Breaking barriers: a psychobiography of Siya Kolisi from a sociocultural perspective.

Siyamthanda (Siya) Kolisi OIG (1992-) is the first black captain of the South African rugby team (Springboks) in its 128 years of existence. The Springboks have long been associated with Afrikaner people and a history of racism. Siya had to navigate a tumultuous upbringing in an environment characterised by various issues such as socioeconomic inequalities, high unemployment among Black people, and lack of resources. Siya was purposively selected for this study as he has become one of the most influential individuals in South Africa. Publicly available biographical data was gathered, analysed, and interpreted using the Phenomenological Variant of Ecological Systems Theory (PVEST; Spencer, 2006). I used the theoretical lens to understand the role of social and cultural context, meaning-making processes in human development, and the transition between different worlds. The findings indicated a need to consider the role of context as a source of consonance or dissonance in human development. The study also sheds light on the importance of viewing marginalised individuals holistically to facilitate smooth boundary transitions. Furthermore, it underscores the importance of recognising that maladaptive and adaptive coping strategies exist on a continuum. The study contributes towards non-WEIRD psychobiographical studies and understanding culture's role on human development.

Collaborative design of a health research training programme for nurses and midwives in Tshwane district, South Africa: a study protocol.

INTRODUCTION: Nurses are essential for implementing evidence-based practices to improve patient outcomes. Unfortunately, nurses lack knowledge about research and do not always understand research terminology. This study aims to develop an in-service training programme for health research for nurses and midwives in the Tshwane district of South Africa. METHODS AND ANALYSIS: This protocol outlines a codesign study guided by the five stages of design thinking proposed by the Hasso-Plattner Institute of Design at Stanford University. The participants will include nurses and midwives at two hospitals in the Tshwane district, Gauteng Province. The five stages will be implemented in three phases: Phase 1: Stage 1-empathise and Stage 2-define. Exploratory sequential mixed methods including focus group discussions with nurses and midwives (n=40), face-to-face interviews (n=6), and surveys (n=330), will be used in this phase. Phase 2: Stage 3-ideate and Stage 4-prototype. A team of research experts (n=5), nurses and midwives (n=20) will develop the training programme based on the identified learning needs. Phase 3: Stage 5-test. The programme will be delivered to clinical nurses and midwives (n=41). The training programme will be evaluated through pretraining and post-training surveys and face-to-face interviews (n=4) following training. SPSS V.29 will be used for quantitative analysis, and content analysis will be used to analyse qualitative data. ETHICS AND DISSEMINATION: The protocol was approved by the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria (reference number 123/2023). The protocol is also registered with the National Health Research Database in South Africa (reference number GP_202305_032). The study findings will be disseminated through conference presentations and publications in peer-reviewed journals.

Understanding of 'generalist medical practice' in South African medical schools.

BACKGROUND: In South Africa, medical students are expected to have acquired a generalist competence in medical practice on completion of their training. However, what the students and their preceptors understand by 'generalist medical practice' has not been established in South African medical schools. AIM: This study aimed to explore what the students and their preceptors understood by 'generalist medical practice'. SETTING: Four South African medical schools: Sefako Makgatho Health Sciences University, University of KwaZulu-Natal, Walter Sisulu University and the University of the Witwatersrand. METHODS: The exploratory descriptive qualitative design was used. Sixteen focus group discussions (FGDs) and 27 one-on-one interviews were conducted among students and their preceptors, respectively. Participants were recruited through purposive sampling. The inductive and deductive data analysis methods were used. The MAXQDA 2020 (Analytics Pro) software was used to arrange data, yielding 2179 data segments. RESULTS: Ten themes were identified: (1) basic knowledge of medicine, (2) first point of contact with all patients regardless of their presenting problems, (3) broad field of common conditions prevalent in the community, (4) dealing with the undifferentiated patient without a diagnosis, (5) stabilising emergencies before referral, (6) continuity, (7) coordinated and (8) holistic patient care, necessitating nurturance of doctor-patient relationship, (9) health promotion and disease prevention, and (10) operating mainly in primary health care settings. CONCLUSION: The understanding of 'generalist medical practice' in accordance with internationally accepted principles augurs well in training undergraduate medical students on the subject. However, interdepartmental collaboration on the subject needs further exploration.Contribution: The study's findings can be used as a guide upon which the students' preceptors and their students can reflect during the training in generalist medical practice.

Influence of vitamin D supplementation on growth, body composition, pubertal development and spirometry in South African schoolchildren: a randomised controlled trial (ViDiKids).

OBJECTIVE: To determine whether weekly oral vitamin D supplementation influences growth, body composition, pubertal development or spirometric outcomes in South African schoolchildren. DESIGN: Phase 3 double-blind randomised placebo-controlled trial. SETTING: Socioeconomically disadvantaged peri-urban district of Cape Town, South Africa. PARTICIPANTS: 1682 children of black African ancestry attending government primary schools and aged 6-11 years at baseline. INTERVENTIONS: Oral vitamin D3 (10 000 IU/week) versus placebo for 3 years. MAIN OUTCOME MEASURES: Height-for-age and body mass index-for-age, measured in all participants; Tanner scores for pubertal development, spirometric lung volumes and body composition, measured in a subset of 450 children who additionally took part in a nested substudy. RESULTS: Mean serum 25-hydroxyvitamin D3 concentration at 3-year follow-up was higher among children randomised to receive vitamin D versus placebo (104.3 vs 64.7 nmol/L, respectively; mean difference (MD) 39.7 nmol/L, 95% CI 37.6 to 41.9 nmol/L). No statistically significant differences in height-for-age z-score (adjusted MD (aMD) -0.08, 95% CI -0.19 to 0.03) or body mass index-for-age z-score (aMD -0.04, 95% CI -0.16 to 0.07) were seen between vitamin D versus placebo groups at follow-up. Among substudy participants, allocation to vitamin D versus placebo did not influence pubertal development scores, % predicted forced expiratory volume in 1 s (FEV1), % predicted forced vital capacity (FVC), % predicted FEV1/FVC, fat mass or fat-free mass. CONCLUSIONS: Weekly oral administration of 10 000 IU vitamin D3 boosted vitamin D status but did not influence growth, body composition, pubertal development or spirometric outcomes in South African schoolchildren. TRIAL REGISTRATION NUMBERS: ClinicalTrials.gov NCT02880982, South African National Clinical Trials Register DOH-27-0916-5527.

Antimicrobial activity of Southern African medicinal plants on Helicobacter pylori and Lactobacillus species.

ETHNOPHARMACOLOGICAL RELEVANCE: Numerous medicinal plants have been used traditionally in South Africa for gastric ulcer treatment. Helicobacter pylori is known for causing inflammation and the onset of gastric ulcers. While several studies explored medicinal plants against H. pylori, investigation of medicinal plants used for gastric ulcers has been neglected, as well as the effects these plants would have on bacteria occurring naturally in the gut microbiome. AIM OF THE STUDY: This study aimed to investigate Southern African medicinal plants used traditionally for treating gastric ulcers against H. pylori , as well as the effects that these plants have when combined with Lactobacillus species and tested against H. pylori. METHODOLOGY: Based on evidence from the ethnobotanical literature, 21 plants were collected. Their antimicrobial activity was assessed against five clinical H. pylori strains, and in combination with each of three Lactobacillus species, using the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) broth microdilution assays. Toxicity was assessed using the brine shrimp lethality assay. RESULTS: Noteworthy activity was observed against at least one H. pylori strain for 12 plant species. The lowest mean MICs were from organic extracts of Carissa edulis Vahl (0.18 mg/mL) and Chironia baccifera L. (0.20 mg/mL), and aqueous extracts of Sansevieria hyacinthoides (L.) Druce (0.26 mg/mL) and Dodonaea viscosa Jacq. (0.30 mg/mL). Aqueous extracts of the investigated plants were combined with Lactobacillus species, and the majority of combinations showed increased antimicrobial activity compared with the extracts alone. Combinations of Lactobacillus rhamnosus with 18 of the 21 aqueous plant extracts showed at least a two-fold decrease in the mean MBC against all H. pylori strains tested. Lactobacillus acidophilus combined with either Protea repens L., Carpobrotus edulis (L.) L. Bolus or Warburgia salutaris (Bertol.f.) Chiov. aqueous extracts had the best anti-H. pylori activity (mean MBCs of 0.10 mg/mL for each combination). Only four organic and one aqueous extract(s) were considered toxic. CONCLUSION: These results highlight the potential of medicinal plants to inhibit H. pylori growth and their role in traditional treatments for the management of ulcers. The results also indicate that aqueous extracts of these plants do not hinder the growth of bacteria that occur naturally in the gut microbiome and play a role in maintaining gut health, as well as show the potential benefit of including Lactobacillus species as potentiators of H. pylori activity.

Effects of Cucurbita Moschata squash (Butternut) seed paste in improving zinc and iron status in children attending Early Childhood Development centres in Limpopo province, South Africa.

Cucurbita moschata (Butternut squash) seeds are a rich source of nutrition containing nutrients including iron, zinc, copper, calcium, potassium, and phosphorus. The aim of this study was to determine if Cucurbita Moschata squash seed paste improves zinc and iron status, anthropometric status, and dietary intake in preschool children. A pretest-posttest control group trial using cluster randomisation was conducted over 6 months. Four preschools were randomly assigned to receive 100 g of intervention or 100 g of a placebo as the control to enhance iron and zinc status. A total of 276 preschool children were recruited from eight government registered Early Childhood Development centres in Limpopo province, South Africa. The control group consumed Cucurbita moschata flesh twice-weekly, while the intervention group consumed Cucurbita moschata seed paste twice-weekly during a six-month period. Iron (serum iron, transferrin, transferrin saturation, ferritin) and zinc (serum zinc) status and anthropometric indices such as weight, height and mid upper arm circumference for children were evaluated at baseline and the endpoint. Iron and zinc-rich food consumption was measured using a 24-hour dietary recall and food record during the study, and dietary intake was estimated using a food frequency questionnaire which was conducted at the beginning and endpoint. The intervention group significantly improved in the mean serum iron 0.23 µg/dL (95% CI: 0.11;0.33); ferritin 0.21µg/dL (95% CI: 0.13;0.39), transferrin saturation 0.33% (0.23;0.74) and zinc 0.16 µmol/dl (95% CI: 0.13;0.25) at the end of the study. In addition, the intervention group exhibited greater mean weight for age of 0.13 z-score (95% CI: 0.28; 0.34) and weight for height of 0.04 z-score (95% CI: 0.12,0.05), as well as the consumption of iron (p < 0,001), zinc (p < 0,001), and vitamin C (p < 0.001). At the end of the trial, fiber (p < 0.001), riboflavin (p = 0.001), vitamin B6 (p < 0.001), and vitamin B12 (p < 0.001) were significantly higher in the control group. Thus, the inclusion of intervention in the diet of children in an impoverished area of South Africa improved the iron and zinc status of these children. This supplement could be a cost effective and sustainable approach to improve nutrient status in rural South Africa. Trial registration: Pan African Clinical Trial Registry (PACTR202308740458863).

The Indiscriminate Chemical Makeup of Secondary Metabolites Derived from Endophytes Harvested from Aloe barbadensis Miller in South Africa's Limpopo Region.

The efficacy of 23 bacterial isolates obtained from surface-sterilized stems and leaves of three medicinal plants (Aloe barbadensis Miller, Artemisia afra, and Moringa oleifera) was investigated in an endeavour to prevent the growth of Mycobacterium bovis using the cross-streak method. Endophytes were isolated by incubating sterile plant materials on nutrient agar at 30 °C for 5 days. Two isolates showing activity were subsequently utilized to produce the extracts. Whole-genome sequencing (WGC) was used to identify the isolates. Secondary metabolites produced after 7 days of growth in nutrient broth were harvested through extraction with ethyl acetate. The extracts were chemically profiled using gas chromatography-high resolution time-of-flight mass spectrometry (GC-HRTOF-MS). NCBI BLAST search results revealed that the isolated endophytes belonged to the Pseudomonas and Enterobacter genera, based on WGC. Two endophytes, Aloe I4 and Aloe I3-I5 from Aloe barbadensis, exhibited potency based on the cross-streak method. The metabolite profiling of the selected endophytes identified 34 metabolites from Aloe I4, including ergotamine, octadecane, L-proline and 143 other metabolites including quinoline and valeramide, which inhibit microbial quorum sensing. These findings suggest that bacterial endophytes from medicinal plants, particularly Aloe barbadensis, hold promise as sources of antimycobacterial agents for human health applications.

Influence of vitamin D supplementation on bone mineral content, bone turnover markers, and fracture risk in South African schoolchildren: multicenter double-blind randomized placebo-controlled trial (ViDiKids).

Randomized controlled trials (RCTs) to determine the influence of vitamin D on BMC and fracture risk in children of Black African ancestry are lacking. We conducted a sub-study (n = 450) nested within a phase 3 RCT of weekly oral supplementation with 10 000 IU vitamin D3 vs placebo for 3 yr in HIV-uninfected Cape Town schoolchildren aged 6-11 yr. Outcomes were BMC at the whole body less head (WBLH) and LS and serum 25-hydroxyvitamin D3 (25(OH)D3), PTH, alkaline phosphatase, C-terminal telopeptide, and PINP. Incidence of fractures was a secondary outcome of the main trial (n = 1682). At baseline, mean serum 25(OH)D3 concentration was 70.0 nmol/L (SD 13.5), and 5.8% of participants had serum 25(OH)D3 concentrations <50 nmol/L. Among sub-study participants, end-trial serum 25(OH)D3 concentrations were higher for participants allocated to vitamin D vs placebo (adjusted mean difference [aMD] 39.9 nmol/L, 95% CI, 36.1 to 43.6) and serum PTH concentrations were lower (aMD -0.55 pmol/L, 95% CI, -0.94 to -0.17). However, no interarm differences were seen for WBLH BMC (aMD -8.0 g, 95% CI, -30.7 to 14.7) or LS BMC (aMD -0.3 g, 95% CI, -1.3 to 0.8) or serum concentrations of bone turnover markers. Fractures were rare among participants in the main trial randomized to vitamin D vs placebo (7/755 vs 10/758 attending at least 1 follow-up; adjusted odds ratio 0.70, 95% CI, 0.27 to 1.85). In conclusion, a 3-yr course of weekly oral vitamin D supplementation elevated serum 25(OH)D3 concentrations and suppressed serum PTH concentrations in HIV-uninfected South African schoolchildren of Black African ancestry but did not influence BMC or serum concentrations of bone turnover markers. Fracture incidence was low, limiting power to detect an effect of vitamin D on this outcome.

Vitamin D­the "sunshine vitamin"­is essential for helping the body to absorb calcium from the diet, which is laid down in bone to improve its strength. There is a lack of clinical trials testing whether vitamin D supplements can improve bone content of calcium and other minerals, or reduce risk of bone fractures (broken bones) in children of Black African ancestry. We therefore conducted such a study, recruiting 1682 schoolchildren aged 6­11 yr living in Cape Town, South Africa. We found that a weekly dose of 10 000 international units (250 micrograms) of vitamin D3, given by mouth for 3 yr, was effective in boosting vitamin D levels in trial participants who received it. However, this did not have any effect on bone content of calcium and other minerals. Relatively few children experienced a broken bone during the study, so we were unable to say with confidence whether or not vitamin D supplements might affect this outcome.

Integrated chronic care models for people with comorbid of HIV and non-communicable diseases in Sub-Saharan Africa: A scoping review.

BACKGROUND: Integrated health care is an approach characterized by a high degree of collaboration and communication among health professionals. Integration of HIV/NCD is recommended to enhance the quality of healthcare services being provided. Duplication of limited resources is minimized, and a holistic care approach is promoted by shifting from acute and reactive care to care that embraces patient-centredness that includes promotive health and disease surveillance. The high burden of HIV disease in sub-Saharan Africa (SSA) combined with the increasing prevalence of chronic non-communicable diseases (NCDs) necessitates a review of how health systems has been doing to deliver quality integrated care for people living with HIV (PLWH) and comorbid chronic NCDs. METHODS: A scoping review was conducted to identify and describe all publications on integrated chronic care management models at the primary care level in the SSA context, particularly those that addressed the care of PLHIV with co-morbid chronic NCDs. The inclusion and exclusion criteria were applied, and duplicates were removed. RESULTS: A total of twenty-one articles were included in the final review. Integrated healthcare systems were reported in only eight SSA countries-(South Africa, Uganda, Kenya, the United Republic of Tanzania, Zambia, Malawi, Zimbabwe and Swaziland). Integrated care systems adopted one of three health models. These included added-on NCD services to previously dedicated HIV care facilities, expansion of primary care facilities to include HIV care and establishment of integrated care services. Short-term benefits included staff capacitation, improved retention of patients and improved screening and detection of NCDs. However, the expansion of existing services resulted in an increased workload with no additional staff. A significant positive change noted by communities was that there was less or no stigmatisation of people living with HIV when attending dedicated HIV clinics. CONCLUSION: Evidence of integrated healthcare services for PLWH and co-morbid of NCDs in SSA is scanty. Data on some short-term benefits of integrated care was available, but evidence was absent on the long-term outcomes. Randomized clinical trials with clearly defined comparator groups and standardized measures of HIV and NCD outcomes are needed to demonstrate non-inferiority of integrated against non-integrated care.

Family practice research in the African region 2020-2022.

BACKGROUND:  The African region produces a small proportion of all health research, including primary health care research. The SCOPUS database only lists the African Journal of Primary Health Care Family Medicine (PHCFM) and the South African Family Practice Journal (SAFP) in the field of family practice. AIM:  To review the nature of all original research (2020-2022) published in PHCFM and SAFP. SETTING:  African region. METHOD:  All 327 articles were included. Data were extracted into REDCap, using a standardised tool and exported to the Statistical Package for Social Sciences. RESULTS:  The median number of authors was 3 (interquartile range [IQR]: 2-4) and institutions and disciplines 1 (IQR: 1-2). Most authors were from South Africa (79.8%) and family medicine (45.3%) or public health (34.2%). Research focused on integrated health services (76.1%) and was mostly clinical (66.1%) or service delivery (37.9%). Clinical research addressed infectious diseases (23.4%), non-communicable diseases (24.6%) and maternal and women's health (19.4%). Service delivery research addressed the core functions of primary care (35.8%), particularly person-centredness and comprehensiveness. Research targeted adults and older adults (77.0%) as well as health promotion or disease prevention (38.5%) and treatment (30.9%). Almost all research was descriptive (73.7%), mostly surveys. CONCLUSION:  Future research should include community empowerment and multisectoral action. Within integrated health services, some areas need more attention, for example, children, palliative and rehabilitative care, continuity and coordination. Capacity building and support should enable larger, less-descriptive and more collaborative interdisciplinary studies with authors outside of South Africa.Contribution: The results highlight the strengths and weaknesses of family practice research in Africa.

THE IMPACT OF SUPPLEMENTARY FEEDING OF PIG CARCASSES ON PLASMA VITAMIN E CONCENTRATIONS IN CAPTIVE CAPE VULTURES (GYPS COPROTHERES).

With vulture population numbers on the decline globally, many countries resort to supplementary feeding to maintain colony health. Despite what is perceived as adequate feeding in South Africa, colonies are still characterized by poor breeding success. One reason could be that supplementary sites fail to meet micronutrient needs of birds. With results from zoological gardens indicating that some carcasses are low in their vitamin E concentrations, vitamin deficiencies may be an underlying problem. For this study it was determined if the feeding of whole pig carcasses, a common food item, could have a negative effect on plasma vitamin E concentrations in a captive colony. Plasma vitamin E concentrations were 7.38 ± 2.92 and 4.51 ± 1.24 after feeding whole pig carcasses (n = 14). Behaviorally, the birds also avoided the viscera and fat when feeding. Reasons for their low vitamin E concentrations could have resulted from the birds consuming only the pork meat, which is known to be low in vitamin E, or from natural peroxidation because of the high fat content of the carcasses. The study thus highlights the need for further research to ascertain the impact of feeding pig carcasses on wild vultures feeding routinely at supplementary feeding sites and also for considerations towards vitamin E supplementation.

South African healthcare reforms towards universal healthcare - where to next?

The National Assembly approval of the National Health Insurance (NHI) Bill represents an important milestone, but there are many uncertainties concerning its implementation and timeline. The challenges faced by the South African healthcare system are huge, and we cannot afford to wait for NHI to address them all. It is critical that the process of strengthening the health system to advance universal healthcare (UHC) begins now, and there are several viable initiatives that can be implemented without delay. This article examines potential scenarios after the Bill is passed and ways in which UHC could be advanced. It begins with an overview of the trajectory of health system reform since 1994, then examines the scenarios that may emerge once the Bill is passed by Parliament and makes a case for finding ways in which UHC could be advanced within the country, regardless of any legal or financial barriers that may delay or limit NHI implementation.

The rationale for South Africa to prioritise mental health care as a critical aspect of overall health care.

BACKGROUND: The publication of South Africa's National Mental Health Policy Framework and Strategic Plan 2023-2030 and the proposed National Health Insurance (NHI) make it timely to review that state of mental health services in the country, and to emphasize the importance of prioritising mental health as a pivotal component of holistic healthcare. METHOD: We searched the published literature on mental health using Google Scholar, Pubmed, and Bing Chat, focusing on these words: epidemiology of mental health disorders, depression and anxiety disorders, mental health services, mental health facilities, human resources, financing and impact of COVID-19 on mental health in South Africa and beyond. We also searched the grey literature on mental health policy that is publicly available on Google. RESULTS: We provided information on the epidemiology and economic impact of mental health disorders, the availability of mental health services, enabling policies, human resources, financing, and the infrastructure for mental health service delivery in South Africa. We detail the high lifetime prevalence rates of common mental disorders, as well as the profound impact of socioeconomic determinants such as poverty, unemployment, and trauma on mental health disorders. We note the exacerbating effect of the COVID-19 pandemic, and emphasize the pressing need for a robust mental health care system. CONCLUSION: In addition to outlining the challenges, such as limited mental health service availability, a shortage of mental health professionals, and financial constraints, the review proposes potential solutions, including task-sharing, telehealth, and increasing the production of mental health professionals. The paper underscores the necessity of crafting a comprehensive NHI package of mental health services tailored to the local context. This envisioned package would focus on evidence-based interventions, early identification, and community-based care. By prioritising mental health and addressing its multifaceted challenges, South Africa can aspire to render accessible and equitable mental health services for all its citizens within the framework of the National Health Insurance.

Randomized Trial to Improve Body Composition and Micronutrient Status Among South African Children.

INTRODUCTION: Physical activity (PA) promotion combined with multimicronutrient supplementation (MMNS) among school-age children may reduce fat mass accrual and increase muscle mass through different mechanisms and so benefit child health. This study determined the efficacy of combined interventions on body composition among South African schoolchildren and determined if micronutrients mediate these effects. STUDY DESIGN: Longitudinal cluster randomized controlled trial of children followed from 2019 to 2021. Statistical analyses carried from 2022 to 2023. SETTING/PARTICIPANTS: A total of 1,304 children 6-12 years of age recruited from public schools in Gqeberha, South Africa. INTERVENTION: Children were randomized by classes to either: (a) a physical activity group (PA); (b) a MMNS group; (c) a physical activity + multimicronutrient supplementation group (PA + MMNS); and (d) a placebo control group. MAIN OUTCOME MEASURES: Trajectories of overall and truncal fat free mass (FFM) and fat mass (FM) estimates in modeled at 9 and 21 months using latent growth curve models (LGCM). Changes in micronutrient concentrations at 9 months from baseline. RESULTS: An increased FFM trajectory was found among children in the MMNS arm at 9 months (Beta 0.16, 95% CI = 0.12, 0.31). The PA and MMNS arms both had positive indirect effects on this trajectory at 9 months (Beta 0.66, 95% CI = 0.44, 0.88 and Beta 0.32 95% CI = 0.1 0.5, respectively) and similarly at 21 months when mediated by zinc concentration changes. A reduced FM trajectory was found among children in the PA promotion arm at 9 months when using this collection point as the referent intercept. This arm was inversely associated with the FM trajectory at 9 months when mediated by zinc changes. CONCLUSIONS: PA and MMNS promotion in school-based interventions directly contributed to reductions in FM and increased FFM among South African children and indirectly through changes in micronutrient status. TRIAL REGISTRATION: ISRCTN, ISRCTN29534081. Registered on August 9, 2018 Institutional review board: Ethikkommission Nordwest- und Zentralschweiz" (EKNZ, project number: Req-2018-00608). Date of approval: 2018.

Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa.

BACKGROUND: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. METHODS: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. RESULTS: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. CONCLUSIONS: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.

An imprecise probability approach-based determination of over-represented southern African plant genera and families used in ethnopharmacology.

ETHNOPHARMACOLOGICAL RELEVANCE: The analyses of patterns of over-representation of southern African traditional medicinal plants at the genus and family level provide information about the differences in plant use among southern African countries and disease categories. 'Over-representation' refers to the phenomenon whereby the proportion of plants belonging to a taxonomic group is higher in ethnobotanical pharmacopoeia than in the total flora. AIM OF THE STUDY: This study aimed to use the Imprecise Dirichlet Model (IDM) to analyse data from ten southern African countries to establish how over-represented medicinal plant families compare with over-represented genera, how over-represented medicinal taxa differ among countries in this region of Africa, and how over-represented taxa differ among six major disease categories. MATERIALS AND METHODS: Floral data for the total species composition of each country were obtained from online databases. Medicinal plant species lists were generated from published surveys, inventories, and books. IDM calculations were executed using the inverse of the cumulative beta probability density function in Microsoft Excel™. Python programming language source code was used to calculate Pearson correlation (r) values and Jaccard coefficients (J). RESULTS: Nine of forty-two over-represented medicinal plant families in southern Africa (group 1) do not have over-represented genera. Seven of the forty genera with the highest margins of over-representation belong to under-represented families. Nineteen of the forty-two over-represented families have margins of over-representation smaller than the cumulative margins of their over-represented genera. Groups of countries with similar overall flora (J ≥ 0.333) are Botswana and Namibia (group 2), Malawi, Mozambique, Zambia and Zimbabwe (group 3). The families and genera with the highest margins of over-representation are Loganiaceae and Albizia in group 1, Combretaceae and Vachellia in group 2, Dioscoreaceae and Senna in group 3, and Sapotaceae and Solanum in group 4 (South Africa). The families and genera with the highest margins of over-representation across disease categories are Ebenaceae and Albizia, Canellaceae and Dicoma, Combretaceae and Pterocelastrus, Ebenaceae and Bersama, Francoaceae and Erythrina, and Aristolochiaceae and Strychnos for plants used in the treatment of STIs, febrile and mosquito-vector diseases, microbial infections, pain, skin conditions, and female sexual/reproductive problems, respectively. CONCLUSIONS: Genus-level calculations are more efficient in generating taxonomic lists that can be used for ethnopharmacological investigations due to the exclusion of under-represented genera. Limiting the size of geographical areas from which medicinal plant lists are sampled and targeting plants used to treat specific types of disease prevents the underestimation of niche over-represented taxa.

Blood purification practices: Some ethnopharmacological insight from a rural community in KwaZulu-Natal, South Africa.

ETHNOPHARMACOLOGICAL RELEVANCE: Blood purification practices, also referred to as blood cleansing or detoxification, is an ancient concept which is widespread within African traditional medicine. There is, however, limited consolidated information about the selection of plant species, the purpose of use and how the preparation is made. An in-depth examination of how regional communities use medicinal plants for blood purification is needed to better understand this ethnopharmacological practice. AIM OF THE STUDY: To gather knowledge on the traditional use of medicinal plants used for the purpose of blood purification by laypersons in northern Maputaland, KwaZulu-Natal, South Africa. METHODS: An ethnobotanical survey was conducted on medicinal plants used in the rural areas of northern Maputaland for blood purification. Interviews were conducted in 55 homesteads, where the most knowledgeable participant per household was interviewed using structured questionnaires. Information collected included knowledge of the concept of blood purification, purpose for medicating, plant selection, and mode of preparation. The most important species and families were identified through indices. RESULTS: Sixty-four plant species from 35 families were recorded as blood purifiers for the treatment of ailments linked to the need for blood purification. Terminalia sericea Burch. ex DC. was the most used plant species (mentioned by 39% of the people interviewed). The conditions that were mostly associated with blood purification were skin complaints, gastro-intestinal disorders, and overall improvement of general health. Blood purification is also commonly used for non-medical purposes such as granting good luck or as a love charm. Six new plant species and five new Zulu vernacular names had not previously been documented for blood purification. CONCLUSION: The frequently mentioned use of medicinal plants for blood purification by the rural community of northern Maputaland clearly emphasises the importance of this cultural practice. There is no doubt that when examining African traditional medicine, holistic terms such as "blood cleansing" cannot be ignored. Future studies may provide a better understanding of this often misunderstood and undocumented practice.

Implementation considerations for a point-of-care Neisseria gonorrhoeae rapid diagnostic test at primary healthcare level in South Africa: a qualitative study.

BACKGROUND: South Africa maintains an integrated health system where syndromic management of sexually transmitted infections (STI) is the standard of care. An estimated 2 million cases of Neisseria gonorrhoeae (N. gonorrhoeae) occur in South Africa every year. Point-of-care diagnostic tests (POCT) may address existing STI control limitations such as overtreatment and missed cases. Subsequently, a rapid lateral flow assay with fluorescence-based detection (NG-LFA) with a prototype reader was developed for N. gonorrhoeae detection showing excellent performance and high usability; however, a better understanding is needed for device implementation and integration into clinics. METHODS: A qualitative, time-series assessment using 66 in-depth interviews was conducted among 25 trained healthcare workers involved in the implementation of the NG-LFA. Findings were informed by the Normalization Process Theory (NPT) as per relevant contextual (strategic intentions, adaptive execution, and negotiation capacity) and procedural constructs (coherence, cognitive participation, collective action, reflexive monitoring) to examine device implementation within primary healthcare levels. Interviews were audio-recorded, transcribed, and then analyzed using a thematic approach guided by NPT to interpret results. RESULTS: Overall, healthcare workers agreed that STI POCT could guide better STI clinical decision-making, with consideration for clinic integration such as space constraints, patient flow, and workload. Perceived NG-LFA benefits included enhanced patient receptivity and STI knowledge. Further, healthcare workers reflected on the suitability of the NG-LFA given current limitations with integrated primary care. Recommendations included sufficient STI education, and appropriate departments for first points of entry for STI screening. CONCLUSIONS: The collective action and participation by healthcare workers in the implementation of the NG-LFA revealed adaptive execution within the current facility environment including team compositions, facility-staff receptivity, and STI management experiences. User experiences support future clinic service integration, highlighting the importance of further assessing patient-provider communication for STI care, organizational readiness, and identification of relevant departments for STI screening.

Integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO): a randomised controlled trial protocol.

INTRODUCTION: South Africa has a high prevalence of gestational diabetes mellitus (GDM; 15%) and many of these women (48%) progress to type 2 diabetes mellitus (T2DM) within 5 years post partum. A significant proportion (47%) of the women are not aware of their diabetes status after the index pregnancy, which may be in part to low postnatal diabetes screening rates. Therefore, we aim to evaluate a intervention that reduces the subsequent risk of developing T2DM among women with recent GDM. Our objectives are fourfold: (1) compare the completion of the nationally recommended 6-week postpartum oral glucose tolerance test (OGTT) between intervention and control groups; (2) compare the diabetes risk reduction between control and intervention groups at 12 months' post partum; (3) assess the process of implementation; and (4) assess the cost-effectiveness of the proposed intervention package. METHODS AND ANALYSES: Convergent parallel mixed-methods study with the main component being a pragmatic, 2-arm individually randomised controlled trial, which will be carried out at five major referral centres and up to 26 well-baby clinics in the Western Cape and Gauteng provinces of South Africa. Participants (n=370) with GDM (with no prior history of either type 1 or type 2 diabetes) will be recruited into the study at 24-36 weeks' gestational age, at which stage first data collection will take place. Subsequent data collection will take place at 6-8 weeks after delivery and again at 12 months. The primary outcome for the trial is twofold: first, the completion of the recommended 2-hour OGTT at the well-baby clinics 6-8 weeks post partum, and second, a composite diabetes risk reduction indicator at 12 months. Process evaluation will assess fidelity, acceptability, and dose of the intervention. ETHICS AND DISSEMINATION: Ethics approval has been granted from University of Cape Town (829/2016), University of the Witwatersrand, Johannesburg (M170228), University of Stellenbosch (N17/04/032) and the University of Montreal (2019-794). The results of the trial will be disseminated through publication in peer-reviewed journals and presentations to key South African Government stakeholders and health service providers. PROTOCOL VERSION: 1 December 2022 (version #2). Any protocol amendments will be communicated to investigators, Human Ethics Research Committees, trial participants, and trial registries. TRIAL REGISTRATION NUMBER: PAN African Clinical Trials Registry (https://pactr.samrc.ac.za) on 11 June 2018 (identifier PACTR201805003336174).

Knowledge and attitudes of midwives towards collaboration with traditional birth attendants for maternal and neonatal healthcare services in rural communities in South Africa.

OBJECTIVES: We assessed the knowledge and attitude of registered midwives towards collaborating with traditional birth attendants for maternal and neonatal healthcare services in rural communities. DESIGN: A descriptive cross-sectional survey was followed in this study. PARTICIPANTS: Registered midwives in selected clinics in the City of Tshwane Municipality. Participants were recruited by stratified random sampling. Data was collected at the Thirty-four primary healthcare facilities in Gauteng province, South Africa. MEASUREMENT AND RESULTS: A self-assessment questionnaire was administered to 304 registered midwives. Two-hundred and sixty respondents returned the questionnaire representing a response rate of 86.6 % which was statistically significant. The majority of Midwives in South Africa displayed a low level of knowledge (mean = 41.8, SD=1.7) on the role and practices of traditional birth attendants). Only 30.8 % (n = 80) of midwives knew of the roles of traditional birth attendants for maternal and neonatal healthcare (MNH) services. With respect to knowledge, there was significant associated with the Professional category (p < 0.015). In terms of attitude, registered midwives displayed negative attitudes towards collaborating with traditional birth attendants (mean = 46.8, SD=2.1). Approximately half (54.2 %, n = 140) of midwives were amenable towards collaborating in the provision of antenatal care, and 70.4 % (n = 183) of midwives agreed to collaborate with traditional birth attendants for extended roles such as accompanying women to health facilities. Association of demographic data and level of attitude showed there was significant relationship (p < 0.05) between registered midwives' level of education and their attitude towards collaboration. KEY CONCLUSIONS: Midwives demonstrated positive attitude towards collaborating with traditional birth attendants at the antenatal care level only. Midwives were not amenable to collaboration at the level of intrapartum and postpartum care. IMPLICATIONS FOR PRACTICE: Based on our results, collaboration should be at antenatal care level to allow for early detection, treatment, and prevention of antenatal complications thus reducing maternal mortality and morbidity.