Electronic Theses and Dissertations (PhDs)
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Item The assessment of patient-centred care among diabetic patients in southern Malawi(University of the Witwatersrand, Johannesburg, 2024) Makwero, Martha; Muula , A; Igumbor, JudeIntroduction: Patient centred care (PCC) is gaining recognition in various quality care reforms, especially in the growing era of chronic care where its effects are palpable yet its functional elements are unknown and hardly measurable. PCC has been shown to improve care processes and patient reported outcomes among chronic care patients such as Diabetes Mellitus (DM). While the Malawi Quality management Directorate (QMD) and the Non-communicable disease and injury (NCDI) policies mention PCC as a strategic quality reform, its functional elements are hardly known and, if it matters, in mediating patient experiences and outcomes. It is clear that the vagueness is thwarting PCC’s implementation, assessment, and advocacy. Thus, as the burden of chronic diseases, including DM grows, there is a need to optimize PCC through the elicitation of its functional elements, its objective assessment, and its recommended implementation strategies. Aim: This study aims to assess the functional elements of PCC and its relationship to outcomes in diabetic patients. Methodology: I conducted a cross-sectional, exploratory mixed methods study in southern Malawi. Sequentially, I employed qualitative and quantitative methods in order to enrich the contextual understanding of the complex PCC construct and its correlates. Therefore, we initially explored the common elements of PCC in LMIC through a scoping review. Building on the findings, in the next phase, I explored PCC conceptualization among three stakeholders (patients, health care providers and policy makers) further, breaking down the PCC construct to its functional elements through a qualitative inquiry. The qualitative themes identified were used to build a tool on important elements of PCC from the same population. A psychometric analysis was done in order to confirm the structure and consistency of the tool to improve the validity of results obtained. Thereafter, I quantitatively measured the current PCC practice ix among patients with DM and its association with baseline adherence to DM care plans, self- efficacy, glycaemic control, and some complications. The study used Covidence to manage the scoping review and Nvivo version 11 for the qualitative data, which was analyzed through the thematic analysis. The quantitative data was analyzed using STATA version 18 and R-studio version 4.2.3. The psychometric analysis employed exploratory and confirmatory factor analysis. Dichotomization of study participants into those who perceived low and high PCC scores was done through K-means clustering was done in R studio. Similarly, correlational studies and Path analysis were conducted to determine the nature and direction of relationships between the perception of PCC during the encounter and adherence, self-efficacy and glycaemic control. Results: The study confirmed the paucity and fragmentation of literature on PCC in LMIC especially in Africa and therefore, the need to situate the elements in our context. The themes identified were interrelated, and differences in expression and emphasis of some of the elements compared to the Eurocentric ones were highlighted. The recurring themes included the facilitating ambience, sharing of information, and patient involvement, the wider organization of care and the macroenvironment in which care takes place. Although they are similar to the Eurocentric themes, our qualitative inquiry identified eight themes and proposed a working definition. Thus, in the Malawian context, PCC was conceptualized as an expected care process that incorporates warm patient reception, where the healthcare provider consciously aims to reduce the patient-HCP power gap to harness a good long-term relationship. This creates a conducive atmosphere that allows the gathering of information that holistically identifies the individual specific problems and all possible interacting factors, ensuring timely access to care and medication. While patients highlighted the value of PCC encounters, particularly shared decision-making, the study documented the x challenges and vulnerabilities faced in an attempt to engage their providers in shared decision making. The psychometric analysis identified three latent themes underlying the PCC elements namely 1) relational aspects of care, 2) individualization and shared decision making and, 3) organizational aspects of care highlighting what is important and the hierarchical nature of the PCC construct. While acknowledging the need for further refinement, the tool exhibited acceptable reliability and validity properties to be used as a measurement framework in the study. The study showed significant deficiencies in the delivery of PCC with 55.8% of patients perceiving low levels, particularly, in the area of individualization and shared decision-making. Higher PCC scores did not have a significant relationship with self-efficacy. Both the perception of PCC and self-efficacy were positive predictors of adherence independently. Having perceived higher PCC scores was associated with a marginal 0.03-point increase in one’s adherence scores (β = 0.03; 95% CI: 0.01 to 0.04, p-value <0.001). Self-efficacy and adherence were both positive predictors of blood sugar control independently. Better self- efficacy was associated with a 0.03 unit decrease in the level of HbA1c (β =-0.03; 95% CI: - 0.04 to -0.022, p-value <0.001). Additionally, as adherence scores went higher, there was a 0.15 unit decrease in HbA1c (β = -0.15; 95% CI: -0.25 to -0.02, p-value <0.05). The results highlight that PCC can affect glycaemic control only indirectly through adherence. Conclusion The study has confirmed the complexity of the PCC construct and the paucity of literature in LMIC. It has highlighted that above and beyond creating a conducive ambiance, medical encounters ought to evoke support and capacitation for patients to undertake self-care behaviors confidently to be able to produce patient outcomes. Even though this study is cross- xi sectional, the initial patterns are promising for the value of PCC in mediating patient-reported experiences and outcomes among DM patients.Item Feasibility and acceptability of a contextualised physical activity and diet intervention for hypertension control in a rural adult population of South Africa(University of the Witwatersrand, Johannesburg, 2024) Sekome, Kganetso; Myezwa, Hellen; Gómez-Olivé , Francesc XavierOver half the population of adults from rural South Africa are hypertensive. Most strokes and ischaemic heart diseases in rural and remote South Africa are because of hypertension, which is a modifiable risk factor. Apart from pharmaceutical treatment, lifestyle changes such as increasing physical activity and reducing dietary salt have been strongly advocated for the control of hypertension. Despite the known benefits of physical activity and diet modifications for hypertension control, adults in rural South African settings still have high levels of uncontrolled hypertension. There is a lack of culturally sensitive, community-based, lifestyle interventions to control hypertension among rural South African adult populations. We designed, implemented, and evaluated a contextual intervention which recommends adjusting daily routine physical activity and dietary behaviour of adults with hypertension - HYPHEN (HYpertension control using PHysical activity and diEt in a rural coNtext). This study aims to evaluate the feasibility and acceptability of HYPHEN in a rural South African community setting. STUDY ONE Methodology: The first study involved establishing a profile of the frequency, intensity, duration, and domain (work or non-work) of self-reported physical activities of rural South African adults living with hypertension. Four hundred and twenty-nine adults diagnosed/self-report with hypertension aged 40 years and above completed the International Physical Activity Questionnaire Long-Form (IPAQ-LF) via telephone interview. Results: Fifty eight percent of participants were women of which 44% were in paid/unpaid work, while 64% of men were in paid/unpaid work. Men reported greater (duration and frequency) vigorous physical activity at work compared to women. Walking frequency as mode of transport was higher for working men and women compared with those not in work. Women reported high frequency of moderate- intensity physical activity inside the house and outside the house compared to men. Non-working men and women spent more time sitting during the week compared to their working counterparts. Conclusion: Sex, work status, and gender roles are related to physical activity among hypertensive adults living in rural South Africa. Further exploration of socioeconomic and cultural factors influencing physical activity in rural African populations is required so that appropriate contextual interventions can be developed and evaluated. vii STUDY TWO Methodology: The second study was a qualitative study to explore the social and cultural beliefs, perceptions and practices regarding physical activity and diet as a hypertension control intervention for adults living in a rural sub-district in South Africa. Nine focus group discussions were conducted with hypertensive adults using a semi-structured interview guide. Results: Participants had a lack of knowledge about blood pressure values. Perceived causes of hypertension were related to psychosocial factors such as family and emotional-related issues. Physical activity practices were influenced by family and community members’ attitudes and gender roles. Factors which influenced dietary practices mainly involved affordability and availability of food. To control their hypertension, participants recommend eating certain foods, emotional control, taking medication, exercising, praying, correct food preparation, and performing house chores. Conclusion: Lifestyle interventions to control hypertension for adults in a rural South African setting using physical activity promotion and dietary control must consider the beliefs related to hypertension control of this population. STUDY THREE Methodology: The third study was the design of a contextualised physical activity and diet intervention using behaviour change models. The intervention comprised of three components: a structured group education session, individualised physical activity education, and individualised dietary education over a period of 10 weeks. Participants were recruited via telephone. Results: Feasibility parameters included recruitment of 30 participants with a self-report hypertension diagnosis over one week, 80% participants retained to completion, 80% engaged with weekly monitoring calls. Acceptability was assessed qualitatively via face-to-face interviews to explore perceived expectations, benefits, motivation, and barriers concerning the intervention. Fidelity parameters included measures of adherence, dosage, quality of intervention delivery, and participant responsiveness. Secondary measures included blood pressure, body mass index, waist- hip ratio, urinary sodium, accelerometer-measured physical activity, and 24-hour diet recall. Conclusion: This study offers a person-centred, sociocultural approach to hypertension control through adaptations to physical activity and dietary intake. This study will determine whether HYPHEN is feasible and acceptable and will inform changes to the protocol/focus that could be tested in a full trial. viii STUDY FOUR Methodology: The fourth study sought to evaluate the feasibility and acceptability parameters of HYPHEN. Results: The evaluation demonstrated high level of feasibility, acceptability, and fidelity. Thirty (100% of target) participants were successfully recruited over two days, 28 (93%) participants were retained, and 28 (93%) provided complete data. Qualitative data demonstrated high acceptability. Fidelity measures demonstrated that adherence was high, dosage of intervention lasted as planned, no deviation was observed from the planned educational content, and all participants engaged with weekly telephonic calls. Conclusion: Although deemed feasible and acceptable, some amendments are required to the intervention procedures that were carried out before a full trial can be rolled out. Implications This study provides the first known evaluation of a contextualized physical activity and diet intervention for hypertension control in rural South Africa. This study shows that a contextually developed intervention for hypertension control has a promise of success if rolled out in a larger trial.Item Pre-exposure prophylaxis (PrEP) for HIV prevention in Eswatini: understanding the barriers, facilitators and opportunities for women(University of the Witwatersrand, Johannesburg, 2024) Bärnighausen, KathrynIn 2015 the World Health Organization confirmed the efficacy and safety of pre-exposure prophylaxis (PrEP) and recommended PrEP for use within populations at high risk of HIV acquisition. In Eswatini – the country with the highest incidence and prevalence globally – the Eswatini Ministry of Health, in partnership with Clinton Health Access Initiative (CHAI), designed a demonstration project which aimed to understand what was needed to successfully introduce PrEP into a national HIV prevention programme for the general population at risk for HIV. Here, using a PrEP prevention cascade to organise our findings, this thesis presents the content of five peer reviewed research articles which stem from a formative qualitative research component built within the demonstration project. Between 2017 and 2020 there were two rounds of rigorous data collection, including 217 semi-structured in-depth interviews, with adult (>18 years) Health Care Workers (HCWs) providing PrEP, relevant stakeholders and PrEP uptake, decline, discontinuation and continuing PrEP clients in Eswatini. Using a constructivist grounded theory approach, this thesis describes qualitatively where – along the cascade – gaps in service provision, demand creation, access, and retention in care for women (and others) are visible. The thesis highlights adaptations made by HCWs and recommendations from participants to address these gaps. The thesis describes the developed and adapted theoretical models we use to demonstrate where resilience can be used to create demand for PrEP, the structural, policy, community, personal and inter-personal levels that influence PrEP uptake, decline, continuance and discontinuance, and how a prevention-effective-adherence approach to PrEP could save resources, limit adherence burdens and mitigate negative perceptions related to stopping and starting PrEP. The work demonstrates the need for community-based demand creation, the inadequacies of the PrEP Promotion Package (PPP), and where changes were made to the PPP based on the analysis and interpretation of our data. While the findings have informed the successful national scale up of PrEP in Eswatini and have contributed to positive programmatic and implementation adaptations, it is also clear how PrEP clients – those most at risk of HIV infection – lie at the intersections of poverty, vulnerability, injustice and inequality. Ensuring the effectiveness of PrEP and the prevention of HIV acquisition requires multilevel approaches that extend far beyond a prevention cascade, and need to consider and incorporate the lived experiences of those in Eswatini and other high incidence settings globally.Item A nexus of student food (in)security, common mental disorders, and academic success in the midst of the covid-19 pandemic(University of the Witwatersrand, Johannesburg, 2024) Wagner, FezileBackground: South African Higher Education Institutions (HEIs), akin to their global counterparts, grapple with the challenge of low throughput and dropout rates, as students often extend beyond the minimum required duration to complete their academic programmes. Research has identified the first year of study as the period carrying the highest risk for student failure and attrition. Factors such as prior academic performance, family background, and the student's ability to integrate into various aspects of university life emerge as significant determinants of academic success. Notably absent from these determinants are considerations pertaining to student wellbeing, encompassing mental health and food security status. These aspects assumed heightened awareness during the coronavirus disease of 2019 (COVID-19) pandemic, which posed threats to social, economic physical, and psychological wellbeing. For university students, the pandemic necessitated a swift adoption of a new pedagogical approach - Emergency Remote Teaching and Learning (ERTL) – along with most students being forced to relocate home, while simultaneously facing the harsh realities of mass job loss, illness, and grief brought on by the pandemic. Objective: This PhD aims to measure the impact of the COVID-19 pandemic on first time, first year university students’ food insecurity and mental health status (specifically, the common mental disorders (CMDs): anxiety, depression and mental distress symptoms), as well as to understand the implications of this on academic success. Methods: Taking place at a large, urban South African university, this research made use of a concurrent triangulation research design. Two cross-sectional surveys were administered in the years 2019 (before the pandemic) and 2020 (during the COVID-19 pandemic). Included in the surveys were validated tools used to measure depression (Patient Health Questionnaire 9-item (PHQ 9)), anxiety (Generalized Anxiety Disorder 7-item (GAD-7)), and mental distress symptoms. The Household Food Insecurity Access Scale (HFIAS) was also included in the two cross-sectional surveys to measure food insecurity levels. This tool was validated before being administered. Academic success was evaluated through two distinct approaches: i) the first method involved scrutinizing student failure rates and progress; ii) the second method focused on assessing retention and dropout rates. Qualitative data collection took place in 2020 and took the form of in-depth interviews (IDIs) and focus group discussions (FGDs). ii Results: Due to the lockdown directive, students living at home during studies increased from 29% in 2019 to 88% in 2020. In terms of the student failure rate, a reduction was noted from 23.4% (95% CI: 20.7- 26.3) in 2019 to 14.6% (95% CI: 12.0- 17.7) in 2020. Teaching staff acknowledged that students seemed to have a better grasp of complex content during ERTL, and feedback from students themselves indicated the benefits of being able to access and replay lecture recordings as well as the flexibility introduced by ERTL. Increased dropout levels were found - increasing from 5.5% (95% CI 4.2- 7.2) in 2020 to 10.5% (95% CI 8.2- 13.2) in 2021. Moderate food insecurity status (OR= 2.50; 95% CI: 1.12- 5.55; p=0.025), and severe mental distress symptoms (OR= 7.08; 95% CI: 2.67- 18.81; p<0.001) increased the odds of student dropout. The adjusted prevalence of food security was found to be better during the later time point - 30.3% (95% CI: 27.4- 33.4) in 2019 before the COVID-19 pandemic, to 37.9% (95% CI: 34.1- 41.9) 2020 during the COVID-19 pandemic. While the prevalence of CMD symptoms worsened over time; the prevalence of severe anxiety symptoms increased from 17.5% (95% CI: 15.2- 20.1) in 2019 to 25.4% (95% CI: 22.0- 29.1) in 2020. Conclusions: The study found an increase in student dropout and a decrease in failure rates during the pandemic, findings corroborated by other studies. Analyses suggest mental distress symptoms and food insecurity were important drivers of student dropout during the pandemic. Findings highlighted a clear decline of food insecurity when compared to figures before the pandemic. Literature highlighted how food and eating practices change when students are at home; this may have reduced food insecurity levels. A significant increase in the prevalence of CMD symptoms during the COVID-19 pandemic was observed and is believed to have been influenced by various intricate factors including grief, job loss and confinement. These findings provide important insights to HEIs in the event of future disruptions and as they embrace hybrid teaching and learning approaches post COVID-19. Although the reduction in failure rates may have been possibly due to changing the delivery of content (ERTL), HEIs must consider economic, social and mental health factors that may exclude certain groups of students when designing these approaches. It is crucial to explore ways to facilitate remote learning for students that address epistemological access challenges while maintaining inclusivity and connectedness as this is likely to contribute positively to academic success.Item Utilisation of maternal, newborn and child healthcare services in three sub-Saharan African countries (DRC, Kenya, and Tanzania) using Demographic Health Surveys data from 2007-2016: Application of Generalised Structural Equation and Machine Learning Models(University of the Witwatersrand, Johannesburg, 2024) Mlandu, Chenai; Musenge, EustasiusBackground: The risk of child deaths within the first month of life is elevated than the later stages of childhood. Globally, Sub-Saharan Africa (SSA) has the highest neonatal mortality. Majority of the countries in SSA including the DRC, Kenya and Tanzania are struggling to meet Sustainable Development Goal (SDG) 3.2 of reducing the neonatal mortality rate to 12 deaths per 1,000 live births by 2030 (2). Most causes of neonatal deaths are preventable and treatable. Universal coverage, timely and effective utilisation of maternal, newborn, and child healthcare (MNCH) services during pregnancy, delivery, and postpartum has the potential to save many lives of newborns in high-burden countries. vii Antenatal care (ANC) is the first service offered to pregnant women in MNCH. The timing and frequency of ANC visits is critical for the mother and her unborn child. The WHO recommends that women initiate ANC within 16 weeks of pregnancy and attend a minimum of four ANC visits for timely and optimum care before delivery (3, 4). The WHO also recommends that pregnant women receive assistance from a skilled worker during delivery and get postnatal checks with their newborns within 6 weeks of delivery (5, 6). Furthermore, utilising the Continuum of Care (CoC) for MNCH could significantly reduce maternal and newborn deaths in SSA. In the context of MNCH, the CoC is an approach that ensures continuous care from the period of pregnancy, through to childbirth, postnatal period, infancy, and the childhood period (7). Despite the recognition of the use of vital services in MNCH, timely and adequate uptake of MNCH services remains poor and the coverage of MNCH is far from universal in SSA. Most pregnant women initiate ANC after 16 weeks and hence fail to receive timely ANC interventions (8). Uptake of ANC visits, skilled birth attendance (SBA) and postnatal care (PNC) is suboptimal (8-11). Studies in SSA have explored various factors associated with MNCH services utilisation, however, our understanding of MNCH services utilisation in SSA is still limited. Trends in utilisation of MNCH services over time such as late ANC uptake have not been thoroughly assessed. Late uptake of ANC is still a common problem in SSA. Tracking women’s progress in the timing of ANC will ascertain if they are any changes in women’s late uptake of ANC and the contributing factors. This information will guide future policies and programmes which focus on improving the timely uptake of ANC in the SGD era. There is also a dearth of empirical evidence on the factors associated with the utilisation of ANC, skilled delivery and postnatal care in the CoC using nationally representative data. The CoC views both the mother and child as a collective rather than as separate/ individual entities. Understanding factors that viii contribute to the full utilisation of drop out from the CoC is essential for the formulation of interventions than enhance the CoC. Furthermore, studies which investigated either the individual utilisation of MNCH services such as timing of ANC, ANC visits, SBA and PNC services or the CoC have tended to use more of the traditional analysis methods such as the logistic regression. The application of more versatile analysis methods such as Machine Learning is not common. Machine Learning methods are capable of extracting information that commonly used methods (logistic regression) fail to do by uncovering hidden patterns and relationships, particularly in large data sets (12). The application of Machine Learning methods can offer opportunities of enhancing existing methods (conventional regression methods) for predicting and classifying MNCH utilisation leading to more effective interventions to improve MNCH utilisation. There is also a limited understanding on the interrelationships between MNCH services utilisation and neonatal outcomes. The associations between MNCH services utilisation and newborn outcomes such as neonatal mortality are commonly assessed using traditional approaches that assume direct associations. Specific analytical methods, such as Generalised Structural Equation Modeling (GSEM) can be used to model complex relationships such as interrelated links between utilisation of different MNCH services and neonatal outcomes. GSEM gives a clear understanding of how different services of MNCH are related to one another with neonatal outcomes by estimating both direct and indirect paths associations for more effective targeted interventions. Given the critical role of MNCH in ending preventable neonatal mortality, the overarching aim of this study was to describe the utilisation of MNCH services and their associations with neonatal mortality using GSEM and Machine Learning models in three sub-Saharan African countries: the DRC, Kenya, and Tanzania. ix Methods: The study utilised cross-sectional secondary data of reproductive-age women from the Democratic Republic of Congo (DRC) (2007-2013/14), Kenya (2008-2014) and Tanzania (2010-2015/16) Demographic Health Surveys. Firstly, the multivariate logistic regression analysed factors associated with late ANC initiation accounting for clusters, survey weights and stratification for the different rounds of the Demographic Health Surveys. Trends in late initiation of ANC over time in each country were assessed by comparing the earlier and later surveys using differences in prediction scores (prediction probabilities generated after running the multivariate logistic regression models). Secondly, the study assessed the main predictors of non-utilisation of PNC using the Decision Tree. The model performance of the Decision Tree was compared to the Logistic Regression using Accuracy, Sensitivity, Specificity and area under the Receiver Operating Characteristics. Thirdly, factors associated with the drop out from the MNCH continuum, defined as not fully utilising either ANC, SBA, or PNC services, were analysed using multivariate logistic regression accounting for clusters, survey weights and stratification. Machine Learning analysis was used to predict the drop out from the MNCH continuum using features (predictors) that were found significant in the multivariate logistic regression. Five classification Machine Learning models were built and developed including the Artificial Neural Network, Decision Tree, Logistic Regression, Random Forest and Support Vector Machine to predict the drop out from the MNCH continuum. The prediction accuracies of the models were then compared using parameters including Accuracy, Precision, Recall, Specificity, F1 score and area under the Receiver Operating Characteristics. Fourthly, the Generalised Structural Equation Modeling (GSEM) was used to assess the mediatory role of MNCH services utilisation on neonatal mortality. The endogenous variables x were ANC attendance, SBA and PNC attendance, low birth weight and neonatal mortality. The GSEM analysis also accounted for survey weights and considered cluster random effects. Results: The findings showed a reduction in late ANC initiation (67.8%-60.5%) between 2008-2014 in Kenya as well as in Tanzania (60.9%-49.8%) between 2010-2016, but an increase was observed in the DRC (56.8%-61.0%) between 2007-2014. In the DRC, higher birth order was associated with ANC initiation delays from 2007-2014, whilst rural residency, lower maternal education and household income was linked to ANC initiation delays in 2014. In Kenya, lower maternal education and household income was associated with ANC initiation delays from 2008-2014, whilst rural residency and increased birth order were linked to ANC initiation delays in 2014. In Tanzania, higher birth order and larger households were linked to ANC delays from 2010-2016, whilst ANC initiation delays were associated with lower maternal education in 2010 and lower-income households in 2016. The results also showed that the Decision Tree models had higher prediction accuracy of non- utilisation of PNC than the Logistic Regression models. Using the Decision Tree, low quality of ANC, home deliveries and unemployment were associated with the highest probability of not utilising PNC (92.0%) in the DRC. In Kenya, home deliveries, unemployment and lack of access to mass media were associated the highest likelihood of not utilising PNC (87.0%). In Tanzania, home deliveries, low quality of ANC and unwanted pregnancies exhibited the highest likelihood of not utilising PNC (100.0%). The results also revealed very high rates of dropping out from the MNCH continuum in the DRC (91.0%), in Kenya (72.3%) and Tanzania (93.7%). Rural residence, lower maternal education and non-exposure to mass media were common predictors of dropping out from the MNCH continuum across the three countries. Further, the influence of factors such as xi household wealth, household size, access to money for medication, travel distance to health facilities, and parity and maternal age varied by country. Results from the Machine Learning analysis showed that the Logistic Regression had the least prediction accuracy, while the Random Forest exhibited the highest prediction accuracy. Using the Random Forest, the study further ranked the most important predictors of the drop out from the MNCH continuum. Household wealth, place of residence, maternal education and exposure to mass media were the top four most important predictors. The results also showed direct and indirect associations between MNCH services utilisation and neonatal mortality. ANC attendance mediated the total effects of PNC attendance on neonatal mortality by 8.8% in Kenya and 5.5% in Tanzania. ANC attendance and SBA also sequentially mediated the total effects of PNC attendance on neonatal mortality by 1.9% in Kenya and 1.0% in Tanzania. The results in Tanzania also showed ANC attendance mediated 2.8% of the total effects of LBW on neonatal mortality. No presence of mediation was observed in the DRC; however, ANC attendance moderated the relationship between parity and neonatal mortality. Conclusions: The study found that late uptake of ANC decreased between the two survey rounds in Kenya and Tanzania but increased in the DRC. Women from various geographic, educational, parity, and economic groups showed varying levels of late ANC uptake. Increasing women’s access to information platforms and strengthening initiatives that enhance female education, household incomes, and localise services may enhance early ANC uptake. The Decision Tree models showed higher prediction accuracy of non-utilisation of PNC than the Logistic Regression models in the DRC, Kenya and Tanzania. Using the Decision Tree, women who had poor quality of ANC, home deliveries, unemployment, unplanned pregnancies, and no mass media access were identified as high-risk subpopulations of non- xii utilisation of PNC. Improving access and quality of care, incorporation of TBAs into the formal health systems, government health financing, increasing access to mass media and integrating maternal healthcare services with family planning services should be considered as top priority interventions to improving the utilisation of PNC. Most women and children drop out of the MNCH continuum in the DRC, Kenya and Tanzania. Rural residence, lower maternal education and non-exposure to mass media were common factors linked to the high dropout in the MNCH continuum. The use of Machine Learning can help support evidence-based decisions in MNCH interventions. Rapid response mechanisms such as web-based applications can also be developed through the use Machine Learning whereby a pregnant woman’s future utilisation of the services in CoC is assessed and monitored in real-time. The GSEM findings showed interconnections between MNCH services utilisation such as timing of ANC, ANC visits, SBA, PNC and neonatal mortality. This suggests that more than direct and indirect factors are accountable for the associations between MNCH services utilisation and neonatal mortality. The mediation role of MNCH services on neonatal mortality indicates critical areas for targeted interventions to reduce neonatal mortality. Overall, the study aimed to describe the utilisation of the MNCH services and associations with neonatal mortality in the DRC, Kenya and Tanzania. The study showed declines in late ANC uptake in two countries, however, early uptake of ANC is far is still not universal. The study also showed very low levels of retention in the CoC, and most women and children drop out in the CoC at postpartum period. The findings also showed the existence of social, health system and individual inequalities in MNCH and their impact on early childhood survival. Women who are vulnerable to unequal and poor MNCH services utilisation are characterised by poverty, rural residence, long travel distances to health facilities, unaffordable medical expenses, home deliveries, low quality of xiii care, low education, high parity, younger age, unemployment, limited exposure to mass media, and unplanned pregnancies. Context-specific intervention programs such as female education, government health financing, MNCH promotion programs through mass media and improved accessibility and quality of care in health facilities, particularly for the most vulnerable groups of the populations such as women of low socioeconomic status and women from underserved rural areas are essential to improve the overall health of mothers and children and meeting the SDG-3 goals. Modern biostatistical models like Machine Learning provide essential tools to understand public health problems. These techniques should be applied to complement the conventional statistical methods, particularly the tree-based models like the Decision Tree and Random Forest for predicting and classifying the utilisation of MNCH services. The GSEM established interconnections between timing of ANC, ANC visits, SBA and PNC and neonatal mortality. The timing of the first ANC contact is an important starting point to a continuation through the COC. It makes women better informed about pregnancy and the subsequent use of MNCH services. All stakeholders should work more on promoting early uptake of ANC by setting up initiatives that increase women’s access to information platforms, enhance female education, improve household incomes, and bring services closer to communities.Item Occupational exposure to chemicals, and health outcomes, among nail technicians in Johannesburg, South Africa(University of the Witwatersrand, Johannesburg, 2023-08) Keretetse, Goitsemang; Brouwer, Derk H.; Nelson, GillIntroduction: Nail technicians are exposed to chemicals emitted from activities performed in nail salons, including simple buffing of nails, basic manicures and pedicures, application of nail polish, and the application and sculpting of artificial nails. The various products used during these processes may contain volatile organic compounds (VOCs), which pose a health risk to both the nail technicians and their clients. Associated health effects include skin, eye, and respiratory irritation, neurologic effects, reproductive effects, and cancer. The aim of this study was to effects within the formal and informal sectors in Johannesburg, South Africa. In this study, informal nail technicians are defined as those working in nail salons that are not licensed or registered with any formal enterprise or establishment, or in their own capacity. The objectives were 1) to estimate the prevalence of self-reported symptoms associated with the use of nail products, 2) to measure exposures to chemicals in nail products used in the formal and informal nail salons, 3) to investigate the feasibility and reliability of self-assessment of exposure as a method of estimating exposure to chemicals, and 4) to investigate the association between respiratory symptoms (chronic and acute) and chemical exposures in both formal and informal nail technicians. Methods: This was a cross-sectional study. A questionnaire, adapted from other studies, was piloted before being administered to the participating nail technicians. Data were collected from 54 formal and 60 informal nail technicians, regarding sociodemographic characteristics, perceptions of working with nail products, and self-reported symptoms of associated health effects. A subset of 20 formal and 20 informal nail technicians was conveniently selected from the 114 participants for the exposure assessment phase. The two groups were further divided into two groups of 10 for the controlled/expert exposure assessment (CAE) and the self-assessment of exposure (SAE). Personal 8-hr exposure measurements were performed using VOC and formaldehyde passive samplers attached to the participant’s breathing zone over three consecutive days. For the SAE approach, participants conducted their own exposure measurements, while the CAE approach was fully conducted by the principal researcher. Task-based measurements were carried out using a photoionization detector (PID) to measure peak concentrations during specific nail application activities. A probabilistic risk assessment was conducted to estimate the carcinogenic and non-carcinogenic life time risks from exposure to VOCs. Chemical analysis was conducted by a SANAS-accredited laboratory. After correcting for their respective evaporation rates, relative to the evaporation rate of d-limonene (the VOC with the lowest evaporation rate), the adjusted total VOC (TVOC) concentrations were calculated using the 13 VOCs that were detected at a frequency of 30% or more. VOC concentration data below the limit of detection (LoD) were imputed, using the regression on order statistic (Robust ROS) approach. The self-reported symptoms were categorised into neurological effects, respiratory effects, eye irritation, and skin irritation. The ACGIH additive effects formula was used to calculate the combined respiratory effect of selected VOCs. Different statistical tools were used to analyse the data for each objective. Results: Formal and informal nail technicians used different nail products, performed different nail applications, serviced different mean numbers of clients, and were exposed to different concentrations of selected VOCs. Acetone concentrations were higher in formal nail salons, due to the soak-off method used for removing existing nail applications, while methyl methacrylate (MMA) concentrations were higher in informal nail salons - related to acrylic methods being used more frequently in the informal than the formal nail salons. All VOC concentrations were below their respective occupational exposure limits, with the exception of formaldehyde (0.21 mg/m3). TVOC levels were higher in formal nail salons, due to the bystander effect from multiple nail technicians performing nail applications simultaneously. Sixty percent of the informal nail technicians reported health-related symptoms, compared to 52% of the formal nail technicians, and informal male nail technicians reported more symptoms than their female counterparts. All nail technicians' median and 95th percentile non-cancer risks exceeded the acceptable risk of 1 for xylene, 2-propanol, and benzene, while the cancer risk estimates (medians and 95th percentiles) for benzene and formaldehyde exceeded the US EPA cancer risk threshold of 1 x 10-6. Conclusion: This is the first study to assess exposures to VOCs in the often-overlooked informal sector and compare these exposures with those in the formal sector of the nail industry. Personal breathing zone concentration data for nail salon workers were generated in this study, including the informal sector, which is always challenging to access for research. Although banned in many countries, MMA is still used in South Africa in the informal nail sector. The SAE study showed that participatory research is feasible and enables a more reliable estimate of the exposure by expanding the amount of data. Using a combination of shift and task-based measurements was particularly effective in creating exposure profiles of employees and identifying activities that require targeted interventions. There is a need for the nail industry, especially the informal salons, to be more closely regulated, concerning the hazardous chemicals frequently encountered in nail products. Nail salons should reduce exposure frequency by regulating working hours, making informed decisions regarding the procurement of nail products, and adopting safe work practices to reduce emissions from harmful chemicals and thus exposure among nail salon workers and their clients.Item Preventing Coal Mine Dust Lung Disease: Application of Bayesian Hierarchical Framework for Occupational Exposure Assessment in The South African Coal Mining Industry(University of the Witwatersrand, Johannesburg, 2023-10) Made, Felix; Brouwer, Derk; Lavoue, Jerome; Kandala, Ngianga-BakwinBackground: The world's largest energy source is coal with nearly 36% of all the fuel used to produce power. South Africa is the world's top exporter and the seventh-largest producer of coal. In the upcoming years, it is expected that South Africa's coal production output rate will rise. Coal mine dust lung disease (CMDLD) is an irreversible lung disease caused by the production of coal, the emission of dust, and prolonged exposure to the dust. When conducting safety evaluation, exposure is typically reported as an eight-hour time-weighted average dust concentration (TWA8h). In occupational exposure contexts, occupational exposure limits (OEL) are often used as a threshold where workers can be exposed repeatedly without adverse health effects. The workers are usually grouped into homogenous exposure groups (HEGs) or similar exposure groups (SEGs). In South Africa, a HEG is a group of coal miners who have had similar levels and patterns of exposure to respirable crystalline silica (RCS) dust in the workplace. Several statistical analysis methods for compliance testing and homogeneity assessment have been put into use internationally as well as in South Africa. The international consensus on occupational exposure analysis is based on guidelines from the American Industrial Hygiene Association (AIHA), the Committee of European Normalisation (CEN), and BOHS British and Dutch Occupational Hygiene Societies' guidelines (BOHS). These statistical approaches are based on Bayesian or frequentist statistics and consider the 90th percentile (P90) and 95th percentile (P95), with- and between-worker variances, and the lognormal distribution of the data. The current existing practices in South Africa could result in poor or incorrect risk and exposure control decision-making. Study Aims: The study aimed to improve the identification of coal dust overexposure by introducing new methods for compliance (reduced dust exposure) and homogeneity (similar dust exposure level) assessment in the South African coal mining industry. Study Objectives: The objectives of this study were: 1. To compare compliance of coal dust exposure by HEGs using DMRE-CoP approach and other global consensus methods. 2. To investigate and compare the within-group exposure variation between HEGs and job titles. 3. To determine the posterior probabilities of locating the exposure level in each of the OEL exposure categories by using the Bayesian framework with previous information from historical data and compare the findings and the DMRE-CoP approach. 4. To investigate the difference in posterior probabilities of the P95 exposure being found in OEL exposure category between previous information acquired from the experts and the current information from the data using Bayesian analysis. Methods: The TWA(8h) respirable coal dust concentrations were obtained in a cross-sectional study with all participants being male underground coal mine workers. The occupational hygiene division of the mining company collected the data between 2009 and 2018. The data were collected according to the South African National Accreditation System (SANAS) standards. From the data, 28 HEGs with a total of 728 participants were included in this study. In objectives 1 and 2, all 728 participants from the 28 HEGs were included in the analysis. For exposure compliance, the DMRE-CoP accepts 10% exceedance of exposure above the OEL (P90 exposure values from HEGs should be below the OEL). The 10% exceedance was compared to the acceptability criterion from international consensus which uses 5% exceedance above the OEL (P95 exposure is below the OEL) of the lognormal exposure data. For exposure data to be regarded as homogenous, the DMRE-CoP requires that the arithmetic mean (AM) and P90 must fall into the same DMRE-CoP OEL exposure category. The DMRE-CoP on assessment of homogeneity was also compared with the international approaches which include the Rappaport ratio (R-ratio) and the global geometric standard deviation (GSD). A GSD greater than 3 and an R-ratio greater than 2 would both indicate non-homogeneity of the exposure data of a HEG. The GSD and DMRE-CoP criteria were used to assess the homogeneity of job titles exposure within a HEG. In objective 3 a total of nine HEGs which have 243 participants, were included in the analysis. To investigate compliance, a Bayesian model was fitted with a Markov chain Monte Carlo (MCMC) simulation. A normal likelihood function with the GM and GSD from lognormal data was defined. The likelihood function was updated using informative prior derived as the GM and GSD with restricted bounds (parameter space) from the HEGs' historical data. The posterior probabilities of the P95 being located in each DMRE exposure band were produced and compared with the non-informative results and the DMRE approach DMRE-CoP using a point estimate inform of the 90 percentiles. In objective 4, a total of 10 job titles were analysed and selected. The selection of the job titles was based on if they have previous year's data so it can be used to develop prior information in the Bayesian model. The same job titles were found across different HEGs, so to ensure the mean is not different across HEGs, the median difference of a job title exposure distribution across HEGs was statistically compared using the Kruskal-Wallis test, a non-parametric alternative to analysis of variance (ANOVA). Job titles with statistically non-significant exposure differences were included in the analysis. Expert judgements about the probability of the P95 located in each of the DMRE exposure bands were elicited. The IDEA (Investigate", "Discuss", "Estimate" and "Aggregate) expert elicitation procedure was used to collect expert judgements. The SHELF tool was then used to produce the lognormal distribution of the expert judgements as GM and GSD to be used as informative prior. A similar Bayesian analysis approach as in objective 3 was used to produce the probability of the P95 falling in each of the DMRE exposure bands. The possible misclassification of exposure arising from the use of bounds in the parameter space was tested in a sensitivity analysis. Results: There were 21 HEGs out of 28 in objectives 1 and 2 that were non-compliant with the OEL across all methods. According to the DMRE-CoP approach, compliance to the OEL, or exposure that is below the OEL, was observed for 7 HEGs. The DMRE-CoP and CEN both had1 HEG with exposures below the OEL. While the DMRE-CoP showed 6 homogeneous HEGs, however, based on the GSDs 11 HEGs were homogeneous. The GSD and the DMRE-CoP agreed on homogeneity in exposures of 4 (14%) HEGs. It was discovered that by grouping according to job titles, most of the job titles within non-homogenous HEGs were homogenous. Five job titles had AMs above their parent HEG. For objective 3, the application of the DMRE-CoP (P90) revealed that the exposure of one HEG is below the OEL, indicating compliance. However, no HEG has exposures below the OEL, according to the Bayesian framework. The posterior GSD of the Bayesian analysis from non-informative prior indicated a higher variability of exposure than the informative prior distribution from historical data. Results with a non-informative prior had slightly lower values of the P95 and wider 95% credible intervals (CrI) than those with an informative prior. All the posterior P95 findings from both non-informative and informative prior distribution were classified in exposure control category 4 (i.e., poorly controlled since exceeding the OEL), with posterior probabilities in the informative approach slightly higher than in the non-informative approach. Job titles were selected as an alternative group to assess compliance in objective 4. The posterior GSD indicated lower variability of exposure from expert prior distribution than historical data prior distribution. The posterior P95 exposure was very likely (at least 98% probability) to be found in exposure control category 4 when using prior distribution from expert elicitation compared to the other Bayesian analysis approaches. The probabilities of the P95 from experts' judgements and historical data were similar. The non-informative prior generally showed a higher probability of finding the posterior P95 in lower exposure control categories than both experts and historical data prior distribution. The use of different parameter values to specify the bounds showed comparable results while the use of no parameter space at all put the posterior P95 in exposure category 4 with 100% probability. Conclusions: In comparison to other approaches, the DMRE-CoP tend to show that exposures are compliant more often. Overall, all methods show that the majority of HEGs were non-compliant. The HEGs that suggest non-homogeneity revealed that the constituent job titles were homogenous. Application of the GSD criterion indicated that HEGs are more likely to be considered as homogeneous than when using the DMRE-CoP approach. When using the GSD and the DMRE-CoP guidelines, alternative grouping by specific job titles showed a greater agreement of homogeneity. The use of job titles showed that using HEGs following the DMRE-CoP current guidelines might not show high-exposure job titles and would overestimate compliance. Additionally, since job titles within a HEG may be homogeneous or have a different exposure to the parent HEG, exposure variability is not properly recorded when using HEGs. In compliance assessment, it is important to use the P95 of the lognormal distribution rather than the DMRE-CoP approach that use the empirical P90. Our findings suggest that the subgrouping of exposure according to job titles within a HEG should be used in the retrospective assessment of exposure variability, and compliance with the OEL. Our results imply that the use of a Bayesian framework with informative prior from either historical or expert elicitation may confidently aid concise decision making on coal dust exposure risk. Contrary to informative prior distribution derived from historical data or expert elicitation, Bayesian analysis using the non-informative uniform prior distribution places HEGs in lower exposure categories. Results from noninformative prior distributions typically show high levels of uncertainty and variability, so a decision on dust control would be reached with less confidence. The Bayesian framework should be used in the assessment of coal mining dust exposure along with prior knowledge from historical data or professional judgment, according to this study. For exposure, findings are to be reported with high confidence and for sound decisions to be reached about risk mitigation, an exposure risk assessment should be considered while using historical data to update the current data. The study also promotes the use of experts in situations where it is necessary to combine current data with historical data, but the historical data is unavailable or inapplicable.Item Initial loss to follow up among tuberculosis patients: the role of ward-based outreach teams (wbots) and short message service (sms) technology(University of the Witwatersrand, Johannesburg, 2023-03) Mwansa-Kambafwile, Judith Reegan Mulubwa; Menezes, Colin; Chasela, CharlesIntroduction: In South Africa, tuberculosis (TB) is still a serious public health problem with rates of initial loss to follow up (initial LTFU) varying between 14.9% and 22.5%. Poor clinician-patient communication resulting in lack of clarity on next steps, patients not prioritizing their healthcare and patients not knowing that their results are ready at the clinic are some reasons for initial LTFU. This PhD aimed to assess the effectiveness of Ward-based Outreach Teams (WBOTs) or Short Message Service (SMS) technology in reducing TB initial LTFU in Johannesburg, South Africa between 2018 and 2020. Methods: A mixed methods approach comprising two phases (formative and intervention) was employed. In the formative phase, secondary data were analyzed for frequency distributions to determine the rates of initial LTFU in the study area. In addition, in-depth interviews with WBOT Managers and with TB Program Managers were conducted to determine their perceived reasons for TB initial LTFU. In the intervention phase, two interventions (WBOTs/SMS technology) were tested using a 3 arm randomized controlled trial (RCT) comparing each of the interventions to standard of care (SOC). The WBOTs delivered paper slip reminders while SMS intervention entailed sending reminder SMS messages to patients as soon as TB results were available. Chi square statistics, Poisson regression and Kaplan-Meier estimates were used to analyze the data. The RCT was followed by in-depth interviews with WBOT members and with some of the trial participants who had tested TB positive and had received reminder messages. To identify themes in the qualitative studies, both inductive and deductive coding were used in the hybrid analytic approach. Results: From the formative phase, the TB initial LTFU among the 271 patients was found to be 22.5% and the overall time to treatment initiation was 9 days. Interviews with managers revealed that relocation and “shopping around” were the main patient related factors found as the reasons for initial LTFU. Health system related factors for initial LTFU were communication and staff rotations. In terms of TB related work, WBOTs screened household members for TB and referred them for TB testing. The services of the WBOT/TB programs which were found to be integrated were: referral of symptomatic patients for TB testing and adherence monitoring in patients already on TB treatment. There was minimal involvement of the WBOTs in the treatment initiation of patients diagnosed with TB. Findings from the trial were that 11% (314/2850) of the participants tested positive for TB. The 314 TB patients were assigned to one of the 3 arms (SOC=104, WBOTs=105, and SMS=105). Overall, 255 patients (81.2%) were initiated treatment across all study arms. More patients in the SMS arm were initiated TB treatment than in the SOC arm (92/105; 88% and 81/104; 78% respectively; P=0.062). Patients in the SMS arm also had a shorter time to treatment initiation than those in the SOC arm (4 days versus 8 days; P<0.001). A comparison of the WBOTs arm and the SOC arm showed similar proportions initiated on treatment (45/62; 73% and 44/61; 72% respectively) as well as similar times to treatment initiation. Findings from the post-trial interviews showed that delivery of the reminder paper slips by the WBOTs during the trial was something new, but possible to incorporate into their daily schedule. The patient interviews revealed that various emotions (happiness, fear, worry etc.) were experienced upon receipt of the reminder messages. Participants also reported that receiving the reminder message did influence their decision to go back to collect the results. Conclusion: Reminder messages to patients are beneficial in TB treatment initiation. National TB programs can use SMS messaging because it is an affordable and feasible method. Although implementation of the WBOTs intervention was suboptimal, findings show that with proper integration of TB and WBOT programs, WBOTs have the potential to contribute to improved treatment initiation.Item Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission dynamics and social contact patterns(University of the Witwatersrand, Johannesburg, 2023-03) Kleynhans, Jacoba Wilhelmina; Cohen, Cheryl; Tempia, StefanoBackground: Understanding the community burden and transmission dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can assist to make informed decisions for prevention policies. Methods: From August through October 2018, before the SARS-CoV-2 pandemic, we performed a cross-sectional contact survey nested in a prospective household cohort in an urban (Jouberton, North West Province) and a rural community (Agincourt, Mpumalanga Province) in South Africa to measure contact rates in 535 study participants. Participants were interviewed to collect details on all contact events (within and outside of the household). During the SARS-CoV-2 pandemic we enrolled 1211 individuals from 232 randomly selected households in the same urban and rural community, and followed the cohort prospectively for 16 months (July 2020 through November 2021), collecting blood every two months to test for SARS-CoV-2 antibodies. Using these longitudinal SARS-CoV-2 seroprevalence estimates and comparing these with reported laboratory-confirmed cases, hospitalizations and deaths, we investigated the community burden and severity of SARS-CoV-2. We also performed a case-ascertained household transmission study of symptomatic SARS-CoV-2 index cases living with HIV (LWH) and not LWH (NLWH) in two urban communities (Jouberton, North West Province and Soweto, Gauteng Province) from October 2020 through September 2021. We enrolled 131 SARS-CoV-2 index cases at primary healthcare clinics. The index cases and their 457 household contacts were followed up for six weeks with thrice weekly visits to collect nasal swabs for SARS-CoV-2 testing on reverse transcription real-time polymerase chain reaction (rRT-PCR), irrespective of symptoms. We assessed household cumulative infection risk (HCIR), duration of virus detection and the interval between index and contact symptom onset (serial interval). By collecting high-resolution household contact patterns in these households using wearable sensors, we assessed the association between contact patterns and SARS-CoV-2 household transmission. Results: During the contact survey, we observed an overall contact rate of 14 (95% confidence interval (CI), 13-15) contacts per day, with higher contact rates in children aged 14-18 years (22, 95%CI 8-35) compared to children <7 years (15, 95%CI 12-17). We found higher contact rates in the rural site (21, 95%CI 14-28) compared to the urban site (12, 95%CI 11-13). When comparing the household cohort seroprevalence estimates to district SARS-CoV-2 laboratory-confirmed infections, we saw that only 5% of SARS-CoV-2 infections were reported to surveillance. Three percent of infections resulted in hospitalization and 0.7% in death. People LWH were not more likely to be seropositive for SARS-CoV-2 (odds ratio [OR] 1.0, 95%CI 0.7–1.5), although the sample size for people LWH was small (159/1131 LWH). During the case-ascertained household transmission study for SARS-CoV-2, we estimated a HCIR of 59% (220/373) in susceptible household members, with similar rates in households with an index LWH and NLWH (60% LWH vs 58% NLWH). We observed a higher risk of transmission from index cases aged 35–59 years (adjusted OR [aOR] 3.4, 95%CI 1.5–7.8) and ≥60 years (aOR 3.1, 95% CI 1.0–10.1) compared with those aged 18–34 years, and index cases with a high SARS-CoV-2 viral load (using cycle threshold values (Ct) <25 as a proxy, aOR 5.3, 95%CI 1.6–17.6). HCIR was also higher in contacts aged 13–17 years (aOR 7.1, 95%CI 1.5–33.9) and 18–34 years (aOR 4.4, 95% CI 1.0–18.4) compared with <5 years. Through the deployment of wearable sensors, we were able to measure high-resolution within-household contact patterns in the same households. We did not find an association between duration (aOR 1.0 95%CI 1.0-1.0) and frequency (aOR 1.0 95%CI 1.0-1.0) of close-proximity contact with SARS CoV-2 index cases and household members and transmission. Conclusion: We found high contact rates in school-going children, and higher contact rates in the rural community compared to the urban community. These contact rates add to the limited literature on measured contact patterns in South Africa. The burden of SARS-CoV-2 is underestimated in national surveillance, highlighting the importance of serological surveys to determine the true burden. Under-ascertainment of cases can hinder containment efforts through isolation and contact tracing. Based on seroprevalence estimates in our study, people LWH did not have higher SARS-CoV-2 community attack rates. In the household transmission study, we observed a high HCIR in households with symptomatic index cases, and that index cases LWH did not infect more household members compared to people NLWH. We found a correlation between age and SARS-CoV-2 transmission and acquisition, as well as between age and contact rates. Although we did not observe an association between household contact patterns and SARS-CoV-2 transmission, we generated SARS-CoV-2 transmission parameters and community and household contact data that can be used to parametrize infectious disease models for both SARS-CoV-2 and other pathogens to assist with forecasting and intervention assessments. The availability of robust data is important in the face of a pandemic where intervention strategies have to be adapted continuously.Item Implementation of universal health coverage in South Africa: formative effects, perceived quality of healthcare and modelling of health service utilisation indicators in a national health insurance pilot district(University of the Witwatersrand, Johannesburg, 2023-01) Mukudu, Hillary; Igumbor, Jude; Otwombe, Kennedy; Fusheini, AdamBackground: According to the World Health Organisation, member countries should attain universal health coverage by 2030. To achieve this goal, South Africa introduced the National Health Insurance programme in 2012. Since then, the first phase of the pilot programme has been implemented in Tshwane and ten other country districts. Historically, no other health system reform in South Africa has generated more interest than the National Health Insurance. This 15-year preliminary plan and pilot received optimism and criticism depending on several factors. The pilot programme focusing on primary health care was implemented along with several other interventions. The components of the intervention included setting up: ward-based primary healthcare outreach teams, integrated school health programmes, district clinical specialist teams, centralised chronic medicine dispensing and distribution programmes, health patient registration systems, stock visibility systems, and contracting of private non-specialised (general) medical practitioners to provide services in public primary health care facilities. These interventions were envisaged to improve healthcare quality at the primary healthcare level and offset the burden of non-emergency (secondary) care at the hospital outpatient level. However, studies have yet to be done to determine population-level formative effects on primary and non-emergency secondary healthcare indicators, their relationships, and interdependencies. These data are needed to forecast and develop measures to meet the possible increase in health service utilisation. In addition, this information is essential to guide the possible scale-up of South Africa's National Health Insurance mechanism. Such guidance may be in setting benchmarks to monitor policy implementation, determine facility staffing, the package of health services, training needs, budget for medicines and consumables, and other resource allocation. Aim: Therefore, this study first aimed to determine the formative effects of implementing the Medical Practitioners' contracting of the National Health Insurance pilot program on primary healthcare utilisation indicators measured at both primary and non-emergency secondary levels of care. A comparison was made between Tshwane national health insurance pilot district and Ekurhuleni district, which is not a pilot district. Furthermore, the study aimed to determine the relationships between healthcare utilisation indicators and their interdependencies and then provide a forecast for 2025. Methods: This quasi-experimental and ecological study used selected primary health care and outpatient department indicators in the District Health Information System monthly reports between January 2010 and December 2019 for the Tshwane district and Ekurhuleni district. Thus, to determine the formative effects on primary healthcare utilisation indicators, the selected period was from June 2010 to May 2014. A total of 48-time periods (months), with 24 before (June 2010 to May 2012) and 24 after (June 2012 to May 2014) implementation of Medical Practitioners contracting of the National Health Insurance pilot programme. Similarly, June 2012 to May 2014 was the selected period to determine the effects on the perceived quality of care. A total of 24 months, with 12 before (June 2012 to May 2013) and 12 after (June 2013 to May 2014) implementation of the Medical Practitioners' contracting of the National Health Insurance pilot programme. To determine the relationship and interdependence between Primary Health Care and Outpatient Department indicators and forecasts for 2025, 113 time periods (quarters) were selected. There were 28 quarters before and 84 quarters after implementing the National Health Insurance pilot programme. Similar methodological approaches were used to determine the effects of Medical Practitioners contracting in the National Health Insurance pilot programme on Primary Healthcare utilisation indicators and perceived healthcare quality. All study data types used in the thesis were continuous; thus, they were initially evaluated descriptively using means (standard deviations) and medians (interquartile ranges). The range was evaluated using minimum and maximum values. An Independent t-test assuming unequal variances was used to compare the means of Outpatient Department indicators in determining the effect of Medical Practitioners contracting in the National Health Insurance pilot programme on the perceived quality of healthcare. Single- and multiple-group (controlled) interrupted time series analysis was used to determine the effect of the National Health Insurance pilot project implementation on the utilisation of selected primary and non-emergency outpatient department indicators and perceived healthcare quality. A different methodological approach was used to determine the interdependencies and relationships between selected primary healthcare and non-emergency outpatient department indicators and their forecasts for 2025. Initially, data were evaluated descriptively using means (standard deviations) and medians (interquartile ranges) and the range was evaluated using minimum and maximum values. Prior to the development of the vector error correction model, several steps were taken. Firstly, a natural log transformation of all time series data was done to enhance additivity, linearity, and validity. Additionally, the level of lags at which variables were interconnected or endogenously obtained was determined due to the sensitivity of causality. Furthermore, the stationarity of time series data was determined using both graphical means and the Augmented Dick Fuller test to confirm the stability of each time series. Finally, cointegration was determined using the Johansen cointegration test to check for the correlation between two or more nonstationary series. After developing the Vector Error Correction Model, the Granger causality test was done to determine whether one series is helpful for forecasting another. Then the Vector Error Correction Model relationships between variables of selected primary healthcare and non-emergency outpatient department indicators were used to forecast the utilisation of both levels of services by 2025. Results: The findings showed changes in primary healthcare indicators measured at primary and non-emergency secondary levels before and after contracting private medical practitioners of the National Health Insurance pilot programme. The study also confirmed the influence of selected primary health care and outpatient department headcounts on each other by finding four cointegration relationships between the variables. There were differences between single-group and controlled interrupted time series analysis findings for Tshwane district and Ekurhuleni district considered independently and collectively on the utilisation of primary health care services. Thus, the positive impact observed in primary healthcare utilisation post-June 2012 is not attributable to the implementation of the Medical Practitioners' contracting of the National Health Insurance pilot programme. Conversely, there were similarities between single-group and controlled interrupted time series analysis findings for Tshwane district and Ekurhuleni district considered independently and collectively on the perceived quality of primary healthcare. In the interpretation of this finding, the similarities indicated that implementing the Medical Practitioners' contracting of the National Health Insurance pilot programme positively influenced the perception of a better quality of primary healthcare in the Tshwane district. Regarding primary healthcare indicators, there were differences between single-group and controlled interrupted time series analysis. Single-group interrupted time series analysis showed a 65% and 32% increase in the number of adults remaining on anti-retroviral therapy in Tshwane and Ekurhuleni districts, respectively (relative risk [RR]: 1.65; 95% confidence interval [CI]: 1.64–1.66; p < 0.0001 and RR: 1.32; 95% CI: 1.32–1.33; p < 0.0001, respectively). However, controlled interrupted time series analysis did not reveal any differences in any of the post-intervention parameters. Furthermore, single-group interrupted time series analysis showed a 2% and 6% increase in the number of clients seen by a professional nurse in the Tshwane and Ekurhuleni districts, respectively (RR: 1.02; 95% CI: 1.01–1.02; p < 0.0001 and RR: 1.06; 95% CI: 1.05–1.07; p < 0.0001, respectively). However, controlled interrupted time series analysis did not show any differences in any of the post-intervention parameters. In addition, single-group interrupted time series analysis revealed that there was a 2% decrease and 1% increase in the primary healthcare headcounts for clients aged ≥5 years in Tshwane and Ekurhuleni district (RR: 0.98; 95% CI: 0.97–0.98; p < 0.0001 and RR: 1.01; 95% CI: 1.01–1.02; p < 0.0001, respectively). Similarly, there was a 2% decrease and a 5% increase in the total primary healthcare headcounts in the Tshwane district and Ekurhuleni districts, respectively (RR: 0.98; 95% CI: 0.97–0.98; p < 0.001 and RR: 1.05; 95% CI: 1.04–1.06, p < 0.0001, respectively). However, controlled interrupted time-series analysis revealed no difference in all parameters before and after intervention in terms of total primary healthcare headcounts and primary healthcare headcounts for clients aged ≥5 years. Regarding secondary non-emergency outpatient department headcounts, single-group and controlled interrupted time series analyses revealed similar findings. Despite these similarities, single-group interrupted time series analysis showed a disparate increase in the outpatient department not referred headcounts, which were lower in the Tshwane district (3 387 [95%CI 901, 5 873] [p = 0.010]) than in Ekurhuleni district (5 399 [95% CI: 1 889, 8 909] [p = 0.004]). Conversely, while there was no change in outpatient department referred headcounts in the Tshwane district, there was an increase in headcounts in the Ekurhuleni district (21 010 [95% CI: 5 407, 36 611] [p = 0.011]). Regarding the outpatient department not referred rate, there was a decrease in the Tshwane district (-1.7 [95% CI: -2.1 to -1.2] [p < 0.0001]), but not in the Ekurhuleni district. Controlled interrupted time series analysis showed differences in headcounts for outpatient department follow-up (24 382 [95% CI: 14 643, 34 121] [p < 0.0001]), the outpatient department not referred (529 [95% CI: 29, 1 029 [p = 0.038]), and outpatient department not referred rate (-1.8 [95% CI: -2.2 to -1.1] [p < 0.0001]) between Tshwane the reference district and Ekurhuleni district. Four common long-run trends were found in the relationships and dependencies between primary healthcare indicators measured at the primary healthcare level and the non-emergency secondary level of care needed to forecast future utilisation. First, a 10% increase in outpatient departments not referred headcounts resulted in a 42% (95% CI: 28-56, p < 0.0001) increase in new primary healthcare diabetes mellitus clients, 231% (95% CI: 156-307, p < 0.0001) increase in primary healthcare clients seen by a public medical practitioner, 37% (95% CI: 28-46, p < 0.0001) increase in primary healthcare clients on ART, and 615% (95% CI: 486-742, p < 0.0001) increase in primary healthcare clients seen by a professional nurse. Second, a 10% increase in outpatient department referrals resulted in an 8% (95% CI: 3-12, p < 0.0001) increase in new primary healthcare diabetes mellitus clients, a 73% (95% CI: 51-95, p < 0.0001) increase in primary healthcare headcounts for clients seen by a medical professional, a 25% (95% CI: 23-28, p < 0.0001) increase in primary healthcare headcounts for clients on ART, and a 44% (95% CI: 4-71, p = 0.026) increase in primary healthcare headcounts for clients seen by a professional nurse. Third, a 10% increase in outpatient department follow-up headcounts resulted in a 12% (95% CI: 8-16, p < 0.0001) increase in primary healthcare headcounts for new diabetes mellitus, 67% (95% CI: 45-89, p < 0.0001) increase in primary healthcare headcounts for clients seen by public medical practitioners, 22% (95% CI: 19-24, p < 0.0001) increase in primary healthcare headcounts for clients on ART, and 155% (95% CI: 118-192, p < 0.0001) increase in primary healthcare headcounts for clients seen by a professional nurse. Fourth, a 10% increase in headcounts for total primary healthcare clients resulted in a 0.4% (95% CI: 0.1-0.8, p < 0.0001) decrease in primary healthcare headcounts for new diabetes clients. Based on these relationships and dependencies, the outpatient department follow-up headcounts would increase from 337 945 in the fourth quarter of 2019 to 534 412 (95% CI: 327 682–741 142) in the fourth quarter of 2025, while the total primary healthcare headcounts would only marginally decrease from 1 345 360 in the fourth quarter of 2019 to 1 166 619 (95% CI: 633 650–1 699 588) in the fourth quarter of 2025. Conclusion: The study findings suggested that improvements in primary health care indicators in National Health Insurance pilot districts could not be attributed to the implementation of contracting private medical practitioners but were likely a result of other co-interventions and transitions in the district. However, it might have resulted in an improved perception of quality of care at primary health care facilities, evidenced by a reduction in the self-referral rate for non-emergency hospital outpatient departments. The study also confirmed the influence of selected primary healthcare and non-emergency outpatient department headcounts on each other by finding four common long-run trends of relationships. Based on these relationships and trends, outpatient department follow-up headcounts are forecasted to increase by two-thirds. Conversely, the total headcount for primary healthcare clients seen by a professional nurse will marginally decrease. Recommendations: Based on the study findings, the bidirectional referral between primary and non-emergency secondary levels of care in the Tshwane district should be strengthened to offset the burden of care at outpatient departments of district hospitals. Thus, the district health information system should include a down-referral indicator to monitor this activity. With the implementation of National Health Insurance, there is a need to improve the perception of quality of care at the primary healthcare level through appropriate training, recruitment, and placement of medical practitioners. Similarly, professional nurses, the core providers of primary healthcare services, should be supported and capacitated in line with the epidemiological transition.