Philosophiae Doctor - PhD (School of Public Health)

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The effects of internal migration and related factors on nutrient intake and anthropometric status of children aged 1-9 years in South Africa, 1999
(University of the Western Cape, 2004) Swart, Elizabeth Catherina; Jackson, Debra; Shel, Robert; School of Public Health; Faculty of Community and Health Sciences
The purpose of this study was to provide a national overview on internal migration of children and to relate these migration patterns to the nutritional status of children. This study specifically investigated the internal migration that took place during the life span of the National Food Consumption Survey study population and relates that to their dietary intake and anthropometric status.
A participatory approach to the design of a child-health community-based information system for the care of vulnerable children
(University of the Western Cape, 2004) Byrne, Elaine; Lehmann, Uta; Sahay, Sundeep; School of Public Health; Faculty of Community and Health Sciences
The existing District Health Information System in South Africa can be described as a facility based Information System, focusing on the clinics and hospitals and not on the community. Consequently, only those who access health services through these facilities are included in the system. Many children do not have access to basic health and social services and consequently, are denied their right to good health. Additionally, they are excluded from the routine Health Information System. Policy and resource decisions made by the District Managers, based on the current health facility information, reinforces the exclusion of these already marginalised children. The premise behind this research is that vulnerability of children can be tackled using two interconnected strategies. The first is through the creation of awareness of the situation of children and the second through mobilising the commitment and action of government and society to address this situation. These strategies can be supported by designing an Information System for action; an Information System that can be used to advocate and influence decisions and policies for the rights of these children; an Information System that includes all children. An interpretive participatory action research approach, using a case study in a rural municipality in South Africa, was adopted for the study of a child-health Community-Based Information System. The context in which the community is placed, as well as the structures which are embedded in it, was examined using Structuration Theory. This theory also influenced the design of the Information System. As the aim of the research is to change the Information System to include vulnerable children, a Critical Social Theoretical and longitudinal perspective was adopted. In particular, concepts from Habermas, such as the creation of a public sphere and the ’Ideal Speech Situation’, informed the methodology chosen and were used to analyse the research undertaken. Based on the research conducted in this municipality, four main changes to the Health Information System were made. These were: • determination of the community’s own indicators; • changes in data collection forms; • creation of forums for analysis and reflection, and; • changes in the information flows for improved feedback. Other practical contributions of the research are the development of local capacities in data collection and analysis, the development of practical guidelines on the design of a child-health Community-Based Information System, and the development of strategies for enabling participation and communication. In line with the action research approach adopted, and the desire to link theory and practice, the research also contributed on a theoretical level. These contributions include extending the use of Structuration Theory, in conjunction with Habermas’ Critical Social Theory, to the empirical context of South Africa; addressing the gap of Community-Based Information Systems in Information System design; extending the debate on participation and communication in Information Systems to ’developing’ countries, and developing generalisations from a qualitative case study.
The role of occupational therapy, physiotherapy and speech and language therapy in education support services in South Africa
(University of the Western Cape, 2005) Struthers, Patricia; Sanders, David
This thesis investigated the education support services provided by occupational therapists, physiotherapists and speech and language therapists in the Western Cape Province of South Africa. Changes in the education policy in South Africa to an inclusive education system have major implications for the way therapists provide support. Therapists have been challenged to move from a medical model of support with a focus on highly specialised treatment for a small number of individual learners with disabilities, to a systemic and health promoting model which focuses on support for the education system, including all learners, teachers and parents. The aim of this research was to develop an appropriate and integrated approach for therapists to support schools within an inclusive and health promoting schools framework in South Africa. Participatory action research using quantitative and qualitative methodology was used. Two surveys were conducted in the Western Cape Province. The first was a survey of all therapists to determine who was working with pre-school and school-aged learners and where. The second survey was of all therapists working in special schools and a small number of private practitioners to identify the roles of the therapists in providing direct and indirect support. In two of the seven education districts in the province, focus group discussions were held with 45 teachers from special and ordinary schools, and 21 parents of school-aged learners - to identify the support they needed. Workshops, incorporating focus groups, were also held with the therapists to, firstly, identify the support they needed to give to learners, teachers, parents and the education system and, secondly, to identify the competencies they needed to give this support. The data from the surveys were subjected to simple descriptive statistical analysis. These analyses reveal that therapists have a very wide range of roles relating to direct support, including: assessment, intervention with individual learners and learners in groups, and evaluation. Interventions include the development of hearing, speech and communication skills; skills for activities of daily living; life skills; home management skills; work related skills; motor function skills; and play and leisure skills. Therapists from different disciplines frequently provide the same type of support. Indirect support provided includes support for the schools system, teachers and parents. Thirty six percent of the therapists in this study want to increase the proportion of time they spent on indirect support. The study also revealed that multidisciplinary collaboration and teamwork were Teachers involved in the study identified that they need an enormous amount of support in fulfilling their crucial roles in identifying barriers to learning; identifying the support learners need; and addressing the barriers. This includes the need for support to teach a diverse group of learners; adapting content, presentation and evaluation of the curriculum; adapting the physical environment; accepting new roles of teachers and therapists; making changes to the school system; developing relationships with the parents; addressing challenges related to socio-economic problems; networking with the community; facilitating positive attitudes to diversity; developing supportive relationships with therapists; and further training poorly developed. Teachers involved in the study identified that they need an enormous amount of support in fulfilling their crucial roles in identifying barriers to learning; identifying the support learners need; and addressing the barriers. This includes the need for support to teach a diverse group of learners; adapting content, presentation and evaluation of the curriculum; adapting the physical environment; accepting new roles of teachers and therapists; making changes to the school system; developing relationships with the parents; addressing challenges related to socio-economic problems; networking with the community; facilitating positive attitudes to diversity; developing supportive relationships with therapists; and further training. Parents in this study indicated that they need access to education and support for their children, including direct support for their children; effective means of communicating with their children; specific competencies to facilitate caring for their children; emotional support; advocates to work with them in support of their children addressing environmental physical and attitudinal barriers, and developing a supportive community; and supportive relationships with therapists.
Epidemiology and burden of chronic pain within the Eastern Cape Province, South Africa
(University of the Western Cape, 2010) Igumbor, Ehimario Uche; Puoane, Thandi
Pain is a complex biopsychosocial phenomenon that can have a profound impact on people's lives (Access Economics [AE], 2007). lts clinical relevance is well known - pain is suggestive of "actual or potential tissue damage" and plays a role in the diagnosis and clinical management of diseases and/or injury (International Association for the Study of Pain [IASP], 1986). It has both sensory and emotional aspects and is behaviourally expressed by how it is communicated by the sufferer and by its effect on the sufferer's behaviour (IASP, 1986; Linton, 2005; AE, 2007). Even though the experience of pain is associated with tissue damage or is described in terms of such damage, this association is variable so that "the size of an injury can be a poor guide as to how much an individual experiences pain" (AE, 2007). In fact, pain can exist without an objective evidence of tissue damage making pain the "ultimate subjective experience" (Odendaal, 2006). This phenomenon may relate to the fact that the interpretation of nociceptive signals as pain is influenced by a number of personal and environmental factors including past experience, integrity of the nervous system, beliefs and the situation in which tissue damage occurs (Eccleston, 2001; Turk, 2002a; Flor and Hermann, 2004; AE, 2007). As such, decisive and objective measurements are difficult to arrive at and pain is not always easily assessed by the healthcare provider. The translation of pain from acute to chronic however, means that pain and discomfort remains beyond the normal time of healing and by definition, persists either continuously or intermittently for 3 months or longer (Elliot et al., 1999). This changes the physiognomy of pain and the condition of chronic pain ensues. Chronic pain is an important but often neglected public health problem. It is disabling and associated with interference in normal activities of daily living (ADLs) such as work, home chores, family and sporting activities. Research shows that chronic pain is a key complaint that motivates many to seek health care (Crook et al., 1984, 1989; Sullivan et al., 1990; Smith et al., 1996; Mantyselka et al., 2001, 2002; Eriksen et al., 2004; AE, 2007) leading to high and ongoing consumption of treatments (AE, 2007). In fact, studies have shown that persons with chronic pain use health services up to five times more frequently than the rest of the population (Von Korff et al., 1990, 1991; Elliot et al., 1999; Eriksen et al., 2004). Side-effects of treatment are common with medication use including gastric problems such as ulcerations, nausea, constipation and mental slowing or confusion which can affect functioning. Chronic pam is also associated with mood and sleep disturbances such as depression or adjustment problems and trouble getting to sleep and/or frequent wakening during the night. For the sufferer, the effect of disuse of the aspect of the body in which pain is experienced is another manifestation of chronic pain. Muscles and joints become de-conditioned and pain sufferers may lose general body fitness (AE, 2007). Within the community, pain is a common cause of considerable suffering and disability affecting the general health and quality of life of individuals (Von Korff et al., 1990, 1992; Magni et al., 1990,1993; Walsh et al., 1992; Smith et al., 1996,2001; Verhaak et al., 1998; Elliot et al., 1999, 2002; Blyth et al., 2001; Reyes-Gibby et al., 2002; Lanteri-Minet et al., 2003). Significant amounts of working days are lost among the labour force impacting a profound economic and social toll on society (Bowsher et al., 1991; Elliot et al., 1999; Blyth et al., 2003; Igumbor et al.,2003). Simply put, "chronic pain is a human tragedy" (Odendaal, 2006). It is a serious and common problem that causes distress to patients and their caregivers, is a burden on health care professionals and health care resources and results in significant lost productivity. Chronic pain is therefore a problem of public health importance.
Community participation in collaborative tuberculosis and HIV activities including prevention of mother- to- child- transmission (PMTCT): development and evaluation of an intervention to enhance integration of TB/HIV/PMTCT services in a rural area of South Africa
(University of the Western Cape, 2012) Uwimana, Jeannine; Jackson, Debra; Zarowsky, Christina; Hausler, Harry
The epidemiological interconnectedness of tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics is well documented. Although international agencies such as the World Health Organisation (WHO) have been advocating for the implementation of collaborative TB/HIV activities at all levels in order to mitigate the impact of the dual epidemic on communities, health care delivery and programme management, its implementation has been very slow, particularly in countries highly burdened with TB/HIV infection, such as South Africa. Provision of integrated TB/HIV services has been partial and sub-optimal at community level. This requires innovative interventions that go beyond health facility boundaries such as engaging community care workers (CCWs). This thesis presents ways of engaging community members such as CCWs in collaborative TB/HIV activities including prevention of mother-to-child transmission of HIV (PMTCT). Methods: Both action research and health systems strengthening research were used as theoretical frameworks. The study was conducted in three phases which consisted of: a situational analysis; design and implementation of the intervention; and evaluation of the intervention. Mixed method research using both quantitative and qualitative research methods in one study was conducted, and various research designs were used depending on the research questions and the study phases. Results: The findings of Phase I of this study highlight partial integration of TB/HIV/PMTCT services at facility and community levels, and sub-optimal provision of integrated services, particularly at community level where only 10% of TB and HIV patients needing care at community level were supported by CCWs. Most TB-HIV co-infected patients were managed at the primary health care (PHC) clinic level of care, compared to other levels (p<0.05), and less than 50% of PHC clinic staff were trained in TB and HIV management. This phase also indicates poor linkage between facility and CCWs through the nongovernmental organizations (NGOs) managing CCWs. In addition, it identifies various health systems barriers that impede the implementation of collaborative TB/HIV/PMTCT activities and involvement of CCWs in the mainstream of the primary health care system. The findings of Phase II and III show that integrating different CCW cadres into one cadre and expanding their scope of practice to provide a comprehensive package of care for TB/HIV/PMTCT is a feasible and an effective intervention to accelerate the implementation of collaborative TB/HIV activities, including PMTCT, at community level. In addition, the findings suggest that up-skilled CCWs contribute significantly to bridging the current service delivery gaps in vertical TB, HIV and PMTCT services by increasing coverage for case finding of TB (38%) and sexually transmitted infections (STIs) (40%), PMTCT services (infant feeding, referral for PCR and AZT adherence support) (30%), and TB and antiretroviral treatment (ART) adherence (30%, 28%). The increase in uptake of TB/HIV/PMTCT services was statistically significant (p<0.05). Provision of home-based HIV counseling and testing by CCWs proved to be acceptable and feasible. Of 684 people offered home based HCT, 634 (82%) accepted to be tested and 45 (7%) tested HIV positive. However, other PHC care services such as integrated management of childhood illnesses (IMCI) and referrals to social welfare were poorly provided. Conclusion and Recommendations: The findings indicated that up-skilling CCWs resulted in improvement of CCW's performance in provision of integrated TB/HIV/PMTCT services, particularly for TB and STI symptom screening, HCT, infant feeding counselling and AZT treatment support for PMTCT, and treatment adherence support for TB and ART. However, this study emphasised the need for addressing contextual and health systems issues such as structural, organisational and managerial constraints. There is a need to reorganise the PHC system to ensure that CCWs are integrated as part of the PHC system. Systematic skills building and consistent CCW supervision, with reliable referral and monitoring and evaluation (M&E) systems are required for efficiency and sustainability of any community based intervention. It is also necessary to ensure that other PHC activities, such as referral for social welfare and IMCI, are not compromised when additional activities are added to the CCW care package.
School-based HIV counselling and testing: providing a youth friendly service.
(University of the Western Cape, 2012) Lawrence, Estelle; Struthers, Patricia; Van Hove, Geert
HIV counselling and testing (HCT) is an essential element in the response to the HIV epidemic. There are still major gaps in research about the best ways to provide HCT, especially to young people. School-based HCT is a model which has been suggested for providing HCT to young people in a youth friendly manner. This study was aimed at producing recommendations for providing a youth friendly school-based HCT service using the World Health Organisation (WHO) framework for youth friendly health services. It was conducted in six secondary schools in Cape Town, where a mobile HCT service is provided by a nongovernmental organisation (NGO). It was an exploratory descriptive study, using a mixed-methods approach. Twelve focus group discussions (FGDs) were held with learners to explore their needs with regards to school-based HCT. An evaluation (which consisted of observation of the HCT site, service provider interviews and direct observation of the HCT counselling process) was done to determine whether the mobile school-based HCT service was youth friendly. A learner survey was conducted with 529 learners to investigate the factors that influence the uptake of HCT and to explore learners’ behaviours and experiences under test conditions. In the FGDs, learners said that they wanted HCT to be provided in schools on condition that their fears and expressed needs were taken into account. They wanted their concerns regarding privacy and confidentiality addressed; they wanted to be provided with information regarding the benefits and procedure of HCT before testing took place; they wanted service providers to be competent to work with young people, and they wanted to be assured that those who tested positive were followed up and supported. On evaluation of the mobile school-based HCT service, it was evident that the service did not meet all the needs of the learners nor did it have all the characteristics of a youth friendly health service. The model of ‘mass testing’ used by the NGO did not fulfil learners’ expressed need for privacy with regards to HCT. Service providers were friendly and non-judgemental but had not been trained to work with young people (especially marginalised groups e.g. young men who have sex with men). The information needs of learners were not addressed, and learners were not involved in the provision of the HCT service. Learners who tested positive were not assisted in accessing care and support. The learner survey revealed a high uptake of HCT (71% of learners) at schools with learners who do not identify themselves as Black, with female learners and older learners being more likely to have had an HIV test. Factors that influenced uptake of HCT were complex, with learners reporting many different motivators and barriers to testing. Of concern was the low risk perception of leaners with regards to HIV infection and the fact that learners who tested HIV positive were not being linked up with treatment and care. Based on the findings of the study, recommendations were made for providing youth friendly school based HCT. A multisectoral approach, with learner and community involvement, was suggested in order to provide a service which is equitable, accessible, acceptable, appropriate and effective.
Roles and competencies of district pharmacists: a case study from Cape Town
(2013) Bradley, Hazel; Lehmann, Uta; Butler, Nadine
This thesis presents research on the emergence of sub-structure and sub-district pharmacists in Cape Town by considering their roles and related competencies, and the support required to establish them in these new positions. The research was carried out in partnership with Metro District Health Services (MDHS) and City Health. Both organisations provide services across the whole of the Cape Metro. The research took place as MDHS was dividing the Cape Town Metro District into four sub-structures, and the research is embedded in these unfolding developments. The four sub-structures were created to be closer in size to WHO health districts than the unmanageably large Metro District. Consequently, sub-structures and sub-structure pharmacists in this study should be considered equivalent to districts and district pharmacists in other settings. I used a participatory action research (PAR) approach to partner with pharmacists and managers in both organisations between 2008 and 2011. The partnership benefitted from the contextual and practice experiences of the health services stakeholders and my evolving research expertise. Including a broad stakeholder group was considered important for developing the shared learning and understanding that would translate into action and changen in the organisations. The flexible and emergent approach of PAR was considered suited to a complex health system in the midst of change. After an initiation stage, the research evolved into a series of five iterative cycles of action and reflection, each providing increasing understanding of the roles and related competencies of sub-structure and sub-district pharmacists, and their experiences as they transitioned into these new management positions in the two organisations. The research centered around two series of three interactive workshops I facilitated, attended by both pharmacists and managers, in which I contributed information from published literature and documentary reviews to the collaborative processes. Semi-structured interviews and focus groups were conducted at various stages during the research, to inform conceptualization and supplement workshops, and later on, during years three and four, to reflect on the experiences of substructure and sub-district pharmacists. The research identified five main roles each for sub-structure and sub-district pharmacists. Four of these roles are the same for each: Sub-structure (sub-district) management Planning, co-ordination and monitoring of pharmaceuticals, human resources, budget, infrastructure Information and advice Quality assurance and clinical governance But their fifth roles are different: Research, for sub-structure pharmacists. Dispensing at clinics for sub-district pharmacists. But although they look similar, there were substantial differences between sub-structure and sub-district pharmacist roles in the two organisations. Their roles were shaped by the differences in leadership and governance, as well as by the services provided by the two organisations. Sub-structure pharmacists were generally involved in strategic level management functions whilst sub-district pharmacists combined sub-district management activities with dispensing in clinics. Essentially the two cadres were working at different management and leadership levels, with sub-structure pharmacists working at middle management level and sub-district pharmacists straddling first level and middle management levels. Five competency clusters were identified for both cadres, each with several competencies. Professional pharmacy practice Health system/public health Management Leadership Personal, interpersonal and cognitive Whilst professional pharmacy practice competencies were particularly valued by substructure and sub-district managers, overall, sub-structure and sub-district pharmacists required generic management and leadership competencies. Along with the more technical management and leadership competencies, both organisations recognised the importance of viii „softer‟ competencies for pharmacists moving into these management positions. Again, although the competencies appear similar, there were differences between the roles, so that the different cadres required different competencies within these competency clusters. Transitioning into these new management positions was an emergent process, which entailed pharmacists changing form performing technical and clinical functions associated with professional pharmacy practice to co-ordinating pharmaceutical services across the substructure or sub-district. They moved from working in a pharmacy to being a member of a multi-professional team in a sub-structure or sub-district. Adjusting to these new management positions took time and was facilitated by several personal and organisational factors which varied in the two organisations. Managers and pharmacists mentioned the positive contribution of the PAR in assisting with this transition through the development of shared understanding of the DHS and the roles and functions of pharmacists working in these management positions. The research assisted with practical aspects including the development of new job descriptions. Several implications for developing competencies in sub-structure and sub-district pharmacists emerged during the research. Firstly, although competency frameworks for substructure and sub-district pharmacists are useful for selecting new staff, conducting performance appraisals and identifying learning needs, they need to be tailored for each setting. Secondly, a mixture of traditional training options, including academic qualifications and short courses, as well as innovative on-the-job support such as mentoring and coaching are required to support sub-structure and sub-district pharmacists, and other similar cadres in these positions.
The dynamics of intimate partner violence during pregnancy and linkages with HIV infection and disclosure in Zimbabwe
(University of Western Cape, 2013) Shamu, Simukai; Zarowsky, Christina; Temmerman, Marleen; Abrahams, Naeemah; Shefer, Tamara
The study assessed the linkages between HIV infection and intimate partner violence (IPV) during pregnancy and after HIV status disclosure in a context where HIV testing has become almost mandatory through the provider-initiated counselling and testing approach and non-disclosure of HIV status to sexual partners has been criminalised in many countries including Zimbabwe. The study also explored women’s experiences of and health workers’ perceptions of IPV during pregnancy.
The association between Crohn's disease activity, serum 25(oh)- vitamin d status, the disease-associated environmental risk factors and the variability of Crohn's disease phenotype in the Western Cape population, South Africa
(University of the Western Cape, 2014) Basson, Abigail Raffner; Swart, Rina
Background: A subtype of inflammatory bowel disease, Crohn' s disease is thought to represent a complex interaction between environmental factors, a defective immune system, the gastrointestinal microbiome and genetic' susceptibility; however; the-prevalence of different susceptibility mutations appears to vary between population groups, implying distinctions in disease pathogenesis or risk. Vitamin D, signaling through the vitamin D receptor, appears to have numerous effects on the immune system, and deficiency has been shown to playa role in both the pathogenesis and severity of experimental inflammatory bowel disease. However, the literature surrounding the association between vitamin D concentrations and disease severity in Crohn's disease is limited, and no such literature exists in South Africa. Furthermore, a paucity of data exists on the racial variability of Crohn' s disease phenotype in the Western Cape population of South Africa, as well as environmental factors in childhood associated with future Crohn's disease development. Aims: The three primary aims of the study were to investigate: 1) the racial variability of, Crohn's disease phenotype, defined by the Montreal classification scheme, as well as Crohn's disease behavior, using predefined definitions, stratified as 'complicated' or 'uncomplicated', based on a cross-sectional study design; 2) the association between childhood environmental exposures and the subsequent development of Crohn's disease, with specific emphasis on the timing of exposure, based on a case-control study design; and 3) the association between serum 25(OH)D concentration with Crohn's disease activity, measured by the Harvey Bradshaw Index, based on a cross-sectional study design; in this process, various vitamin D thresholds for predicting a high disease activity score were investigated, and the serum 25(OH)D concentrations were compared with those of the healthy controls to evaluate the prevalence of vitamin D deficiency. Design: This was a case control study, as well as two cross-sectional evaluations of the case control study data, of all consecutive Crohn's disease patients (ages 18-70 years) seen between September 2011 and January 2013 during their normally scheduled appointments at Schuur Hospital and Tygerberg Hospital. Control subjects for the study were identified from the same populations giving rise to the Crohn's disease cases. An investigator-administrated questionnaire was used to identify numerous demographic and lifestyle variables, as well as childhood environmental exposures during three age intervals; 0-5, 6-10 and 11-18 years. Clinical variables at diagnosis and time of study enrolment were determined via a review of medical and pharmacy records, as well as clinical examination by the consulting gastroenterologist. Serum 25(OH)D was measured using the SIEMENS ADIVA Centaur® XP Vitamin D Immunoassay [Siemens Healthcare Diagnostics Inc., Tarrytown, NY, USA]. Vitamin D status was classified as either 'deficient' or 'sufficient', and was analyzed in 2 ways: ~20 ng/mL versus ~21 ng/mL; and ~29 ng/mL versus ~30 ng/mL, respectively. One year after study completion, a total of 40 (10%) randomly selected participants from the cohort completed the interviewer-administered questionnaire for a second time. A kappa statistic was used in order to measure the agreement between repeated data for the questionnaire. Only data pertaining to the three age intervals (0-5, 6-10 and 11-18 years) was extracted in this process. Results: One hundred and ninety four Crohn's disease patients and 213 controls meeting our inclusion criteria were identified; 35 (18%) and 19 (9%) were White, 152 (78%) and 177 (83%) were Coloured, and 7(4%) and 17 (8%) were South African Black, respectively. No subjects reported being of Asian or Indian ethnicity. Overall, 125 (31%) of the cohort were male. On multiple logistic regression analysis, Coloured Crohn's disease patients were significantly more likely to develop 'complicated' Crohn's disease (60% versus 9%, P = 0.023) during the disease course when compared to White Crohn's disease patients. In addition, significantly more White subjects had successfully discontinued cigarette smoking at study enrolment (31% versus 7% reduction, P = 0.02). No additional interracial differences were found. A low proportion inflammatory bowel diseases family history was observed among the Coloured and Black subjects. When evaluating childhood environmental exposures, multiple logistic regression analysis showed that during the age interval 6-10 years, never having consumed unpasteurized milk [(OR = 6.43; 95% Cl, 3.02-14.81), (K =0.79; 95% Cl, 0.39-1.00)] and never having a donkey, horse, sheep or cow on the property [(OR = 3.10; 95% Cl, 1.42-7.21), (K = 0.84; 95% Cl, 0.12-1.00)], significantly increased the risk of developing future Crohn's disease. During the age interval 11-18 years, an independent risk-association was identified for; never having consumed unpasteurized milk (OR = 2.60; 95% Cl, 1.17-6.10) and second-hand cigarette smoke exposure (OR = 1.93; 95% Cl, 1.13-3.35). For the vitamin Danalysis, 186 Crohn's disease patients and 199 control subjects met the study inclusion criteria. Overall, 113 (29%) of the cohort were male. Forty four percent of the cohort had a deficient vitamin D concentration (::;20 ng/ml.), no participants had severely deficient vitamin D concentrations, and 26% of the cohort had sufficient vitamin D concentrations (:::30 ng/mL). Fifty-three percent of the controls and 34% of the cases had vitamin D concentrations ::;20 ng/mL (P < 0.001). On multiple logistic regression analysis, higher Harvey Bradshaw Index scores and not having taken vitamin D supplementation in the six months prior to enrolment were identified as independent predictors of vitamin D deficiency in Crohn's disease patients; defined either as ::;20 ng/mL, or as ::;29 ng/mL (P < 0.001). Compared to patients with Harvey Bradshaw Index <5, those with Harvey Bradshaw Index 2:8 were 2.5-times more likely to have vitamin D concentrations ::;21 ng/mL (PR = 2.5; 95% Cl, 1.30-6.30). The risk was similar, though not as high, if deficiency was defined as ::;29ng/ml. (PR = 2.0; 95% Cl, 1.20-3.50). Conclusions: Coloured Crohn's disease patients were significantly more likely to develop 'complicated' Crohn's disease over time when compared to White Crohn's disease patients. Limited microbial exposures and exposure to second-hand cigarette smoke during childhood is associated with future development Crohn's diseases. However the inconsistencies between each age interval with regards to the identified risk factors may imply that the effect of different viruses or bacteria on the development of immune structures varies according to the timing of exposure. The finding that lower serum 25(OH)D was associated with moderate to severe Crohn's disease activity suggests that this patient population may benefit from vitamin D supplementation in order to achieve, or maintain a serum 25(OH)D concentration of at least 30 ng/mL.
Paediatric severe-acute malnutrition and the recommended WHO treatment modality: An epidemiological and quality care assessment in the context of HIV/AIDS comorbidity
(University of the Western Cape, 2015) Muzigaba, Moïse; Puoane, Thandi
The current study was, in part, prompted by the high case fatality rates for severe acute malnutrition in two district hospitals in the Eastern Cape Province in South Africa. These case fatality rates were being attributed to Human Immunodeficiency Virus infection rather than to mismanagement by nurses involved in the hospital management of SAM cases. There were also some anecdotes from clinicians in the same hospitals that, depending on the clinical stage of HIV infection, the World Health Organisation's ten-step protocol may show no effect. This left some uncertainties as to whether these guidelines are suitably designed for use during the management of HIV positive children who are severely malnourished and at different HIV clinical stages. This study sought to reinforce the design of a longstanding facility-based intervention originally developed to improve the management of severe acute malnutrition in two district hospitals in South Africa. The aim was to design an improved intervention which was implemented and evaluated to determine its potential effect on treatment outcomes, specifically in the context of high HIV comorbidity. The study also sought to provide the context for the effectiveness of this intervention, in terms of its implementation fidelity and associated moderating factors. Lastly, the study evaluated the sustainability of the intervention after it was discontinued. Methods The current study reports on the development, implementation and evaluation of an intervention to improve the management of severe acute malnutrition in two district hospitals in the Eastern Cape Province. A Sequential Explanatory Mixed Method Design was used. During the study, the effect of HIV infection, disease stage and other clinical characteristics on the survival of children with severe acute malnutrition was assessed. The relationship between the rate of weight gain and duration of hospitalisation based on HIV status and disease stage were also examined. The data were collected prospectively during the study using retrospective record review of a total of 450 severely malnourished children who were admitted and treated at the two facilities from 2009 to 2013.A pre-tested 76- item patient evaluation form was used to collect data on patient characteristics on admission, treatment processes and outcomes. Data analysis was performed using STATA13.0 and involved simple descriptive computation of quantitative variables as well as non-parametric tests to compare groups between and within hospitals. Kaplan-Meier curves and Cox proportional hazard modelling were used to analyse time to event data. The study also assessed the impact of the intervention at time intervals on outcomes of interest. The analysis focused on modelling and plotting monthly mortality statistics collected over a period of 69 months. This was done to detect related trend and level changes before, immediately (after the first two months) and after (following the two months) the removal of the intervention. Lastly ethnographic and focus group enquiries were used to explain the quantitative results. Two focus group discussions were held in each hospital with clinicians and the management staff. This was done at the end of phase three. The focus group data were analysed using the framework analysis approach.
Analysis of aid coordination in a post-conflict country : the case of Burundi and HRH policies
(University of the Western Cape, 2015) Cailhol, Johann; Lehmann, Uta; Gilson, Lucy
Aid coordination in the health sector is known to be challenging in general, but even more in post-conflict settings, due to the multiplicity of actors of development, to the sense of emergency in providing health services, combined with the so-called weak institutional capacities‘ at local level, resulting from the conflict. This study sought to analyze broad determinants of aid coordination using the example of HRH policies in Burundi, during the post-conflict period. Burundi is a country in Central Africa, which experienced cyclic ethnic conflicts since its independence in 1962, the last conflict being the longest (1993-2006).Determinants of coordination were analyzed using the policy-analysis triangle (Gilson et Walt), using data from documents and semi-structured interviews, conducted in 2009 and in 2011, at national, provincial and facility-levels. A conceptual framework, combining organizational and social sciences theories, was devised in order to assess the organizational power of MoH, the one supposed to act as coordinator in the health sector. Findings showed a lack of coordination due to post-conflict specific context, to competition over scarce resources between both donor and recipient organizations and to an insufficiently incentivized and complex coordination process in practical. Most importantly, this research demonstrated the crucial role of post-conflict habitus and mistrust in the behavior of MoH and their influence on organizational power, and, in turn on their capacity to coordinate and exert an appropriate leadership. These findings, together with the growing body of literature on organizational sociology and collective trust, point at the crucial need to rebuild some of the wounded collective trust and organizational leadership in Burundi and in other fragile states.
Feasibility of introducing an onsite test for syphilis in the package of antenatal care at the rural primary health care level in Burkina Faso
(University of the Western Cape, 2015) Yaya Bocoum, Fadima I.K; Zarowsky, Christina; Kouanda, Seni
Background: Syphilis transmission remains a global problem with an estimated 12 million people infected each year. Ninety percent of syphilis cases occur in low income countries. Syphilis is a serious source of adverse pregnancy outcomes for both mother and infant. Ideally, syphilis screening should be provided as part of a package of maternal and newborn health-care services. This thesis reports on a pilot intervention study to develop, implement and evaluate a point of care test for syphilis in antenatal care services in rural Burkina Faso. Methods: This study used a pre post intervention mixed methods quasi-experimental design with a group of health facilities offering ANC services (primary health centers in rural area) as the sampling units. This study was conducted in three phases, which consisted of a situational analysis using qualitative methods (Phase 1), selecting an appropriate test through evaluating 4 candidate tests and the participatory design and implementation of an intervention that included onsite training, provision of supplies and medicines, quality control and supervision (Phase 2), and an evaluation combining review of record tools, interviews, time motion study and estimating incremental costs (Phase 3). The conceptual framework draws on multilevel assessment (MLA), policy triangle framework, MRC framework for designing complex interventions and the Normalization Process Model (NPM). Methods included document review, seventy five interviews were conducted with health providers, district managers, facility managers, traditional healers, pregnant women, community health workers, and Non-Governmental Organizations (NGO) managers in phase I and fourteen in phase III, non-participant observation, time-motion study, incremental cost analysis, and sensitivity, specificity and ease of use analysis of four candidate point-of care tests. Data were collected between 2012 and 2014. Qualitative data were analyzed through thematic analysis supported by Nvivo software. Quantitative data were analyzed through descriptive statistics such as frequency, mean and median supported by SPSS. Findings: Phase I identified barriers to implementation and uptake of syphilis testing at health provider and community levels. The most important barriers at provider level included fragmentation of services, poor communication between health workers and clients, failure to prescribe syphilis test, and low awareness of syphilis burden. Cost of testing, distance to laboratory and lack of knowledge about syphilis were identified as barriers at community level. Phase II: Alere DetermineTM Syphilis was the most sensitive of the four point-of-care tests evaluated. The components of the intervention were successfully implemented in the selected health facilities. Overall, phase III showed that it is feasible and acceptable to introduce a point of care test for syphilis in antenatal care services at primary health care level using the available staff. The intervention was reported as acceptable, but of 812 pregnant women who came for their first visit 39% were screened during the study period. Rural facilities had higher coverage (66.8%) than the urban ones (25.6%). Quality control found no discordance between the rapid test and TPHA results. The average cost of ANC per unscreened pregnant woman was 3.11 USD (±0.14) vs 5.06 USD (±0.16) per screened woman. The main cost driver was the material costs notably the test itself. The test’s cost is comparable to HIV test costs, but funder support for integrating this additional test is less readily available than for HIV tests. Conclusions: The findings suggested that an intervention that introduces point of care test for syphilis at antenatal care services is feasible, acceptable, and of comparable costs to HIV screening in pregnancy. Nonetheless, instructions and supervision need to be clearer to achieve optimal levels of screening and quality control, and barriers identified by health workers need to be overcome. The point-of care test for syphilis is likely to be acceptable by health workers as a routine service and incorporated as a normal practice in Burkina Faso context.
Factors influencing the implementation of health promoting schools : a multiple case study of three secondary schools in a resource limited community in Cape Town
(University of the Western Cape, 2016) Mohamed, Suraya; Stern, Ruth; Struthers, Patricia
Introduction: This study was conducted because of a gap in information on the factors influencing the health promoting schools (HPS) implementation process in South Africa (SA) specifically and in secondary schools globally. The aim of this context- sensitive, practice-based study was to explore and understand the complexity of the factors that influenced the implementation process of HPS in three secondary schools in a resource-limited setting in Cape Town, SA. This research drew on a five year project that initiated the implementation of HPS in these schools. Methodology: An exploratory qualitative study was used, adopting a multiple case study design. The sample included two principals, ten teachers and 30 students involved in HPS implementation at their schools, and the three school facilitators, who served as mentors to the schools. The data collection methods included: individual interviews, focus group discussions, documentary review, secondary data and observations. A conceptual framework was developed drawing on the settings approach and various implementation frameworks and was used to analyse the findings. Thematic analysis was employed and the data for each case were analysed separately first before undertaking cross case analysis. Findings: A combination of several internal and external factors influenced the ability of the schools to implement and integrate HPS as a whole school approach. A key factor was the degree of understanding of the HPS concept by all key actors and where there was lucid understanding, there was better integration. Significant school factors included the schools’ readiness for change; a culture of collaboration and cooperation; existing school structures, practices and workload; the leadership style and management role of the principals; the role and influence of HPS champion teachers; and the role that students played. The major external factors included the role of the education district; the role of project team as external catalysts for change; and the community context. The main achievements in all schools were discrete activities, including co-curricular activities rather than changes to routine school functions. This highlighted the difficulty in implementing HPS as a whole school approach, a challenge typical of all health promoting settings. Conclusion: The findings illustrate the challenge of achieving full integration of HPS, although the influencing factors, and hence level of integration varied mainly according to context. This highlights the complexity of the different factors and their impact. The study demonstrates the paradox of HPS implementation. In that, despite the recognition of the value of HPS, the challenges to address the complexity of factors that would have brought about change through a whole school approach were too great. It was too difficult to change the status quo from what was routinely done to a more radical way of working due to the conservatism of traditional ways of working and extent of adjustment that it would have resulted. It was therefore only possible to put simple, discrete, strategies in place and that was not too resource intensive. The study concluded that this does not imply that HPS should not be attempted, particularly where there are adverse conditions that would benefit from HPS. Starting with marginal changes, it can be effective in increasing the schools’ readiness for change, building on the achievements both in activities and structures, and the resultant commitment by those involved. Once they experience these changes it will more likely enable schools to incrementally attempt more complex changes. The key recommendations for within the school include: building the understanding and capacity of relevant actors to actively support the implementation of HPS; building the capacity of the principal to create an environment which is conducive to change; and providing support for the HPS champions and students. Recommendations for those external to the school include: support from external catalysts who can provide expertise and mentorship; support from the education district, especially in terms of policies on integration, resources, and raising the profile of HPS; and better collaboration between the education and health sectors. Although most of the literature on HPS implementation identifies similar issues to those found in this study, the complexity has not, to date, been sufficiently described. The contribution of this study, therefore, is to take the debate on the complexity of the factors influencing HPS implementation forward.
The development of a street-food vending model that offers healthy foods for sale
(University of the Western Cape, 2016) Hill, Jillian; Puoane, Thandi; Mchiza, Zandile; Steyn, Nelia
Background: Street foods (SF) contribute significantly to the nutritional intake of adults and children in developing countries. They are inexpensive and a major source of income for a vast multitude. A major concern is the so-called ‘nutrition transition’, which has led to an increase in foods high in saturated fats, trans fats, sugar and salt, along with processed food items sold on urban community streets in developing countries. These foods contribute to nutritional disorders in the communities where consumed. South Africa’s stable unemployment rate, estimated at 25%, has further influenced business growth in the informal sector, particularly SF vending. As such, a well-developed SF-vending model (SFVM) could potentially address the challenges of unemployment and improve the nutritional status of poorer South Africans. Aim: To develop a sustainable SFVM for selling healthy and safe SF in the City of Cape Town enabling street vendors to make a decent living, and consumers to make healthy choices regarding food purchasing. Methods: This cross-sectional study employed mixed methodology (collecting qualitative and quantitative data). The study was conducted in three phases. Phase 1a: Situation Analysis. This a SF-vendor survey which collected a) socio-demographic factors, b) vendors’ business operational models, c) food items sold, d) available facilities, e) challenges faced, f) certification, and g) nutrition knowledge using a validated questionnaire. An observational checklist capturing data on the appearance of vendors, their stalls, available equipment and type of food sold, supplemented this survey. Phase 1b: A consumer survey included collecting, a) socio-demographic factors, b) purchasing habits, c) consumption preferences, and d) nutrition knowledge using a validated questionnaire. Phase 2a: Semi-structured-interviews and focus group discussions with Environmental Health Officials and Economic Development Officials from the City of Cape Town were conducted to explore the existing -vending regulations and/or policies in the City of Cape Town and gain insight into the SF-vending operations from a regulatory perspective. Phase 2b: A document review was conducted to identify existing regulations and policies on SF vending. Phase 3: conducted in three steps: Step 1, data integration of the previous phases. Step 2, a participatory action research component checking the relevance, acceptability and practicability of identified themes and resulting components from Step 1. Step 3, development of the proposed SFVM using the findings of the previous two steps. Data Analysis: Quantitative data were analysed using IBM SPSS, 2010 Statistics version 23. Descriptive statistics and cross-tabulations were used to analyse data. Qualitative data were thematically analysed using the qualitative data software package Atlas ti 7.5.7.Results: Phase 1a: vendors in the Cape Town and surrounding areas work long hours up to seven days a week making a minimal income. Types of food items sold by vendors, their nutrition knowledge and hygiene practices were not ideal. A major lack in basic facilities existed. Phase 2a: SF consumers indicated spending a significant amount of their income on SF, and are open to buying healthier options should these be available. Phase 2a: government officials thought the SF-vending business should be guided by national legislature and provincial bylaws, and felt strongly about nutrition and health education for vendors and consumers. Phase 2b: thirteen regulations and bylaws applicable to SF vending were sourced. Phase 3: Data from the previous phases were integrated within a socio-ecological framework to develop the proposed SFVM. The components of this model are divided into four areas, i.e. a business component, food and nutrition component, hygiene component, and a vending cart. Conclusion: The four components in the proposed SFVM take into account various elements of the socio-ecological framework, i.e. intrapersonal/individual, interpersonal, the physical environment/community and the policy environment. This SFVM should be piloted, evaluated, adapted and before rolling it out on a large scale to test its effectiveness.
Understanding the dynamics of accessing chronic medicines in the public sector: Implications for policy in South Africa
(University of the Western Cape, 2016) Magadzire, Bvudzai Priscilla; Ward, Kim; Marchal, Bruno
Access to medicines (ATM), specifically for those medicines that are related to the priority health needs of a population has been cited as a fundamental part of universal health coverage and a key element for service delivery and high-quality care. Therefore, ensuring reliable access to and appropriate use of safe, effective and affordable medicines is one of the core functions of an effective health system. With the rising demand for treatment of chronic diseases (e.g. HIV, diabetes and hypertension), ATM has increasingly received global attention. Yet as of 2011, it was estimated that at least one third of the world's population had no regular access to medicines. Globally, there is a dearth of in-depth country level evidence to influence policy responses, coupled with inadequate understanding of how pharmaceutical systems operate within broader health systems. This thesis comprises two main parts: 1) a situational analysis of the state of chronic medicines provision in the public sector in the Eastern Cape and Western Cape provinces of South Africa; and (2) an evaluation of an existing ATM model in one province. To situate this study within the ATM discourse, a conceptual framework was developed from a review of empirical and theoretical literature. The framework incorporated six ATM dimensions (availability, affordability, acceptability, accessibility, accommodation and quality) and their interplay at multiple levels including: health facility, individual, household and community levels. Then, at a health system level, the interaction of medicines (a health system building block) with other building blocks (information, financing, human resources, infrastructure and governance).
Use of modified respondent driven sampling methodology to enhance identification and recruitment of most at risk persons into an HIV prevention trial in Kisumu, Western Kenya
(University of the Western Cape, 2016) Otieno, Fredrick Odhiambo; Hughes, Gail; Puoane, Thandi
This thesis presents research on the use of modified respondent driven sampling (mRDS) methodology to enhance identification and recruitment of key populations (KP) into an HIV prevention trial in Kisumu, western Kenya through a three phase mixed method study. The study was carried out in Kisumu, western Kenya within the Kenya Medical Research Institute (KEMRI) and the US Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration platform. The three phases included: 1. PHASE I: Identification and determination of categories of KPs and techniques of locating and motivating them to participate in HIV prevention trials.2. PHASE II: Design and Implementation of a mRDS methodology in recruiting Ks into HIV prevention trials.3. PHASE III: Evaluation of the mRDS in recruitment of KPs into an HIV incidence cohort study. Methods Phase I of the study included the conduct of in depth interviews which were used to identify different categories of persons considered to be KPs within Kisumu, identify strategies of locating the KPs and determine motivators and inhibitors of KPs participation in HIV prevention trials. Phase II on the other hand included the administration of a survey that had been refined in Phase I. The survey was used to design a mRDS methodology which was then implemented to recruit KPs into the survey. Phase III evaluated the success of the mRDS in recruiting KPs into an HIV prevention study by assessing the risk profiles for participants screened and enrolled into the Phase III study. Ethical approval for the study was sought from the ethics committee of the Kenya Medical Research Institute, the US CDC and the University of the Western Cape.The study recruited 53 individuals into phase I and was able to 8 identify different categories of people considered to be KPs and the 4 salient strategies that could be used to recruit them into HIV prevention studies. The phase also identified 8 potential motivators and 9 potential inhibitors to participation in HIV prevention research. These categories and salient strategies were used in phase II to develop and pilot a mRDS methodology in recruiting 203 individuals into a survey. The survey was used as a validation tool for the risk levels of persons recruited by the mRDS using the variables of inconsistent condom use and having multiple partners. The validated mRDS was then applied in the recruitment of 1,292 participants in phase III of thestudy. These study participants had characteristics similar to those seen in similar studies and elucidated from phases I and II of the study. HIV seropositivity was used as the variable for validating risk levels of participants in this study and this was found to be higher that that seen in general population and comparable to that seen in other KPs groups in the region. Results: Overall the study was able to identify different categories of people considered to be at high riskof HIV acquisition. The groups identified included people who frequent bars (e.g. bar workers, drunkards, sex workers, businessmen), people who work in transportation (e.g. truck drivers, matatu drivers, motorcycle drivers, taxi drivers, bicycle taxi drivers), fishermen/fishmongers, MSM and hair salon workers. The study also identified using personal contact, link persons, peer mobilisers and leaders as strategies of identifying and locating KPs. The study used the mRDS successfully in recruiting participants with evaluation of inconsistent condom use and multiple sexual partnerships showing the participants to be of high risk behaviour. Of all the females in the study, only 3.3% were pregnant. The prevalence of Chlamydia was 2.9%, gonorrhoea was 5.0%, syphilis was 0.4% and HSV-2 was 46.0%. Those who tested positive for HIV were 26.2% with 42.3% of the HIV positive participants having CD4 counts of between 250 – 500 cells/ml. Recommendations and Conclusion:The mRDS was successful in recruiting KPs in an HIV prevention trial. Majority of the participants reported inconsistent condom use and having multiple sex partners. In addition to MSM, SW and transport industry workers, fisherfolk, discordant couples, widowers, street youth, car washers and police also form part of KPs groups. The HIV prevalence was higher amongst these groups compared to general population with discordant couples having the highest HIV prevalence. The study recommends that mRDS should be used to identify and recruit KPs as it not only allows for faster recruitment of KPs, it also reduces the expense and complexity associated with coupon management in the standard RDS.
A health system perspective on factors influencing the use of health information for decision-making in a district health system
(University of the Western Cape, 2016) Scott, Vera Eileen; Lehmann, Uta; Schneider, Helen
This research explores a poorly understood area of health systems: the nature of managerial decision-making in primary healthcare facilities, and the information that informs decision-making at this level. Located in the emerging field of Health Policy and System Research, this research draws on constructivist and participatory perspectives to understand the role of information and, more broadly, learning and knowledge in decisions that primary healthcare managers make, and the systemic factors influencing this. Using a multiple case study design with iterative cycles of in-depth data collection and analysis over a three year period, it examined the decision-making and information use in three cases of managerial responsibility in 17 primary healthcare facilities in a sub-district in Cape Town. The cases were: improving efficiency of service delivery, implementing programme priorities and managing leave of absence. Using multiple strategies for engaging primary healthcare facility managers, often as co-researchers of their own practice, the research sought to elicit both their explicit and tacit, experience-based knowledge on these phenomena. Key insights gained in the research are that firstly, operational health management at facility level is less linear and simple than policy-makers and planners often assume, and is, instead, characterised by considerable on-the-spot problem solving and people management to meet multiple agendas, which can be surprisingly complex. Secondly, contrary to prevailing views, managers do actively use information in decision-making, but require a wide range of information which is outside of the current, and indeed the globally-advocated, health information system (HIS). Thirdly, they not only use, but generate, information in their management routines and practices, and must learn from experience in order to adapt new interventions for successful implementation in their facilities and communities. This research thus makes explicit the value and use of informal information and knowledge in decision-making. It demonstrates, amongst others, a relationship of functional interdependence between the use of formal information in the HIS, and informal information and knowledge, suggesting that the latter has the potential to improve the use and utility of formal health information by making sense of it within the local context. Furthermore, building on the public policy literature on governance, this research develops a model to understand the multiple contextual influences on decision-making and information use, showing the central role of values and relationships across the health system. It proposes a causal mechanism for strengthening the use of information in decision-making. Finally, in giving priority to the informational needs of facility managers, this research offers a bottom-up perspective which argues for an integrated approach to health system strengthening which moves beyond atomised treatment of HIS strengthening. It suggests the need to re-think how to support facility managers by re-positioning the HIS relative to organisational learning, and leadership and management development.
Development of the Public Health model of Community participation in the Kwazulu - Natal primary health care system
(University of the Western Cape, 2017) Mntambo, Ishmael Mbuso; Puoane, Thandi
The purpose of this study was to develop the public health model of community participation for the KwaZulu-Natal primary health care system. The model is intended to improve the understanding of community participation and to explore its potential value in strengthening the facilitation of health promotion in the health facilities.
Decentralised human resource management in a district health system: case studies in the Western Cape Province, South Africa
(University of the Western Cape, 2017) Mathews, Verona Elizabeth; Lehmann, Uta
The effective management of the public health workforce, in the context of decentralisation and the District Health System, is pivotal to the delivery of primary health care and, ultimately, improved health. This research investigates the phenomena of human resource management in the public health sector, focussing on the factors influencing human resource management (HRM), the internal alignment within the HRM Programme and external alignment with the strategic objectives of the organisation. It takes a frontline perspective to understand how the phenomenon is experienced in a decentralised District Health System.
Quality of life in a fragile state: a study of orphans and vulnerable children living in child-headed households in Zimbabwe
(University of the Western Cape, 2017) Munodawafa, Kudzai Emma Chademana; van Wyk, Brian; Mfecane, Sakhumzi
Households headed by children, adolescents and youths are a growing phenomenon across sub- Saharan Africa. This is largely a result of the increasing mortality of economically active adults, coupled with migration and urbanisation, which have all weakened traditional kinship systems. Children and youth living in these households experience myriad challenges arising from the absence of an adult guardian and economically active household member. Several studies have shown that children living in these child- and adolescent-headed households experience extreme poverty and deprivation. Furthermore, Zimbabwe's precarious socio-economic condition could further exacerbate these children's risks and deprivations. The wellbeing and quality of life of orphans living in these child-headed households is not well understood as there are very few studies that provide a holistic perspective on the experiences and quality of life for those in these households. The aim of this study was to assess the quality of life of orphans living in childheaded households in Zimbabwe, and explore the factors that influence their quality of life.

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