The vulnerability and resiliency of childhood

Life is full of stressors, which have to be confronted efficiently to grow up. However, reaction to stressors is personalized, complex and coordinated. Vulnerable persons adjust poorly to stressors and express inappropriate responses, while resilient persons practice adaptive physiological and psychological responses. Promotion of resiliency is an intricated issue, which demands strategies at both macro and micro-level. Microlevel strategies are focused on the community, family and individual level, while macrolevel strategies formulate the principles. Nevertheless, prediction of vulnerability and resiliency is really a challenge, as different persons facing same stressors react differently. Some are growing as resilient and others as vulnerable. We aimed to discuss resiliency, vulnerability, importance in relation to health outcome, promotion of resiliency and controversies of vulnerability and resiliency

A neuroimaging study in childhood autism

Background: Childhood autism is now widely viewed as being of developmental neurological origin. Abnormality in neuroimaging is reported in autism.Objectives: To delineate the proportion of structural magnetic resonance imaging (MRI) and electro encephalography (EEG) abnormality among the children with Autism and to assess any association of MRI and EEG changes with co morbid mental illness.Methods: It was a cross sectional descriptive study done at a child and adolescent consultation centre, Dhaka. The study was Carried out from January 2009 to December 2009. Both boys and girls were included in the study. A total of 42 children with childhood autism aged between two and 12 years partici­pated in this study. Diagnosis of autism was based on ICD-10(DCR) criteria. Results: Abnormalities were found to be 35.7% in MRI and 42.9% in EEG. EEG abnormalities were found in the form of defuse slow waves activities, generalized faster activities, epileptogenic discharge and mixed discharge. The abnormalities in MRI was found in the form of diffuse cortical atrophic changes, focal cortical atrophy in frontal and temporal cortex with widening of major sulci, prominent ventricles, periventricular degeneration and abnormal basal ganglia. EEG changes were significantly associated with increased number of co-morbid illness (mental retardation, epilepsy and others). Conclusion: A number of abnom1alities that observed in the present study indicative of relations between structural and physiological dysfunctions and childhood autism. Further exploratory and in-depth researches are certainly required in this field. Intervention of autism needs to address co morbidities for better outcome

Lessons learnt from the introduction of the contraceptive implant in South Africa

In 2014, South Africa (SA) introduced the subdermal contraceptive implant with the aim of expanding the contraceptive method mix and availability of long-acting reversible methods in the public sector. Three years on, concerns have been raised about the decline in uptake, early implant removals and challenges in service delivery. This article explores the lessons learnt from the introduction of contraceptive technologieselsewhere and applies these to the SA context. Drawing on the World Health Organization’s conceptual framework for the introduction of new contraceptive methods, and subsequent literature on the topic, lessons are classified into six cross-cutting themes. Recommendations highlight the need for SA to review and explore strategies to strengthen current implant services, including the provision of improved provider training aimed at sensitive, client-centred approaches; increased community engagement; and improved systems for programmatic monitoring and evaluation. With implementation of these recommendations, worrying trends in the provision of implants could be reversed

User perspectives on Implanon NXT in South Africa: A survey of 12 public-sector facilities

Background. Implanon NXT, a long-acting reversible contraceptive, was introduced in South Africa (SA) in early 2014, aiming to expand the method mix and increase its effectiveness. Initial uptake was high, but has since declined considerably. In these early years after the implant’s introduction, it is important to identify reasons for the decline, and remedy gaps in services. Objectives. To determine periods of use, reasons for the use and early removal of the implant Implanon NXT. Methods. In 2016, we recruited 152 women from six clinics in the City of Johannesburg, and six in North West Province, SA. A semistructured interview was administered to 91 women currently using the implant and 61 previous users. We examined user perspectives, factors influencing women’s experiences with the implant and reasons for discontinuation. Results. The participants’ mean age was 30 years, with only 15% aged <25. Implant uptake was motivated by convenience (less frequent visits required than for short-acting methods) and by favourable views of the method among friends, family and healthcare providers. Only about a quarter of women recalled being counselled pre-insertion about implant effectiveness, and half about side-effects pre-insertion. Among discontinuers, the median time to device removal was 8 months (interquartile range 6 - 12), and this was primarily as a result of sideeffects (90%), especially bleeding-pattern changes and headaches. Removals were most common among married and cohabiting women, often ascribed to the effects of bleeding on their sexual relationships. Rumours and misinformation contributed to some removals. Overall, women’s experiences with the implant were rated ‘good’ or ‘very good’ by 74% of those continuing use, many of whom reported not having experienced any side-effects or that these had diminished over time. Conclusion. Levels of acceptability among continuing users were high, mainly linked to the method’s convenience. While early favourable views drove uptake, negative perceptions, if unaddressed, may now undermine services. Deficiencies in counselling around effectiveness and side-effects may extend to contraceptive services more generally. Women require more intensive support when experiencing sideeffects, including effective systematic approaches to ameliorating bleeding and headaches. Implant services could specifically target young women and first-time contraceptive users. These actions together could reverse the persistent decline in implant use in SA. S Afr Med J 2017;107(10):815-82

Uptake and early removals of Implanon NXT in South Africa: Perceptions and attitudes of healthcare workers

Background. The South African (SA) government introduced Implanon NXT, a long-acting subdermal contraceptive implant, in 2014 to expand contraceptive choice. Following an initial high uptake, its use declined considerably amid reports of early removals and frequent side-effects. We examine providers’ perceptions of training and attitudes towards Implanon NXT, as well as their views on the causes of early removals and the impact on the implant service. Objective. To assess healthcare providers’ perceptions and attitudes towards implant services in SA. Methods. In-depth interviews were conducted with eight nurses providing implant services in public facilities in Gauteng and North West Province. Emerging themes were identified, manually coded and thematically analysed following an interpretivism approach. Results. Nurses lacked confidence in providing implant services effectively, particularly removals, which they ascribed to the brief, cascade-type training received. Nurses generally held negative views towards the method. They also reported that side-effects are the most common reason for early removals – particularly irregular bleeding – and that men often do not support their partners who use the method. Lastly, it was found that providers require guidance on counselling regarding the method and standardised guidelines on the management of side-effects. Conclusion. Retraining and support of providers are needed to address competency gaps and negative attitudes towards the method. Assessment of providers’ readiness to perform removal procedures is also important. Finally, effective plans are necessary to improve implant continuation rates, especially among women whose partners are unsupportive.S Afr Med J 2017;107(10):822-82

Gaps in monitoring systems for Implanon NXT services in South Africa: An assessment of 12 facilities in two districts

Background. Implanon NXT, a long-acting subdermal contraceptive implant, was introduced in South Africa (SA) in early 2014 as part of an expanded contraceptive method mix. After initial high levels of uptake, reports emerged of frequent early removals and declines in use. Monitoring of progress and challenges in implant service delivery could identify aspects of the programme that require strengthening. Objectives. To assess data management and record keeping within implant services at primary care facilities. Methods. We developed a checklist to assess the tools used for monitoring implant services and data reporting to district offices. The checklist was piloted in seven facilities. An additional six high-volume and six low-volume implant insertion clinics in the City of Johannesburg (CoJ), Gauteng Province, and the Dr Kenneth Kaunda District, North West Province, were selected for assessment. Results. All 12 facilities completed a Daily Head Count Register, which tallied the number of clients attending the clinic, but not information about implant use. A more detailed Tick Register recorded services that clinic attendees received, with nine documenting number of implant insertions and six implant removals. A more specific tool, an Insertion Checklist, collected data on insertion procedures and client characteristics, but was only used in CoJ (five of six facilities). Other registers, which were developed de novo by staff at individual facilities, captured more detailed information about insertions and removals, including reasons. Five of six low-volume insertion facilities used these registers, but only three of six high-volume facilities. No facilities used the form specifically developed by the National Department of Health for implant pharmacovigilance. Nine of 12 clinics reported data on numbers of insertions to the district office, six reported removals and none provided data on reasons for removals. Conclusion. For data to inform effective decision-making and quality improvement in implant services in SA, standardised reporting guidelines and data collection tools are needed, reinforced by staff training and quality assessment of data collection. Staff often took the initiative to fill gaps in reporting systems. Current systems are unable to accurately monitor uptake or discontinuation, or identify aspects of services requiring strengthening. Lack of pharmacovigilance data is especially concerning. Deficiencies noted in these monitoring systems may be common to family planning services more broadly, which warrants investigation.S Afr Med J 2017;107(10):827-831

Strengthening implant provision and acceptance in South Africa with the ‘Any woman, any place, any time’ approach: An essential step towards reducing unintended pregnancies

Progress in reducing unintended pregnancies in South Africa is slow. The implant, introduced in 2014, expanded the range of available longacting reversible contraceptives (LARCs) and held much promise. Uptake, however, has declined precipitously, in spite of its ‘unmatched effectiveness’ and high levels of satisfaction for most users. We propose policy and provider interventions to raise implant use, underscored by a ‘LARC-first’ approach. Contraceptive counselling should focus on the particular benefits of LARCs and methods be presented in order of effectiveness. Moreover, implants hold particular advantages for certain groups, especially adolescents and young women, in whom it is considered first-line contraception. Provision of immediate postpartum and post-abortion implants is safe and highly acceptable, yet remains under-utilised. Implant services at HIV and tuberculosis clinics are a key priority, as is inclusion of LARC provision within school health services. Implants could also be delivered by existing mobile outreach services, for example in sex worker programmes. Services could be built around nurses dedicated solely to providing implants, with other health workers receiving brief refresher training. Women who experience side-effects, especially abnormal bleeding, require timely interventions, following a standardised protocol, including use of medications. Encouraging return for side-effects, follow-up phone calls and home visits would raise continuation rates. Removal services require doctor support or designated nurses at specific centres. Limited access to removal services, health workers’  resistance or botched procedures will further undermine implant provision. Rapid implant demonstration projects in postpartum wards, schools, outreach services and by dedicated providers may rapidly advance the field. Together, the actions outlined here will ensure that the implant fulfils its potential and reinvigorates family planning services