Social epidemiology

Social epidemiology is the branch of epidemiology concerned with understanding how social and economic characteristics influence states of health in populations. There has been a resurgence recently in interest among epidemiologists about the roles that social and economic factors play in determining health, leading to valuable synergies with the social sciences. The determinants of health commonly studied in social epidemiology include absolute poverty, income inequality, as well as race and discrimination. Recently, social epidemiologists have been at the forefront of conceptual developments within the discipline that view the determinants of health at different levels of social organization. © 2008 Copyright © 2008 Elsevier Inc. All rights reserved

Concomitant contraceptive implant and efavirenz use in women living with HIV: perspectives on current evidence and policy implications for family planning and HIV treatment guidelines.

IntroductionPreventing unintended pregnancies is important among all women, including those living with HIV. Increasing numbers of women, including HIV-positive women, choose progestin-containing subdermal implants, which are one of the most effective forms of contraception. However, drug-drug interactions between contraceptive hormones and efavirenz-based antiretroviral therapy (ART) may reduce implant effectiveness. We present four inter-related perspectives on this issue.DiscussionFirst, as a case study, we discuss how limited data prompted country-level guidance against the use of implants among women concomitantly using efavirenz in South Africa and its subsequent negative effects on the use of implants in general. Second, we discuss the existing clinical data on this topic, including the observational study from Kenya showing women using implants plus efavirenz-based ART had three-fold higher rates of pregnancy than women using implants plus nevirapine-based ART. However, the higher rates of pregnancy in the implant plus efavirenz group were still lower than the pregnancy rates among women using common alternative contraceptive methods, such as injectables. Third, we discuss the four pharmacokinetic studies that show 50-70% reductions in plasma progestin concentrations in women concurrently using efavirenz-based ART as compared to women not on any ART. These pharmacokinetic studies provide the biologic basis for the clinical findings. Fourth, we discuss how data on this topic have marked implications for both family planning and HIV programmes and policies globally.ConclusionThis controversy underlines the importance of integrating family planning services into routine HIV care, counselling women appropriately on increased risk of pregnancy with concomitant implant and efavirenz use, and expanding contraceptive method mix for all women. As global access to ART expands, greater research is needed to explore implant effectiveness when used concomitantly with newer ART regimens. Data on how HIV-positive women and their partners choose contraceptives, as well as information from providers on how they present and counsel patients on contraceptive options are needed to help guide policy and service delivery. Lastly, greater collaboration between HIV and reproductive health experts at all levels are needed to develop successful strategies to ensure the best HIV and reproductive health outcomes for women living with HIV

Dual protection against sexually transmitted infections and pregnancy in South Africa

Promotion of simultaneous protection against sexually transmitted infections (STIs) and unintended pregnancy, referred to as dual protection, represents an important public health intervention. We investigated its prevalence and correlates in South Africa. A cross-sectional survey of 929 sexually active women, aged 15-49 years, was conducted in 89 public primary health care clinics, with dual method use and use of condom alone at last sexual intercourse as outcomes. At last intercourse, 12% of women were protected from both STIs and pregnancy. In multivariate analysis, higher education, being unmarried, and multiple sex partnership in the past year were predictors of dual method use, while younger age, higher education and awareness of the dual function of condoms were predictors of condom use alone. Dual protection is low in this population. The predominance of hormonal contraceptive use in South Africa means that increasing barrier method use among hormonal contraceptive users is an important strategy for increasing dual protectio

Informed choice - the timing of postpartum contraceptive initiation

Background. In South Africa injectable progestogen-only contraceptives (IPC) are typically administered to women immediately after delivery. Several guidelines advise that breast-feeding women should not commence IPC until 6 weeks postpartum on the basis of theoretical risks to the infant.Objective. We examined women's preferences regarding timing of postpartum IPC initiation, as well as women's contraceptive and breast-feeding behaviours and pregnancy risk in the early postpartum period.Design and data collection. A cross-sectional study was conducted among 200 antenatal clinic (ANC) attendees and 180 mothers attending a child health clinic. (CHC). At the ANC, women were given information on the theoretical risks of IPC and re-interviewed about their postpartum contraceptive intentions.Results. Most ANC women planned to use IPCs (92%) and to breast-feed (98%) after delivery. Most CHC mothers had used IPCs (91 %) and had breast-fed (83%) after delivery. When women at the ANC were provided with appropriate information they made decisions about when to initiate IPC by balancing the theoretical risks of IPC to their infant against their personal risk of pregnancy and ability to return to a clinic in the early postpartum period.Conclusion. It is important to include informed choice in postpartum IPC initiation guidelines

Scanning Electron Microscopy of the Small Intestine Mucosa in Children with Celiac Disease After Long-Term Dietary Treatment

Jejunal mucosal specimens from twenty children with celiac disease were studied by light microscopy (LM), scanning electron microscopy (SEM), and transmission electron microscopy (TEM) after one year of dietary treatment. An ultrastructural morphometric study was performed in five patients who had an intestinal permeability (IP) test. Seventeen patients were tested for serum antigliadin antibodies (AGA). In ten children, in whom LM showed partial villous atrophy, SEM and TEM examination confirmed the lesion. In the second group (10 children) with normal morphology at routine LM, SEM showed lesions of variable degree in 70% of cases. The morphological ultrastructural investigation showed good correlation with the immunological and functional data (IP test): ultrastructural damage of the jejunal mucosa after one year of a gluten-free diet was found in patients with positive serum AGA and an abnormal IP test. Furthermore, the morphometric study of the ultrastructural alterations allowed a quantitative, closer correlation between morphological and functional data. Our results suggest: 1) SEM and TEM investigations offer additional and more complete information on celiac patients, over LM alone. 2) The morphometric evaluation of the ultrastructural alterations highlights quantitative and reproducible correlations between morphological and clinical data, not strengthened by the subjective, qualitative study

Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa

This paper is a sequel to a 2004 article thet reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights, laws, policies and programmes, a decade into democracy. Similarly to the previous article this paper focuses on key areas of women's SRH: contraception and fertility abortion maternal health HIV cervical and breast cancer and sexual violence. In the last decade South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion contraception youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions AIDS deaths and vertical HIV transmission as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes and in confronting and ameliorating social norms that undermine SRHR

Uterine fibroid pseudocapsule studied by transmission electronmicroscopy.

OBJECTIVE: The fibroid pseudocapsule is a structure which surrounds the uterine fibroid, separates it from the uterine tissue and contains a vascular network rich in neurotransmitters like a neurovascular bundle. The authors examined the composition of the fibroid pseudocapsule using electron microscopy. STUDY DESIGN: Twenty non-pregnant patients were submitted to laparoscopic myomectomy by the intracapsular method and samples of the removed pseudocapsules were analyzed using transmission electron microscopy. RESULTS: At the ultrastructural level the pseudocapsule cells have the features of smooth muscle cells similar to the myometrium. So, the pseudocapsules are part of the myometrium which compresses the leiomyoma. CONCLUSION: This ultrastructural feature suggests that when removing fibroids their pseudocapsules should be preserved. This study confirms preliminary evidence that pseudocapsules contain neuropeptides together with their related fibers, as a neurovascular bundle. The surgeon's behavior should be directed to carefully control and spare this muscular surrounding tissue during fibroid excision, in order to preserve the myometrium as much as possible

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

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