Research Articles (School of Public Health)

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Girl champ in eSwatini: A strategic marketing campaign to promote demand for sexual and reproductive health services among young women
(AIDS and Behavior, 21) Dlamini, Muhle; Manchia, Amanda; Mabuza, Khabonina; Christie, Sarah
Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.
Obesity in South Africa: The South African Demographic and Health Survey
(Nature Publishing Group, 2002) Puoane, Thandi; Steyn, Krisela; Bradshaw, Debbie; Laubscher, Ria; Fourie, Jean; Lambert, Vicki; Mbanangwa, Nolwazi
To ascertain the anthropometric profile and determinants of obesity in South Africans who participated in the Demographic and Health Survey in 1998. RESEARCH METHODS AND PROCEDURES: A sample of 13,089 men and women (age, _15 years) were randomly selected and then stratified by province and urban and nonurban areas. Height, weight, mid-upper arm circumference, and waist and hip circumference were measured. Body mass index (BMI) was used as an indicator of obesity, and the waist/hip ratio (WHR) was used as an indicator of abdominal obesity. Multivariate regression identified sociodemographic predictors of BMI and waist circumference in the data. RESULTS: Mean BMI values for men and women were 22.9 kg/m2 and 27.1 kg/m2, respectively. For men, 29.2% were overweight or obese (_25 kg/m2) and 9.2% had abdominal obesity (WHR _1.0), whereas 56.6% of women were overweight or obese and 42% had abdominal obesity (WHR _0.85). Underweight (BMI _18.5 kg/m2) was found in 12.2% of men and 5.6% of women. For men, 19% of the variation of BMI and 34% of the variation in waist circumference could be explained by age, level of education, population group, and area of residence. For women, these variables explained 16% of the variation of BMI and 24% of the variation in waist circumference. Obesity increased with age, and higher levels of obesity were found in urban African women. DISCUSSION: Overnutrition is prevalent among adult South Africans, particularly women. Determinants of overnutrition include age, level of education, ethnicity, and area of residence.
Risk factors for undernutrition of young children in a rural area of South Africa
(Cambridge University Press, 2003) Chopra, Mickey
To identify the factors associated with childhood undernutrition. Cross-sectional survey. Hlabisa health district in KwaZulu/Natal, South Africa. Eight hundred and sixty-eight children aged 3–59 months. Questionnaire survey and anthropometric survey of 516 random households with children in the health district. Multivariate analysis took into account the hierarchical relationships between the proposed risk factors. This conceptual model was built up during qualitative studies and with reference to international research in this area. The mean Z-scores for weight-for-age and height-for-age were 20.52 (95% confidence interval (CI) 20.44 to 20.60) and 21.25 (95% CI 21.15 to 21.35), respectively. Of the children, 26.3% (95% CI 23.3–29.3%) were stunted, 12.0% (95% CI 9.8–4.2%) were underweight-for-age (UWFA) and only 1.3% were wasted.
Improving the hospital management of malnourished children by participatory research
(Oxford University Press, 2004) Puoane, Thandi; Sanders, David; Ashworth, Ann; Chopra, Mickey; Strasser, Susan; McCoy, David
OBJECTIVE. To improve the clinical management of severely malnourished children in rural hospitals in South Africa. STUDY DESIGN. A pre- and post-intervention descriptive study in three stages: assessment of the clinical management of severely malnourished children, planning and implementing an action plan to improve quality of care, and monitoring and evaluating targeted activities. A participatory approach was used to involve district and hospital nutrition teams in all stages of the research. SETTING. Two rural Wrst-referral level hospitals (Mary Theresa and Sipetu) in Mount Frere District, Eastern Cape Province. MAIN MEASURES. A retrospective record review of all admissions for severe malnutrition to obtain patient characteristics and case fatality rates, a detailed review of randomly selected cases to illustrate general case management, structured observations in the paediatric wards to assess adequacy of resources for care of malnourished children, and in-depth interviews and focus group discussions with nursing and medical staff to identify barriers to improved quality of care. RESULTS. Before the study, case fatality rates were 50% and 28% in Mary Theresa and Sipetu hospitals, respectively. Information from case studies, observations, interviews, and focus group discussions revealed many inadequacies in knowledge, resources, and practices. The hospital nutrition team developed and implemented an action plan to improve the quality of care and developed tools for monitoring its implementation and evaluating its impact. In the 12-month period immediately after implementation, case fatality rates fell by ∼25% in both hospitals. CONCLUSION. Participatory research led to the formation of a hospital nutrition team, which identiWed shortcomings in the clinical management of severely malnourished children and took action to improve quality of care. These actions were associated with a reduction in case fatality rates.
The school, a viable educational site for interdisciplinary health promotion
(Taylor & Francis, 2004) Waggie, Firdouza; Gordon, Natalie; Brijlal, Priscilla
An interdisciplinary health promotion module, using the community-based teaching approach, is offered by the University of the Western Cape (UWC). Schools in Delft, a poor socio-economic area with high unemployment, crime and a range of social problems, are used as the teaching site
'Big is beautiful' – an exploration with urban black community health workers in a South African township
(South African Journal of Clinical Nutrition, 2005) Puoane, Thandi; Fourie, J.M.; Shapiro, M.; Rosling, L.; Tshaka, N.C.; Oelefse, A.
OBJECTIVES: To explore perceptions about factors associated with body weight and body image among black female community health workers (CHWs) living and working in Khayelitsha, Cape Town. DESIGN: A descriptive, cross-sectional study. Setting. Khayelitsha, a black township in Cape Town, South Africa. SUBJECTS: Forty-four black, female, Xhosa-speaking CHWs working in Khayelitsha. Outcome measures. Anthropometric measures (height, weight, and waist circumference) were taken. Body mass index (BMI) was computed as a measure to estimate total body fat. Waist circumference was used as a measure of abdominal obesity. Focus groups were employed to explore beliefs and attitudes about body size. Information from the focus group discussions was used to develop a semi-structured questionnaire for individual interviews, which were conducted to validate the data from the focus groups, and to assess knowledge on causes and risk factors associated with obesity. A body satisfaction question was also included in the questionnaire. Body image was measured using body shape drawings (pictograms). RESULTS: Of the 44 women measured, 2 had normal weight (BMI 18.5 - 24.9 kg/m2), 2 were overweight (BMI 25 - 30 kg/m2), 25 were obese (BMI 30 - 40 kg/m2) and 15 were extremely obese (BMI ≥ ( 40 kg/m2). A moderately overweight shape (BMI 27 kg/m2) was preferred; this was associated with dignity, respect, confidence, beauty, and wealth. Perceived causes of obesity were eating the wrong food, skipping breakfast and worries about debts, husbands/partners and teenage children. Negative aspects of obesity included body aches and tiredness. CONCLUSION: This study emphasises the prevalence of obesity among urban black women in South Africa, particularly among CHWs. Socio-cultural, behavioural and environmental factors seem to influence the development of obesity in this population.
Information for human resource management
(Health Systems Trust, 2005) Mathews, Verona
This chapter emphasises the need for a routine information system for Human Resources Management (HRM). It provides an assessment of the current information system for HRM using a case study approach. It also outlines a suggested approach for the development of a Routine Information System with an Essential Data Set for HRM. Finally, it provides an overview of proposed indicators to produce information for the management and monitoring of Human Resources for the health sector.
How equitable is the scaling up of HIV service provision in South Africa?
(Health and Medical Publishing Group, 2005) Scott, Vera; Chopra, Mickey; Conrad, Liz; Ntuli, Antoinette
OBJECTIVES. To assess the extent of inequalities in availability and utilisation of HIV services across South Africa. DESIGN. Cross-sectional descriptive study. Setting. Three districts reflecting different socio-economic conditions, but with similar levels of HIV infection, were purposively sampled. Outcome measures. Availability and utilisation of HIV services and management and support structures for programmes were assessed through the collection of secondary data supplemented by site visits. RESULTS. There were marked inequalities in service delivery between the three sites. Compared with two poorer sites, clinics at the urban site had greater availability of HIV services, including voluntary counselling and testing (100% v. 52% and 24% respectively), better uptake of this service (59 v. 9 and 5.5 clients per 1 000 adults respectively) and greater distribution of condoms (15.6 v. 8.2 condoms per adult male per year). Extra counsellors had also been employed at the urban site in contrast to the other 2 sites. The urban site also had far more intensive management support and monitoring, with 1 manager per 12 health facilities compared with 1 manager per more than 90 health facilities at the other 2 sites. CONCLUSION. The process of scaling up of HIV services seems to be accentuating inequalities. The urban site in this study was better able to utilise the extra resources. In contrast, the poorer sites have thus far been unable to scale up the response to HIV even with the availability of extra resources. Unless policy makers pay more attention to equity, efficacious interventions may prove to be of limited effectiveness.
Urban poverty in Cape Town
(Sage Publications, 2005) de Swardt, Cobus; Puoane, Thandi; Chopra, Mickey; du Toit, Andries
This paper describes key findings of a household livelihood survey conducted in impoverished African settlements in Cape Town, one of Africa’s wealthiest cities. Poverty in these areas is strongly shaped by the history of the Eastern Cape’s adverse spatial incorporation into the South African economy. Migrants from the rural areas are highly dependent on and integrated into the increasingly monetized economy – but are simultaneously marginalized and adversely incorporated within it. Survey findings show the costs and implications of this failure of the formal economy to provide adequate livelihoods. While many eke out a living in a vital yet marginal informal economy, these strategies are thoroughly linked to and dependent on the income that can be secured through participation in the formal job market. Those who are unable to find a foothold in the urban economy are highly vulnerable and are at risk of being confined to long-term poverty traps.
Obesity in South Africa: Challenges for government and health professionals
(Nutrition Society, 2005) Kruger, Salome H; Puoane, Thandi; Senekal, Marjanne; Van Der Merwe, Theresa M
OBJECTIVES: To review data on the prevalence, causes and health consequences of obesity in South Africa and propose interventions to prevent and treat obesity and related outcomes. METHODS: Data from existing literature were reviewed with an emphasis on changing eating and activity patterns, cultural factors, perceptions and beliefs, urbanisation and globalisation. Results of studies on the health consequences of obesity in South Africans are also reviewed. RESULTS: Shifts in dietary intakes and activity patterns to higher fat intakes and lower physical activity are contributing to a higher prevalence of obesity. Few overweight black women view themselves as overweight, and some associate thinness with HIV/AIDS. Glucose and lipid toxicity, associated with insulin resistance, play roles in the pathogenesis of the co-morbid diseases of obesity. Elevated free fatty acids in the black population predispose obese black patients to type 2 diabetes. CONCLUSION & RECOMMENDATIONS: Obesity prevention and treatment should be based on education, behaviour change, political support, intersectoral collaboration and community participation, local actions, wide inclusion of the population, adequately resourced programmes, infiltration of existing initiatives, evidence-based planning, and proper monitoring and evaluation. Interventions should have the following components: reasonable weight goals, healthful eating, physical activity and behavioural change. Genes and mutations affecting susceptibility to the development of co-morbidities of obesity and vulnerable periods of life for the development of obesity should be prioritised. Prevention should be managed in community services, identification of high-risk patients in primary healthcare services and treatment of co-morbid diseases in hospital services.
Obesity among black South African women
(Kamla-Raj Enterprises, 2005) Puoane, Thandi; Hughes, Gail; Bradley, Hazel A.
Obesity and associated non-communicable diseases such as Type 2 diabetes, hypertension, and ischaemic heart disease were previously thought to be diseases of affluent countries, but they are becoming increasingly prevalent in developing nations. Accessibility to cheap unhealthy food, global trade and market development influence nutrition transition towards diets with high fat and sugar contents. A decrease in physical activity due to urbanisation and other environmental factors such as crime and violence are thought to lead to an increased risk of obesity. Positive beliefs about body weight among black African women, together with the idea of association of thinness with HIV/AIDS virus infection are believed to fuel the obesity epidemic amongst this population This paper describes some of the contributory factors which black South African women are faced with in making choices about healthy living. A multisectoral approach will be needed to fight the epidemic of obesity and associated diseases.
Dilemmas and paradoxes in providing and changing antenatal care: A study of nurses and midwives in rural Zimbabwe
(Oxford University Press, 2005) Mathole, T; Lindmark, G; Ahlberg, B.M.
This paper describes the experiences of caregivers in a rural district in Zimbabwe, in caring for pregnant women within a context of changing antenatal care routines. Data were generated using individual interviews with 18 nurses and midwives. The caregivers experienced their working situation as stressful and frustrating due to high staff turnover, inconsistent policies, parallel programmes and limited resources, including time. They also faced difficulties when implementing some of the proposed changes. Furthermore, the caregivers had to deal with the pressure and resistance from the pregnant women, whose reasoning and rationale for using care appeared different from those of the health professionals. In light of the above, we stress the necessity for reflecting on and including the experiences and perspectives of caregivers and the users of care, as well as their contexts and realities, when implementing change.
Scaling up health promotion interventions in the era of HIV/AIDS: Challenges for a rights based approach
(Oxford University Press, 2005) Chopra, Mickey; Ford, Neil
A sustained scaled up response to global public health challenges such as HIV/AIDS will require a functioning and efficient health system, based on the foundation of strong primary healthcare. Whilst this is necessary, it is not sufficient. Health promotion strategies need to be put into place to better engage and support families and communities in preventing disease, optimize caring, creating the demand for services and holding service providers to account. There will have to be a move away from the traditional model whereby the problem of HIV/TB/malaria is to be solved by merely increasing resources to a centralized bureaucracy that tries to increase the supply of services including health promotion messages.
Impact of the HIV/AIDS pandemic on non-communicable disease prevention
(South African Medical Association, 2005-04) Puoane, Thandi; Hughes, Gail
HIV/AIDS continues to ravage sub-Saharan Africa, and in South Africa accounts for 30% of all mortality, making it the leading cause of death. The epidemic has had other negative effects, which have not been fully realised. Among these is the fact that, paradoxically, the awareness programmes implemented to prevent major spread of HIV/AIDS have complicated the prevention of non-communicable diseases (NCDs).
Community intervention for the emerging epidemic of non-communicable diseases
(MedPharm Publications, 2006) Puoane, Thandi; Bradley, Hazel A.
BACKGROUND: Community health workers (CHWs) are lay people trained to assist with health care in their communities. This study took place at two sites in Khayelitsha, a township in the Cape Peninsula, from 2000 to 2002. OBJECTIVES: To describe the process of developing an intervention programme for primary prevention of noncommunicable diseases (NCDs) in general and cardiovascular disease in particular, targeting CHWs. METHOD: Forty-four CHWs were assigned to either an intervention or a control group. The intervention group, living in Site C, received training on lifestyle modification with emphasis on healthy eating and physical activity, while the control group, living in Site B, did not receive any training until a year later. The process was undertaken in four stages. Stage 1 involved assessment of the CHWs’ risk factors by obtaining anthropometric measurements. CHWs were interviewed and focus group discussions were held on the socio-cultural factors associated with body weight and body image, and barriers to physical activity. Stage 2 involved developing and implementing a training programme for primary prevention of NCDs among CHWs. Stage 3, conducted at Site C, involved a situational assessment of available resources in the community for promoting healthy lifestyles. The fourth and final stage involved the implementation of community interventions by the CHWs. RESULTS: A large percentage of CHWs were overweight and obese, and therefore at risk for NCDs. They had misconceptions about causes and treatment of these diseases, and also lacked knowledge on nutrition and the risk of high fat intake. Easy access to cheap unhealthy food, rather than fresh fruit and vegetables, limited their ability to make healthy food choices. The findings from stage 1 led to a community participatory intervention. CONCLUSIONS: Developing community-targeted interventions for NCDs can be achieved by involving CHWs at the initial stage and utilising a multifaceted approach. Education of community members and CHWs does not guarantee behaviour modification. Unless the environment encourages healthy living, NCDs will continue to be a burden in the poor populations of South Africa.
Ability to manage diabetes – community health workers’ knowledge, attitudes and beliefs
(SEMDSA (Society for Endocrinology, Metabolism and Diabetes of SA), 2006) Hughes, Gail; Puoane, Thandi; Bradley, Hazel A.
BACKGROUND: Diabetes constitutes a significant health problem in South Africa. Early detection and good management can prevent or delay complications, with national guidelines for diabetes treatment now available to facilitate this. However, problems are being encountered with their implementation and there is evidence that preventive care is still inadequate in South Africa. Community health workers (CHWs) are lay personnel employed to serve as a link between professional health care staff and the community. They visit homes and can be a powerful force for diabetes prevention and adherence to treatment regimens, given appropriate knowledge. METHOD: We conducted a study to evaluate the knowledge, beliefs and attitudes of a group of CHWs serving a poor urban area, using focus groups and personal interviews. RESULTS: The CHWs did not have the requisite knowledge, attitudes and beliefs to make a positive impact on prevention and management of diabetes. For example, they cited eating sugar as a cause of diabetes. They advised folk remedies that purportedly diluted the blood sugar. Their patients took prescribed medication irregularly. Obesity was not considered an important risk factor. Poverty, however, was recognised as an obstacle to proper treatment. CONCLUSION: Training is clearly needed to empower the CHWs with skills to work within their communities to identify risk factors for diabetes and other non-communicable diseases, with emphasis on diet and physical activity.
Fear of sexually transmitted infections among women with male migrant partners – relationship to oscillatory migration pattern and risk-avoidance behaviour
(South African Medical Association, 2006) Hughes, Gail; Hoyo, Catherine; Puoane, Thandi
BACKGROUND: In South Africa, former apartheid laws encouraged rural males seeking employment to migrate to urban areas, moving weekly, monthly or annually between their rural families and urban workplaces. The combination of the migrant labour system and long family separations caused an explosion of serious health consequences, among others sexually transmitted infections (STIs) in the migrant population. OBJECTIVE: To describe some correlates of male migration patterns for the rural women left behind, especially the fear of STIs that this engendered in them and their risk-avoidance behaviour. Setting and subjects. In KwaZulu-Natal, 208 prenatal patients who were partners of oscillating male migrant workers were interviewed to determine their demographic and behavioural characteristics, and their fear of STIs. RESULTS: Thirty-six per cent of the rural women said that they were afraid of contracting STIs from their returning migrant partners. Women who saw their partners infrequently were more fearful of STI transmission, and were less able to have sexual communication. However, almost none of the women protected themselves, while only 8% used condoms, primarily for contraceptive purposes. CONCLUSIONS: These results reflect the gender-based power relationships of South African male migrants and their rural partners, the social and economic dependency of the women on their migrant partners, and the women’s social responsibility to bear children. The results point to the need to go beyond interventions that simply seek to modify behaviour without altering the forces that promote risk taking and discourage risk reduction, and the need to develop appropriate interventions to curb STIs and decrease HIV.
"Nothing new": responses to the introduction of antiretroviral drugs in South Africa
(Lippincott Williams & Wilkins, 2006) Chopra, Mickey; Kendall, Carl; Hill, Zelee; Schaay, Nikki; Nkonki, Lungiswa L.; Doherty, Tanya
Interviews conducted in South Africa found that awareness of antiretroviral therapy was generally poor. Antiretroviral drugs were not perceived as new, but one of many alternative therapies for HIV/AIDS. Respondents had more detailed knowledge of indications, effects and how to access alternative treatments, which is bolstered by the active promotion and legitimization of alternative treatments. Many expressed a lack of excitement about the introduction of antiretroviral therapy, and little change in their attitudes concerning the epidemic.
Communication on sexual issues between migrant males and their partners: a study undertaken in rural South Africa
(University of the Western Cape, 2006) Hughes, Gail; Puoane, Thandi
INTRODUCTION: Women stay alone with their children in rural places while their husbands I partners work away from home for varying periods of time. Such fluctuating migration may cause difficulty in communications and may spread sexual transmittable infections (STI) and the human immunodeficiency virus (HIV). OBJECTIVE: This study explored ways in which black women in rural South Africa communicated with partners, who were migrant workers, on issues related to sexual matters. Method: This is a qualitative study where four focus groups were utilized to allow the women to describe their experiences, and to verbalize their feelings, beliefs, and perceptions in this area. PARTICIPANTS: Four focus groups consisting of six females between the ages of 16 - 48 who had partners that were employed as migrant labourers and do not live at home. Setting: A rural area in Hlabisa jurisdiction. DATA COLLECTION: An interview schedule with open questions were used to facilitate the focus group discussions Findings: The women, who saw their partners infrequently, were unlikely to communicate with them about sexual matters, including STI, HIV, and contraception to prevent unintended pregnancy. Poor communication severely constrained the possibility of reducing the risk of these outcomes. Raising the subject could be interpreted as a violation of the trust attached to the monogamous relationships of these Zulu women. The women felt they owed their returning husbands sexual intimacy and refusal was not an option because it was typically countered with force. CONCLUSION: The desire and need for sexual communication carried a price that was too high for women to pay. Control of their sexuality was mostly in the hands of their partners, upon whom they were economically and socially dependent. At this point in the HIV pandemic is it important to cultivate and identify the relevant social, cultural and behavioural norms that could reduce risk situations that tend to favour the spread of HIV.
Socio-cultural factors influencing food consumption patterns in the black African population in an urban township in South Africa
(Kamla-Raj Enterprises, 2006) Puoane, Thandi; Matwa, Princess; Hughes, Gail; Bradley, Hazel A.
The present study was undertaken to examine socio-cultural factors that influence food intake in different groups of people residing in a black township in Cape Town. Focus group discussions and in-depth interviews were used to explore these factors in men, and women of different age groups. Discussions were recorded, transcribed and analysed according to emerging themes. The main findings of the study indicated that in addition to nourishing the body, food is a sign of warmth, acceptance and friendship. Meat consumption on a daily basis is associated with a high socioeconomic status, while consumption of vegetables only is associated with a low socioeconomic status. Eating large portions of food is associated with affordability. Food is used for celebrations, rituals, and for welcoming guests. Food is also used during social occasions when people get together and meet socially. Sweets, ice cream and cakes are consumed on happy occasions. Fatty meat is a sign of generosity; lean meat and black tea is often used during mourning periods. Eating behaviours are learned during socialization, and carried over from generation to generation. There are socially accepted norms and values surrounding people’s understanding of what food is. This information needs to be used in a more constructive way to help people choose food wisely to prevent over nutrition and associated risks. In conclusion, this paper illustrates the impact of socio-cultural factors on eating patterns in this population and emphasizes the need to take these factors into consideration in development of interventions to promote healthy eating.

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