Philosophiae Doctor - PhD (School of Public Health)

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Complex systems thinking to improve health policy implementation in a resource-limited setting: The case of integration of palliative care into the health system in Zimbabwe
(University of the Western Cape, 2023) Gurupira, Wilfred; Mathole, Thubelihle
Recent research in public health has found that whilst complex systems thinking and implementation research have considerable overlap, they are rarely used in combination, especially for the implementation of health interventions or policies. This deficiency is demonstrated in Zimbabwe where the current approach to implementing health policy is unidimensional and linear, with a cause-effect type of thinking. This approach is limited as it does not consider context or the complexity inherent in the health system. This doctoral study offers a significant and original contribution to knowledge via the improvement of the knowledge, theory, methodology and practice of health policy implementation in a resource-limited setting. This study sought to examine how a more comprehensive approach, complex systems thinking, could be applied to evaluate and improve the process of implementing health policy in a resource-limited setting. The study aim was to monitor and evaluate the policy implementation process of integrating palliative care into the health system at public health facilities in Zimbabwe using the Parirenyatwa Group of Hospitals (PGH) as a case.
Developing strategies to improve the quality of facility based care during labour and childbirth
(University of the Western Cape, 2023) Siseho, Gloria Mutimbwa; Mathole, Thubelihle
Introduction: Globally, 50% of maternal and 60% of newborn deaths are due to poor quality-of-care or are preventable by the health system. According to the 2013 Namibia Demographic Health Survey (NDHS), northeast Namibia’s neonatal mortality rate is higher (27/1 000 live births) than the national (20/1 000 live births) level; with 47.7% of mothers and only =3% of neonates received postnatal care within 48 hours. Yet, no quality-of-care assessment existed to determine the quality of services provided to women and newborns during labour and childbirth, and in the immediate postnatal care. Neither was a maternal and newborn quality improvement programme implemented before this PhD research. The research aimed to implement strategic interventions for improving the quality of facility-based care during labour and childbirth. Methods: The study was conducted in a regional referral hospital, northeast Namibia using mixed methods of quantitative and qualitative survey. The qualitative data was not analysed by time of this thesis submission, thus will not be part of the thesis report. The hospital service three district hospitals, and one region with one district, far northeast of Namibia. This research used a pre-post study design because it was neither randomisation nor the use of a control group. The Every Mother Every Newborn (EMEN) quantitative survey questionnaire or assessment tools were used to collect data by interviewing the facility manager, nurses and doctors working with pregnant women in labour and delivery and postnatal care units, and women who gave birth at their time of discharge before going home.
The development of a protocol for the management of child abuse and neglect
(University of the Western Cape, 1998) Barnes-September, Roseline Lynnette; Sonn, Fanie
The primary intent of this study was to seek solutions to the practical problems experienced by practitioners in their management of child abuse cases. A fundamental problem regarding the current management of child abuse is that there is no guarantee that a child entering the child protective system will be dealt with in terms of a set procedure and/or protected against further abuse. To address this problem in the Western Cape, the Intervention Research (IR) methodology (Rothman & Thomas, 1994) was used to develop a Protocol for the Multi-Disciplinary Management of Child Abuse and Neglect The protocol was designed for agencies that intervene in instances of child abuse. It establishes criteria and procedures for interdisciplinary co-ordination and effective case management, delineates the professional roles and responsibilities and provides step-by-step intervention procedures. The Intervention Research Design and Development methodology provided a useful framework to apply social science research methods to child protective practice and policy reform. IR focuses on the design of practice guidelines for intervention and policy reform. It can be conducted in a diversity of practice settings and therefore enhances collaborative efforts and inter-agency exchange among practitioners and among practitioners and universities. The study evolved through six phases involving inter- as well as intra-disciplinary activities. These activities were guided by systematic and deliberate research procedures, techniques, and instruments. The research phases included: problem analysis; information gathering and synthesis; the development and design of the protocol; testing the protocol through a process of workshops and finally, the launch and dissemination of the protocol.
Paediatric severe - acute malnutrition and the recommended WHO treatment modality: an epidemiological and quality care assessment in the context of HIV comorbidity
(University of the Western Cape, 2015) Muzigaba, Moïse; Puoane, Thandi
The current study was, in part, prompted by the high case fatality rates for severe acute malnutrition in two district hospitals in the Eastern Cape Province in South Africa. These case fatality rates were being attributed to Human Immunodeficiency Virus infection rather than to mismanagement by nurses involved in the hospital management of SAM cases. There were also some anecdotes from clinicians in the same hospitals that, depending on the clinical stage of HIV infection, the World Health Organisation's ten-step protocol may show no effect. This left some uncertainties as to whether these guidelines are suitably designed for use during the management of HIV-positive children who are severely malnourished and at different HIV clinical stages. This study sought to reinforce the design of a longstanding facility-based intervention originally developed to improve the management of severe acute malnutrition in two district hospitals in South Africa. The aim was to design an improved intervention which was implemented and evaluated to determine its potential effect on treatment outcomes, specifically in the context of high HIV comorbidity. The study also sought to provide the context for the effectiveness of this intervention, in terms of its implementation fidelity and associated moderating factors. Lastly, the study evaluated the sustainability of the intervention after it was discontinued.
The effectiveness of front-of-pack warning labels in assisting South African consumers to identify unhealthy packaged foods
(University of the Western Cape, 2024) Bopape, Makoma Melicca; Swart, Rina Elizabeth Catherina
Background: Unhealthy diets that are excessive in energy, saturated fats, trans-fat, sugar and salt are associated with obesity, hypertension, diabetes mellitus, coronary heart diseases and some cancers. Globally there is a decline in consumption of traditional diets and an increase in preference for energy-dense processed food, and South Africa is no exception in this regard. Concurrently, the prevalence of obesity and obesity-related complications is on the increase in South Africa and worldwide. The development of a simplified front-of-pack labelling (FOPL) system is one of the critical steps in assisting consumers to identify unhealthy food products and consequently contribute to stemming the obesity trajectory and its related complications.
Evaluation of a community-based antiretroviral therapy delivery program for adults in Okongo district, Namibia: 2007-2017
(University of the Western Cape, 2024) Shoopala, Naemi N; Brian, Van Wyk
Namibia implemented a community-based ART (C-BART) delivery program in the Okongo District of the Ohangwena Region in northern Namibia in 2007. A C-BART site is a fixed, designated place in the community where ART services are provided on scheduled dates. The WHO recommends differentiated models of ART service delivery for stable patients at the facility and community levels. C-BART models are reported to increase patients' adherence and retention in care, with the ultimate goal of achieving viral suppression (VS). By the end of April 2017, eighteen (18) C-BART sites were established in the Okongo district. At the time of the study, the effectiveness of the C-BART program had not been evaluated. Aim: The study aimed to assess the effectiveness of the C-BART program on improving treatment outcomes (adherence to ART, retention in care, viral load suppression and survival) in comparison to facility-based ART(F-BART) and to describe patients' and healthcare providers' experiences of and challenges with implementing C-BART in the Okongo district.
Dietary diversity and its association with nutritional status of adults at risk of diabetes and the nutrient density and cost of foods
(University of the Western Cape, 2023) Madlala, Samukelisiwe Sthokozisiwe; Faber, Mieke
Background: South Africa has a high prevalence of non-communicable diseases (NCDs), with a triple burden of malnutrition, which includes childhood under- and over-nutrition, micronutrient deficiencies, and overweight and obesity among adults. The current nutrition transition, in combination with high unemployment rates, low household incomes and rising food prices, has contributed to unhealthy diets, malnutrition and NCDs in South Africa. Dietary diversity (DD), a measure of nutrient adequacy promoted globally through food-based dietary guidelines (FBDGs), is low in South African adults. Data on the association of DD with an intake of unhealthy foods and cardiometabolic risk factors for NCDs, including type 2 diabetes mellitus (T2DM) in the South African context, is limited. In addition, data are lacking on the barriers and enablers of consuming a diverse diet. South Africans with lower incomes may have difficulty adhering to the FBDGs because of high food costs. Nutrient profiling models, such as the Nutrient Rich Food Index (NRF9.3) in combination with food prices, can assist in identifying nutritious and affordable foods.
A mixed methods analysis of clostridioides difficile infection and implementation of a quality improvement intervention in public sector hospitals in Cape Town, South Africa
(University of the Western Cape, 2022) Legenza, Laurel; Coetzee, Renier
Background: Clostridioides difficile or Clostridium difficile infection (CDI), is a global health threat known for devastating outbreaks, high-cost complications, readmissions and mortality. While CDI is widely studied in high resource settings, existing literature neglects low resource settings. Prior to this study, no publications were available on the epidemiology of CDI and CDI patient outcomes in the secondary hospitals in the public healthcare sector — gaps this thesis addresses. No publications existed on provider awareness of CDI and CDI management workflow in sub-Saharan Africa. This thesis aims to a) determine baseline CDI patient characteristics, management of and contribution to mortality in SA, b) identify CDI perceptions and practices among healthcare providers in SA secondary hospitals, including facilitators and barriers to providing quality CDI care, and c) develop a CDI intervention and analysis thereof.
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.
The effects of poor menstrual hygiene management on sexual and reproductive health and education outcomes among adolescent schoolgirls in rural Tanzania
(University of the Western Cape, 2023) Ngilangwa, David Paul; Lembani, Martina
Background: In Tanzania, 11 million children are enrolled in primary schools, half of them being girls. As the majority of girls start their menstruation while in primary school, their retention in schools is likely to be hampered by inadequate and poor menstruation hygiene management facilities. It is important to conduct research to understand the association between poor menstruation hygiene management and school absenteeism, psychological well-being, and reproductive tract infections to inform interventions and policies that may enhance the full realization of girls pursuing education successfully. Much research conducted previously has focused on the knowledge and practices of menstruation hygiene management among girls in secondary schools. There is limited evidence of the associations between menstrual hygiene management and particularly sexual and reproductive health and education outcomes, among adolescent schoolgirls in rural Tanzania
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.
Metabolic syndrome and the risk of consuming street food among commercial taxi drivers in South Africa. A cross-sectional study
(University of the Western Cape, 2022) Sekgala, Machoene Derrick; Mchiza, Zandile
Minibus taxi drivers in South Africa are eminent street food (SF) consumers with these affordable foods easily accessible at taxi ranks. Regular SF consumption, in combination, with unhealthy lifestyles associated with taxi driving, predisposes them to develop metabolic syndrome (MetS). Detecting the early onset of MetS allows for early intervention, which may slow the progression to various health consequences. The primary aim of the thesis was to describe the prevalence, extent, and determinants of MetS among male minibus taxi drivers, 20 years and older operating in the Cape Town metropole who rely on SF for their daily calorie and nutrient intake. A secondary aim was to use these outcomes to develop recommendations for targeted interventions to improve their health status and lifestyle.
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.
Improving self-management for Type 2 diabetes and hypertension patients in Peri-urban townships in the Western Cape, South Africa
(University of the Western Cape, 2022) Masupe, Tiny Kelebogile; Delobelle, Peter
The rising burden of Type 2 diabetes mellitus (T2D) and hypertension (HTN) and the impact of non-communicable diseases (NCDs) in general on weak public health systems in low- and middle-income countries (LMICs) require innovative approaches for disease prevention and management. T2D and HTN are major preventable NCDs through early risk factor detection. Once diagnosed with these conditions, patients’ monitoring and control is done to reduce the occurrence of disease complications. We hypothesized that optimized contextual patient self-management plays a critical role in risk factor control, disease management and prevention of complications.
Use of continuous quality improvement to improve prevention of mother to child transmission (pmtct) programme performance in Amathole district municipality of Eastern Cape province, South Africa
(University of the Western Cape, 2022) Oyebanji, Oyebola; Mathole, Thubelihle
Globally, new Human Immunodeficiency Virus (HIV) infections in children reduced by 54% due to implementation of Prevention of Mother to Child Transmission (PMTCT) of HIV since the peak in 1996, increase in Antiretroviral treatment (ART) coverage among children and increase in the proportion of pregnant women receiving ART. In South Africa, significant progress has been made regarding PMTCT programme geared towards the virtual elimination of new HIV infections in children, which has contributed to 40% reduction of new HIV infection in children.
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.
What drives obstetric violence amongst nurses and midwives throughout the continuum of maternal health care in governmental hospitals and antenatal clinics in urban Western Cape
(University of the Western Cape, 2022) Dutton, Jessica; Knight, Lucia
Obstetric violence is a particular form of gender-based violence that harms women physically, emotionally and psychologically. Obstetric violence has been reported throughout South Africa in both the public and private health sectors across the continuum of maternal health care. In the efforts to eradicate obstetric violence within South African maternal healthcare, we require a better understanding of what drives this phenomenon in this context. The perspective of nurses and midwives is indispensable in developing this understanding.
Understanding the components of comprehensive maternity protection available and accessible to non-standard workers in South Africa: Domestic workers as a case study
(University of the Western Cape, 2023) Pereira-Kotze, Catherine Jane (Katie); Doherty, Tanya
Maternity protection refers to a set of entitlements for working women around the time of pregnancy, childbirth and upon return to work, while breastfeeding. Comprehensive maternity protection incorporates health protection at the workplace; a period of maternity leave, cash, and medical benefits while on maternity leave; job security; non-discrimination; access to breastfeeding breaks and childcare support. Maternity protection in South Africa has not previously been comprehensively documented and investigated. Women working in permanent, full-time positions in the formal sector have greater access to maternity protection. Women working in positions of non-standard employment have not been allocated sufficient priority and investigation in the literature and previous research on maternity protection.
Evaluation of a psychosocial support intervention on adherence and retention in care among adolescents on antiretroviral treatment in Ehlanzeni District Municipality, Mpumalanga, South Africa
(University of the Western Cape, 2022) Okonji, Emeka Francis; van Wyk, Brian
In 2021, it was estimated that globally approximately 1.8 million adolescents (aged 10-19 years) were living with HIV, of whom over 90% resided in sub-Saharan Africa. While the global number of adolescents living with HIV fell by 57% from 2000 to 2020, the number of AIDS-related deaths amongst adolescents in eastern and southern Africa increased during the same period. Adolescents living with HIV (ALHIV) face many challenges related to adherence to antiretroviral treatment (ART) and remaining engaged in care. Some of these challenges result from the physiological and psychosocial characteristics of their stage of development. It is hypothesized that providing psychosocial support may mitigate high levels of anxiety, fear of disclosing their HIV-positive status, low self-esteem, low self-efficacy, depressive disorders, and suicide reported amongst adolescents living with HIV.
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.

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