Browsing by Author "Moodley, Jennifer"
Now showing 1 - 20 of 24
Results Per Page
Sort Options
- ItemOpen AccessAccuracy of assessment of eligibility for early medical abortion by community health workers in Ethiopia, India and South Africa(Public Library of Science, 2016) Johnston, Heidi Bart; Ganatra, Bela; Nguyen, My Huong; Habib, Ndema; Afework, Mesganaw Fantahun; Harries, Jane; Iyengar, Kirti; Moodley, Jennifer; Lema, Hailu Yeneneh; Constant, Deborah; Sen, SwapnaleenObjective To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. Design Diagnostic accuracy study. Setting Ethiopia, India and South Africa. METHODS: Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. RESULTS: Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. CONCLUSION: The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.
- ItemOpen AccessAccuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study(BioMed Central, 2017-08-22) Constant, Deborah; Harries, Jane; Moodley, Jennifer; Myer, LandonBackground: The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs) , and explores providers’ and CHWs’ perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. Methods: We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. Results: Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. Conclusions: If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women’s privacy needs and address healthcare workers’ concerns on managing any procedural risk.
- ItemOpen AccessAccuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study(2017) Constant, Deborah; Harries, Jane; Moodley, Jennifer; Myer, LandonBACKGROUND: The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs), and explores providers' and CHWs' perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. METHODS: We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. RESULTS: Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. CONCLUSIONS: If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women's privacy needs and address healthcare workers' concerns on managing any procedural risk.
- ItemOpen AccessBarriers and facilitators to colposcopy attendance following an abnormal pap smear: patient and provider perspectives(2014) Dawood, Shanaaz; Moodley, Jennifer; Harries, JaneCervical cancer is a public health problem particularly in developing countries where incidence of cervical cancer remains high, either due to a lack of screening or poorly organised screening programmes. Cytology based cervical screening is only beneficial if women with abnormal Papanicolaou (Pap) smears are appropriately investigated. Colposcopy attendance following an abnormal Pap smear is a major problem in South Africa. The aim of this study was to explore barriers and facilitators to colposcopy attendance following an abnormal Pap smear result. A qualitative study was conducted at a public sector tertiary hospital colposcopy service and two primary health care clinics in Cape Town, South Africa. Data collection included 32 semi-structured interviews: 12 face-to-face interviews with colposcopy clinic attendees, 12 telephonic interviews with colposcopy clinic non- attendees and 8 face-to-face interviews with health care providers. Client interviews explored barriers and facilitators to colposcopy attendance; knowledge and experiences of Pap smears, cervical cancer and the colposcopy procedure; scheduling of colposcopy appointments; provider communication; reasons for non-attendance; and community support and beliefs. Provider interviews explored barriers and facilitators to colposcopy attendance from a provider’s perspective, the colposcopy referral process, and provider challenges in the provision of Pap smear or colposcopy services. Results from this study highlighted that the main barriers to colposcopy attendance were: poor levels of knowledge of the importance of a Pap smear and the colposcopy procedure; a lack of awareness of cervical cancer as a disease; a fear of cancer; the asymptomatic nature of the disease; and transport costs. Health system factors that impacted negatively on colposcopy clinic attendance included: the inadequate feedback of Pap smear results – clients were not informed of Pap smear results or colposcopy appointments and therefore did not attend; a disjointed system of colposcopy scheduling; and staff shortages which resulted in less time for client tracking. Factors which promoted colposcopy attendance included experiencing symptoms; a family history of cancer due to the experience with death; colposcopy services situated closer to clients; and social support receive d from family members. Addressing these barriers requires promoting client knowledge with educational materials and improving provider communication with clients. In addition, establishing colposcopy services closer to clients and standardising the system of colposcopy scheduling can improve colposcopy adherence.
- ItemOpen AccessClient knowledge, attitudes and practices to cervical screening in Mitchell's Plain, Cape Town, South Africa(2007) Daries, Vanessa Cheryl; Moodley, JenniferBackground: Cervical cancer is a common cause of death among women in developing countries, including South Africa. In 2000, the South African National Department of Health introduced the national cervical cancer screening policy, which states that every woman is entitled to three free Papanicolaou (Pap) smears in her lifetime, at 1 0-year intervals starting at the age of 30 years. A number of studies have indicated that the uptake of cervical cancer screening is dependent on the targeted population's knowledge, attitudes and practices (KAP) related to health-seeking behaviours. The aim of the study is to determine the baseline KAP to Pap smears and cervical cancer of women aged 25 years and older in Mitchell's Plain, Western Cape Province. Methods: A cross-sectional survey was undertaken among clients attending primary health care facilities in the Mitchell's Plain district, Cape Town, Western Cape Province. The study population consisted of women aged 25 years and older who presented at the public health care facilities in Mitchell's Plain between 1 April and 31 July 2002 and who consented to participate in the study. The data were analysed using the STAT A version 8 statistical package. Results: A total of 445 women were interviewed, most of whom were above the age of 30 years (72%), married (68%) and unemployed (68%). Ninety-five per cent said they had heard of a Pap smear; however, when asked what part of the body was examined during a Pap smear, only 4% correctly answered. Only 13% of the women knew that a Pap smear was a test for cancer of the cervix, although 52% recognised it as a test for cancer. Of the women interviewed, 73% had heard of cancer of the cervix. A total of 78% of women had had a Pap smear. The results indicated no significant association between ever hearing of a pap smear and the following predictors: age, educational level, marital status, pregnancy and the use of contraception. Women who were significantly more likely to have had a Pap smear included: older women, those who were in a relationship, owned a radio, were employed, had ever been pregnant or had heard of a Pap smear before. Main sources of information regarding Pap smears were reported to be posters (17%) and the radio (16%). Conclusions: The data suggest that although a very high proportion of the women (95%) had heard of Pap smears, a smaller proportion (78%) had actually had a Pap smear. This study showed that there were missed opportunities that the health workers could possibly have utilised to encourage women in the targeted age group to have a Pap smear while at the health facilities for reasons other than reproductive health. Women who had not been afforded the opportunity to have a Pap smear by the health provider reported a great interest in having a Pap smear, showing willingness to improve their health if afforded the opportunity. In order to reduce the high morbidity and mortality from cervical cancer in South Africa, very large numbers of women in the target age group need to be recruited to the screening programme. To be able to achieve an increase in the cervical cancer screening uptake, huge efforts have to be made to actively recruit women who are within reach of the health services, particularly any women who present at the health facilities.
- ItemOpen AccessA comparative cost analysis of two screening strategies for colorectal cancer in Lynch Syndrome in a tertiary hospital, South Africa(2017) Johnson, Yasmina; Sinanovic, Edina; Moodley, Jennifer; Goldberg, Paul AIndividuals with Lynch Syndrome (LS) have a 25% to 75% lifetime risk of colorectal cancer and the cancer generally presents at an early age. Establishing the costs of strategies to prevent or delay the onset of cancer is, thus, desirable. This study compared the cost of two screening approaches - colonoscopy only (Strategy 1) versus genetic testing for LS followed by colonoscopy for the individuals that tested positive for LS (Strategy 2). A comparative cost analysis was conducted at a tertiary hospital, from the health provider perspective, using a micro-costing, ingredient approach. Probands that were selected, according to the Revised Bethesda Criteria, for genetic testing between 01 November 2014 and 30 October 2015, and their first degree relatives (high risk relatives) were evaluated according to Strategy 1 and Strategy 2. Total costs per strategy were estimated and compared. Sensitivity analyses were performed on adherence rates to colonoscopy, positivity rates of relatives and discount rates. A total of 40 families were studied. The total cost for Strategy 1 amounted to R4 932 718 ($332 617) compared to R390 308 ($26 319) for Strategy 2 (Discount rate 3%; Adherence 75% and Positivity rate of relatives 45%). Base case analysis indicated a difference of 92% less in the total cost for Strategy 2 compared to Strategy 1. Univariate sensitivity analyses showed that the difference in cost between the two strategies was not sensitive to changes in discount rates, adherence rates or positivity rates of relatives. Compared to colonoscopy screening only, colonoscopy combined with genetic testing presented a less costly option by identifying patients at high risk of colorectal cancer for screening. Testing of relatives should be facilitated since, compared to probands, genetic testing of relatives is less costly and is likely to have more benefit. Effectiveness of the screening programmes should be established through further research.
- ItemOpen AccessComparing women's unprompted and prompted knowledge of breast and cervical cancer risk factors and symptoms in Sub- Saharan Africa(2019) Muzenda, Trish; Moodley, Jennifer; Constant, DeborahBreast and cervical cancer are leading causes of female cancer morbidity and mortality in Sub-Saharan Africa (SSA). Despite the high burden of disease, women’s knowledge of evidence-based risk factors and symptoms remains low. To adequately address the apparent knowledge deficits, the underlying knowledge in communities needs to be measured, so as to identify important gaps and contextually address them. To date, cancer knowledge in SSA has been measured using either prompted or unprompted question formats, yielding varying knowledge scores. However, there has been little exploration on the impact of using either question format for assessing disease awareness. This study sought to measure the differences in breast and cervical cancer risk factors and symptoms knowledge reported through prompted and unprompted questions, in South Africa (SA) and Uganda (UG). This was a descriptive cross-sectional study drawing on data collected during validation of an interviewer administered questionnaire (African Woman’s Awareness of Cancer - AWACAN) measuring breast and cervical cancer awareness in SSA. The sample included 139 women recruited from public sector primary health care facilities in two urban districts, Gulu (UG) and Cape Town (SA). Descriptive statistics were used to summarize participant’s socio-demographic characteristics and knowledge about breast and cervical cancer. Composite knowledge scores were calculated by adding up the number of correct responses per individual. The Wilcoxon Singed Rank test was used to compare differences between unprompted and prompted knowledge scores. Regression analyses were used to measure the relationship between unprompted and prompted knowledge. The median age of study participants was 42 years. The majority of women had not completed secondary education (57%) and were unemployed (64%). Unprompted knowledge was considerably lower than prompted knowledge for all breast and cervical cancer risk factors and symptoms. Median scores for unprompted knowledge of breast cancer risk factors (0) and symptoms (1) were significantly lower than for prompted at 6 and 14 respectively. Similarly, the median scores for unprompted knowledge of cervical cancer risk factors (0) and symptoms (1) were lower than prompted knowledge at 6 and 9 respectively. The difference between prompted and unprompted knowledge was least for classical breast and cervical cancer symptoms. For instance, the well-known breast cancer symptom ‘lump in the breast’ was recalled by 57% and 96% with unprompted and prompted questioning respectively. Unprompted questioning identified additional risk lay beliefs such as, ‘itching of the breast’. Combined use of unprompted and prompted questions provides more insight on breast and cervical cancer knowledge patterns in SSA. The low unprompted knowledge scores reported here demonstrate the need for health education interventions to improve knowledge of established breast and cervical cancer risk factors and whilst addressing any predominant lay beliefs about the disease in SSA. This dissertation is divided into three parts. Part A consists of the study protocol outlining the rational for undertaking this study as well as the proposed research methodology. Part B is the literature review that gives a summary of existing literature on the use of prompted and unprompted questions in measuring cancer knowledge thereby providing context for this study. Part C is a journal ready manuscript presenting the results and discussion of study findings.
- ItemOpen AccessContraceptive needs and fertility intentions of women with breast cancer in Cape Town, South Africa: a qualitative study(2020-10-06) Harries, Jane; Constant, Deborah; Cairncross, Lydia; Moodley, JenniferBackground: No known studies have been undertaken in South Africa exploring the contraceptive and fertility needs and preferences of women of reproductive age (18–49) diagnosed with breast cancer. This study set out to understand the contraceptive needs and fertility intentions of women with breast cancer in Cape Town, South Africa. Methods Qualitative in-depth interviews were conducted with 24 women diagnosed with breast cancer and 4 health care providers at a tertiary hospital in Cape Town, South Africa. We explored contraceptive use prior to diagnosis; the impact of breast cancer on future fertility intentions and contraceptive use; understanding of suitable contraceptive methods during and after treatment and women’s fertility related counseling needs during their continuum of care. Data were analysed using a thematic analysis approach. Results Since being diagnosed with breast cancer, of those women using a contraceptive method, the non-hormonal intrauterine device (IUD) was the most commonly used method. However, women reported receiving limited information from health care providers about contraceptive use and future fertility planning post treatment when fertility desires might change. Many women reported limited information received from healthcare providers about the impact of cancer treatment on their future fertility. Most women did not receive information around fertility preservation options, and few were familiar with the concept. Providers focus was more on preventing pregnancy during treatment and ensuring a patient was on a non-hormonal contraceptive method. Providers supported a more holistic, multidisciplinary approach to breast cancer patient’s contraceptive and future fertility needs. Conclusions Limited contraceptive and future fertility counseling were reported by women despite many women being provided with the IUD. There is a need for improved information and counseling regarding the impact of treatment on contraceptive and fertility options. It is important that cancer care providers provide timely information regarding fertility options and communicate with patients about their fertility concerns prior to treatment and throughout the course of survivorship. The development of evidence-based information tools to enhance patient-provider communication and counseling could address knowledge gaps.
- ItemOpen AccessEmergency contraception - lack of awareness among women presenting for termination of pregnancy(2007) Moodley, Jennifer; Morroni, ChelseaEmergency contraception (EC) when used after unprotected intercourse, within defined time limits, can reduce the risk of an unwanted pregnancy. In South Africa EC is available free of charge in public sector clinics and over the counter, i.e. without prescription, in private sector pharmacies. Termination of pregnancy services have been legal in SA since 1996 and have resulted in a marked decrease in abortion-related morbidity and mortality. However, abortion services remain inaccessible for many women because of stigma, provider resistance and lack of trained providers and designated facilities. An increased use of EC could lead to a reduction in both legal and illegal abortion. In this article we report on the awareness and use of EC among women presenting for a termination of pregnancy.
- ItemOpen AccessExpanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa(2014-01-10) Hoke, Theresa; Harries, Jane; Crede, Sarah; Green, Mackenzie; Constant, Deborah; Petruney, Tricia; Moodley, JenniferAbstract Background Clients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods. Methods We examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients. Results Following the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects. Conclusions The intervention failed to improve PMTCT clients’ knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally.
- ItemOpen AccessExploring the feasibility of using mobile phones to improve the management of clients with cervical cancer precursor lesions(2019-01-07) Moodley, Jennifer; Constant, Deborah; Botha, Matthys H; van der Merwe, Frederick H; Edwards, Amanda; Momberg, MarietteAbstract Background Cancer screening programs hold much potential for reducing the cervical cancer disease burden in developing countries. The aim of this study was to determine the feasibility of mobile health (mHealth) phone technology to improve management and follow-up of clients with cervical cancer precursor lesions. Methods A sequential mixed methods design was employed for this study. Quantitative data was collected using a cross-sectional survey of 364 women eligible for a Pap smear at public sector health services in Cape Town, South Africa. Information was collected on socio-demographic status; cell phone ownership and patterns of use; knowledge of cervical cancer prevention; and interest in Pap smear results and appointment reminders via SMS-text messages. Descriptive statistics, crude bivariate comparisons and logistic regression models were employed to analyze survey results. Qualitative data was collected through 10 in-depth interviews with primary health care providers and managers involved in cervical cancer screening. Four focus group discussions with 27 women attending a tertiary level colposcopy clinic were also conducted. Themes related to loss of mobile phones, privacy and confidentiality, interest in receiving SMS-text messages, text language and clinic-based management of a SMS system are discussed. Thematic analyses of qualitative data complemented quantitative findings. Results Phone ownership amongst surveyed women was 98% with phones mostly used for calls and short message service (SMS) functions. Over half (58%) of women reported loss/theft of mobile phones. Overall, there was interest in SMS interventions for receiving Pap smear results and appointment reminders. Reasons for interest, articulated by both providers and clients, included convenience, cost and time-saving benefits and benefits of not taking time off work. However, concerns were expressed around confidentiality of SMS messages, loss/theft of mobile phones, receiving negative results via SMS and accessibility/clarity of language used to convey messages. Responsibility for the management of a clinic-based SMS system was also raised. Conclusions Results indicated interest and potential for mHealth interventions in improving follow-up and management of clients with abnormal Pap smears. Health system and privacy issues will need to be addressed for mHealth to achieve this potential. Next steps include piloting of specific SMS messages to test feasibility and acceptability in this setting.
- ItemOpen AccessFactors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study(BioMed Central Ltd, 2012) Credé, Sarah; Hoke, Theresa; Constant, Deborah; Green, Mackenzie; Moodley, Jennifer; Harries, JaneBACKGROUND: The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa. METHODS: A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined. RESULTS: The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods. CONCLUSIONS: Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.
- ItemOpen AccessFrom symptom discovery to treatment - women's pathways to breast cancer care: a cross-sectional study(BioMed Central, 2018-03-21) Moodley, Jennifer; Cairncross, Lydia; Naiker, Thurandrie; Constant, DeborahBackground Typically, women in South Africa (SA) are diagnosed with breast cancer when they self-present with symptoms to health facilities. The aim of this study was to determine the pathway that women follow to breast cancer care and factors associated with this journey. Methods A cross-sectional study was conducted at a tertiary hospital in the Western Cape Province, SA, between May 2015 and May 2016. Newly diagnosed breast cancer patients were interviewed to determine their socio-demographic profile; knowledge of risk factors, signs and symptoms; appraisal of breast changes; clinical profile and; key time events in the journey to care. The Model of Pathways to Treatment Framework underpinned the analysis. The total time (TT) between a woman noticing the first breast change and the date of scheduled treatment was divided into 3 intervals: the patient interval (PI); the diagnostic interval (DI) and the pre-treatment interval (PTI). For the PI, DI and PTI a bivariate comparison of median time intervals by various characteristics was conducted using Wilcoxon rank-sum and Kruskal-Wallis tests. Cox Proportional-Hazards models were used to identify factors independently associated with the PI, DI and PTI. Results The median age of the 201 participants was 54 years, and 22% presented with late stage disease. The median TT was 110 days, with median patient, diagnostic and pre-treatment intervals of 23, 28 and 37 days respectively. Factors associated with the PI were: older age (Hazard ratio (HR) 0.59, 95% CI 0.40–0.86), initial symptom denial (HR 0.43, 95% CI 0.19–0.97) and waiting for a lump to increase in size before seeking care (HR 0.51, 95% CI 0.33–0.77). Women with co-morbidities had a significantly longer DI (HR 0.67, 95% CI 0.47–0.96) as did women who mentioned denial of initial breast symptoms (HR 4.61, 95% CI 1.80–11.78). The PTI was associated with late stage disease at presentation (HR 1.78, 95% CI 1.15–2.76). Conclusion The Model of Pathways to Treatment provides a useful framework to explore patient’s journeys to care and identified opportunities for targeted interventions.
- ItemOpen AccessHealth care provider perspectives on pregnancy and parenting in HIV-positive individuals in South Africa(BioMed Central, 2014-09-12) Moodley, Jennifer; Cooper, Diane; Mantell, Joanne E; Stern, ErinBackground: Within the health system, limited attention is given to supporting the fertility and parenting desires on HIV-positive people. In this study, we explore health care providers’ knowledge and perspectives on safer conception and alternate parenting strategies for HIV-positive people. Methods Between November 2007 and January 2008, in-depth interviews were conducted with 28 health care workers involved in providing HIV and/or antiretroviral services at public sector clinics in Cape Town, South Africa. Views on sexual and reproductive health services, pregnancy, childbearing and parenting in HIV-positive men and women were explored using a semi-structured interview guide. Data were analyzed using a thematic approach. Results: Providers recognized the sexual and reproductive rights of HIV-positive individuals, but struggled with the tension between supporting these rights and concerns about spreading infection. Limited knowledge of safer conception methods constrained their ability to counsel and support clients in realizing fertility desires. Providers believed that parenting alternatives that do not maintain biological and cultural linkage are unlikely to be acceptable options. Conclusions: Health care provider training and support is critical to providing comprehensive sexual and reproductive health care and meeting the fertility desires of HIV-positive people.
- ItemOpen AccessHIV and pre-neoplastic and neoplastic lesions of the cervix in South Africa: a case-control study(BioMed Central Ltd, 2006) Moodley, Jennifer; Hoffman, Margaret; Carrara, Henri; Allan, Bruce; Cooper, Diane; Rosenberg, Lynn; Denny, Lynette; Shapiro, Samuel; Williamson, Anna-LiseBACKGROUND:Cervical cancer and infection with human immunodeficiency virus (HIV) are both major public health problems in South Africa. The aim of this study was to determine the risk of cervical pre-cancer and cancer among HIV positive women in South Africa. METHODS: Data were derived from a case-control study that examined the association between hormonal contraceptives and invasive cervical cancer. The study was conducted in the Western Cape (South Africa), from January 1998 to December 2001. There were 486 women with invasive cervical cancer, 103 control women with atypical squamous cells of undetermined significance (ASCUS), 53 with low-grade squamous intraepithelial lesions (LSIL), 50 with high-grade squamous intraepithelial lesions (HSIL) and 1159 with normal cytology. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using multiple logistic regression. RESULTS: The adjusted odds ratios associated with HIV infection were: 4.4 [95% CI (2.3 - 8.4) for ASCUS, 7.4 (3.5 - 15.7) for LSIL, 5.8 (2.4 - 13.6) for HSIL and 1.17 (0.75 - 1.85) for invasive cervical cancer. HIV positive women were nearly 5 times more likely to have high-risk human papillomavirus infection (HR-HPV) present compared to HIV negative women [OR 4.6 (95 % CI 2.8 - 7.5)]. Women infected with both HIV and high-risk HPV had a more than 40 fold higher risk of SIL than women infected with neither of these viruses. CONCLUSION: HIV positive women were at an increased risk of cervical pre-cancer, but did not demonstrate an excess risk of invasive cervical cancer. An interaction between HIV and HR-HPV infection was demonstrated. Our findings underscore the importance of developing locally relevant screening and management guidelines for HIV positive women in South Africa.
- ItemOpen AccessThe HIV epidemic and sexual and reproductive health policy integration: views of South African policymakers(BioMed Central, 2015-03-04) Cooper, Diane; Mantell, Joanne E; Moodley, Jennifer; Mall, SumayaBackground: Integration of sexual and reproductive health (SRH) and HIV policies and services delivered by the same provider is prioritised worldwide, especially in sub-Saharan Africa where HIV prevalence is highest. South Africa has the largest antiretroviral treatment (ART) programme in the world, with an estimated 2.7 million people on ART, elevating South Africa’s prominence as a global leader in HIV treatment. In 2011, the Southern African HIV Clinicians Society published safer conception guidelines for people living with HIV (PLWH) and in 2013, the South African government published contraceptive guidelines highlighting the importance of SRH and fertility planning services for people living with HIV. Addressing unintended pregnancies, safer conception and maternal health issues is crucial for improving PLWH’s SRH and combatting the global HIV epidemic. This paper explores South African policymakers’ perspectives on public sector SRH-HIV policy integration, with a special focus on the need for national and regional policies on safer conception for PLWH and contraceptive guidelines implementation. Methods: It draws on 42 in-depth interviews with national, provincial and civil society policymakers conducted between 2008–2009 and 2011–2012, as the number of people on ART escalated. Interviews focused on three key domains: opinions on PLWH’s childbearing; the status of SRH-HIV integration policies and services; and thoughts and suggestions on SRH-HIV integration within the restructuring of South African primary care services. Data were coded and analysed according to themes. Results: Participants supported SRH-HIV integrated policy and services. However, integration challenges identified included a lack of policy and guidelines, inadequately trained providers, vertical programming, provider work overload, and a weak health system. Participants acknowledged that SRH-HIV integration policies, particularly for safer conception, contraception and cervical cancer, had been neglected. Policymakers supported public sector adoption of safer conception policy and services. Participants interviewed after expanded ART were more positive about safer conception policies for PLWH than participants interviewed earlier. Conclusion: The past decade’s HIV policy changes have increased opportunities for SRH–HIV integration. The findings provide important insights for international, regional and national SRH-HIV policy and service integration initiatives.
- ItemOpen AccessHuman papillomavirus prevalence, viral load and pre-cancerous lesions of the cervix in women initiating highly active antiretroviral therapy in South Africa: a cross-sectional study(BioMed Central Ltd, 2009) Moodley, Jennifer; Constant, Deborah; Hoffman, Margaret; Salimo, Anna; Allan, Bruce; Rybicki, Ed; Hitzeroth, Inga; Williamson, Anna LiseBACKGROUND:Cervical cancer and infection with human immunodeficiency virus (HIV) are both important public health problems in South Africa (SA). The aim of this study was to determine the prevalence of cervical squamous intraepithelial lesions (SILs), high-risk human papillomavirus (HR-HPV), HPV viral load and HPV genotypes in HIV positive women initiating anti-retroviral (ARV) therapy. METHODS: A cross-sectional survey was conducted at an anti-retroviral (ARV) treatment clinic in Cape Town, SA in 2007. Cervical specimens were taken for cytological analysis and HPV testing. The Digene Hybrid Capture 2 (HC2) test was used to detect HR-HPV. Relative light units (RLU) were used as a measure of HPV viral load. HPV types were determined using the Roche Linear Array HPV Genotyping test. Crude associations with abnormal cytology were tested and multiple logistic regression was used to determine independent risk factors for abnormal cytology. RESULTS: The median age of the 109 participants was 31 years, the median CD4 count was 125/mm3, 66.3% had an abnormal Pap smear, the HR-HPV prevalence was 78.9% (Digene), the median HPV viral load was 181.1 RLU (HC2 positive samples only) and 78.4% had multiple genotypes. Among women with abnormal smears the most prevalent HR-HPV types were HPV types 16, 58 and 51, all with a prevalence of 28.5%. On univariate analysis HR-HPV, multiple HPV types and HPV viral load were significantly associated with the presence of low and high-grade SILs (LSIL/HSIL). The multivariate logistic regression showed that HPV viral load was associated with an increased odds of LSIL/HSIL, odds ratio of 10.7 (95% CI 2.0 - 57.7) for those that were HC2 positive and had a viral load of [less than or equal to] 181.1 RLU (the median HPV viral load), and 33.8 (95% CI 6.4 - 178.9) for those that were HC2 positive with a HPV viral load > 181.1 RLU. CONCLUSION: Women initiating ARVs have a high prevalence of abnormal Pap smears and HR-HPV. Our results underscore the need for locally relevant, rigorous screening protocols for the increasing numbers of women accessing ARV therapy so that the benefits of ARVs are not partially offset by an excess risk in cervical cancer.
- ItemOpen AccessIs 'planning' missing from our family planning services?(2010) Crede, Sarah; Harries, Jane; Constant, Deborah; Hoke, Theresa Hatzell; Green, Mackenzie; Moodley, JenniferThe role of family planning in achieving the Millennium Development Goals is well recognised. The benefits of family planning, in developing countries in particular, extend beyond decreasing fertility and include poverty reduction, improved health for both mother and child, the promotion of gender equality by increasing women's opportunities beyond reproductive and domestic activities, and environmental sustainability. In addition, prevention of undesired pregnancies among HIV-positive women by eliminating unmet need for contraception is a highly cost-effective means of preventing mother-to-child transmission. In South Africa, free contraceptives are available at public sector health care facilities, and contraception use is high: an estimated 65% of sexually active women use a method.3 The method mix comprises predominantly short-acting methods - primarily injectable contraceptives. Long-acting contraceptives, such as the intra-uterine device (IUD), are highly effective among typical users owing to consistency of function, yet are underutilised in South Africa's public sector facilities. Of importance, especially in South Africa's high HIVprevalent setting, is that the IUD can be safely used on clinically well HIV-positive women. The 2004 Demographic and Health Survey showed that 10% of sexually active women were sterilised, while less than 1% of women were using the IUD. In preparation for an intervention aimed at improving contraceptive options, including long-acting and permanent methods (LAPM), for all postpartum women, we assessed women's knowledge and attitudes to LAPM. We report on findings from our baseline survey, which have prompted the question: Where is the 'planning' in family planning services?
- ItemOpen AccessMeeting the contraceptive needs of HIV positive adolescent females living in urban townships in Western Cape, South Africa: perspectives of clients and primary health care providers(University of Cape Town, 2020) Olagbuji, Biodun Nelson; Moodley, Jennifer; Mathews, Catherine; Cooper, DianeBackground: Contraception remains the cornerstone of the global strategy to prevent unintended pregnancy, as well as horizontal and perinatal/postnatal HIV transmission in women living with HIV (WLHIV), including female adolescents living with HIV (ALHIV). Although increased data and research on WLHIV contraception has provided opportunities to strengthen contraception services in HIV programmes, little is known about ALHIV contraceptive behaviours and needs, as well influences on their access to and utilisation of contraceptive services to inform the design of strategies that would enhance optimal contraceptive services in ALHIV programmes. Methods: A mixed-methods design included a cross-sectional study of female ALHIV (n=303) through a questionnaire survey, and semi-structured in-depth interviews with both system- and service delivery-level providers (N=19). Quantitative data were analysed using Stata 15. Quantitative analyses include descriptive statistics and regression modelling, including multinomial and multivariate logistic regressions. Thematic analysis of qualitative data was conducted using Nvivo 11. Quantitative and qualitative data were triangulated in the interpretation of results. Results: Contraceptive prevalence (83.5%) is extremely high among all the female ALHIV and even higher among sexually active female ALHIV (86.8%), and contraceptive prevalence rates are at least 20% higher than the South Africa Demographic and Health Survey (SADHS) rate for the general population of female adolescents or sexually active female adolescents. The rate of unmet need for contraception (23.6%) remains considerable. Contraceptive prevalence is also high among both female with peri/postnatally acquired HIV (pALHIV) and horizontally acquired HIV (hALHIV). The majority of current contraceptive users relied on injectables (60.5%), followed by condoms alone (27.7%), then long-acting reversible contraceptives [LARC](9.1%) and hormonal pills (2.7%). Almost 1 in 5 (18.8%) female ALHIV had an unintended pregnancy. When contraceptive use consistency was restricted to the three months preceding the survey, levels of consistent condom use and dual-method use were 37.9% and 20.6%, respectively. Also, the quantitative data shows multiple barriers and facilitating factors for contraceptive uptake among female ALHIV. Overall, both the quantitative and qualitative data generally found that the receipt of contraceptive provision and use are similar between female pALHIV and hALHIV; however, the quantitative data suggest that pALHIV were more likely to experience unintended pregnancies compared to hALHIV. Though the quantitative data lack information on the particular hormonal method associated with HIV-specific safety concerns, there is evidence suggesting that the concern about HIV-specific hormonal contraceptive-related risks does not impact hormonal contraceptive uptake among ALHIV. Furthermore, adolescent-friendly services (AFS) appear to have been reasonably well-mainstreamed into routine care in the Cape Town context at least, to the extent that standalone youth clinics do not appear to provide significant added value to contraception-related outcomes among female ALHIV. The qualitative data highlighted preponderance of injectable contraception, inconsistent contraceptive use, fears about the intrauterine device (IUD) use, positive and negative provider attitudes to contraceptive services for ALHIV, and provider competency and training, among others. Conclusion: Overall, the thesis supports socioecological-based approaches to contraceptive care for female ALHIV as well as mainstreaming AFS within public sector facilities. Moreover, potential risk-reducing interventions, such as a client-centred approach to contraceptive care, are needed to improve pALHIV's risk of unintended pregnancies.
- ItemOpen AccessModelling the impact of prevention strategies on cervical cancer incidence in South Africa(2021) van Schalkwyk, Catherina; Johnson, Leigh; Moodley, JenniferBackground: In 2019, the World Health Organisation called for the elimination of cervical cancer as a public health concern. In South Africa, despite having a national screening policy in place since 2000, diagnosed cervical cancer incidence has shown no signs of decline. Since 2014, girls aged 9 have been vaccinated against HPV infection using the bivalent vaccine, with high coverage. However, due to the long delay between HPV infection and progression to cancer, the impact that vaccination will have on cervical cancer incidence will be unobservable in the near future. This thesis sets out to quantify this impact using a mathematical model, and will estimate the impact of scaling up current cancer prevention strategies, as well as proposed alternative strategies. Methods: This research extends a previously developed individual-based model for HIV to include infection with 13 high-risk HPV types and progression to cervical cancer. HPV infection and cervical disease parameters were calibrated to a wide range of South African data sources using a likelihood based approach. In the process of developing an appropriate model for cervical cancer incidence in South Africa, important aspects related to HIV/HPV co-infection dynamics, the natural history of HPV and the current and historic levels of cervical cancer prevention in the Western Cape were investigated. The calibrated and validated model was used to estimate the impact of current and proposed alternative prevention strategies on cervical cancer incidence in the next century. Findings: Using a model structure that does not include a biological transmission co-factor, we show that simulated associations between HIV and HPV transmission are similar to corresponding empirical estimates and therefore these associations may result from residual confounding by sexual behavioural factors and network-level effects. Using simulated vaccine trials, we show that viral latency and reactivation of latent infections is necessary in the natural history of HPV to match results from empirical trials. The model's screening algorithm reflects findings from the Western Cape's public health sector – low levels of screening coverage and linkage to treatment facilities, and poor adherence to screening schedules. The model matches stable trends in diagnosed cervical cancer incidence in South Africa, but it estimates increases in cervical cancer incidence over the last number of years (due to increased life expectancy of women on ART), which will result in sharp increases in diagnoses. While decreasing HIV prevalence and HPV vaccination will substantially reduce cervical cancer incidence in the long term, improvements in South Africa's current screening strategy, as well as switching to new screening technologies, will have significant impact in the short term. Conclusions: This thesis presents an epidemiological model of cervical cancer in South Africa – the first to dynamically simulate infection with both HIV and HPV at national level. It allows for estimation of the impact of both HIV and cervical cancer prevention on cancer incidence, and provides the opportunity to identify the vaccination and screening strategies with the greatest public health significance.