Digital tools for youth health promotion: principles, policies and practices in sub-Saharan Africa.

Although digital health promotion (DHP) technologies for young people are increasingly available in low- and middle-income countries (LMICs), there has been insufficient research investigating whether existing ethical and policy frameworks are adequate to address the challenges and promote the technological opportunities in these settings. In an effort to fill this gap and as part of a larger research project, in November 2022, we conducted a workshop in Cape Town, South Africa, entitled 'Unlocking the Potential of Digital Health Promotion for Young People in Low- and Middle-Income Countries'. The workshop brought together 25 experts from the areas of digital health ethics, youth health and engagement, health policy and promotion and technology development, predominantly from sub-Saharan Africa (SSA), to explore their views on the ethics and governance and potential policy pathways of DHP for young people in LMICs. Using the World Café method, participants contributed their views on (i) the advantages and barriers associated with DHP for youth in LMICs, (ii) the availability and relevance of ethical and regulatory frameworks for DHP and (iii) the translation of ethical principles into policies and implementation practices required by these policies, within the context of SSA. Our thematic analysis of the ensuing discussion revealed a willingness to foster such technologies if they prove safe, do not exacerbate inequalities, put youth at the center and are subject to appropriate oversight. In addition, our work has led to the potential translation of fundamental ethical principles into the form of a policy roadmap for ethically aligned DHP for youth in SSA.

Collaborative design of a health research training programme for nurses and midwives in Tshwane district, South Africa: a study protocol.

INTRODUCTION: Nurses are essential for implementing evidence-based practices to improve patient outcomes. Unfortunately, nurses lack knowledge about research and do not always understand research terminology. This study aims to develop an in-service training programme for health research for nurses and midwives in the Tshwane district of South Africa. METHODS AND ANALYSIS: This protocol outlines a codesign study guided by the five stages of design thinking proposed by the Hasso-Plattner Institute of Design at Stanford University. The participants will include nurses and midwives at two hospitals in the Tshwane district, Gauteng Province. The five stages will be implemented in three phases: Phase 1: Stage 1-empathise and Stage 2-define. Exploratory sequential mixed methods including focus group discussions with nurses and midwives (n=40), face-to-face interviews (n=6), and surveys (n=330), will be used in this phase. Phase 2: Stage 3-ideate and Stage 4-prototype. A team of research experts (n=5), nurses and midwives (n=20) will develop the training programme based on the identified learning needs. Phase 3: Stage 5-test. The programme will be delivered to clinical nurses and midwives (n=41). The training programme will be evaluated through pretraining and post-training surveys and face-to-face interviews (n=4) following training. SPSS V.29 will be used for quantitative analysis, and content analysis will be used to analyse qualitative data. ETHICS AND DISSEMINATION: The protocol was approved by the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria (reference number 123/2023). The protocol is also registered with the National Health Research Database in South Africa (reference number GP_202305_032). The study findings will be disseminated through conference presentations and publications in peer-reviewed journals.

Processed food consumption and risk of non-communicable diseases (NCDs) in South Africa: evidence from Demographic and Health Survey (DHS) VII.

We aimed to analyse the association between processed food consumption and the risk of non-communicable diseases (NCDs) in South Africa. In this empirical study, we analysed nationally representative secondary data obtained from the South African Demographic and Health Survey (SADHS) VII. The survey included 13,288 occupied households, of which 11,083 were interviewed. In the interviewed households, 12,717 eligible adults aged 15 and older were identified and 10,336 were successfully interviewed. The study included four processed food groups (i.e. fried foods, takeaway foods/fast foods, salty snacks/packed chips, and processed meats) and eight NCDs (i.e. hypertension, cardiac arrest, cancer, stroke, hypercholesterolaemia, diabetes, chronic bronchitis, and asthma). As per the logistic regression results following adjustment, none of the disease states showed association with all four processed food groups. However, at least three processed food groups showed a significant positive association with hypertension, cardiac arrest, and diabetes. Two processed food groups showed significant positive association with stroke, and chronic bronchitis; one with hypercholesterolaemia and asthma; and cancer was not associated with any food groups. Processed meat and salted snacks/packed chips were each associated with five chronic conditions. In summary, we found that the consumption of any of the processed food groups increased the risk of NCDs in the South African population. Enabling policy and regulatory efforts in the production and distribution of processed foods, combined with improved awareness among the population need to be prioritised for immediate action. Facilitating the populations to choose traditional healthy diets would be a sustainable strategy for the prevention of NCDs.

Rapid assessment of public interest in drought and its likely drivers in South Africa.

The monthly search volumes for drought were extracted from Google® for South Africa using the Keywordsevery-where.com plugin from January 2004 until June 2022. To identify the potential qualitative drivers for such public interest the following data extracted by the plugin were investigated and analysed: the drought-related keywords, the long-tail keywords similar to drought, and the "people also searched for category" from the South African users. The Google Trends monthly score was extracted for South Africa and the Eastern Cape Province, and specific local municipalities/towns/cities in the province. The aim was to assess the relative significance of the drought interest in comparison to public interest in other search terms. The results of the Kruskal-Wallis analyses of variance by ranks showed that there was a statistically significant difference between individual values of the monthly search volumes for drought in South Africa, as a function of time of data extraction (5 percent level of significance; p-value ≤ 4.7 × 10-14). The monthly search volumes increased with time, which is based on the results of the Mann-Kendall test at a 5 percent level of significance (p-value ≤ 0.0092). Analyses of the Google Trends scores indicate that the relative interest in drought in South Africa and the Eastern Cape Province increased with time between January 2004 and June 2022 (the Mann-Kendall test at a 5 percent level of significance; p-value = 0.0011). The population's searches for drought were relatively low when compared to other search terms on Google. Drought adaptation of the South African community could be considered a driver of the Google searches for drought, but it is a marginal topic compared to other topics in Google searches. It might be necessary to increase this significance by investigating the "Google-search patterns for droughts" in the areas of Tshikaro, Mafusini, Cofimvaba, and Nxotsheni in the Eastern Cape Province of South Africa.

The Moderating Role of HIV Stigma on the Relationship between Perceived Social Support and Antiretroviral Therapy Adherence Self-Efficacy among Adult PLHIV in South Africa.

BACKGROUND: People living with human immune deficiency virus (PLHIV) grapple with distinct challenges, including HIV stigma which affects their antiretroviral therapy (ART) adherence self-efficacy. This study investigates the interaction of HIV stigma and perceived social support on ART adherence self-efficacy among adult PLHIV in South Africa. METHODS: This study utilized a cross-sectional design that involved 201 participants selected using time location sampling at a tertiary health facility in Durban. RESULTS: HIV stigma was significantly and negatively associated with self-efficacy (ß = -7.860, t = -4.654, p = .001), with variations across different stigma levels (ß = -5.844, t = -4.003, p = .001). Social support was significantly and positively associated with self-efficacy at lower HIV stigma levels (ß = 7.440, t = 3.887, p = .001), in contrast to higher levels (ß = -2.825, t = 1.400, p = .163). CONCLUSION: Social support significantly influences ART adherence self-efficacy, particularly at lower levels of HIV stigma, but the effect of support weakens as stigma intensifies.

The relationship between perceived social support and antiretroviral therapy adherence self-efficacy among adult PLHIV in South Africa: The influence of HIV stigma.People living with HIV face unique challenges, such as HIV stigma, which impact their ability to adhere to antiretroviral therapy (ART). This study examined how HIV stigma and perceived social support affect the ART adherence self-efficacy of adults living with HIV in South Africa. This survey involved 201 participants who were selected by using time location sampling at a health facility in Durban, South Africa. The study found that HIV stigma had a significant and negative impact on self-efficacy (ß = −7.860, t = −4.654, p = .001), with variations depending on the level of stigma (ß = −5.844, t = −4.003, p = .001). On the other hand, social support had a significant and positive impact on self-efficacy at lower levels of HIV stigma (ß = 7.440, t = 3.887, p = .001), but this effect weakened at higher levels of stigma (ß = −2.825, t = 1.400, p = .163). Social support plays an important role in influencing self-efficacy, especially when HIV stigma is lower. However, the significant impact of social support diminishes as HIV stigma becomes more intense.

Plasmodium falciparum genetic diversity and multiplicity of infection based on msp-1, msp-2, glurp and microsatellite genetic markers in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: In sub-Saharan Africa (SSA), Plasmodium falciparum causes most of the malaria cases. Despite its crucial roles in disease severity and drug resistance, comprehensive data on Plasmodium falciparum genetic diversity and multiplicity of infection (MOI) are sparse in SSA. This study summarizes available information on genetic diversity and MOI, focusing on key markers (msp-1, msp-2, glurp, and microsatellites). The systematic review aimed to evaluate their influence on malaria transmission dynamics and offer insights for enhancing malaria control measures in SSA. METHODS: The review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Two reviewers conducted article screening, assessed the risk of bias (RoB), and performed data abstraction. Meta-analysis was performed using the random-effects model in STATA version 17. RESULTS: The review included 52 articles: 39 cross-sectional studies and 13 Randomized Controlled Trial (RCT)/cohort studies, involving 11,640 genotyped parasite isolates from 23 SSA countries. The overall pooled mean expected heterozygosity was 0.65 (95% CI: 0.51-0.78). Regionally, values varied: East (0.58), Central (0.84), Southern (0.74), and West Africa (0.69). Overall pooled allele frequencies of msp-1 alleles K1, MAD20, and RO33 were 61%, 44%, and 40%, respectively, while msp-2 I/C 3D7 and FC27 alleles were 61% and 55%. Central Africa reported higher frequencies (K1: 74%, MAD20: 51%, RO33: 48%) than East Africa (K1: 46%, MAD20: 42%, RO33: 31%). For msp-2, East Africa had 60% and 55% for I/C 3D7 and FC27 alleles, while West Africa had 62% and 50%, respectively. The pooled allele frequency for glurp was 66%. The overall pooled mean MOI was 2.09 (95% CI: 1.88-2.30), with regional variations: East (2.05), Central (2.37), Southern (2.16), and West Africa (1.96). The overall prevalence of polyclonal Plasmodium falciparum infections was 63% (95% CI: 56-70), with regional prevalences as follows: East (62%), West (61%), Central (65%), and South Africa (71%). CONCLUSION: The study shows substantial regional variation in Plasmodium falciparum parasite genetic diversity and MOI in SSA. These findings suggest a need for malaria control strategies and surveillance efforts considering regional-specific factors underlying Plasmodium falciparum infection.

Linkage to HIV care and early retention in HIV care among men in the 'universal test-and-treat' era in a high HIV-burdened district, KwaZulu-Natal, South Africa.

INTRODUCTION: Despite the numerous efforts and initiatives, males with HIV are still less likely than women to receive HIV treatment. Across Sub-Saharan Africa, men are tested, linked, and retained in HIV care at lower rates than women, and South Africa is no exception. This is despite the introduction of the universal test-and-treat (UTT) prevention strategy anticipated to improve the uptake of HIV services. The aim of this study was to investigate linkage to and retention in care rates of an HIV-positive cohort of men in a high HIV prevalence rural district in KwaZulu-Natal province, South Africa. METHODS: From January 2018 to July 2019, we conducted an observational cohort study in 18 primary health care institutions in the uThukela district. Patient-level survey and clinical data were collected at baseline, 4-months and 12-months, using isiZulu and English REDCap-based questionnaires. We verified data through TIER.Net, Rapid mortality survey (RMS), and the National Health Laboratory Service (NHLS) databases. Data were analyzed using STATA version 15.1, with confidence intervals and p-value of ≤0.05 considered statistically significant. RESULTS: The study sample consisted of 343 male participants diagnosed with HIV and who reside in uThukela District. The median age was 33 years (interquartile range (IQR): 29-40), and more than half (56%; n = 193) were aged 18-34 years. Almost all participants (99.7%; n = 342) were Black African, with 84.5% (n = 290) being in a romantic relationship. The majority of participants (85%; n = 292) were linked to care within three months of follow-up. Short-term retention in care (≤ 12 months) was 46% (n = 132) among men who were linked to care within three months. CONCLUSION: While the implementation of the UTT strategy has had positive influence on improving linkage to care, men's access of HIV treatment remains inconsistent and may require additional innovative strategies.

Venom diversity in Naja mossambica: Insights from proteomic and immunochemical analyses reveal intraspecific differences.

BACKGROUND: Intraspecific variations in snake venom composition have been extensively documented, contributing to the diverse clinical effects observed in envenomed patients. Understanding these variations is essential for developing effective snakebite management strategies and targeted antivenom therapies. We aimed to comprehensively investigate venoms from three distinct populations of N. mossambica from Eswatini, Limpopo, and KwaZulu-Natal regions in Africa in terms of their protein composition and reactivity with three commercial antivenoms (SAIMR polyvalent, EchiTAb+ICP, and Antivipmyn Africa). METHODOLOGY/PRINCIPAL FINDINGS: Naja mossambica venoms from Eswatini region exhibited the highest content of neurotoxic proteins, constituting 20.70% of all venom proteins, compared to Limpopo (13.91%) and KwaZulu-Natal (12.80%), and was characterized by the highest diversity of neurotoxic proteins, including neurotoxic 3FTxs, Kunitz-type inhibitors, vespryns, and mamba intestinal toxin 1. KwaZulu-Natal population exhibited considerably lower cytotoxic 3FTx, higher PLA2 content, and significant diversity in low-abundant proteins. Conversely, Limpopo venoms demonstrated the least diversity as demonstrated by electrophoretic and mass spectrometry analyses. Immunochemical assessments unveiled differences in venom-antivenom reactivity, particularly concerning low-abundance proteins. EchiTAb+ICP antivenom demonstrated superior reactivity in serial dilution ELISA assays compared to SAIMR polyvalent. CONCLUSIONS/SIGNIFICANCE: Our findings reveal a substantial presence of neurotoxic proteins in N. mossambica venoms, challenging previous understandings of their composition. Additionally, the detection of numerous peptides aligning to uncharacterized proteins or proteins with unknown functions underscores a critical issue with existing venom protein databases, emphasizing the substantial gaps in our knowledge of snake venom protein components. This underscores the need for enhanced research in this domain. Moreover, our in vitro immunological assays suggest EchiTAb+ICP's potential as an alternative to SAIMR antivenom, requiring confirmation through prospective in vivo neutralization studies.

A comparison of risk factor investigation and experts' opinion elicitation analysis for identifying foot-and-mouth disease (FMD) high-risk areas within the FMD protection zone of South Africa (2007-2016).

Foot-and-mouth disease is a controlled disease in accordance with the South African Animal Diseases Act (Act 35 of 1984). The country was classified by the World Organisation for Animal Health (WOAH) as having a FMD free zone without vaccination in 1996. However, this status was suspended in 2019 due to a FMD outbreak outside the controlled zones. FMD control in South Africa includes animal movement restrictions placed on cloven-hoofed species and products, prophylactic vaccination of cattle, clinical surveillance of susceptible species, and disease control fencing to separate livestock from wildlife reservoirs. The objectives of this study were to evaluate differences in identifying high-risk areas for FMD using risk factor and expert opinion elicitation analysis. Differences in risk between FMD introduction and FMD spread within the FMD protection zone with vaccination (PZV) of South Africa (2007-2016) were also investigated. The study was conducted in the communal farming area of the FMD PZV, which is adjacent to wildlife reserves and characterised by individual faming units. Eleven risk factors that were considered important for FMD occurrence and spread were used to build a weighted linear combination (WLC) score based on risk factor data and expert opinion elicitation. A multivariable conditional logistic regression model was also used to calculate predicted probabilities of a FMD outbreak for all dip-tanks within the study area. Smoothed Bayesian kriged maps were generated for 11 individual risk factors, overall WLC scores for FMD occurrence and spread and for predicted probabilities of a FMD outbreak based on the conditional logistic regression model. Descriptively, vaccine matching was believed to have a great influence on both FMD occurrence and spread. Expert opinion suggested that FMD occurrence was influenced predominantly by proximity to game reserves and cattle density. Cattle populations and vaccination practices were considered most important for FMD spread. Highly effective cattle inspections were observed within areas that previously reported FMD outbreaks, indicating the importance of cattle inspection (surveillance) as a necessary element of FMD outbreak detection. The multivariable conditional logistic regression analysis, which was consistent with expert opinion elicitation; identified three factors including cattle population density (OR 3.87, 95% CI 1.47-10.21) and proximities to game reserve fences (OR 0.82, 95% CI 0.73-0.92) and rivers (OR 1.04, 95% CI 1.01-1.07) as significant factors for reported FMD outbreaks. Regaining and maintaining an FMD-free status without vaccination requires frequent monitoring of high-risk areas and designing targeted surveillance.

Blood RNA biomarkers for tuberculosis screening in people living with HIV before antiretroviral therapy initiation: a diagnostic accuracy study.

BACKGROUND: Undiagnosed tuberculosis remains a major threat for people living with HIV. Multiple blood transcriptomic biomarkers have shown promise for tuberculosis diagnosis. We sought to evaluate their diagnostic accuracy and clinical utility for systematic pre-antiretroviral therapy (ART) tuberculosis screening. METHODS: We enrolled consecutive adults (age ≥18 years) referred to start ART at a community health centre in Cape Town, South Africa, irrespective of symptoms. Sputa were obtained (using induction if required) for two liquid cultures. Whole-blood RNA samples underwent transcriptional profiling using a custom Nanostring gene panel. We measured the diagnostic accuracy of seven candidate RNA signatures (one single gene biomarker [BATF2] and six multigene biomarkers) for the reference standard of Mycobacterium tuberculosis culture status, using area under the receiver-operating characteristic curve (AUROC) analysis, and sensitivity and specificity at prespecified thresholds (two standard scores above the mean of healthy controls; Z2). Clinical utility was assessed by calculating net benefit in decision curve analysis. We compared performance with C-reactive protein (CRP; threshold ≥5 mg/L), WHO four-symptom screen (W4SS), and the WHO target product profile for tuberculosis triage tests. FINDINGS: A total of 707 people living with HIV (407 [58%] female and 300 [42%] male) were included, with median CD4 count 306 cells per mm3 (IQR 184-486). Of 676 participants with available sputum culture results, 89 (13%) had culture-confirmed tuberculosis. The seven RNA signatures were moderately to highly correlated (Spearman rank coefficients 0·42-0·93) and discriminated tuberculosis culture positivity with similar AUROCs (0·73-0·80), but none statistically better than CRP (AUROC 0·78, 95% CI 0·72-0·83). Diagnostic accuracy was similar across CD4 count strata, but lower among participants with negative W4SS (AUROCs 0·56-0·65) compared with positive (AUROCs 0·75-0·84). The RNA biomarker with the highest AUROC point estimate was a four-gene signature (Suliman4; AUROC 0·80, 95% CI 0·75-0·86), with sensitivity 83% (95% CI 74-90) and specificity 59% (55-63) at the Z2 threshold. In decision curve analysis, Suliman4 and CRP had similar clinical utility to guide confirmatory tuberculosis testing, but both had higher net benefit than W4SS. In exploratory analyses, an approach combining CRP (≥5 mg/L) and Suliman4 (≥Z2) had sensitivity of 80% (70-87), specificity of 70% (66-74), and higher net benefit than either biomarker alone. INTERPRETATION: RNA biomarkers showed better clinical utility to guide confirmatory tuberculosis testing for people living with HIV before ART initiation than symptom-based screening, but their performance did not exceed that of CRP and fell short of WHO recommended targets. Interferon-independent approaches might be required to improve accuracy of host-response biomarkers to support tuberculosis screening before ART initiation. FUNDING: South African Medical Research Council, European and Developing Countries Clinical Trials Partnership 2, National Institutes of Health National Institute of Allergy and Infectious Diseases, The Wellcome Trust, National Institute for Health and Care Research, Royal College of Physicians London.

A dedicated quality improvement programme can increase access to paediatric minimal access surgery in South Africa.

BACKGROUND: In this project, we reviewed our experience in minimal access paediatric surgery (MAPS) at Greys Hospital over the last decade. This information would provide an overview of our experience and would enable us to identify areas where we can strengthen our surgical service and our training programme. METHODS: All surgical patients are captured in the hybrid electronic medical registry (HEMR). All patients aged 18 years or less who underwent a MAPS procedure between 2012 and 2021 were reviewed. Data collected included demographic information, type of surgery, nature of the surgery (elective or emergency), organ system operated on, whether trainees or consultants performed the surgeries and the morbidities and mortalities experienced. Statistical analysis included linear regression and ANOVA, which was performed using Jamovi software. RESULTS: A total of 1 328 MAPS procedures were performed on 994 patients over nine years. There were 359 female and 635 male patients. There was a steady increase in the number of cases performed per year. The age of the patients ranged from one day of life to 18 years, with a median of 8 years. The multiple linear regression results indicated a very strong collective significant effect between the courses performed, the number of consultants, and the MAPS cases performed. The ANOVA test for the individual factors was not statistically significant, but there was a very strong combined correlation with an r-value of 0.87 and a p-value of 0.014 using the overall model test. The consultants' training also directly impacted on the teaching and training of registrars, with progressively more cases being performed by trainees over the years. Postoperative morbidity was reported in 40 patients. The morbidity rate was three per cent. There were no mortalities. CONCLUSION: It is feasible to deliver MAPS to children in our environment. A comprehensive quality improvement strategy has yielded satisfying results. The increased use of MAPS has resulted in a general transfer of skills to junior staff. Ongoing efforts to support the rollout of MAPS in children are warranted.

Outcomes of substance use and sexual power among adolescent girls and young women in Cape Town: Implications for structural and cultural differences.

Adolescent girls and young women (AGYW) in South Africa experience contextual barriers to HIV risk reduction including incomplete schooling, unintended pregnancy, substance use, and gender-based violence. A cluster randomised trial in Cape Town allocated 24 Black and Coloured communities to a gender-focused HIV risk-reduction intervention or HIV testing, with 500 AGYW total enrolled. We evaluated intervention efficacy by comparing mean differences overall, by community population group (Black and Coloured) and among those with structural barriers based on neighbourhood, education, and employment (n = 406). Both arms reported reductions in alcohol, cannabis, and condomless sex, with no intervention efficacy overall. Among AGYW with barriers, intervention participants reported fewer days of methamphetamine use at 6 months (t(210) = 2·08, p = ·04). In population group analysis, we found intervention effects on alcohol and sexual communication. Intervention participants in Black communities had fewer days of alcohol use at 12 months (t(136) = 2·10, p = ·04). Sexual discussion (t(147) = -2·47, p = ·02) and condom negotiation (t(146) = -2·51, p = ·01) increased for intervention participants at 12 months in Coloured communities. Gender-focused interventions must address population group differences and intersecting barriers to decrease substance use and increase education, skills, and sexual health protection.

Role and knowledge of nurses in the management of non-communicable diseases in Africa: A scoping review.

BACKGROUND: 31.4 million people in low- and middle-income countries die from chronic diseases annually, particularly in Africa. To address this, strategies such as task-shifting from doctors to nurses have been proposed and have been endorsed by the World Health Organization as a potential solution; however, no comprehensive review exists describing the extent of nurse-led chronic disease management in Africa. AIMS: This study aimed to provide a thorough description of the current roles of nurses in managing chronic diseases in Africa, identify their levels of knowledge, the challenges, and gaps they encounter in this endeavor. METHODS: We performed a scoping review following the key points of the Cochrane Handbook, and two researchers independently realized each step. Searches were conducted using five databases: MEDLINE, PyscINFO, CINAHL, Web of Science, and Embase, between October 2021 and April 2023. A descriptive analysis of the included studies was conducted, and the quality of the studies was assessed using the Downs and Black Scale. RESULTS: Our scoping review included 111 studies from 20 African countries, with South Africa, Nigeria, and Ghana being the most represented. Findings from the included studies revealed varying levels of knowledge. Nurses were found to be actively involved in managing common chronic diseases from diagnosis to treatment. Facilitating factors included comprehensive training, close supervision by physicians, utilization of decision trees, and mentorship. However, several barriers were identified, such as a shortage of nurses, lack of essential materials, and inadequate initial training. CONCLUSION: There is significant potential for nurses to enhance the screening, diagnosis, and treatment of chronic diseases in Africa. Achieving this requires a combination of rigorous training and effective supervision, supported by robust policies. To address varying levels of knowledge, tailored training programs should be devised. Further research is warranted to establish the effectiveness of nurse-led interventions on population health outcomes.

Evaluation of radiological capacity and usage in paediatric TB diagnosis: A mixed-method protocol of a comparative study in Mozambique, South Africa and Spain.

INTRODUCTION: Tuberculosis remains one of the top ten causes of mortality globally. Children accounted for 12% of all TB cases and 18% of all TB deaths in 2022. Paediatric TB is difficult to diagnose with conventional laboratory tests, and chest radiographs remain crucial. However, in low-and middle-income countries with high TB burden, the capacity for radiological diagnosis of paediatric TB is rarely documented and data on the associated radiation exposure limited. METHODS: A multicentre, mixed-methods study is proposed in three countries, Mozambique, South Africa and Spain. At the national level, official registry databases will be utilised to retrospectively compile an inventory of licensed imaging resources (mainly X-ray and Computed Tomography (CT) scan equipment) for the year 2021. At the selected health facility level, three descriptive cross-sectional standardised surveys will be conducted to assess radiology capacity, radiological imaging diagnostic use for paediatric TB diagnosis, and radiation protection optimization: a site survey, a clinician-targeted survey, and a radiology staff-targeted survey, respectively. At the patient level, potential dose optimisation will be assessed for children under 16 years of age who were diagnosed and treated for TB in selected sites in each country. For this component, a retrospective analysis of dosimetry will be performed on TB and radiology data routinely collected at the respective sites. National inventory data will be presented as the number of units per million people by modality, region and country. Descriptive analyses will be conducted on survey data, including the demographic, clinical and programmatic characteristics of children treated for TB who had imaging examinations (chest X-ray (CXR) and/or CT scan). Dose exposure analysis will be performed by children's age, gender and disease spectrum. DISCUSSION: As far as we know, this is the first multicentre and multi-national study to compare radiological capacity, radiation protection optimization and practices between high and low TB burden settings in the context of childhood TB management. The planned comparative analyses will inform policy-makers of existing radiological capacity and deficiencies, allowing better resource prioritisation. It will inform clinicians and radiologists on best practices and means to optimise the use of radiological technology in paediatric TB management.

Acceptability and perceived feasibility of the KaziKidz health promotion intervention among educators and caregivers in schools from South Africa: a qualitative descriptive study.

BACKGROUND: Despite the uncontested benefits of physical activity, its promotion lags behind in the public health agenda of low- and middle-income countries (LMICs). School-based interventions are promising strategies to foster health during childhood, but evidence of their effectiveness is limited and inconclusive for LMICs. Thus, further investigation is needed on contextual factors associated with intervention implementation in low-resource settings. We studied the acceptability and feasibility of the KaziKidz health promotion intervention and its implementation and make recommendations to improve future adoption and sustainability. METHODS: KaziKidz was implemented in four primary schools from low-income communities in South Africa in 2019. Semi-structured interviews with four school principals, three focus group interviews with 16 educators, and another three with 16 caregivers were conducted between October and November 2021. Participants were purposively recruited. Interview transcripts were analyzed via thematic analysis using a deductive and reflexive approach. RESULTS: Three main themes influencing intervention implementation and adoption were identified: (1) prioritizing teachers' needs (2), integrating the program into the school structure, and (3) creating opportunities in the community. Supporting recommendations included: (theme 1) adopting intervention approaches that are inclusive of educators' health and providing them with capacity development and external support; (theme 2) fostering a feeling of ownership and belonging among school stakeholders to adapt interventions to specific resources and needs; and (theme 3) raising community awareness to encourage individuals to claim power over and actively engage with the program. CONCLUSIONS: Comprehensive interventions comprising health support, adequate training, and ongoing assistance for educators combined with school-wide and community outreach actions seeking to strengthen program ownership, accountability, and engagement can enhance uptake of school-based interventions and long-term maintenance. TRIAL REGISTRATION: ISRCTN15648510, registered on 17/04/2020.

Post-traumatic stress disorder in international surgeons undertaking trauma electives in a South African trauma centre.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a well-documented psychiatric outcome in patients who experience physical trauma. The phenomenon is less studied in the staff involved in caring for such patients. The aim was to investigate the prevalence of PTSD in visiting international surgeons undergoing elective trauma training and to compare to local and international rates. METHODS: A trauma screening questionnaire (TSQ) survey was conducted among surgeons completing their elective trauma service placements in the Pietermaritzburg Metropolitan Trauma Service. RESULTS: Nineteen surveys were completed (32% response rate). Mean age was 38.9 (SD 6.5). Median postgraduate working experience was 5 (2-10) years. Median time of stay in South Africa was 6 (1-72) months. Compared to preelective experience, there was a five-fold increase in the level of trauma resuscitation experience reported during elective placement. 10.5% of surgeons scored > 5 in the TSQ suggesting probable PTSD. No statistical differences in age, years of prior experience, prior trauma rotation, number of major resuscitations, or length of stay in South Africa were observed in those scoring positive versus negative screening in the TSQ questionnaire. CONCLUSION: Despite being exposed to increased levels of trauma related injury, we observed low rates of positive screening for PTSD in our cohort of visiting international surgeons involved in elective trauma service placements. Investigation of potential protective factors against PTSD in this South African tertiary trauma centre is warranted.

The academic progress of female general surgery and orthopaedic surgery trainees in South Africa.

BACKGROUND: Globally, medical institutes have seen an increase in female graduates, however surgical disciplines remain male-dominated. An epidemiological shift towards non-communicable diseases and trauma may result in a shortage of surgical specialists. One strategy to improve the surgical workforce is the recruitment of female graduates. METHODS: A non-validated questionnaire was administered to females registered for the Master of Medicine (MMED) degree in General and Orthopaedic Surgery at the University of KwaZulu-Natal (UKZN) between 2000 and 2015. The study evaluated reasons for choice of surgery as a career, challenges faced on the domestic and work front, as well as factors that assisted with successful completion of training. RESULTS: Seventy-two female trainees in General Surgery and Orthopaedics were identified from the UKZN databases. The contact details for 62 of these trainees were available. The overall response rate was 71.0% (44/62). A total of 95.5% (42/44) of participants selected surgery due to a passion for the field. Major challenges identified were a poor home and work-life balance (72.1%, 31/43) and poor working conditions (62.8%, 27/43). Female trainees perceived that they were viewed as inferior by patients (65.9%, 29/44). Successful trainees had a good home support system (89.3%, 25/28) and mentorship during training (60.7%, 17/28), and 85.7% (24/28) did not regret their career choice. CONCLUSION: The recruitment and retention of females in surgery will contribute to maintaining an adequate surgical workforce. Training programmes need to improve work-life balance without compromising on producing competent surgeons. Improved visibility of female surgeons in leadership roles should be encouraged to promote mentorship and recruitment of trainees.

Biochemical markers in emergency thoracic surgery in penetrating trauma.

BACKGROUND: Violent interpersonal acts account for a large proportion of unnatural deaths in South Africa. A significant proportion of unnatural deaths are due to penetrating thoracic trauma and preventable haemorrhage. Current indications for emergent thoracotomy are unreliable. We propose the use of lactate, shock index (SI) and base deficit (BD) as a triage tool in patients with penetrating thoracic injuries to identify those requiring surgical intervention. METHODS: A review of the trauma registry of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) was carried out between March 2011 and March 2016. Four hundred and ninety (490) patients were collected consisting of a non-operative group of 246 patients and an operative group of 244 patients. We compared lactate, SI and BD independently and within panels to ascertain which would best predict the need for operative intervention in these patients. Abnormal was defined as lactate ≥ 4 mmol/l, SI ≥ 0.8 and BD ≤ -4 mmol/l. RESULTS: Of the 490 patients, lactate (p < 0.001), SI (p < 0.001) and BD (p < 0.001) differed significantly between operative and non-operative groups. Statistical significance was lost (p = 0.34) once BD was analysed in combination with lactate and SI. Lactate alone was a strong predictor of the need for intervention (area under the curve (AUC) = 0.814). The strongest predictor was a combined panel of lactate and SI (AUC = 0.8308, p < 0.001). CONCLUSION: Lactate and SI in combination are useful as triage tools, and could assist in decision making, by predicting which patients are more likely to require surgical intervention.

Open abdominal wall defects and open spina bifida at a regional hospital in northern KwaZulu-Natal - bellwether conditions for neonatal surgery capacity.

BACKGROUND: Abdominal wall defects (AWDs), such as gastroschisis and omphalocele, and neural tube defects (NTDs) such as open spina bifida (SB) are common congenital anomalies. These anomalies are considered a leading cause of neonatal mortality and have been advocated as bellwether conditions to measure access to surgical care. METHODS: Newborns with open SB or AWD presenting to the nursery at Queen Nandi Regional Hospital over four years (2018-2021) were retrospectively identified. Clinical and electronic database records were reviewed to determine if transfers to definitive tertiary care occurred timeously. Reasons for delays and associated morbidity and/or mortality were investigated. RESULTS: Sixty-five patients were identified and two were excluded due to unavailable or incomplete records. It took a median of 8 days (IQR 2-18 days) to reach tertiary care, with SB cases waiting significantly longer (median 16 days,IQR 8-25 days) (p = 0.000). Lack of tertiary service capacity was the main reason for delays. The COVID-19 pandemic did not affect time intervals (p = 0.676). Complications were common and overall mortality at our facility was high (n = 11/63, 17.46%). CONCLUSION: Newborns with open SB or AWDs experience marked delays in reaching definitive care. This is more pronounced for cases of SB and was not influenced by the pandemic. Lack of tertiary service capacity (including bed availability, limited staff, and theatre time) is the most important limiting factor.