Research Outputs (Public Health)

Permanent URI for this collectionhttps://hdl.handle.net/10539/36984

This collection includes content from the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) which has been operating the Agincourt health and demographic surveillance system since 1992. Work has evolved since then into a robust research infrastructure supporting advanced community-based research with studies ranging from the biomedical to the ethnographic, making rural voices heard.

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Predictors of health care use by adults 50 years and over in a rural South African setting
(2014) Ameh, S; Kahn, K; Tollman, S.M; et al
BACKGROUND: South Africa's epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults. OBJECTIVE: To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa. DESIGN: A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. RESULTS: Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu and fever), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% - e.g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR=2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR=2.49, 95% CI: 1.27, 4.86) compared with those with no formal education. CONCLUSION: Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.
Barriers to accessing health care in Nigeria: implications for child survival
(2014) Adedini, S A; Odimegwu, C; Bamiwuye, S A; et al
Background: Existing studies indicate that about one in every six children dies before age five in Nigeria. While evidence suggests that improved access to adequate health care holds great potential for improved child survival, previous studies indicate that there are substantial barriers to accessing health care in Nigeria. There has not been a systematic attempt to examine the effects of barriers to health care on under-five mortality in Nigeria. This study is designed to address this knowledge gap. Data and method: Data came from a nationally representative sample of 18,028 women (aged 15 49) who had a total of 28,647 live births within the 5 years preceding the 2008 Nigeria Demographic and Health Survey. The risk of death in children below age five was estimated using Cox proportional hazard models and results are presented as hazards ratios (HR) with 95% confidence intervals (CI). Results: Results indicate higher under-five mortality risks for children whose mothers had cultural barriers and children whose mothers had resource-related barriers to health care (HR: 1.44, CI: 1.32 1.57, pB0.001), and those whose mothers had physical barriers (HR: 1.13, CI: 1.04 1.24, pB0.001), relative to children whose mothers reported no barriers. Barriers to health care remained an important predictor of child survival even after adjusting for the effects of possible confounders. Conclusion: Findings of this study stressed the need for improved access to adequate health care in Nigeria through the elimination of barriers to access. This would enable the country to achieve a significant reduction in childhood mortality.
Factors influencing agency nursing and moonlighting among nurses in South Africa
(2014) Rispel, L.C; Blaauw, D; Chirwa, T; et al
BACKGROUND: In South Africa, nurses are the largest category of the health care providers. Their optimal performance is critical for the successful implementation of impending health sector reforms. OBJECTIVE: This paper examines the occurrence of agency nursing, moonlighting, and overtime among nurses in South Africa, and the factors influencing moonlighting. DESIGN: This cross-sectional survey was a one-stage cluster random sample of 80 hospitals in four South African provinces, selected with stratification from the public and private health sectors. On the survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire after giving informed consent. In addition to demographic information, the questionnaire elicited information on the frequency of agency nursing, moonlighting, and overtime, and the nurses' reasons for doing moonlighting. Survey data were weighted and analysed using STATA version 12. RESULTS: The majority of survey participants (n = 3,784) were South African (98.0%), female (92.7%), and employed in government (52.8%). Their mean age was 41.5 years (SD 10.4). The occurrence of moonlighting among nurses in the 12 months preceding the survey was 28.0% [95% CI: 24.2-32.1], the frequency of agency nursing was 37.8% [95% CI: 32.4-43.6], while 56.0% of nurses did overtime [95% CI: 51.4-60.4]. In the multiple logistic regression analysis, predictors of moonlighting were province, sector of primary employment, unit of work, category of nurse, and having children. The odds of moonlighting was 1.51 [95% CI: 1.03-2.21] times higher for private sector nurses than for public nurses, while the odds ratio for auxiliary nurses was 0.61 [95% CI: 0.47-0.79] compared to professional nurses. The odds of moonlighting was 1.49 [95% CI: 1.18-1.89] for nurses with children, compared to those without. CONCLUSIONS: Agency nursing, moonlighting, and overtime are common among South African nurses, but have received insufficient policy attention. These issues need to be addressed as part of the implementation of comprehensive health workforce strategies.
Predictors 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 al
BACKGROUND: 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.
Risk factors for unplanned and unwanted teenage pregnancies occurring over two years of follow-up among a cohort of young South African women
(2014) Christofides, N.J; Jewkes, R.K; Dunkle, K.L; et al
BACKGROUND: Although teenage pregnancies in South Africa have declined, the short and longer term health and social consequences are a potential public health concern. This longitudinal study aimed to describe the range of risk and protective factors for incident unwanted and unplanned pregnancies occurring over 2 years of follow-up among a cohort of adolescent women in the Eastern Cape, South Africa. It also investigated the relationship between gender inequality and gender-based violence and subsequent unplanned and unwanted pregnancies among the cohort. OBJECTIVE: Teenage girls, aged 15-18 years (n=19), who were volunteer participants in a cluster randomized controlled trial and who had data from at least one follow-up were included in this analysis. To assess risk and protective factors for incident unwanted or unplanned pregnancies, we constructed multivariate polytomous regression models adjusting for sampling clusters as latent variables. Covariates included age, having a pregnancy prior to baseline, education, time between interviews, study intervention arm, contraceptive use, experience of intimate partner violence, belief that the teenage girl and her boyfriend are mutual main partners, and socioeconomic status. RESULTS: Overall, 174 pregnancies occurred over the 2-year follow-up period. Beliefs about relationship control were not associated with unwanted and unplanned pregnancies, nor were experiences of forced first sex or coerced sex under the age of 15. Hormonal contraception was protective against unplanned pregnancies (OR 0.40; 95% CI 0.21-0.79); however, using condoms was not protective. Physical abuse (OR 1.69; 95% CI 1.05-2.72) was a risk factor for, and having a pregnancy prior to baseline was protective against an unwanted pregnancy (OR 0.25; 95% CI 0.07-0.80). Higher socioeconomic status was protective for both unplanned and unwanted pregnancies (OR 0.69; 95% CI 0.58-0.83 and OR 0.78; 95% CI 0.64-0.96). Believing that the teenage girl and her boyfriend were mutual main partners doubled the odds of reporting both an unplanned and unwanted pregnancy (OR 2.58 95% CI 1.07-6.25, and OR 2.21 95% CI 1.13-4.29). CONCLUSION: Although some of the measures of gender inequity were not associated with unplanned and unwanted pregnancies, there is evidence of the role of both gender power and socioeconomic status. This was evident in teenage girls who experienced physical violence being more likely to have an unwanted pregnancy. Interventions to prevent teenage pregnancies need to be tailored by socioeconomic status because some teenagers may see having a pregnancy as a way to have a more secure future. Interventions that engage with relationship dynamics of teenagers are essential if unwanted and unplanned pregnancies are to be prevented.
Essential evidence for guiding health system priorities and policies: anticipating epidemiological transition in Africa
(2014) Byass, P; De Savigny, D; Lopez, A.D; et al
BACKGROUND: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way. PROPOSALS: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers. CONCLUSION: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services.
Does moonlighting influence South African nurses' intention to leave their primary jobs?
(2014) Rispel, L; Chirwa, T; Blaauw, D; et al
BACKGROUND: Staff retention and turnover have risen in prominence in the global discourse on the health workforce. Moonlighting, having a second job in addition to a primary job, has not featured in debates on turnover. OBJECTIVE: This paper examines whether moonlighting is a determinant of South African nurses' intention to leave their primary jobs. DESIGN: During 2010, a one-stage cluster random sample of 80 hospitals was selected in four South African provinces. On the survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire after giving informed consent. In addition to demographic information and information on moonlighting, the questionnaire obtained information on the participants' intention to leave their primary jobs in the 12 months following the survey. A weighted analysis of the survey data was done using STATA(®) 13. RESULTS: Survey participants (n=3,784) were predominantly middle-aged with a mean age of 41.5 (SD±10.4) years. Almost one-third of survey participants (30.9%) indicated that they planned to leave their jobs within 12 months. Intention to leave was higher among the moonlighters (39.5%) compared to non-moonlighters (27.9%; p<0.001). Predictors of intention to leave in a multiple logistic regression were moonlighting in the preceding year, nursing category, sector of primary employment, period working at the primary job, and number of children. The odds of intention to leave was 1.40 (95% CI: 1.16-1.69) times higher for moonlighters than for non-moonlighters. The odds ratio of intention to leave was 0.53 (95% CI: 0.42-0.66) for nursing assistants compared to professional nurses and 2.09 (95% CI: 1.49-2.94) for nurses working for a commercial nursing agency compared to those working in the public sector.
Perspectives on healthcare, chronic non-communicable disease, and healthworlds in an urban and rural setting
(2014) Ibanez-Gonzalez, Daniel Lopes
BACKGROUND: 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.
Closing 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.
Contestations and complexities of nurses' participation in policy-making in South Africa
(2014) Ditlopo, P; Blaauw, D; Penn-Kekana, L; et al.
Background: There has been increased emphasis globally on nurses’ involvement in health policy and systems development. However, there has been limited scholarly attention on nurses’ participation in policy-making in South Africa. Objective: This paper analyses the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. Design: Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 frontline nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software. Results: The study found that nurses’ participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses’ participation in nursing policies. There was a disjuncture between nursing leadership and frontline nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses’ views and inputs were considered and incorporated. Conclusions: The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing association

Research Outputs (Public Health)

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