Browsing by Author "Myer Benjamin"

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    Open Access
    An Evaluation of Diagnostic Approaches for Gestational Diabetes Screening in South Africa
    (2024) Mennen, Mathilda; Madlala, Hlengiwe; Myer Benjamin
    Background: Gestational diabetes mellitus (GDM) poses substantial risks to both mothers and their offspring. In South Africa, screening practices vary, and pregnant women are not screened universally due to resource constraints. This study investigates the implications of using point of-care (POC) capillary glucose measures for GDM screening and explores potential strategies to increase screening capacity by eliminating the reliance on central laboratory facilities or reducing the time spent at antenatal facilities for mothers. Objectives: The prevalence of GDM determined by venous blood glucose (VBG) measures obtained during 2-hour oral glucose tolerance tests (OGTTs) was compared to POC capillary glucose (CBG) tests with immediate results. The agreement between VBG and CBG measures was calculated across the whole cohort and in sub-groups, and the clinical and cost implications of each method explored. Methods: A secondary analysis was conducted on data collected from 400 pregnant participants who were enrolled at 24-28 weeks' gestation into a prospective cohort study at an antenatal clinic in Cape Town. Participants were screened for GDM using a gold-standard 75g OGTT and simultaneously underwent POC capillary glucose testing. GDM was diagnosed via each method according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. We calculated the sensitivity and specificity of CBG in detecting VBG-defined GDM at different thresholds and Bland-Altman analyses examined agreement between CBG and VBG. Results: The GDM prevalence was 7% among all participants, resulting from a prevalence of 6% among patients with no risk factors, and 8% among patients with risk factors. Four percent of the cohort was diagnosed with GDM despite having no risk factors. Most cases (96%) were diagnosed on fasting venous measures. Capillary measures overestimated the prevalence of GDM at IADPSG thresholds (25%) and had poor sensitivity (73%). Correlation between venous and capillary measures was lowest in the fasting state (r=0.22, p<0.001). Bland Altman analyses found the average agreement between methods to be lowest in the fasting state. 2 Conclusion: Capillary measures demonstrate poor correlation and agreement with venous measures at 24-28 weeks' gestation, particularly in the fasting state when almost all GDM cases are diagnosed. A fasting plasma glucose, if performed universally as a single measure, outperforms selective risk factor-based OGTT screening and fasting capillary blood glucose in terms of sensitivity and specificity, while reducing the overall number of laboratory-dependent glucose tests performed.
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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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    Identifying risk factors for traumatic injury (TBI) due to road traffic accidents (RTA) and strategies to reduce the burden of secondary brain injury
    (2025) Alberts, Kriste; Figaji, Anthony; Myer Benjamin
    Background: There is a major knowledge gap in South Africa about detailed risk factors contributing to TBI due to RTAs in children. The objectives of this study were to map the burden of disease and examine circumstantial and clinical information to inform potential intervention strategies. Methods: This was a descriptive study of patients with TBI admitted to the Red Cross War Memorial Children's Hospital in Cape Town, Western Cape. A retrospective analysis of basic demographic and clinical data were performed from a large database of children admitted with severe TBI. More detailed information about the circumstances of RTAs causing TBI were prospectively collected through interviews with caregivers. Findings: From a database of 511 paediatric patients with severe TBI (age 13 or less), 403 (78.9%) sustained injuries in RTAs, mostly as pedestrians (71.7%). Males were more often injured (66%) and the median age was 6.8 years. The median time from the accident to tertiary hospital admission was three hours, to obtaining a CT scan was 4.5 hours, and to ICU admission was nine hours. With respect to the circumstances of RTAs, 155 interviews were conducted of which 80.7% involved pedestrian incidents. In 34 incidents (22%), more than one person was injured. Among these, 19 involved parents, with 17 of them (89.5%) dying from their injuries. Among pedestrians, 62% were injured while crossing the road and 57.5% were unaccompanied by an adult. Most commonly, the injured first attended the nearest clinic or day hospital (46%) by travelling with a personal vehicle (53%). Local areas that experienced the most RTAs were Gugulethu (7.7%), Khayelitsha (5.3%) and Mitchells Plain (5.3%). Interpretation: The study indicates a high incidence of RTAs as a cause of TBI in South African children, particularly among pedestrians. The high rate of unaccompanied children crossing roads, suggests a need for improved road safety education and adult supervision. The clustering of RTAs in specific local communities' points to the need for targeted interventions in highrisk locations. The high mortality rate among parents involved in RTAs with their children underscores the broader impact of these accidents on families and communities. Funding: This work was supported by the University of Cape Town Postgraduate Funding Office and the Paediatric Neurosurgery Unit.