Browsing by Author "Mabetha, Khuthala"
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Item A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of the Bukhali randomised controlled trial(Public Library of Science, 2024) Norris, Shane A.; Soepnel, Larske M.; Mabetha, Khuthala; Motlhatlhedi, Molebogeng; Nkosi, Nokuthula; Lye, Stephen; Draper, Catherine E.Community health workers (CHWs) play an important role in health systems in low- and middle- income countries, including South Africa. Bukhali is a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases of Bukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of the Bukhali trial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants’ socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation of Bukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education. HH perspectives on intervention implementation highlighted adaptations across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease. These findings provide recommendations for the next phases of Bukhali, for other CHW-delivered preconception and pregnancy trials, and for the strengthening of CHW roles in clinical settings with similar implementation challenges.Item A qualitative exploration of the reasons and infuencing factors for pregnancy termination among young women in Soweto, South Africa: a Socio-ecological perspective(BioMed Central (BMC), 2024) Norris, Shane A.; Mabetha, Khuthala; Soepnel, Larske M.; Sewanyana, Derrick; Draper, Catherine E.; Lye, StephenBackground: Pregnancy termination is an essential component of reproductive healthcare. In Southern Africa, an estimated 23% of all pregnancies end in termination of pregnancy, against a backdrop of high rates of unintended pregnancies and unsafe pregnancy terminations, which contributes to maternal morbidity and mortality. Understanding the reasons for pregnancy termination may remain incomplete if seen in isolation of interpersonal (including family, peer, and partner), community, institutional, and public policy factors. This study therefore aimed to use a socio-ecological framework to qualitatively explore, in Soweto, South Africa, i) reasons for pregnancy termination amongst women aged 18-28 years, and ii) factors characterising the decision to terminate. Methods: In-depth interviews were conducted between February to March 2022 with ten participants of varying parity, who underwent a termination of pregnancy since being enrolled in the Bukhali trial, set in Soweto, South Africa. A semi-structured, in-depth interview guide, based on the socioecological domains, was used. The data was analysed using reflexive thematic analysis, and a deductive approach. Results: An application of the socio-ecological framework indicated that the direct reasons to terminate a pregnancy fell into the individual and interpersonal domains of the socioecological framework. Key reasons included financial dependence and insecurity, feeling unready to have a child (again), and a lack of support from family and partners for the participant and their pregnancy. In addition to these reasons, Factors that characterised the participants' decision experience were identified across all socio-ecological domains and included the availability of social support and (lack of) accessibility to termination services. The COVID-19 pandemic and resultant lockdown policies also indirectly impacted participants' decisions through detrimental changes in interpersonal support and financial situation. Conclusions: Amongst the South African women included in this study, the decision to terminate a pregnancy was made within a complex structural and social context. Insight into the reasons why women choose to terminate helps to better align legal termination services with women's needs across multiple sectors, for example by reducing judgement within healthcare settings and improving access to social and mental health support.Item The influence of demographic and socioeconomic characteristics on age at first marriage among females in Mozambique(2016) Mabetha, KhuthalaContext: Various reforms that are approved by the law and are intended to foster gender equality have been established by eleven nations in the Southern African Development Community Region (SADC). However, irrespective of the efforts exercised to eliminate practices that inhibit females from being able to attain their human rights, early marriage remains to be one of the discriminatory traditional practices which occur under harmful customary laws and societal norms in a number of SADC nations. The practice of early marriage violates international human rights laws that are aimed at fostering gender equality, in particular, those of females. In addition, early marriage poses a serious threat to the health and social standing of females which often results in females being politically and financially subordinated in relation to their male counterparts as well as being subjected to sexual abuse and control by males. Despite several strategies that have been established by the Mozambican government that intend to improve education and employment as well as decrease the levels of impoverishment, gender inequality is still a predominant phenomenon that leaves females being the most marginalised in relation to males, in all sociocultural, political and financial domains. This research study sought to explore whether demographic and socioeconomic characteristics including region of residence, current age of the respondent, educational level, religious affiliation, type of place of residence, and wealth status are influential on age at first marriage. Methods: This study utilised secondary statistics acquired from the 2011 Mozambique Demographic and Health Survey. The 2011 Mozambique Demographic and Health Survey is a survey that includes a sample of 13 745 females who are between the ages 15-49 years old. The sample of respondents consisted of females who have been or are in a marital union of childbearing ages 15-49. Due to the event of interest being marriage, only 10893 females were or had been in a marital union while the remaining 2852 had never been in a union. Thus the analytic sample size utilised in this study was 10893 and the remaining 2852 cases were simply right censored. The outcome variable was age at first marriage and the predictors were the respondent’s current age, region of residence, educational level, religious affiliation, type of place of residence and wealth status. A Cox Proportional Hazard Regression model was employed in order to analyse the time of first entry into a marital union, systematically. The data analysis was done in three phases. The first phase included descriptive analyses of the variables utilised in the study through a series of frequency tables and discussions. The second stage included Kaplan-Meier graphs which were used to estimate levels of age at first marriage. The third stage included an unadjusted (bivariate) and adjusted (multivariate) Cox Regression model which was employed to determine characteristics that had an influence on age of first marriage. Results: Hazard ratios shown in the multivariate Cox Proportional Hazard Regression model showed that the respondent’s age, level of education and region of residence are significant predictors of age at first marriage among females in Mozambique. These associations indicated that early marriage is highest in Mozambique’s northern regions with females residing in Manica exhibiting a 19% increased hazard ratio of exposure to early marriage, followed by females residing in Cabo Delgado who exhibit an 11% increased hazard ratio of exposure to early marriage. The lowest rates of early marriage were found in Mozambique’s southern regions with females residing in Maputo exhibiting a 20% lower risk of exposure to early marriage, followed by females residing in Gaza who exhibit a 14% lower risk of exposure to early marriage and this can be attributed to cultural and societal differences. Early age of marriage is highest among females in the 15-19 year age groups and early age of marriage starts to decrease with an in increase in the female’s age. This is evident from the presented hazard ratios which indicated that females aged 45-49 exhibited a 73% lower risk of exposure to early marriage, followed by females aged 40-44 who exhibited a 71% lower risk of exposure to early marriage and females aged 35-39 who exhibited a 70% lower risk, in relation to the younger-aged females. Furthermore, the more education a female attains, the more her age of marriage increases. This is evident from the results as they show that females with a primary education have a 5% higher hazard ratio of exposure to early marriage while females with a secondary education have a 21% reduced hazard ratio of exposure, followed by females with a tertiary education who have a 46% reduced hazard ratio of exposure to early marriage. Conclusion: The overall inference drawn from this study was that early marriage is a pervasive phenomenon that is still carried out in the northern regions of Mozambique and is particularly prevalent among young females aged 15-19 who have a primary or no education. Results demonstrated that a number of inequalities exist in the country and these inequalities are not only exclusive between males and females but also exist among young females themselves, particularly those who reside in the rural regions of Mozambique and this is due to the different lifestyles led in the rural and urban areas. Furthermore, the results showed that customary laws of marriage that have been imposed by traditional authorities specifically among citizens living in the rural areas of Mozambique are not aligned with the main civil laws that have been implemented by the Mozambican government and made rigid in order to foster gender equality and improve the situation of women. This thus suggests that there are inconsistencies in the laws and thus they do not sufficiently protect young females from entry into early marriages. Thus, the Mozambican government needs to scale up strategies that will be beneficial in eradicating the practice of early marriage.Item Integration of nutrition support using the FIGO nutrition checklist in the Bukhali trial: a dietitian’s perspective(National Inquiry Services Centre (NISC) & Taylor and Francis Group, 2023) Norris, Shane A.; Mogashoa, Lethabo; Mabetha, Khuthala; Soepnel, Larske; Draper, Catherine E.The burden of malnutrition experienced globally, coupled with the increasing rate of micronutrient deficiencies, compromises the health and well-being of women during their reproductive years. Obesity places young South African women at particular risk during pregnancy, and increases obesity risk for their offspring. To address these risks, the Bukhali trial is being implemented in Soweto, South Africa with 18–28-year-old women, as part of the Healthy Lifestyle Trajectory Initiative. A dietitian is part of the Bukhali intervention team (community health workers) to provide nutritional support for overweight/ obese trial participants, making use of the International Federation of Gynaecology and Obstetrics (FIGO) Nutrition Checklist. This paper reflects on the experiences and lessons learned by the Bukhali dietitian, including the use of the FIGO Nutrition Checklist and Healthy Conversation Skills to facilitate conversations about making healthy dietary behaviour changes. Identified challenges that influence nutrition and behaviour are discussed, including lack of food affordability, cultural and social influences on healthy food choices, unsupportive environments and food insecurity. Strategies to optimise this nutritional support are also mentioned. The Bukhali trial is showing that introducing additional nutrition support by a dietitian for at-risk participants has the potential to encourage young women to prioritise nutrition and health, even in the midst of contextual challenges to both nutrition and health.Item Mobile Technology use in clinical research examining challenges and implivations for health promotion in South Africa: mixed methods study(JMIR Publications, 2024) Norris, Shane A.; Mabetha, Khuthala; Soepnel, Larske M.; Mabena, Gugulethu; Motlhathedi, Molebogeng; Nyathi, Lukhanyo; Draper, Catherine E.Background: The use of mobile technologies in fostering health promotion and healthy behaviors is becoming an increasingly common phenomenon in global health programs. Although mobile technologies have been effective in health promotion initiatives and follow-up research in higher-income countries and concerns have been raised within clinical practice and research in low- and middle-income settings, there is a lack of literature that has qualitatively explored the challenges that participants experience in terms of being contactable through mobile technologies. Objective: This study aims to explore the challenges that participants experience in terms of being contactable through mobile technologies in a trial conducted in Soweto, South Africa. Methods: A convergent parallel mixed methods research design was used. In the quantitative phase, 363 young women in the age cohorts 18 to 28 years were contacted telephonically between August 2019 and January 2022 to have a session delivered to them or to be booked for a session. Call attempts initiated by the study team were restricted to only 1 call attempt, and participants who were reached at the first call attempt were classified as contactable (189/363, 52.1%), whereas those whom the study team failed to contact were classified as hard to reach (174/363, 47.9%). Two outcomes of interest in the quantitative phase were "contactability of the participants" and "participants' mobile number changes," and these outcomes were analyzed at a univariate and bivariate level using descriptive statistics and a 2-way contingency table. In the qualitative phase, a subsample of young women (20 who were part of the trial for ≥12 months) participated in in-depth interviews and were recruited using a convenience sampling method. A reflexive thematic analysis approach was used to analyze the data using MAXQDA software (version 20; VERBI GmbH). Results: Of the 363 trial participants, 174 (47.9%) were hard to reach telephonically, whereas approximately 189 (52.1%) were easy to reach telephonically. Most participants (133/243, 54.7%) who were contactable did not change their mobile number. The highest percentage of mobile number changes was observed among participants who were hard to reach, with three-quarters of the participants (12/16, 75%) being reported to have changed their mobile number ≥2 times. Eight themes were generated following the analysis of the transcripts, which provided an in-depth account of the reasons why some participants were hard to reach. These included mobile technical issues, coverage issues, lack of ownership of personal cell phones, and unregistered number. Conclusions: Remote data collection remains an important tool in public health research. It could, thus, serve as a hugely beneficial mechanism in connecting with participants while actively leveraging the established relationships with participants or community-based organizations to deliver health promotion and practice.Item The role of a community health worker‑delivered preconception and pregnancy intervention in achieving a more positive pregnancy experience: the Bukhali trial in Soweto, South Africa(BMC, 2024) Norris, Shane A.; Soepnel, Larske M.; Mabetha, Khuthala; Motlhatlhedi, Molebogeng; Nkosi, Nokuthula; Klingberg, Sonja; Lye, Stephen; Draper, Catherine E.Background: A patient-centered, human-rights based approach to maternal care moves past merely reducing maternal mortality and morbidity, towards achieving a positive pregnancy experience. When evaluating an intervention, particularly in the context of the complex challenges facing maternal care in South Africa, it is therefore important to understand how intervention components are experienced by women. We aimed to qualitatively explore (i) factors influencing the pregnancy and postpartum experience amongst young women in Soweto, South Africa, and (ii) the influence of Bukhali, a preconception, pregnancy, and early childhood intervention delivered by community health workers (CHWs), on these experiences. Methods: Semi-structured, in-depth interviews were conducted with 15 purposively sampled participants. Participants were 18–28-year-old women who (i) were enrolled in the intervention arm of the Bukhali randomized controlled trial; (ii) were pregnant and delivered a child while being enrolled in the trial; and (iii) had at least one previous pregnancy prior to participation in the trial. Thematic analysis, informed by the positive pregnancy experiences framework and drawing on a codebook analysis approach, was used. Results: The themes influencing participants’ pregnancy experiences (aim 1) were participants’ feelings about being pregnant, the responsibilities of motherhood, physical and mental health challenges, unstable social support and traumatic experiences, and the pressures of socioeconomic circumstances. In terms of how support, information, and care practices influenced these factors (aim 2), four themes were generated: acceptance and mother/child bonding, growing and adapting in their role as mothers, receiving tools for their health, and having ways to cope in difficult circumstances. These processes were found to be complementary and closely linked to participant context and needs. Conclusion: Our findings suggest that, among women aged 18–28, a CHW-delivered intervention combining support, information, and care practices has the potential to positively influence women’s pregnancy experience in South Africa. In particular, emotional support and relevant information were key to better meeting participant needs. These findings can help define critical elements of CHW roles in maternal care and highlight the importance of patient centred solutions to challenges within antenatal care.Item Under-five mortality among children raised in non-orphaned kinship care in South Africa: a mixed-methods study(2021) Mabetha, KhuthalaBackground Non-orphaned kinship care is a family arrangement in which children are raised by relatives in the absence of their biological parents who are alive but are unable to provide parental care. In South Africa, many non-orphaned children live in households where aunts, uncles, or grandparents play the primary caregiver role. Literature has shown that 65% of children (both orphaned and non-orphaned) who do not live in the same household as their biological parents, reside with their grandmothers, close to 20% reside with aunts, 6% with additional extended kin and only 1% reside with non-related adults. Although kinship care is associated with a number of benefits, the spatial diffusion of children to grandparents and other extended kin has been found to be coupled with negative child health outcomes. The issue of under-five mortality is a major public health concern that has been largely debated in the fields of Demography, Public Health and Social Sciences. Under-five mortality is defined as a death that has occurred between birth and the fifth birthday. Several scholars have made considerable efforts to establish individual, household and community-level factors that explain under-five mortality. Scholars have identified maternal individual, household and community-level characteristics such as maternal education, maternal age, breastfeeding status, wealth status and place of residence as the main contributors of under-five mortality. Under-five mortality has received considerable attention in existing demographic literature in relation to family structure although the mortality risks of children raised in alternative care contexts, particularly non-orphaned children raised by extended family members, remain largely unknown.Therefore, this study aimed to investigate under-five mortality in kinship care to examine the role of extended kin on child survival, especially given how the living arrangements of kin caregivers and the kinship system in itself, plays a pivotal role in influencing child health outcomes. This was done by examining how sociodemographic factors, health-seeking behaviours and familial characteristics of kin caregivers influence under-five mortality among children raised in non-orphaned kinship care in South Africa. Methodology This study employed an explanatory sequential mixed-methods design. This research design involves using both quantitative and qualitative research approaches in two distinct phases. The first phase is the analysis of quantitative data, followed by the collection and analysis of qualitative data. The outcome variable in this study was under-five mortality and children who 2 had died before the observation period were right censored. For the quantitative phase, secondary data obtained from the 2014/15 to 2017 (Wave 4 to 5) South African National Income Dynamics Survey (NIDS) was analysed. The weighted sample size of under-five children (using appropriate NIDS sampling weights) who were living with a kin-caregiver in 2014/15 (Wave 4) was 126,859. These children were then followed to investigate their probability of dying in the year 2017 (Wave 5). The weighted sample size of under-five deaths obtained among children raised by kin in Wave 5 was 7,761. Event History Analysis was employed in the study using a series of Kaplan-Meier limit product estimators and Cox Proportional Hazard Regression models. In the follow up qualitative phase, in-depth interviews that explored the influence of kin caregiver health-seeking behaviours and familial characteristics on child survival were conducted. This was conducted with 24 kin caregivers, from the Eastern Cape and KwaZulu-Natal provinces between the period February – April 2019, to help explain and provide an in-depth understanding of the quantitative results. Various methodological strategies were employed in order to ensure validity and reliability of the qualitative findings in order to complement the quantitative findings. Results and Findings The Kaplan-Meier estimates in the quantitative phase showed that there are differences in the hazards of under-five mortality by type of kin caregiver. The hazard of death was highest among children raised by grandparents (almost 80%), followed by children raised by aunts or uncles (>75%). Lower mortality hazards were observed among children who were raised by other extended family members. Key results that emerged from the adjusted Cox Proportional Hazard Regression models showed that grandparent and aunt or uncle perceived health status and age had a significant influence on under-five mortality among children in their care. Results showed that there were 22% increased hazards of death among children whose grandparents perceived their health to be excellent or very good. Further, there were 10% increased hazards of death among children whose aunts or uncles also perceived their health to be excellent or very good. Children whose grandparents were 60 years and above had 22% increased hazards of dying before age 5. Amongst children living with aunts or uncles between the age groups 30-34 there was a 6.87 times higher hazard of death. Perceived health status of non-orphaned under-five children was a child characteristic that had a significant influence on under-five mortality among children raised by grandparents and aunts or uncles. Mortality risks were highest among children who were perceived to have excellent or very good health by their grandparents and aunts or 3 uncles. Perceived health status had a significant influence on under-five mortality. Among children raised by grandparents it was 22.9 times higher and 48% higher among children raised by aunts or uncles who perceived the children’s health to be excellent or very good. Qualitative findings emerging from the thematic analysis adequately explained and corroborated the quantitative results. Various health-seeking practices and beliefs in particular notions and perceptions held by kin caregivers pertaining to health status and illness such as increased reliance in traditional medicine and traditional healers, notion of witchcraft and faith healing were significant impediments that contributed to kin caregivers not accessing healthcare services for the children under their care. In addition, the family environment has helped provide an understanding of the child’s health outcomes as the characteristics of families emerging from the findings have emerged as important determinants of health. Also, the way the family functions and the support and care, or lack thereof, that family members provide to each other influences the families’ subsequent life course outcomes. Specifically, among children raised in such a family institution. Conclusions The findings of this study show that the survival of a child is influenced greatly by complex interactions that occur at the individual and family level. Importantly, the findings suggest that the individual characteristics of kin caregivers, healthcare preferences and behaviours and their family environments are risk factors. These risk factors play a crucial role in compromising the ability of kin caregivers to provide adequate care. These factors also affect caregivers’ ability to provide a conducive caregiving environment to the children under their care, rather than the kinship system itself. These circumstances expose children placed under such care to various risks that may be detrimental to their health and development. Policy and Research Recommendations Kin caregivers need to be provided with adequate counselling and support services to enable them to feel equipped and ready enough to assume the caregiving role. Child welfare authorities need to achieve this by equipping kin caregivers with the necessary knowledge and skills needed to provide adequate care to children. This will ultimately foster positive developmental outcomes. In addition, kin caregivers can be provided with informative training videos that educate them on how to handle situations pertaining to childcare. Further research, in particular longitudinal research, should be conducted to examine the multiple transitions or placement instability in kinship care. Such studies must also investigate 4 the subsequent effect this may have on child developmental outcomes and wellbeing. Such research will provide an important groundwork in understanding this complex relationship and the life trajectories of non-orphaned children who experience these family