Publications by authors named "Taryn Young"

93 Publications

Patient safety education for undergraduate nursing students: a scoping review protocol.

JBI Evid Synth 2021 Sep 13. Epub 2021 Sep 13.

Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

Objective: The objective of the review is to review the literature on the content related to patient safety and the teaching and learning strategies required to help students learn about patient safety in undergraduate nursing curricula in prelicensure nursing education programs.

Introduction: Patient safety is a global concern, and health care professionals, including nurses who are on the frontline of health care delivery, should be equipped with the knowledge to enhance patient safety. Undergraduate nursing curricula should include the relevant patient safety content and supply nurse educators with teaching and learning strategies to help students acquire these skills.

Inclusion Criteria: Based on the Participants, Concept, and Context (PCC) framework, the eligible population will include nursing students who are enrolled in undergraduate nursing programs and nurse educators who teach in undergraduate nursing programs. The concept of interest is patient safety education, namely the curricular content and teaching and learning strategies used to help nursing students learn the content. The context is prelicensure nursing education programs at the college or university level. Eligible studies will include, but not be limited to, quantitative studies, observational, qualitative and mixed-methods studies, systematic reviews, and opinion papers.

Methods: Online databases will be searched across PubMed, CINAHL, and Web of Science. JBI methodology for scoping reviews will be used to conduct the review. Pre-determined inclusion and exclusion criteria will be used to select relevant studies. Data will be extracted and synthesized from studies that describe patient safety content and teaching and learning strategies in prelicensure nursing education.
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http://dx.doi.org/10.11124/JBIES-20-00256DOI Listing
September 2021

Health economic evidence in clinical guidelines in South Africa: a mixed-methods study.

BMC Health Serv Res 2021 Jul 26;21(1):738. Epub 2021 Jul 26.

Cochrane South Africa, South African Medical Research Council, Tygerberg, Cape Town, South Africa.

Background: Evidence-informed clinical practice guidelines (CPGs) are useful tools to inform transparent healthcare decision-making. Consideration of health economic evidence (HEE) during CPG development in a structured manner remains a challenge globally and locally. This study explored the views, current practice, training needs and challenges faced by CPG developers in the production and use of HEE for CPGs in South Africa.

Methods: This mixed-methods study comprised an online survey and a focus group discussion. The survey was piloted and subsequently sent to CPG role players - evidence reviewers, CPG panellists, academics involved with training in relevant disciplines like health economics and public health, implementers and funders. The focus group participants hold strategic roles in CPG development and health economic activities nationally. The survey evaluated mean values, measures of variability, and percentages for Likert scales, while narrative components were thematically analysed. Focus group data were manually coded, thematically analysed and verified.

Results: The survey (n = 55 respondents to 245 surveys distributed) and one focus group (n = 5 participants from 10 people invited) occurred between October 2018 and February 2019. We found the most consistent reason why HEE should inform CPG decisions was 'making more efficient use of limited financial resources'. This was explained by numerous context and methodological barriers. Focus groups participants noted that consideration of complex HEE are not achievable without bolstering skills in applying evidence-based medicine principles. Further concerns include lack of clarity of standard methods; inequitable and opaque topic selection across private and public sectors; inadequate skills of CPG panel members to use HEE; and the ability of health economists to communicate results in accessible ways. Overall, in the absence of clarity about process and methods, politics and interests may drive CPG decisions about which interventions to implement.

Conclusions: HEE should ideally be considered in CPG decisions in South Africa. However, this will remain hampered until the CPG community agree on methods and processes for using HEE in CPGs. Focused investment by national government to address the challenges identified by the study is imperative for a better return on investment as National Health Insurance moves forward.
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http://dx.doi.org/10.1186/s12913-021-06747-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310693PMC
July 2021

Advancing collaborations in health research and clinical trials in Sub-Saharan Africa: development and implementation of a biostatistical collaboration module in the Masters in Biostatistics Program at Stellenbosch University.

Trials 2021 Jul 22;22(1):478. Epub 2021 Jul 22.

Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa.

Background: Sub-Saharan Africa continues to carry a high burden of communicable diseases such as TB and HIV and non-communicable diseases such as hypertension and other cardiovascular conditions. Although investment in research has led to advances in improvements in outcomes, a lot still remains to be done to build research capacity in health. Like many other regions in the world, Sub-Saharan Africa suffers from a critical shortage of biostatisticians and clinical trial methodologists.

Methods: Funded through a Fogarty Global Health Training Program grant, the Faculty of Medicine and Health Sciences at Stellenbosch University in South Africa established a new Masters Program in Biostatistics which was launched in January 2017. In this paper, we describe the development of a biostatistical and clinical trials collaboration Module, adapted from a similar course offered in the Health Research Methodology program at McMaster University.

Discussion: Guided by three core principles (experiential learning; multi-/inter-disciplinary approach; and formal mentorship), the Module aims to advance biostatistical collaboration skills of the trainees by facilitating learning in how to systematically apply fundamental statistical and trial methodological knowledge in practice while strengthening some soft skills which are necessary for effective collaborations with other healthcare researchers to solve health problems. We also share some preliminary findings from the first four cohorts that took the Module in January-November 2018 to 2021. We expect that this Module can provide an example of how to improve biostatistical and clinical trial collaborations and accelerate research capacity building in low-resource settings.

Funding Source: Fogarty International Center of the National Institutes of Health.
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http://dx.doi.org/10.1186/s13063-021-05427-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8295633PMC
July 2021

What are the effects of teaching Evidence-Based Health Care (EBHC) at different levels of health professions education? An updated overview of systematic reviews.

PLoS One 2021 22;16(7):e0254191. Epub 2021 Jul 22.

Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa.

Background: Evidence-based healthcare (EBHC) knowledge and skills are recognised as core competencies of healthcare professionals worldwide, and teaching EBHC has been widely recommended as an integral part of their training. The objective of this overview of systematic reviews (SR) was to update evidence and assess the effects of various approaches for teaching evidence-based health care (EBHC) at undergraduate (UG) and postgraduate (PG) medical education (ME) level on changes in knowledge, skills, attitudes and behaviour.

Methods And Findings: This is an update of an overview that was published in 2014. The process followed standard procedures specified for the previous version of the overview, with a modified search. Searches were conducted in Epistemonikos for SRs published from 1 January 2013 to 27 October 2020 with no language restrictions. We checked additional sources for ongoing and unpublished SRs. Eligibility criteria included: SRs which evaluated educational interventions for teaching EBHC compared to no intervention or a different strategy were eligible. Two reviewers independently selected SRs, extracted data and evaluated quality using standardised instrument (AMSTAR2). The effects of strategies to teach EBHC were synthesized using a narrative approach. Previously published version of this overview included 16 SR, while the updated search identified six additional SRs. We therefore included a total of 22 SRs (with a total of 141 primary studies) in this updated overview. The SRs evaluated different educational interventions of varying duration, frequency, and format to teach various components of EBHC at different levels of ME (UG, PG, mixed). Most SRs assessed a range of EBHC related outcomes using a variety of assessment tools. Two SRs included randomised controlled trials (RCTs) only, while 20 reviews included RCTs and various types of non-RCTs. Diversity of study designs and teaching activities as well as aggregated findings at the SR level prevented comparisons of the effects of different techniques. In general, knowledge was improved across all ME levels for interventions compared to no intervention or pre-test scores. Skills improved in UGs, but less so in PGs and were less consistent in mixed populations. There were positive changes in behaviour among UGs and PGs, but not in mixed populations, with no consistent improvement in attitudes in any of the studied groups. One SR showed improved patient outcomes (based on non-randomised studies). Main limitations included: poor quality and reporting of SRs, heterogeneity of interventions and outcome measures, and short-term follow up.

Conclusions: Teaching EBHC consistently improved EBHC knowledge and skills at all levels of ME and behaviour in UGs and PGs, but with no consistent improvement in attitudes towards EBHC, and little evidence of the long term influence on processes of care and patient outcomes. EBHC teaching and learning should be interactive, multifaceted, integrated into clinical practice, and should include assessments.

Study Registration: The protocol for the original overview was developed and approved by Stellenbosch University Research Ethics Committee S12/10/262.

Update Of The Overview: Young T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLoS One. 2014;9(1):e86706. doi: 10.1371/journal.pone.0086706.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254191PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297776PMC
July 2021

ffects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis.

BMJ Open 2021 07 12;11(7):e043705. Epub 2021 Jul 12.

Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Objectives: To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes.

Design: Systematic review.

Data Sources: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019.

Eligibility Criteria: We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care.

Data Extraction And Synthesis: Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.

Results: Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty).

Conclusions: Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations.

Prospero Registration Number: CRD42018099314.
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http://dx.doi.org/10.1136/bmjopen-2020-043705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276295PMC
July 2021

Strengthening prehospital clinical practice guideline development in South Africa: Reflections from guideline experts.

Afr J Emerg Med 2021 Mar 29;11(1):132-139. Epub 2020 Oct 29.

Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa.

Introduction: (new) guideline development methods are well described and supported by numerous examples, including comprehensive checklists. However, alternative guideline development methods, which draw from existing up to date, high quality clinical practice guidelines instead of re-inventing the wheel, have not been adopted so readily, despite the potential efficiencies of such methods compared to development. In Africa, guideline quality and rigour of development, especially for prehospital care, remains poor. This paper firstly describes the opinions of international guideline experts on the African Federation for Emergency Medicine guideline project, and secondly updates a framework for South African prehospital guideline development.

Methods: We conducted a qualitative study of expert reviews of an evidence-based guideline development project led by the African Federation for Emergency Medicine in 2016 for prehospital care in South Africa. We purposefully sampled key international and regional guideline experts from a range of organisations. Comments and voice memos, following a terms of reference guide, were thematically analysed through manual coding.

Results: A total of seven experts gave feedback. Key themes revolved around existing international clinical practice guidelines not being enough to cover context specific evidence, blurring of guideline responsibilities and output, and transparency of guideline decisions and conflicts of interest. We showcase three fit-for-purpose guideline development approaches and provide an updated alternative guideline development roadmap for low-resource settings.

Conclusion: In order to create clinical practice guidelines that clinicians trust and use on a daily basis to change lives, guideline developers need rigorous yet pragmatic approaches that are responsive to end-user needs. Reflecting on the African Federation for Emergency Medicine prehospital guideline development project in 2016, this paper presents key guiding themes to strengthen guideline development in low- and middle-income countries and other low-resource settings and provides an updated hybrid guideline development approach.
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http://dx.doi.org/10.1016/j.afjem.2020.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910183PMC
March 2021

Developing excellence in biostatistics leadership, training and science in Africa: How the Sub-Saharan Africa Consortium for Advanced Biostatistics (SSACAB) training unites expertise to deliver excellence.

AAS Open Res 2020 22;3:51. Epub 2020 Dec 22.

Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, 2193, South Africa.

The increase in health research in sub-Saharan Africa (SSA) has led to a high demand for biostatisticians to develop study designs, contribute and apply statistical methods in data analyses. Initiatives exist to address the dearth in statistical capacity and lack of local biostatisticians in SSA health projects. The Sub-Saharan African Consortium for Advanced Biostatistics (SSACAB) led by African institutions was initiated to improve biostatistical capacity according to the needs identified by African institutions, through collaborative masters and doctoral training in biostatistics. SACCAB has created a critical mass of biostatisticians and a network of institutions over the last five years and has strengthened biostatistics resources and capacity for health research studies in SSA.  SSACAB comprises 11 universities and four research institutions which are supported by four European universities.  In 2015, only four universities had established Masters programmes in biostatistics and SSACAB supported the remaining seven to develop Masters programmes. In 2019 the University of the Witwatersrand became the first African institution to gain Royal Statistical Society accreditation for a Biostatistics Masters programme. A total of 150 fellows have been awarded scholarships to date of which 123 are Masters fellowships (41 female) of whom 58 have already graduated. Graduates have been employed in African academic (19) and research (15) institutions and 10 have enrolled for PhD studies. A total of 27 (10 female) PhD fellowships have been awarded; 4 of them are due to graduate by 2020. To date, SSACAB Masters and PhD students have published 17 and 31 peer-reviewed articles, respectively. SSACAB has also facilitated well-attended conferences, face-to-face and online short courses. Pooling of limited biostatistics resources in SSA combined with co-funding from external partners has shown to be an effective strategy for the development and teaching of advanced biostatistics methods, supervision and mentoring of PhD candidates.
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http://dx.doi.org/10.12688/aasopenres.13144.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802118PMC
December 2020

Reporting of methodological studies in health research: a protocol for the development of the MethodologIcal STudy reportIng Checklist (MISTIC).

BMJ Open 2020 12 17;10(12):e040478. Epub 2020 Dec 17.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.

Introduction: Methodological studies (ie, studies that evaluate the design, conduct, analysis or reporting of other studies in health research) address various facets of health research including, for instance, data collection techniques, differences in approaches to analyses, reporting quality, adherence to guidelines or publication bias. As a result, methodological studies can help to identify knowledge gaps in the methodology of health research and strategies for improvement in research practices. Differences in methodological study names and a lack of reporting guidance contribute to lack of comparability across studies and difficulties in identifying relevant previous methodological studies. This paper outlines the methods we will use to develop an evidence-based tool-the MethodologIcal STudy reportIng Checklist-to harmonise naming conventions and improve the reporting of methodological studies.

Methods And Analysis: We will search for methodological studies in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, MEDLINE, Web of Science, check reference lists and contact experts in the field. We will extract and summarise data on the study names, design and reporting features of the included methodological studies. Consensus on study terms and recommended reporting items will be achieved via video conference meetings with a panel of experts including researchers who have published methodological studies.

Ethics And Dissemination: The consensus study has been exempt from ethics review by the Hamilton Integrated Research Ethics Board. The results of the review and the reporting guideline will be disseminated in stakeholder meetings, conferences, peer-reviewed publications, in requests to journal editors (to endorse or make the guideline a requirement for authors), and on the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network and reporting guideline websites.

Registration: We have registered the development of the reporting guideline with the EQUATOR Network and publicly posted this project on the Open Science Framework (www.osf.io/9hgbq).
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http://dx.doi.org/10.1136/bmjopen-2020-040478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747548PMC
December 2020

Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations.

Wellcome Open Res 2019 17;4:173. Epub 2020 Aug 17.

Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA.

Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. We included seven randomised and one non-randomised study.  All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
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http://dx.doi.org/10.12688/wellcomeopenres.15412.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438967PMC
August 2020

Enhancing capacity for clinical practice guidelines in South Africa.

Pan Afr Med J 2020 13;36:18. Epub 2020 May 13.

Physiotherapy Division, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

Introduction: Use of good quality, evidence-informed and up-to-date clinical practice guidelines (CPGs) has the potential to impact health outcomes. This paper describes the development, implementation and evaluation of a dedicated CPG training course to address the training needs of CPG stakeholders in South Africa.

Methods: We first reviewed the content and teaching strategies of existing CPG courses. This review consisted of a systematic review of teaching and learning strategies for guideline teams and a document review of existing courses offered by international guideline groups, universities and professional groups. We then strengthened an existing CPG course and evaluated it.

Results: We found no studies on teaching and learning strategies for guideline teams. We identified six CPG courses being offered as full courses (part of a postgraduate degree program) by universities or as independent training for continuing professional education by professional groups. Contents focused on new guideline development. One course included alternative methods of guideline approaches such as contextualization and adaptation. The format varied from face-to-face sessions, to online sessions, group exercises and discussions, seminar format and project based activities. The revised CPG four-month long course that we implemented was designed to be pragmatic, reflective and contextually relevant. It used local guideline examples, authentic tasks, and an online forum for discussions and resources. It covered de novo CPG development, alternative methods of development (adopting, contextualising, adapting), and implementing CPGs. Course evaluation identified strengths and areas for improvement.

Conclusion: Dedicated capacity development has potential to positively influence CPG development and implementation.
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http://dx.doi.org/10.11604/pamj.2020.36.18.20800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388621PMC
December 2020

Evidence synthesis workshops: moving from face-to-face to online learning.

BMJ Evid Based Med 2020 Aug 6. Epub 2020 Aug 6.

Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, Western Cape, South Africa.

Postgraduate training is moving from face-to-face workshops or courses to online learning to help increase access to knowledge, expertise and skills, and save the cost of face-to-face training. However, moving from face-to-face to online learning for many of us academics is intimidating, and appears even more difficult without the help of a team of technologists. In this paper, we describe our approach, our experiences and the lessons we learnt from converting a Primer in Systematic Reviews face-to-face workshop to a 6-week online course designed for healthcare professionals in Africa. We learnt that the team needs a balance of skills and experience, including technical know-how and content knowledge; that the learning strategies needed to achieve the learning objectives must match the content delivery. The online approach should result in both building knowledge and developing skills, and include interactive and participatory approaches. Finally, the design and delivery needs to keep in mind the limited and expensive internet access in some resource-poor settings in Africa.
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http://dx.doi.org/10.1136/bmjebm-2020-111394DOI Listing
August 2020

Strengthening prehospital clinical practice guideline implementation in South Africa: a qualitative case study.

BMC Health Serv Res 2020 Apr 24;20(1):349. Epub 2020 Apr 24.

Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa.

Background: Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, research into alternative methods of CPG development using existing CPG documents (CPG adaptation) - a specific issue for guideline development groups in low- and middle-income countries - is sparse. There are only a few examples showcasing the pragmatic application of such alternative approaches in settings with time and budget constraints, especially in the prehospital setting. This paper aims to describe and strengthen the methods of developing prehospital CPGs using alternative guideline development methods through a case study design.

Methods: We qualitatively explored a CPG development project conducted in 2016 for prehospital providers in South Africa as a case study. Key stakeholders, involved in various processes of the guideline project, were purposefully sampled. Data were collected from one focus group and six in-depth interviews and analysed using thematic analysis. Overarching themes and sub-themes were inductively developed and categorised as challenges and recommendations and further transformed into action points.

Results: Key challenges revolved around guideline implementation as opposed to development. These included the unavoidable effect of interest and beliefs on implementing recommendations, the local evidence void, a shifting implementation context, and opposing end-user needs. Guideline development and implementation strengthening priority actions included: i) developing a national end-user document; ii) aligning recommendations with local practice; iii) communicating a clear and consistent message; iv) addressing controversial recommendations; v) managing the impact of interests, beliefs and intellectual conflicts; and vi) transparently reporting implementation decisions.

Conclusion: The cornerstone of a successful guideline development process is the translation and implementation of CPG recommendations into clinical practice. We highlight key priority actions for prehospital guideline development teams with limited resources to strengthen guideline development, dissemination, and implementation by drawing from lessons learnt from a prehospital guideline project conducted in South Africa.
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http://dx.doi.org/10.1186/s12913-020-05111-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183123PMC
April 2020

Analytical methods used in estimating the prevalence of HIV/AIDS from demographic and cross-sectional surveys with missing data: a systematic review.

BMC Med Res Methodol 2020 03 14;20(1):65. Epub 2020 Mar 14.

Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Francie van Zijl Drive, 7505 Tygerberg, Cape Town, South Africa.

Background: Sero- prevalence studies often have a problem of missing data. Few studies report the proportion of missing data and even fewer describe the methods used to adjust the results for missing data. The objective of this review was to determine the analytical methods used for analysis in HIV surveys with missing data.

Methods: We searched for population, demographic and cross-sectional surveys of HIV published from January 2000 to April 2018 in Pub Med/Medline, Web of Science core collection, Latin American and Caribbean Sciences Literature, Africa-Wide Information and Scopus, and by reviewing references of included articles. All potential abstracts were imported into Covidence and abstracts screened by two independent reviewers using pre-specified criteria. Disagreements were resolved through discussion. A piloted data extraction tool was used to extract data and assess the risk of bias of the eligible studies. Data were analysed through a quantitative approach; variables were presented and summarised using figures and tables.

Results: A total of 3426 citations where identified, 194 duplicates removed, 3232 screened and 69 full articles were obtained. Twenty-four studies were included. The response rate for an HIV test of the included studies ranged from 32 to 96% with the major reason for the missing data being refusal to consent for an HIV test. Complete case analysis was the primary method of analysis used, multiple imputations 11(46%) was the most advanced method used, followed by the Heckman's selection model 9(38%). Single Imputation and Instrumental variables method were used in only two studies each, with 13(54%) other different methods used in several studies. Forty-two percent of the studies applied more than two methods in the analysis, with a maximum of 4 methods per study. Only 6(25%) studies conducted a sensitivity analysis, while 11(46%) studies had a significant change of estimates after adjusting for missing data.

Conclusion: Missing data in survey studies is still a problem in disease estimation. Our review outlined a number of methods that can be used to adjust for missing data on HIV studies; however, more information and awareness are needed to allow informed choices on which method to be applied for the estimates to be more reliable and representative.
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http://dx.doi.org/10.1186/s12874-020-00944-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071763PMC
March 2020

Improving the design of studies evaluating the impact of diagnostic tests for tuberculosis on health outcomes: a qualitative study of perspectives of diverse stakeholders.

Wellcome Open Res 2019 21;4:183. Epub 2019 Nov 21.

School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA 6009, Australia.

Studies evaluating the impact of Xpert MTB/RIF testing for tuberculosis (TB) have demonstrated varied effects on health outcomes with many studies showing inconclusive results. We explored perceptions among diverse stakeholders about studies evaluating the impact of TB diagnostic tests, and identified suggestions for improving these studies. We used purposive sampling with consideration for differing expertise and geographical balance and conducted in depth semi-structured interviews. We interviewed English-speaking participants, including TB patients, and others involved in research, care or decision-making about TB diagnostics. We used the thematic approach to code and analyse the interview transcripts. We interviewed 31 participants. Our study showed that stakeholders had different expectations with regard to test impact and how it is measured. TB test impact studies were perceived to be important for supporting implementation of tests but there were concerns about the unrealistic expectations placed on tests to improve outcomes in health systems with many influencing factors. To improve TB test impact studies, respondents suggested conducting health system assessments prior to the study; developing clear guidance on the study methodology and interpretation; improving study design by describing questions and interventions that consider the influences of the health-care ecosystem on the diagnostic test; selecting the target population at the health-care level most likely to benefit from the test; setting realistic targets for effect sizes in the sample size calculations; and interpreting study results carefully and avoiding categorisation and interpretation of results based on statistical significance alone. Researchers should involve multiple stakeholders in the design of studies. Advocating for more funding to support robust studies is essential. TB test impact studies were perceived to be important to support implementation of tests but there were concerns about their complexity. Process evaluations of their health system context and guidance for their design and interpretation are recommended.
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http://dx.doi.org/10.12688/wellcomeopenres.15551.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041361PMC
November 2019

Does Low-level Laser Therapy Provide Additional Benefits to Exercise in Patients with Shoulder Musculoskeletal Disorders? A Meta-analysis of Randomised Controlled Trials.

Ortop Traumatol Rehabil 2019 Dec;21(6):407-416

Centre for Evidence-based Health Care, Stellenbosch University, Cape Town, South Africa.

Background: Low-level laser therapy as an adjunct to exercise is common in clinical practice; however, existing evidence for its recommendation is low. To determine whether low-level laser therapy provides additional benefits to exercise in patients with various shoulder musculoskeletal disorders.

Material And Methods: An electronic search was conducted on seven databases, including The Cochrane Library, MEDLINE, and CINAH as well as grey literatures, for randomised controlled trials published in English from 1996 to 2018. Selected studies were independently screened and assessed for quality according to the Cochrane Grade of Recommendations, Assessment, Development and Evaluation.

Results: Eleven studies met the inclusion criteria for this review. Moderate evidence indicates that low-level laser therapy provides additional short-term benefit to exercise in improving overall pain (10cm-VAS) (6 RCTs, GRADE quality moderate) (WMD: 1.75; 95% CI: 1.43 to 2.07). However, low evidence indicates that low-level laser therapy provides no additional benefit to exercise for shoulder function [5 RCTs; SWMD: -0.14; 95% CI: -0.79 to 0.25] and range of motions.

Conclusions: 1. Physiotherapists may consider the use of low-laser therapy as an adjunct to exercise in the short run to improve pain in patients with shoulder musculoskeletal disorders. 2. However, low-laser therapy with exercise in the short-term is no more effective than exercise alone in improving shoulder function and range of motions.
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http://dx.doi.org/10.5604/01.3001.0013.7398DOI Listing
December 2019

University Curricula in Evidence-Informed Decision Making and Knowledge Translation: Integrating Best Practice, Innovation, and Experience for Effective Teaching and Learning.

Front Public Health 2019 3;7:313. Epub 2019 Dec 3.

Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Centre for Evidence-Based Health Care, Stellenbosch University, Cape Town, South Africa.

As attention to Evidence Informed Decision Making (EIDM) and Knowledge Translation (KT) in research, policy and practice grows, so does a need for capacity enhancement in amongst evidence producers and evidence users. Recognizing that most researchers enter the professional sphere with little or no appreciation of the importance and power of EIDM, the Centre for Evidence-based Health Care at Stellenbosch University, South Africa, spearheaded the development and accreditation of a foundational course titled Evidence-Informed Decision making: The Art, Science and Complexity of knowledge translation. The curriculum draws on the principles of adult learning and effective teaching that includes integrating seven key aspects: (1) extraction of intuitive and tacit knowledge (2) autonomous knowledge generation (3) diverse perspectives (4) learning by doing (5) peer-support and critique (6) facilitator coaching and (7) constant reflection. In this paper, we reflect on these techniques in enhancing understanding and utilization of KT in advancing EIDM. The in-person short course has been offered 5 times since its launch in September 2017 with attendance by ~85 senior researchers and government officials-each of whom left the workshop with three completed outputs: a stakeholder matrix, an engagement strategy for their chosen stakeholder and a plan for evaluating the impact of their KT strategy. Interest in the course has grown considerably: (a) Requests from local institutes of research for dedicated training to their staff; (b) Incorporation into international program partner capacity enhancing strategies; (c) Publication of a book chapter designed using course content; (d) Adaptation and utilization of the templates and tools as teaching resources (e) Informing organizational stakeholder engagement strategies (f) Adaptation of the modules for conference capacity building workshops. In summary, designing courses that take into consideration adult principles of learning is not a new concept. However, effective delivery of such courses is still nascent. We found that integrating the seven aspects mentioned above, including researchers together with decision-makers in the workshops, and having an experienced facilitator is critical for effective learning. Enhancing knowledge and skills "just in time" rather than "just in case" has demonstrated increased potential for immediate relevance, uptake and sustainability.
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http://dx.doi.org/10.3389/fpubh.2019.00313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901672PMC
December 2019

Advancing research integrity: a programme to embed good practice in Africa.

Pan Afr Med J 2019 13;33:298. Epub 2019 Aug 13.

Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

In Africa, training programmes as well as institutional policies on research integrity are lacking. Institutions have a responsibility to oversee research integrity through various efforts, including policies and training. We developed, implemented and evaluated an institutional approach to promote research integrity at African institutions, comprising a workshop for researchers ("bottom-up") and discussions with senior faculty on institutional policies ("top-down"). During the first day, we facilitated a workshop to introduce research integrity and promote best practices with regards to authorship, plagiarism, redundant publication and conflicts of interest. We used a variety of interactive teaching approaches to facilitate learning, including individual and group activities, small group discussions and case-based learning. We met with senior faculty on the following day to provide feedback and insights from the workshop, review current institutional policies and provide examples of what other research groups are doing. We evaluated the process. Participants actively engaged in discussions, recognised the importance of the topic and acknowledged that poor practices occurred at their institution. Discussions with senior researchers resulted in the establishment of a working group tasked with developing a publication policy for the institution. Our approach kick-started conversations on research integrity at institutions. There is a need for continued discussions, integrated training programmes and implementation of institutional policies and guidelines to promote good practices.
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http://dx.doi.org/10.11604/pamj.2019.33.298.17008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815471PMC
November 2019

Priority setting for new systematic reviews: processes and lessons learned in three regions in Africa.

BMJ Glob Health 2019 26;4(4):e001615. Epub 2019 Jul 26.

Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa.

Priority setting to identify topical and context relevant questions for systematic reviews involves an explicit, iterative and inclusive process. In resource-constrained settings of low-income and middle-income countries, priority setting for health related research activities ensures efficient use of resources. In this paper, we critically reflect on the approaches and specific processes adopted across three regions of Africa, present some of the outcomes and share the lessons learnt while carrying out these activities. Priority setting for new systematic reviews was conducted between 2016 and 2018 across three regions in Africa. Different approaches were used: Multimodal approach (Central Africa), Modified Delphi approach (West Africa) and Multilevel stakeholder discussion (Southern-Eastern Africa). Several questions that can feed into systematic reviews have emerged from these activities. We have learnt that collaborative subregional efforts using an integrative approach can effectively lead to the identification of region specific priorities. Systematic review workshops including discussion about the role and value of reviews to inform policy and research agendas were a useful part of the engagements. This may also enable relevant stakeholders to contribute towards the priority setting process in meaningful ways. However, certain shared challenges were identified, including that emerging priorities may be overlooked due to differences in burden of disease data and differences in language can hinder effective participation by stakeholders. We found that face-to-face contact is crucial for success and follow-up engagement with stakeholders is critical in driving acceptance of the findings and planning future progress.
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http://dx.doi.org/10.1136/bmjgh-2019-001615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6666801PMC
July 2019

Correction to: Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs): Protocol for a systematic review.

Syst Rev 2019 Jan 31;8(1):36. Epub 2019 Jan 31.

Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Breisacher Strasse 153, 79110, Freiburg, Germany.

AbstractFollowing publication of the original article [1], the author reported that their family name was misspelled.
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http://dx.doi.org/10.1186/s13643-019-0943-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354368PMC
January 2019

Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey.

JAMA Netw Open 2018 06 1;1(2):e180281. Epub 2018 Jun 1.

Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia.

Importance: Evidence-based practice (EBP) is necessary for improving the quality of health care as well as patient outcomes. Evidence-based practice is commonly integrated into the curricula of undergraduate, postgraduate, and continuing professional development health programs. There is, however, inconsistency in the curriculum content of EBP teaching and learning programs. A standardized set of minimum core competencies in EBP that health professionals should meet has the potential to standardize and improve education in EBP.

Objective: To develop a consensus set of core competencies for health professionals in EBP.

Evidence Review: For this modified Delphi survey study, a set of EBP core competencies that should be covered in EBP teaching and learning programs was developed in 4 stages: (1) generation of an initial set of relevant EBP competencies derived from a systematic review of EBP education studies for health professionals; (2) a 2-round, web-based Delphi survey of health professionals, selected using purposive sampling, to prioritize and gain consensus on the most essential EBP core competencies; (3) consensus meetings, both face-to-face and via video conference, to finalize the consensus on the most essential core competencies; and (4) feedback and endorsement from EBP experts.

Findings: From an earlier systematic review of 83 EBP educational intervention studies, 86 unique EBP competencies were identified. In a Delphi survey of 234 participants representing a range of health professionals (physicians, nurses, and allied health professionals) who registered interest (88 [61.1%] women; mean [SD] age, 45.2 [10.2] years), 184 (78.6%) participated in round 1 and 144 (61.5%) in round 2. Consensus was reached on 68 EBP core competencies. The final set of EBP core competencies were grouped into the main EBP domains. For each key competency, a description of the level of detail or delivery was identified.

Conclusions And Relevance: A consensus-based, contemporary set of EBP core competencies has been identified that may inform curriculum development of entry-level EBP teaching and learning programs for health professionals and benchmark standards for EBP teaching.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.0281DOI Listing
June 2018

Researcher and policymaker dialogue: the Policy BUDDIES Project in Western Cape Province, South Africa.

BMJ Glob Health 2018 14;3(6):e001130. Epub 2018 Dec 14.

Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK.

Dialogue and exchange between researchers and policy personnel may increase the use of research evidence in policy. We piloted and evaluated a programme of formalised dialogue between researchers and provincial health policymakers in South Africa, called the buddying programme. An external evaluation examined implementation and short-term impact, drawing on documents, in-depth interviews with policymakers, a researcher buddies focus group and our own reflection on what we learnt. We set up buddying with seven policymakers and five researchers on six policy questions. Researchers knew little about policymaking or needs of policymakers. Policymakers respected the contact with researchers, respected researchers' objectivity and appreciated the formalised approach. Having policymaker champions facilitated the dialogue. Scenarios for policy questions and use were different. One topic was at problem identification stage (contraceptives and HIV risk), four at policy formulation stage (healthy lifestyles, chronic illness medication adherence, integrated care of chronic illness and maternal transmission of HIV to infants) and one at implementation stage (task shifting). Research evidence were used to identify or solve a policy problem (two scenarios), to legitimise a predetermined policy position (three scenarios) or the evidence indirectly influenced the policy (one scenario). The formalised dialogue required in this structured buddying programme took time and commitment from both sides. The programme illustrated the importance of researchers listening, and policymakers understanding what research can offer. Both parties recognised that the structured buddying made the dialogue happen. Often the evidence was helpful in supporting provincial policy decisions that were in the roll-out phase from the national government.
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http://dx.doi.org/10.1136/bmjgh-2018-001130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304097PMC
December 2018

Global emergency care clinical practice guidelines: A landscape analysis.

Afr J Emerg Med 2018 Dec 24;8(4):158-163. Epub 2018 Oct 24.

Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Stellenbosch University, South Africa.

Introduction: An adaptive guideline development method, as opposed to a guideline development, is dependent on access to existing high-quality up-to-date clinical practice guidelines (CPGs). We described the characteristics and quality of CPGs relevant to prehospital care worldwide, in order to strengthen guideline development in low-resource settings for emergency care.

Methods: We conducted a descriptive study of a database of international CPGs relevant to emergency care produced by the African Federation for Emergency Medicine (AFEM) CPG project in 2016. Guideline quality was assessed with the AGREE II tool, independently and in duplicate. End-user documents such as protocols, care pathways, and algorithms were excluded. Data were imported, managed, and analysed in STATA 14 and R.

Results: In total, 276 guidelines were included. Less than 2% of CPGs originated from low- and middle income-countries (LMICs); only 15% (n = 38) of guidelines were prehospital specific, and there were no CPGs directly applicable to prehospital care in LMICs. Most guidelines used methods (58%, n = 150) and were produced by professional societies or associations (63%, n = 164), with the minority developed by international bodies (3%, n = 7). National bodies, such as the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), produced higher quality guidelines when compared to international guidelines, professional societies, and clinician/academic-produced guidelines. Guideline quality varied across topics, subpopulations and producers. Resource-constrained guideline developers that cannot afford guideline development have access to an expanding pool of high-quality prehospital guidelines to translate to their local setting.

Discussion: Although some high-quality CPGs exist relevant to emergency care, none directly address the needs of prehospital care in LMICs, especially in Africa. Strengthening guideline development capacity, including adaptive guideline development methods that use existing high-quality CPGs, is a priority.
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http://dx.doi.org/10.1016/j.afjem.2018.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277502PMC
December 2018

Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs) : Protocol for a systematic review.

Syst Rev 2018 11 20;7(1):203. Epub 2018 Nov 20.

Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Breisacher Strasse 153, 79110, Freiburg, Germany.

Background: In low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs.

Methods: We will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χand I tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table.

Discussion: In light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed.

Systematic Review Registration: PROSPERO CRD42018099314 .
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http://dx.doi.org/10.1186/s13643-018-0865-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247752PMC
November 2018

Plagiarism in research: a survey of African medical journals.

BMJ Open 2018 11 8;8(11):e024777. Epub 2018 Nov 8.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.

Objectives: To examine whether regional biomedical journals in Africa had policies on plagiarism and procedures to detect it; and to measure the extent of plagiarism in their original research articles and reviews.

Design: Cross sectional survey.

Setting And Participants: We selected journals with an editor-in-chief in Africa, a publisher based in a low or middle income country and with author guidelines in English, and systematically searched the African Journals Online database. From each of the 100 journals identified, we randomly selected five original research articles or reviews published in 2016.

Outcomes: For included journals, we examined the presence of plagiarism policies and whether they referred to text matching software. We submitted articles to Turnitin and measured the extent of plagiarism (copying of someone else's work) or redundancy (copying of one's own work) against a set of criteria we had developed and piloted.

Results: Of the 100 journals, 26 had a policy on plagiarism and 16 referred to text matching software. Of 495 articles, 313 (63%; 95% CI 58 to 68) had evidence of plagiarism: 17% (83) had at least four linked copied or more than six individual copied sentences; 19% (96) had three to six copied sentences; and the remainder had one or two copied sentences. Plagiarism was more common in the introduction and discussion, and uncommon in the results.

Conclusion: Plagiarism is common in biomedical research articles and reviews published in Africa. While wholesale plagiarism was uncommon, moderate text plagiarism was extensive. This could rapidly be eliminated if journal editors implemented screening strategies, including text matching software.
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http://dx.doi.org/10.1136/bmjopen-2018-024777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231593PMC
November 2018

Output from the CIHR Canadian HIV Trials Network international postdoctoral fellowship for capacity building in HIV clinical trials.

HIV AIDS (Auckl) 2018 16;10:151-155. Epub 2018 Aug 16.

UBC School of Population and Public Health, Vancouver, BC.

As a response to the human immunodeficiency virus (HIV) epidemic and part of Canadian Institutes for Health Research's mandate to support international health research capacity building, the Canadian Institutes for Health Research Canadian HIV Trial Network (CTN) developed an international postdoctoral fellowship award under the CTN's Postdoctoral Fellowship Awards Program to support and train young HIV researchers in resource-limited settings. Since 2010, the fellowship has been awarded to eight fellows in Cameroon, China, Lesotho, South Africa, Uganda and Zambia. These fellows have conducted research on a wide variety of topics and have built a strong network of collaboration and scientific productivity, with 40 peer-reviewed publications produced by six fellows during their fellowships. They delivered two workshops at international conferences and have continued to secure funding for their research, using the fellowship as a stepping stone. The CTN has been successful in building local HIV research capacity and forming a strong network of like-minded junior low- and middle-income country researchers with high levels of research productivity. They have developed into mentors, supervisors and faculty members, who, in turn, build local capacity. The sustainability of this international fellowship award relies on the recognition of its strengths and the involvement of other stakeholders for additional resources.
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http://dx.doi.org/10.2147/HIV.S150107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6101741PMC
August 2018

Cochrane Africa: a network of evidence-informed health-care decision making across sub-saharan Africa.

Pan Afr Med J 2018 3;29:196. Epub 2018 Apr 3.

Cochrane South Africa, South African Medical Research Council, Cape Town, Western Cape, South Africa.

Cochrane Africa is a network of researchers and health stakeholders who aim to support the use of high quality Cochrane evidence to improve health outcomes in Africa. It comprises a coordinating centre in South Africa, a Francophone hub directed from Cameroon, a Southern and Eastern Africa Hub directed from South Africa and a West Africa Hub directed from Nigeria. The network supports the engagement with healthcare decision makers to guide priorities, production of high quality context-relevant Cochrane systematic reviews, capacity building to conduct and use reviews, dissemination of evidence, knowledge translation, partnerships for evidence-informed healthcare and the creation of opportunities to expand the network.
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http://dx.doi.org/10.11604/pamj.2018.29.196.14521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6061814PMC
August 2018

Integration of care for hypertension and diabetes: a scoping review assessing the evidence from systematic reviews and evaluating reporting.

BMC Health Serv Res 2018 06 20;18(1):481. Epub 2018 Jun 20.

Centre of Evidence Based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.

Background: With the rise in pre-mature mortality rate from non-communicable disease (NCD), there is a need for evidence-based interventions. We evaluated existing systematic reviews on effectiveness of integration of healthcare services, in particular with focus on delivery of care designed to improve health and process outcomes in people with multi-morbidity, where at least one of the conditions was diabetes or hypertension.

Methods: We searched MEDLINE, EMBASE, Cochrane Library, and Health Evidence to November 8, 2016 and consulted experts. One review author screened titles, abstracts and two review authors independently screened short listed full-texts and selected reviews for inclusion. We considered systematic reviews evaluating integration of care, compared to usual care, for people with multi-morbidity. One review author extracted data and another author verified it. Two review authors independently evaluated risk of bias using ROBIS and AMSTAR. Inter-rater reliability was analysed for ROBIS and AMSTAR using Cohen's kappa and percent agreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to assess reporting.

Results: We identified five systematic reviews on integration of care. Four reviews focused on comorbid diabetes and depression and two covered hypertension and comorbidities of cardiovascular disease, depression, or diabetes. Interventions were poorly described. The health outcomes evaluated included risk of all-cause mortality, measures of depression, cholesterol levels, HbA1c levels, effect of depression on HbA1c levels, symptom improvement, systolic blood pressure, and hypertension control. Process outcomes included access and utilisation of healthcare services, costs, and quality of care. Overall, three reviews had a low and medium risk of bias according to ROBIS and AMSTAR respectively, while two reviews had high risk of bias as judged by both ROBIS and AMSTAR. Findings have demonstrated that collaborative care in general resulted in better health and process outcomes when compared to usual care for both depression and diabetes and hypertension and diabetes.

Conclusions: Several knowledge gaps were identified on integration of care for comorbidities with diabetes and/or hypertension: limited research on this topic for hypertension, limited reviews that included primary studies based in low-middle income countries, and limited reviews on collaborative care for communicable and NCDs.
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http://dx.doi.org/10.1186/s12913-018-3290-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6011271PMC
June 2018

Predictors of mortality in adults on treatment for human immunodeficiency virus-associated tuberculosis in Botswana: A retrospective cohort study.

Medicine (Baltimore) 2018 Apr;97(16):e0486

Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University Palapye District Health Management Team, Ministry of Health, Palapye, Botswana Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.

Mortality in patients with human immunodeficiency virus (HIV)-associated tuberculosis (TB) is high, particularly in sub-Saharan Africa. This study aimed to compare mortality and predictors of mortality in those who were antiretroviral therapy (ART) naïve to those with prior ART exposure.This retrospective cohort study was conducted in Serowe/Palapye District, Botswana, a predominantly urban district with a large burden of HIV-associated TB with a high case fatality. Between January 1, 2013 and December 31, 2013, patients confirmed with HIV-associated TB were enrolled and followed up. Kaplan-Meier and Cox proportional hazard modeling was undertaken to identify predictors of mortality, with ART initiation included as time-updated variable.Among the 300 patients enrolled in the study, 131 had started ART before TB diagnosis (44%). There were 45 deaths. There was no difference in mortality between ART-naïve patients and those with prior ART exposure. In the multivariate analysis, no ART use during TB treatment (hazard ratio [HR] = 5.6, 95% confidence interval [CI] = 2.9-11; P < .001), opportunistic infections other than TB (HR = 8.5, 95% CI = 4-18.4; P = .013), age ≥60 years (HR = 4.8, 95% CI = 1.8-13; P = .002), hemoglobin <10 g/dL (HR = 2.4, 95% CI = 1.3-4.5) and hepatotoxicity (HR = 5, 95% CI = 1.6-17; P = .007) were associated with increased mortality. In the subgroup analysis, among ART-naïve patients, no ART use during TB treatment (HR = 8.1, 95% CI = 3.4-19.4; P < .001), opportunistic infections other than TB (HR = 16, 95% CI = 6.2-42; P < .001), and hepatotoxicity (HR = 8.3, 95% CI = 2.6-27; P < .001) were associated with mortality. Among patients with prior ART exposure, opportunistic infections other than TB (HR = 6, 95% CI = 2.6-27; P < .001) were associated with mortality.Mortality in patients with HIV-associated TB is still high. To reduce mortality, close clinical monitoring of patients together with initiation of ART during TB treatment is indicated.
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http://dx.doi.org/10.1097/MD.0000000000010486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916691PMC
April 2018

Next generation clinical guidance for primary care in South Africa - credible, consistent and pragmatic.

PLoS One 2018 30;13(3):e0195025. Epub 2018 Mar 30.

Physiotherapy Department, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

Background: Agreed international development standards underpin high quality de novo clinical practice guidelines (CPGs). There is however, no international consensus on how high quality CPGs should 'look'; or on whether high quality CPGs from one country can be viably implemented elsewhere. Writing de novo CPGs is generally resource-intensive and expensive, making this challenging in resource-poor environments. This paper proposes an alternative, efficient method of producing high quality CPGs in such circumstances, using existing CPGs layered by local knowledge, contexts and products.

Methods: We undertook a mixed methods case study in South African (SA) primary healthcare (PHC), building on findings from four independent studies. These comprised an overview of international CPG activities; a rapid literature review on international CPG development practices; critical appraisal of 16 purposively-sampled SA PHC CPGs; and additional interrogation of these CPGs regarding how, why and for whom, they had been produced, and how they 'looked'.

Results: Despite a common aim to improve SA PHC healthcare practices, the included CPGs had different, unclear and inconsistent production processes, terminology and evidence presentation styles. None aligned with international quality standards. However many included innovative succinct guidance for end-users (which we classified as evidence-based summary recommendations, patient management tools or protocols). We developed a three-tiered model, a checklist and a glossary of common terms, for more efficient future production of better quality, contextually-relevant, locally-implementable SA PHC CPGs. Tier 1 involves transparent synthesis of existing high quality CPG recommendations; Tier 2 reflects local expertise to layer Tier 1 evidence with local contexts; and Tier 3 comprises tailored locally-relevant end-user guidance.

Conclusion: Our model could be relevant for any resource-poor environment. It should reduce effort and costs in finding and synthesising available research evidence, whilst efficiently focusing scant resources on contextually-relevant evidence-based guidance, and implementation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195025PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877861PMC
July 2018
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