Questioning a South African hypertension threshold of 150 mm Hg – Authors' reply

We are grateful for the opportunity to respond to Schutte and colleagues. We agree with Schutte and colleagues that the systolic blood pressure (SBP) measurements presented in our study could contain error. However, of the potential sources of measurement error they note (whitecoat effects [+2·5 mm Hg], averaging measurements from two different waves [+3·8 mm Hg], and supine measurements [+3–10 mm Hg]), only the white-coat effects potentially applies to our study. Although we average measurements from 2 different years, we assign the resulting SBP to the last year of data. Therefore, any bias would result in SBP measurements that are conservative, rather than inflated by 3.5 mm Hg. SBP in the National Income Dynamics Survey is also measured in a sitting, not supine, position; however, Schutte and colleagues correctly identified our reporting error, and we have requested a formal correction. On balance, any measurement error is likely to be much smaller than Schutte and colleagues assert and would not change our main study conclusions

Systolic blood pressure and 6-year mortality in South Africa: a country-wide, population-based cohort study

Background: Improving hypertension control is an important global health priority, yet, to our knowledge, there is no direct evidence on the relationship between blood pressure and mortality in sub-Saharan Africa. We aimed to investigate the relationship between systolic blood pressure and mortality in South Africa and to assess the comparative effectiveness of different systolic blood pressure targets for clinical care and population-wide hypertension management efforts. Methods: In this country-wide, population-based cohort study, we used longitudinal data on adults aged 30 years and older from five waves (2008, 2010–11, 2012, 2014–15, and 2017) of the South African National Income Dynamics Study. We estimated the relationship between systolic blood pressure and 6-year all-cause mortality and compared the mortality reductions associated with lowering systolic blood pressure to different targets (120 mm Hg, 130 mm Hg, 140 mm Hg, 150 mm Hg). We also estimated the mean blood pressure reduction required to achieve each target, the share of the population in need of management, and the number needed to treat (NNT) to avert one death under different hypothetical population-wide scale-up scenarios. Findings: Of the 8338 age-eligible respondents in the 2010–11 survey, 4993 had all required data and were included in our study. We found a weak, non-linear relationship between systolic blood pressure and 6-year mortality, with larger incremental mortality benefits at higher systolic blood pressure values: reducing systolic blood pressure from 160 mm Hg to 150 mm Hg was associated with a relative risk of mortality of 0·95 (95% CI 0·90 to 0·99; p=0·033), reducing systolic blood pressure from 150 mm Hg to 140 mm Hg had a relative risk of 0·96 (0·91 to 1·01; p=0·12), with no evidence of incremental benefits of reducing systolic blood pressure below 140 mm Hg. At the population level, reducing systolic blood pressure to 150 mm Hg among all those with a starting systolic blood pressure of more than 150 mm Hg was associated with the lowest NNT (n=50), 3·3 deaths averted (95% CI −0·6 to 0·3) per 1000 population, blood pressure management for 16% (95% CI 15·2 to 17·3) of individuals, and a −2·7 mm Hg mean change in systolic blood pressure required to achieve the 150 mm Hg scale-up target (−3·0 to −2·5; p<0·0001). Interpretation: The relationship between systolic blood pressure and mortality is weaker in South Africa than in high-income and many low-income and middle-income countries. As such, we do not find compelling evidence in support of targets below 140 mm Hg and find that scaling up management based on a 150 mm Hg target is more efficient in terms of the NNT compared with strategies to reduce systolic blood pressure to lower values. Funding: Non

Microfinance and loan officers' work experiences: perspectives from Zambia

This article studies the challenges faced by microfinance institutions in Zambia, whose remit it is to provide financial services to the poor. It focuses on loan officers – the agents of delivery on the ground. With reference to loan officers’ experiences and words, the paper examines how gender and education shape and structure their day-to-day encounters. The study finds that different social spaces – ’the office’ and ‘the field’ – and wider context explains the gendered, culturally complex and multidimensional nature of developmental work at grassroots level. Social expectations emerge as major pressure points more for female loan officers than their male counterparts, making them less suitable for microfinance work, which has traditionally targeted poor women

Strengthening the community health worker programme for health improvement through enhancing training, supervision and motivation in Wakiso district, Uganda

Objective: The objective of the project was to strengthen the community health worker (CHW) programme in Ssisa sub-county, Wakiso district, Uganda by providing a coherent, structured and standardized training, supervision and motivation package so as to enhance their performance. Results: The project trained all 301 CHWs who received non-financial incentives of t-shirts, gumboots and umbrellas, and 75 of them received solar equipment to support lighting their houses and charging phones. Twenty-four of the CHWs who had coordination roles received additional training. Three motorcycles were also provided to enhance transportation of CHW coordinators during their work including supervision. By end of the project, the CHWs had conducted 40,213 household visits, carried out health education sessions with 127,011 community members, and treated 19,387 children under 5 years of age. From the project evaluation, which used both quantitative and qualitative methods, 98% of the CHWs reported having improved competence in performance of their roles. In addition, the CHWs were highly motivated to do their work. The motorcycles were instrumental in supporting the work of CHW coordinators including monthly collection of reports and distribution of medicines. The project demonstrated that by improving training, supervision and motivation, performance of CHW programmes can be enhanced

Ambient PM2.5 Temporal Variation and Source Apportionment in Mbarara, Uganda

Air pollution is the leading environmental cause of death globally, and most mortality occurs in resource-limited settings such as sub-Saharan Africa. The African continent experiences some of the worst ambient air pollution in the world, yet there are relatively little African data characterizing ambient pollutant levels and source admixtures. In Uganda, ambient PM2.5 levels exceed international health standards. However, most studies focus only on urban environments and do not characterize pollutant sources. We measured daily ambient PM2.5 concentrations and sources in Mbarara, Uganda from May 2018 through February 2019 using Harvard impactors fitted with size-selective inlets. We compared our estimates to publicly available levels in Kampala, and to World Health Organization (WHO) air quality guidelines. We characterized the leading PM2.5 sources in Mbarara using x-ray fluorescence and positive matrix factorization. Daily PM2.5 concentrations were 26.7 µg m–3 and 59.4 µg m–3 in Mbarara and Kampala, respectively (p < 0.001). PM2.5 concentrations exceeded WHO guidelines on 58% of days in Mbarara and 99% of days in Kampala. In Mbarara, PM2.5 was higher in the dry as compared to the rainy season (30.8 vs. 21.3, p < 0.001), while seasonal variation was not observed in Kampala. PM2.5 concentrations did not vary on weekdays versus weekends in either city. In Mbarara, the six main ambient PM2.5 sources identified included (in order of abundance): traffic-related, biomass and secondary aerosols, industry and metallurgy, heavy oil and fuel combustion, fine soil, and salt aerosol. Our findings confirm that air quality in southwestern Uganda is unsafe and that mitigation efforts are urgently needed. Ongoing work focused on improving air quality in the region may have the greatest impact if focused on traffic and biomass-related sources

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

South African Paediatric Surgical Outcomes Study : a 14-day prospective, observational cohort study of paediatric surgical patients

BACKGROUND : Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low- and middle-income countries (LMICs). METHODS : We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. RESULTS : We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4–11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2–8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6–1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. CONCLUSIONS : The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings should be used to develop strategies to improve paediatric surgical outcomes in LMICs, and support the need for larger prospective, observational paediatric surgical outcomes research in LMICs. CLINICAL TRIAL REGISTRATION : NCT03367832.Jan Pretorius Research Fund; Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal; Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town; Department of Anaesthesia, University of the Witwatersrand; and the Paediatric Anaesthesia Community of South Africa (PACSA).https://bjanaesthesia.org2020-02-01gl2019Anaesthesiolog

Participatory Forest Carbon Assessment in South-eastern Tanzania: Experiences, costs and future challenges

The aim of this study was to determine the changes in forest carbon in three village forests in Tanzania during 2009-2012 using participatory forest carbon assessment, and to evaluate the capability of the local communities to undertake the assessment, and the costs involved. The results show that forest degradation is caused not only by disturbance as a result of anthropogenic activities; other causes include natural mortality of small trees as a result of canopy closure, and the attraction of wild animals to closed-canopy forests. Thus, mechanisms are required to compensate communities for carbon loss that is beyond their control. However, an increase in the abundance of elephants Loxodonta africana and other fauna should not be considered negatively by local communities and other stakeholders, and the importance of improved biodiversity in the context of carbon stocks should be emphasized by those promoting REDD+ (Reduced Emissions from Deforestation and Forest Degradation). This case study also shows that the cost per ha of USDUSD < 1 for participatory forest carbon assessment is less than that reported for Tanzania and elsewhere (USD 3-5); this is attributed to the large area of forest studied. However, the cost of data analysis and reporting in 2012 (USD 4,519) was significantly higher than the baseline cost (USD 1,793) established in 2009 because of the involvement of external experts

Out scaling of improved cassava processing technology - Uganda lessons

Cassava (Manihot esculenta Crantz) has an immediate potential for use in food and feed industry in East and Central Africa (ECA). However, its industrial utilization in the region remains low, partly due to lack of improved processing technologies, lack of awareness of the alternative uses of cassava and technical know how for commercialization. To tap the potential of cassava in feed industry of Uganda, EARRNET and its partners, NARO, Ugachick and farmers, established in 2005 two pilot processing sites in the districts of Bukedea and Masindi. Site selection was based on the levels and potential for increasing cassava production, existence of farmer groups/association, storage facility, availability of reliable clean water supply and ease of access to market. The objectives of the project were to a) increase awareness on the benefits of using high quality cassava chips in feed industry, b) introduce and promote use of improved processing and drying technologies c) assess the quality of cassava chips and d) develop better marketing strategies for cassava chips. The technology was introduced in a participatory manner through mobilization, sensitization, trainings, quality assessment, collective marketing, monitoring and evaluation. As a result, farmers got to know the potential benefits of cassava chips usage in animal feeds. The introduction of the improved drying facilities enabled farmers reduce drying time from 7-10 days as reported in traditional set-up to 1-2 days. The moisture content of the chips (10-12%) processed using the new technology was significantly (P<0.05) lower than that of traditionally processed cassava chips (14-18%). The aflatoxin contamination of well stored processed chips was significantly (p<0.05) lower (>1ppm) than those traditionally processed (15ppm). Cyanide levels in traditionally processed chips (17-35ppm) was significantly (p5 tonnes). Due to anticipated income generation from improved processing, acreage under cassava production in the project area increased by over 50%. However, though farmers embraced the improved technology, there still exist some hurdles that are discussed in this paper. The lessons learned from the study will help to improve further out scaling of production and utilisation of cassava technologies in the region

Technology enhanced formative assessment for 21st century learning

This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 International License (https://creativecommons.org/licenses/by-nc-nd/3.0/). Original citation: Spector, J. M., Ifenthaler, D., Sampson, D., Yang, J. L., Mukama, E., Warusavitarana, A., …Gibson, D. C. (2016). Technology enhanced formative assessment for 21st century learning. Journal of Educational Technology and Society. 19(3), 58-71. Retrieved from http://www.ifets.info/journals/19_3/7.pdf Spector, J. M., Ifenthaler, D., Samspon, D., Yang, L., Mukama, E., Warusavitarana, A., Lokuge Dona, K., Eichhorn, K., Fluck, A., Huang, R., Bridges, S., Lu, J., Ren, Y., Gui, X., Deneen, C. C., San Diego, J., &amp; Gibson, D. C. (2016 ABSTRACT This paper is based on the deliberations of the Assessment Working Group at EDUsummIT 2015 in Bangkok, Thailand. All of the members of Thematic Working Group 5 (TWG5) have contributed to this synthesis of potentials, concerns and issues with regard to the role of technology in assessment as, for and of learning in the 21 st century. The group decided to focus primarily on formative assessment rather than summative assessment and high stakes testing. Formative assessments and feedback provide an important opportunity to support and enhance student learning. Recognizing shifts in education towards blended and online learning with problembased and inquiry-based approaches led to considerations of technologies that could effectively support formative assessment and informative feedback to 21 st century learners. The paper concludes with a summary of conclusions and recommendations of the working group to be taken up in subsequent efforts