School of Public Health

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https://hdl.handle.net/10566/10

With some exceptions, our work focuses on five inter-related programme areas – HIV/AIDS, TB, maternal and child health, public health nutrition, and non- communicable diseases – and three health systems areas which cut across all programmes – namely human resource development, health information systems and health promotion

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A realist evaluation of the antiretroviral treatment adherence club programme in the metropolitan area of the Western Cape Province, South Africa
(University of the Western Cape, 2018) Mukumbang, Ferdinand C.; van Wyk, Brian
In South Africa, 7.1 million people living with HIV/AIDS (PLWHA) of whom about 56% were accessing antiretroviral therapy (ART) in 2016, accounted for approximately 20% of people on ART globally. The successful initiation of PLWHA on ART has engendered challenges of poor retention in care and suboptimal adherence to medication. While standard treatment and care schemes show the potential to retain patients in ART care, their success is challenged by congested health-care facilities, long waiting times and shortages of health-care providers. The antiretroviral adherence club intervention was rolled out in primary health-care facilities in the Western Cape Province of South Africa to relieve clinic congestion and improve retention in care, and treatment adherence in the face of growing patient loads. Evidence from the literature suggests that these models of ART service delivery are more effective than corresponding facility-based care. Nevertheless, there is little understanding of how these care models work to achieve their intended outcomes. To this end, a theory-driven approach to evaluate the adherence club intervention was proposed.
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.
The acceptability of three vaccine injections given to infants during a single clinic visit in South Africa
(BioMed Central, 2016) Tabana, Hanani; Dudley, Lilian D.; Knight, Stephen; Cameron, Neil; Mahomed, Hassan; Goliath, Charlyn; Eggers, Rudolf; Wiysonge, Charles S.
BACKGROUND: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa. METHODS: A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions. RESULTS: The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators’ care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs. CONCLUSIONS: We found high acceptance by caregivers and vaccinators of three injections. Caregivers’ poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants’ pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI’s expansion in resource-limited countries.
Access to HIV healthcare services by farm workers in sub-Saharan Africa (SSA): A systematic review protocol
(BMJ Publishing Group, 2022) Mlangeni, Nosimilo; Adetokunboh, Olatunji; Lembani, Martina
Sub-Saharan Africa (SSA) region harbours the highest burden of HIV infections in the world. Agricultural work has been reported as one of the occupations with a high prevalence of HIV. Farm workers generally have poor access to health services, which prevents them from receiving proper HIV prevention and care. Furthermore, poor policies and policy implementation, and lack of workplace programmes increases farm workers’ vulnerability to HIV infection. Thus, the aim of this study is to conduct a systematic review to assess HIV prevention and treatment services and national policies governing access to healthcare services by farm workers in SSA.
Access to maternity protection and potential implications for breastfeeding practices of domestic workers in the western cape of South Africa
(MDPI, 2023) Pereira-Kotze, Catherine; Faber, Mieke; Kannemeyer, Luke
Access to comprehensive maternity protection could contribute to improved breastfeeding practices for working women. Domestic workers are a vulnerable group. This study aimed to explore perceptions of and accessibility to maternity protection among domestic workers in the Western Cape, South Africa, and potential implications of maternity protection access for breastfeeding practices. This was a mixed-method cross-sectional study including a quantitative online survey with 4635 South African domestic workers and 13 individual in-depth interviews with domestic workers. Results from the online survey showed that domestic workers had inconsistent knowledge of maternity-protection entitlements. Data from individual in-depth interviews showed that most participants struggled to access all components of comprehensive maternity protection, with some entitlements being inconsistently and informally available. Most domestic workers were unfamiliar with the concept of breaks to breastfeed or express milk. Participants provided suggestions for improving domestic workers’ access to maternity protection.
Access to medicines for asthma, diabetes and hypertension in eight counties of Kenya
(Wiley, 2018) Wirtz, Veronika J.; Turpin, Kristen; Laing, Richard O.; Mukiira, Carol K.; Rockers, Peter C.
OBJECTIVES: To assess access to noncommunicable diseases (NCD) medicines in Kenya for patients diagnosed and prescribed treatment for asthma, diabetes and hypertension. METHODS: Households in eight purposively chosen counties were randomly selected. To be eligible, a household needed to have at least one member aged 18 years or older who had been previously diagnosed and prescribed medicines for one of the following NCDs: asthma, diabetes or hypertension. Using a logistic regression model, we explored the relationship between patient characteristics and the probability that patients had the medicines available at the time of the survey visit. RESULTS: A total of 627 individuals were included in the analysis. The highest percentage of medicines availability was in households with diabetes patients (83.1%), followed by hypertension (77.1%) patients. The lowest availability of medicines was found in households with asthma patients (53.1%). The median household expenditure on medicines per month was US$7.00 for households with diabetes patients; it was US$4.00 for asthma. In general, strong predictors of having medicines at home was being older, having some education compared to no education, few household members, wealth, being diagnosed at private nonprofit facilities and having only one patient with NCDs in the household. CONCLUSIONS: Our study found that nearly three-quarters of patients diagnosed and prescribed a medicine for hypertension, asthma or diabetes had the medicine available at home. Access challenges remain, in particular for patients from low-income households and for those diagnosed with asthma.
Accountability for SRHR in the context of the COVID-19 pandemic
(Taylor & Francis, 2020) George, Asha S.; Schaaf, Marta; Boydell, Victoria
Governments and international organisations are focused on COVID-19 crisis decision-making. As a result, global and national health governance contexts are changing dramatically, as are the social and political determinants of sexual and reproductive health and rights (SRHR). Various gender dimensions of the pandemic are clear. While initial data suggest that men are more vulnerable to COVID-19 related mortality, in many high, middle, and low-income countries, the “essential workers” and informal workers who are disproportionately exposed are disproportionately lower social status women. (Boniol et al., 2019; Wenham et al., 2020) Intersecting injustices mean that certain disadvantaged groups are particularly hard hit. (Morgan & Davies, 2020) They are left to reconcile the often-incompatible demands of precarious jobs, potential exposure to COVID-19, the stress of caring responsibilities under lockdown and, particularly for women, increased isolation exacerbating Gender-Based Violence (GBV).
Action learning for health system governance: the reward and challenge of co-production
(Oxford University Press, 2014-08-26) Lehmann, Uta; Gilson, Lucy
Health policy and systems research (HPSR) is centrally concerned with people, their relationships and the actions and practices they can implement towards better health systems. These concerns suggest that HPS researchers must work in direct engagement with the practitioners and practice central to the inquiry, acknowledging their tacit knowledge and drawing it into generating new insights into health system functioning. Social science perspectives are of particular importance in this field because health policies and health systems are themselves social and political constructs. However, how can social science methodologies such as action research and narrative and appreciative enquiry enable such research, and how can methodologies from different disciplines be woven together to construct and make meaning of evidence for 'this' field? This article seeks to present 'methodological musings' on these points, to prompt wider discussion on the practice of HPSR. It draws on one long-term collaborative action learning research project being undertaken in Cape Town, South Africa. The District Innovation and Action Learning for Health System Development project is an action research partnership between two South African academic institutions and two health authorities focused, ultimately, on strengthening governance in primary health care. Drawing on this experience, the article considers three interrelated issues: The diversity and complexities of practitioner and research actors involved in co-producing HPSR; The nature of co-production and the importance of providing space to grapple across different systems of meaning; The character of evidence and data in co-production. There is much to be learnt from research traditions outside the health sector, but HPSR must work out its own practices-through collaboration and innovation among researchers and practitioners. In this article, we provide one set of experiences to prompt wider reflection and stimulate engagement on the practice of HPSR for people-centred health systems.
Actions of female sex workers who experience male condom failure during penetrative sexual encounters with clients in Cape Town: Implications for HIV prevention strategies
(AOSIS, 2017) Mukumbang, Ferdinand C.
BACKGROUND: Condom failure has always been found to coexist with condom usage, especially among sex workers. OBJECTIVE: To describe the actions of female sex workers when they are faced with situations of condom failure. METHODS: Using the survey design, the participants were selected through the snowball sampling method. Their responses were obtained using a structured questionnaire. A total of 100 questionnaires were analysed. RESULTS: With respect to the immediate actions of sex workers after condom failure, 36% of the respondents continued with the sexual encounter after noticing that the condom was broken. Another 36% stopped immediately when they noticed that the condom had failed, but replaced the condom; 13% of the participants stopped the sexual encounter completely; 3% applied vaginal spermicidal foam; and 5% of the respondents stopped immediately and took a douche when they had the chance. For the actions within the next 24 hours of experiencing condom failure with a client, 53% of the participants did nothing; 4% sought counsel from a professional; 3% of the respondents took alcohol or drugs to forget the incident, 25% went to the clinic for assistance and 8% offered other responses. CONCLUSION: While continuing the sexual encounter without replacing the condom, taking alcohol and drugs or doing nothing could increase the risk of contracting HIV; however, actions like stopping the sexual encounter completely and visiting a clinic or a professional could make a difference between staying HIV negative or seroconverting. There is a need for targeted intervention to address issues of inappropriate behaviours after experiencing condom failure.
Adaptation of the Texas Christian University organisational readiness for change short form (TCU-ORC-SF) for use in primary health facilities in South Africa
(BMJ publishing group, 2022) Wagener, Emma; Petersen-Williams, Petal; Brooke-Sumner, Carrie
Objectives The Texas Christian University Organisational Readiness for Change Scale (TCU-ORC) assesses factors influencing adoption of evidence-based practices. It has not been validated in low-income and middle-income countries (LMIC). This study assessed its psychometric properties in a South African setting with the aim of adapting it into a shorter measure. Methods This study was conducted in 24 South African primary healthcare clinics in the Western Cape Province. The TCU-ORC and two other measures, the Organisational Readiness to Change Assessment (ORCA) and the Checklist for Assessing Readiness for Implementation (CARI) were administered. The questionnaire was readministered after 2 weeks to obtain data on test–retest reliability. Three hundred and ninety-five surveys were completed: 281 participants completed the first survey, and 118 recompleted the assessments. Results We used exploratory factor analysis (EFA) to identify latent dimensions represented in the data. Cronbach’s alpha for each subscale was assessed and we examined the extent to which the subscales and total scale scores for the first and retest surveys correlated. Convergent validity was assessed by the correlation coefficient between the TCU-ORC, ORCA and CARI total scale scores. EFA resulted in a three-factor solution. The three subscales proposed are Clinic Organisational Climate (8 items), Motivational Readiness for Change (13 items) and Individual Change Efficacy (5 items) (26 items total). Cronbach’s alpha for each subscale was >0.80. The overall shortened scale had a test–retest correlation of r=0.80, p<0.01, acceptable convergent validity with the ORCA scale (r=0.56, p<0.05), moderate convergence with the CARI (r=39, p<0.05) and strong correlation with the original scale (r=0.79, p<0.05). Conclusions This study presents the first psychometric data on the TCU-ORC from an LMIC. The proposed shortened tool may be more feasible for use in LMICs. Trial registration number Results stage. Project MIND trial. Pan-African Clinical Trials Registry.
Adapting the diabetes prevention program for low and middle-income countries: Protocol for a cluster randomised trial to evaluate lifestyle Africa
(BMJ, 2019) Puoane, Thandi
Low and middle-income countries like South Africa are experiencing major increases in burden of non-communicable diseases such as diabetes and cardiovascular conditions. However, evidence-based interventions to address behavioural factors related to these diseases are lacking.
Adapting to, integrating and selfmanaging HIV as a chronic illness: a scoping review protocol
(BMJ Publishing Group, 2021) Sematlane, Neo Phyllis; Knight, Lucia; Masquillier, Caroline
The process of adapting to a life with a chronic illness, is a well-researched phenomenon for a number of common chronic illnesses. The construct, adaptation, embeds the notions of integration of the chronic illness into identity and self-management. Integration precedes self-management and is key to living positively with a chronic illness. Adaptation is an important concept in understanding trajectory and outcomes of living with a chronic illness. Applicability of these concepts to HIV as a chronic illness; when suppressive adherence has been achieved, however, is unknown. Specifically, the adaptation process to living with HIV as a chronic illness, the integration of HIV into identity and the resulting selfmanagement behaviours by adults living with HIV are relatively unexplored. We describe a protocol for a scoping review of adaptation to living with HIV, we structure the enquiry around integration of HIV into identity and self-management and interrogate theories, models and frameworks that have been proposed and studied and we evaluate them for relevance and usefulness in the care and management of HIV.
Addressing non-communicable diseases in the Western Cape, South Africa
(PAGEpress, 2019) Solomons, Nasheetah; Kruger, Salome; Pouane, Thandi
Chronic non-communicable diseases (CNCDs) are increasing with grave consequences to countries’ development. The purpose of this study was three-fold: (1) to determine challenges PURE study participants faced regarding CNCD interventions and what they required from a CNCD intervention programme, and (2) to explore courses of action Department of Health (DoH) officials thought would perform best, as well as (3) to determine what DoH officials perceive to be obstacles in addressing the CNCD epidemic.
Addressing social determinants of health in South Africa: the journey continues
(Health Systems Trust (HST), 2017) Scott, Vera; Schaay, Nikki; Schneider, Helen; Sanders, David
With the recent change from the Millennium Development Goals to the 17 new Sustainable Development Goals, the focus of the global development agenda is expanding: there is attention on a broader set of social determinants and, importantly, a specific sensitivity to equity, which could have a substantial effect on health. Addressing social determinants is a cornerstone in the National Department of Health’s Primary Health Care Re-engineering Strategy, and an approach that is embedded in the country’s National Development Plan. However, the translation of this policy commitment to programmatic action at different levels in the health system and in partnership with other sectors remains elusive.
Addressing the social determinants of health: A case study from the Mitanin (Community Health Worker) programme in India
(London School of Hygiene and Tropical Medicine, 2014) Nandi, Sulakshana; Schneider, Helen
The Mitanin Programme, a government community health worker (CHW) programme, was started in Chhattisgarh State of India in 2002. The CHWs (Mitanins) have consistently adopted roles that go beyond health programme- specific interventions to embrace community mobilization and action on local priorities. The aim of this research was to document how and why the Mitanins have been able to act on the social determinants of health, describing the catalysts and processes involved and the enabling programmatic and organiza- tional factors. A qualitative comparative case study of successful action by Mitanin was conducted in two ‘blocks’, purposefully selected as positive exemplars in two districts of Chhattisgarh. One case focused on malnutrition and the other on gender-based violence. Data collection involved 17 in-depth interviews and 10 group interviews with the full range of stakeholders in both blocks, including community members and programme team. Thematic analysis was done using a broad conceptual framework that was further refined. Action on social determinants involved raising awareness on rights, mobilizing women’s collectives, revitalizing local political structures and social action targeting both the community and government service providers. Through these processes, the Mitanins developed identities as agents of change and advocates for the community, both with respect to local cultural and gender norms and in ensuring accountability of service providers. The factors underpinning successful action on social determinants were identified as the significance of the original intent and vision of the programme, and how this was carried through into all aspects of programme design, the role of the Mitanins and their identification with village women, ongoing training and support, and the relative autonomy of the programme. Although the results are not narrowly generalizable and do not necessarily represent the situation of the Mitanin Programme as a whole, the explanatory framework may provide general lessons for programmes in similar contexts.
Addressing the tensions and complexities involved in commissioning and undertaking implementation research in low- and middle-income countries
(BMJ, 2018) Doherty, Tanya; Lewin, Simon; Kinney, Mary; Sanders, David; Mathews, Cathy; Daviaud, Emmanuelle; Goga, Ameena; Bhana, Arvin; Besada, Donela; Vanleeuw, Lieve; Loveday, Marian; Odendaal, Willem; Leon, Natalie
Rapid scale-up of new policies and guidelines, in the context of weak health systems in low/middle-income countries (LMIC), has led to greater interest and funding for implementation research. Implementation research in LMICs is often commissioned by institutions from high-income countries but increasingly undertaken by LMIC-based research institutions. Commissioned implementation research to evaluate large-scale, donor-funded health interventions in LMICs may hold tensions with respect to the interests of the researchers, the commissioning agency, implementers and the country government. We propose key questions that could help researchers navigate and minimise the potential conflicts of commissioned implementation research in an LMIC setting.
Adherence challenges encountered in an intervention programme to combat chronic non-communicable diseases in an urban black community, Cape Town
(AOSIS OpenJournals Publishing AOSIS (Pty) Ltd, 2017) Solomons, Nasheetah; Kruger, Herculina Salome; Puoane, Thandi
Background: Chronic non-communicable diseases (CNCD) have become the greatest contributor to the mortality rate worldwide. Despite attempts by Governments and various non-governmental organisations to prevent and control the epidemic with various intervention strategies, the number of people suffering from CNCD is increasing at an alarming rate in South Africa and worldwide. Objectives: Study's objectives were to explore perceived challenges with implementation of, and adherence to health messages disseminated as part of a CNCD intervention programme; to gain an understanding of participants' expectations of CNCD intervention programmes;, and to explore the acceptability and preference of health message dissemination methods. In addition, participants' awareness of, and willingness to participate in CNCDs intervention programmes in their community was explored. Methods: Participants were recruited from the existing urban Prospective Urban Rural Epidemiology study site in Langa, Cape Town. Focus group discussions were conducted with 47 participants using a question guide. Summative content analysis was used to analyse the data. Results: Four themes emerged from the data analysis: practical aspects of implementation and adherence to intervention programmes; participants' expectations of intervention programmes; aspects influencing participants' acceptance of interventions; and their preferences for health message dissemination. The results of this study will be used to inform CNCDs intervention programmes. Conclusions: Our findings revealed that although participants found current methods of health message dissemination in CNCDs intervention acceptable, they faced real challenges with implementing and adhering to CNCDs to these messages.
Adherence to isoniazid preventive therapy among child contacts in Rwanda: A mixed-methods study
(Public Library of Science, 2019) Birungi, Francine Mwayuma; Graham, Stephen Michael; Uwimana, Jeannine
The World Health Organization recommends isoniazid preventive therapy (IPT) for six months for child contacts without tuberculosis (TB), who are exposed to an adult with active TB. The effectiveness of IPT depends on 80% or greater adherence to medication. In the current study, we assessed IPT adherence and explored barriers to and facilitators of adherence among eligible child contacts in Kigali, Rwanda.A mixed method study design was used to prospectively assess adherence to IPT among eligible child contacts and its associated factors through a quantitative, observational cohort study, and to explore barriers to and facilitators of adherence to IPT through a descriptive qualitative study.
Adolescent access to care and risk of early mother-to-child HIV transmission
(Elsevier, 2017) Ramraj, Trisha; Jackson, Debra; Dinh, Thu-Ha; Olorunju, Steve; Lombard, Carl; Sherman, Gayle
PURPOSE: Adolescent females aged 15–19 account for 62% of new HIV infections and give birth to 16 million infants annually. We quantify the risk of early mother-to-child transmission (MTCT) of HIV among adolescents enrolled in nationally representative MTCT surveillance studies in South Africa. METHODS: Data from 4,814 adolescent (≤19 years) and 25,453 adult (≥20 years) mothers and their infants aged 4–8 weeks were analyzed. These data were gathered during three nationally representative, cross-sectional, facility-based surveys, conducted in 2010, 2011–2012, and 2012– 2013. All infants were tested for HIV antibody (enzyme immunoassay), to determine HIV exposure. Enzyme immunoassay-positive infants or those born to self-reported HIV-positive mothers were tested for HIV infection (total nucleic acid polymerase chain reaction). Maternal HIV positivity was inferred from infant HIV antibody positivity. All analyses were weighted for sample realization and population live births. RESULTS: Adolescent mothers, compared with adult mothers, have almost three times less planned pregnancies 14.4% (95% confidence interval [CI]: 12.5–16.5) versus 43.9% (95% CI: 42.0–45.9) in 2010 and 15.2% (95% CI: 13.0–17.9) versus 42.8% (95% CI: 40.9–44.6) in 2012–2013 (p < .0001), less prevention of MTCT uptake (odds ratio [OR] in favor of adult mothers = 3.36, 95% CI: 2.95– 3.83), and higher early MTCT (adjusted OR = 3.0, 95% CI: 1.1–8.0), respectively. Gestational age at first antenatal care booking was the only significant predictor of early MTCT among adolescents. CONCLUSIONS: Interventions that appeal to adolescents and initiate sexual and reproductive health care early should be tested in low- and middle-income settings to reduce differential service uptake and infant outcomes between adolescent and adult mothers.
Adolescent girls’ perceptions of breastfeeding in two low-income periurban communities in South Africa
(Routledge, 2019) Zweigenthal, Virginia; Strebel, Anna; Hunter-Adams, Jo
In South Africa, exclusive breastfeeding rates are low, and rates of teenage pregnancy are high. Educational policy enables mothers’ return to school, which conflicts with policy emphasizing exclusive breastfeeding. We elicited adolescent women’s perceptions and experiences of infant feeding choices, and conducted six focus groups (N ¼ 57) in two periurban settlements. Participants knew arguments in favor of and against breast and formula-feeding, but in practice, mixed feeding occurred early after birth. While completion of high school was emphasized, exclusive breastfeeding was viewed as impractical. Congruent education policies and infant feeding policies/guidelines must address the constraints and contexts of adolescent mothers.

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