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

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 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

Randomised trials in the South African Medical Journal, 1948- 1997

Objective. To describe randomised controlled trials (RCTs) published in the South African Medical Journal (SAMJ) over a 50-year period from 1948 to 1997 with regard to number, topic and quality.Methods. We hand searched all issues of the SAMJ published during the study period to identify all published RCTs.Outcome measures. Number, topic and quality of RCTs published from 1948 to 1997.Results. Eight hundred and fifty-eight clinical trials were published during the period reviewed. Eighty-four per cent of RCTs were published as full articles. During the 1980s the number of RCTs published increased rapidly,  with a peak of 35 in 1985, but then declined to only 5 in 1997. The majority (92%) of RCTs were conducted in a hospital setting. A varied range of subjects was covered, with gastroenterology taking the lead and no trials in public health. The sample size in more than 50% of RCTs was smaller than 50 patients. Fifty-one per cent (435 trials) used random allocation and 49% (423) quasi-random methods of allocation. Concealment of treatment allocation was judged to be adequate in 46% of studies (N == 200), blinding of observers assessing outcomes was adequate in 28% (123), and all the allocated test subjects were included in the primary analysis in 28% (123). The follow-up period was more than 1 year in 4% (17) and less than 6 days in 16% (71).Conclusions. Compared with other international journals the SAMJ is highly regarded in terms of the number of trials published. There are, however, a number of deficiencies in the quality of the trials

Knowledge and perceptions of nursing staff on the new Road to Health Booklet growth charts in primary healthcare clinics in the Tygerberg subdistrict of the Cape Town metropole district

Objectives: The objectives of the study were to assess the perceptions of nursing staff on the Road to Health Booklet (RTHB), to assess their knowledge of the RTHB growth charts, and to determine whether the level of knowledge was acceptable for successful utilisation of the RTHB growth charts.Design: A cross-sectional descriptive survey.Setting: Twelve primary healthcare clinics in the Tygerberg subdistrict.Subjects: Nursing staff who were going to work with the RTHB on a daily basis.Outcomes measures: The knowledge and perceptions of the nursing staff on the new RTHB were measured using a self-administered questionnaire.Results: The study highlighted that the majority of the nursing staff did not possess sufficient knowledge to successfully utilise the RTHB. The mean score percentage for the total 12 knowledge questions was 55%. Less than a third (n = 13) of participants could correctly interpret the cut-off value for mid-upper-arm circumference. Only 38% and 52% correctly knew that -2 standard deviation for weight-for-age and weight-for-length represents underweight and wasting, respectively. Fifty-five per cent could correctly interpret the growth faltering graph. Forty-three per cent of participants felt the change to the RTHB was unnecessary, and 55% thought that mothers or caregivers would not easily understand the RTHB. More than half (n = 22) of the participants said that they had adequate knowledge to work with the RTHB, while the rest reported that they did not.Conclusion: The RTHB has the potential to decrease the prevalence of malnutrition in children. However, to achieve this, effective usage and understanding of the RTHB is critical.Keywords: Road to Health booklet, growth monitoring, primary healthcare clinics, knowledg

Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers

Background. Diabetes mellitus (DM) may increase the risk of depression as a result of a sense of threat of debilitating complications or because of associated lifestyle changes. Depression may increase the risk of type 2 diabetes as a result of poor health behaviours.Objective. To determine the association between diabetes mellitus, depression and psychological  distress in a cohort of South African (SA) teachers.Methods. Teachers from 111 public schools in the Metro South District of the Cape Metropolitan area,  SA, were invited to participate in this study. The Center for Epidemiologic Studies Depression Scale  (CES-D) and the Kessler Psychological Distress Scale (K10) were used to assess depression and psychological distress, respectively. A professional nurse completed a physical examination and  collected blood for measurement of glucose, cholesterol and serum creatinine.Results. Of the 388 teachers who completed the questionnaires, 67.5% were female and the average age  was 46.2 years (standard deviation 8.7). Psychological distress was identified in 28.1% of the cohort and depression in 15.5%, and 7.7% were found to fulfil criteria for DM. A diagnosis of DM was associated with an increased risk of depression (adjusted odds ratio (AOR) 3.90; 95% confidence interval (CI) 1.33 - 11.37) and psychological distress (AOR 3.62; 95% CI 1.31 - 10.00).Conclusion. The high prevalence of obesity and DM in this cohort of SA teachers is of concern. A  diagnosis of DM was strongly associated with an increased risk of depression and psychological distress

Task-shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy

'Cochrane Corner’ in the August SAMJ offers evidence relating to articles published in this issue, namely ‘Improving access to antiretrovirals in rural South Africa – a call to action’, ‘Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa’ and ‘Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey’, and the editorial by Yach and Alexander, ‘Turbo-charging tobacco control in South Africa’.