School of Public Health (Journal Articles)

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Adult mortality in sub-Saharan Africa using 2001—2009 census data: does estimation method matter?
(Springer Open, 2018-08) Odimegwu, Clifford; Chisumpa, Vesper H.; Somefun, Oluwaseyi Dolapo
Adult mortality is an important development and public health issue that continues to attract the attention of demographers and public health researchers. Controversies exist about the accurate level of adult mortality in sub-Saharan Africa (SSA), due to different data sources and errors in data collection. To address this shortcoming, methods have been developed to accurately estimate levels of adult mortality. Using three different methods (orphanhood, widowhood, and siblinghood) of indirect estimation and the direct siblinghood method of adult mortality, we examined the levels of adult mortality in 10 countries in SSA using 2001–2009 census and survey data. Results from the different methods vary. Estimates from the orphanhood data show that adult mortality rates for males are in decline in South Africa and West African countries, whilst there is an increase in adult mortality in the East African countries, for the period examined. The widowhood estimates were the lowest and reveal a marked increase in female adult mortality rates compared to male. A notable difference was observed in adult mortality estimates derived from the direct and indirect siblinghood methods. The method of estimation, therefore, matters in establishing the level of adult mortality in SSA.
Alcohol industry involvement in the delayed South Africa Draft Liquor Amendment Bill 2016: a case study based on freedom of information requests
(BioMed Central, 2025-03) Goldstein, Susan; Mitchell, Gemma; Siwela, Pfumelani; Diedericks, Aadielah Maker
Background South Africa is reported to have one of the highest per capita rates of alcohol consumption among drinkers globally, with alcohol harms exacerbating socio-economic inequalities in the country. The Draft Liquor Amendment Bill 2016 proposed new restrictions on alcohol advertising, availability, and liability of retailers and manufacturers for harm related to any contravention of the regulations. To date, the Bill has not progressed through the legislative process. The alcohol industry is known to use a diverse set of strategies to delay evidence-based policies globally. Methods We aimed to explore Bill-related activity by industry within the National Economic and Development Labour Council, a multi-stakeholder forum that assesses socio-economic policies before they reach parliament. On 06 July 2023 we made a Request for Access to Record, using form two of the Promotion of Access to Information Act (PAIA), no. 2 of 2000 to the National Economic and Development Labour Council for access to minutes of all meetings, reports, and any other publications related to the Bill between January 2016 and December 2022. Informed by Ulucanlar et al’s (2023) model and taxonomies of corporate political activity, we extracted data on industry Bill-related activity and thematically analysed key events, presented here as a narrative synthesis. Results We identified activity by 14 alcohol industry organisations related to the Bill between 2016 and 2022. Industry representation on five National Economic and Development Labour Council-related committees identified between 2017 and 2021 facilitated their involvement in Bill-related discussions and supported access to other government departments. Community representation was low in all committees compared to industry, labour, and government. Industry funded two socio-economic assessments of the Bill in 2017 and 2022, despite an independent socio-economic impact assessment having already been completed. The 2017 report delayed progress of the Bill, and the 2022 ‘re-evaluation’ was more critical of the proposed measures, with the differing conclusions attributed to different methodologies. During the covid-19 pandemic, industry used a ‘carrot and stick’ approach of legal threats and donations to attempt to move towards self-regulation via a social compact. The National Economic and Development Labour Council confirmed in 2023 that the social compact was unsuccessful. Conclusions Early ‘regulatory capture’ gave the alcohol industry the opportunity to shape assessment of the Bill within the National Economic and Development Labour Council. Our findings are in line with previous studies on corporate influence on policy globally, and support calls for a reassessment of the role and proportion of industry representation within the National Economic and Development Labour Council locally.
Alcohol use and optimal chronic diseases’ treatment outcomes among adults aged 40 years and above in rural South Africa
(Nature Research, 2025-03) Mupfuti, Rumbidzai; Kabudula, Chodziwadziwa. W.; Francis, Joel Msafiri
Chronic diseases are significant problems in South Africa. Chronic diseases’ treatment outcomes are critical to the reduction of morbidity and mortality. There is limited data in South Africa on alcohol use and treatment outcomes of chronic diseases in older people. Understanding the association between alcohol use and chronic diseases treatment outcomes would inform potential interventions to address the duo. We analysed data from wave 1 of the Health and Ageing in Africa-a longitudinal Study in an INDEPTH community (HAALSI) study. We performed descriptive analysis to determine the prevalence of optimal chronic diseases’ treatment outcomes (suppressed HIV viral load, normal blood pressure and normal blood sugar- euglycemia) and applied modified Poisson regression to determine the association between alcohol use and chronic diseases’ treatment outcomes. The prevalence of optimal treatment outcomes was 87.4% suppressed viral load for those living with HIV, 42.7% normal blood pressure for hypertensives, 53.6% with euglycemia among diabetics and 52.4% with normal outcome parameters among those with multimorbidity. Alcohol use did not negatively impact the optimal treatment outcomes for HIV (aRR = 1.00, 95%CI 0.93–1.09), hypertension (aRR = 0.88, 95%CI 0.68–1.14), diabetes mellitus (aRR = 0.73, 95%CI 0.44–1.22), and multimorbidity (aRR = 1.00, 95%CI 0.93–1.09). Alcohol use was not significantly associated with treatment outcomes possibly due to underreporting of alcohol use. There is need to incorporate objective alcohol measurements and alcohol interventions in chronic diseases care settings. Furthermore, there is urgent need to strengthen the management of hypertension and diabetes, by adopting the strategies deployed for HIV management.
Association between internal migration and epidemic dynamics: an analysis of cause-specific mortality in Kenya and South Africa using health and demographic surveillance data
(BioMed Central, 2018-07) Ginsburg, Carren; Bocquier, Philippe; Kahn, Kathleen; Collinson, Mark A.; Béguy, Donatien; Afolabi, Sulaimon; Obor, David; Tanser, Frank; Tomita, Andrew; Wamukoya, Marylene
Background: Many low- and middle-income countries are facing a double burden of disease with persisting high levels of infectious disease, and an increasing prevalence of non-communicable disease (NCD). Within these settings, complex processes and transitions concerning health and population are underway, altering population dynamics and patterns of disease. Understanding the mechanisms through which changing socioeconomic and environmental contexts may influence health is central to developing appropriate public health policy. Migration, which involves a change in environment and health exposure, is one such mechanism. Methods: This study uses Competing Risk Models to examine the relationship between internal migration and premature mortality from AIDS/TB and NCDs. The analysis employs 9 to 14 years of longitudinal data from four Health and Demographic Surveillance Systems (HDSS) of the INDEPTH Network located in Kenya and South Africa (populations ranging from 71 to 223 thousand). The study tests whether the mortality of migrants converges to that of non-migrants over the period of observation, controlling for age, sex and education level. Results: In all four HDSS, AIDS/TB has a strong influence on overall deaths. However, in all sites the probability of premature death (45q15) due to AIDS/TB is declining in recent periods, having exceeded 0.39 in the South African sites and 0.18 in the Kenyan sites in earlier years. In general, the migration effect presents similar patterns in relation to both AIDS/TB and NCD mortality, and shows a migrant mortality disadvantage with no convergence between migrants and non-migrants over the period of observation. Return migrants to the Agincourt HDSS (South Africa) are on average four times more likely to die of AIDS/TB or NCDs than are non-migrants. In the Africa Health Research Institute (South Africa) female return migrants have approximately twice the risk of dying from AIDS/TB from the year 2004 onwards, while there is a divergence to higher AIDS/TB mortality risk amongst female migrants to the Nairobi HDSS from 2010. Conclusion: Results suggest that structural socioeconomic issues, rather than epidemic dynamics are likely to be associated with differences in mortality risk by migrant status. Interventions aimed at improving recent migrant’s access to treatment may mitigate risk.
Comparable safety and non‑inferior immunogenicity of the SARS‑CoV‑2 mRNA vaccine candidate PTX‑COVID19‑B and BNT162b2 in a phase 2 randomized, observer‑blinded study
(Nature Research, 2024) Madhi, Shabir A.; Tran, Richard; Martin‑Orozco, Natalia; Panicker, Rajesh Krishnan Gopalakrishna; Pastrak, Aleksandra; Reiter, Lawrence; Grefrath, Johann; Zidel, Bian; Ostrowski, Mario; Gommerman, Jennifer; Cooper, Curtis
In the aftermath of the COVID-19 pandemic, the evolution of the SARS-CoV-2 into a seasonal pathogen along with the emergence of new variants, underscores the need for dynamic and adaptable responses, emphasizing the importance of sustained vaccination strategies. This observer-blind, double-dummy, randomized immunobridging phase 2 study (NCT05175742) aimed to compare the immunogenicity induced by two doses of 40 μg PTX-COVID19-B vaccine candidate administered 28 days apart, with the response induced by two doses of 30 µg Pfzer-BioNTech COVID-19 vaccine (BNT162b2), administered 21 days apart, in Nucleocapsid-protein seronegative adults 18–64 years of age. Both vaccines were administrated via intramuscular injection in the deltoid muscle. Two weeks after the second dose, the neutralizing antibody (NAb) geometric mean titer ratio and seroconversion rate met the non-inferiority criteria, successfully achieving the primary immunogenicity endpoints of the study. PTX-COVID19-B demonstrated similar safety and tolerability profle to BNT162b2 vaccine. The lowest NAb response was observed in subjects with low-to-undetectable NAb at baseline or no reported breakthrough infection. Conversely, participants who experienced breakthrough infections during the study exhibited higher NAb titers. This study also shows induction of cell-mediated immune (CMI) responses by PTX-COVID19-B. In conclusion, the vaccine candidate PTX-COVID19-B demonstrated favourable safety profle along with immunogenicity similar to the active comparator BNT162b2 vaccine.
Current evidence on improving influenza vaccine uptake in low- and middle-income countries: a scoping review of determinants and interventions
(Elsevier, 2025-03) Tsotetsi, Lerato; Msibi, Tshepiso; Mashamba, Mulalo; Dietrich, Janan; Alam, Prima
Influenza is a vaccine-preventable disease affecting three to five million individuals across the globe annually. Low- and middle-income countries (LMICs) bear substantial health and economic consequences of influenza- related mortality. Despite this disproportionate burden, influenza vaccinations are seldom used across LMICs. In this article, we reviewed current evidence on improving influenza vaccine uptake within LMICs by examining key determinants and interventions. We conducted a scoping review of peer-reviewed studies pertaining to influenza vaccine uptake in LMICs. We searched five electronic databases for articles published 2014–2024, using terms relating to influenza vaccines, interventions, and context. Twenty-four articles met the inclusion criteria with sample sizes ranging from 38 to 9420. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines and synthesized the included articles using thematic analysis. All studies included in this review were cross-sectional and primarily used quantitative surveys. Most of the included studies were conducted in Sub-Saharan Africa (South Africa, Kenya, Malawi, and Sierra Leone) and the Middle East and North Africa (Tunisia, Jordan, Lebanon, and Egypt). Articles predominantly targeted vulnerable populations including elderly, pregnant women, and young children as well as healthcare workers. Participants across the included studies reported high levels of willingness to receive the influenza vaccination but lower levels of uptake. Having positive perceptions and attitudes towards the efficacy and safety of the vaccine, greater belief in disease susceptibility, physician recommendations, and a history of being vaccinated were associated with greater willingness to receive the influenza vaccine. Six articles explored national campaigns or researcher- led interventions to improve influenza vaccine uptake with educational campaigns positively changing attitudes towards influenza vaccination and integration of year-round vaccination campaigns with routine services as an effective vaccine delivery method.
Factors influencing access of pregnant women and their infants to their local healthcare system: a prospective, multicentre, observational study
(BMC, 2018) Madhi, Shabir A.; Rivera, Luis M.; Sáez-Llorens, Xavier; Menéndez, Clara; Carrim-Ganey, Nazira; Cotton, Mark F.; Katzman, Darren; Luttig, Mariëtha M.; Candelario, Rosalba; Baker, Sherryl; Roychoudhury, Mahua
Background: The successful implementation of maternal vaccination relies on results of clinical trials, considering the prenatal and postnatal attendance at selected healthcare institutions. This study evaluated factors influencing maternal/infant access to healthcare facilities to identify potential barriers to participation in future clinical trials on maternal vaccination. Methods: In this prospective, multi-centre, observational study, pregnant women (N = 3243) were enrolled at ten sites across Panama, the Dominican Republic, South Africa, and Mozambique between 2012 and 2014. They completed questionnaires at enrolment, delivery, and infant follow-up (90 days post-partum) visits, including questions on transportation, phone accessibility, alternative childcare, gestational age at enrolment, delivery location, and health status of their infant. Logistic regression was used to identify factors significantly associated with return to study site for delivery or infant follow-up visits. Results: Among 3229 enrolled women with delivery information, 63.6% (range across sites: 25.3–91.5%) returned to study site for delivery. Older women and those at later gestational age at enrolment were more likely to deliver at the study site. While heterogeneities were observed at site level, shorter travel time at delivery and increased transportation costs at enrolment were associated with increased likelihood of women returning to study site for delivery. Among 3145 women with live-born infants, 3077 (95.3%) provided 90-day follow-up information; of these, 68.9% (range across sites: 25.6–98.9%) returned to study site for follow-up visits. Women with other children and with lower transportation costs at delivery were more likely to return to study site for follow-up visits. Among 666 infants reported sick, 94.3% were taken to a healthcare facility, with only 41.9% (range across sites: 4.9–77.3%) to the study site. Conclusion: Although high retention was observed from enrolment through 90 days after delivery, post-partum surveillance should be broadened beyond the study sites and additional follow-up visits should be planned within the neonatal period. The factors influencing maternal/infant access to healthcare facilities and the issues identified in this study should be taken into consideration in planning future clinical studies on maternal immunisation in low- and middle-income countries.
Frontline health workers and exclusive breastfeeding guidelines in an HIV endemic South African community: a qualitative exploration of policy translation
(BioMed Central, 2018-06) Nieuwoudt, Sara; Manderson, Lenore
Background: Mothers rely heavily on health worker advice to make infant feeding decisions. Confusing or misleading advice can lead to suboptimal feeding practices. From 2001, HIV positive mothers in South Africa were counseled to choose either exclusive breastfeeding or exclusive formula feeding to minimize vertical HIV transmission. On the basis of revised World Health Organization guidelines, the government amended this policy in 2011, by promoting exclusive breastfeeding and discontinuing the provision of free formula. We explored how health workers experienced this new policy in an HIV endemic community in 2015–16, with attention to their knowledge of the policy, counselling practices, and observations of any changes. Methods: We interviewed eleven health workers, from four community health clinics, who had counseled mothers before and after the policy change. The transcribed interviews were analyzed thematically, using a hybrid coding approach. Results: The scientific rationale of the policy was not explained to most health workers, who mostly thought that the discontinuation of the formula program was cost-related. The content of their counseling reflected knowledge about promoting breastfeeding for all women, and accordingly they mentioned the nutritional and developmental benefits of breastfeeding. The importance of exclusive breastfeeding for all infants was not emphasized, instead counseling focused on HIV prevention, even for uninfected mothers. The health workers noted an increased incidence of breastfeeding, but some worried that to avoid HIV disclosure, HIV positive mothers were mixed feeding rather than exclusively breastfeeding. Conclusions: Causal links between the policy, counseling content and feeding practices were unclear. Some participants believed that breastfeeding practices were driven by finance or family pressures rather than the health information they provided. Health workers generally lacked training on the policy’s evidence base, particularly the health benefits of exclusive breastfeeding for non-exposed infants. They wanted clarity on their counseling role, based on individual risk or to promote exclusive breastfeeding as a single option. If the latter, they needed training on how to assist mothers with community-based barriers. Infant feeding messages from health workers are likely to remain confusing until their uncertainties are addressed. Their insights should inform future guideline development as key actors.
Genetic therapies for movement disorders ‑ current status
(Springer, 2025-02) Waddington, S. N.; Sartorelli, J.; Ng, J.; Rahim, A. A.; Kurian, M. A.
Movement disorders are a group of heterogeneous neurological conditions associated with alterations of tone, posture and voluntary movement. They may either occur in isolation or as part of a multisystemic condition. More recently, the advent of next generation sequencing technologies has facilitated better understanding of the underlying causative genes and molecular pathways, thereby identifying targets for genetic therapy. In this review, we summarize the advances in genetic therapy approaches for both hyperkinetic and hypokinetic movement disorders, including Parkinson’s Disease, Huntington’s Disease and rarer monogenic conditions of childhood onset. While there have been significant advances in the field, multiple challenges remain, related to safety, toxicity, efficacy and brain biodistribution, which will need to be addressed by the next generation of genetic therapies.
Group-based trajectory modeling to describe the geographical distribution of tuberculosis notifcations
(Springer Nature, 2025-02) Martinson, Neil A.; Lebina, Limakatso; Dagnew, Alemnew F.; Hanrahan, Colleen F.; Dowdy, David W.; Nonyane, Bareng A. S.
Background Tuberculosis (TB) is a major public health problem, and understanding the geographic distribution of the disease is critical in planning and evaluating intervention strategies. This manuscript illustrates the application of Group-Based Trajectory Modeling (GBTM), a statistical method that analyzes the evolution of an outcome over time to identify groups with similar trajectories. Specifically, we apply GBTM to identify the evolution of the number of TB notifications over time across various geographic locations, aiming to identify groups of locations with similar trajectories. Locations sharing the same trajectory may be considered geographic TB clusters, indicating areas with similar TB notifications. We used data abstracted from clinic records in Limpopo province, South Africa, treating the clinics as a proxy for the spatial location of their respective catchment areas. Methods Data for this analysis were obtained as part of a cluster-randomized trial involving 56 clinics to evaluate two active TB patient-funding strategies in South Africa. We utilized GBTM to identify groups of clinics with similar trajectories of the number of TB patients. Results We identified three trajectory groups: Groups 1, comprising 57.8% of clinics; Group 2, 33.9%; and Group 3, 8.3%. These groups accounted for 30.8%, 44.4%, and 24.8% of total TB-diagnosed patients, respectively. The estimated mean number of TB-diagnosed patients was highest in trajectory group 3 followed by trajectory group 2 across the 12 months, with no overlap in the corresponding 95% confidence intervals. The estimated mean number of TB-diagnosed patients over time was fairly constant for trajectory groups 1 and 2 with exponentiated slopes of 0.979 (95% CI: 0.950, 1.004) and 1.004 (95% CI: 0.977, 1.044), respectively. In contrast, there was a statistically significant 3.8% decrease in the number of TB patients per month for trajectory group 3 with an exponentiated slope of 0.962 (95% CI: 0.901, 0.985) per month. Conclusions GBTM is a powerful tool for identifying geographic clusters of varying levels of TB notification when longitudinal data on the number of TB diagnoses are available. This analysis can inform the planning and evaluation of intervention strategies.
HIV testing and counselling experiences: a qualitative study of older adults living with HIV in western Kenya
(BioMed Central, 2018-10) Kiplagat, Jepchirchir; Huschke, Susann
Background: Finding HIV infected persons and engaging them in care is crucial in achieving UNAIDS 90–90-90 targets; diagnosing 90% of those infected with HIV, initiating 90% of the diagnosed on ART and achieving viral suppression in 90% of those on ART. To achieve the first target, no person should be left behind in their access to HIV testing services. In Kenya, HIV prevention and testing services give less emphasis on older adults. This article describes HIV testing experiences of older adults living with HIV and how their age shaped their interaction and treatment received during HIV testing and diagnosis. Methods: We conducted a qualitative study in two HIV clinics (rural and urban) in western Kenya, and recruited 57 HIV infected persons aged ≥50 years. We conducted in depth interviews (IDIs) with 25 participants and 4 focus group discussions (FGDs) with a total of 32 participants and audio recorded all the sessions. Participants recruited were aged between 54 and 79 years with 43% being females. We transcribed audio records and analyzed the data using thematic content analysis method. Results: Older persons’ experiences with HIV testing depended on where they tested (hospital or community setting); whether they actively sought the testing or not; and the age and gender of the healthcare provider who conducted the test. Participants expressed concerns with ageist discrimination when actively seeking HIV care testing services in hospital settings, characterized by providers’ reluctance or refusal to test. The testing and counseling sessions were described as short and hurried within the hospital settings, whereas the interactions with service providers in home-based testing were experienced as appropriate and supportive. Participants in this study expressed preference for healthcare providers who were older and of similar gender. Conclusion: HIV testing services are still not tailored to target older adults’ needs in our setting resulting in late diagnosis among older persons. We argue that a scale-up of community level testing services that provide adequate testing and counselling time and actively reach out to older adults is key to attaining the UNAIDS targets of having 90% of PLWH know their status.
Impact of witnessing abuse of their mother and childhood trauma on men’s perpetration of intimate partner violence in the cross-sectional UN multi-country study on men and violence in Asia and the Pacific
(Elsevier, 2025-01) Jewkes, Rachel; Shai, Nwabisa; Chirwa, Esnat; Naved, Ruchira Tabassum; Abrahams, Naeema; Ramsoomar, Leane; Dekel, Bianca; Gibbs, Andrew; Nothling, Jani; Willan, Samantha
Trauma exposure and witnessing intimate partner violence (IPV) in childhood are recognised risk factors for IPV. Using the UN Multi-country Study on Men and Violence in Asia and the Pacific dataset, we describe the pathways through which they influence adult IPV perpetration. Methods: In nine sites, from six countries, data were collected in a two-stage, randomly-selected household survey, with one man aged 18–49 years interviewed per house. 8379 interviews were completed with ever partnered men in Bangladesh, Cambodia, China, Indonesia, Papua New Guinea (Bougainville) and Sri Lanka. We present a Structural Equation Model (SEM) to understand paths through which childhood trauma and witnessing IPV impacted perpetration of physical or sexual IPV in adulthood. Results: Among the men, 25.5% had witnessed IPV, 47.0% had perpetrated physical or sexual IPV. Both wit nessing IPV and childhood trauma elevated the likelihood of such perpetration. The SEM showed four paths from witnessing IPV and childhood trauma to the latent variable for physical/sexual IPV perpetration. One was direct and three indirect. Paths were mediated by food insecurity, depression, and a latent variable measuring gender inequitable and anti-social masculinities. The masculinity variable indicators were drug use, harmful alcohol use, bullying, gang membership, fighting with other men, having sex with a sex worker and having raped a non partner. The direct and indirect effects showed both childhood trauma and witnessing maternal IPV to be important, but childhood trauma the more so. Conclusions: Both childhood trauma and witnessing IPV were important in driving IPV perpetration, with in dependent effects, however, broader childhood trauma exposure was most strongly associated. The effects were mediated by food insecurity, depression and gender inequitable and anti-social masculinities, all recognised risk factors for IPV perpetration. Thus, gender transformative IPV prevention interventions that include mental health and economic elements can mitigate the influence of these key exposures.
Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system
(2018-08) Oboirien, Kafayat; Harris, Bronwyn; Goudge, Jane; Eyles, John
Background: Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role. Methods: Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts. Results: We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors’ expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery. Conclusion: Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.
Oppression, liberation, wellbeing, and ecology: organizing metaphors for understanding health workforce migration and other social determinants of health
(BioMed Central, 2018-08) Tankwanchi, Akhenaten Benjamin Siankam
Background: The Commission on Social Determinants of Health (CSDH) identifies the maldistribution of power, money, and resources as main drivers of health inequities. The CSDH further observes that tackling these drivers effectively requires interventions to focus at local, national, and global levels. Consistent with the CSDH’s observation, this paper describes the eco-psychopolitical validity (EPV) paradigm, a multilevel and transdisciplinary model for research and action, thus far insufficiently tapped, but with the potential to systematize the exploration of the social determinants of health. Results: Using the physician migration from Sub-Saharan Africa (SSA) to the United States as illustration, this paper articulates how the EPV model can be applied to the systematic analysis of a complex social problem with health inequity implications. To help explore potential determinants of physician migration, a comprehensive coding matrix is developed; with the organizing metaphors of the EPV model–namely oppression, liberation, and wellbeing–serving as analytical categories. Through the lens of the EPV model, migrating physicians are revealed as both ecological subjects enmeshed in a vast web of transnational processes linking source and destination countries, and potential change agents pursuing liberation and wellbeing. While migration may expand the opportunities of émigré physicians, it is argued that, the pursuit of wellbeing by way of migration cannot fully materialize abroad without some efforts to return home, physically or socially. Conclusion: Clarifying the relationship between various social determinants of health and health inequities at different levels of analysis is a more complex but essential endeavor to knowledge generation than using a one-dimensional frame. With its roots in interdisciplinary thinking and its emphasis on both individual and contextual factors, the EPV paradigm holds promise as a model for examining the social determinants of health.
Perceptions of counsellors and youth-serving professionals about sexual and reproductive health services for adolescents in Soweto, South Africa
(BMC, 2018-02) Mulaudzi, Mamakiri; Dlamini, Busisiwe Nkala; Coetzee, Jenny; Sikkema, Kathleen; Gray, Glenda; Dietrich, Jana Janine
Background: Adolescents in South Africa remain vulnerable to HIV. Therefore, it is crucial to provide accessible adolescent-friendly HIV prevention interventions that are sensitive to their needs. This study aimed to investigate the perceptions of HIV counsellors and other youth-serving professionals about the barriers to providing adolescent youth-friendly sexual and reproductive health services to adolescents in Soweto, South Africa. The study also explored how sexual and reproductive health services in South Africa could be improved to become more accessible to adolescents. Methods: The research team conducted two focus group discussions with HIV counsellors, and 19 semi-structured interviews with youth-serving professionals from organisations working with adolescents. Audio-recorded data were transcribed verbatim and analysed using thematic analysis. Results: The results of the study reveal that counsellors were expected to give adolescents HIV counselling and testing (HCT) but felt restricted by what they perceived as inflexible standard operating procedures. Counsellors reported inadequate training to address adolescent psychosocial issues during HCT. Healthcare provider attitudes were perceived as a barrier to adolescents using sexual and reproductive health services. Participants strongly recommended augmenting adolescent sexual and reproductive health services to include counsellors and adolescents in developing age- and context-specific HIV prevention services for adolescents. Conclusion: Continuous upskilling of HIV counsellors is a critical step in providing adolescent-friendly services.
Performance management in times of change: experiences of implementing a performance assessment system in a district in South Africa
(BioMed Central, 2018-09) Nxumalo, Nonhlanhla; Goudge, Jane; Eyles, John; Gilson, Lucy
Background: Health systems globally are under pressure to ensure value for money, and the people working within the system determine the extent and nature of health services provided. A performance assessment (PA); an important component of a performance management system (PMS) is deemed important at improving the performance of human resources for health. An effective PA motivates and improves staff engagement in their work. The aim of this paper is to describe the experiences of implementing a PA practice at a district in South Africa. It highlights factors that undermine the intention of the process and reflects on factors that can enable implementation to improve the staff performance for an effective and efficient district health service. Methods: Data was collected through in-depth interviews, observations and reflective engagements with managers at a district in one of the Provinces in South Africa. The study examined the managers’ experiences of implementing the PA at the district level. Results: Findings illuminate that a range of factors influence the implementation of the PA system. Most of it is attributed to context and organizational culture including management and leadership capacity. The dominance of autocratic approaches influence management and supervision of front-line managers. Management and leadership capacity is constrained by factors such as insufficient management skills due to lack of training. The established practice of recruiting from local communities facilitates patronage - compromising supervisor-subordinate relationships. In addition, organizational constraints and the constant policy changes and demands have compromised the implementation of the overall Performance Management and Development System (PMDS) – indirectly affecting the assessment component. Conclusion: To strengthen district health services, there should be improvement of processes that enhance the performance of the health system. Implementation of the PA system relies on the extent of management skills at the local level. There is a need to develop managers who have the ability to manage in a transforming and complex environment. This means developing both hard skills such as planning, co-ordination and monitoring and soft skills where one is able to focus on relationships and communication, therefore allowing collaborative and shared management as opposed to authoritarian approaches.
Prevalence and factors associated with caesarean section among Tanzanian women of reproductive age: evidence from the 2022 Tanzania demographic and health survey data
(BioMed Central, 2025-02) Olorunfemi, Gbenga; Nahayo, Bonfils; Ndayishimye, Samuel; Nsanzabera, Charles
Background: Caesarean Section (CS) is one of the commonest surgical procedures worldwide. It is an important medical intervention for reducing the risk of poor perinatal outcomes. However, there was increased trends in CS in sub-Saharan Africa as maternal and neonatal mortality and morbidity remains high. This study aims to determine the prevalence and factors associated with CS rates in Tanzania. Methodology: This was a secondary data analysis of 4,768 women of reproductive age (15–49) in Tanzania. The data utilized was from the Tanzania Demographic Health and Survey (TDHS) 2022. The factors associated with CS were identified using multivariable binary logistic regression. Results: Out of 4,768 women of reproductive age in Tanzania, 497 (10.4%) had CS. Attaining primary (Adjusted Odds Ratio (aOR): 1.79,95% CI 1.23–2.60), secondary (aOR:2.07,95% CI 1.36–3.14) and higher education (aOR: 2.35, 95% CI 1.08–5.12); having a husband/partner with higher education; being in richest household wealth quintile (aOR:1.98,95% CI (1.31-3.00), having a job (aOR:1.29, 95% CI: 1.05–1.58 and having attended more than 4 antenatal care (ANC) visits (aOR: 1.36, 95% CI: 1.11–1.67) were associated with a higher odds of undergoing CS compared to their respective counterparts. However, living in rural areas (aOR: 0.74, 95% CI:0.58–0.94), being multiparous women with 2–4 births (aOR: 0.67, 95% CI: 0.53–0.84) and 5 or more births (aOR: 0.44, 95% CI: 0.32–0.60) were associated with lower odds of CS. Conclusion: The overall prevalence of CS among women of reproductive age in Tanzania was 10.4%. The highest educational level, husband/partner’s educational attainment, household wealth quintile, type of residence, employment status, increased ANC number, and high parity were associated with CS. The CS prevalence is at the lower limit of the recommendation of the World Health Organisation of 10–15%. Further researches are necessary to highlight other barriers, facilitators and outcome of CSs in Tanzania to advise policy stakeholders.
Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda
(BioMed Central, 2018-07) Mayora, Chrispus; Kandala, Ngianga-Bakwin; Kitutu, Freddy Eric; Ekirapa-Kiracho, Elizabeth; Peterson, Stefan Swartling; Wamani, Henry
Background: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. Methods: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. Results: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients’ finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. Conclusion: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.
Reagent‑free detection of Plasmodium falciparum malaria infections in feld‑collected mosquitoes using mid‑infrared spectroscopy and machine learning
(Nature Research, 2024) Okumu, Fredos O.; Mwanga, Emmanuel P.; Kweyamba, Prisca A.; Siria, Doreen J.; Mshani, Issa H.; Mchola, Idrisa S.; Makala, Faraja E.; Seleman, Godian; Abbasi, Said; Mwinyi, Sophia H.; González‑Jiménez, Mario; Waynne, Klaas; Baldini, Francesco; Babayan, Simon A.
Field-derived metrics are critical for efective control of malaria, particularly in sub-Saharan Africa where the disease kills over half a million people yearly. One key metric is entomological inoculation rate, a direct measure of transmission intensities, computed as a product of human biting rates and prevalence of Plasmodium sporozoites in mosquitoes. Unfortunately, current methods for identifying infectious mosquitoes are laborious, time consuming, and may require expensive reagents that are not always readily available. Here, we demonstrate the frst feld-application of mid-infrared spectroscopy and machine learning (MIRS-ML) to swiftly and accurately detect Plasmodium falciparum sporozoites in wild-caught Anopheles funestus, a major Afro-tropical malaria vector, without requiring any laboratory reagents. We collected 7178 female An. funestus from rural Tanzanian households using CDC-light traps, then desiccated and scanned their heads and thoraces using an FT-IR spectrometer. The porozoite infections were confrmed using enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR), to establish references for training supervised algorithms. The XGBoost model was used to detect sporozoite-infectious specimen, accurately predicting ELISA and PCR outcomes with 92% and 93% accuracies respectively. These fndings suggest that MIRS-ML can rapidly detect P. falciparum in feld-collected mosquitoes, with potential for enhancing surveillance in malaria-endemic regions. The technique is both fast, scanning 60–100 mosquitoes per hour, and cost-efcient, requiring no biochemical reactions and therefore no reagents. Given its previously proven capability in monitoring key entomological indicators like mosquito age, human blood index, and identities of vector species, we conclude that MIRS-ML could constitute a low-cost multi-functional toolkit for monitoring malaria risk and evaluating interventions.
Refusal of male partner responsibility and pregnancy support: prevalence, associated factors and health outcomes in a cross sectional study in Harare, Zimbabwe
(BioMed Central, 2025-03) Shamu, Simukai; Machisa, Mercilene Tanyaradzwa; Shamu, Patience
Background The phenomenon of fathers refusing responsibility during pregnancy has not received adequate attention in African studies. This paper assesses associated factors and pregnancy-related outcomes when fathers refuse to support partners’ pregnancies and undertake parental responsibilities. Methods A cross-sectional survey of 15–49-year-old postnatal (1–6 weeks) women was conducted at six urban health facilities in Harare. Participants were interviewed about their male partners’ refusal to support their pregnancies and parenting, bride price payments (indicating marriage commitment), partner violence and control, alcohol abuse and family planning decision-making. Pregnancy health outcome data including antenatal care attendance, low birth weight (LBW)(<2500 g) and postnatal depression were collected through interviews and clinic records. Multiple regression models were built to assess gender-related factors and health outcomes associated with male partners’ refusal of parenting responsibilities. Results Of the 2042 women interviewed, 6.4% reported partner refusal to support the pregnancy or parenting. Higher odds of partner refusal of fathering responsibility were associated with partners not paying bride price (aOR 9.31; 95% CI 1.16–74.59), violence perpetration during pregnancy (aOR 2.84; 1.28–6.23), highly controlling behaviours (aOR 4.96; 2.83–8.69), alcohol abuse (aOR 1.78; 1.05–3.02), unintended pregnancy (aOR 3.72; 1.84–7.53) and partner refusal to use contraceptives (aOR 3.64; 1.86–7.14). Women who used contraceptives (aOR 0.40; 0.23–0.71), made joint (aOR 0.30; 0.14–0.67) or individual (aOR 0.25; 0.07–0.94) pregnancy decisions were protected from partner refusal of parenting responsibility. Women’s depressive symptomatology (aOR2.64; 1.52–4.59), LBW (aOR5.30; 1.18–23.74) and partner discouragement of antenatal care attendance (aOR 3.86; 1.13–13.17) were pregnancy outcomes associated with partner refusal of parenting responsibility. Conclusions Male partners’ refusal to acknowledge parenting responsibility was associated with men’s abusiveness, absence of commitment to long-term relationship/marriage, gender unequal practices and negative maternal and child health outcomes. Parenting programmes must be instituted and prioritise transforming traditional gender norms to improve fathering responsibilities.