Browsing by Author "Swartz, Alison"

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    A Systematic Review of Caregiver Interventions in Infancy to Enable Responsive Caregiving and Secure Attachment in Low and Middle-Income Countries
    (2018) Gilmour, Kirsty A; Swartz, Alison; Roman, Nicolette
    The first 1000 days is recognised as the most sensitive period of development of an individual’s life. Infants in low and middle-income countries face significant risks to their development during this period. Research confirms that having a responsive, caring relationship between the infant and caregiver is a considerable protective factor for infants, and results in better longterm outcomes in cognition, language, academic achievement, social skills and behaviour. The aim of this review was to systematically examine the literature to identify interventions in low and middle-income settings that influence infant-caregiver responsivity and attachment and explore the characteristics of the interventions that contribute to its efficacy. Ten electronic databases were searched (Pubmed, Scopus, PsycINFO, PsycARTICLES, Africa-Wide, CINAHL, Health Source, ERIC, SocINDEX & Cochrane Library), as well as hand searching relevant reference lists for published articles in the English language from 1969-2018. A total of 11 765 studies were identified through the search strategy and 24 studies were included in the review. The included studies were critically appraised and then coded descriptively to enable a narrative synthesis of findings. Studies were from low and middle-income countries in Africa, Asia, Europe and South America and consisted predominantly of randomized control trials, but also quasi-experimental studies and a single cohort and qualitative study were included. All but two studies found positive effects on responsivity, attachment or both. For ten of the studies this effect was significant. The findings suggest implementing individual or group interventions in LMICS has a positive effect on caregiver-infant relationships and can be delivered successfully by trained non-professional staff.
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    A systematic review of digital health tools used for decision support by frontline health workers (FLHWs) in low- and middle- income countries (LMICs)
    (2019) De Leeuw, Kirran; Swartz, Alison; Lefevre, Amnesty
    In in low-and middle-income countries (LMIC), where there are very few trained physicians and nurses, community health workers (CHWs) are often the only providers of healthcare to millions of people. Such LMIC are countries that are classified, based on their geographic region and Gross National Income (GNI), as low-middle income by the World Bank Group, the worlds largest development bank. Research has shown digital health tools to be an effective strategy to improve the performance of frontline line health workers. The aim of this review was to systematically examine the literature on digital health tools that are used for decision support in LMIC and describe what we can learn from studies that have used these tools. As part of a larger parent study the following databases were searched: PubMed, Embase, Scopus, CINAHL, Global Health Ovid, Cochrane and Global Idex Medicus, to find ariticles in the following domains: training tools, decision support, data capture, commodity tracking, provider to provider communication, provider to patient communication and alerts, reminders, health information content. These domains were selected based on the World Health Organisation (WHO) framework for classifying digital health interventions. Content from all seven of these domains informed a series of reviews however this review focuses on how digital tools are used to provide decision support to FLHWs. Included studies were conducted in LMIC in Africa, Asia, North America and South America with the most common users of the tools being CHWs. Most tools for FLHW decision-support used in the interventions described in included articles were in either the pilot or prototype phases, and offered maternal and child health care services. Although decision support was the primary digital health function of all these studies, there was considerable variation in the number of digital health functions of each tool with most studies reporting decision support and data capture as their primary and secondary functions respectively. All the studies found their intervention to have beneficial effects on one or more of the following outcomes: beneficiary engagement, provider engagement, health effects and process/outputs. These findings show great potential for the use of decision support digital health tools as a means of improving the outcomes of health systems through; reducing the work load of FLHWs, reducing the costs of health care, improving the efficiency of service delivery and/or improving the overall quality of care.
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    Adolescent girls and young womens' perspectives of how their lives were impacted by participating in a combination HIV-prevention intervention in South Africa: a qualitative study
    (2020) Verwoerd, Wilmé; Duby, Zoe; Swartz, Alison
    Background: HIV incidence among adolescent girls and young women (AGYW) aged 15-24 in sub-Saharan Africa remains exceptionally high. Evidence shows that no single HIV prevention strategy will be effective in controlling the HIV pandemic. Research in recent years demonstrates the need for combination HIV prevention efforts, including biomedical, behavioral, and structural interventions. Given the urgent need to identify strategies that effectively reduce HIV risk among AGYW, it is crucial to understand how best to maximize the impact of combination HIV prevention interventions. This qualitative study explored the perceived impacts of a combination HIV-prevention intervention on the lives of AGYW in South Africa. Methods: The study is based on the findings from a qualitative evaluation of the RISE Club Programme, one component of a combination HIV intervention for AGYW. Using 24 focus group discussions and 63 in-depth interviews with 237 AGYW, we explored participants' experiences and perceptions of participating in a combination HIV prevention intervention and how it was perceived to impact their lives. Results: From the perspectives of AGYW, the intervention was perceived to positively impact their ability to communicate and develop and maintain healthy relationships with family, peers and partners. The findings show that the intervention helped increase their sexual and reproductive health (SRH) knowledge which improved their sexual self efficacy while also encouraging positive behavioural choices such as contraceptive uptake. It was also perceived to improve AGYW lives and personal development, specifically their self confidence and self esteem. However, logistical challenges with the implementation of the intervention and unmet expectations, created frustration and negative perceptions of the intervention in some instances. Conclusions: Overall, the findings demonstrate that intervention recipients perceived mostly positive impacts on their lives as a result of participating in the RISE programme. Understanding the perspectives of AGYW, is helpful in order to assess the benefits and perceived impacts of such an intervention on the lived realities of intended beneficiaries. Taking these perspectives into consideration and understanding some of the unforeseen negative impacts of the intervention can help to inform the design and implementation of future combination HIV prevention interventions for a similar sub-group of the population.
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    An exploration of the health facility staff's perspectives on patients who disengage from HIV care: A qualitative analysis from Khayelitsha, Cape Town, South Africa
    (2021) Nhemachena, Tsephiso; Swartz, Alison; Späth, Carmen
    This project will be completed as a requirement for the Master of Public Health (MPH) degree at the University of Cape Town. This study is linked to an already existing project of Médecins Sans Frontières (MSF), which is called the Welcome Service. The Welcome Service focuses on addressing barriers that HIV+ patients face when they are returning to care after disengagement from treatment. One of the common barriers to re-engaging in treatment that the project seeks to address is the unwelcoming approach that health care workers have towards patients that disengage from treatment. To address this barrier the Welcome Service provides intervention through training packages for health care workers. The training packages seek to address staff behaviour that is unhelpful and unsupportive to patients that intend to reengage with treatment. The Welcome Service was initially implemented at Michael Mapongwana Clinic in Khayelitsha. This Clinic is in a peri-urban settlement in the Western Cape province of South Africa. This was then scaled up to Ubuntu Clinic, also in the same location. To measure the change in the Welcome service project, baseline semi-structured interviews with health facility staff at Ubuntu Clinic were conducted. Health facility staff that were interviewed at baseline will participate in an in-depth interview as a follow-up after attending Welcome Service training. As an MPH project, I will conduct secondary data analysis from baseline interviews of health facility staff at Ubuntu Clinic. The analysis will focus on interviews in which the perceptions and attitudes of health facility staff towards patients who disengage from treatment were gathered. These interviews may also explore health facility staff's perspectives on the reasons for patients disengaging from HIV treatment and reasons that might help patients to reengage with HIV treatment. This current project seeks to address the research question: What are the perspectives of health facilities staff on patients who disengage from HIV care in Khayelitsha, Cape Town, South Africa. This study will use inductive thematic analysis and the analysis will be done in NVivo, a qualitative data management software program. The researcher will identify themes from the trancripts and will not use a predetermined theory to derive themes, but will allow the data to guide theme development. Interviews were conducted by the MSF research team in English. The participants included in the study were doctors, nurses, counsellors, data clerks, security guards, and allied health professionals at Ubuntu Clinic. The respondents were above eighteen years old and were in the capacity to give consent on their own. The MSF research team was responsible for the recruitment of participants. All health facility staff that participated in this study were requested to give written informed consent to participate in the interviews. The findings of the primary study have not been published yet because the project is still in progress. The researcher received the questionnaire that was used in the study and from there the researcher developed a research question for this project. Some of the questions from the questionnaire asked the health facility staff if they feel able to deal with patients who disengage and how they feel when dealing with a patient who is returning to care. A data-sharing agreement was signed by the researcher and MSF before the researcher received the data obtained from MSF's project. The researcher will have access to the transcripts of the interviews, which have already been transcribed. In reporting, the researcher will not include the participants' names or any identifying information to ensure anonymity and confidentiality. This analysis aims to inform current and future health interventions to re-engage people living with HIV (PLWHIV) who have disengaged from care.
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    Assisted Partner Notification for HIV: a qualitative study of providers and female patients perspectives and experiences of assisted partner notification in Cape Town, South Africa
    (2024) Perera, Shehani; Swartz, Alison
    Background Assisted partner notification (APN) is a partner notification approach where trained providers assist individuals newly diagnosed with HIV to notify their partners and then link these partners to testing and treatment services. APN has been found to be more effective at increasing HIVtesting and linkage to care rates than passive referral, where HIV-positive individuals notify partners themselves. In 2016, the WHO published official APN guidelines recommending APN for HIV. However, various factors have influenced the implementation of APN such as human rights concerns and ethical dilemmas, fear of social harm, intimate partner violence or relationship dissolution, and social and cultural factors such as gender. In South Africa, there are no specific guidelines or policies informing the implementation of APN and we are unsure about how implementation unfolds. This study sought to better understand APN by exploring patients' and providers' experiences and perceptions of APN, taking into consideration different factors that shape partner notification documented in local and international literature. The influence of religion and faith and the involvement of faith-based organisations, as well as the impact of the COVID-19 pandemic on APN for HIV also feature in this study. Methods Qualitative research methods were used in this study. Thirty-four individual, semi-structured interviews with providers (n=10), female patients (n=12) and key informants (n=12) were conducted between March 2021 and February 2022. A diary study using the WhatsApp social media platform and fieldwork journals served to triangulate the interview data collected. Data analysis involved thematic analysis incorporating an intersectional lens. The data were transcribed, then coded using NVivo software. The codes were subsequently organised into overarching themes and sub-themes. Ethics approval was obtained from the Human Research Ethics Council at the University of Cape Town (HREC Ref: 840/2020) and the City of Cape Town (Ref: 28185). Results The study found that while there are no official APN guidelines in this setting, an unofficial APN process unfolded, nevertheless. Patients' views of APN were varied; some felt providerassistance for partner notification was not required at all, others felt it was required if their attempts to notify partners failed and a few saw it as a form of interference in their personal and sexual lives. Relationship type and pre-marital HIV-testing were found to influence patients' decision-making around APN engagement. Insider and outsider narratives emerged revealing the complexities involved in making decisions about who to include or exclude during APN. Providers were found to play several roles during APN: education, facilitation/mediation, and protection. Providers also expressed how their relationships with patients could considerably influence whether patients would notify partners. Factors influencing providers' willingness to offer assistance during APN included fears of causing negative events in patients' relationships and partners not maintaining confidentiality after being notified. Providers employed various trust-building strategies to navigate these concerns. Power imbalances and gendered assumptions of health service use influenced APN substantially. Women took on a central role in partner notification due to greater healthcare involvement and societal beliefs around healthcare practices. Female patients often communicated HIV matters with female providers, revealing that caregiving roles were mostly played by women in APN. Indirect and social media based-partner notification as well as 'collusion testing', where providers and patients colluded to bring partners to clinics for testing, emerged as strategies to fulfil rights and responsibilities related to APN. While some of these effectively linked sexual partners to testing and care, it raised ethical concerns about partners' rights. Provision of APN was also found to be different between non-faith-based and faith-based providers who offered either biomedical care or a form of 'umbrella care' which incorporated biomedical and psychosocial and emotional care, respectively. The moralisation of HIV and certain sexual behaviours using religion as a moral framework imposed a sense of obligation to engage in APN. Participants were ambivalent about the involvement of church elders or pastors in APN, seeing providers as being more appropriate due to their HIV-related training. However, many acknowledged the importance of religious support in motivating them to notify partners and finding hope and resilience, if diagnosed with HIV. Conclusion This study highlights the need for clear and context-specific guidelines in implementing APN. The absence of such guidelines resulted in uncertainty among both patients and providers, hindering their participation in APN. While existing policies mention APN, the study highlights partial and limited implementation, calling attention to the need for improved, localised strategies. Trust emerged as the cornerstone of the APN process, shaping both patient and provider engagement. Trust-building strategies were important for establishing a secure environment for APN. Furthermore, the study revealed gendered dynamics in APN through which care responsibilities such as mediating between providers and male sexual partners further exacerbated the feminization of HIV. Thus, the desire for greater control, agency, and shared decision-making became evident. The exploration of FBOs in APN provision also suggests the importance of holistic care, considering spiritual and medical dimensions of healthcare journeys. Drawing parallels between COVID-19 and HIV contact tracing, the study emphasises the unique challenges posed by different contexts.
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    Caregivers readiness to disclose HIV status : experiences and challenges of child disclosure in South Africa
    (2016) Tapscott, Kimberley; Colvin, Christopher J; Swartz, Alison
    Disclosure of HIV status to children is a challenging process for caregivers, as it involves discussing a highly stigmatised disease, which may cause psychological stress to a child. Despite the benefits of disclosing, rates of HIV disclosure remain low as caregivers face various obstacles preventing them from disclosing, and this can have long-lasting effects on the treatment adherence of HIV-positive children. This qualitative study explored the perspectives and experiences of caregivers, in order to understand their readiness to disclose HIV status to their children, and address the factors that assist and hinder the process. Caregivers of HIV positive children (aged 5-15 years) participated in two focus group discussions (11 in each), and in-depth interviews were conducted with eight additional caregivers. Two healthcare workers and 10 NGO staff were also interviewed. Three key themes emerged from the data: caregivers' avoidance or delay of disclosure, factors related to caregivers' motivations to disclose, and caregiver's perception of child readiness for disclosure. The findings support the view that caregiver readiness is a key element of child disclosure. The research identified how caregivers can be educated about the benefits of disclosure, and be guided to take responsibility for the process. As there is a lack of context-specific and culturally-sensitive recommendations for child disclosure in South Africa, this research can be used to broaden the case base to inform the development of standardised guidelines that will assist caregivers to effectively communicate and manage the process of HIV disclosure with their children.
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    Coming of age in Khayelitsha: gendered identity, sexual partnerships and the transition to adulthood
    (2017) Swartz, Alison; Colvin, Christopher J; Harrison, Abigail
    The lives of young people in Khayelitsha are characterised by a series of intersecting challenges. These include inadequate access to education, limited opportunities to find gainful employment, exposure to violence and the risk of contracting HIV. Several conventional avenues of transition to adulthood, for example achieving financial independence, moving out of the parental home or getting married, remain unavailable to many. The majority thus find themselves in a situation of waithood, an interminable period between childhood and adulthood characterised by extreme uncertainty. This thesis takes up questions of what it means to be a young man or woman navigating towards adulthood in this context of socioeconomic marginalisation. In particular, it explores the ways that youth negotiate the tensions between the structures that shape their lives and their opportunities for agency within the domains of gendered identities and sexual partnerships. Public health research and intervention with youth tends to rely more heavily on approaches underpinned by individual-level behaviour change theories, with lesser albeit growing attention paid to the structural forces that shape young lives. This thesis aims to balance the reading of individuals' capacity for agency in decision-making, with the broader structural forces that shape their life trajectories. To this end, a longitudinal, ethnographic approach was employed to capture nuances of context and experience as they unfolded and shifted through time and space. The data presented here is drawn from 18 months of ethnographic fieldwork with young people in the neighbourhood of Town Two, Khayelitsha, primarily collected between 2014 and 2015. Youth transition to adulthood is explored in the two interrelated domains of gendered identity and sexual partnerships. Within these domains, living up to individual and social ideals associated with masculinity and femininity is persistently challenging. Faced with these challenges, young people employ creative and dynamic strategies in their endeavours to maximize the precarious gains they make in their transition towards adulthood. Broadly speaking, these strategies include those linked to their physical bodies, sexual and social networks and the ways that they invoke ideas about what it means to be a young South African citizen. The findings highlight that in their transitions to adulthood, youth in Khayelitsha are neither complete victims, nor entirely free agents with the capacity to radically change their circumstances. This thesis ends by offering some recommendations about how public health programming might take into account the lived experiences of youth as they navigate the transition to adulthood in this context.
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    Community health workers in Khayelitsha : motivations and challenges as providers of care and players within the health system
    (2012) Swartz, Alison; Colvin, Christopher J
    Community health workers (CHWs) play an important role in health care in South Africa and similar countries, but relatively little is known about CHW motivations and experiences in the provision of care. This thesis considers these issues in three parts: 1. A protocol for a study of community health work in Khayelitsha, an impoverished peri-urban settlement near Cape Town, which is home to a number of ‘flagship’ public health interventions aimed at HIV/AIDS and TB. 2. A review of literature on community health work exploring naturalistic versus economistic discourses around care work, and the complex intersections of these discourses. 3. An ethnographic account of CHWs who provide a wide range of community-based care work in Khayelitsha.
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    Digital tools for training frontline health workers in low and middle-income countries: A systematic review
    (2019) Schoeman, Fransien; Swartz, Alison; LeFevre, Amnesty
    The World Health Organization (WHO) has forecast a global shortage of health workers by 2030, predominantly affecting low- and middle-income countries (LMICs). This sits in tension with the United Nations’ (UN) Sustainable Development Goal 3 (healthy lives and well-being) through universal health coverage (UHC). To address this problem, the WHO encourages task shifting, recruitment, training, and deployment of health workers. In lowand middle-income countries (LMICs), frontline health workers (FLHWs) are responsible for expanding the reach of the health system and providing crucial reproductive, maternal, newborn and child health (RMNCH) services. Adequate and appropriate training is fundamental to the success of FLHWs, particularly in contexts where their scope of work may evolve or expand over time. Digital health solutions (defined as the use of digital, mobile and wireless technologies to support the achievement of health objectives) are increasingly being used to support the training of FLHWs. Strategies may rely on use of digital tools, including mobile phones, as the primary modality for training or as tools which augment traditional face-to-face instruction. Digital health has potential for FLHW training as it allows for listening, learning and teaching through interactive health content accessible even on basic mobile phones. This dissertation explored the literature on FLHWs in LMICs, digital health in LMICs, digital health used by FLHWs, and digital health used for training of FLHWs in LMICs. The journal “ready” component is a systematic review which discusses the various aspects of digital training for FLHWs in LMICs. For the purposes of the systematic review, seven electronic databases were searched for articles published in English from 2008-2018. Combinations of medical subheadings (MeSH) that were used were: “mHealth”, “health worker”, “community health worker” and “low- and middle-income country”. From a total of 2628 identified studies, abstracts were screened with four filters to identify studies about “training”, and eventually a total of 16 studies were included. The included studies were critically appraised and coded descriptively to enable a narrative synthesis of findings. Of the sixteen studies, twelve used mobile and/or smartphones for FLHW training. A wide range of digital platforms were used to provide information (and where relevant enable interaction). Duration of training programs varied from five days to six months. Training content was relevant to the various health services and practice areas the FLHWs worked in. Training focused on continuing education through in-service training of new content or in-service refresher courses. Three training pedagogies were used: 1) didactic training techniques – in four studies information was provided passively without an interactive component; 2) interactive training techniques – six studies used platforms to provide information along with an interactive component via multi-media; and, 3) blended-learning approach – six studies delivered training via didactic and interactive approaches by combining live and distance training. Consistent with the literature review, all studies reported increased knowledge and positive perceptions of digital health for FLHW training. Interactive and blended learning approaches, especially when accessed through mHealth technologies, are feasible, effective, appropriate, cost effective and scalable in LMICs. The conclusion from the literature and systematic reviews were that long-term effects (e.g. change in behaviour, improved service provision) need to be researched further.
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    Exploring how Health-related Quality of Life (HRQOL) is experienced among patients living with HIV associated TB in Khayelitsha, South Africa
    (2020) Hickman, John-Henry; Swartz, Alison; Sicwebu, Nmhla
    Health-related quality of life (HRQOL) is a construct that has received attention in research for nearly four decades. However, renewed interest in this field came about with advances in medical technology and health policies. Better treatment options and policies, which enables greater access to health care, have improved health outcomes, such as leading to an extension in life expectancy. This rings particularly true for Human Immunodeficiency virus (HIV) and associated illnesses such Tuberculosis (TB). However, improvements in health outcomes are not necessarily accompanied by satisfactory patient experiences of HRQOL. Health-related quality of life is predominantly studied through quantitative research methodologies. However, the measures used are not entirely tailored to the South African context. Consequently, this mini-dissertation aims to explore HRQOL using qualitative methodological inquiry within the South African context. This mini dissertation is structured around the three following components: A research protocol (Part A) which addresses HRQOL in a South African context with particular focus on HIV and TB. Part B is a literature review examining existing HIV, TB and HRQOL literature, with emphasis on the South African context. The final section (Part C) is a manuscript for a journal article prepared to be published. Part C focuses on the social experience of HRQOL and how it is the central construct to experiencing HRQOL in South Africa as opposed to an individualised view in Western settings. The findings from this mini dissertation can add to the limited existing HRQOL literature in South Africa, by providing a perspective on how HRQOL is experienced in this country. The knowledge obtained here can further aid in the development or improvement of interventions and policies which aim to not only improve patient health outcomes, but HRQOL as well. Lastly, it can provide valuable information to those focused on developing quantitative HRQOL tools that are appropriate for use in South Africa.
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    Factors that influence adolescents condom use decision-making in the Western Cape, South Africa
    (2019) Davids, Eugene Lee; Swartz, Alison; Mathews, Catherine
    This study explores factors that influence condom use decision-making of adolescents from two schools in the Western Cape, South Africa. Thematic analysis was used to analyse the data generated from 16 individual semi-structured interviews. When exploring the factors that influence adolescent’s condom use decision-making, sexual debut and the role that emotion plays in the decision-making process were frequently discussed. The themes which emerged for sexual debut included relationships were about displaying true love which was equated with having sex and respecting parents’ expectations and rules informing decisions not to have sex at this age. When exploring the themes which emerged for condom use decision-making, the adolescents spoke about their concerns for the future and organising their lives. In addition, anticipated fear about falling pregnant, becoming parents and being infected with a disease emerged when exploring adolescent condom use decision-making. Understanding adolescent condom use can assist in aligning sexual and reproductive health (SRH) interventions and supporting healthy SRH decision-making and healthy relationships for adolescents.
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    Fertility Desires and Fertility Control: Young Women's Contraceptive decision-making in Khayelitsha, South Africa
    (2021) Falakhe, Zipho; Swartz, Alison
    Early fertility remains a public health concern in South Africa, with teenage pregnancy rates remaining high, and more significantly among black adolescent girls of low socioeconomic status. This indicates the unmet need of contraception for adolescent girls. Contraceptive use and non-use by young women of low socioeconomic status is a complex issue that reveals a range of political and socio-economic injustices. Barriers to contraceptive access and use have been identified to include: health care access, interaction with healthcare providers, genders norms, knowledge gaps, reproductive choices, socio-cultural attitudes and policing, intimate partner relationship dynamics, parental judgement, and side effects. To address this public health concern there has been an increase in the provision of contraceptives through the introduction of long-acting reversible contraceptive (LARC) methods. However, young women's response to LARC methods has been characterized by low and declining uptake and early removals. A tension exists between the way public health practitioners imagine meeting the contraceptive needs of young women of low-socio economic status and what it is acceptable as contraception by young women. This mini-dissertation aims to examine young women's perceptions of long-term contraception and LARC methods; specifically, the implant and intrauterine device (IUD) contraceptive methods in how they reveal young women's fertility attitudes and how it shapes their contraceptive decision-making. This examination foregrounds the individual, interpersonal relationships and social contexts that shape sexual and reproductive choices of young women. The mini dissertation is structured in two parts: the research protocol (Part A) and a manuscript for a journal article prepared for publication (Part B). Part A explores the factors that influence young women's contraceptive decision-making at three different levels, namely: the individual level, interpersonal relationship level and social and structural context level. For the aim of further understanding young women's contraceptive decision-making, PART B focusses on examining the tensions in the acceptability and uptake of LARC methods and long-term contraception use to explain low and ineffective contraceptive use by young women, which often result in unwanted pregnancies. The findings from this mini dissertation can add to the existing literature that examines why current contraceptive provision has been inadequate in meeting the contraceptive needs of young women of low socioeconomic status and significantly curbing early fertility. Additionally, they can provide valuable information to public health practitioners on how particular factors influence the acceptability of contraceptive methods and as well as the root causes of behaviors that result in ineffective contraceptive use resulting in early fertility. Therefore, providing clear points for public health intervention.
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    Knowledge, Perceptions and Attitudes of Young Adults Towards Electronic-cigarettes
    (2019) Mhazo, Pakhani; Swartz, Alison; Wallace, Melissa
    Electronic cigarettes (e-cigarettes) are deemed to be safer than tobacco cigarettes because they do not contain a number of toxicants and carcinogens that are present in tobacco cigarettes. However, their long-term health effects are unknown. Despite concerns surrounding this, there has been a rapid market penetration of e-cigarettes worldwide. South Africa has no legislation which specifically controls the marketing, sale and use of e-cigarettes and concerns have been raised over the increasing use of e-cigarettes by youth, who are often attracted to these novel products. This study is one of the first studies to explore the knowledge and perceptions of ecigarettes in South Africa. A qualitative approach was used to explore young adults’ perceptions, attitudes and behaviour related to e-cigarettes and assess the factors that shape those perceptions. The sources from which the participants accessed e-cigarette-related information were also explored. The study was conducted at the University of Cape Town and participants were registered male and female students at the university. Focus group discussions and individual interviews were used to collect data and thematic analysis approach was used to analyse the data. The results show that participants generally perceived e-cigarettes as healthier than tobacco cigarettes despite showing limited knowledge of the chemical constituents of e-cigarette liquid. Rather, the majority of the participants felt e-cigarettes were safer because of the pleasant smell. A pleasant smell from e-cigarettes was associated with health and the unpleasant smell was associated with danger. E-cigarettes were also viewed as a symbol of social status. The study recommends that e-cigarette awareness should be increased, and e-cigarettes should be regulated as tobacco products to alter the perception that they are safe.
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    Leveraging community participation through health committees to achieve health rights : the role of power
    (2016) Hasson, Marion; Colvin, Christopher J; Swartz, Alison
    The concept of health committees has been promoted as an effective mechanism for assisting communities to realize their health rights. These committees tend to be formal structures made up of representatives from local government, health facilities and communities. Much of the attention has focused on identifying strategies and interventions to strengthen health committees as vehicles for achieving the right to health and the focus has been on educating, raising awareness, training and policy advocacy. However, it is important to understand what participation looks like on the ground and to take in to account the day-to-day challenges and obstacles that health committees as a vehicle for community participation; interacting with stakeholders; and getting support from health facility managers and staff. These factors impact on the health committees 'ability to facilitate and support community participation, yet they are driven by power dynamics and human interactions and relationships. Little attention has been paid to these dynamics, which play an important role in meaningful community participation at grassroots. The Power Cube framework was used to explore the multiple dimensions of power that hinder or enable the health committees' ability to support the community to realize their right to health. The Power Cube framework allowed for an investigation of how power dynamics are perceived by a particular group, as well as providing for the comparison of different social, economic and political context. It enabled a comparison with different contexts where there are policies for supporting the community participation in health but implementation has been difficult it in practice.
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    Organisational Culture and Mask-Wearing Practices for Tuberculosis Infection Prevention and Control among Health Care Workers in Primary Care Facilities in the Western Cape, South Africa: A Qualitative Study
    (2021-11-19) Kallon, Idriss I; Swartz, Alison; Colvin, Christopher J; MacGregor, Hayley; Zwama, Gimenne; Voce, Anna S; Grant, Alison D; Kielmann, Karina
    Background: Although many healthcare workers (HCWs) are aware of the protective role that mask-wearing has in reducing transmission of tuberculosis (TB) and other airborne diseases, studies on infection prevention and control (IPC) for TB in South Africa indicate that mask-wearing is often poorly implemented. Mask-wearing practices are influenced by aspects of the environment and organisational culture within which HCWs work. Methods: We draw on 23 interviews and four focus group discussions conducted with 44 HCWs in six primary care facilities in the Western Cape Province of South Africa. Three key dimensions of organisational culture were used to guide a thematic analysis of HCWs’ perceptions of masks and mask-wearing practices in the context of TB infection prevention and control. Results: First, HCW accounts address both the physical experience of wearing masks, as well as how mask-wearing is perceived in social interactions, reflecting visual manifestations of organisational culture in clinics. Second, HCWs expressed shared ways of thinking in their normalisation of TB as an inevitable risk that is inherent to their work and their localization of TB risk in specific areas of the clinic. Third, deeper assumptions about mask-wearing as an individual choice rather than a collective responsibility were embedded in power and accountability relationships among HCWs and clinic managers. These features of organisational culture are underpinned by broader systemic shortcomings, including limited availability of masks, poorly enforced protocols, and a general lack of role modelling around mask-wearing. HCW mask-wearing was thus shaped not only by individual knowledge and motivation but also by the embodied social dimensions of mask-wearing, the perceptions that TB risk was normal and localizable, and a shared underlying tendency to assume that mask-wearing, ultimately, was a matter of individual choice and responsibility. Conclusions: Organisational culture has an important, and under-researched, impact on HCW mask-wearing and other PPE and IPC practices. Consistent mask-wearing might become a more routine feature of IPC in health facilities if facility managers more actively promote engagement with TB-IPC guidelines and develop a sense of collective involvement and ownership of TB-IPC in facilities.
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    Reported infant feeding practices and contextual influences on breastfeeding: qualitative interviews with women registered to MomConnect in three South African provinces
    (2020-09-14) Trafford, Zara; Jewett, Sara; Swartz, Alison; LeFevre, Amnesty E; Winch, Peter J; Colvin, Christopher J; Barron, Peter; Bamford, Lesley
    Abstract Background Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage. Methods For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February–March 2018 in South Africa’s KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes. Results Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media. Conclusions Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women’s knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women’s breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.
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    Sexual health in relation to religious beliefs: perceptions of young women living in Khayelitsha
    (2019) Perera, Shehani; Swartz, Alison
    South Africa continues to have the highest HIV-prevalence in the world, in addition to other sexual health-related issues. A vast majority of its population is also religiously affiliated with Christianity. This study sought to understand how young women living in Khayelitsha experience the relationship between sexual health and religion within the context of uncertainty and socio-economic deprivation. How their sexual health-decision making unfolds given the tensions that arise between religious expectations and socio-economic realities and how they perceive the partnership between religious organisations and public health facilities offering sexual health services was also explored. Data collection consisted of ethnographic field notes, 11 semistructured interviews and 3 focus group discussions with 6 people in each group. Data were then analysed using a thematic analysis approach. The findings reveal that young women experience the tension between religious expectations and their socio-economic realities through the “moral dichotomisation of right and wrong” and that this, in addition to the ‘dynamics of hypervulnerability’ consisting of gender inequalities and economic vulnerability, leads to a sense of lacking control over sexual health decision-making. The call for church involvement in sexual health-related matters reveals a deeper desire for various forms of support as they transition to adulthood in the context of uncertainty and socio-economic marginalisation. The article argues that young people navigating uncertainty and dealing with the complexities of transitioning to adulthood may perceive religion and the church to play the role of a custodian in sexual health issues, however, expectations of the church are difficult to live up to and sit in tension with socio- economic realities. Thus, a division of duties between religious organisations and public health facilities should be established to strengthen sexual health promotion and prevention efforts.
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    Stakeholder understandings of the Human Papillomavirus (HPV) vaccine in Sub-Saharan Africa: a qualitative systematic review
    (2019) Deignan, Caroline; Swartz, Alison; Cooper, Sara
    Cervical cancer rates in Sub-Saharan Africa (SSA) are amongst the highest in the world. The World Health Organization currently estimates that worldwide, cervical cancer will kill more than 443,000 women per year by 2030, of which 90% of deaths are predicted to occur in SSA. The Human Papillomavirus (HPV) vaccine provides primary protection against the most common cancer-causing strains of HPV that are responsible for cervical cancer. Over the last five years, there has been a slow increase in the number of African countries that have introduced the HPV vaccine via demonstration and pilot projects, and a minority of African countries that have incorporated the HPV vaccine into their National Immunisation Programmes. As part of this systematic review, a literature review was conducted and revealed that research has been conducted on top-down barriers and facilitators to HPV vaccine uptake and have found that poor health system capabilities, inaccessibility to medical care, low cervical cancer screening levels, inadequate infrastructure, finances, and health worker training are significant systemic barriers to HPV vaccination success in SSA. Little research has been conducted on demand-side or end-user perspectives of, and decisions around, the HPV vaccine. In order to complement existing research, and inform current and future implementation approaches, this qualitative systematic review explored stakeholder understandings of the HPV vaccine in SSA. This review searched the following databases: Embase (via Scopus), Scopus, MEDLINE (via PubMed), PubMed, EBSCOhost, Academic Search Premier, Africa-Wide Information, CINAHL, PsycARTICLES, PsycINFO, SocINDEX, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) and found a total of 259 articles. Of these, 31 articles met the inclusion and exclusion criteria and were included in the review. Braun and Clarke’s six step process for conducting a thematic analysis was used for analysis and studies were assessed for quality using the Critical Appraisal Skills Programme (CASP) checklist. Three major themes emerged from the thematic analysis: knowledge is intertwined with misinformation; fear shapes contradictory perceptions about the HPV vaccine; and social norms and gender dynamics are relevant factors in how stakeholders understand the HPV vaccine in SSA. This review iterates the importance of first working with communities to gauge understandings of the HPV vaccine, before trying to implement change through education, sensitization and behavior change.
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    Stakeholders’ Understandings of Human Papillomavirus (HPV) Vaccination in Sub-Saharan Africa: A Rapid Qualitative Systematic Review
    (2021-05-12) Deignan, Caroline; Swartz, Alison; Cooper, Sara; Colvin, Christopher J
    Cervical cancer rates in Sub-Saharan Africa (SSA) are amongst the highest worldwide. All three of the Human Papillomavirus (HPV) vaccines (9-valent, quadrivalent and bivalent HPV vaccine) provide primary protection against the most common cancer-causing strains of HPV (types 16 and 18) that are known to cause 70% of cervical cancers. Over the last five years, there has been an increase in Sub-Saharan African countries that have introduced the HPV vaccine. The majority of research has been conducted on supply-side barriers and facilitators to HPV vaccination uptake in SSA, yet little research has been conducted on demand-side or end-user perspectives of, and decisions around, HPV vaccination. In order to complement existing research, and inform current and future HPV vaccination implementation approaches, this qualitative systematic review explored Stakeholders’ understandings of HPV vaccination in SSA. This review searched the following databases: Embase (via Scopus), Scopus, MEDLINE (via PubMed), PubMed, EBSCOhost, Academic Search Premier, Africa-Wide Information, CINAHL, PsycARTICLES, PsycINFO, SocINDEX, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) and found a total of 259 articles. Thirty-one studies were found eligible for inclusion and were analyzed thematically using Braun and Clarke’s methods for conducting a thematic analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Three major themes emerged from this analysis; knowledge of HPV vaccination and cervical cancer is intertwined with misinformation; fear has shaped contradictory perceptions about HPV vaccination and gender dynamics are relevant in how stakeholders understand HPV vaccination in SSA.
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    The historical and current roles of Street Committees in strengthening health services in Gugulethu
    (2021) Chidavaenzi, Merlary; Van, Pinxteren Myrna; Swartz, Alison
    Communities are an important part of health systems as they assist in the monitoring of health service quality and providing the end users with a voice. This is particularly important in South Africa where there is a quadruple burden of disease, and a history of social injustice which continues to impact social determinants of health in communities. This presents significant challenges to provide high-quality health services in South Africa. To redress these health challenges, the South African government is relying on community-led mechanisms aimed at enhancing access to and strengthening of health services in communities. By using ethnographic methodologies, this paper explores the role of Street Committees (SC) in strengthening health services in a low-income setting in South Africa. The mini thesis is divided into two parts, a research protocol (Part A) and journal ‘ready' manuscript (Part B). Part A explores the historical, current, and future roles of SC in Gugulethu as well as identifying gaps in literature. Part B focuses on emerging roles from the data collected on SC in strengthening health services in Gugulethu. This thesis shows that although SC do not see themselves as health stakeholders nor are perceived by others as such, they do play a significant role, as they strengthen access to health care services through their numerous roles in the community. SC strengthen access to health services by enhancing physical access to health services, bringing medication to the frail and elderly, informing and educating the community about services and health issues and lastly by advocating for high quality health care in their community. This article also highlights the different roles SC play in strengthening health services through collaboration, advocacy and community education and provides lessons for community engagement in health systems which can be used to provide quality, equitable and people centred health care for all.