Preventing cardiovascular disease in Africa – we must act now

A tsunami of non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, chronic respiratory disease and cancer is threatening to engulf Africa. Globally, the vast majority of NCD deaths occur in low- and middle-income countries placing a significant burden on the world’s poor. In 2004, one-quarter of all deaths in sub-Saharan Africa were due to NCDs; by 2030 this figure will rise to almost half.(2) Age-standardised death rates from NCDs are already higher in some African countries (the Democratic Republic of the Congo, Nigeria, Ethiopia and South Africa) than in high income countries.(3) NCDs share several modifiable risk factors, in particular unhealthy diets, tobacco use, physical inactivity and excessive use of alcohol. This presents an opportunity for action to limit the profound human and economic costs of NCDs predicted for African countries already reeling under the weight of infectious diseases and injuries. A concerted, multi-sectoral and sustained effort will, however, be required which must be implemented without further delay

Does South Africa need a national clinical trials support unit?

ArticleThe original publication is available at http://www.samj.org.zaBackground. No national South African institution provides a coherent suite of support, available skills and training for clinicians wishing to conduct randomised controlled trials (RCTs) in the public sector. We report on a study to assess the need for establishing a national South African Clinical Trials Support Unit. Objectives. To determine the need for additional training and support for conduct of RCTs within South African institutions; identify challenges facing institutions conducting RCTs; and provide recommendations for enhancing trial conduct within South African public institutions. Design. Key informant interviews of senior decision-makers at institutions with a stake in the South African public sector clinical trials research environment. Results. Trial conduct in South Africa faces many challenges, including lack of dedicated funding, the burden on clinical load, and lengthy approval processes. Strengths include the high burden of disease and the prevalence of treatmentnaïve patients. Participants expressed a significant need for a national initiative to support and enhance the conduct of public sector RCTs. Research methods training and statistical support were viewed as key. There was a broad range of views regarding the structure and focus of such an initiative, but there was agreement that the national government should provide specific funding for this purpose. Conclusions. Stakeholders generally support the establishment of a national clinical trials support initiative. Consideration must be given to the sustainability of such an initiative, in terms of funding, staffing, expected research outputs and permanence of location.Publishers' versio

The SASPREN primary care survey - who consults the family doctor?

Objective. To describe selected characteristics of patients consulting general family practitioners in the Western Cape.Design. A cross-sectional survey design was employed in which doctors completed a structured questionnaire during or immediately after each consultation.Setting. Data were collected by family practitioners in private practice who were affiliated to the South African Sentinel Practitioner Research Network (SASPREN).Participants. All patients who had a face-to-face encounter wrth the doctor at his/her surgery. A total of 2 473 such encounters was included. Main outcome measures. Age, sex, race, method of payment and smoking status.Results. Females outnumbered males in all race groups except blacks, where they comprised 48% of patients. Most patients were under the age of 14 years (23.3%) or between 25 and 44 years (33.3%). However, after the demography of the ca1chment population was taken into account, the highest utilisation of general practitioner services was found to be at extremes of age. This utilisation pattern was demonstrated in both sexes and all races. In relation to their distribution in the population. whites and Indians are over~represented in private practice while blacks and coloureds are under-represented. The bulk of patients (67%) pay for general practitioner services via some form of insurance (medical aid or benefit fund). but significant differences exist across race groups. In the case of blacks and Indians, the majority (72% and 64% respectively) of consultations are funded 'out of pocket'. An alamingly high smoking prevalence was found in black and coloured men. In all race/sex groups smoking rates peak between 25 and 44 years. In this age group, 68.6% of black men and 73.3% of coloured men were current smokers.Conclusions. This study provides essential information on patients seen in family practice. Access to family doctor selVices in the Western Cape should be improved for blacks and coIoureds. There is an urgent need for smoking cessation interventions in the region

The advertising of nutritional supplements in South African women’s magazines: a descriptive survey

Objective: Nutritional supplements are inadequately regulated in South Africa. These types of products are increasingly advertised and the advertisements frequently contain health claims. Because advertisements play a considerable role in informing potential consumers, it is crucial that information about supplements in advertisements is accurate. A survey was carried out to determine the extent to which health claims are made in nutritional supplement advertisements and to describe the appropriateness of the research cited within the advertisements in support of the health claims.Design: The design was a descriptive survey.Method: The five women’s magazines with the highest circulation figures in South Africa in July 2010 were identified by the Audit Bureau of Circulations of South Africa as Cosmopolitan, Finesse, Move!, Rooi Rose and Sarie. Issues of these magazines were obtained during the period from September 2010 to August 2011. Pre-specified eligibility criteria were used to identify suitable advertisements and to determine the percentage of nutritional supplements about which health claims were made. The percentage of these supplements for which research was cited in support of the claims was also determined, and the level and appropriateness of the cited research, described.Results: In total, 486 eligible advertisements were identified which referred to 158 nutritional supplements. Of these, 137 (86.7%) made health claims and 9 of the 137 (6.6%) cited research to support their claims. The cited research was judged to be largely inappropriate based on study design and/or the characteristics of the study.Conclusion: South Africans should be wary of advertisements that make claims about the health benefits and safety of nutritional supplements. Regulation of the advertising of nutritional supplements is urgently needed.Keywords: dietary supplements, health claims, regulation, advertising, evidence based health car

Risk factors for myocardial infarction and stroke in Africa

Background: Definitive information on the strength of association between various risk factors and cardiovascular disease in Africa is lacking. Objective: We conducted a systematic review of studies investigating risk factors for acute myocardial infarction (AMI) and stroke in Africa. Data sources: We searched Medline and Embase as well as the reference lists of the included articles. Study eligibility criteria: We included case-control and cohort studies conducted in an African country, which assessed risk factors for first episodes of (AMI) or stroke in people of any age. Methods: Two independent reviewers screened studies for eligibility, extracted data and assessed study quality. We described measures of association (odds ratios) with confidence intervals of risk factors for AMI and stroke separately. Results: Twelve articles reporting results from five case-control studies met our inclusion criteria but only one study (INTERHEART ) investigated risk factors for AMI. No eligible cohort studies were identified. The direction of association for established risk factors for AMI and stroke seem to be similar globally but the strength of association of various risk factors varies between countries and within African ethnic groups. In Africa, diabetes and hypertension had the highest risk associated with AMI and hypertension was the strongest risk factor for stroke. Overall, the quality of the included case-control studies was good. Conclusions and implications: Our results confirm the urgent need for prospective studies investigating risk factors for AMI and stroke in African populations. A few high quality case-control studies exist but these do not adequately represent the cultural and genetic diversity in Africa, or the influence of infections on cardiovascular outcomes. Dynamic risk factors that rely on self-report such as diet, physical activity and stress will be better assessed through longitudinal cohort studies

Co-trimoxazole prophylaxis in HIV : the evidence

BibliographyHuman immunodeficiency virus (HIV) damages the body’s immune system, making secondary (or opportunistic) infections more common. Treatment and prevention of such infections is integral to the management of patients with HIV infection. Co-trimoxazole is a prophylactic treatment that has a wide range of action against common bacteria, parasites, fungi and yeasts. As part of a minimum care package, UNAIDS/ WHO recommends co-trimoxazole prophylaxis for HIVinfected adults with symptomatic disease (WHO stage II, III or IV), or asymptomatic individuals with CD4 counts ≤500 cells/μl, and for all HIV-positive pregnant women after the first trimester.1 Co-trimoxazole is also recommended for use in children with proven HIV infection and infants exposed to HIV (from 4 - 6 weeks of age until infection with HIV is ruled out).2 The object of this report is to summarise the effects of co-trimoxazole prophylaxis on morbidity and mortality among HIV-infected individuals

Occupational stress in a South African workforce: instrument testing, prevalence measurement and risk factor analysis

A research report submitted to the Faculty of Health Sciences of the University of the Witwatersrand in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Community Health (Public Health Medicine). May 2014Background Occupational stress represents a substantial public health challenge. Although there has been an extensive focus on this form of stress within the international setting, there appears to be a paucity of relevant evidence within South Africa. Specifically, within the local context, there are relatively few: (1) reliability testing studies of screening and assessment instruments, (2) prevalence analyses of occupational stress and (3) work-related stress management intervention designs. Methods A cross-sectional descriptive and analytical study was undertaken in a large tertiary hospital in Johannesburg. Primary data were collected between February 2013 and September 2013 using the Copenhagen Psychosocial Questionnaire (COPSOQ). A sample (n=166) of administrative staff was selected, stratified into front line staff (n=54), back office staff (n=90) and managers (n=22). Data analysis included reliability testing of the COPSOQ using the Cronbach‘s alpha statistic. Prevalence measurement was also undertaken to describe the distribution of stress and other variables across the study sample. Finally, logistic regression was used to estimate associations between the exposure variables and the stress outcome (at the p < 0.05 level of significance). Results The Cronbach‘s alpha range for the COPSOQ was 0.31 to 0.85. Two out of 24 scales of the instrument fell below the unacceptability threshold of 0.5. In terms of prevalence, the stress mean for the study sample (on a scale from 0 to 100) was 38.8 (SD 19.8). Furthermore, 68.1% (n=113) of the study sample had a stress value above the reference mean. There were also significant differences in the stress values by job category, with managers having the highest mean at 51.2 (SD 24.2). Adjusting for job category, risk factors significantly associated with occupational stress in the main logistic model were offensive behaviour (OR 3.38, 95% CI: 1.54 – 7.43), quantitative demands (OR 2.83, 95% CI: 1.35 – 5.92) and emotional demands (OR 2.32, 95% CI: 1.08 – 4.96), while quality of leadership (OR 0.32, 95% CI: 0.15 – 0.67) was a protective factor. Further analysis showed that the most harmful risk factor for females was work-family conflict (OR 4.03; 95% CI: 1.45 - 11.21), and for males was exposure to offensive behaviour (OR 4.63; 95% CI: 1.15 - 18.63). Finally, ordinal regression found offensive behaviour (OR 3.60; 95% CI: 1.92 - 6.75) and quantitative demands (OR: 2.38; 95% CI: 1.27 - 4.46) to be significant risks for moving from low stress to high stress, while a commitment to workplace (OR 0.46; 95% CI: 0.24 - 0.86) could help to prevent this. Conclusions The level of occupational stress in the study sample was high relative to reference values. An occupational stress intervention is recommended, which should include primary, secondary and tertiary prevention strategies (according to identified risks). Further development of the instrument is also recommended, so as to improve its reliability in the local context. Finally, future research into occupational stress should explore the impact of factors such as resource constraints and HIV/AIDS, and should include an expansion into other settings and occupational categories. Key words Occupational stress, questionnaire reliability, psychosocial risks, intervention design

The effectiveness of child support grants in South Africa: A case study of Caledon district, Western Cape

Magister Artium (Development Studies) - MA(DVS)This research study addresses the effectiveness of child support grants in South Africa. It specifically asks the questions, what do social policy makers in South Africa want to achieve with the Child Support Grant (CSG) and are they achieving it? If not, how can policy makers ensure that social grants achieve the desired impact? The researcher will establish the effectiveness of the current CSG and how the CSG programme design and implementation might be improved for the CSG system to have its desired effect for children and at the family level

Lack of adherence to the national guidelines on the prevention of rheumatic fever

Objectives. To explore the extent to which current practices for the secondary prevention of rheumatic fever (RF) in Cape Town adhere to those outlined in the national guidelines on the primary prevention and prophylaxis of RF and rheumatic heart disease (RHD) for health professionals at primary level. Methods. A combination of qualitative tools was used to evaluate the four priority issues identified in the guidelines as fundamental elements of a comprehensive programme for the secondary prophylaxis of RF/RHD: (i) health education and promotion; (ii) case detection of RF and RHD; (iii) secondary prophylaxis every 3 - 4 weeks at primary level; and (iv) notification of acute rheumatic fever (ARF). The qualitative tools included parent/child interviews of cases diagnosed with ARF in the Cape metropole area during the period 1999 - 2003; a physician questionnaire focused on awareness and adherence to the national guidelines; and a review of the records on acute rheumatic fever notification in the Cape metropole area from 1999 to 2003. Results. The evaluation revealed four key findings. First, patient knowledge on the disease was almost non-existent. Despite this lack of knowledge, adherence to secondary prophylactic treatment was good. Second, the physicians most likely to encounter a case of rheumatic fever were least likely to be aware of and to comply with the national guideline. Third, the guidelines do not clearly state how increased detection of ARF will be achieved. Finally, the RF notification system is dysfunctional, with discrepancies in the reporting of cases at hospital, city and provincial levels. Conclusions. Since the publication of the national guidelines in 1997, little progress has been made towards achieving the implementation of a comprehensive programme for the secondary prevention of RF/RHD. S Afr Med J 2005; 95: 52-56

African HIV/AIDS Trials Are More Likely to Report Adequate Allocation Concealment and Random Generation than North American Trials

The original publication is available at http:/www.plosone.orgBackground: Adherence to good methodological quality is necessary to minimise bias in randomised conrolled trials (RCTs). Specific trial characteristics are associated with better trial quality, but no studies to date are specific to HIV/AIDS or African trials. We postulated that location may negatively impact on trial quality in regions where resources are scarce. Methods: 1) To compare the methodological quality of all HIV/AIDS RCTs conducted in Africa with a random sample of similar trials conducted in North America; 2) To assess whether location is predictive of trial quality. We searched MEDLINE, EMBASE, CENTRAL and LILACS. Eligible trials were 1) randomized, 2) evaluations of preventive or treatment interventions for HIV/AIDS, 3) reported before 2004, and 4) conducted wholly or partly (if multi-centred) in Africa or North America. We assessed adequacy of random generation, allocation concealment and masking of assessors. Using univariate and multivariate logistic regression analyses we evaluated the association between location (Africa versus North America) and these domains. Findings: The African search yielded 12,815 records, from which 80 trials were identified. The North American search yielded 13,158 records from which 785 trials were identified and a random sample of 114 selected for analysis. African trials were three times more likely than North American trials to report adequate allocation concealment (OR = 3.24; 95%CI: 1.59 to 6.59; p<0.01) and twice as likely to report adequate generation of the sequence (OR = 2.36; 95%CI: 1.20 to 4.67; p = 0.01), after adjusting for other confounding factors. Additional significant factors positively associated with quality were an a priori sample size power calculation, restricted randomization and inclusion of a flow diagram detailing attrition. We did not detect an association between location and outcome assessor masking. Conclusions: The higher quality of reporting of methodology in African trials is noteworthy. Most African trials are externally funded, and it is possible that stricter agency requirements when leading trials in other countries and greater experience and training of principal investigators of an international stature, may account for this difference. © 2008 Siegfried et al.Publishers' Versio