Integrated management of childhood illness (IMCI) - traditional versus new approaches to clinical care

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Reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education

Background. Portfolios are increasingly used across a range of disciplines in health professional education to support reflective practice and to help assess students’ academic and professional development. However, their value in postgraduate education is uncertain.Objectives. To identify the role of portfolios in the development and assessment of professional competencies in postgraduate maternal and child public health education.Methods. A qualitative retrospective review of 35 student portfolios was conducted. Thematic content analysis of portfolios was done, identifying emerging themes and analysing patterns.Results. Two major themes were explored – the benefit of the portfolio to the student and to faculty. For students, portfolios promoted reflective abilities and critical thinking and assisted them in planning learning needs. For faculty, the portfolios assisted in monitoring students’ growth over time, identified learning gaps, helped to establish if expected learning outcomes were being attained and provided feedback on students’ application of academic learning to professional practice. Portfolios also offered students an opportunity to provide critical feedback on curricula content and course pedagogic activities.Conclusion. Portfolios are an under-utilised assessment and self-development tool in postgraduate training. They allow students to self-assess their attainment of personal learning needs, professional growth and competency achievement and provide faculty with useful feedback on curriculum content, educational activities and competency attainment

Infant feeding practices in a high HIV prevalence rural district of KwaZulu-Natal, South Africa

Aim: To describe infant feeding practices at birth and at 14 weeks post-partum in the Ugu-North Health District, KwaZulu-Natal, South Africa.Methods: A prospective, cohort study design was used. Mothers who delivered over a one-month period were interviewed at birth and14 weeks later. Results: Initially, 168 mothers were interviewed within 24 hours of delivery, of whom 117 (70%) were contactable at 14 weeks post-partum. The vast majority (96%) initiated breast-feeding at birth. At birth, less than one-third (55/168 [32.7%]) of mothers declared an intention to both breast and formula (mix) feed in the next 14 weeks, but by the 14th week post-partum over three-quarters (89/117 [76.1%]) actually practised mixed feeding. At 14 weeks, the prevalence of exclusive breast-feeding was 18%: 52% of infants were offered water and 73% solids. The majority (20/23 [87%]) of HIV infected mothers chose to breastfeed their infants at birth. Nevertheless, they were significantly more likely to formula feed their infants compared to HIV negative mothers (3/23 [13.0%] vs 2/145 [1.4%], OR 10.73, 95% CI 1.34 – 99.16, p = 0.02). By 14 weeks, only 11% of HIV positive mothers were still exclusively breast-feeding, while almost two-thirds (12/19 [63%]) practised mixed feeding. This change was mainly ascribed to their need to return to school (40%) or to work (20%). Conclusions: Most infants were fed inappropriately by 14 weeks of age. The failure to maintain exclusive breast-feeding, despite high initiation rates, is of greatest concern. Routine prevention of mother-to-child transmission of HIV services was ineffective in influencing mothers to follow any feeding regimen exclusively

Survival of low-birth-weight infants at Baragwanath Hospital - 1950 - 1996

Objectives. To examine changes in survival rates among lowbirth- weight (LBW) infants between the years 1950 and 1996:Methods. Survival figures were analysed for LBW infants managed at Baragwanath Hospital, a tertiary care centre in Soweto, Johannesburg, over four periods spanning five decades.Results. The overall mortality rates of LBW infants decreased markedly between the early 1950s and the period 1995/96. By the mid-1990s approximately four times the number of infants with birth weight less than 1 500 g were surviving compared with the early 1950s. The reduction in mortality rates occurred in all LBW groups during the first three decades. However, since 1981 infants who weighed less than 1 500 g at birth were the major contributors to the overall reduction in mortality. Between the years 1981/82 and 1995/96, survival increased significantly from 64% to 79% for infants with birth weight 1 000 - 1 499 g, and from 14% to 32% for those with birth weight less than 1 000 g. Since infants in the latter group were seldom offered mechanical ventilation or artificial surfactant, a large part of these increases in survival can be attributed. to improvement in the general level of care.Conclusion. There have been dramatic improvements in the survival of LBW infants over this time period at Baragwanath Hospital. Although newer interventions such as mechanical ventilation and artificial surfactant have played a significant role, improvement in care at primary and secondary levels has been of major importance

Issue in Child Health: Can a new paediatric sub-specialty improve child health in South Africa?

Compared with other middle-income countries, child health in South Africa is in a poor state, and should be addressed by focusing on the healthcare needs of all children across a system or region. Paediatricians have had little effect on this situation, partly because their training is not aligned with South African needs. The proposed re-engineering of primary healthcare will belimited by the skewed distribution of staff and the lack of suitable skills. A ‘community’ placement during specialist training, and the creation of a sub-specialty in Community Paediatrics and Child Health, could address the skills shortage and possibly attract health personnel to under-served areas through creating an appropriate career path. This proposal would also support the Department of Health’s encouraging plans to re-engineer primary healthcare

Child health, infant formula funding and South African health professionals: Eliminating conflict of interest

Despite clear evidence of the benefits of exclusive and continued breastfeeding for children, women and society, far too few children in South Africa (SA) are breastfed. One of the major impediments to improving this situation is the continued and aggressive marketing of breastmilk substitutes (BMSs) and infiltration of the BMS industry into contexts with exposure to health professionals. In this article we, as academics, practitioners and child health advocates, describe contraventions of the regulations that protect breastfeeding in SA and argue that bold, proactive leadership to eliminate conflict of interest in respect of the BMS industry is urgently required, together with far greater investments in proven interventions to promote and support breastfeeding

Child health, infant formula funding and South African health professionals: Eliminating conflict of interest

Letters by Van Niekerk and Khan on article by Lake et al. (Lake L, Kroon M, Sanders D, et al. Child health, infant formula funding and South African health professionals: Eliminating conflict of interest. S Afr Med J 2019;109(12):902-906. https://doi.org/10.7196/SAMJ.2019.v109i12.14336); and response by Lake et al

Comparison of nuisance parameters in pediatric versus adult randomized trials: a meta-epidemiologic empirical evaluation

BACKGROUND We wished to compare the nuisance parameters of pediatric vs. adult randomized-trials (RCTs) and determine if the latter can be used in sample size computations of the former. METHODS In this meta-epidemiologic empirical evaluation we examined meta-analyses from the Cochrane Database of Systematic-Reviews, with at least one pediatric-RCT and at least one adult-RCT. Within each meta-analysis of binary efficacy-outcomes, we calculated the pooled-control-group event-rate (CER) across separately all pediatric and adult-trials, using random-effect models and subsequently calculated the control-group event-rate risk-ratio (CER-RR) of the pooled-pediatric-CERs vs. adult-CERs. Within each meta-analysis with continuous outcomes we calculated the pooled-control-group effect standard deviation (CE-SD) across separately all pediatric and adult-trials and subsequently calculated the CE-SD-ratio of the pooled-pediatric-CE-SDs vs. adult-CE-SDs. We then calculated across all meta-analyses the pooled-CER-RRs and pooled-CE-SD-ratios (primary endpoints) and the pooled-magnitude of effect-sizes of CER-RRs and CE-SD-ratios using REMs. A ratio < 1 indicates that pediatric trials have smaller nuisance parameters than adult trials. RESULTS We analyzed 208 meta-analyses (135 for binary-outcomes, 73 for continuous-outcomes). For binary outcomes, pediatric-RCTs had on average 10% smaller CERs than adult-RCTs (summary-CE-RR: 0.90; 95% CI: 0.83, 0.98). For mortality outcomes the summary-CE-RR was 0.48 (95% CIs: 0.31, 0.74). For continuous outcomes, pediatric-RCTs had on average 26% smaller CE-SDs than adult-RCTs (summary-CE-SD-ratio: 0.74). CONCLUSIONS Clinically relevant differences in nuisance parameters between pediatric and adult trials were detected. These differences have implications for design of future studies. Extrapolation of nuisance parameters for sample-sizes calculations from adult-trials to pediatric-trials should be cautiously done

Oportunidades perdidas na prevenção da sífilis congênita e da transmissão vertical do HIV

OBJECTIVE: To estimate the prevalence of missed opportunities for congenital syphilis and HIV prevention in pregnant women who had access to prenatal care and to assess factors associated to non-testing of these infections. METHODS: Cross-sectional study comprising a randomly selected sample of 2,145 puerperal women who were admitted in maternity hospitals for delivery or curettage and had attended at least one prenatal care visit, in Brazil between 1999 and 2000. No syphilis and/or anti-HIV testing during pregnancy was a marker for missed prevention opportunity. Women who were not tested for either or both were compared to those who had at least one syphilis and one anti-HIV testing performed during pregnancy (reference category). The prevalence of missed prevention opportunity was estimated for each category with 95% confidence intervals. Factors independently associated with missed prevention opportunity were assessed through multinomial logistic regression. RESULTS: The prevalence of missed prevention opportunity for syphilis or anti-HIV was 41.2% and 56.0%, respectively. The multivariate analysis showed that race/skin color (non-white), schooling (OBJETIVO: Estimar la prevalencia de oportunidad de pérdida de prevención de la sífilis y el HIV entre gestantes que tuvieron acceso al pre-natal y factores asociados con la no evaluación de estos agravios. MÉTODOS: Se realizó estudio transversal con muestra aleatoria de 2.145 puérperas de Brasil, 1999 y 2000 admitidas en maternidades para parto o curetaje y que habían realizado al menos una consulta de pre-natal. La no realización del examen de prueba para sífilis y/o anti-HIV durante el embarazo fue usada como marcador para oportunidad de pérdida de prevención. Las mujeres que realizaron sólo examen de sífilis o sólo examen de anti-HIV, o que no realizaron ninguno, fueron comparadas con las que realizaron los dos (categoría de referencia). La prevalencia de oportunidad de pérdida de prevención fue estimada para cada categoría, con intervalo de confianza de 95%. Los factores asociados con la oportunidad de pérdida de prevención fueron analizados por medio de regresión logística multinomial. RESULTADOS: La prevalencia de oportunidad de pérdida de prevención para la realización de la prueba de sífilis o anti-HIV fue de 41,2% e 56,0%, respectivamente. El análisis multivariado indicó que raza/color (no blanca), escolaridad (< 8 años de estudio), estado civil (soltera), renta < 3 salarios mínimos, relación sexual durante el embarazo, no haber tenido sífilis anterior al embarazo actual, realización de seis o mas consultas de pre-natal y la realización de la última visita antes del tercer trimestre de embarazo, estaban asociados con mayor riesgo de tener oportunidad de pérdida de prevención. Se observó una asociación negativa entre estado civil (soltera), lugar de realización de pre-natal (hospital) y la realización de la primera consulta pre-natal en el tercer trimestre con oportunidad de pérdida de prevención. CONCLUSIONES: Altos porcentajes de gestantes no evaluadas señalan fallas en la prevención y control de la infección por HIV y de la sífilis congénita en los servicios de salud. Las gestantes continúan interrumpiendo el cuidado pre-natal precozmente y no logran realizar los procedimientos de selección para HIV y sífilis.OBJETIVO: Estimar a prevalência de oportunidade perdida de prevenção a sífilis e HIV entre gestantes que tiveram acesso ao pré-natal e fatores associados a não-testagem para esses agravos. MÉTODOS: Estudo transversal com amostra aleatória de 2.145 puérperas do Brasil, 1999 e 2000 admitidas em maternidades para parto ou curetagem e que haviam realizado pelo menos uma consulta de pré-natal. A não-realização de exame de teste para sífilis e/ou anti-HIV durante a gravidez foi usada como marcador para oportunidade perdida de prevenção. Mulheres que realizaram apenas exame de sífilis ou apenas o anti-HIV, ou não realizaram nenhum, foram comparadas àquelas que realizaram os dois (categoria de referência). A prevalência de oportunidade perdida de prevenção foi estimada para cada categoria, com intervalo de confiança de 95%. Os fatores associados com oportunidade perdida de prevenção foram analisados por meio de regressão logística multinomial. RESULTADOS: A prevalência de oportunidade perdida de prevenção para a realização do teste de sífilis ou anti-HIV foi de 41,2% e 56,0%, respectivamente. A análise multivariada indicou que raça/cor (não branca), escolaridade (< 8 anos de estudo), estado civil (solteira), rend

Reducing the role of the food, tobacco, and alcohol industries in non-communicable disease risk in South Africa

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs