Browsing by Author "Siegfried, Nandi"
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- ItemOpen AccessComparison of an interactive with a didactic educational intervention for improving the evidence-based practice knowledge of occupational therapists in the public health sector in South Africa: a randomised controlled trial(2014-06-10) Buchanan, Helen; Siegfried, Nandi; Jelsma, Jennifer; Lombard, CarlBackground: Despite efforts to identify effective interventions to implement evidence-based practice (EBP), uncertainty remains. Few existing studies involve occupational therapists or resource-constrained contexts. This study aimed to determine whether an interactive educational intervention (IE) was more effective than a didactic educational intervention (DE) in improving EBP knowledge, attitudes and behaviour at 12 weeks. Methods: A matched pairs design, randomised controlled trial was conducted in the Western Cape of South Africa. Occupational therapists employed by the Department of Health were randomised using matched-pair stratification by type (clinician or manager) and knowledge score. Allocation to an IE or a DE was by coin-tossing. A self-report questionnaire (measuring objective knowledge and subjective attitudes) and audit checklist (measuring objective behaviour) were completed at baseline and 12 weeks. The primary outcome was EBP knowledge at 12 weeks while secondary outcomes were attitudes and behaviour at 12 weeks. Data collection occurred at participants’ places of employment. Audit raters were blinded, but participants and the provider could not be blinded. Results: Twenty-one of 28 pairs reported outcomes, but due to incomplete data for two participants, 19 pairs were included in the analysis. There was a median increase of 1.0 points (95% CI = -4.0, 1.0) in the IE for the primary outcome (knowledge) compared with the DE, but this difference was not significant (P = 0.098). There were no significant differences on any of the attitude subscale scores. The median 12-week audit score was 8.6 points higher in the IE (95% CI = -7.7, 27.0) but this was not significant (P = 0.196). Within-group analyses showed significant increases in knowledge in both groups (IE: T = 4.0, P <0.001; DE: T = 12.0, P = 0.002) but no significant differences in attitudes or behaviour. Conclusions: The results suggest that the interventions had similar outcomes at 12 weeks and that the interactive component had little additional effect.
- ItemOpen AccessComparison of an interactive with a didactic educational intervention for improving the evidence-based practice knowledge of occupational therapists in the public health sector in South Africa: a randomised controlled trial(2014-06-10) Buchanan, Helen; Siegfried, Nandi; Jelsma, Jennifer; Lombard, CarlAbstract Background Despite efforts to identify effective interventions to implement evidence-based practice (EBP), uncertainty remains. Few existing studies involve occupational therapists or resource-constrained contexts. This study aimed to determine whether an interactive educational intervention (IE) was more effective than a didactic educational intervention (DE) in improving EBP knowledge, attitudes and behaviour at 12 weeks. Methods A matched pairs design, randomised controlled trial was conducted in the Western Cape of South Africa. Occupational therapists employed by the Department of Health were randomised using matched-pair stratification by type (clinician or manager) and knowledge score. Allocation to an IE or a DE was by coin-tossing. A self-report questionnaire (measuring objective knowledge and subjective attitudes) and audit checklist (measuring objective behaviour) were completed at baseline and 12 weeks. The primary outcome was EBP knowledge at 12 weeks while secondary outcomes were attitudes and behaviour at 12 weeks. Data collection occurred at participants’ places of employment. Audit raters were blinded, but participants and the provider could not be blinded. Results Twenty-one of 28 pairs reported outcomes, but due to incomplete data for two participants, 19 pairs were included in the analysis. There was a median increase of 1.0 points (95% CI = -4.0, 1.0) in the IE for the primary outcome (knowledge) compared with the DE, but this difference was not significant (P = 0.098). There were no significant differences on any of the attitude subscale scores. The median 12-week audit score was 8.6 points higher in the IE (95% CI = -7.7, 27.0) but this was not significant (P = 0.196). Within-group analyses showed significant increases in knowledge in both groups (IE: T = 4.0, P <0.001; DE: T = 12.0, P = 0.002) but no significant differences in attitudes or behaviour. Conclusions The results suggest that the interventions had similar outcomes at 12 weeks and that the interactive component had little additional effect. Trial registration Pan African Controlled Trials Register PACTR201201000346141 , registered 31 January 2012. Clinical Trials NCT01512823 , registered 1 February 2012. South African National Clinical Trial Register DOH2710093067 , registered 27 October 2009. The first participants were randomly assigned on 16 July 2008.
- ItemOpen AccessEpidemiology, diagnosis and aspects of treatment in persons with serious mental illness and co-occurring substance use disorders(2019) Temmingh, Hendrik; Stein, Dan J; Siegfried, NandiBackground: Co-occurring substance use disorders (SUDs) occur in as many as half to three quarters of patients with severe mental disorders such as schizophrenia and bipolar disorder, a phenomenon also described as dual diagnosis. Past research from high income countries have shown that the presence of co-occurring SUDs are associated with a number of demographic and clinical factors, including worse clinical outcomes. Although the clinical profile and negative impact on prognosis has been well characterised in research on dual diagnosis samples from high income countries, little is known in the low- and middle-income country (LAMIC) context about the prevalence and factors associated with SUDs in patients with SMI, its clinical identification and diagnosis, as well as factors associated with its treatment. Objectives: In part-I of the thesis I investigate the clinical epidemiology of dual diagnosis by determining the prevalence of substance use disorders (SUDs) and its association with various clinical and demographic factors in two datasets, the first dataset containing data from a homogeneous sample of Xhosa South African patients with schizophrenia and the second dataset with data from a clinically more heterogeneous sample of patients with major affective and non-affective psychotic disorders. In part-II of the thesis I determine the psychometric properties of two Xhosa language versions of brief substance screening instruments, the Alcohol, Smoking and Substance Involvement Screening Test (WHO-ASSIST version 3) and the Severity of Dependence Scale (SDS), against a gold standard diagnostic instrument, the Structured Clinical Interview for DSM-IV-TR Axis I disorders (SCID-I for DSM-IV). In part-III of the thesis I examine aspects in the pharmacotherapy of dual diagnosis, firstly the association between methamphetamine use and extra-pyramidal medication side-effects (EPS) in patients treated with antipsychotics, and second in a systematic review, the efficacy of risperidone versus other antipsychotics for people with a dual diagnosis. Methods: This thesis consists of secondary analyses of two datasets (datasets#1 and dataset#2) and a Cochrane systematic review of existing randomised trials. Dataset#1 contains data from case-control study with the original aim of investigating the genomics of schizophrenia in the South African Xhosa population. Dataset#2 contains data collected in a cross-sectional manner from 3 studies; one study that investigating the presentation and psychobiology of psychosis, another which was a pilot randomised controlled trial of a text message treatment partner intervention and a third which was a neuroimaging and electrophysiological study of psychotic disorders. Across dataset #1 and #2, demographic information, clinical variables and psychotic and substance use disorder diagnoses were determined using the SCID-I for DSM-IV. In addition, for dataset #2 (conducted in a multi-cultural and ethnic population) we recorded self-identified ethnicity. For self-identified ethnic groups, the terms “Coloured” “Black” and “Caucasian” and “Other” (Asian), were not intended to reify sociocultural constructs but were instead used to study ongoing health disparities. Psychosocial Axis-IV problems were determined using a checklist from the SCID-I and legal involvement was determined using the legal section of the Addiction Severity Index (ASI). Functioning was determined with the global assessment of function, or GAF scale. The ASSIST and SDS instruments were used in a study based on data from dataset #1 investigating the psychometric properties of these screening tools. In turn, I investigated the relationship between methamphetamine use and medication related extra-pyramidal side effects (EPS) in a heterogeneous sample of patients with major affective and non-affective psychotic disorders (from dataset #2). For this study the Simpson Angus Scale for Parkinsonism (SAS), the Barnes Akathisia Rating Scale (BARS) and the Abnormal Involuntary Movement Scale (AIMS) were used to measure EPS. For the first two objectives, logistic regression modelling was used to determine factors associated with having a cooccurring SUD. For the validation study of the Xhosa language versions of the ASSIST and SDS, I determined the internal consistency, concurrent validity, and discriminant validity of these instruments and compared the sensitivity, specificity and the receiver operating characteristics (ROC) for the ASSIST and SDS. Logistic and ROC regression was used for the comparison of ROC area-under-the-curves for ASSIST versus SDS and for determining the impact of co-variates on ROC respectively. In part III, I determined the association between methamphetamine use and the presence of EPS using logistic regression. Finally, I conducted a Cochrane systematic review of randomised trials after a comprehensive literature search of several databases and duplicate study selection and data extraction. Where possible outcomes were pooled, and meta-analyses conducted using random effects models. Primary outcomes were changes in substance use and mental state. Secondary outcomes included substance craving, subjective-wellbeing, adherence, adverse effects, study retention, quality of life and mortality. Study selection, data extraction and quality appraisals were independently conducted. Random-effects meta-analysis was conducted, and the Cochrane risk of bias and GRADE approach used to assess evidence quality. Results: In both datasets#1 and #2, consisting of a total sample size of N=1420 (dataset#1) and N=248 (dataset#2) we found a high prevalence of lifetime SUDs (47.8% and 55.6%) in patients with schizophrenia and major affective or non-affective psychosis, respectively. In multivariable logistic models younger age, male gender, and legal involvement were significantly associated with co-occurring SUDs. Multiple substances were often used together, and SUDs were significantly correlated with one another. Methamphetamine use disorders were significantly more prevalent in the Western Cape province of South Africa and ethnic differences were also apparent with Coloured participants significantly more likely to use methamphetamine compared to Black participants. In addition, we found significant associations between post-traumatic stress symptoms, anxiety symptoms and suicidality and alcohol use disorders. Inpatient status and higher levels of prior admissions were associated with cannabis and methamphetamine use disorders. In a sample of 351 participants from dataset#1 who completed either the ASSIST (N=190), SDS (N=299), or both (n=138), good internal reliability was obtained for both the ASSIST-TSI (total substance involvement score) (Cronbach α= 0.77) and SDS (Cronbach α=0.80). The ASSIST and SDS demonstrated good concurrent validity (rs= 0.50, p 3 years were significantly more likely to have EPS. We found a significant interaction effect between MA use disorders and standardised antipsychotic dose on the occurrence of EPS (ORadj = 1.01, 95% CI= 1.00-1.01, p=0.042). There were no significant associations with EPS with comorbid alcohol, cannabis, or methaqualone use disorders. In the Cochrane systematic review of randomised controlled trials involving risperidone versus other antipsychotics for dual diagnosis, we identified eight trials containing a total of 1073 participants with SMI and co-occurring SUD. Seven trials contributed useable data to the review. Risperidone was compared to clozapine, olanzapine, perphenazine, quetiapine and ziprasidone. Only one study contained data comparing risperidone with a first-generation antipsychotic (perphenazine). Quality of the included studies varied from low to very low. Outcome data were frequently missing and little, or no data was reported in most studies for craving, subjective-wellbeing, metabolic disturbances, global impression of illness severity, quality of life or mortality. For risperidone versus clozapine we found no clear differences between these two antipsychotics in the reduction of positive psychotic symptoms or reduction in cannabis use, improvement in subjective well-being, numbers discontinuing medication, extrapyramidal side-effects or leaving the study early. Clozapine was associated with lower levels of craving for cannabis. For risperidone versus olanzapine we found no clear differences in the reduction of positive psychotic symptoms, reduction in cannabis use, craving for cannabis, parkinsonism, or leaving the study early. For risperidone versus perphenazine, quetiapine and ziprasidone respectively, we found no clear differences in the number of participants leaving the study early. Conclusion: In the context of a dearth of research into dual diagnosis in LAMIC countries such as South Africa, this thesis contains a large-scale epidemiological investigation into substance use comorbidity in patients with schizophrenia and other psychotic disorders. In addition, for the first time we determine the psychometric properties and validity of the Xhosa language ASSIST and SDS and systematically investigate the relationship between methamphetamine use and extra-pyramidal side effects in people with psychotic disorders treated with antipsychotics. For the first time we also conduct a systematic review of the efficacy of risperidone compared to other antipsychotics for a number of primary and secondary outcomes. Our findings have a number of implications for clinicians and services planners. Firstly, SUDs occur in at least half of the people schizophrenia and other psychotic disorders. Accurate detection of SUDs is possible using brief screening tools such as the ASSIST and SDS. Some populations such a younger male population may need particular attention. Moreover, assessment of patients will need to include current and past legal involvement as well as careful assessment of associated comorbid anxiety, post-traumatic symptomology and suicide risk. In patients with co-occurring methamphetamine use disorders clinicians should regularly assess for the development of EPS and carefully titrate antipsychotic dosage from lower to higher doses to avoid EPS. Currently there is not sufficient high-quality evidence favouring the superiority of risperidone over any other antipsychotic in people with SMI and co-occurring SUDs. Results of ongoing trials are awaited, and future trials need to use consistent methodologies and adhere to CONSORT reporting guidelines.
- ItemOpen AccessMeasuring evidence-based practice knowledge and skills in occupational therapy - a brief instrument(Biomed Central, 2015-10-30) Buchanan, HelenBackground: Valid and reliable instruments are required to measure the effect of educational interventions to improve evidence-based practice (EBP) knowledge and skills in occupational therapy. The aims of this paper are to: 1) describe amendments to the Adapted Fresno Test of Competence in EBP (AFT), and 2) report the psychometric properties of the modified instrument when used with South African occupational therapists. Methods: The clinical utility of the AFT was evaluated for use with South African occupational therapists and modifications made. The modified AFT was used in two studies to assess its reliability and validity. In Study 1 a convenience sample of 26 occupational therapists in private practice or government-funded health facilities in a South African province were recruited to complete the modified AFT on two occasions 1 week apart. Completed questionnaires were scored independently by two raters. Inter-rater, test-retest reliability and internal consistency were determined. Study 2 was a pragmatic randomised controlled trial involving occupational therapists in four Western Cape Department of Health district municipalities (n = 58). Therapists were randomised in matched pairs to one of two educational interventions (interactive or didactic), and completed the modified AFT at baseline and 12 weeks after the intervention. An intention-to-treat analysis was performed. Data were not normally distributed, thus non-parametric statistics were used. Results: In Study 1, 21 of 26 participants completed the questionnaire twice. Test-retest (ICC = 0.95, 95 % CI = 0.88–0.98) and inter-rater reliability (Time 1: ICC = 0.995, 95 % CI = 0.99–0.998; Time 2: ICC = 0.99, 95 % CI = 0.97–0.995) were excellent for total scores. Internal consistency based on time 1 scores was satisfactory (α = 0.70). In Study 2, 28 participants received an interactive educational intervention and completed the modified AFT at baseline and 12 weeks later. Median total SAFT scores increased significantly from baseline to 12-weeks (Z = −4.078, p < 0.001) with a moderate effect size (r = 0.55). Conclusion: The modified AFT has demonstrated validity for detecting differences in EBP knowledge between two groups. It also has excellent test-retest and inter-rater reliability. The instrument is recommended for contexts where EBP is an emerging approach and time is at a premium.
- ItemOpen AccessPractice-based evidence: evaluating the quality of occupational therapy patient records as evidence for practice(2016-04) Buchanan, Helen; Jelsma, Jennifer; Siegfried, NandiBackground: Occupational therapy patient records are required for legal purposes, but may also be used to produce evidence for practice. Our aim was to establish how comprehensively occupational therapists documented patient records. Methodology: We conducted a descriptive cross-sectional study of occupational therapists at public health facilities in a South African province. Trained raters audited five randomly-drawn records per participant using a checklist developed for the study. The maximum possible score was nine and the lowest was zero. Audits were checked for consistency. Results: Forty-nine occupational therapists participated and 240 records were audited. Records contained information on intervention (96%) and changes occurring at impairment (82%) and activity and participation levels (64%). Documentation of baseline assessment (impairment level: 20%; activity and participation level: 10.4%) and re-assessment (impairment level: 7%; activity and participation level: 0.0%) was limited. Audit scores were significantly better in the work practice area (H=16.10, p=0.003) and among therapists in urban areas (U=24.50, p<0.001).There was a significant negative correlation between audit score and number of clients seen per month (rs=-0.46, p<0.001). Conclusion: The low audit scores suggest that the records did not contain sufficient information to produce robust evidence. Manageable ways of documenting occupational therapy practice need to be devised.
- ItemOpen AccessRandomized controlled trials of HIV/AIDS prevention and treatment in Africa: results from the Cochrane HIV/AIDS Specialized Register(Public Library of Science, 2011) Zani, Babalwa; Pienaar, Elizabeth D; Oliver, Joy; Siegfried, NandiIntroduction To effectively address HIV/AIDS in Africa, evidence on preventing new infections and providing effective treatment is needed. Ideally, decisions on which interventions are effective should be based on evidence from randomized controlled trials (RCTs). Our previous research described African RCTs of HIV/AIDS reported between 1987 and 2003. This study updates that analysis with RCTs published between 2004 and 2008. Objectives To describe RCTs of HIV/AIDS conducted in Africa and reported between 2004 and 2008. METHODS: We searched the Cochrane HIV/AIDS Specialized Register in September 2009. Two researchers independently evaluated studies for inclusion and extracted data using standardized forms. Details included location of trials, interventions, methodological quality, location of principal investigators and funders. RESULTS: Our search identified 834 RCTs, with 68 conducted in Africa. Forty-three assessed prevention-interventions and 25 treatment-interventions. Fifteen of the 43 prevention RCTs focused on preventing mother-to-child HIV transmission. Thirteen of the 25 treatment trials focused on opportunistic infections. Trials were conducted in 16 countries with most in South Africa (20), Zambia (12) and Zimbabwe (9). The median sample size was 628 (range 33-9645). Methods used for the generation of the allocation sequence and allocation concealment were adequate in 38 and 32 trials, respectively, and 58 reports included a CONSORT recommended flow diagram. Twenty-nine principal investigators resided in the United States of America (USA) and 18 were from African countries. Trials were co-funded by different agencies with most of the funding obtained from USA governmental and non-governmental agencies. Nineteen pharmaceutical companies provided partial funding to 15 RCTs and African agencies co-funded 17 RCTs. Ethical approval was reported in 65 trials and informed consent in 61 trials. CONCLUSION: Prevention trials dominate the trial landscape in Africa. Of note, few principal investigators and funders are from Africa. These findings mirror our previous work and continue to indicate a need for strengthening trial research capacity in Africa.
- ItemOpen AccessResearch synthesis and dissemination as a bridge to knowledge management: The Cochrane Collaboration(2004) Volmink, Jimmy; Siegfried, Nandi; Robertson, Katharine; Gülmezoglu, MetinIn the current information age, research synthesis is a particularly useful tool for keeping track of scientific research and making sense of the large volumes of frequently conflicting data derived from primary studies. The Cochrane Collaboration is a global initiative "to help people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions". In this paper we set the work of the Cochrane Collaboration in historical perspective, explain what a Cochrane review is, and describe initiatives for promoting worldwide dissemination of synthesized information. We also consider emerging evidence of the Cochrane Collaboration's impact on health-care practice, policy, research, and education. Finally, we highlight the need for increased investment in the preparation and maintenance of Cochrane reviews, particularly those that address health issues that are relevant to people living in low- and middle-income countries.