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Determining the risk profile for chronic kidney disease (CKD) in rural South Africans using genetic risk scores and protein markers
(University of the Witwatersrand, Johannesburg, 2024) Govender, Melanie Ann; Ramsay, Michèle
Chronic kidney disease (CKD) is a global public health concern, with disproportionate morbidity and mortality in low- and middle-income regions, including Sub-Saharan Africa. Recent advancements in multi-omics approaches have explored disease risk indicators and contributed to the understanding of the pathophysiology of CKD in high-income populations. The overall aim of this research was to assess and understand CKD in a Sub- Saharan population using genetic risk models for kidney disease and to evaluate the proteomic profile of individuals with hypertension-associated albuminuria, with a view to detecting indicators of CKD and disease progression in a Sub-Saharan cohort. The first objective was a scoping review that was undertaken to evaluate existing literature for potential biomarkers for CKD and to identify gaps in literature. Key literature gaps identified included the lack of studies that focus on HT in the context of kidney disease and only one study on African individuals residing in Africa. In this work, two research studies were developed based on existing data from the African Research Kidney Disease (ARK) study, a well characterised population-based cohort study of black individuals from Agincourt in the rural Mpumalanga Province, South Africa. The second objective was a genomics study which aimed to examine the potential of using summary statistics from three discovery datasets to assess the predictive accuracy of polygenic scores (PGSs) for CKD and kidney function markers. Limited transferability was observed, explaining <1% of the variability in kidney disease markers in this African cohort. A PGS model derived from the transethnic cohort for estimated glomerular filtration rate (eGFR) explained the highest variability (0.8%) in African individuals and was significantly associated with HT (P<0.001), diabetes (P=0.007), and HIV (P=0.001). The third objective was a proteomics study which aimed to compare proteomic profiles of cases with both HT and albuminuria to controls (neither condition) to identify proteins and pathways involved in hypertension- associated albuminuria. Pathways including immune system (q=1.4x10-45) and innate immune system (q=1.1x10-32) were linked with hypertension-associated albuminuria. Proteins including angiotensinogen, apolipoprotein L1, and uromodulin had the highest disease scores (76–100% confidence). A machine learning approach was able to identify a set of 20 proteins that contributed to classifying disease status (ie, hypertension-associated albuminuria). Page | VI The assessment of PGSs for kidney function markers contribute to understanding of CKD genetic risk prediction in Africa, while the proteomics research added new knowledge to understanding the role of proteins and pathways involved in hypertension-associated albuminuria in Africa. This research addresses the gap of a lack of ‘omics research in resident African populations. It also contributes to the understanding of risk prediction for CKD and identifies potential proteomic markers for hypertension-associated albuminuria that may inform the development of personalised treatment strategies in Africa.
The assessment of patient-centred care among diabetic patients in southern Malawi
(University of the Witwatersrand, Johannesburg, 2024) Makwero, Martha; Muula , A; Igumbor, Jude
Introduction: Patient centred care (PCC) is gaining recognition in various quality care reforms, especially in the growing era of chronic care where its effects are palpable yet its functional elements are unknown and hardly measurable. PCC has been shown to improve care processes and patient reported outcomes among chronic care patients such as Diabetes Mellitus (DM). While the Malawi Quality management Directorate (QMD) and the Non-communicable disease and injury (NCDI) policies mention PCC as a strategic quality reform, its functional elements are hardly known and, if it matters, in mediating patient experiences and outcomes. It is clear that the vagueness is thwarting PCC’s implementation, assessment, and advocacy. Thus, as the burden of chronic diseases, including DM grows, there is a need to optimize PCC through the elicitation of its functional elements, its objective assessment, and its recommended implementation strategies. Aim: This study aims to assess the functional elements of PCC and its relationship to outcomes in diabetic patients. Methodology: I conducted a cross-sectional, exploratory mixed methods study in southern Malawi. Sequentially, I employed qualitative and quantitative methods in order to enrich the contextual understanding of the complex PCC construct and its correlates. Therefore, we initially explored the common elements of PCC in LMIC through a scoping review. Building on the findings, in the next phase, I explored PCC conceptualization among three stakeholders (patients, health care providers and policy makers) further, breaking down the PCC construct to its functional elements through a qualitative inquiry. The qualitative themes identified were used to build a tool on important elements of PCC from the same population. A psychometric analysis was done in order to confirm the structure and consistency of the tool to improve the validity of results obtained. Thereafter, I quantitatively measured the current PCC practice ix among patients with DM and its association with baseline adherence to DM care plans, self- efficacy, glycaemic control, and some complications. The study used Covidence to manage the scoping review and Nvivo version 11 for the qualitative data, which was analyzed through the thematic analysis. The quantitative data was analyzed using STATA version 18 and R-studio version 4.2.3. The psychometric analysis employed exploratory and confirmatory factor analysis. Dichotomization of study participants into those who perceived low and high PCC scores was done through K-means clustering was done in R studio. Similarly, correlational studies and Path analysis were conducted to determine the nature and direction of relationships between the perception of PCC during the encounter and adherence, self-efficacy and glycaemic control. Results: The study confirmed the paucity and fragmentation of literature on PCC in LMIC especially in Africa and therefore, the need to situate the elements in our context. The themes identified were interrelated, and differences in expression and emphasis of some of the elements compared to the Eurocentric ones were highlighted. The recurring themes included the facilitating ambience, sharing of information, and patient involvement, the wider organization of care and the macroenvironment in which care takes place. Although they are similar to the Eurocentric themes, our qualitative inquiry identified eight themes and proposed a working definition. Thus, in the Malawian context, PCC was conceptualized as an expected care process that incorporates warm patient reception, where the healthcare provider consciously aims to reduce the patient-HCP power gap to harness a good long-term relationship. This creates a conducive atmosphere that allows the gathering of information that holistically identifies the individual specific problems and all possible interacting factors, ensuring timely access to care and medication. While patients highlighted the value of PCC encounters, particularly shared decision-making, the study documented the x challenges and vulnerabilities faced in an attempt to engage their providers in shared decision making. The psychometric analysis identified three latent themes underlying the PCC elements namely 1) relational aspects of care, 2) individualization and shared decision making and, 3) organizational aspects of care highlighting what is important and the hierarchical nature of the PCC construct. While acknowledging the need for further refinement, the tool exhibited acceptable reliability and validity properties to be used as a measurement framework in the study. The study showed significant deficiencies in the delivery of PCC with 55.8% of patients perceiving low levels, particularly, in the area of individualization and shared decision-making. Higher PCC scores did not have a significant relationship with self-efficacy. Both the perception of PCC and self-efficacy were positive predictors of adherence independently. Having perceived higher PCC scores was associated with a marginal 0.03-point increase in one’s adherence scores (β = 0.03; 95% CI: 0.01 to 0.04, p-value <0.001). Self-efficacy and adherence were both positive predictors of blood sugar control independently. Better self- efficacy was associated with a 0.03 unit decrease in the level of HbA1c (β =-0.03; 95% CI: - 0.04 to -0.022, p-value <0.001). Additionally, as adherence scores went higher, there was a 0.15 unit decrease in HbA1c (β = -0.15; 95% CI: -0.25 to -0.02, p-value <0.05). The results highlight that PCC can affect glycaemic control only indirectly through adherence. Conclusion The study has confirmed the complexity of the PCC construct and the paucity of literature in LMIC. It has highlighted that above and beyond creating a conducive ambiance, medical encounters ought to evoke support and capacitation for patients to undertake self-care behaviors confidently to be able to produce patient outcomes. Even though this study is cross- xi sectional, the initial patterns are promising for the value of PCC in mediating patient-reported experiences and outcomes among DM patients.
Physical Activity Intervention Plan for Hypertensive Patients of Umlazi Township, KwaZulu-Natal
(University of the Witwatersrand, Johannesburg, 2024) Simamane, Mandisa Jewel; Constantinou, Demitri; Watson, Estelle
Background The global increase in hypertension, fueled by aging populations, sedentary lifestyles, and obesity, presents serious health challenges, including elevated risks of cardiovascular diseases and early mortality. Addressing this issue effectively necessitates a holistic healthcare approach that combines medication with lifestyle changes like physical activity, while also incorporating family support and exercise professionals into primary care for personalised treatment plans and improved adherence. Aim The principal aim of this study was to ascertain whether the implementation of a physical activity intervention plan, coupled with family member involvement within the primary healthcare sector, would contribute to the effective management of hypertension among hypertensive patients residing in the community of Umlazi Township, KwaZulu-Natal. Methods This study adopted a multifaceted methodology to enhance evidence-based hypertension management practices through physical activity. Initiating with a scoping review, it identified and organised relevant literature to establish a solid evidence foundation for a randomised controlled trial. The research included 12 weeks randomised controlled trial into intervention, and the control group assessing the impact of physical activity on hypertension management and secondary outcomes, thus providing a thorough evaluation of the intervention's effectiveness. Moreover, a qualitative inquiry further explored the comprehension and involvement of family members in managing hypertension. Results The review identified nine effective physical activity-based interventions out of 31 studies, indicating their success in reducing blood pressure and strengthening cardiovascular health. Notably, aerobic and interval training emerged as especially beneficial. The trial demonstrated significant progress in the Intervention Group (n = 36) compared to the IX Control Group (n = 37), particularly in 6-minute walk test results, without major changes in cardiovascular and anthropometric metrics over 12 weeks, underscoring the benefits on physical performance and potential heart health advantages. The qualitative analysis (n = 9) exposed a general lack of hypertension awareness among family members and a gap in their support levels. Discussion and Conclusion Conclusively, the study underscored the critical role of augmenting physical activity in managing hypertension, evidenced by its 12-week investigation at the Umlazi Township AA clinic. Though, it reaffirmed the synergy of pharmacological and lifestyle interventions, affirmed by physical activity and familial engagement, in enhancing hypertension care. Despite certain constraints like small sample size and brief intervention span, the findings advocate for an expanded clinical utilisation of physical activity in hypertension treatment, promoting prolonged and consistent exercise routines as integral to a comprehensive management strategy.
Effects of dietary supplementation with β-sitosterol on Cobb 500 broiler chicken productivity, health and product quality
(University of the Witwatersrand, Johannesburg, 2024) Bopape, Malebogo Audrey; Chivandi, Eliton
Antibiotic use as growth promoters in chicken feeds results in antibiotic resistance and environmental pollution. To mitigate these challenges alternatives natural growth promoters are required. Beta-sitosterol is one of several phytosterols with chemical structures similar to that of cholesterol. β-sitosterol has antimicrobial, antioxidant, anti-inflammatory and hypocholesterolaemic activities, thus might replace synthetic antibiotics as a feed supplement in chicken feeds. The current study evaluated β-sitosterol’s potential to replace oxytetracycline in Cobb 500 broiler chicken feeds by determining its effects on growth performance, meat yield and quality and bird health. β-sitosterol replaced oxytetracycline at 0 (control: 50 mg/kg oxytetracycline), 500, 1000 and 1500 mg/kg feed for diet 1 to 4, respectively with doses similar in starter, grower, and finisher diets. Chickens were fed from day 1 to 42 days of age. Body mass and feed intake were measured. Body mass gain, average daily gain and feed conversion ratio were computed. Terminally, broiler chickens were fasted, weighed, humanely slaughtered and dressed. The carcass yield, viscera morphometry and plasma surrogate markers of health were also determined. Meat pH, colour, thawing and cooking loss (TL; CL), water holding capacity (WHC), tenderness and myofibrillar fragmentation length (MFL) and nutrient content were determined. Femora and tibiae mass, length, breaking strength and liver fat content and histology were determined. Dietary β- sitosterol had similar (P > 0.05) effects as oxytetracycline on the chickens’ growth performance and feed intake utilization efficiency, gastrointestinal tract (GIT) and GIT accessory viscera macromorphometry, meat yield, meat colour, pH, TL, CL, WHC, tenderness and MFL. However, breast meat crude protein content of chicken fed diet 4 was higher (P < 0.0001) compared to that of counterparts fed diets 2 and 3. Breast meat fat content of chicken fed diet 2 and diet 4 was higher (P < 0.0001) compared to that of counterparts fed diets 1 and 3. Dietary β-sitosterol had similar (P > 0.05) broiler chickens’ breast meat total saturated fatty acids (TSFAs), monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs), palmitic, oleic and linoleic content as oxytetracycline. Dietary treatments had no effect on chickens’ tibiae masses and breaking strength (P > 0.05) albeit tibiae from chickens fed diet 4 were shorter (P < 0.01) than those of counterparts fed diet 2. Dietary β-sitosterol at 1000 and 1500 mg/kg feed increased (P < 0.05) liver lipid content but had no effect on hepatic microarchitecture. However, at 1500 mg/kg feed it caused micro- and macro hepatic steatosis and lobular inflammation and higher (P < 0.05) non-alcoholic fatty liver disease activity scores (NAS). Compared to control, dietary β- vii sitosterol decreased (P < 0.0001) the chickens’ malondialdehyde (MDA) concentration but increased superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px) activities and glutathione S-transferase (GST) and glutathione (GSH) concentration (P < 0.05). Diet 4 increased (P < 0.01) plasma AST and GGT activities compared to diet 1 (control). At 1000 and 1500 mg/kg feed it increased plasma cholesterol concentration compared to control and β-sitosterol at 500 mg/kg feed. β-sitosterol can replace oxytetracycline as growth promoter in Cobb 500 broiler chicken diets without negatively affecting growth performance, meat yield and quality and potentially mitigates oxidative stress by upregulating systemic antioxidant enzymes activities. However, at 1500 mg/kg feed, it can increase the risk of fatty liver disease development and hypercholesterolaemia.
Myrmecophagous mammals in a changing world: the ecology of aardvarks and temminck’s pangolins in the kalahari
(University of the Witwatersrand, Johannesburg, 2024) Phakoago, Makabudi valery; Fuller, A.
Little is known about the distribution and ecology of the aardvark (Orycteropus afer) and Temminck’s pangolin (Smutsia temminckii) in southern Africa as they are rarely seen and difficult to study. Both species are myrmecophagous (feed on ants and termites), primarily nocturnal, 2and they tend to be solitary. Climate change, which is resulting in hotter and drier environments in most parts of southern Africa, may affect the aardvark and Temminck’s pangolin through direct impacts on the animals and through impacts on their prey resources. Understanding how climate change may impact these two myrmecophagous mammals requires us to gather further insights on how their environment and food sources are changing, how their diets overlap, how they use the environment and alter their activity to source food and buffer themselves from heat and cold, and how they are distributed across southern Africa. Previous research conducted in the semi-arid Kalahari of southern Africa showed that a decline in ant and termite populations (as indicated by counts in pitfall traps) associated with drought resulted in starvation of aardvarks and pangolins and decreased reproductive output of pangolins. Individuals of both species starved, despite previous work indicating that the diets do not overlap, with aardvark preying predominantly on harvester termites (Hodotermes mossambicus) and pangolins preying predominantly on ants (mainly Crematogaster ants). However, the research on each species was conducted at different times, so the dietary differences may have arisen from various factors that differed between the study periods. As part of a long-term project aimed at assessing the potential impacts of climate change on myrmecophagous mammals in the Kalahari ecosystem, the present study collected faecal samples from aardvark and Temminck’s pangolin at the same time in the Kalahari for one year to compare their diets and assess dietary overlap (Chapter 3). In addition to dietary analysis, the study added to our long-term data (since September 2014) of grass cover and counts of ants and termites in pitfall traps, from September 2019 to August 2022 (Chapter 2). These long-term data revealed substantial fluctuations in grass and insect availability over time, with termite populations apparently less likely to recover after drought years compared to ants (Chapter 2). The study also assessed the abundance xiii and orientation of burrows that are available to the aardvark and Temminck’s pangolin in the duneveld in the Kalahari during winter of 2021 (Chapter 4). Lastly, the study assessed the distribution and ecology of the aardvark and Temminck’s pangolin in southern Africa using freely available images and videos from Facebook and Instagram over 10 years (2010 – 2019) (Chapter 5). During the study, the study site, Tswalu Kalahari Reserve, experienced higher than average rainfall (2020 and 2021), resulting in high grass cover and an increase in the number of ants in pitfall traps, following a very hot and dry period in 2019. In contrast, termite numbers remained low. Despite the apparent low number of termites, as reflected in the pitfall traps, aardvark preferred termites over ants in their diet, and consumed predominantly termites of the genus Trinervitermes (45% of their diet) over the study period. Temminck’s pangolin preferred ants over termites and consumed mainly ants of the genus Crematogaster (42%). Although aardvarks and Temminck’s pangolin had preferences for their specific prey items, it was shown for the first time that there was dietary overlap between the two mammal species, with higher overlap when prey resources were readily available during autumn, and lower dietary overlap when prey resources were scarce during spring. The present study, however, was conducted during an unusually wet period characterized by above-average rainfall, so it is important to determine how competition for dietary items will change in hotter and drier years, when insect populations will likely be lower. Ants and termites rely on grasses for their survival; therefore, one would predict that the abundance of burrows, dug primarily by aardvark, is likely to be related to grass cover. The present study site comprised two distinct areas, differing in grass cover as a result of differences in historical grazing pressure. I therefore investigated the availability and use of burrows in the area with low grass cover and the area with high grass cover, during winter. Burrows serve as a beneficial buffer against climatic conditions for burrowing species, offering heat avoidance during the day and warmth during the night. It was found that burrow numbers were positively associated with grass cover. More burrows also were found on the western side of the dunes than on the eastern side, most likely because the xiv western side receives more direct sunlight in the afternoon, providing a warmer microclimate overnight during the cold winter. Finally, the study explored whether social media could provide supplementary information on the distribution and ecology of the aardvark and Temminck’s pangolin in southern Africa. The data, which were collected through examining photos and videos on Facebook and Instagram, confirmed that the aardvark is found throughout South Africa while Temminck’s pangolin is restricted to the northern regions of South Africa. The images also confirmed recent research that poor body condition is associated with greater diurnal activity for the aardvark, likely a response to high energetic demands of being active on cold nights. Little is known about drinking behaviour by the aardvark and Temminck’s pangolin, with only 7 records previously published for the aardvark. It was found a further 32 records for the aardvark, and 7 for the pangolin, showing that both species do occasionally drink opportunistically. The records also provided information on the predation of both myrmecophagous mammals. Predation was observed at almost all times of the year for both species, with leopard (Panthera pardus) the most common predator for the aardvark, and lion (Panthera leo) the most common predator for Temminck’s pangolin. Even though there were far fewer records of images in other southern African countries, social media appears to be a useful tool for collecting data on the distribution and ecology of the aardvark and Temminck’s pangolin. Understanding the ecology and distribution of the aardvark and Temminck’s pangolin in the Kalahari and other regions in relation to available prey resources and local climate is crucial for improving our conservation efforts of the species through informed management practices.
The Utility of Clinical Exome Sequencing as a First-Tier Diagnostic Tool in Critically Ill Infants in South Africa
(University of the Witwatersrand, Johannesburg, 2024) Campell, Lisa; Carstens , Nadia; Krause, Amanda
Genetic disorders are significant contributors to infant mortality, morbidity, hospitalisation, and the need for intensive care globally. The identification and diagnosis of genetic disorders in ill infants is challenging due to their indistinct, and often atypical disease presentations. Diagnosis is traditionally driven by a differential clinical diagnosis; however, broad genotype-first approaches are now the recommended strategy in ill infants. The use of NGS-based testing, including gene panels, whole exome sequencing and whole genome sequencing, has successfully been utilised to diagnose genetic disorders in ill infants and has begun to be implemented in global settings; however, representation of low- and middle-income countries is lacking. Local infrastructure, capacity and expertise significantly affect successful implementation in these contexts. We therefore aimed to investigate the utility and implementation of singleton virtual exome sequencing panels in a cohort of 32 ill infants in the South African State healthcare system, providing the first investigations into the use of NGS in a neonatal intensive care unit setting in Africa. Three virtual panels were used to analyse exome sequencing data: a curated panel of genes implicated in neonatal-onset conditions and enriched for variants in South African populations; a ClinVar panel; and the Developmental Disorders Genotype-to- Phenotype (DDG2P) panel. A diagnostic yield of 22% was achieved across the three virtual panels, providing a definitive molecular diagnosis in seven ill infants. These infants experienced changes in their clinical management as a result of this diagnosis, including the initiation of palliative care, familial screening and prenatal testing for future pregnancies. The adaptation of recommended implementation strategies was necessary in the South African context to address shortages in resources, infrastructure and bioinformatics capacity through the use of gene panels instead of whole exome sequencing and the use of locally available technologies; shortages in the trained genetics workforce through the reliance on primary care clinicians for referrals; and through the singleton sequencing approach to address the unavailability of parents for trio-sequencing and the additional cost factors. This pilot study demonstrated the utility of NGS for the diagnosis and management of ill infants in the South African State healthcare system and explored the challenges in implementing NGS technologies in resource-limited settings. The implementation strategy explored through this research provides a baseline from which advanced NGS diagnostic v strategies can be developed and from which scaled up investigations of utility in the South African State setting can commence.
The Development of a Competency-Based Programme for Management of Disease Outbreaks
(University of the Witwatersrand, Johannesburg, 2024) Engelbrecht, Linette; Schmollgrube, Shelley; Crous, Lizelle
Purpose: The purpose of this study was to develop, a competency-based programme for the management of disease outbreaks. Method: The study utilized an exploratory sequential mixed method approach, using both qualitative and quantitative methods to develop a competency-based program. This study was conducted in South Africa, Gauteng, whilst the country was experiencing the third COVID-19 wave (May 2021 – October 2021), the fourth COVID-19 wave (December 2021 – April 2022), and the fifth (May 2022 – July 2022), as well as the post-pandemic phase. The study was conducted in three phases namely: Phase One: Exploratory phase, Phase Two- Development of the programme Phase Three- Validation of the programme. In phase one, a scoping review on the existing literature was conducted using the Joanna Briggs Institute methodological approach. Following this were individual in-depth interviews with purposively sampled health care professionals as well as professional nurses. Through reflexive thematic analysis themes were identified for inclusion in the Delphi-survey in the next phase. For the second phase, a Delphi-survey was developed based on the data from phase one. The Delphi-survey consisted of two rounds whereby categories were identified to be included in the competency-based curriculum. A programme, consisting of ten modules was developed using the Backward design. In phase three the programme matrix was validated by experts. Results: A total of 62 publications were included in this study. Three categories and eight sub-categories were identified as needs of nurses during disease outbreaks. In-depth interviews with health care professionals resulted in the development of eight themes and 21 sub themes (challenges) of nurses. The in-depth interviews with nurses resulted in the development of 11 themes (challenges) of nurses. The results of the scoping review and in- depth interviews were used to develop a Delphi-survey. Experts in this two-round Delphi survey validated the domains and statements. The results of the Delphi-survey was used to develop a programme matrix consisting of ten modules, which was validated by three experts. Conclusion: A competency-based programme was developed based on the challenges nurses experienced working through the COVID-19 pandemic. This program could contribute to the development of disease outbreak competent nurses.
The Use of Social Media Platforms in Implementing Quality Improvement Initiatives for Quality Assurance of Paediatric Chest Radiographs in Radiological Departments of Varying Radiographer Expertise
(University of the Witwatersrand, Johannesburg, 2024) Hlabangana, Linda Tebogo; Andronikou , Savvas
Introduction Chest radiographs are the most widely performed diagnostic imaging test in children. Good quality radiographs assist in making the correct diagnosis. In resource limited settings, such as in Africa, there are several limiting factors that affect the quality of the radiograph which go beyond the availability of equipment and human resources, including geopolitical and socioeconomic challenges. Novel innovations are required to overcome these challenges by leveraging off technology and the widespread distribution of smart phones. Aim The aim of the study was to evaluate the improvement in the quality of chest radiographs performed in children after initiating quality improvement interventions at three radiology departments. The interventions used the Internet, Facebook® and Twitter®) to remotely communicate with the radiographers. Methods A longitudinal, descriptive study was performed at three radiological centres in South Africa. They study had a retrospective phase (before intervention), and a prospective phase. Over a period of six months, communication on quality factors of chest radiographs and how to improve quality were sent out using Facebook and Twitter. Thereafter, radiographs were collected and the quality assessed. Results A total of 966 radiographs were included in the study. The most common errors overall were “scapula in the way” (38.7%), “rotation” (34.7%) and “poor collimation” (22.2%). The errors “parts cut off” (1.3%) and “wrong/no left/right marker” (1.7%) were the least common. Rahima Moosa Mother and Child Hospital demonstrated non-significant improvement in the quality of radiographs over the duration of the study. The other two centres demonstrated no significant or sustained improvement in the quality of chest radiographs performed. The research did not demonstrate a significant benefit from the intervention. There was vi low engagement with the social media platforms. A total of six radiographers followed the Twitter handle and the Facebook page had 37 friends/followers, eight of these were radiographers participating in the study. Conclusions Although social media have demonstrated impactful use in education and communication, the usage by radiographers in South Africa to improve the quality of chest radiographs is limited. . There was no significant benefit demonstrated from the use of Facebook and Twitter as educational and information tools. Further research using low-data consumption social media apps to create locally relevant and sustainable solutions for quality assurance and quality improvement in radiography are required.
Integrating Rehabilitation Services at Primary Healthcare Level in Johannesburg, South Africa
(University of the Witwatersrand, Johannesburg, 2024) Maseko, Lebogang; Myezwa, Hellen
Rehabilitation is an essential component of attaining true Health for all in South Africa. The National Health Insurance Bill of 2019 specifies primary healthcare (PHC) reengineering as one of the action plans. Similarly, the National Development Plan 2030 specifies providing care to families and communities by PHC teams as one of its action points for the transformation of the health system in South Africa to achieve universal health coverage. The provision of rehabilitation services to the broader population through a reengineered PHC can give at-risk populations greater life expectancy, wellbeing, and productivity. Despite the current provision of rehabilitation services at the primary platform, health service planning and provision in South Africa have overlooked rehabilitation as a component of PHC. The physical, social, and economic impact of many health conditions can be mitigated, resulting in a reduced burden of care, both economic and social, for the family and the state. Thus, the need for evidence for integrated rehabilitation services at a PHC level has critical relevance to ensuring inclusive service delivery. Therefore, it is important to review rehabilitation services at the PHC level to establish the current service delivery landscape and to guide the development of a rehabilitation integration framework for PHC within the proposed National Health Service. This study used a mixed-methods approach with three studies to address the study objectives. A scoping review was conducted to map the service guidelines, models, and protocols used in low- and middle- income countries, specifically Brazil, Russia, India, China, and South Africa (BRICS) (Phase 1). The shortage of rehabilitation personnel and limited access to services, especially in remote areas, impede the integration of rehabilitation services in BRICS. Community-based rehabilitation is confirmed as the most effective approach to integrate rehabilitation in PHC, emphasising community involvement in service provision through trained community health workers and community rehabilitation workers in transdisciplinary teams. Thus, in low- and middle-income countries with limited rehabilitation service access, community health workers, community rehabilitation workers, peer support workers, collaborative care, self-management, and the community-based rehabilitation model may help integrate rehabilitation into PHC. Using a qualitative approach, a second study was conducted with rehabilitation service providers (n = 12) to understand the extent to which rehabilitation services are integrated into PHC service delivery based on the expressed reality of rehabilitation personnel involved in service provision (Phase 2). The findings revealed a reality of structural-level suboptimal, underdeveloped, and poorly integrated rehabilitation services within the Johannesburg Metropolitan District. Despite isolated adaptations to service delivery and the adoption of components from rehabilitation integration models, such as outreach, the service remains unintegrated. As a result, health outcomes remain unmet. Gaps in the referral system, lack of human and other resources, poor knowledge and implementation of policy, and inefficient financial systems were cited as barriers to integrated care. The proactive attitudes of Page 2 of 2 rehabilitation personnel, creative thinking, and interprofessional relationships within a collaborative team dynamic were identified as facilitators and prospects for integrated rehabilitation services. Concurrently, the findings of a retrospective record review of rehabilitation records across the nine provincially funded clinics offering rehabilitation services (Phase 2) provided a profile of the characteristics of rehabilitation users. The characteristics included aspects such as their age, prevalent disabilities, and referral sources. Insights into rehabilitation service provision, including inconsistent record-keeping practices across the various PHC facilities, were also highlighted. The study results revealed the need for a multidisciplinary rehabilitation team to address diverse rehabilitation needs, improve documentation and discharge practices, expand service delivery models, and reduce disparities in service use. To ensure the perspectives of service users were represented, another qualitative study was conducted with rehabilitation service users. This study aimed to understand the nuanced experiences of rehabilitation services, the perceived impact on their functioning, and the factors influencing those experiences (Phase 3). The analysis showed that service users considered rehabilitation services at operational level to have a substantial positive impact on their activity outcomes and participation and rated them highly. Overall satisfaction of service users with rehabilitation services received in the Johannesburg Metropolitan District was expressed and were influenced by factors such as the actions of rehabilitation personnel, service users’ own active involvement in the rehabilitation process, the organisation of the rehabilitation services, improved service accessibility, and notable functional improvements. After understanding the available rehabilitation models, guidelines, protocols, and the status of rehabilitation services from both the provider and user perspectives, the study findings from phases 1- 3 were triangulated. The triangulation informed the development of a patient-centred framework for integrating rehabilitation services in primary health care (PHC) at the district level, emphasising the importance of placing the patient and communities at the centre of care (Phase 4). Understanding the current state of rehabilitation services, experiences of rehabilitation service providers, and experiences of rehabilitation service users shed light on the lack of integrated rehabilitation services in PHC. Integrated rehabilitation service delivery in PHC requires a multi-level approach at the macro, meso and micro levels. Sustainable and long-lasting solutions to accessible rehabilitation services in PHC must focus on strengthening governance and accountability, reorienting the model of care, creating an enabling environment, coordinating services within and across sectors, and engaging and empowering communities.
Comparison of the proteome of Huh7 cells transfected with different (sub)genotypes of Hepatitis B Virus prevailing in sub-Saharan Africa
(University of the Witwatersrand, Johannesburg, 2024) Padarath, Kiyasha; Kramvis, Anna
Hepatitis B Virus (HBV) is classified into nine genotypes, A to I, and at least 35 subgenotypes. In sub-Saharan Africa (SSA), (sub)genotypes A1, D3, and E prevail. Different mutations in the basic core promoter (BCP) and/or precore (PC) region that affect the expression of HBeAg can affect clinical outcomes and progression to hepatocellular carcinoma (HCC). Subgenotype A1, has high oncogenic potential and mutations affecting HBeAg expression at transcriptional, translation and post-translation levels, resulting in early HBeAg seroconversion. G1862T mutation, frequently found in subgenotype A1 HBV isolated from HCC patients, interferes with signal peptide cleavage and leads to a decreased expression of HBeAg. The effect of the SSA HBV (sub)genotypes and the G1862T mutation on protein expression and host signalling pathways has not been studied. Therefore, in this thesis Huh7 cells were transfected with replication-competent clones of (sub)genotypes A1, A2, D3 E and G1862T mutation to study the proteome using mass spectrometry. Proteomic analysis revealed significantly differentially expressed proteins between different SSA (sub)genotypes and A1 with G1862T compared to the wild-type. These differentially expressed proteins were classified into signalling pathways. The different (sub)genotypes and the G1862T mutant of HBV were shown to affect various signalling pathways involved in three hallmarks of cancer including: immune evasion and persistence, sustained proliferative signalling and genome instability and mutation. In particular, subgenotype A1 was shown to favour the dysregulation of MAPK (immune evasion and persistence) and PI3K/Akt/mTOR (sustained proliferative signalling) pathways and when accompanied by the G1862T mutation showed dysregulation of DNA synthesis pathway leading to uncontrolled proliferation (genome instability and mutation). This was the first study that demonstrated, using comprehensive proteomic analysis differences among SSA genotypes and the effect of G1862T in protein expression in vitro. It provides novel insights into the molecular underpinnings of the oncogenic potential of HBV.

3. Electronic Theses and Dissertations (ETDs)

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