Access to health care for persons with disabilities in rural South Africa.

BACKGROUND: Global research suggests that persons with disabilities face barriers when accessing health care services. Yet, information regarding the nature of these barriers, especially in low-income and middle-income countries is sparse. Rural contexts in these countries may present greater barriers than urban contexts, but little is known about access issues in such contexts. There is a paucity of research in South Africa looking at "triple vulnerability" - poverty, disability and rurality. This study explored issues of access to health care for persons with disabilities in an impoverished rural area in South Africa. METHODS: The study includes a quantitative survey with interviews with 773 participants in 527 households. Comparisons in terms of access to health care between persons with disabilities and persons with no disabilities were explored. The approach to data analysis included quantitative data analysis using descriptive and inferential statistics. Frequency and cross tabulation, comparing and contrasting the frequency of different phenomena between persons with disabilities and persons with no disabilities, were used. Chi-square tests and Analysis of Variance tests were then incorporated into the analysis. RESULTS: Persons with disabilities have a higher rate of unmet health needs as compared to non-disabled. In rural Madwaleni in South Africa, persons with disabilities faced significantly more barriers to accessing health care compared to persons without disabilities. Barriers increased with disability severity and was reduced with increasing level of education, living in a household without disabled members and with age. CONCLUSIONS: This study has shown that access to health care in a rural area in South Africa for persons with disabilities is more of an issue than for persons without disabilities in that they face more barriers. Implications are that we need to look beyond the medical issues of disability and address social and inclusion issues as well.

A phase I, pharmacokinetic and pharmacodynamic study of GSK2256098, a focal adhesion kinase inhibitor, in patients with advanced solid tumors.

BACKGROUND: Focal adhesion kinase (FAK) is important in cancer growth, survival, invasion, and migration. The purpose of this study was to determine the maximum tolerated dose (MTD), safety, pharmacokinetics (PK), and pharmacodynamics (PD) of the FAK inhibitor, GSK2256098, in cancer patients. PATIENTS AND METHODS: The dose of GSK2256098 was escalated, in cohorts of patients with advanced cancer, from 80 to 1500 mg, oral twice daily (BID), until the MTD was determined. Serial blood samples were obtained from all patients, and the PK was determined. Paired tumor biopsies were obtained in select patients, and the level of phospho-FAK (pFAK) was determined. RESULTS: Sixty-two patients (39 males, 23 females; median age 61 y.o., range 21-84) received GSK2256098. Dose-limiting toxicities of grade 2 proteinuria (1000 mg BID), grade 2 fatigue, nausea, vomiting (1250 mg BID), and grade 3 asthenia and grade 2 fatigue (1500 mg BID) were reported with the MTD identified as 1000 mg BID. The most frequent adverse events (AEs) were nausea (76%), diarrhea (65%), vomiting (58%), and decreased appetite (47%) with the majority of AEs being grades 1-2. The PK was generally dose proportional with a geometric mean elimination half-life range of 4-9 h. At the 750, 1000, and 1500 mg BID dose levels evaluated, the pFAK, Y397 autophosphorylation site, was reduced by ∼80% from baseline. Minor responses were observed in a patient with melanoma (-26%) and three patients with mesothelioma (-13%, -15%, and -17%). In the 29 patients with recurrent mesothelioma, the median progression-free survival was 12 weeks with 95% CI 9.1, 23.4 weeks (23.4 weeks merlin negative, n = 14; 11.4 weeks merlin positive, n = 9; 10.9 weeks merlin status unknown, n = 6). CONCLUSIONS: GSK2256098 has an acceptable safety profile, has evidence of target engagement at doses at or below the MTD, and has clinical activity in patients with mesothelioma, particularly those with merlin loss.

Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean.

BACKGROUND: Studies suggest a paucity of and lack of prioritisation in mental health research from low- and middle-income (LAMI) countries. AIMS: To investigate research priorities in mental health among researchers and other stakeholders in LAMI countries. METHOD: We used a two-stage design that included identification, through literature searches and snowball technique, of researchers and stakeholders in 114 countries of Africa, Asia, Latin America and the Caribbean; and a mail survey on priorities in research. RESULTS: The study identified broad agreement between researchers and stakeholders and across regions regarding research priorities. Epidemiology (burden and risk factors), health systems and social science ranked highest for type of research. Depression/anxiety, substance use disorders and psychoses; and children and adolescents, women, and people exposed to violence/trauma were prioritised among the disorders and population groups respectively. Important criteria for prioritising research were burden of disease, social justice, and availability of funds. Stakeholder groups differed in the importance they gave to the personal interest of researchers as a criterion for prioritising research. Researchers' and stakeholders' priorities were consistent with burden of disease estimates, however suicide was underprioritised compared with its burden. Researchers' and stakeholders' priorities were also largely congruent with the researchers' projects. CONCLUSIONS: The results of this first ever conducted survey of researchers and stakeholders regarding research priorities in mental health suggest that it should be possible to develop consensus at regional and international levels regarding the research agenda that is necessary to support health system objectives in LAMI countries.

Gut reactions of radioactive nitrite after intratracheal administration in mice.

Intratracheal administration to mice of radioactive nitrite labeled with nitrogen-13 (13NO2-) (half-life, 9.96 minutes) in dosages that do not cause pharmacological perturbation reveals that oxidative and reductive reactions occur in different organs. Oxidation of 13NO2- to radioactive nitrate (13NO3-) predominates in the blood and liver. Reduction of 13NO2- occurs in those mice that harbor intestinal microflora; this reduction does not occur in germ-free mice. The intestinal reduction products include ammonium, glutamate, glutamine, and urea. With a detection limit of about 0.01 percent of the instilled nitrogen-13, no labeled nitrosamines were detected within 30 minutes. Reduced nitrogen-13 is transported out of the intensive into the circulatory system and appears in the urine along with 13NO3-. The biological half-period for 13NO2- destruction is about 7 minutes, and both oxidation and reduction products are formed.

DDE residues and eggshell changes in Alaskan falcons and hawks.

Eggshell thickness after exposure to DDT was reduced by 21.7 percent in Alaskan tundra peregrines, by 16.8 percent in taiga peregrines, by 7.5 percent in Aleutian peregrines, by 3.3 percent in rough-legged hawks, and not at all in gyrfalcons. Tundra peregrine eggs contain an average of 889 parts of DDE per million (lipid basis); taiga peregrine eggs contain 673 parts per million; Aleutian peregrine eggs contain 167 parts per million; rough-legged hawk eggs contain 22.5 parts per million; and gyrfalcon eggs contain 3.88 parts per million. These changes in eggshell thickness and the pesticide residues reflect different degrees of exposure to contamination. There is a highly significant negative correlation between shell thickness and DDE content in peregrine eggs. Tundra and taiga peregrines have fledged progressively fewer young each year since 1966.

"There is not a safe space where they can find themselves to be free": (Un)safe spaces and the promotion of queer visibilities among township males who have sex with males (MSM) in Cape Town, South Africa.

Males who have sex with males (MSM) are prioritised in the global fight against HIV/AIDS, as a key affected population to receive HIV prevention, treatment, and HIV-related care and support (WHO, 2016). There is, however, limited empirical research conducted on how to engage communities of South African MSM in clinical HIV prevention research programs. The development of LGBTIQ safe spaces may potentially be a viable option to promote community-based engagement by bridging the divides between HIV-prevention researchers, marginalised queer populations, and other HIV-prevention stakeholders located in heteronormative spaces (Molyneux et al., 2016). We conducted ten in-depth, qualitative interviews with MSM safe space members who have been involved in HIV prevention research programs. Data were analysed using a thematic analytic strategy (Braun and Clarke, 2006). Our results indicate that the "safe spaces" currently operational in Cape Town are not stable spaces nor are they always safe, but they form part of a broader and much more long-term political and geographical strategy of inclusion and emancipation.

A randomised control study of a fully automated internet based smoking cessation programme.

OBJECTIVE: The objective of this project was to test the short term (90 days) efficacy of an automated behavioural intervention for smoking cessation, the "1-2-3 Smokefree" programme, delivered via an internet website. DESIGN: Randomised control trial. Subjects surveyed at baseline, immediately post-intervention, and 90 days later. SETTINGS: The study and the intervention occurred entirely via the internet site. Subjects were recruited primarily via worksites, which referred potential subjects to the website. SUBJECTS: The 351 qualifying subjects were notified of the study via their worksite and required to have internet access. Additionally, subjects were required to be over 18 years of age, smoke cigarettes, and be interested in quitting smoking in the next 30 days. Eligible subjects were randomly assigned individually to treatment or control condition by computer algorithm. INTERVENTION: The intervention consisted of a video based internet site that presented current strategies for smoking cessation and motivational materials tailored to the user's race/ethnicity, sex, and age. Control subjects received nothing for 90 days and were then allowed access to the programme. MAIN OUTCOME MEASURES: The primary outcome measure was abstinence from smoking at 90 day follow up. RESULTS: At follow up, the cessation rate at 90 days was 24.1% (n = 21) for the treatment group and 8.2% (n = 9) for the control group (p = 0.002). Using an intent-to-treat model, 12.3% (n = 21) of the treatment group were abstinent, compared to 5.0% (n = 9) in the control group (p = 0.015). CONCLUSIONS: These evaluation results suggest that a smoking cessation programme, with at least short term efficacy, can be successfully delivered via the internet.

Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM.

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

Anorexia nervosa as a culture-bound syndrome.

Current psychological theories on anorexia nervosa share a common assumption that symptoms of the condition are related to cultural factors. The present article argues that the disorder can be fruitfully understood in the context of one definition of culture-bound syndromes. By way of introduction two contrasting models of the cross-cultural study of psycho-pathology are outlined in order to contextualize the argument in a particular paradigm. Anorexia nervosa is shown to fit the criteria of the Cassidy/Ritenbaugh definition of culture-bound syndromes, and the definition is shown to have some use in elucidating issues. Implications for a more flexible approach to theory development and therapeutic practice are discussed, and suggestions are made for further work demonstrating the negotiated nature of the disorder.

Illness negotiation: the case of eating disorders.

This article explores the possible relationship between professional writing on eating disorders and the occurrence of symptoms. The clinical situation is seen as one in which negotiation about symptoms affects and is affected by both professional and popular explanatory models. Professional understanding is not necessarily categorically distinct from popular conceptions. Furthermore, it may be that different academic models hold different assumptions about normality and may expect different types of 'normal' behaviour from patients. Professional writing and educative material may be playing a function not dissimilar from material generally seen as exploitative in educating women into development of symptoms. This possibility has implications for the way that professional understanding is viewed and contextualized.

On the edge: ward-rounds in a South African psychiatric emergency department.

Psychiatry, like other institutions in South Africa, is affected by issues of race. An examination of ward-rounds in a South African psychiatric emergency department, however, revealed that as important to an understanding of this unit is the recognition of the place of psychiatry in biomedicine. A key feature affecting staff in the unit was the fact of psychiatry's marginality relative to general medicine. Race was seldom and obliquely discussed, but played an important contributory role. Work towards the transformation of psychiatric care in a democratic South Africa must consider the institutional level as well as the more obvious question of racial inequality.

Professional constructions of a 'lay' illness: 'nerves' in a rural 'coloured' community in South Africa.

As part of a larger study, medical practitioners working in Mamre, a 'coloured' village close to Cape Town, South Africa, were interviewed concerning their use of the term 'nerves' in interaction with their patients. Contrary to the initial perception of researchers and some clinicians, the term is not simply a folk category. It does, however, represent a medium through which psychosocial issues are discussed in the clinical encounter. Differences in the usage of the term by different practitioners seemed to indicate different attitudes towards patient care. The data are presented and discussed in the context of debates concerning the development of more accessible and responsive health services in a future South Africa, and the information gleaned has implications for future training of clinicians.

Political repression and children in South Africa: the social construction of damaging effects.

This article discusses some dilemmas facing mental health and social service workers studying and providing services for children affected by political repression in South Africa. We argue that it is almost inevitable that progressive care providers are affected by an image of childhood as one of passive innocence and vulnerability, an image which is both outmoded in terms of modern developmental psychology and potentially destructive if the aim of intervention is empowerment. Practical experience with children affected by repression has led us to question commonly held views on the nature of psychological damage, and to recognise that our views on stress tend to be class-bound. Questions of partiality and credibility affect both practical work and the way that social service workers conceive of their role. Without an approach to the understanding of repression which takes account of underlying ideological factors, the social construction of illness and symptoms, and the historical antecedents of current abuses of children in South Africa, we are unable adequately to situate and evaluate critically the work we are doing. Even the focus on children as particular victims of apartheid needs to be thoroughly examined.

Reports of the experience of epilepsy in a rural South African village.

It has become increasingly acknowledge that the social and psychological consequences of epilepsy may be more debilitating than the epileptic seizures themselves. This study, which formed part of an ongoing community health project which was carried out in the South African village of Mamre, was aimed at gaining an understanding of some of these psychosocial aspects. Sixteen respondents were as well as their families, had accepted the epilepsy and learnt to cope with it, although some respondents felt stigmatized by the epilepsy and made various attempts to conceal it from outsiders. Problems which were caused by epilepsy included the fear of going out unaccompanied, as well as forgetfulness and irritable mood. Few respondents had epilepsy which could be described as well-controlled, yet none admitted being dissatisfied with their treatment. Implications of the study included the need to assist the respondents and their families to better understand the management of epilepsy, so that every effort would be made to attain maximal seizure control.

Cree Indian healing practices and western health care: a comparative analysis.

In this article, Cree Indian methods of treating disease are compared with the treatment process and procedures used in the Western health Care system. Ethnographic data permitted the identification of the five components of Cree healing: the ritual, contract, treatment, didactic, and closure components. These components are compared with equivalent phases in the physician-patient and nurse-patient relationship. In particular, the process of comparison permits the identification of incongruities that the Cree may encounter when using the Western system. These include the inability to identify one's own state of health and abnormalities; a passive, rather than a participatory role in healing; the incomprehensible notion of "silent" diseases and preventative treatment; the specialization of the caring, curing, and counselling roles of practitioners and the limited perspective of "holism" in health care.

Life events in Xhosas in Cape Town.

A life events scale for research into Xhosa speaking people of Cape Town was developed. It was standardised on 131 residents of Cape Town's three major Black suburbs. Measures of perceived impact and rate of occurrence were elicited. The Spearman Rank correlation between prevalence and impact scores was not significant (r = 0.04). Items were ranked according to composite impact scores. Cultural and social factors were considered to play a part in explaining differences between the present findings and those of other studies. Limitations on the applicability of the scale and methodological issues were discussed. The problems in direct comparison between different cultural groups were emphasized, with particular stress on constraints on life events research in an African setting.

Role of kinaesthesia in arousal and learning behavior.

This article presents a rationale of the significance of kinaesthesia. The development of arousal in the central nervous system is primarily peripheral and based on kinaesthesia. Consistent adaptive behavior results from adequate kinaesthetic perception and is the foundation for intersensory integration. Without kinaesthesia learning develops unevenly, as in children with learning disabilities. Inconsistent, bizarre behavior evident in psychopathology may result from inadequate, distorted kinaesthetic perception. Visual and auditory perceptual processes have been researched but the essential role of kinaesthetic perception has been neglected. The implications of adequate kinaesthesia are relevant to teaching and to psychotherapy.

Non-use of Formal Health Services in Malawi: Perceptions from Non-users.

BACKGROUND: The study upon which this paper is based was undertaken to understand users' and non-users' perceptions concerning facilitators and barriers to equitable and universal access to health care in resource-poor countries such as Malawi. In this study, non-users of health services were defined as people who were not in need of health services or those who had stopped using them due to significant barriers. METHODS: A total of 80 interviews with non-users of health services were conducted in Rumphi, Ntchisi, Phalombe and Blantyre Districts of Malawi. Interviews focused on why informants were not using formal health services at the time of data collection. In order to identify non-users, snowballing was used health surveillance assistants, village headmen and community members also helped. One focus group discussion was also conducted with non-users of health services who were members of the Zion Church. RESULTS: Informants described themselves as non-users of health services due to several reasons: cost of health services; long distances to health facilities; poor attitude of health workers; belief in the effectiveness of traditional medicines; old age and their failure to walk. Others were non-users due to their disability; hence they could not walk over long distances or could not communicate effectively with health providers. Some of these non-users were complete non-users, namely members of the Zion Church and those who believed in traditional medicine, and they stated that nothing could be done to transform them into users of health services. Other non-users stated that they could become users if their challenges were addressed e.g. for those who were non-users of health services due to poor attitudes of health workers, they stated that if these health workers were transferred they would be able to access health services. CONCLUSIONS: Public health education targeting both health workers and non-users, ensuring a functional outreach program and addressing other health system challenges such as shortage of drugs and human resources would assist in transforming non-users into users of health services.

Organising for self-advocacy in mental health: experiences from seven African countries.

OBJECTIVE: This paper reports on overarching strategies which supported the establishment and sustainability of 9 mental health self-help organisations in seven African countries. METHOD: Eleven key informants were identified through snowballing and interviewed regarding their experience in the organisations. Thematic analysis of the interview data and other documentary evidence was guided by a coding scheme derived using a framework analysis approach to defining, categorising, mapping and interpreting textual data. RESULTS: Sustainability strategies include: commitment to members' advocating for their rights and rebuilding their lives within their communities; independent decision-making, user-led membership and leadership; financial self sufficiency, alliances with donor organisations, non-governmental organisations (NGOs), disabled people's organisations (DPOs) and ministries which support self-determination and promote control over agenda-setting and responsiveness to members' needs. Organisations' work include advocacy to destigmatise mental disorders and promote the protection of users rights, activities to improve access to health care and to income generation and social support, participation in legislative and policy reform, and capacity building of members. CONCLUSION: Self-help organisations can provide crucial support to users' recovery in resource-poor settings in Africa. Support of Ministries, NGOs, DPOs, development agencies and professionals can assist to build organisations' capacity for sustainable support to members' recovery.

The accuracy of interpreting key psychiatric terms by ad hoc interpreters at a South African psychiatric hospital.

OBJECTIVE: This study examined the competence and accuracy of ad hoc interpreters in interpreting key psychiatric terms at a South African psychiatric hospital METHODS: Nine individuals were asked to translate key psychiatric terms from English to Xhosa. These translations were then back-translated by independent translators, who do not have knowledge of psychiatric terminology. These back-translations were then compared with the original English. RESULTS: It was clear that not all the participants were fully competent in English. None had formal training in interpreting or psychiatric terminology. Not all of the participants were familiar with the psychiatric concepts that clinicians use and they often made mistakes while interpreting. CONCLUSION: The competency levels of interpreters are unsatisfactory to ensure the optimal delivery of mental health care. It is clear that there is a need for trained interpreters in South Africa, as the continuous use of untrained interpreters compromises the effectiveness of mental health care and could lead to adverse health outcomes.