Community care workers in TB care: identifying and meeting their information needs
- Authors: Okeyo, Ida L A
- Date: 2016
- Language: English
- Type: Thesis , Masters , MPharm
- Identifier: http://hdl.handle.net/10962/4211 , vital:20633
- Description: According to the 2015 World Health Organisation global tuberculosis report, South Africa had 155,473 new TB cases in the last year, 61% of whom were HIV-positive. The tuberculosis (TB) epidemic in South Africa has resulted in the increasing use of community care workers (CCWs) for the management and supervision of TB patients on treatment. CCWs are increasingly being deployed to address the shortages of healthcare workers. CCWs supervising TB patients often act as information providers, advising and counselling patients on general care and medication use. Their effectiveness depends on appropriate knowledge, adequate training and access to good quality information about TB and TB medicines. The hypothesis for this study was that user-friendly, simple, illustrated information can enhance TB knowledge of CCWs, as well as serve as a practice tool in facilitating their counselling and education of patients. A conceptual framework was used to guide the development of an intervention to test this hypothesis through the following objectives: exploring the roles and TB information needs of CCWs working with TB patients; evaluating baseline TB knowledge and health literacy levels of CCWs; developing simple, illustrated information materials to address CCW TB information needs; and assessing the influence of the information materials on TB knowledge and practice of CCWs. Six CCWs from Grahamstown Hospice and 25 CCWs from six primary healthcare clinics in Grahamstown participated in the study, which was conducted in three main phases. Phase 1 began with focus group discussions and individual semi-structured interviews with 14 CCWs to explore their perceptions regarding their roles in TB care and their information needs. This was followed by individual interviews with all 31 CCWs using a structured questionnaire to collect quantitative data on health literacy and establish baseline TB knowledge. For Phase 2, the design of an A5 booklet was informed by the findings from Phase 1 and contained information about TB and TB medication. Pictograms were designed using a rigorous, iterative design process and were included in the booklet which was translated into isiXhosa and Afrikaans. The booklets were individually distributed to CCWs during an information session in which the topics in the booklet were discussed. Three months after completion of Phase 2, individual follow-up interviews were conducted with all CCWs to measure post-intervention TB knowledge. Focus group discussions or semi-structured interviews were conducted with 19 of the CCWs to explore the role and impact of the information materials on everyday CCW practice. Qualitative data were transcribed and analysed thematically by developing codes and identifying themes. Quantitative results were analysed using the t-test, Pearson Chi-square and a Z-test of proportions at a 0.05 level of significance. The conceptual framework provided a useful lens through which to view, and reflect on, the interaction between the elements of the healthcare system in relation to the results obtained. CCWs associated their roles in TB control with helping patients and having an impact in patients’ lives which they perceived as being meaningful. The good relationships with patients noted by study CCWs, as well as the appreciation they received from patients, contributed to their confidence and belief that they were well positioned and able to positively influence health outcomes. This study found that CCWs in the healthcare system were disadvantaged by the lack of support and supervision, deficiencies in training and lack of information materials, all of which reflect a negative interaction between CCWs with the healthcare system. Use of the booklet resulted in an improvement in CCW knowledge about the disease, TB medication, MDR and XDR-TB and HIV/AIDS and TB co-infection. The mean knowledge score significantly increased from 76.1% at baseline to 85.4% at follow up showing that the use of the booklet had a positive impact on TB knowledge. Poor knowledge areas were identified as being related to TB medication-related knowledge and drug-resistant TB, highlighting the need for additional intervention to improve knowledge in these areas. The health literacy level of CCWs, which was assessed using the modified Newest Vital Signs– South Africa test, showed that the majority of CCWs had only marginal health literacy, indicating the need for wider assessment of health literacy within CCWs, and the need to tailor training and information materials to cater for their health literacy levels. The pictorial-based, simple booklet tailored for CCWs was also found to enhance confidence in decision making, and reduce their uncertainty when confronted with difficult care scenarios. CCWs were enthusiastic about the inclusion of pictograms which were reported to enhance recall of TB information and understanding of text. The booklet also served as a patient educational tool, where it reportedly improved communication and had a positive effect on the CCW-patient interpersonal relationship. The simplicity of the booklet and the inclusion of pictograms resulted in a user-friendly appealing information source for patients. Factors contributing to the success of the booklet can be attributed to paying attention to CCW information needs, involving CCWs in the design process, translating the booklet into local dialect, ensuring simplicity of the text and including pictograms that had undergone a rigorous design process. This study was the first to design TB information materials targeted specifically for CCWs that were also suitable as patient education materials. The study demonstrated that these information materials can have a positive outcome on CCW roles in TB care by improving their knowledge and facilitating patient communication and education.
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Gradient high performance liquid chromatographic method for the simultaneous analysis of efavirenz, emtricitabine and tenofovir
- Authors: Koekemoer, Sonya Mariana
- Date: 2016
- Language: English
- Type: text , Thesis , Masters , MPharm
- Identifier: http://hdl.handle.net/10962/54679 , vital:26599
- Description: In 2014, approximately 6.8 million people in South Africa were HIV-positive, and the majority of those affected are aged 15 or older. A fixed-dose combination (FDC) antiretroviral (ARV) dosage form containing one non-nucleotide reverse transcriptase inhibitor (efavirenz) and two nucleotide reverse transcriptase inhibitors (emtricitabine and tenofovir) was licensed in South Africa in April 2013. New consolidated guidelines for HIV management and prevention of mother to child transmission (PMTCT) were published by the South African Department of Health in December 2014 and the FDC is now the recommended first-line treatment for HIV-positive patients. According to these guidelines all such people aged 15 and older, and weighing more than 40 kg, with a CD4 count of ≤ 500/ μl will be eligible for antiretroviral therapy (ART) using the FDC. In addition every pregnant and breastfeeding woman is eligible for lifelong ART regardless of CD4 count and EFV can be used as first-line treatment for pregnant women regardless of the length of gestation state of the pregnancy at that time. The use of this simplified regime is likely to promote much needed and improved adherence to therapy. An investigation into the development of a stability-indicating reversed-phase high performance liquid chromatography (RP-HPLC) method for the simultaneous quantitation of EFV, FTC and TNF was undertaken. Isocratic HPLC analysis was found to be unsuitable due to the highly polar FTC molecule eluting in the void. Therefore a gradient HPLC method was developed and validated. The method was validated according to the International Conference on Harmonisation, now known as International Council for Harmonization (ICH). Correlation coefficients > 0.999 were obtained for each assessment of linearity and FTC, TNF and EFV are linear in the range 0.4-40 μg/ml, 0.6-60 μg/ml and 1.2-120 μg/ml. The equation of the best-fit least squares regression lines for FTC, TNF and EFV were y = 0.0191x+0.0007, y = 0.0163x+0.0116 and y = 0.01x+0.016, respectively. The method is accurate as the y-intercept was < 2% of the detector response for all ARV, and the method is precise in terms of intra- and inter-assay precision as all % RSD < 2%. The stability-indicating nature of the method was demonstrated under acidic, alkaline and oxidative stress in addition to UV exposure and elevated temperatures, and the individual chromatograms were overlaid using Empower® 3 Software to establish whether there was interference with the peaks of interest. The forced degradation studies demonstrated the selectivity of the method for the ARV compounds. The method was applied to assay and in vitro dissolution studies of commercially available tablets. The amount of each active ingredient released from Atripla® was determined and compared to the amount of each drug released from Aspen Efavirenz® and Truvada® (a combination of FTC and TNF). The percent FTC released from Atripla® and Truvada® was similar based on the acceptance criteria for immediate-release BCS class 1 compounds. Statistical analysis was undertaken to compare the dissolution profiles of FTC, TNF and EFV. The percent of these compounds released in these studies indicate that bioequivalence testing would be required to declare these products interchangeable. The validated RP-HPLC and in vitro dissolution test method are suitable for routine quality control testing of solid oral dosage forms containing EFV, FTC and TNF, and as the dissolution method can discriminate between different formulations of the same molecule, these tools can also be used for analysis during formulation development studies. The method is not suitable for the analysis of the ARV plasma due to lack of sensitivity and an inability to quantitate the compounds at the required concentration levels. The use of HPLC with mass spectroscopy for quantitation would enhance the sensitivity of the method and may eliminate the quantitation of the molecules in the presence of interference that was observed when using UV detection. Fixed dose combination tablets are convenient for patient therapy and it is likely that in the future more molecules will be formulated into such dosage forms. However formulations such as these can pose significant difficulties when developing and using analytical methods for the quantitation of all compounds in the dosage form at the same time, in particular when the compounds have vastly different physico-chemical properties that impact the quality of a separation and therefore the analysis. Therefore when embarking on the development of FDC product cognisance of the difficulties of developing single methods for the analyses is required and approaches to overcome these difficulties should be considered.
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Investigation of α-aryl substituted 3-indolylethanones as potential antiplasmodial agents
- Authors: Svogie, Archibald Lesley
- Date: 2016
- Language: English
- Type: text , Thesis , Masters , MPharm
- Identifier: http://hdl.handle.net/10962/55487 , vital:26704
- Description: According to the World Health Organisation (WHO), deaths attributed to Plasmodium falciparum exceeded 584 000 in 2013, with 198 million new cases of malaria being reported. One contributing factor to these alarming figures is the emergence of drug resistance against available antimalarial agents. Therefore, there is a pressing need to develop new therapeutic antimalarial drugs with novel mechanisms of action in order to curb the increasing spread of malaria. The indole scaffold is often associated with biologically active compounds, recently exemplified by the antimalarial agent NITD609, which is currently in phase 1 clinical trials. Based on the biological evaluation of a small series of indolyl-3-amides and esters which showed moderate antimalarial activity, coupled to significant toxicity, we were prompted to investigate the synthesis of a series of indolyl-3-ethanone-α-amines (3.37 and 3.41), ethers (3.39 and 3.44) and thioethers (3.42, 3.43, 3.40, 3.45 – 3.73), where the carbonyl moiety and respective heteroatom were separated by a methine spacer. We further investigated these compounds for in vitro biological activity against P. falciparum and a human HeLa cell line. Our study explored the synthetic pathway of a three-step procedure toward our target compounds, with the initial Friedel-Crafts acetylation of indole, followed by α-bromination of the respective 3-acetylindoles. Finally, the halogen of the α-bromo ketone was substituted with an appropriate nucleophile, to yield our desired compounds. Various reagents were explored to optimise the nucleophilic displacement step, including potassium carbonate and various silver containing compounds. While many of the silver salts were found to assist in nucleophilic substitution, none were superior to the addition of potassium carbonate. The majority of compounds, chiefly the thioethers, displayed promising antimalarial activity, against the chloroquine sensitive 3D7 P. falciparum strain, with two thioethers in particular (3.54 and 3.65) inhibiting P. falciparum in the low nanomolar range. Additionally, active compounds were generally found to be non-toxic against HeLa cells, indicating that indolyl-3-thioethers are selective for the malaria parasite. These findings allowed us to begin hypothesising a structure activity relationship of this class, as well as elucidating the possible pharmacophore. In a speculative attempt to uncover the possible mechanism of action of these active compounds, in silico docking studies were conducted against Staphylococcus aureus HPPK (PDB ID: 4CRJ), which is an enzyme that immediately precedes DHPS in the microbial folate biosynthesis. Inhibition of folate biosynthesis is a validated selective antimalarial pathway and HPPK also exists in P. falciparum. Results from these docking studies suggested that our inhibitors bound well in the HPPK ATP pocket and were supportive of our hypothesized structure activity relationship.
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The participatory development and implementation of a facilitator’s manual for the promotion of exclusive breastfeeding
- Authors: Katsinde, Shingirai Miranda
- Date: 2016
- Language: English
- Type: Thesis , Masters , MPharm
- Identifier: http://hdl.handle.net/10962/4201 , vital:20632
- Description: Background: Breastfeeding is a common practice, but exclusive breastfeeding for the first six months is no longer a cultural norm in the majority of South African communities. Identification of facilitating and constraining factors which affect breastfeeding and exclusive breastfeeding practices is thus important. The promotion of exclusive breastfeeding is essential for improved infant health and development, especially if it takes into consideration the broader cultural and socio-economic aspects influencing these practices. This study follows up on an initial project conducted in Glenmore and Ndwayana, two rural communities in the Eastern Cape, South Africa. The current study aimed at working with community care workers who are associated with two community based organisations, who work within three communities, Glenmore, Ndwayana and Grahamstown. The study objectives were to identify the factors that influence the adoption of exclusive breastfeeding in the communities researched, to conduct workshops with the community workers on exclusive breastfeeding practices, as well as to develop and implement a facilitator’s manual for the promotion of exclusive breastfeeding. Method: Using the community based participatory research approach and the PEN-3 theoretical framework to guide the research process, individual semi-structured interviews were conducted with 14 community care workers to identify the factors that affect breastfeeding and exclusive breastfeeding. Through participatory involvement and a cyclical research process, a facilitator’s manual on breastfeeding was developed, which was used during the workshops in the training of community care workers on breastfeeding and exclusive breastfeeding practices. A pre and post intervention knowledge questionnaire was given to the community care workers to complete before and after the workshops. The facilitator’s manual was modified based on 14 months of consistent interaction with the community care workers, who provided feedback on improving the content as well as on how to enhance the cultural appropriateness of the facilitator’s manual during guided focus group discussions. Readability testing also guided further modification of the facilitator’s manual. Results:The major findings confirmed that exclusive breastfeeding for six months was no longer a common practice in these three communities. Factors affecting breastfeeding and exclusive breastfeeding were classified as perceptions (knowledge attitudes and beliefs), enablers (resources and facilities) and nurturers (people), in accordance with the PEN-3 model thematic categories. The knowledge questionnaire, semi-structured interview results, and data from the workshops showed that the community care workers were not sufficiently equipped with information on breastfeeding and exclusive breastfeeding. The facilitator’s manual development and modification was made possible by inputs from the community care workers and the community based organisation liaisons. A culturally appropriate, community specific facilitator’s manual for the promotion of breastfeeding and exclusive breastfeeding was produced. Conclusion: The factors affecting breastfeeding and exclusive breastfeeding were identified. These factors were useful in facilitating discussions on how to improve breastfeeding and exclusive breastfeeding practices in the communities researched. The facilitator’s manual and the workshops were useful in equipping community care workers with knowledge on breastfeeding and exclusive breastfeeding. The involvement of community based organisations will assist to ensure sustainability of breastfeeding promotion by community care workers by adopting the facilitator’s manual as part of their women and child development programmes.
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