Browsing by Author "Zweigenthal, Virginia"

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    Open Access
    A descriptive analysis of suicides and their interface with healthcare facilities in the Western Cape, South Africa: 2011-2015
    (2022) Mgugudo-Sello, Ziyanda; Zweigenthal, Virginia
    BACKGROUND: Suicide is a preventable public health problem affecting 800 000 people every year and 79% occurs in low to middle incomes countries. Males are mostly affected, and at-risk age groups are adolescents and young adults. Hanging, firearms and ingestion of pesticides are amongst the most common methods of suicide. Prevention strategies have been applied by various countries to target the use of common methods of suicide however there is little evidence that supports detection of suicide risk in healthcare facilities. This study profiles all suicides that occurred in the Western Cape during the year 2011-2015 and their interface with the healthcare facilities up to one year prior to death. OBJECTIVES: This study assesses the incidence of suicides in the Western Cape. It tests for associations between methods of suicide and demographic characteristics for suicide. Ascertains the characteristics of those suicide cases who made previous contact with a healthcare facility in the past 12 months and proposes context specific interventions for the prevention of suicides. METHODS: A retrospective descriptive study was conducted. All suicides recorded by the forensic pathology service during the years 2011-2015 were linked to patient data held by the provincial health data centre. A total of 3 561 suicides were recorded during the study period. Crude suicide rates were calculated using population denominator from the Statistics South Africa's national census projections. Multiple logistic regression was used to determine associations between the group utilising various methods of suicide and demographic characteristics. FINDINGS: Males were found to be four times more likely to die from suicide compared to females. The age groups most at risk were 20-39 years. Hanging was the method of choice by males and overdose on medication, in females. Two thirds of the 2 367 suicides were positively linked to healthcare facilities. Most cases who sought healthcare up to one year prior to suicide were males that presented with ‘other medical conditions' rather than mental health conditions. CONCLUSION: This study highlights missed opportunities for the detection of suicide risk for those who seek healthcare for all healthcare conditions. Although suicide rates have remained constant over the assessment period, a key focus for prevention should be interventions applied at healthcare facilities as well as other ‘upstream' preventions that reduce the availability of various methods for suicide.
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    An Assessment of the integration of Palliative Care in the Health System of the Cape Metro District of South Africa
    (2023) Arendse, Juanita; Zweigenthal, Virginia
    Background Palliative Care (PC) is a neglected yet core component of health care in the public sector. It embodies holistic, people-centred, compassionate care, focussing on vulnerable patients, and their families, with life threatening illness, to enhance their quality of life. Globally and in South Africa (SA), it has been delivered by non-governmental organisations (NGOs) such as hospices. However, in SA in 2017, the National Policy and Strategy for Palliative Care (NPSFPC) prescribed its integration into the public sector health care system. Following the NPFSPC, the Western Cape provincial health and wellness department initiated a PC service without additional resources prior to the COVID-19 pandemic. Aim - The aim of the study is to investigate factors that influenced integration of PC into the Metro Health Services within the Cape Metro District (CMD). Four complementary studies were conducted to assess integration of PC within the CMD public sector health system. Firstly, the state of PC service delivery was compared 24-months on from baseline. Then, perceptions of and identification of enablers and obstacles to PC among managers and external stakeholders at the beginning of the initiative were elicited, followed by the experiences of implementers, and finally the experiences of beneficiaries of the services. Methods - Study methods were informed by a framework for analysing integration of targeted interventions into health systems, for both data collection and data analysis. A mixed methods approach was used - a document review, quantitative before and after implementation design, complemented by qualitative research that aimed to understand the underlying issues. These comprised a review of personnel and services in the public health sector, PC ICD 10 data codes and morphine utilisation data, and 16 individual interviews and 13 focus group discussions. It utilised the conceptual framework of Atun et al. for analysing integration of targeted interventions into health systems. Findings -The project increased the availability of CMD PC services and resulted in a partial integration of PC into primary care services. There was clear commitment to improve the pattern and rate of adoption of PC, towards eventual assimilation into the health system functions. The document analysis found that governance arrangements included PC in provincial priority setting and operational service planning, indicating the growing importance given to thiservice. The COVID-19 pandemic had exposed the gaps in PC provision but had also highlighted the need and opportunities for PC as an essential service. The quantitative data analysis of morphine utilisation and PC attendance did increase, but this was not statistically significant. Managers' and external stakeholders' commitment to a compassionate health system that is patient centred, enabled its integration. Additionally, a PC capacitated workforce, together with leadership and governance that supports PC integration is required. Two years after policy implementation, managers' reflections indicate that a more inclusive policymaking process, together with creating awareness about PC among both staff and communities served, which focussed on reducing stigma, were important. Furthermore, to take PC integration forward requires pandemic planning that includes PC, strategic partnerships, and leading with care and compassion. Front line health providers, the street level bureaucrats (SLBs) in health systems, need to be heard in service package policy making. They need visible managers and senior leadership to support PC service on the frontline. A multi-disciplinary team approach, facilitating inter- professional support, are essential to support integration of PC. Patients and family receiving PC services needed support for family caregiver, and better pain and symptom control. They were frustrated by delayed referrals and service waiting times, and their inability to access other MDT members, particularly during the COVID-19 pandemic. Conclusion and recommendations The study demonstrates that robust well-consulted policymaking processes are required to ensure that policy is relevant and includes the voice of SLBs in clinical policy decision-making. They require leadership that is compassionate and visible together with clear guidance on service changes that facilitate inter-professional support and involves community health workers. Health system changes, such as standardised referral systems that include PC are required which allow flexibility when considering facility and patient context. Training was a gap, and capacity building for PC service provision should be included in undergraduate training for all health professionals, coupled with in-service training for employed health professionals. Furthermore, stakeholder engagements towards collaboratively creating public awareness about PC that drives the compassionate care agenda while addressing social determinants of health, is essential to embed and mainstream the service, support staff, patients and family caregivers. Finally in the light of the experience of the COVID-19 pandemic, planning for future pandemics needs to include ongoing care for PC patients as well as factoring in an increased demand
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    Open Access
    An Assessment of the integration of Palliative Care in the Health System of the Cape Metro District of South Africa
    (2023) Arendse, Juanita; Zweigenthal, Virginia
    Background Palliative Care (PC) is a neglected yet core component of health care in the public sector. It embodies holistic, people-centred, compassionate care, focussing on vulnerable patients, and their families, with life threatening illness, to enhance their quality of life. Globally and in South Africa (SA), it has been delivered by non-governmental organisations (NGOs) such as hospices. However, in SA in 2017, the National Policy and Strategy for Palliative Care (NPSFPC) prescribed its integration into the public sector health care system. Following the NPFSPC, the Western Cape provincial health and wellness department initiated a PC service without additional resources prior to the COVID-19 pandemic. Aim - The aim of the study is to investigate factors that influenced integration of PC into the Metro Health Services within the Cape Metro District (CMD). Four complementary studies were conducted to assess integration of PC within the CMD public sector health system. Firstly, the state of PC service delivery was compared 24-months on from baseline. Then, perceptions of and identification of enablers and obstacles to PC among managers and external stakeholders at the beginning of the initiative were elicited, followed by the experiences of implementers, and finally the experiences of beneficiaries of the services. Methods - Study methods were informed by a framework for analysing integration of targeted interventions into health systems, for both data collection and data analysis. A mixed methods approach was used – a document review, quantitative before and after implementation design, complemented by qualitative research that aimed to understand the underlying issues. These comprised a review of personnel and services in the public health sector, PC ICD 10 data codes and morphine utilisation data, and 16 individual interviews and 13 focus group discussions. It utilised the conceptual framework of Atun et al. for analysing integration of targeted interventions into health systems. Findings -The project increased the availability of CMD PC services and resulted in a partial integration of PC into primary care services. There was clear commitment to improve the pattern and rate of adoption of PC, towards eventual assimilation into the health system functions. The document analysis found that governance arrangements included PC in provincial priority setting and operational service planning, indicating the growing importance given to thiservice. The COVID-19 pandemic had exposed the gaps in PC provision but had also highlighted the need and opportunities for PC as an essential service. The quantitative data analysis of morphine utilisation and PC attendance did increase, but this was not statistically significant. Managers' and external stakeholders' commitment to a compassionate health system that is patient centred, enabled its integration. Additionally, a PC capacitated workforce, together with leadership and governance that supports PC integration is required. Two years after policy implementation, managers' reflections indicate that a more inclusive policymaking process, together with creating awareness about PC among both staff and communities served, which focussed on reducing stigma, were important. Furthermore, to take PC integration forward requires pandemic planning that includes PC, strategic partnerships, and leading with care and compassion. Front line health providers, the street level bureaucrats (SLBs) in health systems, need to be heard in service package policy making. They need visible managers and senior leadership to support PC service on the frontline. A multi-disciplinary team approach, facilitating inter- professional support, are essential to support integration of PC. Patients and family receiving PC services needed support for family caregiver, and better pain and symptom control. They were frustrated by delayed referrals and service waiting times, and their inability to access other MDT members, particularly during the COVID-19 pandemic. Conclusion and recommendations The study demonstrates that robust well-consulted policymaking processes are required to ensure that policy is relevant and includes the voice of SLBs in clinical policy decision-making. They require leadership that is compassionate and visible together with clear guidance on service changes that facilitate inter-professional support and involves community health workers. Health system changes, such as standardised referral systems that include PC are required which allow flexibility when considering facility and patient context. Training was a gap, and capacity building for PC service provision should be included in undergraduate training for all health professionals, coupled with in-service training for employed health professionals. Furthermore, stakeholder engagements towards collaboratively creating public awareness about PC that drives the compassionate care agenda while addressing social determinants of health, is essential to embed and mainstream the service, support staff, patients and family caregivers. Finally in the light of the experience of the COVID-19 pandemic, planning for future pandemics needs to include ongoing care for PC patients as well as factoring in an increased demand.
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    An exploration of knowledge, attitudes and practices of primary health care providers providing contraceptive and family planning services in Cape Town, South Africa: a qualitative study
    (2020) Fataar, Kulthum; Harries, Jane; Zweigenthal, Virginia
    Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counselling. This study explores the experiences and perceptions of primary health care providers delivering contraceptives services in Cape Town to gain a deeper understanding of the delivery of contraceptive services. Ten in-depth interviews were conducted at five public primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included primary health care providers providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analysed using a thematic analysis approach. Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Furthermore, contraceptive prescribing practices were also influenced by medical eligibility criteria and women's preferred bleeding patterns. However, contraceptive prescribing practices were also influenced by providers' attitudes towards younger and older women. Challenges experienced by providers when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and work pressure due to providing other health services. Health care providers play a critical role in facilitating women's right to accessing high quality contraceptive services. Providers in the study perceived themselves as negotiators during contraceptive counselling by considering both women's preferences and provider recommendations for contraception, whilst enabling women to make informed contraceptive decisions through provision of reproductive health information. Consequently, shifting contraceptive counselling to focus on shared decision-making may encourage autonomy during decision-making and help to limit the influence of provider attitudes on contraceptive prescribing and counselling.
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    Assessing the impact of a waiting time survey on reducing waiting times in primary care clinics in Cape Town, South Africa
    (2015) Daniels, Johann Alexander; Zweigenthal, Virginia; Reagon Gavin
    Objective: A waiting time survey (WTS), conducted in 2007 at 94% of clinics in Cape Town, measured length of patient waiting times (WT) for services and provided recommendations to shorten waiting times. Whether subsequent implementation of these recommendations occurred was unknown, hence a study was conducted to assess the impact of the previous waiting time survey recommendations on stimulating efforts to reduce waiting times and whether waiting times had reduced. Methods: A cross-sectional analytical study design assessed the perceptions of 92% of clinic managers in Cape Town, regarding the 2007 survey, while a before and after study design assessed changes in waiting time between 2007 and 2011, using a random sample of 22 clinics. Results: The overall median waiting time of all clinics in the sample decreased by 21 minutes in 2011 (95% CI 11.77-30.23), a 28% decrease from 2007. This reduction was manifest at individual clinic level as well, with 55% of clinics reducing their median waiting time by at least 15 minutes. No specific factors, including whether recommendations to reduce waiting times were implemented, were associated with decreases in waiting times. Implementation of recommendations to reduce waiting times was 2.67 times (95% CI 1.33-5.40) more likely amongst those who received written recommendations and 2.3 times ) 95% CI 1.28-4.19) more likely amongst managers with 5 or more years' experience. Conclusion: The decrease in waiting times in primary care urban clinics subsequent to a waiting time survey, demonstrates the utility of waiting times surveys, although no specific factors associated with the decrease in waiting time were identified.
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    Contraceptive continuation among women aged 15-49 utilizing City of Cape Town family planning services
    (2023) Naidoo, Carron; Zweigenthal, Virginia
    There is a need to provide comprehensive contraceptive services that are consistent and that address the requirements of women, particularly young women who are at risk of unintended pregnancy. Objectives This study describes characteristics of contraceptive users accessing services and their contraceptive method usage patterns, including continuation, at public sector clinics in Cape Town, South Africa. Methods The study reviewed data on contraceptive users (n=217 274), aged 15-49 years accessing services across 102 public sector clinics. We calculated all method continuation and method-specific continuation for all hormonal methods. Multi-variate analysis was used to examine the relationship between sociodemographic and health characteristics with contraceptive continuation. P-values <0.05 were considered significant. Results Of the 217 274 women, 95.6% used short acting methods (68.2% injectables, 9.1% oral pills, 18.2% male & female condoms), while <5% used long-acting methods (implant 3.9%, intrauterine device 0.4%). The proportion of all method continuation was 39.5%, but the norethisterone enanthate injectable had the lowest method-specific continuation at 8%, followed by the oral pill at 11%, the two most popular contraceptive methods used by younger women. Contraceptive continuation was strongly associated with dual method use (OR: 1.78; 95% CI: 1.74-1.84), older age (25-49) (OR: 1.16; 95% CI:1.13-1.18) and had reduced odds if a user was on treatment for TB (OR: 0.64; 0.57-0.73). Conclusions Both method-specific and all-method contraceptive continuation were low, which indicates high rates of contraceptive method discontinuation without women switching their method. This may point to issues requiring attention at health provider, health system and client levels. Expanding patient- centered counselling and education, ongoing in-service education of health providers, and inventory monitoring systems to address issues such as stockouts are needed.
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    Contraceptive continuation among women aged 15-49 utilizing City of Cape Town family planning services
    (2023) Naidoo, Carron; Zweigenthal, Virginia
    There is a need to provide comprehensive contraceptive services that are consistent and that address the requirements of women, particularly young women who are at risk of unintended pregnancy. Objectives This study describes characteristics of contraceptive users accessing services and their contraceptive method usage patterns, including continuation, at public sector clinics in Cape Town, South Africa. Methods The study reviewed data on contraceptive users (n=217 274), aged 15-49 years accessing services across 102 public sector clinics. We calculated all method continuation and method-specific continuation for all hormonal methods. Multi-variate analysis was used to examine the relationship between sociodemographic and health characteristics with contraceptive continuation. P-values <0.05 were considered significant. Results Of the 217 274 women, 95.6% used short acting methods (68.2% injectables, 9.1% oral pills, 18.2% male & female condoms), while <5% used long-acting methods (implant 3.9%, intrauterine device 0.4%). The proportion of all method continuation was 39.5%, but the norethisterone enanthate injectable had the lowest method-specific continuation at 8%, followed by the oral pill at 11%, the two most popular contraceptive methods used by younger women. Contraceptive continuation was strongly associated with dual method use (OR: 1.78; 95% CI: 1.74-1.84), older age (25-49) (OR: 1.16; 95% CI:1.13-1.18) and had reduced odds if a user was on treatment for TB (OR: 0.64; 0.57-0.73). Conclusions Both method-specific and all-method contraceptive continuation were low, which indicates high rates of contraceptive method discontinuation without women switching their method. This may point to issues requiring attention at health provider, health system and client levels. Expanding patient- centered counselling and education, ongoing in-service education of health providers, and inventory monitoring systems to address issues such as stockouts are needed.
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    ETD: Exploring knowledge translation mechanisms in the Western Cape Provincial Health System
    (2018) Edwards Amanda; Olivier, Jill; Zweigenthal, Virginia
    The persistent gap between health research, policy and practice has led to a burgeoning interest in the field of knowledge translation (KT). However, there remains little clarity on what KT mechanisms work in different contexts, particularly in low and middle-income countries. Using mixed methodology this project explores KT mechanisms, barriers, facilitators and outcomes as they function in South Africa’s Western Cape provincial health system. Document review and key informant interviews with health system researchers and provincial health policymakers were synthesised with findings from a random sample of provincial study protocols registered on the National Health Research Database. An evidence-mapping of the literature on KT in African settings complemented this data. Findings indicate variations in the use of health-related research by provincial policymakers and diversity in the mechanisms employed for KT. The important role of organisations, characteristics of available research, relationships and networks play a facilitating role for KT in this context. Resource constraints, system conflicts and politics served as notable barriers. These findings have implications for health researchers and provincial policymakers seeking to “do” KT in the Western Cape health system – including the need for recognition of the important role of context, of the ethical dilemmas within KT processes, and the need for a more systematic approach to KT that includes embedded learning systems.
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    Evaluating adherence to recommended clinical guidelines for the prevention of cardiovascular disease in patients with Type 2 diabetes mellitus at primary care level
    (2017) Langenhoven, William; Zweigenthal, Virginia
    Background: Globally, type 2 diabetes (T2D) is a significant cause of avoidable mortality and morbidity. It is a major risk factor for cardiovascular disease (CVD). Evidence-based guidelines lower cardiovascular risk in diabetics. Adherence to clinical guidelines for the prevention of CVD in South African primary care public sector facilities is unknown. Aim: This study determined adherence of Cape Town primary care clinicians to recommended clinical guidelines for the prevention of cardiovascular disease in T2D. Methods: This 2013 cross-sectional study extracted data from 300 folders of known T2D patients sampled from three Community Health Centres (CHCs). Compliance with guidelines, and patient demographic factors were analysed. Results: Most (71% or 194/273) hypertensive diabetics were appropriately managed with first-line- medication - an Angiotensin Converting Enzyme Inhibitor (ACEI). There was appropriate supporting documentation for only 39% not on first line therapy. A fifth (22%) with drug intolerance received the recommended alternative. Most were appropriately prescribed a statin (74%) and aspirin (69%). Other cardiovascular risk factors were poorly controlled: mean weights were in the obese range (BMI=31.3 [SD: 5.7]); the mean total cholesterol level was 5.5 (SD: 1.4); there was incomplete data for smoking (19% had no record) and 93% had no record of a family history of CVD. Conclusions: Whilst pharmacological interventions for the prevention of CVD were moderately implemented, patient factors – such as obesity and smoking were poorly addressed. Improving documentation, adherence to recommended clinical guidelines and, health promotion to address modifiable risks are required to improve quality of care for T2D.
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    Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems
    (BioMed Central, 2019-02-07) Edwards, Amanda; Zweigenthal, Virginia; Olivier, Jill
    Abstract Background The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries. Methods Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature. Results The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting. Conclusion This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice.
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    Health care providers' experience of research activities in public sector health facilities in the Western Cape Province of South Africa
    (2020) Ndlovu, Linda; Olivier, Jill; Zweigenthal, Virginia
    There is a significant amount of public health research conducted within provincial health facilities in South Africa, whose findings have a positive impact on the delivery of health services. This includes clinical, epidemiological, health systems and health services research, often initiated by post‐graduate students, independent academics researchers, as well as research institutions. Although researchers commonly commit to providing feedback to the provincial department and facilities, there is little evidence to confirm that research feedback is subsequently provided. Little contextualized empirical evidence is available to guide action, particularly for frontline health care providers, who often have the responsibility to host these research activities. The aim of this study was to explore the experiences of healthcare providers with research activities hosted in health facilitiesin the Western Cape province of South Africa. A mixed-method, cross-sectional study was conducted utilising an online survey (n= 19), and semi-structured interviews (n=3) with frontline health care providers (research gatekeepers). Descriptive analyses characterized respondents and their experience of research. Qualitative thematic analysis took on an inductive approach by identifying themes as they emerged from the data and cross comparing these with findings from the scoping literature review. Findings provided insight into how research conduct is experienced by those on the frontline in public health facilities on the provincial district platform. This is particular to the Western Cape province, which has a specific health department administration system. The following themes emerged: perception of research burden on services, understanding of the research approval process, autonomy to deny researchers access to the health facility due to overburden of research, the frequency or occurrence of research feedback after completion of a project, and interpersonal dynamics between researchers and gatekeepers as it relates to research conduct in facilities. This research reports on empirical evidence of perspectives from frontline health care providers on their experience with health research in a particular provincial context. The findings could form the basis of a study with a much larger sample size to inform how research feedback can be translated in a way that directly impacts on the uptake in the frontline.
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    Implementing intimate partner violence care in a rural sub-district of South Africa: a qualitative evaluation
    (2015) Rees, Kate; Zweigenthal, Virginia; Joyner, Kate
    Background: Despite a high burden of disease, in many health districts in the Wes tern Cape, South Africa, intimate partner violence is known to be poorly recognised and managed. To address this gap in service an innovative intersectoral model for the delivery of comprehensive intimate partner violence (IPV) care was piloted in the Witzenberg, a rural, agricultural sub - district known to have a high incidence of IPV. It was not known whether the initiative was a success from the perspective of the women using the service, from the service providers or from the managers. Methods: A qualitative evaluation was conducted. Ten service users were interviewed to explore their experience of the intervention. Two focus groups were conducted amongst health care workers, and one focus group and six interviews were conducted with the intersectoral implementation team, to understand their experience of implementing the intervention. Documents relating to the pilot were also analysed. A contextualized thematic content analysis approach was used, triangulating the various sources of data, and utilising inductive as well as deductive approaches. Results: Over the pilot period 75 women received the intervention. Study participants described their experience of it as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For health care workers, barriers to inquiry about intimate partner violence included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints impacted on the pilot, affecting continuity of care, privacy and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example high levels of alcohol misuse and socioeconomic disempowerment highlighted the need for a multifaceted approach to addressing intimate partner violence. Conclusion: The results of this qualitative evaluation draw attention to the need to take a health systems approach and focus on contextual factors when implementing complex interventions. They will be used to inform decisions about instituting appropriate intimate partner violence care in the rest of the province. Additionally, there is a pressing need for clear policies and guidelines framing intimate partner violence as a health issue.
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    Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa
    (BioMed Central Ltd, 2007) Harries, Jane; Cooper, Diane; Myer, Landon; Bracken, Hillary; Zweigenthal, Virginia; Orner, Phyllis
    BACKGROUND:Worldwide there is growing attention paid to the reproductive decisions faced by HIV-infected individuals. Studies in both developed and developing countries have suggested that many HIV-infected women continue to desire children despite knowledge of their HIV status. Despite the increasing attention to the health care needs of HIV-infected individuals in low resource settings, little attention has been given to reproductive choice and intentions. Health care providers play a crucial role in determining access to reproductive health services and their influence is likely to be heightened in delivering services to HIV-infected women. We examined the attitudes of health care policy makers and providers towards reproductive decision-making among HIV-infected individuals. METHODS: In-depth interviews were conducted with 14 health care providers at two public sector health care facilities located in Cape Town, South Africa. In addition, 12 in-depth interviews with public sector policy makers and managers, and managers within HIV/AIDS and reproductive health NGOs were conducted. Data were analyzed using a grounded theory approach. RESULTS: Providers and policy makers approached the issues related to being HIV-infected and child bearing differently. Biomedical considerations were paramount in providers' approaches to HIV infection and reproductive decision-making, whereas, policy makers approached the issues more broadly recognizing the structural constraints that inform the provision of reproductive health care services and the possibility of "choice" for HIV-infected individuals. CONCLUSION: The findings highlight the diversity of perspectives among policy makers and providers regarding the reproductive decisions taken by HIV-infected people. There is a clear need for more explicit policies recognizing the reproductive rights and choices of HIV-infected individuals.
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    Review of the Effects of Diabetes Mellitus Group Education with Practitioner-directed Insulin Dosage Adjustments on Glycaemic Control at a Public Sector Primary Health Care Clinic in Khayelitsha
    (2023) Neumuller, Caroline; Zweigenthal, Virginia
    Aim: In view of the high burden of poorly controlled diabetes mellitus in South Africa, this study evaluated the effect of diabetes group education sessions, coupled with the provision of practitioner-directed insulin dosage adjustments based on home blood glucose readings, on patients' glycaemic control in the short and medium term. Methods: Using routine data, glycaemic control was assessed before, after and three years after the intervention. Additionally, patients' change in glycaemic control over a three-year period was compared to a control group. Results: After the group education sessions and insulin dosage adjustments, the mean HbA1c of 66 intervention patients decreased by 2.03% in the short term, from 12.57% (95%CI [12.05%, 13.09%]) to 10.54% (95%CI [9.96%, 11.11%]), and by a further 0.43% three years after the intervention. However, this change in glycaemic control after three years was not different to that of the control group. Conclusion: The 2% improvement in HbA1c in the short term is a significant achievement; although this is related to patients' poor initial glycaemic control. The control group's similar improvements over a three-year period is due to the improved clinical care and access to glucose monitors for all patients over the course of the study period at the study facility.
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    Sexual Health Decision-Making and Service Utilisation among Kenyan Queer Womxn and Trans Men
    (2022) Haase, Stephanie; Zweigenthal, Virginia; Muller, Alexander
    Background Queer women and trans men are a neglected populations regarding sexual health status, education, and service provision globally, particularly in low- and middle-income countries. Little is known about their sexual health risk behaviour. In Kenya, the Penal Code criminalises consensual same-sex activity. Public sector health care and information aimed at queer womxn and trans men are lacking, leaving them underserved and at risk of negative sexual health outcomes and other health disparities. Therefore, research is needed to understand the unique sexual health and service needs of Kenyan queer women and trans men and the factors that shape them. Methods Data was collected through a mixed-methods approach in two phases with triangulated quantitative and qualitative elements. A survey based on the literature findings, conceptual models (socioecological model and minority stress model) and previously validated tools was distributed online to a purposive sample of 360 Kenyan queer women and trans men to establish demographics and identify sexual health needs, decision-making, knowledge, behaviour, and barriers to care. Interviews with queer women and trans men were conducted for an in-depth understanding of the factors, experiences, relationships, and health needs that influence decision-making and health-seeking. These were supplemented with interviews with other knowledge-rich stakeholders and expert informants to identify structural barriers as well as feasible solutions to address the gaps. Results The data provided in-depth insight into how Kenyan queer women and trans men's sexual health decision-making and service utilisation are informed. The survey sample represented young, urban, highly-educated queer womxn and trans men. The data identified gaps in all four areas that comprise the socioecological model – societal, community, relationship, personal. Risk behaviours included sexual activities with partners of multiple genders, violence, substance use and low use of barrier methods against pregnancy and sexually transmitted infections. One in three participants had been treated for a sexually transmitted infection in the previous year. Queer womxn and trans men face multiple service-access barriers, many related to stigma and discrimination, as well as fears around provider attitudes. Violations of rights and privacy are a concern. There are insufficient numbers of facilities, programmes, and information to meet the needs of queer womxn and trans men, which results in poor quality of care or patients delaying care. Additional findings suggest that minority stress, including internalised homophobia, external stigma, and concerns around disclosing one's sexual orientation and gender identity, affect the sexual health of Kenyan queer womxn and trans men. Discussion This research found gaps in the sexual health knowledge, the availability of services, and provider attitudes leading to unmet needs around sexual and mental health care. This research demonstrates how restrictive policy and stigmatising environments can contribute to concerns in health and well-being and that the exclusion of queer womxn and trans men's needs is a human rights concern. The findings could be used to inform actions by policy advocates/makers, service providers, educators, and other stakeholders to improve services and tailor information to the needs of queer women and trans men, which could impact their burden of disease and improve quality of life, but also other marginalised populations in low- and middle-income countries.