Masters Degrees (Epidemiology and Biostatistics)

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The association between taking HAART and hypertension
(Stellenbosch : Stellenbosch University, 2017-12) Mangunda, Tichatonga John; Machekano, Rhoderick; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Prevalence of hypertension in patients on HAART compared to pre-ART patients at Sithobela Hospital. Background: The use of Highly Active Anti-retroviral Therapy (HAART) has improved the quality of life among people with HIV/AIDS, but there are concerns about its effect on hypertension and other cardiovascular diseases. Objectives: In this study we sought to find out if HAART is associated with hypertension and to describe lifestyle and socio-demographic factors among people on pre-ART and HAART. Methods: We conducted a cross sectional study of HIV infected patients initiated on HAART and pre-ART at Sithobela health centre. Results: We enrolled a total of 410 participants, 205 in the ART group and 205 in the pre-ART group. The estimated prevalence of hypertension among those on ART was 14.2% [95% CI: 9.3-18.9] and 19%[95% CI: 13.6-24.4] among pre-ART patients. There was no significant difference in the prevalence of hypertension between the two groups (p=0.185). However, after adjusting for age, marital status, level of education, stage of disease, smoking history, waist to hip ratio, occupation, income level, history of smoking and alcohol use, HAART was significantly associated with hypertension (AOR= 0.43 [95% CI: 0.23-0.83]). Patients who reported drinking alcohol were likely to be hypertensive (AOR 10.96 [95% CI: 2.36-50.92]). Smokers were 3 times more likely to be hypertensive compared to non-smokers but this association was found not to be statistically significant on multivariate analysis. Conclusion: our study demonstrated a potential beneficial effect of HAART in reducing hypertension among HIV infected people in Sithobela, Swaziland.
Association of home hygienic practice and diarrhoeal presence in low-cost housing in Cape Town, South Africa
(Stellenbosch : Stellenbosch University, 2017-12) Brand, Amanda; Esterhuizen, Tonya; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Background: Good home hygiene in key high-risk areas shows potential to be a simple and cost-effective intervention for preventing infectious disease transmission in low income homes. Knowledge of good home hygiene does not, however, always translate to practice due to complex factors which hinder translation. The objective of the study was to investigate whether an association between cleanliness and diarrhoeal disease exists, and to understand the factors which impede knowledge translation. Method: This cross-sectional study in low-income areas in Cape Town, South Africa took the format of an administered questionnaire focusing on health, and hygienic behaviour. Interviewer-assessed cleanliness was also recorded for each home. Results: Gastrointestinal symptoms were significantly associated with unclean kitchens and toilets (odds ratio (OR)=5.93 (1.98 – 19.78) and OR=17.67 (5.20 – 63.90), respectively). The presence of diarrhoea was significantly associated with dirty toilet areas (OR=8.94 (2.34 – 40.96)), despite its relatively low prevalence (17% (11 – 25%)). While knowledge of home hygiene and health was high, a lack of association between knowledge and observed cleanliness indicated a gap in the translation of knowledge to practice. Proposed emotional drivers of this process could not be substantiated, but evidence suggested that lack of understanding of underlying reasons plays an important role, but it may be effectively overcome by education. Conclusions: Good home hygiene shows potential for preventing infectious disease risk in low-income areas, but knowledge does not translate to effective practice. This is likely attributable to a lack of understanding of underlying principles, specifically among persons with low levels of formal schooling.
Barriers and facilitators to linkage, adherence and retention in care among HIV positive patients : an overview of qualitative systematic reviews using mega-aggregation framework synthesis
(Stellenbosch : Stellenbosch University, 2019-04) Hendricks, Lynn Avril; Rohwer, Anke; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Background: People living with Human Immunodeficiency Virus (PLHIV) continue to struggle with the complexities related to having a chronic disease and integrating antiretroviral treatment (ART) and care into their daily lives. This overview aimed to assess existing evidence related to self-reported barriers and facilitators to linkage to ART, adherence to ART and retention in care for PLHIV and to identify gaps in the evidence. Methods: The novel pragmatic approach of mega-aggregation framework synthesis was developed, described and applied in this overview using Kaufman’s interpretation of the socio-ecological framework. We included qualitative systematic reviews, up to July 2018, and used a systematic and rigorous approach to select reviews and extract data. We assessed methodological quality using an amended version of the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews. Results: We included 33 systematic reviews, from low, middle and high income countries and included 1 111 964 HIV positive children and adults. Methodological quality varied considerably across reviews. Using the mega-aggregative framework approach, we found 544 unique third order concepts, from the included systematic reviews, and reclassified the third order concepts into 45 fourth order themes within the individual, interpersonal, community, institutional and structural levels of the Kaufman HIV Behaviour Change model. Our overview found that the main barriers and facilitators to linkage, adherence and retention such as psychosocial personal characteristics of perceptions of ART, desires, fears, experiences of HIV and ART, coping strategies and mental health, were interwoven with other factors on the interpersonal, community, institutional and structural level. Conclusions: High quality qualitative review level evidence on self-reported barriers and facilitators of linkage, adherence and retention in care is lacking for adults and even more so for children. Overviews are useful in the identification of evidence gaps to inform new review questions and researchers are encouraged to build on the method of mega-aggregative framework synthesis as the place of overviews become more prominent with the growing body of qualitative reviews. Systematic review registration: The protocol of this overview was registered on PROSPERO (CRD42017078155) on 17 December 2017.
Comparative, cross-sectional study describing agreement and accuracy of emergency centre triage using either a mobile application or manual triage
(Stellenbosch : Stellenbosch University, 2016-03) Khan, Yaseen; Govender, Thashlin; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Background and Purpose: Unacceptable patient waiting times and misidentification of critically ill patients are significant problems within Emergency Centres (ECs). Triage, when performed correctly, is acritical process to address this. The South African Triage Scale (SATS) is widely used. Manually performed triage may be prone to inaccuracies and prolonged triage time. A mobile tablet application to facilitate use of the SATS by automating triage calculation and guiding nurses has been developed. Methods: This is a comparative cross-sectional study to observe the accuracy of triage using the mobile tablet application compared with triage performed manually. Under classroom examination conditions, nurses calculated triage scores on written case scenarios of typical EC presentations. A total of 59 nurses across five hospitals in the Western Cape Province, South Africa were randomized into an ‘app group’ and a ‘manual group’. Results: The app group scored a 23% higher level of agreement with the expert-validated results than the manual group. Kappa of 0.735 (0.719 - 0.770) and 0.597 (0.545 - 0.656) were found respectively. One in five patients are triaged more correctly using the app. Sensitivity for emergency cases was 65.5% and 53% respectively, with and without the app. Conclusions: Nurses triaging written scenarios with the aid of the app were observed to have a higher agreement with the expert-validated results than nurses performing traditional manual triage. The effect size is considerable and of practical relevance. The app could have significant benefit in busy Emergency Centres of public sector hospitals. A larger study involving real patients is recommended.
Completeness of HIV intervention trial protocols : a systematic survey
(Stellenbosch : Stellenbosch University, 2019-04) Samupindi, Shingirayi Irene; Dzikiti, Moleen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Introduction: The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT1) 2013 guideline provides guidance to improve the quality of protocols. The aim of this study was to determine the completeness of randomised controlled trial protocols evaluating the efficacy or effectiveness of HIV prevention, treatment and care strategies using the SPIRIT 2013 checklist, and to identify factors associated with completeness of trial protocols. Methods: We searched MEDLINE, EMBASE, LILACS, Africa-wide information (EBSCOhost), Web of Science, Clinicaltrials.gov and CENTRAL (Wiley Cochrane Library) for randomized controlled trial protocols in May and June 2018. We included protocols for interventions in the HIV prevention, treatment and care fields published between 2008 and 2018. Two individuals independently screened the titles and abstracts. The adapted SPIRIT checklist was pilot tested independently in duplicate on the first 4 (5%) protocols. The rest of the data was collected by a single individual and verified by second reviewer. Disagreements were resolved by consensus. We summarized categorical data using count (percent) and continuous variables using mean (standard deviation). Generalised estimation equations assuming a Poisson distribution were used to assess association of protocol factors with number of checklist items reported. Results: Seventy-nine protocols met the eligibility criteria and were included in the analysis. A mean of 32 (SD= 5) of the possible 51 SPIRIT checklist items were reported in the protocols. Detailed methodological aspects relating to intervention allocation, blinding, data management, study monitoring and dissemination policy information were often missing in the protocols. Intervention category, period of publication (before or after SPIRIT 2013 publication) and study setting were not significantly associated with protocol completeness. Conclusion: There is need for improvement in the reporting of recommended SPIRIT 2013 checklist items in HIV intervention protocols. We recommend active implementation strategies of the SPIRIT guideline from publishing journals and HIV trialists to ensure more improvement in protocol quality.
Identifying gaps using the EPICOT+ framework and exploring the association between funding sources and author conclusions in primary nutrition research addressing non-communicable diseases from Cochrane nutrition reviews : a descriptive-analytical cross-sectional study
(Stellenbosch : Stellenbosch University, 2021-03) Ruzive, Sheena; Naude, Celeste E.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Background: With the rise in non-communicable diseases (NCDs) globally, we aimed to summarise the research gaps and describe the adequacy of the reporting of future research recommendations in Cochrane reviews of nutrition interventions addressing NCDs. We also aimed to explore the influence of funding sources and author- sponsor financial ties on author conclusions in a subset of primary studies included in these reviews. Methods: Two researchers independently screened a Cochrane nutrition reviews database (n=470, July 2015) to identify reviews addressing four NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes). The “implications for research” section of eligible reviews was analysed using the evidence, population, intervention, comparison, outcome, timeframe, study design and burden of disease (EPICOT+) framework to describe the extent of reporting of research recommendations and to summarise gaps. A purposive sample of English full-text studies included in reviews addressing alternative nutrition supplements were analysed to assess reporting of conflict of interest (COI), funding sources and author-sponsor financial ties, and to explore influences of funding sources and author-sponsor financial ties on author conclusions. Results: Ninety-eight eligible reviews were analysed. The EPICOT+ reporting was as follows: evidence 34/98 (33.7%), population 68/98 (69.4%), intervention 90/98 (91.8%), comparison 26/98 (26.5%), outcomes 78/98 (79.6%), study design 85/98 (86.7%), time frame 52/98 (53.1%), and burden of disease 7/98 (7.1%). Studies requiring better quality, different interventions, and outcomes in low- and middle-income countries (LMICs) were highlighted. Seven reviews addressed alternative nutrition supplements, including 51 eligible primary studies. Conflicts of interest were disclosed in 10/51 (19.2%); funding in 27/51 (51.9%), of which, 11/27 (40.7%) were industry and 16/27 (59.3%) were non-industry sponsors; and author-sponsor financial ties in 9/51 (13.4%), of which 1/9 (11.1%) was industry and 8/9 (88.9%) were non-industry. There was no association between authors making favourable conclusions and having industry sponsors and author-sponsor financial ties (8/12) compared with non-industry sponsors and no author-sponsor financial ties (10/24), (Fisher exact p =0.289). Conclusions: EPICOT+ items were not well reported in most reviews. Future studies of better quality, different interventions, outcomes or populations in LMICs are needed. Authors should disclose all COI, funding sources and author-sponsor financial ties. Possible influences of funding sources and author-sponsor financial ties on author conclusions needs further investigation.
The impact of caring for a school-going visually impaired child in Cape Town, Western Cape on the home caregiver and the rest of the family – the health, socio-economic and psychological health burdens
(Stellenbosch : Stellenbosch University, 2021-03) St. Jerry, Marlyse; Barnes, J. M. (Johanna Maria); Nyasule, Peter S; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Background: Visually impaired (VI) children need additional care for daily tasks due to their diminished independent living skills (ILS). In learners in Special Educational Needs (LSEN) schools and specially-adapted mainstream schools, occupational therapy and trained assistants help to bridge the gap that diminished ILS pose to their education. However, in impoverished areas of the Cape Metropole, many families cannot afford trained caregivers in their homes. Typically a maternal figure fulfils the responsibilities of caring for the VI child as well as for the rest of the household; such a person then becomes the VI child’s primary home caregiver. Aims and Objectives: The main focus of the study was to determine the caregiving load and its impact on the caregiver's physical, mental and emotional well-being. Methods: The cross-sectional study used a questionnaire consisting of a self-designed questionnaire based on issues from literature on the subject and the validated Caregiver Strain Questionnaire – Short Form (CGSQ-SF). The CGSQ-SF provides qualitative data on the noticeable, emotional, and overall impact of caregiving. During prescheduled home interview sessions, the caregivers completed the questionnaires. The mixed research method used measurable data such as financial status and qualitative data, such as the emotional experiences associated with caring for a VI child. The University of Stellenbosch ethics committee (S13/03/049) and the Western Cape Education Department (20130704-13796) approved the study. Professor M. Kidd of the Centre for Statistical Services at the University of Stellenbosch carried out the statistical analyses, Mann-Whitney U tests and Kruskal-Wallis tests analysed the relationship of variables with CGSQ-SF scores. Results: Of the population of 320 VI learners from the only school for the VI in the Cape Metropole, 150 learners resided at home during the school term. According to the inclusion criteria, only 95 of the 150 home caregivers were eligible. The study obtained consent from 73 caregivers. The CGSQ-SF scoring showed that the majority of the 73 caregivers experienced moderate strain in terms of overall (55/73; 75.3%), objective (57/73; 78.1%) and subjective internalised caregiver strain (55/73; 75.3%). Elevated caregiver strain frequently occurred with these factors: financial difficulty; diminished ILS; and reluctance to spend time away from the VI child. Conclusion: All the caregivers experienced a considerable caregiving load and subsequently substantial caregiver strain level. All the participating households experienced both poverty and caring for a VI child. This bias in the design made it difficult to attribute what strainload was due to either of these variables. It was not possible to determine whether having a VI child increased the household’s strain compared to those who did not have a VI child. The confounding nature of the design made it challenging to unravel the relationship between poverty and caregiver strain due to the presence of a VI child. Qualitative information from the caregivers suggested that they did not view their child’s special needs as the only cause for the financial struggles they face and that their biggest concern was their child’s future as a disabled adult.
Influence of previous tuberculosis treatment on time to culture conversion for patients receiving a bedaquiline-containing regimen at Sizwe Tropical Disease Hospital, South Africa
(Stellenbosch : Stellenbosch University, 2021-03) Saimen, Amashnee; Esterhuizen, Tonya; Padanilam, Xavier; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Tuberculosis remains one of the leading causes of death worldwide. There is a growing crisis concerning the number of drug resistant TB cases. New drug regimens were urgently needed to improve mortality and morbidity among drug resistant TB patients. Bedaqualine is a newly developed diarylquinoline with a unique mechanism of action. . Studies have reported varying time to culture conversion regarding RR/MDR-TB patients with history of previous TB treatment. The Rv0678 mutation found in patients with prior Rifampicin exposure has demonstrated a more than four-fold increase in the minimum inhibitory concentrations of Bedaquiline. Previously treated TB patients may be more likely to have higher bacterial load due to extensive parenchymal damage. This study will provide information on effective Bedaquiline treatment duration for those previously exposed to TB treatment. Aim: To determine whether previous exposure to TB treatment influences the time to culture conversion as compared to no previous TB treatment exposure in patients receiving a DR- TB regimen containing Bedaquiline. Primary Objective: To compare the time to culture conversion for previously treated and new DR-TB patients receiving the Bedaquiline containing regimen. Secondary Objectives: 1.To evaluate treatment regimens at time of culture conversion for previously treated andnew DR-TB patients 2.To compare the rate of relapse in previously treated and new DR-TB patients receivingthe Bedaquiline containing regimen. 3.To compare the duration of Bedaquiline therapy in previously treated and new DR-TBpatients 4.To establish the severity of disease of previously treated and new DR-TB patients. Setting and Study Population: The study will be conducted at Sizwe Tropical Disease Hospital in Gauteng Province. Sizwe Tropical Disease Hospital serves as a referral centre for complicated MDR/XDR-TB cases in Gauteng. Study Design: A retrospective cohort study will be undertaken for confirmed DR-TB patients who were initiated on DR-TB regimen containing Bedaquiline from April 2016 to March 2019. Inclusion Criteria: Bacteriologically confirmed DR-TB All patients receiving DR-TB Regimens containing Bedaquiline including new DR-TB with no previous history of TB treatment Documented culture conversion Variables: Culture Conversion; Time to culture conversion; Duration of Bedaquiline treatment Sampling Technique: The group sample sizes were determined to be 76 (Previous treatment group) and 304 (New treatment group), power of 80% with a level of significance of α 0.05. Time Frame: The study will be conducted from June 2020 to November2020.
Knowledge of male partner HIV status as a risk factor for HIV indicators in women using prevention of mother-to-child transmission of HIV services in WHO priority countries : a systematic review and meta-analysis
(Stellenbosch : Stellenbosch University, 2022-12) Mmotsa, Tshiamo Moshading; Ngandu, Nobubelo K.; Adetokunboh, Olatunchi O.; Nyasulu, Peter; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Elimination of new maternal and infant Human Immunodeficiency Virus (HIV) cases has been a top global priority and various targets have been introduced to end HIV in pregnant, postpartum women and their infants. To achieve these targets, it is important to understand factors related to unfavourable outcomes in the prevention of mother-to-child transmission of HIV (PMTCT, MTCT) programme cascade. The role of a male partner, especially HIV status non-disclosure is one of several important factors. Our study aimed to determine whether not knowing a male partner’s HIV status was a significant risk factor for HIV indicators, including poor HIV clinical outcomes, among pregnant, postpartum women and their infants in the 21 World Health Organization (WHO) priority countries for eliminating MTCT. We conducted a systematic review and meta-analysis of literature through four electronic databases in April 2022 for eligible studies from the 21 WHO priority countries. We included observational studies examining male partner HIV status non-disclosure as a risk factor for HIV indicators in pregnant, postpartum women and their infants conducted after the implementation of the Option B+ treatment policy (i.e., lifelong antiretroviral therapy (ART) regardless of clinical disease status) were included. We conducted a meta-analysis for studies without heterogeneity and assessed the certainty of the evidence assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for each outcome. Forty-six full-text articles were screened and only three articles were included. The included studies were cross-sectional and retrospective cohort studies, conducted in Malawi, South Africa, and Uganda, with a total of 5248 participants. Sub-optimal ART adherence was significantly greater among women who did not know their male partner’s HIV status compared to those who knew the partner’s HIV status (2 studies; n= 3263: Odds ratio (OR) 1.85; 95% confidence interval (CI) 1.49–2.29; P <0.01) with no significant heterogeneity (P = 0.72; I2 = 0%). Complete ART adherence was significantly less among women who did not know their male partner’s HIV status compared to those with knowledge of the partner’s HIV status (1 study; n= 465: OR 0.47; 95% CI 0.32 – 0.69). MTCT was not significantly associated with male partner HIV status non-disclosure (1 study; n= 2881: OR 1.35; 95% CI 0.84 – 2.15). The certainty of evidence from all the studies was low for all outcomes. We found that there was limited evidence to fully understand the role a male partner’s HIV status disclosure plays in the PMTCT cascade. The available studies showed that the likelihood of ART non-adherence was increased by not knowing a male partner’s HIV status, therefore, highlighting the importance of knowing a male partner’s HIV status in the PMTCT cascade. We could not explore the other HIV indicators i.e., MTCT and other clinical outcomes due to the limited and non-availability of primary studies. More and appropriately designed studies within the WHO priority countries are needed urgently to inform policies and interventions for improving male partner involvement. These studies should also include a clear definition of male partner involvement which also highlights HIV testing and male partner disclosure.
Knowledge, attitudes and practices regarding the prevention of type 2 Diabetes Mellitus among overweight and obese adults in Manzini, Eswatini : a cross-sectional study
(Stellenbosch : Stellenbosch University, 2020-12) Chideme-Chinovhiringa, Karen; Chivese, Tawanda; Dudley, Lilian; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Introduction: Being overweight or obese is one of the strongest risk factors for type 2 diabetes. Eswatini has a high prevalence of undiagnosed type 2 diabetes and half of its adults are either overweight or obese. However, there is a paucity of data on knowledge, attitudes and practices towards the prevention of type 2 diabetes in people at risk in Eswatini. This study aims to assess knowledge, attitudes and practices towards the prevention of type 2 diabetes mellitus among overweight and obese adults presenting at an urban outpatient clinic in Manzini, Eswatini. Methods: A cross-sectional study of adults who were either overweight or obese attending the clinic was carried out. Knowledge, attitudes and practices towards the prevention of type 2 diabetes mellitus were assessed using a validated researcher administered questionnaire. Knowledge, attitudes and practices were compared between overweight and obese participants. In addition, the correlation between knowledge, attitudes and practices was evaluated using a correlation matrix. Results: A total of 105 participants, with a mean age of 35.2 (SD 10.7) years participated in the study. Of these, 55 (52.4%) and 50 (47.6%) were overweight and obese, respectively. The majority of the participants showed acceptable knowledge levels, with 61% of the participants having good knowledge and 30% excellent knowledge. Participants showed positive attitudes towards diabetes prevention, 69.5% of participants had satisfactory attitudes, 21.0% had excellent attitudes and 9.5% had neutral attitudes towards the prevention of type two diabetes mellitus. Practices were generally poor with only 33.3% meeting the World Health Organisation recommended 150 minutes of physical activity per week. Just over half (53.0%) of participants who met the criteria for screening had screened for diabetes. Dietary practices were poor with just over a third (36.2%) of participants meeting the World Health Organisation recommended daily vegetable and/or fruit intake of five servings a day and 85.7% exceeding the World Health Organisation daily recommended limit of sugar intake. There were no significant differences between participants who were overweight and those who were obese in their knowledge, attitudes and practices towards preventing type 2 diabetes mellitus. There was a significant, positive correlation between total knowledge scores and total attitude scores (r= 0.42, p<0.01). Conclusion: Overweight and obese adults visiting the outpatient clinic had satisfactory knowledge and attitude levels towards the prevention of type 2 diabetes. Practices towards prevention were generally poor with few participants meeting the World Health Organisation recommendations for physical activity and fruit and/or vegetable daily intake. Just over half of the eligible participants had screened for diabetes prior to the study. In addition to information, interventions are needed to motivate patients at high risk to adopt healthier dietary and physical activity practices.
Mechanical debridement with antibiotics in the treatment of chronic periodontitis : effect on systemic biomarkers : a systematic review
(Stellenbosch : Stellenbosch University, 2019-04) Munasur, Sudhir L.; Chikte, Usuf M. E.; Turawa, Eunice B.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Background: Chronic periodontitis is an inflammatory oral disease which leads to the destruction of the supporting tissues of the teeth, leading to bone resorption and tooth loss. Destruction of the periodontal attachment apparatus can result in gingival recession and root furcation exposure in advanced stages resulting in tooth mobility and tooth loss. Mechanical debridement is the most frequent treatment for chronic periodontitis, in severe cases systemic antibiotics in conjunction with mechanical debridement have been used. The efficacy and the beneficial effect of this combination on the inflammatory biomarkers require further investigation. Objectives: The aim of this systematic review was to assess the effectiveness of adjunctive antibiotics in the improvement of inflammatory systemic biomarkers in the treatment chronic periodontitis. Search methods: We searched the following electronic databases: Cochrane Oral Health Group Trials Register (30th June 2018). The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2018 – current issue), MEDLINE (1966 to present), EMBASE (1982 to present), CINAHL via EBSCO (1990 -present), Google scholar (1990 - present). Web of Knowledge (1990 to May 2018), The meta-Register of Controlled Trials (www.controlled-trials.com), The US National Institutes of Health On-going Trials Register (www.clinicaltrials.gov). The World Health Organization International Clinical Trials Registry platform (www.who.int/trialsearch) was searched to identify relevant trials for inclusion in the review. Conference proceedings, on-going trials registers (02/06/2018) and reference list of included articles were assessed for relevant trials. No language or date of publication restrictions applied. Selection criteria: We searched for randomised controlled trials (RCTs that evaluated the effectiveness of adjunct antibiotic therapy on the systemic biomarkers in the treatment of chronic periodontitis. All trials that compared adjunctive systemic antibiotics with mechanical debridement or mechanical debridement alone, or scaling and root planning, oral hygiene and prophylaxis or placebo were included in the study. Data collection and analysis: Two reviewers independently examined the titles and abstracts retrieved by the search to identify relevant trials for inclusion in the review. All included trials were assessed for risk of bias and data were extracted for further analysis. The primary outcomes assessed include: changes in serum/blood levels of inflammatory biomarkers such as Matrix Metalloproteinases (MMPs), Tissue Inhibitors of MMPs(TIMs), Cytokines, C-Reactive Protein(CRP) and Glycated haemoglobin(HbA1c). Secondary outcomes include periodontal indices such as bleeding on probing (BOP), gingival index (GI), clinical attachment level (CAL), plaque index (PI) and probing pocket depth (PPD). Main results: Fourteen trials (n=1457 participants) were included in the review. Seven trials reported on MMP-8, with average of 3 months time to event. Five trials reported on IL-1β, three trials on IL-6 and two on IL-8 serum level. Four trials reported on CRP; while eight reported on HbA1c level and one on TIMP-1 level. Trials were assessed for risk of bias and judged as low, high, or unclear of risk of bias. Six studies showed no significant differences in MMP-8 concentration level between the two intervention groups. Significant decrease (60%) in odds of increased MMP-8 levels during 2-year study was reported in one trial (OR 0.40, 95%CI: 0.21 to 0.77, p=0.006). One study reported no significant difference for TIMP-1 (0.96, 95% CI: 0.78 to 1.18, p=0.7), while two studies showed significant reduction in HbA1c (10%) at 3 months. Other studies reported no difference in HbA1c levels (%): (Mean (SD) 7.00 (0.76) versus 7.11 (0.99); p=0.710), (Median (Interquartile Range [IQR]) 6.3 (5.5,7.3) versus 6.7 (6.3, 7.7); p=0.8), (p=0.35, 0.55, 0.33, and 0.62, at baseline, 3 months, 6 months, and after 1 year of treatment respectively. Metaanalysis showed a mean reduction of 0.24mm in the periodontal pockets (PD) at 3 months [MD, -0.25 with 95% CI -0.38 to -0.12]. Two trials revealed no significant difference PD≤3mm at 3 months, [MD, -1, 95% CI -22.54 to 20.53 (p=0.19)]. A decrease in periodontal pockets(PD≥4mm) and a reduction of 3.38mm in favour of SRP+antibiotics after 3 months [MD, -3.38, 95% CI -6.51 to -0.25 (p=0.93, I2=0%)] was observed for probing depth(PD). No significant difference in clinical attachment level (CAL) at 3 months [MD, -0.13, 95% CI -0.34 to 0.07; Chi2=0.98, df=3, p=0.81, I2=0%]. The overall quality of evidence was low largely because of attrition bias (24%; 32%) connoting high risk of bias and wide confidence intervals which suggests imprecision of results. Authors' conclusions: There is limited but low-level of evidence suggesting that systemic antibiotic therapy combined with mechanical debridement improves the systemic biomarker levels during the treatment of chronic periodontitis.
Nursing students' knowledge, attitude and practices of infection prevention and control guidelines at a tertiary institution in the Western Cape : a cross sectional study
(Stellenbosch : Stellenbosch University, 2017-12) Rahiman, Farzana; Chikte, Usuf; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Background: Nurses in sub-Saharan Africa are particularly at a higher risk of acquiring nosocomial infections, considering the increased prevalence of infectious diseases. It is therefore imperative that these nurses have a sound knowledge and understanding of infection prevention procedures. Objective: The main objective of this study was to describe the knowledge, attitudes and practices concerning infection prevention and control precautions among nursing students in a resource limited setting. Method: A cross sectional study design was employed. A self-administered questionnaire concerning infection prevention and control guidelines were made available to students enrolled in a mainstream programme for completion of an undergraduate nursing degree. Setting and participants: A total of 301 students at second, third and final years of study from a tertiary institution in the Western Cape were invited to participate. Results: The final cohort comprised of 301 students with the majority between the ages of 17-26 (88.2%), with a mean age of 23±4.7 (SD) years and the dominant gender being female (83.4%). According to the classification system used in this study, majority of the students were overall evaluated as having good level of knowledge (47.4%) and poor attitude (41.7%) scores, with little difference in practice scores observed between different years of study. There was a positive correlation found between students’ total attitude and total practice scores (r = 0.48 p<0.01). Results showed that a significant association between gender with knowledge (p<0.05), attitudes (p<0.05) and practice (p<0.05) exists. There was also a significant association between province and those who repeated a year with total knowledge scores (p<0.05). Conclusion: Based on the results of this study, it is recommended that interactive infection control courses that promotes critical thinking are implemented at undergraduate level along with more stringent forms of assessments focusing on infection prevention and control, during clinical training.
A prediction risk score for HIV among adolescent girls and young women in South Africa : identifying those in need of HIV pre-exposure prophylaxis
(Stellenbosch : Stellenbosch University, 2022-12) Moyo, Reuben Christopher; Nyasulu, Peter Suwilakwenda; Manda, Samuel; Govindasamy, Darshini; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Background: In sub-Saharan Africa, adolescent girls and young women (AGYW) have the highest risk of acquiring HIV. Risk factors for HIV in AGYM are well studied and known in the literature. However, there is need to combine these factors into a single summary measure that could be used in the identification of the AGYW who are more likely to acquire HIV and who may be linked to HIV Pre-Exposure Prophylaxis (PreP) which has shown to be effective in the prevention of new HIV infections among high-risk populations. This study aimed at developing and validating an HIV risk prediction tool for AGYW. Methods: We analyzed existing HIV-related data on 4,399 AGYW from South Africa. We used multivariable binary logistic regression to model coefficients for use in deriving risk scores. The HIV risk scores were computed from summing predictor coefficients of the resulting logistic regression model. The performance of the final model at discriminating between HIV infected and non-HIV infected AGYM was assessed using area under the receiver-operating curve (AUC) and measures of discriminative abilities such as predictive values, sensitivity, and specificity. The optimal cut-point of the risk score was determined using Youden index. Results: The weighted HIV prevalence among AGYW was 12.4% (11.7 – 14.0). Our risk scores ranged from -1.26 to 3.80 with a mean score of 1.38 and a standard deviation of 0.86. The optimal cut-point of the risk scores was 1.80 with sensitivity of 62% and specificity of 70%. The prediction model’s sensitivity was 15.19% and specificity of 98.92%. The model’s positive predictive value was 67.42% while the negative predictive value was 88.79%. Our model performed well at predicting HIV positivity with training AUC of 0.770 and a testing AUC of 0.751. Conclusion: Our risk score tool has shown good discrimination and calibration at predicting undiagnosed HIV in AGYW. This tool could provide a simple and low-cost strategy for screening AGYW in primary health care clinics or community settings. This risk assessment tool may also help service providers identify and link high-risk AGYW to HIV PreP services.
Prevalence of non-communicable diseases in adults living with Human Immunodeficiency Virus : an overview of systematic reviews
(Stellenbosch : Stellenbosch University, 2019-04) Jaffer, Shahista Mustafa; Young, Taryn; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Background: Non-communicable diseases (NCD’s) are on the rise in patients with HIV and this has been partly attributed to the increasing use of Antiretroviral therapy (ART). Our aim was to consolidate findings on prevalence of NCD in those with HIV, from systematic reviews, to inform the existing body of research and provide evidence to inform planning of healthcare services. Methods: We undertook a comprehensive search in February 2018, with no date limitations, in 7 databases to identify systematic reviews on the prevalence of NCD’s in HIV patients on ART. We included systematic reviews with participants over the age of 13years who were on ART and had one or more of the specified NCD’s including diabetes mellitus type 2, hypertension, dyslipidemia and depression. We then assessed the quality of these systematic reviews using the AMSTAR 2 tool and extracted prevalence’s of the NCD’s from each one of them. Results: We identified 10 systematic reviews meeting our inclusion criteria of which 3 are ongoing. The methodological quality of the seven systematic reviews assessed varied in many aspects. Only one systematic review assessed prevalence of multi-morbidity defined as the presence of two or more NCD’s in people living with HIV (PLHIV) which ranged from 8.4% to 47%, the remaining six only assessed the prevalence of comorbidity of any one NCD in PLHIV. Diabetes mellitus type 2 had the lowest prevalence especially in African countries and it ranged between 7% to 48.6% globally while dyslipidemia had the highest prevalence globally ranging from 6.3% to 100%. Depression in PLHIV who were on ART was considerably high ranging from 25.81% to 64% while hypertension ranged from as low as 4.0% to as high as 67.0%. Conclusions: This overview highlights that NCD’s are highly prevalent in PLHIV on ART. There is a lack of systematic reviews and primary studies focusing on multi-morbidity in the HIV population on ART. PROSPERO registration number - CRD42018104420.
Quality of systematic reviews in African emergency medicine : a cross-sectional methodological study
(Stellenbosch : Stellenbosch University, 2023-03) Van Niekerk, Hendrik Jacques; McCaul, Michael; Rohwer, Anke; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Introduction: Reliable systematic reviews are essential to inform clinical practice guidelines, policies and further research priorities in Africa. For systematic review findings to be trustworthy, they need to be conducted with methodological rigour and reported transparently. We assessed the methodological quality of systematic reviews published in African emergency medicine journals, comparing them to those published in international emergency medicine journals. Additionally, we describe the types of review literature published in the African journals. Methods: We performed a cross-sectional methodological study of systematic reviews published in selected African and international emergency medicine journals from 2012 to 2021. Studies were eligible for inclusion if they were i) published in one of the top five emergency medicine journals in the African region or internationally, ii) a review article on an emergency medicine topic and iii) published between January 2012 and December 2021 in English or French. We searched PubMed, Web of Science and Scopus databases and hand-searched selected journals. Two authors screened titles, abstracts and full texts independently and in duplicate to select reviews for inclusion. Data extraction was performed by one reviewer, using a standardised form, after completing a calibration exercise. We described the characteristics of systematic reviews and assessed methodological quality using AMSTAR II. Results: We identified 34 (37%) African and 511 (54%) international systematic reviews from 92 and 948 review articles respectively across 10 journals. We included all 34 African and a random sample of 100 international systematic reviews. Methodological quality was low or critically low for all the African systematic reviews (n=34, 100%) and all but three international systematic reviews (n=97, 97%). The median number of critical domain weaknesses was 4 (IQR 4;5) and 2 (IQR 2;4) for African and international systematic reviews respectively. The most common weaknesses across both African and international systematic reviews were i) not establishing a priori review protocols, ii) unclear selection of study designs iii) not providing a list of excluded studies and iv) unclear reporting on funding sources for included studies. Conclusion: Emergency medicine systematic reviews published in African and international journals are lacking in methodological quality. Reporting an a priori protocol, developing a comprehensive search strategy, appropriate evidence synthesis and adequate assessment of the risk of bias, heterogeneity and evidence certainty will improve the quality of systematic reviews.
Quality of systematic reviews in African emergency medicine : a cross-sectional methodological study
(Stellenbosch : Stellenbosch University, 2023-03) Van Niekerk, Jacques; Fapohunda, Tomiwa; Rohwer, Anke; McCaul, Michael; Rohwer, Anke; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Introduction: Reliable systematic reviews are essential to inform clinical practice guidelines, policies and further research priorities in Africa. For systematic review findings to be trustworthy, they need to be conducted with methodological rigour and reported transparently. We assessed the methodological quality of systematic reviews published in African emergency medicine journals, comparing them to those published in international emergency medicine journals. Additionally, we describe the types of review literature published in the African journals. Methods: We performed a cross-sectional methodological study of systematic reviews published in selected African and international emergency medicine journals from 2012 to 2021. Studies were eligible for inclusion if they were i) published in one of the top five emergency medicine journals in the African region or internationally, ii) a review article on an emergency medicine topic and iii) published between January 2012 and December 2021 in English or French. We searched PubMed, Web of Science and Scopus databases and hand-searched selected journals. Two authors screened titles, abstracts and full texts independently and in duplicate to select reviews for inclusion. Data extraction was performed by one reviewer, using a standardised form, after completing a calibration exercise. We described the characteristics of systematic reviews and assessed methodological quality using AMSTAR II. Results: We identified 34 (37%) African and 511 (54%) international systematic reviews from 92 and 948 review articles respectively across 10 journals. We included all 34 African and a random sample of 100 international systematic reviews. Methodological quality was low or critically low for all the African systematic reviews (n=34, 100%) and all but three international systematic reviews (n=97, 97%). The median number of critical domain weaknesses was 4 (IQR 4;5) and 2 (IQR 2;4) for African and international systematic reviews respectively. The most common weaknesses across both African and international systematic reviews were i) not establishing a priori review protocols, ii) unclear selection of study designs iii) not providing a list of excluded studies and iv) unclear reporting on funding sources for included studies. Conclusion: Emergency medicine systematic reviews published in African and international journals are lacking in methodological quality. Reporting an a priori protocol, developing a comprehensive search strategy, appropriate evidence synthesis and adequate assessment of the risk of bias, heterogeneity and evidence certainty will improve the quality of systematic reviews.
Risk factors of neurodevelopmental delay in paediatric tuberculous meningitis
(Stellenbosch : Stellenbosch University, 2022-04) Saal, Caro-lee; Solomons, Regan; Esterhuizen, Tonya; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Objective: Neurodevelopmental delay in children is one of the long-term complications of tuberculous meningitis (TBM) with significant social, financial and scholastic implications. The objective of the study was to assess the risk factors in children with case-defined TBM that could predict neurodevelopmental delay at the conclusion of anti-tuberculous treatment, after 6 months in HIV non-infected and 9 months in HIV co-infected. Methods: We conducted a retrospective cohort study of all the children diagnosed with TBM at a large academic hospital in Cape Town, South Africa, over a 30-year period between 1985 and 2015. We assessed the relationship between demographic, clinical, laboratory and neuro-imaging characteristics, with cognitive impairment at conclusion of anti-tuberculous treatment. Results: A total of 327 patients were included. The median age on admission was 28 months (interquartile range(IQR) 15-47) with females accounting for 159 (48.6%) and males 168 (51.4%).Of included participants 170 (52%) were HIV negative. Younger age at diagnosis was more likely to have lower IQ levels. Patients were more likely to have lower IQ levels if they had decreased level of consciousness (LOC) (OR=3.30, 95% CI: 1.80-6.05); brainstem dysfunction (OR=2.39, 95% CI: 1.42-4.02); motor function impairment (OR=1.96, 95% CI:1.14-3.39) and infarcts (OR=2.60, 95% CI: 1.53-4.42). Those with positive CSF culture results were less likely to have lower IQ levels (OR=0.38, 95% CI: 0.20-0.75) Conclusion: This study demonstrated that demographic (age on admission) and clinical characteristics (decreased level of consciousness, impaired motor function, brainstem dysfunction, cerebral infarcts, negative cerebrospinal fluid (CSF) culture) were independent risk factors for lower IQ levels at treatment conclusion, in children with clinically-defined TBM.
A secondary analysis using individual patient data of two pragmatic cluster-randomized control trials evaluating 3 monthly and 6 monthly community-based multimonth dispensing of antiretroviral treatment in Southern Africa
(Stellenbosch : Stellenbosch University, 2021-03) Lopes, John; Fatti, Geoffrey; Lombard, Carl J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Randomized evidence of the effectiveness of community-based multi-month dispensing (MMD) of antiretroviral treatment (ART) is lacking, particularly for 6 months MMD with only annual clinical consultations. Data from two cluster randomized trials (CRTs) were pooled to compare community-based MMD of ART versus non-inferior to standard-of-care facility-based MMD. Methods: Adult people living with HIV (PLHIV) stable on ART for ≥6 months with viral load suppression (VLS) at baseline was included. Community-based 3 monthly (3MC) and 6 monthly (6MC) ART refill dispensing were compared to control facility-based 3 monthly (3MF). Twelve months retention-in-care (primary outcome) was evaluated by intention-to-treat using individual-level regression analyses, with a prespecified non-inferiority margin of -3.25% risk difference (RD). Secondary outcomes evaluated after 12 months were; (1) retention within the study arm (2) VLS, (3) number of unscheduled facility visits, and after 18 months; (4) attrition in ART care. Results: Data pooling yielded a total of 10136 participants with relatively balanced characteristics across the arms, except for age and district. Retention after 12 months was noninferior in the adjusted analysis (3MC: RD=0.3, 95% CI: -0.8 to 1.4 vs 3MF, 6MC: RD=-0.2, 95 % CI: -1.4 to 1.0 vs 3MF). VLS was high (≥97.9%) with no differences between the arms, risk ratio (RR) of 1.0 for 3MC (95 % CI: 1.0 to 1.0, p=0.885) and 6MC (95 % CI: 1.0 to 1.0, p=0.186) compared to 3MF. The incidence rate ratio (IRR) for unscheduled visits showed no difference between 3MC (IRR=0.6, 95 % CI: 0.2 to 2.1, p=0.383) and 6MC (IRR=1.0, 95 % CI: 0.4 to 2.5, p=0.974) compared to 3MF. Participant attrition (0-18 months) for Zimbabwe showed no differences between the arms, facility location or healthcare level. Conclusion: Community-based MMD of ART at 3 and 6 monthly refills for PLHIV stable on ART is safe to scale-up, without increased unscheduled facility visits or compromise in VLS.
Spatially-targeted digital chest radiography-based screening to reduce tuberculosis in high-burden settings : simulation of an adaptive decision-making approach and cost-effectiveness analysis
(Stellenbosch : Stellenbosch University, 2022-04) de Villiers, Abigail Kate; Marx, Florian; Nyasulu, Peter; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY: Background. Interventions to actively detect individuals with tuberculosis (TB) and to enable timely treatment could accelerate TB control. Spatially-targeted interventions that concentrate screening within geographic “hotspots” of tuberculosis incidence, could lead to more effective allocation of already limited resources. However, identifying and prioritizing areas with the highest burdens of undetected TB is challenging. The aim of this thesis was to investigate the effectiveness and cost-effectiveness of an adaptive decision-making approach for spatially-targeted, community-based TB screening in high burden settings. Towards this principal aim, there were three objectives: (1) to develop a Monte-Carlo simulation model of a hypothetical digital chest radiography (dCXR)-based TB screening intervention and then to use the simulation to (2) project, in 24 high TB burden communities in South Africa and Zambia, the case-finding yield under the adaptive approach compared to untargeted (random) allocation of screening resources and to (3) investigate the cost-effectiveness of the adaptive approach relative to random and notification based allocation in 12 high burden communities in metropolitan Cape Town, South Africa. Methods. A probabilistic simulation model to simulate a TB screening intervention with TB prevalence estimates derived from a large community-randomized trial was developed. A hypothetical scenario of TB screening was assumed under which mobile screening units were allocated among communities during a 52-week period. A Thompson sampling algorithm was implemented to adaptively allocate screening units based on Bayesian probabilities of local TB prevalence that are continuously updated during weekly screening rounds. The simulation was used to estimate and compare yields of bacteriologically-confirmed TB patients detected per 1,000 screenings performed. Thereafter, the simulation was extended to estimate costs and disability-adjusted life years averted (DALYs). Results. Random allocation of four screening units among the 24 communities would result in an expected 665 (95% uncertainty interval 523-819) TB cases detected over one year, equivalent to 8.9 (7.5-10.4) per 1,000 screened. Spatially-targeted allocation informed by the adaptive decision-making approach would increase this yield. Balanced, adaptive allocation resulted in an expected 1,234 (983-1,487) TB cases detected, 16.5 (14.5-19.0) per 1,000 screened. Numbers of dCXR-based screenings to find one additional TB case declined during the first 12-14 weeks as a result of Bayesian learning. Random-allocation of three screening units among the 12 communities was estimated to avert 1,523(980 – 2,181) DALYs at a cost of $216 ($149 – $321) per DALY averted. Balanced, adaptive allocation could yield an additional 19% of DALYs at an incremental cost of $61 ($24 – $177) per additional DALY averted relative to random allocation. However, this incremental cost per DALY averted increased with increasing costs incurred to adaptively relocate screening units among communities. Conclusion. An approach for spatially-targeted TB screening is proposed that could reduce the number of dCXR screenings necessary to detect additional TB cases in high-burden settings. Furthermore, the approach could result in additional health benefits at relatively low additional cost. However, the extent to which this approach is cost-effective and feasible depends on the additional logistics and costs incurred to relocate the screening units. Empirical research is needed to determine whether this approach could be successfully implemented.
A study of comorbidities, lifestyle risk factors and fatigue of patients with multiple sclerosis in South Africa
(Stellenbosch : Stellenbosch University, 2019-12) Maartens, Desiree Duane; Heine, Martin; Derman, Wayne; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.
ENGLISH SUMMARY : Background: Multiple Sclerosis (MS) affects approximately 2.3 million people globally. A geographical gradient in the prevalence of MS has been reported, with the lowest prevalence reported for sub- Saharan Africa. The vast contextual differences between sub-Saharan Africa and developing countries may argue for a better understanding of MS in an African setting specifically. Aims and Objectives: The main aims of this thesis were to better understand MS in an African context by reviewing research conducted in Sub-Saharan Africa in the past, and build upon that knowledge by evaluating demographics and characteristics of pwMS in an African country (South Africa [SA]). The objectives were to; (i) scope the existing literature on MS, originating from sub-Saharan Africa (Chapter 2) (ii) evaluate the characteristics and key symptoms of pwMS in SA (Chapter 3), and (iii) investigate the agreement between the reported cut-off values for categorising severe fatigue, one of the key symptoms reported by patients with MS globally, by using three different questionnaires (Chapter 4). Methods: (i) A scoping review of the literature on MS from sub-Saharan Africa was undertaken. (ii) A cross-sectional online survey was developed and distributed to all pwMS in SA affiliated with the Multiple Sclerosis Society of SA (n=1048). Measures were included across all domains of the International Classification of Functioning model. (iii) The fatigue questionnaires (Fatigue Severity Scale (FSS), Fatigue Scale for Motor and Cognitive Functions (FSMC) and PROMIS Fatigue Short Form (SF)) included in the crosssectional study were subsequently used to determine their agreement in identifying patients with severe fatigue using previous reported cut-off values, and Receiver Operating Curves were developed to determine new robust cut-off values which acknowledge the unidimensional character of each questionnaire. Results: Thirty-three studies from sub-Saharan Africa were included for the scoping review. Four themes could be derived to group the included studies; aetiology (n=6), epidemiology (n=9), haematology (n=13) and other (n = 5). Majority of the studies (88%) were conducted in South Africa, and only few reports were from the last decade (9%). No comprehensive report on the characteristics and symptom experience of pwMS in sub-Saharan Africa was identified. Subsequently, 122 pwMS (11.6%) completed the anonymous survey (Age=4710yrs, Male (%) =14). PwMS were generally moderately disabled (30.2%) according to the Patient Determined Disease Steps. Comorbidity was frequent, with 39.3% of pwMS reporting three or more comorbidities. The most common comorbidities being: depression (36.1%), high blood pressure and high cholesterol (20.5%) respectively, migraines (15.6%) and anxiety disorders (13.9%). The FSS, FSMC and PROMIS Fatigue SF categorised 73.9%, 78.9% and 30% respectively as severely fatigued. Using Cohen’s Kappa, a significantly moderate agreement was found between FSS and FSMC, (k = 0.563, p = 0.000), and not the PROMIS Fatigue SF. Cut-off values of 5.8 out of 7 for the FSS and 88.5 out of 100 for FSMC would provide 100% certainty a patient with these values (or higher) would have classified as having severe fatigue on both fatigue measures. Conclusion: Despite an increased reporting of MS in sub-Saharan Africa, there is very little recent research on the epidemiology and characteristics of patients with MS in this context. Intervention studies specifically developed for an African context were absent. A triad of poor lifestyle behaviour, low levels of physical activity, and high burden of comorbidity were reported which are concerning in the light of the global burden of disease. Often hampered by the multi-dimensional character of fatigue, the developed robust cut-off values for fatigue could be used in future research where the presence of fatigue is important in for instance evaluating the benefits of interventions to tackle this key symptom. The results of this thesis can be used to set the stage for developing an African specific research agenda for MS.

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