Research summary

The primary focus of the Knowledge Translation Unit’s research work is to test the effectiveness, acceptability and cost-effectiveness of our programmes on the quality of care and outcomes for patients. We employ mixed methods approaches, conducting qualitative and economic evaluations alongside pragmatic trials completed in real world settings. The outcomes of these evaluations have contributed to the uptake of our programmes at a provincial and national level within South Africa, and elsewhere.

To date, we have completed and published four large randomised controlled trials involving between 15 and 40 clinics, with 2,000 to 15,500 patients enrolled (1, 2, 3, 4). These trials have demonstrated multiple, modest, but consistent and reproducible, positive effects on the quality of care provided by clinics which have received our interventions. These benefits extend to health outcomes, and we have shown positive effects on weight gain among HIV positive patients, gains in CD4 counts, reduced mortality among some patient subgroups and no adverse effects of the nurses' expanded scope of practice. The qualitative evaluations have shown that this combination of simplified guidelines, on-site interactive training and task-shifting prescribing is highly valued by nurses, doctors and managers working in resource-constrained primary care settings (5, 6). The economic evaluations have shown increased utilisation of primary care associated with increased costs, which are partially offset by reductions in the number and length of hospital admissions (7, 8).

Other research has used data collected for the trials to estimate the effectiveness of antiretroviral treatment on mortality, TB incidence and outcomes (9, 10). We have also collaborated with other researchers to model waiting times for ART and survey reasons for encounter among people attending primary care clinics in South Africa (11).

Two other large, pragmatic, cluster randomized trials have just closed. Data collection for the PRIME and COBALT trials closed in December 2017, and data are currently being analysed. The protocol papers of the two trials have been published (12, 13). An e-version of PACK has been evaluated and roll-out started in July 2016. A package for undergraduate medical students has been implemented and evaluated at the University of Stellenbosch, and it showed that the use of PACK in the final phase of undergraduate medical education improved their performance in primary care. The Development and process evaluation of the PACK Child intervention in the Western Cape Province commenced in October 2017 and the study will be completed in June 2019. For details on each of our projects, see the section on past or current research projects.

Page references
  1. Fairall L, Zwarenstein M, Bateman ED, Bachmann OM, Lombard C, Majara B, Joubert G, English RG, Bheekie A, van Rensburg HCJ, Mayers P, Peters AC, Chapman RD. Educational outreach to nurses improves tuberculosis case detection and primary care of respiratory illness: a pragmatic cluster randomized controlled trial BMJ. 2005; 331:750-754
  2. Zwarenstein M, Fairall LR, Lombard C, Mayers P, Bheekie A, English RG, et al. Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial. BMJ. 2011;342:d2022.
  3. Fairall, Lara, Max O Bachmann, Carl Lombard, Venessa Timmerman, Kerry Uebel, Merrick Zwarenstein, Andrew Boulle, et al. Task Shifting of Antiretroviral Treatment from Doctors to Primary-care Nurses in South Africa (STRETCH): a Pragmatic, Parallel, Cluster-randomised Trial. Lancet 380, no. 9845 (September 8, 2012): 889–898. doi:10.1016/S0140-6736(12)60730-2.
  4. Fairall LR, Folb N, Timmerman V, Lombard C, Steyn K, Bachmann MO, Bateman ED, Lund C, Cornick R, Faris G, Gaziano T, Georgeu-Pepper D, Zwarenstein M, Levitt NS. Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial. PLoS Med. 2016 Nov 22;13(11):e1002178. doi: 10.1371/journal.pmed.1002178. eCollection 2016 Nov.
  5. Stein, J., S. Lewin, L. Fairall, P. Mayers, R. English, A. Bheekie, E. Bateman, and M. Zwarenstein. Building Capacity for Antiretroviral Delivery in South Africa: A Qualitative Evaluation of the PALSA PLUS Nurse Training Programme. BMC Health Services Research 8, no. 1 (November 18, 2008): 240. doi:10.1186/1472-6963-8-240.
  6. Georgeu, Daniella, Christopher J. Colvin, Simon Lewin, Lara Fairall, Max O. Bachmann, Kerry Uebel, Merrick Zwarenstein, Beverly Draper, and Eric D. Bateman. Implementing Nurse-initiated and Managed Antiretroviral Treatment (NIMART) in South Africa: a Qualitative Process Evaluation of the STRETCH Trial. Implementation Science 7, no. 1 (July 16, 2012): 66. doi:10.1186/1748-5908-7-66.
  7. Fairall, Lara, Max O Bachmann, Merrick Zwarenstein, Eric D Bateman, Louis W Niessen, Carl Lombard, Bosielo Majara, et al. Cost-effectiveness of Educational Outreach to Primary Care Nurses to Increase Tuberculosis Case Detection and Improve Respiratory Care: Economic Evaluation Alongside a Randomised Trial. Tropical Medicine & International Health: TM & IH 15, no. 3 (March 2010): 277–286. doi:10.1111/j.1365-3156.2009.02455.x.
  8. Barton GR, Fairall L, Bachmann MO, Uebel K, Timmerman V, Lombard C, et al. Cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment in South Africa: pragmatic cluster randomised trial. Tropical Medicine & International Health. 2013 Jun;18(6):769–77.
  9. Fairall, Lara R, Max O Bachmann, Goedele M C Louwagie, Cloete van Vuuren, Perpetual Chikobvu, Dewald Steyn, Gillian H Staniland, et al. Effectiveness of Antiretroviral Treatment in a South African Program: a Cohort Study. Archives of Internal Medicine 168, no. 1 (January 14, 2008): 86–93. doi:10.1001/archinternmed.2007.10.
  10. Cornell, Morna, Anna Grimsrud, Lara Fairall, Matthew P Fox, Gilles van Cutsem, Janet Giddy, Robin Wood, et al. Temporal Changes in Programme Outcomes Among Adult Patients Initiating Antiretroviral Therapy Across South Africa, 2002-2007. AIDS (London, England) 24, no. 14 (September 10, 2010): 2263–2270. doi:10.1097/QAD.0b013e32833d45c5.
  11. Mash, Bob, Lara Fairall, Olubunmi Adejayan, Omozuanvbo Ikpefan, Jyoti Kumari, Shaheed Mathee, Ronit Okun, and Willy Yogolelo. A Morbidity Survey of South African Primary Care. PLoS ONE 7, no. 3 (March 16, 2012): e32358. doi:10.1371/journal.pone.0032358.
  12. Fairall L, Petersen I, Zani B, Folb N, Georgeu-Pepper D, Selohilwe O, Petrus R, Mntambo N, Bhana A, Lombard C, Bachmann M, Lund C, Hanass-Hancock J, Chisholm D, McCrone P, Carmona S, Gaziano T, Levitt N, Kathree T, Thornicroft G; CobALT research team. Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial. Trials. 2018 Mar 22;19(1):193. doi: 10.1186/s13063-018-2517-7.
  13. Petersen I, Bhana A, Folb N, Thornicroft G, Zani B, Selohilwe O, Petrus R, Mntambo N, Georgeu-Pepper D, Kathree T, Lund C, Lombard C, Bachmann M, Gaziano T, Levitt N, Fairall L; PRIME-SA research team. Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial. Trials. 2018 Mar 22;19(1):192. doi: 10.1186/s13063-018-2518-6

Number of individual recommendations in the PACK Global Adult guide

number of individual recommendations in the PACK Global Adult guide

guides distributed

guides distributed

research trials

pragmatic trials

Percent reduction in mortality among moderately ill AIDS patients awaiting antiretroviral treatment

percent reduction in mortality among moderately ill AIDS patients awaiting antiretroviral treatment

Research interviews with patient participants

research interviews with patient participants

Percent of recommendations in PACK Global Adult recommendations linked to the BMJ’s Best Practice or WHO recommendations

percent of recommendations in PACK Global Adult recommendations linked to the BMJ’s Best Practice or WHO recommendations



health workers trained

health workers trained



guide editions

guide editions

Median percent improvement in TB case detection in the 3 trials which measured it

median percent improvement in TB case detection in the 3 trials which measured it

Patients enrolled

patients enrolled