Browsing by Author "Zarowsky, Christina"

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    Formative research for the development of an appropriate, acceptable and feasible intervention aimed at reducing type 2 diabetes risk in disadvantaged women after gestational diabetes in South Africa
    (2021) Muhwava, Lorrein Shamiso; Murphy, Katherine; Zarowsky, Christina; Levitt, Naomi
    Background Gestational diabetes mellitus (GDM) is one of the most common obstetric complications, affecting 18.4 million live births globally. In South Africa, the high prevalence of GDM estimated to be up to 25.8%, is driven by the high rates of obesity. Women with a history of GDM have a seven-fold increased lifetime risk of developing type 2 diabetes. In addition, children born of women with GDM are susceptible to impaired glucose tolerance and obesity in adulthood. Prioritising GDM as a public health issue is critical for improving maternal and child health care services and non-communicable disease prevention efforts. There is consistent evidence demonstrating that, in at-risk populations, lifestyle change can reduce the risk of developing type 2 diabetes and among women with GDM, continuation of lifestyle changes after a GDM pregnancy can prevent progression to type 2 diabetes. Understanding women's lived experiences and views around GDM is critical for the development of behaviour change interventions. Further, insights from women's experiences of the healthcare system for GDM care are important for informing health policy and improving the quality of care. At present, little is known about the policies and practices relating to the management of GDM in low- and middle- income countries and health systems interventions that support and facilitate continuity of care are lacking. This thesis constitutes the formative research for a complex intervention study aimed at developing and evaluating a novel health system intervention to reduce the subsequent risk of developing type 2 diabetes among women with GDM. The findings will inform the planning, development and testing of an appropriate and innovative intervention for women with GDM, to be integrated into existing health services in South Africa. Methods and Results The first study used document reviews of policy documents and clinical practice guidelines for the management of GDM in South Africa and 11 key informant interviews with policy makers, health service managers from the Department of Health and clinicians working in the public health services to explore the existing policies and reported clinical practices relating to antenatal and postnatal care for women with GDM in the public health sector in South Africa and identified important factors in delivering an integrated mother - baby postpartum health service. We found that the management of GDM in South Africa is aligned with international standards, in addition to locally developed guidelines and protocols for clinical practice. Our findings also confirmed that postpartum follow-up for women with GDM is a significant problem in South Africa as a result of fragmentation of care and the absence of standardised postnatal care services. Key informants also raised patient – related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for women with GDM. The second study was a descriptive qualitative study which explored the lived experiences of 35 women with prior GDM using content analysis and the COM-B model to identify factors influencing lifestyle change during and beyond the GDM pregnancy. The results suggest that the COM-B model's concepts of capability (knowledge and skills for behaviour change), opportunity (resources for dietary change and physical activity) and motivation (perception of future diabetes risk) are relevant to lifestyle change among women with GDM in South Africa. The third study was an in- depth exploration of women's lived experiences of GDM, their context and perceived needs. Women discussed the emotional and psychological burden of having GDM, highlighting (i) their initial emotional reactions to receiving a GDM diagnosis, (ii) their experience of adjusting to the constraints of living with GDM (iii) their feelings of apprehension about childbirth and their maternal role and (iv) their feelings of abandonment in the post-partum period once the intensive support from both health system and family ends. The fourth study further explored women's perspectives of and satisfaction with GDM care in the public health sector as well as their views on the feasibility and acceptability of the proposed intervention using the Donabedian's quality of care framework. Key sub-themes relating to ‘structure' of care were the organisation of GDM health services, efficiency of the referral, efficiency of management practices, quality of hospital facilities and services and the availability of adequate healthcare resources. Overall satisfaction with GDM care processes was influenced by women's unmet need for education and behaviour change counselling, interpersonal support from health care providers and peers and the health services' capacity to enable them to actively participate in their care. Conclusion The management of GDM is currently foetal - centric and over-medicalised, focusing on clinical care processes to achieve glycaemic control and safeguard foetal health. There is a critical need for woman-centred approaches to be incorporated in the management of GDM in order to improve women's overall experiences of care. Behaviour change interventions for women with GDM should target factors within the physical and social environments, that influence women's capacity for lifestyle change. In addition, we recommend routine mental health and psychosocial vulnerability screening and monitoring for women diagnosed with GDM throughout pregnancy and postpartum to improve prognoses. Finally, holistic interventions and health policies that directly support continuity of care are urgently needed if high rates of progression to type 2 diabetes in this population are to be avoided.
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    Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study
    (2020-06-26) Mutabazi, Jean Claude; Gray, Corie; Muhwava, Lorrein; Trottier, Helen; Ware, Lisa J; Norris, Shane; Murphy, Katherine; Levitt, Naomi; Zarowsky, Christina
    Background Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. Methods A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. Results Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. Conclusions Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.
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    Perspectives on the psychological and emotional burden of having gestational diabetes amongst low-income women in Cape Town, South Africa
    (2020-10-12) Muhwava, Lorrein S; Murphy, Katherine; Zarowsky, Christina; Levitt, Naomi
    Background The diagnosis of gestational diabetes mellitus (GDM) may affect women’s mental wellbeing, functioning and quality of life, with potentially negative effects on treatment adherence. Identifying and addressing the psychological and emotional needs of women with GDM, could have benefits for sustainable long-term behavioural change following the affected pregnancy. This study explored the lived experiences of women with GDM and the impact of GDM on their experience of pregnancy and sense of well-being. Methods Purposive sampling was used to recruit women who had been diagnosed with GDM in their previous pregnancy and received antenatal care at a tertiary hospital in Cape Town, South Africa. This was a descriptive qualitative study using a combination of focus groups and in-depth interviews for an in- depth exploration of women’s lived experiences of GDM, their context and perceived needs. Data analysis followed an iterative thematic analysis approach. Results Thirty-five women participated in nine focus groups and five in-depth interviews. Women discussed the emotional and psychological burden of having GDM, highlighting (i) their initial emotional reactions to receiving a GDM diagnosis, (ii) their experience of adjusting to the constraints of living with GDM (iii) their feelings of apprehension about childbirth and their maternal role and (iv) their feelings of abandonment in the post-partum period once the intensive support from both health system and family ends. Conclusions The current biomedical model used in the management of GDM, is highly foetal-centric and fails to acknowledge important psychological factors that contribute to women’s overall wellbeing and experience of pregnancy. These results demonstrate the importance of incorporating mental health support in the management and care for women with GDM in public health services, along with facilitating emotional support from partners and family members. Based on our findings, we recommend routine mental health and psychosocial vulnerability screening and monitoring for women diagnosed with GDM throughout pregnancy and postpartum to improve prognoses.
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    Policies and clinical practices relating to the management of gestational diabetes mellitus in the public health sector, South Africa – a qualitative study
    (BioMed Central, 2018-05-10) Muhwava, Lorrein Shamiso; Murphy, Katherine; Zarowsky, Christina; Levitt, Naomi
    Background Women with a prior gestational diabetes have an increased lifetime risk of developing type 2 diabetes. Although post-partum follow-up for GDM women is essential to prevent progression to type 2 diabetes, it is poorly attended. The need for health systems interventions to support postpartum follow-up for GDM women is evident, but there is little knowledge of actual current practice. The aim of this study was to explore current policies and clinical practices relating to antenatal and post-natal care for women with GDM in South Africa, as well as health sector stakeholders’ perspectives on the barriers to -- and opportunities for -- delivering an integrated mother - baby health service that extends beyond the first week post-partum, to the infant’s first year of life. Methods Following a document review of policy and clinical practice guidelines, in-depth interviews were conducted with 11 key informants who were key policy makers, health service managers and clinicians working in the public health services in South Africa’s two major cities (Johannesburg and Cape Town). Data were analysed using qualitative content analysis procedures. Results The document review and interviews established that it is policy that health services adhere to international guidelines for GDM diagnosis and management, in addition to locally developed guidelines and protocols for clinical practice. All key informants confirmed that lack of postpartum follow-up for GDM women is a significant problem. Health systems barriers include fragmentation of care and the absence of standardised postnatal care for post-GDM women. Key informants also raised patient - related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for GDM women. All participants supported integrated primary health services but cautioned against overloading health workers. Conclusion Although there is alignment between international guidelines, local policy and reported clinical practice in the management of GDM, there is a gap in continuation of care in the postpartum period. Health systems interventions that support and facilitate active follow-up for women with prior GDM are needed if high rates of progression to type 2 diabetes are to be avoided.