The burden of diabetes mellitus in KwaZulu-Natal’s public sector: A 5-year perspective

Background. Diabetes mellitus (DM), together with its devastating complications, has a huge impact on both the patients it affects and the global economy as a whole. The economies of developing countries are already under threat from communicable diseases. More needs to be done to stem the tide of non-communicable diseases like DM. In order for us to develop new strategies to tackle this dread disease we need to obtain and analyse as many data as possible from the geographical area where we work.Objective. To describe the burden of DM in the public sector of the province of KwaZulu-Natal (KZN), South Africa (SA).Method. Data on the number of diabetes visits, DM patients that were initiated on treatment, defaulters and DM-related amputations were accessed from the Department of Health records for the period 2010 - 2014 inclusive.Results. There was a decline in the number of patients initiated on treatment per 100 000 population from 2010 to 2014 inclusive (265.9 v. 197.5 v. 200.7 v. 133.4 v. 148.7). Defaulter rates for 2013 compared with 2014 were 3.31% v. 1.75%, respectively and amputation rates were 0.09% v. 0.05% for 2013 and 2014, respectively. There was a strong proportional relationship observed between the number of defaulters and number of diabetes-related amputations (r=0.801; p=0.000) (Pearson correlation). A notable percentage of DM patients ranging between 63% and 80% were commenced on pharmacological therapy at their local clinics rather than at hospitals in the province.Conclusion. Strategies directed towards detection and treatment of DM, together with decreasing defaulter rates and thereby decreasing diabetes-related amputations, need to be addressed urgently. The majority of patients were initiated on therapy at the clinic level. This emphasises the need to strengthen our clinics in terms of resources, staffing, and nursing and clinician education, as this is where diabetes control begins. Although this study was based solely in KZN, the second most populous province in SA, it probably reflects the current situation regarding DM in other provinces of SA as well

Bellwether operations in KwaZulu-Natal Province, South Africa, are performed at regional and tertiary rather than district hospitals

Background. Previous work from KwaZulu-Natal (KZN) Province, South Africa, has suggested that public sector district hospitals are not providing adequate access to surgical care in the form of bellwether operations (caesarean section (CS), open reduction of fractures (ORF) and laparotomy).Objectives. To review the surgical output of regional and tertiary institutions, to quantify their contribution to providing bellwether procedure coverage for the province.Methods. Data on bellwether operations conducted at all district, regional, tertiary and central hospitals in the public health sector of KZN for the period 1 July - 31 December 2015 were collected from operating theatre registers.Results. Between 1 July and 31 December 2015, a total of 20 926 CSs, 3 947 laparotomies and 3 098 ORFs were performed in KZN provincial hospitals. This translates to a provincial rate for each bellwether procedure of 192/100 000 (CS), 36/100 000 (laparotomy) and 28/100 000 (ORF). The rate of  bellwether operations across the province during the study period was 256/100 000, with numbers as follows: CSs – 10 542 in district hospitals, 8 712 in regional hospitals, 1 538 in tertiary hospitals and 134 in the central hospital; laparotomies – 235 in district hospitals, 2 314 in regional hospitals, 1 259 in tertiary hospitals and 139 in the central hospital; and ORFs – 196 in district hospitals, 1 660 in regional hospitals, 1 201 in tertiary hospitals and 41 in the central hospital.Conclusions. Regional and tertiary hospitals are performing the bulk of non-obstetric bellwether operations in KZN. This imbalance has major implications for planning future delivery of surgical care in the province.

Self, life and writing in selected South African autobiographical texts.

Thesis (Ph.D.)-University of Natal, Durban, 1994.Autobiographical writing acquired increasing importance during the apartheid period, with greater numbers of autobiographical texts being published by a more representative range of South Africans across race, class and gender categories. This thesis analyzes the implications of shifts in autobiographical production, in English, during the years 1948-1994 through the examination of selected texts. The readings are informed by poststructuralism, modified by information about indigenous black South African cultural practices, as well as by input supplied by some of the autobiographical texts themselves. This theoretical approach may be referred to as a "pratique de metissage" (Glissant). The texts selected for close reading are from a field of over 120 autobiographical texts. They were chosen for their ability to illustrate important trends in South African autobiographical writing, specifically with regard to the three constituent parts of autobiography: autos, bios, and graphe. The chapter dealing with the depiction of self interrogates the hierarchized discourses of male-biased humanism in Roy Campbell's Light on a Dark Horse (1951). In Ellen Kuzwayo's Call Me Woman (1985) I analyze the melding of the conceptual frameworks of indigenous black cultures and Western individualism by which the autobiographical subject is defined. Breyten Breytenbach's The True Confessions of an Albino Terrorist (1984) is read as an exploration of the postmodernist decentred self. In the chapter focusing on the portrayal of life experiences, I examine the ways in which the narrator of Albert Luthuli's Let My People Go (1962) seeks to secure the reader's approval of his version of recent South African history; while the analysis of the sub-genre referred to here as worker autobiography is principally concerned with the politics of life-writing. In Chapter 5, I look at how Godfrey Moloi's My Life: Volume One (1987) uses the discourses of popular American movies of the 40s and 50s in order to validate a self victimized by racism, and also at the ways in which Lyndall Gordon's Shared Lives (1992) probes the limits and possibilities of biography through autobiographical speculation. In general, apartheid autobiography moves away from individualism to contribute, through various means, to social and political change

Exploring stakeholder perceptions and practices regarding research in provincial health facilties.

Master of Social Science in Psychology. University of KwaZulu-Natal, Pietermaritzburg, 2018.This thesis aimed to explore the perceptions and practices of key stakeholders regarding research conducted in provincial public health facilities. Research plays a vital role in improving health and health care globally, as well as in KwaZulu-Natal (KZN), South Africa, where it has resulted in significant health gains particularly in the field of HIV/AIDS. However, in spite of a robust regulatory framework and guiding documents, health research may be fraught with challenges. In KZN, the Provincial Health Research and Ethics Committee (PHREC) is responsible for providing final permission for researchers to access public health facilities to conduct their research, or to recruit potential participants from these facilities. This permission is based on the support of health managers of public health facilities and programmes who provide the first level of permission in the PHREC approval process. This study explored the perceptions and practices of researchers and health managers regarding research conducted in provincial public health facilities, and regarding their inter-stakeholder relationships. A qualitative study design was adopted, using in-depth interviews as the means of data collection. Eighteen interviews were conducted – eight with health managers and ten with researchers. Interviews were analysed using Thematic Analysis. Three important themes were generated from the analysis: varying perceptions around the ‘social value’ of research, strained inter-stakeholder relations, and recommendations for strengthening research and relations. Although all participants agreed that health research was valuable, researchers tended to place more emphasis on its contribution to new knowledge and future beneficiaries, whilst health managers tended to emphasise its concrete and current contribution to the functioning of the healthcare system. Respondents perceived that their relationships were strained at all stages of the research process. Particular concerns included a lack of involvement of health managers in the conceptualization of research questions, frustration of researchers with a prolonged, onerous research application process, and poor feedback of research results to health managers. Important relationship issues included lack of trust, accountability, and transparency. Both stakeholder groups had a shared view regarding how to strengthen both the research process and inter-stakeholder relations. There was strong agreement on, amongst others, improving communication through more regular, formal and informal meetings, and entrenching a culture of research within the KZN Department of Health. The study concludes that researchers and health managers had subtly differing perceptions of what makes health research in provincial health facilities valuable, and that tensions between these groups were perceived across the life-cycle of the research process. The study makes various recommendations on how to build stronger relations between stakeholders, in order to facilitate the conduct of high quality research in such settings, that is valued by affected role-players

Economic support to improve TB treatment outcomes in South Africa : a pragmatic cluster randomized controlled trial

Thesis (PhD)--Stellenbosch University, 2013.ENGLISH ABSTRACT: This thesis focused on the provision of economic support to improve the outcomes of patients on TB treatment. Although the association between poverty and tuberculosis is generally acknowledged, there is little evidence to guide the use of economic interventions to improve tuberculosis control. In South Africa, a high burden country with extensive poverty, such evidence is particularly important. The first part of this thesis is a Cochrane systematic review of evidence from randomized controlled trials regarding the effectiveness of economic support among patients with tuberculosis. Eleven trials were included: ten conducted among marginalised groups in the United States on economic support for people on prophylactic treatment for latent TB; and one from Timor-Leste on economic support for patients with active TB. The review found that the use of economic interventions in patients with latent TB may increase the return rate for reading tuberculin skin test results, probably improves clinic re-attendance for initiation or continuation of prophylaxis and may improve completion of prophylaxis, compared to normal care. However, it is uncertain if economic support improves treatment completion in patients with active TB (low quality evidence). The second part of the thesis reports the findings of a pragmatic, cluster randomized controlled trial to evaluate the feasibility and effectiveness of delivering economic support to patients on treatment for active TB in South Africa. Patients with drug sensitive pulmonary TB were offered a monthly voucher valued at ZAR120 until completion of treatment or a maximum of eight months. Patients in control clinics received usual TB care. A parallel process evaluation provided contextual information to explain the trial findings. The qualitative component of this evaluation consisted of in-depth interviews with a sample of trial participants, including patients, nurses and health managers, to assess responses to the voucher and its administration. The quantitative component included a survey of patients’ household expenditure to assess patients’ levels of poverty and the effects of the voucher on these, and an analysis of the goods on which patients spent their vouchers. 4091 patients were included in the trial: 1984 in the control arm (10 clinics) and 2107 in the intervention arm (10 clinics). Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (-1.2; 12.3%), p = 0.107). Fidelity to the intervention was low, partly because nurses preferred to issue vouchers based on perceived financial need, rather than on eligibility. Logistical difficulties in delivering vouchers to clinics also undermined fidelity. The vouchers did not significantly increase patients’ household expenditure, but were experienced by patients as helpful, especially in providing more food with which to take their tablets. Factors related to the administration of economic support may undermine its effectiveness in improving TB treatment outcomes. Further research is needed to explore how best to deliver such economic support to those eligible to receive it, particularly in low and middle income countries where the burden of tuberculosis is highest.AFRIKAANSE OPSOMMING: Hierdie tesis was toegespits op die verlening van ekonomiese steun om die uitkomste van pasiënte op tuberkulose- (TB-) behandeling te verbeter. Hoewel die verband tussen armoede en TB in die algemeen erken word, is daar nie veel bewyse om die gebruik van ekonomiese intervensies ter verbetering van TB-beheer te staaf nie. In Suid-Afrika – ’n land met ’n hoë TB-las en wydverspreide armoede – is sulke bewyse veral belangrik. Die eerste deel van hierdie tesis behels ’n sistematiese Cochrane-oorweging van bewysmateriaal afkomstig van verewekansigde, gekontroleerde proewe oor die doeltreffendheid van ekonomiese steun aan pasiënte met tuberkulose. Altesame 11 proewe is ingesluit: Tien is gedoen onder gemarginaliseerde groepe in die Verenigde State met die fokus op ekonomiese ondersteuning aan mense wat profilaktiese behandeling vir latente TB ontvang het. Een, van Timor-Leste, was gefokus op ekonomiese ondersteuning aan pasiënte met aktiewe tuberkulose. Die ondersoek het aan die lig gebring dat, vergeleke met normale sorg, die gebruik van ekonomiese intervensies by pasiënte met latente tuberkulose tog die omdraaikoers vir die lees van tuberkulien-veltoetsresultate kan verhoog, waarskynlik hertoelating tot klinieke vir die inisiëring of voortsetting van profilakse verbeter, en die voltooiing van profilakse kan verbeter. Die tweede gedeelte van die tesis behels ’n verslag oor die bevindings van ’n pragmatiese, trosverewekansigde gekontroleerde proef, om te bepaal hoe doenlik en doeltreffend dit sou wees om ekonomiese steun te verleen aan pasiënte wat in Suid-Afrika vir aktiewe tuberkulose behandel word. Pasiënte met middelsensitiewe pulmonêre tuberkulose het tot en met die voltooiing van hul behandeling, of tot ’n maksimum van agt maande, ’n maandelikse koopbewys ter waarde van ZAR120 ontvang. Pasiënte in kontroleklinieke het die gewone TB-sorg ontvang. ’n Parallelle prosesevaluering het kontekstuele inligting voorsien ter verklaring van die bevindinge van die proef. Die kwalitatiewe komponent van hierdie evaluering het bestaan uit diepte-onderhoude met ’n steekproef van alle deelnemers aan die proefneming, insluitend pasiënte, verpleegpersoneel en gesondheidsbestuurders, om hul reaksies te bepaal op die koopbewys self sowel as op die administrasie daarvan. Die kwantitatiewe komponent het ’n opname oor pasiënte se huishoudelike besteding ingesluit, ter vasstelling van hul armoedevlak en die moontlike uitwerking van die koopbewys daarop, asook ’n ontleding van die goedere waarop pasiënte hul koopbewyse bestee het. Altesame 4 091 pasiënte is by die proef ingesluit – 1 984 in die kontrole-afdeling (10 klinieke) en 2 107 in die intervensie-afdeling (10 klinieke). ’n Voorneme-om-te-behandel- (ITT-) ontleding toon ’n klein dog nie-betekenisvolle verbetering in behandelingsuksessyfers in intervensieklinieke (intervensie 76,2%; kontrole 70,7%; risikoverskil 5,6% (-1,2; 12,3%), p = 0.107). Getrouheid aan die intervensie was laag – deels omdat verpleegkundiges verkies het om die koopbewyse op grond van veronderstelde finansiële behoeftigheid eerder as volgens die studiekriteria uit te deel. Die koopbewyse het nie pasiënte se huishoudelike besteding beduidend verhoog nie, maar pasiënte het dit wél as nuttig ervaar, veral omdat hulle daarmee meer kos kon koop om saam met hul pille in te neem. Faktore wat verband hou met die administrasie van ekonomiese ondersteuning kan die doeltreffendheid van sodanige steun in die verbetering van TB-behandelingsuitkomste ondermyn. Verdere navorsing word vereis om te verken wat die beste manier sou wees om sodanige ekonomiese steun te bied aan diegene wat daarvoor in aanmerking kom, veral in lae- en middel-inkomstelande, waar die TB-las die hoogste is

The burden of diabetes mellitus in KwaZulu-Natal’s public sector: A 5-year perspective

Background. Diabetes mellitus (DM), together with its devastating complications, has a huge impact on both the patients it affects and the global economy as a whole. The economies of developing countries are already under threat from communicable diseases. More needs to be done to stem the tide of non-communicable diseases like DM. In order for us to develop new strategies to tackle this dread disease we need to obtain and analyse as many data as possible from the geographical area where we work. Objective. To describe the burden of DM in the public sector of the province of KwaZulu-Natal (KZN), South Africa (SA).Method. Data on the number of diabetes visits, DM patients that were initiated on treatment, defaulters and DM-related amputations were accessed from the Department of Health records for the period 2010 - 2014 inclusive.Results. There was a decline in the number of patients initiated on treatment per 100 000 population from 2010 to 2014 inclusive (265.9 v. 197.5 v. 200.7 v. 133.4 v. 148.7). Defaulter rates for 2013 compared with 2014 were 3.31% v. 1.75%, respectively and amputation rates were 0.09% v. 0.05% for 2013 and 2014, respectively. There was a strong proportional relationship observed between the number of defaulters and number of diabetes-related amputations (r=0.801; p=0.000) (Pearson correlation). A notable percentage of DM patients ranging between 63% and 80% were commenced on pharmacological therapy at their local clinics rather than at hospitals in the province.Conclusion. Strategies directed towards detection and treatment of DM, together with decreasing defaulter rates and thereby decreasing diabetes-related amputations, need to be addressed urgently. The majority of patients were initiated on therapy at the clinic level. This emphasises the need to strengthen our clinics in terms of resources, staffing, and nursing and clinician education, as this is where diabetes control begins. Although this study was based solely in KZN, the second most populous province in SA, it probably reflects the current situation regarding DM in other provinces of SA as well.

Spatial-temporal trends and risk factors for undernutrition and obesity among children (<5 years) in South Africa, 2008–2017: findings from a nationally representative longitudinal panel survey

Objectives To assess space-time trends in malnutrition and associated risk factors among children (<5 years) in South Africa. Design Multiround national panel survey using multistage random sampling. Setting National, community based. Participants Community-based sample of children and adults. Sample size: 3254 children in wave 1 (2008) to 4710 children in wave 5 (2017). Primary outcomes Stunting, wasting/thinness and obesity among children (<5). Classification was based on anthropometric (height and weight) z-scores using WHO growth standards. Results Between 2008 and 2017, a larger decline nationally in stunting among children (<5) was observed from 11.0% to 7.6% (p=0.007), compared with thinness/wasting (5.2% to 3.8%, p=0.131) and obesity (14.5% to 12.9%, p=0.312). A geographic nutritional gradient was observed with obesity more pronounced in the east of the country and thinness/wasting more pronounced in the west. Approximately 73% of districts had an estimated wasting prevalence below the 2025 target threshold of 5% in 2017 while 83% and 88% of districts achieved the necessary relative reduction in stunting and no increase in obesity respectively from 2012 to 2017 in line with 2025 targets. African ethnicity, male gender, low birth weight, lower socioeconomic and maternal/paternal education status and rural residence were significantly associated with stunting. Children in lower income and food-insecure households with young malnourished mothers were significantly more likely to be thin/wasted while African children, with higher birth weights, living in lower income households in KwaZulu-Natal and Eastern Cape were significantly more likely to be obese. Conclusions While improvements in stunting have been observed, thinness/wasting and obesity prevalence remain largely unchanged. The geographic and sociodemographic heterogeneity in childhood malnutrition has implications for equitable attainment of global nutritional targets for 2025, with many districts having dual epidemics of undernutrition and overnutrition. Effective subnational-level public health planning and tailored interventions are required to address this challenge

Economic support to improve tuberculosis treatment outcomes in South Africa : a pragmatic cluster-randomized controlled trial

The original publication is available at http://www.trialsjournal.com/content/14/1/154Abstract Poverty undermines adherence to tuberculosis treatment. Economic support may both encourage and enable patients to complete treatment. In South Africa, which carries a high burden of tuberculosis, such support may improve the currently poor outcomes of patients on tuberculosis treatment. The aim of this study was to test the feasibility and effectiveness of delivering economic support to patients with pulmonary tuberculosis in a high-burden province of South Africa. Methods This was a pragmatic, unblinded, two-arm cluster-randomized controlled trial, where 20 public sector clinics acted as clusters. Patients with pulmonary tuberculosis in intervention clinics (n = 2,107) were offered a monthly voucher of ZAR120.00 (approximately US$15) until the completion of their treatment. Vouchers were redeemed at local shops for foodstuffs. Patients in control clinics (n = 1,984) received usual tuberculosis care. Results Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (95% confidence interval: -1.2%, 12.3%), P = 0.107). Low fidelity to the intervention meant that 36.2% of eligible patients did not receive a voucher at all, 32.3% received a voucher for between one and three months and 31.5% received a voucher for four to eight months of treatment. There was a strong dose–response relationship between frequency of receipt of the voucher and treatment success (P <0.001). Conclusions Our pragmatic trial has shown that, in the real world setting of public sector clinics in South Africa, economic support to patients with tuberculosis does not significantly improve outcomes on treatment. However, the low fidelity to the delivery of our voucher meant that a third of eligible patients did not receive it. Among patients in intervention clinics who received the voucher at least once, treatment success rates were significantly improved. Further operational research is needed to explore how best to ensure the consistent and appropriate delivery of such support to those eligible to receive it. Trial registration Current Controlled Trials ISRCTN50689131Publishers' Versio

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa : a meta-synthesis protocol

INTRODUCTION : In sub-Saharan Africa (SSA), Human Immunodeficiency Virus (HIV) is the leading cause of morbidity and mortality. Community healthcare workers (CHWs) worldwide have been reported to be effective in strengthening the HIV programme by providing services such as adherence support, HIV education and safe sex education as part of their roles. The main aim of this meta-synthesis is to synthesise qualitative evidence on studies that have been conducted in SSA countries to understand the barriers to and facilitators of providing HIV services by CHWs across all settings METHODS AND ANALYSIS : This meta-synthesis will be guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An initial search was conducted on 15 November 2019 for studies published between 2009 and 2019 using the population exposure outcome nomenclature. We searched the EBSCOHost- (ERIC; Health Source-Nursing/ Academic Edition), Google Scholar and PubMed databases for the relevant studies. The Ritchie and Spencer framework will be used for data synthesis and the Supporting the Use of Research Evidence Framework analysis will be used to analyse data. We will conduct critical appraisal on selected studies using the Qualitative Assessment and Review Instrument to limit risk of bias.http://bmjopen.bmj.comam2022School of Health Systems and Public Health (SHSPH

The Textualities of the AutobiogrAfrical

In your mind’s eye, summon a map of the world—that famous text. There, there is Africa. The familiar, highly visible bulge of head to horn and curve, and the islands as you travel down to the continent’s southernmost point. It is likely that your imagination, like ours, has archived the inherited template of a Mercator projection, the powerful sixteenth-century cartography which remains influential offline and e-nfluential on Google Maps, even though it misleadingly distorts the size of continents. The 30.2 million square kilometers of the African continent appear much smaller than, say, the areas of the US (9.1 million square kilometers), Russia (16.4 million square kilometers), or China (9.4 million square kilometers). In comparison, the corrective cartographic morphing of the GallPeters projection revises the habituated representational geography of the world’s landmasses, showing the relational sizes of continents more accurately.1 Such tensions are not surprising, for the map, we know, is not to be equated with the territory and, in the context of our interest in this special issue in the textualities of the AutobiogrAfrical, divergent cartographies of the same space, drafted from different ideological perspectives, remind us to ask questions about how life narratives might make Africa intelligible. If, as Frances Stonor Saunders observes, “the self is an act of cartography, and every life a study of borders,” then “[e]nvisioning new acts of cartography that give substance and dynamism to the spaces between borders … produces new selves—or, at the very least, new ways of thinking about selfhood—and thus new objects of autobiographical enquiry.” 2 Any map of Africa reflects assumptions about a collective (“Africa”), as well as the political-geographical divisions of nation-states. “Africa” implies degrees of commonality among the (possibly more than) fifty-four countries that comprise the continent. Yet we know the dangers of a single story. Africa is not, after all, a country. Bear in mind, too, that our editorial team is located at the bottom end of the continent in South Afric