Philosophiae Doctor - PhD (School of Public Health)

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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.
Agricultural migrant workers navigating the health system: Access, continuity of care and the role of community health workers in De Doorns, Western Cape
(University of the Western Cape, 2018) Jalal, Nafeesa; Zarowsky, Christina
South Africa has an estimated two million documented and undocumented immigrants. In addition, Statistics South Africa (2014) notes very significant internal migration. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, although it has a Constitutional right to health and healthcare. Their quality of healthcare and disease control also affects the general population and the burden on the health system can be increased by inadequately managed chronic conditions as well as acute health care needs. Access to healthcare and continuity of care reflect both patient agency and the health system. Community Health Workers (CHWs) play an important role in linking communities and patients to health services and vice versa. The aim of this study was to understand how agricultural migrants in the Cape Winelands District of Western Cape Province of South Africa navigated the healthcare system to access healthcare services including securing continuity of care, and in particular the role of CHWs in this process, in order to inform policy and practice.
An evaluation of the effect of essential newborn care group motivational interviewing health education delivered in a maternity waiting home setting on the mothers' knowledge and practice and on early neonatal morbidity in rural eastern province of Zambia
(University of the Western Cape, 2018) Menda, Dhally Mutombo; Mathole, Thubelihle; Jackson, Debra
The study assesses the effect of the Essential Newborn Care family package health education messages delivered to pregnant mothers and their caregivers by the Safe Motherhood Action Groups members (SMAGs) in a Maternity Waiting Home (MWH) setting, using a client centered education methodology that uses the Group Motivational Interviewing philosophy, on the mothers' Essential Newborn Care (ENC) knowledge, mothers' ENC practice, and early neonatal morbidity. The study also explored the prevailing newborn care practices in the mothers' communities, and the mothers' level of satisfaction of the Essential Newborn Care Group Motivational Interviewing Health Education (ENCGMI HE) sessions.
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.
Assessing the influence of gender socialization on early adolescents’ behaviors and perceptions towards sexual and reproductive health and gender-based violence in low socio-economic, urban neighborhoods, Cape Town: a quantitative study
(University of the Western Cape, 2023) Kinoshita, Rinko; Cooper, Diane
Early adolescents (EAs), aged between 10 and 14, account for half of 1.2 billion adolescents worldwide. During early adolescence (EA), many EAs experience puberty and social and cognitive shifts. This is a period when gender norms are shaped manifesting in their perceptions and behaviors. Unequal gender norms may negatively affect adolescents’ sexual and reproductive health (ASRH), including early pregnancy, violence, and mental health. There is a paucity of evidence on how EAs construct gender norms, and how unequal gender norms may impact their health and well-being.
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.
Breaking the bttleneck: Understanding the intractable bottlenecks and data-informed decision-making to deliver life-saving commodities for women and children
(University of the Western Cape, 2021) Nemser, Bennett; Jackson, Debra
Access to life-saving commodities and related services for women and children is a fundamental component of universal health coverage. However, countries confront numerous intractable challenges, such as aligning regulatory practices, enhancing health workforce capacity, and effectively managing supply chains, to ensure essential reproductive, maternal, newborn and child health (RMNCH) commodities and services reach all communities. To address these entrenched obstacles, the UN Commission on Life Saving Commodities for Women and Children (UNCoLSC) in 2012 outlined a series of recommendations to improve access to 13 low-cost and high-impact commodities. This thesis explores the improvements and remaining barriers to accessing life-saving commodities for women and children in sub-Saharan Africa and Southeast Asia. In addition, this thesis showcases how effective data-informed decision-making can support prioritized RMNCH investments and equitycentered action.
Burden of multimorbidity in South Africa: Implications for health policy and service delivery
(University of the Western Cape, 2022) Roomaney, Rifqah Abeeda; van Wyk, Brian
South Africa is challenged to manage the quadruple burden of disease experienced by its population. Furthermore, the burden of multimorbidity – that is, people living with more than one disease condition – is increasing. Multimorbidity challenges the way the health system is organised as it traverses different health programmes. However, little research has investigated the phenomenon in South Africa. The study describes the epidemiology – prevalence, patterns and risk factors - of multimorbidity in South Africa, and makes recommendations for health policy and service delivery.
Community insights into, and an international perspective on the role food environments and diet play in the self-management of type 2 diabetes mellitus in urban and rural South Africa
(The University of the Western Cpae, 2018) Spires, Mark Haydn; Puoane, Thandi
Type 2 diabetes mellitus (T2DM) and pre-diabetes contribute increasingly to the global burden of disease. Along with other behavioural risk factors, diet plays a key role in the onset and management of the disease, in turn largely determined by what foods are immediately accessible in local food environments. With this in mind, this thesis aims to answer the research question: What role do local food environments play in promoting or inhibiting access to healthy foods as part of the self - management of T2DM in urban and rural communities in South Africa, and what can be learned from an international perspective? Specific research objectives include, to: 1. Understand the current national-level policy context with regard to the observed rise in NCDs, their proximal determinants (specifically an observed change in diet patterns), and contributing environmental factors; 2. Identify the current food-related environmental factors associated with the onset and/or management of T2DM in an urban and a rural setting (as well as in four additional international settings in order to provide an international perspective); 3. Explore community perspectives of the role the local food environment plays in the self-management of T2DM in an urban and a rural setting; and, consequently 4. Recommend intervention- and/or policy-related actions that can be implemented based on study findings. A review of the literature and relevant policies was conducted towards achieving the first research objective. Quantitative data were systematically collected at an urban and rural site in South Africa through the creation of an ‘environmental profile’ in an attempt to achieve the second objective – comparable urban and rural data was also collected as part of a larger study at two other international sites (Kampala, Uganda and Stockholm, Sweden) to provide an international perspective. Included in the third objective is the collection of qualitative data through a community based participatory research method at the same urban and rural sites in South Africa. Finally, intervention and/or policy-related recommendations are developed based on study findings and in consultation with relevant stakeholders through interviews.
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.
Conceptualisation and operationalisation of mental wellness: Developing an instrument to measure mental wellness among adolescents living with HIV in South Africa
(University of the Western Cape, 2022) Orth, Zaida; van Wyk, Brian
Adolescents living with HIV (ALHIV) are a key population in the fight against HIV and AIDS. The comparatively poorer treatment outcomes of ALHIV in relation to child and adult HIV populations indicate the need for a health response to improve adolescent ART service delivery. Research suggests that improving mental wellness may be imperative to improving HIV-treatment behaviours such as long-term adherence and engagement in care. However, little is known about what mental wellness means for ALHIV. It is further unknown what critical mental wellness concepts should be targeted in adolescent interventions. Ultimately, understanding mental wellness in ALHIV is essential to design programmes that will help them navigate their chronic condition to lead healthy and productive lives.
The decentralised drug-resistant TB programme in South Africa: From policy to implementation
(University of the Western Cape, 2022) Jassat, Waasila; Schneider, Helen
South Africa is one of the high burden countries for drug-resistant tuberculosis (DR-TB) globally. A policy supporting decentralised DR-TB treatment provision was introduced in 2011 but to date implementation has been suboptimal with variable coverage and quality. This thesis opens the ‘black box’ explaining sub-national policy implementation of DR-TB decentralisation in two provinces of South Africa, Western Cape and KwaZulu-Natal. The thesis is grounded in the field of policy analysis and adopts the methodological approach of a qualitative multiple case study, comparing 15 embedded district and subdistrict cases in the two provinces, through data collected in 94 in-depth interviews, document reviews, and observations. Applying Walt and Gilson’s Policy Analysis Triangle framework, the case studies of DR-TB in the two provinces revealed how aspects of actors’ engagement with the policy instrument, influenced by organisational dynamics and the wider context, resulted in varying effectiveness of policy implementation.
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.
Developing a comprehensive nutrition workforce planning framework for the public health sector to respond to the nutrition-related burden in South Africa
(University of the Western Cape, 2018) Goeiman, Hilary Denice; Swart, Elizabeth; Hughes, Roger
South Africa has not responded well to recommendations in national evaluation reports to address human resource challenges associated with the implementation of nutrition programmes and improved service delivery. Twenty-four years have passed since the dawning of democracy and the nutrition situation within the population has actually deteriorated, with persistently high levels of stunting in young children and the growing prevalence of overweight and obesity in all age groups. These conditions not only rob people of their potential, but they carry a high cost for the state and society as a whole. This study aimed to develop a comprehensive and empirically sound nutrition workforce development planning framework for the public health sector so that it is better equipped to address the nutrition-related burden of disease in South Africa. The study explored the provision of nutrition services in South Africa, focusing on the nutrition-specific work components of health personnel ‒ doctors, nurses, dietitians, nutritionists, health promoters and community health workers working at the primary health care level in the public health sector. Evidence-based workforce information was collected through a mixed methodology comprising: literature reviews, document reviews, analysis of scopes of practice, job descriptions, competencies, workforce surveys, key informant interviews and consensus assessments through the application of the Delphi technique. Permission was obtained to adapt and use questionnaires from an Australian workforce study. Ethical approval, permission to conduct the study and informed consent were obtained prior to the commencement of the interviews. Data was then analysed using descriptive statistics, content and thematic analysis and triangulation of all findings, followed by consensus assessments to describe the nutrition workforce and delineate the roles and functions thereof. The comprehensive planning framework that was developed was applied to the Western Cape province.
The development of a nutrient profiling model assessing healthfulness of packaged foods for adults in the low-income context of South Africa
(University of the Western Cape, 2022) Frank, Tamryn Caron; Swart, Elizabeth (Rina)
South Africa is facing high, and increasing levels of overweight, obesity and nutritionrelated non-communicable diseases. These conditions have been linked to poor health outcomes that disproportionately affect the poorest, and place an undue burden on the health system and South African economy. The proliferation of ultra-processed products (UPPs) is in part to blame for this. To assess dietary intake and UPP consumption amongst low-income adults in South Africa, and to develop and test a nutrient profiling model (NPM) assessing healthfulness of foods available and consumed by adults in the low-income context of South Africa to the extent that it provides the potential to underpin a front-of-package warning label system.
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.
The development of an anti-substance abuse initiative for high schools in the Capricorn district, Polokwane
(University of Western Cape, 2021) Shuro, Linda; Waggie, Firdouza
Substance abuse among adolescents is a Public Health concern globally with approximately 25 million adolescents (aged 13-15 years) who smoke tobacco, one in every ten girls and one in every five boys. In low- and middle-income countries, 14 % of girls and 18% of boys (13-15years old) are engaged in alcohol use. The Global Status Report on Alcohol and Health of 2018, reports that among the 15- to 19-year-olds, greater than a quarter were current alcohol drinkers. Cannabis (marijuana/dagga) is highly used globally with approximately 3.8% between 15 and 64 years, about 188 million people used it once or more times in 2017. The most commonly abused substances are alcohol, tobacco, and cannabis (marijuana/dagga). In South Africa, most adolescents are found in schools and the average age of drug experimentation is 12 years with early onset of use at about ten years of age.
Development of an approach for measurement and monitoring of the continuum of care for maternal health in the South African health system
(University of the Western Cape, 2021) Mothupi, Mamothena Carol; Knight, Lucia; Tabana, Hanani
The continuum of care is a public health framework for improving maternal health outcomes by providing comprehensive health services, at different levels of the health system and across the lifecycle. The framework emphasizes the importance of interventions to address the social determinants of health as well, alongside healthcare services. Although the framework is useful for visualizing service organization, it has not been adequately integrated into policy and practice in South Africa. In addition, there is currently no comprehensive approach to monitor and evaluate service provision along the continuum of care. The current approach is fragmented across programs and sectors and focuses on only a handful of indicators. This research explores an approach for measurement and monitoring of a comprehensive continuum of care for maternal health in South Africa, with implications for application in other low- and middle-income countries (LMICs).
Development of an integrated model of care for use by community health workers working with chronic non-communicable diseases in Khayelitsha, South Africa
(University of the Western Cape, 2018) Tsolekile, Lungiswa Primrose; Puoane, Thandi; Schneider, Helen; Levitt, Naomi
Non-communicable diseases (NCD) continue to be a public health concern globally and contribute to the burden of disease. The formal health system in developing countries lacks the capacity to deal with these NCD as it is overburdened by communicable diseases. Thus, community health workers (CHWs) have been suggested as a solution for alleviating the burden for primary health facilities, by extending NCD care to the community. This thesis aims to develop an integrated model of care for CHWs working with patients with non-communicable diseases by describing and exploring current CHW roles, knowledge and practices in relation to community-based NCD care. The specific objectives for this study included 1) the exploration of the NCD roles of generalist CHWs in the context of a limited resource urban setting; 2) determining the NCD-related knowledge of CHWs, and factors influencing this in a limited resource urban setting and 3) a comparison of actual and envisaged roles in the management and prevention of NCD using the integrated chronic diseases management model (ICDM) as a benchmark, and propose key competencies and systems support for NCD functions of CHWs in South Africa Mixed methods were used to achieve the objectives of this study. First, a qualitative enquiry was conducted using observations to respond to the first objective. A quantitative cross-sectional design was then used to achieve the second objective, and a questionnaire was used to interview CHWs. A comparison of findings from both the quantitative and qualitative studies with policy guidelines was undertaken to address the third objective.
Development of evidence-based context appropriate public policy reform models that coherently promote healthy food environments and food consumption patterns in Zambia
(University of the Western Cape, 2022) Mukanu, Mulenga Mary; Mchiza, Zandile June-Rose
The double burden of malnutrition is a growing concern globally. In Zambia, it is estimated that of children under five years, 35% are stunted, while 5% are either overweight or obese. In the adult population, 24% are overweight, while 90% do not meet the dietary requirement of consuming five portions of fruit a day. Evidence suggests that unhealthy dietary habits developed by children can contribute to poor health outcomes in adulthood. However, Zambia's nutrition policies are not changing rapidly enough to address the development of new challenges associated with the double burden of malnutrition. Policy reforms should be implemented to re-engineer food environments to support access to healthier food options and make these foods preferable to consumers in critical age groups like adolescence.

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