Electronic Theses and Dissertations (PhDs)

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    Engaging the public in priority setting for health in rural South Africa
    (University of the Witwatersrand, Johannesburg, 2023-10) Tugendhaft, Aviva Chana; Hofman, Karen; Kahn, Kathleen; Christofides, Nicola
    Introduction: The importance of public engagement in health priority setting is widely recognised as a means to promote more inclusive, fair, and legitimate decision-making processes. This is particularly critical in the context of Universal Health Coverage, where there is often an imbalance between the demands for and the available health resources. In South Africa, public engagement is protected in the Constitution and entrenched in policy documents; yet context specific tools and applications to enable this are lacking. Where public engagement initiatives do occur, marginalised voices are frequently excluded, and the process and outcomes of these initiatives are not fully evaluated. This hampers our understanding of public engagement approaches and how to meaningfully include important voices in the priority setting agenda. The aim of this doctoral (PhD) research was to investigate the feasibility and practicality of including the public in resource allocation and priority setting for health in a rural setting in South Africa using an adapted deliberative engagement tool called CHAT (Choosing All Together). Methods: The PhD involved the modification and implementation of the CHAT tool with seven groups in a rural community in South Africa to determine priorities for a health services package. For the modification of CHAT, desktop review of published literature and policy documents was conducted, as well as three focus group discussions, with policy makers and implementers at national and local levels of the health system and the community, and modified Delphi method to identify health topics/issues and related interventions appropriate for a rural setting in South Africa. Cost information was drawn from various national sources and an existing actuarial model used in previous CHAT exercises was employed to create the board. The iterative participatory modification process was documented in detail. The implementation process was analysed in terms of the negotiations that took place within the groups and what types of deliberations and engagement with trade-offs the participants faced when resources were constrained. In terms of the outcomes, the study focused on what priorities were most important to the rural community within a constrained budget and the values driving these priorities, but also how priorities might differ amongst individuals within the same community and the characteristics associated with these choices. Qualitative data were analysed from the seven group deliberations using the engagement tool. Content analysis was conducted, and inductive and deductive coding was used. Descriptive statistics was used to describe the study participants using the data from a demographic questionnaire and to show the group choices from the stickers allocated on the boards from the groups rounds. The investment level (sticker allocation) of all study participants was recorded at each stage of the study. From these the number of stickers allocated to each topic by the participants was calculated by adding up the number of stickers across interventions selected by the participant by topic. The median and interquartile range across study participants was calculated for the topic totals. To examine differences in sticker allocations, Wilcoxon rank sum tests were performed for differences across participant categories and sticker allocations in the final round of CHAT. Findings: Based on the outcomes, seven areas of health need and related interventions specific for a rural community context were identified and costed for inclusion in the CHAT board. These include maternal, new-born and reproductive health; child health; woman and child abuse; HIV/AIDS and TB; lifestyle diseases; quality/access; and malaria. The CHAT SA board reflects both priority options of policymakers/ experts and of community members and demonstrates some of the context specific coverage decisions that will need to be made under NHI. The CHAT implementation shows that the rural communities mostly prioritised curative services over primary prevention due to perceived inefficacy of existing health education and prevention programmes. The exercise fostered strong debates and deliberations. Specifically, the groups engaged deeply with trade-offs between costly treatment for HIV/AIDS and those for non-communicable disease. Barriers to healthcare access were of particular concern and some priorities included investing in more mobile clinic. The individual level priorities were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics such as age. The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and enhance the legitimacy and acceptability of the decision-making process. In terms of reconciling plurality in priority setting for health, group deliberative approaches help to identify social values and reconcile some of the differences, but additional individual voices may also need to be considered alongside group processes, especially among the most vulnerable. Conclusion: This research marks the first instance of modifying and implementing a deliberative tool for priority setting in a South African rural context. The findings shed light on the process and some of the outcomes of this approach within a vulnerable community, offering insights into public engagement in priority setting more broadly. The study demonstrates that participatory methods are feasible in modifying public engagement tools such as CHAT and can be adapted to different country contexts, potentially enhancing the priority setting process. Regarding the implementation of CHAT, the study provides an example of how a rural community grappled with resource allocation decisions, considered different perspectives and societal implications, and set priorities together. The research also highlights the priorities of this rural community, the social values driving their choices, and individual characteristics that are important to consider when setting priorities. The work demonstrates that meaningful public engagement includes various factors that interrelate and impact one another and that could inform a dynamic and cyclical approach going forward, as well as the importance of transparency during all stages of the process.
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    Adolescent health in rural South Africa: building an evidence-base to inform a health promotion intervention supporting healthier lifestyles
    (University of the Witwatersrand, Johannesburg, 2024) Seabi, Tshegofatso Martha; Kahn, Kathleen; Wagner, Ryan G
    Background Low- and middle-income countries (LMICs), including South Africa, face the persisting double burden of malnutrition, with undernutrition and overnutrition coexisting within the population. This issue is particularly pronounced among rural adolescents, who experience limited access to healthcare services, inadequate infrastructure, poverty, and a scarcity of nutritious foods. Addressing this double burden of malnutrition is essential for improving the health outcomes of rural adolescents and breaking the intergenerational cycle of malnutrition. Community health worker-led interventions have shown promise in promoting healthier lifestyles in this population, making it crucial to understand the feasibility and acceptability of such interventions. Aim This thesis aims to provide context-specific information on the changing distribution of Body Mass Index (BMI) and views on obesity among rural South African adolescents to inform the development of a targeted behaviour change intervention. Furthermore, it seeks to determine the feasibility, acceptability, and overall experience of implementing a complex intervention aimed at promoting healthier lifestyles in this population. Methods Using a mixed methods approach focusing on adolescents 12-20 years of age living in rural South Africa. This work is nested within the MRC/Wits rural public health and health transitions research unit (Agincourt) Health and Demographic Surveillance System, which is where the sample was drawn and provided explanatory variables such as SES. This work includes data from two studies with comparable measures, conducted in 2007 (n= 1309) and in 2018 (n=518), this study analysed comprehensive data on the prevalence and trends of BMI, including both undernutrition and overweight/obesity, among rural adolescents in 2007 and 2018. This was done through weight and height measures. Growth z-scores were used to determine stunting, underweight and overweight and overweight/obesity was generated using the 2007 WHO growth standards for adolescents aged up to 17 years and adult cut-offs of BMI of <=18.5 for underweight and =>30 kg/m2 for overweight and obese respectively for adolescents 18 to 20 years. Qualitative data was collected in the form of focus group discussions and in-depth interviews. Pre-intervention, three focus group discussions were held with male (n = 16) and female adolescents (n = 15) focusing on obesity to capture views, attitudes and perceptions surrounding obesity. Post-interventions, six focus group discussions were held with male and female adolescents. In-depth interviews were conducted with adolescents (n=20), parents (n=5) and CHWs (n=3), focusing on the feasibility and acceptability of the health promotion intervention. All qualitative data were analysed using inductive thematic analysis. Results This study found that there is a persistent double burden of malnutrition amongst rural adolescents. The pattern of underweight and overweight/obesity remains similar between 2007 and 2018, with an increase in overweight and obesity, and a decrease in underweight observed across different age and gender groups throughout this period. The prevalence of stunting and underweight, particularly in males in both 2007 and 2018 was substantial although lower in the later year. Adolescents expressed conflicting views of obesity, highlighting their knowledge of the cause and long-term consequences of obesity. In regard to the intervention, participants expressed support for the CHWs and the community-based intervention guided by them. The findings demonstrated the feasibility of providing the intervention to adolescents in a rural context, with modifications needed to ensure participant uptake, such as changes to the time and location. Responses from participants show how the intervention, which included dietary and quantity modifications, was acceptable to adolescents. The gathered information in this study serves as a foundation for developing a health promotion intervention tailored to the specific needs and circumstances of rural adolescents, considering both undernutrition and overweight and obesity. Conclusion This research provides valuable context-specific insights into the burden of malnutrition and perceptions of obesity among rural South African adolescents, considering the complexities of the double burden of malnutrition. The findings contribute to the development of tailored health promotion interventions that address both undernutrition and overweight/obesity in this population. Understanding the feasibility and acceptability of such interventions is vital for successful implementation and sustainability in rural communities.
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    Attrition in the dental therapy profession: an exploration of the contributing factors
    (University of the Witwatersrand, Johannesburg, 2024) Sodo, Pumla Pamella; Jewett, Sara
    Background: A new type of oral health profession called dental therapy was introduced to address the growing need for affordable and accessible oral healthcare services, especially among marginalised communities. Extensive global research has demonstrated that dental therapists provide cost-effective and high-quality services, effectively addressing the issue of limited access to basic oral health services. The introduction of dental therapy into the South African healthcare system took place in 1977, however, disparities in accessing basic oral healthcare persist, particularly among some population groups where the highest prevalence of oral diseases has been reported. Despite being established over four decades ago, the number of registered dental therapists remains low, and there have been reports of attrition within this professional group. This PhD aimed to explore the factors contributing to attrition in the dental therapy profession. The first objective was to determine South African dental therapists' attrition rate and demographic profile over 42 years (1977-2019). The second objective explored factors contributing to attrition, while the third objective explored the applicability of the Hertzberg Two-Factor Theory in the context of dental therapy attrition in South Africa. Methods: This was a concurrent mixed methods study, involving registered graduate dental therapists, former dental therapists, and key stakeholders. The conceptual framework that guided the study was derived from Hertzberg's Two-Factor Theory. Data sources included the HPCSA registry and primary data collected using a quantitative survey investigating job satisfaction and intention to leave among registered graduate dental therapists and qualitative in-depth interviews with former dental therapists and key stakeholders to gain insights into their perspectives on attrition in the dental therapy profession. The attrition rate was determined by using the formula (Attrition Rate = Number of dental therapists who left the profession divided by the total number of dental therapists registered during the period of interest, multiplied by 100). Quantitative data was analysed in STATA version 15 using descriptive and inferential statistics, and qualitative data was analysed using thematic analysis. Findings: A total of 1232 dental therapists were registered with HPCSA over 42 years, with only 714 registered in 2019, two-thirds of whom were Africans. The attrition rate over the 42 years was 40%, while it reduced to 9% during the 10 years from 2010 to 2019. Of the 200 registered dental therapists who took part in the survey, 74.5% being Africans, approximately 51.5% expressed their intention to leave the profession and a notable 69.5% reported job dissatisfaction. In logistic regression analysis, job satisfaction correlated positively with several factors, including qualification from UKZN (AOR= 2.28, CI: 1.06-4.91), post-graduation job availability (AOR=3.87, CI: 1.73-8.69), awareness of postgraduate opportunities (AOR=2.28, CI: 1.05-4.96), and feeling valued (AOR= 6.91, CI: 1.45-26.36). Conversely, job satisfaction was negatively associated with becoming aware of the scope of work only after enrolment (AOR= 0.31, CI: 0.21-0.81). Job satisfaction was inversely correlated with the intention to leave; satisfied individuals had significantly lower odds of intending to leave (AOR= 0.25, CI: 0.11-0.57). In-depth interviews with 14 former dental therapists identified diverse reasons for enrolling in dental therapy and a shared enthusiasm for the dental therapy profession. Most reasons they cited for attrition, such as inadequate remuneration, job scarcity, poor working conditions, lack of career advancement opportunities, and policy implementation gaps aligned with Herzberg's Two-Factor Theory. One novel factor contributing to attrition not covered by the theory was a lack of professional identity. The 12 key stakeholders who were interviewed echoed similar factors contributing to the attrition of dental therapists. To address limitations in moving from a description of factors to recommendations on how to address system-level challenges, I adapted a framework that is a combination of Herzberg's Two-Factor Theory and the Human Resources for Health System Development framework. This new framework addresses multifaceted issues affecting dental therapists, covering production, deployment, and retention. Conclusion: This study sheds light on challenges within South Africa's dental therapy profession, highlighting their profound implications for both the profession and the broader healthcare system. Despite comparable attrition rates to other mid-level health professionals, there were alarmingly high job dissatisfaction levels and intentions to leave the profession, demanding immediate attention and intervention. Identifying key factors contributing to attrition and the novel insight into the lack of professional identity collectively highlight the multifaceted nature of the issue. To address these challenges, embracing a comprehensive human resource retention framework is imperative. This study emphasizes the urgent need for proactive measures to ensure the sustainability and contentment of dental therapists, ultimately benefiting the healthcare system and the communities it serves. Addressing these factors will lead to increased retention rates and improved access to basic oral health services nationwide