Research Articles (School of Public Health)

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Sustainability starts with spending: public financial management lessons from Kenya’s universal health care pilot
(BioMed Central Ltd, 2025) Jackson, Debra; Adjagba, Alex Olateju; Oguta, James Odhiambo
Background: Effective public financial management (PFM) is a foundational enabler of sustainable progress toward Universal Health Coverage (UHC). Achieving UHC requires not only increased funding for the health sector but also the efficient, equitable, and accountable use of resources. In 2019, Kenya piloted a UHC initiative across four counties to generate evidence to inform national scale-up. This study examines the PFM processes underpinning the pilot implementation, with a focus on how financial planning, budget execution, and accountability mechanisms influenced the delivery of UHC interventions at the county level. Methods: This study employed a qualitative research design to explore PFM processes during the implementation of Kenya’s UHC pilot in four counties. Data were collected through 51 in-depth interviews and five focus group discussions with key stakeholders, including healthcare workers, patient representatives, and senior members of the County Health Management Teams (CHMTs). An inductive thematic analysis approach was employed to identify patterns and themes that emerged from the data. The analysis was facilitated using Dedoose software (Version 9.0.17), which enabled systematic coding and organization of the qualitative data.
Supporting community health workers in South Africa for context-specific food and nutrition literacy: implementation of a multi-media education-entertainment intervention
(BioMed Central Ltd, 2025) Alaba, Olufunke; Lembani, Martina; Mchiza, Zandile
Background: Multimedia technology, recognized for its efficacy in education, offers a complementary approach to traditional health education. In South Africa, community health workers (CHWs) play a pivotal role in improving population health, but often lack comprehensive health knowledge. This study explores the effectiveness of using a multimedia education-entertainment (MM-EE) intervention to enhance food and nutrition literacy among CHWs in resource-challenged townships. Methods: Seventy-seven participants completed a baseline and 6-month post-intervention follow-up survey. The MM-EE intervention comprised short stories conveyed via comic booklets and 30-second video clips, covering food knowledge, use of food labels, meal preparation, planning, and eating behaviour. Materials were distributed via mobile messaging services, including WhatsApp (as the primary social media platform), MMS, and SMS. Descriptive statistics, chi-square tests, Wilcoxon signed-rank tests, and multivariate linear regression were conducted using R studio version 4.3.3. Results: Over 70% of participants were classified as having obesity, and 18.2% as overweight, leading to 88.3% of participants being classified as overweight or having obesity. A significant proportion of participants (68.8%) reported having an existing non-communicable disease (NCD). The MM-EE intervention significantly improved CHWs’ food and nutrition literacy, reflected in improved median scores for meal preparation (43.1% [IQR: 19.6] pre- vs. 62.7% [IQR: 11.7] post-intervention), planning (58.6% [IQR: 12.1] pre- vs. 67.2% [IQR: 13.4] post-intervention), and overall food and nutrition literacy (63.0% [IQR: 8.1] pre- vs. 69.4% [IQR: 10.9] post-intervention; p <.001). Conclusion: The study showed effective MM-EE intervention outcomes, positioning this method of health dissemination as suitable for improving the food and nutrition literacy of CHWs in South Africa. The study suggests the potential effectiveness of MM-EE approaches to enhance the health knowledge of the South African population. However, adaptation for the wider population will require further research on scalability, sustainability and an improved intervention design to address all dimensions of literacy.
Actor sensemaking and its role in implementation of the decentralized drug-resistant tuberculosis policy in South Africa
(Oxford University Press, 2025) Jassat, Waasila; Schneider, Helen; Moshabela, Mosa
South Africa has a high burden of drug-resistant tuberculosis (DR-TB). A policy to decentralize DR-TB treatment from specialized central hospitals to more accessible district facilities was introduced in 2011, but to date implementation has been suboptimal, with variable pace, coverage, and models of care emerging. This study explored multilevel policy implementation of DR-TB decentralization in two provinces of South Africa, Western Cape and KwaZulu-Natal. Applying interpretive policy analysis, this paper describes how actors across health system levels and geographies made sense of the DR-TB policy and how this shaped implementation. In an embedded qualitative case study, districts of the two provinces were compared, through data collected in 94 in-depth interviews, and analysed using Vickers’ framework of reality, value, and action judgements. Five district cases characterize variation in the pace of implementation and models of DR-TB care that emerged. Individual and collective attitudes for and against the policy were underpinned by different systems of meaning for interpreting policy problems and making decisions. These meaning systems were reflected in actor stances on whether DR-TB care needed to be specialized or generalized, nurse- or doctor-led, and institutionalized or ambulatory. Actors’ stances influenced their actions and implementation strategies adopted. Resistance to decentralized DR-TB care related to perceived threats of budget cuts to and loss of authority of central facilities, and was often justified in fears of increased transmission, poor quality of care, and inadequate resources at lower levels. New advances in diagnosis and treatment to address the growing burden of DR-TB in South Africa will have little impact unless implementation dynamics are better understood, and attention paid to the mindsets, interests, and interpretations of policy by actors tasked with implementation. Deliberative policy implementation processes will enhance the quality of discourse, communication and cross-learning between policy actors, and critical for reaching synthesis of meaning systems.
Who is at the table and who has the power? Case study analysis of decision-making processes for the Global Financing Facility in Tanzania
(Taylor and Francis Ltd., 2025) Kinney, Mary; George, Asha; Shamba, Donat
Background: In 2015, Tanzania joined the Global Financing Facility (GFF), a global health initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). Despite its resource mobilization goals, little is known about power dynamics in GFF policy processes. This paper presents the first power analysis of Tanzania’s GFF engagement. Objective: To examine policy processes in developing GFF documents during its first two phases in Tanzania. Methods: An exploratory qualitative case study using document reviews (*n* = 22) and key informant interviews (*n* = 21) conducted in 2022–2023. Data were thematically analyzed and interpreted using Gaventa’s power cube (levels, spaces, and forms of power). Results: Stakeholders praised the GFF’s country-led, evidence-based approach and local autonomy. However, closed-door decision-making in phase one excluded civil society and the private sector. Invisible power imbalances in funding allocations left stillbirths and adolescent health without dedicated budgets, while vulnerable groups (e.g. people with disabilities) were overlooked.
Institutionalising community participation in decision-making in maternal and newborn health services in low-and middle-income countries: an analysis from 102 national health ministries
(Public Library of Science, 2025) Jackson, Debra; Cocoman, Olive; Ruysen, Harriet
In 2024, 194 countries endorsed World Health Assembly Resolution (WHA77.2) to strengthen participation in health-related decision-making. Achieving this requires strong leadership to institutionalise community participation by embedding it into health system functions. However, efforts are often fragmented and short-term, hindering both sustainability and scalability. There is limited understanding of how well countries have institutionalised community participation in decision-making for quality maternal and newborn health services. A secondary analysis of maternal and newborn health survey data was conducted using responses from 102 Ministries of Health in low-and middle-income countries. The analysis assessed progress in adopting and implementing maternal and newborn health recommendations on community participation. A descriptive approach was used to summarise the frequency of reported community participation activities. Percentages were applied to describe the data, which was disaggregated by 2024–2025 World Bank classifications for income level, and fragile and conflict-affected settings. Country responses were categorised using Lasswell’s Policy Cycle heuristic. The findings indicate substantial gaps in institutionalising community participation in maternal and newborn health. Only half of countries reported integrating participation into national plans, and just one-third into implementation. In 90% of countries, parent groups were reported to be either absent or lacking influence on policymaking. National research on community participation, essential for evidence-based decision-making, was rarely reported. Across all regions, countries had varied progress, reflecting a diverse and uneven landscape of community participation. Stronger efforts are required to institutionalise community participation across the maternal and newborn health policy cycle. Strengthening this integration will require clear metrics to track implementation, enabling more accurate assessments of progress and accountability. Identifying countries where institutionalisation is advancing can surface positive deviance cases. Studying these in-depth may reveal drivers and effective strategies for fostering community participation to guide the adaption and integration of successful approaches into national health systems.
Patterns of transition of adolescents in an HIV care programme in peri-urban Cape Town, South Africa: a photovoice study
(SAGE Publications, 2025) Petinger, Charné; van Wyk, Brian; Crowley, Talitha
Successful transition from paediatric to adult HIV care programme is a critical developmental milestone in the care trajectory of adolescents living with HIV (ALHIV). The transition process involves a shift from a structured, caregiver-supported healthcare model to one that requires independence and self-management. This process should be guided and supportive to ensure continued engagement in care and optimal adherence when ALHIV are transferred. This study utilised photovoice methods to explore the transition experiences of ALHIV in the Cape Town Metropole. Audio-recorded focus group data were transcribed verbatim and subjected to reflexive thematic analysis. Three distinctive patterns of behaviour from ALHIV were identified as themes. Type 1: socially reliant, dependent adolescent who heavily relies on family and peer support and struggles with adherence. Type 2: socially disconnected, hyper-independent adolescent, who is self-reliant, seeks solitude, and is generally resistant to external support. We configured a third (ideal) type, who is interdependent and able to self-manage their chronic condition, but within a supportive health care environment that provides positive healthcare and transition experiences. The findings underscore the need for supportive transition models promoting self-management skills, while facilitating a symbiotic relation with healthcare staff promoting sustained engagement in care well into adulthood. We recommend that adolescent or youth friendly services for ALHIV be expanded to support and monitor the transition process and outcomes in the adult HIV program.
Born too soon: progress and priorities for respectful and rights-based preterm birth care
(Springer Nature, 2025) Kinney, Mary; Ateva, Elena; Cocoman, Olive
Progress: Human rights related to preterm birth encompass access to respectful, evidence-based care; informed consent; protection from discrimination, detention, and unnecessary separation of mother and newborn; and broader social entitlements, such as parental leave and early disability support. Since the 2012 Born Too Soon report, global recognition of these rights has expanded through international treaties, global guidelines, national legal reforms, and social movements. Demand for respectful care, including respectful maternity care and family centred care, has led to its incorporation into global guidelines and policies and a greater evidence-base. However, persistent challenges, such as workforce shortages, discriminatory policies, and the erosion of sexual and reproductive rights, continue to threaten progress. Programmatic Priorities: Ensuring respectful and rights-based preterm birth care requires coordinated action across the continuum of care and across sectors, with the mother–baby dyad at the centre. Programmatic priorities at the individual level include implementing respectful maternity care and family-centred care. Ensuring high-quality, respectful care demands that providers themselves are supported, protected, and empowered to deliver such care. Their well-being is a critical enabler of the rights of patients and an essential component of effective, compassionate service delivery. At the facility-level, health systems must be purposefully designed to safeguard the fundamental human rights of the individuals with them, both care seekers and care providers. Implementing respectful, rights-based care relating to preterm birth requires structural and social changes, as well as robust data systems for accountability. Multi-stakeholder action requires strengthening accountability mechanisms at all levels and partnering with those affected by preterm birth—particularly women, families and healthcare providers—in policy processes, and the design, implementation and monitoring of care.
Paternal factors affecting under-five immunization status in Sub-Saharan Africa: A systematic review and meta-analysis
(Elsevier Ltd, 2025) Mano, Oscar; Musuka, Godfrey; Moyo, Enos
While maternal influences on childhood immunization have been extensively studied in sub-Saharan Africa (SSA), paternal socioeconomic factors remain underexplored despite their potential impact on vaccination outcomes. This systematic review and meta-analysis aimed to synthesize current evidence on the influence of paternal characteristics on full childhood immunization status in SSA. A comprehensive literature search was conducted in PubMed, Google Scholar, Embase, and Scopus for studies published between January 2014 and March 2025. Studies were included if they examined paternal factors, such as education, employment, and decision-making power, in relation to childhood immunization among children under five in SSA. Data were extracted from 16 eligible studies, and a meta-analysis was conducted using MetaXL and IBM SPSS to calculate pooled prevalence and effect sizes. The Downs and Black checklist was used for risk of bias assessment. Of the 16 studies included, seven contributed data to the meta-analysis on full immunization. The pooled prevalence of full immunization was 60 % (95 % CI: 37–81 %) across SSA. Children of fathers with primary education or higher were nearly three times more likely to be fully immunized than those whose fathers had no formal education (OR = 2.72, 95 % CI: 1.22–6.03, I2 = 98 %). While the association between paternal employment status and child immunization was statistically non-significant (OR = 1.74, 95 % CI: 0.10–29.20, I2 = 91 %), qualitative findings suggest employment influences health-seeking behavior. Decision-making power within households also emerged as an important factor, with joint parental decision-making linked to higher immunization coverage. Interventions aiming to improve immunization outcomes should consider strategies to engage fathers, promote joint decision-making, and address underlying gender norms. Further research is needed to understand better the mechanisms through which paternal factors influence vaccine uptake in diverse SSA settings.
Experiences of adolescents living with HIV on transitioning from pediatric to adult HIV care in low- and middle-income countries: a qualitative evidence synthesis
(Multidisciplinary Digital Publishing Institute (MDPI), 2025) Petinger, Charné; Crowley, Talitha; van Wyk, Brian
(1) Background: Adolescents living with HIV (ALHIVs) experience significant challenges in adhering to treatment and remaining engaged in care as they transition from pediatric to adult HIV care programs. The aim of this qualitative evidence synthesis (QES) was to review qualitative studies that describe how ALHIVs experience transition practices in low- and middle-income countries. (2) Methods: The following databases were searched: PubMed, Wiley Library Online, EbscoHost (PsychARTICLES, MEDLINE, Scopus, CINAHL), the WHO database, Google Scholar, and reference mining of the included studies. The inclusion criteria were as follows: ALHIV 10–19 years old, interventions on the transition period or studies describing transition practices, published between 2012 and 2023, conducted in low- and middle-income countries, English language, and qualitative and mixed-method studies. This review adheres to the PRISMA guidelines. CASP and MMAT were used for methodological quality assessment, and GRADE CERQual was used for the confidence in review findings. (3) Results: Seven articles were included in the final review. The five overarching themes described: (1) transition readiness during the pre-transition phase; (2) structural (health systems) barriers and treatment literacy as challenges during the transition period; and (3) provided accounts of successful post-transition experiences and recommendations for improving the transition process (when these were not experienced as positive), while also describing the individual and collective contexts in which transition took place, as they outlined (4) individual (psychological) barriers and the facilitative role that (5) a supportive environment played in the outcome of the transition process. There was a high level of confidence in transition readiness, while the other themes were assessed as having moderate confidence due to methodological limitations and minor concerns about adequacy or relevance. (4) Conclusions: There is a dearth of qualitative studies on the transition experiences of ALHIVs and on how the transition process impacts adherence, retention in care, and mental well-being. We recommend the development of interventions in the form of a guided transition protocol to improve the transition experiences of ALHIVs.
Age-specific all-cause mortality rates among adolescents and youth living with and without HIV: evidence from a cohort study in South Africa
(John Wiley and Sons Inc, 2025) Knight, Lucia; Zhou, Siyanai; Toska, Elona
Introduction: Mortality among adolescents living with HIV (ALHIV) remains a global health problem. We lack granular (age- and sex-disaggregated) data on mortality among ALHIV, hence, this study aims to assess all-cause mortality among ALHIV in a low-resource setting. Methods: All adolescents ever initiated on antiretroviral treatment (ART, N = 1107) and their HIV-negative peers (N = 456) aged 10–19 years, recruited as part of the Mzantsi Wakho study cohort, were followed up between 2014 and 2022 (yielding 12,427.7 person-years of follow-up). First, we assessed the proportion of deaths and estimated crude mortality incidence rates per 100 person-years of follow-up and their 95% confidence intervals, stratified by HIV status, sex and mode of HIV acquisition (vertical vs. sexual). We then estimated adjusted incidence rate ratios (IRRs) using Poisson regression adjusted for time-varying age, sex and time on ART. Last, we used the Cox proportional hazards regression model to estimate the risk of death by ART adherence. Results: A total of 1563 adolescents and young people were included in this analysis, 70.8% ALHIV and 57% female. More deaths occurred in ALHIV compared to their HIV-negative peers (8.3% vs. 0.4%, p<0.001). Among ALHIV, we observed a significantly higher proportion of deaths among males compared to females (10.7% vs. 7.1%, p = 0.036). Overall, mortality increased significantly with age, and males had a higher risk of mortality compared to females. Adolescents and youth living with vertically acquired HIV had a higher risk of mortality than those living with sexually acquired HIV. Comparing mortality rates by mode of HIV acquisition stratified by age and sex, mortality risk was higher among females aged 20+ years with vertically acquired HIV (IRR: 3.61, 95% CI 1.48–8.82) compared to females with sexually acquired HIV of the same age group. In a sub-sample analysis, sustained ART adherence was associated with a lower risk of death (aHR: 0.44, 95% CI 0.23–0.85).
Newsprint representation of the alcohol sales bans during the Covid-19 pandemic in South Africa: A mixed methods analysis
(Kettil Bruun Society for Social and Epidemiological Research on Alcohol, 2024) Theron, Marieke; Harker, Nadine; Swart, Nadine
Aims: Content analysis of newspapers covering the alcohol sales bans during Covid-19 in South Africa. Methods: Mixed method content analysis of the highest circulated, paid for, English language newspapers published by four newspaper outlets in South Africa, between 26 February to 26 September 2020 (seven months). Setting: South African Bibliographic Information Network (Sabinet) and Arena Holdings Media databases were used. Participants: 317 newspaper articles were identified for analysis from four newspapers: Sunday Times (Arena Holdings), Daily Sun (Naspers), The Star (Independent Media) and the Mail and Guardian (Media Development Investment Fund). Measures: Qualitative data: a structured coding frame was used to identify themes. Quantitative data: date, agency, placement/page number in the newspaper, number of graphics, words in heading and in article and whether the article was based on opinion or fact. The media vectors: framing, responsibility and newspaper media exposure were calculated. Findings: Articles were predominantly unfavourable toward the alcohol sales bans, indicated that government should take responsibility for prevention of harmful alcohol use, and focused mainly on the negative economic impact of the alcohol sales bans. Conclusions: News agencies should make a concerted effort to ensure balanced reporting on matters of health and put measures in place to prevent undue influence on journalists by large corporations, such as the alcohol industry.
Exploring and prioritising strategies for improving uptake of postnatal care services in Thyolo, Malawi: A qualitative study
(Public Library of Science, 2024) Jackson, Debra; Nyondo-Mipando, Alinane Linda; Chirwa, Marumbo
Although postnatal care services form a critical component of the cascade of care in maternal, newborn, and child health the uptake of these services has remained low worldwide. This study explored and prioritised the strategies for optimising the uptake of postnatal care (PNC) services in Malawi. A qualitative descriptive study followed by nominal group techniques was conducted at three health facilities in Malawi from July to December 2020 and in October 2021. We conducted focus group discussions among postnatal mothers, fathers, healthcare workers, elderly women, and grandmothers. We conducted in-depth interviews with midwives and key health managers. Nominal group techniques were used to prioritise the main strategies for the provision of PNC. The demand strategies include appointment date reminders, provision of free health passport books, community awareness campaigns, and involvement of men in the services. The supply strategies included training health providers, improving clinic operations: task-shifting and hours of operation, having infrastructure for the services, and linkage to other services. Having services delivered near end-user residences was a crosscutting strategy. Refresher training and improvement in the clinic operations especially on hours of operation, appointment date reminders, and linkage to care were the prioritised strategies. There is a need to use acceptable and contextualised strategies to optimise the uptake and delivery of postnatal care services. Educating the healthcare workers and the community on postnatal services is key to increasing the demand and supply of the services.
To what extent are digital health interventions targeting HIV care cascade among mobile populations feasible, acceptable, and effective? A mixed methods systematic review protocol
(BioMed Central Ltd, 2025) Knight, Lucia; Mathenjwa, Thulile; Malila, Bessie
Introduction: Human mobility is associated with an increased risk of HIV acquisition and disengagement from HIV care, leading to poorer health outcomes among highly mobile individuals compared to less mobile individuals. Mobile individuals, broadly defined as those who temporally, seasonally, or permanently move from one place to another for voluntary or involuntary reasons, face many challenges in accessing HIV care services. These challenges include logistical difficulties, interruptions in HIV care continuity, and limited access to services across different locations, which together hinder timely testing, treatment initiation, and viral suppression. Digital health interventions offer flexible approaches that can adjust to the mobile individual’s location to improve HIV care engagement and health outcomes for this underserved and hard-to-reach population. However, evidence on the feasibility, acceptability, and efficacy of digital health interventions across the HIV care cascade among mobile populations has not yet been appraised. Objectives: We seek to synthesize empirical evidence on the feasibility, acceptability, and efficacy of digital health interventions targeting the HIV care cascade among mobile populations. Methods: We will conduct a mixed methods systematic review of peer reviewed studies published between 1 January 2010 and 31 July 2024 that evaluated digital health interventions targeting the HIV care cascade among mobile populations. We will search PubMed, Web of Science, and EBSCOhost (Academic Search Premier, Africa-Wide information, CINAHL, Health Source: Nursing/Academic Edition, APA PsycInfo, APA PsycArticles) electronic databases. Bibliographies of retrieved studies will also be reviewed for relevant citations. Only studies published in English language and involved a digital health intervention, report an outcome related to the HIV care cascade, and involve mobile populations either partially or completely will be included. Two reviewers will independently screen titles and abstracts against the inclusion criteria, followed by full text screening for eligible articles. In case of disagreements, consensus will be sought from a third reviewer. Data synthesis will follow the Joanne Briggs Institute’s convergent segregated approach. If sufficient quantitative studies with comparable outcome measures are available, a meta-analysis will be performed. Discussion: This review will address a critical evidence gap by consolidating data on digital health interventions’ feasibility, acceptability, and efficacy across the HIV care cascade among mobile populations. The results will inform the development of tailored digital health interventions to enhance HIV care delivery and health outcomes for this hard-to-reach population, supporting global HIV prevention and treatment goals. Systematic review registration: This protocol is registered on PROSPERO (CRD42024528122).
Secondary prevention medications in 17 countries grouped by income level (pure): a prospective cohort study
(Elsevier Inc., 2025) Puoane, Thandi; Joseph, Philip; Avezum, Álvaro
Background: It is unclear whether global use of medications for secondary cardiovascular (CVD) prevention is improving over time. Objectives: This study across 17 high-, middle- and low-income countries described variations in secondary CVD prevention medication use over a median follow-up of 12 years. Methods: In the multinational PURE (Prospective Urban Rural Epidemiology) cohort study, we conducted a repeated cross-sectional analysis to examine temporal variations in the use of secondary prevention medications in participants with CVD. In participants with coronary artery disease, we focused on antiplatelet agents, statins, renin-angiotensin system (RAS) inhibitors, and β-blockers. In participants with stroke, we focused on antiplatelet agents, statins, RAS inhibitors, and other blood pressure–lowering drugs. Medications were collected at baseline and on 4 subsequent follow-up visits. Results: The analysis included 7,409 participants with a diagnosis of CVD at the baseline visit, 8,792 at the second visit, 9,236 at the third visit, 11,082 at the fourth visit, and 11,677 at the last visit. The median age at baseline was 58.0 years, and 52.9% of the participants were female. The median follow-up was 12 years, with the median year of the baseline visit in 2007 and the fifth visit in 2019. Over this period, use of 1 or more classes of medications for secondary CVD prevention was 41.3% (95% CI: 40.2%-42.4%) at baseline, peaked at 43.1% (95% CI: 42.0%-44.1%), and then decreased to 31.3% (95% CI: 30.4%-32.1%) by the last study visit. In high-income countries, this use decreased from 88.8% (95% CI: 86.6%-91.0%) to 77.3% (95% CI: 74.9%-79.6%). In upper-middle-income countries, this use increased from 55.0% (95% CI: 52.8%-57.3%) to 61.1% (95% CI: 59.1%-63.1%). In lower-middle-income countries, use of at least 1 class of medications was 29.5% (95% CI: 28.1%-30.9%) at baseline, peaked at 31.7% (95% CI: 30.4%-33.1%), and then decreased to 13.4% (95% CI: 12.5%-14.2%) by the last visit. In low-income countries, use of at least 1 class of medications was 20.8% (95% CI: 18.1%-23.5%) at baseline, peaked at 47.3% (95% CI: 44.8%-49.9%), and then decreased to 27.5% (95% CI: 25.2%-29.9%) by the last study visit. Conclusions: Globally and in most country income-level groups, the use of medications for secondary CVD prevention has been low, with little improvement over time.
A qualitative process evaluation of community-based participatory research and human-centered design in the ‘let’s talk about vaccines’ approach in Mozambique and Malawi
(BioMed Central Ltd, 2025) Shuro, Linda; De Man, Jeroen; Knight, Lucia; Tabana, Hanani; Schneider, Helen
Background: Ensuring full coverage of childhood vaccination programmes is a persistent challenge in low- and middle-income countries. Urgent action is required to ensure catch up of missed immunisations in children, while simultaneously building trust and demand within communities to sustainably address existing immunization gaps. This paper summarizes the findings of a process evaluation of the ‘Let’s talk about vaccines’ approach by VillageReach in Mozambique and Malawi. The approach used community-based participatory research to identify the barriers to childhood vaccination faced by caregivers and healthcare workers, with human-centered design to codesign potential interventions to improve under two immunization access and uptake. Methods: To evaluate the implementation of the ‘Let’s talk about vaccines’ approach we conducted a qualitative process evaluation guided by the Reach Effectiveness Adoption Implementation Maintenance framework and Consolidated Framework for Implementation Research (CFIR). We completed a total of 76 qualitative interviews and 85 self-administered surveys among caregivers, healthcare workers, health officials and other stakeholders involved in the approach. We transcribed the interviews verbatim and analysed them using thematic analysis and constructs of the RE-AIM and CFIR frameworks. We analysed the survey results in Excel. Results: Key elements of the approach contributing to high fidelity to community-based participatory research principles in both countries, included diverse collaborative study and project teams, involvement of eight caregiver researchers, novel and traditional participatory methods, and extensive mobilization efforts. Success factors for human-centered design in the ideation and prototyping phase included fostering equal participation and empathy, value placed on each participant’s input, mitigating inherent power differences, interactive feedback processes, and extensive iterative processes leading to tangible solutions. Challenges included adjusting to new methods and contextual realities. Factors influencing the potential adoption of the approach included locally developed solutions, participant involvement, collaboration, a major advantage over alternative approaches, ease of use of the co-created interventions, alignment with government objectives, and adaptability for system-wide integration into immunization programming. The potential sustainability of the approach was supported by the involvement of health ministries, health professionals, community representatives, and capacity building of local structures. However, resource and incentive constraints posed as a potential challenge to maintaining long-term motivation and action. Conclusion: The evaluation findings from the ‘Let’s talk about vaccines’ approach highlighted key elements for applying community-based participatory research and human-centered design to collaboratively identify immunization barriers and create tangible solutions to overcome them. By integrating these approaches into routine immunization programs, it can potentially improve vaccination efforts for children under two in low and middle-income countries, leading to lasting change. Supporting policies that prioritize community involvement in research, program design and implementation and sustainable funding enhances immunization strategies, ensuring that they are tailored to local needs.
Mapping the transition of adolescents to adult HIV care: a mixed-methods perspective from the Cape Town Metropole, South Africa
(Multidisciplinary Digital Publishing Institute (MDPI), 2025) Petinger, Charné; van Wyk, Brian; Crowley, Talitha
(1) Background: Globally, an estimated 1.7 million adolescents (aged 10–19 years) were living with HIV in 2023, with 82% residing in sub-Saharan Africa. For ALHIV, transitioning to adult care involves assuming responsibility for their own health and disease management, posing significant challenges to persistent engagement in care. There is a paucity in health policies guiding this transition in many sub-Saharan African countries. Overburdened and poorly functioning health systems struggle to provide optimal care for ALHIV amidst the rising HIV pandemic in this priority population. (2) Methods: This study employed a mixed-methods design, comprising a descriptive qualitative study with healthcare workers and managers and a cross-sectional survey to examine the practices and pathways in which the transition to adult HIV care occurs in the Cape Town Metropole, South Africa. (3) Results: We delineate three distinct ways in which transition occurs (transfer-only, adolescent-friendly, and supportive transition). A successful transition involves a sufficient level of self-management of their chronic condition and healthcare journey, which is preceded by adequate preparation pre-transition, and the monitoring of engagement post-transition. This ideally requires developing relevant health policies and implementing guidelines signaling political will and providing the impetus and agency of implementation at the service level in South Africa.
Irrational medicine use and its associated factors in conflict-affected areas in Mali: a cross-sectional study
(Taylor and Francis Ltd., 2025) Ravinetto, Raffaella; Ahmed, Mohamed Ali Ag; Seydou, Alassane
Background: Rational use of essential medicines is a critical step towards prevention and treatment of many illnesses. However, it represents a significant challenge worldwide, and particularly for under-resourced health systems in conflict-affected areas. Objective: To assess barriers to rational use of essential medicines at primary healthcare level in conflict-affected areas of Mali. Methods: We conducted a cross-sectional study in twenty randomly selected community health centres (CHCs) in four health districts, by applying the World Health Organisation and International Network on Rational Use of Drugs core forms for the rational use of medicines. Seven hundred eighty-nine (789) prescriptions were retrospectively selected and analysed; four hundred forty-three (443) patients were interviewed: and health facility-related indicators were collected prospectively from the 20 CHCs. Results: The average number of medicines per prescription was 3.89 ± 1.83; out of these, 94.0% were prescribed by generic name, and 91.0% belonged to Mali’s National List of Essential Medicines. Overall, 68% of the assessed prescriptions included antibiotics; 58% included injectables; and 75.79% were characterized by polypharmacy, i.e. more than two medicines per prescription.
The anti-politics of food in South Africa: transformation, accountability and the nutrition policy subsystem
(Cambridge University Press, 2025) Moyo, Busiso Helard; Kroll, Florian; Thow, Anne Marie
Objective: To examine power and governance arrangements in food and nutrition policy formulation and agenda-setting in South Africa Design: Analysis of the policy implementation environment and in-depth interviews were conducted focussing on: existing policy content and priorities across food system sectors; institutional structures for cross-sectoral and external stakeholder engagement; exercise of power in relation to food system policies; and opportunities to strengthen action on nutrition. Setting: South Africa Participants: Interviews were conducted with 48 key stakeholders involved in the food and nutrition policy sphere: government sectors relevant to food systems (n=21), the private sector (n=4), academia (n=10), NGOs (n=11) and farmers (n=2). Results: This study found that there are power dynamics involved in shaping the planning agenda that is inadvertently generating a food system that undermines the right to food. The concept of nutrition governance remains poorly defined and applied in different ways and usually based on a relatively narrow interpretation - therefore limiting policy coherence and coordination. South Africa has strong legal institutions and practices, and social policies that support public provisioning of food, but a non-interventionist approach to the food system. Conclusions: The right to food and nutrition, as outlined in the South African Constitution, has not yet been effectively utilized to establish a robust normative and legal basis for tackling the dual challenges of food insecurity and malnutrition. Currently, the governance of the food system is grappling with substantial obstacles, balancing the influence of powerful stakeholders who uphold the status quo against its responsibilities for food justice.
Structural barriers and facilitators to accessing HIV services for marginalized working populations: insights from farm workers in South Africa
(Oxford University Press, 2025) Lembani, Martina; Mlangeni, Nosimilo; Adetokunboh, Olatunji
Farm workers are vulnerable working populations who face significant inequalities in accessing health services, including those for human immunodeficiency virus (HIV) prevention, treatment and care. This descriptive phenomenological study aimed to explore farm workers’ experiences when accessing HIV services and was conducted in Limpopo province, South Africa. Eighteen in-depth interviews were conducted in four health facilities from two districts, and two focus group discussions were conducted in one of the farms within the province. Purposive sampling and systematic random sampling were used to select study participants. A deductive thematic approach was used to analyse data, informed by the social–ecological model of health. The results reveal that farm workers perceive multiple interdependent factors that inhibit or enable their access to HIV healthcare services. Key barriers to HIV healthcare were transport affordability, health worker attitudes, stigma and discrimination, models of HIV healthcare delivery, geographic location of health facilities and difficult working conditions. Key facilitators to HIV healthcare included the availability of mobile health services, the presence of community health workers and a supportive work environment. The findings suggest disparities in farm workers’ access to HIV services, with work being the main determinant of access. We, therefore, recommend a review of HIV policies and programmes for the agricultural sector and models of HIV healthcare delivery that address the unique needs of farm workers.
Beliefs of pentecostal pastors on the use of antiretroviral treatment among pentecostal christians living with HIV in a suburb of Cape Town-South Africa: a community health systems lens
(Oxford University Press, 2025) Azia, Ivo Nchendia; Nyembezi, Anam; Carelse, Shernaaz
The global public health community accepts antiretroviral therapy (ART) for controlling and managing human immunodeficiency virus (HIV). However, within some communities, claims of faith or miraculous healing of HIV and acquired immunodeficiency syndrome (AIDS) by Pentecostal pastors continue to spark controversies. This paper reports on an exploratory qualitative study to explore the beliefs held by Pentecostal pastors regarding the use of ART among Pentecostal Christians who are living with HIV. Twenty (20) purposively selected Pentecostal pastors from two informal settlements in Cape Town, South Africa, participated in the study. Open-ended, semi-structured, in-depth individual interviews were conducted on their religious beliefs concerning ART adherence. Interviews were conducted in English, audiotaped and transcribed verbatim before being imported into the Atlas.ti 2023 software program for thematic data analysis. Since our study was guided by the relational community health system model a hybrid deductive–inductive thematic analysis was used. Two contrasting themes about the influence of the religious beliefs of Pentecostal pastors were identified. The first theme and its associated subthemes highlight the lack of basic HIV and ART knowledge among pastors. Consequently, these pastors tend to nudge their Christians to rely more on faith and spiritual healing at the expense of adherence to ART. The second theme and its related sub-themes suggest that some pastors possess some basic HIV knowledge and understand the role of ART and how it works. This group of pastors advise their congregants to use ART and other healthcare services in tandem with spiritual rituals, faith and prayers. Our findings highlight the need for functional community-based structures, such as community health committees and health facility management committees, in settings where complex interaction within the belief systems, practices and norms of some stakeholders can influence people’s health-seeking behaviours such as adherence to chronic medications like ART.

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