School of Public Health (ETDs)

Permanent URI for this communityhttps://hdl.handle.net/10539/37953

Browse

Now showing 1 - 20 of 75

Understanding intimate femicide in South Africa
(2010-09-22) Mathews, Shanaaz
When a woman is killed she is most likely to be murdered by an intimate partner. This form of homicide known as intimate femicide is conceptualised to be the most extreme consequence of intimate partner violence. Not much is known about such killings in South Africa or in other developing settings. This thesis studied intimate femicide using two complimentary studies from two methodological perspectives. The first study was quantitative with the aim of describing the incidence and pattern of intimate femicide in South Africa. The second study used qualitative methods and explored the social construction of the early formation of violent masculinities. Five papers written from these two studies are presented in this thesis. Study one was a retrospective national mortuary-based study and collected data on all female homicides, 14 years and older, who died in 1999 from a stratified, multi-stage sample of 25 mortuaries. Data was collected from the mortuary file, autopsy report, and a police interview. The second study used a cluster of qualitative in-depth interviews with 20 incarcerated men in prison who have been convicted for the murder of an intimate partner, as well as interviews with family and friends of both the perpetrator and the victim. Overall it was found that 50.3% of women murdered in South Africa are killed by an intimate partner, with an intimate femicide rate of 8.8/100 000 and an intimate-femicide suicide rate of 1.7/100 000 females 14 years and older. Blunt force injuries were shown to be associated with intimate killings, while gun ownership was associated with intimate femicide-suicides. vi elevated Blood Alcohol Concentration (BAC) combined with unemployed status was also found to be associated with intimate killings. The qualitative study showed that traumatic childhood experiences such as violent and neglectful parenting practises particularly by mothers made these men feel unloved, inferior and powerless with this found to be a pathway to violent models of masculinity used as a means to attain power and respect. This study shows that such traumatic experiences can lead to a suppression of emotions. It is argued that cognitive dissonance act as a protective mechanism which allows these men to perpetrate acts of violence without consideration of its impact. These findings suggests that intimate femicide is a complex phenomenon with a “web” of associated and mediating factors which all contribute to it excessive levels in South Africa. It shows that intimate femicide is an extension of intimate partner violence and as such has to take into account the unequal gender relations in society. Building gender equity and shifting patterns of femininity and masculinity is a key strategy in reducing this form of violence.
Levels and factors associated with homicide-related deaths in a rural South African population
(2011-03-25) Otieno, George Omondi
Background: World Health Organization (WHO) estimates that more than 1.6 million people die every year because of violence and out of these deaths, homicide accounts for almost one third. Ninety percent (90%) of homicide are thought to occur in low and middle income countries. South Africa has one of the most disturbing rates of homicide in the world. These high homicide rates besides resulting in reduced life expectancy also have serious health, social and economic consequences. Aim: The study aimed at quantifying the burden as well as and identifying factors associated with homicide deaths in rural KwaZulu-Natal in South Africa during the period of 2000 to 2008. Objectives: To estimate a 9 year period (2000-2008) homicide incidence rates as well as identify factors associated with homicide-related deaths. Further, the analysis described spatial distribution of homicide-related deaths in a rural South African population. Design: Analytical longitudinal study. Methods: Using data drawn from the Verbal Autopsies (VAs) conducted on all deaths recorded during annual demographic and health surveillance over a 9-year period (2000-2008), Kaplan-Meier (K-M) survival estimates of incidence rates were used to estimate the cumulative probability of death until the end of the period. Estimates were reported by sex and residency. Weibull regression methods were used to investigate factor associated with homicide deaths. Kulldorff spatial scan statistics was used to describe homicide clustering. Results: With 536 homicide-related deaths, and 814, 715 total Person Years of contribution, the study found an overall incidence rate of 66 (95% CI= (60, 72) per 100, 000 Person Years of v Observation (PYOs) for the period studied. Death due to firearm was reported the leading cause of mortality (65%). Most deaths occurred over the weekends (43%), followed by Friday (16.2%).The highest homicide incidence rates were recorded in 2001 (90; 95% CI= (71, 111) per 100,000 person years at risk and 2004 (86; 95% CI= (68, 108) per 100,000 person years at risk. Males had a rate that was about six times more than females 115 (95% CI=105,127) per 100,000 PYOs. Age-specific homicide rate were highest among males aged 25-29 years (209.90 per 100,000 PYOs) and females aged 50-54 years (78 per 100,000 PYOs). Resident, age, sex, education, socioeconomic status, and employment independently predicted homicide risk. The study identified two geographical clusters with significantly elevated homicide risk. Conclusion: A significant six fold difference in homicide rate existed between males and females. Sex differential increases with age, with males aged 15-54 years the most likely to be killed, and females aged 55 years and above having the highest homicide rate. Increase in wealth status and level of education increases one‘s risk of homicide. Employment per se was protective from homicide risk. Firearm was the leading cause of mortality. Most deaths occur over the weekend. Two geographical areas with elevated homicide risk were observed. These findings underscore the need to have timely information and strategies for effective violence prevention program to subgroups and areas at risk.
The relationship between awareness of violence against women prevention campaigns and gender attitudes and talking about violence among women in Gauteng
(2016-10-12) Mataba, Rumbidzayi B.
Introduction: Gender based violence (GBV) is a public health problem with as many as 35% of women having been subjected to either physical and or sexual violence globally. Gender attitudes and silence around gender based violence, are factors that exacerbate GBV. Global and local awareness campaigns are means for preventing violence against women. Campaigns have the potential to challenge women and men’s underlying gender beliefs and attitudes that contribute to unequal power relations between women and men. The overall objective of this study was to examine the association between awareness campaigns and gender attitudes or talking about domestic violence among women in Gauteng, South Africa. Materials and Methods: This study is a secondary analysis of data from a cross-sectional study conducted in Gauteng, South Africa from April to July 2010. The study aimed to describe the prevalence and patterns of experiences of GBV, HIV risk, gender attitude and awareness of GBV prevention campaigns in Gauteng. The main exposure variable in this study is having heard about 16 Days of Activism for No Violence Against Women and Children campaign and the 365 Days National Action Plan to End Gender Based Violence. The two primary outcomes are gender attitudes and discussing about domestic violence. Gender attitudes were measured using three scales: the Gender Equitable Women’s Scale, the Ideas about Gender Relations Scale and the Ideas about Rape Scale. Univariate analysis was conducted to describe the socio-demographic characteristics, awareness of campaigns, gender attitudes and talking about domestic violence among the participants. Multivariate analysis was conducted to examine the associations between awareness of campaigns and the outcomes while adjusting for age, education, employment, nationality, race and relationship status. Results: The results show that only a minority of the participants had heard of the 16 Days of Activism for No Violence Against Women and Children campaign (32.6%) and the 365 Days National Action Plan to End Gender Based Violence (9.2%) campaigns. Most of the participants had progressive gender attitudes; GEWS (71.7%), IGRS (82.1%) and the IRS (88.1%) while less than half (48.7%) had spoken about domestic violence to someone else. Women who were exposed to the 16 Days of Activism for No Violence Against Women and Children campaign were twice as likely to have progressive gender attitudes measured by the Gender Equitable Women’s Scale (aOR 2.2, 95% CI 1.2-3.8) compared to those who had not been exposed. Education, relationship status and nationality were found to be significantly associated with gender attitudes on the same scale. No association was found between awareness of 16 Days of Activism for No Violence Against Women and Children campaign and gender attitudes measured through the Ideas about Gender Relations Scale and the Ideas about Rape Scale. Awareness of 16 Days of Activism for No Violence Against Women and Children campaign was also associated with talking about domestic violence (aOR 1.9, 95% CI 1.2 - 3.0). Age and education were also significantly associated with talking about domestic violence. Gender attitudes were also significantly associated with talking about domestic violence (aOR 1.2 95% CI 1.1 – 3.6). No association was found between exposure to the 365 Days National Action Plan to End Gender Based Violence and gender attitudes or talking about domestic violence. Conclusions: From this study, the majority of the women interviewed had progressive gender attitudes. However, the majority of the women had never spoken about domestic violence to someone else. Women exposed to GBV campaigns had more progressive gender attitudes and spoke about domestic violence more than those who were not exposed. These findings are evidence to the need for wider coverage and different messaging approaches in the implementation of GBV campaigns in South Africa. Wider coverage of campaigns is only possible with more funding for national, provincial and local GBV programmes. Key messages in GBV campaigns need to include a priority focus on addressing the underlying social and cultural norms that contribute to the imbalances of power due to gender difference.
Transformation of human resources for health in South Africa: contributions to knowledge and policy
(2022) Rispel, Laetitia Charmaine
A health system is defined as “all organisations, people, and actions whose primary intent is to promote, restore, or maintain health. This includes the organisation of people, institutions, and resources (also known as the building blocks) that deliver health care services, as well as intersectoral action to address the determinants of health” (WHO, 2007, p. 2). The core goals of health systems are to improve population health outcomes, ensure responsiveness to communities, and make efficient use of available resources (WHO, 2000).
The psychosocial work environment of women construction workers: an integrative literature review
(2022) Williams, Thato Leslie-Ann
Background: There is an increase in the number of women in the construction industry, which was considered as a masculine trade for decades. This is prone to have a bearing on the psychosocial work environment of women employed in this male dominated field of work. Women face unique challenges as opposed to their male counterparts who are employed in the same trade. These challenges include discrimination, sexual harassment, overlooked for promotions and being office bound regardless of education. These challenges can impact the psychosocial work environment of women in the workplace, which can result in them opting to exit the industry. Aims and objectives: To gather and critically analyse scientific literature to describe the psychosocial work environment of women employees in the construction industry. Design: An integrative literature review using the Whittemore and Knafl (2005) framework’s stages was used. These stages included problem identification, literature search, data evaluation, data analysis and presentation of findings. Methods: A comprehensive literature search was performed using Asce Library, Emerald, Science Direct electronic databases and from reference list of included articles. The studies were in English, published between January 1993 to November 2018. A total of 3764 studies were retrieved from the search. The inclusion and exclusion criteria were applied, and 57 studies were eligible for abstract reading, which yielded 7 eligible studies that were used in the study. Results: Four themes that emerged include, less representation of women in the construction industry due to inability of retaining women. Discussion and conclusion: Discrimination due to the benevolent sexism that women face. Stressful work environment which is amplified for women as it affects work-life balance. Labour laws, they are implemented and hardly reviewed. Women are an un-tapped resource and by eradicating these challenges by interventions the industry can be inclusive.
Exposure and risk assessment of benzene, toluene, ethyl benzene and xylene (btex) in a petrochemical depot at Heidelberg, South Africa
(2022) Mdlalose, Richard John
Background: The International Labour Organization estimated 2.2 million workers are dying yearly from work-related accidents and occupational diseases, whilst about 270 million suffer serious injuries, and 160 million become ill due to their work. It is further estimated that work-related accidents and diseases cause 4% of annual Global Gross Domestic Product or US $1.25 trillion due to lost working time, workers’ compensation, the interruption of production, and medical expenses. In 2005, the ILO estimated that 440 000 people died throughout the world because of exposure to hazardous chemicals. In 2018 chemicals production was the second largest production sector in the world. Chemicals are indispensable and critical part of life. Their visible positive outcomes are quite palpable. They are well recognized for instance pesticides improve the quality of food production, pharmaceuticals cure illness, cleaning products help to establish hygienic living conditions. Chemicals are key development of final products that make life little easy for human beings, etc. Controlling employees ‘exposure to chemicals and preventing or minimizing emissions remains a significant challenge in workplaces throughout the world. The production, storage, and handling of petrochemical products particularly BTEX emissions are known and associated with potential harm to human and aquatic organisms. Some of the health effects associated with exposure to BTEX are the health effects on hematopoietic system, including pancytopenia. The benzene exposure leads to an acute myelogenous leukemia. The exposure to toluene, ethylbenzene, and xylene have been linked to the damaging the central nervous system and irritation of the respiratory system. Benzene and ethylbenzene are confirmed carcinogens (Benzene is classified as a Group 1 and ethylbenzene is a Group 2 B carcinogens). Purpose: To characterize, assess exposure and health risk assessment to benzene, toluene, ethylbenzene, and xylene (BTEX) at the petrochemical depot at Heidelberg in Gauteng, South Africa. Methods: Exposure sampling was done using a MiniRAE 3000 Photoionization detector (PID). The PID (equipment) was calibrated before the commencement of the monitoring program following the manufacturer’s operating manual. The PID equipment was used to collect the BTEX samples. The PID was mounted on a marked tripod stand at 1.5 m above ground and approximately 0.2 m to 0.5 m in the microenvironment (Exposure scenario) of the depot workers (Controllers and/or laboratory assistant) with the probe extended or placed within 30cm of the breathing zone of the depot workers. Sampling was conducted at three different exposure scenarios (workstations) i.e., density huts, laboratory, and during plant equipment cleaning in the plant (strainer removal) over three days period. The sampling started from 08h00 to 17h00. One workstation was sampled per day. The sampling of BTEX per workstation took 30 minutes per hour over ten hours, every hour BTEX was sampled for a duration of 30 minutes and in totality ten samples were collected per 12- hour shift, a total of 30 BTEX samples were collected over the 3 days period. Additionally, the measured BTEX concentrations were used to obtain dose estimates. Data from the equipment was exported to a Microsoft Excel spreadsheet. All outliners were removed from the data and a correction factor was applied to derive the final concentration. Thereafter, statistical tests using student F-test and Test were performed to evaluate for significant differences amongst paired comparisons. Results : The highest average BTEX concentrations were measured in the laboratory, followed by density huts and the least was measured during the removal of the strainer (plant equipment cleaning). The activity areas (exposure scenarios) served as direct sources for the BTEX vapours. The average benzene concentrations measured in three activity areas ranged from 469 ppm to 542 ppm. The highest benzene concentration was found to be 542 times higher than the current South African Occupational Exposure Limits of 1ppm. The average toluene concentrations measured ranged from 1335 pm to 1542 pm; the highest toluene concentration was found to be more than 30 times above the South African Occupational Exposure Limits of 50 ppm. The average ethylbenzene concentrations measured ranged from 433 ppm to 500 ppm; the highest concentration was found to be 5 times above the South African Occupational Exposure Limits of 100 ppm. The average xylene concentrations measured ranged from 1372 ppm to 1584 ppm, the highest concentration was found to be more than 15 times above the South African Occupational Exposure Limits of 100 ppm. All the measured BTEX compounds were found to be above their respective South African Occupational Exposure Limits. The cancer risk was determined to be 13 x 10-2 (male) and 10 x 10-2 (female), 14 x 10-2 (male) and 11x 10-2 (female), 16 x 10-2 (male) and 13 x 10-2 (female), 12 x 10-3 (male) and 10 x 10-3 (female) for the workers in the density huts, laboratory, strain remover (plant equipment cleaning), respectively. In all exposure scenarios (male and female) the cancer risk was found to be higher than the acceptable risk levels of 1E-4 . There were 13 males and 10 females in the population of 100 controllers who were likely to develop cancer when working density huts environment. In the laboratory work environment, 14 males and 11 females in a population of 100 controllers were likely to develop cancer, whereas 16 males and 13 female laboratory workers were likely to develop cancer in a population of 100 laboratory workers, and during plant equipment cleaning 12 males and 10 female controllers were likely to develop cancer in a population of 1000. Therefore, the potential of developing cancer was heightened by working in the laboratory and density huts. The risk of the number of employees who were likely to develop cancer was reduced when doing plant equipment cleaning. In all three activity areas, cancer risk for males was higher than for their female counterparts. This finding denotes that male were more vulnerable than females even though the exposure concentration is the same. The higher number of males who were likely to develop cancer in all the activity areas were influenced by two factors i.e., males have a shorter average life expectancy and higher average body weight versus their females’ counterparts. A hazard quotient was used to determine the non-carcinogenic health effects, a hazard quotient of greater than 1 was used as a reference value. A value greater than 1 denoted a higher possibility that depot workers will get health effects from exposure to the Toluene, ethylbenzene, and xylene (TEX). The hazard quotient for males ranged from 4.6 to 577.5, the highest hazard quotient was more than 577 times above the HQ reference value. The lowest was at density huts for xylene and the highest was at the laboratory for a chemist for xylene. The hazard quotient for females ranged from 3.15 to 399.00, the highest hazard quotient was more than 399 times above the HQ reference value. The lowest was at density for xylene and the highest was at the laboratory for laboratory assistant. From the results, both males and females had a hazard quotient far above 1 which means health effects arising from TEX exposure were anticipated. Conclusion: The results showed highest constant BTEX concentrations in the three exposure scenarios over the 12 hours shift. The BTEX emissions were generated by activities that were performed by the depot workers. Highest BTEX concentrations were measured at laboratory, followed by density huts and the least was measured during the removal of the strainer (plant equipment cleaning). The lack of effective vapour recovery system and natural ventilation in the laboratory and in density huts also contributed to the high BTEX concentrations measured in these areas. Individual BTEX component results measured in the three activity areas indicated concentrations that were far above the South African Occupational Exposure Limits for individual BTEX. The cancer risk score was found to be far above the reference USEPA cancer risk value and denoting that depot workers were likely to develop cancer. The hazard quotient for the three exposure scenarios was also found to be greater than the reference value of 1 which indicates the potential to develop non-carcinogenic health effects due to exposure in three exposure scenarios. Recommendations: The following recommendations are made to assist management of the depot to control employees’ exposure to BTEX emissions per activity area: Density huts: The practicality of introducing a vapour recovery system on workbenches to extract the VOCs generated during sample collection and from density measuring jugs should be investigated or alternatively, the introduction of an online fuels and density analysis should be investigated or the practicality of introducing sample bombs to collect fuel samples should be investigated. Keep the windows opened to promote an ingress of fresh air and allow BTEX emissions to escape. A practicality of introducing a controlled mechanical ventilation to blow vapours away from the breathing zone of the depot workers should be investigated. Laboratory: The practicality of automating or modifying the GC equipment in the laboratory to be able to conduct an online petrochemical analysis to control employees’ exposure should be investigated. The tasks that require rinsing of testing tubes with fuels, refilling of the testing tubes, and discarding of superfluous samples should be performed under controlled conditions, the practicality of introducing a vapour recovering system to control vapours emissions should be investigated. The current practice of keeping the decanting drum open should be discontinued to prevent the accumulation of vapours in the laboratory or alternatively, it should be kept under a vapour recovery system. The practicality of keeping the retained fuel samples under the vapour recovery system in the laboratory storage should also be investigated. The fume hood and two extraction units should be serviced on a regular basis. Cleaning of plant equipment (strainer removal): The practicality of automating the removal and lifting the strainer to be cleaned to increase the distance between the strainer and receptors (controllers) should be investigated. The practicality of putting the clogged-up strainer in degreaser bath to remove and clean the strainer with the view of automating the task to prevent employees ‘exposure to VOC emissions. Recommendations applicable to all activity areas: Employees exposed to BTEX including the other petrochemicals should undergo a risk-based medical surveillance program including biological monitoring to evaluate the efficacy of the existing controls and as part of a preventative medical surveillance program. Provide information, instruction, and training at regular interval about: - petrochemicals (BTEX) that employees are potentially exposed to at workplace and duties of persons who are likely to be exposed to VOCs vapour. The names and potential harmfulness of the BTEX at the workplace and the employees who are likely to be exposed. Significant findings of the BTEX exposure assessment (an occupational health risk assessment survey). Information on how to access the relevant safety data sheets and information that each part of an SDS provides. The work practices and procedures that must be followed for the use, handling, storage, transportation, spillage, and disposal of samples, in emergency situations, as well as for good housekeeping and personal hygiene. The necessity of personal exposure air sampling, biological monitoring, and medical surveillance; The need for engineering controls and how to use and maintain them. The need for personal protective equipment, including respiratory protective equipment, and its use and maintenance. The precautions that must be taken by an employee to protect themselves against health risks associated with exposure, including wearing and using protective clothing and respiratory protective equipment. The necessity, correct use equipment, maintenance and potential of safety facilities and engineering control measures provided. Supervisor/Line Manager must give written instructions of the procedures to be followed in the event of spillages, leakages, or any similar emergency situations to employees. Once the aforementioned information, instruction and training have been provided, enforce the wearing of the prescribed PPE including ABEK respirator and no employee should be allowed to enter and remain in respiratory zone without the prescribed PPE and respiratory protection equipment (ABEK respirator).
Evaluation of implementation fidelity to national guidelines on management of tuberculosis in paediatric patients in Homa-Bay County, Kenya
(2022) Kiptoon, Sharon Cherono
Background: Tuberculosis (TB) has been a major public health concern for a long time. Infection in children has not been given a lot of focus as in adults despite children being a vulnerable population with weaker immunity. Prognosis is worse when there is HIV/TB coinfection. The WHO rolled out guidelines for the management of TB in pediatric patients which were adopted by the Kenya Government. Health care workers then implement the guidelines. The Objectives of this study were to measure adherence to national guidelines on the management of Tuberculosis in Pediatric patients (up to 14 years) and to identify moderators affecting implementation fidelity. Methods: A convergent parallel mixed method design was used to collect information from TB treatment sites in Homa bay County. The study was conducted during the months of August, September and October 2018.Quantitative data collected focused on Pediatric patients between ages zero and 14. A checklist based on the guidelines was designed to review 442 records in the clinics for a four-year period (2014 to 2018). Qualitative data was collected through in-depth interviews with eight Sub-County TB coordinators. Interview moderators were based on Carrol et al Implementation Fidelity framework. Summation of "yes" and "No" responses were tallied to get an adherence score for the County as a whole and for the sub-counties individually. The qualitative analysis used the thematic method in excel spreadsheets. Results: Results showed high adherence for the County with a median of 80% (IQR 66.66-93.33%). Four of the sub-counties with normally distributed scored had a mean score of 79% and while the other four had a median score of 80% (66.66 – 93.33). Guidelines which had low implementation fidelity scores were those involving follow up tests i.e., sputum, gene X-pert and X-ray during duration of treatment. In the qualitative aspect good facilitation strategies were found to be in place from both the County and national TB programs. An attitude of fear, lack of knowledge on infection prevention, lack of skills to produce specimens for TB testing and staff shortages affected quality of treatment delivery. The health care workers reported ease in following the guidelines especially with the roll out of new guidelines which simplified diagnosis of TB in children, drugs which are dispersible and in fixed dose combination. Participant’s response to the intervention was poor with both health care workers and patients expressing difficulties with direct observed therapy schedule which required frequent visits and frequent follow up tests. Conclusion and recommendations: In conclusion, implementation fidelity to guidelines on management of tuberculosis is high. Good facilitation strategies is a positive moderator towards achieving high implementation fidelity. The national TB program in Kenya is doing well so far in monitoring the process of guideline implementation once rolled out, however, to be able to achieve the sustainable development goal eradicating TB, further follow up is needed in the facilities to improve the levels of adherence from 80% to 100%. Use of the conceptual framework by Carroll has proved to be a good guide in evaluating healthcare worker’s performance in implementing treatment guidelines It is recommended that health workers should undergo more sensitization on why certain guidelines have been put in place e.g., repeating sputum samples at different phases of treatment in order to improve quality of care. More training on vital procedures e.g., gastric aspirate should also be done to improve health workers' confidence and ease diagnosis of TB at younger age. Further research on implementation fidelity on other evidence based interventions would go a long way to improve service delivery and ensure other program goals are met.
Determinants of sub-optimal glycaemic control among patients enrolled in a medicine dispensing programme in Kwazulu-Natal: A cohort study, 2018 – 2021
(University of the Witwatersrand, Johannesburg, 2023) Johnston, Leigh Clare
Background: In South Africa, type 2 diabetes mellitus (T2DM) is a growing public health problem, thus, by 2030, 50% of T2DM patients, receiving treatment, must achieve optimal glycaemic control (haemoglobin A1c (HbA1c) ≤7%). The CCMDD (Central Chronic Medicines Dispensing and Distribution) programme allows glycaemically-stable patients to collect their medication from community-based pick-up points. While the CCMDD is a large public health programme, there is a paucity in stakeholder’s knowledge of T2DM patients glycaemic control over time. We determined glycaemic control for CCMDD-enrolled T2DM patients in eThekwini, South Africa from 2018-2021, as well as the rate and predictors of becoming sub-optimally controlled. Methods: We performed a cohort study, linking HbA1c data from the National Health Laboratory Service to CCMDD-enrolled patients in eThekwini, South Africa from 2018–2021. We included patients optimally controlled at their baseline HbA1c, and having ≥1 repeat test available. We used Kaplan Meier analysis to assess survival rates and Cox regression to determine associations between time to sub-optimal control (HbA1c > 7%) and several factors. Adjusted hazard ratios (aHR), 95% confidence interval (95% CI), and p-values are reported. Results: Of 41145 T2DM patients enrolled in the CCMDD, 7960 (19%) had an available HbA1c result over the study period. A quarter of patients (2147/7960; 27%) were optimally controlled at their baseline HbA1c. Of those controlled at baseline, 695 (32%) patients had a repeat test available, with 35% (242/695) changing their status to sub-optimal control. Patients prescribed dual-therapy had a higher risk of sub-optimal glycaemic control (aHR: 1.503; 95% CI: 1.16–1.95; p-value=0.002) compared to those on monotherapy. HbA1c testing frequency per national guidelines (aHR: 0.46; 95% CI: 0.24–0.91; p-value=0.024) was associated with a lower hazard of sub-optimal glycaemic control. Conclusions: HbA1c monitoring, in line with testing frequency guidelines, is needed to flag sub- optimally controlled patients who become ineligible for CCMDD enrolment. Patients receiving dual-therapy may require special consideration. Addressing these shortfalls can assist planning and implementation to achieve 2030 targets.
The burden of severe Hepatitis A disease in South Africa’s public sector: A cross sectional study using routine laboratory data from 2016 to 2021
(University of the Witwatersrand, Johannesburg, 2023) Khoza, Mariana Makhanani; Mazanderani, Ahmad Haeri; Somaroo, Harsha
Background Hepatitis A virus (HAV) is a common cause of acute viral hepatitis in South Africa, however, there is limited data on the burden of severe HAV disease in the South African population. Objective To describe the burden of severe HAV disease in South Africa’s public sector by describing the prevalence of laboratory diagnosed acute liver failure (ALF) in patients with HAV infection, during the period January 2016 to December 2021. Methods This was a cross-sectional study using retrospective secondary data from the National Health Laboratory Service (NHLS), from January 2016 to December 2021. Laboratory patient records that were positive for HAV IgM were extracted and merged with International Normalised Ratio (INR) test records, using the NHLS Corporate Data Warehouse (CDW) record linking algorithm. All patients with a positive HAV IgM result linked to an INR result >1.5 were reported as having laboratory diagnosed ALF. Descriptive statistics and regression analyses were conducted using STATA 17 SE. Results A total of 15 261 laboratory patient records were positive for HAV infection. Of the patients with HAV infection a total of 7 824 (51.27%) were linked with an INR test result, and of those a total of 1 420 (18.15%) patients had ALF. The average annual burden of patients with ALF was 237 patients per year (range: 136–333). Children <10 years had the highest number of HAV infections (n= 6 227, 40.80%) and ALF (n=576, 40.56%) for the study period. Patients 50-59 years with HAV infection were most likely to have ALF compared to children <10 years (OR 2.95, 95% CI 2.207 - 3.935, p<0.000). Conclusion Whereas adults with acute HAV infection are more likely to develop ALF, severe HAV disease is predominantly a childhood disease in South Africa. This study emphasises the need to strengthen HAV prevention strategies to limit the incidence and burden of severe HAV disease
The in vitro diffusion across exercised porcine skin of various formulations of compounds used topically in the treatment of skin afflictions
(University of the Witwatersrand, Johannesburg, 2023) Elonga, Jessica; Eyk, Van
Introduction and Aim: Skin afflictions have been treated with topically applied active compounds since the ancient Greek era. Topical compounds mostly avoid first-pass metabolism and move directly into the local region of the skin or mucous membranes to exert their therapeutic effects. In this study, the aim was to investigate the in vitro diffusion characteristics of active compounds commonly used in topical formulations, such as caffeine, theophylline, retinol, L-carnitine, and Co-enzyme Q10 across porcine skin, used as a model for human skin. These compounds were tested alone and in combination within different topical formulations (liquid, gel, and cream) to investigate skin permeation, skin accumulation and effect on skin integrity. Methods: Method development and validation were performed to detect and quantitate all compounds tested by using a RP C18 HPLC system. Mobile phases included the following: caffeine and theophylline (Methanol:water [40:60], 20oC), retinol (Methanol:water [95:5], 20oC), L-carnitine (Sodium Phosphate buffer (pH 3.0):Methanol [99:1], 40oC) and Co-enzyme Q10 (Methanol:2-propanol [40:60], 25oC). All analyses were performed at 1 ml/min and injection volume of 20 μl. In vitro diffusion studies were performed using a PermeGear 7-in- line flow-through system. Either caffeine (2.5%), theophylline (2%), retinol (0.3%), L-carnitine (2%) or Coenzyme Q10 (0.5%) in various formulations alone, and in combinations were loaded into the donor compartments and PBS (pH 7.4) was pumped through the acceptor chambers at 1.5 ml/h (32°C, over 4 hours and 24 hours). The fluid collected (every 30 min or 2 hours) was analysed by RP HPLC. Skin accumulation for each compound was performed after completion of each experiment and skin integrity was established by measuring tissue resistance. Results: HPLC methods were found to be sensitive and valid for linearity, precision, accuracy and robustness. Retention times were as follows: caffeine 2.57±0.02 min, theophylline 2.18±0.03 min, retinol 2.91±0.02 min, L-carnitine 3.0±0.009 min and Co-enzyme Q10 3.15 ±0.003 min. From the in vitro diffusion studies of active compounds alone, caffeine within all formulations had the highest diffusion rate compared to theophylline and L-carnitine (caffeine>theophylline>L-carnitine). Retinol and Co-enzyme Q10 did not diffuse across the skin within a 24-hour time-period. In combination with Co-enzyme Q10, the diffusion of caffeine increased from both gel and cream formulations (p<0.05), while retinol increased the diffusion of theophylline from a liquid formulation (p<0.05). Theophylline increased the diffusion of L-carnitine from both liquid and gel formulations (p<0.05). Liquid and gel formulations without compounds, decreased the skin’s integrity after 24 hours and 2 hours, respectively. After 24 hours, the skin’s integrity decreased after exposure to all compounds tested (liquid and gel formulations), while the cream formulation mostly kept the integrity of the skin intact. Caffeine accumulated much more in the skin (>13%) compared to all the other compounds (<2.5%) for all three different formulations tested (caffeine>>L- carnitine>theophylline>retinol>Co-enzyme Q10). Combination studies mostly caused a decrease in accumulation of all compounds within the skin, except the following: retinol increased theophylline accumulation from a gel formulation and vice versa, Co-enzyme Q10 increased caffeine accumulation from all formulations and L-carnitine’s accumulation mostly increased when combined with other compounds. Conclusion: Caffeine was found to diffuse across and accumulate within the skin to a higher extent as compared to all the other compounds due to its ideal physicochemical characteristics. Very lipophilic compounds like retinol and Co-enzyme Q10 only accumulated to some degree in the skin. The findings indicated that the preferable combinations to increase efficacy, would be Co-enzyme Q10 in combination with caffeine, especially from a cream formulation, retinol in combination with theophylline (gel) and any of the compounds combined with L-carnitine (gel and cream). Cognisance must however be taken about possible systemic side effects
The relationship between mental distress and somatization in hospital based health care workers in Gauteng during covid-19 pandemic in 2020
(University of the Witwatersrand, Johannesburg, 2023) Ramuedi, Ntsako Khosa; Kerry Wilson, Nioh
Background Mental distress among Health Care Workers (HCWs) is an urgent health concern, and somatization is a known outcome of mental distress. The Covid-19 pandemic increased stress for HCWs globally due to working with Covid-19 patients and resource limitations. Although there was already a lot of mental distress in HCWs in prior years, the coronavirus pandemic made matters worse, with 45% of people reporting that the pandemic had a significant negative impact on their lives. Somatization can lead to increased use of health services, sick leave and poor health. Service delivery is also impacted negatively if the service providers are not well or are suffering from the mental distress and are also showing symptoms. Aim To identify if a relationship exists between mental distress and somatization symptoms in Gauteng hospital-based health care workers in 2020. Objectives. To describe the prevalence of mental distress and somatization among health care workers by socio demographic status. To identify the somatization symptoms associated with high GHQ-12 scores in health care workers during Covid-19. To describe the association between mental distress and somatization among health care workers during covid-19 adjusting for demographic variables. Methods Health care workers can be described as anyone working in the health sector or at a health facility. All staff in the three selected hospital facilities in Johannesburg, were given the opportunity participate in the study. The PHQ-15 and GHQ-12 tools were used to collect information on HCWs somatization and mental distress after the first wave of the Covid-19 pandemic in South Africa. The anonymous questionnaire consisted of the two tools and demographic questions was used. The responses to each question on the tools were summed in order to determine severity of mental distress and somatization in HCWs, a higher score indicating more stress and or more somatization. Logistic regression was used to determine the adjusted relationship between somatization and mental distress. Results The study had a sample size of 295. A large proportion of participants (52%) reported suffering somatic symptoms. Males mean somatization score was significantly lower than the females. The majority (62%) of HCWs were troubled indicating a high burden of mental distress in the health care sector. The most commonly reported symptoms were back pain, headaches and being tired or low energy, all three were significantly associated with mental distress among others. There was a positive moderate correlation between PHQ-15 and GHQ-12 scores (0.30592) (p < 0.0001). Logistic regression indicated somatization was significantly associated with mental distress with a significant OR 2.14 (p = 0.0029) adjusted for demographic factors in these workers. Conclusions There was a statistically significant positive relationship between somatization and poor mental health. Health care workers with mental distress may be at risk of somatization, particularly specific symptoms such as back pain, headache and having low energy. Females were more bothered by most of the somatoform symptoms as compared to their male counterparts. Support for health care worker’s mental health is required as well as increased awareness of somatization linked to mental distress. Policies and services need to be developed to protect and support HCWs mental health during times of stress in the sector
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
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.
Evaluation of osayidelera, a campaign addressing risk perceptions of COVID-19 in Blantyre, Malawi
(2024) Maganga, Chiyembekezo Focus
Background- Osayidelera COVID-19 was a national campaign that was implemented as part of Malawi’s Risk Communication and Community Engagement response for the pandemic. The campaign was designed to address low COVID-19 risk perceptions and enhance compliance to preventive behaviours. Despite massive resources that were channeled towards the campaign, there were no studies that had evaluated the effectiveness of Osayidelera in addressing low risk perception in Malawi, and that had measured the association between the risk perceptions and preventive behaviours in Malawi. This study set out to change that, by testing associations between exposure to the campaign and both risk perceptions and protective behaviours in the context of Blantyre, one of areas hardest hit by COVID-19 in Malawi. Methods- A cross-sectional survey was conducted in Blantyre from 6 to 20 May, 2022. A sample of 224 adults (18 and older) were drawn from rural, peri-urban and urban locations in Blantyre using a multi-stage sampling technique. Data were cleaned in Microsoft Excel and analysed in STATA. Descriptive statistics were used to characterise the study sample, campaign exposure, risk perceptions and behaviours. Logistic regression models were used to test associations between campaign exposure and risk perceptions, and risk perceptions and protective behaviours. Results- Overall, 63% of the sample reported low COVID-19 risk perceptions. The only sociodemographic variables associated with low risk perception in the multivariate logistic vi model were those who were divorced (aOR=0.20, p=0.046 CI=0.04-0.97) and widowed (aOR=0.10, p=0.009 CI=0.02-0.57); they had significantly lower odds of low risk perceptions than those who were single. Exposure to COVID-19 campaign was generally low, with only 27% of the respondents reporting high levels of exposure. The proportion of respondents who could recall exposure to the name “Osayidelera” was even lower, at 16%. In the multivariate logistic model, males had higher odds of high exposure to the campaign as compared to females (aOR=3.75, p=0.001 CI=1.66-7.69) with those odds even higher among respondents in periurban areas versus rural areas (aOR=6.15, p=0.043 CI=1.06-35.71). High COVID-19 knowledge was also significantly associated with exposure to the COVID-19 campaign (aOR=2.48, p=0.013 CI=1.21 - 5.06). The results showed no significant association between campaign exposure and risk perceptions (p>0.05). In the adjusted multivariate logistic regression model, only those living in Blantyre urban had significantly higher odds of low risk perceptions as compared to those living in Blantyre rural (aOR=4.83, p=<0.001, CI= 2.15- 10.85) All other factors were non-significant. Finally, we found that adherence to preventive behaviours was generally poor, with only 29% reporting high levels of adherence, regardless of their COVID-19 risk perceptions. Risk perceptions were not associated with preventive behaviours. Conclusion- This study established that there was low reach of the campaign in Blantyre, and that the relationship between risk perceptions and adoption of preventive behaviours was not as strong and positive as hypothesized by the campaign. Campaign designers may need to revisit assumptions about their theory of change. The study contributes to growth of scholarship on health promotion campaigns and risk communication by showing factors associated with the reach of the campaign and with risk perceptions
A survey of the professional quality of life of pharmacists and rehabilitation therapists at three public sector hospitals in Gauteng, South Africa
(2024) Moyo, Nonkazimulo
Background- The global goal of Universal Health Coverage (UHC) cannot be achieved without a wellmotivated and productive health workforce. Central to their motivation and productivity is the notion of professional quality of life (ProQOL) that captures both the positive and negative emotions of caring work. However, there is a dearth of empirical studies on the ProQOL of pharmacists and rehabilitation therapists, especially in an African setting. Study aim -The aim of the study was to examine the self-reported ProQOL of pharmacists and rehabilitation therapists at three public sector hospitals in the Gauteng Province of South Africa. Methodology- During 2021, a cross-sectional analytical study was conducted at three public sector hospitals in the Gauteng Province of South Africa. Following informed consent, all eligible pharmacists, pharmacist assistants, occupational therapists, physiotherapists and speech therapists and audiologists completed a self-administered questionnaire electronically. In addition to sociodemographic information, the questionnaire obtained information on compassion satisfaction, burnout, and secondary traumatic stress using the ProQOL scale (version 5) and work-related experiences during the COVID-19 pandemic. STATA® 17 was used for descriptive and multivariate analysis of the survey data. Results- A total of 118 pharmacists and rehabilitation therapists completed the survey. The majority were female (83.00%), single (63.46%), with mean age 30.77 years (SD=9.08). The results revealed moderate mean scores for compassion satisfaction (39.62; SD=5.48), burnout (24.26; SD=5.12) and secondary traumatic stress (23.03; SD=6.31). The predictors of compassion satisfaction were moderate positive COVID-19 experiences score (β=+2.61;95% CI 0.54; 4.68; p=0.014) and high positive COVID-19 experiences score (β =+ 2.68; 95%CI 0.40; 4.96; p=0.021); moderate overall job satisfaction score (β =+ 3.17; 95% CI 0.16; 6.18; p=0.039) and high overall job satisfaction score (β =+ 7.26; 95% CI 4.06; 10.47; p<0.001). The predictors of burnout were being single (β=+2.02 95% CI 0.07; 3.97; p=0.042), full professional registration (β=+4.23; 95% CI 1.79; 6.67; p=0.001), direct involvement in patient care (β=+3.24; 95% CI 0.22; 6.26; p=0.036) and reporting a heavy workload (β=+ 2.61; 95% CI 0.75; 4.48; p=0.007). The predictors of secondary traumatic stress were being male (β=+ 3.26; 95% CI 0.36; 6.15; p=0.028), and full registration (β=+ 5.72; 95% CI 2.41; 9.03; p<0.001). Conclusion- The ProQOL of pharmacists and rehabilitation therapists is influenced by a combination of individual, workplace, and health system factors, suggesting the need for a multifaceted approach to optimise their contribution to the achievement of UHC. Such approach should include provincial health, hospital management, and peer support as well as self-care activities.
The impact of the covid-19 pandemic on essential public healthcare services in Gauteng province, South Africa
(2024) Fonka, Cyril Bernsah
Background: The Covid-19 pandemic like previous outbreaks has the potential to adversely impact essential healthcare services. Even though the Gauteng province was considered the epicentre of the Covid19 outbreak in South Africa, there is no comprehensive assessment of the effect of Covid-19 on the service utilisation, delivery and health outcomes of routine healthcare services in Gauteng province. Aim: To assess the impact of the Covid-19 pandemic on the utilisation, delivery and health outcomes of essential maternal, neonatal and child health (MNCH) services in Gauteng province, South Africa. Methods: This was a mixed methods study. A longitudinal study design was used to analyse data from the District Health Information Software (DHIS). We compared key MNCH indicators in the pre-Covid-19 period (March 2019-February 2020) to corresponding periods during the Covid-19 outbreak (March 2020- February 2021). The differences were analysed using time plots, linear regression, and Interrupted Time Series Analysis (ITSA) in Stata 17.0, at a 5% level of alpha for statistical significance. In-depth interviews were conducted with senior managers in the Gauteng Department of Health (GDoH) using MS Teams, to explore their perspectives on the impact of Covid-19 on routine healthcare services in the province and their recommendations for dealing with future pandemics. The interviews were recorded, transcribed, coded and analysed thematically using MS word 2016. Results: The Covid-19 pandemic disrupted the utilisation of essential MNCH services in the Gauteng province. The disruption was observed in the time trend plots, and then quantified by comparing the indicator means for the 12-month periods before and during Covid-19. The impact was a statistically significant decline in the mean of three indicators: PHC headcount <5 years declined by 77 103.9 visits (p<0.001), ANC 1st visits before 20 weeks decreased by 3.0% (p=0.002) and PNC visits within 6 days decreased by 10.2% (p<0.001) (Error! Reference source not found.). The ITS regression provided a more nuanced analysis. The decrease in PHC headcount t <5 years and PNC visits within 6 days were due to the immediate effect of the March 2020 Covid-19 lockdown which led to a drop in utilisation services. However, the effect on ANC 1st visits before 20 weeks was a continuous decline in utilisation throughout the Covid-19 period (Error! Reference source not found.). Service delivery and outcome indicators were negatively affected though not significantly. There were no significant recoveries and some indicators rather became worse post-lockdown. The nature of the adverse impact of Covid-19 on MNCH indicators was similar across all five districts, although the degree of disruption varied among the districts and services. The decline in service utilisation for PHC headcount <5 years ANC 1st visits before 20 weeks and PNC visits within 6 days was statistically significant in all districts, except for ANC 1st visits in Johannesburg (Error! Reference source not found.). The decline in PHC headcount <5 years was significantly larger in the three metropolitan districts (Johannesburg, Ekurhuleni and Tshwane) compared to the two non-metropolitan districts (Sedibeng and West Rand) (Table 5). ANC 1st visits before 20 weeks significantly declined in the Ekurhuleni, Sedibeng and West Rand districts compared to Johannesburg. While the decrease in PNC visits within 6 days significantly deteriorated in Johannesburg compared to the other four districts (Error! Reference source not found.). Pneumonia fatality <5 years significantly declined in the pooled analysis, in the Tshwane district alone. The majority of the respondents agreed that the Covid-19 pandemic disrupted essential healthcare services but a few disagreed. Several reasons were advanced for the disruption. On the supply side, they included: (i) the reallocation of resources to fighting Covid-19; (ii) healthcare worker shortages due to Covid-19 illness; (iii) healthcare facilities turning away non-Covid-19 patients; and (iv) Covid-19 screening that increased waiting times. On the demand side are; (i) restrictions on movement and limited public transport during the lockdown; (ii) fears of being infected by Covid-19 at health facilities; and (iii) misinterpretation of health information about the availability of non-Covid services. According to the respondents, the disruption of essential healthcare services had significant consequences, particularly for chronic patients, including treatment interruption, loss of follow-up, and death. The ‘catch-up’ plan and technology were used to improve service delivery during Covid-19. Conclusion: The Covid-19 pandemic disrupted the utilisation of essential healthcare services for MNCH. Although service delivery and health outcomes were less impacted, some outcome indicators at district levels went worst. While there were recovery attempts for service delivery like immunisation, some services rather deteriorated post-Covid-19 lockdown. However, there were mixed findings, fewer routine services were not affected by Covid-19. It is important to continuously assess and redress the unintended impacts of outbreaks even while they are occurring. This requires an understanding of the reasons and mechanisms of service disruption from demand and supply perspectives. Critical policies like lockdowns should be a collective decision, implemented without undermining routine services. High-level policymakers must consider addressing geographical variations of an outbreak’s impact on essential healthcare services. Covid19 may have more complex long-term effects, especially for individuals with adverse social determinants. And it may take longer for some healthcare services to fully recover hence, the need for health systems interventions to prioritise the affected services.
Nurses’ experiences in implementing Nurse Initiated Management of Anti-Retroviral Therapy (NIMART) in primary health care facilities in Dr Ruth Segomotsi Mompati District, North West Province
(2024) Sibisi, Nthabiseng
Aim of study- This study aimed to explore the nurses’ experiences in the implementation of NIMART in Dr Ruth Segomotsi Mompati District since its inception in 2010 to 2017. Methods This study employed an exploratory qualitative research design. The study setting included nine PHC facilities in three sub-districts. The study included only those nurses who had been trained to implement the NIMART in the district PHC facilities from 2010-2017. The final sample included Sixteen (16) nurses, comprising of three males and thirteen females from the three eight-hour operational clinics and six 24-hour Community Health Centres (CHCs). Data were therefore collected using in-depth interviews lasting thirty-five minutes (minimum) one and half hours 1h30 minutes (maximum). These interviews were guided by a semistructured interview guide. Data were later transcribed verbatim using an electronic software O’ Transcribe, and then analysed using MAXQDA 2018v, where inductive coding was applied. Thematic analysis was employed to interpret and represent data, which was finally presented as themes based on participants’ dominant narratives. Results- There were five key themes that emerged from this study. These included: perceptions about the NIMART programme mostly related to it being a task-shifting strategy when managing HIV and Aids and the programme benefits; contextual elements affecting access and adherence to NIMART, and challenges such as socio-cultural factors, social norms, socio-political and governance factors; facilitators of NIMART implementation in terms of functional health information management system and clinical guidelines, multidisciplinary team and skilled personnel, impactful counselling services, and intrinsic nurse motivators. Challenges of NIMART implementation included insufficient human resources for health, services integration, poor management and health-service support systems, lack of capacity building, ART unavailability and poor patient compliance to ART, and nurse demotivation. The proposed interventions by the nurses included provision of training, increasing staff to curb workload, management support, and debriefing, health service support resources and patient support improvement. Conclusion Task-shifting and successful NIMART implementation are complex notions, which can be successful if accompanied by training, reorganisation of services, mentoring, supervision, and ongoing support from existing health-service system structures. The rural health context must be considered as unique, and policies should be tailored to suit the needs of rural healthcare workers and patients. Dr RSM case-study has shows the plight of farm labourers and the need for a multisectoral approach to address patient related issues in this context. The challenges to successful NIMART implementation suggest a need for reorientation of health-services to fit rural contexts.
Surveillance of gastrointestinal infections in individuals over the age of 5 years in South Africa
(2024) Johnstone, Siobhan Lindsay
Gastrointestinal infections cause significant mortality and morbidity, especially in Africa. While children ≤5 years of age bear the brunt of diarrhoeal disease, there is a significant burden in older age groups. Limited data on aetiology in these older age groups limits appropriate interventions. Diarrhoeal surveillance is important for monitoring disease trends in a population and should inform testing and treatment guidelines, and interventions. This body of work evaluated the epidemiology of diarrhoea at each level of the surveillance pyramid to assist in interpretation of routine health data and identify gaps in surveillance. A household survey was conducted in Soweto to estimate community diarrhoeal prevalence, associated risk factors and healthcare seeking behaviors. An analysis of diagnostic testing practices for diarrhoeal diseases was done, using a doctors’ survey, at three public hospitals in South Africa. Routine diagnostic data and enhanced surveillance data were compared to evaluate patient-related factors associated with requests for diagnostic investigation, type of diagnostic testing offered and the efficiency of available tests. A hospital surveillance study investigated the infectious causes of diarrhoea in hospitalised patients >5 years. Results indicated a high diarrhoeal burden across all age groups in South Africa (5.3% of respondents reported an episode in the preceding 2 weeks). While the majority of infections were mild, 40% required healthcare. Many of those requiring healthcare (34%), specifically adults, were unable to access the required care. Those that did access healthcare were treated empirically and seldom had stool samples collected for diagnostic investigations (approximately 10% of admitted cases). Available diagnostics in public health laboratories detected pathogens in only 13.7% of these submitted stools due to pre-analytical and analytical issues including not testing for all relevant pathogens. Diarrhoeal prevalence was particularly high among HIV-infected patients (67.5% of patients >5 years admitted for diarrhoea were HIV-infected) and these patients presented with a unique aetiology. This research highlights the need for diarrhoeal testing and treatment guidelines based on local epidemiological data with a focus on HIV-infected patients. Current diagnostics require optimisation including specimen collection, standardisation, pathogens included in routine testing panels, turnaround time and methods of detection. This will guide decisions on future public health interventions including vaccines.
Understanding the roles and experiences of key stakeholders involved in the design of the novel imagine social outcomes-based contract in South Africa
(2024) Moodley, Gillian Pryadarshini
The Imagine Social Outcomes-Based Contract (SOBC) is an innovative health financing mechanism in South Africa applied to sexual and reproductive health outcomes of adolescent girls and young women. The Imagine SOBC is led by the South African Medical Research Council (SAMRC) and supported by other stakeholders. Its uniqueness stems from the role played by the SAMRC, as an intermediary on behalf of the South African government. Eleven semi-structured interviews were held with stakeholders who played intermediary, technical advisor, and implementation service provider roles during the Imagine SOBC design phase. Interviews were transcribed and analysed using the six steps of thematic analysis. The thematic findings of this study are the dynamics of working together, politics and processes, challenges and looking to the future. Despite internal collaboration and alignment among interviewees, the biggest challenge during the design phase of the Imagine SOBC was obtaining approvals from the government departments due to complex approval processes in the public sector. The lessons generated are important as the SAMRC intends to replicate the outcomes-based contract model for other disease priorities. These findings are valuable for policymakers and future outcomes-based contract practitioners who are considering a transaction of this nature and its application to public health. The findings will also assist in the development of a guiding practice note for policymakers and government officials who grant approvals.
The relationship between violence across the life course, protective factors and mental disorders among adult women living in a slum setting in Ibadan, Nigeria
(2024) Sekoni, Olutoyin Olubunmi
Research suggests that adult women in Nigeria have experienced traumatic events (TE) across their life course. Violence is a TE that can occur within intimate relationships as well as other spheres of life. TE and adverse life events can increase risk of a mental disorder such as: depression, anxiety and Post Traumatic Stress Disorder (PTSD). Despite experience of TE or adverse life events, some women do not experience the onset of a mental disorder which may be due to protective factors such as resilience and social support. The links between lifecourse TE and the development of common mental disorders have not been well researched on the African continent particularly in slum settings. This thesis aimed to investigate the relationships between adult women’s childhood trauma, experiences of Intimate Partner Violence (IPV) and adverse life events and common mental disorders among adult women living in a slum setting in Ibadan, Nigeria. The thesis also sought to examine the presence of protective factors in these relationships. Methods -A community-based cross-sectional household survey utilizing multistage sampling was carried out among 550 women. Childhood trauma was measured using the short form of the Childhood Trauma Questionnaire. IPV was measured using the WHO Multi-country Study on Women's Health and Domestic Violence Questionnaire. Common mental disorders were measured using the short version of the Depression, Anxiety and Stress Scale (DASS-21) while the Harvard Trauma Questionnaire was used to measure PTSD. Recent stressors were measured using the Life Events Questionnaire. The protective factors of resilience, social support, social connectedness and self- esteem were measured using the Wagnild and Young resilience scale, the Multidimensional Scale of Perceived Social Support, the Social Connectedness Scale (Revised) and the Rosenberg self-esteem scale respectively. Bivariate and multivariate analysis were conducted to identify any associations and net effect of the key independent variables on the primary outcomes of interest while controlling for socio demographic characteristics. Results The prevalence of lifetime and past year experience of IPV were 31.5% and 14.8% respectively. The prevalence of the TE during childhood ranged from 8.9% (sexual abuse), 50.4% physical abuse and 70.4% emotional abuse, while 30.8%, 41.6% and 5.8% had experienced one, two and three forms of childhood trauma respectively. Women who had experienced all three forms of childhood trauma had five times the odds of reporting a lifetime experience of IPV compared to those who had not had any experience of childhood trauma (OR= 5.21; CI= 2.30-11.76). Common mental disorders were reported by 14.0% of the respondents, with PTSD reported by 4.18%. Resilience and social support were found to be protective against reporting symptoms of common mental disorders. Women who reported higher levels of social support and resilience were less likely to report common mental disorders (OR:0.96, 95% CI 0.93, 0.98) and (OR:0.95, 95% CI 0.91, 0.99) respectively. Women who were 65 years and older were also less likely to report the occurrence of common mental disorders (OR:0.38, 95% CI 0.15, 0.98) compared to those aged 18–34 years. Conclusion- The findings from this study show that trauma over the life course is prevalent among the women in these slums as a result of childhood trauma, IPV and recent stressors. The findings also show that even though many of the women were exposed to trauma, most of them did not develop mental disorders. Resilience and social support appeared to play an important role in mitigating the effects of adversity among this population of women even in the light of their extant circumstances within the slum setting. Addressing the use of both child protection programs and IPV reduction as well as fostering resilience and social support among women would be of benefit in reducing the burden of common mental disorders.