Browsing by Subject "public health"

Now showing 1 - 20 of 21
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    Open Access
    “A case study evaluating the effectiveness of adherence clubs in Gugulethu as a strategy for mobilizing and engaging men in HIV treatment”
    (2022) Ncube, Petronella; Colvin, Christopher J; Mbokazi, Nonzuzo
    The existing global literature shows that men living with HIV need efficient antiretroviral treatment (ART) delivery. Adherence clubs (ACs) have been identified as one way to improve retention of stable patients living with Human Immunodeficiency Virus (HIV). ACs are among several strategies that have been said to potentially assist in the engagement and mobilization of men in HIV services. However, very few have been evaluated to see whether they are effective in this regard. This qualitative study examines the facilitating factors that help retain and engage men in HIV services by trying to understand the perceived effectiveness of the Adherence Club in Gugulethu. The study employs a qualitative approach to explore the facilitating factors which help retain and engage men in HIV services. A total of 12 participants participated in in-depth telephonic interviews. The participants included stakeholders of the AC such as the health workers (facilitators, nurse, community health worker (CHW) and adherence counsellors), men attending the club and family members who are indirectly involved in supporting participants engagement in the AC as patients. Interviews were conducted in IsiXhosa and for data analysis, they were translated to English, and a thematic analysis was done. The findings show facilitating factors in all stages of the socio-ecological model with the patient level being the vital stage which allows for the integration of other level factors. This study shows that when men properly utilize the different resources provided for their HIV treatment, their engagement and retention in the AC improves. It is therefore key for policy makers to consider planning for male-focused health services to ensure that men view health services as spaces which are inclusive and tailored for them to improve their engagement and retain them in health services.
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    A multi-state model of treatment states in an antiretroviral treatment programme cohort in Cape Town
    (2022) Moolla, Haroon; Johnson, Leigh F
    Introduction A recent systematic review estimated that almost a quarter of patients in low- and middle-income countries are not retained on antiretroviral treatment (ART) beyond one year. Further, it is difficult to determine whether a patient who is not retained in care has interrupted their treatment, transferred to another treatment facility, or died. Previous studies have been deterministic in classifying loss to follow-up and treatment interruption. This study investigates treatment interruption and resumption rates when accounting for uncertainty in the occurrence of interruptions. The primary objective is to estimate the rate at which ART is interrupted and the rate at which ART is resumed after an interruption. Methods We fitted a multi-state model to data from the Khayelitsha cohort of the International Epidemiologic Databases to Evaluate AIDS. Between 2001 and 2012, 6796 adult patients starting ART were included. Potential treatment interruption periods were defined between contact points 3 or more months apart. To aid the model in determining if a patient truly interrupted treatment a CD4 count model was used. CD4 counts were modelled to drop to baseline by 3 months after the start of a treatment interruption. Bayesian estimation and Markov chain Monte Carlo were used to obtain posterior distributions of parameters. Several scenarios were used in sensitivity testing, including varying the threshold used to define potential treatment interruption periods, and either adjusting or excluding the data of those with CD4 counts that drop below baseline. Results The baseline annual rate of treatment interruption had a posterior mean of 0.060 (95% CI 0.038- 0.087) which is significantly lower than the prior distribution that had a mean of 0.145 (95% CI 0.080-0.229). The posterior distribution of the baseline annual rate of treatment resumption (mean 1.09; 95% CI 0.68-1.65) was consistent with the prior distribution (mean 1.46; 95% CI 0.21-3.90). The posterior distributions of the parameters related to treatment interruption and resumption did not change significantly in sensitivity testing. Conclusion This study indicates that treatment interruption rates may be significantly lower than previously estimated. The methodology of this study may be useful to those measuring retention within ART programmes. An important limitation was that the CD4 count model did not allow for CD4 counts to fall below baseline during periods of treatment interruption. This limits the generalisability of the posterior estimates of the parameters of the CD4 count model. Further research may require a more flexible CD4 count model.
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    Acceptability, safety, and patterns of use of oral pre-exposure prophylaxis to prevent HIV in healthy, South African adolescents
    (2022) Gill, Katherine; Bekker, Linda-Gail
    Background: HIV incidence amongst adolescents in Southern Africa remains extremely high. The importance of adolescent HIV prevention strategies in tackling the epidemic worldwide is increasingly recognised with a global target from UNICEF to reduce new adolescent HIV infections by 75% by 2020. Adolescent vulnerability to HIV infection is a result of a complex interplay between structural, economic, socio-cultural, and biological factors during a phase when behaviours associated with HIV acquisition and sexual and reproductive health-seeking are initiated. The vulnerability of young people to HIV is particularly manifest in South Africa, where young women aged 15-24 accounted for almost 40% of new HIV infections in 2017. PreExposure Prophylaxis (PrEP) has been demonstrated to be effective for preventing HIV infection in adults but there is little data on its implementation among young people. Given the HIV incidence rates amongst adolescents in Southern Africa, oral PrEP for this group is likely to have an impact on population-level HIV incidence. We designed an open-label demonstration study known as Pluspills, for adolescents aged 15-19 years in South Africa to understand the safety, feasibility, and patterns of use of oral pre-exposure prophylaxis (PrEP) as part of a broad package of interventions, to prevent HIV. Methods: Pluspills was conducted in two distinct peri-urban settings in Johannesburg and Cape Town. The aim was to study the safety and acceptability of oral PrEP (tenofovir disoproxil fumarate/Emtricitabine) in two adolescent populations in South Africa. HIV-negative participants between 15-19 years old participated in an open-label oral PrEP study over 52 weeks. Participants took daily PrEP for the first 12 weeks and were then given the choice to opt-in or opt-out of PrEP use at three-monthly intervals. Serial plasma and DBS tenofovir concentrations were measured at every PrEP refill visit, and results were discussed with participants during adherence counselling sessions. Testing for sexually transmitted infections (STI's) was conducted at baseline, twelve and forty-eight weeks. Findings: Overall 148 participants were enrolled (median age 18 years; 67% female) and initiated PrEP. STI prevalence at the study start was high at 41% (60/148) and remained high throughout the study. The decision to stop using PrEP was made by 26 (18%) participants at 6 the 12-week visit. Cumulative PrEP opt-out at weeks 24 and 36 comprised 41% (60/148) and 43% (63/148) of the total cohort respectively. PrEP was relatively well tolerated with few reported adverse events. Tenofovir diphosphate (TFV-DP) levels as measured in dried blood spot samples were detectable (>16fmol/punch) in 92% (108/118)) of participants who reported PrEP use at week 12, 74% at week 24 (74/100), and 58% (22/37) by the end of the study. One HIV seroconversion occurred during the study (0.76/100 person-years) in a 19-yearold female participant who had chosen to stop taking PrEP, 24 weeks before diagnosis. Interpretation: In this small cohort of South African adolescents at risk of HIV acquisition, PrEP was safe and well-tolerated in those who continued to use it. PrEP use decreased throughout the study as visit frequency declined. The incidence of sexually transmitted infections remained high, despite low HIV incidence. The study confirms that this population needs access to PrEP with particular attention to tailored adherence support. Young people would also possibly benefit from the option for more frequent and flexible visit schedules.
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    Analysing the effectiveness of pictograms as a hazard communication mechanism to reduce child exposure to chemicals in South Africa
    (2021) Louw, Tatum; Rother, Hanna-Andrea
    Hazard communication mechanisms are essential for informing child caregivers of the dangers associated with chemical products. However, for caregivers to protect their own health and their children from the harm of toxic chemicals, it is important that they understand label information as scientifically intended. Therefore, to accommodate parts of society that have a lack of access to education, the placement of hazard communication pictograms on labels have been introduced to overcome literacy barriers. Many research studies have been conducted on the comprehensibility of pictograms and have found that many barriers exist in end-users being able to understand the intended message behind the pictogram. This study, therefore, explores further the awareness and comprehension of pictogram comprehensibility among caregivers in South Africa that have different backgrounds and living experiences. The study employed a mixed-methods cross-sectional design. The study was conducted with farmworkers from a farm in Paarl and students from the University of Cape Town. Two different data collection tools were used: a face-to-face questionnaire was administered to farmworkers (taking into account literacy barriers) and an online questionnaire to students due to unforeseen circumstances (COVID-19), that put a pause on face-to-face questionnaires being administered among UCT students. Both groups received the same questions except for small adjustments made to the online questionnaire to accommodate the platform. Data for the face-to-face questions were stored in the data collection application, CommCare, and transferred to Excel for quantitative analysis. The online questionnaire was administered through a Google form that was emailed to all students at the university by the Department of Student Affairs and data were then transferred to excel for quantitative analysis. The qualitative data were analysed using a thematic analysis approach where themes were created from theory in the literature and word repetitions that emerged from the respective group responses. Based on the overall results, comprehension of the pictograms varied greatly between caregiver groups indicating harmonization is necessary. Although beyond the scope of this study, the difference amongst the perception of danger warrants further analysis on whether age, educational level, perception of danger, lived experiences, and environmental exposure play a role in the two groups' comprehension of pictograms. The study focused on the already existing Globally Harmonized System of Classification and Labelling of Chemicals (GHS) pictograms as well as newly proposed ones to communicate the “Keep out of reach of children” message. Based on the overall results, what the pictograms represented varied greatly between the different caregiver groups, indicating that comprehension differs largely, and harmonization has not been entirely achieved as desired by the GHS. However, the study concludes that participants place responsibility on the chemical industry to make information about the harmful effects about their products more accessible to communities through educational talks, social media, experts at the point of sale to explain any potential hazards, and through the use of billboards and flyers. Though difficult to achieve, it is suggested that conversation amongst chemical legislators and industry commence on how to include the voice of end-users in the development and implementation of hazard communication strategies.
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    Beyond hearing aid fitting: Investigating the feasibility of providing tele-rehabilitation for adult hearing aid users in a South African public health context
    (2021) Khatib, Nuha; Hlayisi, Vera-Genevey; Ramma, Lebogang
    Introduction: Disabling hearing loss is one of the most common sensory deficits; affecting approximately 466 million people worldwide. In the South African context, public health facilities have an uneven ratio between audiologists and patients in need and thus audiological services are often minimal. Successful application of tele-health may increase the scope of audiological services for hearing aid (HA) users. Research is needed to investigate feasibility of tele-health for audiological rehabilitation programmes such as auditory training (AT). Aim and Objectives: This study aimed to investigate the feasibility of implementing a telerehabilitation programme in a South African public health context. Objectives included: 1) determining online AT compliance; 2) determining the effect of online AT on speech perception in noise; 3) assessing experience and benefit of tele-rehabilitation through questionnaires and interviewing; and 4) cost estimation around tele-rehabilitation implementation. Research Design: A convergent mixed methods design with a feasibility approach was utilized. Data collection was through questionnaires, in-booth speech assessments, online AT and face-to-face interviewing. Participants undertook online AT over four weeks. Pre-/post- online AT: the APHAB, QuickSIN, Entrance/Exit Questionnaires, Interviews and System Usability Scale were administered. Descriptive statistics were used to analyse the quantitative data collected, and descriptive thematic analysis was used for the qualitative data. Study sample: Purposive sampling was used and three female adult (35 - 55 years) HA users from a public health facility participated. Results: 1) High compliance rate (84.82%) with 3 hours 25 minutes total clinician contact time, 2) clinical benefit with improvement in listening skills and perceived HA benefit, 3) positive participant feedback, and 4) estimated cost at R1350.00 per person. Conclusions: Findings from this feasibility study can be seen as positive indicators towards the use of tele-health as a delivery modality for audiological rehabilitation, also a tele-health hybrid model is recommended. However, larger-scaled research is needed.
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    Costing analysis of levofloxacin as antibiotic prophylaxis for pediatric household contacts of multi-drug resistant tuberculosis patients in a South African setting
    (2021) Fortuin, Suereta; Wilkinson, Thomas
    Background The incidence of TB in children under 15 years, accounts for 8% of the global TB burden. In 2018, the World Health Organisation (WHO) estimated that there were approximately 11 000 multi-drug resistant (MDR) TB cases in South Africa. Despite having very clear guidelines on TB treatment programs and management, availability of inexpensive diagnostic tests, curative and preventive therapies, and the widespread use of the BCG vaccines, South Africa continues to have the highest the number of MDR-TB cases per capita. Levofloxacin is used as part of the group of fluoroquinolones in the drug regimen recommended in the treatment of MDR-TB patients. In addition to investigating the clinical impact of levofloxacin as preventative antibiotic therapy, the expected costs of the intervention will be a critical input to determining feasibility and costs effectiveness, which will inform policy and implementation considerations. Methods We performed a cost analysis on using existing data from the Tuberculosis Child Multi-drug-resistant Preventative Therapy (TB-CHAMP) trial, conducted from a TB control program perspective. We used data from 510 childhood household contacts of MDR-TB patients in South Africa that were treated with levofloxacin for 6 months as a preventative therapy for MDR-TB. In our analysis we evaluated the estimated health system cost associated with provision of levofloxacin to childhood contacts of MDRTB patients in South Africa. Results The mean total cost of treating a child household contact, irrespective of their weight band is ZAR 5,289.79. When the cost were analysed by weight categories we found that the cost increased by weight category; ZAR 2,146.78 (under 5 kg), ZAR 4,714.58 (between 5-15.9 kg) and ZAR 6,606.67 (over 16 kg). We performed a comprehensive sensitivity analysis and found that the scheduled clinic visits were the major cost driver. Aside from the scheduled visits we observed that there was an increase in additional health service utilization for children with a weight more than 5kg. Conclusion We envisage that based on our analysis we will be able to inform policy decisions about the management and prevention of childhood household contacts of MDR-TB patients in developing TB themselves.
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    Disability Studies poster collection from Africa Day 2012
    (2012) Disability Studies Division
    This poster collection, developed by the Disability Studies Division and presented for Africa Day in May 2012, address the issue of disability from a range of social justice, inclusion and developmental perspectives. Poster 1 looks at the inclusion of disability in the University of Cape Town; Poster 2 explores residential options for intellectually disabled adults in the Western Cape; Poster 3 outlines the roles, purpose and scope of the Disability Studies Unit itself; and Poster 4 explores how the childhood experiences of community disability workers (CDWs) in rural communities in South Africa, Botswana and Malawi influenced their career choices and how their current experiences influence their work.
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    Exploring factors causing the high incidence of sexually transmitted infections in the township of Du Noon
    (2022) Dookhith, Azhaar Bibi Faatimah; Abdul-Aziez, Isaacs; Razack, Adil
    Introduction: Sexually transmitted infections (STIs) are of major public health concern in South Africa. STIs contribute largely to the burden of disease in South Africa and are recognized as major contributors to the Human Immunodeficiency Virus (HIV) epidemic. Du Noon is a small township situated in Milnerton, Cape Town, South Africa. Du Noon CHC has a large HIV population of approximately 8000 people and recent data obtained from Du Noon CHC statistics, from Nov 2019-Feb 2020 showed 1760 people being treated for STI as per the headcount. Aim: This study intends to explore the factors which may be responsible for the high prevalence of STI among the population of Du Noon Township in Cape Town, South Africa. Methodology: A cross- sectional study with 40 respondents aged between 18 and 45 years was conducted. One-on-one patient interviews using open-ended questions, as well as structured questionnaires, were used to gather data. The questionnaires were analysed using the Likert Scale and open-ended questions were analysed using exploratory descriptive methods. Results: Cultural beliefs, having multiple partners, lack of partner notification, alcohol consumption and lack of condom usage were found to be the main contributing factors to the high incidence of STIs. Sex education at schools appear to be lacking or not in sufficient detail to inform students. The study's findings echoed themes and larger ideas from previous research. It reflects the other well-known cultural and socioeconomic issues confronting South African rural communities e.g., poverty and sex, age -disparate relationships, polygamous relationships. Conclusion: This study fills a gap in the local literature by highlighting how health education challenges, interpersonal relationships, and socioeconomic barriers are still important factors in STI transmission. Although the study's findings may only be applicable to this community, they may have an impact on other communities with comparable populations. The widespread preliminary understanding and framing of HIV as a STI and how it is transmitted needs further investigations and research. As a result, there is an urgent need to shift cultural ideology and norms within the youth of the Du Noon community.
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    Exploring how Health-related Quality of Life (HRQOL) is experienced among patients living with HIV associated TB in Khayelitsha, South Africa
    (2020) Hickman, John-Henry; Swartz, Alison; Sicwebu, Nmhla
    Health-related quality of life (HRQOL) is a construct that has received attention in research for nearly four decades. However, renewed interest in this field came about with advances in medical technology and health policies. Better treatment options and policies, which enables greater access to health care, have improved health outcomes, such as leading to an extension in life expectancy. This rings particularly true for Human Immunodeficiency virus (HIV) and associated illnesses such Tuberculosis (TB). However, improvements in health outcomes are not necessarily accompanied by satisfactory patient experiences of HRQOL. Health-related quality of life is predominantly studied through quantitative research methodologies. However, the measures used are not entirely tailored to the South African context. Consequently, this mini-dissertation aims to explore HRQOL using qualitative methodological inquiry within the South African context. This mini dissertation is structured around the three following components: A research protocol (Part A) which addresses HRQOL in a South African context with particular focus on HIV and TB. Part B is a literature review examining existing HIV, TB and HRQOL literature, with emphasis on the South African context. The final section (Part C) is a manuscript for a journal article prepared to be published. Part C focuses on the social experience of HRQOL and how it is the central construct to experiencing HRQOL in South Africa as opposed to an individualised view in Western settings. The findings from this mini dissertation can add to the limited existing HRQOL literature in South Africa, by providing a perspective on how HRQOL is experienced in this country. The knowledge obtained here can further aid in the development or improvement of interventions and policies which aim to not only improve patient health outcomes, but HRQOL as well. Lastly, it can provide valuable information to those focused on developing quantitative HRQOL tools that are appropriate for use in South Africa.
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    The impact of reduced drug prices on the cost-effectiveness of HAART in South Africa
    (National Inquiry Services Centre, 2005) Nattrass, Nicoli; Geffen, Nathan
    South Africa has started ‘rolling out’ highly active anti-retroviral therapy (HAART) through the public health sector, but implementation has been slow. Studies have shown that in Africa AIDS prevention may be more cost-effective than providing HAART; such published results provide some support for the South African government’s apparent reluctance to implement a large-scale rapid HAART roll-out. However, previous studies have not linked treatment and prevention plans, and do not, for the most part, consider the potential savings to the public health sector (e.g., fewer hospital admissions) that may arise from the introduction of HAART. The South African costing exercise summarised here avoids both these limitations. It provides an update of earlier work and takes into account the recent decline in antiretroviral drug prices. It shows that once HIV-related hospital costs are included in the calculation, the cost per HIV infection averted is lower in a treatment-plus-prevention intervention scenario than it is in a prevention-only scenario. This suggests that it is economically advantageous to fund a large-scale comprehensive intervention plan and that the constraints for doing so are political. Once human-rights considerations are included, the case for providing HAART is even more compelling.
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    Is the golden hour optimally used in South Africa for children presenting with polytrauma?
    (2013) Zuidgeest, J; Jonkheijm, A; Van Dijk, M; Van As, A
    BACKGROUND: The major paediatric public health problem worldwide is injury or trauma. In 2004, 950 000 children died as a result of injury. OBJECTIVE: The aim of this study was to evaluate the logistics of medical care after paediatric polytrauma within the first hours after arrival into a trauma unit - the so-called Golden Hour. METHODS: Children presenting with polytrauma to the Trauma Unit at the Red Cross War Memorial Children's Hospital between May 2011 and August 2011 were considered for inclusion in the study. RESULTS: Fifty-five children were included in the final analysis. The median duration of stay in the Trauma Unit was 205 minutes (interquartile range 135 - 274). CONCLUSION: Several factors were identified that unnecessarily prolonged the time that patients stayed in the trauma unit following arrival in hospital for polytrauma management.
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    Missed opportunities to address mental health of people living with HIV in Zomba, Malawi: a cross-sectional clinic survey
    (2020) Kawiya, Harry Henry; Sorsdahl, Katherine; Lund, Crick
    Background. Common mental disorders (CMDs), including depression and anxiety disorders, and risky alcohol use are highly prevalent among people living with HIV. Yet, many studies have found that most people who suffer from mental disorders do not receive treatment, especially in low-income countries. Given people living with HIV frequent health services, this represents a missed opportunity for identification and treatment that could improve physical and mental health outcomes. The aim of this study was to identify missed opportunities to address mental health of people living with HIV in Malawi. Four types of missed opportunities were operationalised for this study. The first two address missed opportunities for screening or identification For missed opportunity #1, a respondent had to screen positive for mental health problem (depression/anxiety or alcohol use ; and in any of their visits to the clinic in the past 12 months, the clinical officer or nurse did not ask about their mental health. Missed opportunity definition #2 was a more nuanced missed opportunity for identification of probable mental health problems. A respondent had to be undetected for mental health problems; and in any of his or her visits to the clinic in the past 12 months, the clinical officer or nurse did not ask about his or her mental health and s/he wanted to receive advice or treatment about his or her mental health problems. The second to definitions address missed opportunities for treatment. For missed opportunity definition #3, a respondent had to screen positive for mental health problem and if in any of his or her visits to the clinic in the past 12 months, and s/he did not receive advice or treatment. For missed opportunity definition #4, a more nuanced missed opportunity for the treatment of probable mental health problem: a respondent had to screen positive for a mental health problem; s/he wanted to receive advice or treatment about his or her mental health problems/alcohol use; and in any of their visits to the clinic in the past 12 months, s/he did not receive treatment for a mental disorder/risky alcohol use. Methods. A a random of participants receiving HIV care were approached while they were waiting for their consultation at three ART clinics namely: Tisungane, Matawale and Domasi. Those who consented to participants were interviewed in a private room. The Self-Reporting Questionnaire-20 (SRQ-20) and the Alcohol Use Disorders Identification Test (AUDIT) were used to detect probable cases of CMDs and clients consuming alcohol at risky levels. Following v administration of the SRQ-20 and AUDIT, participants were asked if clinical officers (COs) or nurses inquired about their feelings (sad or worried) or alcohol consumption during their routine visits to ART clinics, thus eliciting data on identification by healthcare workers or identification of CMD symptoms. The participants were also asked whether advice or treatment was recommended and whether they would have liked to receive advice or treatment regarding their feelings or risky alcohol use. Descriptive statistics were utilized to calculate prevalence estimates of missed opportunities and multiple logistic regression models were used to determine the factors associated with missed opportunities for mental health service provision. Results. The study had 382 participants. The proportion of participants who screened at risk was 77 (20.2%) for probable CMDs and 16 (4.2%) for risky alcohol use. The proportion of participants who screened at risk for any mental health problem (depression, anxiety and risky alcohol use) was 87 (22.8%). Participants who were asked by clinical officers and nurses about CMD symptoms and alcohol use were 92 (24.1%) and 89 (23.3%) respectively. Of the entire sample, 351 (91.9%) participants wanted to receive advice or treatment and 26 (29.9%) received advice or treatment. Missed opportunities to address the mental health of people living with HIV were found to be as follows: definition #1, 40 participants (46.0%); definition #2, 35 participants (40.2%); definition #3, 87 participants (100%) and definition #4, 66 participants (75.9%). After adjusting for other variables in the model female gender was significantly associated with missed opportunity definition #1. After adjusting for other variables in the model female participants were more likely to meet criteria for missed opportunity definition #2 than male participants. Furthermore, older participants were less likely to meet criteria for missed opportunity definition #2 compared to younger participants. Participants who were employed were less likely to meet criteria for missed opportunity definition #2. In the same vein, participants who were spending less were less likely to meet criteria for missed opportunity definition #2. Given all participants met criteria, we were unable to develop logistic regression models. There were no significant associations for missed opportunity definition #4. Conclusion. Approximately one fifth of the sample recruited screened at risk for CMDs and most clients wanted to receive advice or treatment. Despite over 40% of the participants reporting being asked about CMD symptoms, PHC workers did not provide advice or treatments to 75.9% of clients. There is need to advocate for screening of mental health problems including alcohol use and treatment in all ART clinics in Malawi.
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    Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme
    (2013) Govender, Veloshnee; Chersich, Matthew F; Harris, Bronwyn; Alaba, Olufunke; Ataguba, John E; Nxumalo, Nonhlanhla; Goudge, Jane
    BackgroundIn 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues.ObjectivesThis study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment.MethodsMulti-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression.ResultsNotwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs.ConclusionBarriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.
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    The National Planning Commission and the National Health Insurance Proposal
    (2012) Hoosen, Coovadia
    Lecture presented by Emeritus Professor Hoosen Coovadia, Paediatrics and Child Health and HIV/AIDS Research, University of KwaZulu-Natal, and member of South Africa's Planning Commission. This audio lecture will be of interest to those who wish to know more about public health in SA and current policies and proposals.
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    Perspectives on etonogestrel implant use in HIV-infected women in Cape Town, South Africa: a qualitative study among providers and stakeholders
    (2018) Brown, Anna; Morroni, Chelsea; Harries, Jane
    Access to a range of safe and effective modern contraceptive methods enables women to make free and informed choices about their reproductive lives and broadly improves maternal and child health outcomes. Successful avoidance of unintended pregnancy and the corresponding ability to plan for pregnancy are especially valuable in the context of Human Immunodeficiency Virus (HIV) infection. Revised South African national guidelines seeking to expand overall contraceptive access were released in 2012 and, in response to the severity of the domestic HIV epidemic, specifically detailed the sexual and reproductive health rights and needs of HIV-positive women. Six years later, evaluation of the implementation and impact of these guidelines, as well as of more recent policy responses in this area, is necessary. This need for evaluation is outlined in Part A of this mini-dissertation in the form of a research proposal. A literature review (Part B) assesses what is currently known about considerations surrounding contraceptive decision-making in the context of HIV and antiretroviral therapy (ART). The use of the subdermal Long Acting Reversible Contraceptive (LARC) implant in HIV-positive women is explored in depth, given that the 2012 guidelines introduced the method as an entirely new option for South African women, as well as in light of recent controversy surrounding the implant’s provision to women taking the first-line ART drug, efavirenz (EFV). A journal-style article structured for submission to BMC Public Health (Part C) then uses thematic qualitative methodology to explore primary family planning provider and other relevant stakeholder perspectives on the provision of implants to HIV-positive women clients attending Cape Town primary care facilities. The study adds to existing literature regarding implant provision in the context of HIV and ART, and offers new insight into the impact of a 2014 South African Department of Health decision to recommend against the then-newly introduced implant as an option for women taking EFV-based ART. This research finds that several converging factors may have lead primary providers to view the implant as broadly contraindicated in all HIV-positive clients regardless of their iii exposure to EFV, namely: insufficient provider training; provider and community unfamiliarity with and scepticism about the new method; structural pressures on providers to keep up to date with and provide wide-ranging integrated services in busy clinical environments; and inadequate stakeholder consultation surrounding the wording and overall appropriateness of the implant/EFV guidance itself. Recommendations are provided in the article, including the need for: the retraining of primary healthcare providers in rights and choice-based family planning (particularly in implant provision and counselling); simplified counselling messages and user-friendly decision-making tools to help providers facilitate informed contraceptive choice for HIV-positive women; generalized beneficiary and community sensitization/education about implants including in the context of HIV and ART; and more comprehensive stakeholder/beneficiary consultation in future contraceptive policy-related endeavors.
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    Public health in Cape Town 1923-1944: diphtheria, dairies and the discovery of the child
    (2000) Watermeyer, Katy
    The idea of modernity, I suggest, was one of the chief tropes through which Europe constructed itself as a centre, as the centre, and the rest of the planet as a – its – periphery ...
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    Reducing sugar intake in South Africa: a multilevel policy analysis of how global and regional diet policy recommendations find expression at country level
    (2022) Mccreedy, Nicole; Shung-King Maylene
    High intake of sugar has been recognised as a contributing factor to diet-related overweight and obesity, and as a determinant for non-communicable disease (NCD) emergence in LMICs. In 2015, the World Health Organization (WHO) released a guideline giving specific advice on limiting sugar intake in adults and children. Policy guidance has also been provided to promote healthy diets and/or restrict unhealthy eating habits at country-level. The study explored the extent to which global policy recommendations and directives on reducing sugar intake to prevent and control NCDs have found expression in policies issued at the Africa region, South African national or sub-national Western Cape provincial level. A systematic policy document review was conducted to identify policies between 2000 and 2020, at different levels of government using search terms related to sugar, sugar sweetened beverages (SSBs) and NCDs. NVivo 12 software was used to code and thematically analyse the data. A policy transfer conceptual framework was applied for the policy analysis to assess what ideas were transferred, including why and to what extent transfer occurred. Forty-eight policy documents were included in this review. Most were global or national level policies. It was evident that several global policy ideas on unhealthy diets and reduction of sugar intake had found expression in South African health policies, as well in the education and finance sectors. Global recommendations for effectively tackling unhealthy diets and NCDs are to implement a mix of cost-effective policy options employing a multisectoral approach. Local policy action has followed the explicit guidance from international agencies, and ideas on reducing sugar intake have found expression in sectors outside of health, to a limited extent. Together with the adoption of the sugar-sweetened beverages (SSBs) health tax, South Africa's experience offers learnings for other LMICs.
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    Scaling up ART in Rwanda: the financial and economic costs
    (2007) Karengera, Stephen; Cleary, Susan
    Rwanda has been rolling-out free antiretroviral treatment (ART) since 2004. This scale up could only be realised through significantly increased funding to the HIV/AIDS sub-account. Funding grew from US$9 million in 2003 to US$43 million in 2004 (UNAIDS, 2006b) and has continued to grow since this time given increased grants from GFATM and PEPFAR. Although international funding has been pivotal in the initiation of ART roll-out in resource poor settings, national programmes must look inwards for long term sustainability. This raises the question of whether the country will be able to sustain this level of funding once these grants cease ot are significantly reduced. This question could be answered to a large extent if one knew the lifetime costs of providing ART in Rwanda and the capacity of the country to raise domestic revenue. Unfortunately the body of evidence on unit and lifetime costs for providing ART in Rwanda is nonexistent. The study aimed to determine the economic costs of scaling up ART in Rwanda. Costing from the provider's perspective was undertaken based on data from 3,310 patients in 3 ART sites. The health care utilisation and cost data obtained, supplemented by appropriate secondary data, were used to estimate the cost perpatient period and lifetime costs. These were then used to model the costs of scaling up and to explore the financial sustainability of ART in Rwanda.
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    Screening strategies for adults with type 2 diabetes mellitus
    (2022) Mearns, Helen; Kagina, Benjamin M; Kredo, Tamara; Schmidt, Bey-Marrié
    There are insufficient randomized controlled trials to address whether screening for type 2 diabetes mellitus (T2DM) improves health outcomes. This systematic review sought to cast a wider net and synthesise evidence from non-randomised intervention studies to assess the effectiveness of T2DM screening in adults for reducing mortality and T2DM-associated morbidity. We searched PubMed/MEDLINE, Scopus, Web of Science, CINAHL, Academic Search Premier and Health Source Nursing Academic (inception onwards; last search July 2021). We included non-randomised intervention studies that assessed T2DM screening compared to no screening, in adults without known T2DM. Screening was performed independently by two reviewers. Data was abstracted by one reviewer and checked by a second, as was risk of bias (ROBINS-I) and certainty of evidence (GRADE). A narrative summary was performed. We screened 10,892 records, retrieving 67 for full-text screening with one record meeting inclusion criteria. The study was a prospective cohort comparing T2DM screening versus no screening. It included adults, 40 - 65 years, with no known T2DM from a single community practice in Ely, England (N = 4,936) and evaluated outcomes at two time periods. The study was assessed as having moderate risk of bias. There may be little or no difference in mortality between those who were invited to screening versus those who were not invited (1990-1999: adjusted hazard ratio (aHR) 0.79 [95% confidence interval (CI) 0.63 – 1.00], n = 4,936, low certainty evidence and 2000 - 2008: aHR 1.18 [95% CI 0.93 - 1.51], n = 3,002, low certainty evidence). We found only one study reporting the effectiveness of screening for T2DM in adults. Therefore, despite ongoing T2DM screening in clinical care, this review highlights an important research gap in understanding the true health benefits of screening.
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    The [un]knowing director: a critical examination of directing within the context of devising performance
    (2022) Thulo, Kabi; Fleishman, Mark; Sitas, Ari
    This thesis is a critical examination of directing within the context of devising performance practice. It emanates from my need to make sense of the particular ways in which I work as a theatre director who engages with devising performance coupled with an identified lack in the literature that speaks to directing and devising performance from a Southern African perspective. The notion of the [un]knowing director is posited as the central concept that is evidently plausible for the particular context of devising performance practice argued for in the thesis. The key argument expressed in this thesis is that [un]knowing is a way of knowing realised through intuition and collaboration as co-constitutive or symbiotic aspects applicable to the study's particular contexts of directing and devising performance practice. To be more specific, the study investigates how the [un]knowing director makes artistic discoveries and decisions/choices during the moment-to-moment unfolding of a devising process. The notion of the [un]knowing is conceptually explicated by drawing from Tim Ingold's ideas of wayfaring and wayfinding (2000 & 2011), Henri Bergson's (1907) philosophical conception of time understood as duration, and Leopold Senghor's Africanist philosophy that speaks of rhythmic attitude, reason-eye and reason embrace (Diagne, 2019). This thesis is located within the sphere of nonrepresentational theory and purports for knowledge, within the context of directing and devising performance, as an undertaking that is non-predetermined and emergent in character. In terms of its methodology, this study is generally located within the methodological terrain of qualitative research and specifically employs practice as research. Specifically, its methodology entailed a structured questionnaire responded to by seven Southern African devising performance directors. The questionnaire's general research aim was to identify the plausibility of the [un]knowing director concept based on other director's experiences of devising performance. Thereafter, three creative research projects in the form of devising performance processes, were undertaken. These projects served as related case studies constituting an investigative cycle. The research method of autoethnographical devising session note-taking and reflective accounts was used in generating the necessary data through the creative research projects. Essentially, this thesis concludes that the [un]knowing director knows through intuition and collaboration in ways that are particular to its critical examination of directing and devising performance. These two ways of knowing are complex in their nature and characterised by the elements of initiation, facilitation and decision making during the moment-to-moment unfolding of a devising session. Relatedly, this thesis refers to the [un]knowing director's momentary undertakings as the molecular, micro and macro levels of artistic activity. Ultimately, this thesis concludes that the [un]knowing director has a complex genealogy emanating from the Southern African oral performance tradition. Thus, the [un]knowing director's practice is story-like and significantly affected by time.