Browsing by Author "Peer, Nasheeta"

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    Cardiovascular disease risk factors in the urban black population in Cape Town
    (2013) Peer, Nasheeta; Steyn, Krisela; Levitt, Dinky
    Includes abstract. Includes bibliographical references.
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    Co-morbid cardiometabolic diseases among people living with HIV/AIDS in Cameroon
    (2024) Ebasone, Peter Vanes; Kengne, Andre Pascal; Peer, Nasheeta; Dzudie, Anastase
    Background and Purpose: To investigate the effects and mediators of HIV infection and related treatment on the prevalence and incidence of cardiometabolic diseases (CMDs) including hypertension, type 2 diabetes mellitus (T2D), and obesity in people living with HIV (PLWH) in Cameroon. Additionally, three systematic reviews were conducted to assess the global prevalence of hypertension, T2D, and obesity among ART-naïve PLWH; and to evaluate the methodological approaches to mediation analysis and handling missing data in studies on CMDs in PLWH. Methods: The study utilized data from 14,279 PLWH enrolled in the Cameroon arm of the International Epidemiology Databases to Evaluate AIDS (IeDEA). Analyses comprised multinomial and binomial logistic regressions, causal mediation analysis, and Cox proportional hazards regression. Systematic reviews were conducted by searching multiple databases, pooling the prevalence rates of hypertension, T2D, and obesity using a random-effects meta-analysis. Results: In Cameroon, significant determinants of hypertension and T2D included age over 50 years, male sex, and overweight/obesity. ART use was linked to lower odds of T2D, and BMI partially mediated the relationship between ART use and hypertension. Prevalence of overweight/obesity was 37.7% overall, and higher in females. Older age, female sex, and higher CD4 count were associated with increased odds of overweight/obesity, while current smoking was linked to reduced odds. The incidence rate of hypertension was 121.1 per 1,000 person-years, with older age, male sex, and overweight/obesity as predictors. ART exposure reduced the risk of hypertension. The systematic review with meta-analysis revealed a global prevalence of 13.6% for hypertension, 4.0% for T2D, and 12.3% for obesity among ART-naïve PLWH. The review on mediation analysis showed increased adoption of casual mediation frameworks but inconsistencies in reporting. The missing data review revealed both under reporting of missing data and how it was handled. Conclusion: The burden of CMDs in PLWH is significant, driven mainly by established risk factors. emphasizing the need for integrated healthcare strategies that address both HIV/AIDS and CMDs. It also underscores the importance of methodological rigor, which significantly impacts the interpretation and reliability of results.
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    The converging burdens of infectious and non-communicable diseases in rural-to-urban migrant Sub-Saharan African populations: a focus on HIV/AIDS, tuberculosis and cardio-metabolic diseases
    (Biomed Central Ltd, 2015) Peer, Nasheeta
    Africa has the unenviable challenge of dealing with a double burden of disease: infectious diseases (IDs) such as HIV/AIDS and tuberculosis are high while non-communicable diseases (NCDs) are rapidly rising in the region. Populations with increased susceptibility to both include migrants. This review highlights the susceptibility of rural-to-urban migrants in Sub-Saharan Africa to the IDs of HIV/AIDS and tuberculosis, and to NCDs, particularly cardiovascular diseases. The disruption that occurs with migration is often accompanied by unhealthy exposures and environments. These include partaking in risky sexual practices and a subsequent greater risk for HIV infection in migrants than the general populations which contributes to the spread of the disease. Migrants frequently work and live in conditions that are poorly ventilated and overcrowded with suboptimal sanitation which increases their risk for tuberculosis. Considering that migrants have an increased risk of acquiring both HIV/AIDS and tuberculosis, and in view of the interaction between these diseases, they are likely to be at high risk for co-infection. They are also likely to facilitate the geographical spread of these infections and serve as conduits of disease dissemination to rural areas. Changes in lifestyle behaviours that accompany migration and urbanisation are exemplified primarily by shifts in physical activity and dietary patterns which promote the development of obesity, diabetes, hypertension and cardiovascular diseases. Urban living and employment is generally less physically exerting than rural routines; when migrants relocate from their rural residence they adapt to their new environment by significantly reducing their physical activity levels. Also, nutritional patterns among migrants in urban centres change rapidly with a shift to diets higher in fat, sugar and salt. Consequently, increases in weight, blood pressure and glucose levels have been reported within a year of migration. Interactions between IDs and NCDs are common; considering that migrants have an increased susceptibility to IDs and demonstrate a rapid rise in their risk for NCDs, the concurrent prevalence of both is likely in this population. There is a need for a combined strategy to combat IDs and NCDs with screening and treatment programmes geared towards this high risk group.
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    Determining the prevalence and optimising the diagnosis of metabolic syndrome in people living with HIV
    (2017) Nguyen, Kim Anh; Kengne, André Pascal; Peer, Nasheeta
    Background and Purpose: With the introduction of potent antiretroviral therapy (ART) leading to longevity, cardio-metabolic diseases are emerging health concerns in people living with HIV. This thesis aims to 1) to quantify the burden of metabolic syndrome (MS), which is a constellation of cardio-metabolic risk factors, in people living with HIV infection (PLWHIV) from a global perspective; and in ≥18-year-old PLWHIV receiving HIV-care in the Western Cape, South Africa to 2) determine the MS prevalence and the agreement between the popular MS diagnostic criteria, 3) assess the distribution of cardio-metabolic risk factor clustering by adiposity levels, 4) determine the optimal waist circumference (WC) thresholds, and 5) HbA1c to define abdominal obesity and dysglycaemia, respectively, for the purpose of MS screening in South African PLWHIV. Methods: A systematic review with meta-analysis was conducted to determine the MS prevalence globally. The main study comprised a representative cross-sectional study of PLWHIV receiving HIV-care at 17 public healthcare clinics across the Western Cape, South Africa. Results: The global prevalence of MS was 16.7%-31.3% by different diagnostic criteria with substantial heterogeneity not explained by major study characteristics. The prevalence was higher in women than in men (International Diabetes Federation [IDF]-2005, 23.2% vs. 13.4%, p=0.030), in antiretroviral therapy (ART) versus non-ART users (Adult Treatment Panel III [ATPIII]-2001, 18.4% vs. 11.8%, p=0.001), and varied significantly by participant's age, duration of HIV diagnosis, CD4 count level, ART regimens. In the study conducted in the Western Cape (N=748, median age 38 years), MS prevalence among PLWHIV was 28.2% (JIS-2009), 26.5% (IDF-2005), and 24.1% (ATPIII-2005), which was higher in women, participants with longer duration of diagnosed HIV infection, ART users not receiving 1st line regimen (all p≤0.039). There was a good agreement between sets of the criteria that was not affected by HIV-related factors (all kappa ≥0.81). Cardio-metabolic risk factors clustered across all categories of adiposity levels: 11.7% of normal-weight, and 15.1% of obese PLWHIV had two or more factors, and this distribution was not affected by HIV-specific features. The optimal WC thresholds for abdominal obesity were 92 cm (sensitivity 64%, specificity 64%) in women and 87 cm (sensitivity 48%, specificity 85%) in men, which differed from the internationally recommended 80 cm (women) and 94 cm (men). The optimal HbA1c thresholds to define oral glucose tolerance test diagnosed dysglycaemia was 5.75% (39.3 mmol/mol) (sensitivity 52%, specificity 85%), similar to the threshold of 5.7% (39 mmol/mol) recommended by the American Diabetes Association. The MS prevalence by the JIS was 28.2% and 29.7% using glucose-defined and HbA1c-defined dysglycaemia, with a good agreement between the original and modified criteria (kappa=0.81). Conclusions: The high prevalence of cardio-metabolic risk factor clustering in PLWHIV highlights the need for effective management strategies. Optimal performance of MS criteria in South African PLWHIV requires the use of the African-population-specific WC thresholds, while using HbA1c to diagnose dysglycaemia could be both effective and more practical than blood glucose defined dysglycaemia. However, these findings need to be confirmed and the effects of their introduction in routine care on healthcare behaviour and patient outcomes assessed through impact and implementation studies.
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    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.
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    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.
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    A meta-analysis of the Metabolic Syndrome prevalence in the global HIV-infected population
    (Public Library of Science, 2016) Nguyen, Kim A; Peer, Nasheeta; Mills, Edward J; Kengne, Andre P
    BACKGROUND: Cardio-metabolic risk factors are of increasing concern in HIV-infected individuals, particularly with the advent of antiretroviral therapy (ART) and the subsequent rise in longevity. However, the prevalence of cardio-metabolic abnormalities in this population and the differential contribution, if any, of HIV specific factors to their distribution, are poorly understood. Therefore, we conducted a systematic review and meta-analysis to estimate the global prevalence of metabolic syndrome (MS) in HIV-infected populations, its variation by the different diagnostic criteria, severity of HIV infection, ART used and other major predictive characteristics. METHODS: We performed a comprehensive search on major databases for original research articles published between 1998 and 2015. The pooled overall prevalence as well as by specific groups and subgroups were computed using random effects models. RESULTS: A total of 65 studies across five continents comprising 55094 HIV-infected participants aged 17-73 years (median age 41 years) were included in the final meta-analysis. The overall prevalence of MS according to the following criteria were: ATPIII-2001:16.7% (95%CI: 14.6-18.8), IDF-2005: 18% (95%CI: 14.0-22.4), ATPIII-2004-2005: 24.6% (95%CI: 20.6-28.8), Modified ATPIII-2005: 27.9% (95%CI: 6.7-56.5), JIS-2009: 29.6% (95%CI: 22.9-36.8), and EGIR: 31.3% (95%CI: 26.8-36.0). By some MS criteria, the prevalence was significantly higher in women than in men (IDF-2005: 23.2% vs. 13.4, p = 0.030), in ART compared to non-ART users (ATPIII-2001: 18.4% vs. 11.8%, p = 0.001), and varied significantly by participant age, duration of HIV diagnosis, severity of infection, non-nucleoside reverse transcriptase inhibitors (NNRTIs) use and date of study publication. Across criteria, there were significant differences in MS prevalence by sub-groups such as in men, the Americas, older publications, regional studies, younger adults, smokers, ART-naïve participants, NNRTIs users, participants with shorter duration of diagnosed infection and across the spectrum of HIV severity. Substantial heterogeneities across and within criteria were not fully explained by major study characteristics, while evidence of publication bias was marginal. CONCLUSIONS: The similar range of MS prevalence in the HIV-infected and general populations highlights the common drivers of this condition. Thus, cardio-metabolic assessments need to be routinely included in the holistic management of the HIV-infected individual. Management strategies recommended for MS in the general population will likely provide similar benefits in the HIV-infected.
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    Prevalence, concordance and associations of chronic kidney disease by five estimators in South Africa
    (2020-08-27) Peer, Nasheeta; George, Jaya; Lombard, Carl; Steyn, Krisela; Levitt, Naomi; Kengne, Andre-Pascal
    Abstract Background To determine the prevalence, distribution, concordance and associations of chronic kidney disease (CKD) determined by five glomerular filtration rate (GFR) formulae in urban black residents of Cape Town. Methods Data collection in this cross-sectional study included interviews, clinical measurements and biochemical analyses, including serum creatinine and cystatin C levels. GFR was based on the CKD Epidemiology Collaboration (CKD-EPI) equations (CKD-EPI creatinine (CKD-EPIcr), CKD-EPI cystatin C (CKD-EPIcys), CKD-EPI creatinine-cystatins (CKD-EPIcr-cys)), Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault formula (CGF). GFR < 60 mL/min/1.73 m2 defined CKD. Results Among 392 men and 700 women, mean GFR, was between 114.0 (CKD-EPIcr) and 135.4 mL/min/1.73 m2 (CGF) in men, and between 107.5 (CKD-EPIcr-cys) and 173.4 mL/min/1.73 m2 (CGF) in women. CKD prevalence ranged from 2.3% (CKD-EPIcr and MDRD) to 5.1% (CKD-EPIcys) in men and 1.6% (CGF) to 6.7% (CKD-EPIcr-cys) in women. The kappa statistic was high between CKD-EPIcr and MDRD (0.934), and CKD-EPIcys and CKD-EPIcr-cys (0.815), but fair-to-moderate between the other eqs. (0.353–0.565). In the basic regressions, older age and body mass index ≥30 kg/m2, but not gender, were significantly associated with CKD-EPIcr-defined CKD. In the presence of these three variables, hypertension, heart rate ≥ 90 beats/minute, diabetes and low-density lipoprotein cholesterol were significant predictors of prevalent CKD. Conclusions Varying CKD prevalence estimates, because of different GFR equations used, underscores the need to improve accuracy of CKD diagnoses. Furthermore, screening for CKD should be incorporated into the routine assessment of high-risk patients such as those with hypertension or diabetes.
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    Rising diabetes prevalence among urban-dwelling black South Africans
    (Public Library of Science, 2012) Peer, Nasheeta; Steyn, Krisela; Lombard, Carl; Lambert, Estelle V; Vythilingum, Bavanisha; Levitt, Naomi S
    Objective: To examine the prevalence of and the association of psychosocial risk factors with diabetes in 25-74-year-old black Africans in Cape Town in 2008/09 and to compare the prevalence with a 1990 study. Research Design and METHODS: A randomly selected cross-sectional sample had oral glucose tolerance tests. The prevalence of diabetes (1998 WHO criteria), other cardiovascular risk factors and psychosocial measures, including sense of coherence (SOC), locus of control and adverse life events, were determined. The comparison of diabetes prevalence between this and a 1990 study used the 1985 WHO diabetes criteria. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%). The age-standardised (SEGI) prevalence of diabetes was 13.1% (95% confidence interval (CI) 11.0-15.1), impaired glucose tolerance (IGT) 11.2% (9.2-13.1) and impaired fasting glycaemia 1.2% (0.6-1.9). Diabetes prevalence peaked in 65-74-year-olds (38.6%). Among diabetic participants, 57.9% were known and 38.6% treated. Using 1985 WHO criteria, age-standardised diabetes prevalence was higher by 53% in 2008/09 (12.2% (10.2-14.2)) compared to 1990 (8.0% (5.8-10.3)) and IGT by 67% (2008/09: 11.7% (9.8-13.7); 1990: 7.0% (4.9-9.1)). In women, older age (OR: 1.05, 95%CI: 1.03-1.08, p<0.001), diabetes family history (OR: 3.13, 95%CI: 1.92-5.12, p<0.001), higher BMI (OR: 1.44, 95%CI: 1.20-1.82, p = 0.001), better quality housing (OR: 2.08, 95%CI: 1.01-3.04, p = 0.047) and a lower SOC score (≤40) was positively associated with diabetes (OR: 2.57, 95%CI: 1.37-4.80, p = 0.003). Diabetes was not associated with the other psychosocial measures in women or with any psychosocial measure in men. Only older age (OR: 1.05, 95%CI: 1.02-1.08, p = 0.002) and higher BMI (OR: 1.10, 95%CI: 1.04-1.18, p = 0.003) were significantly associated with diabetes in men. CONCLUSIONS: The current high prevalence of diabetes in urban-dwelling South Africans, and the likelihood of further rises given the high rates of IGT and obesity, is concerning. Multi-facetted diabetes prevention strategies are essential to address this burden.
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    Temporal changes in the cardiometabolic disease risk profile of the Bellville south mixed-ancestry community between 2008/09 AND 2014/16
    (2022) Davids, Saarah Fatoma Gadija; kengne, Andre; Matsha, Tandi Edith; Peer, Nasheeta
    Background/purpose: The burden of cardiovascular disease (CVD) is growing rapidly and has shifted from high-income countries to low-middle income countries, including South Africa. In the South African Mixed-ancestry population, there is a dearth of trend studies examining the changes in cardiometabolic risk factors and their behavioural, socio-demographic, and lifestyle determinants. This thesis aimed to determine the temporal changes between 2008/09 and 2014/16 in (1) absolute blood pressure levels and hypertension prevalence; (2) distribution and change in obesity or body size phenotypes; and (3) the prevalence of insulin resistance (IR), inflammatory biomarkers, and their determinants. Methodology: Participants, aged ≥20 years, residing in Bellville South and Belhar, Cape Town, were recruited in two independent cross-sectional surveys conducted during 2008/09 (N=928) and 2014/16 (N=1969). Data were obtained through questionnaires, clinical measurements (anthropometric measurements and BP), and biochemical assessments (oral glucose tolerance tests, lipid profile, and sub-clinical inflammation markers). Obesity phenotype was defined using a combination of body mass index (BMI) categories and abnormal cardiometabolic status. The latter was defined as the presence of ≥ 2 cardiometabolic risk factors. Indices used to assess IR included: insulin fasting, HOMA-IR, QUICKI, McAuley and Matsuda. Biomarkers defining sub-clinical inflammation included Ultra-Sensitive-C-Reactive Protein (usCRP) and gamma-glutamyl transferase (gamma GT). Statistical packages used for data analysis were Statistica v.13 (TIBCO Software Inc., 2017) and SPSS v.25 (IBM Corp, 2011). Measures of central tendencies and dispersion characteristics are reported to summarize survey data. The crude and age standardised prevalence of hypertension were compared across years. With regards to obesity phenotype, IR, and sub-clinical inflammation, change in the distribution was investigated using interaction tests across the years of study. Linear and logistic regression analyses adjusted for year of study, age, and gender, were applied for all three studies. Results: Participants were older in 2008/09 (54.3 years) compared to 2014/16 (49.6 years), the majority (>75%) of whom were female. Mean systolic blood pressure increased from 124 to 136 mmHg and mean diastolic blood pressure from 75 to 85 mmHg over the 7-year period. The prevalence of newly detected hypertension increased from 11.6% to 24.8% and remained significant after adjusting for confounding variables. Importantly, there was a shift in the peak prevalence of hypertension from older ages (≥ 70 years) in 2008/09 to younger individuals (40-49 years) in 2014/16. The BMI distribution between 2008/09 vs 2014/16 improved significantly with decreases in overweight (27.4% vs 23.6%) and obese (45.3% vs 42.2%) participants (p=0.001). However, across all BMI categories in both metabolic healthy and abnormal participants, anthropometric and biochemical measurements, and glucose and lipid profiles linearly increased (all p ≤ 0.018 for linear trends). Over the 7-year period, there was an increase in the prevalence of sub-clinical inflammation: us-CRP (54.7% vs 57.1%) and gamma-GT (29.6% vs 33.4%). Furthermore, multivariable analyses revealed that obesity levels, glycated haemoglobin, and fasting insulin levels were prominent risk factors associated with increased IR or subclinical inflammation, after adjusting for confounding variables. Conclusion: A significant increase in hypertension prevalence was uncovered with a rightward shift in absolute BP. The majority of these increases were amongst newly detected hypertension, suggesting a non-optimal detection of the disease. Therefore, increased awareness and screening drives for hypertension detection is crucial to reduce the prevalence of hypertension in this population group. Complications and nominal costs related to severity of hypertension must be incorporated on a greater scale than is currently practised in order to manage and prevent CVD development. A significant proportion of normal weight participants presented with metabolic abnormalities, while a substantial percentage of obese participants presented as metabolically healthy. Additional research is required to improve risk stratification for obesity phenotypes. Additionally, sub-clinical inflammation increased over the seven-year period, and was linked to strong predictors of CVDs, i.e., IR and metabolic syndrome components. Therefore, before substantial changes in CVD are observed in the population, monitoring the pathophysiological development of sub-clinical inflammation and IR biomarkers may provide early information on the trajectory of CVD burden.
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    The effectiveness of peer and community health worker-led self-management support programs for improving diabetes health-related outcomes in adults in low- and-middle-income countries: a systematic review
    (2020-06-06) Werfalli, Mahmoud; Raubenheimer, Peter J; Engel, Mark; Musekiwa, Alfred; Bobrow, Kirsten; Peer, Nasheeta; Hoegfeldt, Cecilia; Kalula, Sebastiana; Kengne, Andre P; Levitt, Naomi S
    Objective Community-based peer and community health worker-led diabetes self-management programs (COMP-DSMP) can benefit diabetes care, but the supporting evidence has been inadequately assessed. This systematic review explores the nature of COMP-DSMP in low- and middle-income countries’ (LMIC) primary care settings and evaluates implementation strategies and diabetes-related health outcomes. Methods We searched the Cochrane Library, PubMed-MEDLINE, SCOPUS, CINAHL PsycINFO Database, International Clinical Trials Registry Platform, Clinicaltrials.gov, Pan African Clinical Trials Registry (PACTR), and HINARI (Health InterNetwork Access to Research Initiative) for studies that evaluated a COMP-DSMP in adults with either type 1 or type 2 diabetes in World Bank-defined LMIC from January 2000 to December 2019. Randomised and non-randomised controlled trials with at least 3 months follow-up and reporting on a behavioural, a primary psychological, and/or a clinical outcome were included. Implementation strategies were analysed using the standardised implementation framework by Proctor et al. Heterogeneity in study designs, outcomes, the scale of measurements, and measurement times precluded meta-analysis; thus, a narrative description of studies is provided. Results Of the 702 records identified, eleven studies with 6090 participants were included. COMP-DSMPs were inconsistently associated with improvements in clinical, behavioural, and psychological outcomes. Many of the included studies were evaluated as being of low quality, most had a substantial risk of bias, and there was a significant heterogeneity of the intervention characteristics (for example, peer definition, selection, recruitment, training and type, dose, and duration of delivered intervention), such that generalisation was not possible. Conclusions The level of evidence of this systematic review was considered low according to the GRADE criteria. The existing evidence however does show some improvements in outcomes. We recommend ongoing, but well-designed studies using a framework such as the MRC framework for the development and evaluation of complex interventions to inform the evidence base on the contribution of COMP-DSMP in LMIC.
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    Trends in adult tobacco use from two South African demographic and health surveys conducted in 1998 and 2003
    (2009) Peer, Nasheeta; Bradshaw, Debbie; Laubscher, Ria; Steyn, Krisela
    Introduction: Since tobacco use peaked in the early 1990s in South Africa, it has declined significantly. This reduction has been attributed to the government’s comprehensive tobacco control policies that were introduced in the 1990s. Objective: To assess the pattern of tobacco use between the South African Demographic and Health Surveys in 1998 and 2003. Methods: Multi-stage sampling was used to select approximately 11 000 households in cross-sectional national surveys. Face-to-face interviews, conducted with 13 826 adults (41% men) aged ≥15 years in 1998 and 8 115 (42% men) in 2003, included questions on tobacco use according to the WHO STEP-wise surveillance programme. Logistic regression analysis was used to assess the independent effects of selected characteristics on smoking prevalence. Results: Daily or occasional smoking prevalence among women remained unchanged at 10-11%; among men it decreased from 42% (1998) to 35% (2003). The decline for men was significant among the poorest and those aged 25-44 years. Strong age patterns were observed, peaking at 35-44 years, which was reduced for men in 2003. Higher income and education were associated with low prevalence of smoking while living in urban areas was associated with higher rates. African men and women smoked significantly less than other population groups. Conclusion: Despite decreasing smoking rates in some subgroups, a gap exists in the efforts to reduce tobacco use as smoking rates have remained unchanged in women and young adults, aged 15-24 years.