Towards Improving Stroke Services in Africa: Results from the Africa-UK Stroke Partnership [AUKSP] Surveys.

BACKGROUND: The African Stroke Organization (ASO) in partnership with the University of Central Lancashire's Stroke Research Team launched the Africa-UK Stroke Partnership (AUKSP). AUKSP undertook two (stroke expert and hospital Stroke Unit (SU)) on-line surveys mapping existing capacity and capability to deliver African stroke care. METHODS: An on-line expert survey tool was sent to 139 stroke experts in 54 African countries October 2021- March 2022 and the hospital SU survey to 120 hospital SUs (identified from the expert survey) June-October 2022. Both survey tools were prepared according to the World Stroke Organisation's Roadmap for Delivering Quality Stroke Care. Completed responses were exported from Qualtrics into Microsoft excel and were analysed descriptively. RESULTS: Forty-five expert responses and 62 hospital SU responses were analysed, representing 54(87%) public hospitals, 7(11%) private and 1(2%) charitable organization. In both surveys, three main priorities for improvement of stroke services were: a rapid and prompt stroke diagnosis; effective primary and secondary stroke prevention, and acute stroke management. Survey findings suggest that there is a low presence of national stroke surveillance systems and registries, and heterogeneity in availability of diagnostic services, SUs, endovascular treatments, and rehabilitation. CONCLUSION: Significant gaps exist in Africa's capacity and capability to deliver essential elements of effective and quality stroke care. Tackling these challenges requires urgent and sustained multi-stakeholder action including: government, administrators, policy makers and other partners. Our survey findings highlight key priority areas for multi-stakeholder engagement and crafting of a pragmatic, prioritized and context-sensitive African Stroke Action Plan.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam.

OBJECTIVE: To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC). DESIGN: Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy. SETTING: Argentina, Mongolia, South Africa and Vietnam. PARTICIPANTS: Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes. RESULTS: Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts. CONCLUSIONS: Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Cuban medical training for South African students: a mixed methods study.

BACKGROUND: Achieving universal health care coverage will require greater investment in primary health care, particularly in rural and underserved populations in low and middle-income countries. South Africa has invested in training black students from disadvantaged backgrounds in Cuba and large numbers of these Cuban-trained students are now returning for final year and internship training in South Africa. There is controversy about the scheme, the quality and relevance of training received and the place of Cuban-trained doctors in the health care system. Exploring the experiences of Cuban- and South African-trained students, recent graduates and medical school faculty may help understand and resolve the current controversy. METHODS: Using a mixed methods approach, in-depth interviews and a focus group discussion were held with deans of medical schools, senior faculty, and Cuban-trained and South African-trained students and recent graduates. An online structured questionnaire, adapted from the USA medical student survey, was developed and administered to Cuban- and South African-trained students and recent graduates. RESULTS: South African students trained in Cuba have had beneficial experiences which orientate them towards primary health care and prevention. Their subsequent training in South Africa is intended to fill skill gaps related to TB, HIV and major trauma. However this training is ad hoc and variable in duration and demoralizing for some students. Cuban-trained students have stronger aspirations than those trained in South Africa to work in rural and underserved communities from which many of them are drawn. CONCLUSION: Attempts to assimilate returning Cuban-trained students will require a reframing of the current negative narrative by focusing on positive aspects of their training, orientation towards primary care and public health, and their aspirations to work in rural and under-served urban areas. Cuban-trained doctors could be part of the solution to South Africa's health workforce problems.

Perceived barriers and facilitators for healthy behaviours among parents of adolescents receiving mental health care in a public hospital in Cape Town, South Africa: A qualitative study.

Objective: To explore the perceived barriers and facilitators for healthy behaviours among parents and caregivers of adolescents receiving mental health care in Cape Town, South Africa. Method: Thirty-five qualitative in-depth interviews were conducted with parents and caregivers of adolescents receiving mental health treatment by six facilitators matched for language. The data was analysed using thematic analysis. Results: The participants were predominantly female (n = 28, 80%) and parents (n = 29, 83%) of the adolescents. Personal barriers to good health included unhealthy eating, substance use and physical inactivity. Environmental barriers were inherited medical conditions, the easy availability of unhealthy foods and the absence of recreational facilities in communities. Perceived facilitators to good health were parental role modelling, planning and preparing healthy meals, exercise opportunities providing by walking long distances to work, and doing physically demanding jobs and household chores. Conclusion: Parents and caregivers are essential to adolescents' healthy development as they may influence adolescent health behaviours. It is likely that the promotion of positive health behaviours may be achieved though family-based interventions.

The association between adolescent risk behaviours and feelings of sadness or hopelessness: a cross-sectional survey of South African secondary school learners.

Poor mental health in adolescents has shown associations with engagement in other risk behaviours. However, evidence of this association in Sub-Saharan Africa, particularly South Africa, is lacking. This study examines the associations between pertinent risk behaviours and feelings of sadness or hopelessness amongst a nationally representative sample of South African school going adolescents. Data was analysed from the South African Youth Risk Behaviour Survey 2011 (n=10,997), a cross-sectional national survey among grades 8-11 school learners. Logistic regression examined the association of demographic, substance use, violent behaviour, sexual activity and suicidal plans and attempts with the primary outcome, feelings of sadness or hopelessness. Having feelings of sadness or hopelessness was significantly associated with more senior grades, being bullied (AOR:1.67, 95% CI: 1.42-1.96), being assaulted by a partner (1.33 [1.05-1.68]), forced sex (1.78 [1.37-2.32]); gang membership (1.32 [1.06-1.65]), binge drinking (1.37 [1.14-1.65]), ever having sex (1.23 [1.02-1.47]), having ≥1 partner/s in preceding three months (1.25 [1.02-1.53]), having made a plan to attempt suicide (2.50 [1.95-3.21]) and suicide attempt (1.49 [1.21-1.85]). Adolescents in South Africa are experiencing a multiple burden of risk. Health promotion strategies targeting adolescent mental health and risk behaviours need to be developed and implemented in a timely and comprehensive manner.

Predictors of knowledge about tuberculosis: results from SANHANES I, a national, cross-sectional household survey in South Africa.

BACKGROUND: South Africa is one of the 22 high tuberculosis burden countries that contribute 80% of the global tuberculosis cases. Tuberculosis is infectious and due to its rapid and easy transmission route poses a threat to population health. Considering the importance of social and psychological factors in influencing health outcomes, appraising knowledge and awareness of tuberculosis, remain vital for effective tuberculosis control. The main aim of this study was to investigate the factors that predict knowledge about tuberculosis among 18-64 year old adults in South Africa. METHODS: A cross-sectional survey method was used. Multi-stage disproportionate, stratified cluster sampling was used to select households within enumeration areas stratified by province and locality type. Based on the Human Sciences Research Council 2007 master sample, 500 Enumerator Areas representative of the socio-demographic profile of South Africa were identified and a random sample of 20 households was randomly selected from each Enumerator Area, yielding an overall sample of 10,000 households. The tuberculosis module contained in the South African National Health And Nutrition Examination Survey I was the only module that examined the social determinants of an infectious disease. This module was questionnaire-based with no biomarkers obtained to screen for the presence of tuberculosis disease among the participants. Data was collected by administering a researcher developed individual level questionnaire. Simple and multiple linear regression was used to determine the independent variables associated with tuberculosis knowledge. RESULTS: Half the sample (52.6%) was female and the majority of the respondents were black African (76.5%). More than two thirds (68.0%) resided in urban areas, 56.9% did not complete high school and half were not in formal employment. Significant predictors of tuberculosis knowledge were race, sex, completion of high school, being in employment, having a diagnosis of the disease in ones' life-time and learning about tuberculosis from television, brochures, health workers, and teachers. CONCLUSIONS: To reduce the burden of tuberculosis in South Africa, media campaigns targeting both rural and urban communities should include conveying accurate information about the disease. Policy makers should also address structural barriers that vulnerable communities face.

Predictors of nurses' and midwives' intentions to provide maternal and child healthcare services to adolescents in South Africa.

BACKGROUND: Adolescent mothers are at a much higher risk for maternal mortality compared to mothers aged 20 years and above. Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects such as early onset of adult diabetes than newborns of older mothers. Few studies have investigated the determinants of adequate quality maternal and child healthcare services to pregnant adolescents. This study was conducted to gain an understanding of nurses' and midwives' intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa. METHODS: A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Pearson's correlation analysis was conducted to determine the association between knowledge, attitude, subjective norms, self-efficacy, and intention variables for FP and MCH services. A 2-step linear regression analysis was then conducted for both FP and MCH services to predict the intentions to provide FP and MCH services to adolescents. RESULTS: Self-efficacy to conduct MCH services (ß = 0.55, p < 0.01) and years of experience as a nurse- midwife (ß = 0.14, p < 0.05) were associated with stronger intentions to provide the services. Self-efficacy to provide FP services (ß = 0.30, p < 0.01) was associated with stronger intentions to provide FP services. CONCLUSIONS: Self-efficacy has a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. There is a need to improve and strengthen nurses' and midwives' self-efficacy in conducting both MCH and FP services in order to improve the quality and utilization of the services by adolescents in South Africa.

Psychological distress and its relationship with non-adherence to TB treatment: a multicentre study.

BACKGROUND: The successful cure of tuberculosis (TB) is dependent on adherence to treatment. Various factors influence adherence, however, few are easily modifiable. There are limited data regarding correlates of psychological distress and their association with non-adherence to anti-TB treatment. METHODS: In a trial of a new TB test, we measured psychological distress (K-10 score), TB-related health literacy, and morbidity (TBscore), prior to diagnosis in 1502 patients with symptoms of pulmonary TB recruited from clinics in Cape Town (n = 419), Harare (n = 400), Lusaka (n = 400), Durban (n = 200), and Mbeya (n = 83). Socioeconomic, demographic, and alcohol usage-related data were captured. Patients initiated on treatment had their DOTS cards reviewed at two-and six-months. RESULTS: 22 %(95 % CI: 20 %, 25 %) of patients had severe psychological distress (K-10 ≥ 30). In a multivariable linear regression model, increased K-10 score was independently associated with previous TB [estimate (95 % CI) 0.98(0.09-1.87); p = 0.0304], increased TBscore [1(0.80, 1.20); p <0.0001], and heavy alcohol use [3.08(1.26, 4.91); p = 0.0010], whereas male gender was protective [-1.47(-2.28, -0.62); p = 0.0007]. 26 % (95 % CI: 21 %, 32 %) of 261 patients with culture-confirmed TB were non-adherent. In a multivariable logistic regression model for non-adherence, reduced TBscore [OR (95 % CI) 0.639 (0.497, 0.797); p = 0.0001], health literacy score [0.798(0.696, 0.906); p = 0.0008], and increased K-10 [1.082(1.033, 1.137); p = 0.0012], and heavy alcohol usage [14.83(2.083, 122.9); p = 0.0002], were independently associated. Culture-positive patients with a K-10 score ≥ 30 were more-likely to be non-adherent (OR = 2.290(1.033-5.126); p = 0.0416]. CONCLUSION: Severe psychological distress is frequent amongst TB patients in Southern Africa. Targeted interventions to alleviate psychological distress, alcohol use, and improve health literacy in newly-diagnosed TB patients could reduce non-adherence to treatment.

Social and structural factors associated with vulnerability to HIV infection among young adults in South Africa.

There is increasing focus on social and structural factors following the marginal success of individual-level strategies for HIV prevention. While there is evidence of decreased HIV prevalence among young individuals in South Africa, there is still a need to monitor HIV incidence and prevalence in this vulnerable group as well as track and prevent high-risk sexual behavior(s). This study investigated the social and structural factors that shape the context of vulnerability to increased risk of exposure to HIV infection. A mixed-methods approach including qualitative and quantitative design components was employed. Young adults in the age group 18-24 were interviewed from four provinces in South Africa. The qualitative results produced strong support for the effectiveness of loveLife's HIV prevention programs. The household-based survey results showed that the strongest predictors of self-reported HIV infection (indicating a greater chance of being infected) using adjusted odds ratios (aOR) are: being diagnosed with an STI in a lifetime (aOR 13.68 95% Confidence Interval (CI) [4.61-40.56]; p < .001), inconsistent condom use (aOR 6.27 95% CI [2.08-18.84]; p < .01), and difficulty in accessing condoms (aOR 2.86 95% CI [1.04-7.88]; p < .05). The strongest predictors that indicated a decreased chance of being infected with the HI virus are: talking with partner about condom use in the past 12 months (aOR .08 95% CI [.02-.36]; p < .001) and having a grade 8 (aOR .04 95% CI [.01-.66]; p < .05) and higher educational level (aOR .04 95% CI [.01-.43]). These results show that social and structural factors serve as risk and protective factors for HIV prevention among young people. Intervention programs need to continue to focus on effective communication strategies and healthy relationships. Structural adjustments have to be made to encourage school attendance. Finally, social/health policies and health service delivery have to also be refined so that young people have access to youth friendly health services.

Identifying community risk factors for HIV among South African adolescents with mental health problems: a qualitative study of parental perceptions.

High risk sexual behaviour, alcohol and drug use, and mental health problems combine to yield high levels of HIV-risk behaviour among adolescents with mental health problems. In South Africa, little research has been conducted on parental perspectives of HIV-risk among this population. We conducted a series of focus group discussions with 28 mothers of adolescents receiving services at two mental health clinics in South Africa to identify, from their perspectives, the key community problems facing their children. Participants indicated that HIV remained a serious threat to their adolescent children's well-being, in addition to substance abuse, early sexual debut, and teenage pregnancy. These social problems were mentioned as external to their household dynamics, and thus seemingly beyond the purview of the parent-adolescent relationship. These data have implications for the design of family-based interventions to ameliorate the factors associated with HIV-risk among youth receiving mental health services.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief.

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

No association between cumulative traumatic experiences and sex in risk for posttraumatic stress disorder among human immunodeficiency virus-positive adults.

This study examined the association between the type and number of traumatic experiences and the conditional risk for posttraumatic stress disorder (PTSD), stratified by sex, in human immunodeficiency virus (HIV). We evaluated 465 (114 male and 350 female) HIV-positive adults attending HIV clinics in Cape Town, South Africa. Demographic and clinical data were collected, and the participants were screened for current PTSD and traumatic event exposure using the Mini-International Neuropsychiatric Interview and the Life Events Checklist, respectively. The highest attributable risk for PTSD was derived from sexual assault (17.4%) and transport accidents (16.9%). Only sexual assault was significantly (p = 0.002) associated with current PTSD. Although sex had no effect on the prediction of current PTSD, HIV-infected men tended to experience more lifetime traumas than HIV-infected women, with the men having significantly higher rates of exposure than women to physical assault (p = 0.018) and assault with a weapon (p = 0.001). These data highlight the importance of considering trauma type in contributing to the burden of PTSD in HIV-infected adults.

Predictors of tuberculosis (TB) and antiretroviral (ARV) medication non-adherence in public primary care patients in South Africa: a cross sectional study.

BACKGROUND: Despite the downward trend in the absolute number of tuberculosis (TB) cases since 2006 and the fall in the incidence rates since 2001, the burden of disease caused by TB remains a global health challenge. The co-infection between TB and HIV adds to this disease burden. TB is completely curable through the intake of a strict anti-TB drug treatment regimen which requires an extremely high and consistent level of adherence.The aim of this study was to investigate factors associated with adherence to anti-TB and HIV treatment drugs. METHODS: A cross-sectional survey method was used. Three study districts (14 primary health care facilities in each) were selected on the basis of the highest TB caseload per clinic. All new TB and new TB retreatment patients were consecutively screened within one month of anti-tuberculosis treatment. The sample comprised of 3107 TB patients who had been on treatment for at least three weeks and a sub-sample of the total sample were on both anti-TB treatment and anti-retro-viral therapy(ART) (N = 757). Data collection tools included: a Socio-Demographic Questionnaire; a Post-Traumatic-Stress-Disorder (PTSD) Screen; a Psychological Distress Scale; the Alcohol Use Disorder Identification Test (AUDIT); and self-report measures of tobacco use, perceived health status and adherence to anti-TB drugs and ART. RESULTS: The majority of the participants (N = 3107) were new TB cases with a 55.9% HIV co-infection rate in this adult male and female sample 18 years and older. Significant predictors of non-adherence common to both anti-TB drugs and to dual therapy (ART and anti-TB drugs) included poverty, having one or more co-morbid health condition, being a high risk for alcohol mis-use and a partner who is HIV positive. An additional predictor for non-adherence to anti-TB drugs was tobacco use. CONCLUSIONS: A comprehensive treatment programme addressing poverty, alcohol mis-use, tobacco use and psycho-social counseling is indicated for TB patients (with and without HIV). The treatment care package needs to involve not only the health sector but other relevant government sectors, such as social development.

Screening and brief interventions for hazardous and harmful alcohol use among patients with active tuberculosis attending primary public care clinics in South Africa: results from a cluster randomized controlled trial.

BACKGROUND: In 2008 the World Health Organization (WHO) reported that South Africa had the highest tuberculosis (TB) incidence in the world. This high incidence rate is linked to a number of factors, including HIV co-infection and alcohol use disorders. The diagnosis and treatment package for TB and HIV co-infection is relatively well established in South Africa. However, because alcohol use disorders may present more insidiously, making it difficult to diagnose, those patients with active TB and misusing alcohol are not easily cured from TB. With this in mind, the primary purpose of this cluster randomized controlled trial was to provide screening for alcohol misuse and to test the effectiveness of brief interventions in reducing alcohol intake in those patients with active TB found to be misusing alcohol in primary public health care clinics in three districts in South Africa. METHODS: Within each of the three provinces targeted, one district with the highest TB burden was selected. Furthermore, 14 primary health care facilities with the highest TB caseload in each district were selected. In each district, 7 of the 14 (50%) clinics were randomly assigned to a control arm and another 7 of the 14 (50%) clinics assigned to intervention arm. At the clinic level systematic sampling was used to recruit newly diagnosed and retreatment TB patients. Those consenting were screened for alcohol misuse using the Alcohol Use Disorder Identification Test (AUDIT). Patients who screened positive for alcohol misuse over a 6-month period were given either a brief intervention based on the Information-Motivation-Behavioural Skills (IMB) Model or an alcohol use health education leaflet. RESULTS: Of the 4882 tuberculosis patients screened for alcohol and agreed to participate in the trial, 1196 (24.6%) tested positive for the AUDIT. Among the 853 (71%) patients who also attended the 6-month follow-up session, the frequency of positive screening results at baseline/follow-up were 100/21.2% for the AUDIT (P < 0.001) for the control group and 100/16.8% (P < 0.001) for the intervention group. The intervention effect on the AUDIT score was statistically not significant. The intervention effect was also not significant for hazardous or harmful drinkers and alcohol dependent drinkers ( AUDIT: 7-40), alcohol dependent drinkers and heavy episodic drinking, while the control group effect was significant for hazardous drinkers ( AUDIT: 7-19) (P = 0.035). CONCLUSION: The results suggest that alcohol screening and the provision of a health education leaflet on sensible drinking performed at the beginning of anti-tuberculosis treatment in public primary care settings may be effective in reducing alcohol consumption. TRIAL REGISTRATIONS: PACTR201105000297151.

Prevalence of post-traumatic stress symptoms and associated factors in tuberculosis (TB), TB retreatment and/or TB-HIV co-infected primary public health-care patients in three districts in South Africa.

High rates of tuberculosis (TB) and TB/HIV co-infection is often linked with mental health issues such as post-traumatic stress disorder (PTSD) symptoms, which is further associated with poor health outcomes. In a country such as South Africa where rates of these infectious diseases are high, it is concerning that there is limited/no data on prevalence rates of mental disorders such as PTSD and its associated factors. Therefore, the aim of this study was to establish the prevalence of PTSD symptoms and associated factors in TB, TB retreatment and/or TB-HIV co-infected primary public health-care patients in three districts in South Africa. Brief screening self-report tools were used to measure: PTSD symptoms, psychological distress (anxiety and depression) and alcohol misuse. Other relevant measures, such as adherence to medication, stressful life events and sexual risk-taking behaviours, were obtained through structured questions. A total of 4900 public primary care adult patients from clinics in high TB burden districts from three provinces in South Africa participated. All the patients screened positive for TB (either new or retreatment cases). The prevalence of PTSD symptoms was 29.6%. Patients who screened positive for PTSD symptoms and psychological distress were more likely to be on antidepressant medication. Factors that predicted PTSD symptoms were poverty, residing in an urban area, psychological distress, suicide attempt, alcohol and/or drug use before sex, unprotected sex, TB-HIV co-infected and the number of other chronic conditions. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of TB and HIV.

Quality of life among tuberculosis (TB), TB retreatment and/or TB-HIV co-infected primary public health care patients in three districts in South Africa.

INTRODUCTION: TB and HIV co-morbidity amount to a massive burden on healthcare systems in many countries. This study investigates health related quality of life among tuberculosis (TB), TB retreatment and TB-HIV co-infected public primary health care patients in three districts in South Africa. METHODS: A cross sectional study was conducted among 4900 TB patients who were in the first month of anti-TB treatment in primary public health care clinics in three districts in South Africa. Quality of life was assessed using the social functioning (SF)-12 Health Survey through face to face interviews. Associations of physical health (Physical health Component Summary = PCS) and mental health (Mental health Component Summary = MCS) were identified using logistic regression analyses. RESULTS: The overall physical and mental health scores were 42.5 and 40.7, respectively. Emotional role, general health and bodily pain had the lowest sub-scale scores, while energy and fatigue and mental health had the highest domain scores. Independent Kruskal-Wallis tests found significant positive effects of being TB-HIV co-infected on the domains of mental health functioning, emotional role, energy and fatigue, social function and physical role, while significant negative effects were observed on general health, bodily pain and physical function. In multivariable analysis higher educational, lower psychological distress, having fewer chronic conditions and being HIV negative were significantly positively associated with PCS, and low poverty, low psychological distress and being HIV positive were positively significantly associated with MCS. CONCLUSION: TB and HIV weaken patients' physical functioning and impair their quality of life. It is imperative that TB control programmes at public health clinics design strategies to improve the quality of health of TB and HIV co-infected patients.

Prevalence of psychological distress and associated factors in tuberculosis patients in public primary care clinics in South Africa.

BACKGROUND: Psychological distress has been rarely investigated among tuberculosis patients in low-resource settings despite the fact that mental ill health has far-reaching consequences for the health outcome of tuberculosis (TB) patients. In this study, we assessed the prevalence and predictors of psychological distress as a proxy for common mental disorders among tuberculosis (TB) patients in South Africa, where over 60 % of the TB patients are co-infected with HIV. METHODS: We interviewed 4900 tuberculosis public primary care patients within one month of initiation of anti-tuberculosis treatment for the presence of psychological distress using the Kessler-10 item scale (K-10), and identified predictors of distress using multiple logistic regressions. The Kessler scale contains items associated with anxiety and depression. Data on socio-demographic variables, health status, alcohol and tobacco use and adherence to anti-TB drugs and anti-retroviral therapy (ART) were collected using a structured questionnaire. RESULTS: Using a cut off score of ≥28 and ≥16 on the K-10, 32.9 % and 81 % of tuberculosis patients had symptoms of distress, respectively. In multivariable analysis older age (OR = 1.52; 95 % CI = 1.24-1.85), lower formal education (OR = 0.77; 95 % CI = 0.65-0.91), poverty (OR = 1.90; 95 % CI = 1.57-2.31) and not married, separated, divorced or widowed (OR = 0.74; 95 % CI = 0.62-0.87) were associated with psychological distress (K-10 ≥28), and older age (OR = 1.30; 95 % CI = 1.00-1.69), lower formal education (OR = 0.55; 95 % CI = 0.42-0.71), poverty (OR = 2.02; 95 % CI = 1.50-2.70) and being HIV positive (OR = 1.44; 95 % CI = 1.19-1.74) were associated with psychological distress (K-10 ≥16). In the final model mental illness co-morbidity (hazardous or harmful alcohol use) and non-adherence to anti-TB medication and/or antiretroviral therapy were not associated with psychological distress. CONCLUSIONS: The study found high rates of psychological distress among tuberculosis patients. Improved training of providers in screening for psychological distress, appropriate referral to relevant health practitioners and providing comprehensive treatment for patients with TB who are co-infected with HIV is essential to improve their health outcomes. It is also important that structural interventions are promoted in order to improve the financial status of this group of patients.

The Child Posttraumatic Stress Disorder Checklist in a sample of South African youth: establishing factorial validity.

To address the diverse health effects of posttraumatic stress disorder (PTSD) in youth, reliable and valid screening and diagnostic instruments that can be adapted to the specific context in which they are used, are required. Here, we assessed the psychometric properties (factorial validity, concurrent validity, and internal consistency) of the Child PTSD Checklist in treatment-seeking youth using secondary data. The scale demonstrated high internal consistency (Cronbach α = 0.93). Exploratory factor analysis revealed a three-factor structure (anxiety and avoidance, anger and dissociation, and depressive symptoms) that accounted for 41.9% of the total variance. Concurrent validity was fair between the Child PTSD Checklist and the diagnostic Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version when assessing for PTSD. The Child PTSD Checklist seems to be a promising tool for assessing PTSD in trauma-exposed youth in clinic settings. However, further studies are needed to address the checklist's broader utility.

Inconsistent condom use among public primary care patients with tuberculosis in South Africa.

The high rate of HIV infections among tuberculosis (TB) patients in South Africa calls for urgent HIV reduction interventions in this subpopulation. While correct and consistent condom use is one of the effective means of HIV prevention among sexually active people, there is insufficient research on condom use among TB patients in South Africa. The aim of this paper was to determine the prevalence of inconsistent condom use among public primary care TB patients and its associated factors using a sample of 4900 TB patients from a cross-sectional survey in three health districts in South Africa. Results indicated that when asked about their consistency of condom use in the past 3 months, 63.5% of the participants reported that they did not always use condoms. In the multivariable analysis, being married (OR = 1.66; 95% CI 1.25-2.20) or cohabitating or separated, divorced, or widowed (OR = 3.67; 1.85-7.29), lower educational level (OR = 0.66; 0.46-0.94), greater poverty (OR = 1.60; 1.25-2.20), not having HIV status disclosed (OR = 0.34; 0.25-0.48), sexual partner on antiretroviral treatment (OR = 0.38; 0.23-0.60), and partner alcohol use before sex (OR = 1.56; 1.30-1.90) were significantly associated with inconsistent condom use in the past 3 months. The low proportion of consistent condom use among TB patients needs to be improved.