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Arrhythmogenic right ventricular cardiomyopathy type 6 (ARVC6) : support for the locus assignment, narrowing of the critical region and mutation screening of three candidate genes
(BioMed Central, 2006-03) Matolweni, Luzuko O.; Bardien, Soraya; Rebello, George; Oppon, Ekow; Munclinger, Miroslav; Ramesar, Rajkumar; Watkins, Hugh; Mayosi, Bongani M.
Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable disorder characterized by progressive degeneration of right ventricular myocardium, arrhythmias and an increased risk of sudden death at a young age. By linkage analysis, ARVC type 6 was previously mapped to a 10.6 cM region on chromosome 10p12-p14 in a large North American kindred. To date, the genetic defect that causes ARVC6 has not been identified. Methods: We identified a South African family of 13 members with ARVC segregating as an autosomal dominant disorder. The diagnosis of ARVC was based on international diagnostic criteria. All available family members were genotyped with microsatellite markers at six known ARVC loci, and positional candidate gene screening was performed. Results: Genetic linkage and haplotype analysis provided lod scores that are highly suggestive of linkage to the ARVC6 locus on chromosome 10p12-p14, and the narrowing of the critical region to ~2.9 Mb. Two positional candidate genes (ITG8 and FRMD4A) were screened in which defects could possibly disrupt cell-cell adhesion. A non-positional candidate gene with apoptosis inducing properties, LAMR1P6 (laminin receptor 1 pseudogene 6) was also screened. Direct sequencing of DNA from affected individuals failed to detect disease-causing mutations in the exonic sequences of the three genes investigated. Conclusion: The narrowing of the ARVC6 critical region may facilitate progress towards the identification of the gene that is involved in ARVC. Identification of the causative genes for ARVC will contribute to the understanding of the pathogenesis and management of this poorly understood condition.
Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era : the investigation of the management of Pericarditis in Africa (IMPI Africa) registry
(BioMed Central, 2006-01) Mayosi, Bongani M.; Wiysonge, Charles Shey; Ntsekhe, Mpiko; Volmink, Jimmy A.; Gumedze, Freedom; Maartens, Gary; Aje, Akinyemi; Thomas, Baby M.; Thomas, Kandathil M.; Awotedu, Abolade A.; Thembela, Bongani; Mntla, Phindile; Maritz [Late], Frans; Ngu Blackett, Kathleen; Nkouonlack, Duquesne C.; Burch, Vanessa C.; Rebe, Kevin; Parish, Andy; Sliwa, Karen; Vezi, Brian Z.; Alam, Nowshad; Brown, Basil G.; Gould, Trevor; Visser, Tim; Shey, Muki S.; Magula, Nombulelo P.; Commerford, Patrick J.
Background: The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa. Methods: Consecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status. Results: A total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs. Conclusion Patients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.
Co-trimoxazole prophylaxis in HIV : the evidence
(Health and Medical Publishing Group (HMPG), 2008-04) Oliphant, C. E. M.; Young, T.; Araoyinbo, I.; Volmink, J.
Human immunodeficiency virus (HIV) damages the body’s immune system, making secondary (or opportunistic) infections more common. Treatment and prevention of such infections is integral to the management of patients with HIV infection. Co-trimoxazole is a prophylactic treatment that has a wide range of action against common bacteria, parasites, fungi and yeasts. As part of a minimum care package, UNAIDS/ WHO recommends co-trimoxazole prophylaxis for HIVinfected adults with symptomatic disease (WHO stage II, III or IV), or asymptomatic individuals with CD4 counts ≤500 cells/μl, and for all HIV-positive pregnant women after the first trimester.1 Co-trimoxazole is also recommended for use in children with proven HIV infection and infants exposed to HIV (from 4 - 6 weeks of age until infection with HIV is ruled out).2 The object of this report is to summarise the effects of co-trimoxazole prophylaxis on morbidity and mortality among HIV-infected individuals.
Conducting a meta-ethnography of qualitative literature : lessons learnt
(BioMed Central, 2008-04) Atkins, Salla; Lewin, Simon; Smith, Helen; Engel, Mark; Fretheim, Atle; Volmink, Jimmy
Background: Qualitative synthesis has become more commonplace in recent years. Meta-ethnography is one of several methods for synthesising qualitative research and is being used increasingly within health care research. However, many aspects of the steps in the process remain ill-defined. Discussion: We utilized the seven stages of the synthesis process to synthesise qualitative research on adherence to tuberculosis treatment. In this paper we discuss the methodological and practical challenges faced; of particular note are the methods used in our synthesis, the additional steps that we found useful in clarifying the process, and the key methodological challenges encountered in implementing the meta-ethnographic approach. The challenges included shaping an appropriate question for the synthesis; identifying relevant studies; assessing the quality of the studies; and synthesising findings across a very large number of primary studies from different contexts and research traditions. We offer suggestions that may assist in undertaking meta-ethnographies in the future. Summary: Meta-ethnography is a useful method for synthesising qualitative research and for developing models that interpret findings across multiple studies. Despite its growing use in health research, further research is needed to address the wide range of methodological and epistemological questions raised by the approach.
Confronting the illusion of certainty : what has clinical epidemiology contributed?
(Stellenbosch : University of Stellenbosch, 2006) Volmink, Jimmy
Evidence-based African first aid guidelines and training materials
(Public Library of Science (PLOS), 2011-07) Van de Velde, Stijn; De Buck, Emmy; Vandekerckhove, Philippe; Volmink, Jimmy
This Health in Action report describes the African First Aid Materials project (AFAM, http://www.afam.redcross.be/). This project developed evidence-based guidelines on how basic first responders should be trained to manage emergency situations in an African context. The project also includes the development of training materials to support the implementation. The objective of this manuscript is to inform educators and health care professionals about these guidelines and training materials and to promote their use when developing first aid training programmes for sub-Saharan Africa.
Influences on the choice of health professionals to practise in rural areas
(Health and Medical Publishing Group (HMPG), 2007-11) Couper, I. D.; Hugo, J. F. M.; Conradie, H.; Mfenyana, K.
Background: Training health care professionals (HCPs) to work in rural areas is a challenge for educationalists. This study aimed to understand how HCPs choose to work in rural areas and how education influences this. Methods. Qualitative individual interviews were conducted with 15 HCPs working in rural areas in SA. Results. Themes identified included personal, facilitating, contextual, staying and reinforcing factors. Personal attributes of the HCPs, namely rural origin and/or their value system, determine consideration of rural practice. The decision to 'go rural' is facilitated by exposure to rural practice during training, an understanding of rural needs and exposure to rural role models. Once practising in a rural area, the context and nature of work and the environment influence the decision to remain, supported by the role of family and friends, ongoing training and development, and the style of health service management. Personal motivation is reinforced by a positive relationship with the community, and by being an advocate and role model for the local community. Educational factors were often felt to work against the decision to practise in rural areas. Discussion. The results show the complexity of the interaction between a large number of factors working together to make HCPs choose to go and stay in rural areas. Factors other than educational ones seem more important. A comprehensive approach is needed to attract and retain HCPs in rural areas. Issues for educationalists to address include helping rural-origin students to connect with their own values and communities.
“It’s for a good cause, isn’t it?” – exploring views of South African TB research participants on sample storage and re-use
(BioMed Central, 2012-07) Van Schalkwyk, Gerrit; De Vries, Jantina; Moodley, Keymanthri
Background: The banking of biological samples raises a number of ethical issues in relation to the storage, export and re-use of samples. Whilst there is a growing body of literature exploring participant perspectives in North America and Europe, hardly any studies have been reported in Africa. This is problematic in particular in light of the growing amount of research taking place in Africa, and with the rise of biobanking practices also on the African continent. In order to investigate the perspectives of African research participants, we conducted a study with research participants in a TB study in the Western Cape, South Africa. Methods: Semi-structured interviews were conducted using an interview guide which drew on the most prominent themes expressed in current literature on sample storage, re-use and exportation. Interviews were conducted in Afrikaans and subsequently translated into English by the same interviewer. Interviews were transcribed verbatim and analysed qualitatively. Results: The results of our study indicate that the majority of participants were supportive of giving one-time consent to the storage and re-use of their samples. The concept of research being for a 'good cause' was a central prerequisite. Additionally, a significant minority requested that they be re-contacted if a future use was not stipulated on the original consent. There was also considerable variation in how participants understood the concept of a 'good cause', with participants describing three distinct categories of research, of which two were generally thought to constitute 'good cause' research. Research that was for-profit was considered to fall outside the spectrum of 'good cause' research. Participants displayed confidence in the abilities of the researchers to make future decisions regarding sample use, but seemed unaware of the role of ethics committees in either this process or more generally. Conclusions: Participants expressed a wide and complex range of views about issues of sample storage and re-use, and they showed a great deal of trust in researchers. Participants' willingness to have their samples stored and re-used is consistent with findings from existing studies. However, in contrast to existing literature, participants were generally not in favour of for-profit research. Further research needs to be done to explore these ideas in other communities, both in South Africa and other countries
It’s my blood : ethical complexities in the use, storage and export of biological samples : perspectives from South African research participants
(BioMed Central, 2014-01) Moodley, Keymanthri; Sibanda, Nomathemba; February, Kelsey; Rossouw, Theresa
Background: The use of biological samples in research raises a number of ethical issues in relation to consent, storage, export, benefit sharing and re-use of samples. Participant perspectives have been explored in North America and Europe, with only a few studies reported in Africa. The amount of research being conducted in Africa is growing exponentially with volumes of biological samples being exported from the African continent. In order to investigate the perspectives of African research participants, we conducted a study at research sites in the Western Cape and Gauteng, South Africa. Methods: Data were collected using a semi-structured questionnaire that captured both quantitative and qualitative information at 6 research sites in South Africa. Interviews were conducted in English and Afrikaans. Data were analysed both quantitatively and qualitatively. Results: Our study indicates that while the majority of participants were supportive of providing samples for research, serious concerns were voiced about future use, benefit sharing and export of samples. While researchers view the provision of biosamples as a donation, participants believe that they still have ownership rights and are therefore in favour of benefit sharing. Almost half of the participants expressed a desire to be re-contacted for consent for future use of their samples. Interesting opinions were expressed with respect to export of samples. Conclusions: Eliciting participant perspectives is an important part of community engagement in research involving biological sample collection, export, storage and future use. A tiered consent process appears to be more acceptable to participants in this study. Eliciting opinions of researchers and research ethics committee (REC) members would contribute multiple perspectives. Further research is required to interrogate the concept of ownership and the consent process in research involving biological samples.
Life expectancies of South African adults starting antiretroviral treatment : collaborative analysis of cohort studies
(Public Library of Science, 2013-04-09) Johnson, Leigh F.; Mossong, Joel; Dorrington, Rob E.; Schomaker, Michael; Hoffmann, Christopher J.; Keiser, Olivia; Fox, Matthew P.; Wood, Robin; Prozesky, Hans; Giddy, Janet; Belen Garone, Daniela; Cornell, Morna; Egger, Matthias; Boulle, Andrew
Background Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low- and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults. Methods and Findings Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2–30.2) at age 20 y and 10.1 y (95% CI: 9.3–10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0–39.7) and 14.4 y (95% CI: 13.3–15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1–46.0) if her baseline CD4 count was ≥200 cells/µl, compared to 29.5 y (95% CI: 26.2–33.0) if her baseline CD4 count was <50 cells/µl. Life expectancies of patients with baseline CD4 counts ≥200 cells/µl were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%–20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations. Conclusions South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/µl. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well.
Non-communicable diseases in Sub-Saharan Africa : the case for cohort studies
(Public Library of Science, 2010-05-11) Holmes, Michelle D.; Dalal, Shona; Volmink, Jimmy; Adebamowo, Clement A.; Njelekela, Marina; Fawzi, Wafaie W.; Willett, Walter C.; Adami, Hans-Olov
We believe there is an urgent need for longitudinal cohorts based in sub-Saharan Africa (SSA). This conclusion is drawn from the fact that non-communicable diseases (NCDs) cause a large and growing disease burden (please see Box 1) [1–6]. In the past, public health in SSA has focused on communicable diseases. The advent of HIV/AIDS reinforced this image of infections as SSA’s major health burden. However, NCDs, including cardiovascular diseases, mental illnesses, trauma, cancer, and diabetes, are now major sources of morbidity and mortality and are projected to overtake infectious diseases by 2030 [7,8]. We argue that SSA lacks adequate resources to respond to this problem. Prospective cohort studies can be used to study multiple complex diseases and risk factors simultaneously over an individual’s lifetime. Such studies have proved crucial in understanding the etiology, course, and outcome of NCDs in other populations and have informed the design of prevention programs. In addition, cohort studies provide an incomparable resource for the training of public health researchers. Because the payoff from cohort studies continues—and often grows—over time, they are a long-term investment in public health. In order to highlight the potential impact of cohort studies in SSA, we compared published literature on NCDs from longitudinal studies in high-income countries to publications from Africa. Further, we estimated the costs of establishing cohort studies in SSA and describe the response needed to correct the disparities in research investment between SSA and the world’s more wealthy regions.
Patient adherence to tuberculosis treatment : a systematic review of qualitative research
(Public Library of Science, 2007-07-24) Munro, Salla A.; Lewin, Simon A.; Smith, Helen J.; Engel, Mark E.; Fretheim, Atle; Volmink, Jimmy
ENGLISH SUMMARY : Background Tuberculosis (TB) is a major contributor to the global burden of disease and has received considerable attention in recent years, particularly in low- and middle-income countries where it is closely associated with HIV/AIDS. Poor adherence to treatment is common despite various interventions aimed at improving treatment completion. Lack of a comprehensive and holistic understanding of barriers to and facilitators of, treatment adherence is currently a major obstacle to finding effective solutions. The aim of this systematic review of qualitative studies was to understand the factors considered important by patients, caregivers and health care providers in contributing to TB medication adherence. Methods and Findings We searched 19 electronic databases (1966–February 2005) for qualitative studies on patients’, caregivers’, or health care providers’ perceptions of adherence to preventive or curative TB treatment with the free text terms ‘‘Tuberculosis AND (adherence OR compliance OR concordance)’’. We supplemented our search with citation searches and by consulting experts. For included studies, study quality was assessed using a predetermined checklist and data were extracted independently onto a standard form. We then followed Noblit and Hare’s method of meta-ethnography to synthesize the findings, using both reciprocal translation and line-of-argument synthesis. We screened 7,814 citations and selected 44 articles that met the prespecified inclusion criteria. The synthesis offers an overview of qualitative evidence derived from these multiple international studies. We identified eight major themes across the studies: organisation of treatment and care; interpretations of illness and wellness; the financial burden of treatment; knowledge, attitudes, and beliefs about treatment; law and immigration; personal characteristics and adherence behaviour; side effects; and family, community, and household support. Our interpretation of the themes across all studies produced a line-of-argument synthesis describing how four major factors interact to affect adherence to TB treatment: structural factors, including poverty and gender discrimination; the social context; health service factors; and personal factors. The findings of this study are limited by the quality and foci of the included studies. Conclusions Adherence to the long course of TB treatment is a complex, dynamic phenomenon with a wide range of factors impacting on treatment-taking behaviour. Patients’ adherence to their medication regimens was influenced by the interaction of a number of these factors. The findings of our review could help inform the development of patient-centred interventions and of interventions to address structural barriers to treatment adherence.
Perspectives on key principles of generalist medical practice in public service in Sub-Saharan Africa: a qualitative study
(2011-07-04) Reid, Stephen J.; Mash, Robert; Downing, Raymond V.; Moosa, Shabir
Abstract Background: The principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context. Methods A descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed. Results The respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being life-long learners themselves. However, their role in the community, was found to be more aspirational than real. Conclusions The study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.
Predictors of condom use and refusal among the population of Free State province in South Africa
(BioMed Central, 2012-05) Chandran, Thoovakkunon Moorkoth; Berkvens, Dirk; Chikobvu, Perpetual; Nostlinger, Christiana; Colebunders, Robert; Williams, Brian Gerard; Speybroeck, Niko
Background: This study investigated the extent and predictors of condom use and condom refusal in the Free State province in South Africa. Methods: Through a household survey conducted in the Free Sate province of South Africa, 5,837 adults were interviewed. Univariate and multivariate survey logistic regressions and classification trees (CT) were used for analysing two response variables 'ever used condom' and 'ever refused condom' .Results: Eighty-three per cent of the respondents had ever used condoms, of which 38% always used them; 61% used them during the last sexual intercourse and 9% had ever refused to use them. The univariate logistic regression models and CT analysis indicated that a strong predictor of condom use was its perceived need. In the CT analysis, this variable was followed in importance by 'knowledge of correct use of condom', condom availability, young age, being single and higher education. 'Perceived need' for condoms did not remain significant in the multivariate analysis after controlling for other variables. The strongest predictor of condom refusal, as shown by the CT, was shame associated with condoms followed by the presence of sexual risk behaviour, knowing one's HIV status, older age and lacking knowledge of condoms (i.e., ability to prevent sexually transmitted diseases and pregnancy, availability, correct and consistent use and existence of female condoms). In the multivariate logistic regression, age was not significant for condom refusal while affordability and perceived need were additional significant variables.ConclusionsThe use of complementary modelling techniques such as CT in addition to logistic regressions adds to a better understanding of condom use and refusal. Further improvement in correct and consistent use of condoms will require targeted interventions. In addition to existing social marketing campaigns, tailored approaches should focus on establishing the perceived need for condom-use and improving skills for correct use. They should also incorporate interventions to reduce the shame associated with condoms and individual counselling of those likely to refuse condoms.
Prioritising between direct observation of therapy and case-finding interventions for tuberculosis : use of population impact measures
(BioMed Central, 2006-12) Heller, Richard F.; Gemmell, Islay; Edwards, Richard; Buchan, Iain; Awasthi, Shally; Volmink, Jimmy
Background: Population impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritising potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding. Methods: PIMs were calculated using published literature and national data for India, and applied to a notional population of 100 000 people. Data included the incidence or prevalence of smear-positive TB and the relative risk reduction from increasing case finding and the use of direct observation of therapy (applied to the baseline risks over the next year), and the incremental proportion of the population eligible for the proposed interventions. Results: In a population of 100 000 people in India, the directly observed component of the Directly Observed Treatment, Short-course (DOTS) programme may prevent 0.188 deaths from TB in the next year compared with 1.79 deaths by increasing TB case finding. The costs of direct observation are (in international dollars) I$5960 and of case finding are I$4839 or I$31702 and I$2703 per life saved respectively. Conclusion: Increasing case-finding for TB will save nearly 10 times more lives than will the use of the directly observed component of DOTS in India, at a smaller cost per life saved. The demonstration of the population impact, using simple and explicit numbers, may be of value to policy-makers as they prioritise interventions for their populations.
Reporting of health equity considerations in cluster and individually randomized trials
(BMC (part of Springer Nature), 2020-04-03) Petkovic, Jennifer; Jull, Janet; Yoganathan, Manosila; Dewidar, Omar; Baird, Sarah; Grimshaw, Jeremy M.; Johansson, Kjell A.; Kristjansson, Elizabeth; McGowan, Jessie; Moher, David; Petticrew, Mark; Robberstad, Bjarne; Shea, Beverley; Tugwell, Peter; Volmink, Jimmy; Wells, George A.; Whitehead, Margaret; Cuervo, Luis G.; White, Howard; Taljaard, Monica; Welch, Vivian
Background: The randomized controlled trial (RCT) is considered the gold standard study design to inform decisions about the effectiveness of interventions. However, a common limitation is inadequate reporting of the applicability of the intervention and trial results for people who are “socially disadvantaged” and this can affect policy-makers’ decisions. We previously developed a framework for identifying health-equity-relevant trials, along with a reporting guideline for transparent reporting. In this study, we provide a descriptive assessment of healthequity considerations in 200 randomly sampled equity-relevant trials. Methods: We developed a search strategy to identify health-equity-relevant trials published between 2013 and 2015. We randomly sorted the 4316 records identified by the search and screened studies until 100 individually randomized (RCTs) and 100 cluster randomized controlled trials (CRTs) were identified. We developed and pilottested a data extraction form based on our initial work, to inform the development of our reporting guideline for equity-relevant randomized trials. Results: In total, 39 trials (20%) were conducted in a low- and middle-income country and 157 trials (79%) in a high-income country focused on socially disadvantaged populations (78% CRTs, 79% RCTs). Seventy-four trials (37%) reported a subgroup analysis across a population characteristic associated with disadvantage (25% CRT, 49% RCTs), with 19% of included studies reporting subgroup analyses across sex, 9% across race/ethnicity/culture, and 4% across socioeconomic status. No subgroup analyses were reported for place of residence, occupation, religion, education, or social capital. One hundred and forty-one trials (71%) discussed the applicability of their results to one or more socially disadvantaged populations (68% of CRT, 73% of RCT). Discussion: In this set of trials, selected for their relevance to health equity, data that were disaggregated for socially disadvantaged populations were rarely reported. We found that even when the data are available, opportunities to analyze health-equity considerations are frequently missed. The recently published equity extension of the Consolidated Reporting Standards for Randomized Trials (CONSORT-Equity) may help improve delineation of hypotheses related to socially disadvantaged populations, and transparency and completeness of reporting of health-equity considerations in RCTs. This study can serve as a baseline assessment of the reporting of equity considerations.
A review of health behaviour theories : how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS?
(BioMed Central, 2007-06) Munro, Salla A.; Lewin, Simon A.; Swart, Tanya; Volmink, Jimmy
Background: Suboptimal treatment adherence remains a barrier to the control of many infectious diseases, including tuberculosis and HIV/AIDS, which contribute significantly to the global disease burden. However, few of the many interventions developed to address this issue explicitly draw on theories of health behaviour. Such theories could contribute to the design of more effective interventions to promote treatment adherence and to improving assessments of the transferability of these interventions across different health issues and settings. Methods: This paper reviews behaviour change theories applicable to long-term treatment adherence; assesses the evidence for their effectiveness in predicting behaviour change; and examines the implications of these findings for developing strategies to improve TB and HIV/AIDS medication adherence. We searched a number of electronic databases for theories of behaviour change. Eleven theories were examined. Results: Little empirical evidence was located on the effectiveness of these theories in promoting adherence. However, several models have the potential to both improve understanding of adherence behaviours and contribute to the design of more effective interventions to promote adherence to TB and HIV/AIDS medication. Conclusion: Further research and analysis is needed urgently to determine which models might best improve adherence to long-term treatment regimens.
Screening for diabetic retinopathy in primary care with a mobile fundal camera - Evaluation of a South African pilot project
(Health and Medical Publishing Group (HMPG), 2007-12) Mash, Bob; Powell, Di; Du Plessis, Felicity; Van Vuuren, Unita; Michalowska, M.; Levitt, N.
Background and aims: In South Africa diabetes makes a significant contribution to the burden of disease. Diabetic retinopathy is a leading cause of adult blindness, and screening can reduce the incidence. This project aimed to implement and evaluate a new service for retinal screening that uses a non-mydriatic mobile fundal camera in primary care. This is the first time such a service has been evaluated in an African primary care context. Methods. The service was implemented as an operational research study at three community health centres and data were collected to evaluate the operational issues, screening, reporting and referral of patients. Results. Out of 400 patients screened 84% had a significantly reduced visual acuity, 63% had retinopathy (22% severe non-proliferative, 6% proliferative and 15% maculopathy), 2% of eyes could not be screened and 14% of patients required dilatation. Referral was necessary in 27% of cases for cataracts, in 7% for laser treatment and in 4% for other specialist services. Repeat photography was needed in 8% and urgent follow-up in 12%. A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. Conclusion. Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician should be able to photograph almost 10 000 patients a year.
South African medical schools : current state of selection criteria and medical students’ demographic profile
(Health & Medical Publishing Group, 2016-01) Van der Merwe, L. J.; Van Zyl, G. J.; St. Clair Gibson, A.; Viljoen, M.; Iputo, J. E.; Mammen, M.; Chitha, W.; Perez, A. M.; Hartman, N.; Fonn, S.; Green-Thompson, L.; Ayo-Ysuf, O. A.; Botha, G. C.; Manning, D.; Botha, S. J.; Hift, R.; Retief, P.; Van Heerden, B. B.; Volmink, J.
ENGLISH SUMMARY : Background: Selection of medical students at South African (SA) medical schools must promote equitable and fair access to students from all population groups, while ensuring optimal student throughput and success, and training future healthcare practitioners who will fulfil the needs of the local society. In keeping with international practices, a variety of academic and non-academic measures are used to select applicants for medical training programmes in SA medical schools. Objectives: To provide an overview of the selection procedures used by all eight medical schools in SA, and the student demographics (race and gender) at these medical schools, and to determine to what extent collective practices are achieving the goals of student diversity and inclusivity. Methods: A retrospective, quantitative, descriptive study design was used. All eight medical schools in SA provided information regarding selection criteria, selection procedures, and student demographics (race and gender). Descriptive analysis of data was done by calculating frequencies and percentages of the variables measured. Results: Medical schools in SA make use of academic and non-academic criteria in their selection processes. The latter include indices of socioeconomic disadvantage. Most undergraduate medical students in SA are black (38.7%), followed by white (33.0%), coloured (13.4%) and Indian/Asian (13.6%). The majority of students are female (62.2%). The number of black students is still proportionately lower than in the general population, while other groups are overrepresented. Conclusion: Selection policies for undergraduate medical programmes aimed at redress should be continued and further refined, along with the provision of support to ensure student success.

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