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Sugar-sweetened beverage (SSB) taxes are recognised as an effective intervention to prevent obesity. More countries are adopting SSB taxes, but the process of the adoption is politically complex.This study aimed to analyse how public participation processes influenced the South African tax.We conducted a content analysis of documents associated with the process of adopting the tax. Records were identified utilising the Parliamentary Monitoring Group database, including draft bills, meeting minutes and written submissions. The records were categorised and then inductively coded to identify themes and arguments.We identified six cross-cutting themes advanced by stakeholders: economic considerations, impact on the vulnerable, responsiveness of an SSB tax to the problem of obesity, appropriateness of an SSB tax in South Africa, procedural concerns, and structure of the tax. Stakeholder views and arguments about the tax diverged based on their vested interests. The primary policymaker was most responsive to arguments concerning the economic impact of a tax, procedural concerns and the structure of the tax, reducing the effective rate to address industry concerns.Both supportive and opposing stakeholders influenced the tax. Economic arguments had a significant impact. Arguments in South Africa broadly echoed arguments advanced in many other jurisdictions.

Summary Background The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15–49 years and a tuberculosis prevalence of 0·7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19. Methods In this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality. Findings Among the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23·3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37·4%) of 163 350, diabetes in 43 885 (27·4%) of 159 932, and HIV in 13 793 (9·1%) of 151 779. Tuberculosis was reported in 5282 (3·6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1·34, 95% CI 1·27–1·43), past tuberculosis (1·26, 1·15–1·38), current tuberculosis (1·42, 1·22–1·64), and both past and current tuberculosis (1·48, 1·32–1·67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1·45, 95% CI 1·22–1·72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29·2% compared with 30·8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased COVID-19 in-hospital mortality risk in both people with HIV and HIV-uninfected individuals. Interpretation Individuals identified as being at high risk of COVID-19 in-hospital mortality (older individuals and those with chronic comorbidities and people with HIV, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation as well as early referral and treatment. Funding South African National Government.

Background Responding to adolescents’ educational needs in sexual and reproductive health and rights (SRHR) is central to their sexual health and achieved through school-based comprehensive sexuality education (CSE). In 2016, Rwanda introduced CSE through the competence-based curriculum in schools to enhance learners’ knowledge about sexuality, gender, and reproductive health issues, including HIV/AIDS. However, globally, the content of CSE is sometimes dissimilar, and little evidence surrounds its scope in many settings, including Rwanda. In addition, the extent to which CSE aligns with international guidelines has yet to be well known. This study assesses major areas of CSE for early adolescents in Rwanda, analyses how CSE correlates with international guidelines and makes recommendations accordingly. Methods We reviewed the Rwandan competence-based curriculum to map CSE competences for early adolescents and conducted semi-structured interviews with key informants (N = 16). Eleven of the 23 curriculum documents met the selection criteria and were included in the final review. We manually extracted data using a standard form in Microsoft Excel and analysed data using frequency tables and charts. Interviews were thematically analysed in NVivo 11 for Windows. Findings We found 58 CSE competences for early adolescents across various subjects, increasing with school grades. All recommended CSE areas were addressed but to a variable extent. Most competences fall under four recommended areas: sexual and reproductive health; human body and development; values, rights, and sexuality; and understanding gender. The least represented area is violence and staying safe. Of the 27 expected topics, there are two to six CSE competences for 13 topics, one CSE competence for each of the six others, and none for the eight remaining ones. Qualitative findings support these findings and suggest additional content on locally controversial but recommended areas of sexual pleasure, orientation, desire and modern contraceptive methods. Conclusion This study explores the CSE content for early adolescents in Rwanda and how they align with sexuality education standards. Ensuring equal coverage of CSE areas and addressing missing topics may improve CSE content for this age group and foster their SRHR.

Knowledge of eukaryotic life cycles and associated genome dynamics stems largely from research on animals, plants, and a small number of "model" (i.e., easily cultivable) lineages. This skewed sampling results in an underappreciation of the variability among the many microeukaryotic lineages, which represent the bulk of eukaryotic biodiversity. The range of complex nuclear transformations that exists within lineages of microbial eukaryotes challenges the textbook understanding of genome and nuclear cycles. Here, we look in-depth at Foraminifera, an ancient (∼600 million-year-old) lineage widely studied as proxies in paleoceanography and environmental biomonitoring. We demonstrate that Foraminifera challenge the "rules" of life cycles developed largely from studies of plants and animals. To this end, we synthesize data on foraminiferal life cycles, focusing on extensive endoreplication within individuals (i.e., single cells), the unusual nuclear process called Zerfall, and the separation of germline and somatic function into distinct nuclei (i.e., heterokaryosis). These processes highlight complexities within lineages and expand our understanding of the dynamics of eukaryotic genomes.

Background: Responding to adolescents' educational needs in sexual and reproductive health and rights is central to their sexual health. In 2016, Rwanda introduced the Competence-based curriculum (CBC) that integrated comprehensive sexuality education (CSE). However, globally, the content of CSE is sometimes dissimilar, and little evidence surrounds its scope in many settings. This study aimed to assess major topic areas of the school-based CSE for early adolescents, analyse how this CSE correlates with international guidelines, and make recommendations accordingly.Methods: We reviewed the CBC and conducted semi-structured interviews with key informants concerned with sexuality education to map sexuality education contents and related CSE competences for pre-primary, primary and lower secondary levels. We selected eleven of the 23 CBC documents for the final review. We manually extracted data using a standard form in Microsoft Excel. We conducted a descriptive analysis (frequency tables and charts) of review data and a thematically analysed interviews in NVivo 11 for Windows using the International Technical Guidance of Sexuality Education (ITGSE).Findings: Overall, we found 58 CSE competences from the CBC. CSE competences increased with school grades: 4/58 (6.9%) in pre-school, 5/58 (8.6%) in lower-primary, 17/58 (29.3%) in upper-primary, and 32/58 (55.2%) in lower-secondary levels. Subjects of Kinyarwanda (13/58, 22.4%), Biology (10/58, 17.2%), and Social studies (9/58, 15.5%) abounded in CSE. Four ITGSE key concepts abounded most in CSE competences: Sexual and reproductive health (13/58, 22.4%); Human body and development (11/58, 19%); Values, rights, and sexuality (9/58, 15.5%); and Understanding gender (8/58, 13.8%). The CBC CSE covered least the area of Violence and staying safe (2/58, 3.4%). Six of 27 ITGSE topics had only one CSE competence, and eight ITGSE topics were not represented in the CBC. Recommended additional contents are sexual pleasure, sexual orientation, sexual desire and modern contraceptive methods such as condoms.Conclusion: CSE for early adolescents is delivered mainly in three subjects and aligns, to some extent, with the international guidelines for sexuality education. CSE intensifies with school grades and emphasises more on some topics than others that are equally important. The study recommends additional topics for CSE for this age group.

With the growing burden of non-communicable diseases (NCDs), countries across the globe are finding ways to reduce the consumption of ultra-processed food and drinks including sugar-sweetened beverages (SSBs). South Africa implemented a health promotion levy (HPL) in April 2018 as one strategy to reduce sugar intake. Such efforts are frequently countered or mitigated by industry action in various ways, including through marketing and advertising strategies. To better understand trends in the extent of advertising, this paper analyses advertising expenditures and exposure of children to SSB advertisements in South Africa. Using Nielsen’s monthly data on advertising expenditure before and after the introduction of the HPL, for the period January 2013 to April 2019, the results show that manufacturers spent ZAR 3683 million to advertise their products. Advertising expenditure on carbonated drinks accounted for over 60% (ZAR 2220 million) of the total expenditure on SSBs. The results also show that companies spend less in advertising powdered SSBs (an average of ZAR 0.05 million per month). Based on expenditure patterns, television (TV) was the preferred medium of advertisements, with companies prioritizing what is often considered children’s and family viewing time. Urgent mandatory regulations are needed to prevent child-directed marketing.

Globally, the adoption of COVID-19 containment measures, such as lockdowns, have been used to curb the rapid spread of the pandemic. However, these action regulations have caused substantial challenges to livelihoods. We explored the perceptions and experiences of COVID-19 implications for urban informal food traders in South Africa during the initial lockdown period that lasted five weeks. A rapid qualitative study was conducted during October–November 2020. Twelve key informants (seven men and five women) categorized into informal traders and food system expert groups were interviewed. Data were analyzed thematically using MAXQDA software. Participants perceived informal trading as a main source of livelihood for many individuals. Negative lockdown impacts described included forced business closure, increased food costs and reduced demand. The consensus among participants was that the government’s lack of formal recognition for informal food traders pre-COVID-19 contributed to challenges they faced during the pandemic, as evidenced by their exclusion as “essential service providers’’ at the start of lockdown. Policies that fail to recognize and consider informal food traders during ‘normal’ times lead to widened social inequality gaps among already vulnerable groups during natural disasters and disease outbreaks. In the case of COVID-19 in South Africa, this caused severe hunger, food insecurity and income loss.

Background Acces to sexual and reproductive health and rights information during adolescence is a basic human right. This study investigated the key informants’ perspectives on the benefits, sources of information, and the determinants (enablers and hindrances) of sexual and reproductive health and rights information among early adolescents in Rwanda. Methods a qualitative study using semi-structured interviews with purposively selected public and private key informants in Rwanda was conducted. Interview transcripts were imported in Nvivo 11 for thematic analysis. Results In total, sixteen interviews involving an equal number of male and female participants were conducted. Despite it being perceived as a taboo topic, participants acknowledged sexuality education as beneficial for early adolescents and confirmed that there are various channels for accessing gender and sexuality information. The school comprehensive sexuality education was depicted as a common source of information, while parents were not. Participants highlighted disparities in information access between rural and urban settings. Faith-based organizations and public institutions did not share the same perspective on the topics that should be covered in gender and sexuality education. Faith-Based Organizations focused on moral values of abstinence and virginity, while public institutions emphasized ways of having safe sex including the use of modern contraceptive methods. Participants noted the need to address the confusion about the concept of gender. Participants’ reflections on gender dynamics revealed that compared to girls, boys culturally override sexual health. Participants thought that access to gender and sexuality information by early adolescents depended on multiple factors at the individual (curiosity, age, behaviours), relationships (discussions with parents, peer sexual norms), community (the content of the curriculum, culture, religious beliefs), and societal (economic challenges, policy, and laws) levels. Conclusion Participants from various backgrounds acknowledged the benefits of sexuality education, as well as the various channels available to younger adolescents for accessing SRHR information, even though their perspectives on the content differed. The study’s multi-layered analysis revealed potential areas for improving early adolescents’ access to gender and SRHR information.

Objective The primary objective of this document is to clarify the indications for pelvic examination. Intended Users Physicians, including gynaecologists, obstetricians, family physicians, and emergency physicians; nurses, including registered nurses and nurse practitioners; midwives, including midwives in clinical practice and midwifery trainees; medical trainees, including medical students, residents, and fellows; and all other health care providers who care for women. Target Population This publication provides evidence and expert-based recommendations for pelvic examination in adult women (18 years and older) both with and without gynaecologic symptoms. Outcomes This publication clarifies indications for pelvic examination in the context of recently published national task force statements on the utility of pelvic examination. We aim to ensure that women who have clinical indications for examination receive proper clinical investigation with minimal delays to diagnosis of treatable disease. Evidence For this committee opinion, relevant studies were identified in PubMed and Medline using the following terms, either alone or in combination, with the search limited to English-language materials and human subjects and no publication date cut-off: pelvic examination, bimanual examination, speculum examination, rectovaginal examination, ovarian cancer screening, asymptomatic women, periodic health examination. The search was performed in May and June 2018. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines and national task force statements, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified by cross-referencing the identified publications. A formal systematic review was not conducted for all topics discussed due to the paucity of evidence and number of different subtopics discussed. The total number of publications included in this review was 66. Validation Methods The content and recommendations were drafted and agreed upon by the principal authors. The Boards of the Society of Gynecologic Oncology of Canada (GOC), the College of Family Physicians of Canada (CFPC), and the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication after review by their respective representative committees. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request. Benefits, Harms, and Costs This committee opinion should benefit all women with and without gynaecologic symptoms who present to gynaecologists and primary care practitioners. It will help guide practitioners in identifying indications for pelvic examination to reduce unnecessary examination with related potential harm while also increasing indicated examination to reduce delays in diagnosis of treatable gynaecologic conditions. Guideline Update This SOGC Committee Opinion will be automatically reviewed 5 years after publication to determine if all or part of the committee opinion should be updated. However, this review may be performed earlier if new high-impact research is published in the interim. SUMMARY STATEMENTS 1National and international statements and guidelines on pelvic examination should not be interpreted to suggest that the pelvic examination is irrelevant or noncontributory to physical assessment or that the pelvic examination in symptomatic women should be omitted. 2Pelvic examination may include visual inspection, speculum examination, bimanual examination, single digit examination, and/or rectovaginal examination depending on the indication for examination. 3No study published to date has adequately evaluated any component of the pelvic examination as a screening method for any type of malignant gynaecologic disease, except for the speculum examination for cervical cancer cytology screening. As such, any universal recommendations for or against pelvic examinations for other indications can only be made based on expert opinion and low-quality evidence. 4In asymptomatic women at average risk for cervical cancer, cervical cytology screening reduces both the incidence of, and mortality from, cervical cancer by detecting pre-invasive, treatable lesions. 5In asymptomatic women at average risk of malignancy, a visual and bimanual examination at the time of obtaining cervical cytology samples may add value to this screening manoeuvre: Women might not raise certain gynaecologic concerns until the time of pelvic examination; the examination provides an opportunity for patient education and practitioner skill maintenance; and, although inadequately studied to date, there may be positive effects on ovarian and vulvar malignancy that require further investigation. These potential benefits should be weighed against potential harms like patient discomfort and false positives/negatives that may result in inappropriate reassurance or unnecessary investigations/interventions. RECOMMENDATIONS Symptomatic Women 1Any woman with gynaecologic complaints including, but not limited to, vulvar complaints, vaginal discharge, abnormal premenopausal bleeding, postmenopausal bleeding, infertility, pelvic organ prolapse symptoms, urinary incontinence, new and unexplained gastrointestinal symptoms (abdominal pain, increased abdominal size/bloating, and difficulty eating/early satiety), pelvic pain, or dyspareunia should undergo appropriate components of the pelvic examination to identify benign or malignant disease (strong, low). 2Health care providers may consider discussing the risks and benefits of performing a baseline pelvic examination including visual and bimanual examination prior to prescribing hormonal replacement therapy/menopausal hormonal treatment (weak, very low). Asymptomatic Women 3Health care practitioners should perform cervical cytology cancer screening in accordance with provincial/territorial guidelines (strong, strong). 4There is insufficient evidence to guide recommendations on screening pelvic examination for noncervical gynaecologic malignancy or any benign gynaecologic disease in healthy, asymptomatic women with average risk of malignancy. However, health care practitioners may consider performing a screening pelvic examination including visual, speculum, and bimanual examinations in concert with cervical cytology sampling intervals as recommended by provincial/territorial guidelines. This practice may identify clinically important benign or malignant disease not recognized or reported by the patient (weak, very low). 5In women over age 70 who no longer require screening with cervical cytology, health care practitioners should consider continuing periodic screening of asymptomatic women for vulvar disease with inspection of the vulva, perineum, and anus to identify benign or malignant disease unrecognized by this population. There is insufficient evidence to guide recommendations on frequency of this examination (weak, low). 6Women with a personal history of gynaecologic malignancy, a genetic diagnosis that increases gynaecologic malignancy risk, or a history of in utero diethylstilbestrol exposure may benefit from more frequent screening pelvic examinations to identify early primary, recurrent, or metastatic malignancy in the absence of symptoms. Because there is inadequate evidence to define these screening intervals, they should be in accordance with provincial/territorial guidelines and expert opinion (weak, very low). 7Non-invasive and self-collection screening options for chlamydia and gonorrhea are acceptable in asymptomatic women, but pelvic examination, including visual inspection, speculum examination, and bimanual examination, is required in the presence of symptoms to rule out pelvic inflammatory disease or tubo-ovarian abscess (strong, low). 8No pelvic examination is required prior to prescription of hormonal contraception in a healthy woman with no gynaecologic symptoms (strong, low).

OBJECTIF L'objectif principal du present document est de clarifier les indications de l'examen pelvien. UTILISATEURS CONCERNeS: Medecins, y compris les gynecologues, obstetriciens, medecins de famille, urgentologues; infirmieres, y compris les infirmieres autorisees et les infirmieres praticiennes; sages-femmes, y compris les sages-femmes en pratique clinique et les apprenties sages-femmes et les apprentis en medecine, y compris les etudiants de medecine, residents, stagiaires (fellows); et tous les autres fournisseurs de soins de sante qui prodiguent des soins aux femmes. POPULATION CIBLE La presente publication fournit des donnees probantes et des recommandations fondees sur des avis d'experts sur l'examen pelvien chez les femmes adultes (18 ans et plus) avec et sans symptomes gynecologiques. ISSUES La presente publication clarifie les indications de l'examen pelvien dans le contexte des declarations de groupes d'etude nationaux recemment publiees sur l'utilite de l'examen pelvien. L'objectif est de veiller a ce que les femmes qui presentent des indications cliniques d'examen fassent rapidement l'objet d'une evaluation clinique adequate pour diagnostiquer les maladies traitables. DONNeES PROBANTES Pour la presente opinion de comite, les etudes pertinentes ont ete reperees dans PubMed et Medline a l'aide des termes suivants, seuls ou combines, et les recherches ont ete limitees aux publications en anglais portant sur des humains sans date limite de publication : pelvic examination, bimanual examination, speculum examination, rectovaginal examination, ovarian cancer screening, asymptomatic women, periodic health examination. La recherche a ete effectuee en mai et en juin 2018. Les donnees probantes pertinentes ont ete retenues dans l'ordre suivant : meta-analyses, revues systematiques, lignes directrices et declarations des groupes d'etude nationaux, essais cliniques randomises, etudes de cohorte prospective, etudes observationnelles, revues non systematiques, etudes de serie de cas et rapports. Des articles supplementaires ont ete reperes en consultant les notices bibliographiques des publications selectionnees. Une revue systematique officielle n'a pas ete menee pour tous les sujets discutes en raison du manque de donnees probantes et du nombre de differents sous-themes abordes. Le nombre total de publications examinees dans le cadre de cette revue etait de 66. MeTHODES DE VALIDATION Les auteurs principaux ont redige le contenu et les recommandations et ils se sont entendus sur ces derniers. Les conseils d'administration de la Society of Gynecologic Oncology of Canada (GOC), de College des medecins de famille du Canada (CMFC) et de la Societe des obstetriciens et gynecologues du Canada (SOGC) ont approuve la version definitive aux fins de publication apres que leurs comites representatifs respectifs l'aient passee en revue. La qualite des donnees probantes utilisees dans le present document a ete evaluee au moyen des criteres du cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). (Tableaux 1 et 2) Le resume des conclusions est disponible sur demande. AVANTAGES, PReJUDICE ET COuTS La presente opinion de comite devrait aider toutes les femmes qui souffrent ou non de symptomes gynecologiques qui se presentent chez le gynecologue et un fournisseur de soins primaires. Elle aidera les praticiens a determiner les indications d'examen pelvien afin de reduire le nombre d'examens inutiles et susceptibles de porter prejudice tout en augmentant le nombre d'examens indiques afin de reduire les retards de diagnostic des affections gynecologiques traitables. MISE a JOUR DE LA DIRECTIVE CLINIQUE La presente opinion de comite de la SOGC sera automatiquement passee en revue cinq ans apres sa publication pour determiner si une partie ou l'ensemble de l'opinion de comite devrait etre mis a jour. Cependant, cette revue peut etre effectuee plus tot si de nouvelles recherches revolutionnaires sont publiees entre-temps. DECLARATIONS SOMMAIRES 1) Les declarations et les directives nationales et internationales sur l'examen pelvien ne devraient pas etre interpretees comme si l'examen pelvien est superflu, qu'il ne contribue pas a l’evaluation physique ou que l'examen pelvien chez les femmes symptomatiques devrait etre omis. 2) L'examen pelvien peut comprendre les examens visuels, au speculum, bimanuel, a un doigt ou rectovaginal selon l'indication d'examen. 3) Aucune etude publiee a ce jour n'a evalue adequatement quelque composante que ce soit de l'examen pelvien comme methode de depistage pour quelconque type de maladie gynecologique maligne, a l'exception de l'examen au speculum pour le depistage cytologique du cancer du col de l'uterus. Ainsi, toute recommandation universelle, pour ou contre les examens pelviens pour d'autres indications ne peut qu’etre faite selon l'opinion des specialistes et des donnees probantes de faible qualite. 4) Chez les femmes asymptomatiques dont le risque de cancer du col de l'uterus est moyen, le depistage cytologique du cancer du col de l'uterus reduit a la fois son incidence et son taux de mortalite en detectant les lesions preinvasives traitables. 5) Chez les femmes asymptomatiques dont le risque de tumeur ou affection maligne est moyen, un examen visuel et bimanuel au moment d'obtenir des echantillons cytologiques cervicaux peut apporter une valeur ajoutee a cette methode de depistage. Les femmes peuvent ne pas soulever certaines inquietudes sur le plan gynecologique jusqu'au moment de l'examen pelvien; l'examen offre une occasion de sensibiliser les patientes et de maintenir les competences du praticien; de plus, meme si le sujet n'a pas encore ete etudie adequatement, il pourrait comporter des effets positifs sur les tumeurs ou affections malignes ovariennes et vulvaires qui necessiteraient des analyses plus poussees. Ces avantages potentiels devraient etre soupeses par rapport aux prejudices potentiels comme l'inconfort de la patiente et les faux positifs ou negatifs qui pourraient la rassurer a tort ou entrainer des analyses et des interventions non justifiees. RECOMMANDATIONS Femmes symptomatiques 1) Toute femme qui exprime des plaintes de nature gynecologique, y compris, mais sans s'y limiter, des plaintes concernant la vulve, des pertes vaginales, des saignements premenopausiques anormaux, des saignements postmenopausiques, l'infertilite, des symptomes de prolapsus des organes pelviens, l'incontinence urinaire, de nouveaux symptomes gastro-intestinaux inexpliques (douleur abdominale, distension abdominale ou ballonnement et difficulte a manger ou satiete precoce), la douleur pelvienne ou la dyspareunie, devrait subir des composantes pertinentes de l'examen pelvien afin de detecter les maladies benignes ou malignes (forte, basse). 2) Les fournisseurs de soins de sante peuvent envisager de discuter des risques et avantages de l'execution d'un examen pelvien de base qui comprend un examen visuel et un examen bimanuel avant de prescrire une hormonotherapie substitutive ou un traitement hormonal de la menopause (faible, tres basse). Femmes asymptomatiques 3) Les professionnels de la sante devraient faire le depistage cytologique du cancer du col de l'uterus conformement aux lignes directrices provinciales ou territoriales (forte, forte). 4) Les donnees sont insuffisantes pour orienter les recommandations sur l'examen pelvien aux fins de depistage de tumeurs ou affections malignes de nature gynecologique non cervicales ou de toute maladie gynecologique benigne chez les femmes asymptomatiques en sante dont le risque de tumeur ou affection maligne est moyen. Cependant, les professionnels de la sante peuvent envisager d'effectuer un examen pelvien aux fins de depistage comprenant les examens visuel, bimanuel et au speculum conjointement avec le prelevement d’echantillons cytologiques cervicaux selon les intervalles recommandes dans les lignes directrices provinciales ou territoriales. Cette pratique pourrait permettre de detecter d'importantes maladies benignes ou malignes non reconnues ou signalees par la patiente (faible, tres basse). 5) Chez les femmes âgees de plus de 70 ans qui n'ont plus a subir de depistage cytologique cervical, les professionnels de la sante devraient envisager de continuer chez les femmes asymptomatiques le depistage periodique des maladies vulvaires en examinant la vulve, le perinee et l'anus afin de detecter les maladies benignes ou malignes meconnues de cette population. Les donnees sont insuffisantes pour determiner des recommandations sur la frequence de cet examen (faible, basse). 6) Des examens pelviens de depistage plus frequents pour deceler les signes precoces de tumeurs ou affections malignes primitives, recidivantes ou metastatiques en l'absence de symptomes pourraient s'averer benefiques pour les femmes qui ont des antecedents personnels de tumeurs malignes de nature gynecologique, un diagnostic genetique qui augmente le risque de tumeurs ou affections malignes gynecologiques ou des antecedents d'exposition in utero au diethylstilbestrol. Puisque les donnees pour determiner ces intervalles de depistage sont inadequates, on devrait les determiner en fonction des lignes directrices provinciales ou territoriales et de l'opinion des specialistes (faible, tres basse). 7) Les options non effractives et par auto-prelevement de depistage de la chlamydia et de la gonorrhee sont acceptables chez les femmes asymptomatiques, mais l'examen pelvien, qui comprend les examens visuel, bimanuel et au speculum, est requis en presence de symptomes pour ecarter la possibilite d'une maladie inflammatoire pelvienne ou d'un abces tubo-ovarien (forte, basse). 8) Aucun examen pelvien n'est requis avant la prescription de contraception hormonale chez une femme en sante qui ne presente aucun symptome gynecologique (forte, basse).

Funder: National Institute for Health Research (NIHR); Grant(s): GHR: 16/137/34), 16/137/34, Rates of obesity and related non-communicable diseases are on the rise in sub-Saharan Africa, associated with sub-optimal diet and physical inactivity. Implementing evidence-based interventions targeting determinants of unhealthy eating and physical inactivity in children and adolescents' immediate environments is critical to the fight against obesity and related non-communicable diseases. Setting priorities requires a wide range of stakeholders, methods, and context-specific data. This paper reports on a novel participatory study design to identify and address contextual drivers of unhealthy eating and physical inactivity of children and adolescents in school and in their home neighborhood food and built environments. We developed a three-phase mixed-method study in Cameroon (Yaoundé) and South Africa (Johannesburg and Cape Town) from 2020-2021. Phase one focused on identifying contextual drivers of unhealthy eating and physical inactivity in children and adolescents in each setting using secondary analysis of qualitative data. Phase two matched identified drivers to evidence-based interventions. In phase three, we worked with stakeholders using the Delphi technique to prioritize interventions based on perceived importance and feasibility. This study design provides a rigorous method to identify and prioritize interventions that are tailored to local contexts, incorporating expertise of diverse local stakeholders.

The impacts of pandemics are recognized to go beyond infection, physical suffering, and socio-economic disruptions. Other consequences include psychological responses. Using a mental wellbeing lens, we analyzed COVID-19-related stressors in healthcare workers (HCWs) and community members who provided and regularly accessed health services in South Africa, respectively. From February to September 2021, during the second COVID-19 wave we conducted a qualitative study in one urban and one rural district. In-depth interviews and focus group discussions were used to collect data among 43 HCWs and 51 community members purposely and conveniently selected. Most participants experienced mental health challenges regarding multiple aspects of the COVID-19 pandemic and its resulting lockdown, with a few reporting positive adjustments to change. COVID-19 impacts on mental health were consistent among both HCWs and community members in urban and rural alike. Participants’ COVID-19-induced psychological responses included anxiety and fear of the unknown, perceived risk of infection, fear of hospitalization, and fear of dying. Physical effects of the pandemic on participants included COVID-19 infection and associated symptoms, possibilities of severe illness and discomfort of using personal protective equipment. These distresses were exacerbated by social repercussions related to concerns for family wellbeing and infection stigma. Lockdown regulations also intensified anxieties about financial insecurities and social isolation. At times when common coping mechanisms such as family support were inaccessible, cultural consequences related to lack of spiritual gatherings and limited funeral rites posed additional stress on participants. In preparation for future public health emergencies, recognition needs to be given to mental health support and treatment.

Objective:To obtain a community perspective on key nutrition-specific problems and solutions for mothers and children.Design:A qualitative study comprising nine focus group discussions (FGD) following a semi-structured interview guide.Setting:The township of Soweto in South Africa with a rising prevalence of double burden of malnutrition.Participants:Men and women aged ≥18 years (n 66). Three FGD held with men, six with women.Results:Despite participants perceived healthy diet to be important, they felt their ability to maintain a healthy diet was limited. Inexpensive, unhealthy food was easier to access in Soweto than healthier alternatives. Factors such as land use, hygiene and low income played a fundamental role in shaping access to foods and decisions about what to eat. Participants suggested four broad areas for change: health sector, social protection, the food system and food environment. Their solutions ranged from improved nutrition education for women at clinic visits, communal vegetable gardens and government provision of food parcels to regulatory measures to improve the healthiness of their food environment.Conclusions:South Africa’s current nutrition policy environment does not adequately address community-level needs that are often linked to structural factors beyond the health sector. Our findings suggest that to successfully address the double burden of malnutrition among women and children, a multifaceted approach is needed combining action on the ground with coherent policies that address upstream factors, including poverty. Further, there is a need for public engagement and integration of community perspectives and priorities in developing and implementing double-duty actions to improve nutrition.

Background: The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis (TB) are unclear, particularly in low- and middle-income countries (LMIC) in Africa. We investigated this interaction using a nationally representative hospital surveillance system in South Africa. Methods: A national surveillance system for laboratory-confirmed COVID-19 hospital admissions (DATCOV) was established. Using DATCOV data, we describe the demographic characteristics, clinical features, and in-hospital mortality among individuals admitted to public and private hospitals with COVID-19 during 5 March to 11 August 2020. Multivariable logistic regression models were used to compare individuals who were HIV-infected and HIV-uninfected and determine the factors associated with in-hospital mortality. Findings: Hospital admissions peaked at 1,560 admissions per day, in late July. Among the 41,877 individuals admitted with laboratory-confirmed COVID-19, 7,662 (18.3%) died. Comorbidities were documented in 27,555 (65.8%) individuals, most commonly observed were hypertension (36.8%), diabetes (29.6%), obesity (19.7%), and HIV (8.7%); TB was reported in 0.7% of individuals. Increased risk of in-hospital mortality was associated with HIV and TB, as well as other described risk factors for COVID-19, such as increasing age, male sex, non-White race (Black, mixed and Indian race), chronic underlying conditions particularly hypertension, diabetes and obesity. In addition, HIV-infected individuals with immunosuppression had increased risk of mortality (adjusted odds ratio 2.2; 95% confidence interval 1.6-3.1). Among HIV-infected individuals, the prevalence of other comorbidities associated with severe COVID-19 outcomes was 39.9%. The effect of multiple comorbidities on mortality was similar in HIV-infected and -uninfected individuals. Interpretation: These data provide a better understanding of the interaction of non-communicable diseases, chronic infectious diseases like HIV and TB and COVID-19. Increasing age and presence of chronic underlying comorbidities (particularly hypertension and diabetes) are important additional factors associated with COVID-19 mortality in a middle-income African setting and are common among HIV-infected individuals. HIV- and TB-infected individuals, particularly those with additional comorbidities, would benefit from COVID-19 prevention and treatment programmes.

Background The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis (TB) are unclear, particularly in low- and middle-income countries in Africa. South Africa has a national adult HIV prevalence of 19% and TB prevalence of 0.7%. Using a nationally representative hospital surveillance system in South Africa, we investigated the factors associated with in-hospital mortality among individuals with COVID-19. Methods Using data from national active hospital surveillance, we describe the demographic characteristics, clinical features, and in-hospital mortality among hospitalised individuals testing positive for SARS-CoV-2, during 5 March 2020 to 27 March 2021. Chained equation multiple imputation was used to account for missing data and random effect multivariable logistic regression models were used to assess the role of HIV-status and underlying comorbidities on in-hospital COVID-19 mortality. Findings Among the 219,265 individuals admitted with laboratory confirmed SARS-Cov-2, 51,037 (23.3%) died. Most commonly observed comorbidities among individuals with available data were hypertension (61,098/163,350; 37.4%), diabetes (43,885/159,932; 27.4%), and HIV (13,793/151,779; %), while TB was reported in 3.6% (5,282/146,381) of individuals. While age was the most important predictor, other factors associated with in-hospital COVID-19 mortality were HIV infection [aOR 1.34, 95% CI: 1.27-1.43), past TB [aOR 1.26, 95% CI: 1.15-1.38), current TB [aOR 1.42, 95% CI: 1.22-1.64) and both past and current TB [aOR 1.48, 95% CI: 1.32-1.67) compared to never TB, as well as other described risk factors for COVID-19, such as male sex, non-white race, and chronic underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy. After adjusting for other factors, PLWH not on ART [aOR 1.45, 95% CI: 1.22-1.72] were more likely to die in-hospital compared to PLWH on ART. Among PLWH, the prevalence of other comorbidities was 29.2% compared to 30.8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased mortality risk in both PLWH and HIV-uninfected individuals. Interpretation Identified high risk individuals (older individuals and those with chronic comorbidities and PLWH, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation, as well as early referral and treatment. Funding South African National Government Research in context Evidence before this study Since the emergence of the COVID-19 pandemic, studies have identified older age, male sex and presence of underlying comorbidities including heart disease and diabetes as risk factors for severe disease and death. There are very few studies, however, carried out in low- and middle-income countries (LMIC) in Africa, many of whom have high poverty rates, limited access to healthcare, and high prevalence of chronic communicable diseases, such as HIV and tuberculosis (TB). Data are also limited from settings with limited access to HIV treatment programmes. Early small cohort studies mainly from high income countries were not conclusive on whether HIV or TB are risk factors for disease severity and death in COVID-19 patients. Large population cohort studies from South Africa’s Western Cape province and the United Kingdom (UK) have found people living with HIV (PLWH) to have a moderately increased risk of COVID-19 associated mortality. Of these, only the Western Cape study presented data on mortality risk associated with presence of high viral load or immunosuppression, and found similar levels of severity irrespective of these factors. Recent meta-analyses have confirmed the association of HIV with COVID-19 mortality. No studies reported on the interaction between HIV-infection and other non-communicable comorbidities on COVID-19 associated mortality. We performed separate literature searches on PubMed using the following terms: “COVID-19” “risk factors” and “mortality”; “HIV” “COVID-19” and “mortality”; “TB” “COVID-19” and “mortality”. All searches included publications from December 1, 2019 until May 5, 2021, without language restrictions. Pooled together, we identified 2,786 published papers. Additionally, we performed two literature searches on MedRxiv using the terms “HIV” “COVID-19” and “mortality”, and “TB” “COVID-19” and “mortality” from April 25, 2020 until May 5, 2021, without language restrictions. Pooled together, we identified 7,744 pre-prints. Added value of this study Among a large national cohort of almost 220,000 individuals hospitalised with COVID-19 in a setting with 19% adult HIV prevalence and 0.7%TB prevalence, we found that along with age, sex and other comorbidities, HIV and TB were associated with a moderately increased risk of in-hospital mortality. We found increasing risk of in-hospital mortality among PLWH not on ART compared to those on ART. Among PLWH, the prevalence of other comorbidities was high (29%) and the effect of increasing numbers of comorbidities on mortality was similar in PLWH and HIV-uninfected individuals. Our study included 13,793 PLWH from all provinces in the country with varying levels of access to HIV treatment programmes. Implications of all the available evidence The evidence suggests that PLWH and TB-infected individuals should be prioritised for COVID-19 prevention and treatment programmes, particularly those with additional comorbidities. Increasing age and presence of chronic underlying illness are important additional factors associated with COVID-19 mortality in a middle-income African setting. The completeness of data is a limitation of this national surveillance system, and additional data are needed to confirm these findings.

Objective:In the past decade, South Africa’s obesity epidemic has increased in both children and adults, and being overweight is becoming the norm. Several contributing factors lead to the normalisation of obesity. One of these is the culturally entrenched likeness of larger body sizes or shapes within a milieu of easily accessible unhealthy food and beverages. This qualitative study advances knowledge about the influence of socio-cultural norms and obesogenic environments on weight under estimation and ‘obesity normalisation’ amongst black South Africans living in an urban setting.Design:A theory-based qualitative study used focus group discussions (FGDs) with a semi-structured interview guide. FGDs were transcribed verbatim and analysed thematically using a constant comparison method.Setting:Soweto, Johannesburg, South Africa, is a setting which has undergone rapid urbanisation and nutrition transition with ubiquitous availability of processed and fast-foods.Participants:Adults older than 18 years living in Soweto (n 57).Results:There is a wide misperception about obesity amongst black Africans living in an urban setting in Soweto. Participants who admitted to being fat or overweight did not view themselves as such. This could be attributed to unchanging socio-cultural factors that reinforce the acceptability of bigger bodies and living in obesogenic environment.Conclusions:Without addressing socio-cultural norms that attribute bigger bodies to beauty and wealth, motivating individuals to address weight gain will prove difficult especially for populations living in obesogenic environments. A multi-faceted strategy is required to address obesity in urban South African settings.

Young women in South Africa are at high risk for HIV, particularly after they leave school. There are few studies examining the long-term impact of school-based public health interventions aimed at protecting young women from HIV. We undertook a long-term evaluation of an extracurricular, school-based HIV prevention program, that leveraged off a mass media television series in South Africa.We recruited 403 women aged 18-28 years. One hundred and seventy were members of Soul Buddyz Clubs (SBCs) between 2004 and 2008 and 233 were matched controls from the same communities as the ex-Buddyz. Face-to-face interviews were conducted and HIV testing undertaken. Analysis was restricted to 320 women who had ever had sex (136 ex-Buddyz and 184 controls). Multivariate analysis in Stata v14 was conducted.16.4% of women tested HIV positive. Ex-Buddyz were more likely to be HIV negative than controls (AOR 2.92, 95% CI 1.26-6.77, p = 0.013). Ex-Buddyz were more likely to have only had one sexual partner in the past year (AOR 2.14, 95% CI 1.17-3.89, p = 0.013) and 1.7 times more likely to have used a condom at first sex (95% CI 0.99-2.92, p = 0.053).Participation in an SBC is associated with a decrease in young women's HIV risk and suggests an impact on some key risky sexual behaviors. School-based prevention programs that leverage off of other media platforms demonstrate a positive outcome on health status.

L'objectif principal du présent document est de clarifier les indications de l'examen pelvien. UTILISATEURS CONCERNéS: Médecins, y compris les gynécologues, obstétriciens, médecins de famille, urgentologues; infirmières, y compris les infirmières autorisées et les infirmières praticiennes; sages-femmes, y compris les sages-femmes en pratique clinique et les apprenties sages-femmes et les apprentis en médecine, y compris les étudiants de médecine, résidents, stagiaires (fellows); et tous les autres fournisseurs de soins de santé qui prodiguent des soins aux femmes.La présente publication fournit des données probantes et des recommandations fondées sur des avis d'experts sur l'examen pelvien chez les femmes adultes (18 ans et plus) avec et sans symptômes gynécologiques.La présente publication clarifie les indications de l'examen pelvien dans le contexte des déclarations de groupes d'étude nationaux récemment publiées sur l'utilité de l'examen pelvien. L'objectif est de veiller à ce que les femmes qui présentent des indications cliniques d'examen fassent rapidement l'objet d'une évaluation clinique adéquate pour diagnostiquer les maladies traitables.Pour la présente opinion de comité, les études pertinentes ont été repérées dans PubMed et Medline à l'aide des termes suivants, seuls ou combinés, et les recherches ont été limitées aux publications en anglais portant sur des humains sans date limite de publication : pelvic examination, bimanual examination, speculum examination, rectovaginal examination, ovarian cancer screening, asymptomatic women, periodic health examination. La recherche a été effectuée en mai et en juin 2018. Les données probantes pertinentes ont été retenues dans l'ordre suivant : méta-analyses, revues systématiques, lignes directrices et déclarations des groupes d'étude nationaux, essais cliniques randomisés, études de cohorte prospective, études observationnelles, revues non systématiques, études de série de cas et rapports. Des articles supplémentaires ont été repérés en consultant les notices bibliographiques des publications sélectionnées. Une revue systématique officielle n'a pas été menée pour tous les sujets discutés en raison du manque de données probantes et du nombre de différents sous-thèmes abordés. Le nombre total de publications examinées dans le cadre de cette revue était de 66.Les auteurs principaux ont rédigé le contenu et les recommandations et ils se sont entendus sur ces derniers. Les conseils d'administration de la Society of Gynecologic Oncology of Canada (GOC), de Collège des médecins de famille du Canada (CMFC) et de la Société des obstétriciens et gynécologues du Canada (SOGC) ont approuvé la version définitive aux fins de publication après que leurs comités représentatifs respectifs l'aient passée en revue. La qualité des données probantes utilisées dans le présent document a été évaluée au moyen des critères du cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). (Tableaux 1 et 2) Le résumé des conclusions est disponible sur demande.La présente opinion de comité devrait aider toutes les femmes qui souffrent ou non de symptômes gynécologiques qui se présentent chez le gynécologue et un fournisseur de soins primaires. Elle aidera les praticiens à déterminer les indications d'examen pelvien afin de réduire le nombre d'examens inutiles et susceptibles de porter préjudice tout en augmentant le nombre d'examens indiqués afin de réduire les retards de diagnostic des affections gynécologiques traitables.La présente opinion de comité de la SOGC sera automatiquement passée en revue cinq ans après sa publication pour déterminer si une partie ou l'ensemble de l'opinion de comité devrait être mis à jour. Cependant, cette revue peut être effectuée plus tôt si de nouvelles recherches révolutionnaires sont publiées entre-temps.1) Les déclarations et les directives nationales et internationales sur l'examen pelvien ne devraient pas être interprétées comme si l'examen pelvien est superflu, qu'il ne contribue pas à l’évaluation physique ou que l'examen pelvien chez les femmes symptomatiques devrait être omis. 2) L'examen pelvien peut comprendre les examens visuels, au spéculum, bimanuel, à un doigt ou rectovaginal selon l'indication d'examen. 3) Aucune étude publiée à ce jour n'a évalué adéquatement quelque composante que ce soit de l'examen pelvien comme méthode de dépistage pour quelconque type de maladie gynécologique maligne, à l'exception de l'examen au spéculum pour le dépistage cytologique du cancer du col de l'utérus. Ainsi, toute recommandation universelle, pour ou contre les examens pelviens pour d'autres indications ne peut qu’être faite selon l'opinion des spécialistes et des données probantes de faible qualité. 4) Chez les femmes asymptomatiques dont le risque de cancer du col de l'utérus est moyen, le dépistage cytologique du cancer du col de l'utérus réduit à la fois son incidence et son taux de mortalité en détectant les lésions préinvasives traitables. 5) Chez les femmes asymptomatiques dont le risque de tumeur ou affection maligne est moyen, un examen visuel et bimanuel au moment d'obtenir des échantillons cytologiques cervicaux peut apporter une valeur ajoutée à cette méthode de dépistage. Les femmes peuvent ne pas soulever certaines inquiétudes sur le plan gynécologique jusqu'au moment de l'examen pelvien; l'examen offre une occasion de sensibiliser les patientes et de maintenir les compétences du praticien; de plus, même si le sujet n'a pas encore été étudié adéquatement, il pourrait comporter des effets positifs sur les tumeurs ou affections malignes ovariennes et vulvaires qui nécessiteraient des analyses plus poussées. Ces avantages potentiels devraient être soupesés par rapport aux préjudices potentiels comme l'inconfort de la patiente et les faux positifs ou négatifs qui pourraient la rassurer à tort ou entraîner des analyses et des interventions non justifiées.Femmes symptomatiques 1) Toute femme qui exprime des plaintes de nature gynécologique, y compris, mais sans s'y limiter, des plaintes concernant la vulve, des pertes vaginales, des saignements préménopausiques anormaux, des saignements postménopausiques, l'infertilité, des symptômes de prolapsus des organes pelviens, l'incontinence urinaire, de nouveaux symptômes gastro-intestinaux inexpliqués (douleur abdominale, distension abdominale ou ballonnement et difficulté à manger ou satiété précoce), la douleur pelvienne ou la dyspareunie, devrait subir des composantes pertinentes de l'examen pelvien afin de détecter les maladies bénignes ou malignes (forte, basse). 2) Les fournisseurs de soins de santé peuvent envisager de discuter des risques et avantages de l'exécution d'un examen pelvien de base qui comprend un examen visuel et un examen bimanuel avant de prescrire une hormonothérapie substitutive ou un traitement hormonal de la ménopause (faible, très basse). Femmes asymptomatiques 3) Les professionnels de la santé devraient faire le dépistage cytologique du cancer du col de l'utérus conformément aux lignes directrices provinciales ou territoriales (forte, forte). 4) Les données sont insuffisantes pour orienter les recommandations sur l'examen pelvien aux fins de dépistage de tumeurs ou affections malignes de nature gynécologique non cervicales ou de toute maladie gynécologique bénigne chez les femmes asymptomatiques en santé dont le risque de tumeur ou affection maligne est moyen. Cependant, les professionnels de la santé peuvent envisager d'effectuer un examen pelvien aux fins de dépistage comprenant les examens visuel, bimanuel et au spéculum conjointement avec le prélèvement d’échantillons cytologiques cervicaux selon les intervalles recommandés dans les lignes directrices provinciales ou territoriales. Cette pratique pourrait permettre de détecter d'importantes maladies bénignes ou malignes non reconnues ou signalées par la patiente (faible, très basse). 5) Chez les femmes âgées de plus de 70 ans qui n'ont plus à subir de dépistage cytologique cervical, les professionnels de la santé devraient envisager de continuer chez les femmes asymptomatiques le dépistage périodique des maladies vulvaires en examinant la vulve, le périnée et l'anus afin de détecter les maladies bénignes ou malignes méconnues de cette population. Les données sont insuffisantes pour déterminer des recommandations sur la fréquence de cet examen (faible, basse). 6) Des examens pelviens de dépistage plus fréquents pour déceler les signes précoces de tumeurs ou affections malignes primitives, récidivantes ou métastatiques en l'absence de symptômes pourraient s'avérer bénéfiques pour les femmes qui ont des antécédents personnels de tumeurs malignes de nature gynécologique, un diagnostic génétique qui augmente le risque de tumeurs ou affections malignes gynécologiques ou des antécédents d'exposition in utero au diéthylstilbestrol. Puisque les données pour déterminer ces intervalles de dépistage sont inadéquates, on devrait les déterminer en fonction des lignes directrices provinciales ou territoriales et de l'opinion des spécialistes (faible, très basse). 7) Les options non effractives et par auto-prélèvement de dépistage de la chlamydia et de la gonorrhée sont acceptables chez les femmes asymptomatiques, mais l'examen pelvien, qui comprend les examens visuel, bimanuel et au spéculum, est requis en présence de symptômes pour écarter la possibilité d'une maladie inflammatoire pelvienne ou d'un abcès tubo-ovarien (forte, basse). 8) Aucun examen pelvien n'est requis avant la prescription de contraception hormonale chez une femme en santé qui ne présente aucun symptôme gynécologique (forte, basse).

Despite relatively high vaccination coverage rates in the European Region, vaccine hesitancy is undermining individual and community protection from vaccine preventable diseases. At the request of its European Technical Advisory Group of Experts on Immunization (ETAGE), the Vaccine-preventable Diseases and Immunization Programme of the WHO Regional Office for Europe (WHO/EURO) developed tools to help countries address hesitancy more effectively. The Guide to Tailoring Immunization Programmes (TIP), an evidence and theory based behavioral insight framework, issued in 2013, provides tools to (1) identify vaccine hesitant population subgroups, (2) diagnose their demand- and supply-side immunization barriers and enablers and (3) design evidence-informed responses to hesitancy appropriate to the subgroup setting, context and vaccine. The Strategic Advisory Group of Experts on Immunization (SAGE) through its Working Group on Vaccine Hesitancy has closely followed the development, implementation, use and evolution of TIP concluding that TIP, with local adaptation, could be a valuable tool for use in all WHO regions, to help address countries' vaccine hesitancy problems. The TIP principles are applicable to communicable, noncommunicable and emergency planning where behavioral decisions influence outcomes.

The SAGE Working Group on Vaccine Hesitancy concluded that vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence. The Working Group retained the term ‘vaccine’ rather than ‘vaccination’ hesitancy, although the latter more correctly implies the broader range of immunization concerns, as vaccine hesitancy is the more commonly used term. While high levels of hesitancy lead to low vaccine demand, low levels of hesitancy do not necessarily mean high vaccine demand. The Vaccine Hesitancy Determinants Matrix displays the factors influencing the behavioral decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine/vaccination-specific influences.

Despite a wide array of safe and effective vaccines in use globally, with major impacts on health worldwide, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization has been repeatedly confronted with reports of hesitancy towards accepting specific vaccines or vaccination programmes. This paper summarizes the rationale for a SAGE review of the issue of vaccine hesitancy, its impact and ways to address it, and the convening of a Vaccine Hesitancy Working Group in March 2012 to prepare for the SAGE review. It describes the methods used and mode of operations, and advances in the relatively new field of research on vaccine hesitancy. It further elaborates and references the work conducted, including a series of products, conclusions and recommendations that emerged from the SAGE review in October 2014.

Resume Objectif Passer en revue l'utilisation du morcellement tissulaire dans le cadre de la chirurgie gynecologique a effraction minimale. Issues Dans le cadre d'une chirurgie gynecologique, le morcellement peut etre utilise en vue de permettre le retrait de prelevements uterins de grandes dimensions, ce qui permet l'offre d'une option chirurgicale a effraction minimale aux patientes visees. Les issues oncologiques indesirables du morcellement tissulaire devraient etre attenuees par l'intermediaire d'une meilleure selection des patientes, d'explorations preoperatoires et de techniques novatrices qui minimisent la dispersion tissulaire. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et Medline au printemps 2014 au moyen d'un vocabulaire controle (« leiomyomsarcoma », « uterine neoplasm », « uterine myomectomy », « hysterectomy ») et de mots cles (« leiomyoma », « endometrial cancer », « uterine sarcoma », « leiomyosarcoma », « morcellation » et « MRI ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete imposee en matiere de date; toutefois, les resultats ont ete limites aux documents rediges en anglais ou en francais. Les recherches ont ete mises a jour de facon reguliere et ont ete integrees a la directive clinique jusqu'en aout 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Avantages, desavantages et couts Les gynecologues peuvent offrir l'option de la chirurgie a effraction minimale a leurs patientes, ce qui pourrait mettre en jeu le morcellement tissulaire et l'utilisation d'un morcellateur motorise a des fins de retrait de prelevements. Les femmes devraient etre avisees que, dans les cas ou l'on en vient a constater un sarcome uterin ou un cancer de l'endometre dont la presence etait insoupconnee, l'utilisation d'un morcellateur est associee a un risque accru de dissemination tumorale. Une formation adequate et des pratiques sures devraient etre mises en œuvre avant que l'on puisse offrir le recours au morcellement tissulaire. Declarations sommaires 1.Les sarcomes uterins peuvent etre difficiles a diagnostiquer de facon preoperatoire. Dans le cadre d'une chirurgie visant un leiomyome uterin supposement benin, le risque de constater un sarcome uterin dont la presence etait insoupconnee est d'environ 1 sur 350; dans le cas des leiomyosarcomes, ce risque est de 1 sur 500. (II-2) Un tel risque augmente avec l'âge. (II-2) 2.Dans les cas ou l'on constate un sarcome uterin dont la presence n'etait pas soupconnee, la tenue d'une chirurgie primaire donnant lieu a une rupture tumorale (y compris le morcellement de la tumeur) pourrait mener a la propagation intra-abdominale de la tumeur et a l'aggravation du pronostic. (II-2) 3.Les techniques chirurgicales permettant de preserver l'uterus demeurent une option sure pour les patientes presentant des leiomyomes symptomatiques qui souhaitent demeurer fertiles. (II-1) Recommandations 1.De nombreuses techniques peuvent etre utilisees aux fins du morcellement d'un prelevement uterin; les medecins devraient envisager l'utilisation de techniques qui minimisent la rupture des prelevements et leur propagation intra-abdominale. (III-C) 2.Toutes les patientes qui presentent un leiomyome uterin devraient faire l'objet d'une evaluation cherchant a determiner la presence possible d'une tumeur maligne, en fonction de leurs facteurs de risque et des resultats de l'imagerie preoperatoire, et ce, bien que la valeur de ces parametres soit limitee. (III-C) 3.La tenue preoperatoire d'une biopsie endometriale et d'une evaluation du col uterin en vue de chercher a eviter le morcellement de tumeurs malignes et premalignes potentiellement detectables est recommandee. (II-2A) 4.Les syndromes cancereux hereditaires donnant lieu a une hausse du risque de constater la presence d'une tumeur uterine maligne devraient etre consideres comme etant une contre-indication a la tenue d'un morcellement uterin non confine. (III-C) 5.Le morcellement de l'uterus est contre-indique pour ce qui est des femmes chez qui la presence d'un cancer est etablie ou soupconnee. (II-2A) Face a un fort indice de suspicion quant a la presence d'un sarcome uterin avant la chirurgie, les patientes devraient etre avisees de choisir de subir une hysterectomie abdominale totale, une salpingectomie bilaterale et peut-etre meme une ovariectomie. (II-2C) Une consultation en gyneco-oncologie devrait etre mise en œuvre. 6.La mise en œuvre de techniques de morcellement tissulaire necessite une formation et une experience adequates. Des initiatives visant a assurer la surete de la technique et du materiel de morcellement utilises devraient etre mises en œuvre au niveau local. (II-3B) 7.Le morcellement constitue une option acceptable pour le retrait de prelevements uterins benins et pourrait faciliter la mise en œuvre d'une approche chirurgicale a effraction minimale (laquelle est associee a des risques perioperatoires moindres). Des services de counseling devraient etre offerts a toutes les patientes au sujet des risques potentiellement associes a l'utilisation du morcellement (y compris les risques associes a la presence sous-jacente d'une tumeur maligne). (III-C)

Globally, communication plays an integral role in public health strategies, from infectious diseases to diseases related to lifestyles. The evolution of the field of social and behaviour change communication (SBCC), combined with the need for evidence based practice and multi-level interventions to promote health, and human resource gaps in sub-Saharan Africa have led to the imperative to standardise and formalise the field. Moreover, current practitioners come from different disciplinary backgrounds underlining the need to define common core skills and competencies. This paper describes the partnership between theWits School of Public Health and the Soul City Institute for Health and Development Communication and how the partners responded to this need. It highlights the factors influencing sustainable institutional capacity to provide quality assured, accredited training. We describe an unexpected positive response from a number of practitioner organisations that have chosen to send multiple staff members for training, specifically to build a critical mass within their organisations. Finally, we note the interest from (mostly) southern-based academic institutions in setting up similar programmes and postulate that southsouth collaborations can contribute to building sustainable context specific and evidence-informed SBCC programmes in the global south. Keywords : SBCC; competency-based curriculum; southsouth collaboration; institutional capacity strengthening; Africa; practitioner academic partnership; donor responsiveness (Published: 24 January 2013) Citation: Glob Health Action 2013, 6 : 19300 - http://dx.doi.org/10.3402/gha.v6i0.19300

Many countries and communities are dealing with groups and growing numbers of individuals who are delaying or refusing recommended vaccinations for themselves or their children. This has created a need for immunization programs to find approaches and strategies to address vaccine hesitancy. An important source of useful approaches and strategies is found in the frameworks, practices, and principles used by commercial and social marketers, many of which have been used by immunization programs. This review examines how social and commercial marketing principles and practices can be used to help address vaccine hesitancy. It provides an introduction to key marketing and social marketing concepts, identifies some of the major challenges to applying commercial and social marketing approaches to immunization programs, illustrates how immunization advocates and programs can use marketing and social marketing approaches to address vaccine hesitancy, and identifies some of the lessons that commercial and non-immunization sectors have learned that may have relevance for immunization. While the use of commercial and social marketing practices and principles does not guarantee success, the evidence, lessons learned, and applications to date indicate that they have considerable value in fostering vaccine acceptance.