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Chatham AA, Petruzzi LJ, Patel S, Brode WM, Cook R, Garza B, Garay R, Mercer T, Valdez CR. Structural Factors Contributing to Compassion Fatigue, Burnout, and Secondary Traumatic Stress Among Hospital-Based Healthcare Professionals During the COVID-19 Pandemic. Qual Health Res 2024; 34:362-373. [PMID: 38011747 PMCID: PMC10905984 DOI: 10.1177/10497323231213825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
High levels of burnout among healthcare providers (HCPs) have been a widely documented phenomenon, which have been exacerbated during the COVID-19 pandemic. In the United States, qualitative studies that are inclusive of HCPs in diverse professional roles have been limited. Therefore, we utilized a qualitative-quantitative design to examine professional quality of life in terms of compassion fatigue, burnout, and secondary traumatic stress among hospital-based HCPs, including social workers, hospitalists, residents, and palliative care team members during COVID-19. HCPs (n = 26) participated in virtual semi-structured focus groups or individual interviews and online surveys (n = 30) including the Professional Quality of Life (ProQOL) Scale. While ProQOL scores indicated low levels of compassion fatigue, burnout, and secondary traumatic stress, thematic analysis of our qualitative data included rich descriptions of compassion fatigue, burnout, and secondary traumatic stress. Safety concerns and value misalignment characterized structural stressors perceived to contribute to HCP compassion fatigue, burnout, and secondary traumatic stress. The discrepancy between our qualitative and quantitative findings may be indication that modifications to current screenings are warranted. These findings also suggest a need to identify and implement structural and policy changes that increase HCPs' physical and emotional safety and promote better alignment of institutional interests with HCP values.
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Affiliation(s)
- Ana A. Chatham
- Steve Hicks School of Social Work at The University of Texas at Austin, Austin, TX, USA
| | - Liana J. Petruzzi
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Snehal Patel
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
- Internal Medicine Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - W. Michael Brode
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
- Internal Medicine Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Rebecca Cook
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
- Internal Medicine Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Brenda Garza
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Ricardo Garay
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Tim Mercer
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
- Internal Medicine Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Carmen R. Valdez
- Steve Hicks School of Social Work at The University of Texas at Austin, Austin, TX, USA
- Population Health Department, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
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Jacobson BF, Schapkaitz E, Takalani A, Rowji P, Louw VJ, Opie J, Bekker LG, Garrett N, Goga A, Reddy T, Yende-Zuma N, Sanne I, Seocharan I, Peter J, Robinson M, Collie S, Khan A, Takuva S, Gray G. Vascular thrombosis after single dose Ad26.COV2.S vaccine in healthcare workers in South Africa: open label, single arm, phase 3B study (Sisonke study). bmjmed 2023; 2:e000302. [PMID: 37063238 PMCID: PMC10083528 DOI: 10.1136/bmjmed-2022-000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 02/23/2023] [Indexed: 04/05/2023]
Abstract
ObjectiveTo assess the rates of vascular thrombotic adverse events in the first 35 days after one dose of the Ad26.COV2.S vaccine (Janssen/Johnson & Johnson) in healthcare workers in South Africa and to compare these rates with those observed in the general population.DesignOpen label, single arm, phase 3B study.SettingSisonke study, South Africa, 17 February to 15 June 2021.ParticipantsThe Sisonke cohort of 477 234 healthcare workers, aged ≥18 years, who received one dose of the Ad26.COV2.S vaccine.Main outcome measuresObserved rates of venous arterial thromboembolism and vaccine induced immune thrombocytopenia and thrombosis in individuals who were vaccinated, compared with expected rates, based on age and sex specific background rates from the Clinical Practice Research Datalink GOLD database (database of longitudinal routinely collected electronic health records from UK primary care practices using Vision general practice patient management software).ResultsMost of the study participants were women (74.9%) and median age was 42 years (interquartile range 33-51). Twenty nine (30.6 per 100 000 person years, 95% confidence interval 20.5 to 44.0) vascular thrombotic events occurred at a median of 14 days (7-29) after vaccination. Of these 29 participants, 93.1% were women, median age 46 (37-55) years, and 51.7% had comorbidities. The observed to expected ratios for cerebral venous sinus thrombosis with thrombocytopenia and pulmonary embolism with thrombocytopenia were 10.6 (95% confidence interval 0.3 to 58.8) and 1.2 (0.1 to 6.5), respectively. Because of the small number of adverse events and wide confidence intervals, no conclusions were drawn between these estimates and the expected incidence rates in the population.ConclusionsVaccine induced immune thrombocytopenia and thrombosis after one dose of the Ad26.COV2.S vaccine was found in only a few patients in this South African population of healthcare workers. These findings are reassuring if considered in terms of the beneficial effects of vaccination against covid-19 disease. These data support the continued use of this vaccine, but surveillance is recommended to identify other incidences of venous and arterial thromboembolism and to improve confidence in the data estimates.Trial registrationClinicalTrials.govNCT04838795.
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Affiliation(s)
- Barry Frank Jacobson
- Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elise Schapkaitz
- Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Azwi Takalani
- Hutchinson Centre Research Institute of South Africa (HCRISA), Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Pradeep Rowji
- The Southern African Society of Thrombosis and Haemostasis, Neurology Association of South Africa, Johannesburg, South Africa
| | - Vernon Johan Louw
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jessica Opie
- Division of Haematology, Department of Pathology, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ameena Goga
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- Nelson R Mandela School of Medicine, Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, University of the Witwatersrand Faculty of Sciences, Johannesburg, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Jonny Peter
- Division of Allergy and Clinical Immunology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Amber Khan
- Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simbarashe Takuva
- School of Health Systems and Public Health, University of Pretoria, Faculty of Health Sciences, Pretoria, South Africa
- Perinatal HIV Research Unit, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Glenda Gray
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
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McCormick KA, Chatham A, Klodnick VV, Schoenfeld EA, Cohen DA. Mental Health Service Experiences Among Transition-Age Youth: Interpersonal Continuums that Influence Engagement in Care. Child Adolesc Social Work J 2022; 40:1-12. [PMID: 36373126 PMCID: PMC9638293 DOI: 10.1007/s10560-022-00890-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
Purpose. Transition-age youth (TAY) who have experienced or are experiencing complex trauma, system involvement and homelessness are at increased risk for serious mental health needs and related challenges. However, these vulnerable and historically marginalized TAY typically have low rates of mental health service engagement. This study examines how and why TAY experiencing system involvement, homelessness, and serious mental health and substance use symptoms engage in mental health services, and what facilitates and/or hinders their engagement in services. Methods. Twenty-one TAY completed a virtual interview about their previous and current mental health service experiences, and why they did or did not engage with mental health services. A modified grounded theory qualitative analysis approach was used to understand how participants' personal sense of meaning interacted with programmatic factors to construct participant experiences with mental health services. Results. Most participants (81%, n = 17) received mental health services, namely psychiatry (76%, n = 16) and counseling/therapy (48%, n = 10), and peer support (10%, n = 2). Participants described their mental health service experiences along three interpersonal and relational continuums between themselves and their providers: feeling (mis)understood, being treated with (dis)respect, and experiencing (dis)trust. Discussion. Study findings reveal that for these particularly vulnerable and marginalized TAY, relational and interpersonal factors significantly influenced their engagement in mental health services. Study findings call for providers to re-imagine their working alliance with highly vulnerable TAY through culturally-attuned practices that promote understanding, respect, and trust. Findings also call for TAY-serving programs and policies to re-imagine peer support as a mental health service option for this highly vulnerable population.
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Affiliation(s)
- Katie A. McCormick
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, 78712 Austin, TX United States
| | - Ana Chatham
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, 78712 Austin, TX United States
| | - Vanessa V. Klodnick
- Youth & Young Adult Services Research and Innovation, 4101 N. Ravenswood Ave, 60613 Thresholds, Chicago, IL United States
- Texas Institute for Excellence in Mental Health, The University of Texas at Austin, 1823 Red River, 78701 Austin, TX United States
| | - Elizabeth A. Schoenfeld
- LifeWorks, 835 N. Pleasant Valley Rd, 78702 Austin, TX United States
- Department of Human Development & Family Sciences, School of Human Ecology, The University of Texas at Austin, 108 E. Dean Keeton St, 78712 Austin, TX United States
| | - Deborah A. Cohen
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, 78712 Austin, TX United States
- Texas Institute for Excellence in Mental Health, The University of Texas at Austin, 1823 Red River, 78701 Austin, TX United States
- Dell Medical School Department of Psychiatry and Behavioral Sciences, The University of Texas at Austin, 1601 Trinity St., Bldg, B, 78712 Austin, TX United States
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Nwosu CO, Kollamparambil U, Oyenubi A. Food insecurity and health outcomes during the coronavirus pandemic in South Africa: a longitudinal study. Health Econ Rev 2022; 12:32. [PMID: 35723759 PMCID: PMC9207854 DOI: 10.1186/s13561-022-00375-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 05/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Given that South Africa experienced significant food insecurity even before the COVID-19 pandemic, it is not surprising that the pandemic would result in even greater food insecurity in the country. This paper provides additional evidence on the relationship between food insecurity and health. METHODS Data came from the National Income Dynamics Study-Coronavirus Rapid Mobile Survey, a longitudinal survey of adult South Africans. Health was a self-reported indicator of general health, while food insecurity was measured by household hunger, the frequency of household hunger, and households running out of money to buy food. We performed descriptive and econometric analyses. RESULTS Food insecurity has remained high even in the face of greater re-opening of the economy. Moreover, among hunger-affected households, between a quarter and a third struggled with hunger almost daily or daily. Belonging to a hunger-affected household was associated with a 7-percentage point higher probability of worse health compared to not experiencing hunger. Compared to being unaffected by hunger, being hungry everyday was associated with a 15-percentage point higher probability of worse health in wave 1, an effect that became statistically insignificant by wave 4. CONCLUSIONS These results show the enormity of the hunger problem in South Africa and its adverse effects on health. In the face of economic uncertainty and the removal of COVID-19 palliatives like the grant top-ups, we enjoin policy makers to protect the vulnerable from food insecurity by continuing the implementation of anti-hunger policies and other measures that enhance food security in the country.
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Affiliation(s)
- Chijioke O. Nwosu
- Department of Economics and Finance, University of Free State University of the Free State, Bloemfontein, 9301 South Africa
| | | | - Adeola Oyenubi
- School of Economics & Finance, University of the Witwatersrand, Johannesburg, South Africa
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Takuva S, Takalani A, Seocharan I, Yende-Zuma N, Reddy T, Engelbrecht I, Faesen M, Khuto K, Whyte C, Bailey V, Trivella V, Peter J, Opie J, Louw V, Rowji P, Jacobson B, Groenewald P, Dorrington RE, Laubscher R, Bradshaw D, Moultrie H, Fairall L, Sanne I, Gail-Bekker L, Gray G, Goga A, Garrett N. Safety evaluation of the single-dose Ad26.COV2.S vaccine among healthcare workers in the Sisonke study in South Africa: A phase 3b implementation trial. PLoS Med 2022; 19:e1004024. [PMID: 35727802 PMCID: PMC9212139 DOI: 10.1371/journal.pmed.1004024] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 05/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Real-world evaluation of the safety profile of vaccines after licensure is crucial to accurately characterise safety beyond clinical trials, support continued use, and thereby improve public confidence. The Sisonke study aimed to assess the safety and effectiveness of the Janssen Ad26.COV2.S vaccine among healthcare workers (HCWs) in South Africa. Here, we present the safety data. METHODS AND FINDINGS In this open-label phase 3b implementation study among all eligible HCWs in South Africa registered in the national Electronic Vaccination Data System (EVDS), we monitored adverse events (AEs) at vaccination sites through self-reporting triggered by text messages after vaccination, healthcare provider reports, and active case finding. The frequency and incidence rate of non-serious and serious AEs were evaluated from the day of first vaccination (17 February 2021) until 28 days after the final vaccination in the study (15 June 2021). COVID-19 breakthrough infections, hospitalisations, and deaths were ascertained via linkage of the electronic vaccination register with existing national databases. Among 477,234 participants, 10,279 AEs were reported, of which 138 (1.3%) were serious AEs (SAEs) or AEs of special interest. Women reported more AEs than men (2.3% versus 1.6%). AE reports decreased with increasing age (3.2% for age 18-30 years, 2.1% for age 31-45 years, 1.8% for age 46-55 years, and 1.5% for age > 55 years). Participants with previous COVID-19 infection reported slightly more AEs (2.6% versus 2.1%). The most common reactogenicity events were headache (n = 4,923) and body aches (n = 4,483), followed by injection site pain (n = 2,767) and fever (n = 2,731), and most occurred within 48 hours of vaccination. Two cases of thrombosis with thrombocytopenia syndrome and 4 cases of Guillain-Barré Syndrome were reported post-vaccination. Most SAEs and AEs of special interest (n = 138) occurred at lower than the expected population rates. Vascular (n = 37; 39.1/100,000 person-years) and nervous system disorders (n = 31; 31.7/100,000 person-years), immune system disorders (n = 24; 24.3/100,000 person-years), and infections and infestations (n = 19; 20.1/100,000 person-years) were the most common reported SAE categories. A limitation of the study was the single-arm design, with limited routinely collected morbidity comparator data in the study setting. CONCLUSIONS We observed similar patterns of AEs as in phase 3 trials. AEs were mostly expected reactogenicity signs and symptoms. Furthermore, most SAEs occurred below expected rates. The single-dose Ad26.COV2.S vaccine demonstrated an acceptable safety profile, supporting the continued use of this vaccine in this setting. TRIAL REGISTRATION ClinicalTrials.gov NCT04838795; Pan African Clinical Trials Registry PACTR202102855526180.
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Affiliation(s)
- Simbarashe Takuva
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- * E-mail:
| | - Azwidhwi Takalani
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Family Medicine and Primary Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ishen Seocharan
- South African Medical Research Council, Durban, South Africa
| | | | - Tarylee Reddy
- South African Medical Research Council, Durban, South Africa
| | | | | | - Kentse Khuto
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Carmen Whyte
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Veronique Bailey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | | | - Jonathan Peter
- Division of Allergy and Clinical Immunology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jessica Opie
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Vernon Louw
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | | | - Barry Jacobson
- Department of Molecular Medicine and Haematology, Charlotte Maxeke Johannesburg Academic Hospital National Health Laboratory System Complex and University of the Witwatersrand, Johannesburg, South Africa
| | - Pamela Groenewald
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Rob E. Dorrington
- Centre for Actuarial Research, Faculty of Commerce, University of Cape Town, Cape Town, South Africa
| | - Ria Laubscher
- South African Medical Research Council, Durban, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Harry Moultrie
- National Institute for Communicable Diseases, National Health Laboratory Service, Sandringham, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
- King’s Global Health Institute, King’s College London, London, United Kingdom
| | - Ian Sanne
- Right to Care, Johannesburg, South Africa
| | - Linda Gail-Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
| | - Ameena Goga
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
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Johnson R, Sharma JR, Ramharack P, Mangwana N, Kinnear C, Viraragavan A, Glanzmann B, Louw J, Abdelatif N, Reddy T, Surujlal-Naicker S, Nkambule S, Mahlangeni N, Webster C, Mdhluli M, Gray G, Mathee A, Preiser W, Muller C, Street R. Tracking the circulating SARS-CoV-2 variant of concern in South Africa using wastewater-based epidemiology. Sci Rep 2022; 12:1182. [PMID: 35064174 PMCID: PMC8783013 DOI: 10.1038/s41598-022-05110-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/31/2021] [Indexed: 12/13/2022] Open
Abstract
This study uses wastewater-based epidemiology (WBE) to rapidly and, through targeted surveillance, track the geographical distribution of SARS-CoV-2 variants of concern (Alpha, Beta and Delta) within 24 wastewater treatment plants (WWTPs) in the Western Cape of South Africa. Information obtained was used to identify the circulating variant of concern (VOC) within a population and retrospectively trace when the predominant variant was introduced. Genotyping analysis of SARS-CoV-2 showed that 50% of wastewater samples harbored signature mutations linked to the Beta variant before the third wave, with the Delta variant absent within the population. Over time, the prevalence of the beta variant decreased steadily. The onset of the third wave resulted in the Delta variant becoming the predominant variant, with a 100% prevalence supporting the theory that the Delta variant was driving the third wave. In silico molecular docking analysis showed that the signature mutations of the Delta variant increased binding to host proteins, suggesting a possible molecular mechanism that increased viral infectivity of the Delta variant.
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Affiliation(s)
- Rabia Johnson
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa.
- Division of Medical Physiology, Faculty of Medicine and Health Sciences, Centre for Cardiometabolic Research in Africa, Stellenbosch University, Stellenbosch, South Africa.
| | - Jyoti R Sharma
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
| | - Pritika Ramharack
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
- Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban, 4001, South Africa
| | - Noluxabiso Mangwana
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
| | - Craig Kinnear
- Genomics Centre, South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Amsha Viraragavan
- Genomics Centre, South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
| | - Brigitte Glanzmann
- Genomics Centre, South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Johan Louw
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
| | - Nada Abdelatif
- Biostatistics Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Swastika Surujlal-Naicker
- Scientific Services, Water and Sanitation Department, City of Cape Town Metropolitan Municipality, Cape Town, South Africa
| | - Sizwe Nkambule
- Environment and Health Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Nomfundo Mahlangeni
- Environment and Health Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Candice Webster
- Environment and Health Research Unit, South African Medical Research Council (SAMRC), Johannesburg, South Africa
| | - Mongezi Mdhluli
- Office of the President, South African Medical Research Council, Tygerberg, 7050, South Africa
| | - Glenda Gray
- Office of the President, South African Medical Research Council, Tygerberg, 7050, South Africa
| | - Angela Mathee
- Environment and Health Research Unit, South African Medical Research Council (SAMRC), Johannesburg, South Africa
| | - Wolfgang Preiser
- Division of Medical Virology at NHLS Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Christo Muller
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg, 7505, South Africa
- Division of Medical Physiology, Faculty of Medicine and Health Sciences, Centre for Cardiometabolic Research in Africa, Stellenbosch University, Stellenbosch, South Africa
| | - Renee Street
- Environment and Health Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
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Street R, Mathee A, Mangwana N, Dias S, Sharma JR, Ramharack P, Louw J, Reddy T, Brocker L, Surujlal-Naicker S, Berkowitz N, Malema MS, Nkambule S, Webster C, Mahlangeni N, Gelderblom H, Mdhluli M, Gray G, Muller C, Johnson R. Spatial and Temporal Trends of SARS-CoV-2 RNA from Wastewater Treatment Plants over 6 Weeks in Cape Town, South Africa. Int J Environ Res Public Health 2021; 18:12085. [PMID: 34831841 PMCID: PMC8618134 DOI: 10.3390/ijerph182212085] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 11/22/2022]
Abstract
Recent scientific trends have revealed that the collection and analysis of data on the occurrence and fate of SARS-CoV-2 in wastewater may serve as an early warning system for COVID-19. In South Africa, the first COVID-19 epicenter emerged in the Western Cape Province. The City of Cape Town, located in the Western Cape Province, has approximately 4 million inhabitants. This study reports on the monitoring of SARS-CoV-2 RNA in the wastewater of the City of Cape Town's wastewater treatment plants (WWTPs) during the peak of the epidemic. During this period, the highest overall median viral RNA signal was observed in week 1 (9200 RNA copies/mL) and declined to 127 copies/mL in week 6. The overall decrease in the amount of detected viral SARS-CoV-2 RNA over the 6-week study period was associated with a declining number of newly identified COVID-19 cases in the city. The SARS-CoV-2 early warning system has now been established to detect future waves of COVID-19.
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Affiliation(s)
- Renée Street
- Environment & Health Research Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (A.M.); (M.S.M.); (S.N.); (C.W.); (N.M.)
| | - Angela Mathee
- Environment & Health Research Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (A.M.); (M.S.M.); (S.N.); (C.W.); (N.M.)
- Environmental Health Department, Faculty of Health Sciences, University of Johannesburg, Johannesburg 2092, South Africa
| | - Noluxabiso Mangwana
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
- Department of Microbiology, Stellenbosch University, Stellenbosch 7600, South Africa;
| | - Stephanie Dias
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
| | - Jyoti Rajan Sharma
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
| | - Pritika Ramharack
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
| | - Johan Louw
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
- Department of Biochemistry and Microbiology, University of Zululand, KwaDlangezwa 3886, South Africa
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa;
| | - Ludwig Brocker
- Department of Microbiology, Stellenbosch University, Stellenbosch 7600, South Africa;
| | - Swastika Surujlal-Naicker
- Scientific Services, Water and Sanitation Department, City of Cape Town Metropolitan Municipality, Cape Town 8000, South Africa;
| | - Natacha Berkowitz
- Community Services and Health, City Health, City of Cape Town, Hertzog Boulevard, Cape Town 8001, South Africa;
| | - Mokaba Shirley Malema
- Environment & Health Research Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (A.M.); (M.S.M.); (S.N.); (C.W.); (N.M.)
| | - Sizwe Nkambule
- Environment & Health Research Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (A.M.); (M.S.M.); (S.N.); (C.W.); (N.M.)
| | - Candice Webster
- Environment & Health Research Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (A.M.); (M.S.M.); (S.N.); (C.W.); (N.M.)
| | - Nomfundo Mahlangeni
- Environment & Health Research Unit, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (A.M.); (M.S.M.); (S.N.); (C.W.); (N.M.)
| | - Huub Gelderblom
- COVID-19 Prevention Network (COVPN), Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA;
| | - Mongezi Mdhluli
- Office of the President, South African Medical Research Council, Tygerberg 7050, South Africa;
| | - Glenda Gray
- Chief Research Operations Office, South African Medical Research Council, Tygerberg 7050, South Africa;
| | - Christo Muller
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
- Department of Biochemistry and Microbiology, University of Zululand, KwaDlangezwa 3886, South Africa
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
| | - Rabia Johnson
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (N.M.); (S.D.); (J.R.S.); (P.R.); (J.L.); (C.M.); (R.J.)
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
- Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban 4001, South Africa
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Lanza K, Alcazar M, Hoelscher DM, Kohl HW. Effects of trees, gardens, and nature trails on heat index and child health: design and methods of the Green Schoolyards Project. BMC Public Health 2021; 21:98. [PMID: 33413276 PMCID: PMC7792068 DOI: 10.1186/s12889-020-10128-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/23/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Latinx children in the United States are at high risk for nature-deficit disorder, heat-related illness, and physical inactivity. We developed the Green Schoolyards Project to investigate how green features-trees, gardens, and nature trails-in school parks impact heat index (i.e., air temperature and relative humidity) within parks, and physical activity levels and socioemotional well-being of these children. Herein, we present novel methods for a) observing children's interaction with green features and b) measuring heat index and children's behaviors in a natural setting, and a selection of baseline results. METHODS During two September weeks (high temperature) and one November week (moderate temperature) in 2019, we examined three joint-use elementary school parks in Central Texas, United States, serving predominantly low-income Latinx families. To develop thermal profiles for each park, we installed 10 air temperature/relative humidity sensors per park, selecting sites based on land cover, land use, and even spatial coverage. We measured green features within a geographic information system. In a cross-sectional study, we used an adapted version of System for Observing Play and Recreation in Communities (SOPARC) to assess children's physical activity levels and interactions with green features. In a cohort study, we equipped 30 3rd and 30 4th grade students per school during recess with accelerometers and Global Positioning System devices, and surveyed these students regarding their connection to nature. Baseline analyses included inverse distance weighting for thermal profiles and summing observed counts of children interacting with trees. RESULTS In September 2019, average daily heat index ranged 2.0 °F among park sites, and maximum daily heat index ranged from 103.4 °F (air temperature = 33.8 °C; relative humidity = 55.2%) under tree canopy to 114.1 °F (air temperature = 37.9 °C; relative humidity = 45.2%) on an unshaded playground. 10.8% more girls and 25.4% more boys interacted with trees in September than in November. CONCLUSIONS We found extreme heat conditions at select sites within parks, and children positioning themselves under trees during periods of high heat index. These methods can be used by public health researchers and practitioners to inform the redesign of greenspaces in the face of climate change and health inequities.
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Affiliation(s)
- Kevin Lanza
- Michael and Susan Dell Center for Healthy Living, School of Public Health in Austin, The University of Texas Health Science Center at Houston, 1616 Guadalupe St. Suite 6.300, Austin, TX 78701 USA
| | - Melody Alcazar
- Austin Parks and Recreation Department, 919 W 28th 1/2 St, Austin, TX 78705 USA
| | - Deanna M. Hoelscher
- Michael and Susan Dell Center for Healthy Living, School of Public Health in Austin, The University of Texas Health Science Center at Houston, 1616 Guadalupe St. Suite 6.300, Austin, TX 78701 USA
| | - Harold W. Kohl
- Michael and Susan Dell Center for Healthy Living, School of Public Health in Austin, The University of Texas Health Science Center at Houston, 1616 Guadalupe St. Suite 6.300, Austin, TX 78701 USA
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health in Austin, The University of Texas Health Science Center at Houston, 1616 Guadalupe St. Suite 6.300, Austin, TX 78701 USA
- Department of Kinesiology and Health Education, The University of Texas at Austin, 2109 San Jacinto Blvd, Austin, TX 78712 USA
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Haile D, Luo H, Vosti SA, Dodd KW, Arnold CD, Engle-Stone R. Micronutrient Fortification of Commercially Available Biscuits Is Predicted to Have Minimal Impact on Prevalence of Inadequate Micronutrient Intakes: Modeling of National Dietary Data From Cameroon. Curr Dev Nutr 2020; 4:nzaa132. [PMID: 32908959 PMCID: PMC7467246 DOI: 10.1093/cdn/nzaa132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/14/2020] [Accepted: 07/27/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Voluntarily fortified snack products are increasingly available but are not necessarily formulated to meet known dietary nutrient gaps, so potential impacts on population micronutrient intake adequacy are uncertain. OBJECTIVES We modeled the impacts of hypothetical micronutrient-fortified biscuits on inadequate micronutrient intake in children and women of reproductive age (WRA) in Cameroon. METHODS In a nationally representative survey stratified by macro-region (North, South, and Yaoundé/Douala), 24-h dietary recall data were collected from 883 children aged 12-59 mo and from 912 WRA. We estimated usual nutrient intake by the National Cancer Institute method for vitamin A, folate, vitamin B-12, zinc, and iron. We simulated the impact of biscuit fortification on prevalence of micronutrient intake below the estimated average requirement, given observed biscuit consumption, in the presence and absence of large-scale food fortification (LSFF) programs. RESULTS Biscuit consumption in the prior 24-h by children and WRA, respectively, ranged from 4.5% and 1.5% in the South, to 20.7% and 5.9% in Yaoundé/Douala. In the absence of LSFF programs, biscuits fortified with retinol (600 μg/100 g), folic acid (300 μg/100 g), and zinc (8 mg/100 g) were predicted to reduce the prevalence of inadequacy among children by 10.3 ± 4.4, 13.2 ± 4.2, and 12.0 ± 6.1 percentage points, respectively, in Yaoundé/Douala. However, when existing vitamin A-fortified oil, and folic acid-fortified and zinc-fortified wheat flour programs were considered, the additional impacts of fortified biscuits were reduced substantially. Micronutrient-fortified biscuits were predicted to have minimal impact on dietary inadequacy in WRA, with or without LSFF programs. CONCLUSIONS Given observed patterns of biscuit consumption in Cameroon, biscuit fortification is unlikely to reduce dietary inadequacy of studied micronutrients, except possibly for selected nutrients in children in urban areas in the absence of LSFF programs. As voluntary fortification becomes increasingly common, modeling studies could help guide efforts to ensure that fortified products align with public health goals.
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Affiliation(s)
- Demewoz Haile
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Hanqi Luo
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA, USA
| | - Kevin W Dodd
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
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Haidar A, Ranjit N, Archer N, Hoelscher DM. Parental and peer social support is associated with healthier physical activity behaviors in adolescents: a cross-sectional analysis of Texas School Physical Activity and Nutrition (TX SPAN) data. BMC Public Health 2019; 19:640. [PMID: 31132999 PMCID: PMC6537420 DOI: 10.1186/s12889-019-7001-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/17/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Parental and peer support can influence children's physical activity; however, these associations have not been fully examined in a multi-ethnic population across early and late adolescence. The objective of this study was to examine associations between perceived parental/peer social support, perceived parental disapproval for not exercising, and physical activity/screen time behaviors among a multi-ethnic sample of adolescents. METHODS The Texas School Physical Activity and Nutrition (TX SPAN) survey is a cross-sectional statewide probability-based survey, used to assess obesity-related behaviors such as diet and physical activity. The SPAN 2009-2011 study measured 8th and 11th grade students using a self-report questionnaire with established psychometric properties, along with objectively measured height and weight. Associations were examined using multiple logistic and linear regression. RESULTS For every 1-point increase in parental physical activity support, adolescents had 1.14 higher odds of engaging in five or more days of moderate physical activity per week (p < 0.001), and 1.12 higher odds of engaging in three or more days of vigorous physical activity per week (p < 0.001). For every 1-point increase in peer physical activity support, adolescents had 1.17 higher odds of engaging in five or more days of moderate physical activity per week (p < 0.001), and 1.15 higher odds of engaging in three or more days of vigorous physical activity per week (p < 0.001). CONCLUSIONS Parental and peer social support is associated with positive physical activity behaviors in adolescents. Strategies to focus on parent and peer support should be integral to intervention programs designed to increase physical activity in adolescents in middle and high schools.
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Affiliation(s)
- Amier Haidar
- Michael & Susan Dell Center for Healthy Living, UTHealth School of Public Health, 1616 Guadalupe St, Suite 6.300, Austin, TX 78701 USA
| | - Nalini Ranjit
- Michael & Susan Dell Center for Healthy Living, UTHealth School of Public Health, 1616 Guadalupe St, Suite 6.300, Austin, TX 78701 USA
| | - Natalie Archer
- Texas Department of State Health Services, 1100 W 49th Street, Austin, TX 78756 USA
| | - Deanna M. Hoelscher
- Michael & Susan Dell Center for Healthy Living, UTHealth School of Public Health, 1616 Guadalupe St, Suite 6.300, Austin, TX 78701 USA
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Wang G, Peng B. Script of Scripts: A pragmatic workflow system for daily computational research. PLoS Comput Biol 2019; 15:e1006843. [PMID: 30811390 PMCID: PMC6411228 DOI: 10.1371/journal.pcbi.1006843] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 03/11/2019] [Accepted: 01/29/2019] [Indexed: 01/22/2023] Open
Abstract
Computationally intensive disciplines such as computational biology often require use of a variety of tools implemented in different scripting languages and analysis of large data sets using high-performance computing systems. Although scientific workflow systems can powerfully organize and execute large-scale data-analysis processes, creating and maintaining such workflows usually comes with nontrivial learning curves and engineering overhead, making them cumbersome to use for everyday data exploration and prototyping. To bridge the gap between interactive analysis and workflow systems, we developed Script of Scripts (SoS), an interactive data-analysis platform and workflow system with a strong emphasis on readability, practicality, and reproducibility in daily computational research. For exploratory analysis, SoS has a multilanguage scripting format that centralizes otherwise-scattered scripts and creates dynamic reports for publication and sharing. As a workflow engine, SoS provides an intuitive syntax for creating workflows in process-oriented, outcome-oriented, and mixed styles, as well as a unified interface for executing and managing tasks on a variety of computing platforms with automatic synchronization of files among isolated file systems. As illustrated herein by real-world examples, SoS is both an interactive analysis tool and pipeline platform suitable for different stages of method development and data-analysis projects. In particular, SoS can be easily adopted in existing data analysis routines to substantially improve organization, readability, and cross-platform computation management of research projects.
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Affiliation(s)
- Gao Wang
- Department of Human Genetics, The University of Chicago, Chicago, IL, United States of America
| | - Bo Peng
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
- * E-mail:
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Pettee Gabriel K, Mason JM, Sternfeld B. Recent evidence exploring the associations between physical activity and menopausal symptoms in midlife women: perceived risks and possible health benefits. Womens Midlife Health 2015; 1:1. [PMID: 30766688 PMCID: PMC6214216 DOI: 10.1186/s40695-015-0004-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/22/2015] [Indexed: 01/18/2023] Open
Abstract
Although the health benefits of physical activity are well established, the prevalence of midlife women accumulating sufficient physical activity to meet current physical activity guidelines is strikingly low, as shown in United States (U.S.) based surveillance systems that utilize either (or both) participant-reported and device-based (i.e., accelerometers) measures of activity. For midlife women, these low prevalence estimates may be due, in part, to a general lack of time given more pressing work commitments and family obligations. Further, the benefits or "reward" of allocating limited time to physical activity may be perceived, by some, as too distant for immediate action or attention. However, shifting the health promotion message from the long term benefits of physical activity to the more short-term, acute benefits may encourage midlife women to engage in more regular physical activity. In this article, we review the latest evidence (i.e., past 5 years) regarding the impact of physical activity on menopausal symptoms. Recent studies provide strong support for the absence of an effect of physical activity on vasomotor symptoms; evidence is still inconclusive regarding the role of physical activity on urogenital symptoms (vaginal dryness, urinary incontinence) and sleep, but consistently suggestive of a positive impact on mood and weight control. To further advance this field, we also propose additional considerations and future research directions.
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Affiliation(s)
- Kelley Pettee Gabriel
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston: School of Public Health -- Austin Regional Campus, Austin, TX USA
- School of Public Health, Austin Regional Campus, 1616 Guadalupe Street, Suite 6.300, Austin, TX 78701 USA
- Michael & Susan Dell Center for Healthy Living; University of Texas Health Science Center in Houston, Houston, TX USA
| | - Jessica M. Mason
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston: School of Public Health -- Austin Regional Campus, Austin, TX USA
- School of Public Health, Austin Regional Campus, 1616 Guadalupe Street, Suite 6.300, Austin, TX 78701 USA
- Michael & Susan Dell Center for Healthy Living; University of Texas Health Science Center in Houston, Houston, TX USA
| | - Barbara Sternfeld
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
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