Exploring effort-reward imbalance and professional quality of life among health workers in Cape Town, South Africa: a mixed-methods study.

BACKGROUND: In the context of a growing appreciation for the wellbeing of the health workforce as the foundation of high-quality, sustainable health systems, this paper presents findings from two complementary studies to explore occupational stress and professional quality of life among health workers that were conducted in preparation for a task-shifting intervention to improve antenatal mental health services in Cape Town. METHODS: This mixed-methods, cross-sectional study was conducted in public sector Midwife Obstetric Units and associated Non-Profit Organisations in Cape Town. Semi-structured interviews and a quantitative survey were conducted among facility-and community-based professional and lay health workers. The survey included demographic as well as effort-reward imbalance (ERI) and professional quality of life (PROQOL) questionnaires to examine overall levels of work-related psychosocial stress and professional quality of life, as well as differences between lay and professional health workers. Qualitative data was analysed using a thematic content analysis approach. Quantitative data was analysed using STATA 12. RESULTS: Findings from 37 qualitative interviews highlighted the difficult working conditions and often limited reward and support structures experienced by health workers. Corroborating these findings, our quantitative survey of 165 professional and lay health workers revealed that most health workers experienced a mismatch between efforts spent and rewards gained at work (61.1% of professional and 70.2% of lay health workers; p = 0.302). There were few statistically significant differences in ERI and PROQOL scores between professional and lay health workers. Although Compassion Satisfaction was high for all health worker groups, lay health workers also showed elevated levels of burnout and compassion fatigue, with community-based health workers particularly affected. CONCLUSIONS: Findings of this study add to the existing evidence base on adverse working conditions faced by South African public-sector health workers that should be taken into consideration as national and local governments seek to 're-engineer' South Africa's Primary Health Care system. Furthermore, they also highlight the importance of taking into consideration the wellbeing of health workers themselves to develop interventions that can sustainably foster resilient and high-quality health systems.

Factors associated with recent unsuppressed viral load in HIV-1-infected patients in care on first-line antiretroviral therapy in South Africa.

Unsuppressed viral load (VL) in patients on antiretroviral therapy (ART) occurs when treatment fails to suppress a person's VL and is associated with decreased survival and increased HIV transmission. The objective of this study was to evaluate factors associated with unsuppressed VL (VL > 400 copies/ml) in patients currently in care on first-line ART for ≥ 6 months attending South African public healthcare facilities. We analysed electronic medical records of ART patients with a VL result on record who started ART between January 2004 and April 2016 from 271 public health facilities. We present descriptive and multivariable logistic regression for unsuppressed VL at last visit using a priori variables. We included 244,370 patients (69% female) on first-line ART in April 2016 for ≥ 6 months. Median age at ART start was 33 years (7% were < 15 years old). Median duration on ART was 3.7 years. Adjusting for other variables, factors associated with having an unsuppressed VL at the most recent visit among patients in care included: (1) < 15 years old at ART start (adjusted odds ratio [aOR]=2.58; 95% CI = 2.37, 2.81) versus 15-49 years at ART start, (2) male gender (aOR = 1.29; 95% CI = 1.25, 1.35), (3) 6-12 months on ART versus longer (aOR = 1.34; 95% CI = 1.29, 1.40), (4) on tuberculosis (TB) treatment (aOR = 1.78; 95% CI = 1.48, 2.13), and (5) prior ART exposure versus none (aOR = 1.20; 95% CI = 1.08, 1.32). Approximately 85% of the ART cohort who were in care had achieved viral suppression, though men, youth/adolescents, patients with prior ART exposure, those with short duration of ART, and patients on TB treatment had increased odds of not achieving viral suppression. There is a need to develop and evaluate targeted interventions for ART patients in care who are at high risk of unsuppressed VL.

What is the plasma cofactor required by diuretics for direct vascular relaxant effect in vitro?

OBJECTIVE: To determine the plasma cofactor which is required by diuretics (hydrochlorothiazide, chlorthalidone, indapamide, and furosemide) for direct vasorelaxant effects in vitro. DESIGN: A randomized, double-blind, vehicle-control design was used to avoid experimenter bias. METHODS: We plotted concentration-response curves for responses to hydrochlorothiazide, chlorthalidone, indapamide, and furosemide of male Wistar rat aortic rings in the presence of different bath solutions containing various plasma factors. RESULTS: Plasma was found both to make possible and facilitate the vasodilator action of the diuretics tested by an action on the membrane and to decrease the action by binding the diuretics. The diuretics retained their vasorelaxant properties in Krebs solution alone, 30 min after having been incubated in a 50:50 solution of Krebs solution and plasma for 1 h. All four diuretics exerted significant vasorelaxant actions in Krebs solution-plasma, Krebs solution-serum, and Krebs solution plus human or bovine albumin (40 g/l) media. No vasorelaxant action was found in Krebs solution alone, Krebs solution plus denatured plasma, Krebs solution plus egg albumin, and Krebs solution plus insulin. CONCLUSION: Albumin is the main cofactor required by the diuretics tested for direct relaxant action in vitro, and these findings may explain some of the contradictory evidence concerning this action in the literature.

Demonstration of an in vitro direct vascular relaxant effect of diuretics in the presence of plasma.

OBJECTIVE: To determine whether diuretics have direct vascular actions and to compare the in vitro effects of a loop diuretic with thiazide and thiazide-like diuretics. DESIGN: A randomized, double-blind, vehicle-controlled design was used to avoid experimenter bias. METHODS: Concentration-response curves to hydrochlorothiazide, chlorthalidone, indapamide, and furosemide were tested on the following male Wistar rat vascular smooth muscle preparations: rat aortic rings, rat pulmonary artery rings, and rat mesenteric portal vein. RESULTS: All four diuretics demonstrated no vasorelaxant action in Krebs solution. They all exhibited vasorelaxant actions in aortic and pulmonary artery rings when plasma was mixed with Krebs solution in a 50:50 ratio. The magnitude of the relaxation was greater in the aortic ring preparation. This direct vascular action was found to be concentration dependent and endothelium independent. The order of potency of the vasorelaxant action of the diuretics was (from most to least) indapamide, hydrochlorothiazide, chlorthalidone, and furosemide on both aortic and pulmonary artery rings. CONCLUSION: Diuretics possess direct vasorelaxant effects that are dependent upon the presence of plasma; this action may contribute to their antihypertensive properties.

Effects of K+ channel openers on the vascular actions of human gamma globulin.

The aim of this study was to determine if the stimulatory action of human gamma globulin on the spontaneous activity of the rat mesenteric portal vein is due to decreased K+ conductance. Glibenclamide potentiated the action of human gamma-globulin on the portal vein by 45% and on its own had a concentration- and time-dependent biphasic (increase followed by a decrease) effect on the spontaneous activity of the portal vein. Diazoxide and pinacidil both inhibited the action of human gamma-globulin on the rat mesenteric portal vein. Levcromakalim (BRL 38227) potentiated the stimulatory action of human gamma-globulin on the integrated force of the spontaneous contractions of the rat mesenteric portal vein by 40% and 49% at concentrations of 0.5 and 5 microM, respectively. These studies suggest that human gamma-globulin can act by directly modulating a K+ channel.

Stimulant effect of human gamma globulin on smooth muscle preparations.

The effects of human gamma globulin on the contractile activity of spontaneously active rat mesenteric portal vein and guinea-pig taenia caeci and quiescent rat aorta and guinea-pig trachea muscles were studied in vitro. Human gamma globulin significantly increased the contractile activity of the spontaneously active muscles with respect to both amplitude and frequency of contraction whereas it had no significant effect on the contractile activity of quiescent muscle preparations. These findings suggest that immunoglobulins directly modulate smooth muscle including vasculature by modifying the membrane electrical activity associated with the generation of spontaneous activity.