The effect of a roving nurse mentor on household coverage and quality of care provided by community health worker teams in South Africa: a longitudinal study with a before, after and 6 months post design.

OBJECTIVE: Community health workers (CHW) are undertaking more complex tasks as part of the move towards universal health coverage in many low- and middle-income settings. They are expected to provide promotive and preventative care, make referrals to the local clinic, and follow up on non-attendees for a range of health conditions. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle due to inadequate supervision, low levels of CHW literacy, and the marginalized status of CHW in the health system. In this paper, we assess the effect of a roving nurse mentor on the coverage and quality of care of the CHW service in two vulnerable communities in South Africa. PARTICIPANTS: CHW, their supervisors, household members. INTERVENTION: Roving professional nurse mentor to build skills of supervisors and CHW teams. METHODS: Three household surveys to assess household coverage of the CHW service (baseline, end of the intervention, and 6 months after end of intervention); structured observations of CHW working in households to assess quality of care. RESULTS: The intervention led to a sustained 50% increase in the number of households visited by a CHW in the last year. While the proportion of appropriate health messages given to household members by CHW remained constant at approximately 50%, CHW performed a greater range of more complex tasks. They were more likely to visit new households to assess health needs and register the household in the programme, to provide care to pregnant women, children and people who had withdrawn from care. CHW were more likely to discuss with clients the barriers they were facing in accessing care and take notes during a visit. CONCLUSION: A nurse mentor can have a significant effect both on the quantity and quality of CHW work, allowing them to achieve their potential despite their marginalised status in the health system and their limited prior educational achievement. Supportive supervision is important in enabling the benefit of having a health cadre embedded in marginalised communities to be realised.

Household coverage, quality and costs of care provided by community health worker teams and the determining factors: findings from a mixed methods study in South Africa.

OBJECTIVE: Community health workers (CHWs) are undertaking more complex tasks as part of the move towards universal health coverage in South Africa. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle with insufficient supervision. In this paper, we assess coverage (proportion of households visited by a CHW in the past year and month), quality of care and costs of the service provided by CHW teams with differing configurations of supervisors, some based in formal clinics and some in community health posts. PARTICIPANTS: CHW, their supervisors, clinic staff, CHW clients. METHODS: We used mixed methods (a random household survey, focus group discussions, interviews and observations of the CHW at work) to examine the performance of six CHW teams in vulnerable communities in Sedibeng, South Africa. RESULTS: A CHW had visited 17% of households in the last year, and we estimated they were conducting one to two visits per day. At household registration visits, the CHW asked half of the questions required. Respondents remembered 20%-25% of the health messages that CHW delivered from a visit in the last month, and half of the respondents took the action recommended by the CHW. Training, supervision and motivation of the CHW, and collaboration with other clinic staff, were better with a senior nurse supervisor. We estimated that if CHW carried out four visits a day, coverage would increase to 30%-90% of households, suggesting that some teams need more CHW, as well as better supervision. CONCLUSION: Household coverage was low, and the service was limited. Support from the local facility was key to providing a quality service, and a senior supervisor facilitated this collaboration. Greater investment in numbers of CHW, supervisors, training and equipment is required for the potential benefits of the programme to be delivered.

Institutionalizing research capacity strengthening in LMICs: A systematic review and meta-synthesis.

Background: Evidence on effective strategies to ensure sustainability of research capacity strengthening interventions in low- and middle-income country (LMIC) institutions is lacking. This systematic review identified publications describing research capacity building programs and noted their effect, their contexts, and the mechanisms, processes and social actors employed in them. Methods: We searched online databases for the period 2011-2018. Inclusion criteria were that the publications 1) described the intervention; 2) were implemented in LMICs; 3) were based in, or relevant to, university staff or post docs; 4) aimed to improve research capacity; 5) aimed to effect change at the institutional level. Two reviewers screened titles, abstracts and full text in consecutive rounds, a third resolved disagreements. Two people extracted the data of each full text using a data extraction tool covering data relevant to our question. Results: In total 4052 citations were identified and 19 papers were included, which referred to 14 interventions. Only three interventions mentioned using a conceptual framework to develop their approach and none described using a theory of change to assess outcomes. The most frequent inputs described were some method of formal training, promotion of a research-conducive environment and establishment of research support systems. A range of outcomes were reported, most frequently an increased number of publications and proportion of staff with PhDs. When factors of success were discussed, this was attributed to a rigorous approach to implementation, adequate funding, and local buy-in. Those who mentioned sustainability linked it to availability of funds and local buy-in. The lack of a common lexicon and a framework against which to report outcomes made comparison between initiatives difficult. Conclusions: The reduced number of interventions that met the inclusion criteria suggests that programs should be well-described, evaluated systematically, and findings published so that the research capacity strengthening community can extract important lessons.

Development of a tool for assessing quality of comprehensive care provided by community health workers in a community-based care programme in South Africa.

OBJECTIVE: To develop a tool for use by non-clinical fieldworkers for assessing the quality of care delivered by community health workers providing comprehensive care in households in low- and middle-income countries. DESIGN: We determined the content of the tool using multiple sources of information, including interactions with district managers, national training manuals and an exploratory study that included observations of 70 community health workers undertaking 518 household visits collected as part of a wider study. We also reviewed relevant literature, selecting relevant domains and quality markers. To refine the tool and manual we worked with the fieldworkers who had undertaken the observations. We constructed two scores summarising key aspects of care: (1) delivering messages and actions during household visit, and (2) communicating with the household; we also collected contextual data. The fieldworkers used the tool with community health workers in a different area to test feasibility. SETTING: South Africa, where community health workers have been brought into the public health system to address the shortage of healthcare workers and limited access to healthcare. It was embedded in an intervention study to improve quality of community health worker supervision. PRIMARY AND SECONDARY OUTCOMES: Our primary outcome was the completion of a tool and user manual. RESULTS: The tool consists of four sections, completed at different stages during community health worker household visits: before setting out, at entry to a household, during the household visit and after leaving the household. Following tool refinement, we found no problems on field-testing the tool. CONCLUSIONS: We have developed a tool for assessing quality of care delivered by community health workers at home visits, often an unobserved part of their role. The tool was developed for evaluating an intervention but could also be used to support training and management of community health workers.

Task shifting to improve the provision of integrated chronic care: realist evaluation of a lay health worker intervention in rural South Africa.

INTRODUCTION: Task shifting is a potential solution to the shortage of healthcare personnel in low/middle-income countries, but contextual factors often dilute its effectiveness. We report on a task shifting intervention using lay health workers to support clinic staff in providing chronic disease care in rural South Africa, where the HIV epidemic and an ageing population have increased demand for care. METHODS: We conducted a realist evaluation in a cluster randomised controlled trial. We conducted observations in clinics, focus group discussions, in-depth interviews and patient exit interviews, and wrote weekly diaries to collect data. RESULTS: All clinic managers had to cope with an increasing but variable patient load and unplanned staff shortages, insufficient space, poorly functioning equipment and erratic supply of drugs. These conditions inevitably generated tension among staff. Lay health workers relieved the staff of some of their tasks and improved care for patients, but in some cases the presence of the lay health worker generated conflict with other staff. Where managers were able to respond to the changing circumstances, and to contain tension among staff, facilities were better able to meet patient needs. This required facility managers to be flexible, consultative and willing to act on suggestions, sometimes from junior staff and patients. While all facilities experienced an erratic supply of drugs and poorly maintained equipment, facilities where there was effective management, teamwork and sufficient space had better chronic care processes and a higher proportion of patients attending on their appointed day. CONCLUSION: Lay health workers can be valuable members of a clinic team, and an important resource for managing increasing patient demand in primary healthcare. Task shifting will only be effective if clinic managers respond to the constantly changing system and contain conflict between staff. Strengthening facility-level management and leadership skills is a priority. TRIAL REGISTRATION NUMBER: ISRCTN12128227.

Time to review policy on screening for, and managing, hypertension in South Africa: Evidence from primary care.

BACKGROUND: Current policy in South Africa requires measurement of blood pressure at every visit in primary care. The number of patients regularly visiting primary care clinics for routine care is increasing rapidly, causing long queues, and unmanageable workloads. METHODS: We used data collected during a randomised control trial in primary care clinics in South Africa to estimate how changes in policy might affect workloads and improve identification of undiagnosed hypertension. RESULTS: The prevalence of raised blood pressure increased with age; 65% of individuals aged over 60 years had a raised blood pressure, and 49% of them were not on any treatment. Over three months, eight health facilities saw 8,947 individual chronic disease patients, receiving 22,323 visits from them. Of these visits, 60% were related to hypertension, with or without HIV, and a further 35% were related to HIV alone. Long waits for blood pressure checks caused friction at all levels of the clinics. Blood pressure machines frequently broke down due to heavy use, and high blood pressures readings were often ignored. If chronic disease patients without a diagnosis of hypertension had their blood pressure checked only once a year, the number of checks would be reduced by more than 80%. Individuals with hypertension had a blood pressure check on average once every 7 weeks, but South African guidelines recommend that this should be done every 3 months at most. CONCLUSIONS: The numbers of chronic disease patients in primary care clinics in South Africa is rising rapidly. New policies for measuring blood pressure in these patients attending clinics are urgently needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12128227 5th March 2014.

Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases.

Task-shifting to non-physician health workers (NPHWs) has been an effective model for managing infectious diseases and improving maternal and child health. There is inadequate evidence to show the effectiveness of NPHWs to manage cardiovascular diseases (CVDs). In 2012, the Global Alliance for Chronic Diseases funded eight studies which focused on task-shifting to NPHWs for the management of hypertension. We report the lessons learnt from the field. From each of the studies, we obtained information on the types of tasks shifted, the professional level from which the task was shifted, the training provided and the challenges faced. Additionally, we collected more granular data on 'lessons learnt ' throughout the implementation process and 'design to implementation' changes that emerged in each project. The tasks shifted to NPHWs included screening of individuals, referral to physicians for diagnosis and management, patient education for lifestyle improvement, follow-up and reminders for medication adherence and appointments. In four studies, tasks were shifted from physicians to NPHWs and in four studies tasks were shared between two different levels of NPHWs. Training programmes ranged between 3 and 7 days with regular refresher training. Two studies used clinical decision support tools and mobile health components. Challenges faced included system level barriers such as inability to prescribe medicines, varying skill sets of NPHWs, high workload and staff turnover. With the acute shortage of the health workforce in low-income and middle-income countries (LMICs), achieving better health outcomes for the prevention and control of CVD is a major challenge. Task-shifting or sharing provides a practical model for the management of CVD in LMICs.

Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa.

INTRODUCTION: In low/middle-income countries with substantial HIV and tuberculosis epidemics, health services often neglect other highly prevalent chronic conditions, such as hypertension, which as a result are poorly managed. This paper reports on a study to assess the effect on hypertension management of lay health workers (LHW) working in South African rural primary healthcare clinics to support the provision of integrated chronic care. METHODS: A pragmatic cluster randomised trial with a process evaluation in eight rural clinics assessed the effect of adding two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months. Control clinics continued with usual care. The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure (BP) before and after the intervention, as measured by two cross-sectional population surveys. RESULTS: There was no improvement in BP control among users of intervention clinics as compared with control clinics. However, the LHWs improved clinic functioning, including overall attendance, and attendance on the correct day. All clinics faced numerous challenges, including rapidly increasing number of users of chronic care, unreliable BP machines and cuffs, intermittent drug shortages and insufficient space. CONCLUSION: LHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients, the dominance of the vertically funded HIV programme and the poor standards of equipment in clinics. TRIAL REGISTRATION NUMBER: ISRCTN12128227.

Randomised controlled trial evaluating the effectiveness and cost-effectiveness of 'Families for Health', a family-based childhood obesity treatment intervention delivered in a community setting for ages 6 to 11 years.

BACKGROUND: Effective programmes to help children manage their weight are required. 'Families for Health' focuses on a parenting approach, designed to help parents develop their parenting skills to support lifestyle change within the family. Families for Health version 1 showed sustained reductions in mean body mass index (BMI) z-score after 2 years in a pilot project. OBJECTIVE: The aim was to evaluate its effectiveness and cost-effectiveness in a randomised controlled trial (RCT). DESIGN: The trial was a multicentre, investigator-blind RCT, with a parallel economic and process evaluation, with follow-up at 3 and 12 months. Randomisation was by family unit, using a 1 : 1 allocation by telephone registration, stratified by three sites, with a target of 120 families. SETTING: Three sites in the West Midlands, England, UK. PARTICIPANTS: Children aged 6-11 years who were overweight (≥ 91st centile BMI) or obese (≥ 98th centile BMI), and their parents/carers. Recruitment was via referral or self-referral. INTERVENTIONS: Families for Health version 2 is a 10-week, family-based community programme with parallel groups for parents and children, addressing parenting, lifestyle, social and emotional development. Usual care was the treatment for childhood obesity provided within each locality. MAIN OUTCOME MEASURES: Joint primary outcome measures were change in children's BMI z-score and incremental cost per quality-adjusted life-year (QALY) gained at 12 months' follow-up (QALYs were calculated using the European Quality of Life-5 Dimensions Youth version). Secondary outcome measures included changes in children's waist circumference, percentage body fat, physical activity, fruit/vegetable consumption and quality of life. Parents' BMI and mental well-being, family eating/activity, parent-child relationships and parenting style were also assessed. The process evaluation documented recruitment, reach, dose delivered, dose received and fidelity, using mixed methods. RESULTS: The study recruited 115 families (128 children; 63 boys and 65 girls), with 56 families randomised to the Families for Health arm and 59 to the 'usual-care' control arm. There was 80% retention of families at 3 months (Families for Health, 46 families; usual care, 46 families) and 72% retention at 12 months (Families for Health, 44 families; usual care, 39 families). The change in BMI z-score at 12 months was not significantly different in the Families for Health arm and the usual-care arm [0.114, 95% confidence interval (CI) -0.001 to 0.229; p = 0.053]. However, within-group analysis showed that the BMI z-score was significantly reduced in the usual-care arm (-0.118, 95% CI -0.203 to -0.034; p = 0.007), but not in the Families for Health arm (-0.005, 95% CI -0.085 to 0.078; p = 0.907). There was only one significant difference between groups for secondary outcomes. The economic evaluation, taking a NHS and Personal Social Services perspective, showed that mean costs 12 months post randomisation were significantly higher for Families for Health than for usual care (£998 vs. £548; p < 0.001). The mean incremental cost-effectiveness of Families for Health was estimated at £552,175 per QALY gained. The probability that the Families for Health programme is cost-effective did not exceed 40% across a range of thresholds. The process evaluation demonstrated that the programme was implemented, as planned, to the intended population and any adjustments did not deviate widely from the handbook. Many families waited more than 3 months to receive the intervention. Facilitators', parents' and children's experiences of Families for Health were largely positive and there were no adverse events. Further analysis could explore why some children show a clinically significant benefit while others have a worse outcome. CONCLUSIONS: Families for Health was neither effective nor cost-effective for the management of obesity in children aged 6-11 years, in comparison with usual care. Further exploration of the wide range of responses in BMI z-score in children following the Families for Health and usual-care interventions is warranted, focusing on children who had a clinically significant benefit and those who showed a worse outcome with treatment. Further research could focus on the role of parents in the prevention of obesity, rather than treatment. TRIAL REGISTRATION: Current Controlled Trials ISRCTN45032201. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 1. See the NIHR Journals Library website for further project information.

Randomised controlled trial and economic evaluation of the 'Families for Health' programme to reduce obesity in children.

OBJECTIVE: Evaluating effectiveness and cost-effectiveness of 'Families for Health V2' (FFH) compared with usual care (UC). DESIGN: Multicentre randomised controlled trial (RCT) (investigators blinded, families unblinded) and economic evaluation. Stratified randomisation by family; target of 120 families. SETTING: Three National Health Service Primary Care Trusts in West Midlands, England. PARTICIPANTS: Overweight or obese (≥91st or ≥98th centile body mass index (BMI)) children aged 6-11 years and their parents/carers, recruited March 2012-February 2014. INTERVENTIONS: FFH; a 10-week community-based family programme addressing parenting, lifestyle change and social and emotional development. UC; usual support for childhood obesity at each site. MAIN OUTCOME MEASURES: Primary outcomes were 12-months change in children's BMI z-score and incremental cost per quality-adjusted life-year gained (QALY). Secondary outcomes included changes in children's physical activity, fruit and vegetable consumption and quality of life, parents' BMI and mental well-being, family eating/activity, parent-child relationships and parenting style. RESULTS: 115 families (128 children) were randomised to FFH (n=56) or UC (n=59). There was no significant difference in BMI z-score 12-months change (0.114, 95% CI -0.001 to 0.229, p=0.053; p=0.026 in favour of UC with missing value multiple imputation). One secondary outcome, change in children's waist z-score, was significantly different between groups in favour of UC (0.15, 95% CI 0.00 to 0.29). Economic evaluation showed that mean costs were significantly higher for FFH than UC (£998 vs £548, p<0.001). Mean incremental cost-effectiveness of FFH was estimated at £552 175 per QALY. CONCLUSIONS: FFH was neither effective nor cost-effective for the management of obesity compared with UC. TRIAL REGISTRATION NUMBER: ISRCTN45032201.

Building the capacity to solve complex health challenges in sub-Saharan Africa: CARTA's multidisciplinary PhD training.

OBJECTIVES: To develop a curriculum (Joint Advanced Seminars [JASs]) that produced PhD fellows who understood that health is an outcome of multiple determinants within complex environments and that approaches from a range of disciplines is required to address health and development within the Consortium for Advanced Research Training in Africa (CARTA). We sought to attract PhD fellows, supervisors and teaching faculty from a range of disciplines into the program. METHODS: Multidisciplinary teams developed the JAS curriculum. CARTA PhD fellowships were open to academics in consortium member institutions, irrespective of primary discipline, interested in doing a PhD in public and population health. Supervisors and JAS faculty were recruited from CARTA institutions. We use routine JAS evaluation data (closed and open-ended questions) collected from PhD fellows at every JAS, a survey of one CARTA cohort, and an external evaluation of CARTA to assess the impact of the JAS curriculum on learning. RESULTS: We describe our pedagogic approach, arguing its centrality to an appreciation of multiple disciplines, and illustrate how it promotes working in multidisciplinary ways. CARTA has attracted PhD fellows, supervisors and JAS teaching faculty from across a range of disciplines. Evaluations indicate PhD fellows have a greater appreciation of how disciplines other than their own are important to understanding health and its determinants and an appreciation and capacity to employ mixed methods research. CONCLUSIONS: In the short term, we have been effective in promoting an understanding of multidisciplinarity, resulting in fellows using methods from beyond their discipline of origin. This curriculum has international application.

Dementia and Physical Activity (DAPA) - an exercise intervention to improve cognition in people with mild to moderate dementia: study protocol for a randomized controlled trial.

BACKGROUND: Dementia is more common in older than in younger people, and as a result of the ageing of the population in developed countries, it is becoming more prevalent. Drug treatments for dementia are limited, and the main support offered to people with dementia and their families is generally services to mitigate against loss of function. Physical exercise is a candidate non-pharmacological treatment for dementia. METHODS/DESIGN: DAPA is a randomised controlled trial funded by the National Institute for Health Research Health Technology Assessment programme to estimate the effect of a 4-month, moderate- to hard-intensity exercise training programme and subsequent advice to remain active, on cognition (primary outcome) at 12 months in people with mild to moderate dementia. Community-dwelling participants (with their carers where possible), who are able to walk 3 metres without human assistance, able to undertake an exercise programme and do not have any unstable or terminal illness are recruited. Participants are then randomised by an independent statistician using a computerised random number generator to usual care or exercise at a 2:1 ratio in favour of exercise. The exercise intervention comprises 29, 1-hour-long exercise classes, run twice weekly at suitable venues such as leisure centres, which include aerobic exercise (on static bikes) and resistance exercise (using weights). Goals for independent exercise are set while the classes are still running, and supported thereafter with phone calls. The primary outcome is measured using ADAS-cog. Secondary outcome measures include behavioural symptoms, functional ability, quality of life and carer burden. Primary and secondary outcomes will be measured at baseline and at 6 and 12 months after randomisation, by researchers masked to participant randomisation in the participants' own homes. An economic evaluation will be carried out in parallel to the RCT, as will a qualitative study capturing the experiences of participants, carers and staff delivering the intervention. DISCUSSION: The DAPA study will be the first large, randomised trial of the cognitive effects of exercise on people with dementia. The intervention is designed to be capable of being delivered within the constraints of NHS service provision, and the economic evaluation will allow assessment of its cost-effectiveness. TRIAL REGISTRATION: DAPA was registered with the ISRCTN database on 29 July 2011, registration number ISRCTN32612072 .

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme.

BACKGROUND: The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. METHODS: Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. RESULTS: There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation. CONCLUSIONS: The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.

Fitness predicts long-term survival after a cardiovascular event: a prospective cohort study.

OBJECTIVES: To identify the role of fitness, fitness change, body mass index and other factors in predicting long-term (>5 years) survival in patients with coronary heart disease. DESIGN: Cohort study of patients with coronary heart disease recruited from 1 January 1993 to 31 December 2002, followed up to March 2011 (1 day to 18 years 3 months, mean 10.7 years). SETTING: A community-based National Health Service (NHS) cardiac rehabilitation programme serving the Basingstoke and Alton area in Hampshire, UK. PARTICIPANTS: An unselected cohort of NHS patients, 2167 men and 547 women aged 28-88 years, who attended the rehabilitation programme following acute myocardial infarction, an episode of angina or revascularisation, and had a baseline fitness test. MAIN OUTCOME MEASURES: Cardiovascular mortality and all-cause mortality. RESULTS: A high level of fitness (VO2≥22 mL/kg/min for men, VO2≥19 mL/kg/min for women) at completion of the programme was associated with decreased all-cause death, as was a prescription for statins or aspirin, and female gender. Increase in all-cause mortality was associated with higher age and ACE inhibitors prescription. Higher risk of cardiovascular mortality was associated with increasing age, prescriptions for ACE inhibitor, and diagnosis of myocardial infarction or angina as compared with the other diagnoses. CONCLUSIONS: Prior fitness and fitness improvement are strong predictors of long-term survival in patients who have experienced a cardiac event or procedure. Some secondary prevention medications make a significant contribution to reducing all-cause mortality and cardiovascular mortality in these patients. This study supports public health messages promoting fitness for life.

Challenges for providing genetic counselling in Colombian genetic clinics: the viewpoint of the physicians providing genetic consultations.

This study explores the provision of clinical genetic services in Colombia, in order to promote improvements in these services. We carried out semi-structured interviews with 20 doctors working in genetic clinics, and we report the challenges in providing genetic counselling that they have identified. Education and training in genetics in Colombian medical schools were described as inadequate, and interviewees found that many of their medical colleagues knew too little to be able to refer appropriately to a genetics service. The doctors interviewed recognised their own limitations, including lack of knowledge, absence of training in communication skills and the strong influence of religious beliefs on the consultations of some colleagues. There may also be communication problems during the consultation: patients may fail to understand the explanations given or to accept the incurable nature of genetic conditions. There are also problems with access, because genetic services are not covered by the health insurance system in Colombia. More training in genetics is required at medical schools in Colombia, at the undergraduate and postgraduate level. There was a consensus that most medical specialities are limited in their knowledge, awareness and understanding of genetics. Furthermore, many medical geneticists did not believe that other health professionals should work as genetic counsellors. These findings may assist in the development of improved genetic counselling services in Colombia and in the establishment of an enhanced academic curriculum of basic and clinical genetics at Colombian universities.

Cardiometabolic disease risk and HIV status in rural South Africa: establishing a baseline.

BACKGROUND: To inform health care and training, resource and research priorities, it is essential to establish how non-communicable disease risk factors vary by HIV-status in high HIV burden areas; and whether long-term anti-retroviral therapy (ART) plays a modifying role. METHODS: As part of a cohort initiation, we conducted a baseline HIV/cardiometabolic risk factor survey in 2010-2011 using an age-sex stratified random sample of ages 15+ in rural South Africa. We modelled cardiometabolic risk factors and their associations by HIV-status and self-reported ART status for ages 18+ using sex-stratified logistic regression models. RESULTS: Age-standardised HIV prevalence in women was 26% (95% CI 24-28%) and 19% (95% CI 17-21) in men. People with untreated HIV were less likely to have a high waist circumference in both women (OR 0.67; 95% CI 0.52-0.86) and men (OR 0.42; 95% CI 0.22-0.82). Untreated women were more likely to have low HDL and LDL, and treated women high triglycerides. Cardiometabolic risk factors increased with age except low HDL. The prevalence of hypertension was high (40% in women; 30% in men). CONCLUSIONS: Sub-Saharan Africa is facing intersecting epidemics of HIV and hypertension. In this setting, around half the adult population require long-term care for at least one of HIV, hypertension or diabetes. Together with the adverse effects that HIV and its treatment have on lipids, this may have serious implications for the South African health care system. Monitoring of the interaction of HIV, ART use, and cardiometabolic disease is needed at both individual and population levels.

The Impact of Online Social Networks on Health and Health Systems: A Scoping Review and Case Studies.

Interaction through online social networks potentially results in the contestation of prevailing ideas about health and health care, and to mass protest where health is put at risk or health care provision is wanting. Through a review of the academic literature and case studies of four social networking health sites (PatientsLikeMe, Mumsnet, Treatment Action Campaign, and My Pro Ana), we establish the extent to which this phenomenon is documented, seek evidence of the prevalence and character of health-related networks, and explore their structure, function, participants, and impact, seeking to understand how they came into being and how they sustain themselves. Results indicate mass protest is not arising from these established health-related networking platforms. There is evidence of changes in policy following campaigning activity prompted by experiences shared through social networking such as improved National Health Service care for miscarriage (a Mumsnet campaign). Platform owners and managers have considerable power to shape these campaigns. Social networking is also influencing health policy indirectly through increasing awareness and so demand for health care. Transient social networking about health on platforms such as Twitter were not included as case studies but may be where the most radical or destabilizing influence on health care policy might arise.

The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial.

BACKGROUND: South Africa has a high and rising prevalence of hypertension. Many affected individuals are not using medication, and few have controlled blood pressure. Until recently, primary care clinics focused on maternal and child health and management of acute conditions, but new government initiatives have shifted the focus to chronic diseases, including HIV/AIDS and hypertension. METHODS/DESIGN: The Nkateko trial will test the effectiveness of clinic-based lay health workers (LHWs) in supporting hypertension management. It is a pragmatic, cluster randomised controlled trial based in the Agincourt subdistrict of northeast South Africa, and it is underpinned by long-term health and demographic surveillance. Eight primary care facilities, with their catchment communities, are randomised to usual care or the addition of LHWs focused on chronic care. All clinics (intervention and control) will be provided with a clerk to collect information on clinic attendees and will match them to preexisting surveillance records. Intervention clinics will have LHWs working alongside nursing staff and focusing on health care for people with chronic conditions, particularly hypertension. The LHWs will be supported by an implementation manager, who will work with clinic staff to develop the most effective role for the LHWs. Control clinics will continue to provide usual care. The primary outcome will be the change between two population surveys conducted before and after the intervention in the proportion of the population with uncontrolled hypertension and a risk profile indicating at least moderate risk of cardiovascular disease. A process evaluation will be based on a realist approach using patient exit interviews, clinic observations and interviews with health professionals, LHWs and patients to document the intervention and its implementation. DISCUSSION: There are challenges in the design of this trial. Assessing change through population surveys may reduce measurable effects; however, we feel this is appropriate because we aim to attract those who currently do not use clinics, and we hope to improve care for clinic users. Clinics were randomised at an open meeting because we were concerned that a remote process of randomisation would not be trusted by the community. We are constantly working to achieve an effective balance between the intervention and process evaluations. TRIAL REGISTRATION: ISRCTN12128227 (registered 5 March 2014).

Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.

OBJECTIVE: To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal fractures. DESIGN: Pragmatic, multicentre, two arm, parallel group, assessor blinded randomised controlled trial (UK Heel Fracture Trial). SETTING: 22 tertiary referral hospitals, United Kingdom. PARTICIPANTS: 151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to operative (n=73) or non-operative (n=78) treatment. MAIN OUTCOME MEASURES: The primary outcome measure was patient reported Kerr-Atkins score for pain and function (scale 0-100, 100 being the best possible score) at two years after injury. Secondary outcomes were complications; hindfoot pain and function (American Orthopaedic Foot and Ankle Society score); general health (SF-36); quality of life (EQ-5D); clinical examination; walking speed; and gait symmetry. Analysis was by intention to treat. RESULTS: 95% follow-up was achieved for the primary outcome (69 in operative group and 74 in non-operative group), and a complete set of secondary outcomes were available for 75% of participants. There was no significant difference in the primary outcome (mean Kerr-Atkins score 69.8 in operative group v 65.7 in non-operative group; adjusted 95% confidence interval of difference -7.1 to 7.0) or in any of the secondary outcomes between treatment groups. Complications and reoperations were more common in those who received operative care (estimated odds ratio 7.5, 95% confidence interval 2.0 to 41.8). CONCLUSIONS: Operative treatment compared with non-operative care showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures.Trial registration Current Controlled Trials ISRCTN37188541.