Electronic Theses and Dissertations (PhDs)
Permanent URI for this collectionhttps://hdl.handle.net/10539/37996
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Item Intersecting Epidemics: The implications of COVID-19 in the utilisation of HIV treatment services among people living with HIV on antiretroviral treatment (ART) in Zimbabwe(University of the Witwatersrand, Johannesburg, 2024) Tapera, Talent; Odimegwu, CliffordZimbabwe has been working towards the last mile of controlling the Human Immunodeficiency Virus (HIV) epidemic where keeping people that are living with HIV on antiretroviral therapy (ART) is primarily important. Ensuring they are virally suppressed and can thwart opportunistic infections is key. The advent of COVID-19 potentially posed a threat of derailing or reversing the gains attained in the fight against HIV. Zimbabwe has more than one million people living with HIV (United Nations Programme on HIV and AIDS [UNAIDS], 2020). The question of whether the COVID-19 pandemic intensified barriers and redefined the utilisation of HIV treatment services by people who are living with HIV on ART in Zimbabwe has remained largely unanswered in the literature currently available. Thus, the main purpose of this research was to examine the implications of COVID-19 in the utilisation of HIV care treatment services among people who are living with HIV on ART in Zimbabwe and the factors associated with it. This study defined, the utilisation of HIV treatment services as accessing and taking up a package of services expected to be received by people who are living with HIV on ART such as scheduled ART drug refill collections, viral load monitoring, Tuberculosis (TB) preventative therapy and TB screening. In addition, the study investigated the predisposition of people who are living with HIV in using the COVID-19 vaccine and the reasons behind not getting vaccinated. The study was anchored in the fifth revision of the Andersen behavioural model of healthcare utilisation. This model argues that the use of health services is a based on of three factors classified as (1) predisposing, (2) enabling and (3) need factors. The fifth model version of the model allowed the addition of environmental factors. The dependent variable was the utilisation of HIV treatment services and also COVID-19 vaccination among people living with HIV. As such, it was critical to anchor the study in this framework as it sought to identify the critical factors of utilisation of HIV treatment services and COVID-19 vaccination among people living with HIV. Therefore, following the Anderson model, the predisposing factors for this study were age, sex, marriage, religion, education and COVID-19 vaccination. The enabling factors were COVID-19 lockdown restrictions, COVID- 19 transport stoppages, distance to a health facility, transport cost to a health facility, fear of contracting COVID-19, non-availability of community healthcare services, and COVID-19 related stigma among healthcare workers. The need factors were opportunistic infection during the COVID- 19 period, COVID-19 infection, and contact with a COVID-19 case, while environmental factors were residence and type of health facility.Item The social contexts of childhood malnutrition in South Africa(University of the Witwatersrand, Johannesburg, 2024) Sello, Matshidiso Valeria; Odimegwu, Clifford; Adedini, SundayBackground: Childhood malnutrition is a major public health challenge of global importance. It may result from either excessive or deficient nutrients. Despite investments and several efforts made by the South African government and civil society organizations to improve child health, the prevalence of childhood malnutrition remains high in South Africa. South Africa is still lagging in in achieving the sustainable development goals 1-3 (i.e., 1- no poverty, 2 – zero hunger and 3 –good health and wellbeing). This is because the indicators of childhood malnutrition are significantly higher with one in four children being stunted, 13% overweight, and 7.5% underweight. These figures highlight a troubling trend that is echoed in many other African nations, where malnutrition rates are similarly concerning. For instance, while countries like Nigeria and Ethiopia face severe challenges with stunting rates exceeding 30%, South Africa’s rates are comparatively lower but still indicative of a significant public health challenge. In contrast, developed nations such as the United States report much lower stunting rates—around 3.4%—and face different nutritional issues, such as rising obesity rates among children. The current malnutrition status is worrisome in South Africa given that these conditions have not changed much in nearly three decades. Among other factors recognised as the leading causes of poor nutrition outcomes is food insecurity in households -defined as the lack of regular access to safe, sufficient, and nutritious foods, disrupted eating patterns and reduced food intakes. Despite South Africa being a net exporter of food, it is characterised by high poverty, reduced opportunities for higher education, employment challenges, environmental hazards, substandard housing, and health disparities, still have challenges in access to affordable safe nutritious foods. Furthermore, due to the complexity of childhood malnutrition, an integrated multisectoral approach among families, communities, and government systems is critical to ensuring positive child health and nutritional outcomes. Addressing poor nutritional outcomes among under-5 children requires policy-relevant evidence. While the literature shows that childhood malnutrition is a multifaceted issue influenced by poverty and poor socio-economic outcomes, evidence is sparse on how structural and environmental factors operating at different levels influence childhood malnutrition. Therefore, an understanding of social contexts of childhood malnutrition is required to improve children’s health outcomes in South Africa. Hence, this study examined the social context of childhood malnutrition in South Africa with a focus on individual child, 15 caregiver, and household-level characteristics. The study addressed five specific objectives: i) to determine the levels and patterns of childhood malnutrition in South Africa, (ii) to examine the individual child, caregiver, and household factors associated with childhood malnutrition in South Africa, (iii) to investigate the influence of food insecurity on childhood malnutrition, (iv) to explore the extent to which the socio-cultural and childcare practices of caregivers predispose under-5 children to malnutrition in selected low-income communities in South Africa, and (v) to investigate the role of a multi-sectorial approach in improving child nutritional outcomes in SA. This study was guided by the 2020 UNICEF conceptual Framework on Maternal and Child Nutrition as well as the Food and Nutrition Security Theory. Methods: This study adopted an explanatory sequential mixed methods design (i.e., analysis of quantitative data followed by qualitative data collection and analysis). The research methodology was broken into the quantitative and qualitative study. The quantitative study entailed analysing the quantitative secondary data from the 2017 South Africa National Income Dynamics Study (NIDS Wave 5). The NIDS data was nationally representative. The sample was weighted using post-stratified weights. Data of 2 966 children and their mothers were analysed. These children were selected on the basis that they had complete anthropometric measurements (height and weight measurements) and were suitable and selected for the investigation of childhood malnutrition (stunting, overweight, and underweight). We also conducted qualitative in-depth interviews with Early Childhood Development (ECD) practitioners to gain a deeper understanding of their experiences in childcare and perceptions of feeding practices. They were key informants since under-5 children spent a lot of time at ECD centres. Data were analysed at the univariate level to obtain descriptive statistics, and at the bivariate level using the chi-square test of association. At the multivariate level, multi-level binary logistic regression was employed, and odds ratios were reported. The multilevel analysis involved two levels – the individual level (child and mother characteristics) and the household-level characteristics. Data were analysed using Stata software (version 17). The selection of the independent variables was guided by the literature review and conceptual framework of the study. The second part of the study was qualitative and was collected between June and August 2022. Twenty in-depth interviews, and five focus group discussions with mothers of under-5 children, and five in-depth interviews with early childhood development practitioners (ECD practitioners) were conducted. Interviews were conducted using semi-structured questionnaires in selected low-income communities in urban 16 Gauteng (i.e., Thulani in Soweto), and in rural Limpopo (i.e., GaMasemola in Sekhukhune District). These communities were selected based on high poverty and unemployment rates, had substandard houses, insufficient infrastructure and environmental issues. The qualitative data provided deeper understanding about ethe quantitative findings and explored questions that were not available to the researcher in the NIDS dataset. The focus group discussions and key-in- depth interviews further provided a follow-up and an explanation of the quantitative findings. Thematic analysis was used to analyse qualitative data. Key findings from objective 1: In terms of descriptive findings, found that 22.16% of children were stunted, 16.40% were overweight, and 5.04% were underweight. The distribution of children among female and male children in the study population was almost the same. About 40% of the children had a low birth weight (<3 kg), 80.59% relied on the child support grant, and 67.22% were cared for at home during the day. Different patterns of malnutrition were observed. The highest percentage of children ages 12-23 months were stunted (33.43%) and overweight (32.69%), while the highest proportion of children ages 0-11 months and 48-59 months were underweight. Among children with a low birth weight of 1-2.9 kg, the highest percentage of stunting (30.07%) (p = 0.001, χ² = 71.2) and underweight (7.05%) (p = 0.026, χ² = 16.9) was observed. There was a relationship between access to medical aid, access to the child support grant, and childhood stunting (p < 0.05), while being cared for at home during the day was associated with stunting (24.98%) and overweight (18.99%) (p = 0.002, χ² = 36.3). Caregivers’ religion was associated with overweight (p = 0.007, χ² = 25.6) among under-5 children, while caregiver’s ethnicity (p = 0.024, χ² = 18.4) was associated with underweight. Key findings from objective 2: Female children had a lower likelihood (0.63 times) of being stunted compared to males. Children aged 12-23 months face a 60% higher risk of being overweight than those aged 0-11 months (AOR = 1.6). However, the risk of overweight declines steadily as age increases. Children aged 48-59 months are 83% less likely to be overweight compared to the youngest group of 0-11 months (AOR = 0.17). Children with a birthweight of 3 kg are 63% less likely to be underweight compared to those weighing 1-2 kg at birth (AOR = 0.37). Children attending crèches/day moms are 69% less likely to be underweight compared to those cared for at home (AOR = 0.31). Children cared for at home are 1.5 times more likely to be stunted (AOR=1.49) compared to children at a creche/day mom. Caregivers who were Nguni 17 had a 26% lower likelihood of having stunted children. Caregivers of other religions had 2 times higher likelihood of having overweight children compared to Christian caregivers (AOR=1.21). Middle-income households were associated with having overweight children (AOR=1.35) compared to low-income households. Children from structurally sound households had a 54% of high risk of being overweight compared to children from dilapidated household structures. The study found that a significant portion of the variation in child malnutrition (stunting, overweight, and underweight) occurred within communities. This is evident from the intraclass correlation of stunting (ICC) values from 27.9% to 30.2% variation, 34.3% to 38.2% overweight variation and 19.6% to 33,9% underweight variation within communities. The increase in ICC after adding additional variables suggest that these factors explain more of the variation within communities. Key findings from objective 3: The results showed that nearly 30% of the households were below the lower-bound food poverty line of R890 per person per month in South Africa, and just about half of the households did not always have enough available foods all the time. The qualitative findings show that the COVID-19 pandemic exacerbated the food insecurity during the COVID-19 lockdown, when many caregivers lost their income sources due to job losses. Food affordability and availability in the households became a major issue, forcing households to make hard decisions between deciding on foods with high nutrition that should be eaten against diverting financial resources and paying for other household expenses such as rent or electricity. Caregivers understood that they should be feeding their children nutritious foods but due to financial constraints, they were forced to give children the available but less nutritious foods in the households. Key findings from objective 4: Qualitative findings further showed that caregivers had various socio-cultural and childcare practices which influenced children’s nutritional and health outcomes. Socio-cultural practices that influenced childhood malnutrition included dietary choices – these were not necessarily affected by cultural beliefs, but they were rather influenced by the lack of income. Traditional beliefs on food- such as foods like eggs and dairy products such as milk or yoghurts were not given to girls. This was from a belief that this food would make girls more fertile and grow much faster. Traditional healing practices influence the dietary restrictions, limiting access to some nutritious foods, which are based on superstitions and lead to stigma. With regards to the childcare practices, there was also a lack of clarity by caregivers 18 on the duration of exclusive breastfeeding as well as the duration when the children should stop breastfeeding. Caregivers did not have adequate knowledge about when to resume weaning. Some caregivers highlighted that the last time they received nutrition knowledge was when their children were infants, and they had taken the children for vaccinations. Caregivers were not aware of how responsive caregiving such as child feeding frequency and portion sizes could improve children’s nutritional outcomes. Key findings from objective 5: From the qualitative interviews with early childhood development (ECD) practitioners, findings indicated a growing disintegration of childcare systems, including the family, health, and social systems, where a lack of parental support in nutrition programmes, a lack of support in health services and other social services when making referrals. Furthermore, various systems of care were working in silos in childcare service provision, resulting in children facing multiple adversities. Conclusions: The study demonstrated that individual-level child characteristics appear to exacerbate childhood malnutrition more than the mother and household-level characteristics. For example, the child level characteristics showed high significance, with age, sex, and child support grant, compared to the caregiver characteristics such as education, employment, and income. At the household level, variables such as household size and income did not show any significance. While this is the case, it does not necessarily mean that the mother and household-level characteristics were not important. This gap can be explained by the small sample, which can cause challenges of limited statistical power, making it harder to detect statistically significant differences. Furthermore, the qualitative assessment filled some gaps regarding these findings and gave an in-depth understanding on how the income disparities among caregivers and households result from high unemployment rates, highlighting the importance of socio-economic status and food security in child nutritional outcomes. From the ECD practitioners’ interviews, given the disintegration of childcare systems, the coordination and multisectoral collaboration of different sectors of care for children is urgently needed to improve children’s nutritional outcomes. Understanding the social context in which a child is brought up is important for the design of programmes and policies that will be effective in addressing this public health challenge. This understanding will enable efficient and effective service referral and service delivery to improve childhood nutrition in South Africa. This study highlights the need for a good 19 coordination of food, family, health, and social systems to ensure a positive childhood nutritional outcome.Item Occupational Stress and Burnout among Clinical Officers at Public Hospitals in Malawi: Impact Shifting to the General Public(University of the Witwatersrand, Johannesburg, 2023-08) Chinguwo, Paliani; Kenny, Bridget; Matshiditsho, Rajohane; Scully, BenIn Malawi, there is a cadre of mid-level health workers called clinical officers who undertake duties conventionally designated for medical doctors in the wake of an acute shortage of the latter. The use of clinical officers as substitutes for medical doctors is one example of a strategy called task shifting that is implemented as a temporary remedy for the shortage of human resources in healthcare. This is a study on the experiences of clinical officers with occupational stress and burnout at public hospitals in Malawi. The study adopted a qualitative research design with a case study as a research strategy. The study was conducted at four district hospitals and one central hospital, all of which are state-owned. One shortcoming of the framing of occupational safety and health in Malawi is the narrow scope and coverage of the regulation on occupational safety and health. This narrow scope of the regulation of occupational safety and health is limited to physical, chemical, and biological hazards. The psychosocial hazards are therefore neglected by the regulation on occupational safety and health. Another shortcoming of the framing of occupational safety and health in Malawi is that the coverage of the regulation on occupational safety and health exempts service sectors like healthcare. This exemption, therefore, gives the impression that healthcare in Malawi is immune to occupational safety and health hazards. This study challenges the narrow scope and coverage of the regulation on occupational safety and health in Malawi that neglects psychosocial hazards and exempts healthcare. The overall aim of the study was to expose the impacts on public health that can be associated with the neglect of psychosocial hazards and the exclusion of healthcare from the regulation of occupational safety and health. This study demonstrates that there are psychosocial hazards at public hospitals that predispose clinical officers to occupational stress and burnout. These are excessive workload, long hours of work, poor interprofessional relations, restructuring, COVID-19 responses, and the absence of occupational and safety management systems. The study further illustrates that psychosocial hazards at public hospitals are a breeding ground for various health problems among clinical officers that emanate from occupational stress and burnout. These health problems include emotional and cognitive effects; injuries; high blood pressure (hypertension); muscle tension or pain; and severe headaches. These health problems negatively affect the quality of life among clinical officers and their performance on the job. The study, therefore, concludes that occupational stress and burnout among clinical officers ultimately affect health outcomes in the broader population. For instance, the study demonstrates how the consequences of OS and burnout among clinical officers are consequently externalised to patients and the general public through the poor quality of healthcare services. In this study, the externalisation of the negative effects of occupational stress and burnout on clinical officers to the patients and the general public, is referred to as impact shifting. This study conceptualises and proposes a theoretical framework for analysing occupational safety and health in Malawi, with a particular focus on psychosocial hazards at public hospitals. The theoretical framework comprises three theoretical perspectives, namely: attribution theory, job demands-resources model, and fundamental cause theory. This study, therefore, offers a theoretical foundation and empirical evidence drawn from the experiences of clinical officers with occupational stress and burnout. The theoretical foundation and empirical evidence can inform the reframing of the scope and coverage of the regulation on occupational safety and health. Finally, this study also conceptualises and proposes a framework for the formulation of a comprehensive policy on occupational safety and health for public health facilities in the context of Malawi.