) group had higher energy, carbohydrate and protein intakes (p<0.05) and lower PA levels than Insulin Sensitive (IS) group (P<0.001), but there were no differences in RER or RER:FQ between groups. However, nearly 50% of the variance in HOMA-IR was explained by age, body fat %, VAT, RER:FQ and FH DM (adjusted R2=0.50, p<0.0001). Insulin-resistant women, and those with FH DM had a higher RER:FQ than their counterparts (p<0.01), independent of body fat % or distribution. CONCLUSION: In these apparently healthy, weight-stable women, insulin resistance and FH DM were associated with lower fat oxidation in relation to dietary fat intake, suggesting lower metabolic flexibility.
Open Access
Formative research for the development of an appropriate, acceptable and feasible intervention aimed at reducing type 2 diabetes risk in disadvantaged women after gestational diabetes in South Africa
(2021) Muhwava, Lorrein Shamiso; Murphy, Katherine; Zarowsky, Christina; Levitt, Naomi
Background Gestational diabetes mellitus (GDM) is one of the most common obstetric complications, affecting 18.4 million live births globally. In South Africa, the high prevalence of GDM estimated to be up to 25.8%, is driven by the high rates of obesity. Women with a history of GDM have a seven-fold increased lifetime risk of developing type 2 diabetes. In addition, children born of women with GDM are susceptible to impaired glucose tolerance and obesity in adulthood. Prioritising GDM as a public health issue is critical for improving maternal and child health care services and non-communicable disease prevention efforts. There is consistent evidence demonstrating that, in at-risk populations, lifestyle change can reduce the risk of developing type 2 diabetes and among women with GDM, continuation of lifestyle changes after a GDM pregnancy can prevent progression to type 2 diabetes. Understanding women's lived experiences and views around GDM is critical for the development of behaviour change interventions. Further, insights from women's experiences of the healthcare system for GDM care are important for informing health policy and improving the quality of care. At present, little is known about the policies and practices relating to the management of GDM in low- and middle- income countries and health systems interventions that support and facilitate continuity of care are lacking. This thesis constitutes the formative research for a complex intervention study aimed at developing and evaluating a novel health system intervention to reduce the subsequent risk of developing type 2 diabetes among women with GDM. The findings will inform the planning, development and testing of an appropriate and innovative intervention for women with GDM, to be integrated into existing health services in South Africa. Methods and Results The first study used document reviews of policy documents and clinical practice guidelines for the management of GDM in South Africa and 11 key informant interviews with policy makers, health service managers from the Department of Health and clinicians working in the public health services to explore the existing policies and reported clinical practices relating to antenatal and postnatal care for women with GDM in the public health sector in South Africa and identified important factors in delivering an integrated mother - baby postpartum health service. We found that the management of GDM in South Africa is aligned with international standards, in addition to locally developed guidelines and protocols for clinical practice. Our findings also confirmed that postpartum follow-up for women with GDM is a significant problem in South Africa as a result of fragmentation of care and the absence of standardised postnatal care services. Key informants also raised patient – related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for women with GDM. The second study was a descriptive qualitative study which explored the lived experiences of 35 women with prior GDM using content analysis and the COM-B model to identify factors influencing lifestyle change during and beyond the GDM pregnancy. The results suggest that the COM-B model's concepts of capability (knowledge and skills for behaviour change), opportunity (resources for dietary change and physical activity) and motivation (perception of future diabetes risk) are relevant to lifestyle change among women with GDM in South Africa. The third study was an in- depth exploration of women's lived experiences of GDM, their context and perceived needs. Women discussed the emotional and psychological burden of having GDM, highlighting (i) their initial emotional reactions to receiving a GDM diagnosis, (ii) their experience of adjusting to the constraints of living with GDM (iii) their feelings of apprehension about childbirth and their maternal role and (iv) their feelings of abandonment in the post-partum period once the intensive support from both health system and family ends. The fourth study further explored women's perspectives of and satisfaction with GDM care in the public health sector as well as their views on the feasibility and acceptability of the proposed intervention using the Donabedian's quality of care framework. Key sub-themes relating to ‘structure' of care were the organisation of GDM health services, efficiency of the referral, efficiency of management practices, quality of hospital facilities and services and the availability of adequate healthcare resources. Overall satisfaction with GDM care processes was influenced by women's unmet need for education and behaviour change counselling, interpersonal support from health care providers and peers and the health services' capacity to enable them to actively participate in their care. Conclusion The management of GDM is currently foetal - centric and over-medicalised, focusing on clinical care processes to achieve glycaemic control and safeguard foetal health. There is a critical need for woman-centred approaches to be incorporated in the management of GDM in order to improve women's overall experiences of care. Behaviour change interventions for women with GDM should target factors within the physical and social environments, that influence women's capacity for lifestyle change. In addition, we recommend routine mental health and psychosocial vulnerability screening and monitoring for women diagnosed with GDM throughout pregnancy and postpartum to improve prognoses. Finally, holistic interventions and health policies that directly support continuity of care are urgently needed if high rates of progression to type 2 diabetes in this population are to be avoided.
Open Access
Health promotion services for patients having non-comminicable diseases: Feedback from patients and health care providers in Cape Town, South Africa
(BioMed Central Ltd, 2012) Parker, Whadi-ah; Steyn, Nelia; Levitt, Naomi; Lombard, Carl
BACKGROUND: Due to a paucity of data regarding the availability and efficacy of equipment, health promotion methods and materials currently used by health professionals for the management of patients with non-communicable diseases (NCDs) at primary health care (PHC) facilities in Cape Town, an audit was undertaken. METHODS: A multi-centre cross-sectional study was undertaken to interview patients (n=580) with NCDs at 30 PHC facilities. A questionnaire was used to obtain information on preferences for health promotion methods for lifestyle modification. Individual semi-structured interviews were conducted with selected health professionals (n=14) and captured using a digital recorder. Data were transferred to the Atlas ti software programme and analysed using a thematic content analysis approach. RESULTS: Blood pressure measurement (97.6%) was the most common diagnostic test used, followed by weight measurement (88.3%), urine (85.7%) and blood glucose testing (80.9%). Individual lifestyle modification counselling was the preferred health education method of choice for the majority of patients. Of the 64% of patients that selected chronic clubs/support groups as a method of choice, only a third rated this as their first choice. Pamphlets, posters and workshops/group counselling sessions were the least preferred methods with only 9%, 13% and 11% of patients choosing these as their first choice, respectively. In an individual counselling setting 44.7% of patients reported that they would prefer to be counselled by a doctor, followed by a nurse (16.9%), health educator (8.8%) and nutrition advisor (4.8%). Health professionals identified numerous barriers to education and counselling. These can be summarised as a lack of resources, including time, space and equipment; staff-related barriers such as staff shortage and staff turnover; and patient-related barriers such as patient load and patient non-compliance. CONCLUSION: The majority of patients attending PHC facilities want to receive lifestyle modification education. There is not however, one specific method that can be regarded as the gold standard. Patients' preferences regarding health education methods differ, and they are more likely to be susceptible to methods that do not involve much reading. Health education materials such as posters, pamphlets and booklets should be used to supplement information received during counselling or support group sessions.
Open Access
A high burden of hypertension in the urban black population of Cape Town: the cardiovascular risk in Black South Africans (CRIBSA) study
(Public Library of Science, 2013) Peer, Nasheeta; Steyn, Krisela; Lombard, Carl; Gwebushe, Nomonde; Levitt, Naomi
Objective To determine the prevalence, associations and management of hypertension in the 25-74-year-old urban black population of Cape Town and examine the change between 1990 and 2008/09 in 25-64-year-olds. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Cardiovascular disease risk factors were determined by administered questionnaires, clinical measurements and fasting biochemical analyses. Logistic regression models evaluated the associations with hypertension. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%) in 2008/09. Age-standardised hypertension prevalence was 38.9% (95% confidence interval (CI): 35.6-42.3) with similar rates in men and women. Among 25-64-year-olds, hypertension prevalence was significantly higher in 2008/09 (35.6%, 95% CI: 32.3-39.0) than in 1990 (21.6%, 95% CI: 18.6-24.9). In 2008/09, hypertension odds increased with older age, family history of hypertension, higher body mass index, problematic alcohol intake, physical inactivity and urbanisation. Among hypertensive participants, significantly more women than men were detected (69.5% vs. 32.7%), treated (55.7% vs. 21.9%) and controlled (32.4% vs. 10.4%) in 2008/09. There were minimal changes from 1990 except for improved control in 25-64-year-old women (1990∶14.1% vs. 2008/09∶31.5%). CONCLUSIONS: The high and rising hypertension burden in this population, its association with modifiable risk factors and the sub-optimal care provided highlight the urgent need to prioritise hypertension management. Innovative solutions with efficient and cost-effective healthcare delivery as well as population-based strategies are required.
Open Access
Informing the development of a self-management care programme for older people with type 2 diabetes attending community health centres in Cape Town, South Africa
(2019) Werfalli, Mahmoud; Levitt, Naomi; Kalula, Sebastiana Z
Diabetes is a growing problem globally, with the major impact being experienced in low and middle-income countries. In 2017, there were an estimated 122.8 million people over the age of 65 years living with diabetes globally, with a prevalence of 18.8% and 3.2 million deaths at this age. If the trends continue, the number of people living with diabetes over the age of 65 years will be 253.4 million in 2045.This is being driven by demographic changes including the ageing of the population. In South Africa, diabetes is a major cause of morbidity and mortality and a burden to the overstretched health services, community, family and people with the disease. Self- care management is a cornerstone of diabetes care. The purpose of this thesis is to inform the development of a self-care management programme for older people attending public sector primary health care services in Cape Town, South Africa by using the PRECEDE planning model. This model provides an eight-phase framework for health care professionals to determine, develop, implement and assess health promotion programmes, as well as the application of health promotion theories systematically within such programmes. The thesis incorporates five interlinked studies, presented as five publications, two published and three in review: The first was a systematic review of studies that assessed the prevalence of type 2 diabetes mellitus among older people in African countries conducted between 2000 and 2015 with the objective of providing data for the monitoring of future trends. This demonstrates that type 2 diabetes is not rare in individuals aged 55 years and older across Africa – the overall prevalence of diabetes was 13.7% (95% CI 11·3–16·3) and was twofold higher in studies based on the oral glucose tolerance test than in those using fasting plasma blood glucose. The second is a secondary analysis of the Study on global AGEing and adult health (SAGE) South Africa Wave 1 data that examined the prevalence of self-reported diabetes and the association between diabetes and each of health-related quality of life and disability amongst South Africa’s older adults. The results were that diabetes was associated with lower quality of life and greater disability: it represented not only a risk factor for disability but was associated with a range of impairments and co-morbidities predisposing to loss of autonomy. The third, a cross-sectional survey, examines the knowledge of older people with diabetes attending primary care clinics in Cape Town, South Africa, about living with and managing their diabetes; and aims to determine the relationship of social support, especially that of family and friends with their self-management. Its major finding is that there was a lack of knowledge about the complications of diabetes, suggesting that the available diabetes educational opportunities have not been effective. Importantly, however, social support was positively associated with both knowledge and a number of self-care aspects. The fourth is a qualitative study consisting of documentary review and individual interviews with key informants to investigate the current policies, programmes and any other interventions as they relate to older people with diabetes. This found that generally older persons face numerous barriers in managing their condition. Further, there are multiple efforts to re-orientate the healthcare system to focus more effectively on non-communicable diseases for the population which would benefit older patients with diabetes. Finally, the study includes a systematic review of peer and non-professional health worker-led diabetes self-management programmes (COMP-DSMP) in low and middle-income country primary health care settings, and also examines the implementation strategies and associated diabetes-related health outcomes This found equivocal evidence supporting the use of COMP-DSMP for people with diabetes in these countries and suggested that the models of a peer/CHW-led programme need to be further explored, especially given the inevitability of a professional healthcare workforce shortage in LMICs. In conclusion, this research study has described the extent of the need for developing and evaluating education programmes that focus on older people with diabetes and emphasises the role of family and friends. Whilst there have been some significant policy interventions pertaining to the protection of the health and welfare of older persons in SA, the needs of this vulnerable group remain relatively low on the list of priorities in terms of focus and resource allocation. In this context, older people, as a distinct group, are also not a strong focus in current health policy relating to the provision of NCD care. This thesis alerts policymakers and clinicians to some of the specific issues considered to be pertinent and important in the care and management of older persons with diabetes. Many of these would also be applicable to older individuals with other chronic conditions.
Open Access
Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study
(2020-06-26) Mutabazi, Jean Claude; Gray, Corie; Muhwava, Lorrein; Trottier, Helen; Ware, Lisa J; Norris, Shane; Murphy, Katherine; Levitt, Naomi; Zarowsky, Christina
Background Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. Methods A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. Results Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. Conclusions Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.
Open Access
Intervention development of a brief messaging intervention for a randomised controlled trial to improve diabetes treatment adherence in sub-Saharan Africa
(2021-01-15) Leon, Natalie; Namadingo, Hazel; Bobrow, Kirsty; Cooper, Sara; Crampin, Amelia; Pauly, Bruno; Levitt, Naomi; Farmer, Andrew
Background Brief messaging interventions, including Short Message Service (SMS) text-messages, delivered via mobile device platforms, show promise to support and improve treatment adherence. To understand how these interventions work, and to facilitate transparency, we need clear descriptions of the intervention development process. Method We describe and reflect on the process of designing and pretesting an evidence- and theory-informed brief messaging intervention, to improve diabetes treatment adherence in sub-Saharan Africa. We followed the stepwise approach recommended by the Medical Research Council, United Kingdom (MRC UK) Framework for Development and Evaluation of Complex Health Interventions and guidance for mobile health intervention development. Results We used a four-phase, iterative approach that first generated primary and secondary evidence on the lived experience of diabetes, diabetes treatment services and mobile-phone use. Second, we designed a type 2 diabetes-specific, brief text-message library, building on our previous hypertension text-message library, as well as drawing on the primary and secondary data from phase one, and on expert opinion. We then mapped the brief text-messages onto behaviour change (COM-B) theoretical constructs. Third, we refined and finalised the newly developed brief text-message library through stakeholder consultation and translated it into three local languages. Finally, we piloted the intervention by pre-testing the automated delivery of the brief text-messages in the trial sites in Malawi and South Africa. The final SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention was tested in a randomised controlled trial in Malawi and South Africa (trial registration: ISRCTN70768808 ). Conclusion The complexity of public health interventions requires that we give more attention to intervention development work. Our documentation and reflection on the StAR2D intervention development process promotes transparency, replicability, assessment of intervention quality, and comparison with other studies.