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

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

Global core indicators for measuring WHO's paediatric quality-of-care standards in health facilities: development and expert consensus.

BACKGROUND: There are currently no global recommendations on a parsimonious and robust set of indicators that can be measured routinely or periodically to monitor quality of hospital care for children and young adolescents. We describe a systematic methodology used to prioritize and define a core set of such indicators and their metadata for progress tracking, accountability, learning and improvement, at facility, (sub) national, national, and global levels. METHODS: We used a deductive methodology which involved the use of the World Health Organization Standards for improving the quality-of-care for children and young adolescents in health facilities as the organizing framework for indicator development. The entire process involved 9 complementary steps which included: a rapid literature review of available evidence, the application of a peer-reviewed systematic algorithm for indicator systematization and prioritization, and multiple iterative expert consultations to establish consensus on the proposed indicators and their metadata. RESULTS: We derived a robust set of 25 core indicators and their metadata, representing all 8 World Health Organization quality standards, 40 quality statements and 520 quality measures. Most of these indicators are process-related (64%) and 20% are outcome/impact indicators. A large proportion (84%) of indicators were proposed for measurement at both outpatient and inpatient levels. By virtue of being a parsimonious set and given the stringent criteria for prioritizing indicators with "quality measurement" attributes, the recommended set is not evenly distributed across the 8 quality standards. CONCLUSIONS: To support ongoing global and national initiatives around paediatric quality-of-care programming at country level, the recommended indicators can be adopted using a tiered approach that considers indicator measurability in the short-, medium-, and long-terms, within the context of the country's health information system readiness and maturity. However, there is a need for further research to assess the feasibility of implementing these indicators across contexts, and the need for their validation for global common reporting