Browsing by Department "Division of Public Health"

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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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    Breaking Bars: An investigation into how performance art as an intervention program inside prison may lead to a behavior change among male gang members in Cape Town, South Africa
    (2018) Lingaas, Ingebjørg; Colvin, Christopher J
    Violence has been declared a public health problem by the World Health Organisation (1996). Violence prevention strategies are actively used in efforts to rehabilitate offenders during their incarceration, and are intended to prepare them for reintegration into society and to prevent recidivism. Given the lack of research undertaken on violence prevention strategies in the gang-ridden context of Cape Town, South Africa, this dissertation looks at a prison intervention programme, Help I am Free, that uses performance arts as a case study to investigate the potential impacts of such intervention strategies. The paper does so by outlining the experiences of five male gang members before, during, and after their time in prison. Using a cross-sectional qualitative research design, the dissertation explores participants’ life histories and seeks to shed light on the ways in (and degrees to) which such programmes may influence the men’s attitudes towards themselves and others, and the likelihood of their successful reintegration into society. The theoretical frameworks used draw on applied theatre theories, social-cognitive theories, and theories of masculinities. The paper argues that programmes such as Help I am Free may impact participants’ perceptions of self and others strongly, and may also lead to an increased sense of self-worth and motivation to change lifestyle. However, it also indicates the limitations of the programme to achieve sustained success, given the structural barriers which afflict South Africa. The paper outlines a number of challenges that the men face while on parole, and concludes that while prison intervention programmes, and art programmes specifically, may trigger a sense of healing and encourage more positive notions of self, there are more comprehensive strategies in post-release urgently needed in order to prevent recidivism and to achieve authentic social re-integration.
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    Consortium for Health Policy & Systems Analysis in Africa
    (2014-09-15) Gilson, Lucy
    All CHEPSAA’s African members have produced reports that provide an overview of the HPSR+A capacity needs and assets in their organizations and its wider context. They each include recommendations about how to develop capacity. The assessment reports are from Ghana, South Africa, Tanzania, Kenya and Nigeria, and there are also comparative assessments with guidance on how to approach the needs assessment. CHEPSAA (the Consortium for Health Policy & Systems Analysis in Africa) works to develop the emerging field of health policy and systems research and analysis (HPSR+A) in Africa through harnessing synergies among a consortium of African and European universities.
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    Disability in the Middle Ramu, Madang Province, Papua New Guinea: perceptions, prevalence and the role of community based rehabilitation
    (2002) Veenstra, Nina; Byford, Julia; Ehrlich, Rodney
    [pg 1,2,15,16,18-32,37-41,44,45 missing] Worldwide, disability is a major public health problem and the socio-economic impact of disability puts disabled individuals at risk of being amongst the poorest in society. Many disabilities in developing countries are preventable. Community Based Rehabilitation (CBR) is a rehabilitation model promoted by the World Health Organisation for addressing the problems of disability in developing countries. However, for this model to be effective accurate information is required about the socio-economic and cultural context prior to implementation. The purpose of this research was to gain a better understanding of disability in the remote Middle Ramu district, Madang Province, Papua New Guinea. Baseline data concerning the prevalence and types of disability, biomedical and culturally perceived causes of disability, and help-seeking behaviour was collected. A two-phase village screening was done, first to identify and register disabled individuals for the study. Following this in-depth interviews were conducted with selected key informants. The purpose of these interviews was to determine the participation of disabled individuals in community life, as well as the impact of cultural attitudes and perceptions on their lives. The overall prevalence of disability in the area studied was calculated at 3.2%, using the two-phase screening method. A high proportion of disabilities were found to be due to trauma and accidents, while disabilities affecting hearing were frequently associated with illness or infection. The onset of disability was most commonly attributed to social or supernatural causes. Western medicine was widely accepted and utilised. Most disabled individuals were physically well rehabilitated, and there was little or no stigma associated with disability. However, disabled individuals and their families identified a range of outstanding needs. Analysis of these needs suggests that any future CBR program in the area should focus on disability prevention, the construction of mobility aids out of local resources, the provision of accurate information concerning disability, social support for caregivers, and income generation for families with a disabled individual.
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    Exploring the importance, meaning and experience of hope for adult patients with advanced cancer and their family caregivers in KwaZulu-Natal
    (2023) Cox, Colleen; Von Pressentin, Klaus
    Background: The importance of hope for patients with cancer and other life-threatening illness has been widely reported in international literature. Hope enhances patients' quality of life and facilitates coping. Towards end-of-life, hope is typically directed at “being” rather than at “doing”, and at preparing for a peaceful death. Patients and their families reportedly look to healthcare professionals to give them hope. In South African palliative care settings, patients describe their need for psychosocial and spiritual care and for their hope to be upheld. There is however not a clear understanding of what hope means in the South African healthcare setting, particularly around issues such as “hope for a cure” and “false hope”. Also, while several hope-fostering interventions have been validated internationally, the benefits of such interventions in South Africa are unknown. Aim: The study aimed to describe the importance, meaning and experience of hope for adult patients with advanced cancer and their family caregivers in KwaZulu-Natal (KZN). Method: Two study sites in KZN were chosen, a state hospital oncology unit and a hospice. The study followed a qualitative descriptive cross-sectional design, involving in-depth analysis of semistructured interviews with patients with advanced cancer and their family caregivers. Each patient and their family caregiver were managed as a dyad. Questions around the importance, meaning and experience of hope were explored. Data collection continued via purposive sampling until data adequacy was achieved. Data were coded and analysed thematically. Data were also analysed in the context of the clinical, socio-economic and cultural contexts of the patients and their caregivers. Results: The study sample included 11 patients and 11 family caregivers. Purposive sampling achieved variance in most clinical and socio-economic factors. Identified limitations of the study however included the lack of young adults in the study sample, and that each study participant had a religious affiliation, either Christian, African Ancestral, Hindu or Muslim. Despite wider screening, there were no atheist or agnostic participants. There was unanimous affirmation from all patients and caregivers that hope was important to them, particularly in the face of a cancer diagnosis or caregiving role. Thematic analysis of the meaning of hope revealed a strong correlation with spirituality, human connection and support, and physical and psychological comfort. Hope was also associated with psychological fortitude, having a goal and purpose, and living well while being ready to die. The study demonstrated the tension of oscillating between hoping for a cure and accepting a poor prognosis. As with meaning, the hope experience was strongly influenced by spirituality, human connection and support, and physical and psychological comfort. The role of overcoming previous adversity as a source of hope for most participants was an unexpected finding. Almost all participants expressed a preference for truthful communication regarding their diagnosis or prognosis and described how hope assisted them to cope with bad news and to reach acceptance. Participants described how doctors and nurses can give hope to patients and families. Conclusion: The study confirmed the importance of hope in assisting patients with cancer and their family caregivers to cope and to live well in the face of life-threatening illness. Interventions including H - human connection and support, O - (reflections on) overcoming previous adversity, P - physical and psychological comfort, and E - existential or spiritual support, are expected to enhance hope for patients with cancer and their family caregivers in the South African setting. Further research to validate hope-fostering interventions in South Africa is recommended
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    Intersectoral Action for Addressing NCDs through the Food Environment: An Analysis of NCD Framing in Global Policies and Its Relevance for the African Context
    (2021-10-26) Weimann, Amy; Shung-King, Maylene; McCreedy, Nicole; Tatah, Lambed; Mapa-Tassou, Clarisse; Muzenda, Trish; Govia, Ishtar; Were, Vincent; Oni, Tolu
    Noncommunicable diseases contribute the greatest to global mortality. Unhealthy diet—a prominent risk factor—is intricately linked to urban built and food environments and requires intersectoral efforts to address. Framings of the noncommunicable disease problem and proposed solutions within global and African regional diet-related policy documents can reveal how amenable the policy landscape is for supporting intersectoral action for health in low-income to middle-income countries. This study applied a document analysis approach to undertake policy analysis on global and African regional policies related to noncommunicable disease and diet. A total of 62 global and 29 African regional policy documents were analysed. Three problem frames relating to noncommunicable disease and diet were identified at the global and regional level, namely evidence-based, development, and socioeconomic frames. Health promotion, intersectoral and multisectoral action, and evidence-based monitoring and assessment underpinned proposed interventions to improve education and awareness, support structural changes, and improve disease surveillance and monitoring. African policies insufficiently considered associations between food security and noncommunicable disease. In order to effectively address the noncommunicable disease burden, a paradigm shift from ‘health for development’ to ‘development for health’ is required across non-health sectors. Noncommunicable disease considerations should be included within African food security agendas, using malnutrition as a possible intermediary concept to motivate intersectoral action to improve access to nutritious food in African low-income to middle-income countries.
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    Living with hearing loss: exploring the lived experience of identity construction among adolescents and young adults
    (2022) Sekoto, Lieketseng; Hlayisi, Vera-Genevey; Petersen, Lucretia
    Background: Identity construction is the predominant developmental task in adolescence and young adulthood. Disabling hearing loss (HL) exacerbates the psychosocial challenges faced by adolescents and young adults (AYA) in their identity construction. The primary goal of this research study was to describe how AYA with disabling HL feel about and perceive their identity. Further, to understand the aspects underlying identity construction, with a focus on self-perception, navigating disability, social roles and relations, and community assimilation. Methodology: A qualitative interpretive phenomenological approach was adopted. Participants were a purposive sample of 5 Deaf and Hard-of-hearing AYA, aged 15 to 19 years. All participants were enrolled in schools for the deaf in the Western Cape and partook in semi-structured phenomenological conversations, where they narrated detailed accounts of their lived experiences with identity construction. Results: Interpretive phenomenological analysis was used to formulate themes. The superordinate themes of creating a self-concept, belonging, stress and being deaf emerged from participants' narratives. Identity construction occurs concurrently at several levels. At the personal level, deaf AYA create self-conceived ideals of who they are (Creating a self-concept), at relational level identity is nurtured through person-to-person and person-to-group interactions (Belonging). At societal level deaf AYA ascertain their position as individuals within the larger society (Being deaf). Protective factors, enabling factors and barriers that threaten positive identity construction, audiological health, and the psychosocial wellbeing of deaf AYA were identified. Overall, findings from this study indicate that the experience of identity construction for AYA with HL is layered and laden with challenges. Identity formation, albeit portrayed as a process of differentiation, is a balancing act. Identity is self-defined and equally exists in a collective identity with others. Identity construction also subjected participants to stress arising from the emotional burdens of HL, stigmatisation, and resultant psychological effects. Amid unique challenges, deaf AYA consciously developed coping mechanisms, some constructive and others detrimental to their audiological health, all while negotiating their position in the larger society. Conclusion: Study findings appeal to individuals in the caring professions such as audiologists, teachers, educational psychologists, and social workers to understand the nuances of identity construction for the successful transitional care of deaf adolescents moving into adulthood. Counselling needs to be responsive to the needs of deaf AYA, identity domains should be upheld in the provision of person-centered care and possible trajectories for identity crisis should be evaluated when considering school placement. Benefits of group counselling and peer support groups should be explored. There is a need for interventions that curb negative audiological health behaviours through assertiveness training and self-advocacy. The micro implementation of employment equity policies and legislation is critical to ensure the realisation of AYA's prospective identities in the South African workforce. Findings call for the reorientation of audiological rehabilitation and strengthening of interdisciplinary collaboration to meet the psychosocial needs of AYA with disabling HL.
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    The Pan-University Network for Global Health: framework for collaboration and review of global health needs
    (BioMed Central, 2016) Winchester, M S; BeLue, R; Oni, T; Wittwer-Backofen, U; Deobagkar, D; Onya, H; Samuels, T A; Matthews, S A; Stone, C; Airhihenbuwa, C
    In the current United Nations efforts to plan for post 2015-Millennium Development Goals, global partnership to address non-communicable diseases (NCDs) has become a critical goal to effectively respond to the complex global challenges of which inequity in health remains a persistent challenge. Building capacity in terms of wellequipped local researchers and service providers is a key to bridging the inequity in global health. Launched by Penn State University in 2014, the Pan University Network for Global Health responds to this need by bridging researchers at more than 10 universities across the globe. In this paper we outline our framework for international and interdisciplinary collaboration, as well the rationale for our research areas, including a review of these two themes. After its initial meeting, the network has established two central thematic priorities: 1) urbanization and health and 2) the intersection of infectious diseases and NCDs. The urban population in the global south will nearly double in 25 years (approx. 2 billion today to over 3.5 billion by 2040). Urban population growth will have a direct impact on global health, and this growth will be burdened with uneven development and the persistence of urban spatial inequality, including health disparities. The NCD burden, which includes conditions such as hypertension, stroke, and diabetes, is outstripping infectious disease in countries in the global south that are considered to be disproportionately burdened by infectious diseases. Addressing these two priorities demands an interdisciplinary and multi-institutional model to stimulate innovation and synergy that will influence the overall framing of research questions as well as the integration and coordination of research.
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    Patterns of HIV, TB, and non-communicable disease multi-morbidity in peri-urban South Africa- a cross sectional study
    (BioMed Central, 2015-01-17) Oni, Tolu; Youngblood, Elizabeth; Boulle, Andrew; McGrath, Nuala; Wilkinson, Robert J; Levitt, Naomi S
    Background: Many low and middle-income countries are experiencing colliding epidemics of chronic infectious (ID) and non-communicable diseases (NCD). As a result, the prevalence of multiple morbidities (MM) is rising. Methods: We conducted a study to describe the epidemiology of MM in a primary care clinic in Khayelitsha. Adults with at least one of HIV, tuberculosis (TB), diabetes (DM), and hypertension (HPT) were identified between Sept 2012-May 2013 on electronic databases. Using unique patient identifiers, drugs prescribed across all facilities in the province were linked to each patient and each drug class assigned a condition. Results: These 4 diseases accounted for 45% of all prescription visits. Among 14364 chronic disease patients, HPT was the most common morbidity (65%). 22.6% of patients had MM, with an increasing prevalence with age; and a high prevalence among younger antiretroviral therapy (ART) patients (26% and 30% in 18-35 yr and 36–45 year age groups respectively). Among these younger ART patients with MM, HPT and DM prevalence was higher than in those not on ART. Conclusions: We highlight the co-existence of multiple ID and NCD. This presents both challenges (increasing complexity and the impact on health services, providers and patients), and opportunities for chronic diseases screening in a population linked to care. It also necessitates re-thinking of models of health care delivery and requires policy interventions to integrate and coordinate management of co-morbid chronic diseases.
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    Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?
    (BioMed Central, 2016-09-07) Rabbani, Fauziah; Shipton, Leah; White, Franklin; Nuwayhid, Iman; London, Leslie; Ghaffar, Abdul; Ha, Bui T T; Tomson, Göran; Rimal, Rajiv; Islam, Anwar; Takian, Amirhossein; Wong, Samuel; Zaidi, Shehla; Khan, Kausar; Karmaliani, Rozina; Abbasi, Imran N; Abbas, Farhat
    Background: Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005–2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. Main text: The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs). Conclusion: SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.
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    Some public health associations with specific enteropathogens in childhood diarrhoea in Cape Town
    (2009) Moeng, Helimamy; Swingler, George
    Background: Diarrhoea remains one of the leading causes of mortality in young children. After dehydration and malnutrition, electrolytes disturbances are an important complication of diarrhoea. In Cape Town, fluctuation of plasma sodium and potassium has been observed in childhood diarrhoea and were seasonal in their occurrence. A study conducted at Red Cross Children's Hospital found that seasonal fluctuations of plasma sodium and potassium were associated with specific enteropathogens but did not identify associations that suggested potential public health interventions that could target the electrolytes disturbances. It is possible that by identifying association with the enteropathogens directly, one could identify public health interventions to avoid seasonal electrolyte disturbances. Objectives: To identify clinical, nutritional, socio-economic, socio-demographic and seasonal associations with childhood diarrhoea caused by the enteropathogens Shigella, Salmonella, enterotoxigenic E. coli, enteropathogenic E.coli, Cryptosporidium, rotavirus or Campylobacter. Methods: This study was a secondary analysis of a cross-sectional study of infants less than 2 years old admitted to the Rehydration Unit of the Red Cross Children's Hospital with diarrhoea. Data were obtained through routine medical records and a questionnaire. Multiple logistic regression was performed to identify determinants of the diarrhoea-associated electrolytes disturbances. Results: Height for age was negatively associated with enteropathogenic E.coli (OR: 0.82, p-value: 0.039), Campylobacter (OR: 0.87, p-value: 0.082) and Salmonella (OR: 0.79, 0-value: 0.029) in the bi-variate analysis. Weight forheight and height for age were associated respectively to rotavirus (OR: 1.24, p-value: 0.011) and enterotoxigenic E.coli (OR: 1.16, p-value: 0.064 ). Water source was positively associated with Enteropathogenic E. coli, Campylobacter and inversely associated with rotavirus. Toilet was positively associated with enteropathogenic E. coli and Salmonella. Average temperature was positively associated with Enteropathogenic E. coli, Enterotoxigenic E. coli, Salmonella and Shiga/la. In the multivariate analysis breast feeding was negatively associated with Cryptosporidium infection (OR: 0.13; 95% Cl 0.20-0.62) while average humidity was positively associated with Cryptosporidium infection (OR: 1.1 O; 95% Cl 1.05-1.16). Enteropathogenic E. coli infection was positively associated with average ambient temperature (OR: 1.16, 95% Cl 1.03- 1.30).The child's age was a determinant of Campylobacter, (OR: 1.05; 95% Cl 1.00-1.11 ). Formula feeding, (OR: 0.45; 95% Cl 0.20-0.99) average temperature (OR: 0.87; 95% Cl 0.81-0.95) and humidity (OR: 0.91; 95% Cl 0.80-0.94) were all protective of rotavirus infection. None of the socioeconomic variables were associated with specific enteropathogens. Discussion: The only determinant associated with Enteropathogenic E coli identified in this study was average temperature. This concurs with its summer isolation. No significant determinant was identified for Enterotoxigenic E. coli in this analysis. For Cryptosporidium, in the multivariate analyses were duration of diarrhoea, breast-feeding and average humidity were identified as significant determinants. With the exception of breast-feeding, none of these determinants could be amended through public health intervention. For Campylobacter, age and adequacy of drinking were identified as significant determinants during the multivariate analysis. Adequacy of drinking was the only significant determinant associated with Salmonella. Formula feeding, plasma pH, average humidity and average temperature were associated with rotavirus while associations identified with Shiga/la were duration of vomiting, plasma pH and average temperature. As above, none of the identified determinants could be changed to modify the occurrence of these enteropathogenic diarrhoea. Conclusion: Although associations with specific enteropathogens were identified, none of the associations identified suggest public health interventions to avoid seasonal electrolyte disturbances.
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    Systematic Reviews
    (BioMed Central, 2016) Njau, Bernard; Damian, Damian J; Abdullahi, Leila; Boulle, Andrew; Mathews, Catherine
    Background: HIV is still a global public health problem. More than 75 % of HIV-infected people are in Africa, and most of them are unaware of their HIV status, which is a barrier to accessing antiretroviral treatment. Our review aims, firstly, to determine whether HIV self-testing is an effective method to increase the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment. Secondly, we aim to review the factors that facilitate or impede the uptake of HIV self-testing. Methods/design: Participants will be adults living in Africa. For the first aim, the intervention will be HIV self-testing either alone or in addition to HIV testing standard of care. The comparison will be HIV testing standard of care. The primary outcomes will be (i) uptake of HIV testing and (ii) yield of new HIV-positive diagnoses. The secondary outcomes will be (a) linkage to antiretroviral (ARV) treatment and (b) incidence of social harms. For the second aim, we will review barriers and facilitators to the uptake of self-testing. We will search PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, WHOLIS, Africa Wide, and CINAHL for eligible studies from 1998, with no language limits. We will check reference lists of included studies for other eligible reports. Eligible studies will include experimental and observational studies. Two authors will independently screen the search output, select studies, and extract data, resolving discrepancies by consensus and discussion. Two authors will use Cochrane risk of bias tools for experimental studies, the Newcastle-Ottawa Quality Assessment Scale for observational studies, and the Critical Appraisal Skills Programme (CASP) quality assessment tool for qualitative studies. Discussion: Innovative and cost-effective community-based HIV testing strategies, such as self-testing, will contribute to universal coverage of HIV testing.
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    Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province
    (BioMed Central, 2014-11-29) Schneider, Helen; English, Rene; Tabana, Hanani; Padayachee, Thesandree; Orgill, Marsha
    Background: Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes. Methods: Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province. Results: Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of ‘community dialogues’ and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation. Conclusions: These features resonate with the deliberative, multi-level and context sensitive approaches described as the “simple rules” of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.
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    Workload and casemix in Cape Town emergency departments
    (2007) Wallis, Lee A; Twomey, Michele
    Introduction. Little is known about the nature of patients presenting to emergency departments (EDs) in South Africa. This study aimed to provide evidence on ED usage in Cape Town by studying patients at four community health centre (CHC) EDs, with details of the severity of their presentation and their disposal. Methods. A total of 16 392 patients presented in this 8-week prospective observational study, and 15 681 were included in the descriptive data analysis. One-quarter were children. Results. There were clear and predictable peaks in attendance after 16h00 and at weekends, with a steady stream of patients presenting overnight. Case severity was evenly distributed between emergency, urgent and routine care. Nearly 10% of patients were referred on to a higher level of care. Conclusion. The data from this study present a model for staffing and resource allocation. It has implications for the provision of emergency care in CHC EDs.