Faculty of Health Sciences (ETDs)
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Item The role of small genetic variants in the aetiology of developmental disorders in South Africa - a whole exome sequencing study(University of the Witwatersrand, Johannesburg, 2024) Molatoli, Mhlekazi Cathrine; Lombard, ZanéDevelopmental disorders (DD) are a diverse group of chronic conditions characterized by significant limitations to both mental and physical development. Genetic variants have been identified as the underlying aetiology in about 40-50% of DD cases. Whole exome sequencing (WES) is the recommended first-line genetic test in this group of patients and is associated with diagnostic yields of 16-45%. However, in South Africa and other resource-poor settings, karyotype testing and MLPA analysis (offering low diagnostic rates of 3% and ~9% respectively) are still being utilized for genetic testing. Thus, a higher proportion of patients remain with unexplained DD due to the limitations of these diagnostic tools and limited genetic services. The main challenge facing the clinical implementation of WES in African settings is the complex data analysis and interpretation associated with the large amount of variant data produced. This is especially challenging as African ancestry individuals have been demonstrated to have a high level of genetic diversity resulting in a higher number of novel variants reported compared to European ancestry individuals. This study seeks to investigate whether the clinical utility of WES can be replicated in an African setting. Additionally, we seek to make recommendations for variant filtering and prioritization, thus making the process of WES data analysis for DD patients more efficient. To achieve these, WES was performed in 117 patients with unexplained DD and their 180 unrelated parents. Variant data was filtered and prioritized using two in-house semi-automated pipelines. The first pipeline, prioritized variants overlapping known DD genes, as identified using the G2P-DDG2P bioinformatics analysis tool. The second pipeline identified de novo variants in trio families using the trio-dnm bioinformatics analysis tool. Sanger sequencing was used to validate low-quality prioritized variants prior to in-house interpretation and curation, and all subsequently identified putative disease-causing variants prior to reporting. Of the 117 patients from 115 families analysed, a positive molecular diagnosis was achieved for 29 families, resulting in a diagnostic yield of 25.2% (29/115). Leveraging currently available DD data, our findings demonstrate the diagnostic and clinical utility of WES which resulted in recommendations for improving patient clinical management and surveillance. This study has also developed and made recommendations for variant filtering and prioritization strategies, which can be implemented in both research and diagnostic settings to streamline and aid in the identification of putative disease-causing variants in DD patientsItem Community-orientated primary health care: Exploring the interface between community health workers, the healthcare system and communities in South Africa(University of the Witwatersrand, Johannesburg, 2024) Malatji, Hlologelo; Goudge, Jane; Griffiths, FrancesBackground: To achieve universal health coverage, low and middle income countries (LMICs) are extending primary health care (PHC) services using community health worker (CHW) programmes. However, CHWs are marginalized within the healthcare system. Community-orientated primary health care (COPC) and supportive supervision are two interventions being used to strengthen CHW programmes. Primary aim: To understand whether and how the COPC and supportive supervision approaches strengthen CHW programmes in South Africa. Methods: Data was collected between 2016 and 2019 using qualitative methods in nine PHC facilities in rural and semi-urban areas of Mpumalanga and Gauteng provinces, South Africa. Purposive and snowball sampling techniques were used to recruit participants. The participants included: CHWs, supervisors, facility staff members and community members. Data was collected using focus group discussions, individual interviews and observations, and was analysed thematically. Findings: In line with the COPC approach, there were efforts to engage communities in the implementation of the CHW programmes but community members prioritised other challenges such as lack of housing and running water. In some facilities, in-service training increased CHWs knowledge and skills but challenges such as lack of supervision, lack of resources and outsourced employment without benefits demotivated the CHWs (Paper 1 / Objective 1, Published). In response to challenges, in the semi-urban sites, CHWs unionised to present their grievances to government. This resulted in an increase in stipend but not permanent government employment. During the height of the COVID-19 pandemic, when decision- makers recognised the essential role of CHWs higher remuneration was secured. CHWs in rural areas were not active in demanding permanent employment (Paper 2 / Objective 2, Published). Supportive supervision provided by a nurse mentor over 14 months, (1) trained CHWs and their supervisors resulting in increased knowledge and new skills, (2) addressed their fears of learning and failing and (3) established operational systems to address inefficiencies in CHW core activities (household registration and medication delivery). The intervention was disrupted by union activities. The communities’ demonstrated little interest in the functioning of CHW programmes (Paper/ Objective 3, Published). Conclusion: Both the COPC approach and supportive supervision can reduce marginalisation of CHW within the health systemItem Efficacy of noise control measures at high noise zones from a copper mine in Zambia(University of the Witwatersrand, Johannesburg, 2024) Nchimunya, Bbautu; Hayumbu, Patrick; Masekameni, Masilu DanielNoise exposure is a global problem, it is estimated that about 30 million workers in the United States of America (USA) are exposed to high noise levels while across Europe, 28% of the workers are exposed to high noise levels. Hazardous noise exposure is associated with a wide range of health effects that include noise induced hearing loss (NIHL), stress, poor concentration, communication difficulties and fatigue due to lack of sleep. The mining industry worldwide is struggling with hearing loss due to noise overexposure and in a copper mining set-up, the concentrator section is assumed to be among high noise zones exposing workers to noise above the occupational exposure limit (OEL) of 85 dB(A). This study aimed at evaluating the efficacy of noise control measures at various sections at Konkola Copper Mine concentrator section in Zambia. This quantitative cross-sectional study was conducted at Konkola Copper Mines (KCM) Konkola Business Unit (KBU) in Chililabombwe District in the Copperbelt Province of Zambia. A walk through survey was conducted to collect information to describe the operations, identify noise sources, understand noise release mechanisms and describe noise control measures. Quality control was achieved by triplicate noise measurement per location using an instrument with a valid annual calibration certificate. Raw data was pre-processed by cleaning to make it ideal for use. An ethical waiver W-CBP-230428-01 was granted as this study did not involve animal or human subjects but only area noise samples using CR: 172B SLM. The study identified the noise sources, described noise release mechanisms, described the noise controls and assessed the efficacy of noise controls in four sections within the concentrator of a copper mine in Zambia. Seventeen noise generating equipment were identified with about 53% of the equipment operated at the crushing section, 18% operated at the Flotation and Filtration section respectively and 11% at Milling section. A substantial portion (65%) of the identified noise sources in the concentrator are not housed, and among these, 36% are mobile in nature. It was also found that none of the noise areas were demarcated There are three types of noise controls (enclosure, silencer & HPD) that are in use at the concentrator and they fall in two categories of the hierarchy of controls (engineering & PPE). Out of the nine noise sources at the Crushing section, 56% (5 of the 9) utilized enclosure as control, 33% (3 of the 9) had HPDs as control and 11% (1 of the 9) source was installed with a silencer as a control. Enclosure is utilized to control noise from the two sources found in the Milling section while HPDs and enclosure are the noise control measures in use at both Flotation and Filtration sections of the concentrator. Enclosure is the most available control in the concentrator at 53%, followed by HPDs at 41%, and the least available is silencer at 6 %. About 76.5% (13) of the noise controls at the concentrator had efficacy strong enough to reduce noise levels to below the OEL while 23.5% (4) of the controls had weak efficacy that failed to reduce noise levels to below the OEL. This has prompted the need to strengthen efficacy in areas where controls were found to be weak. There is need to sustain controls that were found to be strong to maintain their efficacy. About 75% (3 of the 4) of the controls with lower efficacy were from the Crushing section while 25% (1 of the 4) was from Filtration sectionItem Occupational characteristics and economic activities of health workers in the quarterly labour force survey: 2008-2017(University of the Witwatersrand, Johannesburg, 2024) Dinga, Aphiwe; Blaauw, Duaneackground There is global emphasis on the importance of research and analyses of health labour markets. The latter is defined as dynamic systems consisting of the demand and supply of health workers, influenced by a country’s regulations and institutions. However, there is limited national data to inform a health labour market analysis. Aim The aim of the study was to analyse the demographic, occupational characteristics and the economic activities of health workers who were surveyed in the Quarterly Labour Force Survey (QLFS) from 1 January 2008 to 31 December 2017. Methodology This study was a cross-sectional secondary data analysis of the health workers captured in the QLFS, a household survey that is conducted every three months by Statistics South Africa. The survey focuses on the labour market activities of individuals aged 15 to 64 years who live in South Africa. The sample analysed for this study was all health workers surveyed in the QLFS during the study period. Both the South African Standard Classification of Occupations (SASCO) and the Standard Industry Classification (SIC) codes were used to extract data on all health occupations to ensure that the entire health workforce in the QLFS was included in the current study. To identify predictors of employment a multiple logistic regression was carried out. STATA ® 15 was used for the statistical analysis. Results The study sample comprised a total of 5 502 health workers. Nurses constituted the highest proportion of health workers in the survey (60.1%) while medical doctors and dentists represented 10.0%. Nurses were older than the other categories of health workers with a mean age of 43.6 years (SD±10.3), compared to the mean age of 41.8 (SD±10.8) for doctors, 38.6 (SD±10.4) for mid-level health workers and 37.8 (±10.8) for allied health workers. The majority (59.0%) of health workers were employed in the public sector, and in urban areas (83.8%). Only 4.6% of doctors and 7.0% of allied health workers were employed in rural areas. Overall, the study found that fewer than 1% of health workers reported more than one job during the 10-year period. The results of the logistic regression showed that the odds of employment were approximately two times higher for health workers between the ages of 36-45 and 46-55 years old and 1.8 times higher for health workers between the ages of 26-35. There were 0.5 odds of employment for health workers aged 56-64 years compared to the reference age group of 18–25-year-olds. Females were less (0R=0.56) likely to be employed as compared to males. Compared to health workers in urban areas, those in rural areas were less (0.47) likely to be employed. Health workers were 0.53 times less likely to be employed outside the health industry as compared to being employed in the health industry. Conclusion Although the QLFS provides useful information on the health workforce in South Africa, the results highlight the need for investment in a robust human resources for health information systemItem Exploring inter-professional collaboration between community health workers and health care providers in two clinics in the City of Johannesburg district(University of the Witwatersrand, Johannesburg, 2024) Bokaba, Dorah Dorothea; Nxumalo, NonhlanhlaBackground: Large-scale community health worker (CHW) programmes gained renewed interest over time. This was more pronounced during the emergence of the Coronavirus disease 2019 (COVID-19) pandemic, with CHWs exemplifying the role of task-shifting to alleviate already fragile and resource-scarce health systems. Many low- to middle-income countries (LMICs), including South Africa, implemented CHW programmes to complement health workforce. Thus, health care providers (HCPs) including professional nurses, health promoters, allied health workers, operational manager clinic, social workers, and CHWs are expected to collaborate with CHWs to provide health care service. Aim: The aim of the study was to explore inter-professional collaborations (IPC) between CHWs and HCPs in two primary health care (PHC) facilities in the City of Johannesburg, Gauteng Province. Methodology: This study used an exploratory qualitative design. In-depth semi-structured interviews were conducted with purposively sampled CHWs (n=12) and HCPs (n=10) in two PHC facilities from two sub-districts. All interviews were transcribed verbatim. Thematic content analysis was used to analyse the data. Results: Team structures were reported to be centred around the CHWs and Outreach team leader (OTLs), however other HCPs like nurses, health promoters, and social workers also played a role. Reporting procedures were hierarchical, with CHWs reporting to OTLs, who reported to operational managers (OPMs). CHWs were at the bottom of the hierarchy with the reporting structures being described as challenging as they were related to power dynamics. Communication was poor and with unplanned meetings. Participants suggested the need for improved support and communication to strengthen IPCs. Conclusion: IPC between the HCPs and CHW is critical in ensuring patient care continuity. Some dimensions of IPC, such as shared responsibility and mutual understanding of roles by team members, were evident. The communication processes showed some weaknesses, including the consequences in power relations. In order to enhance the contribution of CHWs in PHC and universal health coverage (UHC), it is necessary to explore ways to strengthen IPC between HCPs and CHWsItem A Multicenter Retrospective audit on the treatment modalities of sternal sepsis: A 10-year review(University of the Witwatersrand, Johannesburg, 2024) Phalafala, Refilwe Palesa Mokgadi; Ndobe, Elias; Fru, PascalineBackground: Mediastinitis is a life-threatening complication, of a septic sternal wound. The key treatment is for early radical debridement and adequate reconstruction. The aim of this study was to perform a comparative review of the management modalities undertaken on patients with sternal sepsis from 2007–2017 at one public and two private surgical practices in Johannesburg, South Africa. Methodology: The study was a retrospective series of 120 chronologically selected patients from three hospital units (40 from each unit): The Cardiothoracic Unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH - public) and two private plastic surgery practices within Netcare Milpark Hospital (NMH). The patients were categorized into three groups: 1) Vacuum-Assisted Closure (VAC), 2) VAC and reconstruction (muscle flaps or alloplastic material) and 3) reconstruction alone (muscle flaps or alloplastic material). Results: Of the120 patients, the median age, was 58yrs (19yrs – 89yrs). Hypertension was the most common comorbidity. Patients in NMH were more likely to undergo VAC dressing for a shorter period. Patients in NMH were more likely to be reconstructed with a flap (44%, n=35/78), of which the bilateral pectoralis major flaps (19%, n=43) was more frequent. Out of the 120 patients, 61% had one debridement and VAC therapy as a temporizing modality prior to reconstruction. CMJAH had a higher mean length of hospital stay of 41 days and re-do operations 27% (n=11/40) compared to NMH which had a mean hospital stay of 31 days and a re-do operations of 16% (n= 13/78). Plastic surgeons were more likely to be involved in initial debridement’s in NMH 96% (n=32/33) compared to CMJAH with 3% (n= 1/33). Conclusion: NMH, private hospital, demonstrated to have statistically significant better outcomes with a shorter hospital stay compared to its counterpart CMJAH, public hospital, with regards to management of sternal sepsis. NMH, showed a shorter VAC dressing period to be an effective temporizing modality, however the most efficient management of, sternal sepsis, would be to involve a plastic surgeon early on for radical and fewer number of debridements, and early reconstruction. The bilateral pectoralis major flap was the option of choice in this study. The incidence of sternal sepsis from both hospitals was in keeping with international rates.Item Anaesthetic nurses’ knowledge and skills in perioperative airway management at Chris Hani Baragwanath Academic Hospital(University of the Witwatersrand, Johannesburg, 2024) Dold, MatthewBackground: Airway management in the peri-operative period carries specific inherent risks, and the benefit of assistance by a skilled anaesthetic nurse cannot be over-stated. The aim of this study was to assess the theoretical and clinical knowledge regarding perioperative airway management in anaesthetic nurses at Chris Hani Baragwanath Academic Hospital (CHBAH). Method: A quantitative, contextual, cross-sectional and descriptive survey was performed by means of a self-administered anonymous questionnaire using convenience sampling. The questionnaire assessed identification of airway equipment, knowledge of the cleaning, maintenance and use of equipment and clinically applicable insight into perioperative airway procedures and emergencies. It’s adequacy and validity were ensured by means of the Angoff standard setting method. Data was analysed in consultation with a biostatistician. Results: A total of 68 nurses took part in the study. By distribution of rank, 78% (n=53) enrolled nurses, 19% (n=13) professional nurses and 3% (n=2) nursing assistants. The incidence of prior airway training was 41% (n=28). The overall mean questionnaire score was 69,8% (SD: 9.6%) with a range of 45% - 97%. Only 19% (n=13) of nurses achieved adequate overall scores. Years of experience was positively associated with overall mean scores (p=0.0009) and adequacy of knowledge (OR 1.28, p=0.004). Airway training showed a small increase mean scores (mean difference=4.63%, p=0.049). There were no statistically significant associations between adequate knowledge and age, prior airway training and nurse qualification. Conclusion: This study found that the theoretical and clinical knowledge of perioperative airway management of many anaesthetic nurses at CHBAH is inadequate. Knowledge adequacy improved with increasing experience but not with current forms of formal training. This may be attributed to the low frequency of training as well as the type of training methods currently employed; both of which should be addressed to improve anaesthetic nurse competence and ultimately patient perioperative safetyItem Factors associated with burnout among healthcare workers in a rural context, South Africa: a cross-sectional study(2024) Moses, AlexandraBackground. Healthcare providers (HCP) were at risk of burnout related to high levels of occupational stress in the workplace. However, there was little research in rural and primary care settings in subSaharan Africa. This study aimed to describe the individual and workplace factors of public sector HCP working in Mpumalanga province, their experience of burnout and to examine the factors associated with burnout.. Methods. A quantitative study design using a cross-sectional survey was employed. The research site was Nkomazi Local Municipality in Mpumalanga Province. All HCPs (n=1 139) working at the primary healthcare clinics, community health centres and district hospitals were invited to participate in the survey. Data were collected between April and September 2022 via a selfadministered, electronic questionnaire. A demographic and occupational questionnaire, the General Help Seeking Questionnaire and the Health and Safety Executive (HSE) indicator tool were used to assess individual and workplace factors. Burnout was assessed using the Maslach Burnout Inventory– Human Services Survey. Univariate and multivariate regression analyses were used to examine factors associated with burnout. Results. Just over a quarter (n=302; 26.5%) of HCP participated. Participants were aged between 23 and 61 years, mostly female (n=252; 83.44%) and nurses (n=235; 77.81%). Most participants (n=215; 71.19%) would seek help if they had an emotional problem, most likely from mental health professionals, and least likely from traditional healers. Increased work-related stress was present due to the demands and roles of HCP. High levels of burnout were observed for Emotional Exhaustion (Median score 26 (IQR: 18)) and Personal Accomplishment (median score 29 (IQR: 9)) but not for Depersonalisation (median score 7 (IQR: 9)). On univariate regression analysis, the individual factor of being married and the workplace factor of increased years of experience were statistically significant to all three subscales of burnout. HSE factors of demands, control, management support, peer support, relationships, role and change were highly statistically significant to Emotional Exhaustion, Depersonalisation and Personal Accomplishment. On multivariate regression analysis, no individual demographic, occupational or HSE factors were significantly associated with Emotional Exhaustion or Depersonalisation. Personal Accomplishment ii improved by 0.49 (95%CI: 0.10-0.89) for every one point increase towards improved work demands, by 0.84 (95%CI: 0.01-1.67) for every point score increase towards improved management support, and by 1.19 (95%CI: 0.48-1.90) for every point score increase towards having improved role. Conclusions. During 2022, HCPs working in a rural area in South Africa displayed high levels of burnout for Emotional Exhaustion and Personal Accomplishment but not for Depersonalisation. Improvements in work demands, managerial support and role were significantly associated with an increase in the experience of Personal Accomplishment. Further research is recommended to better understand the nuances of the work environment. Solutions should be explored and implemented to prevent burnout, with special consideration given to work demands, managerial support and role clarity as part of the effort to retain rural HCP in the public health system.