School of Public Health

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Author: search.filters.author.Rhian TwineHas files: Yes

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    CHAT SA: Modification of a Public Engagement Tool for Priority Setting for a South African Rural Context
    (2022-02-01) Aviva Tugendhaft; Marion Danis; Nicola Christofides; Kathleen Kahn; Agnes Erzse; Marthe Gold; Rhian Twine; Audrey Khosa; Karen Hofman1
    Background: Globally, as countries move towards universal health coverage (UHC), public participation in decision making is particularly valuable to inform difficult decisions about priority setting and resource allocation. In South Africa (SA), which is moving towards UHC, public participation in decision-making is entrenched in policy documents yet practical applications are lacking. Engagement methods that are deliberative could be useful in ensuring the public participates in the priority setting process that is evidence-based, ethical, legitimate, sustainable and inclusive. Methods modified for the country context may be more relevant and effective. To prepare for such a deliberative process in SA, we aimed to modify a specific deliberative engagement tool - the CHAT (Choosing All Together) tool for use in a rural setting. Methods: Desktop review of published literature and policy documents, as well as 3 focus groups and modified Delphi method were conducted to identify health topics/issues and related interventions appropriate for a rural setting in SA. Our approach involved a high degree of community and policy-maker/expert participation. Qualitative data were analysed thematically. Cost information was drawn from various national sources and an existing actuarial model used in previous CHAT exercises was employed to create the board. Results: Based on the outcomes, 7 health topics/issues and related interventions specific for a rural context were identified and costed for inclusion. These include maternal, new-born and reproductive health; child health; woman and child abuse; HIV/AIDS and tuberculosis (TB); lifestyle diseases; access; and malaria. There were variations in priorities between the 3 stakeholder groups, with community-based groups emphasizing issues of access. Violence against women and children and malaria were considered important in the rural context. Conclusion: The CHAT SA board reflects health topics/issues specific for a rural setting in SA and demonstrates some of the context-specific coverage decisions that will need to be made. Methodologies that include participatory principles are useful for the modification of engagement tools like CHAT and can be applied in different country contexts in order to ensure these tools are relevant and acceptable. This could in turn impact the success of the implementation, ultimately ensuring more effective priority setting approaches.
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    Short- and long-read metagenomics of urban and rural South African gut microbiomes reveal a transitional composition and undescribed taxa
    (2022-02-22) Fiona B Tamburini; Dylan Maghini; Ovokeraye H Oduaran; Ryan Brewster; Michaella R Hulley; Venesa Sahibdeen; Shane A Norris; Stephen Tollman; Kathleen Kahn; Ryan G Wagner; Alisha N Wade; Floidy Wafawanaka; F Xavier Gómez-Olivé; Rhian Twine; Zané Lombard; H3Africa AWI-Gen Collaborative Centre; Scott Hazelhurst; Ami S Bhatt
    Human gut microbiome research focuses on populations living in high-income countries and to a lesser extent, non-urban agriculturalist and hunter-gatherer societies. The scarcity of research between these extremes limits our understanding of how the gut microbiota relates to health and disease in the majority of the world's population. Here, we evaluate gut microbiome composition in transitioning South African populations using short- and long-read sequencing. We analyze stool from adult females living in rural Bushbuckridge (n = 118) or urban Soweto (n = 51) and find that these microbiomes are taxonomically intermediate between those of individuals living in high-income countries and traditional communities. We demonstrate that reference collections are incomplete for characterizing microbiomes of individuals living outside high-income countries, yielding artificially low beta diversity measurements, and generate complete genomes of undescribed taxa, including Treponema, Lentisphaerae, and Succinatimonas. Our results suggest that the gut microbiome of South Africans does not conform to a simple "western-nonwestern" axis and contains undescribed microbial diversity.
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    The impact of conditional cash transfers for HIV prevention on peer relationships: perspectives from female recipients and non‑recipients in HPTN 068
    (2022) Makhosazane Nomhle Ndimande‑Khoza; Fiona Scorgie; Sinead Delany‑Moretlwe; Amanda Selin; Rhian Twine; Kathleen Kahn; Audrey Pettifor; Catherine MacPhail
    CCTs are currently being explored for HIV prevention among adolescent girls and young women (AGYW) in South‑ ern Africa. However, little is known about how CCT geared towards adolescents’ infuence peer relationships, despite evidence that peer relationships form a critical part of development in adolescence. This article presents fndings from a qualitative study that explored CCT recipients’ and non-recipients’ perspectives on the impact of CCTs paid to AGYW on peer relationships. HPTN 068 was a randomised controlled trial that assessed whether providing CCT to AGYW and their households reduces AGYW’s risk of acquiring HIV. As part of this trial, we conducted interviews and focus group discussions with sub-samples of AGYW (n=39), who were both cash recipients and non-recipients. Through content analysis, we explored ways in which the CCT positively or negatively impacted on peer relationships. From the recipients’ viewpoint, the CCT improved their social standing within their peer groups. It facilitated peer identity and promoted social connectedness among AGYW receiving the CCT. Receipt of the CCT enabled AGYW to resemble and behave like their peers who had money, allowing their poverty to become “invisible”. The CCT facilitated social interactions, information sharing, and instrumental social support among AGYW. CCT recipients experienced an increase in their social capital, evident in their ability to network, share, and reciprocate with others. However, the CCT also evoked negative emotions such as jealousy, anxiety, and resentment among non-recipients and led to a deterio‑ ration of personal relationships. CCTs have enormous benefts for AGYW, but they may also have a negative impact on peer relationships. The imple‑ mentation of HIV prevention interventions focused on structural drivers needs to be conscious of these dynamics and ensure that the negative consequences do not outweigh benefts.
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    Emotional Violence is Associated with Increased HIV Risk Behavior Among South African Adolescent Girls and Young Women in the HPTN 068 Cohort
    (2021-11-06) Anna M. Leddy; Amanda Selin; Sheri A. Lippman; Linda J. Kimaru; Rhian Twine; Xavier Gómez‑Olivé; Kathleen Kahn; Audrey Pettifor
    Limited research has explored how emotional intimate partner violence (IPV) shapes HIV risk behaviors. Using crosssectional data from the HPTN 068 post-trial visit (N=1942), we assessed the association between emotional IPV and its sub-domains (verbal abuse and threats) with condomless sex, transactional sex, and frequent alcohol use among young women in South Africa. In adjusted multivariable logistic regression models, any emotional IPV and verbal IPV were associated with increased odds of condomless sex (aOR: 1.47; 95% CI: 1.15, 1.87; and aOR: 1.48; 95% CI: 1.15, 1.89), transactional sex (aOR: 2.32; 95% CI: 1.74, 3.08; and aOR: 2.02; 95% CI: 1.51, 2.71) and alcohol use (aOR: 1.88; 95% CI: 1.39, 2.53; and aOR: 1.87; 95% CI: 1.37, 2.55). Threats were associated with transactional sex (aOR: 3.67; 95% CI: 2.62, 5.14). Future research should examine this relationship over-time and HIV prevention programs should consider and address emotional IPV.
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    Examining Mediators of the Relationship Between Community Mobilization and HIV Incidence Among Young South African Women Participating in the HPTN 068 Study Cohort
    (2021-10-07) Anna M. Leddy; Torsten B. Neilands; Rhian Twine; Kathleen Kahn; Jennifer Ahern; Audrey Pettifor; Sheri A. Lippman
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    A community mobilization intervention to improve engagement in HIV testing, linkage to care, and retention in care in South Africa: a cluster-randomized controlled trial
    (2022-09) Sheri A. Lippman; Audrey Pettifor; Mi-Suk Kang Dufour; Chodziwadziwa Whiteson Kabudula; Rhian Twine; Dean Peacock; Rhandzekile Mathebula; Aimée Julien; Rebecca West; Torsten B. Neilands; Ryan Wagner; Ann Gottert; F. Xavier Gómez Olivé; Dumisani Rebombo; Nicole Haberland; Julie Pulerwitz; Louis Pappie Majuba; Stephen Tollman; Kathleen Kahn
    Background: Community Mobilization (CM), engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. We assessed whether CM increased HIV testing, linkage to, and retention in care over time in intervention relative to control communities. Methods: Fifteen communities in Mpumalanga, South Africa were randomized to either a CM intervention engaging residents to address social barriers to HIV testing and treatment or to control. Implementation occurred from August 2015-July 2018. Outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among 18-49 year-old residents of intervention and control communities over the three years of study. Intention-to-treat analyses employed generalized estimating equations stratified by sex. ClinicalTrials.gov number NCT02197793. Findings: Residents in eight intervention communities (N=20,544) and seven control communities (N=17,848) contributed data. Among men, HIV testing increased quarterly by 12·1% (Relative Change (RC):1·121, 95%CI:1·099-1·143) in intervention communities and 9·5% (RC:1·095, 95%CI:1·075-1·114) in control communities; differences by arm were marginally significant (exponentiated interaction coefficient:1·024, 95%CI:0·997-1·052, p-value=0·078). Among women, HIV testing increased quarterly by 10·6% (RC:1·106, 95%CI:1·097-1·114) in intervention and 9·3% (RC:1·093, 95%CI:1·084-1·102) in control communities; increases were greater in intervention communities (exponentiated interaction coefficient:1·012, 95%CI:1·001-1·023, p-value=0·043). Quarterly linkage increased significantly among intervention community women (RC:1·013, 95%CI:1·002-1·023) only. Quarterly retention fell among women in both arms; however, reductions were tempered among intervention women (exponentiated interaction coefficient:1·003, 95%CI:<1·000-1·006, p-value=0·062). No significant differences were detected in linkage or retention among men. Interpretation: CM was associated with modest improvements in select trial outcomes. The sum of these incremental, quarterly improvements achieved by addressing social barriers to HIV care engagement can impact epidemic control. However, achieving optimal impacts will likely require integrated efforts addressing both social barriers through CM and provision of improved service delivery.
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    Associations between WASH-related violence and depressive symptoms in adolescent girls and young women in South Africa (HPTN 068): a cross-sectional analysis
    (2022-07-05) Ruvani T Jayaweera; Dana Goin; Rhian Twine; Torsten B Neilands; Ryan G Wagner; Sheri A Lippman; Kathleen Kahn; Audrey Pettifor; Jennifer Ahern
    Objective: There is a lack of research on experiences of WASH-related violence. This study aims to quantify the association between experience or worry of violence when using the toilet or collecting water and depressive symptoms among a cohort of young women in South Africa. Methods: Data are from visit 3 of the HPTN 068 cohort of adolescent girls in rural Mpumalanga Province, South Africa. Participants (n=1798) included in this analysis were aged 13-21 at baseline. Lifetime experience of violence or fear of violence when using the toilet and collecting water was collected by self-report; depressive symptoms in the past week were measured using the Center for Epidemiological Studies Depression Scale (CES-D). We used G-computation to calculate the prevalence difference (PD) and prevalence ratio of depression (CES-D score >15) associated with each domain of violence, controlling for baseline covariates. Findings: A total of 15.1% of respondents reported experiencing violence when using the toilet; 17.1% reported experiencing violence when collecting water and 26.7% reported depression. In adjusted models, those who reported experiencing violence when using the toilet had an 18.1% higher prevalence of depression (95% CI: 11.6% to 24.4%) than those who did not experience violence when using the toilet. Adjusted prevalence of depression was also higher among those who reported violence when collecting water (PD 11.9%, 95% CI: 6.7% to 17.2%), and who worried about violence when using the toilet (PD 12.8%, 95% CI: 7.9% to 19.8%), as compared with those who did not report these experiences. Worrying about violence when collecting water was not associated with depression after adjusting for covariates. Conclusion: Experience of WASH-related violence is common among young women in rural South Africa, and experience or worry of experiencing violence is associated with higher prevalence of depressive symptoms.
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    Lessons from community participation in primary health care and water resource governance in South Africa: a narrative review
    (2022) Jennifer Hove; Lucia D’Ambruoso; Kathleen Kahn; Sophie Witter; Maria van der Merwe; Denny Mabetha; Kingsley Temboh; Rhian Twine
    Background: In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decisionmaking in the development and implementation of public services. Objective: This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). Methods: Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. Results: There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. Conclusion: Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery.
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    The Sky is the Limit; I am Going There”: Experiences of Hope Among Young Women Receiving a Conditional Cash Transfer in Rural South Africa
    (2021-05-05) Kaitlyn Atkins; Catherine MacPhail; Suzanne Maman; Nomhle Khoza; Rhian Twine; F Xavier Gomez-Olive; Audrey Pettifor; Kathleen Kahn
    Young women in South Africa face elevated risk of HIV infection compared to male peers. Cash transfers may mitigate their risk for HIV; however, there is limited understanding of mechanisms of impact. We explored hope as one potential mechanism. Longitudinal qualitative analysis was used to explore how cash transfer recipients in the HPTN 068 study conceptualised hope and how the intervention influenced their hope over time. We found the intervention increased confidence, alleviated financial stressors and instilled in young women the belief that a better life, defined as being educated, independent and supportive to family, was attainable. Findings support hope as a critical outcome of cash transfer and other economic strengthening interventions.
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    Associations between WASH-related violence and depressive symptoms in adolescent girls and young women in South Africa (HPTN 068): a crosssectional analysis
    (2022-06-13) Ruvani T Jayaweera; Dana Goin; Rhian Twine; Torsten B Neilands; Ryan G Wagner; Sheri A Lippman; Kathleen Kahn; Audrey Pettifor; Jennifer Ahern
    Objective There is a lack of research on experiences of WASH-related violence. This study aims to quantify the association between experience or worry of violence when using the toilet or collecting water and depressive symptoms among a cohort of young women in South Africa. Methods Data are from visit 3 of the HPTN 068 cohort of adolescent girls in rural Mpumalanga Province, South Africa. Participants (n=1798) included in this analysis were aged 13–21 at baseline. Lifetime experience of violence or fear of violence when using the toilet and collecting water was collected by self-report; depressive symptoms in the past week were measured using the Center for Epidemiological Studies Depression Scale (CES-D). We used G-computation to calculate the prevalence difference (PD) and prevalence ratio of depression (CES-D score >15) associated with each domain of violence, controlling for baseline covariates. Findings A total of 15.1% of respondents reported experiencing violence when using the toilet; 17.1% reported experiencing violence when collecting water and 26.7% reported depression. In adjusted models, those who reported experiencing violence when using the toilet had an 18.1% higher prevalence of depression (95% CI: 11.6% to 24.4%) than those who did not experience violence when using the toilet. Adjusted prevalence of depression was also higher among those who reported violence when collecting water (PD 11.9%, 95% CI: 6.7% to 17.2%), and who worried about violence when using the toilet (PD 12.8%, 95% CI: 7.9% to 19.8%), as compared with those who did not report these experiences. Worrying about violence when collecting water was not associated with depression after adjusting for covariates. Conclusion Experience of WASH-related violence is common among young women in rural South Africa, and experience or worry of experiencing violence is associated with higher prevalence of depressive symptoms.