Electronic Theses and Dissertations (PhDs)

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The effects of indigenous South African plant extracts (cotyledon c. orbiculata and tulbaghia. violacea) on triple negative breast cancer cells
(University of the Witwatersrand, Johannesburg, 2024) Alaouna, Mohammed; Dlamini, Zodwa
This dissertation explored the potential therapeutic applications of water and methanol extracts of C. orbiculata and Tulbaghia violacea, indigenous to Southern Africa, targeting triple-negative breast cancer (TNBC). TNBC, a significant subset of breast cancer cases, is notably challenging because of the absence of key hormone receptors, often leading to less favourable patient outcomes and a high relapse rate within five years. The research approach was both thorough and meticulous, utilising two cell lines: one representing normal breast tissue and the other representing TNBC. Extensive cytotoxicity assays were conducted to determine the IC50 values for TNBC cells, which is critical for understanding how plant extracts affect cellular activities such as migration, invasion, adhesion, cell cycle regulation, and apoptosis induction. Additionally, the antioxidant properties of these extracts were examined, which showed significant effects, especially in the aqueous extract of Tulbaghia violacea, on TNBC cellular dynamics. This study employed a comprehensive array of analytical techniques, including Fourier transform infrared spectroscopy (FTIR), gas chromatography-mass spectrometry (GC-MS), and nuclear magnetic resonance (NMR) spectroscopy, to identify the specific molecular constituents of these extracts. Computational docking studies have focused on the interactions between these molecules and the anti-apoptotic protein, COX2. Whole transcriptome sequencing of RNA from both TNBC and normal breast cells treated with T. violacea extract provided valuable insights into the affected signaling pathways. An antibody array assay further elucidated protein changes in the receptor tyrosine kinase (RTK) pathway. The half-maximal inhibitory concentration (IC50) values were determined for the aqueous and methanol extracts of T. violacea at 400 μg/mL and 820 μg/mL, respectively, and for C. orbiculata at 830 μg/mL and 700 μg/mL, respectively. Exposure to the water-soluble extract of T. violacea resulted in a marked increase in apoptosis in TNBC cells, with approximately 82% undergoing programmed cell death, compared to 32% in normal breast cells. Chemical profiling identified a range of compounds, including 36 distinct compounds identified through GC-MS and 61 identified through NMR, many of which bear structural similarities to known anti-cancer agents. Notably, five compounds demonstrated a high affinity forbinding to COX2, with d-glycero-d-galacto-heptose achieving an impressive docking score, surpassing several established COX2 inhibitors. This study highlights the therapeutic potential of T. violacea compounds and lays the groundwork for further exploration of their mechanisms of action and potential applications in cancer treatment. This emphasises the importance of investigating natural plant extracts as a source for the development of new and effective treatments for TNBC, which is an area of urgent need in oncology
An ethico-legal analysis of broad consent for biobank research in South Africa: Towards an enabling framework
(University of the Witwatersrand, Johannesburg, 2024) Maseme, Mantombi Rebecca
Biobanks preserve collections of human biological material and data for the benefit of medical research. Using and transferring human biological data and materials both inside and outside of South Africa is often a requirement of biobank research. Broad consent is allowed by the South African National Department of Health Ethics Guidelines but appears to be prohibited by section 13(1) of the Protection of Personal Information Act 4 of 2013. Additionally, the Act mandates that all personal data (including biobank sample data) be collected for legitimate, definite, and clearly stated purposes. There is room for several interpretations of the Act because of this discord between the two instruments. Given the connection between the transfer of samples and data, the long-term nature of biobanking, which makes it impractical to provide too much or adequate information because it is simply not available at the time of sample collection, and the various ways that the Protection of Personal Information Act 4 of 2013 have been interpreted, I aim to respond to the following question: How should South Africa’s current regulatory framework appropriately permit broad consent use for biobank research where the transfer of samples and their associated data are contemplated? The research question is addressed by applying ethical principles and theories, as well as analysing and evaluating relevant ethico-legal frameworks and literature. The study involves no research participants and no collection or analysis of any new data. Arguments for and against using broad consent for biobank research are discussed by demonstrating the potential for biobank research to do a great deal of good for humanity; the ambiguity in the current regulatory framework regarding whether broad consent is permissible for personal information/data; and the ethical justifiability of broad consent. In summary, the proposed regulatory framework amendments are those that would be required to allow for ethically justifiable biobank research broad consent use. These include removing regulatory ambiguity regarding broad consent use, ensuring adequate safeguards for research participants by specifying rules for data access and personal information processing, and incorporating consent form information requirements into the national Consent Template as specified in the National Department of Health Ethics Guidelines
Medical students’ professional identity formation during a social upheaval: a qualitative study
(University of the Witwatersrand, Johannesburg, 2023) Mokhachane, Mantoa
This phenomenological qualitative study, with an autoethnographic aspect, explored the University of the Witwatersrand’s medical students’ experiences of professionalism and professional identity formation amidst protests and social upheaval, namely, #FeesMustFall protests. The socio-historical autoethnographic sections emanate from my undergraduate journey in the same medical school 32 years before this study. I interviewed 13 participants. The participants’ stories echoed my own story during my undergraduate years in medical training, hence the inclusion of autoethnography. In this study, I question the under- representation of previously marginalised groups in the discourse of professionalism and professional identity formation. I also question the lack of an African influence on professionalism and professional identity formation. This study was conducted at the University of the Witwatersrand after obtaining Human Research Ethics Committee approval. I used an interpretive qualitative phenomenological enquiry in order to understand the meaning of students’ experiences. I also did not want to bracket myself, as my experiences resonated with those of the contemporary students, hence the choice of an interpretive instead of a descriptive phenomenological approach. A purposive sample was drawn from medical students. Thirteen semi-structured interviews were conducted in 2020, during the Covid-19 pandemic. Interviews were conducted with 13 participants, eight final-year medical students and five recent graduates who were in the first- or second-year internship (residency) training. The participants were five women (four Black and one White) and eight men (five Black and three White). An interview guide was used to probe the students’ journeys towards becoming doctors, their experiences during the #FeesMustall protests, experiences of professionalism and how #FeesMustFall impacted their professional identity development. Interviews were transcribed verbatim and analysed in MAXQDA 2020. I used an inductive approach, where each transcript was analysed as an individual case for the essence of its meaning and how participants’ experiences influenced their being and becoming doctors. When analysing the data through an African lens, Ubuntu, I used metaphors to allow the reorientation of professional identity formation, what professionalism means to contemporary students and how professionalism is weaponised against those who do not fit the western ideals of a medical professional. Racism was the foundation of many ills in medical education, particularly in the clinical spaces at the hospitals affiliated with the University of the Witwatersrand. This study highlights the contribution of Ubuntu-based values on professional identity formation and the influence of Ubuntu on the meaning of professionalism to contemporary medical students and recent graduates. It adds an African voice to the global western professional identity theories. This study encourages other researchers to explore their contexts to define professionalism and how professional identity is attained. I recommend reconstructing professionalism using Ubuntu as professionalism in medical education through letsema, Ubuntu, advocacy, and the acceptance of the intersectionality with which trainees enter medical education
Developing a framework to improve glycaemic control among patients with type 2 diabetes mellitus in Kinshasa, democratic republic of the Congo
(University of the Witwatersrand, Johannesburg, 2023) Lubaki, Jean-Pierre Fina
Diabetes mellitus is a significant problem globally with a higher impact in developing countries. Glycaemic control is one of the main goals of type 2 diabetes treatment, as it delays or avoids the occurrence of diabetes related complications. In sub-Saharan Africa, including the Democratic Republic of the Congo, glycaemic control rates are sub optimal. This study aimed to develop a framework to improve glycaemic control among patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo. This project comprises four sub-studies. The first sub-study was a systematic review and meta-analysis of studies published from 2012 to 2022 on the prevalence and factors driving glycaemic control in sub-Saharan Africa. Younger and older age, gender, lower income, absence of health insurance, low level of education, place of residence, family history of diabetes, longer duration of diabetes, pill burden, treatment regimen, side effects, use of statins or antihypertensives, alcohol consumption, smoking, presence of comorbidities/complications, and poor management were associated with poor glycaemic control. On the other hand, positive perceived family support, adequate coping strategies, high diabetes health literacy, dietary adherence, exercise practice, attendance at follow-up visits, and medication adherence were associated with good glycaemic control. The second sub-study was a concurrent parallel mixed methods cross-sectional analytical study among a total of 643 patients with type 2 diabetes — 23 in the qualitative phase and 620 in the quantitative phase — on factors associated with poor glycaemic control in Kinshasa. Five themes were identified as explanations for poor glycaemic control: financial constraints, limited social and relational support, difficulties with lifestyle changes, beliefs and practices about diabetes, and ability to adapt to caring for the illness. The quantitative phase showed that about two-thirds of the participants (67.8%; n=420) had poor glycaemic control and more than half were on insulin monotherapy (53.9%; n=334). No sociodemographic or lifestyle characteristics were associated with poor glycaemic control. Participants on monotherapy with insulin (AOR: 1.72 (95%CI:1.17-2.55)) had increased odds of poor glycaemic control compared to participants on oral hypoglycaemic drugs. In contrast, participants having and those having uncontrolled blood pressure (AOR: 0.60 (95%CI:0.39-0.92)) were less likely to have poor glycaemic control compared to participants having controlled blood pressure. The third sub-study was a qualitative study on the perspectives of 16 healthcare providers and 10 patients with type 2 diabetes on improving glycaemic control in Kinshasa. From the healthcare providers statements regarding improving glycaemic control, three themes were identified: strengthening the healthcare system, supporting persons with diabetes/population, and adopting supportive health policies. From the persons with diabetes perspectives three themes were also identified: need for support for caring of the illness, need for enhanced knowledge about diabetes, and the need for better communication with healthcare providers. Using the results of the first three studies, the fourth sub-study, a Delphi study, brought together 36 experts on the management of diabetes, who developed and agreed on the following strategies for improving glycaemic control in Kinshasa: strengthening the healthcare system, enhancing the awareness of diabetes, alleviating the financial burden of diabetes, enhancing the adoption of lifestyle modifications, and reducing the proportion of undiagnosed diabetes. These five strategies included a total of 39 potential interventions. Strengthening the healthcare system for better care promotes better organization and provision of services for diabetes care. Enhancing the awareness of diabetes among the population/patients stresses the need to develop and share information about diabetes through the most appreciated channels by the population. Alleviating the financial burden of diabetes targets for the long-term the need for universal health coverage, and meanwhile, encouraging the development of community-based health insurance. It also includes the search for a reduction in costs of diabetes medicines and materials through public-private partnerships. Enhancing the adoption of lifestyle modifications in our setting passes through the provision of accurate information on the content of lifestyle changes, and developing realistic exercise and dietary plans. Reducing the proportion of undiagnosed patients with diabetes needs to increase the detection of diabetes by targeting high risk groups at the level of primary care settings. This study highlighted the need to ensure that patients with type 2 diabetes benefitted from the full package required for diabetes care in a broader framework of managing non-communicable diseases in Kinshasa
Children on the streets of Ibadan, Nigeria: experiences, family dynamics and health status
(University of the Witwatersrand, Johannesburg, 2023) Obimakinde, Abimbola Margaret; Moosa, Shabir
Background This research explored the phenomenon of children-on-the-streets of Ibadan, Nigeria. These children are found on the streets without any adult supervision. They constitute the majority of street children but are linked to their families and therefore they come from and return home daily. The Bronfenbrenner ecological system theory on children’s development and interactions within contextual ecosystems, underpinned this study. This research aimed to understand the phenomenon of children on the streets of Ibadan, specifically their family dynamics, lived experiences, health, and needs. Method This was mixed-method research, although largely a qualitative approach was employed to obtain the narratives of children on the streets and significant adults in the children’s exosystem. All ethical principles were observed in the conduct of the studies. In-depth interviews, street photographs, field notes and observation were employed during the data collection, between June 2021 to September 2021. Fifty-three (53) participants including street shop owners, children on the street, Oyo State’s child welfare officers and parental figures were selected from a street in each of Ibadan's five urban Local Government Areas (LGAs). These LGAs include the Ido, Northwest (NW), Southwest (SW), North(N) and Northeast (NE). Relevant quantitative data was collected from the children only. The sampling of participants was initially purposive and subsequently by snowball technique. Framework analysis supported with Atlas Ti version 22, was conducted and the data was triangulated, for a robust understanding of the lived experiences, health, family dynamics and needs of children on the streets of Ibadan. Principal component analysis and frequencies were conducted with SPSS version 21 for the descriptive quantitative data obtained from the 21 recruited children, solely for thick description. The quantitative data included the Household Hunger Scale (HHS), Wealth Index (WI), and Body Mass Index (BMI). Results The participants comprised, 12 child welfare officers, 10 street shop-owners, 10 parental figures and 21 children on the street. The children were average 15.8 years old and had spent at least 4 years on the streets. The children had structurally defective families including broken large-sized families (18 of the 21 children were from families with > 4 children) with attendant poor socioeconomic resources and poor filial interpersonal relationships. More than half of the children were from families with poor WI scores. The lived experiences of children on the street included beneficial experiences related to the monetary gains on the streets with overwhelming challenging experiences. The challenging experiences included financial crisis, school failure, initiation into prostitution and street gangs, induction into substance use, harassment on the street, risk of kidnapping and ritual killing. The physical health problems of the children on the streets included poor nutrition, poor toilet habits, allergies, infectious diseases, and physical minor and major injuries (40% of them had evident facial or limb scars) sustained on the streets. Half of the children had a BMI in the “underweight” range and a third had HHS scores which indicated moderate household hunger. The mental health problems included sexual, verbal and substance abuse, although psychological strength was found in a few children on the street, more than half of the children responded “yes” to feelings of sadness or hopelessness. The children on the streets of Ibadan had many unmet needs due to governmental shortcomings including failure of the Oyo State’s education systems, inadequate vocational training programs for uneducable children, lax State child welfare laws, difficult rehabilitation of children on the street and poor policies on family size. There were bits of interventions which catered to children on the streets including parental poverty alleviation schemes and community-based child welfare alert programmes. Discussion The family dynamics driving child streetism for family-connected children in Ibadan are devaluation of family life, parental irresponsibility, and poor filial relationship, underscored by large family size, economic constraints and socio-cultural decadence. The family setting is that of broken homes with many children from a monogamous union or blended families with poor financial and social resources. The mothers were either in a monogamous unwedded union with “absent” fathers cohabiting with another woman. There was an economic-oriented filial relationship with the parentification of the children. The lived experiences of children on the street included beneficial experiences centred around monetary gains, overshadowed by challenging experiences. Monetary gains were meagre and predominantly through the hawking of edible produce. The challenging experiences included the loss or theft of money made on the streets by these children, school failure, initiation into prostitution and street gangs, induction into substance use, street harassment, risk of kidnapping and ritual killing. The physical health problems included poor carbohydrate-based diet with consequent undernutrition, open defecation with attendant health risks, predisposition to allergies, acquisition of infections including STIs, minor physical injuries and a few deaths from Road Traffic Accidents (RTAs). Sexual, verbal and substance abuse were common mental health problems, although few children acquired mental resilience. The governmental shortcoming which feds the epidemic of children on the street included the failure of the Oyo State’s education systems, inadequate vocational training programs for uneducable children, lax State child welfare laws, difficult rehabilitation of children on the street and poor policies on family size. The parental poverty alleviation scheme was one of the state’s government interventions, however, jurisdictional failure overshadows the efforts against child streetism in Ibadan. Conclusion The continuing influx of children on the streets of Ibadan is due to the peculiar family dynamics and the prevailing governmental jurisdictional failure. The presence of children on the street is fraught with a lot of difficult lived experiences and health problems. An appreciation of these factors, and synchronized targeted multi-level interventions within the ecosystems can positively influence measures to combat the epidemic of children on the streets of Ibadan, Oyo state, South- west Nigeria
Adverse childhood experiences and social and health outcomes in later life
(2024) Naicker, Sara N.
Background: Well-established literature points to early life experiences and childhood adversities setting the foundation for health and development and influencing life trajectories. Nurturing, responsive caregiving in a safe and stable environment is associated with healthy, productive lives throughout adulthood. On the other hand, adverse experiences in childhood are associated with poor health and wellbeing, risky behaviour and reduced human capital. How this adversity is measured and the context in which it is measured may provide insight into the relationship between adversity and outcomes over and above what has been found in high income countries. Aim: The overall aim of this study is to examine adverse childhood experiences (ACEs) in a South African birth cohort. Specific objectives of the study include: a) developing prospective and retrospective profiles of ACEs in the sample, b) establishing levels of agreement between these two profiles of ACEs, c) estimating the prevalence and clustering of ACEs in this population-based urban sample, d) examining the associations between exposure to ACEs and a range of physical and mental health and social outcomes, and e) understanding the role that recent stress plays in the relationship between exposure to ACEs and poor outcomes. Methods: This study uses a secondary analysis design using data from the longitudinal Birth to Thirty cohort. The cohort began in 1990 with the enrolment of 3,273 pregnant mothers and has followed the children born to these women for more than thirty years. The 10-item ACE Index developed by the CDC-Kaiser’s ACEs Study was expanded to include five additional ACEs common in the South African context – chronic unemployment, violence in the community, household death, parent death, and separation from parents. Prospective profiles of ACEs were collated from data collected over the first 18 years of the child’s life, initially reported by primary caregivers until age 11, then self-reported from ages 11 to 18. Retrospective profiles of ACEs were collected in young adulthood when the participants were 22 years old, along with an index of recent stressors. A series of human capital outcomes – those encompassing physical and mental health and psychosocial adjustment, were assessed at age 28. ACEs in the sample were conceptualized in three ways ‒ as single adversities, such as physical or sexual abuse, cumulative adversity in the form of the ACE score, and clusters of adversity determined by their patterning. Cohen’s kappa statistics and concordance rates were generated to establish the levels of agreement and consistency between prospective and retrospective reports of ACEs (timing) and between reports given by caregivers and children at age 11 (source). Descriptive statistics and latent class analysis were used to estimate the prevalence of ACEs and to explore the patterning of ACEs among participants. Logistic regression analysis explored associations between all three conceptualizations of ACEs and outcomes, disaggregated by sex. Mediation and moderation analyses were conducted to examine the influence of recent stress on mental health outcomes. Findings: Comparisons between prospective and retrospective reports of ACEs show that there is relatively low-to-moderate agreement between timing and sources of reports of ACEs. Agreement varies depending on the adversity in question – with greater levels for objective Naicker, S.N. 2023. Adverse Childhood Experiences and Social and Health Outcomes in Later Life experiences such as parental death and lower levels for subjective experiences such as chronic unemployment. Differences in agreement were partly due to prospective and retrospective reports identifying largely different groups of people; those who only report high exposure prospectively, those who only report high exposure retrospectively and those that overlap. Using either prospective or retrospective reports, the prevalence of ACEs in this sample were high, although there were significant decreases in prevalence from prospective reporting to retrospective reporting. ACEs tended to co-occur, and where one ACE was reported, the likelihood of others increased. Clusters of ACEs split distinctively into high-low:dysfunction abuse categories; with one group likely to have low exposure, another with high generalized exposure to all ACEs, a third with moderate exposure characterized by household dysfunction and a fourth with moderate exposure driven by emotional abuse and/or neglect. All three conceptualizations of ACEs were significantly associated with poorer outcomes. Single ACEs such as physical, sexual and emotional abuse, and exposure to intimate partner violence, were independently and strongly associated with poorer outcomes in adulthood. Increased exposure to ACEs, or cumulative adversity, was also linked to poorer outcomes in a graded manner, with the likelihood of experiencing poor outcomes increasing along with exposure. The clusters with high levels of exposure to ACEs and moderate levels of exposure driven by emotional abuse were most at risk for poor outcomes. There were significant differences in exposure to ACEs, outcomes and the associations between the two by sex. Associations also differed for prospective and retrospective reporting with the strength of association varying depending on the outcome in question. Recent stressors were found to play a confounding role in the relationship between ACEs exposure and poor outcomes. Although recent stressors had a different impact on those who reported high ACEs exposure prospectively versus those who reported high ACEs exposure retrospectively. The influence of recent stressors on the mental health of those who reported high exposure to ACEs prospectively supported a sensitization model. In contrast, the role of recent stressors on the mental health of those who reported high exposure to ACEs retrospectively supported a stress inoculation model. This suggests two potential pathways for risk. Conclusion: In combination and accumulation, it is demonstrated here that adverse experiences in childhood have an impact on health and wellbeing in adulthood. Specific individual ACEs can be teased out for their independent effect on outcomes, but the additive effects of multiple adversities lead to almost exponential increases in the risk for a myriad of negative physical and mental health and social outcomes. These findings provide important links from South Africa’s context of high levels of violence in all forms and multiple hardships that families with large burdens of care endure, with little support, to many of the human capital outcomes on which productive, healthy and happy lives depend. Born at the dawn of democracy, with anticipation for opportunity, many of the children in this cohort were raised in contexts of adversity that may have been experienced as normative in those settings. Regardless of whether these experiences leave enough of a mark to be recalled later in life, the strain of cumulative adversity has had persistent and serious effects on their mental health, their ability to finish school, find a job and stay out of trouble.
Integrated biological and behavioural assessment of human immunodeficiency virus and sexually transmitted infections among tertiary student men who have sex with men in Nairobi, Kenya: project bespoke
(2024) Mwaniki, Samuel Waweru
Aims: The aims of this study were to: assess the appropriateness and acceptability of using respondent-driven sampling (RDS) as a strategy for recruiting tertiary student MSM (TSMSM) in a HIV/STIs bio-behavioural survey, estimate HIV/STIs prevalence and associated risk factors among TSMSM, explore experiences of TSMSM with access and use of health services, and assess healthcare providers’ (HCPs’) attitudes and perspectives towards care for TSMSM. Methods: The study was done in Nairobi, Kenya. During the first phase in September and October 2020, formative in-depth qualitative interviews were held with key personnel working in MSMfriendly health facilities (n=3), and TSMSM peer leaders (n=13), to assess the appropriateness and acceptability of using RDS to recruit TSMSM in a bio-behavioural survey. Subsequently, during the second phase in February and March 2021, six TSMSM selected from the 13 in the first phase, started off the RDS recruitment of another 242 TSMSM who participated in a cross-sectional biobehavioural survey to estimate HIV/STIs prevalence and associated risk factors. The survey was digitally self-administered on REDCap® platform. Participants received serological testing for HIV and Treponema pallidum, and pooled molecular testing for Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae, and Trichomonas vaginalis using urethral, anorectal and oropharyngeal samples. The third phase in September 2021 involved qualitative work to assess health access and delivery for TSMSM. In-depth interviews were held with TSMSM (n=22) purposely selected from the TSMSM (n=248) who participated in the biobehavioural survey. The interviews explored experiences of TSMSM with access and use of health services. During the same month, HCPs (n=36) took part in six focus group discussions to assess their attitudes and perspectives towards care for TSMSM. Qualitative data was analysed 2 thematically using NVivo v.11 (first phase) and v.12 (third phase), and quantitative data was analysed using Stata v.15 and RDS-Analyst v0.72 (second phase). Results: Formative qualitative work demonstrated that RDS was both appropriate and acceptable for recruiting TSMSM in the bio-behavioural survey. The median age of TSMSM who participated in the bio-behavioural survey was 21 years (interquartile range 20-22 years). RDS-adjusted prevalence of HIV, at least one of the five STIs, chlamydia, gonorrhea, Mycoplasma genitalium infection, trichomoniasis and latent syphilis were: 3.6%, 58.8%, 51.0%, 11.3%, 6.0%, 1.5% and 0.7%, respectively. Higher risk of HIV infection was independently associated with studying in private tertiary institutions, preferring a sex partner of any age, last sex partner being >25 years, meeting the last sex partner online and prevalent gonorrhea infection. Inconsistent condom use, and the last sex partner being a regular partner were independently associated with testing positive for at least one of the five STIs. From the qualitative work in the last phase, TSMSM vocalized experiences of prejudice, stigma and discrimination in public and institution-based health facilities, but felt they were equitably handled in community pharmacies, private and MSM-friendly health facilities. A majority of HCPs articulated positive attitudes towards care for TSMSM, while a minority expressed discomfort and displayed attitudes that likely reflected on their lived biases as it related to offering care and services to TSMSM. Conclusion: The demonstrated high HIV prevalence among TSMSM in Nairobi reflects the urgent need for tailored structural, biomedical and behavioural prevention interventions for this young key population. Structural interventions are required to address the environmental, social and economic factors that influence individual risk and protective behaviours in relation to HIV infection. Biomedical interventions such as pre-exposure prophylaxis are necessary to reduce the chances of transmission of HIV. The observed high prevalence of curable STIs calls for interventions to improve prevention, as well as prompt detection and treatment of these STIs. This is important because untreated STIs biologically potentiate the transmission and acquisition of HIV, and cause considerable morbidity on their own. Furthermore, there is a need for interventions that foster inclusive attitudes among, and improve the knowledge/skills of HCPs in tertiary institution-based health facilities, so as to make services more culturally competent, equitable and accessible for TSMSM.
Potential protein biomarker discovery for gallbladder cancer in a South African cohort
(2024) Baichan, Pavan
Gallbladder cancer (GBC) has a poor prognosis with the prevalence of GBC varying according to geographical location. The prevalence of GBC in South Africa is poorly tracked, and the molecular mechanisms associated with GBC in African patients are inadequately understood. This study aimed to determine dysregulated proteins in tissue and blood plasma in South African GBC patients to identify potential molecular mechanisms of disease progression and plausible biomarkers. Following ethical approval, tissue from 27 GBC, 13 gallstone disease (GD), and five normal tissues were obtained. Blood plasma was collected from 54 GBC and 73 benign biliary pathology (BBP) patients who consented to the study. A bottom-up proteomics approach was undertaken, using PAC and HILIC digestion methods, and SWATHMS for quantitative proteomic profiling. Hierarchical cluster analysis, PCA analysis, and Spearman’s rank correlation analysis were performed. Furthermore, pathway and network analyses were conducted. There were 62, 194, and 105 dysregulated proteins in the GBC/Normal, GBC/GD, and GD/Normal group comparisons, respectively, and 33 dysregulated proteins in the GBC/BBP plasma comparison. The dysregulated proteins in GBC patients enriched pathways involved in smooth muscle contraction, metabolism, extracellular matrix organisation and interactions, innate immunity, and platelet and neutrophil degranulation. Further analysis showed that S100A8 and S100A9 were downregulated in GBC plasma patients with GD history compared to those with no GD history. Additionally, APOE and ITIH3 were elevated in non-metastatic staging GBC patients. Seven proteins were found to be commonly dysregulated in GBC/GD and GBC/BBP comparisons and another two proteins were commonly dysregulated in the GBC/Normal, GBC/GD, and GBC/BBP comparisons, termed “Commonly dysregulated proteins (CDPs)”. Quality control assessment of the MS2 fragment ion chromatograms of the CDPs indicated strong signal-to-noise ratios and correct fragment-to-precursor matching. The CDPs could distinguish between GBC and controls and the Spearman’s rank correlation test showed significant correlations between the expression of the CDPs. The identified dysregulated proteins aid in further understanding the molecular mechanisms associated with GBC in patients with African ancestry. The alteration of specific proteins in tissue and plasma samples suggests their potential use as biomarkers for GBC patients in this sample cohort.
Long-term outcomes of HIV infected, and uninfected children aged 1-59 months following inpatient management of severe acute malnutrition
(2024) Bwakura-Dangarembizi, Mutsawashe
Children with complicated severe acute malnutrition (SAM) are at a high risk for mortality and morbidity in the time after hospital discharge, and those with HIV are particularly vulnerable. What is not known is whether this higher risk for poor outcomes in children with HIV has improved in the era of treating all who are infected. The thesis' main aim was to characterize the 52-week outcomes of children aged 1 to 59 months who were hospitalized for complicated SAM and to identify the characteristics present at hospital discharge that were most predictive of these outcomes. The thesis utilised the HOPE SAM study, an observational cohort established in Zimbabwe and Zambia that enrolled children hospitalised for complicated SAM and followed them up for one year after discharge from hospital. The study outcomes were death, morbidity, nutritional recovery and body composition assessed using skinfold thickness and bioelectrical impedance analysis. There were 3 main findings from the thesis; nearly 1 in 10 children treated for SAM died and the risk of dying continued throughout the one year following discharge. Children living with HIV had an almost 4-fold higher mortality compared to those without HIV regardless of whether they were receiving antiretroviral therapy or not; wasted children and those with ongoing SAM had a 2-fold higher mortality compared to those who had oedema on admission; and cerebral palsy was associated with a nearly 6-fold higher mortality risk. Similar risk factors, with the exception of HIV infection and addition of stunting were associated with impaired anthropometric recovery and increased hospital readmission. In this cohort, the time to hospital readmission was correlated with low peripheral fat mass and low lean mass. Overall, this thesis emphasizes the vulnerability of children treated for SAM even after they are released from the hospital and identifies high-risk populations that require focused interventions to enhance outcomes
Support programme for healthcare professionals involved in adverse events in public hospitals in Gauteng
(2024) Nkosi, Elizabeth Malefu
Background: Adverse events in the healthcare services result not only in administrative and financial costs to the healthcare institution, but also in personal costs to the patients and their families, who are often angry, disappointed, and sad. In the current litigious healthcare climate, relatives, supported by legal advisors, often seek redress as a way of managing their distress. Thus, patients are not the only victims of adverse events. The healthcare professionals that are directly involved often shoulder the blame, sometimes fairly, and sometimes unfairly, while they too need psychological support. A culture of blame in institutions can lead to healthcare professionals involved in an adverse event being marginalised, feeling personally responsible for the event and that they have failed the patient, and they are left to suffer in silence. While anecdotal evidence exists that such stress may lead to negative coping mechanisms, the researcher has not identified any research study conducted in public hospitals in Gauteng, South Africa that identifies and describes the influence that the involvement in an adverse event has on healthcare professionals. Such evidence is required to develop a support programme that could assist healthcare professionals who have been directly involved in adverse events, to minimise the concomitant stress, and to enable these professionals to continue to provide quality care after such an event. Aim: The purpose of this study was to develop, describe, and evaluate the implementation of a support programme for healthcare professionals involved in adverse events in public hospitals. Methodology: A sequential, multimethod research design was used. The study was conducted in five phases. Phase 1 consisted of a scoping review of the international literature that focused on the experiences of the nurses and doctors. The question asked in the scoping review was: What is known from existing literature about the support programmes for healthcare professionals involved in adverse events in clinical settings, and are they effective? Phase 2 involved storytelling that explored the impact of adverse events on involved healthcare professionals. Smith and Liehr’s (2005) methodology was used, that is, healthcare professionals who were directly involved in or affected by one or more adverse events in the public hospitals in Gauteng narrated their experiences. Phase 3 used semi-structured interviews with the managers to explore how best to support health professionals involved in adverse events. Phase 4 involved developing a support programme according to the Wits Trauma Model developed by Eagle, Friedman and Shumkler, from the Psychology Department of the University of the Witwatersrand, in 1993 (Eagle, 2000). Phase 5 focused on confirming and validating the programme to support healthcare professionals involved in adverse events in public hospitals. This phase was subdivided into two sections: Phase 5.1 comprised the Delphi group; and Phase 5.2 comprised the Focus group. In the first round involving the Delphi group, technical data was collected from the experts who validated the programme by means of the survey that was distributed on Research Electronic Data Capture. Concerns arising out of the first round with the Delphi group and that required attention were addressed during the Focus group discussion. Results: Hospitals were not aware of the magnitude of second victimhood and hence the delay in reviewing the structures in place to provide support to those involved. Just (fair) culture principles were not adhered to as there were no guidelines for their implementation, hence the second victims were left traumatised and in isolation following their involvement in adverse events, and they experienced blaming by management instead of being provided with much needed support. Limitations: The limitations to the study include the small sample size during the data collection phases, due to the Coronavirus disease of 2019 pandemic. Due to the restrictions that were implemented it was not possible to contact all the staff as they had been relocated to other healthcare facilities, were absent, or had resigned. Those who were snowballed were no longer at the facilities where they were originally identified, and therefore the researcher was unable to capture their experiences. Objectivity was not maintained as the documents for the Delphi group were hand-delivered, participants were able to identify the researcher, and hence the social desirability concern. The face-to-face encounters made adherence to anonymity impossible. The model components were not practical in terms of the developed programme. Round two of the Delphi group could not be scheduled, thus challenging the study model. Conclusion: The impact of adverse events on healthcare professionals remains an underestimated health concern. Experiences are magnified by unsupportive work environments, and are evident in increased hostility, blaming, fear of punishment, and reputational harm. The second victims require support to enable them to recover and learn from their involvement. The programme was developed, which included the summarised structure and the detailed process for implementation by hospital management on how to manage the adverse events in public hospitals in Gauteng.
Predicting in-hospital mortality in heart failure patients using machine learning
(2024) Mpanya, Dineo
The age of onset and causes of heart failure differ between high-income and low-and-middle-income countries (LMIC). Heart failure patients in LMIC also experience a higher mortality rate. Innovative ways that can risk stratify heart failure patients in this region are needed. The aim of this study was to demonstrate the utility of machine learning in predicting all-cause mortality in heart failure patients hospitalised in a tertiary academic centre. Six supervised machine learning algorithms were trained to predict in-hospital all-cause mortality using data from 500 consecutive heart failure patients with a left ventricular ejection fraction (LVEF) less than 50%. The mean age was 55.2 ± 16.8 years. There were 271 (54.2%) males, and the mean LVEF was 29 ± 9.2%. The median duration of hospitalisation was 7 days (interquartile range: 4–11), and it did not differ between patients discharged alive and those who died. After a prediction window of 4 years (interquartile range: 2–6), 84 (16.8%) patients died before discharge from the hospital. The area under the receiver operating characteristic curve was 0.82, 0.78, 0.77, 0.76, 0.75, and 0.62 for random forest, logistic regression, support vector machines (SVM), extreme gradient boosting, multilayer perceptron (MLP), and decision trees, and the accuracy during the test phase was 88, 87, 86, 82, 78, and 76% for random forest, MLP, SVM, extreme gradient boosting, decision trees, and logistic regression. The support vector machines were the best performing algorithm, and furosemide, beta-blockers, spironolactone, early diastolic murmur, and a parasternal heave had a positive coefficient with the target feature, whereas coronary artery disease, potassium, oedema grade, ischaemic cardiomyopathy, and right bundle branch block on electrocardiogram had negative coefficients. Despite a small sample size, supervised machine learning algorithms successfully predicted all-cause mortality with modest accuracy. The SVM model will be externally validated using data from multiple cardiology centres in South Africa before developing a uniquely African risk prediction tool that can potentially transform heart failure management

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