Upskilling nursing students and nurse practitioners to initiate and manage patients on ART: An outcome evaluation of the UKZN NIMART course

Background. Currently, there is a need in South Africa to implement strategies to upskill nurses in the clinical management of HIV and AIDS, for effective and efficient management of people living with HIV. One such strategy is the nurse-initiated management of antiretroviral therapy (NIMART) course.Objectives. To evaluate the effectiveness of the NIMART course in increasing the knowledge of trainees in select clinical competencies, to assess whether perceived knowledge gain varied according to individual-level characteristics of trainees, and to determine trainee perceptions of the value and delivery of the course.Methods. A 5-day training course focusing on various areas of HIV was developed and delivered by experts in the field of HIV to multiple cohorts of fourth-year nursing students at the University of KwaZulu-Natal, and to post-basic nursing practitioners, over a 5-year period. A single-group pre- and post-quasi-experimental design was used to assess knowledge change and perceptions about the course among 1 369 trainees who had benefitted from the course during the implementation period.Results. Post-workshop test scores were significantly higher than pre-workshop scores (p<0.0001), based on both pooled and cohort-specific data. For pooled analysis, the pre-test median score was 67% (interquartile range (IQR) = 60% - 73%) and the post-test median score was 77% (IQR = 70% - 80%), with p<0.0001. The knowledge gain was the highest in respect of HIV prevention, followed by prevention of mother-to-child transmission, then HIV treatment and lastly, general knowledge of HIV. The vast majority were very satisfied with the content of the training, although 31.3% strongly disagreedthat they were ready to apply the knowledge they had learned in their workplace.Conclusion. The training was generally well received, and improved the knowledge of participants in HIV and its management. However, this outcome represents short-term benefits of the programme, and there is a need for on-the-job mentorship and support in order to maximise on clinical outcomes related to HIV

The impact of HIV infection and disease stage on the rate of weight gain and duration of refeeding and treatment in severely malnourished children in rural South African hospitals

BACKGROUND: Evidence of the effects of HIV infection and clinical stage on the duration of refeeding and treatment (DRT) and the rate of weight gain (RWG) in severely malnourished children remains inconclusive. OBJECTIVES: To determine whether the RWG and DRT differ by baseline clinical characteristics, and to assess the effect of HIV status and disease stage on the relationship between these two clinical outcomes. METHODS: This was a retrospective record review of 346 patiens discharged between 2009 and 2013 following treatment for severe acute malnutrition (SAM) at two rural hospitals in South Africa. RESULTS: A third of the sample was HIV-positive, the RWG (measured as g/kg/day) was significantly slower in HIV-positive patients compared with HIV-negative cases (mean 5.2, 95% confidence interval (CI) 4.47 - 5.93 v. mean 8.51; CI 7.98 - 9.05; p<0.0001) and cases at stage IV of HIV infection had a significantly slower RWG (mean 3.97; CI 2.33 - 5.61) compared with those at stages I (mean 7.64; CI 6.21 - 9.07) (p<0.0001) and II (mean 5.87; CI 4.74 - 6.99). The mean DRT was longer in HIV-positive cases and those at advanced stages of HIV infection. HIV-positive cases were renourished and treated for almost 3.5 times longer than their HIV-negative counterparts to achieve a moderate RWG (5 - 10 g/kg/day). CONCLUSION: This study highlights the need to reconsider energy requirements for HIV-positive cases at different clinical stages, for more rapid nutritional recovery in under-resourced settings where prolonged hospitalisation may be a challenge.DHE

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

Experiences of lifestyle change among women with gestational diabetes mellitus (GDM): A behavioural diagnosis using the COM-B model in a low-income setting

Lifestyle change can reduce the risk of developing type 2 diabetes among women with prior gestational diabetes mellitus (GDM). While understanding women’s lived experiences and views around GDM is critical to the development of behaviour change interventions to reduce this risk, few studies have addressed this issue in low- and middle- income countries. The aim of the study was to explore women’s lived experiences of GDM and the feasibility of sustained lifestyle modification after GDM in a low-income setting

Household, community, sub-national and country-level predictors of primary cooking fuel switching in nine countries from the PURE study

Introduction. Switchingfrom polluting (e.g. wood, crop waste, coal)to clean (e.g. gas, electricity) cooking fuels can reduce household air pollution exposures and climate-forcing emissions.While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood. Methods.We examined longitudinal survey data from 24 172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology study.We assessed household-level primary cooking fuel switching during a median of 10 years offollow up (∼2005–2015).We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching. Results. One-half of study households(12 369)reported changing their primary cookingfuels between baseline andfollow up surveys. Of these, 61% (7582) switchedfrom polluting (wood, dung, agricultural waste, charcoal, coal, kerosene)to clean (gas, electricity)fuels, 26% (3109)switched between different polluting fuels, 10% (1164)switched from clean to polluting fuels and 3% (522)switched between different clean fuels

Perceived and actual cost of healthier foods versus their less healthy alternatives: A case study in a predominantly black urban township in South Africa

Objectives There is an increasing awareness of the role played by the food retail characteristics in determining individuals’ healthy food purchasing and consumption behaviors. The perceived costs of healthier food alternatives have been shown to contribute negatively to individual’s food choices in developed societies. However, there is still a dearth of knowledge regarding this phenomenon in low to middle income countries particularly in Africa. This study explored health club member’s experiences in buying healthier food options and compared their perceived cost of selected healthier and less healthy foods with actual market costs in a South African township.Method: A cross-sectional study design using quantitative and qualitative research methods. The study was conducted in Khayelitsha, a township in the Western Cape Province in South Africa. Participants were 50 members of a health club, mostly female and above 50 years of age. The study was conducted in three phases. The first phase involved interviews with all 50 health club members. During the second phase ten purposively selected members participated in in-depth interviews based on their unhealthy food-purchasing and consumption patterns identified in the first phase. The third phase involved food price audits from supermarkets as well as convenient stores located in the study setting. Quantitative data were subjected to descriptive statistical analysis, while content analysis was used to analyze qualitative data.Results: Most of the members were illiterate and unemployed, largely dependent on government grants. Qualitative findings showed that low household incomes, their inability to read and interpret nutritional information and personal food preferences contributed to Health club members’ unhealthy food-purchasing behaviour. When objectively measured in local stores, the healthier food options proved to be more expensive than their less healthy equivalents. This was consistent with subjects’ perceptions about the relative cost of the same foods in their local stores.Conclusion: Healthier foods tended to be more expensive than their less healthy options in local shops audited – both in reality and in the perceptions of health club members. Low income was reported to militate against health club members’ healthy food-purchasingbehaviour.Keywords: Healthy food cost, food retail milieu, South African Township, perceived, actua

Independent and interactive effects of HIV infection, clinical stage and other comorbidities on survival of children treated for severe malnutrition in rural South Africa: a retrospective multicohort study

Background. There is still limited to no evidence on the independent and interactive effects of HIV infection, disease stage, baseline disease severity and other important comorbidities on mortality risk among young children treated for severe acute malnutrition (SAM) in South Africa (SA, using the World Health Organization (WHO) recommended treatment modality. Objectives. To determine baseline clinical characteristics among children with SAM and assess whether HIV infection, disease stage, critical illness at baseline and other comorbidities independently and interactively contributed to excess mortality in this sample. Methods. We followed up children aged 6 - 60 months, who were admitted with and treated for SAM at two rural hospitals in SA, and retrospectively reviewed their treatment records to abstract data on their baseline clinical characteristics and treatment outcomes. In total, 454 children were included in the study. Descriptive statistical tests were used to summarise patients’ clinical characteristics. Kaplan-Meier failure curves were created for key characteristics and compared statistically using log-rank tests. Univariate and multivariate Cox regression was used to estimate independent and interactive effects. Results. The combined case fatality rate was 24.4%. HIV infection, clinical disease stage, the presence of lower respiratory tract infection, marasmus and disease severity at baseline were all independently associated with excess mortality. The critical stage for higher risk of death was when cases were admitted at WHO stage III. The interactions of two or three of these characteristics were associated with increased risk of death when compared with having none, with HIV infection and critical illness showing the greatest risk (hazard ratio 22, p<0.001). Conclusion. The high HIV prevalence rate in the study setting and the resultant treatment outcomes support the notion that the WHO treatment guidelines should be revised to ensure that mechanisms for effective treatment of HIV comorbidity in SAM are in place. However, a much more rigorous study is warranted to verify this conclusion

Predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in South Africa

Background. There is a dire need for medical schools in South Africa to train medical doctors who have the capacity and willingness to work in primary healthcare facilities, particularly in rural areas.Objectives. To assess the effect of students’ gender, race, place of birth and place of high school completion on their choice of training site location and to assess the extent to which the training programme enhanced students’ learning experiences relevant to primary care across training sites.Methods. A survey design involving six cohorts of 4th-year undergraduate medical students (N=187) who were part of the 2013 Family Medicine rotation at the Nelson R Mandela School of Medicine. Self-administered questionnaires were completed by students at the end of each rotation. Data analyses involved descriptive computations and inferential statistical tests, including non-parametric tests for group comparison and generalised polynomial logistic regression.Results. Students believed that their knowledge and skills relevant to primary care increased after the rotation (p&lt;0.0001). There were statistically significant differences between rural and urban sites on certain measures of perceived programme effectiveness. Male students were less likely to choose urban sites. Black students were less likely to choose rural sites compared with their white and Indian counterparts, as were students who attended rural high schools (odds ratio (OR) 9.3; p&lt;0.001). Students from a rural upbringing were also less likely to choose rural sites (OR 14; p&lt;0.001).Conclusion. Based on the findings, an objective approach for student allocation that considers students’ background and individual-level characteristics is recommended to maximise learning experiences

WHO standards-based tools to measure service providers' and service users' views on the quality of hospital child care: Development and validation in Italy

Objectives Evidence showed that, even in high-income countries, children and adolescents may not receive high quality of care (QOC). We describe the development and initial validation, in Italy, of two WHO standards-based questionnaires to conduct an assessment of QOC for children and young adolescents at inpatient level, based on the provider and user perspectives. Design Multiphase, mixed-methods study. Setting, participants and methods The two questionnaires were developed in four phases equally conducted for each tool. Phase 1 which included the prioritisation of the WHO Quality Measures according to predefined criteria and the development of the draft questionnaires. In phase 2 content face validation of the draft questionnaires was assessed among both experts and end-users. In phase 3 the optimised questionnaires were field tested to assess acceptability, perceived utility and comprehensiveness (N=163 end-users). In phase 4 intrarater reliability and internal consistency were evaluated (N=170 and N=301 end-users, respectively). Results The final questionnaires included 150 WHO Quality Measures. Observed face validity was excellent (kappa value of 1). The field test resulted in response rates of 98% and 76% for service users and health providers, respectively. Among respondents, 96.9% service users and 90.4% providers rated the questionnaires as useful, and 86.9% and 93.9%, respectively rated them as comprehensive. Intrarater reliability was good, with Cohen's kappa values exceeding 0.70. Cronbach alpha values ranged from 0.83 to 0.95, indicating excellent internal consistency. Conclusions Study findings suggest these tools developed have good content and face validity, high acceptability and perceived utility, and good intrarater reliability and internal consistency, and therefore could be used in health facilities in Italy and similar contexts. Priority areas for future research include how tools measuring paediatric QOC can be more effectively used to help health professionals provide the best possible care