Background. HIV continues to be a global pandemic. Despite significant achievements in reaching the global 95-95-95 targets, advanced HIV disease (AHD) continues to contribute to substantial morbidity and mortality, with 600 000 deaths worldwide in 2022 including 51 000 in South Africa (SA). The patient demographic has shifted from antiretroviral therapy (ART)-naïve individuals to those facing treatment interruptions or non-adherence. Objective. To explore the factors associated with AHD in patients within the Tshwane District drainage area, SA, where high treatment coverage has not fully curbed mortality rates. Method. This cross-sectional analytical study employs both quantitative and qualitative methods, utilising structured questionnaires and blood samples to assess ART levels, specifically dolutegravir. A minimum of 10 participants will undergo semi-structured interviews to explore their treatment experiences. Quantitative data will be analysed using descriptive and inferential statistics, while qualitative data will be examined through thematic analysis. Conclusion. This research aims to enhance the understanding of AHD-related factors to inform effective interventions and policies for HIV care.
Background. Cervical cancer is a major global public health concern, particularly in South Africa (SA), where it is the second most prevalent cancer among women. This prevalence can be attributed to several factors including poor screening rates and the prevalence of HIV. Objective. To examine the association between intimate partner violence (IPV) and cervical cancer screening (CCS) in SA, while considering the influence of other sociodemographic factors. Methods. The study used cross-sectional data from the 2016 South Africa Demographic and Health Survey, focusing on women of childbearing age who underwent CCS. Bivariate analysis was conducted to investigate the relationship between CCS and each independent variable. A binary regression model was used to determine the association between intimate partner violence and CCS while controlling for other variables. Results. The study found that 32% of women aged 15 to 49 years in SA had undergone CCS at least once in their lifetime. No significant association was established between IPV and CCS uptake (unadjusted odds ratio (uOR) 1.05, 95% CI 0.84 - 1.31; p>0.05 and adjusted odds ratio (aOR) 1.16, 95% CI 0.89 - 1.51; p>0.05 ). However, sociodemographic factors, including area of residence, age, education level, wealth, race and health insurance status, were significant predictors of CCS. Older women, those with higher education, wealthier individuals and those with health insurance were more likely to undergo screening. Conclusion. In the present study, IPV was not a significant factor directly influencing CCS uptake. Instead, a complex interplay of sociodemographic factors was identified as predictors of CCS rates. These findings highlight the need for interventions that address the barriers to CCS, particularly in rural areas and among underprivileged and minority populations. Improving education, healthcare coverage and accessibility can potentially enhance screening rates and reduce the burden of cervical cancer in SA.
Background. Medical management for heavy menstrual bleeding (HMB) in low- and middle-income countries is limited. The National Institute for Health and Care Excellence recommends the levonorgestrel intrauterine device (LNG-IUD) as first-line management for HMB. However, since 2019, South Africa’s (SA) Essential Medicines List (EML) guidelines have listed it as the last medical treatment option in the public health sector. An economic analysis conducted from a payer’s perspective found the LNG-IUD dominant at 5 years and more cost-effective at 1 year than other medical treatment options. However, it would no longer be dominant if the 5-year discontinuation rate exceeded 40%. Assumptions about continuation rates of the LNG-IUD for HMB were made, as no local SA data are available. Objectives. To assess the discontinuation rate of the LNG-IUD for HMB after 1 year and explore the reasons for discontinuation. Methods. This was a retrospective, folder-based study of patients who received the LNG-IUD for HMB at Tygerberg Hospital, Cape Town, SA between 2014 and 2020. Results. The hospital records of all women who received the LNG-IUD were reviewed. Incomplete records, duplications or prescriptions for contraception were excluded. Complete records were available for 100 patients, of whom 68 reported symptom improvement after 1 year and continued use. Thirty-two patients discontinued use, of whom eight experienced spontaneous expulsions and 24 requested removals. Reasons for discontinuation included ongoing symptoms (n=18), adverse effects (n=4) and the desire for fertility (n=2). Fourteen of the 24 patients who requested removal had a hysterectomy. The study showed a 68% continuation rate for the LNG-IUD, which is lower than in higher-income countries (82 - 88%). This rate is considered sufficient to endorse the affordability of LNG-IUD for HMB over 5 years. Conclusion. Offering LNG-IUD as the primary treatment may potentially improve the continuation rate. Further research is needed to assess the feasibility of recommending LNG-IUD as the first-line treatment in national policy, following patient discussion.
This commentary addresses the urgent need for responsible research practices when conducting research on populations of people with lived experiences of homelessness. Recognising the marginalisation of this group by scientific investigators in both societies, this commentary seeks to address the ethical considerations, consent processes, and community engagement necessary to conduct meaningful and respectful investigative research in this population. By summarising basic approaches that prioritise data collection, participation and engagement, this piece aims to promote a deeper understanding of the unique challenges faced by people with lived experience of homelessness and the responsibilities of researchers choosing to work on this topic.
Clinical economics or medical economics refers specifically to the economic aspects of clinical decision-making and practices in the healthcare realm, especially at the individual patient level. It is essential for management of complex hospital systems by optimising resource allocation, driving quality improvement, promoting patient-centred care, reducing disparities, informing health policy, and managing clinical as well as financial risks. By integrating economic principles with clinical practice, hospitals can achieve better patient outcomes while ensuring the efficient use of resources. The practice of clinical economics includes cost-effectiveness analyses of different treatment options, resource utilisation in clinical settings, and other economic considerations in the context of individual patient care. It could also assist in balancing the focus from the perspectives of patients, doctors and managers by reaching a consensus among them with regard to different perceptions and values for clinical decisions. Training in clinical economics should therefore become a mandatory component of education for all healthcare professionals, and should include continuing professional education (such as conferences and journal clubs), recertification programmes and practice guideline development.
Cervical cancer constitutes 20 - 25% of cancers in women in Sub-Saharan Africa. It is a preventable disease, subject to adequate screening, management and follow up. Nevertheless, more than half a million women worldwide develop invasive cervical cancer annually, with middle-and low-income countries achieving only 19% of successful screening coverage compared with high-income countries (63%). The age-standardised incidence rate for cervical cancer in South Africa is 24.71 per 100 000 women.
Public health and preventive medicine (PHPM) specialist physicians focus on the population rather than individuals as their patients. These specialists assess the health status of a community and subsequently develop, implement and evaluate effective interventions at the population level to improve health. This work brings together their medical expertise, population health approach and management/ leadership skills. The Royal College of Physicians and Surgeons of Canada (RCPSC) states that ‘the Public Health and Preventive Medicine or community medicine (as called previously) specialist uses population health knowledge and skills to play leading and collaborative roles in the maintenance and improvement of the health and well-being of the community’. It is a broad speciality that requires strong generalist skills including in preventive medicine, management, epidemiology, emergency response, health promotion, and health protection.
Health technology encompasses interventions developed to prevent, diagnose or treat medical conditions; promote health; provide rehabilitation or organise healthcare delivery. The intervention can be a test, device, medicine, vaccine, procedure, program or system.[1] Health technology assessment (HTA) is a multidisciplinary evaluation process that assesses the properties of health technologies and interventions. It uses specific methods to determine the value of a health technology at different points in its lifecycle. The purpose of the HTA is to inform decision-making to promote equitable, efficient and high-quality health and health care systems. [1,2] It bridges the gap between the realms of research, policy making and service delivery.
The term “médecine sociale” (social medicine in English) was first coined in 1848 during the French Revolution by Dr. Jules Guérin. It is a branch of medicine that focuses on the impact of social and economic conditions on health, disease, and the practice of medicine, with the intention of creating a healthier society. It is an interdisciplinary program between medicine and social sciences, expected to equip medicine with the knowledge and skills needed for analyzing the social causes of health and illness, akin to how the alliance between medicine and laboratory sciences provided insights into the biological, chemical, and physical bases of diseases. Social medicine is also interconnected with social determinants of health. While social determinants of health specifically target social and environmental conditions that affect health, social medicine has a broader scope, encompassing the entire social context of health, including societal structures and cultural factors. In the post-apartheid era, social medicine could play an important role in transforming the healthcare system to ensure equity and inclusivity, leading to improved health outcomes. This would require re-engineering the education of health professionals in South Africa at both undergraduate and postgraduate levels, as practiced in many parts of the world. This will assist South Africa in joining the global movement of social medicine for the promotion of human rights and social justice in medicine, and a better understanding of the impact of social factors on the aetiology and management of medical disorders in the 21st century.
Background. Blood products, though potentially lifesaving, are a scarce and costly resource. Trauma injuries, which contribute to the demand for these resources, increase in proportion to alcohol consumption. South Africa’s COVID-19 lockdown measures included a ban on alcohol sales and curfews.Objective. To investigate the effect of these societal measures on blood product usage. Methods. We retrospectively compared medical patient data from the South African National Blood Service database of red cell concentrate (RCC) usage in four disciplines during the COVID-19 period with data from the 3 years preceding the pandemic. We also examined trauma case patterns using an institutional database from the Harry Gwala Regional Hospital (HGRH) Emergency Department during the same periods. Results. In total, 16 922 RCCs at HGRH and 528 734 RCCs in KwaZulu-Natal were issued across the four disciplines, from March 2017 - March 2021. RCC usage significantly decreased among trauma patients at institutional and provincial levels during the COVID-19 period (provincial pre-lockdown mean 10.99 units per day; SD 6.89, 95% CI 10.63 - 11.35 v. lockdown 7.46 units per day; SD 5.42, 95% CI 6.14 - 8.79; p<0.01). Further, RCC usage significantly increased during the weekend immediately following the lifting of the first alcohol ban, along with a significant decrease in the number of trauma patients seen during hard lockdown periods. Conclusions. Societal restrictions, including curfews and banning alcohol consumption, decreased the use of RCCs in trauma patients. Government policies aimed at reducing alcohol-related traumatic injuries would likely have a significant impact on RCC usage.
Background. Bipolar disorder (BD) is a severe mental illness associated with multimorbidity, psychosocial disability and significant public health issues. However, guideline heterogeneity clouds therapeutic decisions, particularly in relapse prevention. Polypharmacy and poor health outcomes are common. For low- and middle-income countries, deciding which medicines to procure and how to treat BD in an integrated manner remains elusive. Although South Africa (SA) is committed to universal health coverage, the estimated treatment gap for mental disorders in the public health sector is 91%. An Essential Medicines List (EML) enables equitable access to medicines, while Standard Treatment Guidelines (STGs) facilitate rational prescribing and quality care. Objectives. To describe the medicine selection process for the treatment of BD in the SA public health sector, and the treatment algorithms developed to guide integrated care. Methods. Evidence-based medicine principles, stakeholder consultation and consensus decision-making were used. The existing (2015) BD guideline and stakeholder comments were reviewed by a ministerially appointed expert review committee, following which a research question with eligibility criteria was formed, and rapid systematic evidence synthesis conducted. PubMed and Cochrane databases were searched for systematic reviews of randomised controlled trials and observational studies of acute and maintenance treatment in BD, with an additional PubMed search for primary research. Quality of the systematic reviews was appraised using the 11-item assessment of multiple systematic reviews. After costing to ensure affordability, final recommendations were made to the National EML Committee (NEMLC) using the strength of recommendation taxonomy classification. Following approval by the NEMLC, proposed medicines were incorporated into the 2019 National Department of Health Adult Hospital STGs. As the STGs are updated every 3 years, stakeholder input was sought in 2021 and 2023, with no changes to the medicine selection. Results. Seven systematic reviews and one observational study were included in the evidence synthesis. Six medicines were selected as essential for maintenance treatment: lithium, valproate, lamotrigine, olanzapine, quetiapine and clozapine. While risperidone and benzodiazepines were retained for acute mania, carbamazepine and fluoxetine were removed from acute depression. Treatment algorithms for predominantly manic and depressive courses of illness were constructed to encourage person-centred care, aiming for euthymia, individual functioning and relapse prevention. Conclusion. Evidence-based medicine principles enabled the NEMLC to select a range of essential medicines for the management of BD in a middle-income country. Local monitoring and evaluation are needed to inform future editions of the STGs and EML.
Background. Excessive usage of smartphones has been linked to forward head posture (FHP) leading to musculoskeletal disorders of the spine. Objective. To determine the effect of smartphone applications on pain and disability levels in the neck, shoulder, lower back and FHP among young adults with excessive smartphone usage. Methods. In this randomised controlled pilot study, 31 young adults (24 female and 7 male, aged 21.35 (standard deviation 1.74 years) who exhibited excessive smartphone usage were enrolled. They were recruited from the College of Medicine, University of Lagos in Nigeria and randomly allocated to three groups: smartphone application (SPA) only, SPA with ergonomic advice (SPA+EA) and EA only. Outcome assessments were conducted before, at 4 weeks, and after 8 weeks of the intervention. Results. The outcome of this study revealed significant improvements in the assessed variables across all three groups (SPA, SPA+EA, EA) post intervention, including FHP (p=0.0001, p=0.003, p=0.002), pain intensity in the neck (p=0.01, p=0.02, p=0.0001), neck disability level (p=0.0001, p=0.0001, p=0.0001), functional disability (p=0.001, p=0.001, p=0.007) and shoulder pain disability (p=0.0001, p=0.001, p= 0.0001). However, no significant between-group differences (p>0.05) were noted in the outcomes across the groups, except for FHP (p=0.027) at the end of the 8th week of intervention. Conclusion. It was concluded that the SPA group was more effective in improving FHP, though all the groups displayed significant effects in all the outcomes.
Implementing research in low‐ and middle‐income countries (LMICs) involves multiple operational and socioeconomic challenges. In order to make global health research equitable, it is essential to overcome these challenges and implement research where the burden lies. We describe cultural, socioeconomic, recruitment and retention challenges experienced in our paediatric research in South Africa. We found that additional strategies and resources were required to address the specific cultural and socioeconomic aspects in order to conduct high‐ quality research in our facility.
Appropriate public health policy, and the associated budgetary decisions, are extremely important to society, and rely on expert scientific input. Scientists who provide this input, typically medical researchers alongside statisticians specialising in medical data, are required to produce objective, transparent analysis that will aid the politicians who make these crucial policy decisions. In this article we give examples of how scientists who publish work in the area of public health can overlook critical aspects of data analysis and arrive at inappropriate conclusions not supported by the data. We believe that all data used in such studies should be freely available, and suggest principles that scientists and journals should adhere to in order to ensure that the statistical models used on the data and the conclusions reached on the basis of the statistical analysis have been subjected to intensive interrogation by as large a pool of scientists as possible.
Background. Breast cancer (BC) is the most common invasive cancer in women, and the second leading cause of death in women worldwide. In Sudan, BC was the most predominant type of cancer among females according to the records of the Radiation Isotope Center Khartoum and Gezira Institute for Cancer Treatment and Molecular Biology.Objective. To assess the knowledge, attitudes and practice of Sudanese medical students regarding breast self-examination (BSE). Methods. A descriptive cross-sectional study was conducted during June - August 2019 among university medical students in Sudan. Data were collected using a self-administered, semi-structured and pre-tested questionnaire. The questionnaire comprised five parts: participants’ sociodemographic characteristics; knowledge of BSE; knowledge of symptoms of BC; attitudes toward BSE; and attitudes towards BSE practice. Data were analysed using descriptive statistics. Results. Three hundred questionnaires were distributed among female students, with 295 responses (98.3%). The findings revealed that 285 (96.6%) of the respondents had heard about BSE before, and 293 (99.3%) of them were aware of the monthly BSE test, and agreed that BSE is a good practice test for early BC detection. Two hundred and ninety-one (91.2%) were knowledgeable about BC symptoms. In addition, 191 (64.7%) of the respondents agreed that they could detect BC by themselves, while 277 (76.9%) of respondents said that BSE is not time- consuming. A total of 257 (87.1%) of the respondents agreed that BSE was important and useful in the early detection of abnormalities. For the practice score, three-quarters (n=221; 74.9%) of the respondents practise BSE because they are aware of its benefit. Conclusion. The intensive awareness campaign of BSE practice and BC should be done on a regular basis using mass media to increase the level of awareness of BC.
Background: Poor qualities of antenatal and intrapartum care are associated with poor maternal and neonatal health outcomes. Audit of care is an essential tool to identify gaps for standard protocols and guidelines that can assist with evidence based intervention to ensure consistent quality of care during antenatal and delivery. Objectives: To measure the compliance on the specific antenatal and delivery care indicators based on national guidelines. Method: A cross-sectional study was conducted of women who had childbirths between January and June 2021 in a midwife obstetric unit. Descriptive statistics were used to describe continuous and categorical variables. Both the mean and standard deviation (SD) were calculated for continuous and proportions for categorical variables. Results; The mean age and gestational age of the sample were 26 years and 16 weeks respectively. Teenage pregnancy constituted 13.5%. Most of the antenatal and delivery care indicators had good compliance (> 95%). However, gaps were identified for: recording of Last Menstrual Period (78.5%), syphilis treatment at antenatal booking (72.7%), repeat syphilis test at 32 weeks (43.4%) and completion of basic antenatal care checklist (46.3%) during antenatal care. Lower rate for delivery care indicators were: recording of measurement of length and head circumference of the neonates (76.5%) and use of pain relief (5.4%) to mothers at delivery. The outcome indicators measured were good as Low Birth Weight, delivery complications and neonatal death rates were 11.6%, 10.7% and 1.4% respectively. Conclusions: Though the study found good compliance with antenatal and delivery care provided but the few basic indicators such as basic antenatal checklist, completion of syphilis treatment and use of pain relief were poor. These results are vital for a quality improvement programme including training of midwives on basic antenatal care including maternity care guidelines in PHC facilities. A multi-centre study is also recommended for further study.
Maternal smoking during pregnancy is a severe behavioural problem that raises significant public health concerns. A notable amount of research has been published, and its evolution based on citations, knowledge structure, and impact on the scientific community is not entirely understood. This study identifies and describes the top most frequently cited 100 articles on maternal smoking during pregnancy. The top 100 articles were identified using the Scopus data database. Metadata were collected and analysed using bibliometrix and R package. The 100 most-cited articles (83 articles and 17 reviews) were published between 1971 and 2018. Those articles were cited 28 550 times, with a mean number of citations of 285.5 and a range of 189 - 812. A statistically significant positive correlation was observed in the number of the articles and citations score per year (r=0.635, p<0.001). Fifty-eight of the articles originated from the USA, with 52 in single-country publications and 6 in multiple-country publications. These articles were published in 58 journals, and the American Journal of Epidemiology published the most significant number of articles (n=8). Analysis through source clustering using Bradford’s Law indicated that the top 7 journals are in zone 1 (core journal) for the fields. The most prolific author is Gilliland, with h_index 5. The highest frequency keywords are pregnancy, smoking, maternal smoking, asthma, prenatal, environmental tobacco smoke, infant, abruptio placentae, birthweight and child. Our study offers researchers a thorough examination of the traits of the 100 articles on maternal smoking during pregnancy that have received the most citations, and a way to pinpoint any remaining research gaps.
