SAJCH Vol 10, No 2 (2016)

CHILD HEALTH THE SOUTH AFRICAN JOURNAL OF

June 2016

Volume 10

No. 2

• Kidney diseases in developing countries • Are we screening for infant hearing?

• Referral pathways and utilisation of short-stay wards • Is the early diagnosis and management of HIV in infants a reality?

• Do paediatric registrars encourage adolescent preventive services in Nigeria?

CHILD HEALTH THE SOUTH AFRICAN JOURNAL OF

EDITOR J M Pettifor FOUNDING EDITOR N P Khumalo

103 Childhood kidney disease in developing countries: Is it a forgotten disease?

EDITORIAL BOARD Prof. M Adhikari (University of KwaZuluNatal, Durban) Prof. M Kruger (Stellenbosch University) Prof. H Rode (Red Cross War Memorial Children's Hospital, Cape Town) Prof. L Spitz (Emeritus Nuffield Professor of Paediatric Surgery, London) Prof. A Venter (University of the Free State, Bloemfontein) Dr T Westwood (Red Cross War Memorial Children's Hospital, Cape Town) Prof. D F Wittenberg (University of Pretoria)

B Rajendra, U Kala

HEALTH & MEDICAL PUBLISHING GROUP:

Short Report

CEO AND PUBLISHER Hannah Kikaya

JULY 2016

Volume. 10

No. 2

CONTENTS Editorial

104 Exploring South African adolescents’ knowledge of abortion legislation and attitudes to abortion: Sexual status and gender differences

D Ramiyad, C J Patel

Congress Report

N McKerrow, H Saloojee, M Morgan

106 The 6th South African Child Health Priorities Conference: ‘Walking the Talk’

Research

107 Current practice of adolescent preventive services among paediatric residents in Nigeria

M T Abiodun, A I Omoigberale, M O Ibadin

110 The effects of iron deficiency and anaemia on primary school learners’ scholastic performance

B P S Hlatswayo, S Ntshangase, F P R de Villiers

115 Barriers, facilitators and recommendations for the early infant diagnosis and treatment (EIDT) cascade: A qualitative study in Malawi

E A Bobrow, A G Yemaneberhan, M Phiri, L Katirayi, A Ahimbisibwe, F Chimbwandira, N Buono

120 The prevalence of paediatric skin conditions at a dermatology clinic in KwaZulu-Natal Province over a 3-month period

O S Katibi, N C Dlova, A V Chateau, A Mosam

125 The long-term concerns post cochlear implantation as experienced by parents/ caregivers of prelingually deaf children between the ages of 3 and 5 years in Gauteng Province, South Africa

N Moroe, N Kathrada

129 Risk profiles of infants ≥32 weeks’ gestational age with oropharyngeal and oesophageal dysphagia in neonatal care

C Pike, M Pike, A Kritzinger, E Krüger, M Viviers

133 The impact of a change in referral pathway on a paediatric short-stay ward in Cape Town, South Africa

H Finlayson, L Smit, T M Esterhuizen, M Kruger

138 Infant hearing screening at primary healthcare immunisation clinics in South Africa: The current status

L Petrocchi-Bartal, K Khoza-Shangase

145

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©Copyright: Health and Medical Publishing Group (Pty) Ltd

EXECUTIVE EDITOR Bridget Farham MANAGING EDITORS Ingrid Nye Claudia Naidu TECHNICAL EDITORS Emma Buchanan Paula van der Bijl NEWS EDITOR Chris Bateman PRODUCTION MANAGER Emma Jane Couzens DTP AND DESIGN Carl Sampson HEAD OF SALES AND MARKETING Diane Smith | Tel. 012 481 2069 Email: dianes@hmpg.co.za ONLINE SUPPORT Gertrude Fani | Tel. 072 463 2159 Email: publishing@hmpg.co.za FINANCE Tshepiso Mokoena HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Dr M J Grootboom, Mrs H Kikaya, Prof. E L Mazwai, Dr M Mbokota, Dr G Wolvaardt HEAD OFFICE Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext. 3, Pretoria, 0181 EDITORIAL OFFICE Suites 9 & 10, Lonsdale Building, Gardener Way, Pinelands, 7405 Tel. 021 532 1281 | Cell. 072 635 9825 Email: publishing@hmpg.co.za ISSN 1994-3032

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EDITORIAL

Childhood kidney disease in developing countries: Is it a forgotten disease?

Kidney disease affects millions of adults and children worldwide. The 11th World Kidney Day was celebrated on 10 March 2016, and was dedicated to childhood kidney diseases. Many children may be at risk of developing kidney disease at an early age, and this year, World Kidney Day aimed to increase awareness around the fact that many adults have had kidney disease since early childhood. The spectrum of kidney disease in children ranges from treatable disorders without long-term sequelae to life-threatening conditions. Children with acute kidney injury (AKI) may develop long-term consequences leading to chronic kidney disease (CKD) later in life. [1] Worldwide, epidemiological information on the incidence and prevalence of paediatric AKI and CKD is limited, often imprecise, and flawed by methodological differences between the various data sources, although increasing in scope. This is particularly pertinent in Africa, where the focus is on communicable diseases with lack of proper documentation and renal registries.[2] As a result there are insufficient data to guide the authorities responsible for resource allocation. This increases the challenges of providing care for children with kidney disease in a resource-limited environment. The rising incidence of kidney diseases in children highlights the need for early detection and healthy lifestyle, starting at birth and continuing into adult life.

The main aim of World Kidney Day 2016 was to inform parents, caregivers, young patients, the general public, and policymakers of the importance of the early detection and appropriate management of childhood kidney disease.

The spectrum of renal disease in African children

There is a dearth of literature on the spectrum and extent of renal disease in African children. This is due to the slow development of the subspecialty, the lack of trained personnel and the fact that highly technical resources such as renal histopathology, dialysis fluids, machines, immunosuppressive drugs and transplantation services are not readily available. The percentage of renal-related admissions to secondary and tertiary hospitals varies widely from 3.5 to 8.9% among different centres and countries. The most common cause of admission is AKI due to dehydration and septic shock syndromes. [3,4] This has improved owing to the introduction of oral rehydration, but many rural areas still do not have easy access to clean water and sanitation. In South Africa (SA) the three most common causes of AKI in older children are haemolytic uraemic syndrome (35%), acute tubular necrosis (31%) and acute glomerulonephritis (GN) (16%), whereas 39% of AKI is caused by acute gastroenteritis and nephrotic syndrome in Nigeria,[5] and 26% was reported to be due to sepsis and malaria.[3] In Ghana, 11% of AKI reported was as a result of haemoglobinuria from haemoglobinopathies (for example, sickle cell and G-6-phosphates deficiency).[3] The spectrum of chronic glomerular diseases varies in the different geographical regions of the continent, with the epidemiology of infectious agents implicated in its causation varying considerably as one traverses from the most northern regions of Africa to the south.[6] Schistosoma haematobium and Schistosoma mansoni, together with Salmonella typhi, have been reported as the most highly prevalent forms of GN and nephrotic syndrome in Egypt, while a post-infectious type of proliferative nephropathy is seen in Tunisia (northern Africa).[6,7] In the malarial-infested regions of Kenya, Nigeria, Uganda, and parts of Ghana, Plasmodium malariae is the most frequent cause of GN. In Zimbabwe (southern Africa) a post-infectious, diffuse proliferative, exudative form of GN is most 103

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often seen.[7] Hepatitis B-related nephropathy contributed to a fair percentage as a cause of nephrotic syndrome in black children prior to 1994 in SA. In KwaZulu-Natal (KZN) Province, the rate was 34.3%,[7] while it was 12% in Johannesburg (Gauteng Province),[8] but following the introduction of hepatitis B immunisations in 1994, the disease has almost been eradicated with only two sporadic cases seen in the last decade in KZN.[9] With better screening and treatment for syphilis, congenital syphilis associated membranous nephropathy has also almost disappeared. The increasing prevalence of HIVrelated nephropathy in the era of limited or no access to treatment was menacing, with HIV causing an increased burden of all diseases, especially severe gastroenteritis leading to dehydration and prerenal AKI. As a result of the severely immunocompromised state, bacterial, viral, fungal and parasitic infections causing septicaemia and septic shock syndromes also contributed to the development of AKI. The use of nephrotoxic drugs such as aminoglycosides, acyclovir and antifungal agents such as amphotericin B further affected kidney function. [10] Studies in the USA have shown the African American population possesses an 18- to 50-fold increased risk for developing HIV-1-associated focal segmental glomerulosclerosis (FSGS).[11] Significant evidence of the influence of genetic factors on this disparity is that individuals of African ancestry from other geographical regions also show an increased risk for developing FSGS.[12] Fortunately early treatment with highly active antiretroviral therapy and the prevention of mother-to-child treatment programmes, together with screening for proteinuria and haematuria at HIV treatment centres has made an impact on the prevalence of HIV-associated nephropathy with a massive reduction in the incidence of the disease. Autoimmune diseases such as systemic lupus erythematosus and systemic vasculitis, e.g. Takayasu’s arteritis, which are occasionally seen in children and have a good prognosis, need to be recognised and referred early.[13] Congenital abnormalities of the kidney and the urinary tract, which include the obstructive uropathies, can be detected with a prenatal sonar. Obstructive uropathy is more common than reflux nephropathy in black African children. Over a 19-year period at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, only 21 of 2 159 cases (<1%) of documented urinary tract infections (UTIs) had primary vesicoureteric reflux (Kala – personal communication).

The prevalence of posterior urethral valves and pelviureteric junction obstruction (unilateral or bilateral) is common; some are associated with hypoplastic and dysplastic kidneys that carry a very poor prognosis. An important aspect of minimising renal damage in obstructive uropathy is the availability of prenatal ultrasound in pregnant women. Most mothers in the public health sector do not have access to ultrasonography and are therefore diagnosed late, usually after a UTI, thus compromising kidney function further. [4] One also needs to be alert to the possibility of metabolic and genetic diseases such as renal tubular acidosis, cystinosis, and oxalosis that are sometimes seen in the black African population. The high incidence of premature and small for gestational age (SGA) births in developing countries as a risk factor for kidney disease in adulthood, in the absence of evident kidney disease in early life, has been explained by the Barker hypothesis.[14,15] Steps need to be taken to decrease the premature birth rate by educating mothers to book early for antenatal screening, encourage proper nutrition and monitoring by health personnel on the progress of the pregnancy, thus preventing eventual hypertension, metabolic syndrome and possible type 2 diabetes mellitus.[16] It is therefore imperative to follow

JULY 2016 Vol. 10 No. 2

EDITORIAL kidney function and blood pressure throughout life in premature and SGA babies. Also supplementing folic acid to potential mothers will decrease spinal dysraphism and lower urinary tract abnormalities.

Transition from paediatric to adult renal services

The transitioning of children from paediatric to adult services is inadequate due to patient load and poorly trained staff. This leads to poor compliance and loss of an already vulnerable adolescent patient to follow up. It is vital that there is good communication between paediatric and adult services for effective patient handover. Support for this age group of patients should be developed on both sides. If there is familial or societal instability or a disease crisis, transition may need to be slowed, paused, or even temporarily reversed.[17]

Call for action

In developing countries, infections and other non-communicable diseases such as cardiovascular disease, diabetes, cancer, and chronic respiratory disorders, eclipse resource allocation for kidney diseases.

Efforts need to be focused on increasing education and awareness on the impact of kidney diseases as a multiplier disease on infections and non-communicable diseases. There must be a greater focus on early detection and management of kidney disease in childhood by health authorities. This is consistent with the objectives of the World Health Organization to reduce mortality from non-communicable diseases with a 10-year target population level initiative focusing on changes in lifestyle (including tobacco and alcohol use reduction, salt intake control and dietary energy control), and effective interventions (including blood sugar, cholesterol and blood pressure control).

Bhimma Rajendra

Department of Paediatrics and Child Health, School of Clinical Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa bhimma@ukzn.ac.za

Udai Kala

Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesberg, South Africa

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1. Goldstein SL. Acute kidney injury in children and its potential consequences in adulthood. Blood Purif 2012;33(1-3):131-137. DOI:10.1159/000334143 2. Ladapo TA, Esezobor CI, Lesi FE. Pediatric kidney diseases in an African country: Prevalence, spectrum and outcome. Saudi J Kidney Dis Transpl 2014;25(5):1110-1116. DOI:10.4103/1319-2442.139976 3. Antwi SSA, Amoah A, Appia AS, Obeng E. Acute kidney injury in children: 3 year data review from Ghana. Int J Pediatr Res 2015;1:2.

4. Elzouki AY, Amin F, Jaiswal OP. Prevalence and pattern of renal disease in eastern Libya. Arch Dis Child 1983;58(2):106-109.

5. Choopa MS, van Biljoen G. Acute kidney injury in children - not just for the nephrologist. S Afr Fam Pract 2015;2015(57):30-33.

6. Seggie J, Davies PG, Ninin D, Henry J. Patterns of glomerulonephritis in Zimbabwe: Survey of disease characterised by nephrotic proteinuria. Q J Med 1984;53(209):109-118. DOI: 10.1007/BF00869837 7. Bhimma R, Coovadia HM, Adhikari M. Nephrotic syndrome in South African children: Changing perspectives over 20 years. Pediatr Nephrol 1997;11(4):429434. DOI:10.1007/s004670050310 8. Kala U, Jacobs DWC, Meyers KEC, Thomson PD. Nephrotic syndrome in children at the Baragwanath and Johannesburg Hospitals: 1982-1998 Inclusive.

Kidney Int 1991;39:359.

9. Bhimma R, Coovadia HM, Adhikari M, Connolly CA. The impact of the hepatitis B virus vaccine on the incidence of hepatitis B virus-associated membranous nephropathy. Arch Pediatr Adolesc Med 2003;157(10):10251030. DOI:10.1001/archpedi.157.10.1025 10. Bhimma R, Purswani MU, Kala U. Kidney disease in children and adolescents with perinatal HIV-1 infection. J Int AIDS Soc 2013;16:18596. DOI:10.7448/ IAS.16.1.18596 11. Eggers PW, Kimmel PL. Is there an epidemic of HIV Infection in the US ESRD program? J Am Soc Nephrol 2004;15(9):2477-2485.

12. Kitiyakara C, Kopp JB, Eggers P. Trends in the epidemiology of focal segmental glomerulosclerosis. Semin Nephrol 2003;23(2):172-182. DOI:10.1053/ snep.2003.50025 13. Faller G, Thomson PD, Kala U, Hahn D. Demographics and presenting clinical features of childhood systemic lupus erythematosus. S Afr Med J 2005;95(6):424-427. DOI:10.1080/22201009.2005.10872120 14. Barker DJ. Fetal origins of cardiovascular disease. Ann Med 1999;31 Suppl 1:3-6.

15. Hoy WE, Ingelfinger JR, Hallan S, Hughson MD, Mott SA, Bertram JF. The early development of the kidney and implications for future health. J Dev Orig Health Dis 2010;1(4):216-233. DOI:10.1017/S204017441000022X 16. Hoy WE, Rees M, Kile E, Mathews JD, Wang Z. A new dimension to the Barker hypothesis: Low birthweight and susceptibility to renal disease. Kidney Int 1999;56(3):1072-1077. DOI:10.1046/j.1523-1755.1999.00633.x 17. Watson AR, Harden P, Ferris M, Kerr PG, Mahan J, Ramzy MF. Transition from pediatric to adult renal services: A consensus statement by the International Society of Nephrology (ISN) and the International Pediatric Nephrology Association (IPNA). Pediatr Nephrol 2011;26(10):1753-1757.

DOI:10.1007/s00467-011-1981-z

S Afr J Child Health 2016;10(2):103. DOI:10.7196/SAJCH.2016.v10i2.1144

SAJCH JULY 2016 Vol. 10 No. 2

SHORT REPORT

Exploring South African adolescents’ knowledge of abortion legislation and attitudes to abortion: Sexual status and gender differences D Ramiyad, MSocSc (Health Promotion); C J Patel, MA (Counselling Psychology) School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: C J Patel (patelc@ukzn.ac.za)

This study explored adolescents’ knowledge of the Choice on Termination of Pregnancy Act (No 92 of 1996) and attitudes toward abortion.

A sample of 150 secondary school learners (aged 15 - 19 years), from a low socioeconomic area in Durban, KwaZulu-Natal Province, South Africa was surveyed. Twenty percent of the sample indicated that they found abortion acceptable. The sexually active (have had sex) respondents had more positive attitudes toward abortion for elective reasons than the sexually inactive (have not had sex) sample. On traumatic reasons the gender difference was found to be a function of sexual status. Sexually active females showed greater support than males. While the majority of those sampled were aware of the legal status of abortion in this country, they demonstrated a lack of knowledge on specific aspects of the Act. Recognition of adolescents’ right to information is central to responsible decision-making among the youth about sexual and reproductive health issues.

S Afr J Child Health 2016;10(2):104-105. DOI:10.7196/SAJCH.2016.v10i2.1137

For public health initiatives to be realised, there needs to be greater recognition of adolescence as the life phase in which adult health behaviours are set.[1] South Africa (SA)’s National Adolescent Sexual and Reproductive Health and Rights (ASRH&R) framework strategy (2015)[2] sets out the country’s commitment to improving the sexual and reproductive health of its youth.

There are a number of governmental efforts (including the national Department of Education’s attempt at improving knowledge and skills of SA youth through life orientation (LO) subjects at school) and non-governmental initiatives aimed at addressing youth sexual and reproductive health.[3] Most of these are designed to tackle youth susceptibility to HIV and AIDS. The Choice on Termination of Pregnancy (CTOP) Amendment Act (No 1 of 2008)[4] allows SA women (including teenagers) the legal right to terminate pregnancies. The ASRH&R framework (2015)[2] reports lack of knowledge about legal rights relating to sexual health and risks, particularly on termination of pregnancy and emergency contraception, as one of the emerging trends in research findings and identifies it as one of the challenges impeding progress in the field of sexual and reproductive health. Twenty-five percent of all unsafe abortions in sub-Saharan Africa are carried out on girls aged between 15 and 19 years.[1] Apart from the study of grade 11 learners in the Eastern Cape Province,[5] research studies aimed at gauging knowledge of abortion legislation among the youth in this country appear to be rather limited. The aim of the present study was to explore gender differences in knowledge of CTOP legislation and attitudes to abortion in a small sample of adolescents from a low socioeconomic suburb in the KwaZulu-Natal (KZN) area.

Methods

A survey was conducted using a convenience sample of 150 (89 female and 61 male) learners aged 15 - 19 years, from a secondary school in a low socioeconomic suburb in the Durban area. The self-administered questionnaire contained three sections: (i) biographical information, which covered age, gender and sexual status (have had sex/have not had sex); (ii) a measure of abortion attitudes using a 7-point response format ranging from ‘strongly disapprove’ (1) to ‘strongly approve’ (7);[6] (iii) a set of 13 questions based on the Termination of Pregnancy 105

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Act No 92 of 1996, assessing knowledge of various components of the SA abortion legislation as devised by D Ramiyad.

Ethical clearance was obtained from the Faculty of Humanities, Development and Social Sciences, University of KZN and permission to access the school site was provided by the relevant authorities.

Signed parental consent for 159 grade 11 learners was received.

The questionnaires were administered in the LO class, a holistic class that focuses on the emotional, physical, spiritual, moral and cultural development of learners. A total of 150 complete questionnaires were used in the study. The abortion attitude items were subjected to a principal components analysis with varimax rotation. In order to assess group differences, 2 × 2 (gender × sexual status) analysis of variance (ANOVA) was conducted on the attitude scales and the knowledge measure. SPSS software (IBM, USA) was used for the analyses.

Results

Two factors were extracted from the analysis of the abortion items: • Elective reasons for abortion: (choice linked to low income, not wanting more children, single status, personal decision) with loadings ranging from 0.63 to 0.80 • Traumatic reasons for abortion: (rape, poor health, fetal defects), with loadings ranging from 0.68 to 0.78.

These factors were treated as subscales in further analyses. The results of the tests of difference (gender and sexual status) are presented in Table 1. No gender or sexual status differences were found on the knowledge items. The results showed that: • although 80% of the sample was aware of the legal status of abortion in this country, they showed limited knowledge of specific aspects of the Act • 10.7% were aware of the period of gestation when termination is allowed • 6.7% knew the age at which a person could request an abortion without parental permission • 20.7% were aware of the different methods of abortion • 28.7% knew who is allowed to perform the procedure • 29.3% were aware that it is a criminal offence to prevent or obstruct access to a legal abortion.

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RESEARCH Table 1. Gender by sexual status: ANOVA results of knowledge, elective reasons, traumatic reasons Male (N=61), mean (SD)

Female (N=89), mean (SD)

5.51 (2.77)

5.92 (2.49)

Total, mean (SD)

f-test

Knowledge Gender

1.26

Sexual status

0.77

Yes

5.75 (3.10)

6.05 (2.31)

5.86 (2.82)

No

5.05 (1.99)

5.87 (2.57)

5.68 (2.46)

Gender by sexual status

0.28

Elective reasons Gender

14.40 (5.11)

12.36 (6.40)

0.54

Yes

15.33 (4.85)

14.64 (6.32)

15.08 (5.39)

No

12.47 (5.20)

11.58 (6.29)

11.78 (6.04)

Sexual status

7.47*

Gender by sexual status

0.01

Traumatic reasons Gender

11.43 (3.68)

4.40†

12.93 (5.10)

Sexual status

opposition to the availability of legal abortion in this country.

Conclusion

Although this sample does not claim to represent the youth of South Africa, the findings correspond with the emerging pattern of lack of information and low levels of support for abortion from other studies.

Among recommendations[1] regarding adolescent health in general is the importance of understanding adolescence in terms of a life-course perspective, of co-ordinated multi-pronged initiatives, of establishing efficient information systems, and of giving adolescents a stronger voice by involving them in identifying their concerns and in finding the solutions. Recognition of the right to information as the most basic aspect of reproductive rights[5] should be central in the LO classes offered in schools and in the efforts of non-government organisations if youth knowledge and awareness is to improve.

0.15

Yes

10.86 (3.17)

14.71 (4.70)

12.28 (4.21)

No

12.56 (4.41)

12.34 (5.13)

12.39 (4.95)

References 5.48†

Gender by sexual status * p<0.01. † p<0.05.

Compared with the study using a similar age group,[5] a higher percentage of the present sample was aware of the obligatory pre- and postcounselling offered to women.

On the whole, however, similar findings were observed across the two studies. In the present sample, those respondents who had had sex were significantly more supportive for elective reasons than those who had not had sex. A gender by sexual status interaction effect was observed on the traumatic reasons subscale with difference in gender dependent on whether they had had sex or not: females of the former group

were more supportive of abortion than their counterparts.

The relatively higher endorsement among these females needs to be treated with caution however, since the actual level of support is in the low to moderate range. In addition just 20% of the sample indicated that they found abortion acceptable. Perhaps the results need to be considered in terms of levels of opposition rather than in terms of support – translating into lower levels of opposition among the sexually active individuals. This trend is in keeping with public surveys which reveal strong public

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1. Sawyer SM, Afifi RA, Bearinger LH, et al.

Adolescence: A foundation for future health.

Lancet 2012;379(9826):1630-1640. DOI:10.1016/ S0140-6736(12)60072-5 2. National Department of Social Development, South Africa. National Adolescent Sexual and Reproductive Health and Rights Framework Strategy.

2015..http://www.dsd.gov.za/index2. php?option=com_docman&task=doc_ view&gid=578&Itemid=3 (accessed 10 April 2015).

3. Beksinska ME, Pillay L, Milford C, Ranchod V. The sexual and reproductive health needs of youth in South Africa – history in context. S Afr Med J 2014;104(10):676-678. DOI:10.7196/SAMJ.8809 4. Choice on Termination of Pregnancy Amendment Act No 1 of 2008. http://www.gov.za/sites/www. gov.za/files/a1-08.pdf (accessed 10 April 2015).

5. Macleod C, Seutlwadi L, Steel G. Cracks in reproductive health rights: Buffalo City learners’ knowledge of abortion legislation. Health SA Gesondheid 2014;19(1). DOI:10.4102/hsag. v19i1.743 6. Esposito CL. Basow SA. College students’ attitudes toward abortion: The role of knowledge and demographic variables. J Appl Soc Psychol 1995;25(22):1996-2017.

CONGRESS REPORT The 6th South African Child Health Priorities Conference: ‘Walking the Talk’

The 6th Child Health Priorities Conference was convened by the South African Child Health Priorities Association at the University of KwaZulu-Natal in Pietermaritzburg from 3 to 5 December 2015.

The theme of the conference, ‘Walk the Talk’, tackled the challenges of implementing the recommendations from the reports of two child health-related ministerial committees.

The conference opening address by Prof. Saloojee (University of the Witwatersrand) summarised progress in the child health arena in 2015. He argued that the intervening year had been an exciting one during which ‘the talk’ continued but ‘the walk’ remained ‘underwhelming’. The year 2015 saw the completion of the Millennium Development Goals (MDGs) era and the dawn of the Sustainable Development Goals (SDGs) era. Although the MDGs precipitated a global decline in the level of poverty, incidence of HIV infections and stunting rates, with a concomitant increase in primary school enrolment, the overall rate of progress was disappointing and inequality remains a reality. Only 62 countries met their MDG4 target of a two-thirds reduction in under-5 mortality, although a further 74 managed to reduce the rate by at least half. The new SDGs are more ambitious, with 17 goals, 169 targets and 304 indicators, but allow countries an opportunity to complete unfinished business from the MDGs. The year also saw the release of two important reports – a midterm review of the national Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition in South Africa, 2012 - 2016, and a review of the District Clinical Specialist Team programme. Both reports identified some successes, but major implementation gaps remain. Two initiatives matured legally with the gazetting of an Early Childhood Development Policy and recognition of a qualification for Community Paediatrics and Child Health. The road-to-health booklet (RtHB) was the focus of two circulars: one promoting easier access and replacement and the other supporting the withholding of HIV status disclosure by caregivers (through tearing out of the RtHB pages). The latter created some disquiet and requires urgent reversal. President Zuma introduced Operation Phakisa as a tool for the ongoing rapid review of public programmes and policies, the ‘Ideal Clinic’ initiative being one such activity. The non-event of the year was considered to be the failure to release the national health insurance (NHI) white paper.

The latest data from the perinatal (NaPeMMCo) and child (CoMMiC) mortality ministerial committees were considered.

These highlighted the stagnation in the reduction of neonatal and child mortality across the country. The neonatal mortality rate remains just above 10 per 1 000 live births, while the recent rapid decline in under-5 mortality has plateaued and this now remains unchanged at around 40 per 1 000 live births. Both committee reports emphasised the need to strengthen the quality and coverage of existing programmes rather than to search for new initiatives.

Prof. Saunders (University of the Western Cape) discussed the complex context of child wellbeing and emphasised the role of upstream factors, social determinants and behaviour on childhood illness. He illustrated how the greatest and most cost-effective impact on child survival can be achieved at source and presented a strong case for supporting midlevel healthcare workers operating at the community level.

The first themed plenary session explored an essential package of care (EPaC) for children, a recommendation emanating from CoMMiC. As the EPaC is the cornerstone of the NHI for children, this session reviewed the philosophy behind the NHI, the current status of NHI implementation in one pilot site, the role of the Office

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of Standards Compliance in supporting NHI as well as the EPaC for children. The lack of any specific provision for children in the NHI or the core standards was evident, which strengthened the case for an EPaC to ensure that a future health service can meet the needs of children. The components of an EPaC are currently being debated by child health practitioners.

One conference session focused on the preventive pathway throughout the life-cycle. The session started by reviewing the challenges of creating adolescent-friendly services and ensuring responsible teenage sexual behaviour. Insights were provided into how KwaZulu-Natal increased exclusive breastfeeding rates from 7.4% to 45.1%. The value of the RtHB was revisited and participants were introduced to upcoming initiatives from the National Department of Health to optimise its use in supporting child wellbeing. Suggestions were provided on strengthening the use of existing tools for the recognition of acutely ill children at all levels in the health system, and an update was provided on the implementation of the integrated school health programme – six provinces have achieved their target number of school health teams.

A 360° view of outreach programmes was provided, with an overview of various models of outreach as well as the experiences of outreach from all perspectives, both the provider and the recipient. There was consensus that outreach programmes are an essential tool for strengthening service but they are inconvenient for all implementing parties. This insight needs to guide the implementation of outreach activities to ensure maximal benefit for all participants.

The final conference session discussed community engagement.

It explored the need, benefits and limitations of integrating Western and traditional medicine including modes of interaction, the use of modern technology such as the cell phone messaging service MomConnect and household visits by community caregivers.

The South African Child Health Priorities Association is a child health advocacy group providing forums for interaction of child health professionals from a variety of fields (such as health, social development and law). The next Child Health Priorities Conference will be held in Cape Town from 1 to 3 December 2016. Visit the association’s website http://childhealthpriorities.co.za for more detail, and to view conference presentations.

Neil McKerrow

Executive member: South African Child Health Priorities Association; Head: Paediatrics and Child Health, KwaZulu-Natal Department of Health, Pietermaritzburg; Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZuluNatal, Durban, South Africa neil.mckerrow@kznhealth.gov.za

Haroon Saloojee

Treasurer: South African Child Health Priorities Association; Head: Division of Community Paediatrics, Department of Paediatric and Child Health, University of the Witwatersrand, Johannesburg, South Africa

Mary Morgan

Conference organiser: South African Child Health Priorities Association; Head: Department of Paediatrics and Child Health, Pietermaritzburg Hospitals Complex; Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa S Afr J Child Health 2016;10(2):106. DOI:10.7196/SAJCH.2016.v10i2.1178

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RESEARCH

Current practice of adolescent preventive services among paediatric residents in Nigeria M T Abiodun, FWACP (Paed); A I Omoigberale, FWACP (Paed); M O Ibadin, FMC (Paed) Department of Child Health, University of Benin Teaching Hospital, Benin City, Nigeria Corresponding author: M T Abiodun (biodunmt27@yahoo.com) Background. There has been a growing recognition of the challenge of Nigerian adolescents’ health issues and the need to address it. adolescent preventive services (APS) constitute an effective mechanism to reduce adolescent morbidities.

Objective. To evaluate the current practice of APS among Nigerian paediatric residents.

Methods. For this cross-sectional survey, we designed an anonymous questionnaire based on Guidelines of APS of the American Medical Association to elicit information on residents’ current practice regarding screening adolescents for specific morbidities.

Results. A total of 103 residents participated in the study; nearly 60% were from federal teaching hospitals. The majority (78.6%) attended to adolescents at least once a week. In the last month, the adolescent medicine service most commonly provided by respondents was general health guidance (66.7%). Altogether, less than one-fifth of the residents have recently asked at least two specific questions to screen adolescents for eating disorders, violence, safety issues, depression, substance or sexual abuse. Senior registrars were more likely than registrars to screen adolescents for hypertension (75.0% v. 29.1%, p=0.032), depression (50.0% v. 16.5%, p=0.043) and abuse (62.5% v.

22.1%, p=0.023). Also, residents with <5 years in practice were more likely to screen for relationship issues (p=0.045).

Conclusion. The current level of practice of APS is low among paediatric residents in Nigeria. There is a need to restructure their ongoing practice and training to emphasise preventive paediatrics and other issues pertinent to adolescent care.

S Afr J Child Health 2016;10(2):107-109 DOI:10.7196/SAJCH.2016.v10i2.717

The provision of adolescent preventive services (APS) is imperative globally among clinicians, especially paediatricians.[1] Adolescents are at a developmental stage that is characterised by experimentation and risk-taking owing to their emerging cognitive abilities and social experiences.[1,2] They are therefore vulnerable to a wide range of morbidities. Besides general health problems, adolescents are often susceptible to violence, substance abuse, and behavioural and reproductive health issues.[2,3] For instance, according to a 2010 UNICEF report, only about one-quarter of adolescents aged 15 19 years in Nigeria have comprehensive knowledge of HIV, and almost half of the females (46.2%) and about a quarter of the males (22.1%) have engaged in sexual intercourse.[4] This knowledge gap can be bridged by general health education and provision of adolescentfriendly services to the populace.[5] Again, the persistently high levels of adolescent morbidity and mortality over recent decades further attest to the need for adolescent-oriented preventive services in our societies.[6,7] Anticipatory guidance and other preventive services should be integrated into routine clinical practice by all clinicians attending to adolescents. This is particularly necessary in developing countries where child welfare clinics are poorly attended and routine health checks have not been imbibed into the health-seeking culture of most families.[8] People visit health facilities mainly to seek curative services that could not effectively control prevalent morbidities among adolescents and other age groups in the society.[8] There has been a limited emphasis on adolescent medicine (AM) in Nigeria previously, despite the fact that adolescents constitute about onefifth of the Nigerian population, and one in five African adolescents is a Nigerian.[4] Consequently, there are no Nigerian guidelines on APS. AM services are incorporated into school health programmes, community/preventive paediatrics and other core areas of paediatrics during residency training in Nigeria.[9] Based on the current training curriculum contents, the level of competence in the provision of APS expected of Nigerian paediatrics residents is comparable with that specified in Guidelines of Adolescent Preventive Services (GAPS) of the American Medical Association,[1] recommended for all primary 108

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healthcare providers. This study describes the provision of AM services and the current level of practice of APS among Nigerian paediatric residents.

Methods

The study was carried out from 19 February to 4 March 2013 at the multipurpose hall of Oba Akenzua Complex at the University of Benin Teaching Hospital, Benin City, Nigeria. The participants were resident doctors in paediatrics attending the Intensive Course in Paediatrics of the National Postgraduate Medical College of Nigeria at the venue. Permission was sought from the local organising committee of the revision course. Informed consent was obtained from every study participant.

We conducted a descriptive cross-sectional study. A total of 105 residents out of an estimated 160 paediatric residents attending the revision course took part in the survey. Two residents were later excluded because they had been on leave for the month preceding this study; they were otherwise similar to the other respondents.

A self-administered, anonymous questionnaire was designed, comprising the following sections: (i) resident’s sociodemographic features and practice settings; (ii) clinical practice pertinent to adolescents; (iii) screening adolescents for specific morbidities in the last month (excerpt of GAPS questionnaire).[1] Open-ended questions enabled respondents to specify any other screening questions asked of adolescents recently. Respondent’s training institutions were classified into federal, state and others. Their institutions were simply described by geopolitical zones. Specific names and addresses were not required, in order to ensure confidentiality.

The data were analysed using the SPSS version 20.0 (IBM Corp., USA). Categorised data such as sex, status and geographical zones were presented as proportions. The frequencies for the responses were calculated. Fisher’s exact test or Pearson’s χ2 was used to compare federal and state residents’ practices of APS, and to assess for any significant difference between northern and southern geopolitical zones. A two-sided p-value <0.05 was considered significant.

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RESEARCH Results

A total of 103 residents participated in the survey, 68% and 32% from southern and northern geopolitical zones, respectively.

Nearly 60% were from the Federal Teaching Hospital while the rest where mainly from state facilities. Over 90% of them were registrars. The mean (SD) age of the respondents was 32.6 (4.3) years. Further details of participants’ characteristics are shown in Table 1. Roughly one-third of the residents attended to adolescents daily, while about 50% of them met adolescents in their clinical practice weekly (Table 2).

In the last month, the AM services most commonly provided by respondents were general health guidance (66.7%) and specific screening for morbidity (51.1%).

Table 1. Sociodemographic and practice characteristics of the respondents

Characteristics

n (%)

Sex

Case managements or anticipatory health guidance related to diabetes mellitus, dyslipidaemia, depression and violence were carried out by less than one-fifth of the residents (Table 3). Senior registrars were more likely than registrars to screen adolescents for hypertension (75.0% v.

29.1%, p=0.032) and depression (50.0% v. 16.5%, p=0.043). Duration of medical

practice did not influence the number of AM services provided by the respondents.

The practice of screening adolescents for specific morbidities using standard questions was quite low among residents in this survey, although 51.1% of them initially identified ‘specific screening for morbidity’ as a part of the AM services they provided in their clinical practice. Altogether, <20% of

Table 3. Resident’s provision of AM services in the last month n (%) AM services

Yes

No

I don’t know

Specific screening for morbidity, n=88

45 (51.1)

43 (48.9)

0 (0.0)

Counselling to reduce risk, n=95

46 (48.4)

49 (51.6)

0 (0.0)

Immunisation, n=90

17 (18.9)

73 (81.1)

0 (0.0)

General health guidance, n=93

62 (66.7)

31 (33.3)

0 (0.0)

Hypertension, n=94

31 (33.0)

62 (66.0)

1 (1.1)

Obesity, n=95

26 (27.4)

68 (71.6)

1 (1.1)

79 (84.0)

1 (1.1)

Hyperlipidaemia, n=94

14 (14.9)

Male

47 (45.6)

Type 2 diabetes mellitus, n=93

7 (7.5)

85 (91.4)

1 (1.1)

Female

56 (54.4)

Violence, n=96

13 (13.5)

82 (85.4)

1 (1.0)

Depression, n=93

18 (19.4)

75 (80.6)

0 (0.0)

Duration of practice (years) <5

44 (42.7)

≥5

59 (57.3)

Current status

Table 4. Screening adolescents for specific morbidities using GAPS questionnaire (N=103)

Registrar

95 (92.2)

Screening questions for specific morbidities

Senior registrar

8 (7.8)

Eating disorder

Current institution of residency Federal Teaching Hospital

61 (59.2)

Federal Medical Centre

24 (23.3)

State Teaching Hospital/ others

18 (17.5)

Geopolitical zones

Yes, n (%) No, n (%)

Are you satisfied with your eating habit?

14 (13.6)

89 (86.4)

Do you spend a lot of time thinking about ways to be slim?

13 (12.6)

90 (87.4)

Have you tried to lose weight by vomiting, taking laxatives or starving yourself?

15 (14.6)

88 (85.4)

Have you ever been in trouble with the law?

11 (10.7)

92 (89.3)

Are you worried about violence or your safety?

19 (18.4)

84 (81.6)

Violence/safety

North-east

7 (6.8)

North-west

10 (9.7)

In the past year, have you carried a gun, knife, club, etc. for protection?

8 (7.8)

95 (92.2)

North-central

16 (15.5)

Do you usually wear a helmet when you ride a bicycle or motorcycle?

7 (6.8)

96 (93.2)

South-east

17 (16.5)

Do you usually wear a seat belt when you ride in a vehicle?

8 (7.8)

95 (92.2)

South-west

27 (26.2)

South-south

26 (25.3)

Do you ever smoke cigarettes?

27 (26.2)

76 (73.8)

Do any of your close friends ever smoke cigarettes or chew tobacco?

23 (22.3)

80 (77.7)

In the past month, did you get drunk or very high on alcohol?

19 (18.4)

84 (81.6)

Do you ever use marijuana (grass, weed, etc.) or other drugs?

15 (14.6)

88 (85.4)

Table 2. Frequency of adolescent patient visits in resident’s clinical practice

Tobacco/alcohol/drugs

Adolescent patient visits

n (%)

Relationship/abuse/bullying

Daily

32 (31)

Are you dating someone?

33 (32.0)

70 (68.0)

Weekly

49 (47)

Have any of your friends ever had sex?

22 (21.4)

81 (78.6)

Every 2 months

7 (6.8)

Have you ever felt pressured by anyone to have sex?

22 (21.4)

81 (78.6)

Others

15 (14.6)

Have you seen physically, emotionally or sexually abused?

26 (25.2)

77 (74.8)

Total

103 (100)

Have you been bullied in school in the last 1 month?

25 (24.3)

78 (75.7)

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RESEARCH the respondents had screened an adolescent for depression in the last month, asking for the presence of some of the following symptoms for ≥2 weeks: low self-esteem and feelings of worthlessness, insomnia or hypersomnia, psychomotor agitation or retardation, and preoccupation with death and/or suicide. Similarly, less than one-fifth of the residents had asked at least two specific questions to screen adolescents for eating disorders, violence, safety issues, substance or sexual abuse in the last month.

Table 4 summarises residents’ responses to the use of standard questions extracted from a GAPS questionnaire in the last month.

Moreover, only 21.4% of the respondents could specify other screening questions (mainly related to tobacco/alcohol/drug abuse) asked of adolescents recently. More senior registrars than registrars (62.5% v. 22.1%, p=0.023) asked adolescents: ‘Have you ever been physically, emotionally or sexually abused?’ Also, residents who had practised for <5 years were more likely than older ones to ask adolescents a screening question on relationships, e.g. ‘Are you dating someone?’ (p=0.045). Otherwise, current status, and length and sites of practice did not influence the use of standard direct questioning to screen adolescents for specific morbidities.

Discussion

This survey confirmed that adolescents are regularly seen by paediatric residents in Nigeria. General health guidance constituted the predominant AM service provided by approximately seven out of ten residents. Similarly, about half of the residents provided specific screening for morbidities. However, detailed evaluation of adolescents for medico-psycho-social dysfunction was lacking among the residents. This is not surprising because the specialty is at its infancy in the country, with limited resources available for training residents.[10] Also, the Faculty Board of Paediatrics’ requirements on duration and sites of clinical rotations in AM during residency are currently vague in Nigeria.[9,10] There is a need for a concerted effort to improve the scope of AM services provided by paediatricians, who are the best clinicians to manage this age group, considering their developmental perspective in healthcare delivery.[11] This would ensure the provision of comprehensive care to adolescents.

Significant morbidities related to obesity, abuse, substance use, and reproductive and psychological problems have been reported among Nigerian adolescents.[3,6] Therefore, widespread delivery of primary and secondary preventive services by all primary healthcare providers, including paediatricians, would improve the health status of Nigerian adolescents.[8] In this survey, we found that provision of APS is grossly inadequate among residents. Only about three out of ten residents have attempted to screen adolescents for depression in the month preceding the survey, despite the fact that a majority (78.6%) attended to adolescents at least once a week. The screening questions for specific morbidities on the GAPS questionnaire used for this study are based on the widely accepted diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and recommended checklists during history taking.[12] Hence, unfamiliarity with the tool used in this survey could not be the reason for the low level of practice of APS found in this survey. Moreover, only a minority of participants could specify other screening questions or tools used regularly in their practice to assess adolescents. We found that the senior registrars were more likely than registrars to screen adolescents for all types of abuse. This could be due to the high level of proficiency typical of this cadre, having stayed longer in residency and possibly acquired subspecialty

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interests, including AM. However, the above assertion is negated by the finding that residents who had been in medical practice for <5 years screened adolescents for relationship issues more than those older in practice, including senior registrars. Hence, the apparently improved performance of senior registrars in the practice of some aspects of APS may be due to their under-representation in this survey, constituting <10% of the participants. The practice setting of the residents did not influence their provision of AM services.

This is consistent with our findings in a recent national survey on AM training in Nigeria, which showed low coverage of curriculum contents pertinent to AM, limited physical facilities and professionals in all training centres nationwide. [10] Thus, the unsatisfactory level of AM practice among residents found in this study reflects the low emphasis previously placed on the AM subspecialty in postgraduate medical education in Nigeria. The strength of this study includes its high response rate (64.4%), which often is not attainable in physician surveys.[13,14] Our results clearly depict the current practice of registrars in the country, and perhaps the subregion. The limited numbers of senior registrars recruited in this survey may not be representative of the current practice of this cadre of residents. Also, this suggests substantial caution in extrapolating our data to reflect the level of APS practice of specialist paediatricians in the country.

Conclusion

There is a need to restructure the ongoing practice and training of paediatrics residents in Nigeria to emphasise preventive paediatrics and other issues pertinent to adolescent care. GAPS should be developed and adopted for use in various zones of the country.

References

1. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS) Recommendations Monograph. 1997:1-12. http://www.ama-assn.org (accessed 22 January 2013).

2. Nwokocha ARC. Adolescence and associated problems. In: Azubike JC, Nkanginieme KEO, eds. Paediatrics and Child Health in a Tropical Region, 2nd ed. Owerri: African Educational Services, 2007:91-100.

3. Federal Ministry of Education FMOE/UNICEF. Assessment of violence against children at the basic education level in Nigeria. http://www.unicef.org/nigeria/ ng_publications_ Violence_reportOAU.pdf (accessed 22 January 2013).

4. UNICEF 2013: Statistics at a glance: Nigeria. http://www.unicef.org/ infobycountry/nigeria_statistics.html (accessed 23 April 2016).

5. National Strategic Framework on the Health and Development of Adolescents and Young People in Nigeria (2007-2011). Abuja: Federal Ministry of Health, 2007:1-128.

6. Nwobodo EI, Panti A. Adolescent maternal mortality in north-west Nigeria.

West Afr J Med 2012;31(4):224-226.

7. Viner RM, Barker M. Young people’s health: The need for action. BMJ 2005;330(7496):901-903. DOI:10.1136/bmj.330.7496.901 8. Nkanginieme KEO, Nte AR. Preventive paediatrics. In: Azubike JC, Nkanginieme KEO, eds. Paediatrics and Child Health in a Tropical Region, 2nd ed. Owerri; African Educational Services, 2007:21-27.

9. West African College of Physicians. Faculty of Paediatrics Training Curriculum.

Lagos: WACP Press, 2012:1-28.

10. Abiodun MT, Omoigberale AI, Ibadin MO. Evaluation of adolescent medicine subspecialty training in Nigeria: Trainees’ perspectives. East Afr Med J 2015;92(6):291-296.

11. Marks A, Fisher M, Lasker S. Adolescent medicine in pediatrics practice. J Adolesc Health Care 1990;11(2):149-153.

12. Jenkins RR. Delivery of health care to adolescents. In: Kliegman RM, Behrman RE, Jenson HB, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders Elsevier, 2007:111.

13. Sallis JF, Fortmann SP, Solomon DS, Farquhar JW. Increasing returns of physician surveys. Am J Public Health 1984;74(9):1043.

14. Nicholls K, Chapman K, Shaw T, et al. Enhancing response rates in physician surveys: The limited utility of electronic options. Health Serv Res 2011;46(5):1675-1682. DOI:10.1111/j.1475-6773.2011.01261

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RESEARCH

The effects of iron deficiency and anaemia on primary school learners' scholastic performance B P S Hlatswayo,1 BSc, MMed (Paed); S Ntshangase,2 MA; F P R de Villiers,1 BA, FCPaed, FACP, PhD Department of Paediatrics and Child Health, Medical University of South Africa, Sefako Makgatho Health Sciences University (SMU), Pretoria, South Africa 2 Department of Psychology, University of South Africa, Pretoria, South Africa 1

Corresponding author: F de Villiers (alfafrancois@yahoo.co.uk) Background. Iron deficiency anaemia (IDA) is a preventable cause of cognitive impairment and other negative effects on the academic potential of learners.

Objectives. To determine the local prevalence of IDA among grade 2 learners in a resource-poor community and to evaluate the association between IDA and the learnersâ&#x20AC;&#x2122; scholastic performance.

Methods. This was a case-control observational design study. Data were collected using a stadiometer and an electronic scale, HemoCue Hb 201+ system and official grade 1 school reports.

Results. The point prevalence of IDA was found to be 9.8% (n=19), with a higher prevalence among girls (58%). There was no statistically significant difference between the performances of the two groups (p=0.511) in mathematics. There was a statistically significant difference for life skills (p=0.00017), and the difference between the groups in literacy or languages approached statistical significance (p=0.071).

Conclusions. The results of this study suggest that IDA is prevalent and may have negative effects on learnersâ&#x20AC;&#x2122; scholastic performances. Such negative effects warrant early preventive measures so as to avoid the possibilities of school failure, drop-out and poor productivity in adulthood.

S Afr J Child Health 2016;10(2):110-114. DOI:10.7196/SAJCH.2016.v10i2.887

Iron deficiency (ID) is the most common nutritional disorder in the developing world and, as a result, a large number of children under the age of 5 years do not reach their developmental potential.[1,2] ID and ID anaemia (IDA) are widespread health problems among children. Approximately 40% of children are anaemic across various African and Asian settings.[2] South African (SA) studies have indicated a high national prevalence of IDA among children; rural children were found to have the highest prevalence (43.2%) of ID.[3] A study conducted in disadvantaged communities in the Western Cape found 32% of coloured infants and 46% of black infants to have IDA,[4] while Van Stuijvenberg et al.[5] found a prevalence of 27.8% among 6 - 11-year-old primary school learners in KwaZulu-Natal (KZN) Province, and the most recent study, done in Kimberley in the Northern Cape Province, found the prevalence of ID to be 30.6%.[6] Iron is an essential micronutrient necessary for maintaining the normal structure and function of virtually all cells of the body. It is a component of many proteins, including Hb, which is important for transporting oxygen to tissues throughout the body. Oxygen is poorly soluble in plasma and the iron atoms in the haem group of Hb can bind reversibly to oxygen molecules, thus providing transport to 98.5% of the total oxygen to body tissues.[7] Total body balance depends on dietary uptake and gastrointestinal loss of iron. No organ performs the physiological role of iron excretion; ~1 mg of iron is lost each day through sloughing of cells from mucosal surfaces and the skin. Consequently, absorption is the sole means of regulating body iron stores rather than control of excretion.[7] ID develops gradually. ID without anaemia occurs when Hb synthesis is impaired but Hb levels have not fallen sufficiently to meet the definition of anaemia. The first stage entails the depletion of iron stores, leading to reduced ferritin levels. This reflects a decrease in iron concentration in the liver, spleen and bone marrow. This is followed by iron-deficient erythropoiesis, whereby erythroid iron supply is diminished, but Hb remains in the normal range. There is a reduction of mean corpuscular volume and mean corpuscular Hb and low serum iron with low transferrin saturation. The third stage is IDA, where the low iron supply restricts Hb production leading 111

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to the development of detectable anaemia. Features include low Hb values, reduced red blood cell size and reduced transferrin saturation (<16%).[8] According to the Centers for Disease Control and Prevention (CDC) in the USA,[9] IDA leads to weakness, poor physical growth and a compromised immune system. It also impairs cognitive performance and delays psychomotor development. However, IDA is a preventable cause of cognitive impairment and other negative effects on the academic potential of children. For instance, Angeles et al.[10] reported improved growth in iron-deficient preschool learners following iron supplementation in Indonesia. The developmental deficits related to IDA can to some extent be corrected with iron treatment. However, some deficits are not reversible with iron treatment. Irreversible developmental delays in children and the fact that iron is needed continuously throughout the entire period of brain growth are strong arguments for the active and effective combatting and prevention of ID. The highest risk of IDA occurs during periods of rapid growth and nutritional demand. Therefore infants, children and adolescents are likely to be the most affected.[4] The association of IDA and poor scholastic performance has been well studied internationally,[11,12] with some of the studies focusing on learning areas such as mathematics[13-15] and life skills or general knowledge.[12,16] However, in SA, despite the high prevalence of IDA, there are limited data on the association of IDA and school performance. Therefore this study intended to determine the local prevalence of IDA among grade 2 learners and investigate whether the association of IDA and poor school performance holds true for SA primary schoolgoing children.

The hypothesis was that participants from the control group would perform better in three selected school subjects than in the case group. The study was to be done in a local community in the Winterveldt area, north of Pretoria in the Gauteng Province of SA. Winterveldt is a historically disadvantaged peri-urban area, which is typically characterised by poverty, low standards of living and low socioeconomic conditions. The last SA census estimated the population of Winterveldt as 120 826, with 30.9% under the age of

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RESEARCH 15 years (i.e. 37 335 children).[17] There are 24 primary schools in the area, and each primary school has ~120 learners in grade 2 in each year.[18] There are no private schools in the area.

Methods

This quantitative study used a case-control observational design.

The sample was selected from primary schoolgoing learners doing grade 2 in three public sector primary schools, which were accessible from the university and close to each other. All grade 2 learners from each of the targeted schools were screened for ID, by using a finger-prick Hb meter. Two groups resulted from this screening procedure: group A with no anaemia (Hb >11.5 g/dL) and group B with anaemia. Further testing was done on the anaemic group to determine iron status, using ferritin and C-reactive protein (CRP).

IDA was diagnosed in learners with Hb <11.4 g/dL, low ferritin levels (<12 µg/L) and normal CRP (<10 mg/L). Severe non-IDA was defined as Hb <10 g/dL (severe anaemia), with normal ferritin levels (>12 µg/L) and normal CRP (<10 mg/L), i.e. such learners did not have ID. After blood results were available, controls and cases were recruited at a 2:1 ratio by attempting to match anthropometry. The learners with ferritin lower than 12 µg/L (with IDA) and those with severe non-IDA were identified as cases. The controls were taken from group A (the non-anaemic group). Hb increases with age, and by definition 1 - 6 year-olds must have Hb <11.5 g/dL to be classified as anaemic. Sex was used as an independent variable as there is no sex difference in Hb values for children <12 years of age.[14] For the purpose of maintaining anonymity, study numbers ranging from 1 to 194 were allocated to participants. The research instruments that were used for data collection were a Seca 214 (Seca, Germany) height measuring device. Height was measured to the nearest millimetre and weight was measured using a Safeway electronic digital scale, model EB727 (Safeway, South Africa), which records weight to the nearest decigram. Subjects were weighed without shoes and heavy clothing such as jerseys and jackets. These measurements were done twice to ensure data quality.

The HemoCue Hb 201+ system was used for the screening of all participants. The test entails collecting a drop of blood by finger-prick onto a test strip with immediate Hb value displayed. The HemoCue Hb 201+ system provides quick, simple and accurate quantitative Hb results with the same performance as a large haematology analyser.[19- 21] It has an internal electronic self-test. When the analyser is turned on, it will automatically verify the performance of the optronic unit. Other benefits include no calibration between cuvette batches and it can automatically compensate for turbidity due to lipids and leukocytosis.[22] Official grade 1 school reports were collected from each school after cases and controls were identified and recruited. All reports were of the standard format that is prescribed for all public primary schools in SA. A national coding system is used for all the foundation phase years, and learners are tested on three areas: literacy (languages), numeracy (mathematics) and life skills (life orientation). Each learner is allocated a score from 1 to 4 for each of the three subjects separately, where 1 means that competence was not achieved, 2 represents partial achievement, 3 represents satisfactory achievement and 4 is for excellent achievement. Assessment is done for each of the four terms of the school year. The maximum total for each term (terms 1, 2, 3 and 4) is 12 points. Not all learners had reports for all four terms, so analysis of school performance was done as the average of each school subject over the four terms. Therefore the maximum total obtainable by each participant was 12 points.

Each participant’s rating scores were then recorded as an indication of participants’ scholastic performances.

Participants found to be anaemic were enrolled for iron status testing. Blood for ferritin levels and CRP was collected to define IDA (4 mL of blood per subject). CRP test was done to rule out 112

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acute infection/inflammation, which could have resulted in falsely elevated ferritin. Blood samples were transported in a cooler box to the teaching hospital’s National Health Laboratory Services as soon as possible for further testing. Blood results were recorded on the data sheet. Once blood results were available, the participants were allocated to either the experimental or the control group. In addition to the learners who had ferritin <12 µg/L and CRP <10 mg/L (learners with IDA, for example), learners with severe anaemia but with normal ferritin levels were also included in the experimental group; these were labelled non-IDA. Therefore, a case refers to those subjects with IDA and also to those subjects with severe non-IDA. Learners who were found to have IDA or severe anaemia were referred to the hospital where further tests, including full blood count and HIV enzyme-linked immunosorbent assay, were done.

None of the learners had an HIV-positive test result. Learners with proven IDA were started on iron supplements as per the guidelines for weight (10 - 18 kg: 200 mg FeSO4; 18 - 25 kg: 300 mg FeSO4; 25 30 kg: 400 mg FeSO4) and vitamin C (to improve absorption of iron) and were then referred to the local clinic for monthly treatment and given a 6-months follow-up date.

Epi Info software version 3.4.3 (CDC, USA) was used to analyse the results of the study. Information from the data collection sheet comprising the study number, anthropometry, screening Hb, blood tests and marks from school reports were entered twice to ensure data quality. The Data Compare Module of the Epi Info was used to check for differences between the two sets of data and corrections were made. Anthropometric data were entered as the average of the two measurements. School marks were entered as an average of the term mark per subject using the national coding of score 1 - 4. The Epi Info software was also used to verify the nutritional status of the learners by using the Nutrition Program to compare our data with the percentiles from the CDC reference data from the National Center of Health Statistics (NCHS); the Epi Info software uses the NCHS data in calculating z-scores for individuals. The 50th percentile was taken as the population median. Data from the final study sample of 90 participants were entered and analysed. We computed weight-for-age and height-for-age.

The χ2 test was used to test for associations between the variables and to compare the two groups. Comparisons were done between controls and cases in the academic scores, IDA and cognitive function, anthropometry and gender. The 95% confidence interval was used to test for significance. Other calculations included the means of weight, height, Hb, ferritin, CRP and school marks. The range and standard deviation (SD) were also calculated. Totals of gender and group categories were calculated, as well as frequencies of other parameters such as IDA and anaemia.

Ethics

Ethical clearance was granted by the Medical University of Southern Africa (MEDUNSA) research ethics committee, Gauteng Department of Education, and the management of the three schools.

Parents gave informed consent, learners gave assent, and they could withdraw at any time without providing a reason, or it affecting their schooling. Data collection commenced after permission, assent and informed consent had been obtained. Learners’ names were included in this initial screening but recorded at the back of the data sheet for identification during case and control sampling. Only the researchers had access to the data sheet to ensure confidentiality.

Results

There was a total of 383 grade 2 learners in the three schools: 209 boys and 174 girls. The parents of 189 learners refused consent. A total of 194 learners were enrolled to be screened for anaemia. There were 119 (61.3%) learners with normal Hb by definition (World Health Organization: Hb >11.5 g/dL for 6 - 12-year-olds regardless of sex).

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RESEARCH Table 1. Summary of results Cases

Controls

Statistical results

85.20

84.05

p=0.807, t=0.868

Age (months) Mean Median

84.00

84.00

Range

79 - 99

76 - 98

Male

13 (43.33)

28 (46.66)

Female

17 (56.66)

32 (53.33)

Sex, n (%) p=0.764, χ2=0.09

Weight (kg) Mean

20.74

20.78

Median

20.50

20.40

Range

15.60 - 25.30

15.4 - 26.5

117.28

117.32

p=0.484, t=0.04

Median

117.00

117.20

Range

109.00 - 127.50

106.5 - 127.5

10.19

12.58

p=0.488, t=–0.031

Hb (g/dL) Mean Median

10.1

12.5

Range

8.3 - 11.4

11.5 - 14.3

p=0.004, t=–3.021

Ferritin (µg/L) Mean

15.30

Median

9.40

Range

3.40 - 43.00

CRP (mg/L) Mean

1.80

Median

1.00

Range

1.00 - 8.00

Subject

Cases, N=29

Controls, N=59

Mean

2.88

2.87

Median

3.0

3.0

Range

1.0 - 4.0

1.0 - 4.0

SD

6.54

6.57

Mathematics

Life skills Mean

2.93

3.23

Median

2.8

3.0

Range

2.0 - 4.0

2.0 - 4.0

SD

5.35

5.54

Literacy

Height (cm) Mean

Table 2. Comparison of scholastic performance scores between cases and controls

Seventy-five (38.7%) of these learners were found to be anaemic and qualified for iron studies. Of the 75, 19 had IDA (9.8%) (ferritin <12 µg/L and CRP <10 mg/L). Fifty-six had normal ferritin levels; of these, 11 (5.7%) had severe anaemia (Hb <10 g/dL) and were thus also included in the cases, leaving 45 cases (23.2%) of mild nonIDA. There were more girls (11 out of 19, 58%) who were found to have IDA, and of the 11 learners with severe non-IDA anaemia, there were six boys (55%) and five girls. The final study sample of 90 participants comprised 60 controls and 30 cases (experimental group). In matching the controls to the cases, the initial criteria for close matching could not be sustained; we were left with a control group rather than matched controls.

The mean weight of the boys (20.97 kg) did not differ statistically from that of the girls (20.47 kg), and neither did their height (116.83 v.

116.86 cm). There were also no statistically significant differences in anthropometry of the cases and the controls (Table 1). Compared with the CDC’s NCHS data, 23% of the learners had a weight-forage below the 5th percentile, and 19.3% had a height-for-age below the 5th percentile. There was no difference between the genders, or controls v. cases with regard to either stunting or underweight.

The association between IDA and scholastic performance is shown in Table 2. Five learners had reports for only the 4th term, and 15 had reports for the 3rd and 4th terms, i.e. two reports, because of 113

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Mean

2.64

2.76

Median

2.8

3.0

Range

1.0 - 4.0

1.0 - 4.0

SD

7.29

6.39

p-value

χ2

0.511

1.34, df=2

0.00017

22.36, df=4

0.071

5.59, df=2

df = degrees of freedom.

transfers between the schools. The remaining 70 learners had reports for all four terms. As indicated in Table 2, mathematics scores ranged from 1.0 - 4.0 for both the cases and the controls, with a mean of 2.88 and 2.87, respectively; there was no statistically significant difference in the two groups (p=0.511). There was also no significant genderrelated difference in the mathematics scores (χ2=0.51, df=2, p=0.511).

In literacy the means were different, with 2.64 for cases and 2.78 for controls; the p-value approached significant levels (p=0.071). No gender differences were found between the scores (χ2=0.33, df=2, p=0.845). Life skills was the only area with a wide difference in the scores: the cases had a mean of 2.93 and controls had a mean of 3.23.

For life skills, a statistically significant difference was found between cases and controls, with the control group, as expected, having better scores (p=0.00017). No gender differences were found between the scores (p=0.592).

Discussion

The point prevalence for IDA in the poorly resourced Winterveldt area was found to be 9.8%, which is clinically important but somewhat less than the previous studies. For instance, a study in the Western Cape Province indicated a range of 32 - 46%,[4] a study by Van Stuijvenberg et al.[5] conducted in KZN indicated a prevalence of 27.8% among 6 - 11-year-old primary school learners, and a study conducted in the Northern Cape Province found the prevalence of ID to be 30.6%.

[6] The results of this study and the previous studies may be due to the overall poor socioeconomic status that prevails in the rural and periurban areas of SA. However, more recent studies paint a different picture. The South African Vitamin A Consulting Group (SAVACG) survey in 1995 found a prevalence of 5.0% of IDA,[23] the National Food Consumption Survey (NFCS) (2005) study a prevalence of 11.3%[24] and the South African National Health And Nutrition Examination Survey (SANHANES) a low prevalence of 1.9%.[25] Cumulatively, the studies indicate that there is a reduction in IDA in the country as a whole. In the study area, the consumption of dark leafy vegetables such as spinach and morogo as well as samp and beans is common, and the latter are also included in the school feeding scheme.

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RESEARCH Anaemia (from all causes) was also found to be highly prevalent among the participants in this study (38.7%), which could be related to the poor nutritional status of the subjects or other confounding factors such as helminth or chronic infections, particularly HIV/ AIDS and tuberculosis. In previous national surveys such as the SAVACG survey in 1995, a lower prevalence of 21.4% was found,[23] and in the NFCS study prevalence was 28.9%.[24] A comparison of recent studies from four provinces indicated a lower prevalence of anaemia, ranging from 7.1% in the North West Province to 20.9% in KZN.[26] In the recent SANHANES, the anaemia prevalence was even lower at 10.7%.[25] It therefore appears that the anaemia prevalence in primary learners has declined in most areas in SA.[25,26] This makes the high prevalence of anaemia, nearly 40%, in our study the more perplexing, as is the fact that nearly three-quarters of the anaemic cases are non-IDA anaemia. IDA is a preventable cause of cognitive impairment. The purpose of the study was to explore the effects of IDA on scholastic performance. The results of the research indicated a negative correlation between IDA and performance in such learning areas as life skills and languages. These findings are consistent with the literature. The control group scored better in life skills compared with the experimental group (p=0.00017) and this is in agreement with most of the studies where learners with IDA performed poorly in general knowledge.[12,16] The subject of life skills, also known as life orientation, intends to equip learners for successful and meaningful living in our rapidly changing society. Its aim is to develop skill, knowledge, values and attitudes that empower learners to make informed and morally responsible decisions and act responsibly with regard to health promotion, and their own social, personal and physical development and movement.[27] The results of this study, which show a statistically significant difference between the scores of learners with IDA compared with non-anaemic learners, with controls achieving higher scores, are in line with the findings of previous studies.[12] As indicated by a study by the CDC in the USA,[9] this could suggest possible cognitive impairment among the learners with IDA. Such an impairment could be making it difficult for them to make informed and accountable decisions and take appropriate actions for successful living. The test for literacy and IDA approached significance (p=0.071). The small sample size could have influenced this result. However, the association between IDA and mathematics was not statistically significant, which was contrary to previous studies that found a positive correlation between IDA and poor mathematics scores.[13,14] Such findings may be attributed to low standards of mathematical knowledge expected in SA schools. Over the past few years, research has indicated that SA schoolchildren perform poorly in mathematics compared with the rest of the world. [28-30] In the SACMEQ III report[31] (one of the Department of Basic Education’s publications) it was found that only 30% of grade 6 learners possess adequate numeracy skills. If more than two-thirds of learners are so poor at mathematics, or rather arithmetic, then it is logical to conclude that the quality of the teaching and the standards required are not adequate; and that these deficiencies probably start in grade 1. Therefore, the fact that the average of the two groups in our study is the same, and that the learners are allocated rather high scores in the early grades (2.9 out of a possible maximum of 4; i.e. an average of 72.5%) is not surprising, and reflects the low standards. We therefore conclude that grade 1 school mathematics assessments cannot discriminate between learners who have good skills in mathematics and those who do not. Furthermore, these assessments would not be able to pinpoint learners who suffer cognitive impairment due to nutritional causes. SA has an IDA policy on iron supplementation in children and food fortification legislation (2003),[32] but there is no comprehensive monitoring on the coverage of both policies. It has been shown that fortifying brown bread has not affected the iron status in SA children.[33] Researchers have speculated that the food fortification programme is ineffective as they 114

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calculated that at the current dosage the bioavailable elemental iron is too low.[26] We feel that since iron screening is not done routinely in infants, the exact magnitude of the problem is unknown. Therefore, infants are not routinely given supplements and early treatment is not given. Since dietary history and knowledge of fortified foods was not investigated, we cannot draw conclusions as to whether these fortified foods had been consumed by the study population. The poor socioeconomic status of our study population, however, would make it quite possible that fortified foods are unlikely to be consumed by them. The following recommendations can assist in alleviating the problem of high prevalence of IDA and anaemia: • Infants should be the target group for screening and treatment because they are at the age of accelerated brain growth, and some studies show that once the damage is done, the effects cannot be reversed.

• Iron supplements should be provided during the first 3 years of life, targeting the poor/vulnerable communities. Although this is feasible up to the age of 18 months, which coincides with the 18 months vaccines, it can be achieved by increased awareness of the micronutrient deficiencies.

• Brief educational sessions to enhance awareness should be offered at the clinics when parents bring their infants for vaccinations.

Study limitations

Firstly, in view of the small sample size, the results may not be generalisable to all children. Furthermore, the school report used as an instrument for this study may not have been the best measure of school performance as its validity and reliability were not tested.

Factors which may affect school performance, such as parental education, marital status and socioeconomic status have not been accounted for in the study, although we know that in general, Winterveldt is a low socioeconomic area. Furthermore, it is not clear what the quality of the schools’ education is, although one can again speculate that as they are all rural schools they are unlikely to be excellent. Nevertheless, the results of this study were largely consistent with the literature and were representative of primary school-going learners in the Winterveldt area.

Conclusion

This study provides evidence that IDA may have negative effects on school performance. Such negative effects warrant early preventive measures so as to avoid the possibilities of school failure, drop-out and eventually poor productivity in the adult population.

Acknowledgements. We would like to thank the school and the

learners who took part in the study and their parents.

Source of funding. Department of Paediatrics and Child Health, Medical University of Southern Africa (MEDUNSA), Faculty of Medicine (University of Limpopo), Pretoria.

References 1. Wu AC, Lesperance L, Bernstein H. Screening for iron deficiency. Pediatr Rev 2002;23(5):171-178. DOI:10.1542/pir.23-5-171 2. Hall A, Bobrow E, Brooker S, et al. Anaemia in school children in eight countries in Africa and Asia. Public Health Nutr 2001;4(3):749-756. DOI:10.1079/ PHN2000111 3. Faber M, Wenhold F. Nutrition in contemporary South Africa. Water SA 2007;33(3):393-400. http://www.wrc.org.za (accessed 15 June 2013).

4. Jacobson D. Prevention and treatment of iron deficiency anaemia in children.

Cont Med Educ 2008;26(5):242-244.

5. Van Stuijvenberg ME, Kvalsvig JD, Faber M, et al. Effect of iron-, iodine- and β-carotene-fortified biscuits on the micro-nutrient status of primary school children: A randomised controlled trial. Am J Clin Nutr 1999;69(3):497-503.

6. Troesch B, van Stuijvenberg ME, Smuts CM, et al. A micronutrient powder with low doses of highly absorbable iron and zinc reduces iron and zinc deficiency and improves weight-for-age Z-scores in South African children.

J Nutr 2011;141(2):237-242. DOI:10.3945/jn.110.129247

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RESEARCH 7. Miller DR, Baehmer RL. Blood diseases of infancy and childhood. 6th ed.

St Louis: The OCV Mosby Company, 1995:170-175.

8. Nathan DG, Orkin SH. Nathan and Oski’s Haematology of Infancy and Childhood. 5th ed. Pennsylvania, WB Saunders, 1998:425-441.

9. Centers for Disease Control and Prevention. Recommendations to prevent and control of iron deficiency in the USA. MMWR Morbidity, Mortality Weekly Report. 1998. http://www.cdc.gov/mmwr/pdf/rr/rr4703.pdf (accessed 18 June 2013).

10. Angeles IT, Schultink WJ, Matulessi P, et al. Decreased rate of stunting among anaemic Indonesian preschool children through iron supplementation. Am J Clin Nutr 1993;58(3):339-342.

11. Berry L, Hall K, Hendricks M. Nutrition – Stunting in Children. Cape Town: Children’s Institute, University of Cape Town, 2010. http://www.childrencount. ci.org.za (accessed 29 October 2014).

12. Pollitt E. Iron deficiency and educational deficiency. Nutr Rev 1997;55(4):133141. DOI:10.1111/j.1753-4887.1997.tb06464.x 13. Stoltzfus RJ, Mullany L, Black RE. Iron deficiency anaemia. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: Global and regional burden of disease attributable to selected major risk factors.

Geneva: World Health Organization, 2004:163-209.

14. Sungthong R, Mo-suwan L, Chongsuvivatwong V. The effects of haemoglobin and serum ferritin on cognitive function in school children. Asia Pac J Clin Nutr 2002;11(2):177-182. DOI:10.1046/j.1440-6047.2002.00272.x 15. Lozoff B, Jimenez E, Smith JB. Double burden of iron deficiency in infancy and low socioeconomic status: A longitudinal analysis of cognitive tests scores to age 19 years. Arch Pediatr Adolesc Med 2006;160(11):1108-1113. DOI:10.1001/ archpedi.160.11.1108 16. Aboussaleh Y, Ahami A, El Hioui M, Bonthoux F. Cognitive Performance of Anaemic School Children. North-western Morocco. Micronutrient Forum Meeting http://www.micronutrientforum.org/meeting2009/PDFs/Poster%20 Presentations/4Friday/MCHDO/F66-Aboussaleh.pdf (accessed 15 September 2009).

17. Statistics South Africa. Census 2011. Pretoria: Statistics South Africa, 2011. http://beta2.statssa.gov.za/?page id =3839 (accessed 27 October 2014).

18. Schools4SA. Schools in Winterveldt at Schools4SA. South Africa. 2014. http:// www.schools4sa..co.za/province/gauteng/winterveldt/ (accessed 27 October 2014).

19. Ali A, Fathy GA, Fathy HA, El-Ghaffar NA. Epidemiology of iron deficiency anaemia: Effect on physical growth in primary school children, the importance of hookworms. Int J Acad Res 2011;3(1):495-500. DOI:10.7813/20754124.2011/3-1/B.73 20. Ferreira MU, da Silva-Nunes M, Bertolino CN, Malafronte RS, Muniz PT, Cardoso MA. Anaemia and iron deficiency in school children, adolescents,

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and adults: A community-based study in rural Amazonia. Am J Pub Health 2007;97(2):237-239. DOI:10.2105/AJPH.2005.078121 21. World Health Organization. Iron Deficiency Anaemia: Assessment, Prevention and Control. A Guide For Programme Managers 2001. http://www.int/ nutrition/publications/en/ida_assessment_prevention_control.pdf (accessed 29 October 2014).

22. HemoCue Products. 2004. http://www.hemocue.com/index.php?page=2004 (accessed 23 March 2009).

23. Labadarios D, van Middelkoop A, eds. Children aged 6 - 71 months in South Africa 1994: Their anthropometric, vitamin A, iron and immunisation coverage and status. The South African Vitamin A Consulting Group (SAVACG): Johannesburg 1995. http://indicators.hst.org.za/healthstats/211/data#sthash. zRy85Nko.dpuf (accessed 26 October 2014) 24. Labadarios D, ed. The National Food Consumption Survey-Fortification Baseline (NFCS-FB): South Africa, 2005. Stellenbosch: National Department of Health; 2007.

25. Shisana O, Labadarios D, Rehle T, et al. South African National Health and Nutrition Examination Survey (SANHANES-I). Cape Town: Human Sciences Research Council Press, 2013.

26. Taljaard C, Covic NM, Van Graan A, Kruger HS, Jerling JC. Studies since 2005 on South African primary schoolchildren suggest lower anaemia prevalence in some regions. S Afr J Clin Nutr 2013;26(4):168-175.

27. National Department of Education, South Africa. HIV and AIDS Lifeskills and Sexuality Education Primary School Programme Resource Guide. Pretoria: SA Government Publishers, 2006. http://www.thutong.doe.gov.za/Default.aspx? (accessed 3 January 2015).

28. Howie S. Mathematics and Science Performance in Grade 8 South Africa 1998/1999. Pretoria: Human Sciences Research Council, 2001.

29. Siyepu S. The zone of proximal development in the learning of mathematics.

S Afr J Educ 2013;33(2):1-13.

30. Bansilal S, James A, Naidoo M. Whose voice matters? Learners. S Afr J Educ 2010;30(1):153-165.

31. Moloi MQ, Chetty M. The SACMEQ III Project in South Africa: A Study of The Conditions of Schooling and the Quality of Education. Pretoria: Department of Basic Education, 2010.

32. National Department of Health, South Africa. Foodstuffs, Cosmetics and Disinfectants Act No. 54 of 1972. Pretoria: NDoH, 2003. http://www.doh.gov. za/docs/regulations/2003/Regulations_Fortification.pdf (accessed 3 January 2015).

33. Van Stuijvenberg ME, Smuts CM, Lombard CJ, Dhansay MA. Fortifying brown bread with sodium iron EDTA, ferrous fumarate, or electrolytic iron does not affect iron status in South African school children. J Nutr 2008;138(4):782-786.

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RESEARCH

Barriers, facilitators and recommendations for the early infant diagnosis and treatment (EIDT) cascade: A qualitative study in Malawi E A Bobrow,1 PhD, MPH; A G Yemaneberhan,2 MD, MPH; M Phiri,2 MPH; L Katirayi,1 MS; A Ahimbisibwe,2 MB ChB, MPH; F Chimbwandira,3 MBBS, MPH; N Buono,2 MPH Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, USA Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi 3 Ministry of Health, Lilongwe, Malawi 1 2

Corresponding author: E A Bobrow (ebobrow@pedaids.org) Background. Identifying and testing all HIV-exposed infants (HEIs) by 2 months of age with rapid antiretroviral therapy (ART) initiation for those infected is critical to survival. Yet in 2009 only 29% of HEIs in need of ART received treatment in Malawi.

Objectives. To understand barriers, facilitators and recommendations for five key steps in the early infant diagnosis and treatment (EIDT) cascade: (1) identification of HEIs; (2) infant testing; (3) sample processing and transport; (4) reporting results to mothers; (5) ART initiation for HEI. Methods. Semistructured interviews were conducted through convenience sampling with mothers of infants eligible for EIDT (n=47) and with healthcare workers (HCWs) providing EIDT (n=20) in five facilities, in April 2013.

Results. (1) Reliance on the health passport to identify HEIs is both barrier, as women may not attend appointments with their passports, and facilitator, for documentation of HIV-exposure status. Use of trained health surveillance assistants in EIDT enhances cascade steps 1 and 2, but requires increased supervision. (2) Women struggle to accept their own HIV status, yet test results for an HEI is a motivator.

Sensitisation through local leadership facilitates EIDT. (3) A reliable transport system is needed. (4) Maintaining appointments to report results to women motivates them. (5) Mothers were reluctant to give ART to young, apparently healthy infants.

Conclusion. Both women and healthcare workers are motivated by test results for HEIs. The inclusion of community education can improve all steps in the EIDT cascade, including information that HEIs need ART. S Afr J Child Health 2016;10(2):115-119. DOI:10.7196/SAJCH.2016v10i2.982

Globally, 3.2 million children under 15 years old were living with HIV in 2013, comprising 9.1% of all people living with HIV. Of these children, 91% live in sub-Saharan Africa, and only 24% were receiving antiretroviral therapy (ART). Without ART, half of the children infected with HIV at birth or in infancy will die before their second birthday, and 80% will die before their fifth birthday.[1] Although the early diagnosis of HIV in infants is improving in many countries, in 2013 only 42% of infants born to mothers living with HIV in low- and middle-income countries received HIV testing within 2 months of birth as recommended.[1] Even if children are tested for HIV, not all receive the result or are treated as needed.

Opportunities to optimise infant outcomes may be lost at each step in a cascade of early infant diagnosis and treatment (EIDT).[2] The EIDT cascade includes a number of sequential steps, specifically: (1) identification of HIV-infected infants (HEIs); (2) infant HIV testing; (3) sample processing and transport; (4) reporting results to caregivers; and (5) ART initiation for HEIs. In Malawi, 13.8% of HEIs in 2009 were HIV-infected, but only 29% of those in need of ART received treatment.[3] Studies of antenatal care (ANC), EIDT and paediatric HIV programmes in Blantyre and Lilongwe, Malawi, revealed that there are significant drop-outs at each step of EIDT cascade.[4] Similarly, a Blantyre study identified factors related to failure by women to return for their infantâ&#x20AC;&#x2122;s EID test results.

The main barriers were expense due to travel time and costs (adjusted risk ratio (aRR) 1.93; 95% confidence interval (CI) 1.1â&#x20AC;&#x201A; - 3.4), and disclosure by women to their husbands or partners that the infant was being tested (aRR 1.97; 95% CI: 1.0 - 3.8).[5] Policy changes in Malawi that support ART initiation for HEI include the Paediatric HIV Care Scale-up Plan (2009 - 2013), which 116

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authorised all levels of healthcare workers (HCWs) to prescribe ART. However, in practice, paediatric HIV testing, care and treatment were not adequately provided in facilities. Reasons include limited integration of HIV in maternal and paediatric services, lack of social support to women, fear of disclosure of infant HIV status, stigma and lack of knowledge of timing for paediatric testing.[4,6-8] Noted recommendations are to address multiple barriers across the system to improve coordination and to design interventions to increase access to EIDT services, and to ensure that HEIs receive ART soon after diagnosis.[8] With the global target of elimination of motherto-child transmission (eMTCT),[9] adopted by the Government of Malawi, EID of HIV and early initiation of ART are critical for the survival of HEIs and infected children. The goal of this qualitative study was to explore and contribute to an improved understanding of barriers, facilitators and potential solutions in EIDT service delivery at key points throughout the EID cascade.

Methods Design

Semistructured interviews were conducted with HCWs who were involved with EIDT activities, and with mothers of HEIs. Convenience sampling was utilised to recruit participants. Ethical approval was received from the Malawi National Health Sciences Research Committee (NHSRC).

Settings and participants

The study was conducted within five purposively selected health facilities within three districts in Malawi that were supported with funding from ViiV-Healthcare to the Elizabeth Glaser Pediatric

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RESEARCH AIDS Foundation (EGPAF). HCWs interviewed included nurses in the ART clinics, ANC and maternity wards, laboratory assistants and health surveillance assistants (HSAs), who are a cadre of trained health outreach workers who work in health facilities and in communities. The HSAs in the selected districts were specifically trained to identify HEIs, to obtain dried blood spot (DBS) samples, and to assist with providing test results plus referral and follow-up for women with HEIs. The HCWs who participated in the study were recruited from antenatal and postnatal clinics as they had received training to identify HEIs, and to provide ART. Mothers eligible for the study included those who had HEIs <12 months of age. Women were recruited from the maternal and child health (MCH) clinics. At the time of data collection, many of the health facilities were in the process of using an electronic medical record (EMR) system in the ART clinics to track individuals.

Data collection and analysis

Data collection occurred in April 2013. All study personnel who interacted with participants or with their data received training on study-specific data collection methods, interview guides and research ethics. All participants provided written informed consent prior to participation. Interviews were conducted individually in a private place. Audio recordings of all interviews were transcribed and translated into English. Transcript files in Microsoft Word (Microsoft Corp., USA) were analysed using MAXqda (Marburg, Germany), a qualitative data analysis software package. Data collection and analysis were structured along the five EIDT cascade steps. The code list and definitions were developed based on research questions.

Matrices of coded responses by each participant group for each step in the cascade were developed and compared.[10,11] Themes within each step in the cascade focused on the process of completing each step, the barriers experienced, the facilitators identified, and

Table 1. Barriers and facilitators for each step in the EIDT cascade from study participants* Steps in the EIDT cascade

Barriers

Facilitators

Step 1: Identification of HEIs

n=32 Women do not bring their health passport, a record of relevant health information, including HIV status, to the health facilities Lack of follow-up supervision with HSAs who provide EIDT services Lack of disclosure of HIV status to the partners/husbands

n=54 Identification of the HEI through the health passport HSAs have been trained to identify HEIs Referrals and coordination between the clinics within the health centre working well Health education about EIDT in the community is happening with limited coverage New PMTCT/ART guidelines have HCWs enrolling HEIs into HIV care system immediately after delivery to facilitate better tracking

Step 2: Infant HIV testing

n=44 Lack of space at health centres Difficulties with obtaining blood specimens from infants for DBS testing Lack of acceptance of HIV status Women want to check with their husbands about having the infant tested

n=74 HSAs have been meeting amongst themselves to reinforce their DBS training and to mentor those with less experience HCWs report more support from village leadership to promote testing and treatment has been important Women want to protect their infants by knowing their HIV status

Step 3: Sample processing and transport

n=30 No reliable transport system and lack of fuel for specimen transport Specimens arriving too late at the lab – after the person receiving samples has left for the day

n=52 Address transport issues by using HSAs on motorbikes, reimbursements for transport, use the ambulance as much as possible Some sites started regular meetings at the health centre level to discuss issues and solve problems Some places had a SMS system in place that helped with receiving results

Step 4: Reporting results to caregivers

n=97 Coming to facility to discover that the results are not available as expected is discouraging – if it happens more than once, unlikely to ever return for results Unpredictable and irregular return of results Traveling long distances to the facility is a common complaint – cost of transport, difficulty in travel, and long days Request for privacy so that neighbours do not know your business Long queues in different rooms for services

n=83 Good coordination between clinics in health centres and to the community HCWs believe that most women are willing to know the status of their child Follow-up system at the health centre – motivated by appointments made with women to give them the results Women reinforce belief of HCWs that they feel encouraged and well informed by knowing the HIV result of their infant

Step 5: ART initiation for HIV-infected infants

n=29 Some places have ART clinic only on certain days of the week and if not on day of a woman’s MCH appointment, it is a hardship to make long trip again It is popularly believed that starting ART in young children will cause complications so people delay getting results or starting ART

n=19 EID log tracks patients across services/facilities makes follow-ups easier Testing the infant in good time and having facility nearby Home visits from HCW provide needed support Women’s expectations are changed when ART works and the baby survives

SMS = short message service *Items in the table are listed from most frequently mentioned to least frequent within each step in the cascade.

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RESEARCH recommendations for improved service delivery. Questions for the women included motivation for having their infant tested and for collecting the test result, challenges faced when interacting with the health facility and with HCWs, methods for overcoming challenges, and suggestions for improvement. Questions for HCWs followed a similar sequence for each step in the cascade, for example, ‘What do you do to overcome challenges?’ For two of the steps in the cascade, specifically identification of HEI (step 1) and sample processing and transport (step 3), relevant questions were only asked to HCWs.

Results

The results are reported on the main barriers, facilitators (Table 1) and recommendations (Table 2) for each cascade step that emerged during analysis. As noted in the tables, relevance of the results is indicated by the order of the themes, with the most frequent responses listed first and subsequent responses listed in descending order. In addition, the results in the text are also in order of importance. Comparisons in responses between mothers and HCWs are noted when relevant.

Demographics

A total of 47 mothers were interviewed (8 - 10 per site). Their ages ranged from 19 - 48 years with an average of 31 years. A total of 41 women (87%) were married. Overall, 6 (13%) women had no education, 28 (60%) completed primary education only, 12 (25%) completed secondary education, and 1 (2%) completed tertiary education. All children received HIV testing; 39 (83%) mothers knew their child’s HIV status and 8 (17%) mothers had not yet received the results. There were 5 HIV-infected children among those with known status, all of whom were initiated on ART. A total of 20 HCWs across service delivery areas were interviewed (10 nurses, 7 HSAs, 2 laboratory assistants, 1 clinical officer).

Step 1: Identification of HEIs – responses from HCWs only

Reliance on the health passport, a record of relevant health information including HIV status, was both a barrier and a facilitator to identifying HEIs. Women retain the passport and are asked to

bring it to each visit. HCWs rely on this record and on the mother’s willingness and memory to bring their passport. ‘… some clients are more ‘clever’; they hide their health profile … and get another one or … they take off a page or change the facility … but nowadays people are coming out in the open; many are not doing that anymore through sensitisation.’ (HCW) A facilitator centred on the role of the HSAs, who have become an integral part of EIDT. Almost all HSAs at the study sites were trained to identify (step 1) and collect DBS specimens from HEIs (step 2). The need for consistent support and supervision of HSAs was noted. ‘… the more they are staying without supervision, the more we are compromising the whole system. If anything, there has to be a regular supervision schedule.’ (HCW)

Step 2: Infant HIV testing

HCWs felt that mothers struggle to accept their own HIV status and therefore have difficulty having their infants tested. Some women are not comfortable to test their children without the knowledge and permission of their husband. ‘… they have to go home and explain first to their husbands. If he accepts, they will come back together. But what happens is that when she comes for next visit she gives excuses like “we have not yet discussed it” or “we should wait”.’ (HCW) Other barriers include difficulties with obtaining blood samples from infants. In some facilities, HSAs reported meeting as a group to reinforce the training they received on taking DBS samples from infants. One of the main facilitators is the support of local leaders to promote HIV testing and treatment for HEIs. ‘In the community, the village headmen assert that they would like all HIV-infected women in their villages to get services and that no one needed to be shy about their HIV status.’ (HCW) An aspect of the sensitisation that has been helpful is a focus on the fact that mothers can protect their children by testing them for HIV, thus overcoming the barrier of women accepting their HIV results as a key to good care for their HIV-exposed child. Mothers indicated

Table 2. Recommendations for each step in the EIDT cascade from study participants* Steps in the EIDT cascade

Summary of recommendations from participants

Step 1: Identification of HEIs (n=28)

Educate HIV-infected women on the importance of bringing their health passports to appointments, for the health of their infants Expand the EMR system, which at the time of data collection only existed for people on ART, to the MCH clinics to enhance and fill gaps in identification of HEIs Support healthcare workers with additional training related to EIDT related tasks, e.g. taking blood from infants Enhance sensitisation in the communities about HIV testing of infants Address stock-out issues at central supply and within district leadership

Step 2: Infant HIV testing (n=40)

Conduct regular supportive supervision of healthcare workers to reinforce skills and knowledge Provide sensitisation in the communities by engaging the local leadership and highlighting the need for women to have HIV test results for their child for either continued prevention or treatment Encourage HIV-infected women to talk to other HIV-infected women, possibly one-on-one or in support groups

Step 3: Sample processing and transport (n=39)

Establish a lab sample transportation system Have a transport system for taking specimens to the lab Systematically follow up on results Utilise SMS system for reporting results back to the health centre

Step 4: Reporting results to caregivers (n=87)

Enhance counselling on the process for testing and reporting Counsel women at the health centre and directly in communities Honour appointments for reporting results or contact women, possibly using mobile phones, to reschedule

Step 5: ART initiation for HEIs (n=36)

Provide education on the need to start ART in HIV-infected children – even if they are young or do not seem sick

*Items in the table are listed from most frequently mentioned to least frequent within each step in the cascade.

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RESEARCH that knowing the status of their children encouraged them to care properly for their babies. ‘… when you know the HIV status of a child, you give them the much-needed care, and they also start medication right away. When you face any difficulties or challenges, you come to the hospital … in such a way you prevent the baby from getting infected.’ (HIVinfected mother)

Step 3: Sample processing and transport – responses from HCWs only

The main barrier mentioned was a lack of a reliable transport system from health centres to the central labs where the DBS samples are analysed. An interrelated barrier was the lack of provision at the central lab for leaving DBS samples after hours once the lab has closed. Many sites have tried to address transportation difficulties, including having HSAs take the samples by motorbike, or having a reimbursement system in place for individuals who transport specimens to the central lab. Participants at each study site mentioned how, at the time of data collection, ambulances that are supposed to be available for specimen transport to the central lab are often occupied locally. Having an established system for transport and for the timely communication of results that functions reliably between the health facilities and the central lab was a facilitator.

Appointments given to women to receive test results for their HEIs (step 4) should serve as motivators, as these serve as deadlines for test results to be available from the central labs. Some sites have established regular meetings with HCWs to discuss EIDT issues as they arise, to solve problems as a team, and to remind them to schedule appointments with the mothers to receive test EIDT results. In some places, mobile phone SMS messages have been used to transmit test results from the central lab to either the district lab or the health facility.

Step 4: Reporting results to mothers

The primary barrier identified by both HCWs and mothers was that health facilities fail to have the EID results ready when women return for scheduled appointments. Mothers reported spending money on transport and wasting their time unnecessarily to return to the facility.

‘I waited too long without getting the results. I came five times and found no results. So you can imagine that we use money for transport and for someone to be coming and finding nothing. It’s frustrating.’

(HIV-infected mother) Health centres needs to honour the appointments given to women for their infant’s result. Appointments scheduled during the DBS sample collection in step 2 raise expectations. HCWs generally felt that women are willing to know the status of their child even if they are fearful, which was echoed by the women.

‘I wanted to be a free person, not worrying about his health and seeing him suffer.’ (HIV-infected mother) ‘You feel comfortable, and also if the baby is not okay, you know how best to take care of him.’ (HIV-infected mother)

Step 5: ART initiation for HEI

One main barrier noted was that at many facilities, ART clinics only occur on certain days of the week and thus women have to return to the health centre on multiple days for various types of care. At the study sites, HEIs are initiated on ART and receive follow-up care in ART clinics only. HCWs also report that women often believe that ART is not appropriate for infants who are young and healthy, a belief that is a barrier to women initiating their HEI on ART. As one healthcare worker explained: ‘The perception they have is that you can only be tested or start ART when you are sick. Thus, the people’s mindsets are something to be dealt with. Otherwise, one cannot force them to do the tests.’

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At the facility, a number of interventions have improved initiation of ART for infants, specifically the use of EID log books to track patients, having a nearby ART clinic for children, and enhanced counselling.

Recommendations from participants for each step in the EIDT cascade

Table 2 presents a summary of participant recommendations for each step in the EIDT cascade. The results are listed from most frequent responses to least frequent for each step in the cascade.

For the identification of HEIs in step 1, HCWs suggested enhanced messages directed to women, specifically emphasising the importance of bringing their health passports to each visit, and of disclosing their HIV status to their partners. HCWs recommended expanding the existing EMR system, which at the time of data collection was only used for patients on ART. In the community, they recommended enhancing sensitisation about HIV testing of infants. For sample collection in step 2, recommendations included promoting community sensitisation through local leadership with an emphasis on prevention and treatment once a mother knows the HIV status of her child. In addition, HCWs strongly suggested higher-quality, comprehensive counselling at the facility, including encouragement for women to talk to other HIV-infected women.

Improved counselling could increase the demand for EIDT services and improve the acceptability of the EIDT services within the community. For sample processing and transport in step 3, the HCWs recommended the need for reliable, designated transport system for taking specimens to the lab, systematic follow-up for all results, use of electronic data management systems, utilisation of SMS to report results back to the health centres, regular followup with the lab, and sending a district-based or facility-based lab person with the samples or at least providing orientation to drivers delivering samples. For reporting results to mothers in step 4, HCWs recommended setting realistic expectations for the arrival of DNA-PCR results. Airtime for mobile phones was recommended by both the HCWs and the mothers. As a mother said: ‘They should call us to tell us the results since we come from far distances.’ For ART initiation of HEIs in step 5, HCWs suggested education in the community and comprehensive counselling in the facility on the need and benefits of initiating HIV-infected children on ART, even if they are young or do not seem sick.

Discussion

Women are motivated by receiving the test results for their HEIs. HCWs agree that improving the system to increase the number of HEIs tested and the number of women receiving results is critical.

For every step in the EIDT cascade, the inclusion of community education is essential, particularly including information that all HEIs need ART regardless of their age and health status.

The study highlights specific actions to enhance steps along the EIDT cascade. The identification of HEIs (step 1) may benefit from an enhanced tracking system of HEIs, either through a paper-based system throughout the health facility or, as stated as a recommendation, through adding key data related to EIDT for the entire cascade to the existing EMR system, which at the time of the data collection was only utilised to track individuals on ART. Expanding the EMR system, thus decreasing the reliance on health passports that was identified as both a barrier and facilitator in step 1, may improve follow-up with women and their HEIs through the time of testing (step 2) and obtaining results (step 4).

Increasing testing of HEIs (step 2) needs community-based support. Connecting women, either individually or in support groups, can address the identified barriers of reluctance to disclose to husbands. Another study focused on EIDT recommended sensitisation campaigns through radio and advertisements to increase uptake of EID.[12]

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RESEARCH Sample processing and transport (step 3) results indicate the need for the establishment of a strong sample transport system and a laboratory information system possibly using SMS.[13] In addition, having procedures that work for after-hours sample delivery and for reporting of results would address barriers. Another study encourages initiation with point-of-care testing as the best solution to avoid issues of sample transport and hence fast delivery of results.[14] Recommendations indicate that if an appointment is scheduled with a woman to receive test results (step 4), it either needs to be kept or the woman needs to be contacted to reschedule the appointment.

One study found that HIV-infected mothers enrolled in HIV care were less likely to fail to return for their infant’s HIV test result (aRR 0.51; 95% CI (0.3 - 0.9),[5] therefore providing ART to all pregnant women may lead to a better return. This is encouraging for Malawi, which is implementing lifelong ART for all HIV-positive pregnant women regardless of CD4 count.

ART initiation for HEIs (step 5) may benefit from an emphasis on interactions with other women, on counselling from HCWs and on community-level sensitisation from HSAs and local leaders on how children improve and live longer lives when on treatment. A study in South Africa found similar results related to how support of women, specifically by seeing health benefits of children on treatment, was a motivating factor for improved EIDT.[15] These peer-to-peer connections were also mentioned as a method to improve testing for HIV-exposed child (step 2).

More training for HSAs and other HCWs would enhance multiple steps in the EIDT cascade. Training topics could include techniques to communicate with women about the importance of their health passports (step 1), to successfully take blood from infants for EID tests (step 2), to help women accept their HIV status and to have their HEIs tested (step 2), to follow-up with leaders in the facility to address stock-outs (step 1) and to give feedback on the transport system (step 3), to counsel mothers about putting HEIs on ART once they test HIV-positive (step 5). Increased supervision would be needed as follow-up to enhanced training.

One strength of this study is that while other studies have reported decreases in the number of infants moving through the EIDT cascade,[3,4] and on barriers and facilitators to EIDT in general,[12,15] previous studies have not focused on distinct motivators, challenges and solutions for each step along the EIDT cascade. Limitations include that we only interviewed women who had their HIV-exposed child tested and were at the health facility for the result. The study also only included women with HIV-infected children who initiated ART. In addition, voices of mothers were limited to only three of the five steps in the cascade in the study.

Conclusion

Findings from this study provide relevant and important information to improve service delivery and to increase uptake of EIDT along five key steps in the EIDT cascade. The study also expands on current literature by assessing HCWs’ and mothers’ perspectives on barriers and facilitators of EIDT. The findings have implications for future

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interventions at the health facilities and in the community for HCWs and for mothers to ensure that EIDT operates optimally for the survival of HIV-exposed and -infected children.

Acknowledgements. The authors wish to thank all the healthcare workers and mothers who participated in this study, and the staff members in the EGPAF Malawi and US offices who provided technical and programmatic support for carrying out the study. We acknowledge the Ministry of Health, HIV/AIDS Department, and the District Offices of Dedza, Ntcheu, and Lilongwe for their collaboration and support of the study. This study was funded by ViiV Healthcare.

References 1. Joint United Nations Programme on HIV/AIDS (UNAIDS). The Gap Report.

2014. http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/ documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdf (accessed 1 December 2015).

2. Ciaranello AL, Park JE, Ramirez-Avila L, et al. Early infant HIV-1 diagnosis programs in resource-limited settings: Opportunities for improved outcomes and more cost-effective interventions. BMC Med 2011;9:59. DOI:10.1186/17417015-9-59 3. Dube Q, Dow A, Chirambo C, et al. Implementing early infant diagnosis of HIV infection at the primary care level: Experiences and challenges in Malawi. Bull World Health Organ 2012; 90(9):699-704. DOI:10.2471/BLT.11.100776 4. Braun M, Kabue MM, McCollum ED, et al. Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe. J Acquir Immune Defic Syndr 2011;56(5):e122-128. DOI:10.1097/ QAI.0b013e31820a7f2f 5. Cromwell EA, Dow AE, Low D, et al. Barriers to successful early infant diagnosis of HIV infection at primary care level in Malawi. Pediatr Infect Dis J 2015;34(3):273-275. DOI:10.1097/inf.0000000000000625 6. Adeniyi VO, Thomson E, Ter Goon D, Ajayi IA. Disclosure, stigma of HIV positive child and access to early infant diagnosis in the rural communities of OR Tambo District, South Africa: A qualitative exploration of maternal perspective. BMC Pediatr 2015;15:98. DOI:10.1186/s12887-015-0414-8 7. Cherutich P, Inwani I, Nduati R, Mbori-Ngacha D. Optimizing paediatric HIV care in Kenya: Challenges in early infant diagnosis. Bull World Health Organ 2008;86(2):155-160. DOI:10.2471/blt.07.040402 8. Feucht UD, Meyer A, Thomas WN, Forsyth BW, Kruger M. Early diagnosis is critical to ensure good outcomes in HIV-infected children: Outlining barriers to care. AIDS Care 2016;28(1):32-42. DOI:10.1080/09540121.2015.1066748 9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Countdown to Zero: Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, 2011 - 2015. http://files.unaids.org/en/ media/unaids/contentassets/documents/unaidspublication/2011/20110609_ JC2137_Global-Plan-Elimination-HIV-Children_en.pdf (accessed 1 December 2015).

10. Miles MB, Huberman AM. Qualitative Data Analysis. London: Sage Publications, 1994:325.

11. Ulin P, Robinson E, Tolley E. Qualitative Methods in Public Health: A Field Guide for Applied Research. San Fransisco: Jossey-Bass, 2005.

12. Boender TS, Sigaloff KC, Kayiwa J, et al. Barriers to initiation of pediatric HIV treatment in Uganda: A mixed-method study. AIDS Res Treat 2012;2012:817506.

DOI:10.1155/2012/817506 13. Finocchario-Kessler S, Gautney BJ, Khamadi S, et al. If you text them, they will come: Using the HIV infant tracking system to improve early infant diagnosis quality and retention in Kenya. AIDS 2014;28(3):S313-321. DOI:10.1097/ QAD.0000000000000332.

14. Anderson DA, Crowe SM, Garcia M. Point-of-care testing. Curr HIV/AIDS Rep 2011;8(1):31-37. DOI:10.1007/s11904-010-0067-z 15. Yeap AD, Hamilton R, Charalambous S, et al. Factors influencing uptake of HIV care and treatment among children in South Africa - a qualitative study of caregivers and clinic staff. AIDS Care 2010;22(9):1101-1107.

DOI:10.1080/09540121003602218

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RESEARCH

The prevalence of paediatric skin conditions at a dermatology clinic in KwaZulu-Natal Province over a 3-month period O S Katibi,1,2 MBBS, FMCPaed, MMedSci; N C Dlova,2 MB ChB, FCDerm, PhD; A V Chateau,2 BSc, MB ChB, DCH, FCDerm, MMedSci; A Mosam,2 MB ChB, FCDerm, MMed, PhD 1 2

Dermatology Unit, Department of Paediatrics and Child Health, University of Ilorin, Kwara State, Nigeria Department of Dermatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: O S Katibi (oskatibi@gmail.com) Background. Skin conditions are common in children, and studying their spectrum in a tertiary dermatology clinic will assist in quantifying skin diseases associated with greatest burden.

Objective. To investigate the spectrum and characteristics of paediatric skin disorders referred to a tertiary dermatology clinic in Durban, KwaZulu-Natal (KZN) Province, South Africa.

Methods. A cross-sectional study of children attending the dermatology clinic at King Edward VIII Hospital, KZN, was carried out over 3 months. Relevant demographic information and clinical history pertaining to the skin conditions were recorded and diagnoses were made by specialist dermatologists. Data were analysed with EPI Info 2007 (USA).

Results. There were 419 children included in the study; 222 (53%) were males and 197 (47%) were females. A total of 64 diagnosed skin conditions were classified into 16 categories. The most prevalent conditions by category were dermatitis (67.8%), infections (16.7%) and pigmentary disorders (5.5%). For the specific skin diseases, 60.1% were atopic dermatitis (AD), 7.2% were viral warts, 6% seborrhoeic dermatitis and 4.1% vitiligo. Dermatitis was significantly more common in males (p<0.05). AD was the most common condition below 12 years of age, while the presence of viral warts was the most prevalent disorder among HIV-infected children. Approximately one-third (37.5%) of the disorders referred by other medical practitioners were misdiagnosed.

Conclusions. AD constituted the highest burden both numerically and economically. Viral infections were a major contribution from HIV infection. The diverse spectrum and characteristics of skin diseases referred will assist in modifying the dermatology educational curriculum and bridge knowledge gaps among healthcare providers treating children.

S Afr J Child Health 2016;106(7):120-124. DOI:10.7196/SAJCH.2016v106i7.985

The spectrum of skin disorders seen in a population may reflect the level of hygiene, social development and health status of that community.[1] A higher number of infectious skin disorders have been found in developing countries compared with allergic disorders, which are more prominent in developed countries.[2,3] Paediatric dermatological problems are common, with some conditions requiring specialist consultation. Often appropriate diagnosis and therapy are delayed because specialist dermatology services are only available in the larger cities and patients cannot access these readily.

Conditions such as atopic dermatitis (AD) may be associated with negative psychosocial impact and impaired quality of life for both the patients and affected family.[4] Vitiligo and viral warts are also common diseases that lead to loss of self-esteem and psychological problems.[5] At the time of the study, there was no recent documentation of the prevalence of skin disorders in children. The previous study of childhood-associated dermatoses was conducted 41 years ago by Findlay et al.[6] in Pretoria, with a focus mainly on white children.

As such, it is imperative to study the current spectrum of skin diseases seen in children in a tertiary dermatology clinic, to assist in identifying diseases of greatest burden. This is paramount for public health intervention and future health planning. Therefore, this study aims to document the spectrum of paediatric skin diseases, investigating their relationship with age and gender, compare referring doctors’ diagnoses with those of dermatologists, describe management modalities and estimate treatment costs.

Methods

This was a cross-sectional study involving all children (regardless of HIV status) aged 0 - 18 years and attending the dermatology outpatient 121

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department of King Edward VIII Hospital, a regional hospital and the main teaching hospital for the Nelson R Mandela School of Medicine, University of KwaZulu-Natal (KZN), Durban. Children were recruited consecutively between May and August (autumn/winter) after ethical approval was granted by the Biomedical Research Ethical Committee (BREC) of the University of KZN in 2014 (BE026/14). A clear explanation of the study was given to each child’s parent or caregiver, and signed informed consent was then obtained. Patients were reviewed by specialist dermatologists, and diagnoses were clinical and corroborated by appropriate investigations where necessary. Data collection sheets recorded relevant clinical history, demographics and therapeutic management of the skin disorder. Data were entered into a Microsoft (USA) Excel spreadsheet 2007 and analysed with EPI Info 2007 (USA).

Direct costs of major skin conditions were calculated based on average cost of consultation (ZAR40) and the commercial cost of the standard medications for each condition. This was calculated in South African Rands (ZAR) and converted to US dollars (USD) using the average prevailing exchange rate at the time of the study (1 USD to 10 ZAR).

Results

Characteristics of study participants

A total of 419 children were studied. There were 367 (87.6%) black children, 40 (9.5%) Indians, 11 (2.6%) mixed race and 1 white child (0.2%). There were slightly more male patients 222 (53%) than female patients 197 (47%). Ages ranged from 1 week to 18 years with a mean (standard deviation) age of 56.04 (49.14) months. Infants (<2 years) accounted for 30.3%, preschool (2 - 5 years) 33.7%, school age (6 11 years) 28.2% and adolescents (12 - 18 years) 7.8%.

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RESEARCH Spectrum of skin disorders found

A total of 64 skin diseases were diagnosed and classified into 16 categories. The most prevalent disorders by category were dermatitis (67.8%), infections (16.7%), pigmentary (5.5%), papulosquamous (4.5%), appendageal (3.1%), vascular (2.4%) and genodermatoses (1.2%) (Table 1 and Fig. 1). Multiple diagnoses were made in 9.8% of the patients.

Skin disorders in relation to gender and age groups

A higher preponderance of males with dermatitis was seen (odds ratio 1.57, 95% confidence interval 1.13 - 2.19; p=0.007). Table 1 shows the gender distribution of skin lesions. AD was the most common disorder below 12â&#x20AC;&#x201A; years of age while viral warts and acne vulgaris were most common above this age. Seborrhoeic dermatitis, impetigo, nappy dermatitis and infantile haemangioma were most common in infancy (Table 2).

Comparison of diagnoses of referring doctors to those of dermatologists

Among children referred with a skin diagnosis, 65 (62.5%) had a correct diagnosis while 39 (37.5%) had an incorrect diagnosis. Three cases each of chronic bullous disease of childhood, pityriasis rosea, verruca plana and scabies were newly referred and they were all misdiagnosed by referring doctors. AD was appropriately diagnosed in 90.2% of cases.

Dermatoses in HIV-infected children

Infections were seen in 23 (82.1%) of the 28 HIV-infected children.

Viral warts (60.7%) were the most common conditions and accounted for 56.7% of the warts seen in the whole study population. AD (28.6%) was the most common non-infectious disease (Table 3).

Management modalities and treatment costs

Skin biopsy was carried out in 16 (3.8%) patients while 35 (8.4%) had blood assays done. Management modalities included topical therapy (92.8%), systemic therapy (14.3%), wet wrap therapy (2.1%), cryotherapy (1.9%) and counselling alone (1.9%). Some of these treatment modalities were used in combination. The estimated costs of consultation of the common diseases based on costs of prescription medications are highlighted in Table 4.

Discussion

The spectrum of paediatric skin diseases in a tertiary dermatology centre gives an insight into the diseases that are associated with diagnostic difficulty, chronicity and/or severity and greater financial implication.

Spectrum of skin disorders

A variety of skin disorders were seen, including inflammatory, infections and pigmentary disorders. Multiple diagnoses were made in 9.8% of the studied population and this is similar to the 11% reported by Hon et al.[7] in China. Some of the co-existent conditions in this study, viz. alopecia areata and impetigo were totally unrelated, while other conditions like AD and molluscum contagiosum were closely linked. This should prompt medical practitioners to look out for other lesions on the skin apart from the presenting skin complaint. The prevalent disease categories were dermatitis (67.8%), infections (16.7%) and pigmentary problems (5.5%).

This pattern was also reported by Shibeshi[8] in Ethiopia, where allergic skin diseases accounted for 55.1%, followed by the infections (32.8%) and photodermatoses (8%). Hon et al.[7] in China also found allergic skin diseases and eczema to be the most common. However, infections were the highest in studies from Egypt and Nigeria, where poor hygiene, low socioeconomic levels and poor health awareness are prevalent.[1,2]

Dermatitis/eczema

AD (60.1%) occurred in every second child seen in the clinic. This prevalence rate, which is one of the highest reported in literature, 122

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is three times more than the 18.7% documented 40 years ago in Pretoria.â&#x20AC;&#x201A;[6] This high rate may be attributed to higher standards of Table 1. Prevalence of cutaneous disorders and gender distribution Cutaneous lesion

Male

Female

n (%)

Dermatitis

158

126

284 (67.8)

AD

140

112

252 (60.1)

Seborrhoeic dermatitis

16

9

25 (6.0)

Nappy dermatitis

2

2

4 (1.0)

Papular urticaria

1

3

4 (1.0)

Contact eczema

0

2

2 (0.5)

Lip-licking dermatitis

1

0

1 (0.2)

Perioral dermatitis

0

1

1 (0.2)

Foot dermatitis

1

0

1 (0.2)

Erythroderma

0

1

1 (0.2)

Infections

38

32

70 (16.7)

Viral

23

23

46 (11)

Viral warts

14

16

30 (7.2)

Molluscum contagiosum

9

7

16 (3.8)

Chicken pox

1

1

2 (0.5)

9

5

14 (3.3)

Dermatophytosis

8

4

12 (2.9)

Oral candidiasis

1

0

1 (0.2)

Nappy candidiasis

0

1

1 (0.2)

Pityriasis vesicolor

1

0

1 (0.2)

Fungal

Bacterial

4

6

10 (2.4)

Impetigo

2

5

7 (1.7)

Folliculitis

2

1

3 (0.7)

Furuncles

0

1

1 (0.2)

Parasitic

3

0

3 (0.7)

Scabies

3

0

3 (0.7)

1

0

1 (0.2)

Mycobacterial

1

0

1 (0.2)

Pigmentary

Lupus vulgaris

12

11

23 (5.5)

Vitiligo

10

7

17 (4.1)

Albinism

1

4

5 (1.2)

Mongolian spots

1

0

1 (0.2)

7

12

19 (4.5)

Psoriasis

1

2

3 (0.7)

Pityriasis rosea

2

2

4 (1)

Pityriasis alba

0

2

2 (0.5)

Pityriasis lichenoides chronica

1

2

3 (0.7)

Lichen planus

1

1

2 (0.5)

Lichen nitidus

0

1

1 (0.2)

Lichen spinulosus

0

1

1 (0.2)

Gianotti crosti syndrome

1

1

2 (0.5)

LP/LE overlap

1

0

1 (0.2)

Papulosquamous

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Continued ...

RESEARCH living in the new cohort, industrialisation, migration from rural to urban and suburban areas, and a westernised lifestyle compared

4

1

5 (1.2)

with other parts of sub-Saharan Africa. Further research is needed to determine environmental or genetic predispositions to this disorder.

Since the diagnostic accuracy for physicians referring AD patients was good, the treatment of this disorder may have been a challenge to first-line healthcare providers, hence the high numbers referred to the clinic for possible second-line treatment. Further attention therefore needs to be given to the appropriate management of these children at the primary care level. This will improve outcome and decrease referral to tertiary centres.

Seborrhoeic dermatitis (6%) has been strongly associated with HIV infection. Despite the endemic nature and high prevalence of HIV in KZN, only one of the 25 children with seborrhoeic dermatitis was HIV-infected. Human T-cell lymphotropic virus 1 (HTLV-1) infective dermatitis presents in a similar pattern to seborrhoeic dermatitis but none of the patients seen had this disorder. The reduction in prevalence of seborrhoeic dermatitis after infancy is presumably due to reduced stimulation of maternal androgens transferred to the infant in utero.[9] In this cohort, the success of the widespread roll-out of antiretroviral medications to HIV-infected pregnant women has most likely caused the reduction in HIV prevalence in children.

Giant congenital melanocytic naevus

1

0

1 (0.2)

Infections

Epidermal naevus

0

1

1 (0.2)

Naevus sebaceous

1

0

1 (0.2)

ILVEN

1

0

1 (0.2)

Xeroderma pigmentosum

1

0

1 (0.2)

1

3

4 (1.0)

1

3

4 (1.0)

0

4

4 (1.0)

Table 1. (continued) Prevalence of cutaneous disorders and gender distribution Appendages

7

6

13 (3.1)

Acne vulgaris

5

3

8 (1.9)

Alopecia areata

2

1

3 (0.7)

Onycholysis

0

1

1 (0.2)

Miliaria crystalline

0

1

1 (0.2)

3

7

10 (2.4)

Infantile haemangioma

2

4

6 (1.4)

Phakomatosis pigmentovascularis

0

1

1 (0.2)

Nevus flammeus

1

1

2 (0.5)

Klippel trenaunay

0

1

1 (0.2)

Vascular

Genodermatoses

Disorders of cornification Ichthyosis Sclerosing disorders Morphea

0

4

4 (1.0)

Vesicobullous

2

2

4 (1.0)

Acropustulosis of infancy

0

1

1 (0.2)

CBDC

2

1

3 (0.7)

Urticaria

3

1

4 (1.0)

1

0

1 (0.2)

Angioneurotic oedema Chronic urticaria

2

1

3 (0.7)

1

2

3 (0.7)

Mastocytosis

1

1

2 (0.5)

Erythema nodosum

0

1

1 (0.2)

0

2

2 (0.5)

Discoid lupus erythematosus

0

1

1 (0.2)

Mixed connective tissue diagnosis

0

1

1 (0.2)

1

1

2 (0.5)

0

1

1 (0.2)

Dermis & subcutaneous nodules

Connective tissue diagnosis

Malignancy Actinic keratosis Squamous cell cancer

1

0

1 (0.2)

1

0

1 (0.2)

1

0

1 (0.2)

4

0

4 (1.0)

Primary immune deficiency

1

0

1 (0.2)

Leukaemoid reaction

1

0

1 (0.2)

Skin necrosis (IV fluid)

1

0

1 (0.2)

Arthropod bite

1

0

1 (0.2)

Drug reaction Fixed drug reaction Miscellaneous

LP/LE = lichen planus/lupus erythematosus; ILVEN = inflammatory linear verrucous epidermal naevus; CBDC = chronic bullous dermatosis of childhood.

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Viral infections (11%) were the most prevalent infections. In studies where AD is most prevalent, viral infections tend to be the most commonly associated infections.[3,7,10] These are reports from tertiary dermatology centres and may indicate that among the infections, viral dermatoses pose the greatest management challenge for primary care doctors. Orogenital warts accounted for 20 of the 30 cases of warts encountered. HIV infection may be responsible for this because over half of the viral warts in this study were found in HIV-infected children. High rates of sexual abuse could account for the increased frequency of these type of warts.[11] This trend should alert managing doctors to take an in-depth history into child abuse and notify the relevant health authorities. Heckâ&#x20AC;&#x2122;s disease, a variant of oral warts (Fig.â&#x20AC;&#x201A; 2) seen in some patients, has been found to be more common in some regions of the world, including South Africa.[12] About 40% of the patients with molluscum contangiosum were HIV-infected, and this could also be a contribution of HIV to paediatric dermatoses. Tinea capitis was the predominant type of superficial dermatophytosis seen (2.9%), with a male preponderance. Its occurrence in a specialty clinic may be due to inadequate treatment, as oral antifungal medication is indicated for at least 6 weeks. The prevalence rate of impetigo (1.7%) was relatively low compared with the findings in Egypt (19.1%), where overcrowding, lack of hygiene and antibiotic resistance from indiscriminate use have been implicated.[1]

Pigmentary

There were more male patients with vitiligo (4.1%), with ages ranging between 2 and 11 years. Management included potent topical steroids, vitamin D analogues and topical calcineurin inhibitors. Albinism was more common in females (80%), with one patient presenting with actinic keratosis at the age of 6 years. Education about the dangers of ultraviolet exposure in this group is paramount.

Others

Acne vulgaris was seen only in adolescents and supports the role of higher production of sebum and androgens in the pathogenesis of the disorder in this age group. Most of the papulosquamous dermatoses were seen in children 6 years and above. A variety of vascular problems (2.4%) and genodermatoses (1.2%) were seen. Infantile haemangiomas involved areas like the lips, scalp, labia and cheek.

Xeroderma pigmentosum was seen in an 11-year-old black boy who developed squamous cell carcinoma (SCC) on the scalp (Fig. 3).

This rare autosomal recessive condition is characterised by severe photosensitivity and defective DNA repair. Solar keratosis and SCC

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RESEARCH

Morphea

1.0

Pityriasis rosea

1.0

Papular urticaria

1.0

Nappy dermatitis

1.0

Albinism

1.2

Infantile haemangioma

1.4

Impetigo

1.7

Acne vulgaris

1.9

Dermatophytosis

Fig. 2. Heck’s disease, a variant of oral warts.

2.9

Molluscum contagiosum

3.8

Vitiligo

4.1 6.0

Seborrhoeic dermatitis

11.0

Viral warts Atopic dermatitis

60.1 0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Prevalent (%) Fig. 1. Most prevalent skin disorders seen among the study population.

Table 2. Distribution of most common skin diseases by age group 0 - <2 years (n=127)

2 - 5 years (n=141)

6 - 11 years (n=118)

12 - 18 years (n=33)

AD (63.8%)

AD (68.8%)

AD (59.3%)

Acne vulgaris (24.2%)

Seborrhoeic dermatitis (11.8%)

Viral warts (7.8%)

Viral warts (9.3%)

Viral warts (24.2%)

Infantile haemangioma (3.1%)

Vitiligo (5.7%)

Molluscum AD (12.1%) contagiosum (6.8%)

Impetigo (3.1%)

Dermatophytosis (5.0%)

Vitiligo (5.1%)

Nappy dermatitis (3.1%)

Seborrhoeic dermatitis (5.0%)

are complications that arise early in life and are characterised by a rapid and devastating course.

Relationship between age, sex and skin disorders

A higher male preponderance was found in children under the age of 5 years compared with older children. This was noted by Findlay et al.,[6] and attributed to increasing concern and awareness of the skin among females as they approach puberty. Marrone et al.[13] noted more fungal and parasitic infections in males and this is corroborated

Vitiligo (7%)

in this study. The more adventurous nature of boys leading to more play outside in the sand may account for this picture. The trend of AD peaking in the preschool age and reducing significantly in adolescence is consistent with previous observations that this condition improves with age.

Referring to the dermatologist’s diagnosis

Skin diseases are usually referred to the dermatologist because of treatment difficulty or diagnostic dilemma. Diseases such as AD that were well recognised in this study fall into 124

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Fig. 3. Xeroderma pigmentosum in an 11-year-old child who developed SCC on the scalp.

the former, while others like verruca plana and scabies which were misdiagnosed fall into the latter category. This information will be useful in educating general practitioners and paediatricians.

Management modalities of skin diseases and estimated costs

Documentations in referral dermatology clinics have shown skin biopsy rates between 0.8 and 12%, which is consistent with our finding of 3.8%.[3,7] Biopsies were performed for less-common diseases such as actinic keratosis, SCC, chronic bullous disease of childhood, psoriasis and connective tissue diseases. Afsar et al.,[14] in Turkey, reported Henoch-Schönlein purpura and various papulosquamous diseases as the most common reason for biopsy in children. Skinprick test was the most common investigation in Switzerland, and this is most likely due to incorporation of allergology with paediatric dermatology.[3] About 80% of patients in this study had topical treatments in the form of steroids, antibiotics, calcineurin inhibitors and keratolytics. Topical steroids were part of

RESEARCH Table 3. Comparison of skin disorders between HIV-positive and other children in the population Skin disorders Infections

HIV-positive, n (%) (n=28)

Other, n (%) Total, n (%) (n=391) (N=419)

23 (82.1)

47 (12.0)

70 (16.7)

17 (60.7)

13 (3.3)

30 (11.0)

Anogenital warts

4 (14.3)

7 (1.8)

11 (2.6)

Oral papillomas

4 (14.3)

5 (1.3)

9 (2.1)

Plane warts

7 (25.0)

2 (0.5)

9 (2.1)

Verruca vulgaris

3 (10.7)

0 (0.0)

3 (0.7)

Molluscum contagiosum

7 (25.0)

9 (2.3)

16 (3.8)

Dermatophytosis

4 (14.3)

8 (2.0)

12 (2.9)

Tinea capitis

3 (10.7)

7 (1.8)

10 (2.4)

Viral warts

Tinea cruris

1 (3.6)

0 (0.0)

1 (0.2)

8 (28.6)

276 (70.6)

284 (67.8)

AD

6 (21.4)

246 (62.9)

252 (60.1)

Seborrhoeic dermatitis

1 (3.6)

24 (6.1)

25 (6.0)

Perioral dermatitis

1 (3.6)

0 (0.0)

1 (0.2)

Pityriasis alba

1 (3.6)

1 (0.3)

2 (0.5)

Dermatitis

Papulosquamous Pityriasis lichenoides chronica Appendages Acne vulgaris

1 (3.6)

18 (4.6)

19 (4.5)

1 (3.6)

2 (0.5)

3 (0.7)

1 (3.6)

12 (3.1)

13 (3.1)

1 (3.6)

7 (1.8)

8 (1.9)

Table 4. Direct cost of consultation and medication of skin diseases per visit Skin disorder

Cost per patient (USD)

Total cost for all patients (USD)

AD

86.97

21 916.4

Viral warts

46.81

2 340.5

Seborrhoeic dermatitis

86.97

2 174.3

Vitiligo

96.33

1 637.6

Molluscum contagiosum

46.81

749.0

Dermatophytoses

54.28

651.4

Acne vulgaris

142.93

1 143.4

management in 47% of the patients in China, while in Switzerland, 66% of the patients had local therapy.[3,7] Cryotherapy was used for oral papillomas, some cutaneous warts and molluscum contagiosum. There are few reports in the literature that document the impact of costs on the management of paediatric skin diseases. In a study sponsored by the American Academy of Dermatology,[15] the direct cost of treatment in the general population was highest with skin ulcers, acne vulgaris, cutaneous fungal infections and AD. This is reflected in this study, as AD is the most common of these diseases in the paediatric age group and has the highest economic burden that is about 20 times that of acne vulgaris. Most of these costs are largely owing to prescription medications.

Conclusion

The spectrum of paediatric skin diseases in KZN is diverse. AD constituted a high burden both numerically and financially.

Viral infections were a major contribution from HIV infection. Diseases such as scabies, chronic bullous dermatosis of childhood and verruca planar that were misdiagnosed by referring primary care doctors will help inform modification of dermatology educational curriculum.

The knowledge of spectrum of diseases will assist in prioritising drugs that can be included in the ‘essential drug lists’ of clinics and hospital in the province and help improve medical drug supplies. Age- and gender-related dermatoses as well as the financial implications of common paediatric 125

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skin diseases would be useful for future health planning in order to reduce disease burden.

Acknowledgements. We are extremely grateful to the staff of the Department of Dermatology, University of KwaZulu-Natal, for the support given in publishing this manuscript.

References 1. El-Khateeb EA. The spectrum of paediatric dermatoses in a university hospital in Cairo, Egypt.

J Eur Acad Dermatol Venereol 2011;25(6):666672. DOI:10.1111/j.1468-3083.2010.03846.x 2. Ogunbiyi AO, Daramola OO, Alese OO. Prevalence of skin diseases in Ibadan, Nigeria. Int J Dermatol 2004;43(1):31-36. DOI:10.1111/j.13654632.2004.01967.x 3. Wenk C, Itin PH. Epidemiology of pediatric dermatology and allergology in the region of Aargau, Switzerland. Pediatr Dermatol 2003;20(6):482-487.

DOI:10.1111/j.15251470.2003.20605.x 4. Carroll CL, Balkrishnan R, Feldman SR, et al. The burden of atopic dermatitis: Impact on the patient, family, and society. Pediatr Dermatol 2005;22(3):192199. DOI:10.1111/j.1525-1470.2005.22303.x 5. Hill-Beuf A, Porter JD. Children coping with impaired appearance: Social and psychologic influences. Gen Hosp Psychiatry 1984;6(4):294301. DOI:10.1016/0163-8343(84)90024-0 6. Findlay GH, Vismer HF, Sophianos T. The spectrum of paediatric dermatology. Analysis of 10 000 cases. Br J Dermatol 1974;91(4):379-387.

DOI:10.1111/j.1365-2133.1974.tb13075.x 7. Hon KL, Leung TF, Wong Y, et al. Skin diseases in Chinese children at a pediatric dermatology center. Pediatr Dermatol 2004;21(2):109-112.

DOI:10.1111/j.0736-8046.2004.21203.x 8. Shibeshi D. Pattern of skin disease at the EthioSwedish pediatric hospital, Addis Ababa, Ethiopia. Pediatr Dermatol 2000;17(5):357-359.

DOI:10.1046/j.1525-1470.2000.017005357.x 9. Berth Jones J. Rook’s eczema, lichenification, prurigo and erythroderma. In: Burns DA, Breathnach SM, Cox NH, Griffiths CEM, eds.

Rook’s Textbook of Dermatology. 8th ed. West Sussex: Blackwell Publishing Ltd, 2010:23-29.

DOI: 10.1002/9781444317633.ch23 10. Nanda A, Al-Hasawi F, Alsaleh QA. A prospective survey of pediatric dermatology clinic patients in Kuwait: An analysis of 10000 cases. Pediatr Dermatol 1999;16(1):6-11. DOI: 10.1046/j.15251470.1999.99002.x 11. Violence against Children in South Africa.

Pretoria: Department of Social Development/ Department of Women, Children and People with Disabilities/UNICEF, 2012. http://www. cjcp.org.za/uploads/2/7/8/4/27845461/vac_final_ summary_low_res.pdf. (accessed 2 May 2015).

12. van Wyk W, Harris A. Focal epithelial hyperplasia: A survey of two isolated communities in the Cape Province of South Africa. Community Dent Oral Epidemiol 1987;15(3):161-63. DOI: 10.1111/ j.1600-0528.1987.tb00506.x 13. Marrone R, Vignally P, Rosso A, et al.

Epidemiology of skin disorders in Ethiopian children and adolescents: An analysis of records from the Italian Dermatological Centre, Mekelle, Tigray, Ethiopia, 2005 to 2009. Pediatr Dermatol 2012;29:442-447.

DOI:10.1111/j.1525-1470.2011.01698.x 14. Afsar FS, Aktas S, Diniz G, et al. The role of biopsy in pediatric dermatopathology.

Turkdurm 2011;45(3):137-139. DOI:10.4274/ turkderm.87894 15. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004: A joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology.

J Am Acad Dermatol 2006;55(3):490-500.

DOI:10.1016/j.jaad.2006.05.048

RESEARCH

The long-term concerns post cochlear implantation as experienced by parents/caregivers of prelingually deaf children between the ages of 3 and 5 years in Gauteng Province, South Africa N Moroe, MA (Audiology); N Kathrada, (BA) Speech and Hearing Therapy Speech Therapy and Audiology Department, School of Human and Community Development, Humanities Faculty, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: N Moroe (nomfundo.moroe@wits.ac.za) Background. Cochlear implantation aims to provide an effective means of spoken communication for prelingually deaf children. However, studies in this field are mostly clinically orientated, with little focus on the experiences and long-term concerns of families post cochlear implantation (CI).

Objective. To describe the long-term concerns post CI as experienced by parents/caregivers of prelingually deaf children between the ages of 3 and 5 years, and to determine the role of support groups with regard to effective intervention and coping post CI. Methods. A phenomenological, non-experimental research design was conducted through semi-structured, indepth, one-on-one inter­ views with five parents/caregivers.

Results. Caregivers reported concerns with changes in family support, financial difficulties, poor communication, and schooling and vocational prospects for their children.

Conclusion. The findings of this study highlight a need for continued support for parents and families with children who have been fitted with cochlear implants. This should be through the use of a family systems perspective model that takes into account the impact on the quality of life of families with children who have a hearing loss or who are fitted with cochlear implants. There is a need for a contextualised longitudinal study where, based on previous observations and experiences, parents/caregivers are reminded about the continual long-term expenses associated with CI. This includes maintenance costs, hospital visits and school placement when the children reach school-going age.

S Afr J Child Health 2016;106(7):125-128. DOI:10.7196/SAJCH.2016v106i7.1049

Studies on cochlear implantation (CI) have mostly highlighted the rollercoaster emotions experienced by families when a diagnosis of a hearing impairment is made.[1] The experiences of caregivers post CI have largely been neglected. For this article, the term caregiver refers to the natural parents or any family members who may assume the role of caring for a child who may not be their biological child.[2] In South Africa (SA) many children are being raised by grandparents mostly due to divorce, substance abuse, child abuse/neglect, HIV/AIDS, unemployment or death.[3,4] Furthermore, SA is a developing country characterised by high rates of poverty, unemployment, poor access to healthcare facilities and a high burden of disease.[5] There are also discrepancies in gender equality where women, often grandparents, are the ones who assume the caregiver role,[6] and in most cases, these grandparents are above the age of employment, thereby relying on government’s pension grant for income.[3] Consequently, caregivers inherit the ‘caregiver burden’,[7] described as the ‘consequences of the activities involved in providing necessary direct care to a relative or friend that result in observable and perceived costs to the caregiver’.[7] In this case the caregiver burden is associated with raising a child with cochlear implants.

Background

Globally, 6 in 1 000 babies are born with a hearing impairment. [8] This affects language acquisition, since language development relies heavily on hearing.[9] Unless hearing impairment is identified and managed early, a child with a hearing impairment may miss an opportunity to develop spoken language.[9] Although SA is a developing country with access to developed world technology,[5] the public healthcare sector is marred by poor service delivery, and this 126

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affects the early detection and management of hearing impairments.[5] While rehabilitative services are essential, they are not a high priority when compared with life-threatening diseases such as tuberculosis (TB) or HIV/AIDS.[10] Cochlear implants are highly recommended in children with severe-to-profound sensorineural loss,[11] and who meet the candidacy criteria as discussed by Gray et al.[12] However, cochlear implants are costly. Kerr et al.[10] found that in the first 10 years of implantation, the average estimated cost for a paediatric CI was ZAR455 225. This figure may have since increased, affecting families with children who are fitted with cochlear implants. The CI process is also lengthy and emotionally draining. According to Luterman,[13] having a child with a hearing impairment creates stress within the family owing to continuous decisions such as suitable schools and the mode of communication for the family. There are ~10 schools in Gauteng Province, SA, that cater for children with hearing impairments (Peel EL. Inclusive Practice in South Africa.

A Deaf Education Perspective. 2004: unpublished). The mode of communication offered and the proximity of the school may cause a concern for parents. Parents may enrol children at boarding schools or alternatively choose a local mainstream school or a school for learners with special educational needs. These often fail to cater for a child with cochlear implants.

Methods

A purposive sampling strategy was used to recruit three biological mothers and two caregivers. Parents/caregivers of children who were prelingually deafened between the ages of 3 and 5 years, fitted with cochlear implants and currently attending paediatric aural rehabilitation (AR), were recruited (Table 1).

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RESEARCH Table 1. Participants’ profiles Participants

1

2

3

4

5

Relationship to child

Mother

Mother

Foster parent

Mother

Grandmother

Race

Black

Black

Black

Indian

Black

Gender of parent / caregiver

Female

Female

Female

Female

Female

Home language

Sesotho

Tshivenda

isiZulu

English

isiZulu

Language interview was conducted in

Sesotho

English

English

English

English

Residence

Johannesburg south

Johannesburg south

Johannesburg south

Johannesburg south

Johannesburg south

Employment

Unemployed

Employed

Employed

Employed

Unemployed

Education

-

Tertiary

Grade 11

Tertiary

Diploma

Children with CI, n

1

2

1

1

1

Aetiology of hearing impairment

Unknown

Waardenburg syndrome

Meningitis

Ototoxicity

Unknown

Age of child

4

8 (child 1), 2.5 (child 2)

5

5

3

Gender of child

Female

Female (child 1), male (child 2)

Male

Male

Male

AR

Yes

Yes

Yes

Yes

Yes

CI support group

No

Yes

Yes

No

Yes

The study received ethical clearance from the University of the Witwatersrand Human Research Ethics Committee (non-medical) (clearance certificate number: H14/03/16). Once clearance had been attained, a Speech Therapy and Audiology Department of a local hospital in Johannesburg, which offers paediatric AR, was approached for possible participants. A proposal of the study was submitted to the hospital’s ethics committee for approval and permission to conduct the study was granted. The participants were approached through the audiologist responsible for the paediatric AR clinic. The audiologist identified possible participants, informed them about the study and requested their permission to forward their contact details to the researcher. The participants were contacted telephonically to request their permission to participate in the study. Initially, eight participants were contacted; two participants declined and another participant did not meet the inclusion criteria. The remaining five participants were invited to participate in an interview.

One-on-one, open-ended interviews were conducted to collect data. The participants were interviewed at the hospital when they were attending their paediatric AR appointment. On the day of the interview, participants were given the information letter and a consent letter to sign. Permission to use a tape-recorder was also requested. The interviews were approximately 60 minutes long and were conducted in English for four participants and SeSotho for the fifth. The interview conducted in SeSotho was translated into English for transcription.

Informed consent, autonomy and confidentiality were discussed with the participants. Anonymity was maintained by assigning a code system instead of participant names.

Participants were made aware that they were free to choose not to participate or withdraw from the study at any time without any negative consequences. There were no identified or assumed risks associated with this study nor were there any immediate benefits related.

Thematic analysis as outlined by Altschuld and White[14] was used to analyse the themes that emerged, which were: unrealistic expectations, family support, education, communication, hidden financial costs and vocational prospects.

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Results

All the participants expressed that they were informed that AR is a long process. Despite this, they still had unrealistic expectation with regards to cochlear implants.

‘I thought in 6 months or something everything will be fine and she will speak, but they (the therapists) explained to me again.’ - P1 ‘I thought after few days he would say I’m hungry or I love you but I understand it’s a process now.’ - P3 However, with support and debriefing with the audiologists, the process was explained again and the participants were able to reconstruct realistic expectations.

‘Now I feel like I am able to deal and accept the challenges, it is just one obstacle that I can overcome.’ - P4 All participants agreed that family support was even more crucial post CI, but there were mixed feelings from their families. Two participants stated that initially they sought advice from the elders in the family. However, when they did not receive support, they made their own decisions.

‘They didn’t want to accept the hearing loss or the cochlear implants. They gave support after a long long time. We first went to traditional methods to ease the family but the father and I chose cochlears. For my son it was easier because I knew what to do.’ - P2 One participant stated that cultural differences affected decision making.

‘They are very Zulu. Very cultural and they were in denial. They said that there is no one in their family who is disabled. And so they blamed my daughter. But we had hope and we could see changes after cochlears. So their denial was their own.’ - P5 Another participant revealed that her disagreements with her partner delayed intervention and eventually this led to a permanent separation.

‘We are not together anymore. It was too much fighting and no support.’ - P2

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RESEARCH All participants expressed difficulty in finding a crèche or schools as many schools rejected their children due to the school’s lack of understanding of cochlear implants.

‘No crèche wanted to take him. They just hear ‘hearing loss’ and they say no.’ - P2 Three participants visited schools for learners with special educational needs were unhappy with the quality of education and the availability of resources.

‘Remedial schools close to our home seemed to cater for many children with disabilities but nothing seemed to be done to actually assist their needs. Also, I didn’t think putting him in a special needs school was best. He is okay academically, he just has a language delay’. - P4 Participant 3 revealed that despite the school claiming to accept her child, she noticed various inconsistencies in the school.

‘I don’t know if what they say is what they do. Last time I forgot to pack his battery, the cochlear battery for two or three days because I was working overtime and came home very late. My sister used to pack my son’s lunch and all that. But anyways I realised there was no questions about the battery from the school and that simply means they are not putting his cochlears on or checking.’ - P3 All the participants also expressed private schools were well equipped to cater for their children; however, they were unaffordable.

‘There are schools in the North, remedial schools. But economically there is no way a normal man can afford those schools. It was R5 000 a month when we asked, that does not include spending or travelling costs.’ - P1 Participants felt the government should play a role in ensuring fair and equal education for children with cochlear implants.

‘The government should include courses, not special ones, but for all teachers so that they know how to help children with disability or needs.’ - P5 All participants highlighted that they are concerned with the mode of communication used at home.

‘Language is a major problem. His vocabulary is extremely limited.

We always try to correct his speech and language. Up to now he always forgets to say the last part of a word.’ - P2 ‘People don’t know about sign language and everything. There are no opportunities for us. Even I can see that I am failing my son.

There is no communication for him until the next morning at school.

I really am failing my son.’ - P3 Participants indicated that owing to poor communication at home, some children present with challenging behaviours.

‘I am worried about his behaviour. He gets angry quickly because we don’t understand him most of the time. The message isn’t put across.’ - P4 ‘He throws a lot of tantrums, he is always frustrated with the long journey, the communication and also with learning in therapy.’ - P2 All participants commented that poor communication has negatively affected their children’s social wellbeing.

‘He doesn’t have a friend, especially one who is deaf or uses Sign Language. He only communicates at school.’ - P1 Participants with other hearing children also stated that one of the challenges they face is ensuring equality in the family. It is easy for their implanted child to be left out of conversations and have limited participation in the family. All the participants agreed that they were informed of the ongoing therapy sessions and device maintenance 128

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post CI; however, four participants stated that their financial circumstances have since changed.

‘I couldn’t work because no one would give me off every week to come for therapy. But now I am going to try and look for a job.

I’ve been out of work because we have to come to therapy but my husband can’t work alone now. We don’t have a grant.’ - P1 ‘The therapists really like me to come every week but I don’t have means. I don’t have financial …uh… to come every week cause if I come here I have to be out of work.’ - P3 All participants also commented on the maintenance of the cochlear implant device.

‘It is not a cheap thing to maintain, but then we obviously went into it knowing this. But you don’t realise it until you are placed into the situation and then you’re like woah this is an expensive device.’ - P4 ‘And life is very expensive. Transport is like R700 a month. He have to eat. He have to be warm. He have to have medication for flu whatever, you see. And school is R7 500. We do save and tell him to be careful, but he is a child, a boy, he has to play.’ - P3 Two participants are currently receiving the state’s social grant, while two participants are not eligible for a grant and one has not applied for a grant. The participants who receive the social grant indicated that even though the grant helps, it is not enough as life is very expensive.

Participants expressed concerns regarding vocational prospects and the future for their children.

‘I have many concerns for the future. It worries me every day.

My most important concern is his education. I think I may have to take him out of school at the first point of exit which is grade nine.

Don’t you think he’ll need to go into a career in which he has to do something hands on instead of education?’ - P1 ‘I want him to grow up and do things for himself. I don’t want to close the doors for him.’ - P3 ‘Right now we are there to assist him with finances, in the long term going into the work force with a severe disability will he be able to maintain those cochlears? The parts are ridiculously priced.

It’s thousands for repairs uh… parts and batteries and a hearing disability means a lower income.’ - P4

Discussion

The findings suggest that parents/caregivers had unrealistic expectations regarding CI, as some parents expected their children to talk instantly post CI. When these expectations were not met, the parents/caregivers experienced disappointment. Parents are active participants in the CI process, but because the process is lengthy, they may start having unrealistic expectations and may forget the discussions they had with the audiologists regarding realistic expectations. Therefore parents and audiologists need to remind each other about the benefits, limitations and the process of CI. Cohen[15] asserts that constant provision of information at every stage allows parents to view the ongoing CI process in a rational and reasonable manner. Furthermore, these findings highlight the importance of constant feedback to prevent the unresolved feelings from resurfacing. Tye-Murray[16] cautions that grief is not experienced in a sequential manner and parents may not necessarily resolve all negative emotions and experiences. As the child grows and interacts in different social contexts, it may trigger unresolved feelings for the parents. It is therefore necessary for parents to have information and a support base from professionals and family members as they go through the CI process.

Participants had mixed feelings regarding the availability of support from family members and audiologists. Throughout this journey, it is crucial for parents/caregivers to have a support base as they are faced with making informed choices regarding intervention, mode of communication and educational choices for the child. [17]

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RESEARCH Most et al.[17] states that each family is different, and may implement different coping strategies; however, the presence of a hearing impairment may cause instability in the family. There is a need for continued assessment to establish the support and emotional status of the family. Jackson and Turnbull[18] assert that the presence of a hearing impairment in any family can negatively affect the wellbeing of the family. Therefore, CI team members, through the family systems perspective model, need to adopt a holistic view of the family, so as to take into account the family interactions, resources, parenting and support for a child with a hearing impairment.[18] From the outset, despite the fact that participants were aware of the financial burden associated with cochlear implants, they were not fully prepared to meet the ongoing financial demands post CI. Kerr et al.[10] advise that cochlear implants candidates should be informed about the ongoing costs and the likely time periods post CI as this knowledge will assist in assessing the affordability of intervention and planning for the long-term successful use of implants. Audiologists should realistically consider the candidate’s ability to afford cochlear implants so that candidates are not unintentionally burdened beyond their affordability to achieve good results. Adopting the family system perspective model may assist in identifying the financial burdens the parents may be facing and how best the family can be assisted.[18] It is worth noting that audiologists may not be in a position to financially assist the family with ongoing costs of cochlear implants. They can, however, assist through referrals to other services such as counselling or social services for social grants (if they haven’t been referred). Furthermore, audiologists can implement a contextualised longitudinal study where experiences of other parents/caregivers who have engaged in the CI process can be shared with the parents enrolling in this programme. These experiences may be shared to provide insight into the continual long-term expenses and challenges associated with CI. Participants felt that the schools were either not well equipped or were inconsistent around how they provided access to children with cochlear implants. Furthermore, schools that adequately cater for children with cochlear implants were expensive. De Villiers[19] voiced that the limited number of schools for children with hearing impairment is largely due to the government’s failure in the education and training of people with this affliction. This failure has left children with hearing impairment with vocational education as one of the available limited options. The South African education system and school programmes do not seem to promote or empower children with hearing impairment to be productive and working citizens of SA.[20] Ultimately, it is the child with a hearing loss who suffers as they are unable to access good schools due to their high cost. This calls for policies regarding the quality of education for children with hearing impairment as poor quality education has lifetime effects on the vocational prospects for the hearing-impaired children and their parents.

The findings of this study also highlighted the parents/caregivers’ plight with regard to communication at home. This is largely due to the different modes of communication used in the home.

The parents/caregivers were more concerned that their children developed behavioural problems and were socially isolated by their peers due to restricted communication between them and their peers. This difficulty in communication may be expected as an ineffective mode of communication between caregiver and child can lead to parental stress, which consequently may lead to negative developmental outcomes as well as behavioural problems in the child with hearing impairments.[13] These challenges can also be addressed through the family systems perspective models, where support for a child with a hearing impairment is taken into consideration. In this case, support may speak to access to services such as AR, which may help with communication strategies for the family, support for the

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child to make friends and inclusion of the child in the community.[18] Since this model takes into account the wellbeing of the whole family, it will go a long way in ensuring that the needs of a family as a whole are addressed.

Conclusion

There is a need to adopt a holistic model that takes into account the wellbeing of family with a child fitted with cochlear implants. Jackson and Turnbull[18] created a family systems perspective model which addressed the impact of deafness and the quality of life in the family.

This model highlights the importance of family interactions, family resources, parenting and support for the child. Such a model will assist in evaluating the financial affordability of the parents/caregivers as they continue with the CI process. Furthermore, audiologists working or interacting with parents/caregivers of children with cochlear implants need to embrace the family systems perspective model to ensure that families have access to services that they may require as a family. These services may include referrals to other professionals such as counsellors to address issues expressed by parents/caregivers with regards to the lack of support from their families and finding suitable schools. Lastly, multidisciplinary professionals should provide continual screening and support throughout the intervention, as familyies financial and support needs may change or progress over time. This may be achieved through conducting a contextualised longitudinal study where the experiences of other parents/caregivers who have engaged in the process may be shared with the parents/ caregivers who are enrolled in the programme.

References 1. Anagnostou F, Graham J, Crocker S. A preliminary study looking at parental emotions following cochlear implantation. Cochlear Implants Int 2007;8(2):6886. DOI:10.1002/cii.331 2. Bouvard M. Mothers in All but Name: Grandmothers, Aunts, Sisters, Friends, Strangers, Nannies. Nicholasville, Kentucky: Wind Publications, 2009.

3. Park H. Grandmothers raising grandchildren: Family well-being and economic assistance. Focus 2005;24(1):19-27.

4. Turner J. Grandparents Raising Grandchildren. Washington DC: American Association of Retired Persons, 2005.

5. Störbeck C, Moodley, S Cochlear Implantation in an Early Intervention Programme in South Africa. Conference Proceedings: 10th European Symposium on Paediatric Cochlear Implantation, 12-14 May 2001, Athens.

6. Barrow M. Aging, the Individual and Society. 6th ed. London: West Publishing Company, 1999.

7. Hunt CK. Concepts in caregiver research. J Nurs Sch 2003;35(1):27-32.

DOI:10.1111/j.1547-5069.2003.00027.x 8. Swanepoel D, Störbeck C, Friedland P. Early hearing detection and intervention in South Africa. Int J Pediatr Otorhinolaryngol 2009;73(6):783-786. DOI:10.1016/j. ijporl.2009.01.007 9. Clark EV. First Language Acquisition. 2nd ed. Cambridge: Cambridge University Press, 2009.

10. Kerr G, Tuomi S, Müller A. Costs involved in using a cochlear implant in South Africa. S Afr J Commun Disord 2012;59(1):16-26. DOI:10.7196/SAJCD.117 11. Le Roux T, Laurent C. Open access guide to audiology and hearing aids for otolaryngologists. Cape Town: University of Cape Town, 2013.

12. Gray RF, Jones F, Shipgood L, Court I. Paediatric cochlear implantation: The balance between professional caution and urgency of treatment. Cochlear Implants Int 2003;4(1):45-51. DOI:10.1002/cii.64 13. Luterman D. Counselling parents about cochlear implants. The American Speech-Language-Hearing Association Leader 2003;8(10)6-21.

14. Altschuld JW, White JL. Needs Analysis: Analysis and Prioritization. 4th ed.

Thousand Oaks, California: SAGE Publications Inc., 2010.

15. Cohen LJ. The Handy Psychology Answer Book. Canton: Visible Ink Press, 2011.

16. Tye-Murray N. Foundations of Aural Rehabilitation: Children, Adults and Their Family Members. New York: Delmar, 2009.

17. Most T, Zaidman-Zait A. The needs of parents of children with cochlear implants. Volta Rev 2007;103:99-113.

18. Jackson CW, Turnbull AP. Impact of deafness on family life: A review of the literature. Topics Early Child Spec Educ 2004;24(1):15-29. DOI:10.1177/0271 1214040240010201 19. De Villiers D. Vocational training in school programs and occupational training at colleges in South Africa. American Annals of the Deaf 2010;155(4):504-506.

20. Hintermair M. Parental resources, parental stress, and socio-emotional development of deaf and hard of hearing children. J Deaf Stud Deaf Educ 2006;11(4):493-513. DOI:10.1093/deafed/enl005

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RESEARCH

Risk profiles of infants ≥32 weeks’ gestational age with oropharyngeal and oesophageal dysphagia in neonatal care C Pike, BComm Path; M Pike, BComm Path; A Kritzinger, DPhil; E Krüger, MComm Path; M Viviers, MComm Path Department of Speech-Language Pathology and Audiology, Faculty of Humanities, University of Pretoria, South Africa Corresponding author: E Krüger (esedra.kruger@up.ac.za)

Background. Infants in neonatal intensive care are at risk of swallowing difficulties, in particular oropharyngeal dysphagia (OPD) and oesophageal dysphagia (OD). OPD is treated by speech-language therapists while OD is managed by doctors. Diagnosis of dysphagia is a challenge as equipment for instrumental evaluations is not readily available. Additional information to guide clinical assessment may be valuable.

Objective. To determine whether risk profiles of infants (≥32 weeks' gestation) in a neonatal intensive care unit (NICU) and diagnosed with OPD or OD were distinctly different from one another.

Methods. Non-probability convenience sampling was used to select 49 participants. Based on modified barium swallow (MBS) examinations, three groups of participants were identified: no dysphagia (n=11), OPD (n=13) and OD (n=25). Clinical data were collected to investigate associations between risk profiles and type of dysphagia.

Results. Factors such as gestational age, birth weight, poor weight gain and Apgar scores showed no association with either type of dysphagia in the sample of infants with a mean gestational age of 35.53 weeks. Increased NICU stay, increased chronological age, problematic breastfeeding and use of tube feeding showed an association with OPD. Three risk factors, namely intrauterine growth restriction, premature rupture of membranes and nutritive sucking difficulties were associated with OD. Conclusion. Risk profiles associated with the two types of dysphagia may guide NICU personnel and speech-language therapists, especially in settings where no MBS equipment is available.

S Afr J Child Health 2016;10(2):129-132. DOI:10.7196/SAJCH.2016.v10i2.1051

Assessment of paediatric dysphagia is a challenge, particularly in hospitals where equipment for instrumental evaluation is not readily available. Diagnosis of dysphagia is often based solely on clinical evaluations, which may fail to accurately identify difficulties in the swallowing mechanism that would otherwise be identifiable with instrumental evaluation such as modified barium swallow (MBS) examinations.[1] Since successful feeding is one of the criteria for discharge from a neonatal intensive care unit (NICU),[2] any additional information that may guide clinical assessment is therefore important. Paediatric dysphagia can occur as a result of preterm birth and low birth weight, and other medical and developmental conditions.[3,4] Knowledge of risks associated with different types of dysphagia, such as oropharyngeal dysphagia (OPD) and oesophageal dysphagia (OD), may not only guide speech-language therapists and doctors, but will be valuable to personnel in a NICU by assisting early identification and referral. OPD is treated by speech-language therapists while OD is managed by doctors. Early identification of dysphagia in infants is critical, as secondary complications such as aspiration pneumonia, failure to thrive, gastro-oesophageal reflux (GOR) as well as insufficient nutrition and hydration, may arise.[5] Interference with the nutritional requirements of infants may cause negative psychological consequences for caregivers and even death in infants.[6] The incidence of dysphagia is increasing, partially due to the improved survival of preterm infants and those with complex medical conditions.[4] Studies associate preterm birth and related complications, such as necrotising enterocolitis, respiratory distress syndrome (RDS), tachypnoea and apnoea, bronchopulmonary dysplasia (BPD) with dysphagia.[3-5] Primary difficulty in swallowing in preterm infants may be due to neurodevelopmental immaturity.

[7] Literature on the risks associated with specific types of paediatric dysphagia is limited. Existing literature appears to focus on the 130

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prevalence of types of dysphagia within specific conditions, rather than identifying specific risks associated with each type of dysphagia.

Lefton-Greif et al.,[8] however, explain that risks for OPD in infants include preterm birth, gastrointestinal tract and airway abnormalities, central nervous system impairments, neurodevelopmental delay and syndromes affecting craniofacial structures. Conditions associated with OD appear to be mainly GOR, which may also be associated with preterm birth.[2] Since preterm birth is a known risk for both OPD and OD, studying dysphagia in infants of ≥32 weeks’ gestation may identify risks other than preterm birth.

Methods

A three-group comparative study design was used. MBS data were prospectively collected and participants were assigned to the categories OPD, OD and no dysphagia. The study was conducted in a 29-bed NICU and high care in an urban, tertiary-care hospital, where expressed breastmilk via cup feeding followed by breastfeeding is promoted. Non-probability convenience sampling[9] was used to select as many participants as possible within the study’s time limit.

Prospective participants could be of any gender, present with any neonatal condition, but had to be ≥32 weeks’ gestational age and in the NICU or high care. The sample included 49 participants with slightly more males (n=26; 53%) than females (n=23; 47%). The mean birth weight was 2.11 kg (standard deviation (SD) 0.74 kg; range 0.95 - 3.64 kg). The mean gestational age was 35.53 (SD 2.95; range 32 - 42) weeks. The participants’ chronological age at data collection was 10.73 (SD 9.36; range 2 - 49) days.

A risk assessment checklist[10] was used to record pre- and perinatal risks. A neonatal feeding assessment scale was used to observe feeding performance. MBS examinations were conducted in the lateral view to diagnose the presence and type of dysphagia. A

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RESEARCH SYSCO 19’ version Multi DiagnostEleva FD screening machine (Philips, Netherlands/Holland) was used. The classification of dysphagia was guided by symptoms described by Arvedson and Brodsky.[2] The following symptoms were considered indicative of OPD: poor bolus formation, liquid spilling from the mouth, liquid adhering to the tongue or hard palate or that entered the sulci, piecemeal deglutition, delayed oral and/or pharyngeal transit time, aspiration before/after swallowing, pooling in the valleculae and pyriform sinuses and/or pharyngeal recesses, velopharyngeal incoordination, reduced pharyngeal motility and laryngeal penetration. OD symptoms included cricopharyngeal dysfunction, reduced oesophageal motility, GOR, tracheo-oesophageal fistula, oesophagitis and obstruction of the oesophagus.[2] Ethical clearance was granted by the Faculty of Health Sciences and the Faculty of Humanities of the University of Pretoria. Informed consent was obtained from all parents. Data were collected by a qualified speech-language therapist and three undergraduate

speech-language therapy students trained in the procedures.

Participants’ medical records were reviewed and a structured interview was conducted with the parents. Thereafter, the mothers were observed feeding their infants. All participants were scheduled for an MBS examination within 8 days of initial contact.

Data were collected prospectively until at least 10 participants with no dysphagia were included as to allow statistical comparison between the three groups. MBS examinations were performed by two independent speech-language therapists experienced in the procedure in infants. The MBS team was blind to the participants’ medical history and feeding observations. The MBS procedure was conducted according to recommendations for paediatric assessments.[2] Infants were positioned in a stable position at 45°, and a thin barium mixture was presented in a bottle. Participants with positive MBS results received feeding intervention. Data from the three groups of participants were analysed. Association of discrete risk factors and dysphagia were determined using the

Table 1. Discrete data of risks associated with different types of dysphagia

Prenatal and delivery factors

Risk factor

Normal (n=11), % (n)

OD (n=25), % (n)

OPD (n=13), % (n)

Fisher’s exact p-value

Dysphagia type

RRR

95% CI

p-value

IUGR

18.20 (2)

56.00 (14)

53.90 (7)

0.089

OD

5.73

1.02 - 32.10

0.047*

OPD

5.25

0.80 - 34.43

0.084

C-section

63.60 (7)

68.00 (17)

30.80 (4)

0.091

OD

1.21

0.27 - 5.38

0.798

OPD

0.25

0.05 - 1.39

0.114

OD

0.07

0.01 - 0.76

0.029*

OPD

0.32

0.05 - 2.22

0.248

Preterm PROM

36.40 (4)

4.00 (1)

15.40 (2)

0.030*

Respiratory factors

Respiratory support

9.09 (1)

0 (0)

23.08 (3)

0.036*

Perinatal conditions and treatment

Neonatal convulsions

0 (0)

0 (0)

15.40 (2)

0.113

Insufficient data for further analysis

Medications received during hospitalisation

54.55 (6)

57.50 (21)

100 (13)

0.012*

Insufficient data for further analysis

Feeding and related factors

Fussy during feedings

0 (0)

0 (0)

15.38 (5)

0.118

Insufficient data for further analysis

Breathing difficulties during/after feeding

0 (0)

0 (0)

15.38 (2)

0.118

Insufficient data for further analysis

Rooting reflex present

100 (11)

66.67 (16)

76.92 (10)

0.097

Insufficient data for further analysis

Feeding tube

27.27 (3)

33.33 (8)

76.92 (10)

0.020*

OD

1.33

0.28 - 6.44

0.72

OPD

8.89

1.40 - 56.57

0.021*

Problematic breastfeeding

20.00 (2)

5.26 (1)

63.64 (7)

0.002*

Choking

0 (0)

20.83 (5)

53.85 (7)

0.007*

Positing of milk during/after feeding

0 (0)

12.50 (3)

38.46 (5)

0.034*

Hyperextension during feeding

0 (0)

0 (0)

23.08 (3)

0.026*

Nutritive sucking difficulties

36.36 (4)

75.00 (18)

41.67 (5)

0.042*

Insufficient data for further analysis

OD

0.22

0.02 - 2.82

0.246

OPD

7

0.97 - 50.57

0.054*

Insufficient data for further analysis

CI = confidence interval; C-section = caesarean section. *Statistically significant.

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OD

5.25

1.13 - 24.42

0.034*

OPD

1.25

0.23 - 6.71

0.795

RESEARCH Fisher’s exact test and the relative risk ratio (RRR) from a multinomial logistic regression. Although the sample was small, it was deemed valuable to identify which dysphagia type (OPD or OD) showed a significant association with a certain risk factor. Differences between OPD and OD and continuous risk factors were assessed using a one-way analysis of variance (ANOVA). Following the ANOVA, a pairwise comparison was conducted with Bonferroni adjustments. Associations of ≥0.05 were deemed significant.

Results

From the total of 49 participants, 11 (22.5%) infants had no dysphagia, while 13 (26.5%) presented with OPD and the majority had OD (n=25 or 51%). Potential risks were grouped into categories that were kept constant across two tables, with Table 1 indicating discrete data and Table 2 showing continuous data tested for associations. Factors that showed no significance in this sample of participants with a mean gestational age of 35.53 weeks, included gestational age, birth weight, poor weight gain, number of days in incubator, Apgar score, meconium aspiration, RDS, patent ductus arteriosus and other congenital heart conditions, intraventricular haemorrhage, meningitis, septicaemia, hyperbilirubinaemia, congenital conditions such as craniofacial deformities, slow feed­ ing, increased duration of tube feeding, refusing feeds and gagging and vomiting. It could be that the sample was too small to indicate correlations between some of these conditions and OPD and OD.

Prenatal and delivery factors

A statistically significant correlation between intrauterine growth restriction (IUGR) and OD (p=0.047), premature rupture of mem­ branes (PROM) and OD (p=0.029) was found (Table 1). The RRR indicated that participants with OD were 5.73 more times likely to present with IUGR.

Perinatal factors

Participants with OPD were significantly older (p=0.007) and remained longer in the NICU (p=0.003) than those without dysphagia (Table 2). Both these findings were supported by significant Bonferroni adjustments. Statistically significant associa­ tions between the three groups of dysphagia with regard to respiratory support and medications received (Table 1) could not be analysed further as data were not sufficient.

Feeding and related factors

Statistically significant results were found for the remainder of feeding and related characteristics: Participants with OPD were likely to be fed via feeding tubes (p=0.02) and

Table 2. Continuous data of risks associated with different types of dysphagia

Mean (SD)

Fisher’s exact p-value

Results after Bonferroni adjustments, compared with no dysphagia

0.004*

-

Risk factor

Groups

Chronological age (days)

Normal

5.73 (3.07)

OD

10.20 (8.01)

OPD

16.00 (12.70)

Normal

5.73 (3.04)

OD

9.54 (7.20)

0.118

OPD

15.31 (12.98)

0.007*

Days in NICU

0.084 0.003* 0.01*

-

*Statistically significant

Table 3. Risk factors according to types of dysphagia Factors associated with OPD

Factors associated with OD

Increased chronological age Increased stay in the NICU Tube feeding Problematic breastfeeding

IUGR Nutritive sucking difficulties Preterm PROM

experience difficulties with breastfeeding (p=0.002). Results showed that nutritive sucking difficulties were significantly associated with OD (p=0.042). According to Table 1, both types of dysphagia were associated with choking (p=0.007), positing of milk (p=0.034) and hyperextension during feeding (p=0.026). Due to insufficient data only some risks for feeding could be analysed further and were found to differentiate between OPD and OD. The RRR for tube feeding and breastfeeding difficulties were strong, indicating that participants with OPD were 8.89 times more likely to be fed with a tube and 7 times more likely to experience breastfeeding difficulties. The RRR indicated that participants with OD were 5.25 times more likely to present with nutritive sucking difficulties.

Discussion

In this sample of 49 participants, 51% presented with OD and 26.5% presented with OPD. When compared with an MBS diagnosis of OD or OPD, only a few clinical factors were found to be significantly associated with the two types of dysphagia in the sample of mostly late preterm infants (mean gestational age 35.53 weeks). The participants with OPD were in the NICU for longer and were older than participants with OD and no dysphagia.

The correlation between increased time in the NICU and increased chronological age with both types of dysphagia is logical as infants that are seriously ill and born preterm may require longer hospitalisation.[2] These two seemingly similar risk factors (days in NICU and chronological age) differ, as some infants may have been born before arrival to 132

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the hospital and would therefore have spent fewer days in NICU than their age in days.

The results show that those with dysphagia were not discharged early from the NICU. The purpose of early dysphagia intervention would be to prevent a lengthy NICU stay. OPD was also associated more with tube feeding than OD. While tube feeding is often the initial approach to manage feeding difficulties, it can also prolong dysphagia in preterm infants, delay treatment, negatively influence oral feeding and may increase GOR.[2,11] Problematic breastfeeding was associated more with OPD. This is consistent with the various symptoms that may be present during feeding of an infant with dysphagia.[2,5] Hyperextension during feeding influences the alignment of pharyngeal structures and places infants at risk for aspiration, a symptom of OPD.[2] Stressful mealtimes and fussiness are associated with dysphagia.[5] IUGR was associated with OD, indicating that the smaller the infant, the more likely it will present with dysphagia. Infants born small-for-gestational age are at increased risk of respiratory illnesses, including BPD and RDS, and longer use of ventilator support and oxygen supplementation. [12] The frequency of GOR, a condition asso­ cia­ ted with OD, is increased in infants with BPD due to an increase in positive abdominal pressure.[13] BPD and RDS have a known association with dysphagia,[3-5] which may further explain this result. Participants with OD were significantly more likely to present clinically with nutritive sucking difficulties than those with OPD, which is in itself a symptom of possible OPD. The reason for not observing sucking difficulties in participants with OPD may

RESEARCH be that 76.92% of those with OPD were feeding via a tube (Table 1), thereby masking any sucking difficulties that may have been present.

Only 33.33% of participants with OD were feeding via a tube, thereby allowing observations of nutritive sucking in more infants than in the OPD group. PROM is associated with OD in the sample, which may indicate an indirect risk. Preterm PROM accounts for 30 - 40% of preterm births and is associated with RDS in infants,[14] both of which have been associated with dysphagia. Both IUGR and nutritive sucking difficulties possibly indicate maturational problems found in participants with OD. It has been suggested that GOR, a condition associated with OD, is often a consequence of lower oesophageal sphincter immaturity.[13] Table 3 provides a summary of statistically significant factors associated with OD and OPD. The small sample size and the exclusion of extremely preterm neonates from the sample could have contributed to the few associations found.

Conclusion

Apart from preterm birth, OPD and OD showed distinct risk profiles that were tested against the MBS results of dysphagia in this sample of mostly late preterm infants. Although an MBS is the ideal, knowledge of the risk profiles of OPD and OD may enable personnel and speech-language therapists in the NICU and high care to identify, assess and treat infants with dysphagia timeously. Risk factors found in this study may be used as a starting point for the development of an instrument to assist in the early identification of dysphagia, which would be valuable in resource-poor settings. A larger sample is required to determine if the data can be used to indicate OPD and OD in other clinical settings.

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References 1. DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol 2005;47(3):149-157. DOI:Â 10.1111/j.14698749.2005.tb01108.x 2. Arvedson JC, Brodsky L. Pediatric Swallowing and Feeding: Assessment and Management. New York: Thomson Delmar Learning, 2002.

3. Groher ME, Crary MA. Dysphagia: Clinical Management in Adults and Children. Maryland Heights: Mosby Elsevier, 2009. p 50-71 4. Miller CK. Updates on pediatric feeding and swallowing problems. Curr Opin Otolaryngol Head Neck Surg 2009;17(3):194-199. DOI:10.1097/ MOO.0b013e32832b3117 5. Prasse JE, Kikano GE. An overview of pediatric dysphagia. Clin Pediatr 2009;48(3):247-251. DOI:10.1177/0009922808327323 6. Barratt J, Ogle V. Recorded incidence and management of dysphagia in an outpatient paediatric neurodevelopmental clinic. S Afr J Child Health 2010;4(2):38-41. DOI:10.7196/sajch.223 7. Heuschkel RB, Fletcher K, Hill A, Buonomo C, Bousvaros A, Nurko S. Isolated neonatal swallowing dysfunction: A case series and review of the literature.

Dig Dis Sci 2003;48:30-35.

8. Lefton-Greif MA, Carroll JL, Loughlin GM. Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors. Pediatr Pulmonol 2006;41(11):1040-1048. DOI:10.1002/ppul.20488 9. Leedy PD, Ormrod JE. Practical Research: Planning and Design. 10th ed. New Jersey: Pearson Education, 2014. p 190-231 10. Kritzinger A. VroeĂŤ kommunikasieontwikkeling van biologiese risikobabas.

Masters dissertation. Pretoria; University of Pretoria, 1994.

11. Bingham PM. Deprivation and dysphagia in premature infants. J Child Neurol 2009;24(6):743-749. DOI:10.1177/0883073808329530 12. Qiu X, Lodha A, Shah PS, et al. Neonatal outcomes of small for gestational age preterm infants in Canada. Am J Perinatol 2012;29(2):87-94.

DOI:10.1055/s-0031-1295647 13. Wolf LS, Glass RP. Feeding and Swallowing Disorders in Infancy. Assessment and Management. Tucson: Therapy Skill Builders, 1992. p 297-398 14. Rogers B, Arvedson J. Assessment of infant oral sensorimotor and swallowing function. Ment Retard Dev Disabil Res Rev 2005;11(1):74-82.

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RESEARCH

The impact of a change in referral pathway on a paediatric short-stay ward in Cape Town, South Africa H Finlayson,1 FCPaed (SA), Cert Id (SA) (Paed); L Smit,1 MMed (Paed), FCPaed (SA), MPhil; T M Esterhuizen,2 MSc (Epidemiology); M Kruger,1 MMed (Paed), MPhil, PhD 1 2

Tygerberg Hospital and Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa Biostatistics Unit, Centre for Evidence-Based Health Care, Community Health Division, Stellenbosch University, Cape Town, South Africa

Corresponding author: H Finlayson (finlayson@sun.ac.za) Background. The opening of the new Khayelitsha District Hospital in April 2012 coincided with a change in referral pathway to Tygerberg Hospital (TBH) for children requiring specialist care.

Objective. To determine the disease burden impact of the referral pathway change on paediatric short-stay ward admissions at TBH. Methods. A retrospective cohort study, analysing routine health information as captured in ward admissions registers over two similar seasonal periods: 1 April - 30 September 2011 (prior to referral change) and 1 April - 30 September 2012 (post referral change).

Results. Paediatric short-stay ward admissions remained similar, but a statistically significant increase in the number of admissions from Khayelitsha sub-district (SD) (p<0.001) was seen. The median age was 13 months over the two time periods. Children from Khayelitsha (median age 9.49 months for 2011 and 5.2 months for 2012) were, however, significantly younger than those from other SDs (median age 26.31 months in 2011 and 26.44 months in 2012) (p=0.001). Khayelitsha children were more likely to require admission to a TBH paediatric ward (p<0.001, adjusted odds ratio (aOR) 0.57), while children from other SDs were more likely to be discharged home or transferred to a district hospital (p<0.001, aOR 1.75). Respiratory illnesses accounted for the majority of admissions during both time periods (54% in 2011 and 51% in 2012).

Conclusion. Children from Khayelitsha were significantly younger and more likely to be admitted to a TBH inpatient ward compared with other SDs. These findings necessitate a review of current health service resource allocation.

S Afr J Child Health 2016;10(2):133-137. DOI:10.7196/SAJCH.2016.v10i2.1054

South Africa (SA) has made major progress towards improving the social circumstances of its children since democracy in 1994 with the ratification of the United Nationa (UN) Convention on the Rights of the Child,[1] the unconditional inclusion of basic socioeconomic rights for children in the SA Constitution,[2] free healthcare for children under 6 years and pregnant women,[3] the adoption of the Millennium Developmental Goals[4] and the revision of the Child Care Act.[5] Yet, SA is one of the few countries globally where under-5 mortality has increased rather than decreased, comparing poorly with other lowand middle-income countries. This increase in mortality has coincided with the HIV/AIDS epidemic, the increase in tuberculosis and weak healthcare systems in certain regions of SA.[6] Preventable or treatable diseases such as HIV/AIDS, diarrhoea, lower respiratory infections, malnutrition and perinatal complications account for more than three-quarters of under-5 deaths in SA,[7] highlighting the need for the urgent escalation of public health interventions to limit morbidity and mortality in children.[8] Malnutrition contributes substantially to the burden of childhood disease as both a direct cause for mortality and as an underlying synergistic factor in other major causes of death such as pneumonia, diarrhoea and HIV/AIDS.[9] The Western Cape Province has the lowest under-5 mortality rate in SA, but is one of the most inequitable provinces, with young child mortality varying by a factor of three between the worst and the best areas.[10] The dominant pattern of childhood mortality and morbidity, similar to the rest of the country, remains one of nutritional deficiency and communicable diseases.[7] In 2003 the Cape Metropolitan Region (Cape Metro) was divided into two districts, namely Metro East and Metro West. Metro East is subdivided further into four sub-districts (SDs): Khayelitsha, Tygerberg, Northern and Eastern, with specific referral pathways from primary to secondary and tertiary care facilities for each SD. Khayelitsha is one of the largest SDs, but it is the poorest.[11] It has a young population, with 12% (n=46 773) under-5 years of age in 134

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2011, the highest proportion in Metro East.[12,13] It was found to have the highest levels of mortality in all main cause groups of premature mortality in Cape Town,[14] with the 2009 reported infant mortality rate of 35/1 000 the highest in Cape Town. The 2010 under-5 mortality rate was 45% higher in Khayelitsha compared with other SDs. A new 230bed Khayelitsha District Hospital (KDH) was opened in April 2012, providing support to the surrounding primary healthcare facilities to ensure that patients receive care at the lowest level of entry into the healthcare system. A change in the Khayelitsha SD referral pathway was simultaneously implemented. Before, most children requiring acute care were sent directly from primary health clinics to Red Cross War Memorial Childrenâ&#x20AC;&#x2122;s Hospital (RCWMCH), and a smaller number living east of Spine Road were referred to Karl Bremer Hospital, if they required primary or secondary care. A small number of patients were referred to Tygerberg Hospital Paediatric Emergency and Ambulatory Care Unit owing to incorrect use of referral pathways or during patient diversions, as a result of bed pressure across the Cape Metro.

From 2008, a paediatric ward looking after children from Khayelitsha needing level 1 care was opened at Tygerberg Hospital (TBH), but was administered and staffed independently. This was a transition period before the opening of the new hospital. Patients accessed this ward by down-referral from RCWMCH (or TBH should they have been admitted there). All patients requiring more advanced levels of care were to be referred to TBH from April 2012. TBH serves as the primary care referral centre for the Tygerberg SD, and the secondary and tertiary care referral centre for all Metro East SDs. The paediatric ambulatory unit at TBH accepts and manages all patients from primary health clinics, district hospital emergency centres, as well as patients arriving from home. The service includes a 24-bed short-stay ward where patients requiring ongoing observation and treatment due to their medical condition are admitted.[15] With the anticipated increase in paediatric referrals to TBH, health service planning calculations

JULY 2016 Vol. 10 No. 2

RESEARCH

Methods

The study was conducted in the paediatric ambulatory unit at TBH and was approved by the Stellenbosch University Faculty of Health Sciences Health Research Ethics Committee (N12/06/032). This was a retrospective co­hort study, analysing the routine health information as captured in the ward admissions register over two similar seasonal periods: 1 April - 30 September 2011 (prior to the referral pathway change) and 1 April - 30 September 2012 (after the referral pathway change). Cases with a surgical diagnosis admitted to surgical wards via the emergency and short-stay ward were excluded. Data collected were entered directly from the ward admission registers into an Excel (Microsoft Corp., USA) spreadsheet.

Each patient was given a unique identifier and all identifying variables including patient names, hospital numbers and physical addresses were removed from the data set to ensure anonymity during data analysis.

The hospital administrative system was used to find any incomplete data. Readmissions were included in the data collection. The data collected included the demographic data (date of birth, sex and residential suburb), date of admission, diagnosis, date of discharge or inpatient admission, weight, outcome (discharge, admission or death) and International Classification of Diseases (ICD)-10 diagnosis. For the purpose of the study, the following definitions were used: • Children: all children <18 years of age • SD: the Cape Metro SD in which the patient resides • Underweight for age: World Health Organization’s weight-for-age z-scores (WAZ) ≤–2 • Level 1 facility: a district hospital children’s ward staffed by a medical officer • Level 2 facility: a secondary-level ward with general paediatric care on site • Level 3 facility: a tertiary-level ward with highly specialised paediatric care on site, such as TBH subspecialty wards • PICU: the paediatric intensive care unit at TBH, or RCWMCH if no space was available at TBH • Diagnosis: International Classification of Diseases (ICD)-10 coding of disease at discharge, transfer or death. If no discharge diagnosis was entered, the admission

diagnosis was used. For simplification, diagnoses were grouped into disease categories according to systems affected or disease categories such as respiratory, neurological or gastrointestinal • Length of stay: duration in days from date of admission to date of discharge from the short-stay ward.

statistics were used to analyse diagnoses at discharge, mortality rates, age group burdens, referral rates to secondary and tertiary hospital beds, and length of stay. Multivariate binary logistic regression analysis was used to identify differences between outcomes of children from Khayelitsha SD compared with the other SDs.

Statistical analysis

Results

Data were analysed using STATA version 12 (StataCorp, USA). Comparisons between the two cohorts were based on χ2 statistical tests in the case of categorical outcomes, and Mann-Whitney U-tests in the case of nonparametric numerical outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess impact. Descriptive

Of the 6 679 and 7 285 patients seen in the ambulatory unit in 2011 and 2012, respectively, 39% (n=2 639) were admitted to the short-stay ward in 2011 compared with 35% (n=2 672) in 2012. A total of 399 surgical admissions were excluded over the two time periods, as complete clinical and outcome data were not available. The

2011

2012

Total number of patients seen in ambulatory unit 6 679

Total number of patients seen in ambulatory unit 7 285

Admissions to short-stay ward 2 639 (39%)

Admissions to short-stay ward 2 672 (35%)

197 surgical admissions excluded

202 surgical admissions excluded

2 442 patients included

209 (9%) from Khayelitsha

2 470 patients included

2 233 (91%) from other sub-districts

336 (14%) from Khayelitsha

2 134 (86%) from other sub-districts

Fig. 1. Flow diagram indicating the sampling of paediatric admissions over the two study periods: actual numbers of patients (%).

80 70 Percentage (%)

identified the need for additional resources.

Due to budget constraints, limited resources were added to the TBH service platform.

The aim of this study was to determine the impact of the referral pathway change on the admission profile of children admitted to the TBH short-stay ward, both in terms of patient outcome and service demands; specifically whether Khayelitsha patients had a higher burden of disease compared with children from other SDs.

60 50 40

Home

30 20

Primary care clinic

10

Hospital

0

r te

s Ea

n

a

er

sh

K

lit ye a h

N

th or

n g Ty

Fig. 2. Origin of referral for each SD for 2011.

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t

g er

b er

JULY 2016 Vol. 10 No. 2

M

ro

et

es W

e

sid

t Ou

M

ro

et

RESEARCH

Percentage (%)

remaining total of 4 912 admissions were included for data analysis. Fig. 1 shows the admissions over the two time periods. While numbers for each year remained similar, there was an increase in the number of admissions from Khayelitsha SD in 2012 (p<0.001). The majority of admissions came from the Tygerberg SD: 66% (n=1 625/2 442) in 2011 and 61% (n=1 517/2 470) in 2012.

In 2011, 60% (n=1 459/2 442) of children were referred from primary care clinics, and in 2012, 59% (n=1 461/2 470). In 2011, 13% (n=327/2 470) arrived as walk-ins from home, increasing to 12% (n=301/2 470) in 2012. Patterns of referral from each SD are shown in Figs 2 and 3.

Patient characteristics over the two time periods are shown in Table 1. Children admitted to the ward were young, with 48% 90 80 70 60 50 40 30 20 10 0

under 1 year. The median age for all SDs did not change over the two time periods (p=0.084), except for children admitted from Khayelitsha, who were younger in both time periods, with a significant decrease in median age in 2012 (median age 5 months, interquartile range (IQR) 2 - 23 months) v.

2011 (median age 10 months, IQR 4 - 21 months) (p=0.001).

The most common diagnoses were respiratory illnesses, which accounted for approximately half of admissions in both time periods (54% in 2011 and 51% in 2012), followed by gastrointestinal infections, including gastroenteritis (22% in 2011 and 19% in 2012), and neurological conditions, including tuberculous meningitis (12% in 2011 and 17% in 2012). A fifth (20%) of children were underweight for their age.

Home Primary care clinic Hospital r te

s Ea

n

ha

er

its

K

l ye ha

th or

N

n

t

g er

g Ty

b er

M

tro

es W

e

e

sid

t Ou

M

ro

et

Fig. 3. Origin of referral for each SD for 2012.

Table 1. Comparison of the characteristics of children admitted to the short-stay ward over the two study periods overall 2011, n (%)

2012, n (%)

p-value

1 356 (57)

1 305 (54)

0.024

Gender (male) All admissions Other SDs

1 245 (57)

1 129 (54)

0.031

Khayelitsha SD

111 (56)

176 (53)

0.560

Age categories of admissions Age (months), median (IQR) All admissions

13 (5 - 32)

13 (4 - 34)

0.084

Other SDs

27 (5 - 33)

26 (4 - 34)

0.783

Khayelitsha SD

10 (4 - 21)

5 (2 - 23)

0.001

1 156 (48)

1 189 (49)

0.600

Age <1 year All admissions Other SDs

1 037 (47)

977 (46)

0.680

Khayelitsha SD

1 19 (58)

212 (63)

0.280

2 132 (88)

2 150 (88)

0.700

Age <5 years All admissions Other SDs

1 935 (87)

1 848 (88)

0.980

Khayelitsha SD

197 (97)

302 (90)

0.003

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Although the WAZ score for children from Khayelitsha was significantly lower in 2012, at –0.99 (IQR –2.4 - 0.1) compared with 2011 at –0.5 (IQR –2.3 - 0.8) (p=0.029), the proportion of children underweight for age did not significantly change between the two time periods in both Khayelitsha (22% and 24%, p=0.588) and the other SDs (20% and 21%, p=0.574). Outcomes for the children admitted to the emergency and short-stay wards are shown in Table 2; the majority of children were discharged directly home.

However, the number of children requiring admission as an inpatient was significantly higher in 2012 (n=1 008; 41%) compared with 2011 (n=871; 34%) (p<0.001). Admissions to district hospitals increased overall, but this was only significant for SDs other than Khayelitsha (p<0.001). Admissions to TBH significantly increased during the two time periods (n=742 v. n=835; p=0.001), while children being discharged home or transferred to a primary care hospital had decreased (n=1672 v. n=1624; p=0.04). The increase in admissions from Khayelitsha occurred across all levels of care at TBH, but was only significant for highly specialised (tertiary) admissions (p<0.001). Only admissions to the PICU had a significant increase (p=0.04) between the two time periods for the other SDs. There was no change in length of stay between the two time periods or mortality in the emergency and short-stay wards (p=0.064).

There was no difference between malnutrition and mortality rates across the SDs (Table 2). However, children from Khayelitsha were less likely to be admitted to a district hospital or be discharged from the TBH short-stay ward (p<0.001, OR=0.57) and more likely to be admitted to a TBH ward (general, highly specialised or ICU) (p<0.001, OR=1.75) after adjusting for the differences between 2012 and 2011 (Table 3).

Discussion

Audits have a role in identifying and targeting gaps in the provision of healthcare in terms of coverage, quality and equity.[16] Audits are, however, only effective if there is accountability for action, resulting in quality improvement. Although individual healthcare workers play a role in local processes, the availability of human resources, health facility infrastructure, supply systems and shifts in health systems also have a fundamental impact on the quality of healthcare provided at the population level.

During the reporting period in our study, 35% (2012) and 39% (2011) of all attendances to the paediatric ambulatory unit were admitted to the short-stay ward.

This is higher than the reported 4 - 10% in studies from developed countries,[17,18] and may be due to the unit functioning as

RESEARCH Table 2. Outcome of children admitted to the short-stay ward over the two study periods 2011, n (%)

2012, n (%)

p-value

Discharged home

1 579 (64)

1 462 (59)

<0.001*

Admitted as inpatient at any hospital

871 (34)

1 008 (41)

Discharged or down-referred to a district hospital

1 672 (69)

1 624 (66)

0.040

Admitted to TBH (general or highly specialised or paediatric ICU)

742 (30)

835 (34)

0.001

Overall

102 (4)

162 (7)

<0.001

Other SD

79 (4)

141 (7)

<0.001

Khayelitsha SD

23 (11)

21 (6)

0.046

Overall

482 (20)

482 (20)

0.838

Other SD

437 (20)

388 (18)

0.241

Khayelitsha SD

45 (22)

94 (28)

0.099

Overall

212 (9)

271 (11)

0.007

Other SD

203 (9)

210 (10)

0.397

Khayelitsha SD

9 (4)

61 (18)

<0.001

Overall

48 (2)

82 (3)

0.003

Other SD

41 (2)

59 (3)

0.040

Khayelitsha SD

7 (3)

23 (7)

0.084

Overall

7 (0.3)

9 (0.4)

0.640

Other SD

6 (0.3)

7 (0.3)

0.726

Khayelitsha SD

1 (0.5)

2 (0.6)

0.861

Overall

1 (1 - 2)

1 (1 - 2)

0.711

Other SD

1 (1 - 2)

1 (1 - 1)

0.577

Khayelitsha SD

1 (1 - 2)

1 (0 - 2)

0.672

Admission to hospital ward

Admission to TBH

Admissions by level of care District hospital

General paediatrics in TBH

Highly specialised paediatrics in TBH

Paediatric ICU

Mortality

LOS, median (IQR)

LOS = length of stay.

Table 3. Binary logistic regression for various outcomes comparing Khayelitsha with other SDs p-value

Outcome

aOR*

95% CI

Malnutrition

0.13

1.19

0.96 - 1.48

Discharged or down-referred to district hospital

<0.001

0.57

0.47 - 0.68

Admitted to TBH ward (general, highly specialised or paediatric ICU)

<0.001

1.75

1.46 - 2.09

Died

0.36

1.81

0.51 - 6.42

*OR adjusted for year (2012 v. 2011).

an emergency referral centre for primary and district hospitals rather than a walkin service. During our study, 13% (2011)

and 12% (2012) were walk-ins from home.

Therefore, ~90% of patients had already been assessed by a healthcare provider in 137

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the community who thought the acuity or complexity of illness required referral to our unit for further management. The high admission rate may also indirectly reflect the lack of a primary care hospital in the Tygerberg SD, from where the majority of our patients are referred.

The benefit of short-stay wards is that they may reduce the rate of admission to inpatient units, with reduced length of stay in hospital for patients.[19,20] Our study, however, reports higher admission rates to inpatient wards from the short-stay ward compared with other units, with our admission rate of 34% (2011) and 39% (2012) higher than the 15 - 25% reported in other studies.[15,18,21] Similar to other units, respiratory illnesses, gastroenteritis and infectious diseases were the most common diagnoses.[21,22] Reported clinical features predicting inpatient admission vary, and include acuity level, age under 3 months, bronchiolitis or other respiratory illnesses requiring oxygen therapy, need for intravenous fluids and medication, and sub-specialty consultation.[22,23] The high percentage of young infants seen, the high percentage of respiratory illness, and the higher acuity level of referred patients probably contribute to our unitâ&#x20AC;&#x2122;s higher admission rates. Even though malnutrition accounts for more than 10% of SAâ&#x20AC;&#x2122;s under-5 mortality rate, with 60% of children dying being underweight for age and a third severely malnourished,[24] underweight for age in our study, while high, did not increase over the two time periods and there was not a significant difference between Khayelitsha and other SDs. As expected, there was a significant increase in the number of patients being referred from Khayelitsha SD after the change in referral pathways. These children were younger and more likely to be admitted to TBH inpatient wards, compared with children from other SDs, confirming the use of appropriate referral pathways and the higher morbidity described in children from this area, as patients are admitted according to level of care required.[14] There was also significant decline in the age of children referred from Khayelitsha between the two time periods. The majority of children were referred from community clinics in 2011, while in 2012 the majority were from the new hospital. This would suggest that older children were effectively managed and treated at the hospital while only the younger and sicker children were referred, thus lowering the median age of children seen at TBH. Our study clearly shows the increasing need for highly specialised and ICU care for children from Metro East. While the number of patients admitted to the short-stay ward has not increased, the level of acuity has, as demonstrated by the increased number of admissions to the highly specialised wards

RESEARCH and almost doubling of admissions to the ICU. Of note is that the significant increase of inpatient admissions was seen in both the Khayelitsha and other SD groups. This identifies severity of disease in Metro East as a whole, and a potential need to strengthen the primary, secondary and tertiary healthcare systems in Metro East.

Study limitations

Being a retrospective study, it was reliant on routine, real-time record keeping. This can be incomplete at times, but we were able to capture most incomplete data from the hospital data system. While some data may have been incomplete, the data collection was unlikely to have changed over the 2-year period and thus comparison would be appropriate. Our study started soon after the opening of KDH and change in the referral pathway, when systems and staffing were still in the introductory phase. Therefore, there may have been incorrect referral along the old pathway as well as new inexperienced doctors more likely to refer to a higher level of care. This did not seem the case in our study, as fewer patients were referred back to KDH compared with other primary care facilities. Finally, our study looked at acute admissions only, but did not evaluate direct ward or paediatric ICU admissions. It also did not evaluate bed occupancy rates in these wards, which may have identified additional burden of disease, needing additional resources.

Conclusion

Understanding burden of disease is fundamental to evidence-based health planning. It identifies health needs and allows for monitoring of the implementation of programmes and health services. Although a significant increase in the overall number of patients referred was not identified after the change in referral pathway, an increase in severity of disease with increasing paediatric ICU and highly specialised admissions across all SDs was observed. Children from Khayelitsha were significantly younger and more likely to be admitted to a TBH ward compared with other SDs. These findings necessitate a review of current health service resource allocation.

Sources of funding. This research was supported by the Desmond Tutu TB Centre, Department of Paediatrics, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; and funded by the US Agency for International Development (USAID) Cooperative Agreement (TREAT TB – Agreement No. GHN-A-00-800004). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID.

References 1. Goldhagen J. Children’s rights and the United Nations Convention on the Rights of the Child. Pediatrics 2003;112(3 Part 2):742-745.

2. Annas GJ. The right to health and the nevirapine case in South Africa. N Engl J Med 2003;348(8):750-754. DOI:10.1056/NEJMlim022737 3. Wilkinson D, Sach ME, Abdool Karim SS. Examination of attendance patterns before and after introduction of South Africa’s policy of free health care for children aged under 6 years and pregnant women. BMJ 1997;314(7085):940941. DOI:10.1136/bmj.3114.7085.940

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4. Kleinert S, Horton R. South Africa’s health: Departing for a better future?

Lancet 2009;374(9693):750-760. DOI:10.1016/S0140-6736(09)61306-4 5. Jamieson L, Lake L. Children’s Act Guide for Health Professionals, 2013. 5th ed.

Cape Town: Children’s Institute, University of Cape Town, 2013.

6. Chopra M, Daviaad E, Pattinson R, Fonn S, Lawn JE. Saving the lives of South Africa’s mothers, babies, and children: Can the health system deliver? Lancet 2009;374(9692):835-846. DOI:10.1016/S0149-6736(09)61123-5 7. Bradshaw D, Bourne D, Nannan N. What are the leading causes of death among South African children? MRC Policy Brief No. 3, December 2003. Burden of Disease. Research Unit, Medical Research Council. http://www.mrc.ac.za/ policybriefs/childmortality.pdf. (accessed 15 May 2012).

8. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Karim SSA, Coovadia HM. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380(9858):2029-2043. DOI:10.1016/S0140-6736(12)61814-5 9. Heikens GT, Bunn J, Amadi B, et al. Case management of HIV-infected severely malnourished children: Challenges in the area of highest prevalence. Lancet 2008:371(9620):1305-1307. DOI:10.1016/S0140-6736(08)60565-6 10. City of Cape Town. http://capetown.gov.za/clusters/health.asp?IDPathString= 1123-1374-3256&clusid=245&catparent=3256 (accessed 30 December 2015).

11. City of Cape Town. www.capetown.gov.za/en/stats/2011 Census Health District Profiles/Khayelitsha Health District.pdf (accessed 30 December 2015).

12. City of Cape Town. A Population Profile of Khayelitsha: Socio-economic Information from the 2001 Census. 2005. http://www.capetown.gov.za/en/ stats/CityReports/Documents/Population%20Profiles/A_Population_Profile_ of_Khayelitsha_1052006142120_359.pdf (accessed 30 December 2015).

13. Western Cape Provincial Treasury, Local Government Budget Office. Regional Development Profile of City of Cape Town. 2012. https://www.westerncape. gov.za/assets/departments/treasury/dc0_city_of_cape_town_sep-lg_ profile_02_2013.pdf#page=11&zoom=auto,-133,769 (accessed 30 December 2015) 14. Groenewald P, Bradshaw D, Daniels J, et al. Local-level mortality surveillance in resource-limited settings: A case study of Cape Town highlights disparities in health. Bull World Health Organ 2010;88(6):444-451. DOI:10.2471/ BLT.09.069435 15. Crocetti MT, Barone MA, Amin DD, Walker MD. Pediatric observation status beds on an inpatient unit: An integrated care model. Pediatr Emerg Care 2004;20(1):17-21. DOI:10.1097/01.pec.0000106238.72265.5f 16. Kinney MV, Kerber KJ, Black RE, et al. Sub-Saharan Africa’s mothers, newborns and children: Where and why do they die? PLoSMed 2010;7(6):e1000294.

DOI:10.1371/journal.pmed.1000294 17. Scribano PV, Wiley JF, Platt K. Use of an observation unit by a pediatric emergency department for common pediatric illnesses. Pediatr Emerg Care 2001;17(5):321-323. DOI:10.1097/00006565-200110000-00001 18. Levett I, Berry K, Wacogne I. Review of a paediatric emergency department observation unit. Emerg Med J 2006;23(8):612-613. DOI:10.1136/emj.2005.

029470 19. Coon JT, Martin A, Abdul-Rahman A, et al. Interventions to reduce acute paediatric hospital admissions: A systematic review. Arch Dis Child 2012;97(4):304-311. DOI:10.1136/archdischild-2011-301214 20. Ogilvie D. Hospital based alternatives to acute paediatric admission: A systematic review. Arch Dis Child 2005;90(2):138-142. DOI:10.1136/ adc.2003.035543 21. Macy ML, Kim CS, Sasson C, Lozon MM, Davis MM. Pediatric observation units in the United States: A systematic review. J Hosp Med 2010;5(3):172-182.

DOI:10.1002/jhm.592 22. Xie J, Lin Y, Kissoon N. Factors associated with prolonged stay in a pediatric emergency unit of an urban tertiary children’s hospital in China. Pediatr Emerg Care 2013;29(2):183-190. DOI:10.1097/PEC.0b013e3182809b64 23. Alpern ER, Calello DP, Windreich R, Osterhoudt K, Shaw KN. Utilization, and unexpected hospitalization rates of a pediatric emergency department 23hour observation unit. Pediatr Emerg Care 2008;24(9):589-594. DOI:10.1097/ PEC.0b013e3181850c80 24. Patrick M, Stephen C, eds. Saving Children 2005: A survey of child healthcare in South Africa. Pretoria: Child PIP group and MRC Unit for Maternal and Infant Health Care Strategies; 2007. MRC Unit for Maternal and Infant Health Care Strategies, 2007.

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RESEARCH

Infant hearing screening at primary healthcare immunisation clinics in South Africa: The current status L Petrocchi-Bartal, MA; K Khoza-Shangase, PhD Department of Speech Pathology and Audiology, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: K Khoza-Shangase (katijah.khoza@wits.ac.za) Background. In the developing world, it is critical that the acceptable principle that early hearing detection and intervention (EHDI) programmes be contextually useful, given the extensive level of difficulties faced by these regions. The Health Professions Council of South Africa (HPCSA) has recommended specific contexts in which to actualise EHDI application. One of these contexts relates to hearing screening at immunisation clinics within the first 6 weeks of life.

Objective. To explore the current status of the implementation of the HPCSA’s 2007 guidelines for clinic-based hearing screening within the South African primary healthcare clinic (PHC) setting.

Methods. Within a qualitative research design, 30 PHC nurses representing 30 PHC clinics in the North West and Gauteng Provinces were interviewed using a structured questionnaire. Qualitative as well as thematic content analysis strategies were adopted in analysing data.

Results. There is a lack of formal EHDI implementation at PHC clinics in both provinces. Lack of equipment, budgetary constraints and human resource challenges are the reasons for this. Regardless of the province’s socioeconomic development based on the deprivation index, EHDI implementation at clinic level is not feasible unless the barriers are addressed.

Conclusion. There is a need to ensure that context-specific studies in EHDI are conducted. This will ensure that national position statements are sensitive to contextual challenges and that they allow for evidence-based practice. This is particularly relevant in developing countries where resource constraints dictate the success or failure of any well-intentioned programme. The HPCSA’s 2007 position statement needs to be reviewed taking careful cognisance of feasibility study findings such as the current one. Findings have implications for nurses training, future studies, and policy formulation, as well as clinical plans for EHDI in developing contexts.

S Afr J Child Health 2016;10(2):138-142. DOI:10.7196/SAJCH.2016.v10i2.1114

The negative influence that impaired hearing has on a child’s development may be pervasive, affecting areas such as cognition,[1] language, educational, social and emotional competence,[2] literacy development,[3] as well as eventual vocational[4] and thus financial outcomes.[3-5] Decreased social burden and improved quality of life depend on the ability of a hearing screening programme to identify hearing problems in infants at the earliest opportunity. [6] Internationally, positing universal newborn hearing screening (UNHS) as a function of early hearing detection and intervention (EHDI) has been accepted as a measure of best practice pertaining to child healthcare[1] and has also been highlighted as the favoured approach for private and public sector hearing healthcare.[7,8] As they pertain to audiology, early intervention principles include a proposal for diagnosis of hearing impairment, with early intervention services effected by 6 months of age internationally,[9] and in South Africa (SA) by a maximum of 8 months of age.[10] Many developed countries[9] and some developing countries[11] have in fact promulgated hearing screening policy based on Joint Committee on Infant Hearing principles.[9] Most developing world contexts have not formally recognised the advantages that UNHS presents and have consequently not legislated any hearing screening protocols.[12] The reasons for the lack of EHDI in these contexts are uncertain and complex. One can deduce that additional burdens often endemic to areas such as subSaharan Africa, including poverty[4] and the burden of life-threatening diseases such as HIV/AIDS and TB,[13] are of influence. In these contexts, hearing impairment may be viewed as relatively less urgent, which renders EHDI implementation as low priority.[1] The acceptable precept that EHDI programmes must be contextually relevant is even more critical in the developing world, where the challenges faced are 139

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considerable when compared with developed world environments.[14] Within sub-Saharan Africa, only Nigeria and SA have documented evidence on aspects of EHDI as they apply within varying contexts in this part of the developing world.[15] In these countries, the available literature reveals a fragmented approach to gathering evidence, showing a need for systematic and thorough research into all aspects of EHDI. To date, not enough published evidence emanating from SA studies on EHDI exists; although this lacunae in the literature is slowly receiving increased attention. Three of these investigations are comparatively recent research efforts, with previous publications issued during the period 2006 to 2010. Within the private sector, Swanepoel et al.[16] explored newborn hearing screening in an SA private healthcare hospital, and Meyer et al.[17] investigated early detection of infant hearing loss in the SA private healthcare sector.

Scheepers et al.[18] examined the reasons parents in the SA context refuse hearing screening and default on follow-up screening. Four studies investigated different aspects of hearing screening within the government sector. Specifically, Swanepoel et al.[14] conducted a study on infant hearing screening (IHS) at immunisation clinics in SA, Theunissen and Swanepoel[19] investigated public health sector EHDI services in SA, Kanji et al.[20] conducted a retrospective review on hearing screening follow-up return rates in very-low-birth-weight infants, and Friderichs et al.[21] analysed the efficacy of a communitybased hearing screening programme utilising existing clinic staff in the Western Cape. Most recently, Khoza-Shangase and Harbinson[22] reported on the evaluation of UNHS in SA primary care. This paucity in evidence reflects a lack of realised hearing screening in different settings of community practice. As such, either directly or by implication, these studies recommend extensions of the current

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RESEARCH research scope for further expansion of knowledge in the field of EHDI in the SA context so as to enable the promulgation of evidencebased hearing screening protocols.

With appropriate combining of logistical and theoretical paradigms, key issues within the specific screening milieu must be identified and explored if inroads are to be made towards realising the ultimate aim of decreasing disability through application of a contextually relevant UNHS programme. The current study explored the feasibility of implementing the Health Professions Council of South Africa (HPCSA) 2007 guidelines for clinic based hearing screening in the SA primary healthcare clinic (PHC) setting.

Objective

The main objective of the study was to explore the feasibility of implementing the HPCSA’s 2007 guidelines for clinic-based hearing screening in the SA PHC setting. Specific objectives included establishing trends of the number of IHS programmes conducted at PHC immunisation clinics in the North West Province (NWP) and Gauteng Province (GP), as well as determining and exploring the possible factors considered to influence the implementation of IHS programmes at this level of healthcare.

Methods

Ethical clearance was secured from the University of the Witwatersrand’s Human Ethics Committee (Medical) (protocol no.: M091040). Through non-probability purposive sampling, 30 PHC, English-speaking clinic nurses in charge of 30 PHC immunisation clinics within the NWP and GP (15 per province) were recruited according to accessibility and according to the district demographic classification.[23] These nurses were either officially within the position of operations manager or acting operations manager, or heading the clinic at the time if the incumbent was unavailable for the interview.

The main reason the clinic manager was selected as interviewee was that being at the helm implies insight as to the detailed workings of the particular clinic in question. It is within these clinics where yield (actual immunisations generated out of the possible population in the area) is reported to be 91.8% in GP and 71.4% in the NWP. [23] Community nurses and lay volunteers within the maternal child woman’s health cluster provide services, including implementation of immunisation programmes. These clinics incorporate the specific targeted population of infants requiring immunisations at 6, 10 and 14 weeks, 9 and 18 months, and 5 years, and may be described as predominantly outpatient facilities.[24] As estimated from the Community Survey’s deprivation index,[25] the NWP population group is considered to be more disadvantaged socioeconomically than that of GP.[23] It is because of these demographic differences that the two provinces were selected, where these overall provincial differences were aimed at facilitating a ruralurban divide. These were considered to be useful for determining hearing healthcare outcome determinants within the context of the current study. Specific districts within these provinces were selected.

The research design adopted was qualitative in nature, with a questionnaire administered in a structured face-to-face interview with each participant. The interview location (for all interviews including those conducted for the pilot project) was the participant’s immunisation clinic. The interview schedule and questionnaire used were structured, where most questions presented were factual and closed ended. These were supplemented by several open-ended questions to enable documentation of free thought processes that the researcher transcribed verbatim. The questionnaire was adapted from a self-administered questionnaire previously used in a study conducted in a collaborative effort by EHDI SA, the Centre for Deaf Studies and Deaf Education, the University of Pretoria and the University of the Witwatersrand.[19] The structured questionnaire consisted of demographic information, information related to work 140

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context and hearing screening context, as well as information management and quality control measures. The interviews were also tape recorded. Data were collected via verbatim documentation of respondents’ answers and audio-taped recordings of interviews, which were transcribed. The researcher asked questions in numerical order to ensure consistency of format and organisation between interviews. Question explanation and probing was not applied beyond the methodological protocol in order to ensure consistency between interviews. Conducting consistent and structured interview sessions, as per the procedures delineated, ensured uniformity between and within interviews in order to enhance the study’s reliability.

Subject bias, such as the Hawthorne effect where participants have a heightened awareness that they form part of an evaluation process, may have influenced performance in the current study; however, the researcher attempted to minimise the impact of this by having verbally ensured participant confidentiality with regard to their responses, with the added assurance that their job security could not be affected in any way. The time frame for administering the structured interviews spanned a maximum of 1 hour per interview.

Data were analysed qualitatively and through thematic content analysis, where transcriptions were evaluated to determine and code the emerging themes. Quantitative data analysis, through the use of frequency calculations, was condensed into tabular format for ease of frequency comparison between regions. Comparisons and contrasts were evaluated between the two provincial sample groups and their sub-groups located in the NWP and GP. In order to ensure research reliability, controls were exercised pertaining to participant variables as well as with regard to those relating to the questionnaire used to obtain data. Careful control of the consistency of the interview procedures employed was also ensured. To further ensure reliability and validity, site observations as well as use of an independent rater during data analysis were done over and above a pilot study on three nurses who did not form part of the main study to pretest the data collection tool and procedures prior to the main study. The first author was the sole interviewer of the nurses; she visited the sites and was able to view and describe the facilities.

Results

Data from the current study allowed for a clear depiction of the current status of newborn IHS programmes conducted at PHC immunisation clinics in the NWP and GP. Furthermore, useful and practical rationale influencing implementation of such services was obtained. Thematic content analysis as well as qualitative descriptive data analysis allowed for themes to be drawn from the data, with frequencies for such themes (Tables 1 and 2).

As depicted in Table 1, none of the PHC clinics offer or provide formalised newborn IHS. All participants reported that their clinics did not have the equipment to provide hearing screening. Of further interest is that 40% of all respondents (8 GP and 4 NWP respondents) felt that general budgetary issues were plausible reasons for the absence of hearing screening services at their clinics, with an overwhelming majority of respondents (86.7%) regarding human resource (HR) constraints to be the major contributing factor to the lack of hearing screening services offered. Although only cited by 10% of respondents (3 NWP respondents), district issues (referred to as management decisions made at a district level) were considered to be an influence in rendering newborn IHS services. NWP respondents elaborated that if the matter was not sanctioned at a district level, provision of a hearing screening service would not be taken seriously and would not be implemented.

When comparing the number of newborn IHS between the two provinces, findings reflected that all GP respondents related the lack of newborn/IHS service delivery to HR issues, with 53.3% of GP respondents attributing lack of hearing screening services

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RESEARCH Table 1. Number of newborn/IHS programmes conducted/not conducted in each province and rationale (N=30) Issue

GP (n=15), n (%) NWP (n=15), n (%)

Total (N=30), n (%)

Is formalised hearing screening conducted?

No, 15 (100)

No, 15 (100)

No, 30 (100)

Is formalised hearing screening equipment available?

No, 15 (100)

No, 15 (100)

No, 30 (100)

Is budgetary allocation the reason for the above?

Yes, 8 (53.3) No, 0 (0) Maybe, 7 (46.7)

Yes, 4 (26.7) No, 1 (6.7) Maybe, 7 (46.7) District level issue, 3 (20)

Yes, 12 (40) No, 1 (3.3) Maybe, 14 (46.7) District level issue, 3 (10)

Is HR allocation the reason for the lack of formalised hearing screening?

Yes, 15 (100)

Yes, 11(73.3) No, 3 (20) Maybe, 1 (6.7)

Yes, 26 (86.7) No, 3 (10) Maybe, 1 (3.3)

Are HPCSA hearing screening guidelines followed?

No, 15 (100)

No, 15 (100)

No, 30 (100)

What equipment is used for hearing screening? (as per themes raised)

Otoscopic examination sometimes used

Discussion

Yes, 14 (93.3) No, 1 (6.7)

Yes, 14 (93.3) No, 1 (6.7)

Yes, 28 (93.3) No, 2 (6.7)

At Road to Health Chart immunisations or milestone review, baby’s behavioural responses to environmental sound stimuli incorporating noisemaker and/or verbal stimuli assessed Yes, 6 (40)

Yes, 3 (20)

Yes, 9 (30)

Reviewing of medical records when an auditory problem was indicated Yes, 10 (67)

Yes, 13 (86.7)

Yes, 23 (76.7)

Reviewing of medical records at Road to Health Chart immunisations or milestone review Are HPCSA hearing screening guidelines used?

Yes, 8 (53.3)

Yes, 11 (73.3)

Yes, 19 (63.3.3)

No, 15 (100)

No, 15 (100)

No, 30 (100)

Table 2. Number of newborn/his programmes and rationale – HR reasons provided (N=30)* HR issue/theme raised

appropriate training in newborn or IHS to be a central reason that influenced the provision of newborn/IHS services. This was followed by the staff shortages as mentioned by 13.3% of respondents. NWP highlighted a spread of HR related factors such as (but not limited to) budgetary issues and staff shortages.

GP (n=15), n (%)

NWP (n=15), n (%)

Total (N=30), n (%)

HR budgetary issue?

Theme not raised

Yes, 1 (6.7)

Yes, 1 (3.3)

Reduced staff training

10 (66.7)

3 (20)

13 (43.3)

Unspecified general budgetary issue

1 (6.7)

2 (13.3)

3 (10)

Staff shortage

2 (13.3)

2 (13.3)

4 (13.3)

Space

Theme not raised

1 (6.7)

1 (3.3)

Unsure

1 (6.7)

Theme not raised

1 (3.3)

* As respondents may not have elaborated spontaneously, or may have offered more than one alternative, frequency calculations may not be equal to n.

rendered to general budgetary constraints (referred to as general lack of government funding to PHC service providers). In contrast, 73.3% of NWP respondents related the lack of newborn IHS service delivery to HR issues, with 26.7% citing general

budgetary issues to the lack of such services rendered. Similar trends were present at a sub-district level. Table 2 shows results from further in-depth analysis of HR issues. The total sample (N=30), 43.3% of respondents (mainly from GP) considered the lack of 141

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Current findings revealed that no PHC clinics within the NWP and GP were conducting formalised hearing screening as promulgated by the HPCSA 2007 EHDI position statement. Budgetary and HR issues (mainly staff training and staff shortages) were highlighted as the main reasons for this lack of formalised hearing screening implementation. It appears that economic indicators may have impinged on logistical and operational factors such as the clinic’s physical structure, staff training, equipment availability and staff complement. The reported inequities in district finance distribution[26] may have contributed to the differences in responses obtained between provinces.

Current findings reveal a rather depressing picture about the feasibility of the implementation of the HPCSA 2007 position statement on EHDI at PHC clinics; a level of healthcare most accessible to the majority of the SA population. Inability and failure to implement EHDI has significant implications that have been well documented, although these are often not seen as an important health priority when the burden of disease is as high as it is in SA. Nonetheless, current findings are viewed in light of the WHO’s definition of health. The WHO defines health to not only encompass the absence of infirmity or disease, but to include the individual’s complete physical, mental and social wellbeing.[27] This reflects a tenet beyond the concept of survival and emphasises the urgent need for EHDI to improve life outcomes beyond existence for those infants with hearing loss. Early hearing intervention services, inclusive of early identification, are considered the foundation for attaining most favourable results in infants with hearing loss.[28] Unfortunately, the generally less resourced public healthcare sector within SA’s developing world context, is the option upon which 85% of the population relies.[28] If current findings are replicated throughout SA’s nine provinces; a less than favourable picture is drawn for the public sector. Arguably one might rationalise these findings when considering the burden of disease. Globally, SA has one of the highest burden of TB and HIV/AIDS.[29] These diseases continue to receive precedance over non life- threatening conditions such as hearing loss.[1] EHDI services within the SA context, are in their infancy with very little

ARTICLE contextually relevant evidence for their efficacy and applicability.[30] A paucity of scientific data as well as a lack of investigative studies into EHDI implementation in the SA context prevails.[16,18] Current findings highlight and provide evidence that supports the importance of advocating for the responsibility of legislation mandating EHDI, which is currently lacking.[28] Current evidence indicates that primary alerts to possible hearing loss lie with the caregiver. Here their concerns may relate to speech-language delays, atypical behaviour or otitis media complications.[15] Hearing screening is not occurring at PHC clinics and this is where most mothers or caregivers take their infants and neonates for healthcare.

As per the HPCSA recommendations, the current study aimed to provide supportive contextual evidence as input to concretely guide the SA EHDI actualisation process. Fundamental to the current study was specific consideration to theoretical constructs and clinical outcomes in the SA PHC immunisation clinic context. Based on the current findings, it can be strongly argued that implementing the HPCSA’s EHDI clinic guidelines does not appear feasible at this stage because of the overriding barriers revealed, although assets within the PHC immunisation context were identified. These central barriers, which included reduced clinic infrastructure and resources and reduced staff complement and training, preclude successful EHDI implementation. An overwhelming 86.7% of the participants reported HR constraints, 40% presented budget challenges, 43.3% believed lack of appropriate training in EHDI the significant barriers which should be taken seriously. A range of assets were identified and these included overall respondent willingness to implement formalised hearing screening as part of the PHC immunisation schedule. Other assets included patient return rates for immunisation, highlighting the favourable context the immunisation programme offers in terms of high patient yield. This is regarded as fundamental in a UHS programme.[15] The unexpected differences between provinces and districts within provinces, with specific mention by NWP of the important role of district level governance may be related to differences within the specific regional and district management styles and priorities, especially given the greater level of authority the individual district is now able to exercise.[26] Within the Department of Health (DoH) strategic plan, decentralised management of health districts has been strengthened for improved local accountability. [26] The HPCSA 2007 position statement recommends inclusion of the responsible DoH agency to jointly facilitate the appropriate hearing screening programme. [10] In this instance, it would appear that district level direct involvement in recommended hearing screening protocols is paramount in terms of the hearing screening programme’s fit and application, where newborn/IHS may need to be more flexibile than implied

by HPCSA 2007 recommended protocols. In addition, not only has inequity in DoH provincial financing been described, but inequality in DoH district financing has also been reported.[25] Swanepoel et al.[28] acknowledge that the SA public health sector is often less resourced than the state-of-the-art private health care sector. Theunissen and Swanepoel[19] refer to a lack of equipment and staff shortages as the major contributing factors to reduced NHS services in the SA context, evidence that is consistent with current findings. What was unexpected was the extent to which the lack of staff training was cited as the main contributing reason for the lack of newborn/IHS service provision at a PHC level.

It is therefore recommended that district level DoH financing, participation and autonomy be considered when negotiating inclusion of newborn/IHS services with varied government level departments. It is suggested that specific DoH district policies and protocols be investigated in depth to ascertain specific levels of district financing and autonomy and how these relate to hearing healthcare service delivery.

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Although current findings have significance in the EHDI initiatives in SA, they should be interpreted with due consideration of study design and analysis limitations identified. Firstly; the sample size of 30 clinics in only two provinces limits the generalisability of the findings. and this is raised as an implication for future studies.

Secondly, this study only focused at one level of care, that of PHC. One can argue, although without evidence, that hearing screening occurs at other levels of healthcare such as secondary and tertiary levels. This is an implication for future studies.

Conclusion

Current findings at PHC/clinic level highlight the importance of carefully constructed studies investigating the feasibility of HPCSA 2007 protocol implementation. Continuously assessing feasibility of guidelines and/or position statements not only ensures evidencebased practice; but also enforces programme implementation that is contextually relevant and specific at any given point in time.

This is particularly true where programme implementation can be significantly influenced by barriers such as resource allocations.

Acknowledgements. A faculty ad hoc grant and a faculty research promotion grant from the University of the Witwatersrand were received and enabled this research to be conducted.

References 1. Olusanya BO. Can the world’s infants with hearing loss wait? Int J Pediatr Otorhinolaryngol 2005;69:735-738. DOI:10.1016/j.ijporl.2005.03.024 2. Northern JL, Downs MP. Hearing in Children. 4th ed. Baltimore: Williams & Wilkins; 1991:28-31.

3. DesJardin JL, Ambrose SE, Martinez AS, Eisenberg LS. Relationships between speech perception abilities and spoken language skills in young children with hearing loss. Int J Audiol 2009;48(5):248-259. DOI:10.1080/14992020802607423 4. Olusanya BO. Hearing impairment prevention in developing countries: making things happen. Int J Pediatr Otorhinolaryngol 2000;55(3):167-171.

DOI:10.1016/S0165-5876(00)00392-X 5. Olusanya BO, Ruben R, Parving A. Reducing the burden of communication disorders in the developing world: An opportunity for the millenium development project. J Am Med Assoc 2006;296:441-444. DOI:10.1001/ jama.296.4.441 6. Hutt N, Rhodes C. Post-natal hearing loss in universal neonatal hearing screening communities: Current limitations and future directions. J Pediatr Child Health 2008;44(3):87-91. DOI:10.111/j.1440-1754.2007.01275.x 7. Joint Committee on Infant Hearing. Year 2000 position statement: Principles and guidelines for early hearing detection and intervention programs.

Pediatrics 2000;106(4):798-817. DOI:10.1044/1059-0889(2000/005) 8. Olusanya BO, Luxon LM, Wirz SL. Screening for early childhood hearing loss in Nigeria. J Med Screen 2005;12(3):115-118. DOI:10.1258/0969141054855274 9. Joint Committee on Infant Hearing Screening. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 2007;120(4):898-92. DOI:10.1542/peds.2007-2333 10. Health Professions Council of South Africa. Early Hearing Detection and Intervention Programmes in South Africa, Position Statement Year 2007. http://www.hpcsa.co.za/hpcsa/UserFiles/Files/Speech%20language%20and% 20hearing/EHDI5position%20statement%20(HPCSA%2007).pdf (accessed 29 October, 2010) 11. Yee-Arellano HM, Leal-Garza F, Pauli-Muller K. Universal newborn hearing screening in Mexico: Results of the first 2 years. Int J Pediatr Otorhinolaryngol 2006;70:1863-1870.

12. Olusanya BO. Addressing the global neglect of childhood hearing impairment in developing countries. PLoS Med 2007;4(4):626-630. DOI:10.1371/journal. pmed.0040074 13. Streefland P. Public health care under pressure in sub-Saharan Africa. Health Policy 2005;71(3):375-382. DOI:10.1016/j.healthpol.2004.06.002 14. Swanepoel de W, Louw B, Hugo R. A novel service delivery model for infant hearing screening in developing countries. Int J Audiol 2007;46(6):321-327.

DOI:10.1080/14992020601188583 15. Olusanya BO, Okolo AA. Early hearing detection at immunization clinics in developing countries. Int J Pediatr Otorhinolaryngol 2006;70(8):1495-1498.

DOI:10.1016/j.ijporl.2006.04.002 16. Swanepoel D, Ebrahim S, Joseph A, Friedland PL. Newborn hearing screening in a South African private health care hospital. Int J Pediatr Otorhinolaryngol 2007;71(6):881-887. DOI:10.1016/j.ijporl.2007.02.009 17. Meyer ME, Swanepoel DW, Le Roux TL, Van der Linde M. Early detection of infant hearing loss in the private health care sector of South Africa. Int J Otorhinolaryngol 2012;76(5):698-703. DOI:10.1016/j.ijporl.2012.02.023 18. Scheepers LJ, Swanepoel DW, Le Roux TL. Why parents refuse newborn

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RESEARCH hearing screening and default on follow-up rescreening â&#x20AC;&#x201C; A South African perspective. Int J Pediatr Otorhinolaryngol 2014;78(4):652-658. DOI:10.1016/ j.jporl.2014.01.026 19. Theunissen M, Swanepoel DW. Early hearing detection and intervention services in the public health sector in South Africa. Int J Audiol 2008;47(Supplement1):S23-S29. DOI: 10.1080/14992020802294032 20. Kanji A, Khoza-Shangase K, Ballot D. Hearing screening follow-up return rate in a very low birth weight project: A retrospective record review. S Afr J Child Health 2010;4(4):95-99.

21. Friderichs N, Swanepoel DW, Hall J. Efficacy of a community-based hearing screening program utilizing existing clinic personnel in Western Cape, South Africa. Int J Pediatr Otorhinolaryngol 2012;76(4):552-559. DOI:10.1016/j. ijporl.2012.01.015 22. Khoza-Shangase K, Harbinson S. Evaluation of universal newborn hearing screening in South African primary care, African Journal of Primary Health Care & Family Medicine 2015;7(1):12. DOI:10.4102/phcfm.v7i1.769 23. Day C, Gray A. Indicators: Health and Related Indicators. South Africa Health Review 2008. Durban: The Health Systems Trust, 2008.

24. Office of the President, K Motlanthe. SA yearbook 2008/2009, health chapter

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12. In: Burger D, ed. SA Yearbook 2008/2009, 16th ed. Pretoria: Government Communication and Information System (GCIS), 2009:310-331.

25. Statistics South Africa. Community Survey 2007 (revised version), (Statistical Release P30301). Pretoria: Statistics South Africa, 2007. http://www.statssa.gov.za/ PublicationsHTML/P03112997/html/P030112007.html (accessed 16 June 2010).

26. National Department of Health, South Africa. Strategic plan 2010/11 2012/13. Pretoria: NDoH, 2010. http://www.nationalplanningcycles.org/sites/ default/files/country_docs/South%20Africa/south_africa_strategic_health_ plan_2010-2013.pdf (accessed 29 May 2010).

27. World Health Organization. WHO definition of health, 2003. http://who.int/ about/definition/en/print.html (accessed 1 July 2010).

28. Swanepoel D, Storbeck C, Friedland P. Early hearing detection and intervention in South Africa. Int J Pediatr Otorhinolaryngol 2009;73(6):783-786.

DOI:10.1016/j.ijporl.2009.01.007 29. Matjila MJ, Hoosen AA, Stolz A, Cameron N. STIs, HIV and TB: Progress and challenges. In: Barron P, Roma-Reardon J, eds. South African Health Review.

Durban: Health Systems Trust, 2008.

30. Swanepoel DC, Delport SD, Swart GJ. Universal newborn hearing screening in South Africa - a first-world dream? S Afr Med J 2004;94(8):634-635.

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CPD July 2016 CPD questionnaires must be completed online at www.mpconsulting.co.za

True (T) or False (F): Regarding South African adolescentsâ&#x20AC;&#x2122; knowledge of abortion legislation, and attitude to abortion 1. The majority of adolescents considered abortion an acceptable option for pregnancy.

2. Only 10% of adolescents were aware of the period of gestation when termination is allowed.

3. Information on the basic aspects of reproductive rights should be central to Life Orientation classes in schools.

Regarding adolescent preventive services 4. Anticipatory guidance and preventive services should be offered to adolescents during routine clinical practice.

5. Adolescents make up one-fifth of the population in Nigeria.

Regarding iron deficiency in primary school learners 6. Iron deficiency anaemia is associated with a high serum ferritin level.

7. In primary school learners in the Pretoria region, iron deficiency is the most common cause of anaemia.

8. Children with iron deficiency anaemia perform less well than controls in learning areas such as life skills and language.

Regarding the early diagnosis and treatment (EIDT) of HIV in infants 9. In 2013 it was estimated that ~25% of children <15 years old living with HIV in sub-Saharan Africa were on antiretroviral therapy.

10. EIDT aims to identify and test all HIV-exposed infants and commence treatment of those infected by 24 months of age.

Regarding dermatological conditions seen in a specialised outpatient clinic in KwaZulu-Natal 11. Two-thirds of children referred to a dermatology clinic have the correct diagnosis made by the referring doctor.

12. Infective skin conditions are the most common cause for referral.

Regarding cochlear implantation in South Africa 13. Globally ~1:175 babies are born with hearing impairment.

14. Cochlear implantation is only available in the private health sector in SA. Regarding dysphagia in neonates 15.

Tube feeding is an effective management of oropharyngeal dysphagia in neonates.

16.

A modified barium swallow is considered an appropriate diagnostic aid in the diagnosis of dysphagia in neonates.

Regarding short-stay ward admissions in the Cape Peninsula 17. Preventable or treatable diseases make up 75% of all under-5 deaths in South Africa.

18. The Western Cape has the least variation in under-5 mortality between regions of all the provinces in South Africa.

Regarding infant hearing screening 19. Formalised hearing tests in infants are conducted in the majority of primary healthcare clinics in Gauteng.

20. In planning early hearing detection and intervention programmes, district health structures need to be consulted and involved.

A maximum of 3 CEUs will be awarded per correctly completed test.

CPD questionnaires must be completed online via www.mpconsulting.co.za. After submission you can check the answers and print your certificate. Accreditation number: MDB015/177/02/2016 (Clinical)

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