Household Food Insecurity and Demographic Factors, Low Birth Weight and Stunting in Early Childhood: Findings from a Longitudinal Study in South Africa.

BACKGROUND: Low birthweight (LBW) as well as early childhood stunting are risk factors for increased childhood morbidity in low-and middle-income countries (LMIC). The Covid 19 pandemic has exacerbated food insecurity and unemployment globally, prompting concerns for maternal and child health. OBJECTIVES: We used data from the great recession of 2008 to examine the relationship between household food security and other risk factors with LBW and stunting using a longitudinal sample of South African women and their offspring. METHODS: Food security indicators, alcohol use, blood pressure and other characteristics were examined in relation to LBW (≤ 2500 g), stunting (height for age ≤ 2SD) and severe stunting (height for age ≤ 3SD). Regression modelling with clustering at maternal ID level were employed to adjust for maternal characteristics and women who gave birth more than once during the reference period. RESULTS: Birthweight data were available for 1173 children and height for age 1216 children. The prevalence of LBW was 14.7% while stunting and severe stunting was 17.8% and 14.5%. Child hunger in the household, maternal hypertension and alcohol use were associated with low birthweight. Food expenditure below the Stats SA poverty line and low dietary diversity was associated with stunting and severe stunting respectively. Maternal height and low birthweight were associated with both stunting and severe stunting. CONCLUSIONS FOR PRACTICE: Interventions that can improve household food security and nutritional status during the periconceptional and antenatal period may reduce the prevalence of low birthweight and subsequent stunting in low- and middle-income countries.

Dietary diversity, food insecurity and the double burden of malnutrition among children, adolescents and adults in South Africa: Findings from a national survey.

Childhood stunting remains a global public health problem. Many stunted children live in the same household as overweight or obese adults (the so-called double burden of malnutrition), evidence that quality as well as quantity of food is important. In recent years, food security measurement has shifted away from anthropometry (e.g., stunting) to experiential measures (e.g., self-reported hunger). However, given the continued problem of stunting, it is important that national surveys identify malnutrition. Objectives: To examine the associations between a variety of food security indicators, including dietary diversity, with adult, child (0-4 years) (5-9 years) and adolescent (10-17 years) anthropometry. To estimate the prevalence of double burden households. Methods: The study utilized cross-sectional data from the South African National Income Dynamics Survey NIDS (2008). We examined the associations between five food security indicators and anthropometry outcomes. The indicators were adult and child hunger in the household, self-reported household food sufficiency, food expenditure>60% of monthly expenditure and household dietary diversity. Multinomial and logistic regression models were employed to examine the associations with adult BMI categories and children's stunting and BMI. Results: The prevalence of stunting was 18.4% and the prevalence of wasting and overweight was 6.8 and 10.4%, respectively. Children <5 and adolescents with medium dietary diversity were significantly more likely to be stunted than children with high dietary diversity. Among children <5, child hunger and medium dietary diversity were significantly associated with wasting. None of the food security indicators were associated with stunting in children aged 5-9. Among stunted children, 70.2% lived with an overweight or obese adult. Among adults, increased dietary diversity increased the risk of overweight and obesity. Conclusion: Dietary diversity can be used as a proxy for poor nutritional status among children <5 years and adolescents but the relationship between dietary diversity and adult obesity is more complex. Given the double burden of malnutrition in many low- and middle-income countries, indicators of dietary quality remain important. These tools can be further refined to include an extra category for processed foods. Given the relative simplicity to collect this data, national surveys would be improved by its inclusion.

Evidence of an active Cushing reflex in a preterm neonate with hyaline membrane disease: a case report.

BACKGROUND: The Cushing reflex does not appear to have been described in preterm neonates. This case report shows the presence of an active Cushing reflex in a 32-week preterm neonate with hyaline membrane disease. CASE PRESENTATION: The 1.94 kg Caucasian infant was delivered by caesarean section following concerns about possible maternal infection and fetal compromise. Chest X-ray showed mild-to-moderate hyaline membrane disease and treatment was initiated with supplemental oxygen and nasal continuous positive airway pressure. It is probable that a pneumothorax occurred at 5-6 hours of age, with progression during the day. Interstitial air, pneumomediastinum, and tension pneumothorax were diagnosed on subsequent X-ray, and ultrasound of the brain showed a grade IV intraventricular hemorrhage. A review of the nurses' recordings of heart rate, blood pressure, and respiratory rate showed a progressive increase in blood pressure accompanied by slowing of the heart rate and irregular respiration. These are features of the Cushing reflex that is elicited in response to raised intracranial pressure. CONCLUSION: While well-described in older children and adults, in neonates the Cushing reflex has mainly been described in animal experiments and infants who have developed hydrocephalus. It is likely that in this case, the reflex was elicited as a result of a progressive increase in intracranial pressure due to the combination of elevated intrathoracic pressure, obstructed venous return from the brain, and concurrent intraventricular hemorrhage.

Demographic and Clinical Factors Associated with Development of Type 2 Diabetes: A Review of the Literature.

Diabetes mellitus is a complex and chronic condition that requires lifelong management and interaction with a healthcare system. Failure to control risk factors through preventive care may lead to a host of diabetes-related complications. Underperforming healthcare systems and poor awareness among the general population/healthcare professionals has been suggested as reasons why so many patients remain undiagnosed. Due to the asymptomatic nature of early and even intermediate diabetes mellitus, several years may pass without any diagnosis before complications begin to manifest. Other factors include age, gender, ethnicity, education, marital and unemployment status which may also increase the risk of developing morbidity and mortality associated with diabetes mellitus. This review summarizes the current demographic risk factors and clinical characteristics associated with diabetes mellitus. A literature search was conducted using PubMed, MEDLINE, and Sabinet by using the following search terms: diabetes mellitus, risk factors, characteristics and complications.

Utilization of over-the-counter analgesics in two private medical insurance schemes in South Africa.

INTRODUCTION: In South Africa there is an easy access to over-the-counter (OTC) medicines and expenditure is high. Certain OTC products are available to the public in general stores, while others may only be available at pharmacies. It is also common for OTC medicines to be prescribed by a doctor for treatment of minor illnesses. Individuals with medical insurance usually have cover for these products, but typically only to a limited extent. AIM: To investigate the utilization patterns in two medical insurance schemes of OTC analgesic products in the Anatomical Therapeutic Chemical (ATC) category N02BE51 which includes medicines containing paracetamol and varying combinations of codeine, caffeine and antihistamines. METHODOLOGY: Data were obtained for two benefit plans, one with generous, high benefits (HI), the other with lower benefits (LO). Data covered utilization of OTC medicines in the N02BE51 group, indicating whether the medicines were purchased at a pharmacy or dispensed by a doctor. Doctors were further categorised as contracted/network or non-network providers. Product costs and volumes were analysed according to access directly by the beneficiary, recommendation by a pharmacist, or prescription from a doctor. RESULTS: Compared to doctors, pharmacists issued more-expensive products. Average costs were higher in the HI plan compared to the LO plan. Pharmacists showed a preference for dispensing larger and more expensive pack sizes. Doctors showed better cost containment: the average cost of products in HI was twice that of LO. Doctors dispensing directly to patients issued smaller pack sizes and lower-priced products. Contracted network doctors did not appear to impact on costs. CONCLUSION: Among the privately-insured individuals studied, the avaiIability, cost and formulation of N02BE51 OTC products appeared to be poorly regulated, whether by the consumer, pharmacist, medical insurance scheme or legislation. Doctors demonstrate better cost containment by prescribing less costly, smaller pack-size alternatives compared to pharmacists.

Quality of care delivered to type 2 diabetes mellitus patients in public and private sector facilities in Johannesburg, South Africa.

PURPOSE: With the realities of resource constraints existing in South Africa's public sector and the evidence of disparities in health care between populations, the study sought to compare the quality of diabetes care and health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus (T2DM) receiving care within two specialized settings: one in the public and the other in the private sector. Particular emphasis was placed on complication rates at the two sites. PATIENTS AND METHODS: Quantitative and qualitative data were collected between June and October 2016 from existing patients' records at each setting. Data included patient demographics, potential barriers to accessing care, medical history, laboratory results, pharmacological treatment and diabetes-related clinical, biochemical and HRQoL outcomes. With outcome measurements being the priority, methodology incorporated the Donabedian model in which "structure" of health care systems, access to care and processes of care are key to determine outcomes. RESULTS: A total of 290 T2DM patients were enrolled. Analysis revealed that private patients were predominantly Caucasian with higher socioeconomic indicators (p<0.01) and education levels (p<0.0001) and experienced fewer access barriers to clinical services/care (p<0.00001). Private patients also had more frequent consultations with dietitians (p<0.0001), podiatrists (p<0.0001) and biokineticists (p<0.0001). In the important area of complications, which ultimately determine the course of T2DM, rates of micro- and macrovascular disease as well as HRQoL scores and sub-scores were similar between the sites, which were measured by the EuroQoL-5 dimension (EQ-5D) assessment tool. While results indicated that public sector care may be equivalent in terms of the latter outcomes, a smaller number of patients are treated in the clinic than would be ideal in terms of the public sector burden of T2DM. CONCLUSION: Contrary to expectation, despite differences in patient demographics and resources, the HRQoL and quality of care, particularly in terms of T2DM-related complications, were found to be similar across the two settings.

The integration of blended learning into an occupational therapy curriculum: a qualitative reflection.

BACKGROUND: This paper presents a critical reflection of the integration of Blended Learning (BL) into an undergraduate occupational therapy curriculum which was delivered through Problem Based Learning (PBL). METHOD: This is a qualitative reflection of a Participatory Action Research (PAR) study using Brookfield's model for critical reflection of an educator's practice. The model uses four 'lenses' through which to focus enquiry: Lens 1) our autobiography as a learner of practice; Lens 2) our learners' eyes; Lens 3) our colleagues' experiences; and Lens 4) the theoretical literature. Grounded theory analysis was applied to the data. RESULTS: The factors that contributed to successful integration of technology and e-Learning into an existing curriculum, the hurdles that were navigated along the way, and how these influenced decisions and innovation are explored. The core categories identified in the data were "drivers of change" and "outcomes of BL integration". Key situations and pivotal events are highlighted for their role in the process that led to the project maturing. Each lens reflects the successes and hurdles experienced during the study. CONCLUSION: Brookfield's model provides an objective method of reflection which showed that despite the hurdles, e-Learning was successfully integrated into the curriculum.

Aspects of birth history and outcome in diplegics attending specialised educational facilities.

AIM: We aimed to study functional mobility and visual performance in spastic diplegic children and adolescents attending specialised schools. METHODS: Spastic diplegia (SD) was confirmed by clinical examination. Birth and related history were added to explore relationships between SD, birth weight (BW) and duration of pregnancy. Place of birth, BW, gestational age (GA) and length of hospital stay were obtained by means of parental recall. Outcome measures included the functional mobility scale (FMS) and Beery tests of visuomotor integration (VMI) and visual perception (VIS). RESULTS: Forty participants were included (age 7 years 5 months - 19 years 6 months). Term and preterm births were almost equally represented. Functional mobility assessments showed that 20 were walking independently in school and community settings and the remainder used walking aids or wheelchairs. There were no significant correlations between BW or GA and outcomes (FMS, VIS-Z scores or VMI-Z scores) and Z scores were low. VIS scores correlated significantly with chronological age (p=0.024). There were also significant correlations between VIS and VMI scores and school grade appropriateness (p=0.004;p=0.027 respectively). INTERPRETATION: Both term and preterm births were represented, and outcomes were similar regardless of GA. VIS and VMI were affected in both groups. Half of the group used assistive mobility devices and three-fifths were delayed in terms of their educational level. These problems require specialised teaching strategies, appropriate resources and a school environment that caters for mobility limitations.

Application of different measures of skeletal maturity in initiating weaning from a brace for scoliosis: two case reports.

INTRODUCTION: Various measures of skeletal maturity are used to initiate weaning from a brace in patients suffering from idiopathic scoliosis, resulting in different outcomes. We present two cases with double major curves, treated with the Rigo System Cheneau brace, and weaned using different criteria. CASE PRESENTATION: Case 1 was a South African, Caucasian girl who was initially treated with a brace at 14.75 years and who began weaning at 16.25 years on the basis of the Greulich and Pyle Index. She was out of her brace in 6 months, at least 11 months before reaching skeletal maturity as shown by the Risser Sign. Case 2 was a South African, Caucasian girl, initially treated with a brace at 14.25 years and who began the weaning process at 17.67 years on the basis of skeletal maturity according to the Risser Sign and static height for a period of 6 months. She was out of the brace 12 months later. In Case 1, the thoracic Cobb angle progressed during weaning and scoliometer readings deteriorated. The iliac apophysis fused 11 months after the wrist. In Case 2, the therapeutic gains made during the period of bracing were maintained during weaning, that is the improvement in the lumbar Cobb angle was maintained until the brace was removed, and scoliometer readings improved. The iliac apophysis fused 8.5 months after the wrist. CONCLUSIONS: In patients with idiopathic scoliosis, it would seem to be more appropriate to base the timing of weaning on the Risser Sign and static height measurements rather than on traditional methods such as the Greulich and Pyle Index.

The relationship between quality of life and compliance to a brace protocol in adolescents with idiopathic scoliosis: a comparative study.

BACKGROUND: Corrective bracing for adolescent idiopathic scoliosis (AIS) has favourable outcomes when patients are compliant. However, bracing may be a stressful and traumatic experience and compliance with a bracing protocol is likely to be dependent upon patients' physical, emotional and social wellbeing. The Brace Questionnaire (BrQ), a recently-developed, condition-specific tool to measure quality of life (QOL) has enabled clinicians to study relationships between QOL and compliance. METHODS: The BrQ was administered to 31 AIS patients after a minimum of 1 year of wearing a brace. Subjects were 13-16 year old South African girls with Cobb angles of 25-40 degrees. Participants were divided into two groups according to their level of compliance with the bracing protocol. Brace Questionnaire sub- and total scores were compared between the two groups using the t-test for comparison of means. RESULTS: Twenty participants were classified as compliant and 11 as non-compliant. Mean total BrQ scores (expressed as a percentage) were 83.7 for the compliant group and 64.4 for the non-compliant group (p < 0.001), and on analysis of the 8 domains that make up the BrQ, the compliant group scored significantly higher in the 6 domains that measured vitality and social, emotional and physical functioning. CONCLUSION: Poor compliance with a brace protocol is associated with poorer QOL, with non-compliant patients lacking vitality and functioning poorly physically, emotionally and socially. Quality of life for adolescents with idiopathic scoliosis may relate more to psychosocial coping mechanisms than to physical deformity and its consequences. It is important to establish whether remedial programmes are capable of addressing personal, group and family issues, improving QOL and promoting compliance.

Employees' perceptions of the Aid-for-AIDS disease-management programme, South Africa.

It is estimated that 18-20% of South Africa's more than 5 million HIV-positive individuals are formally employed. Disease management programmes for these employees vary in scope and sophistication, with services provided by the employer, or third-party specialist disease managers, or through medical aid schemes. This study surveyed 215 HIV-positive employees in two organisations contracted to the Aid for AIDS (AfA) disease management programme through their in-house medical aid schemes. The two organisations differed in their overall approach to HIV and AIDS: one mainly relies on on-site access to voluntary counselling and testing (VCT) and AfA's management of registered HIV-positive employees, while the other has invested in and actively developed a comprehensive programme that also extends to families and the community as well as links employees to the AfA programme. Responses received from 28 of the 215 employees surveyed indicate that fear of disclosure of one's HIV status and of stigmatisation are reasons for late registration with the AfA programme or non-utilisation of other available support programmes. Respondents mentioned that confidence in the employer's ability to maintain confidentiality was also an issue. Respondents' important suggestions for change included: a) on-site educational and awareness programmes for management personnel and staff in order to reduce HIV discrimination and stigmatisation; b) information directed at HIV-positive employees publicising the benefits and effectiveness of medical treatment; c) support groups for HIV-positive employees; and d) management personnel to engage with HIV-infected employees who are willing to take an active role in staff education and the development of workplace policies and programmes.

Screening for abdominal aortic aneurysm--a pilot study in six medical schemes.

OBJECTIVE: A pilot study to assess the feasibility and affordability of a targeted screening programme for abdominal aortic aneurysms in a group of employer-based medical schemes. DESIGN: Administrative database review and data extraction. Member enrolment by mail. Analysis using simple descriptive statistics. Review of international experience. OUTCOME MEASURES: Screening uptake and findings, type and cost of interventions recommended by providers. RESULTS: Database review identified 2187 age-eligible subjects (males between 60 and 65 years) who were advised to consult with their doctor/s if they had a history of smoking/and or cardiovascular disease. Two hundred and seven were referred for abdominal ultrasound screening, and aneurysms > or = 3.0 cm were found in 11 (5.3%). Only 1 subject had an aneurysm of sufficient size to justify early surgical intervention, and which resulted in the patient's death. Total cost of this pilot study approached R1 million. Analysis indicated that the sampling rate would have to be increased if such a programme were to be introduced as a routine medical benefit. CONCLUSIONS: International experience has been that screening for abdominal aortic aneurysms reduces morbidity and mortality but at a significant cost. Opinion of the researchers and trustees of the participating medical schemes was that this cost would be beyond the means of schemes at this time. Screening programmes, particularly those that increase health care costs in the early phases by identifying subjects for costly interventions, are unlikely to enjoy support as long as the health funding environment maintains its focus on short-term costs and benefits.