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    Comparing health inequalities in maternal health: An analysis of the South African Demographic and Health Surveys (SADHS) 1998 and 2016
    (University of the Witwatersrand, Johannesburg, 2023-09) Holden, Celeste Claire; Blaauw, Duane
    Background: Inadequate access to maternal health services (MHS) is directly linked to maternal and neonatal mortality and morbidity. South Africa (SA) is known to be an unequal society. Researching and documenting the utilisation and access to MHS can assist in the appropriate redirection of services to ensure equitable service delivery. The study identifies differences in MHS access between ethnicity groups, residence, province, maternal education level and household wealth quintile. The study quantifies the inequalities in access to MHS in SA in 1998 and 2016, and then evaluates the change in inequalities between the two periods. Methods: Data was analysed from the 1998 and 2016 South African Demographic and Health Surveys. First. the study identifies differences in MHS access between ethnic groups, residence, province, maternal education level and household wealth quintile using regression analyses. Then, the inequalities related to access of MHS in 1998 and 2016 are calculated using the relative (RII) and slope (SII) index of inequality and the concentration index (CI). Lastly, the inequalities between 1998 and 2016 were compared using generalised linear models, indicating whether inequalities increased, decreased, or remained the same. All analyses were done in Stata and adjusted for the multistage-stratified sampling of the surveys. Results: Utilisation of MHS in SA varies between different groups based on ethnicity, residence, province, mothers’ education level, and wealth quintile. In 1998 and 2016, Black/African women have the least utilisation of all MHS. A clear pattern is seen where women with higher education and high wealth quintile, have increased MHS utilisation. In most cases, the inequalities narrowed between 1998 and 2016 for all MHS. However, inequalities are still present in 2016 for many MHS. For example, using simple inequality measures, the largest inequalities in 2016 are seen between women of different ethnicities accessing four or more antenatal visits (ANC4), where there is a 11.1 percentage point difference between the highest group (White & Indian/Asian) and the lowest group (Black/African). For complex inequality measures, there are still significant relative and absolute inequalities in antenatal visits in 2016 for maternal education (RII: 1.25; SII: 1.14) and household wealth quintile (RII: 1.23; SII: 1.11). Conclusions: Between 1998 and 2016, population-level utilisation to MHS increased in all MHS and the majority of within group inequalities narrowed over time. However, inequalities still exist in all maternal health outcomes. SA has implemented multiple programmes and policies to address inequalities in MHS and decrease maternal mortality and morbidity. However, these need to be continuously monitored and evaluated based on the latest data to ensure that efforts are going towards addressing the specific groups where inequalities are still present.
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    Experiences of healthcare workers using the AwezaMed translation application in antenatal settings
    (University of the Witwatersrand, Johannesburg, 2023-06) Cason, Caroline Marian; Slemming, Wiedaad; Wilken, Ilana
    Introduction: Language barriers impede quality health care service in South Africa. Trained interpreters could alleviate this problem, but they are not employed in public or private health settings. Health care workers rely on informal interpreters, who do not necessarily provide an adequate service, and may be resentful of this extra task. AwezaMed is a smart application developed by the Council for Scientific and Industrial Research (CSIR) with content developed for maternal health settings. The aim of this study was to assess usability and user experience relating to AwezaMed. Methods: A user experience study was conducted using mixed methods. The systems usability scale (SUS) was employed, surveying 12 users, to generate a quantitative score, representing the overall usability of the system. Interviews were conducted with 14 users and analysed thematically to identify themes of usability and user experience, and recognise factors which contribute to use of the application. Results: The application (app) achieved a total score of 66.25, rating it between ‘OK/Fair’ and ‘Good’. Understandability, operability, attractiveness, and trust were important usability themes. Users also reported using the app as an aid to language learning. Factors which influenced the use of the app included previous experience with mHealth, experiencing a language barrier in health settings, and unavailability of, or problems with interpreters. Discussion: While the app was received positively, it did not meet users’ expectations, as two-way communication could not be achieved. Due to the often-strained relationship between healthcare workers and informal interpreters, there remains a demand for a usable, trustworthy mHealth solution. A framework is proposed, based on these findings, to evaluate mHealth translation applications in South Africa in the future.
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    Reporting Silica Dust Exposure Measurements in South African Gold and Coal Mines: 2005 to 2016
    (University of the Witwatersrand, Johannesburg, 2023-10) Mongoma, Brian Tshepo; Nelson, Gill; Brouwer, Derk
    Background: Arising from the Mine Health and Safety Act 29 of 1996 (MHSA), one of the measures to protect mine workers is monitoring exposure to airborne pollutants. Mines are statutorily required to report airborne pollutant concentrations to the Department of Mineral Resources and Energy (DMRE) on a regular basis. Based on the DMRE's 2013 report, it was determined that 76% of workers were exposed to airborne pollutants at concentrations less than 10% of their respective occupational exposure limits (OELs). Using the same exposure data from the DMRE, the Chamber of Mines of South Africa reported a 14% improvement in the exposure to the airborne pollutants from 2005 to 2013. However, these reported reduced exposures to airborne pollutants are based on the summation of all airborne pollutant exposures by the DMRE. The annual reports refer to the percentage of employees exposed to the combined airborne pollutants, rather than to specific pollutants, such as silica dust – a hazard that is high on the occupational health agenda of the mining industry. From these reports, broad (and perhaps incorrect) conclusions are reached with regard to trends in silica dust and other exposures. The limitations of the SAMI include inaccurate data, self-regulation, incomplete employment and exposure records, and historical biases, which hinder its ability to effectively handle occupational health risks. This emphasizes the immediate need for clear and consistent regulations, accurate data collection, and impartial research approaches to protect the health of mine workers. Objectives: The objectives of this study were to describe trends in combined airborne pollutant and silica dust concentrations from 2005 to 2016, and to evaluate the DMRE Mandatory Code of Practice (MCoP) and the EN 689 methods (for testing exposure levels in the workplace against the OEL of 0.1 mg/m3) as published by the European Committee for Standardization (CEN), using reported silica dust concentrations from 2015 and 2016. Methods: This was a cross-sectional study in which secondary airborne pollutants exposure data, reported to the DMRE by coal and gold mining members of the Minerals Council, were analysed. The 282 870 data points were pooled together to describe trends in airborne pollutant exposures as they comprised 69 airborne pollutants reported by different mines with various mining methods, activities, and occupations. The exposure data was categorized into coal and gold mines, and further into four three-yearly periods (i.e. period 1: 2005-2007, period 2: 2008-2010, period 3: 2011-2013, and period 4: 2014-2016). This was conducted in order to have a consistent metric to allow for uniform assessment across different pollutants with varying OELs. Dividing the exposure concentration by its OEL provided a ratio, similarly to the way that an Air Quality Index is calculated. As a result, the data was normalized by dividing each pollutant exposure concentration by its occupational exposure limit (OEL) to obtain a ratio, termed Q. The arithmetic mean, standard deviation, geometric mean, and geometric standard deviation of the Qs were calculated for each of the three groups i.e. coal and gold mines combined, b) coal mines, and c) gold mines, for each period. Jeffreys’s Amazing Statistics Program was used to analyse the Qs and silica dust concentrations. The Kruskal–Wallis test was used to identify statistically significant differences among the four time periods for each commodity group. Additionally, Scheffe’s post-hoc test in JASP was conducted for further analysis and comparison of differences across all observed periods. Two methods, namely the EN 689 and the method required by the DMRE MCoP, were used to assess compliance. EXPOSTATS Tool 1 was used to calculate the arithmetic mean (AM), median, standard deviation (SD), geometric mean (GM), geometric standard deviation (GSD), and 90th and 95th percentiles of the exposure data derived from EN 689. Microsoft Excel was used to calculate the 90th and 95th percentiles of the exposure data based on MCoP method. A total of 127 014 silica dust data points from 2005 to 2016 out of the 282 870 were utilized to describe silica dust exposure trends, and 44 990 data points from the 127 014 were used to assess compliance for the years 2015 and 2016. Results: A total of 282 870 personal airborne pollutant concentrations from 2005 to 2016, obtained from DMRE, were included the analysis. Analysis of the pooled airborne pollutant exposure concentrations indicated that there was a high variability (data points were far apart and also far from the GM) as the GSDs ranged from 6.37 to 7.53, 7.8 to 8.43, and 5.7 to 6.16 for the coal and gold mines combined, coal mines alone, and gold mines alone, respectively. The variabilities of the silica dust concentrations were less than that of the pooled airborne pollutant data. The GSDs of the silica dust concentrations were < 3.5 for all three groups compared to the GSDs calculated from the pooled airborne pollutants concentrations, where the lowest GSD was 5.7. The trends in the pooled airborne pollutant exposure concentrations over the 12-year period, for all three groups, showed that there was a reduction in reported exposures to combined airborne pollutants. The AMs of the ratios (Q) indicated that the reduction in exposures for coal and gold mines combined, gold mining alone and coal mining alone, were 57%, 55% and 26%, respectively. The corresponding GMs of the ratios (Q) for gold mining alone, coal and gold mines combined, and coal mining alone, reduced by 64%, 45% and 15%, respectively, from 2005 to 2016. The distribution of the airborne pollutant data was skewed, which affected AM more than GM, and resulted in differences between the two measures. This was evident in the gold mining data, where the AM decreased by 55% but the GM decreased by 64%. Data for the period 2005-2007 had the highest AM (1.54) and standard deviation (2.75), suggesting that there were outliers. In this period, ratios (Q) ranged from 0.003 to 7.7, impacting the AM and creating a gap between median and AM values. From 2008 to 2010, the AM (1.26) and SD (2.04) decreased, showing reduced variability. A similar trend was observed from 2011 to 2013, with increased numbers of observations and further reduced variability. In 2014-2016, the AM decreased to 0.67 and SD to 1, indicating stability. The GMs for the coal and gold mines combined, coal mines alone and gold mines alone ranged from 0.17 to 0.31, from 0.22 to 0.28, and from 0.16 to 0.45, respectively. The trends in reported silica dust concentrations in all three groups showed a reduction over the 12-year period. The AMs indicated that the reductions for coal and gold mines combined, gold mining alone and coal mining alone, were 61%, 38% and 34%, respectively. The GMs of the silica dust concentrations indicated that the reductions in exposures for coal and gold mines combined, coal mining alone, and gold mining alone, were 54%, 35% and 31%, respectively. The AMs of the silica dust concentrations for coal and gold mines combined ranged from 0.17 to 0.44 mg/m3, while the coal mines ranged from 0.67 to 1.02 mg/m3 from 2005 to 2016. For gold mines, the AMs ranged from 0.13 to 0.23 mg/m3. Similarly, the GMs of the silica dust concentrations for the coal and gold mines combined ranged from 0.11 to 0.24 mg/m3, whereas coal mines ranged from 0.41 to 0.63 mg/m3, and gold mines ranged from 0.09 to 0.13 mg/m3. The 90th percentiles for the silica dust concentrations almost correlated with the AMs as they reduced by 67%, 40% and 34% for coal and gold mining combined, gold mining alone, and coal mining alone, respectively. The 90th percentiles for silica dust concentrations for the coal and gold mines ranged from 1.64 to 2.48 mg/m3, and 0.29 to 0.51 mg/m3, respectively. Although the trends indicated a reduction in exposure to silica dust concentrations, the AM, GM, 90th and 95th percentiles exceeded the OEL of 0.1 mg/m3 for the entire study period for the three groups, except for the gold mines alone in 2016. In that year, the GM was 0.09 mg/m3 (rounded to 0.1 mg/m3). For coal mining only, the 90th percentiles ranged from 1.64 to 2.48 mg/m3, whereas the 95th percentiles ranged from 2.16 to 3.16 mg/m3. For gold mining only, the 90th percentiles ranged from 0.29 to 0.51 mg/m3, and the 95th percentiles ranged from 0.35 - 0.63 mg/m3. A total of 44 990 silica dust concentrations were used from 2015 to 2016 to compare the 95th percentiles according to EN 689, and the 90th percentiles according to the MCoP. The DMRE MCoP method was shown to underestimate the exceedance of the occupational exposure limit by 5-26%, when compared with the EN 689 method. Conclusion: Despite the variabilities and challenges associated with pooling the airborne pollutants concentrations in the coal and gold mining industries, exposures to the airborne pollutants in the three commodity groups decreased from 2005 to 2016. However, reporting employee exposure as pooled airborne pollutants concentrations is flawed and obscures exposures to individual pollutants such as silica dust. The three commodity groups showed a decrease in silica dust exposure measurements from 2005 to 2016. However, there was still overexposure to silica dust in the three groups (greater than the OEL of 0.1 mg/m3). Inhalation of particles containing silica was higher in the coal than the gold mines, which is contradictory to what is known about the silica content of the ores in which the two commodities are found. The DMRE MCoP approach to compliance with silica dust levels underestimated the exceedance of the OEL in comparison to the EN 689’s approach. The current DMRE reporting methodology, i.e. the pooling of all data, does not allow accurate reporting of silica dust exposures and as a result, it does not provide direction or support for carrying out measures to decrease exposure to silica dust. The MCoP method for compliance testing revealed higher 90th-percentiles for coal mining compared to the 90th-percentile estimated for the population (EN 689). For gold mining it was the opposite. The EN 689 method is a more precise means of estimating OEL compliance, which is crucial for managing silica dust and specific pollutant health hazards and should be used in favour of the method in the MCoP.
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    Indoor/outdoor PM4 (respirable dust) and respirable crystalline silica source tracking in households located in close proximity to gold mine tailing dumps
    (University of the Witwatersrand, Johannesburg, 2023-10) Makhubele, Nkateko Rawendar; Mizan, Gabriel; Manganyi, Jeanneth; Masekameni, Masilu Daniel
    Background: Particulate matter (PM) is a major contributor to air pollution in indoor and outdoor environmental spaces. Exposure to respirable dust (PM4) and respirable crystalline silica (RCS) indoor and outdoor in communities located in close proximity to gold mine tailings dumps in South Africa has not yet been determined. Aim: The aim of this study was to investigate the concentration of RCS and PM4 mass in samples measured indoor and outdoor of the nine (9) selected households located in close proximity to a gold mine tailings dumps. Methodology: Sampling locations were separated according to grids, based on the distance from the mine tailings dumps. Three different grids were determined as follows: A (<500m from the dump), B (>500m<1km) and C (1km – 3 km). Three households were selected from each grid zone to measure indoor and outdoor PM4 samples continuously over a 24-hour period using GilAir constant sampling pumps calibrated at the flowrate of 2.2 L/min in both the dry and wet seasons. PM4 samples were collected on a 37mm polyvinyl chloride (PVC) filter with a pore size of 0.8, which was assembled on the Higgin Dewell cyclones fitted with a filter pad of the same pore size. PM4 sample filters were gravimetrically weighed before and after sampling to determine the mass concentration of PM4. The respirable crystalline silica in PM4 samples were analysed by an X-ray diffraction method by South African National Accreditation System (SANAS) accredited laboratory of the National Institute for Occupational Health (NIOH). Samples were collected during the dry and wet seasons in the Riverlea community, Johannesburg. Results: During the wet and dry seasons, the mean indoor and outdoor PM4 mass concentration ranged from 0.02±0.01 µg/m3 to 2.26±0.02 µg/m3, respectively. The dry season mean PM4 mass concentrations were higher than the wet season PM4 mass concentrations in all zones. The pairwise comparison of PM4 mass concentration for dry and wet season revealed no statistically significance difference (p<0.05) at 95% confidence interval. Results presented in Figure 5 depicts the mean indoor PM4 mass concentration distribution for the dry season. The zone with the highest mean indoor PM4 mass concentration was zone A, followed by zone B. Since the mean outdoor PM4 concentration in zone C was the lowest, this suggests that the mine tailings dumps were the primary source of PM. The dry season mean indoor/outdoor ratio was greater than one across all zones; indicating that indoor activities were the primary source of PM. In both seasons, the mean indoor and outdoor percentages of crystalline silica ranged from 0.08±0.01% to 0.08±0.01%. The mean indoor and outdoor 24hr RCS concentrations in both seasons were below the California Office of Environmental Health Hazard Assessment (OEHHA) defined 24hr ambient exposure threshold of 3µg/m3. Recommendations: The results of this study suggest that nearby mine tailings dumps may be the primary source of PM in the indoor and outdoor environments; however the strength of this source in comparison to other sources remains unknown. Therefore, it is recommended that further studies focusing on source apportionment be carried out to determine the relative contribution of the mine tailings dust to the overall PM load in the environment. Although the difference was not statistically significant, indoor and outdoor PM4 concentrations were greater in Zones A&B, with the lowest PM4 concentrations in Zone C. The I/O ratio indicated that there was contribution of PM from outdoor. It is also recommended that further studies be conducted, with focus on monitoring PM4 over a 30 days period, to determine the level of free crystalline silica that may be present in PM4 mass concentrations. Conclusion: In the South African context, studies that focus on the investigation of indoor and outdoor PM4 concentrations in households located in close proximity to gold mine tailings are limited. The findings of this study can be used to provide valuable information on the indoor and outdoor PM4 concentrations, which can be used in modelling exposure and conducting probabilistic health risk assessment. High dust levels are related with dry season weather conditions due to strong wind conditions. Therefore, the PM4 mass concentrations in all zones were higher during the dry season than during wet season. Since the mean outdoor PM4 concentration in zone C was the lowest, this suggests that the mine tailings dumps were the primary source of PM.
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    A Cost Comparison study of the electronic tick register with a paper based tick register in clinics within the Ekurhuleni District
    (University of the Witwatersrand, Johannesburg, 2023-08) Khoza, Courage Macduff; Thomas, Leena Susan
    Introduction & Background: A paper-based register is used to capture routine health information from Primary Health Care (PHC) clinics into the District Health Information System (DHIS) in South Africa. However, DHIS data was reportedly unreliable and inaccurate, as the paper-based system was error-prone. To address this, the Ekurhuleni Health District in the Gauteng Department of Health (GDOH) developed and piloted an electronic (E-tick) PHC register in three of its facilities. Upon completing the pilot in 2019, the implementation of this system was halted as it was not incorporated into the GDOH budget, partly due to inadequate information on its costs compared to the paper-based system. Aim: This study aims to cost and compare the expenditure of the electronic tick register and the paper-based tick register systems and determine provider views on their use in the Ekurhuleni Health District. Methods: Two methods were used: a) a descriptive cost-comparison study of the paper-based tick and the E-tick registers from November 2017 to December 2019 and b) a descriptive cross-sectional study using interviewer-administered questionnaires about health worker experiences using both registers during the stated period. Results: The study found that the E-tick register was less costly than the paper-based register. The year 2018/19, which was the only complete financial year in the study period is used for comparison. The paper-based register cost the district R42.4 per patient, while the E-tick cost R29.9 (29.5% cheaper). Of ten study theme areas explored in the interviews, the E-tick was advantageous in eight, these were: Convenience, easy accesses, quick recording time, safe information storage, immediate data capturing, ability to add more elements, fewer errors and good font size and legibility. The paper-based register was found to be advantageous in just four study themes which were: Convenience, easy accesses, independence from electricity supply and sufficient writing space. Conclusions: The E-tick register was found to be preferred over the paper-based register as it was quicker, cheaper, and acceptable to most of the health workers who used it. These are important findings for the health district as the study generates local evidence that the Ekurhuleni Health District and the Gauteng Department of Health can use to justify investments in scaling up and sustaining locally developed innovative digital solutions such as the E-tick register. This further enables the health district to improve recording times and compliance with record management legislation.
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    An evaluation of the integration of oral pre-exposure prophylaxis (prep) as standard of care for HIV prevention in clinical trials in South Africa
    (University of the Witwatersrand, Johannesburg, 2023) Beesham, Ivana; Mansoor, Leila E; Beksinska,Mags
    Background: Oral tenofovir-based pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option. In 2015, the World Health Organization (WHO) recommended oral PrEP for those at substantial risk of HIV infection, and several countries have since adopted oral PrEP into their national guidelines. In the context of trials, HIV endpoint-driven trials frequently enrol individuals who are at elevated risk of acquiring HIV. Ethical guidelines recommend that study sponsors and investigators should provide access to a package of HIV prevention methods to trial participants, as recommended by WHO, including adding new prevention methods as these are validated. In 2017, the South African Medical Research Council recommended that oral PrEP be provided in HIV prevention trials. The Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial was ongoing at the time and incorporated oral PrEP into the trial’s HIV prevention package, including the onsite provision of oral PrEP at the South African trial sites during the last eight months of the trial. The ECHO Trial, conducted from 2015 to 2018, enrolled women aged 16-35 years, from 12 research sites in four African countries, and assessed the effect of three contraceptives on HIV incidence. In 2019, when this PhD project was conceptualised, there was a lack of data on the integration of oral PrEP as part of the HIV prevention package in HIV endpoint-driven trials. To address this gap, I evaluated the integration of oral PrEP as standard of care for HIV prevention in clinical trials in South Africa. Objectives: 1. To describe the process of implementing oral PrEP provision, the uptake of oral PrEP and the characteristics of women who initiated (versus those who did not initiate) oral PrEP during the ECHO Trial. 2. To evaluate oral PrEP adherence and factors associated with adherence by conducting plasma tenofovir (TFV) drug level testing using stored blood samples among a subset of women from South Africa who reported current oral PrEP use at the final ECHO Trial visit. 3. To describe the experiences of women who initiated oral PrEP at the Durban, South Africa, ECHO Trial site. 4. To explore post-trial access to oral PrEP, and barriers and enablers to post-trial oral PrEP access, among a subset of women from the Durban, South Africa, ECHO Trial site. 5. To review the current status of oral PrEP as standard of care for HIV prevention in clinical trials in South Africa. Methods: This was a mixed methodology study, conducted from 2019 to 2022, and both qualitative and quantitative methods were utilized. I describe the process undertaken by the ECHO Trial team to incorporate oral PrEP delivery into the trial’s HIV prevention package, including the onsite provision of oral PrEP by ECHO Trial staff at the South African trial sites. Characteristics between women who ever initiated oral PrEP versus those who had access to but did not initiate oral PrEP, were assessed using Chi-squared/Fisher’s exact tests for categorical variables and t-tests for continuous variables. HIV seroincidence comparisons between participants who never versus ever initiated oral PrEP were modelled using exact Poisson regression. To objectively measure adherence to oral PrEP, plasma samples collected at the final ECHO Trial visit, from a subset of women enrolled at the South African ECHO Trial sites, who reported ongoing PrEP use, were tested for TFV. Bivariate logistical regression was used to evaluate participant characteristics associated with quantifiable TFV at the final ECHO Trial visit. 10 | P a g e To understand experiences of women who used oral PrEP and patterns of oral PrEP use, we conducted questionnaires with women who initiated oral PrEP onsite at the Durban, South Africa, ECHO Trial site. Face-to-face questionnaires were conducted approximately three months following oral PrEP initiation, and explored reasons for using and discontinuing oral PrEP, side effects experienced, oral PrEP adherence and disclosure of oral PrEP use. I also evaluated factors associated with oral PrEP continuation at the final ECHO Trial visit using univariate and multivariate logistical regression. Among women continuing oral PrEP at ECHO Trial exit, telephonic follow-up was conducted 4-6 months later, to briefly explore oral PrEP access and ongoing use following study exit. Additional face-to-face, participant in-depth interviews were conducted in 2021 with a subset of women from the Durban, South Africa, ECHO Trial site, who reported ongoing oral PrEP use at ECHO Trial exit and who were given a 3-month PrEP supply at study exit. The interviews explored barriers and enablers to post-trial oral PrEP access. Finally, telephonic in-depth interviews were held with key stakeholders from research sites across South Africa known to conduct HIV endpoint-driven clinical trials to explore their perspectives on providing oral PrEP as HIV prevention standard of care in clinical trials in South Africa. Participant and stakeholder interviews were audio-recorded and transcribed, and thematic analysis was facilitated using NVivo. Results: Our key findings indicate that it was feasible to integrate oral PrEP as standard of care for HIV prevention in the ECHO Trial. PrEP uptake was 17.2% (622/3626) among those eligible for oral PrEP when it became available. Women who initiated oral PrEP were more likely to be unmarried, not living with their partner, having multiple partners; and less likely to be earning their own income and receiving financial support from partners (all p<0.05). There were 37 HIV seroconversions among women who had access to oral PrEP but did not initiate oral PrEP, and 2 seroconversions among women who initiated oral PrEP (HIV incidence 2.4 versus 1.0 per 100 person-years; Incidence Risk Ratio = 0.35; 95% confidence interval (CI) = 0.04 to 1.38). Among the 260 plasma samples from the eight South African ECHO Trial sites that were available for TFV testing, plasma TFV was quantified in 36% of samples (94/260). Women >24 years old had twice the odds of having TFV quantified compared to younger women (Odds Ratio (OR) = 2.12; 95% CI = 1.27 to 3.56). Women who reported inconsistent/no use of condoms had lower odds of TFV quantification (age-adjusted OR = 0.47; 95% CI = 0.26 to 0.83). The ancillary study conducted at the Durban, South Africa ECHO Trial site found that onsite oral PrEP uptake was high (43%, 138/324). Almost all women who initiated oral PrEP at the trial site agreed to participate in the ancillary study (96%, 132/138). Of these, 88% reported feeling at risk of acquiring HIV. Most women (>90%) heard of oral PrEP for the first time from trial staff. Oral PrEP continuation via self- report was 87% at month-1, 80% at month-3, and 75% elected to continue using oral PrEP at trial exit and were referred to off-site facilities for ongoing access. Disclosure of oral PrEP use was associated with five-fold increased odds of continuing oral PrEP at trial exit (adjusted OR = 4.98; 95% CI = 1.45 to 17.13; p=0.01). At telephonic follow-up 4-6 months after women exited the ECHO Trial, >50% reported discontinuing PrEP. Qualitative interviews conducted with a subset of women from the Durban, South Africa ECHO Trial site identified several barriers to post-trial oral PrEP access at facilities such as long queues, facilities being located far from women’s homes, unsuitable clinic operating hours, negative attitudes from providers, and oral PrEP being unavailable at some clinics. Interviews with key stakeholders from research sites in South Africa found that most stakeholders reported incorporating oral PrEP provision as part of the HIV prevention package offered to participants in HIV endpoint-driven trials. Stakeholders identified barriers to oral PrEP 11 | P a g e uptake, adherence, persistence, and post-trial access. Demand creation, and education and counselling about oral PrEP were reported as factors that facilitated uptake. Conclusion: The ECHO Trial provides evidence that it was feasible to successfully integrate oral PrEP provision as part of the trial’s HIV prevention package offered to study participants. Other HIV endpoint-driven trials can utilize our findings as a model to integrate oral PrEP provision into the HIV prevention package offered in a trial. The ancillary study findings on PrEP uptake, adherence and persistence can be utilized to guide oral PrEP trials and implementation programs. While post-trial oral PrEP access was concerning and several barriers were identified, it is possible that with the scale-up of oral PrEP in the public sector in South Africa after the ECHO Trial was completed, participants exiting trials and desiring to continue oral PrEP could have better access
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    Salient beliefs, preferences and intention to use HIV pre- exposure prophylaxis among pregnant and breastfeeding women in Zambia
    (University of the Witwatersrand, Johannesburg, 2024) Hamoonga, Twaambo Euphemia
    Pregnant and breastfeeding women living in sub-Saharan Africa are at substantial risk for HIV infection, and maternal seroconversion may affect the quality of life for the mother, and is a risk for vertical transmission of HIV. Despite the adoption of PrEP into national guidelines for HIV prevention, its uptake in antenatal and postnatal settings in Zambia remains low. We used an exploratory sequential mixed methods design to explore facilitators and barriers to uptake of PrEP among pregnant and breastfeeding women (18 years or older) not living with HIV in Zambia. We purposively recruited 24 women for the qualitative component and conveniently selected 389 women for the quantitative component of the study at Chipata Level 1 Hospital in Lusaka. For qualitative data, Nvivo was used for data management and data was analysed using thematic analysis. Quantitative data was analysed using chi-square test, pearson correlation coefficient (r) and logistic regression analysis using Stata v.16. Findings from our qualitative study showed that women had positive attitudes and favourable intentions to use PrEP. Most women felt that people who are important to them, especially their male partners, would not support PrEP use during pregnancy and breastfeeding. The anticipated disapproval from partners made women believe that PrEP use would not entirely be under their control, with some reporting that they would not use PrEP if their partners disapproved. Women also cited rude health care provider attitude as a potential barrier to uptake. Some women preferred receiving PrEP from a health facility for fear of stigma in the community while others preferred community-based delivery as an avenue for creating PrEP awareness. This paper was published in Frontiers in Reproductive Health In our second paper, we determined intention to use PrEP during pregnancy and breastfeeding and also identified salient beliefs associated with it. Participants had positive attitude and favourable intention to use PrEP during pregnancy and breastfeeding (mean = 6.65, SD = 0.71 and mean = 6.01, SD = 1.36), respectively. They felt that people who are important to them would approve of their use of PrEP (mean = 6.09, SD = 1.51) and also believed that they would be able to use PrEP if they desired (mean = 6.52, SD = 1.09). All salient beliefs positively and significantly predicted intention to use PrEP during pregnancy and breastfeeding: attitude (β = 0.24, p<0.01); subjective norms (β = 0.55, p<0.01); and perceived behavioural control (β = 0.22, p < 0.01). This paper was published in Global Public Health. The third paper discusses findings from a discrete choice experiment (DCE) on preferences for PrEP service delivery among pregnant and breastfeeding women. In this study, waiting time, travel time, health care provider attitude and amount of PrEP supply at each refill were important considerations likely to influence PrEP use during pregnancy and breastfeeding (all p<0.01). Women expressed strong preference for 3-month’s supply of PrEP compared to other attribute levels (β= 1.69, p<0.01). They were willing to wait for 5 hours at the facility, walk for more than an hour to a facility dispensing PrEP, encounter a health care provider with a negative attitude as long as they received PrEP enough for 3 months. This paper is under review in Frontiers in Reproductive Health. The overall contribution of this PhD research to the body of knowledge on HIV prevention strategies is the ability to identify beliefs about PrEP and how each salient belief influences intention to use PrEP during pregnancy and breastfeeding. It is also one of the first to estimate the benefit (value or satisfaction) that women derive from different attributes of PrEP service delivery for pregnant and breastfeeding populations interested in using PrEP. This information could provide guidance on specific beliefs and service delivery attributes of PrEP that women prefer the most and therefore need to be prioritized if PrEP uptake is to improve in antenatal and postnatal settings
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    Adolescent health in rural South Africa: building an evidence-base to inform a health promotion intervention supporting healthier lifestyles
    (University of the Witwatersrand, Johannesburg, 2024) Seabi, Tshegofatso Martha; Kahn, Kathleen; Wagner, Ryan G
    Background Low- and middle-income countries (LMICs), including South Africa, face the persisting double burden of malnutrition, with undernutrition and overnutrition coexisting within the population. This issue is particularly pronounced among rural adolescents, who experience limited access to healthcare services, inadequate infrastructure, poverty, and a scarcity of nutritious foods. Addressing this double burden of malnutrition is essential for improving the health outcomes of rural adolescents and breaking the intergenerational cycle of malnutrition. Community health worker-led interventions have shown promise in promoting healthier lifestyles in this population, making it crucial to understand the feasibility and acceptability of such interventions. Aim This thesis aims to provide context-specific information on the changing distribution of Body Mass Index (BMI) and views on obesity among rural South African adolescents to inform the development of a targeted behaviour change intervention. Furthermore, it seeks to determine the feasibility, acceptability, and overall experience of implementing a complex intervention aimed at promoting healthier lifestyles in this population. Methods Using a mixed methods approach focusing on adolescents 12-20 years of age living in rural South Africa. This work is nested within the MRC/Wits rural public health and health transitions research unit (Agincourt) Health and Demographic Surveillance System, which is where the sample was drawn and provided explanatory variables such as SES. This work includes data from two studies with comparable measures, conducted in 2007 (n= 1309) and in 2018 (n=518), this study analysed comprehensive data on the prevalence and trends of BMI, including both undernutrition and overweight/obesity, among rural adolescents in 2007 and 2018. This was done through weight and height measures. Growth z-scores were used to determine stunting, underweight and overweight and overweight/obesity was generated using the 2007 WHO growth standards for adolescents aged up to 17 years and adult cut-offs of BMI of <=18.5 for underweight and =>30 kg/m2 for overweight and obese respectively for adolescents 18 to 20 years. Qualitative data was collected in the form of focus group discussions and in-depth interviews. Pre-intervention, three focus group discussions were held with male (n = 16) and female adolescents (n = 15) focusing on obesity to capture views, attitudes and perceptions surrounding obesity. Post-interventions, six focus group discussions were held with male and female adolescents. In-depth interviews were conducted with adolescents (n=20), parents (n=5) and CHWs (n=3), focusing on the feasibility and acceptability of the health promotion intervention. All qualitative data were analysed using inductive thematic analysis. Results This study found that there is a persistent double burden of malnutrition amongst rural adolescents. The pattern of underweight and overweight/obesity remains similar between 2007 and 2018, with an increase in overweight and obesity, and a decrease in underweight observed across different age and gender groups throughout this period. The prevalence of stunting and underweight, particularly in males in both 2007 and 2018 was substantial although lower in the later year. Adolescents expressed conflicting views of obesity, highlighting their knowledge of the cause and long-term consequences of obesity. In regard to the intervention, participants expressed support for the CHWs and the community-based intervention guided by them. The findings demonstrated the feasibility of providing the intervention to adolescents in a rural context, with modifications needed to ensure participant uptake, such as changes to the time and location. Responses from participants show how the intervention, which included dietary and quantity modifications, was acceptable to adolescents. The gathered information in this study serves as a foundation for developing a health promotion intervention tailored to the specific needs and circumstances of rural adolescents, considering both undernutrition and overweight and obesity. Conclusion This research provides valuable context-specific insights into the burden of malnutrition and perceptions of obesity among rural South African adolescents, considering the complexities of the double burden of malnutrition. The findings contribute to the development of tailored health promotion interventions that address both undernutrition and overweight/obesity in this population. Understanding the feasibility and acceptability of such interventions is vital for successful implementation and sustainability in rural communities.
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    Attrition in the dental therapy profession: an exploration of the contributing factors
    (University of the Witwatersrand, Johannesburg, 2024) Sodo, Pumla Pamella; Jewett, Sara
    Background: A new type of oral health profession called dental therapy was introduced to address the growing need for affordable and accessible oral healthcare services, especially among marginalised communities. Extensive global research has demonstrated that dental therapists provide cost-effective and high-quality services, effectively addressing the issue of limited access to basic oral health services. The introduction of dental therapy into the South African healthcare system took place in 1977, however, disparities in accessing basic oral healthcare persist, particularly among some population groups where the highest prevalence of oral diseases has been reported. Despite being established over four decades ago, the number of registered dental therapists remains low, and there have been reports of attrition within this professional group. This PhD aimed to explore the factors contributing to attrition in the dental therapy profession. The first objective was to determine South African dental therapists' attrition rate and demographic profile over 42 years (1977-2019). The second objective explored factors contributing to attrition, while the third objective explored the applicability of the Hertzberg Two-Factor Theory in the context of dental therapy attrition in South Africa. Methods: This was a concurrent mixed methods study, involving registered graduate dental therapists, former dental therapists, and key stakeholders. The conceptual framework that guided the study was derived from Hertzberg's Two-Factor Theory. Data sources included the HPCSA registry and primary data collected using a quantitative survey investigating job satisfaction and intention to leave among registered graduate dental therapists and qualitative in-depth interviews with former dental therapists and key stakeholders to gain insights into their perspectives on attrition in the dental therapy profession. The attrition rate was determined by using the formula (Attrition Rate = Number of dental therapists who left the profession divided by the total number of dental therapists registered during the period of interest, multiplied by 100). Quantitative data was analysed in STATA version 15 using descriptive and inferential statistics, and qualitative data was analysed using thematic analysis. Findings: A total of 1232 dental therapists were registered with HPCSA over 42 years, with only 714 registered in 2019, two-thirds of whom were Africans. The attrition rate over the 42 years was 40%, while it reduced to 9% during the 10 years from 2010 to 2019. Of the 200 registered dental therapists who took part in the survey, 74.5% being Africans, approximately 51.5% expressed their intention to leave the profession and a notable 69.5% reported job dissatisfaction. In logistic regression analysis, job satisfaction correlated positively with several factors, including qualification from UKZN (AOR= 2.28, CI: 1.06-4.91), post-graduation job availability (AOR=3.87, CI: 1.73-8.69), awareness of postgraduate opportunities (AOR=2.28, CI: 1.05-4.96), and feeling valued (AOR= 6.91, CI: 1.45-26.36). Conversely, job satisfaction was negatively associated with becoming aware of the scope of work only after enrolment (AOR= 0.31, CI: 0.21-0.81). Job satisfaction was inversely correlated with the intention to leave; satisfied individuals had significantly lower odds of intending to leave (AOR= 0.25, CI: 0.11-0.57). In-depth interviews with 14 former dental therapists identified diverse reasons for enrolling in dental therapy and a shared enthusiasm for the dental therapy profession. Most reasons they cited for attrition, such as inadequate remuneration, job scarcity, poor working conditions, lack of career advancement opportunities, and policy implementation gaps aligned with Herzberg's Two-Factor Theory. One novel factor contributing to attrition not covered by the theory was a lack of professional identity. The 12 key stakeholders who were interviewed echoed similar factors contributing to the attrition of dental therapists. To address limitations in moving from a description of factors to recommendations on how to address system-level challenges, I adapted a framework that is a combination of Herzberg's Two-Factor Theory and the Human Resources for Health System Development framework. This new framework addresses multifaceted issues affecting dental therapists, covering production, deployment, and retention. Conclusion: This study sheds light on challenges within South Africa's dental therapy profession, highlighting their profound implications for both the profession and the broader healthcare system. Despite comparable attrition rates to other mid-level health professionals, there were alarmingly high job dissatisfaction levels and intentions to leave the profession, demanding immediate attention and intervention. Identifying key factors contributing to attrition and the novel insight into the lack of professional identity collectively highlight the multifaceted nature of the issue. To address these challenges, embracing a comprehensive human resource retention framework is imperative. This study emphasizes the urgent need for proactive measures to ensure the sustainability and contentment of dental therapists, ultimately benefiting the healthcare system and the communities it serves. Addressing these factors will lead to increased retention rates and improved access to basic oral health services nationwide
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    Exploring the relationship between orphanhood status, living arrangements and sexual and reproductive health outcomes among female adolescents in Southern Africa
    (University of the Witwatersrand, Johannesburg, 2024) Shoko, Mercy; Kahn, Kathleen; Ginsburg, Carren
    Adolescent Sexual and Reproductive Health (ASRH) is high on the global development agenda. Among the respective research conducted is the various social contexts that may contribute to adverse SRH outcomes, including the overlapping issues of orphanhood and living arrangements. These are crucial given that the presence or absence of parents emerges as critical for the sexual and reproductive well-being of adolescents. While orphanhood, particularly in the context of the HIV epidemic in Southern Africa, receives considerable attention, this study highlights a noteworthy gap in the literature – the limited focus on living arrangements and its influence on ASRH, often overshadowed by orphanhood. This research is important given the evidence suggesting that the African traditional kinship care systems offer support for orphans. However, recent research also highlights the crucial role of biological parents in providing effective care and support for adolescents. The study aims to contribute by exploring the relationship between orphanhood status, living arrangements, and ASRH in Southern Africa. Utilising cross-sectional Demographic and Health Survey (DHS) data, the analysis delves into key dimensions of SRH, including sexual debut, HIV knowledge, and adolescent fertility, which are all critical links to HIV risk. The findings underscore a significant association between non-coresidency with parents, whether due to orphanhood or separate living arrangements, and a heightened risk of adverse SRH outcomes. This suggests that interventions aimed at addressing adolescent SRH in Southern Africa should encompass a holistic understanding of parental presence or absence. The study emphasises the complex interplay between orphanhood, parental absence, and various individual, household, and geographic factors that collectively contribute to the vulnerability of female adolescents in the context of ASRH. Despite that the results suggest that the data on orphanhood and living arrangements may be of acceptable quality, the study recognises the potential for detailed insights through future research employing longitudinal data. Such an approach could offer a more nuanced and comprehensive understanding of ASRH over time, subsequently informing targeted policies and interventions in the unique socio-cultural context of Southern Africa