Browsing by Subject "Public Health and Family Medicine"

Now showing 1 - 20 of 71
  • Thumbnail Image
    Item
    Open Access
    A multi-component theory-based behaviour change intervention to increase HIV self–testing uptake and linkage to HIV prevention, care and treatment among hard to reach adults in Northern Tanzania
    (2021) Njau, Bernard Joseph; Mathews, Catherine; Boulle, Andrew
    To achieve the WHO targets of 95–95–95 by 2030, whereby 95% of all people living with HIV (PLHIV) know their status, 95 % of all people with an HIV diagnosis receive sustained antiretroviral therapy (ART), and 95 % of all people receiving ART achieve viral suppression, it is imperative to introduce novel community–based testing approaches such as HIV self-testing (HIVST). HIV self–testing has been shown to empower non– testers in both developed and underdeveloped countries, to be aware of their HIV status. However, no studies on the uptake of HIVST have been conducted on hard to reach populations in Northern Tanzania. The hard to reach populations for this thesis were female bar workers (FBWs) and mountain climbing porters (MCPS) in Northern Tanzania, who exhibit high-risk behaviours for HIV infection and low rates of HIV testing and / or repeat testing. It is important to find ways to increase the uptake of HIV testing in these populations and HIVST is proposed as a means of improving HIV testing coverage in hard-to-reach populations in the context of a long-standing HIV testing program. Existing implementation science literature suggests that behaviour change interventions (BCIs) guided by behaviour change theories and using planning and evaluation frameworks (i.e. PRECEDE-PROCEED model) can be effective in increasing HIV-related behaviour change. However, the current evidence on the effectiveness of HIV-related BCI is from studies conducted in high-income countries. To address the low HIV testing rates and/or repeat testing, it was important to undertake a project of research to develop and evaluate a theory-based behaviour change intervention (BCI) to increase HIVST uptake and linkage to HIV prevention, care and treatment among FBWs and MCPs in Northern Tanzania. This thesis aimed to develop and evaluate a multi-component theory-based BCI to increase HVST uptake and linkage to HIV prevention, care and treatment among female bar workers and mountain climbing porters in Northern Tanzania.
  • Thumbnail Image
    Item
    Open Access
    A systematic review of interventions to improve adherence to anti-diabetic medications in patients with type 2 diabetes in sub-Saharan Africa
    (2022) Iyun, Oluwatosin Busola; Myer, Landon
    Background: Diabetes Mellitus is a worldwide public health issue that affects millions of people. It is among the ten-leading causes of death worldwide. In 2019, the International Diabetes Federation projected that 463 million adults had diabetes and 4.2 million died from the disease and its complications. Given that diabetes can be effectively controlled with education, counselling, and the adaptation of healthy lifestyles, as well as drug therapy, the number of deaths is high. Increasing evidence of alarmingly low adherence rates, which limit clinical benefits, suggests that improving the effectiveness of adherence interventions can impact public health much better than any advancement in definitive medical therapies. The World Health Organisation has strongly supported the recommendations for evaluating the effectiveness of health interventions in practice, especially those addressing adherence. Methods: This is a systematic review that aims to undertake a quantitative review of interventions to improve adherence to anti-diabetic medications for adults with type 2 diabetes in subSaharan Africa, and the impact of these interventions in achieving good glycaemic control. For the evaluation of these interventions, only randomized controlled trials will be considered. We will perform electronic searches of all published papers available on PubMed. The reference lists of all relevant articles, abstracts, and conference published records will be manually searched. A search of Grey literature sites such as Google and Google scholar, as well as the Networked Digital Library of Theses and Dissertations, will be undertaken. A data extraction form will be used. All studies will be screened by two independent reviewers for articles that meet the inclusion criteria. Relevant data will be extracted, and the methodological quality of all included studies will be assessed based on selection, performance, attrition, detection, and reporting biases. We will perform a meta-analysis on the included studies. The statistical heterogeneity in the included studies will be determined using the Chi-squared test (χ2) test of homogeneity and quantified using I 2 statistic. A narrative summary of findings will be presented if data is too heterogeneous. Discussion: This review will provide evidence to assist policymakers and public health experts in making decisions and prioritizing effective interventions that have been identified.
  • Thumbnail Image
    Item
    Open Access
    Alcohol and problem drinking as risk factors for tuberculosis
    (2009) Mkandawire, Tiwonge Jaranthowa; Ehrlich, Rodney
    [Background] Tuberculosis is a major public health concern for South Africa which has one of the highest recorded incidence rates in the world. Previous research [1998 South African Demographic and Health Survey (SADHS)] reported a crude association between alcohol use and tuberculosis. This study aimed to examine evidence for a relationship, and the size thereof, between alcohol consumption and previous tuberculosis in the 2003 SADHS as a means of informing tuberculosis prevention. [ Methods ] This study was a secondary analysis of cross sectional data collected as part of the 2003 SADHS. Tuberculosis lifetime risk was derived from respondent reports of past tuberculosis episodes based on being informed by a healthcare worker. Alcohol consumption, problem drinking as well as selected explanatory variables were generated from similar questions from the adult questionnaire of the SADHS. The CAGE questionnaire was used to measure symptoms of alcohol problems. Logistic regression was used to model the relationship between past tuberculosis and both alcohol consumption and CAGE. [ Results ] Current and previous alcohol consumption were found to be associated with an increase in odds of tuberculosis in both men and women, with odds ratios ranging iii from 1.1 (95% CI 0.9 - 2.5) to 2.8 (95% CI 1.4 - 5.7) after adjusting for potential confounding effects of socioeconomic factors, smoking, nutritional status and age. Having a CAGE score of either 1 to 2 or 3 to 4 was associated with a doubling [OR 2.2 (95% CI 1.0 - 4.8) and quadrupling [OR 4.4 (95% CI 1.4 - 13.4)] in the odds of tuberculosis respectively. [ Discussion ] and conclusion Behavioural and biological mechanisms of effect of alcohol on tuberculosis may explain the findings. Impairment of the immune system, both acute and long term, has been suggested as the mechanism of increased susceptibility to tuberculosis. On the other hand, high risk living conditions and behaviour associated with problem drinking provide potential for increased exposure and susceptibility to tuberculosis infection. The study was able to control for several potentially confounding socioeconomic predictor variables although not HIV infection. The results complement a body of research that has documented the adverse effects of alcohol consumption on health in general and tuberculosis specifically. The findings thus provide more evidence for public health practitioners to tackle the problem of tuberculosis via specific efforts to control alcohol use and abuse, in addition to other methods of tuberculosis control.
  • Thumbnail Image
    Item
    Open Access
    An analysis of overweight and obesity in South Africa: the case of women of childbearing age
    (2022) Nglazi, Mweete Debra; Ataguba, John E
    This thesis used nationally representative data from the 2008 - 2017 National Income Dynamics Study, 1998 and 2016 South African Demographic and Health Surveys and 2005/06 and 2010/11 Income and Expenditure Surveys to examine prevalence, socioeconomic inequality, and determinants of overweight and obesity among non-pregnant women of childbearing age (15 to 49 years) (WCBA) in South Africa over time. It also assessed socioeconomic inequality in the intergenerational transmission of overweight and obesity from mothers to their offsprings among 10,735 mother-offspring pairs and decomposed socioeconomic inequality in household ultra-processed food (UPF) product spending in samples of 16,209 households in 2005/06 and 17,217 households in 2010/11. Overweight and obesity in WCBA in South Africa increased between 1998 and 2017 with factors including increased age, self-identifying with the Black African population group, higher educational attainment, residing in an urban area, and wealth contributing to the rise. Smoking had a protective effect on being overweight and obese. Overweight and obesity were also increasingly prevalent among wealthier than poorer WCBA in South Africa between 1998 and 2016. It was found that UPF expenditure increased between 2005/6 and 2010/11, accounting for a substantial share of poorer households' expenditures than their wealthier counterparts over time. Although factors explaining socioeconomic inequality in the intergenerational transmission of overweight and obesity differed by offspring sex, intergenerational overweight and obesity occur more frequently among wealthier mother-offspring pairs than their poorer counterparts. Key factors explaining inequalities in intergenerational overweight and obesity include the mother's socioeconomic status, education and exercise habits. This study improves the empirical understanding of the burgeoning overweight and obesity challenges among women, especially in South Africa, who are likely to transmit them to their offspring. Policy to address these issues should not only be about health services but also focus on the social determinants of health inequalities.
  • No Thumbnail Available
    Item
    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.
  • Thumbnail Image
    Item
    Open Access
    An assessment of the ‘PHC Facility Governance Structures Trainer-of-Facilitator Learning Programme’ in Nkangala District, Mpumalanga Province
    (2018) Esau, Natasha; King, Maylene Shung; English, René
    Background In South Africa, as part of specified governance requirements, clinic committees were established to provide management oversight at Primary Health Care facilities. In order for them to better understand their roles they needed training. Facilitators in the district were selected to participate in the 'PHC Facility Governance Structures Trainer-of-Facilitator (ToF) Learning Programme’ in order to train the clinic committees. This study assessed the training of facilitators. Methods This retrospective single case study used qualitative methods and was guided by the Illuminative Evaluation Framework. It assessed whether the aims, objectives and methodology of the training programme was clearly conveyed by the trainers, whether this was understood by the participants and whether the participants were able to transfer the training programme as intended to the clinic committees. Qualitative data were collected through key informant interviews and focus group discussions, face to face and telephonically. These were complimented by a document and literature review. Study participants were purposively selected based on their involvement in the development, facilitation or training of the programme. Interviews were conducted in English, with semi-structured open ended questions pertaining to participants’ perceptions and understanding of the training, and whether the ToF Learning Programme was delivered to the clinic committees. After participants signed consent forms interviews were audio recorded and transcribed verbatim. Data analysis was done manually and guided by the methodology presented by Ritchie and Lewis. Results A total of 13 participants participated in the study and 23 (national, provincial and partner) documents were reviewed. Despite the different perceptions and understandings of the ToF Learning Programme its overall goal was achieved. Participants’ capacity was strengthened and they trained the clinic committees. The document review showed inconsistency across legislations with regards to clinic committees. Conclusion The ToF Learning Programme has reached its overall goal despite the deviation in the process of delivery and can be recommended for implementation
  • No Thumbnail Available
    Item
    Open Access
    An exploratory qualitative study of menstrual hygiene management among adult women of reproductive ages from an under-resourced community in Cape Town, South Africa
    (2023) Ncube, Semkelisiwe; Knight, Lucia
    Background: Poor menstrual hygiene management can result in health concerns for women, particularly in low-and-middle-income countries. The evidence for the lived menstruation experiences of adult women of reproductive ages is limited. This study sought to understand the menstrual hygiene management experiences of adult women from an under-resourced community in Cape Town in South Africa. Methods: In this exploratory qualitative research design, qualitative in-depth interviews were conducted using a semi-structured interview guide with 10 women aged 25 and 49 and three key informants namely a maternal health nurse and two community health care workers. The study occurred over a period of three months and all participants were purposively selected using a homogenous sampling strategy and key informants were purposively sampled using an intensive sampling strategy. Data was manually analysed using Braune & Clarke (2016) thematic data analysis and coding was done deductively and inductively to look for emergent codes. Findings were organized around a conceptual framework developed to map the distal and proximal factors affecting girls and women menstrual hygiene management in LMICs. Results: Women menstrual experiences were shaped by their socio-cultural context and resource limitations. The main findings include psychological impacts of poor menstrual hygiene management namely shame, discomfort, culminating in feelings of powerlessness, loss of confidence, increased anxiety, and negative perceptions of menstruation. Physical health challenges related to compromised menstrual hygiene including skin irritation and rashes, increased risk of reproductive tract infections. Financial challenges culminating in poor access to and use of pain relief medication and use of substandard sanitary materials. Poor menstrual hygiene management also led to environmental pollution caused by disposal of sanitary materials and in day-to-day activities, poor menstrual hygiene led to avoidance of sexual activities and public places, reduced performance, and participation at work. Conclusion: Adult women from an under-resourced community in Cape Town experience poor menstrual hygiene management affecting their physical and psychological health. Recommendations: There is need for health education about menstruation, improved access to resources and health services required for proper MHM and further research and programming among adult populations.
  • No Thumbnail Available
    Item
    Open Access
    An umbrella review of the available evidence syntheses to inform vaccination practices and policies for the COVID-19 pandemic in Africa
    (2023) Els, Krisna; Kagina, Benjamin; Muloiwa Rudzani
    Background: In Africa, the rollout of COVID-19 vaccines lags other continents. The rollout in Africa started in the latter part of the first quarter of 2021 compared with earlier periods in high income settings. Optimal COVID-19 vaccination rollout in Africa should be guided by context-specific and up to date evidence. We conducted an umbrella review to identify, analyze and characterize the evidence syntheses that is available and has the potential to inform COVID-19 vaccination practices and policies in Africa. Methods: A systematic search for scoping reviews, systematic reviews, rapid reviews, and meta-analyses was performed in PubMed/Medline, Web of Science, Scopus (EMBASE), Epistemonikos and The Cochrane Library. Search outputs were exported to Rayyan software for screening. From the included studies, predefined outcomes were extracted and recorded on a data extraction form. Study characteristics, number and types of evidence syntheses were reported. Pooled results from the included studies were reported, including the statistical methods used. Where pooling of reported results had not been done and was feasible to do so, we conducted our own data pooling. Results: A total of 1111 papers were retrieved from all the databases. After removing duplicates and screening for inclusion, 15 papers were included: systematic reviews (n=4), systematic reviews and meta-analysis (n=7), meta-analysis alone (n=2), rapid review and meta- analysis (n=1), and a review of surveys (n=1). Results from the included studies were from 36 (66%) out of 55 African countries. The most abundant evidence was on the seroprevalence of antibodies against SARS-CoV-2 which ranged from 8.2% (95% CI: 0.8-22.3%) to 22% (95% CI 14%-31%). Conclusions: At the time of conducting this study, there was paucity of systematized evidence from majority of the African countries. Evidence syntheses gaps were evident for the incidence and severity of COVID-19 related outcomes, including hospitalization and mortality, as well as vaccine acceptance rates. Open Science Framework Registration: 10.17605/OSF.IO/PTB9W
  • No Thumbnail Available
    Item
    Open Access
    Anaemia in early childhood pneumonia ? prevalence, predictors, and associated growth in the Drakenstein child health study (DCHS)
    (2023) Prentice, Carley; Myer, Benjamin
    Background: Concurrent anaemia and pneumonia in under-fives living in LMICs is a complex relationship associated with high morbidity and mortality. Ascertaining whether there is an increased prevalence of anaemia among pneumonia infected under-fives can provide valuable insights for more effective treatments. Additionally, highlighting individual and maternal risk factors of anaemia as well as associated adverse growth outcomes among under-fives can bring about findings to prioritise resource allocation for anaemia prevention and treatment. Methods: This cross-sectional sub-study analysed data from the Drakenstein Child Health Study (DCHS), a South African population-based birth cohort which enrolled pregnant women. Mother-child pairs were followed prospectively, and a subgroup of children had additional data collected (including haemoglobin (g/dL) measurements) during episodes of LRTI/pneumonia. Prevalence ratios were used to assess the impact of LRTI/pneumonia severity on anaemia status. Binary logistic regression models were used to analyze the effects of predictors on risk of child anaemia and linear regression models were used to analyze the effect of anaemia on adverse growth outcomes (WAZ and HAZ). Results: 28% of first LRTI/pneumonia episodes co-occurred with anaemia (95% CI, 24.9 - 31.8), and median child age was 8.4 months during the episode. When all LRTI/pneumonia episodes were included, anaemia prevalence was higher among under-fives treated in hospital compared to those treated in ambulatory care (38.9% compared to 30.3% respectively, p=0.04). Additionally, children who experienced recurrent LRTI/pneumonia (2+ episodes) were 1.28 times as likely to have anaemia compared to children experiencing a first episode (95% CI, 1.03 - 1.59, p=0.023). Overall, children aged 6-59 months, with low socioeconomic status, and were exclusively breastfed for more than 1 month were strongly associated with anaemia (p<0.05). Children with concurrent LRTI/pneumonia and anaemia were found to be at increased risk of wasting (WAZ) and decreased risk of stunting (HAZ). Conclusions: This study provides evidence of a high prevalence of concurrent LRTI/pneumonia and anaemia among under-fives in South Africa. It demonstrates the complex interplay between these conditions and various risk factors including older child age, maternal anaemia, exclusive breastfeeding, low socioeconomic status, and food insecurity. These findings highlight the need for multi-sectoral approaches to address the medical treatment and underlying social determinants of health that contribute to the burden of LRTI/pneumonia and anaemia in under-fives.
  • No Thumbnail Available
    Item
    Open Access
    Analysing the technique of blood pressure measurement in primary care: a single pilot study
    (2023) Etonu, Joseph Benedict; Ras, Tasleem
    Background: Accurate blood pressure (BP) measurement is essential for the diagnosis and management of hypertension. However, BP measurement technique is often suboptimal in primary healthcare facilities, potentially leading to misdiagnosis and inappropriate management. Objective: To assess the quality of BP measurement technique in a primary healthcare facility in the Western Cape, South Africa, and to identify factors that may affect the accuracy of BP recordings. Methods: A cross-sectional study was conducted using a questionnaire and clinical point of care audit to assess the knowledge, attitude, and skills of healthcare workers involved in BP measurement. Digital BP machines were also audited for calibration and cuff size appropriateness. BP measurements were observed for 102 patients to audit the technique of BP measurement and compared to measurements obtained by the research team using a pre- validated, standardised technique. Results: Knowledge of BP measurement was adequate (>60% on knowledge quiz) amongst 72% of doctors, and inadequate (<60% on knowledge quiz) amongst 81% of nurses. We found widespread use of improper BP cuff sizes and non-calibrated digital BP machines. The use of digital BP machines produced significantly higher systolic BP readings than manual readings (145 vs 141.1; p=0.031), with non-significant differences in diastolic and mean arterial pressures. Conclusion: This study successfully piloted a novel method of assessing BP measurement technique, and identified several factors that could influence measurement outcomes, potentially impacting on clinical care. Recommendations for further research and targeted staff training are suggested.
  • No Thumbnail Available
    Item
    Open Access
    Antibiotic prescribing practice and adherence to IMCI guidelines among CNPs in children younger than 5 years withrespiratory tract infections at Crossroads clinic, Cape Town,South Africa: retrospective audit
    (2023) Machina, Baba; Isaacs, Abdul-Aziez
    Background. Antibiotic use is especially high among children globally. In South Africa (SA), children under 5 years (U5) are typically prescribed an appreciable number of antibiotics in primary health care (PHC). There have been several published studies on antibiotic prescribing practice among Health Care Workers (HCWs) in PHC in low-resource setting. However, no published study has been reported on antibiotic prescribing practice among clinical nurse practitioners (CNPs) in PHC low-resource setting in Cape Town. Antimicrobial Stewardship Programme (ASP) in PHC has strengthened the use of evidence-based guidelines to support appropriate antimicrobial prescribing; however, adherence to these guidelines seems to be low. Objective. To assess antibiotic prescribing practices amongst CNPs and adherence to Integrated Management of Childhood Illnesses (IMCI) guidelines for U5 children with respiratory tract infections (RTIs), as well as to make recommendations with the aim to promote appropriate antibiotic prescribing at PHC Level. Methods. This is a retrospective audit that included folder review of children U5 with RTIs for which antibiotic was prescribed by CNPs for the period July 2021 to December 2021 at Crossroads community day clinic (CDC). Data was obtained on site by sequential non-random sampling of patient folders from medical records in the baby clinic admission book, with a total sample size of 120. This study determined the appropriateness or otherwise of antibiotics prescribed to U5 children by CNPs, and additionally makes recommendations to mitigate the effect of rising prevalence of antimicrobial resistance (AMR) in PHC setting. Results. A total of 120 folders included in this study were audited. Of the 120 folders analyzed, (60%) (n=72) did not adhere to guidelines. Guidelines were adhered to in only (40%) (n=48). Of those non adherent to the guidelines, (18.05%) (13/72) had no diagnosis documented in patient folder, (31.94%) (23/72) had incorrect dose prescribed, (40.27%) (29/72) had no weight documented, (18.05%) (13/72) had no allergies documented; duration of antibiotic prescribed not documented in (9.72%) (7/72), the antibiotic prescribed was different from what was recommended in the IMCI guidelines in (6.94%) (5/72) and only (6.94%) (5/72) were non adherent owing to frequency of antibiotic prescribed per day not documented. Adherence variation was observed between the 3 antibiotics, with significantly higher adherence to guidelines for prescriptions containing Amoxicillin (53.53%) (53/99) than other antibiotics. Adherence to guidelines also differed by diagnosis, prescriptions for pneumonia was more likely to adhere to guideline (55.00%) (33/60) than other RTIs. A strong association was observed between weight documented and adherence to guidelines. 51.64% (47/91) of the prescriptions in which weight was done adhered to guidelines. When weight was done, the prescriptions were more likely to be correct, Fishers exact test = 0.000 (P<0.05). Conclusions. In a resource-limited environment, CNPs play a pivotal role in order to meet community healthcare needs. This study gives insight into antibiotic prescribing practices amongst CNPs and it demonstrated low adherence to IMCI guidelines. Focus should be directed towards CNPs prescribing adherence with aim of improving appropriate antibiotic use and the fight against AMR in PHC in low-resource setting in Cape Town. Future clinical research in this setting should explore qualitative research approach including interviewing both CNPs and caregivers to assess their knowledge and understanding of prescribing guidelines and antibiotic use respectively. The views and expertise of stakeholders should be incorporated to shape policies in the fight against AMR in PHC.
  • No Thumbnail Available
    Item
    Open Access
    Assessing and addressing missed opportunities for vaccination in Cape Town through a collaborative quality improvement approach
    (2024) Nnaji, Chukwudi; Lesosky, Maia Rose; Myer Benjamin
    Background: While significant investments and efforts have been made to promote universal access to immunisation services in South Africa, current evidence shows substantial coverage gaps across the country. Missed opportunities for vaccination (MOV) have been recognised as a major contributor to sub-optimal immunisation coverage globally. The overall aim of the research and its component studies was to assess and address MOV in primary health care (PHC) settings in Cape Town. To achieve this overarching goal, the research sought to address five specific objectives. It started with quantitative and qualitative assessments of the magnitude and multi-dimensional factors associated with MOV among children aged 0-23 months attending PHC facilities in the Cape Town Metro Health District. The goal of that formative assessment was to help inform the design, implementation and evaluation of contextually appropriate quality improvement interventions targeted at reducing MOV in participating PHC facilities. In addition, the research sought to contribute important evidence on the feasibility, effectiveness and sustainability of quality improvement interventions in addressing MOV in PHC contexts. Study rationale, supporting literature and specific objectives are described in detail in Chapters 1-2. Methods: The research used a mixed-methods approach, incorporating data from both quantitative and theory-informed qualitative studies. To address the five specific objectives, the research had five component studies. The first study involved a quantitative assessment of the magnitude of MOV and associated factors (Chapter 3), consolidated with two qualitative studies to provide deeper understanding and contextualisation of the first study's quantitative findings from the perspectives of caregivers and health workers (Chapter 4). These were followed by a non-randomised controlled study to evaluate the effectiveness of the package of quality improvement strategies implemented in participating health facilities (Chapter 5) and a post-intervention mixed-methods evaluation of the factors facilitating or hindering the successful implementation of quality improvement interventions (Chapter 6). Study design, methodological considerations and conceptual underpinnings are described in detail in various study chapters (Chapters 3-6). Strengths and limitations of each study design are also discussed in their respective chapters, as are their implications for further research. Results: The first component study (reported and discussed in detail in Chapter 3) involved a quantitative study that aimed to assess the prevalence and determinants of MOV in PHC settings in Cape Town. It found a prevalence of 14% and identified individual and health system factors associated with MOV. The second study (reported and discussed in Chapter 4) used a qualitative design (focus group discussions with caregivers) to explore the factors that may influence MOV among children in the study setting. Similarly, the third study (reported also in Chapter 4) employed another qualitative design (in-depth interviews) to explore the factors that may influence MOV from the perspectives of healthcare workers. Both qualitative studies provided important contextual insights that complemented and enhanced understanding of the findings from the quantitative MOV assessment. In the fourth component study (reported and discussed in Chapter 5), findings from the quantitative and qualitative baseline assessments were used to design and evaluate a package of facility-level quality improvement interventions. From the evaluation using a non-randomised controlled design, we found that implementing contextually appropriate quality improvement strategies was feasible and effective at reducing MOV occurrence in participating PHC facilities. In the final study, we used a mixed-methods evaluation design to conduct a post-implementation evaluation of the quality improvement intervention. From that, we were able to identify the quality improvement implementation facilitators and barriers and how they influenced participants' experiences and perceptions of implementation outcomes, the understanding of which is important for informing the adaptation and sustainability of future MOV-targeted quality improvement strategies. Conclusion Overall, the research has demonstrated that there was a substantial burden of MOV among children in Cape Town. It has also provided some scientifically robust evidence on the feasibility, effectiveness and adaptability of a facility-level quality improvement intervention for addressing MOV in primary health care contexts in Cape Town and similar contexts. Implications of study findings for policy, practice and further research have been discussed with specific recommendations in various study chapters (Chapters 3-6) and consolidated in the integrated discussion in the final chapter (Chapter 7).
  • Thumbnail Image
    Item
    Open Access
    Assessing the effectiveness of integrated non-communicable disease and antiretroviral adherence clubs in Cape Town, South Africa
    (2020) Gausi, Blessings; Oni, Tolullah; Jacob, Nisha
    The growing burden of HIV and non- communicable disease (NCD) syndemic in Sub Saharan Africa, has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs. However, there is paucity of literature on long term treatment outcomes for multimorbid patients attending integrated care. We describe long term treatment outcomes among multimorbid patients who attended integrated ART and NCD clubs (IC), a novel model of care piloted in 2014 by the Western Cape Government in South Africa. We followed up multimorbid patients for 12 months, who enrolled for IC at Matthew Goniwe and Town II clinics before September 2016. Median adherence proportions, HIV viral suppression and retention rates were calculated at 12 months before and after IC enrolment. Rates for achieving targets for blood pressure and glycosylated haemoglobin were determined at 12 months prior, at IC enrolment and at 12 months post IC enrolment. We describe demographic and clinical variables among all patients at IC enrolment and used multivariable logistic regression to evaluate for predictors of NCD control 12 months post IC enrolment. As of 31 August 2017, 247 patients in total had been enrolled into IC for at least 12 months. Of these, 221 (89.5%) had hypertension, 4 (1.6%) had diabetes mellitus and 22 (8.9%) had both in addition to HIV. Adherence was maintained before and after IC enrolment with median adherence proportions of 1 (IQR 1-1) and 1 (IQR 1-1) respectively. HIV viral suppression rates were 98.6%, 99.5% and 99.4% at the three time points respectively. Retention in care was high with 6.9% lost to follow up at 12 months post IC enrolment. Optimal blood pressure control was achieved in 43.1%, 58.9% and 49.4% of participants whereas optimal glycaemic control was achieved in 47.4%, 87.5% and 53.3% of diabetic participants at the three time points respectively. Multivariable logistic analyses showed no independent variables significantly associated with NCD control. Multi-morbid people living with HIV achieved high levels of HIV control in integrated HIV and NCD clubs. However, intensified interventions are needed to maintain NCD control in the long term.
  • Thumbnail Image
    Item
    Open Access
    The body count : using routine mortality surveillance data to drive violence prevention
    (2012) Matzopoulos, Richard; Myers, J E; Thompson, Mary Lou
    This thesis describes the conceptualisation, development and implementation of a mortuary-based system for the routine collection of information about homicide. It traces the evolution of the system from its conceptualisation in 1994, through various iterations as a city-level research tool, to a national sentinel system pilot, as a multicity all-injury surveillance system, and finally its institutionalisation as a provincial injury mortality surveillance system in the Western Cape. In so doing, it demonstrates that the data arising from medico-legal post-mortem investigations described in this thesis were an important source of descriptive epidemiological information on homicide. The 37,037 homicide records described in the thesis were drawn from Cape Town, Durban, Johannesburg, Port Elizabeth and Pretoria, for which the surveillance system maintained full coverage from 2001 to 2005. The aim was to apply more complex statistical analysis and modelling than had been applied previously.
  • Thumbnail Image
    Item
    Open Access
    A brief intervention to promote IUD use among women in Cape Town
    (2013) Trasada, Phumelele; Myer, Landon
    While the Copper T intrauterine device (IUD) is one of the most used methods of contraception around the world, only 1% of women in sub-Saharan Africa use this method. The IUD is a safe and highly effective form of long-acting contraception that provides protection for up to 10 years and has a lowrisk of pregnancy (less than 1% during the first year of use). The IUD is highly beneficial in that it can provide protection for women who want to delay or space childbearing and unlike methods such as the injectable or oral contraceptive, does not require users to make numerous visits to their health care facility or obtain a further supply. The IUD is free in the public sector in South Africa, but remains an unpopular choice among women. The purpose of this study was to test the effectiveness of a brief counselling intervention on the uptake of the IUD among women in Cape Town, South Africa. Part A of this dissertation (Protocol) is comprised of a proposal that was accepted by the University of Cape Town (UCT) Human Research Ethics Committee (HREC) and the Provincial Government of the Western Cape (PGWC). It describes the study background and methods. Part B (Literature Review) presents the current state of IUD use in sub-Saharan Africa as well as the level ofunmet need for contraception in the region. It illustrates the effectiveness of the IUD and gives a summary of interventions related to IUD uptake. It also discusses the need for increased use of the long acting and permanent methods in sub-Saharan Africa. Part C (Article) presents the results as a journal article. The incidence of the primary outcome was lower than expected. Five percent of women assigned to the control group went to family planning to make an appointment for IUD insertion, while 4% of those in the intervention group made an IUD insertion appointment. Knowledge of the IUD was not high with only 46% of women having heard of the method. After being given a description of the IUD, 36% of women said they would consider using the IUD. Twenty-seven percent of women stated that they would be interested in receiving an IUD that day. The method was not often mentioned to clients as only 16% reported having discussed the IUD with a health provider. Chi-squared analysis identified characteristics which were related to a participant being aware of the IUD. In this regard, being older and having higher gravidity were both significantly associated factors. The results suggest that IUD is a method that women are interested in learning more about and potentially using. It is clear that a more intensive and comprehensive campaign is needed in order to increase demand for the IUD in South Africa.
  • Thumbnail Image
    Item
    Open Access
    Client knowledge, attitudes and practices to cervical screening in Mitchell's Plain, Cape Town, South Africa
    (2007) Daries, Vanessa Cheryl; Moodley, Jennifer
    Background: Cervical cancer is a common cause of death among women in developing countries, including South Africa. In 2000, the South African National Department of Health introduced the national cervical cancer screening policy, which states that every woman is entitled to three free Papanicolaou (Pap) smears in her lifetime, at 1 0-year intervals starting at the age of 30 years. A number of studies have indicated that the uptake of cervical cancer screening is dependent on the targeted population's knowledge, attitudes and practices (KAP) related to health-seeking behaviours. The aim of the study is to determine the baseline KAP to Pap smears and cervical cancer of women aged 25 years and older in Mitchell's Plain, Western Cape Province. Methods: A cross-sectional survey was undertaken among clients attending primary health care facilities in the Mitchell's Plain district, Cape Town, Western Cape Province. The study population consisted of women aged 25 years and older who presented at the public health care facilities in Mitchell's Plain between 1 April and 31 July 2002 and who consented to participate in the study. The data were analysed using the STAT A version 8 statistical package. Results: A total of 445 women were interviewed, most of whom were above the age of 30 years (72%), married (68%) and unemployed (68%). Ninety-five per cent said they had heard of a Pap smear; however, when asked what part of the body was examined during a Pap smear, only 4% correctly answered. Only 13% of the women knew that a Pap smear was a test for cancer of the cervix, although 52% recognised it as a test for cancer. Of the women interviewed, 73% had heard of cancer of the cervix. A total of 78% of women had had a Pap smear. The results indicated no significant association between ever hearing of a pap smear and the following predictors: age, educational level, marital status, pregnancy and the use of contraception. Women who were significantly more likely to have had a Pap smear included: older women, those who were in a relationship, owned a radio, were employed, had ever been pregnant or had heard of a Pap smear before. Main sources of information regarding Pap smears were reported to be posters (17%) and the radio (16%). Conclusions: The data suggest that although a very high proportion of the women (95%) had heard of Pap smears, a smaller proportion (78%) had actually had a Pap smear. This study showed that there were missed opportunities that the health workers could possibly have utilised to encourage women in the targeted age group to have a Pap smear while at the health facilities for reasons other than reproductive health. Women who had not been afforded the opportunity to have a Pap smear by the health provider reported a great interest in having a Pap smear, showing willingness to improve their health if afforded the opportunity. In order to reduce the high morbidity and mortality from cervical cancer in South Africa, very large numbers of women in the target age group need to be recruited to the screening programme. To be able to achieve an increase in the cervical cancer screening uptake, huge efforts have to be made to actively recruit women who are within reach of the health services, particularly any women who present at the health facilities.
  • No Thumbnail Available
    Item
    Open Access
    Complex interventions in complex health systems: Hepatitis B birth-dose vaccination programs in the African region
    (2023) Rakiep, Tasneem; Olivier, Jill; Amponsah-Dacosta Edina
    Background: Of the 296 million chronic carriers of hepatitis B virus (HBV) infection worldwide, the majority are found in the African and Western Pacific regions. Neonates who acquire the infection from their mothers (mother-to-child transmission or MTCT) carry a 90% risk of chronicity. To prevent serious liver complications such as liver cancer, cirrhosis, and premature death, the World Health Organization (WHO) recommends hepatitis B vaccination at birth, followed by vaccination during infancy. Despite the longstanding implementation of universal hepatitis B infant vaccination programs, the African region maintains the highest prevalence (2.5%) of chronic HBV infection among children ≤5 years of age. While optimal coverage of the hepatitis B birth-dose vaccine could avert further infections in this region, weak implementation and poor program performance have raised global concern. This study provides a comprehensive update on the status of HBV MTCT in Africa and explores how complex interactions between intervention and the health system may influence the performance of hepatitis B birth-dose vaccination programs in the region. Methods: This qualitative systematic review study was conducted in two phases where phase 1 involved a scoping review and phase 2 the systematic review. The scoping review mapped current evidence on HBV MTCT and hepatitis B birth-dose vaccination programs in Africa. In addition, the scoping phase informed the development of an adapted systems-based logic model for assessing complexity in the design or causal pathway of hepatitis B birth-dose vaccination programs. For the qualitative systematic review, a Boolean search strategy was utilized to retrieve relevant peer-reviewed literature published between 2009–2022 indexed in PubMed, EBSCOhost databases, Scopus, and Web of Science, with supplementary searches conducted to identify any missed articles. No language restrictions were applied. Data extraction, synthesis and analysis were guided by the systems-based logic model tailored to systematic reviews of complex interventions. Results: Findings from the scoping review provided compelling evidence on the risk of HBV MTCT in Africa, spurred by the considerable burden of HIV co-infections in the region. Despite this, only 15 WHO African member states have so far adopted hepatitis B birth-dose vaccination programs, with noteworthy inconsistenciesin performance. Previous scoping reviews exploring the determinants of program success have been limited by the scanty representation of evidence from the African region. Furthermore, these reviews have failed to adequately address the complexities within the intervention or the multiple interactions across the intervention, the health systems and contexts which deliver them. Our systematic review search yielded 672 published records. Of these, 28 were judged to be eligible for inclusion. Among the 12 African states represented, the origin of evidence weighted highest in Nigeria (n=12) and Senegal (n=5). The performance of hepatitis B birth-dose vaccination programs across African states highlighted underlying complexities across multiple themes. The findings further emphasized the need for improved compliance with global recommendations when formulating national vaccine policies and guidelines; limitations of current vaccine supply chain systems; the need for renewed commitment towards intensified domestic investments complemented by donor support; ensuring capable and skilled cadres of health care workers, accurate and appropriate data collection and usage; expanded immunization services with outreach programs, and developments in maternal education and socio-economic status. Conclusion: We highlight the complex interactions between hepatitis B birth-dose vaccination programs and the health systems that deliver them. We further demonstrate how these complex interactions contribute to the sub-optimal performance of hepatitis B birth-dose vaccination programs in the African region. By identifying sources of complexity at the intersection of hepatitis B birth-dose vaccination programs and health systems in Africa, we can better inform the design of immunization programs responsive to the contexts they are embedded in. Ultimately, the performance of hepatitis B birth-dose vaccination programsin Africa extends beyond vaccine supply and is further driven by a multiplicity of program-specific, system-wide determinants that should be considered if the region is to progress towards improved control of HBV MTCT
  • Thumbnail Image
    Item
    Open Access
    Coverage of prevention of mother-to-child transmission services in Cape Town, South Africa
    (2012) Stinson, Kathryn Lee; Myer, Landon
    The effectiveness of prevention of mother-to-child of HIV (PMTCT) programmes depends on the successful coverage of a series of interventions through pregnancy, intrapartum and postpartum. Routine monitoring systems based on service data and limited to women on the PMTCT programme may overestimate intervention coverage at multiple points along this cascade. Methods: Cord blood specimens with individually linked anonymous demographic and pregnancy data were collected from three delivery services in the Western Cape Province, South Africa, and screened for HIV. Seropositive specimens were tested for the presence of antiretrovirals.
  • No Thumbnail Available
    Item
    Open Access
    COVID-19 alcohol availability and suicide rates in South Africa
    (2024) Hodgson, Anthony; Matzopoulos, Richard
    Investigations into COVID-19 and suicide have predominantly found no significant evidence of increased suicide rates, but few studies have been conducted in low- and middle-income countries and none in Sub-Saharan Africa. We used data from two nationally representative surveys of post-mortem investigations to estimate changes in suicide rates in South Africa associated with the COVID-19 pandemic and related events. We specifically explored variance in suicide rates coinciding with lockdown stages and periods of alcohol prohibition. We found no significant differences between suicide rates during the pandemic period (April 2020 to March 2021) compared to the prior survey period of 2017, but significant variation within the pandemic period. Periods of alcohol prohibition were protective with an estimated 5.82 [5.78, 5.86] fewer suicide deaths per day compared to periods of no or partial alcohol restriction. This constituted a 30% decrease in expected suicides under normal trading conditions. Cessation of alcohol prohibition had a negative effect and suicide rates during periods of no or partial alcohol restriction were significantly higher than in 2017. We conclude that in South Africa the observed null effect of the COVID-19 pandemic on annual suicide rates masks considerable temporal variation associated with restrictions, and periods of alcohol prohibition in particular.
  • No Thumbnail Available
    Item
    Metadata only
    Determinants of HIV voluntary counselling and testing among the youth: The case of Botswana
    (2010) Mokalake, Ellen N; Cooper, Di
    This study was conducted in Gaborone city, Botswana. Botswana is a small country in south central part of Africa with a population of 1.7 million (Botswana population census, 2001) The overall aim of the study was to examine barriers and facilitating factors influencing the readiness for and acceptability of voluntary HIV testing among the youth aged 18-24 years in Gaborone, Botswana. A quantitative methodology was used in this study. A multistage sampling strategy was also used to recruit one hundred and forty four (144) participants. Information on socio-demographic characteristic, knowledge and utilization of VCT sexual behaviour and perception of risk was gathered by use of a self administered structured questionnaire. STATA version 8 was used to analyse the results of this study. Summary statistics, chi-square test and logistic regression were employed in the analysis. Participants comprised of students from senior secondary schools and tertiary education institutions from the sampled schools of Gaborone. The modal level of education was secondary and the more than half of participants (56%) were females. Their age ranged from 18-24 years. The majority of participants (75%) were sexually active and just over a third 36% of all participants considered themselves not at risk of HIV. VCT knowledge was reported by a significant proportion (59%) who also reported knowledge of VCT sites. HIV testing was reported by a minority of participants 42% and the most commonly reported reason for testing was media campaigns encouraging HIV testing whilst the most commonly reported reason for not testing was never been sexually active. Findings from this study revealed that, HIV test acceptance among the youth is still an area that needs greater attention. The facilitation of HIV testing amongst the young people and removal of barriers to testing can be achieved through a focus on use of strategies that seem vii to work such as the media. Also, there is need to ensure utilization of VCT services by youth through making them understand of the role that VCT plays in preventing HIV and AIDS.