Hazel Bradley

How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis.

Objective To quantify the effect of first-line antihypertensive treatment with beta-blockers on mortality, morbidity and withdrawal rates, compared with the other main classes of antihypertensive agents. Methods We identified eligible trials by searching the Cochrane Controlled Trials Register, Medline, Embase, reference lists of previous reviews, and contacting researchers. We extracted data independently in duplicate and conducted meta-analysis by analysing trial participants in groups to which they were randomized, regardless of subsequent treatment actually received. Results Thirteen trials with 91 561 participants, meeting inclusion criteria, compared beta-blockers to placebo (four trials; n = 23 613), diuretics (five trials; n = 18 241), calcium-channel blockers (CCBs) (four trials; n = 44 825), and renin–angiotensin system (RAS) inhibitors, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (three trials; n = 10 828). Compared to placebo, beta-blockers reduced the risk of stroke (relative risk 0.80; 95% confidence interval 0.66–0.96) with a marginal fall in total cardiovascular events (0.88, 0.79–0.97), but did not affect all-cause mortality (0.99, 0.88–1.11), coronary heart disease (0.93, 0.81–1.07) or cardiovascular mortality (0.93, 0.80–1.09). The effect on stroke was less than that of CCBs (1.24, 1.11–1.40) and RAS inhibitors (1.30, 1.11–1.53), and that on total cardiovascular events less than that of CCBs (1.18, 1.08–1.29). In addition, patients on beta-blockers were more likely to discontinue treatment than those on diuretics (1.80; 1.33–2.42) or RAS inhibitors (1.41; 1.29–1.54). Conclusion Beta-blockers are inferior to CCBs and to RAS inhibitors for reducing several important hard end points. Compared with diuretics, they had similar outcomes, but were less well tolerated. Hence beta-blockers are generally suboptimal first-line antihypertensive drugs.

Ability to manage diabetes—community health workers' knowledge, attitudes and beliefs

Background. Diabetes constitutes a significant health problem in South Africa. Early detection and good management can prevent or delay complications, with national guidelines for diabetes treatment now available to facilitate this. However, problems are being encountered with their implementation and there is evidence that preventive care is still inadequate in South Africa. Community health workers (CHWs) are lay personnel employed to serve as a link between professional health care staff and the community. They visit homes and can be a powerful force for diabetes prevention and adherence to treatment regimens, given appropriate knowledge. Method. We conducted a study to evaluate the knowledge, beliefs and attitudes of a group of CHWs serving a poor urban area, using focus groups and personal interviews. Results. The CHWs did not have the requisite knowledge, attitudes and beliefs to make a positive impact on prevention and management of diabetes. For example, they cited eating sugar as a cause of diabetes. They advised folk remedies that purportedly diluted the blood sugar. Their patients took prescribed medication irregularly. Obesity was not considered an important risk factor. Poverty, however, was recognised as an obstacle to proper treatment. Conclusion. Training is clearly needed to empower the CHWs with skills to work within their communities to identify risk factors for diabetes and other non-communicable diseases, with emphasis on diet and physical activity.

Emerging roles and competencies of district and sub-district pharmacists: a case study from Cape Town

BackgroundDistrict and sub-district pharmacist positions were created during health sector reform in South Africa. High prevalence of HIV/AIDS, tuberculosis and increasing chronic non-communicable diseases have drawn attention to their pivotal roles in improving accessibility and appropriate use of medicines at the primary level. This research describes new roles and related competencies of district and sub-district pharmacists in Cape Town.MethodsBetween 2008 and 2011, the author (HB) conducted participatory action research in Cape Town Metro District, an urban district in the Western Cape Province of South Africa, partnering with pharmacists and managers of the two government primary health care (PHC) providers. The two providers function independently delivering complementary PHC services across the entire geographic area, with one provider employing district pharmacists and the other sub-district pharmacists. After an initiation phase, the research evolved into a series of iterative cycles of action and reflection, each providing increasing understanding of district and sub-district pharmacists’ roles and competencies. Data was generated through workshops, semi-structured interviews and focus groups with pharmacists and managers which were recorded and transcribed. Thematic analysis was carried out iteratively during the 4-year engagement and triangulated with document reviews and published literature.ResultsFive main roles for district and sub-district pharmacists were identified: district/sub-district management; planning, co-ordination and monitoring of pharmaceuticals; information and advice; quality assurance and clinical governance; and research (district pharmacists)/dispensing at clinics (sub-district pharmacists). Although the roles looked similar, there were important differences, reflecting the differing governance and leadership models and services of each provider. Five competency clusters were identified: professional pharmacy practice; health system and public health; management; leadership; and personal, interpersonal and cognitive competencies. Whilst professional pharmacy competencies were important, generic management and leadership competencies were considered critical for pharmacists working in these positions.ConclusionsSimilar roles and competencies for district and sub-district pharmacists were identified in the two PHC providers in Cape Town, although contextual factors influenced precise specifications. These insights are important for pharmacists and managers from other districts and sub-districts in South Africa and inform health workforce planning and capacity development initiatives in countries with similar health systems.

Cochrane corner: beta-blockers for hypertension

Beta-blockers refer to an assorted group of medications that block the action of endogenous catecholamines on beta-adrenergic receptors.1 The β1 and β2 receptors are the primary beta-adrenergic receptors in the human cardiovascular system. Beta-blockers differ in their β1/β2-receptor selectivity and vasodilatory properties. Based on this diversity, beta-blockers have been categorised into first, second and third generation. First-generation beta-blockers, also referred to as non-selective blockers, possess equal affinity for β1 and β2 receptors. Second-generation (or selective) beta-blockers exercise more affinity for β1 than β2 receptors. Neither of these traditional beta-blockers has vasodilatory properties, which is an intrinsic characteristic of third-generation beta-blockers.2 Beta-blockers have been known to play a role in blood pressure control since 1949.3 We summarise the findings of a Cochrane Review we published in 2017 on the comparative effects of beta-blockers as initial treatment for hypertension.4 This is an update of a review we first published 10 years ago.5–7 ### Concise methods We searched the Cochrane Library, MEDLINE, EMBASE and ClinicalTrials.gov using a comprehensive database-specific …

Re-engineering of South Africa’s primary health care system: where is the pharmacist?

Abstract South Africa’s transition towards a district-based health system (DHS) aims to offer health promotion and prevention services at community level, through re-engineered primary health care (PHC) services. Along with pharmacy workforce shortages and service delivery challenges, health reform is a clarion call to strategically re-position the pharmacist’s role in DHS strengthening. The pharmacist’s involvement in the three DHS streams, namely the clinical specialist support teams, school health services and municipal ward-based PHC outreach teams, is pertinent. This paper contextualises pharmacists’ current peripheral role in the health system, discusses a team-based approach and identifies opportunities to integrate pharmacy students into the re-vitalised PHC framework. Re-positioning of pharmacists within district clinical specialist support and school health teams could create opportunities for community-based and population-based services whereby a range of clinical and pharmaceutical services could materialise. Pharmacy training institutions could strengthen the DHS through established partnerships with the community and health services. Academic service learning programmes could integrate pharmacy students as part of the PHC outreach teams to promote community health. Interdependence between the health services, pharmacy schools and the community would create a platform to contextualise learning and dismantle existing silos between them. Multi-sectoral engagement could enable pharmacy schools to design strategies to optimise pharmaceutical service delivery and align their activities towards social accountability.

Participatory Action Research in Pharmacy Practice

Participatory action research is part of a broad family of approaches and includes as its distinctive features action, reflection and partnership. In participatory action research, knowledge is created in the interplay between research and practice, thus requiring researchers to work with practitioners as active researchers and agents of change through iterative cycles of action and reflection. The purpose of participatory action research is to understand and effect change through generating new learning and knowledge whilst empowering participants. The approach facilitates in-depth understanding of issues in complex settings, which is perhaps not possible with narrower, traditional research approaches. Participatory action researchs emergent nature is particularly suited to research in changing circumstances, such as professional development of pharmacists or developing pharmacy services in new settings.