Search

Tuberculous meningitis (TBM) occurs when tuberculosis (TB) bacilli disseminate and seed into the meninges, triggering a severe inflammatory response that often leads to brain infarction. It is the most severe and debilitating form of childhood TB with high mortality, and children who survive TBM often suffer lifelong physical and neuro-disability resulting in emotional, social, and economic burdens for families. In the early stages the symptoms may be non-specific and so the diagnosis is often made late when the patient already has significant brain injury. To facilitate earlier diagnosis, it is important to understand how patients are evaluated. This study aimed to chart health systems for paediatric TBM care at both primary healthcare (PHC) and hospital level in Cape Town, South Africa. We conducted fourteen in-depth interviews and eight days of semi-structured observations of patient flow across eight healthcare facilities. We found that children with TBM navigate multiple levels of care categorised into pre-admission and primary care, hospital admission and inpatient care, and post-discharge follow-up care. Healthcare workers identified the following health system barriers along the TBM care pathway for children: limited post-training and mentorship opportunities to manage TBM, overburdened facilities, time constraints, lack of recognition of TBM symptoms, delays in referral between PHC and hospital, lack of standardized diagnostic algorithms, limited diagnostic tests and a lack of child-friendly, easy-to-administer treatment. Regular and compulsory training on TB and TBM in children, including continuous mentoring and support to healthcare workers working in child health and TB services in high TB-burden settings, can facilitate early recognition of symptoms and rapid referral for diagnosis. Algorithms outlining referral criteria for patients with possible TBM at both PHC facilities and district level hospitals can guide healthcare providers and facilitate timely referral between different levels of healthcare services. An integrated data system and alert functions could flag multiple healthcare visits and improve communication between different healthcare facilities during diagnosis and treatment. Children and families affected by TBM are an especially vulnerable sub-population requiring high priority attention and support., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Patience Baloyi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Computational audiology (CA) has grown over the last few years with the improvement of computing power and the growth of machine learning (ML) models. There are today several audiogram databases which have been used to improve the accuracy of CA models as well as reduce testing time and diagnostic complexity. However, these CA models have mainly been trained on single populations. This study integrated contextual and prior knowledge from audiogram databases of multiple populations as informative priors to estimate audiograms more precisely using two mechanisms: (1) a mapping function drawn from feature-based homogeneous Transfer Learning (TL) also known as Domain Adaptation (DA) and (2) Active Learning (Uncertainty Sampling) using a stream-based query mechanism. Simulations of the Active Transfer Learning (ATL) model were tested against a traditional adaptive staircase method akin to the Hughson-Westlake (HW) method for the left ear at frequencies ω = 0.25 , 0.5 , 1 , 2 , 4 , 8 kHz, resulting in accuracy and reliability improvements. ATL improved HW tests from a mean of 41.3 sound stimuli presentations and reliability of ± 9.02 dB down to 25.3 ± 1.04 dB. Integrating multiple databases also resulted in classifying the audiograms into 18 phenotypes, which means that with increasing data-driven CA, higher precision is achievable, and a possible re-conceptualisation of the notion of phenotype classifications might be required. The study contributes to CA in identifying an ATL mechanism to leverage existing audiogram databases and CA models across different population groups. Further studies can be done for other psychophysical phenomena using ATL., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Twinomurinzi, Myburgh and Barbour.)

Background: Brazil, India and South Africa are among the top 30 high TB burden countries globally and experienced high rates of SARS-CoV-2 infection and mortality. The COVID-19 response in each country was unprecedented and complex, informed by distinct political, economic, social and health systems contexts. While COVID-19 responses have set back TB control efforts, they also hold lessons to inform future TB programming and services., Methods: This was a qualitative exploratory study involving interviews with TB stakeholders ( n = 76) in Brazil, India and South Africa 2 years into the COVID-19 pandemic. Interview transcripts were analysed using an inductive coding strategy., Results: Political will - whether national or subnational - enabled implementation of widespread prevention measures during the COVID-19 response in each country and stimulated mobile and telehealth service delivery innovations. Participants in all three countries emphasised the importance of mobilising and engaging communities in public health responses and noted limited health education and information as barriers to implementing TB control efforts at the community level., Conclusions: Building political will and social mobilisation must become more central to TB programming. COVID-19 has shown this is possible. A similar level of investment and collaborative effort, if not greater, as that seen during the COVID-19 pandemic is needed for TB through multi-sectoral partnerships., Competing Interests: Conflicts of interest: none declared., (© 2023 The Union.)

Current antiretroviral therapy (ART) adherence monitoring is premised on patients' self-reported adherence behaviour (prone to recall error) and verified by blood viral load measurement (which can delay results). A newly developed Urine Tenofovir Rapid Assay (UTRA) assesses tenofovir in urine at point-of-care and is a novel tool to test and immediately respond to adherence levels of people living with HIV (PLHIV). We explored PLHIV and health workers' initial perceptions about integrating the UTRA into routine medical care for adherence support. We conducted a series of once-off in-depth qualitative interviews with PLHIV ( n  = 25) and health workers ( n  = 5) at a primary care health facility in Cape Town, South Africa. Data analysis involved descriptive summaries of key emergent themes with illustrative case examples. We applied a deductive, outcomes-driven analytic approach to the summaries using the Implementation Outcomes Framework proffered by Proctor et al. (2011). The three relevant concepts from this framework that guided our evaluation were: acceptability, appropriateness, and feasibility. We found positive perceptions about the UTRA from many PLHIV and health worker participants. Many PLHIV reported that the immediate results offered by the UTRA could enable them to have constructive discussions with health workers on how to resolve adherence challenges in real-time. Few PLHIV reported concerns that drinking alcohol could affect their UTRA results. Many health workers reported that the UTRA could help them identify patients at risk of treatment failure and immediately intervene through counselling, though some relayed that they would support the UTRA's implementation if more staff members could be added in their busy facility. Overall, these findings show that the UTRA was widely perceived to be acceptable and actionable by many PLHIV and health workers in the study.

Background: The global COVID-19 pandemic has reversed many of the hard-won gains made in TB programmes and the associated reduction in the number of TB deaths, case notifications and incidence over the last three decades. Modelling estimates show that the impact will be lasting. There are global calls to recover the shortfalls along the TB care cascade that have resulted from COVID-19, with the recognition that the COVID-19 response holds lessons to inform more robust and comprehensive TB programmes and services., Objective: To explore lessons from response measures to the COVID-19 pandemic in two high TB burden South African provinces., Design: This was an exploratory qualitative study. We conducted interviews with TB programme stakeholders (managers and facility-level staff: n = 35) between February and June 2022., Results: We identified eight facilitators of the COVID-19 response, including political will, rapid policy development, multi-sectoral collaboration, patient-centred models of care delivery, community engagement, mHealth and telehealth technologies, rigorous contact tracing and widespread mask wearing. Political will was singled out as a critical driver of the response., Conclusion: Leveraging COVID-19 inspired collaborations, technologies and avenues for health service delivery is an opportunity to maximise benefits for the TB programme. Reinvestment in national TB programmes and political prioritisation of TB are critical., (© 2023 The Union.)

Internet of things (IoT)-enabled wireless body area network (WBAN) is an emerging technology that combines medical devices, wireless devices, and non-medical devices for healthcare management applications. Speech emotion recognition (SER) is an active research field in the healthcare domain and machine learning. It is a technique that can be used to automatically identify speakers' emotions from their speech. However, the SER system, especially in the healthcare domain, is confronted with a few challenges. For example, low prediction accuracy, high computational complexity, delay in real-time prediction, and how to identify appropriate features from speech. Motivated by these research gaps, we proposed an emotion-aware IoT-enabled WBAN system within the healthcare framework where data processing and long-range data transmissions are performed by an edge AI system for real-time prediction of patients' speech emotions as well as to capture the changes in emotions before and after treatment. Additionally, we investigated the effectiveness of different machine learning and deep learning algorithms in terms of performance classification, feature extraction methods, and normalization methods. We developed a hybrid deep learning model, i.e., convolutional neural network (CNN) and bidirectional long short-term memory (BiLSTM), and a regularized CNN model. We combined the models with different optimization strategies and regularization techniques to improve the prediction accuracy, reduce generalization error, and reduce the computational complexity of the neural networks in terms of their computational time, power, and space. Different experiments were performed to check the efficiency and effectiveness of the proposed machine learning and deep learning algorithms. The proposed models are compared with a related existing model for evaluation and validation using standard performance metrics such as prediction accuracy, precision, recall, F1 score, confusion matrix, and the differences between the actual and predicted values. The experimental results proved that one of the proposed models outperformed the existing model with an accuracy of about 98%.

Tuberculosis (TB) is a leading cause of death globally. In 2015, the World Health Organization hailed patient-centred care as the first of three pillars in the End TB strategy. Few examples of how to deliver patient-centred care in TB programmes exist in practice; TB control efforts have historically prioritised health systems structures and processes, with little consideration for the experiences of people affected by TB. We aimed to describe how patient-centred care interventions have been implemented for TB, highlighting gaps and opportunities. We conducted a scoping review of the published peer-reviewed research literature and grey literature on patient-centred TB care interventions between January 2005 and March 2020. We found limited information on implementing patient-centred care for TB programmes (13 research articles, 7 project reports, and 19 conference abstracts). Patient-centred TB care was implemented primarily as a means to improve adherence, reduce loss to follow-up, and improve treatment outcomes. Interventions focused on education and information for people affected by TB, and psychosocial, and socioeconomic support. Few patient-centred TB care interventions focused on screening, diagnosis, or treatment initiation. Patient-centred TB care has to go beyond programmatic improvements and requires recognition of the diverse needs of people affected by TB to provide holistic care in all aspects of TB prevention, care, and treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Myburgh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: South Africa has one the highest TB and HIV burdens globally. TB preventive therapy (TPT) reduces the risk of TB disease and TB-related mortality in adults and children living with HIV and is indicated for use in TB-exposed HIV-negative individuals and children. TPT implementation in South Africa remains suboptimal., Methods: We conducted a pragmatic review of TPT implementation using multiple data sources, including informant interviews ( n = 134), semi-structured observations ( n = 93) and TB patient folder reviews in 31 health facilities purposively selected across three high TB burden provinces. We used case descriptive analysis and thematic coding to identify barriers and facilitators to TPT implementation., Results: TPT programme implementation was suboptimal, with inadequate monitoring even in health districts with well-functioning TB services. Health workers reported scepticism about TPT effectiveness, deprioritised TPT in practice and expressed divergent opinions about the cadres of staff responsible for implementation. Service- and facility-level barriers included ineffective contact tracing, resource shortages, lack of standardised reporting mechanisms and insufficient patient education on TPT. Patient-level barriers included socio-economic factors., Conclusions: Improving TPT implementation will require radically simplified and more feasible systems and training for all cadres of health workers. Partnership with communities to stimulate demand driven service uptake can potentially facilitate implementation., Competing Interests: Conflicts of interest: none declared., (© 2022 The Union.)

Stigma is a critical barrier for TB care delivery; yet data on stigma reduction interventions is limited. This review maps the available literature on TB stigma reduction interventions, using the Health Stigma and Discrimination framework and an implementation analysis to identify research gaps and inform intervention design. Using search terms for TB and stigma, we systematically searched PubMed, EMBASE and Web of Science. Two independent reviewers screened all abstracts, full-texts, extracted data, conducted a quality assessment, and assessed implementation. Results were categorized by socio-ecological level, then sub-categorized by the stigma driver or manifestation targeted. After screening 1865 articles, we extracted data from nine. Three studies were implemented at the individual and interpersonal level using a combination of TB clubs and interpersonal support to target internal and anticipated stigma among persons with TB. Two studies were implemented at the interpersonal level using counselling or a video based informational tool delivered to households to reduce stigma drivers and manifestations. Three studies were implemented at the organizational level, targeting drivers of stigma among healthcare workers (HW) and enacted stigma among HWs. One study was implemented at the community level using an educational campaign for community members. Stakeholder consultation emphasized the importance of policy level interventions and education on the universality of risk to destigmatize TB. Review findings suggest that internal and anticipated TB stigma may be addressed effectively with interventions targeted towards individuals using counselling or support groups. In contrast, enacted TB stigma may be better addressed with information-based interventions implemented at the organizational or community level. Policy level interventions were absent but identified as critical by stakeholders. Implementation barriers included the lack of high-quality training and integration with mental health services. Three key gaps must be addressed in future research: consistent stigma definitions, standardized stigma measurement, and measurement of implementation outcomes., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2022 Foster et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: The objective of this study was to examine the uptake, user characteristics, and performance of the free WHO smartphone hearing screening test ( hearWHO ) as a global hearing health promotion initiative., Method: We retrospectively examined the data of 242 626 tests conducted by adults (> 18 years) on the hearWHO app between February 2019 and May 2021. Test uptake was evaluated by country, WHO world region, test date, and demographics of age and gender., Results: The hearWHO test was completed in nearly every country globally ( n  = 179/195), with the greatest uptake seen in China and India. Uptake was greatest in the Western Pacific (32.9%) and European (24.8%) WHO regions. There was a high uptake of tests (44%) by young adults under the age of 30 years. Referral rates were typically higher for older age groups in most WHO regions, except for the African and Eastern Mediterranean regions, where overall hearWHO test uptake was lowest. Most testing (49%) took place in March (2019-2021) coinciding with World Hearing Day (3rd of March) each year., Conclusions: Digital mhealth tools provide many benefits in healthcare, including health promotion, access to information, and services for hearing loss. The hearWHO test was mainly reaching younger adults, positioning it as an important measure for public health advocacy to prevent hearing loss. Since hearing loss is primarily age related, more targeted campaigns or community-based initiatives should be directed toward older adults., (© The Author(s) 2022.)

Background: Otitis media includes several common inflammatory conditions of the middle ear that can have severe complications if left untreated. Correctly identifying otitis media can be difficult and a screening system supported by machine learning would be valuable for this prevalent disease. This study investigated the performance of a convolutional neural network in screening for otitis media using digital otoscopic images labelled by an expert panel., Methods: Five experienced otologists diagnosed 347 tympanic membrane images captured with a digital otoscope. Images with a majority expert diagnosis ( n = 273) were categorized into three screening groups Normal, Pathological and Wax, and the same images were used for training and testing of the convolutional neural network. Expert panel diagnoses were compared to the convolutional neural network classification. Different approaches to the convolutional neural network were tested to identify the best performing model., Results: Overall accuracy of the convolutional neural network was above 0.9 in all except one approach. Sensitivity to finding ears with wax or pathology was above 93% in all cases and specificity was 100%. Adding more images to train the convolutional neural network had no positive impact on the results. Modifications such as normalization of datasets and image augmentation enhanced the performance in some instances., Conclusions: A machine learning approach could be used on digital otoscopic images to accurately screen for otitis media.

'Universal' access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous 'test and treat' trials and implementation studies in sub-Saharan Africa suggest that bringing 'universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O'Malley's six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker-client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa's HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

In contexts of scarcity, managing comorbidities is a complex process, shaped by divergent understandings of causes, prognoses, and social meanings of illness. Drawing on research with one young South African woman living with HIV and epilepsy, and 13 other people with comorbidities, we describe how concepts of "public" and "private" shape the management of co-morbid conditions. Despite narratives of HIV "normalization," participants labored to keep their HIV status private, while sharing other illness experiences more publicly. We challenge simple dichotomies between public and private spheres and emphasize the need for more fluid understandings of how people negotiate social space.

Tuberculosis is the number one infectious cause of death globally. Young children, generally those younger than 5 years, are at the highest risk of progressing from tuberculosis infection to tuberculosis disease and of developing the most severe forms of tuberculosis. Most current tuberculosis drug formulations have poor acceptability among children and require consistent adherence for prolonged periods of time. These challenges complicate children's adherence to treatment and caregivers' daily administration of the drugs. Rapid developments in mobile technologies and apps present opportunities for using widely available technology to support national tuberculosis programs and patient treatment adherence. Pilot studies have demonstrated that mobile apps are a feasible and acceptable means of enhancing children's treatment adherence for other chronic conditions. Despite this, no mobile apps that aim to promote adherence to tuberculosis treatment have been developed for children. In this paper, we draw on our experiences carrying out research in clinical pediatric tuberculosis studies in South Africa. We present hypothetical scenarios of children's adherence to tuberculosis medication to suggest priorities for behavioral and educational strategies that a mobile app could incorporate to address some of the adherence support gaps faced by children diagnosed with tuberculosis. We argue that a mobile app has the potential to lessen some of the negative experiences that children associate with taking tuberculosis treatment and to facilitate a more positive treatment adherence experience for children and their caregivers., (©Rachel M Morse, Hanlie Myburgh, David Reubi, Ava E Archey, Leletu Busakwe, Anthony J Garcia-Prats, Anneke C Hesseling, Stephanie Jacobs, Sharon Mbaba, Kyla Meyerson, James A Seddon, Marieke M van der Zalm, Dillon T Wademan, Graeme Hoddinott. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 11.11.2020.)

Background: South Africa has one of the highest incidences of Tuberculosis (TB) globally. High co-morbid HIV prevalence complicates TB management and treatment outcomes. Growing evidence suggests that integrating the TB and HIV programmes will improve the overall results., Objectives: To describe how TB programme staff at various levels of the South African health system responded to the transition from a paper-based to an electronic register of TB data integrated with HIV programme data., Method: Three primary health service facilities in the Cape Winelands district, Western Cape province, South Africa served as pilot sites for implementation. Semi-structured interviews were conducted with 21 TB programme staff purposively selected at facility, sub-district, district and provincial levels of the health system, based on their involvement in implementing electronic TB data. An objective-driven thematic frame was used to analyse the data., Results: Fears about the transition included reductions in data quality, changes to the status quo and a lack of computer literacy. Participants acknowledged benefits of reduced workloads, speed of accessing patient-level data and click-of-a-button reporting. Three factors influenced the ease of adopting the new system: firstly, implementation challenged the vertical position of the TB programme, TB data and staff's conventional roles and responsibilities; secondly, perceptions of the paper-based register as functional and reliable made the transition to electronic seem unnecessary; and thirdly, lack of a process of change management challenged staff's ability to internalise the proposed change., Conclusion: A process of change management is critical to facilitate the efficiency and effectiveness with which the electronic in-facility TB register is implemented., Competing Interests: The authors have declared that no competing interests exist., (© 2020. The Authors.)

Disclosing to a child that s/he is living with HIV is necessary to promote adherence to treatment and improve health outcomes. Facilitating disclosure between caregivers and children remains a challenge for health workers. Understanding how health workers are involved in and perceive the disclosure process is integral to engaging with such challenges. We held group discussions with and surveyed 73 physicians, nurses, and counselors across 16 randomly selected facilities in two rural South African health districts, exploring their experiences of supporting disclosure between caregivers and children. Ninety percent of those surveyed agreed that children should be informed of their HIV status. Differences between categories of health workers regarding training, involvement in the disclosure process, and perceived responsibility for disclosure support led to inconsistent disclosure practices within facilities. Disclosure-strengthening interventions must consider the composition of the health worker team and the role that each category of health worker performs in their local settings., (Copyright © 2018 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate how electronic data management systems affect data use practices in antiretroviral therapy (ART) programs within local health districts, and individual health facilities., Methods: We used a data quality audit to establish a baseline of the quality of data in the electronic register alongside in-depth interviews with health workers and managers, to understand perceptions of data quality, data use by facility staff and challenges affecting data use., Results: The findings provide a four-level continuum of data use that can be applied to other settings and recommendations for optimising facility-level data use., Conclusion: By defining four levels of data use our findings suggest the potential to encourage a structured process of moving from passive data use, to more active and engaged data use, where data could be used to anticipate patient behaviour and link that behaviour to differentiated care plans., (© 2018 John Wiley & Sons Ltd.)

Introduction: Population distributions, family and household compositions, and people's sense of belonging and social stability in southern Africa have been shaped by tumultuous, continuing large-scale historical disruptions. As a result, many people experience high levels of geographic and social fluidity, which intersect with individual and population-level migration patterns. We describe the complexities of household fluidity and HIV service access in South Africa and Zambia to explore implications for health systems and service delivery in contexts of high household fluidity., Methods: HPTN 071 (PopART) is a three-arm cluster randomized controlled trial implemented in 21 peri-urban study communities in Zambia and South Africa between 2013 and 2018. A qualitative cohort nested in the trial included 148 purposively sampled households. Data collection was informed by ethnographic and participatory research principles. The analysis process was reflexive and findings are descriptive narrative summaries of emergent ideas., Results: Households in southern Africa are extremely fluid, with people having a tenuous sense of security in their social networks. This fluidity intersects with high individual and population mobility. To characterize fluidity, we describe thematic patterns of household membership and residence. We also identify reasons people give for moving around and shifting social ties, including economic survival, fostering interpersonal relationships, participating in cultural, traditional, religious, or familial gatherings, being institutionalized, and maintaining patterns of substance use. High fluidity disrupted HIV service access for some participants. Despite these challenges, many participants were able to regularly access HIV testing services and participants living with HIV were especially resourceful in maintaining continuity of antiretroviral therapy (ART). We identify three key features of health service interactions that facilitated care continuity: disclosure to family members, understanding attitudes among health services staff including flexibility to accommodate clients' transient pressures, and participants' agency in ART-related decisions., Conclusions: Choices made to manage one's experiential sense of household fluidity are intentional responses to livelihood and social support constraints. To enhance retention in care for people living with HIV, policy makers and service providers should focus on creating responsive, flexible health service delivery systems designed to accommodate many shifts in client circumstances., (© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.)

Background: Smartphone-based threshold audiometry with automated testing has the potential to provide affordable access to audiometry in underserved contexts., Purpose: To validate the threshold version (hearTest) of the validated hearScreen™ smartphone-based application using inexpensive smartphones (Android operating system) and calibrated supra-aural headphones., Research Design: A repeated measures within-participant study design was employed to compare air-conduction thresholds (0.5-8 kHz) obtained through automated smartphone audiometry to thresholds obtained through conventional audiometry., Study Sample: A total of 95 participants were included in the study. Of these, 30 were adults, who had known bilateral hearing losses of varying degrees (mean age = 59 yr, standard deviation [SD] = 21.8; 56.7% female), and 65 were adolescents (mean age = 16.5 yr, SD = 1.2; 70.8% female), of which 61 had normal hearing and the remaining 4 had mild hearing losses., Data Analysis: Threshold comparisons were made between the two test procedures. The Wilcoxon signed-ranked test was used for comparison of threshold correspondence between manual and smartphone thresholds and the paired samples t test was used to compare test time., Results: Within the adult sample, 94.4% of thresholds obtained through smartphone and conventional audiometry corresponded within 10 dB or less. There was no significant difference between smartphone (6.75-min average, SD = 1.5) and conventional audiometry test duration (6.65-min average, SD = 2.5). Within the adolescent sample, 84.7% of thresholds obtained at 0.5, 2, and 4 kHz with hearTest and conventional audiometry corresponded within ≤5 dB. At 1 kHz, 79.3% of the thresholds differed by ≤10 dB. There was a significant difference (p < 0.01) between smartphone (7.09 min, SD = 1.2) and conventional audiometry test duration (3.23 min, SD = 0.6)., Conclusions: The hearTest application with calibrated supra-aural headphones provides a cost-effective option to determine valid air-conduction hearing thresholds., (American Academy of Audiology)

Background: A pragmatic three-tiered approach to monitor the world's largest antiretroviral treatment (ART) programme was adopted by the South African National Department of Health in 2010. With the rapid expansion of the programme, the limitations of the paper-based register (tier 1) were the catalyst for implementation of the stand-alone electronic register (tier 2), which offers simple digitisation of the paper-based register. This article engages with theory on implementation to identify and contextualise enabling and constraining factors for implementation of the electronic register, to describe experiences and use of the register, and to make recommendations for implementation in similar settings where standardisation of ART monitoring and evaluation has not been achieved., Methods: We conducted a qualitative evaluation of the roll-out of the register. This comprised twenty in-depth interviews with a diverse sample of stakeholders at facility, sub-district, and district levels of the health system. Facility-level participants were selected across five sub-districts, including one facility per sub-district. Responses were coded and analysed using a thematic approach. An implementation science framework guided interpretation of the data., Results & Discussion: We identified the following seven themes: 1) ease of implementation, 2) perceived value of an electronic M&E system, 3) importance of stakeholder engagement, 4) influence of a data champion, 5) operational and logistical factors, 6) workload and role clarity, and 7) importance of integrating the electronic register with routine facility monitoring and evaluation. Interpreting our findings through an implementation theory enabled us to construct the scaffolding for implementation across the five facility-settings. This approach illustrated that implementation was not a linear process but occurred at two nodes: at the adoption of the register for roll-out, and at implementation at facility-level., Conclusion: In this study we found that relative advantage of an intervention and stakeholder engagement are critical to implementation. We suggest that without these aspects of implementation, formative and summative outcomes of implementation at both the adoption and coalface stages of implementation would be negatively affected.