Research Articles (Health Sciences)

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    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.
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    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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    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.
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    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.
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    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.