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Item The challenges of managing breast cancer in the developing world- a perspective from sub- Saharan Africa(2014-05) Edge, J; Buccimazza, I; Cubasch, H; et al.Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer, and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.Item Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness(2014) Jack, H; Wagner, R G.; Petersen I; et al.Background: Nearly one in three South Africans will suffer from a mental disorder in his or her lifetime, a higher prevalence than many low- and middle-income countries. Understanding the economic costs and consequences of prevention and packages of care is essential, particularly as South Africa considers scalingup mental health services and works towards universal health coverage. Economic evaluations can inform how priorities are set in system or spending changes. Objective: To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use (MNS) disorders and the cost-effectiveness of treatment interventions. Design: Narrative overview methodology. Results and conclusions: Reviewed studies indicate that integrating mental health care into existing health systems may be the most effective and cost-efficient approach to increase access to mental health services in South Africa. Integration would also direct treatment, prevention, and screening to people with HIV and other chronic health conditions who are at high risk for mental disorders. We identify four major knowledge gaps: 1) accurate and thorough assessment of the health burdens of MNS disorders, 2) design and assessment of interventions that integrate mental health screening and treatment into existing health systems, 3) information on the use and costs of traditional medicines, and 4) cost-effectiveness evaluation of a range of specific interventions or packages of interventions that are tailored to the national context.Item Contestations and complexities of nurses' participation in policy-making in South Africa(2014) Ditlopo, P; Blaauw, D; Penn-Kekana, L; et al.Background: There has been increased emphasis globally on nurses’ involvement in health policy and systems development. However, there has been limited scholarly attention on nurses’ participation in policy-making in South Africa. Objective: This paper analyses the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. Design: Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 frontline nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software. Results: The study found that nurses’ participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses’ participation in nursing policies. There was a disjuncture between nursing leadership and frontline nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses’ views and inputs were considered and incorporated. Conclusions: The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing associationItem The cost of harmful alcohol use in South Africa(2014-02) Matzopoulos, R G; Truen, S; Bowman, B; et al.Background. The economic, social and health costs associated with alcohol-related harms are important measures with which to inform alcohol management policies and laws. This analysis builds on previous cost estimates for South Africa. Methods. We reviewed existing international best-practice costing frameworks to provide the costing definitions and dimensions. We sourced data from South African costing literature or, if unavailable, estimated costs using socio-economic and health data from secondary sources. Care was taken to avoid possible causes of cost overestimation, in particular double counting and, as far as possible, second-round effects of alcohol abuse. Results. The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of the 2009 gross domestic product (GDP). The tangible financial cost of harmful alcohol use alone was estimated at R37.9 billion, or 1.6% of the 2009 GDP. Discussion. The costs of alcohol-related harms provide a substantial counterbalance to the economic benefits highlighted by the alcohol industry to counter stricter regulation. Curtailing these costs by regulatory and policy interventions contributes directly and indirectly to social well-being and the economy. Conclusions. Existing frameworks that guide the regulation and distribution of alcohol frequently focus on maximising the contribution of the alcohol sector to the economy, but should also take into account the associated economic, social and health costs. Current interventions do not systematically address the most important causes of harm from alcohol, and need to be informed by reliable evidence of the ongoing costs of alcohol-related harms.Item The danger of heating mercury in dental surgeries(1977) Letcher, T. M.; Cleaton-Jones, P.; Albers, M.; et al.Item Diurnal mucosal temperature variations(1987) Volchansky, A.; Cleaton-Jones, P.; Smith, M.; et al.Item Does nitrous oxide harm the dentist?(1975) Cleaton-Jones, P.; Austin, J. C.; Banks, D.; et al.Item Examiner performance with visual, probing and FOTI caries diagnosis in the primary dentition(2001) Cleaton-Jones, P.; Daya, N.; Hargreaves, J. A.; et al.To compare clinical reproducibility of dental caries diagnosis in the primary dentition under field conditions, a convenience sample of 5-year-old children in a nursery school in Germiston, was examined for dental caries by four dentists using visual (mirror), visual plus tactile (mirror plus probe) and fibre-optic transillumination (FOTI) methods. Seventeen children were examined on day one and 11 re-examined on day two. Inter-examiner agreement was high, above 90%. Visual examination on its own is comparable with the traditional visual plus tactile method and to FOTI under field conditions. New caries data collected by visual diagnosis alone may, reasonably, be compared with historical data diagnosed with visual + tactile examination.Item Hepatitis-B virus infection and the dental profession: a survey in the Witwatersrand area(1981) Lownie, J. F.; Cleaton-Jones, P. E.; Struthers, P. J.; et al.Item Is true caries diagnosis possible as we approach 2000?(1998) Grossman, E. S.; Hargreaves, J. A.; Cleaton-Jones, P. E.; et al.Item National expenditure on health research in South Africa : What is the benchmark ?(2014-07) Paruk, F.; Blackburn, J.M.; Friedman, I.B.; et al.The Mexico (2004), Bamako (2008) and Algiers (2008) declarations committed the South African (SA) Ministry of Health to allocate 2% of the national health budget to research, while the National Health Research Policy (2001) proposed that the country budget for health research should be 2% of total public sector health expenditure. The National Health Research Committee has performed an audit to determine whether these goals have been met, judged by: (i) health research expenditure as proportions of gross expenditure on research and development (GERD) and the gross domestic product (GDP); and (ii) the proportion of the national health and Department of Health budgets apportioned to research. We found that total expenditure on health research in SA, aggregated across the public and private sectors,was R3.5 billion in 2009/10, equating to 16.7% of GERD. However, the total government plus science council spend on health research that year was only R729 million, equating to 3.5% of GERD (0.03% of the GDP) or 0.80% of the R91.4 billion consolidated government expenditure on health. We further found that R418 million was spent through the 2009/2010 Health Vote on health research, equating to 0.46% of the consolidated government expenditure on health or 0.9% of the R45.2 billion Health Vote. Data from other recent years were similar. Current SA public sector health research allocations therefore remain well below the aspirational goal of 2% of the national health budget. We recommend that new, realistic, clearly defined targets be adopted and an efficient monitoring mechanism be developed to track future health research expenditure.Item Partial denture teaching programmes presented to undergraduate students at Dental Schools in the Republic of South Africa(1982) Collis, J.; Slabbert, J. C. G.; Cleaton-Jones, P. E.; et al.Item Pulpal responses to two luting cements(1982) Valcke, C. F.; Cleaton-Jones, P. E.; Austin, J. C.; et al.Item Relationship between fluoride concentration in enamel, DMFT Index, and degree of fluorosis in a community residing in an area with a high level of fluoride(1976) Bischoff, J. I.; Van Der Merwe, E. H. M.; Retief, D. H.; et al.The DMFT index, degree of fluorosis (DEGF), fluoride concentration in enamel (F), and depth of etch (D) were determined in participants living in an area with a high fluoride level. A statistically significant difference was found between men and women for F and D. A significant correlation was established between F and DEGF and between F and age for men, but not for women.Item Setting ART initiation targets in response to changing guidelines : The importance of addressing both steady-state and backlog(2014-06) Martin, C; Naidoo, N P; Venter, W D F; et al.Background: Target setting is useful in planning, assessing and improving antiretroviral treatment (ART) programmes. In the past 4 years, the ART initiation environment has been transformed due to the change in eligibility criteria (starting ART at a CD4+ count <350 cells/μl v. <200 cells/μl) and the roll-out of nurse-initiated management of ART. Objective: To describe and illustrate the use of a target-setting model for estimating district-based targets in the era of an expanding ART programme and changing CD4+ count thresholds for ART initiation. Method: Using previously described models and data for annual new HIV infections, we estimated both steady-state need for ART initiation and backlog in a North West Province district, accounting for the shift in eligibility. Comparison of actual v. targeted ART initiations was undertaken. The change in CD4+ count threshold adds a once-off group of newly eligible patients to the pool requiring ART – the backlog. The steady-state remains unchanged as it is determined by the annual rate of new HIV infections in previous years. Results: The steady-state need for the district was 639 initiations/month, and the backlog was ~15 388 patients. After the shift in eligibility in September 2011, the steady-state target was exceeded over several months with some backlog addressed. Of the total backlog for this district, 72% remains to be cleared. Conclusion: South Africa has two pools of patients who need ART: the steady-state of HIV-infected patients entering the programme each year, determined by historical infection rates; and the backlog created by the shift in eligibility. The healthcare system needs to build longterm capacity to meet the steady-state need for ART and additional capacity to address the backlog.Item Social class and dental caries in 11-12-year-old South African schoolchildren(1989) Cleaton-Jones, P.; Hargreaves, J. A.; Williams, S. D. L.; et al.The objective of this study was to examine effects of social class on dental caries in five African populations. Definitions of social class that could be used for the different ethnic groups are outlined. A total of 1 154 children from rural black, urban black, urban Indian, urban coloured and urban white groups were clinically examined and classified into social class by parental occupations. Within group comparisons showed no statistically significant differences in DMFT or DMFS scores by social class. Comparison of the urban white children to a similar group in South Wales showed slightly lower caries in South African children of similar social class. The complexity of the different ethnic groups in South Africa, in respect of social classification, is difficult to assess for comparison with social systems in developed countries. It is recommended that an appropriate social classification be developed for South Africa ’s developed/developing population mixture. Also as we enter the 1990’s sound baseline caries data need to be collected for longitudinal evaluation of changes in the disease patternItem South African Menopause Society revised consensus position statement on menopausal hormone therapy, 2014(2014-08) Guidozzi, F; Alperstein, A; Bagratee, J S; et al.The South African Menopause Society (SAMS) consensus position statement on menopausal hormone therapy (HT) 2014 is a revision of the SAMS Council consensus statement on menopausal HT published in the SAMJ in May 2007. Information presented in the previous statement has been re-evaluated and new evidence has been incorporated. While the recommendations pertaining to HT remain similar to those in the previous statement, the 2014 revision includes a wider range of clinical benefits for HT, the inclusion of non-hormonal alternatives such as selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors for the management of vasomotor symptoms, and an appraisal of bioidentical hormones and complementary medicines used for treatment of menopausal symptoms. New preparations that are likely to be more commonly used in the future are also mentioned. The revised statement emphasises that commencing HT during the ‘therapeutic window of opportunity’ maximises the benefit-to-risk profile of therapy in symptomatic menopausal women.Item Tuberculosis control in South Africa : Successes challenges and recommendations(2014-03) Churchyard, G J; Mametja, L D; Mvusi, L; et al.Tuberculosis (TB) remains a global health threat, and South Africa (SA) has one of the world’s worst TB epidemics driven by HIV. Among the 22 countries with the highest burden of TB, SA has the highest estimated incidence and prevalence of TB, the second highest number of diagnosed multidrug-resistant TB cases, and the largest number of HIV-associated TB cases. Although SA has made notable progress in reducing TB prevalence and deaths and improving treatment outcomes for new smear-positive TB cases, the burden of TB remains enormous. SA has the means to overcome this situation. In addition to better implementing the basics of TB diagnosis and treatment,scaling up the use of Xpert MTB/RIF as a replacement for sputum smear microscopy, strengthening case finding in and beyond healthcare facilities and a greater focus on TB prevention for people living with HIV, particularly earlier initiation of and scaling up antiretroviral therapy and scaling up continuous isoniazid preventive therapy, will have a substantial impact on TB control. New TB drugs, diagnostics and vaccines are required to further accelerate progress towards improved TB control in SA and beyondItem Tuberculosis preventive therapy : An underutilised strategy to reduce individual risk of TB and contribute to TB control(2014-05) Churchyard, G J; Chaisson, R E; Maartens, G; et al.Tuberculosis (TB) remains a global health problem, and South Africa (SA) has one of the world’s worst TB epidemics. The World Health Organization (WHO) estimated in 1999 that one-third of the world’s population was latently infected with TB. In SA up to 88% of HIV-uninfected young adults (31 - 35 years) are latently infected with TB. In the most recent meta-analysis, 6 - 12 months of isoniazid preventive therapy (IPT) was associated with a lower incidence of active TB than placebo (relative risk (RR) 0.68; 95% confidence interval (CI) 0.54 - 0.85), with the greatest benefit among individuals with a positive tuberculin skin test (TST) (RR 0.38; 95% CI 0.25 - 0.57). A clinical trial of IPT given with antiretroviral therapy (ART) for 12 months reduced TB incidence by 37% compared with ART alone (hazard ratio (HR) 0.63; 95% CI 0.41 - 0.94). The effect of IPT is limited in high-burden countries. IPT for 36 months v. 6 months reduced TB incidence among HIV-positive, TST-positive participants by 74% (HR 0.26; 95% CI 0.09 - 0.80). A study of more than 24 000 goldminers confirmed that IPT is safe, with only 0.5% experiencing adverse events. A meta-analysis of studies of IPT since 1951 did not show an increased risk of developing resistance. Alternative TB preventive therapy regimens, including high-dose isoniazid and rifapentine given weekly for 3 months, have been shown to have similar efficacy to IPT. Mathematical modelling suggests that scaling up continuous IPT targeted to HIV-positive persons, when used in combination with other treatment and prevention strategies, may substantially improve TB control.Item Use of DI-S and CPITN as predictors in dental caries studies in the primary dentition(1991) Cleaton-Jones, P.; Hargreaves, J. A.; Beere, D.; et al.The DI-S (simplified oral debris index), CPITN (Community Periodontal Index of Treatment Needs) and dmfs (dental caries experience in the primary dentition were recorded in 395 5-year-old black children living in rural and urban areas of Southern Africa. The DI-S and CPITN were grouped, independently and together, to examine their use as simple field methods of predicting dental caries. For each grouping the sensitivity, specificity and positive and negative predictor values were calculated. A CPITN grouping of 0 or of two or more sextants with bleeding, provided the most convenient specificity, sensitivity and predictor values. It is recommended that this simple method should now be used in prospective studies of caries activity.