Juliet Iwelunmor

An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective

BackgroundSub-Saharan African (SSA) countries are currently experiencing one of the most rapid epidemiological transitions characterized by increasing urbanization and changing lifestyle factors. This has resulted in an increase in the incidence of non-communicable diseases, especially cardiovascular disease (CVD). This double burden of communicable and chronic non-communicable diseases has long-term public health impact as it undermines healthcare systems.PurposeThe purpose of this paper is to explore the socio-cultural context of CVD risk prevention and treatment in sub-Saharan Africa. We discuss risk factors specific to the SSA context, including poverty, urbanization, developing healthcare systems, traditional healing, lifestyle and socio-cultural factors.MethodologyWe conducted a search on African Journals On-Line, Medline, PubMed, and PsycINFO databases using combinations of the key country/geographic terms, disease and risk factor specific terms such as diabetes and Congo and hypertension and Nigeria. Research articles on clinical trials were excluded from this overview. Contrarily, articles that reported prevalence and incidence data on CVD risk and/or articles that report on CVD risk-related beliefs and behaviors were included. Both qualitative and quantitative articles were included.ResultsThe epidemic of CVD in SSA is driven by multiple factors working collectively. Lifestyle factors such as diet, exercise and smoking contribute to the increasing rates of CVD in SSA. Some lifestyle factors are considered gendered in that some are salient for women and others for men. For instance, obesity is a predominant risk factor for women compared to men, but smoking still remains mostly a risk factor for men. Additionally, structural and system level issues such as lack of infrastructure for healthcare, urbanization, poverty and lack of government programs also drive this epidemic and hampers proper prevention, surveillance and treatment efforts.ConclusionUsing an African-centered cultural framework, the PEN3 model, we explore future directions and efforts to address the epidemic of CVD risk in SSA.

Family Systems and HIV/AIDS in South Africa

This study examines the role of family in the care and support of people living with HIV/AIDS (PLWHA) as a way of reducing the burden of stigma in the family. The PEN-3 model provided the cultural framework for this study. Data were drawn from participants responses in 27 focus groups interviews conducted in South Africa. Participants were asked to discuss experiences of people living with HIV and AIDS in the family. The results highlight the positive and supportive aspects of the family, acknowledge the existential and unique aspects, and discuss the negative experiences shared by participants. This studys findings stress the need to take into account families experiences with HIV and AIDS in the development of interventions aimed at reducing the burden of the disease on family systems and improving care and support for PLWHA.

“My Mother Told Me I Must Not Cook Anymore”—Food, Culture, and the Context of HIV− and AIDS-Related Stigma in Three Communities in South Africa

The purpose of this study was to examine the role of food as an instrument in expressing and experiencing HIV/AIDS stigma by HIV-positive women and their families, with the goal of reducing discrimination. It goes beyond willingness to share utensils, which has been identified in HIV/AIDS research. As part of an ongoing capacity-building HIV/AIDS stigma project in South Africa, 25 focus groups and 15 key informant interviews were conducted among 195 women and 54 men in three Black communities. Participants were asked to discuss how they were treated in the family as women living with HIV and AIDS, and data was organized using the PEN-3 model. Findings highlight both the positive and negative experiences HIV-positive women encounter. Women would not disclose their HIV status to avoid being isolated from participating in the socio-cultural aspects of food preparation, while others that have disclosed their status have experienced alienation. The symbolic meanings of food should be a major consideration when addressing the elimination of HIV/AIDS stigma in South Africa.

Cultural implications of death and loss from AIDS among women in South Africa.

Over 1.8 million people have died of AIDS in South Africa, and it continues to be a death sentence for many women. The purpose of this study was to examine the broader context of death and loss from HIV/AIDS and to identify the cultural factors that influenced existing beliefs and attitudes. The participants included 110 women recruited from 3 communities in South Africa. Focus group methodology was used to explore their perceptions surrounding death and loss from HIV/AIDS. Using the PEN-3 cultural model, our findings revealed that there were positive perceptions related to how women cope and respond to death and loss from HIV/AIDS. Findings also revealed existential responses and negative perceptions that strongly influence how women make sense of increasing death and loss from HIV/AIDS. In the advent of rising death and loss from HIV/AIDS, particularly among women, interventions aimed at reducing negative perceptions while increasing positive and existential perceptions are needed. These interventions should be tailored to reflect the cultural factors associated with HIV/AIDS.

Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana

Background Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage (HIC) alone versus a nurse-led task shifting strategy for hypertension control (TASSH) plus HIC on systolic blood pressure (SBP) reduction among patients with uncontrolled hypertension in Ghana. Methods and findings Using a pragmatic cluster randomized trial, 32 community health centers within Ghana’s public healthcare system were randomly assigned to either HIC alone or TASSH + HIC. A total of 757 patients with uncontrolled hypertension were recruited between November 28, 2012, and June 11, 2014, and followed up to October 7, 2016. Both intervention groups received health insurance coverage plus scheduled nurse visits, while TASSH + HIC comprised cardiovascular risk assessment, lifestyle counseling, and initiation/titration of antihypertensive medications for 12 months, delivered by trained nurses within the healthcare system. The primary outcome was change in SBP from baseline to 12 months. Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months. Of the 757 patients (389 in the HIC group and 368 in the TASSH + HIC group), 85% had 12-month data available (60% women, mean BP 155.9/89.6 mm Hg). In intention-to-treat analyses adjusted for clustering, the TASSH + HIC group had a greater SBP reduction (−20.4 mm Hg; 95% CI −25.2 to −15.6) than the HIC group (−16.8 mm Hg; 95% CI −19.2 to −15.6), with a statistically significant between-group difference of −3.6 mm Hg (95% CI −6.1 to −0.5; p = 0.021). Blood pressure control improved significantly in both groups (55.2%, 95% CI 50.0% to 60.3%, for the TASSH + HIC group versus 49.9%, 95% CI 44.9% to 54.9%, for the HIC group), with a non-significant between-group difference of 5.2% (95% CI −1.8% to 12.4%; p = 0.29). Lifestyle behaviors did not change appreciably in either group. Twenty-one adverse events were reported (9 and 12 in the TASSH + HIC and HIC groups, respectively). The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits, if any, of the TASSH + HIC group. Conclusions Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone, among patients with uncontrolled hypertension in Ghana. Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost–benefit analysis. Trial registration ClinicalTrials.gov NCT01802372

Transferring Stroke Knowledge from Children to Parents: A Systematic Review and Meta-Analysis of Community Stroke Educational Programs

BACKGROUNDnThe purpose of this systematic review and meta-analysis on child-to-parent communication of stroke information (Child-Mediated Stroke Communication, CMSC) is to provide the highest levels of evidence supporting the role of this approach in community education.nnnMETHODSnDatabases such as PubMed, Google Scholar, PsycINFO, Web of Science, MEDLINE, and CINHAL were searched to gather information on CMSC followed by a meta-analysis. The eligibility criteria were as follows: (a) children aged 9-15years and parents, (b) randomized or nonrandomized trials, and (c) outcome variables that included the proportions of parents answering the pretest and post-test on stroke knowledge regarding risk factors, symptoms, and what to do in the event of stroke.nnnRESULTSnOf the 1668 retrieved studies, 9 articles were included. Meta-analytical findings yielded that the proportions of correct answers for stroke symptoms and its risk factors among parents were 0.686 (95% CI: 0.594-0.777) at baseline and increased to 0.847 (95% CI: 0.808-0.886) at immediate post-test and 0.845 (95% CI: 0.804-0.886) delayed post-test. The proportions of correct answers for behavioral intent to call 911 when witnessing stroke was 0.712 (95% CI: 0.578-0.846) at baseline, rising to 0.860 (95% CI: 0.767-0.953) at immediate post-test, and 0.846 (95% CI: 0.688-1.004) at delayed post-test.nnnCONCLUSIONSnCMSC is effective for educating families. More work is needed to increase the use of validated stroke literacy instruments and behavioral theory, and to reduce parental attrition in research studies.

Determinants of HIV testing and receipt of test results among adolescent girls in Nigeria: The role of assets and decision-making

Abstract Purpose Many adolescent girls in Nigeria do not test for HIV despite being at high risk. While the influence of psychosocial factors on HIV testing has been examined, there is less evidence regarding the impact of assets and control of assets on HIV testing. This study investigated the protective effects of specific adolescent girls’ assets on decision-making regarding HIV testing. Methods Cross-sectional data from the 2013 Nigeria Demographic and Health Survey was analyzed. The main outcome variables were self-reports of having been tested for HIV and knowledge of a place that offers HIV testing. Binary logistic regression was used with employment, education, wealth index, home ownership, land ownership and decision making as potential predictors. Demographic characteristics were controlled in the analysis. Results Age [odds ratio (OR = 1.49)], employment (OR = 3.38), education (OR = 3.16), wealth index (OR = 1.33) and decision making (OR = 3.16) were positively associated with HIV testing. Age (OR = 1.20), employment (OR = 1.33), education (OR = 1.38), wealth (OR = 1.64), land ownership (OR = 1.42), and decision making (OR = 1.26) were positively associated with knowledge of an HIV testing location. Conclusion Our findings suggest that assets play an important role with HIV testing decisions for adolescent girls. Further research to elucidate the specific asset-based needs of adolescent girls will be needed to enhance decisions surrounding uptake of HIV testing and receipt of test results in Nigeria.

Freedom to Make Choices for Health: Plus 40 Years

In the 1969 inaugural issue of the School Health Review, Douglass (1) examined four major issues he felt were central to the question of choices one has about health: (1) problems with health care delivery methods; (2) persistent poverty in our population and its impact on health; (3) systemic problems inherent in social and institutional arrangements, what he referred to as the network of health and health related pathologies; and (4) difficulty communicating or clarifying values in society, as evidenced by our failure to reconcile the values we preach with the health care that we practice. To begin his thesis, he argued that a person must be understood as a totality rather than as a sum of component parts. To address this perspective, he believed that health professionals must embrace a multidisciplinary approach to health care. W.E.B. Dubois had expressed the same opinion in a study 70 years earlier, addressing a health system which compared the health statistics of blacks with those of whites. Even then, he challenged us to focus on the absolute condition rather than their relative status. (2(p. 148)) To provide some historical context for the time in which Douglass paper was written, we gathered statistics on key health indicators such as poverty rate, life expectancy and infant mortality. Poverty rate is a key indicator that defines the very notion of choice and freedom, In 1966, whereas the poverty rate for blacks was 41.8% compared to just 11.3% for whites, in 2008, the poverty rate for blacks was 24.7% and 8.6% for whites. (3) As one could assume, the gaps remain for the other health indicators. In 1960, life expectancy was 70.6 years for whites and just 63.6 years for blacks. (4) Nearly 40 years later, there was still inequity between the two groups. In 2007, life expectancy was 78.3 years for whites and 73.7 years for blacks. (5) Infant mortality rate (IMR) followed a similar pattern. In 1960, IMR was 22.9 for whites and 44.3 for blacks; (6) the IMR in 2005 was 5.76 for whites and 13.63 for blacks. (7) Although many of these overall statistics have improved remarkably over the last few decades, persistent gaps remain between whites and blacks. With all of the progress in the field of health care over the last three decades, why do these staggering statistical differences still exist? These gaps reveal intergroup differences as well as intra-group differences that are not commonly examined. Intra-group differences, as will be seen later, often correspond to systemic problems that remained unaddressed. Are we free to make choices for health? When Douglass asked this question in 1969, he proposed that the inherent structure of the system makes it impossible for individuals to select health. Therefore, understanding the meaning of choice (i.e., right, power, or ability to decide among selections or alternatives) provides a potentially useful perspective in studying the persistent gaps in health inequity from the late 1960s, to today. Furthermore, the question of having choices in health care evokes memories of the 2009 town hall debates (or shouting matches, as it were), in which the question of health care reform became a polarizing discourse. This national debate is at the core of the question regarding choices for health care in the context of the four issues raised by Douglass: a broken down and unsustainable health care system, persistent poverty and the plight of the uninsured, health-related pathologies exemplified in the roles of the tobacco and food industries in todays health problems, and conflicts between American values (e.g., out of many, one; versus looking out for number one). When these four basic factors are combined, the issues of choice and freedom to choose boil down to a question of available options and the comparative benefits that may arise from each. Secondly, there is also the notion that health choices refer specifically to health care. Yet when we explore the context of health conditions, it is clear that health choices made long before clinical encounters create varying levels of vulnerability to ill health. …