Browsing School of Public Health by Issue Date
Results Per Page
ItemAids and the workplace with a specific focus on employee benefits: Issues and responses(Centre for Health Policy - School of Public Health - University of the Witwatersrand, 2001) Stevens, MarionEXECUTIVE SUMMARY
This report reflects the first activity in a three-year research project, funded by the European Union, which is part of a programme of support to NGOs which are working with communities to combat discrimination against and provide support for people with HIV/AIDS. The aim of the project is to investigate, using a variety of methods, the world of AIDS and the workplace with a specific focus on employee benefits. These benefits include medical schemes and other health benefits, death, disability and pension funds. The research will concentrate on the experience of formally employed, unskilled or semi-skilled workers who are vulnerable because employers consider them dispensable or replaceable should they get ill or die, and whose employee benefits may be eroded in the face of HIV. By creating workplaces which are supportive of individual employees, one sustains households and, in turn, the broader society. This report presents the findings of an initial situational analysis of responses to HIV in the workplace, using a policy analysis methodology, which combined documentation review and key informant interviews with 27 players in the field.
The report starts with a review of the South African literature and documentation on HIV/AIDS and the workplace. Available evidence on the direct and indirect impacts of HIV on workplaces and the current models used to project impacts are presented; the legal and policy frameworks relevant to AIDS in the workplace are summarised; and a chronology of key events and processes that have informed this area are noted.
The main body of the report outlines responses to HIV/AIDS of the three major players: government, the private sector including NGOs, and trade unions. In each sector consideration is given to the areas of: leadership and organisational responses, networking and policy processes, and workplace policies and programmes including health care.
While a legal framework and a set of legal precedents for a rights-based orientation to HIV in the workplace have been established, prohibiting, for example, pre-employment HIV testing, a consistent and sound response to HIV in the workplace has yet to emerge. The report concludes that there is a need for strong, bold and coherent leadership in all sectors of society.
Responsibility for workplace HIV/AIDS programmes has generally been delegated to human resource departments, rather than being seen as a core management issue. The overall view noted by stakeholders was of strategic failures in managing HIV/AIDS in the workplace due to the lack centralised responsibility and commitment within organisations. The business sector and the trade union movement need to ensure that HIV/AIDS is fore-grounded as an issue and that it is the concern of the most senior leaders in their sectors. Many interviewees also felt that there was a need for better alliances and networking on workplace issues, and that government needed to play a leadership role in this regard.
Respondents across sectors called for planning to be informed by better data. These data need to be independent, open to scrutiny and separate from private interests.
Workplace benefits have undergone considerable restructuring in response to HIV. In the early-nineties schemes changed from defined benefit to defined contributions, motivated by the perceived impact of HIV on risk benefits. During the late-nineties some schemes evolved from group schemes to individualised packages, anti-retroviral drugs became more available in medical schemes, the outsourcing of unskilled functions appeared as a particular response to HIV and new HIV insurance packages became available for workplaces. During v AIDS and THE WORKPLACE WITH A SPECIFIC FOCUS ON EMPLOYEE BENEFITS: ISSUES AND RESPONSES 2001. Centre for Health Policy. 2001, several companies announced their intentions to provide anti-retroviral treatment for semi-skilled and unskilled employees. These changes have been in response to assessments of direct and indirect HIV-related costs and the requirement to adapt to the reforming legal framework. Developments in the field have prompted the emergence of a range of new players dealing with disease management and impact assessments.
The effect of this restructuring has been several fold. Individuals often have to negotiate for benefits directly with insurance companies, as opposed to their companies taking responsibility for this. This has left employees more vulnerable. While routine pre-employment testing is no longer legal, it is apparent that many individuals are losing cover through pre-benefit testing. As a contrary trend, there is a growing realisation, in the face of declining drug prices, that HIV/AIDS treatment is affordable and cost effective in managing the health of employees. However, there is the danger that anti-retroviral therapy, for example, will be offered to some employees and not others. This is clearly of concern in terms of equity and discrimination.
Finally, there is a need to counter the notion that businesses will be able to cope with the HIV/AIDS pandemic because of ‘the ease of substitution’ . This rationale is neither positive nor constructive. Businesses need to balance their fiduciary duties by remaining profitable and viable yet being fair and socially responsible.
ItemA rapid appraisal of maternal health services in South Africa(Centre for Health Policy - School of Public Health - University of the Witwatersrand, 2002) Penn-Kekana, Loveday; Blaauw, DuaneThis report is a rapid appraisal of maternal health services in South Africa. It reflects the first activity in a five-year research programme, funded by DFID. The research project is a multi-country project involving researchers from the London School of Hygiene and Tropical Medicine, (UK) Manchester University (UK) and research institutions in Uganda, Bangladesh, Russia as well as South Africa. The programme aims to develop theoretical frameworks and methodologies to better understand health system functioning in developing countries, and to apply these insights to strengthening health system development. As part of this project maternal health has been identified as a possible probe or tracer to illuminate particular features of health system functioning and performance. ItemThe Integration of HIV/AIDS Care and Support into Primary Health Care in Gauteng Province(Centre for Health Policy - School of Public Health - University of the Witwatersrand, 2002-07) Modiba, P; Schneider, H; Weiner, R; Blaauw, D; Gilson, L; Zondi, T; Kunene, X; Brown, KThis study aimed to assess the integration of HIV/AIDS care and support in Gauteng’s primary health care (PHC) services. With this aim in mind, the research sought to provide answers to three main sets of questions. Firstly, are care and support services for people with HIV/AIDS being provided at PHC clinics, what is the quality of these services, and to what extent are these services being utilised? Secondly, are the inputs (e.g. staff knowledge and attitudes) and support systems (e.g. drug supplies), necessary for good quality, accessible HIV/AIDS care, present in the PHC infrastructure? Thirdly, what if any, systems changes are required to improve the access and quality of PHC services for people living with HIV/AIDS? This research was conducted in collaboration with, and partly funded by, the Gauteng Provincial Department of Health which is in the process of disseminating primary health care clinical guidelines in the Province. ItemThe state of sexual assualt services: Findings from a situation analysis of services in South Africa(Centre for Health Policy - School of Public Health - University of the Witwatersrand, 2003-10) Christofides, Nicola; Webster, Naomi; Jewkes, Rachel; Penn-Kekana, Loveday; Martin, Lorna; Abrahams, Naeema; Kim, JuliaWomen often receive very poor quality medical care after sexual assault. This has been highlighted in work done by Human Rights Watch, Suffla and others that explored services in some provinces. No systematic investigation of services in all provinces had been carried out. In 2001, the National Department of Health prioritised improving sexual assault services and the research presented in this report was conducted to inform this process. The aim was to investigate sexual assault services provided by health sector in South Africa with an in-depth look at North West province. Two district hospitals; a regional hospital and a tertiary hospital (where they existed) were randomly sampled in all provinces. The total number of hospitals in the sampling frame varied from province to province. This was adjusted for in analysis through weighting. At each hospital, we interviewed two doctors and two nurses who examined or assisted in the management of a patient who presented at the hospital after rape. A primary health care clinic, which referred patients to the sampled hospital in each district, was identified and a nurse at the clinic was interviewed. A total of 155 providers were interviewed. A facility checklist was completed at each hospital. In North West Province, 199 nurses and doctors were interviewed from 20 hospitals and a primary health care clinic that referred patients to these hospitals. In addition, district managers, police, social workers and representatives of NGOs addressing gender-based violence were interviewed. ItemHIV Prevalence Study and Costing Analysis undertaken for the development of an HIV/AIDS Workplace Strategy for Buffalo City Municipality(Medical Research Council, 2005) Thomas, EP; Colvin, M; Rosen, SB; Zuccarini, C; Petzer, SIn contrast to most private sector employers in South Africa, local government has been slow to put in place HIV workplace strategies. While general workplace policies are available, there is an absence of specific guidelines for local authorities in their response as employers and as service delivery agencies to HIV/AIDS. The Buffalo City Municipality (BCM) embarked upon an innovative approach involving research and an inclusive process to develop a response to HIV/AIDS. This response is advocated as good practice. The report outlines the steps taken towards the development and adoption of a Buffalo City Municipality HIV strategy in late 2004. Lessons learned are documented for the benefit of other local authorities in the development of their own HIV strategies. The success in the development of the Buffalo City Municipality HIV/AIDS strategy is based on two important legs. Firstly, the process adopted and secondly the research initiative to provide the data to inform the HIV strategy. The process: BCM is to be commended for its innovative and proactive stance. Key to the success has been the leadership of the initiative where political councillors, departmental heads, and all levels of managers have supported the process. The outcome of the political support has been shown in the high rate of HIV testing in the sampled group, the enthusiastic take-up of Voluntary Counseling and Testing (VCT) by the employees, and the commitment to the resultant BCM HIV/AIDS Cross-cutting Strategy. Further, the involvement of staff from human resources and engineering through to finance and planning in the development of the BCM strategy again attests to the recognition that addressing HIV in the workforce and the broader community must be treated as an inter-sectoral and cross-cutting issue. The success of the process added considerably to the value and accomplishment of the research. The SA Medical Research Council (MRC) (an external group) was commissioned to undertake an HIV prevalence study, as they were seen to be independent and authoritive, as well as to carry out a Knowledge, Attitudes and Practice study (KAP) and to facilitate a VCT process. In addition, a health economist was requested to assess the cost implications of HIV for BCM as an employer. A team of external researchers worked closely with a BCM staff team in the design and setting up of the studies. The fieldwork took place in June 2004 and the overall BCM strategy was completed within two months, in August 2004. From a sample of 20% of the employees, the study found that 10.3% were HIV infected. Key findings are that temporary employees had a higher prevalence (7.7%) than permanent staff (9.3%). Women had a higher prevalence rate than men (10,2 and 9% respectively). The highest prevalence was in the 20-29 year age group. All job bands were infected but levels of infection were highest amongst the lower skill levels (11.7%) and black Africans (12.6%). There was no difference in infection level between employees with different educational levels. ItemAre South Africa’s new health policies making a difference?(2008-03-31T08:35:30Z)Since 1994 the South African government has placed equity at the heart of its health policy goals. Yet, how successful have the policies been in reducing inequity? This study provides some answers, based on evidence from household studies carried out between 1992 and 2003. Based on Gilson, L. and McIntyre, D. 2007) Post-apartheid challenges: household access and use of care. International Journal of Health Services 37(4): 673-691 ItemFocus on 14 sewage treatment plants in the Mpumalanga Province, South Africa in order to gauge the efficiency of wastewater treatment(2009-07) Samie, A; Obi, C L; Ingumbor, J A; et alIn order to identify the treatment methods used in different sewage treatment plants (STPs) in the Mpumalanga Province and to determine the efficiency of wastewater treatment by these plants, municipal STPs were surveyed, and raw and treated wastewater samples collected. A total of 14 STPs were visited and the collected samples were analysed for physicochemical and microbiological parameters using standard methods. The treatment methods identified included ponds, activated sludge and trickling filters. The reduction of turbidity by the plants varied between 6.2 and 99.6% while conductivity, pH and temperature varied slightly between the influent and the effluent wastewater. Thirteen (92.8%) of the plants used chlorine for disinfection of the final effluent, however only 2 (14.2%) of the plants managed to produce effluent with 0 (zero) faecal conforms per 100 m€. Common pathogenic bacteria isolated from the final effluent included Salmonella, Shigella, Escherichia coli, Vibrio spp. and Enterococcus spp. The final effluent was used for irrigation and recycling purposes in 4 plants, all the other treatment plants discharged the effluent into the river or to the environment. The present study indicated that there is a move toward the renovation of wastewater treatment by the municipalities in the Mpumalanga Province with the adoption of biological treatment. All the STPs reduced the turbidity of wastewater as well as the different microbial indicators counts; however, several pathogenic bacterial organisms could still be detected in the final effluent. Further studies are needed to confirm the role of the treatment procedures on nutrient reduction and elimination of other viral and parasitic pathogens by the sewage treatment plants. ItemChildren left behind: the effects of temporary labour migration on child care and residence patterns in rural South Africa(2010-01-22T11:43:34Z) Kautzky, Keegan Joseph MichaelBackground: The rural South African population is characterised by high and stable levels of male temporary migration and rapidly rising levels of female temporary migration, with approximately 60% of men and 20% of women between the ages of 20 and 60 years absent from the home for more than 6 months of the year. Despite the magnitude of this social phenomenon, limited research exists analysing its effect on child care and children’s residence patterns. Objectives: The purpose of this study is to examine temporary labour migration patterns as a household coping strategy in rural northeast South Africa in 2002 and 2007, describe characteristics of the children left behind, and to assess the effect of temporary migration on child care patterns, specifically analysing household variation in child care and residence by sex and refugee status of the migrant. Methods: An analytic cross-sectional study was conducted on approximately 83,000 individuals in 14,000 households in 25 villages of the Agincourt sub-district of the Bushbuckridge region of Limpopo Province. Data was collected in a special module on temporary migration incorporated into the annual Agincourt Health and Demographic Surveillance System census update in 2002 and 2007. Secondary analysis of the data utilised descriptive statistics and Pearson Chi2 tests of association. Results: The proportion of temporary migrants in the population rose between 2002 and 2007 and now constitutes nearly one-fifth of the population. Nearly three-quarters – 13% of the total population – are labour migrants. A slight increase in the proportion of female and Mozambican descent migrants is observed. Today, three-quarters of temporary labour migrants are male and one-quarter female, three-quarters are South African descent and more than one-quarter are Mozambican descent. Temporary labour migrants with children constitute nearly 6% of the total population. Temporary labour migrants overwhelmingly rely on a single care strategy. Complex care arrangements are far less common, constituting the response of only 5% of migrants. Highly complex care arrangements are rare, but do exist. Child care strategies are becoming increasingly complex over time for all migrants. Female migrants and migrants of South African descent are more likely than male and Mozambican descent migrants to rely on complex care arrangements. The overwhelming majority of migrants keep all children in the same household, maintaining relative stability in care and residence, 10% move children with them, 2% move children elsewhere for care and less than 1% move a childcarer into the household while they are away for work. Less stable child care arrangements are increasingly utilised over time. If the migrant is male, children are more likely to remain in the same household; if the migrant is female, children are more likely to move with the migrant. Approximately one-fifth of children in the population are effectively left behind by temporary labour migrants today, a decline from nearly one-third in 2002. There is significant variation in child care, residence and decision-making authority among relatives: mothers and stepmothers provide the majority of care in the absence of a migrant, with grandmothers a secondary and female siblings and aunts a tertiary source of child care. ItemOccupational health and safety activities of Port Elizabeth's integrated Department of Labour Inspectorate in 2005(2010-01-28T07:06:42Z) Huna, Bulelwa Daniswa DeniseThis study was aimed at describing the nature of Occupational Health and Safety (OHS) inspections and blitzes conducted in the Port Elizabeth Integrated Department of Labour (DoL) in 2005, the nature and number of prohibitions, contraventions, as well as improvement notices issued. The objectives were to determine the number of OHS inspections conducted in the Port Elizabeth Labour Centre (PELC) in 2005; to describe the nature of the inspections and the type of industries inspected in the PELC in 2005; and to determine the frequency and nature of prohibitions, contraventions and improvement notices issued. The data was obtained from the PELC. The results of the study revealed that the inspectorate conducted a total of 1258 and this exceeded the target of 800 OHS inspections for the PELC. However, it is questionable how this target was developed. The target is not representative and does not give an overall picture of conditions in the workplace. The results indicated that inspectors were not competent in conducting boiler inspections as well on Major Hazardous Installation (MHI) since none of these inspections were conducted. On the inception of the OHS task team, there was a sudden increase in inspections conducted in the construction industry in October 2005 as well as the rate of finalisation of incidents in November 2005 and this was attributed to the fact that they were not conducting inspections on other labour laws and were only focusing on OHS. An assessment of the inspectors’ inspection checklists revealed that the inspections were being reduced to just a yes or no tick exercise, with no recommendation on appropriate action to be taken by the employer. It became evident that the inception of a special team in September 2005 contributed to an increased number of OHS inspections, since they were only focusing on OHS issues. This team ensured that in November 2005 there were 43 incidents finalised as compared to the 101 finalised over 11 months. They also ensured that a total of 258 OHS inspections were conducted from September 2005 to December 2005. Although these inspectors were not fully competent in addressing health and s afety issues their momentary focus on OHS activities ensured that they made a difference in the rate of finalisation of incidents. However, when some of the cases were taken to court no successful prosecution could be obtained because there are no OHS focused prosecutors, which have a clear understanding of Act. Discussions with the inspectors revealed that there was a lack of morale and loss of interest in their work, thus causing them not to put in much effort. These discussions revealed that this lack of morale was caused by the frustrations they often experienced in the execution of their duties due to lack of training as well as lack of cooperation from the employers. Furthermore, the inspectors revealed that the great number of resignations from inspectors who were leaving for greener pastures left them with a lot of work with no financial incentive. It also became apparent that there was no objective strategy underlying the number of inspections required relative to the purpose of the inspections, taking into account the nature and complexity of the industry that is to be inspected. The failure of the Service Delivery Unit to give a direction on how qualitative inspections should be measured demoralised them because the focus was only on the quantity (240 inspections per annum) of inspections that are to be conducted by each inspector. It is recommended that training, which should include a proper career path be conducted for inspectors to improve the inspectors’ capability and to motivate them. Strong relations with the South African Police Services and the Department of Justice should be promoted to ensure effectiveness of service delivery. These relations will ensure that inspectors are readily assisted by the police when they deal with uncooperative employers. Training of prosecutors will ensure that they understand the OHSA and its implementation and therefore effectively defend cases that are taken to court. The targets set for inspections should be scientifically supported and take into account the nature and complexity of the production processes. Lastly, revision of salary packages should be looked into to ensure retention of competent staff. The above recommendations will only be effective if the Business Unit Manager and the Regional Manager address them through the National Department of Labour since their implementation will affect all inspectors. ItemProviders' responses to the patients' rights charter in South Africa: a case study in policy implementation(2010-01-28T11:52:57Z) Raphaely, Nika ThandiweAbstract The Patient Rights’ Charter is one of several progressive health policies in South Africa with disappointing implementation in practice. Barriers to implementation have already been described. Policy analysis theory and empirical studies suggest that power and resistance may contribute to implementors’ responses to policies. This secondary analysis of existing semistructured interviews with health providers in Limpopo explicitly examined the influence of power and resistance on their implementation of the Patients’ Rights Charter. Open coding yielded themes of implementation experience, to which a deductive analysis applied a heuristic framework, derived from the literature, to examine power and resistance. The critical importance of implementors in translating policy into practice, and of discursive manifestations of power, were reiterated. Resonances in the data of the functionalist ‘sick role’ brought together surveillance, expert knowledge and the loss of health workers’ influential voice, in a way not previously discussed. Implications for future management strategies are considered. ItemThe right of access to health care services in South Africa: a critical analysis of the realisation of the right(2010-01-28T13:36:29Z) Peter, Lulamile Lester ItemIs there an association between bacterial vaginosis infection and HIV-1 infection acquisition among women aged 18-35 years in Soweto(2010-01-29T06:57:47Z) Chimbatata, Nathaniel Weluzani BandaBACKGROUND Studies suggest an association between Bacterial Vaginosis (BV) and HIV infection; however, its temporal effect has not been greatly investigated. METHODS This is a secondary data analysis of a cohort study: set out to describe the association between BV infection and HIV acquisition. There were 750 participants enrolled in the primary cohort study. The main exposure, BV, was measured from a gram stain slide prepared from a vaginal swab. The slide was read in a laboratory qualitatively and scored by Nugents scoring. A score of 7 or above was considered positive for BV. The outcome variable (HIV) was determined by dual rapid tests and confirmed in the laboratory by a third generation ELISA. Descriptive statistics was done to describe demographic characteristics and the prevalence of BV and STIs. HIV incidence rate was calculated. Kaplan Meier survival time analysis and log rank test for significance were performed. Cox regression (univariate and multivariate) was done to determine association of BV with HIV infection. RESULTS The baseline prevalence of BV was 52 %, 95 % CI; 45 – 59. There were 21 HIV seroconversions experienced of which 7 had BV results missing and were excluded in the analysis. The remaining 14 seroconversions were followed for a mean time of 0.40 of a year and accumulated follow up time at risk of 286 person years, this represented an HIV incidence rate of 4.9 per 100 person years of follow up, 95 % CI: 2.9 – 8.27. Kaplan Meier curves revealed a higher risk of HIV-1 acquisition among women who were BV positive than the women who were BV negative. A log rank test showed that the v probability of seroconversion was different among the women depending on BV status, chi-square value 3.8, p 0.05. Controlling for confounding variables, seroconversion was high, but not significant, among BV positive women, adjusted hazard ratio 3.21; 95 % CI; 0.85-12.12, p value 0.08. CONCLUSION This study suggests that BV increases HIV seroconversion risk though statistical significance was not achieved. Vaginal cleansing education, screening and treating women with BV could maintain normal vaginal flora and reduce their susceptibility to HIV. ItemImpact of AIDS care and level of burnout among nurses in selected hospitals in Limpopo Province, South Africa(2013) Ingumbor, J O; Davhana-Maselesele, MSouth Africa has one of the worst AIDS epidemics in the world and nurses bear the brunt of caring for people living with HIV and AIDS (PLWHA). This situation exacerbates the existing challenge of nursing staff shortage in South Africa as a whole and more profound in rural areas. Despite this, there is limited information on the nature and magnitude of the impact of caring for PLWHA on nurses in rural South Africa. This study therefore investigated the impact of AIDS care and the level of burnout and symptoms of depression among nurses in rural areas. One hundred and seventy four nurses involved in the care of people living with AIDS participated in the study. A structured interview guide was used as the instrument for data collection. The instrument incorporated the AIDS Impact Scale (AIS), Maslach Bumoql Inventory (MBI), Beck Depression Inventory (BDI) and the participants’ demographic and professional profiles. The study participants were conveniently drawn from five randomly selected hospitals in Limpopo Province. We found that the participants’ level of physical and emotional exhaustion were positively associated with age and years of experience respectively. Personal accomplishment was also associated with level of training and qualification. AIS items contributed more to the prediction of physical and emotional exhaustion when compared to their contribution to the prediction of depersonalization and personal accomplishment. The AIS items contributed over 40% to the prediction of emotional exhaustion. The stigma related AIS items were the contributors to the variation in depersonalization. This study therefore re-emphasizes the need to address social stigma, develop psycho-social support programmes and promote social incentives and recognition of the role of nurses in AIDS care. ItemComparison of the health related quality of life, CD4 count and viral load of AIDS patients with HIV who have been on treatment for 12 months in rural South Africa(2013-03) Ingumbor J; Steward A; Holzemer W; et alThis study compared the level of CD4 count, viral load and health-related quality of life (HRQOL) between treatment-naive AIDS patients and a cohort of people living with HIV who have been on treatment for 12 months. This study is based on a secondary data analysis of the records of 642 people with HIV consisting of 311 treatment-naive AIDS patients and 331 people with HIV who have been on treatment for 12 months. The study findings are mostly presented in tables and analysed using the f-test to compare HRQOL scores, CD4 count and viral load in the two groups. The study generally noted poor financial capacity and low activity tolerance among the participants. Significant changes were noted in all the domains of HRQOL compared between the treatment-naive patients and the 12 months treatment cohort. In the same manner, the median CD4 cell count and viral load differed significantly between both groups. The treatment-naive and the 12 months treatment cohorts consistently reported much lower quality of life scores in the level of dependence domain which includes the measures of mobility, activity of daily living, dependence on medication and work capacity. There were little or no associations between the biomedical markers (CD4 count and viral load) and HRQOL indicators. However, the quality of life tended to increase with increase in the CD4 cell count. The poor to no association between the biomedical markers and HRQOL indicators show that these cannot be direct proxies of each other and that the CD4 cell count and viral load alone may be inadequate eligibility criteria for social support. ItemPerspectives on healthcare, chronic non-communicable disease, and healthworlds in an urban and rural setting(2014) Ibanez-Gonzalez, Daniel LopesBACKGROUND: Amidst diverging discourses describing chronic non-communicable disease (NCD) and healthcare access, the hermeneutical tradition within sociology, particularly as exemplified in the work of Jurgen Habermas, provides a starting point for exploring and interpreting the experiences of chronic illness and healthcare access. In this study, we aimed to understand how women living with NCDs experience their illness and access healthcare in an urban and rural context. METHODS: This study was a mixed-methods comparative case study of the healthcare access experiences of women with NCDs in an urban and rural area in South Africa. The core of the study methodology was a comparative qualitative case study, with quantitative methods serving to contextualise the findings. RESULTS: The cross-sectional survey describes a low resource population with a high prevalence of NCDs. Slightly over half the respondents in urban Soweto (50.7%) reported having at least one NCD. Only around a third (33.3%) of these participants reported accessing formal healthcare services in the past 6 months. Similar trends were found in the review of research carried out in rural Agincourt. The qualitative case study in Soweto is characterised by a preoccupation with how medicine from the clinic interacts with the body. The Agincourt qualitative case study highlights the importance of church membership, particularly of African Christian Churches, as the strongest factor motivating against the open use of traditional medicine. DISCUSSION: A consideration of the findings suggests five broad themes for further research: 1) processes of constructing body narratives; 2) encounters with purposive-rational systems; 3) encounters with traditional medicine; 4) encounters with contemporary informal medicine; and 5) religion and healthcare. These five themes constitute the beginning of a comprehensive schema of the lifeworld/healthworld. ItemMigration and the epidemiological transition: insights from the Agincourt sub-district of northeast South Africa(2014) Collinson, M.A; White, M.J; Bocquier, PBACKGROUND: Migration and urbanization are central to sustainable development and health, but data on temporal trends in defined populations are scarce. Healthy men and women migrate because opportunities for employment and betterment are not equally distributed geographically. The disruption can result in unhealthy exposures and environments and income returns for the origin household. OBJECTIVES: The objectives of the paper are to describe the patterns, levels, and trends of temporary migration in rural northeast South Africa; the mortality trends by cause category over the period 2000-2011; and the associations between temporary migration and mortality by broad cause of death categories. METHOD: Longitudinal, Agincourt Health and Demographic Surveillance System data are used in a continuous, survival time, competing-risk model. FINDINGS: In rural, northeast South Africa, temporary migration, which involves migrants relocating mainly for work purposes and remaining linked to the rural household, is more important than age and sex in explaining variations in mortality, whatever the cause. In this setting, the changing relationship between temporary migration and communicable disease mortality is primarily affected by reduced exposure of the migrant to unhealthy conditions. The study suggests that the changing relationship between temporary migration and non-communicable disease mortality is mainly affected by increased livelihood benefits of longer duration migration. CONCLUSION: Since temporary migration is not associated with communicable diseases only, public health policies should account for population mobility whatever the targeted health risk. There is a need to strengthen the rural health care system, because migrants tend to return to the rural households when they need health care. ItemTwo decades of mortality change in rural northeast South Africa(2014) Kabudula, C.W; Tollman, S; Mee, PBackground: The MRC/Wits University Agincourt research centre, part of the INDEPTH Network, has documented mortality in a defined population in the rural northeast of South Africa for 20 years (1992 2011) using long-term health and socio-demographic surveillance. Detail on the unfolding, at times unpredicted, mortality pattern has been published. This experience is reviewed here and updated using more recent data. Objective: To present a review and summary of mortality patterns across all age-sex groups in the Agincourt sub-district population for the period 1992 2011 as a comprehensive basis for public health action. Design: Vital events in the Agincourt population have been updated in annual surveys undertaken since 1992. All deaths have been rigorously recorded and followed by verbal autopsy interviews. Responses to questions from these interviews have been processed retrospectively using the WHO 2012 verbal autopsy standard and the InterVA-4 model for assigning causes of death in a standardised manner. Results: Between 1992 and 2011, a total of 12,209 deaths were registered over 1,436,195 person-years of follow-up, giving a crude mortality rate of 8.5 per 1,000 person-years. During the 20-year period, the population experienced a major HIV epidemic, which resulted in more than doubling of overall mortality for an extended period. Recent years show signs of declining mortality, but levels remain above the 1992 baseline recorded using the surveillance system. Conclusions: The Agincourt population has experienced a major mortality shock over the past two decades from which it will take time to recover. The basic epidemic patterns are consistent with generalised mortality patterns observed in South Africa as a whole, but the detailed individual surveillance behind these analyses allows finer-grained analyses of specific causes, age-related risks, and trends over time. These demonstrate the complex, somewhat unpredicted course of mortality transition over the years since the dawn of South Africa’s democratic era in 1994. ItemDeterminants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study(2014) Mee, P; Collinson, M.A; Madhavan, SBACKGROUND: Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities. DESIGN: This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality. RESULTS: Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes. ItemClosing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness(2014) Jack, H; Wagner, R G.; Petersen I; et al.Background: Nearly one in three South Africans will suffer from a mental disorder in his or her lifetime, a higher prevalence than many low- and middle-income countries. Understanding the economic costs and consequences of prevention and packages of care is essential, particularly as South Africa considers scalingup mental health services and works towards universal health coverage. Economic evaluations can inform how priorities are set in system or spending changes. Objective: To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use (MNS) disorders and the cost-effectiveness of treatment interventions. Design: Narrative overview methodology. Results and conclusions: Reviewed studies indicate that integrating mental health care into existing health systems may be the most effective and cost-efficient approach to increase access to mental health services in South Africa. Integration would also direct treatment, prevention, and screening to people with HIV and other chronic health conditions who are at high risk for mental disorders. We identify four major knowledge gaps: 1) accurate and thorough assessment of the health burdens of MNS disorders, 2) design and assessment of interventions that integrate mental health screening and treatment into existing health systems, 3) information on the use and costs of traditional medicines, and 4) cost-effectiveness evaluation of a range of specific interventions or packages of interventions that are tailored to the national context. ItemPredictors of adherence to screening guidelines for chronic diseases of lifestyle, cancers, and HIV in a health-insured population in South Africa(2014) Adonis, L; Basu, D; Luiz, J; et alBACKGROUND: Adherence to screening guidelines has been widely accepted to reduce morbidity, mortality, and cost outcomes. The aim of this study was to identify predictors of adherence to screening guidelines for chronic diseases of lifestyle (CDL), cancers, and HIV in a health-insured population in South Africa, some of whom voluntarily opt into a wellness program that incentivizes screening. METHOD: A cross-sectional study for the period 2007-2011 was conducted using a random sample of 170,471 health insurance members from a single insurer. Adherence to screening guidelines was calculated from medical claims data. RESULTS: Adherence to screening guidelines ranged from 1.1% for colorectal cancer to 40.9% for cholesterol screening. Members of the wellness program were up to three times more likely to screen for diseases (odds ratio [OR] = 3.2 for HIV screening, confidence interval [CI] = 2.75-3.73). Plan type (full comprehensive plan) was most strongly associated with cholesterol screening (OR = 3.53, CI = 3.27-3.80), and most negatively associated (hospital-only core plan) with cervical cancer screening (OR = 0.44, CI = 0.28-0.70). Gender was a negative predictor for glucose screening (OR = 0.88, CI = 0.82-0.96). Provincial residence was most strongly associated with cervical cancer screening (OR = 1.89, CI = 0.65-5.54). CONCLUSION: Adherence to screening recommendations was <50%. Plan type, gender, provincial residence, and belonging to an incentivized wellness program were associated with disproportionate utilization of screening services, even with equal payment access.