Browsing by Subject "family medicine"

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    A multi-state model of treatment states in an antiretroviral treatment programme cohort in Cape Town
    (2022) Moolla, Haroon; Johnson, Leigh F
    Introduction A recent systematic review estimated that almost a quarter of patients in low- and middle-income countries are not retained on antiretroviral treatment (ART) beyond one year. Further, it is difficult to determine whether a patient who is not retained in care has interrupted their treatment, transferred to another treatment facility, or died. Previous studies have been deterministic in classifying loss to follow-up and treatment interruption. This study investigates treatment interruption and resumption rates when accounting for uncertainty in the occurrence of interruptions. The primary objective is to estimate the rate at which ART is interrupted and the rate at which ART is resumed after an interruption. Methods We fitted a multi-state model to data from the Khayelitsha cohort of the International Epidemiologic Databases to Evaluate AIDS. Between 2001 and 2012, 6796 adult patients starting ART were included. Potential treatment interruption periods were defined between contact points 3 or more months apart. To aid the model in determining if a patient truly interrupted treatment a CD4 count model was used. CD4 counts were modelled to drop to baseline by 3 months after the start of a treatment interruption. Bayesian estimation and Markov chain Monte Carlo were used to obtain posterior distributions of parameters. Several scenarios were used in sensitivity testing, including varying the threshold used to define potential treatment interruption periods, and either adjusting or excluding the data of those with CD4 counts that drop below baseline. Results The baseline annual rate of treatment interruption had a posterior mean of 0.060 (95% CI 0.038- 0.087) which is significantly lower than the prior distribution that had a mean of 0.145 (95% CI 0.080-0.229). The posterior distribution of the baseline annual rate of treatment resumption (mean 1.09; 95% CI 0.68-1.65) was consistent with the prior distribution (mean 1.46; 95% CI 0.21-3.90). The posterior distributions of the parameters related to treatment interruption and resumption did not change significantly in sensitivity testing. Conclusion This study indicates that treatment interruption rates may be significantly lower than previously estimated. The methodology of this study may be useful to those measuring retention within ART programmes. An important limitation was that the CD4 count model did not allow for CD4 counts to fall below baseline during periods of treatment interruption. This limits the generalisability of the posterior estimates of the parameters of the CD4 count model. Further research may require a more flexible CD4 count model.
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    A study of the association of prenatal inflammatory diet and adverse infant birth outcomes in a birth cohort in Uganda
    (2022) Ndlovu, Davies; Lesosky, Maia
    Background: Low birth weight (LBW) and low infant lung capacity among others are risk factors for childhood and adulthood chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma. These respiratory diseases are among the leading causes of death and disability worldwide. The aetiology of these respiratory diseases and other inflammatory conditions has recently been linked to maternal diet during pregnancy. As such it has been important to study the role of maternal diet during pregnancy to find any association with maternal and infant outcomes. Highly diverse diets have been thought to be a proxy to maternal nutrient adequacy as well as healthy diet. Diverse diets may offer protection from inflammatory airway diseases and other inflammatory diseases by evening out inflammatory and anti-inflammatory food components. Purpose: To investigate the effect of Dietary diversity (DD) and Dietary inflammatory index (DII), on infant birth outcomes particularly birth weight and lung function and to determine if there is any association. Methods: In this study we analysed data obtained from 564 women who attended antenatal care facilities in Kalungu district of rural Uganda. These women were recruited by convenience sampling as they walked into the facilities for antenatal care. Those who gave consent were asked about their diets and socioeconomic statuses by means of questionnaires. Infant outcomes were measured by healthcare professionals at presentation for postnatal care at 6 weeks ofage. Dietary scores were created as the number of unique food groups obtained from the data collected. The scores ranged from 0-14, with 14 representing those who consumed all 14 unique food groups identified in the study. Dietary inflammatory index was also calculated from the data obtained. The methods for calculating the DII will be explained in detail under methods. The data collection for this purpose was based on 24hr recall. Results: The mean Dietary Diversity score was 4.61 +/- 1.79 SD. In the previous 24 h, 84.8% of the participating women had consumed tubers such as cassava, 57.1% reported consuming grains or cereal, 12.6% vegetables, 19.3% Fruits, 1.2% meat and 7.4% eggs. There were statistically significant differences in dietary practices of the women according to their level of education, with 81% of those who attained tertiary education having adequate dietary diversity. Starches were the most consumed food group with an average of 16 servings per week while meat, processed starches (samosas, etc), fruits and vegetables were consumed at=<2 serving per week, with meat the least consumed at an average of less than 1 serving per week. Although marginal, the diets of the participants were mostly anti-inflammatory with an average dietary inflammatory score of -1.2. Those with the lowest inflammatory score were associated with more servings of legumes, green leafy vegetables, fish and less servings of processed starches and animal oil. There was no association observed between dietary diversity and infant birth outcomes, birth weight and lung function. No association was also observed between Dietary inflammatory scores and infant lung function.
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    Assessing socio-economic inequalities in the use of antenatal care in the Southern African Development community
    (2019) Selebano, Keolebogile Mable; Ataguba, John
    Introduction Despite the unprecedented efforts of national governments along with various NGOs to achieve the third SDG, which is to reduce global maternal mortality to less than 70 per 100 000 live births by 2030, developing countries seem to be lagging far behind in reaching this goal (UNDP, 2016). This paper focuses on socioeconomic inequalities in the use of ANC services as an important aspect of MHC in SADC countries. Methods The data used in this study are obtained from the Demographic and Health Survey (DHS). Three mutually exclusive variables were created to assess ANC inequality, namely, 1) No ANC visits 2) Less than four ANC visits and 3) At least four ANC visits. A fourth variable that assesses the actual number of ANC visits that a pregnant woman had received was created and called 'Intensity’. ANC and SES using the wealth index were used to construct the concentration curves and indices to determine whether health care utilization is concentrated among the poor or the rich. Results Over 70% of all who lived in rural areas had '0 ANC’, with Namibia and Tanzania as the only exception to this finding. In four of the eleven countries, over 58.36% of women were married and were likely to make an adequate number of ANC visits. Namibia and Lesotho are two of the eleven countries that had a great majority of women educated up to the secondary level, 65.61% and 49.90% of which attained at least 4 ANC visits, respectively. Women who worked in agricultural settings had the least likelihood of attaining any ANC visits. Discussions and conclusion ANC use was consistently lower in women with no education, doing agricultural work and those residing in rural areas in the SADC region. Overall, marriage is inconclusive in determining ANC use. Inequality in wealth makes ANC utilization more predominant among the rich. Saving mothers and babies is ultimately saving the population and knowledge of the patterns of maternal health usage is imperative to draw relevant policies that are evidence based.
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    Co-occurrence of shedding Herpes Simplex Virus type-2 (HSV-2), Human Papilloma Virus (HPV) and Human Immunodeficiency Virus 1 (HIV-1) in the female genital tract among HIV-infected women
    (2019) Hu, Nai-Chung; Myer, Landon; Todd, Catherine S
    Introduction: Human Immunodeficiency Virus remains as one of the largest pandemics in the world, with the prevalence of more than 70% of HIV-infected individual reside in Sub-Saharan Africa. Moreover, other sexually transmitted viral infection such as Human Papillomavirus and Herpes Simplex Virus also show a high prevalence in Sub-Saharan Africa. Recent studies show the presence of other viral STI in the genital region may have increased HIV shedding in the genital region. However, it not clearly known if the presence of ART or HIV may affect the shedding of other viral STI in the genital region and if the combination of other viral STI treatment and ART is necessary to treat an individual with multiple STI infection. Methods: This is a secondary data analysis study, based on analysing the data collected from a single-site, double-blinded randomized control study (2-IUD study). The research site was the Gugulethu Community Health Centre, Cape Town, South Africa and samples were collected between 2014 and 2018. Analysis was conducted on genital tract specimens of study participants obtained via the Menstrual Cup (MC) and Endocervical Swabs (ECS), collected at baseline, 3 and 6 months’ follow up visit from randomly selected 52 ART-Naïve participants and 56 age-matched women from the ART-Using group of the primary study. Logistic regression models were constructed to measure the associations between possible risk factors and viral STIs. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results: ART-Naïve women had higher rates of HIV shedding in the genital tract at each visit. However, more than half of women using ART, most of them virally suppressed, had detectable genital HIV at one or more visits. Most of the participants showed pre-exposure to HSV-2, but shedding of HSV-2 was substantially less common. HPV was detected in 72% of the participants, with no significant difference by ART status. Overall, 70.3% of samples had at least one viral pathogen detected - 60.4% among ART-Using women compared to 82.8% in ART-Naïve women (P<0.001). Compared to ART-Naïve women, ART-Using women were significantly less likely to have co-occurrence of viral shedding overall. However, ART-Using women with higher VL had levels of viral co-occurrence similar to those of ART-Naïve women. Conclusion: Our analysis demonstrated that the ART-Using women were less likely to shed HIV, HSV-2, HPV and viral STI co-infection in the genital tract compared to ART-Naïve women. This may be be driven by plasma VL levels where ART-Using women with lower VL are less likely to shed these viruses compared to women with elevated VL, including those not on ART.
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    Communication and collaboration: an exploration of clinical governance Interventions in the Western Cape Department of Health over the past twenty years
    (2020) Singh, Yesheen; Gilson, Lucy
    Background: The tension between the increasing cost of healthcare provision and the need to provide a quality level of care to a rising number of people is a global phenomenon. A focus on one over the other could result in a rise in adverse patient outcomes, or a health system too costly to be sustainable. Clinical governance is an approach policymakers can use to walk the middle line of creating a healthcare service that meets quality of care standards in a cost-effective manner, as has been done in Australia, Burundi, Egypt, Spain, UK and Yemen (Goyet et al, 2019; Abd El Fatah et al, 2019, Mannion et al, 2015; Aguilar Martin et al, 2019). This study examines the practice of clinical governance in one LMIC setting that has been able to successfully do this balancing walk for 20 years. Understanding how this was done in the Western Cape province of South Africa helps inform how clinical governance can be used to continue adding value as the health system moves towards universal healthcare. In addition, this South African experience adds to the still small pool of relevant experience from low- and middle-income countries reported in the international literature. Methods: A mixed methods qualitative design was used for data collection and involved three phases: (1) a document review of all policies in the province to identify clinical governance structures; (2) observation of these structures in action, comparing lived to written experience of clinical governance; and (3) interviews with key stakeholders in the province to get their perspectives on past, present and future forms of clinical governance. The Donabedian model was used to frame analysis into three dimensions of care, viz. structure, process and outcome. Results: Beyond a comprehensive policy framework, collaborative structures and consultative leadership styles facilitated strengthened clinical governance in the Western Cape. For example, although corporate-governance-inspired structures, such as clinical audits and M&E events, may become punitive and corrosive, the potential negative impact on clinical governance outcomes and organisational culture was tempered by healthy communication and supportive relationships between colleagues. Family physicians have become the champions of clinical governance in a decentralized health system and when supported in this by policy and management, the quality of care in health systems thrive. Conclusions Clinical governance is an effective strategy or tool LMICs can use to ensure quality of care is maintained or improved upon, even in resource-challenged settings. But while some structures, processes and outcomes may be borrowed from other LMIC or HIC settings, these need to be contextualized to local conditions. Appropriate clinical governance champions need to be identified and given the appropriate mandate. Human relationships are key to the successful implementation of interventions of this nature and space needs to be created in policy for this to be cultivated.
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    Community systems strengthening project: the successes and challenges perceived and experienced in Gugulethu, South Africa
    (2022) Mautsa, Tafadzwa Forsina; London, Leslie; Olivier, Jill
    Community participation is an effective strategy for strengthening health systems and progressively realising health rights. For meaningful community participation to occur, the capacity of formal or informal community organisations and mechanisms involved in addressing social determinants of health needs to be strengthened. One way of doing this is through training. There is minimal research on the efforts of community structures set up to address social determinants of health and health needs in communities, following training to strengthen their capacity. This study sought to evaluate the successes and challenges of a particular Community Systems Strengthening Project which, between 2016 and 2019, set out to train health committee members and community health activists in Gugulethu, South Africa. In so doing, it investigated whether and how the health committee members and Community Health Activists assumed an activist role in the community and are engaging in meaningful community participation. A mixed methods evaluative study was conducted in two phases during 2020-2021. The first phase was a scoping review of available literature, followed by an evaluative study including review of project documents, observation by attending events organised by the project and other community organisations, and in-depth interviews with health committee members (2), community health activists (4) and project staff (4). The training intervention was found to have influenced the health committee members and Community Health Activists thinking, understanding and practice in their community efforts to address social determinants of health. Therefore, adequate support, training, and an enabling environment can facilitate meaningful community participation in health. Ultimately, these measures will contribute to the progressive realisation of the right to health and the right to community participation, and ultimately health system transformation. The limited adaptability of the intervention, limited resources, participant perceptions and sustainability were found to be obstacles to meaningful community participation. This dissertation consists of two parts. The study protocol, Part A, outlines the rationale of undertaking this research and the proposed methods. Part B consists of the journal ready manuscript which presents the results and discussion of the research findings.
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    Conducting a cost analysis to address issues of budget constraints on the implementation of the indoor residual spray program. an intervention to control and eliminate Malaria in two districts of Maputo Province, Mozambique
    (2019) Canana, Neide Mércia de Orlando Hussene; Cleary, Susan
    Introduction: Over the past few years, the capacity of the government of Mozambique to sustain the cost of payment of salaries to operationalize the Indoor Residual Spray (IRS), a widely recommended tool to control and prevent malaria, is facing numerous challenges. This is due to recent restrictions of the Official Development Assistance (ODA), an external aid scheme and the main source of financing of the Mozambican government budget. Objective: The objective of this study was to estimate the cost of IRS operationalization activities in Matutuine and Namaacha districts health directorates, in Maputo Province, Mozambique. Methods: A cost analysis using an approach from the provider’s perspective was conducted in two district health directorates in the Maputo province, Matutuine and Namaacha. The institutions were purposely selected since in 2014 in both districts the expenditure on salaries to operationalize IRS was funded by the government budget. Cost information was collected retrospectively and both economic and financial costs were calculated. Uncertainty of results was tested using “one-way” deterministic sensitivity analysis. Results: The average total annual economic cost was 117,351.34 US$. The average economic cost per households sprayed totalled 16.35 US$. On average the economic costs per person protected is 4.09 US$ in total. In the financial analysis, the average total annual financial costs totalled 69,174.83 US$. The average financial cost per household sprayed and per person protected were 9.84 US$ and 2.46 US$ respectively. Vehicles, personnel salaries and consumables were the major substantial cost components. Conclusion: Setting aside the ODA restriction and focusing on the aim of implementing IRS within the existing resources, the study makessuggestions for improving efficiency by focusing on areas with a higher need and pays attention to cost drivers in order to reduce the costs.
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    Experiences and perceptions of participants and staff involved in HIV research in Gugulethu, South Africa
    (2019) Gomba, Yolanda; Colvin, Christopher; Trafford Zara
    It is important to understand the experiences and perceptions of HIV research from the perspectives of persons who have either participated in or worked on HIV research in lowresource settings. Obtaining such information is important because research in low-resource settings presents several ethical challenges that result in the vulnerability of participants due to factors such as low literacy levels, high rates of food insecurity and unemployment. Conducting research on the aforementioned can help researchers to design studies that mitigate some of the ethical challenges associated with conducting HIV research in lowresource communities. This dissertation adds on to existing literature on the experiences and perceptions of HIV research participants and staff involved in HIV research in low-resource settings. This dissertation is divided into three parts. Part A (Research protocol) discusses the importance of evaluating research participants’ experiences and perceptions of HIV studies conducted in lowresource settings. The section also outlines the purpose of the study, research questions, methodology, ethical considerations, rigour, reimbursement and dissemination of results. Part B (Literature review) presents an overview of the literature on HIV research in low-resource settings, with a specific focus on: ethical challenges, factors that contribute to participants’ decisions to participate in HIV research and findings from other studies which examined experiences and perceptions of HIV research in low-resource settings. The section also identifies gaps in the existing literature. Part C (Journal article) presents the findings of the study and the implications thereof.
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    Faith-based mental health provision in Africa: a mixed methods systematic review
    (2022) Nanji, Nadine; Olivier, Jill
    Faith-based mental health provision as a model of mental health service delivery is not widely acknowledged or researched, despite being highly utilised, especially in the African context. There is currently limited empirical research or review work on the various types of faith-based health providers which contribute mental health services, the magnitude of these services, or their quality. This mixed-methods systematic review study looked at these aspects of faith-based mental health provision in the African context. In the first phase of this study, we conducted a scoping review with a wider, which resulted in a typology of models of faith-based mental health provision The typology included five different types of faith-based health individual and organisational providers (herbalists, traditional and faith healers, Christian and Muslim clergy, faith-based organisations, and chaplains). In the second phase of the study, we conducted a systematic review based on the typology in which we assessed these models of FBHP against service type and level (facility or community, individual or organisational providers); medical provision type (biomedical or alternative). There were 53 studies included in this systematic review and the findings suggest that there is a wide array of types of faith-based providers providing a variety of mental health services across Africa. The research question formulated for the purposes of the systematic review aim to address the types, magnitude and quality of faith-based mental health services in Africa. For the purposes of this review, magnitude was categorised as including frequency of utilisation and availability of faith-based mental health services, but the information was limited. In addition, there are red flags regarding the quality of these mental health services which include human rights abuses that were discussed in this review. This exploratory review demonstrates some of the challenges in dealing with the complex variety of 'religious entities' in Africa. To some degree, developing conclusions that are applicable to all faith-based mental health providing entities is counterproductive - and instead a main conclusion is that future research and engagement needs to take this variety into account. There are a few common trends - for example challenges facing most faith-based providers in relation to faith-based provision of mental health services is financial support for mental health services. Regarding both traditional/alternative and biomedical mental health services, it has been noted that, there is a need to consider cost to the patient (e.g., reduce out of pocket payments). In addition, the literature suggests that better training for some types of faith-based health providers is urgently needed, especially those working close to community. Community mental health education interventions could strengthen faith-based provision of mental healthcare, and prevent some human rights abuses (religious perils), and improve the quality of faith-based mental health service provision. Better referral systems and improved communication between faith-based health providers and biomedical practitioners is required. In addition, varied types of faith-based health providers need to be included in mental health policy development and implementation. Finally, the most comprehensive conclusion of this exploratory review, is that further research is needed on specific types of faith-based providers engaged in mental health service provision, and further research is needed on the integration of mental health services in African health systems.
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    Health systems constraints and facilitators of national immunization programs in low- and middle- income countries
    (2019) Amponsah-Dacosta, Edina; Olivier, Jill; Kagina, Benjamin
    Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned.
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    Isoniazid preventative therapy penetrance at a community health centre in South Africa: a cross sectional study
    (2022) Steyn, Johannes; De Vries, Elsje Maria
    Background: Tuberculosis (TB) remains a major contributor to morbidity and mortality in people living with HIV (PLHIV). The use of Isoniazid preventative therapy (IPT) has been proven to be effective and safe to reduce this burden. Despite overwhelming evidence, uptake op IPT is poor. This study evaluated an urban population of PLHIV and described associations with the delivery of IPT. Methods: A retrospective folder review. Results: A total of 198 folders were reviewed of which 31 had been/currently were on IPT. In the no-IPT group the fast majority, 86%, of the patients were eligible (according to current national HIV guidelines) for IPT. Only 4% had true contraindications. Factors favouring the delivery of IPT was the duration on ART (p=0.0038) and being part of the ART adherence club(AC) system (<0.0001). Conclusion: The vast majority of patients are screened but do not receive TPT. The duration of ART increased the likelihood of a patient to receive IPT. However, patients recently started on ART are at higher risk of TB disease and will benefit greatly from IPT. Patients who were enrolled in the AC system had a higher IPT penetrance. Quality improvement cycles should be implemented to address the situation. Increasing the role that adherence clubs play may be an option for future interventions.
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    Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit
    (2019) Nya, Anthony; Ras, Tasleem; Cupido, Clint
    Background: Hospital discharge letters are an essential part of good patient record keeping that ensures transmission of the healthcare information of a patient from the hospital of admission to the primary care practitioner. These letters were traditionally handwritten, but the medical ward in Victoria hospital Wynberg in adapting to current progress in clinical record keeping has transited from paper to the use of electronic discharge letters. Objectives: To audit the structure and contents of the electronic discharge summaries and find out to what extent they meet universally accepted criteria. Methodology: A retrospective clinical record audit of 60 patient records was conducted, spanning a period of 12 months (January-December) of 2018. Sequential sampling was used to select five folders from each months’ discharge records, making a total study sample of 60 patient records. A checklist of prescribed criteria was developed and used to collect data which was analysed descriptively. Ethical approval was obtained from University of Cape Towns’(UCT) Human Research Ethics Committee (HREC) and the Western Cape Government Provincial Research Committee. Electronic discharge letters compiled in the period 1 January- 31 December 2018 with corresponding folders found properly indexed in the medical records department were included in the sample, while discharge letters where the folders could not be found were excluded, as were the folders of patients who died during the hospital admission. Results: Nearly all clinical records contained biodata (100%), contact details (93%) and clinical details (93%). Only two-thirds of the folders contained information on other diagnoses(67%) and investigations matched clinical issues 63%.). The least compliant category was medication changes(53%), with just under half the folders containing this information. Conclusion: This study found that clinical records met 67% of the standards that define clinical and medico-legal compliance in the internal medicine ward in Victoria Hospital Wynberg. Several areas for future intervention were identified. A useful audit tool was also developed for ongoing quality improvement cycle.
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    Reducing sugar intake in South Africa: a multilevel policy analysis of how global and regional diet policy recommendations find expression at country level
    (2022) Mccreedy, Nicole; Shung-King Maylene
    High intake of sugar has been recognised as a contributing factor to diet-related overweight and obesity, and as a determinant for non-communicable disease (NCD) emergence in LMICs. In 2015, the World Health Organization (WHO) released a guideline giving specific advice on limiting sugar intake in adults and children. Policy guidance has also been provided to promote healthy diets and/or restrict unhealthy eating habits at country-level. The study explored the extent to which global policy recommendations and directives on reducing sugar intake to prevent and control NCDs have found expression in policies issued at the Africa region, South African national or sub-national Western Cape provincial level. A systematic policy document review was conducted to identify policies between 2000 and 2020, at different levels of government using search terms related to sugar, sugar sweetened beverages (SSBs) and NCDs. NVivo 12 software was used to code and thematically analyse the data. A policy transfer conceptual framework was applied for the policy analysis to assess what ideas were transferred, including why and to what extent transfer occurred. Forty-eight policy documents were included in this review. Most were global or national level policies. It was evident that several global policy ideas on unhealthy diets and reduction of sugar intake had found expression in South African health policies, as well in the education and finance sectors. Global recommendations for effectively tackling unhealthy diets and NCDs are to implement a mix of cost-effective policy options employing a multisectoral approach. Local policy action has followed the explicit guidance from international agencies, and ideas on reducing sugar intake have found expression in sectors outside of health, to a limited extent. Together with the adoption of the sugar-sweetened beverages (SSBs) health tax, South Africa's experience offers learnings for other LMICs.
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    Relationship between sexual partnerships, intimate partner violence and sexually transmitted infections in pregnant women living with HIV and not living with HIV in Cape Town, South Africa
    (2022) Qayiya, Yamkela; Davey, Dvora Joseph
    Background: Women are at high risk of HIV and sexually transmitted infections (STIs) prior to and during pregnancy. There is limited research on the link between quality of sexual relationships, intimate partner violence (IPV) and STIs in pregnancy. This study aims to evaluate the association between relationship type and quality, IPV, and STI diagnosis in pregnant women. Methods We conducted a cohort study of 242 pregnant women ≥18 years attending their first antenatal care visit in Cape Town, South Africa between February 2017 and February 2019. We conducted interviews and tested pregnant women for three different STIs: Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG) and Trichomonas vaginalis (TV) using point-of-care PCR testing (GeneXpert, Cepheid, USA). We used multivariable logistic regression to evaluate the association between relationship quality, STI, and IPV during pregnancy, adjusting for maternal age, gestational age and relationship status. Results In 242 pregnant women (median age 29 years [IQR = 24–34], and median gestational age 19 weeks [IQR= 14-24]), 78 (32%) were diagnosed with CT, NT, and/or TV at baseline. Unmarried, non-cohabiting women had almost 2-times the odds of having an STI during pregnancy (aOR=1.92, 95% CI=1.06-3.48); women living with HIV had increased odds of having an STI (aOR=1.97, 95% CI=1.07-3.62) adjusting for covariates. Overall, 5% of women who had an STI reported experiencing IPV during the past year (n=4) and 2% of the women who tested STI-negative (n=4). Women who reported having high relationship quality in their primary relationship had decreased odds of experiencing IPV (aOR=0.11, 95% CI=0.017-0.073) compared to those who reported low relationship quality, adjusting for covariates, but this was not associated with STI diagnosis. Reporting recent IPV was not associated with STI acquisition (aOR=2.41, 95% CI=0.55-10.45). Conclusion: We found a high prevalence of STIs among pregnant women. Women who were unmarried or noncohabiting with the father of the baby or were living with HIV had increased odds of having a STI during pregnancy. Women who reported better relationship quality were associated with decreased odds of experiencing IPV. Experiencing IPV was not associated with STI acquisition.
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    Screening strategies for adults with type 2 diabetes mellitus
    (2022) Mearns, Helen; Kagina, Benjamin M; Kredo, Tamara; Schmidt, Bey-Marrié
    There are insufficient randomized controlled trials to address whether screening for type 2 diabetes mellitus (T2DM) improves health outcomes. This systematic review sought to cast a wider net and synthesise evidence from non-randomised intervention studies to assess the effectiveness of T2DM screening in adults for reducing mortality and T2DM-associated morbidity. We searched PubMed/MEDLINE, Scopus, Web of Science, CINAHL, Academic Search Premier and Health Source Nursing Academic (inception onwards; last search July 2021). We included non-randomised intervention studies that assessed T2DM screening compared to no screening, in adults without known T2DM. Screening was performed independently by two reviewers. Data was abstracted by one reviewer and checked by a second, as was risk of bias (ROBINS-I) and certainty of evidence (GRADE). A narrative summary was performed. We screened 10,892 records, retrieving 67 for full-text screening with one record meeting inclusion criteria. The study was a prospective cohort comparing T2DM screening versus no screening. It included adults, 40 - 65 years, with no known T2DM from a single community practice in Ely, England (N = 4,936) and evaluated outcomes at two time periods. The study was assessed as having moderate risk of bias. There may be little or no difference in mortality between those who were invited to screening versus those who were not invited (1990-1999: adjusted hazard ratio (aHR) 0.79 [95% confidence interval (CI) 0.63 – 1.00], n = 4,936, low certainty evidence and 2000 - 2008: aHR 1.18 [95% CI 0.93 - 1.51], n = 3,002, low certainty evidence). We found only one study reporting the effectiveness of screening for T2DM in adults. Therefore, despite ongoing T2DM screening in clinical care, this review highlights an important research gap in understanding the true health benefits of screening.
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    Structure and agency in the economics of public policy for TB control
    (2019) Foster, Nicola; Cleary, Susan; Sinanovic, Edina; Vassall, Anna
    Globally, Tuberculosis remains a devastating disease, despite the availability of treatment. The disease is associated with poverty, and those with the disease incur a high cost of accessing care, while simultaneously experiencing income loss due to a loss in productivity. A key challenge in TB programmes remains the accurate diagnosis of the disease, especially in people who are HIV positive. Diagnosing TB can be very resource intensive and the accuracy of diagnosis is dependent on a range of disease, health service organisation and provider behaviour factors. This thesis seeks to enhance understanding of how the behaviour of healthcare workers mediates the value of TB diagnostic algorithms, and how this may affect the costs, outcomes as well as the economic burden associated with the disease in South Africa. The work presented is based on empirical work done alongside a pragmatic cluster randomized control trial. Empirically, it examines the longitudinal economic burden of TB diagnosis and treatment in South Africa. The discrepancies between the time at which patients incur the greatest cost and income loss, and the available social protection are highlighted. Based on empirical work, a purpose-built state-transition mathematical model of TB diagnosis and treatment was developed to estimate the cost-effectiveness, from the perspective of the health service and the patient, of health systems interventions to strengthen TB diagnosis. Recognising healthcare workers as those who ultimately express policies, the behaviour of healthcare workers was included in the cost-effectiveness analysis by 1) using data from a pragmatic trial reflecting routine practice and clinical decision-making at the time of the study; 2) developing a conceptual framework of the relationship between behaviour at decision points and disease outcomes; and 3) investigating how these interactions may influence the value of the diagnostic algorithm. Possible public policy levers to improve TB diagnosis in healthcare facilities, as well as the potential mediators of costs and effects were explored. The thesis concludes with recommendations for further methodological work to expand on the approach explored in this thesis to improve how heterogeneity in estimates of cost-effectiveness is presented to decision-makers.
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    Open Access
    The uptake of the Prepex and Shang ring male circumcision devices among adolescent and adult males in Africa, a systematic review
    (2018) Rajab, Kakaire Menyha; Kagina, Benjamin; Abdullahi, Leila Hussein
    Voluntary medical male circumcision (VMMC) programs have been implemented in fourteen countries in sub Saharan Africa since 2007. The uptake of services has been suboptimal in some of the countries partly due to the widespread use of surgical methods. Circumcision using device methods was postulated to increase the uptake of VMMC services by making the procedure quicker and more appealing to men. We conducted a systematic review to establish the uptake and acceptability of the Prepex and Shang ring male circumcision devices in VMMC program countries. A metaanalysis was also performed. Methods: A comprehensive literature search from several databases was carried out to identify studies reporting VMCC coverage, uptake or acceptability of either the Prepex or Shang ring device methods. Search terms included, “non-surgical methods, male circumcision instrumentation as well as the individual device names such as Prepex, Shang ring, Gomco, Mogen, Plastibell, Accucirc, Alisklamp, Ismail Clamp, Tara Klamp, Unicirc, Smartclamp”. Electronic searches were complemented by going through the reference lists of the included studies. All searches were carried out on 12th May, 2017. Included studies must have been conducted between 1st April, 2007 and 28th February, 2017.The search was limited to studies among adolescents and adults in VMMC implementing countries. Two reviewers independently reviewed, rated, and abstracted data from each article. Uptake estimates were pooled in a meta-analysis and stratified according to the device method and participant age using Stata. Acceptability of device methods among recipients was summarized using four criteria and presented as proportions. Results: Of the 391 total articles retrieved, 25 studies incorporating observational and interventional study designs met the inclusion criteria. Of these 25 studies, 7 articles reported uptake of device method, 5 and 2 being on the Prepex and Shang ring devices respectively. The pooled uptake estimate was 75% (95% confidence interval 62% to 89%). Prepex uptake was estimated to be 73% while the Shang ring estimates were 82%. On stratification by population group, uptake of device methods among adolescents was 82% compared to 72% by adults. Majority (21) of the studies reported at least one of the criteria used to assess device acceptability. Acceptability of the two device methods was high: 95% of participants reported satisfaction with a device procedure. The devices were not associated with lengthy periods out of work, with 87% of participants reported to have resumed normal activities within two days after the procedure. Almost all (97%) participants circumcised with the device methods indicated they would recommend a device procedure to a friend or relative. Conclusion: Our findings showed a high uptake and acceptability of the two circumcision devices methods that have been prequalified by WHO for use among adolescents and adults. There is a dearth of evidence on the extent of utilization of devices for adolescent or adult circumcision and whether this has improved the overall uptake of VMMC services, thus emphasizing the need for more studies on this topic.
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    Tracing ‘paper', discovering people: three ethnographic case studies exploring the use of health information to improve health services in Gugulethu
    (2020) Van, Pinxteren Myrna; Colvin, Christopher
    Health information plays a vital role in the larger health system. Over the last twenty-five years, South Africa has developed several health information systems (HISs) that aim to collect high-quality health information to be used to inform clinical decision-making, shape new policies and programmes and strengthen other components of the health system. To date, most research in this area has focused on the production of health information and the technical challenges that appear when developing and implementing HISs. Much less is known about how health information is used in practice. This research explores how both community actors and health systems stakeholders at different levels of the health system gain access to, use and exchange health information, both for their own decisionmaking and practice, but also to address persistent health challenges. This research adopted an ethnographic approach, whereby I conducted extensive qualitative research for a period of 18 months in Gugulethu, an underprivileged peri-urban neighbourhood in Cape Town. Three case studies emerged from this research that provide a lens to analysing the role of health information in South Africa. The use and exchange of health information in the larger health system is inherently complex. Key findings from this research project show that firstly, there is a wide interest among a diverse group of stakeholders, including community representatives and NGOs, to use health information. Secondly, despite the interest for using health information, this data is not always available for a variety of reasons, which encourages stakeholders to develop creative strategies to collect new forms of evidence or to gain access to existing forms of data. Thirdly, adopting new strategies, health actors use a combination of routinely collected, semi-formal, and informal data, often concurrently. Lastly, this research demonstrates that health information is never neutral or value-free, but is produced, used and exchanged within a larger social, cultural and religious context, and is thus shaped by these contexts. This research challenges several assumptions about how health information is used in South Africa, and who can, or should, have access to this information. To answer these questions, it is important to open the health information system (HIS) to a more a diverse group of people actively in order to make available a variety of information that informs health stakeholders' daily work, influences health programmes and provides new perspectives on current health issues. Lastly, to further stimulate the use and exchange of health information for health system strengthening purposes, there is a need to provide a dedicated third space, where establishing new relationships and strengthening existing ones among actors at different levels of the health system is actively encouraged as a way to stimulate further use and sharing of health information.