Research Articles (School of Public Health)

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Policy implementation and recommendations to address the double burden of malnutrition in South Africa: expert assessment using the expanded Healthy Food Environment Policy Index (Food-EPI)
(BioMed Central Ltd, 2025) Mchiza, Zandile June-Rose; Holliday, Nicole; Delobelle, Peter
Background: South Africa faces a double burden of malnutrition (DBM), the coexistence and interaction of multiple forms of malnutrition (undernutrition, micronutrient deficiencies, and overweight/obesity) within individuals and households and across the life course. A healthy food environment is necessary to reduce this DBM. The Healthy Food Environment Policy Index (Food-EPI) can be used to evaluate the implementation of public nutrition and food environment policies in comparison with international best practices. The aim of this study was to assess the extent of implementation of healthy food environment policies in South Africa using an expanded DBM Food-EPI framework, benchmark policies against international best practices, develop priority policy recommendations, and compare implementation progress since the 2016 South African Food-EPI assessment. Methods: From October 2023 to March 2024, a panel of 23 national experts from different tiers of government (Department of Health), academia, and civil society was invited to participate in the Food-EPI assessment. Through two workshops and online feedback, experts evaluated the implementation of food environment policies across 60 indicators, compared these policies to international best practices, and proposed and prioritized a list of policy actions based on perceived implementation gaps. Results: Of the 23 invited experts, 13 participated in the benchmarking workshop in which about 70% of indicators were rated at very low to low levels of implementation. Overall, of the 48 original indicators, the mean level of implementation improved from 2016 to 2024. Of the 12 indicators that addressed the DBM, eight were rated at very low to low levels of implementation. The experts (original panel plus four additional participants) then proposed ten priority actions, mainly across the domains of Food Promotion, Food Prices, Funding, and Platforms for Interaction. Conclusions: Application of the expanded Food-EPI in South Africa showed improvements for the original indicators compared with 2016 and highlights the need for additional policy efforts to improve public nutrition policy and address the DBM.
Global maternal child health initiatives and programs 1974 to 2023
(Springer, 2025) Jackson, Debra
Aim: This review paper aims to review Global MCH initiatives and note trends across the last five decades (1974–2023). Methods: As an organizing framework, MCH initiatives and programs have been classified into five categories: Global Health Conferences, Declarations or Strategies; Global Health Surveys; Global MCH Programs; Global MCH related Data Initiatives or Working/Advisory Groups; and Global MCH Partnerships or Networks. Results: Over 50 Global MCH initiatives and programs have been implemented during this period. The first International Conference on Primary Health Care and the Alma Ata Declaration in 1978 initiated a new era of global public health. International conferences building on Alma Ata with a focus on population health and MCH, along with global surveys to measure the health status of populations across countries and global working groups to analyze these data, emerged over the next decades. Global MCH partnerships also emerged for advocacy and coordination of an increasing number of efforts to improve maternal, newborn, child and adolescent health and well-being—towards achieving the Millennium (2000–2015) and Sustainable (2016–2030) Development Goals. Conclusion: Four trends were noted across these five decades: (1) MCH Mortality decreased but unacceptable inequities persist with COVID-19, ongoing conflicts and climate change threatening these gains. (2) Implementation of primary health care (PHC) as envisioned by Alma Ata in 1974 continues to see a debate about selective versus comprehensive programs. (3) As mortality declined (Survive), the field expanded focus to child well-being (Thrive) and across preconception through adolescents (Transform). (4) Global MCH issues are relevant across high-income (HIC) and low-middle income (LMIC) settings to achieve health and well-being of all women and children everywhere.
Perceived accuracy and utilisation of DHIS2 data for health decision making and advocacy in Kenya: a qualitative study
(Public Library of Science, 2025) Oware, Phoene Mesa; Omondi, Gregory; Adipo, Celestine
Reliable health information systems (HIS) are critical for effective decision-making in the delivery of Primary Health Care and Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (PHC/RMNCAH+N) services. In Kenya, the District Health Information Software 2 (DHIS2) platform serves as the primary HIS for tracking health indicators. This qualitative study explored perceptions of DHIS2 data accuracy and use for decision-making among PHC/RMNCAH+N stakeholders across 15 counties in Kenya. 89 Key Informant Interviews were conducted with PHC/ RMNCAH+N stakeholders, to explore experiences, barriers, and facilitators of DHIS2 data use. Thematic network analysis was employed to identify recurrent themes and generate insights into the utility of DHIS2-generated information. Sociotechnical challenges included limited technical capacity among health staff, inadequate analytical skills, and reliance on a small pool of Health Records Information Officers (HRIOs). However, positive practices emerged, such as the use of DHIS2 dashboards and user-friendly outputs, which were valued for supporting evidence-based decision-making and advocacy, particularly at higher levels of health management. In some counties, visual displays of data, including scorecards and performance trends, facilitated budget advocacy and community engagement. Contextual challenges and constraints, such as use of inconsistent data collection tools across counties post-devolution, human resource shortages, and limited integration of private sector data, contributed to incomplete reporting. These challenges underpinned perceived inaccuracy of DHIS2 data, arguably, hindering the complete reliance on DHIS2 data for planning and decision making. The study highlights the need for targeted investments to improve DHIS2 data accuracy and use through stronger stakeholder coordination, enhanced data synthesis skills, and fostering a culture of data ownership among a wide range of stakeholders in health, including political actors.. Addressing these gaps will contribute to improvement in DHIS2 data quality, enhanced ownership and reliance on DHIS2 data by PHC/RMNCAH+N stakeholders for decision making in Kenya.
Strategies and responses to the effects of climate change on health systems in Sub-Saharan Africa: a scoping review protocol
(Public Library of Science, 2025) Chimatiro, Chancy Skenard; Mianda, Solange; Lembani, Martina
Background Climate change is recognized as the greatest global health threat of the 21st century. Projections suggest that the Sub-Saharan African region will face more consequences of climate change than any other region globally. The health systems within the region have been affected by the negative effects of climate change. Mapping strategies and responses used in the region to address the effects of climate change on health systems in Sub-Saharan Africa could be a starting point for understanding evidence-based decision-making to inform best practices. Methods This scoping review will follow the methodological framework by Arksey & O’Malley. A wide range of databases will be searched to identify articles published on the strategies and responses to the effects of climate change on the health systems in Sub-Saharan Africa. Only peer-reviewed articles (original quantitative and qualitative studies, mixed methods, systematic reviews, editorials, and commentaries) published in English Language between 2010 and 2024 will be reviewed. All Book chapters and the grey literature (dissertations, conference proceedings, abstracts, reports) and publications primarily focusing on climate change strategies and responses without effects on health systems will be excluded. Covidence software will be used during study selection, data extraction, and summary. Deductive thematic analysis will be performed using predetermined themes from the objectives. Dissemination The results of this scoping review will be disseminated at local and international research conferences. Furthermore, the findings will be published in open-access journals targeting different audiences. The findings will also be shared with the Ministry of Health in Malawi for possible policy considerations.
Perceptions of South Africa’s master of public health graduates on the degree’s contribution to their leadership at work and in society
(Frontiers Media SA, 2025) Schaay, Nikki; Tshitangano, Takalani; Zweigenthal, Virginia
Introduction: Integrating public health functions into national health systems is essential to enhance population health. The Master of Public Health (MPH) degree is an important foundation for public health practice in low-and middle-income countries such as South Africa. However, insufficient evidence on individual motivations for undertaking the MPH and the perceptions of graduates on the utility of the degree at work and in society and its contribution to their leadership skills informed this study. Methods: A consortium of academics from eight South African universities developed a self-administered questionnaire to measure inter alia the socio-demographic characteristics, motivations, career paths, perceptions of the utility of the degree, and its contribution to their professional and personal development. The study population comprised the 2012–2016 cohort of MPH graduates from eight universities. Following informed consent, eligible graduates completed an online survey via REDCap. The data were analyzed using Stata. Results: A total of 221 graduates completed the survey. The mean age of respondents was 35 years, and the majority were from South Africa (53.2%) or other African countries (43.2%). The majority (91.1%) completed the MPH to improve their skills or to promote their personal development for senior management and leadership roles. Approximately 75% used identified leadership skills at work, but only half these skills were obtained from the MPH. Over 80% of respondents positively impacted on their workplace and in society, using skills mostly derived from the MPH in all domains. Discussion: This cohort of MPH graduates exercised leadership in different settings, but many stated that these skills were not obtained from the MPH programs. The COVID-19 pandemic underscored the need for public health leaders skilled in communication, collaboration, and crisis management, amidst considerations of social justice and equity. Hence, leadership skills need to be intentionally included in MPH programs in South Africa.
Global prioritised indicators for measuring WHO’s quality-of-care standards for small and/or sick newborns in health facilities: development, global consultation and expert consensus
(BMJ Group, 2025) Jackson, Debra; Day, Louise Tina; Vaz, Lara M E
Objectives The aim of this study was to prioritise a set of indicators to measure World Health Organization (WHO) quality-of-care standards for small and/or sick newborns (SSNB) in health facilities. The hypothesis is that monitoring prioritised indicators can support accountability mechanisms, assess and drive progress, and compare performance in quality-of-care (QoC) at subnational levels. Design Prospective, iterative, deductive, stepwise process to prioritise a list of QoC indicators organised around the WHO Standards for improving the QoC for small and sick newborns in health facilities. A technical working group (TWG) used an iterative four-step deductive process: (1) articulation of conceptual framework and method for indicator development; (2) comprehensive review of existing global SSNB-relevant indicators; (3) development of indicator selection criteria; and (4) selection of indicators through consultations with a wide range of stakeholders at country, regional and global levels. Setting The indicators are prioritised for inpatient newborn care (typically called level 2 and 3 care) in high mortality/morbidity settings, where most preventable poor neonatal outcomes occur. Participants The TWG included 24 technical experts and leaders in SSNB QoC programming selected by WHO. Global perspectives were synthesised from an online survey of 172 respondents who represented different countries and levels of the health system, and a wide range of perspectives, including ministries of health, research institutions, technical and implementing partners, health workers and independent experts. Results The 30 prioritised SSNB QoC indicators include 27 with metadata and 3 requiring further development; together, they cover all eight standard domains of the WHO quality framework. Among the established indicators, 10 were adopted from existing indicators and 17 adapted. The list contains a balance of indicators measuring inputs (n=6), processes (n=12) and outcome/impact (n=9). Conclusions The prioritised SSNB QoC indicators can be used at health facility, subnational and national levels, depending on the maturity of a country’s health information system. Their use in implementation, research and evaluation across diverse contexts has the potential to help drive action to improve quality of SSNB care. WHO and others could use this list for further prioritisation of a core set.
A systematic review assessing the association between extreme temperature exposure and cardiovascular health outcomes in Africa
(Academic Press Inc., 2025) Sello, Mamakase G.; Kyeyune, Jemimah; Kgatla, Hellen; Mchiza, Zandile J
The African continent is grappling with a rising prevalence of cardiovascular diseases (CVDs) in conjunction with the growing threat of climate change and its associated extreme temperatures. This systematic review aims to assess the relationship between extreme temperature exposures (heat and cold exposure) and cardiovascular health outcomes in African populations. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in compiling this evidence. A comprehensive literature search was performed on PubMed-Medline, Scopus, Web of Science, and Google Scholar as the primary databases to identify relevant studies published from January 1990 to October 2024. Both hot and cold temperature extremes were linked to detrimental cardiovascular outcomes related to stroke. Exposure to sudden drops in minimum temperature exceeding 2.4 °C was linked with a 43 % higher risk of stroke. Elderly women (≥65-years) exposed to cold had the highest mortality rates and were more vulnerable to air pollution interactions during moderate temperatures (20–23 °C). Exposure to high temperatures (>37 °C) was associated with increased rates of heart failure and stroke. Hypertension was identified as a significant risk factor, with 37.6 % of stroke patients having pre-existing hypertension; notably, 86.2 % of these cases were linked to heat exposure. The highest CVD vulnerability was observed among females, older adults, and rural dwellers. The evidence presented in this systematic review suggests that exposure to both extreme cold and heat significantly contributes to the development of cardiovascular diseases. However, further studies are needed to validate and strengthen these findings.
Knowledge translation platforms: Broker, intermediary or more? A scoping review of definitions, functions and characteristics
(BioMed Central Ltd, 2025) Shmidt, Bey-Marrié; Mulopo, Chanelle; Späth, Carmen
Background: Knowledge translation platforms (KTPs), also referred to as intermediaries, play a key role in supporting evidence-informed decision-making. Numerous KTPs exist globally, striving to translate evidence into policy. However, these platforms are described in varying ways, and some KTPs do not explicitly identify themselves as such. This makes identification, recognition and leveraging of KTPs suboptimal. It also hinders opportunities for learning, adapting and scaling of such platforms. Objective: This scoping review aimed to synthesize the literature on the variety of definitions, functions and characteristics of a KTP with a view to harmonize these aspects of KTPs and offer a revised framework of functions. Methods: This review was conducted using recommended methods and reporting guidelines. Searches were performed in PubMed, Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) using a predetermined search strategy, without date or geographical restrictions. Included studies were analysed and synthesized in ATLAS.ti, following Braun and Clarke’s six steps of thematic analysis. Findings: With one exception, all KTPs did not identify themselves as such in their names. Five common elements emerged across the KTP definitions: (i) a physical or virtual platform (ii) that engages with and convenes different stakeholders (iii) through a set of knowledge translation activities and outputs (iv) to contribute to health decision-making. We identified KTP activities that aligned with the core functions described in the Valmeekanathan et al. (Valmeekanathan et al. in Tert Educ Manag 27:227–256, 2021) framework – namely knowledge exchange, dialogue and capacity – but also additional activities, including engaging funders, planning for sustainability and scalability, providing training grants and initiating innovative knowledge translation processes that integrate knowledge across projects and sectors to maximize impact. Conclusion: This review provides a synthesized definition of KTPs while expanding on the three core functions described in the Valmeekanathan et al. (Valmeekanathan et al. in Tert Educ Manag 27:227–256, 2021) framework. To maximize their impact, sustained investment, stronger institutional support and integration into national policy ecosystems are essential.
Monitoring District Health System performance in South Africa: a proposed dashboard based on key pragmatic indicators
(South African Medical Association, 2025) Schneider, Helen; Barron, Peter; Mahomed, Hassan
Effective monitoring and evaluation (m&e) systems are central to ensuring the performance and accountability of the district health system (dhs). Current systems in south africa are suboptimal and poorly oriented to the decision-making needs of district managers. Drawing on a who measurement framework for the performance of primary healthcare, and as a follow-up to a first article describing the challenges of m&e systems in the dhs, this article proposes a dhs performance monitoring dashboard that is both practical and pragmatic. The dashboard was constructed in an iterative and consultative process, and consists of 20 indicators for quarterly monitoring a set of general criteria underpinning the choice of indicators is spelled out (e.g. The data are readily available and reliable). Indicators that do not have much variability, or are better suited to annual evaluation (e.g. Number of community health workers per 1 000 population) are not included. The dashboard includes the name or description of the indicator, the definition of the indicator, why it is useful, challenges and pitfalls to be considered when analysing the indicator and how it can be used for decision-making. We propose that these indicators be assessed, tracked and monitored on a quarterly basis by relevant managers at the facility sub district and district levels. We emphasise that the purpose of this dashboard is not external compliance, but rather to support district managerial decision-making and accountability.
Developing a strategic action plan for reducing the burden of stroke in Africa: report of the first African Stroke Leaders' Summit
(Frontiers, 2025) Akinyemi, Rufus; Naidoo, Pamela; Olowoyo, Paul
Introduction: Stroke is a leading cause of adult neurologic disability, cognitive decline, and death worldwide, and particularly in Africa. Stroke research in Africa has exposed challenges militating against the translation of research evidence into practice and policy. The evidence-based, context-sensitive multilevel strategies required to surmount these challenges are presented in this report on the first African Stroke Leaders' Summit (ASLS) organized to tackle the burden of stroke in Africa. Methods: The Africa–UK Stroke Partnership (AUKSP) Project had a Steering Committee (SC) and four theme-based Working Groups (WGs): stroke services, stroke training/capacity building, research and stroke advocacy, each with defined terms of reference. These groups generated 20 priorities (five per thematic area) during breakout sessions at the first ASLS which were further refined into four topmost priorities (one per thematic area) at the general consensus session. Results: The topmost priorities included promoting the development of acute stroke services (stroke services), strengthening population-based stroke education focusing on prevention and symptom recognition (stroke training), research on hypertension control to reduce stroke risk (stroke research), and developing national stroke action plans (advocacy). Conclusion: Sustained reduction of stroke burden in Africa requires the adaptation of best practices to the African context, building the capacity of African stroke care professionals and using available resources with political support. Improving stroke literacy in African communities is a complementary strategy to reinforce healthy lifestyle choices and improve screening and detection of hypertension and other modifiable stroke risk factors.
Mpox and the ethics of outbreak management: lessons for future public health crises
(John Wiley and Sons Inc, 2025) Kleinsmidt, Anita; Obasa, Adetayo; Botes, Marietjie
Mpox, first identified in captive monkeys in 1958 and recognized in humans by 1970 in the Democratic Republic of Congo, was historically confined to sporadic zoonotic outbreaks in Central and West Africa. These outbreaks, often driven by rodent‐to‐human transmission in resource‐limited settings, reflect persistent systemic health disparities. In recent years, mpox has also been reported in high‐income countries (including the United States, United Kingdom and Europe), underscoring its global health implications beyond traditionally endemic regions. This article examines the mpox outbreak through the lens of public health ethics, evaluating how core ethical frameworks—justice (encompassing equitable vaccine distribution and addressing health inequities), solidarity and respect for rights (including intellectual property considerations)—shape outbreak management strategies. These strategies are ensuring equitable access to vaccines and therapeutics amid intellectual property barriers, combating stigma and misinformation through transparent risk communication and fostering international solidarity in coordinating responses. The analysis highlights how neglect of these principles exacerbates existing disparities and undermines the effectiveness of interventions. Integrating ethical principles into outbreak responses is critical for building public trust, accountability and community resilience. By distilling lessons from the mpox response, this article contributes to ongoing debates in public health ethics and outbreak preparedness, arguing that ethically grounded approaches are essential for fair and effective management of future public health crises.
Synergistic effects of drought and heat stress on Medicago truncatula: understanding growth response and photosynthetic mechanisms
(Institute of Experimental Botany, ASCR, 2025) Ludid, Ndiko; Maiza, Nourhene; Mnafgui, Wiem
Drought and heat stress significantly threaten forage crop development and photosynthetic activity in the Mediterranean region. This study investigated the physiological responses and photosynthetic activity of two lines TN6.18 and F83005.5 (F83), to single and combined heat and drought stress treatments. Biomass traits, leaf gas exchange, and photosystem activities were evaluated. Our findings indicate a reduction in biomass parameters under heat, drought, and combined stress on both lines, particularly in F83. The stomatal conductance and photosynthetic parameters exhibited differential responses, with F83 reducing its stomatal conductance under drought stress, while TN6.18 was adapted by opening its stomata. Moreover, in TN6.18, combined stress enhanced protection mechanisms in PSI, while F83 showed changes in PSII efficiency. These insights deepen our understanding of plant responses to abiotic stresses and offer strategies for improving tolerance and resilience in changing environmental conditions.
Behind the billions: policies, politics and power of the Global Financing Facility for women’s, children’s, and adolescents’ health
(Taylor and Francis Ltd, 2025) George, Asha; Kinney, Mary; Lawn, Joy
The landscape of global health financing has shiftedprofoundly in recent years – with redirection of donor aid to national security spending, economic shocks from the COVID-19 pandemic, and rising debt burdens – placing immense pressures on low- and middle-income countries (LMICs) to self-finance theirhealth systems . Sudden major donor cuts to global health amplify the need to transform health financing to more sustainable and equitable models that protect vulnerable populations, especially women, children, and adolescents . Many LMICs, and notably those in sub-Saharan Africa, are off track or haveslowed down in progressing towards the Sustainable Development Goals targets for ending preventable maternal, neonatal and child deaths by 2030. This requires urgent action and increased investment. Concurrently, global health initiatives (GHIs), including the Global Financing Facility (GFF), are also beingreimagined to better support countries on their path towards Universal Health Coverage . The GFF launched in 2015 with a compelling mission: to close financing gaps for women’s, children’s, and adolescents’ health through smarter, more sustainable investments . Framed as a ‘country-led’ mechanism that could both mobilize and coordinate domestic and external financing, the GFF promised to move beyond traditional aid models by catalyzing investment cases tailored to each country’s priorities. A decade since its inception, there remains relatively little peer-reviewed research about how the GFF operates in practice, how its promises of country leadership and catalytic financing are realized, and what lessons can be drawn for the future of global health financing .
Dispensing of medicines for asthma and chronic obstructive pulmonary disease through the government health insurance in Syria: a retrospective analysis
(Taylor and Francis Ltd, 2025) Ravinetto Raffaella; Aljadeeah Saleh; Tomas Ana
Asthma and chronic obstructive pulmonary disease (COPD) are common noncommunicable diseases, exacerbated in conflict settings by the heightened environmental exposure to triggers, weakened health systems, and poor access to medicines and healthcare. However, accurate data on medicines dispensing in this context are generally scarce. We examined the patterns and rates of medicines dispensing for asthma and COPD among the beneficiaries of the Syrian governmental health insurance scheme between June 2018 and March 2021. We retrospectively analyzed the outpatient dispensing records for 125,371 adults. Medicines for asthma and COPD were identified using the Anatomical Therapeutic Chemical (ATC) classification system. Dispensing rates were calculated as the number of packages per 1,000 beneficiaries per month, stratified by age, sex, and route of administration. Out of our sample, 15.02% received at least one package of a medicine for asthma or COPD. Oral formulations were the most frequently dispensed (92.67% of patients), particularly oral salbutamol and xanthines. Inhaled medicines, including inhaled corticosteroids (ICS) and ICS long-acting β2-agonists (ICS-LABA) combinations, were markedly under-dispensed (17.08% of patients). Dispensing rates were higher in females and older adults. Seasonal variation showed peaks in autumn and winter, with a notable decline in April 2020, coinciding with the early COVID-19 period. The study highlights substantial gaps in dispensing of medicines for asthma and COPD, with particularly low rates for inhalers, likely reflecting barriers driven by the conflict, economic instability, and sanctions. Robust coordinated action is needed to improve their availability in Syria.
Examining sustained sub-national health system development: experience from the Western Cape province, South Africa, 1994-2016
(Oxford University Press, 2024) Schneider, Helen; Gilson, Lucy; Vallabhjee, Krish
Governance and leadership are recognised as central to health system development in low- and middle-income countries, yet few existing studies consider the influence of multi-level governance systems. South Africa is one of many (quasi-)federal states. Provincial governments have responsibility for managing health care delivery within national policy frameworks and norms. The early post-apartheid period saw country-wide efforts to address the apartheid legacy of health system inequity and inefficiency, but health system transformation subsequently stalled in many provinces. In contrast, the Western Cape provincial health department sustained service delivery reform and strengthened management processes over the period 1994-2016. This department can be considered a ‘pocket of relative bureaucratic effectiveness’ (POE): an organisational entity that, compared to others, is relatively effective in carrying out its functions in pursuit of the public good. This paper considers what factors enabled the development of the Western Cape health system in the period 1994-2016. Two phases of data collection entailed document review, participatory workshops, 43 in-depth interviews with purposively selected key informants from inside and outside the Western Cape, and a structured survey testing initial insights (response rate 42%). Analysis included triangulation across data sets, comparison between the Western Cape and other provincial experience and deeper reflection on these experiences drawing on POE theory and public administration literature. The analysis highlights the Western Cape experience of stable and astute sub-national governance and leadership and the deepening of administrative and technical capacity over time - within a specific provincial historical and political economy context that sustained the separation of political and administrative powers. Multi-level governance systems can create the space for sub-national POEs to emerge in their mediation of wider political economy forces, generating spaces for skilled reform leaders to act in the public interest, support the emergence of distributed leadership and develop robust management processes.
A combined strategies intervention on the world health organization prescribing indicators: a quasi-randomised trial
(AOSIS (pty) Ltd, 2024) Ncube, Nondumiso B.Q.; Mukumbang, Ferdinand C; Laing, Richard; Schneider, Helen; Laing, Richard
Background: Irrational medicine use is a global problem that may potentiate antimicrobial resistance. Aim: This study aims to assess prescribing practices and the effect of a prescription audit and feedback coupled with small-group education intervention on prescribing indicators. Setting: The study was conducted in public-sector healthcare facilities in Eswatini. Methods: A cluster quasi-randomised controlled study was conducted from 2016 to 2019 using the World Health Organization/International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators at baseline, post-intervention and post-follow-up. A 6-month unblinded intervention was tested in 32 healthcare facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing practices were assessed post-intervention, and 6 months after the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparisons of WHO or INRUD prescribing indicators were conducted using the intention-to-treat analysis at the two times. Results: At baseline, in both arms, rational prescribing standards were met by the number of medicines per prescription and the use of injections. Antibiotic use was above 50% in both arms. After adjustment for baseline antibiotics use, region and level of care, there were no significant differences in all prescribing indicators between the two arms, post-intervention and at 6 months follow-up. Conclusion: In a lower middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback and small-group education intervention had no benefits in improving rational prescribing. Contribution: Multifaceted strategies, strengthening of pharmacy and therapeutics committees, and holistic monitoring of medicine use are recommended to promote rational medicine use.
COVID-19 and immigrant status: A qualitative study of Malawian immigrants living in South Africa
(Wiley-Hindawi, 2024) David, Ifeolu; Lembani, Martina; Majee, Wilson
Migration to South Africa is motivated by the pursuit of employment, safety, and improved living conditions. However, immigrants encounter significant challenges, such as restricted access to essential services, which were exacerbated by the COVID-19 pandemic. This paper investigates the impact of the COVID-19 pandemic on Malawian immigrants in South Africa, addressing the lack of attention given to this immigrant population by highlighting their vulnerabilities. Using a qualitative exploratory and descriptive approach, in-depth interviews were conducted with 24 Malawi immigrants who were over 18 years old and had established residency in South Africa before the onset of the COVID-19 pandemic. Five key stakeholders were also interviewed for additional perspectives and to ensure triangulation and improve data reliability. The interviews were transcribed verbatim and analyzed using thematic analysis strategies and coding with Nvivo12 software. The study highlighted the exacerbated struggles of Malawian immigrants in South Africa amid the COVID-19 pandemic, uncovering systemic discrimination in healthcare, marked by longer wait times and reluctance from health workers to treat undocumented immigrants. The study also revealed a dire security situation, with immigrants living in high-crime areas and feeling particularly targeted due to their foreign status, a situation worsened by the pandemic's economic effects. Additionally, the economic downturn induced by COVID-19 significantly impacted employment opportunities, with many immigrants facing prolonged unemployment and job losses, especially in sectors where they traditionally found work. The detailed accounts of participants highlight not only the multifaceted challenges imposed by the pandemic but also the critical need for inclusive policies and support systems that ensure healthcare access, safety, and economic resilience for immigrants, particularly during global health emergencies. Future research should focus on effective interventions for socioeconomic integration and well-being, particularly for immigrants from other African countries.
Experiences of transfer of care among postpartum women living with HIV attending primary healthcare services in South Africa
(Taylor and Francis Ltd., 2024) Odayar, Jasantha; Knight, Lucia
Transfers between health facilities for postpartum women living with HIV are associated with disengagement from care. In South Africa, women must transfer from integrated antenatal/HIV care to general HIV services post-delivery. Thereafter, women transfer frequently e.g. due to geographic mobility. To explore barriers to transfer, we conducted in-depth interviews >2 years post-delivery in 28 participants in a trial comparing postpartum HIV care at primary health care (PHC) antiretroviral therapy (ART) facilities versus a differentiated service delivery model, the adherence clubs, which are the predominant model implemented in South Africa. Data were thematically analysed using inductive and deductive approaches. Women lacked information including where they could transfer to and transfer processes. Continuity mechanisms were affected when women transferred silently i.e. without informing facilities or obtaining referral letters. Silent transfers often occurred due to poor relationships with healthcare workers and were managed inconsistently. Fear of disclosure to family and community stigma led to transfers from local PHC ART facilities to facilities further away affecting accessibility. Mobility and the postpartum period presented unique challenges requiring specific attention. Information regarding long-term care options and transfer processes, ongoing counselling regarding disclosure and social support, and increased health system flexibility are required.
Applying grade-CERQual to interpretive review findings: Reflections from a Cochrane meta-ethnography on childhood vaccination acceptance
(SAGE Publications Inc., 2024) Cooper, Sara; Schmidt, Bey-Marrie
Grade-CERQual (confidence in the evidence from reviews of qualitative research) was developed to support the use of evidence from qualitative reviews within policy- and decision-making. To date, the approach has been applied predominantly to aggregative synthesis methodologies and descriptive review findings. Grade-CERQual guidance recommends the approach be tested on more diverse review methodologies and outputs to support its evolution. This paper contributes to this evolution by reflecting on our experiences of applying Grade-CERQual to findings that emerged from a recent Cochrane meta-ethnography on childhood vaccination. Specifically, we describe the similarities and differences, challenges and dilemmas we experienced applying the approach to more interpretive versus more descriptive review findings. We found that we were able to apply the core criteria and principles of Grade-CERQual in ways that were congruent with the methodologies and epistemologies of a meta-ethnography and its findings. We also found that the practical application processes were similar across review finding types. The main differences related to the level of demand placed on the evidence and the level of complexity involved with the decisions. Compared to more descriptive findings, more interpretive findings required evidence that was richer, thicker, more contextually situated and methodologically stronger for us to have the same level of confidence in them. Making the assessments for these findings also involved more complicated forms of judgement. We provide practical examples to illustrate these complexities and how we approached them, which others applying Grade-CERQual to more interpretive review findings could draw upon. We also highlight areas requiring further discussion, in the hope that this will offer a platform for engagement and the potential future refinement of the approach. Ultimately, this could enhance the usability of Grade-CERQual for a larger range of qualitative review findings and in turn expand the kinds of knowledges that count within decision-making.
Infant growth and body composition from birth to 24 months: are infants developing the same?
(Springer Nature [academic journals on nature.com] [Commercial Publisher], 2024) Shane A. Norris; Lukhanyo H. Nyati
A good start to life is critical to offset later risks including lower school achievement, reduced adult income, non-communicable disease susceptibility, and intergenerational risk [1]. Growth failure and/or rapid weight gain in early life is also associated with an array of adverse health effects in later life [2–4]. The WHO growth standards have provided better means of interpreting length and weight assessments independent of where the child is born. Along with normative data for foetal growth [5], the child growth standards form part of recent advances in monitoring child development. Normative data for body composition have been described as the next logical level of advancement [6]. The multicenter infant body composition reference study (MIBCRS) has come close to achieving this by developing reference charts for body composition using a multi-ethnic sample, to represent a suitable reference for body composition gain [7]. Data from the MIBCRS emphasise the important role of context [8], home environment and feeding practices [9] in shaping body composition. However, the performance of body composition relative to ideal growth, which is the gold standard for assessing child development in both clinical and epidemiological settings, remains unclear. While anthropometric measurements may provide better reproducibility and are easy to obtain, body composition assessments may provide a more precise picture of the biological response to the interplay of genetic, nutrition, and environmental effects than measures of body size. A better understanding of infant body composition patterns in addition to linear growth may present possible intervention opportunities to reduce the obesity risk in infancy and childhood, and possibly offset the risk of non-communicable disease in adulthood. Therefore, our aim was to investigate longitudinal sex and country differences in infant body composition relative to ideal growth in six countries under conditions that are more likely to facilitate improved linear growth. We hypothesised that children born to mothers selected accordingly to the WHO MGRS [10] will track the WHO growth standards median and have similar FMI and FFMI during infancy irrespective of which country they were born in.

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