Short-term and sustained effects of a health system strengthening intervention to improve mortality trends for paediatric severe malnutrition in rural South African hospitals

BACKGROUND. Case fatality rates for childhood severe acute malnutrition (SAM) remain high in some resource-limited facilities in South Africa (SA), despite the widespread availability of the World Health Organization treatment guidelines. There is a need to develop reproducible interventions that reinforce the implementation of these guidelines and assess their effect and sustainability. OBJECTIVES. To assess the short-term and sustained effects of a health system strengthening intervention on mortality attributable to SAM in two hospitals located in the Eastern Cape Province of SA. METHODS. This was a theory-driven evaluation conducted in two rural hospitals in SA over a 69-month period (2009 - 2014). In both facilities, a health system strengthening intervention was implemented within the first 32 months, and thereafter discontinued. Sixty-nine monthly data series were collected on: (i) monthly total SAM case fatality rate (CFR); (ii) monthly SAM CFR within 24 hours of admission; and (iii) monthly SAM CFR among HIV-positive cases, to determine the intervention’s effect within the first 32 months and sustainability over the remaining 37 months. The data were analysed using Linden’s method for analysing interrupted time series data. RESULTS. The study revealed that the intervention was associated with a statistically significant decrease of up to 0.4% in monthly total SAM CFR, a non-statistically significant decrease of up to 0.09% in monthly SAM CFR within 24 hours of admission and a non-statistically significant decrease of up to 0.11% in monthly SAM CFR among HIV-positive cases. The decrease in mortality trends for both outcomes was only slightly reversed upon the discontinuation of the intervention. No autocorrelation was detected in the regression models generated during data analyses. CONCLUSION. The study findings suggest that although the intervention was designed to be self-sustaining, this may not have been the case. A qualitative enquiry into the moderating factors responsible for failure to sustain such an intervention, as well as the process of care, would add value to the findings presented in this study.DHE

Dynamic Regulation of T Cell Immunity by CD43

During a viral response, Ag-specific effector T cells show dramatically increased binding by the mAb 1B11 and the lectin peanut agglutinin (PNA). We investigated the contribution of CD43 expression to 1B11 and PNA binding as well as its role in generation and maintenance of a CD8 T cell response. Analysis of CD43(-/-) mice revealed no increased 1B11 binding and reduced PNA binding on virus-specific CD8 T cells from -/- mice compared with +/+ mice. Furthermore, we examined the role of CD43 in the kinetics of an immune response. We show that CD43 expression modestly effects generation of a primary virus-specific CD8 T cell response in vivo but plays a more significant role in trafficking of CD8 T cells to tissues such as the brain. More interestingly, CD43 plays a role in the contraction of the immune response, with CD43(-/-) mice showing increased numbers of Ag-specific CD8 T cells following initial expansion. Following the peak of expansion, Ag-specific CD8 T cells from -/- mice show similar proliferation but demonstrate increased Bcl-2 levels and decreased apoptosis of Ag-specific effector CD8 T cells in vitro. Consistent with a delay in the down-modulation of the immune response, following chronic viral infection CD43(-/-) mice show increased morbidity. These data suggest a dynamic role of CD43 during an immune response: a positive regulatory role in costimulation and trafficking of T cells to the CNS and a negative regulatory role in the down-modulation of an immune response

Ethics of Engagement and Insider-Outsider Perspectives: Issues and Dilemmas in Cross-Cultural Interpretation

This article offers insights into the ethics of engagement and methodological issues and dilemmas in cross-cultural interpretation for researchers who are positioned at different points of the insider-outsider spectrum. The discussion uses examples from qualitative research with Sikh families in Britain and focuses on the design of the methodology and co-interpretation of data from in-depth interviews, both during the interactive data gathering phase and the post-interview analysis and interpretation phase. The researchers represent differing degrees of insider-outsiderness in relation to the British Sikh community; one is a cultural insider (a Sikh) whilst the other is an outsider (non-Sikh). In other respects they share a number of characteristics, including gender, a history of migration, bilingualism and living and teaching in superdiverse communities which all impact on the nature of their engagement with the research participants and with each other as co-researchers. Our reflexive analysis shows that established binary distinctions and polarities in research practice, such as insider/outsider, are inadequate for conceptualising the fluidity and complexity of the ethics of engagement in co-researching. We argue that both theoretically and empirically a more nuanced conceptualisation reflects the realities of multiple researcher positionalities, interpretations and power relations

Stepped Care for Maternal Mental Health: A Case Study of the Perinatal Mental Health Project in South Africa

As one article in a series on Global Mental Health Practice, Simone Honikman and colleagues from South Africa provide a case study of the Perinatal Mental Health Project, which delivered mental health care to pregnant women in a collaborative, step-wise manner, making use of existing resources in primary care

Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa

We have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management. Patient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained

Fragile x syndrome and autism: from disease model to therapeutic targets

Autism is an umbrella diagnosis with several different etiologies. Fragile X syndrome (FXS), one of the first identified and leading causes of autism, has been modeled in mice using molecular genetic manipulation. These Fmr1 knockout mice have recently been used to identify a new putative therapeutic target, the metabotropic glutamate receptor 5 (mGluR5), for the treatment of FXS. Moreover, mGluR5 signaling cascades interact with a number of synaptic proteins, many of which have been implicated in autism, raising the possibility that therapeutic targets identified for FXS may have efficacy in treating multiple other causes of autism

The limits of India’s ethno-linguistic federation: understanding the demise of Sikh nationalism

From 1984 until 1993, the Indian state of Punjab witnessed a sustained insurgency by Sikh militants campaigning for a separate sovereign state. This insurgency was ultimately defeated by the overwhelming use of security force that officially resulted in the deaths of 30,000 people. By the mid-1990s, a ‘normalcy’ had returned to Punjab politics, but the underlying issues which had fuelled the demand for separatism remain unaddressed. This paper examines critically the argument that India’s ethno-linguistic federation is exceptional in accommodating ethno-nationalist movements. By drawing on the Punjab case study, it argues that special considerations apply to the governance of peripheral regions (security, religion). Regional elites in these states struggle to build legitimacy because such legitimacy poses a threat to India’s nation and state-building. In short, India’s ethno-linguistic federation is only partially successful in managing ethno-linguistic demands in the peripheral Indian states

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