Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa.

BACKGROUND: While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence. METHODS: Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory. RESULTS: The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers. CONCLUSIONS: This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.

When Lightning Strikes: Sports and Recreational Activities Safety.

ABSTRACT: Lightning strikes and their sequela are well-known sources of injury associated with sports and outdoor activities. While mortality is relatively rare and has steadily decreased over the years, the potentially catastrophic effects make knowledge about lightning strike injuries continually relevant. The primary focus of lightning-related safety is prevention and newer literature over the last 2 years has been largely case reports. Attempts to reduce lightning-related injuries in outdoor sports have been made with easily recalled guidelines by the National Athletic Trainers' Association, as well as the National Collegiate Athletic Association. Newer technology related to lightning safety uses digital and app-based monitoring systems to aid in injury prevention strategies. Occupational lightning exposure continues to be a hazard, especially for those who work outdoors, including certain military personnel. Service members, athletes, and outdoor enthusiasts should remain vigilant, especially during times with higher likelihood of lightning strikes.

Cyclical Engagement in HIV Care: A Qualitative Study of Clinic Transfers to Re-enter HIV Care in Cape Town, South Africa.

Long-term patient engagement and retention in HIV care is an ongoing challenge in South Africa's strained health system. However, some patients thought to be "lost to follow-up" (LTFU) may have "transferred" clinics to receive care elsewhere. Through semi-structured interviews, we explored the relationship between clinic transfer and long-term patient engagement among 19 treatment-experienced people living with HIV (PLWH) who self-identified as having engaged in a clinic transfer at least once since starting antiretroviral therapy (ART) in Gugulethu, Cape Town. Our findings suggest that patient engagement is often fluid, as PLWH cycle in and out of care multiple times during their lifetime. The linear nature of the HIV care cascade model poorly describes the lived realities of PLWH on established treatment. Further research is needed to explore strategies for reducing unplanned clinic transfers and offer more supportive care to new and returning patients.

A qualitative exploration of continuity of TB care in clinics after discharge from hospitals in Cape Town, South Africa.

BACKGROUND: Continuity of care remains a challenge for TB patients who are discharged from hospital and referred to primary health care clinics in South Africa. The aim of this study was to explore the experiences and perceptions of patients, health care workers and family members regarding continuity of TB care in a Cape Town health district. METHODS: We conducted one-on-one interviews, using semi-structured interview guides, with TB patients and their families and health care workers. We also conducted focus group interviews with other health care workers who performed similar duties. Field notes were kept and patients' home circumstances were also physically observed. Data saturation was achieved after 31 interviews. We used Miles and Huberman's qualitative data analysis framework to interpret the data. RESULTS: Themes identified in the interviews were grouped into two categories: (1)  patients' socio-economic circumstances including complex family relationships, good or lack of family support, inadequate income, and agency; and (2) health system challenges, including inadequate referral links between the clinic and the hospital and negative emotions as a result of poor service delivery experienced by patients. CONCLUSION: Some TB Patients experienced poor continuity of care on discharge from hospitals to primary health clinics and perceived that this resulted from socio-economic conditions and health system-related problems that triggered negative emotions. Proper communication between the hospital and clinic regarding patients' care, adequate counselling, and patient-centred treatment are required to address poor continuity of care among patients with TB down-referred to clinics.

A qualitative study of patients and healthcare workers' experiences and perceptions to inform a better understanding of gaps in care for pre-discharged tuberculosis patients in Cape Town, South Africa.

BACKGROUND: Many people diagnosed with Mycobacterium tuberculosis (TB) in tertiary and district hospitals in South Africa do not arrive at their primary care clinic for continued care after they are discharged from the hospital. This loss to follow up is a major, ongoing problem for public health in South Africa, and contributes to drug-resistant TB strains. The objective of this paper was to explore patients' experiences and perceptions of diagnosis and treatment before their discharge from hospital. We use a framework known as patient-centred care to illustrate how these patient narratives point to lapses in these principles within the hospital system, and to show how such lapses may contribute to loss to follow up and inconsistent TB care. METHODS: We employed a qualitative study using semi-structured interviews to investigate patient and healthcare workers' experiences and perceptions of TB care in two Western Cape hospitals. We purposefully sampled 17 patients, 10 healthcare workers, and two key informant policy makers, all of whom had relevant experiences and insights. Data collection was done between October 2015 and February 2017. Data were analysed using Miles and Huberman's qualitative analysis framework. RESULTS: Hospitals did not achieve patient-centred care. Newly diagnosed patients were provided with inadequate TB education, diseased-focused approaches were favoured over patient-focused approaches, and there was limited engagement with patients to understand their needs and feelings during the critical period between diagnosis and discharge. Consequently, some patients felt anxious prior to their discharge from hospital. Coupled with their overwhelming socio-economic barriers and complex family situations, some patients felt hopeless and powerless as they prepared for discharge. Finally, there was a lack of patient-provider partnership due to problems including healthcare workers' time constraints and heavy workloads, which detracted from a focus on patients' needs and feelings. CONCLUSIONS: Improving the three intersecting elements of patient-centred care (health education, engaging with patients' needs and feelings, and shared decision-making) has the potential to positively influence patients' continuity of care for TB in South Africa. It would be helpful to also proactively address how patients plan to stay connected to care, on treatment, and supported, in light of their family situation or socio-economic circumstances. Detailed and unique pre-discharge counselling for each patient may be valuable in this regard.

Blood and Blood: Anti-retroviral Therapy, Masculinity, and Redemption among Adolescent Boys in the Eastern Cape Province of South Africa.

Adolescents living with perinatally acquired HIV are among the first generation in South Africa to grow up with anti-retroviral therapy and democratic freedoms. In this article, we explore the biosocial lives of adolescent boys and young men living with HIV in the Eastern Cape Province of South Africa. We conducted qualitative research with 36 adolescent boys and young men in 2016-2018, including life history narratives, semi-structured interviews, and analysis of health facility files. [masculinity, South Africa, HIV, adolescence].

Patient Transfers and Their Impact on Gaps in Clinical Care: Differences by Gender in a Large Cohort of Adults Living with HIV on Antiretroviral Therapy in South Africa.

For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012-2013 from ART initiation in 2012-2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)-17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2-21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8-10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83-3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis.

BACKGROUND: Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination. OBJECTIVES: - Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020. SELECTION CRITERIA: We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided. DATA COLLECTION AND ANALYSIS: We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review. MAIN RESULTS: We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness. AUTHORS' CONCLUSIONS: Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Community health workers at the dawn of a new era: 8. Incentives and remuneration.

BACKGROUND: This is the eighth in our series of 11 papers on "CHWs at the Dawn of a New Era". Community health worker (CHW) incentives and remuneration are core issues that affect the performance of individual CHWs and the performance of the overall CHW programme. A better understanding of what motivates CHWs and a stronger awareness of the social justice dimensions of remuneration are essential in order to build stronger CHW programmes and to support the professionalization of the CHW workforce. METHODS: We provide examples of incentives that have been provided to CHWs and identify factors that motivate and demotivate CHWs. We developed our findings in this paper by synthesizing the findings of a recent review of CHW motivation and incentives in a wide variety of CHW programmes with detailed case study data about CHW compensation and incentives in 29 national CHW programmes. RESULTS: Incentives can be direct or indirect, and they can be complementary/demand-side incentives. Direct incentives can be financial or nonfinancial. Indirect incentives can be available through the health system or from the community, as can complementary, demand-side incentives. Motivation is sustained when CHWs feel they are a valued member of the health system and have a clear role and set of responsibilities within it. A sense of the "do-ability" of the CHW role is critical in maintaining CHW motivation. CHWs are best motivated by work that provides opportunities for personal growth and professional development, irrespective of the direct remuneration and technical skills obtained. Working and social relationships among CHWs themselves and between CHWs and other healthcare professionals and community members strongly shape CHW motivation. CONCLUSION: Our findings support the recent guidelines for CHWs released by WHO in 2018 that call for CHWs to receive a financial package that corresponds to their job demands, complexity, number of hours worked, training, and the roles they undertake. The guidelines also call for written agreements that specify the CHW's role and responsibilities, working conditions, remuneration, and workers' rights.

Estimating retention in HIV care accounting for clinic transfers using electronic medical records: evidence from a large antiretroviral treatment programme in the Western Cape, South Africa.

BACKGROUND: Estimates of retention in antiretroviral treatment (ART) programmes may be biased if patients who transfer to healthcare clinics are misclassified as lost to follow-up (LTFU) at their original clinic. In a large cohort, we estimated retention in care accounting for patient transfers using medical records. METHODS: Using linked electronic medical records, we followed adults living with HIV (PLWH) in Cape Town, South Africa from ART initiation (2012-2016) through database closure at 36 months or 30 June 2016, whichever came first. Retention was defined as alive and with a healthcare visit in the 180 days between database closure and administrative censoring on 31 December 2016. Participants who died or did not have a healthcare visit in > 180 days were censored at their last healthcare visit. We estimated the cumulative incidence of retention using Kaplan-Meier methods considering (i) only records from a participant's ART initiation clinic (not accounting for transfers) and (ii) all records (accounting for transfers), over time and by gender. We estimated risk differences and bootstrapped 95% confidence intervals to quantify misclassification in retention estimates due to patient transfers. RESULTS: We included 3406 PLWH initiating ART. Retention through 36 months on ART rose from 45.4% (95% CI 43.6%, 47.2%) to 54.3% (95% CI 52.4%, 56.1%) after accounting for patient transfers. Overall, 8.9% (95% CI 8.1%, 9.7%) of participants were misclassified as LTFU due to patient transfers. CONCLUSIONS: Patient transfers can appreciably bias estimates of retention in HIV care. Electronic medical records can help quantify patient transfers and improve retention estimates.

CONTEXTE: Les estimations de la rétention dans les programmes de traitement antirétroviral (ART) peuvent être biaisées si les patients qui sont transférés dans des cliniques de soins de santé sont classés à tort comme perdus au suivi (PS) dans leur clinique d'origine. Dans une large cohorte, nous avons estimé la rétention dans les soins en tenant compte des transferts de patients à l'aide des dossiers médicaux. MÉTHODES: A l'aide de dossiers médicaux électroniques reliés entre eux, nous avons suivi des adultes vivant avec le VIH (PVVIH) à Cape Town, en Afrique du Sud, depuis le début de l'ART (2012-2016) jusqu'à la clotûre de la base de données à 36 mois ou au 30 juin 2016, selon la première éventualité. La rétention a été définie comme étant en vie et avec une visite médicale dans les 180 jours entre la clôture de la base de données et recensement administrative le 31 décembre 2016. Les participants qui sont décédés ou qui n'ont pas eu de visite médicale dans un délai de plus de 180 jours ont été recensés lors de leur dernière visite médicale. Nous avons estimé l'incidence cumulative de la rétention en utilisant les méthodes de Kaplan-Meier en considérant: (i) uniquement les dossiers de la clinique d'initiation de l'ART d'un participant (sans tenir compte des transferts) et (ii) tous les dossiers (en tenant compte des transferts), au cours du temps et par sexe. Nous avons estimé les différences de risque et avons considéré des intervalles de confiance à 95% pour quantifier les erreurs de classification dans les estimations de rétention dues aux transferts de patients. RÉSULTAT: Nous avons inclus 3.406 PVVIH qui ont commencé un ART. La rétention sous ART est passée de 45,4% (IC 95%: 43,6-47,2) à 54,3% (IC 95%: 52,4-56,1) après avoir tenu compte des transferts de patients. Dans l'ensemble, 8,9% (IC 95%: 8,1-9,7) des participants ont été classés à tort dans la catégorie PS en raison des transferts de patients. CONCLUSIONS: Les transferts de patients peuvent biaiser sensiblement les estimations de la rétention dans les soins liés au VIH. Les dossiers médicaux électroniques peuvent aider à quantifier les transferts de patients et à améliorer les estimations de rétention.

Quantifying the HIV treatment cascade in a South African health sub-district by gender: retrospective cohort study.

OBJECTIVES: To quantify the HIV care cascade in a Cape Town sub-district to understand rates of linkage to and engagement in HIV care. METHODS: We used routinely collected data to reconstruct the treatment cascade for 8382 infected individuals who tested HIV + in 2012/2013. We obtained data on patient gender, year of initial HIV-positive test, age at testing and initial CD4 cell count and defined five stages of the HIV care cascade. We quantified attrition across cascade stages. RESULTS: Two-thirds of the sample (5646) were women. Men were older at time of first testing (36.5 vs. 31.3 years) and had more advanced HIV disease at diagnosis (298 vs. 404 CD4 cells/µL for women). The median duration of follow-up was 818 days. Among women, 90.5% attended an initial HIV care visit, 54.6% became eligible for antiretroviral therapy under local guidelines during follow-up, 49.3% initiated ART and 45.6% achieved a therapeutic response. Among men, 88.0% attended an initial HIV care visit, 67.4% became ART eligible during follow-up, 48.0% initiated ART and 42.4% achieved a therapeutic response. Approximately 3% of women and 5% of men died during follow-up. CONCLUSIONS: We were able to reconstruct the HIV treatment cascade using routinely collected data. In this setting, rates of engagement in care differ by gender in key stages of the cascade, with men faring worse than women at each cascade point. This highlights the need for interventions aimed at encouraging earlier testing, linkage, ART initiation and retention among men.

OBJECTIFS: Quantifier la cascade des soins du VIH dans un sous-district de Cape Town pour comprendre les taux de liaisons et d'engagement avec les soins du VIH. MÉTHODES: Nous avons utilisé des données collectées en routine pour reconstruire la cascade de traitement pour 8.382 personnes infectées, testées positives pour le VIH en 2012/13. Nous avons obtenu des données sur le sexe du patient, l'année du premier test positif pour le VIH, l'âge au moment de ce test et le nombre initial de cellules CD4, et avons défini cinq étapes de la cascade des soins du VIH. Nous avons quantifié l'attrition au long des étapes de la cascade. RÉSULTATS: Deux tiers de l'échantillon (5.646) étaient des femmes. Les hommes étaient plus âgés au moment du premier test (36,5 contre 31,3 ans) et avaient la maladie du VIH plus avancée au moment du diagnostic (298 contre 404 cellules CD4/µL pour les femmes). La durée médiane de suivi était de 818 jours. Parmi les femmes, 90,5% ont pris part à une première visite pour des soins du VIH, 54,6% sont devenues éligibles au traitement antirétroviral selon les directives locales au cours du suivi, 49,3% ont commencé une ART et 45,6% ont atteint une réponse thérapeutique. Chez les hommes, 88,0% ont pris part à une première visite pour les soins du VIH; 67,4% sont devenus éligibles à l'ART au cours du suivi, 48,0% ont commencé l'ART et 42,4% ont atteint une réponse thérapeutique. Environ 3% des femmes et 5% des hommes sont décédés au cours du suivi. CONCLUSIONS: Nous avons pu reconstruire la cascade de traitement du VIH en utilisant des données collectées en routine. Dans ce contexte, les taux d'engagement dans les soins diffèrent selon le sexe dans les étapes clés de la cascade, les hommes s'en tirant moins bien que les femmes à chaque point de la cascade. Cela met en évidence la nécessité d'interventions visant à encourager le dépistage précoce, la liaison, l'initiation de l'ART et la rétention chez les hommes.

Low Frontal Alpha Power Is Associated With the Propensity for Burst Suppression: An Electroencephalogram Phenotype for a "Vulnerable Brain".

BACKGROUND: A number of recent studies have reported an association between intraoperative burst suppression and postoperative delirium. These studies suggest that anesthesia-induced burst suppression may be an indicator of underlying brain vulnerability. A prominent feature of electroencephalogram (EEG) under propofol and sevoflurane anesthesia is the frontal alpha oscillation. This frontal alpha oscillation is known to decline significantly during aging and is generated by prefrontal brain regions that are particularly prone to age-related neurodegeneration. Given that burst suppression and frontal alpha oscillations are both associated with brain vulnerability, we hypothesized that anesthesia-induced frontal alpha power could also be associated with burst suppression. METHODS: We analyzed EEG data from a previously reported cohort in which 155 patients received propofol (n = 60) or sevoflurane (n = 95) as the primary anesthetic. We computed the EEG spectrum during stable anesthetic maintenance and identified whether or not burst suppression occurred during the anesthetic. We characterized the relationship between burst suppression and alpha power using logistic regression. We proposed 5 different models consisting of different combinations of potential contributing factors associated with burst suppression: (1) a Base Model consisting of alpha power; (2) an Extended Mechanistic Model consisting of alpha power, age, and drug dosing information; (3) a Clinical Confounding Factors Model consisting of alpha power, hypotension, and other confounds; (4) a Simplified Model consisting only of alpha power and propofol bolus administration; and (5) a Full Model consisting of all of these variables to control for as much confounding as possible. RESULTS: All models show a consistent significant association between alpha power and burst suppression while adjusting for different sets of covariates, all with consistent effect size estimates. Using the Simplified Model, we found that for each decibel decrease in alpha power, the odds of experiencing burst suppression increased by 1.33-fold. CONCLUSIONS: In this study, we show how a decrease in anesthesia-induced frontal alpha power is associated with an increased propensity for burst suppression, in a manner that captures individualized information above and beyond a patient's chronological age. Lower frontal alpha band power is strongly associated with higher propensity for burst suppression and, therefore, potentially higher risk of postoperative neurocognitive disorders. We hypothesize that low frontal alpha power and increased propensity for burst suppression together characterize a "vulnerable brain" phenotype under anesthesia that could be mechanistically linked to brain metabolism, cognition, and brain aging.

Definitions, components and processes of data harmonisation in healthcare: a scoping review.

BACKGROUND: Data harmonisation (DH) has emerged amongst health managers, information technology specialists and researchers as an important intervention for routine health information systems (RHISs). It is important to understand what DH is, how it is defined and conceptualised, and how it can lead to better health management decision-making. This scoping review identifies a range of definitions for DH, its characteristics (in terms of key components and processes), and common explanations of the relationship between DH and health management decision-making. METHODS: This scoping review identified relevant studies from 2000 onwards (date filter), written in English and published in PubMed, Web of Science and CINAHL. Two reviewers independently screened records for potential inclusion for the abstract and full-text screening stages. One reviewer did the data extraction, analysis and synthesis, with built-in reliability checks from the rest of the team. We developed a narrative synthesis of definitions and explanations of the relationship between DH and health management decision-making. RESULTS: We sampled 61 of 181 included to synthesis definitions and concepts of DH in detail. We identified six common terms for data harmonisation: record linkage, data linkage, data warehousing, data sharing, data interoperability and health information exchange. We also identified nine key components of data harmonisation: DH involves (a) a process of multiple steps; (b) integrating, harmonising and bringing together different databases (c) two or more databases; (d) electronic data; (e) pooling data using unique patient identifiers; and (f) different types of data; (g) data found within and across different departments and institutions at facility, district, regional and national levels; (h) different types of technical activities; (i) has a specific scope. The relationship between DH and health management decision-making is not well-described in the literature. Several studies mentioned health providers' concerns about data completeness, data quality, terminology and coding of data elements as barriers to data utilisation for clinical decision-making. CONCLUSION: To our knowledge, this scoping review was the first to synthesise definitions and concepts of DH and address the causal relationship between DH and health management decision-making. Future research is required to assess the effectiveness of data harmonisation on health management decision-making.

Inhibitors of Mycobacterium tuberculosis DosRST signaling and persistence.

The Mycobacterium tuberculosis (Mtb) DosRST two-component regulatory system promotes the survival of Mtb during non-replicating persistence (NRP). NRP bacteria help drive the long course of tuberculosis therapy; therefore, chemical inhibition of DosRST may inhibit the ability of Mtb to establish persistence and thus shorten treatment. Using a DosRST-dependent fluorescent Mtb reporter strain, a whole-cell phenotypic high-throughput screen of a ∼540,000 compound small-molecule library was conducted. The screen discovered novel inhibitors of the DosRST regulon, including three compounds that were subject to follow-up studies: artemisinin, HC102A and HC103A. Under hypoxia, all three compounds inhibit Mtb-persistence-associated physiological processes, including triacylglycerol synthesis, survival and antibiotic tolerance. Artemisinin functions by disabling the heme-based DosS and DosT sensor kinases by oxidizing ferrous heme and generating heme-artemisinin adducts. In contrast, HC103A inhibits DosS and DosT autophosphorylation activity without targeting the sensor kinase heme.

Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis.

BACKGROUND: Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES: (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS: We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA: We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS: We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS: We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. AUTHORS' CONCLUSIONS: Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.

A multidimensional approach to inform family planning needs, preferences and behaviours amongst women in South Africa through body mapping.

BACKGROUND: In recent decades there have been great improvements in the reproductive health of women in low- and middle-income countries and increases in the use of modern contraceptive methods. Nonetheless, many women are not able to access information, contraceptive technologies and services that could facilitate preventing unintended pregnancies and planning the number and timing of desired pregnancies. In South Africa, the contraceptive prevalence rate is 64.6%. However, this relatively high contraceptive prevalence rate masks problems with quality contraceptive service delivery, equitable access, and women's ability to correctly and consistently, use contraceptive methods of their choice. This study set out to understand the specific family planning and contraceptive needs and behaviours of women of reproductive age in South Africa, through a lived experience, multisensory approach. METHODS: Participatory qualitative research methods were used including body mapping workshops amongst reproductive aged women recruited from urban and peri urban areas in the Western Cape South Africa. Data including body map images were analysed using a thematic analysis approach. RESULTS: Women had limited biomedical knowledge of the female reproductive anatomy, conception, fertility and how contraceptives worked, compounded by a lack of contraceptive counseling and support from health care providers. Women's preferences for different contraceptive methods were not based on a single, sensory or experiential factor. Rather, they were made up of a composite of sensory, physical, social and emotional experiences underscored by potential for threats to bodily harm. CONCLUSIONS: This study highlighted the need to address communication and knowledge gaps around the female reproductive anatomy, different contraceptive methods and how contraception works to prevent a pregnancy. Women, including younger women, identified sexual and reproductive health knowledge gaps themselves and identified these gaps as important factors that influenced uptake and effective contraceptive use. These knowledge gaps were overwhelmingly linked to poor or absent communication and counseling provided by health care providers. Body mapping techniques could be used in education and communication strategies around sexual and reproductive health programmes in diverse settings.

The problem or the solution? Early fertility and parenthood in the transition to adulthood in Khayelitsha, South Africa.

In South Africa, early fertility and teenage pregnancy have become a central focus of both political and public health concern. In this article, we explore the ways that young men and women have used their fertility and performance of parenthood to navigate the transition from childhood to adulthood. For these young people, the persistent inequities related to income poverty, inadequate education, lack of employment opportunities and a high burden of disease remain significant barriers to achieving this transition. This article draws on ethnographic data collected between 2014 and early 2016 with young adults (17-25 years) in Town Two, Khayelitsha. Participant observation was the primary data collection method. Narratives and experiences of 15 young people are presented here. We argue that in addition to immediate fertility desires, young people's contraceptive decision-making was significantly shaped by gendered ideals and social norms. Young women's fertility operated as both an aspiration and a threat within partnerships. Some couples partially achieved relationship stability or longevity through having a child. Entering parenthood in the context of a seemingly stable relationship was perceived as a movement towards an accepted, albeit tenuous, form of social adulthood. Although living up to the ideal of good parent was challenging, it was partially achieved by young mothers who provided care and young fathers who provided financially for children. In the absence of other accepted markers of transition to adulthood and within a context of deprivation and exclusion, early fertility, though clearly a public health problem, can become a solution to social circumstances.

Experiences of HIV-positive postpartum women and health workers involved with community-based antiretroviral therapy adherence clubs in Cape Town, South Africa.

BACKGROUND: The rollout of universal, lifelong treatment for all HIV-positive pregnant and breastfeeding women ("Option B+") has rapidly increased the number of women initiating antiretroviral treatment (ART) and requiring ART care postpartum. In a pilot project in South Africa, eligible postpartum women were offered the choice of referral to the standard of care, a local primary health care clinic, or a community-based model of differentiated ART services, the adherence club (AC). ACs have typically enrolled only non-pregnant and non-postpartum adults; postpartum women had not previously been referred directly from antenatal care. There is little evidence regarding postpartum women's preferences for and experiences of differentiated models of care, or the capacity of this particular model to cater to their specific needs. This qualitative paper reports on feedback from both postpartum women and health workers who care for them on their respective experiences of the AC. METHODS: One-on-one in-depth qualitative interviews were conducted with 19 (23%) of the 84 postpartum women who selected the AC and were retained at approximately 12 months postpartum, and 9 health workers who staff the AC. Data were transcribed and thematically analysed using NVivo 11. RESULTS: Postpartum women's inclusion in the AC was acceptable for both participants and health workers. Health workers were welcoming of postpartum women but expressed concerns about prospects for longer term adherence and retention, and raised logistical issues they felt might compromise trust with AC members in general. CONCLUSIONS: Enrolling postpartum women in mixed groups with the general adult population is feasible and acceptable. Preliminary recommendations are offered and may assist in supporting the specific needs of postpartum women transitioning from antenatal ART care. TRIAL REGISTRATION: Number NCT02417675 clinicaltrials.gov/ct2/show/record/NCT02417675 (retrospective reg.).

Conceptions of agency and constraint for HIV-positive patients and healthcare workers to support long-term engagement with antiretroviral therapy care in Khayelitsha, South Africa.

In the context of the optimism around antiretroviral therapy (ART) as prevention of HIV/AIDS, addressing the barriers to long-term ART adherence is critical. This is particularly important given the tendency to individualise or use a blame discourse when exploring why HIV-infected patients "fail" to adequately adhere to ART, and not sufficiently exploring contextual reasons for poor adherence that may require varying solutions. This study took place at three clinics and one hospital in Khayelitsha, South Africa, to document the contextual factors that challenged ART adherence in this community. Interviews were conducted with 20 HIV-infected patients who had defaulted on their ART and were subsequently admitted to Khayelitsha hospital for clinical complications, and 9 ART service providers including doctors, nurses and HIV counsellors. Interviews assessed the reasons patients defaulted on ART and explored ways this could be prevented. Data from both groups were analysed collectively using thematic analysis. While the interviews revealed a landscape of environmental risks threatening adherence to ART, all patients managed to overcome the identified barriers at some point in their treatment phase, indicating the fluidity of patients' needs and decision making. Patients reported that distrustful relationships with service providers could inhibit their understanding of ART and/or interrupt their follow-up at clinics. Patients described their rationale and agency underlying non-adherence, such as testing their bodies' physical limits without ART medication. The study speaks to the need to appreciate contextual social and structural barriers related to ART adherence, and how these are negotiated differently by specific sub-groups, to support an appropriate response. It is imperative to not solely emphasise loss to follow-up but also assess patients' subjective trajectory of their ART journey, decision making and agency with adhering to ART, their relations with healthcare workers, and how these dynamics are intertwined with broader constraints in health systems.