School of Public Health (ETDs)

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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.
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
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.
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
Implementation of universal health coverage in South Africa: formative effects, perceived quality of healthcare and modelling of health service utilisation indicators in a national health insurance pilot district
(University of the Witwatersrand, Johannesburg, 2023-01) Mukudu, Hillary; Igumbor, Jude; Otwombe, Kennedy; Fusheini, Adam
Background: According to the World Health Organisation, member countries should attain universal health coverage by 2030. To achieve this goal, South Africa introduced the National Health Insurance programme in 2012. Since then, the first phase of the pilot programme has been implemented in Tshwane and ten other country districts. Historically, no other health system reform in South Africa has generated more interest than the National Health Insurance. This 15-year preliminary plan and pilot received optimism and criticism depending on several factors. The pilot programme focusing on primary health care was implemented along with several other interventions. The components of the intervention included setting up: ward-based primary healthcare outreach teams, integrated school health programmes, district clinical specialist teams, centralised chronic medicine dispensing and distribution programmes, health patient registration systems, stock visibility systems, and contracting of private non-specialised (general) medical practitioners to provide services in public primary health care facilities. These interventions were envisaged to improve healthcare quality at the primary healthcare level and offset the burden of non-emergency (secondary) care at the hospital outpatient level. However, studies have yet to be done to determine population-level formative effects on primary and non-emergency secondary healthcare indicators, their relationships, and interdependencies. These data are needed to forecast and develop measures to meet the possible increase in health service utilisation. In addition, this information is essential to guide the possible scale-up of South Africa's National Health Insurance mechanism. Such guidance may be in setting benchmarks to monitor policy implementation, determine facility staffing, the package of health services, training needs, budget for medicines and consumables, and other resource allocation. Aim: Therefore, this study first aimed to determine the formative effects of implementing the Medical Practitioners' contracting of the National Health Insurance pilot program on primary healthcare utilisation indicators measured at both primary and non-emergency secondary levels of care. A comparison was made between Tshwane national health insurance pilot district and Ekurhuleni district, which is not a pilot district. Furthermore, the study aimed to determine the relationships between healthcare utilisation indicators and their interdependencies and then provide a forecast for 2025. Methods: This quasi-experimental and ecological study used selected primary health care and outpatient department indicators in the District Health Information System monthly reports between January 2010 and December 2019 for the Tshwane district and Ekurhuleni district. Thus, to determine the formative effects on primary healthcare utilisation indicators, the selected period was from June 2010 to May 2014. A total of 48-time periods (months), with 24 before (June 2010 to May 2012) and 24 after (June 2012 to May 2014) implementation of Medical Practitioners contracting of the National Health Insurance pilot programme. Similarly, June 2012 to May 2014 was the selected period to determine the effects on the perceived quality of care. A total of 24 months, with 12 before (June 2012 to May 2013) and 12 after (June 2013 to May 2014) implementation of the Medical Practitioners' contracting of the National Health Insurance pilot programme. To determine the relationship and interdependence between Primary Health Care and Outpatient Department indicators and forecasts for 2025, 113 time periods (quarters) were selected. There were 28 quarters before and 84 quarters after implementing the National Health Insurance pilot programme. Similar methodological approaches were used to determine the effects of Medical Practitioners contracting in the National Health Insurance pilot programme on Primary Healthcare utilisation indicators and perceived healthcare quality. All study data types used in the thesis were continuous; thus, they were initially evaluated descriptively using means (standard deviations) and medians (interquartile ranges). The range was evaluated using minimum and maximum values. An Independent t-test assuming unequal variances was used to compare the means of Outpatient Department indicators in determining the effect of Medical Practitioners contracting in the National Health Insurance pilot programme on the perceived quality of healthcare. Single- and multiple-group (controlled) interrupted time series analysis was used to determine the effect of the National Health Insurance pilot project implementation on the utilisation of selected primary and non-emergency outpatient department indicators and perceived healthcare quality. A different methodological approach was used to determine the interdependencies and relationships between selected primary healthcare and non-emergency outpatient department indicators and their forecasts for 2025. Initially, data were evaluated descriptively using means (standard deviations) and medians (interquartile ranges) and the range was evaluated using minimum and maximum values. Prior to the development of the vector error correction model, several steps were taken. Firstly, a natural log transformation of all time series data was done to enhance additivity, linearity, and validity. Additionally, the level of lags at which variables were interconnected or endogenously obtained was determined due to the sensitivity of causality. Furthermore, the stationarity of time series data was determined using both graphical means and the Augmented Dick Fuller test to confirm the stability of each time series. Finally, cointegration was determined using the Johansen cointegration test to check for the correlation between two or more nonstationary series. After developing the Vector Error Correction Model, the Granger causality test was done to determine whether one series is helpful for forecasting another. Then the Vector Error Correction Model relationships between variables of selected primary healthcare and non-emergency outpatient department indicators were used to forecast the utilisation of both levels of services by 2025. Results: The findings showed changes in primary healthcare indicators measured at primary and non-emergency secondary levels before and after contracting private medical practitioners of the National Health Insurance pilot programme. The study also confirmed the influence of selected primary health care and outpatient department headcounts on each other by finding four cointegration relationships between the variables. There were differences between single-group and controlled interrupted time series analysis findings for Tshwane district and Ekurhuleni district considered independently and collectively on the utilisation of primary health care services. Thus, the positive impact observed in primary healthcare utilisation post-June 2012 is not attributable to the implementation of the Medical Practitioners' contracting of the National Health Insurance pilot programme. Conversely, there were similarities between single-group and controlled interrupted time series analysis findings for Tshwane district and Ekurhuleni district considered independently and collectively on the perceived quality of primary healthcare. In the interpretation of this finding, the similarities indicated that implementing the Medical Practitioners' contracting of the National Health Insurance pilot programme positively influenced the perception of a better quality of primary healthcare in the Tshwane district. Regarding primary healthcare indicators, there were differences between single-group and controlled interrupted time series analysis. Single-group interrupted time series analysis showed a 65% and 32% increase in the number of adults remaining on anti-retroviral therapy in Tshwane and Ekurhuleni districts, respectively (relative risk [RR]: 1.65; 95% confidence interval [CI]: 1.64–1.66; p < 0.0001 and RR: 1.32; 95% CI: 1.32–1.33; p < 0.0001, respectively). However, controlled interrupted time series analysis did not reveal any differences in any of the post-intervention parameters. Furthermore, single-group interrupted time series analysis showed a 2% and 6% increase in the number of clients seen by a professional nurse in the Tshwane and Ekurhuleni districts, respectively (RR: 1.02; 95% CI: 1.01–1.02; p < 0.0001 and RR: 1.06; 95% CI: 1.05–1.07; p < 0.0001, respectively). However, controlled interrupted time series analysis did not show any differences in any of the post-intervention parameters. In addition, single-group interrupted time series analysis revealed that there was a 2% decrease and 1% increase in the primary healthcare headcounts for clients aged ≥5 years in Tshwane and Ekurhuleni district (RR: 0.98; 95% CI: 0.97–0.98; p < 0.0001 and RR: 1.01; 95% CI: 1.01–1.02; p < 0.0001, respectively). Similarly, there was a 2% decrease and a 5% increase in the total primary healthcare headcounts in the Tshwane district and Ekurhuleni districts, respectively (RR: 0.98; 95% CI: 0.97–0.98; p < 0.001 and RR: 1.05; 95% CI: 1.04–1.06, p < 0.0001, respectively). However, controlled interrupted time-series analysis revealed no difference in all parameters before and after intervention in terms of total primary healthcare headcounts and primary healthcare headcounts for clients aged ≥5 years. Regarding secondary non-emergency outpatient department headcounts, single-group and controlled interrupted time series analyses revealed similar findings. Despite these similarities, single-group interrupted time series analysis showed a disparate increase in the outpatient department not referred headcounts, which were lower in the Tshwane district (3 387 [95%CI 901, 5 873] [p = 0.010]) than in Ekurhuleni district (5 399 [95% CI: 1 889, 8 909] [p = 0.004]). Conversely, while there was no change in outpatient department referred headcounts in the Tshwane district, there was an increase in headcounts in the Ekurhuleni district (21 010 [95% CI: 5 407, 36 611] [p = 0.011]). Regarding the outpatient department not referred rate, there was a decrease in the Tshwane district (-1.7 [95% CI: -2.1 to -1.2] [p < 0.0001]), but not in the Ekurhuleni district. Controlled interrupted time series analysis showed differences in headcounts for outpatient department follow-up (24 382 [95% CI: 14 643, 34 121] [p < 0.0001]), the outpatient department not referred (529 [95% CI: 29, 1 029 [p = 0.038]), and outpatient department not referred rate (-1.8 [95% CI: -2.2 to -1.1] [p < 0.0001]) between Tshwane the reference district and Ekurhuleni district. Four common long-run trends were found in the relationships and dependencies between primary healthcare indicators measured at the primary healthcare level and the non-emergency secondary level of care needed to forecast future utilisation. First, a 10% increase in outpatient departments not referred headcounts resulted in a 42% (95% CI: 28-56, p < 0.0001) increase in new primary healthcare diabetes mellitus clients, 231% (95% CI: 156-307, p < 0.0001) increase in primary healthcare clients seen by a public medical practitioner, 37% (95% CI: 28-46, p < 0.0001) increase in primary healthcare clients on ART, and 615% (95% CI: 486-742, p < 0.0001) increase in primary healthcare clients seen by a professional nurse. Second, a 10% increase in outpatient department referrals resulted in an 8% (95% CI: 3-12, p < 0.0001) increase in new primary healthcare diabetes mellitus clients, a 73% (95% CI: 51-95, p < 0.0001) increase in primary healthcare headcounts for clients seen by a medical professional, a 25% (95% CI: 23-28, p < 0.0001) increase in primary healthcare headcounts for clients on ART, and a 44% (95% CI: 4-71, p = 0.026) increase in primary healthcare headcounts for clients seen by a professional nurse. Third, a 10% increase in outpatient department follow-up headcounts resulted in a 12% (95% CI: 8-16, p < 0.0001) increase in primary healthcare headcounts for new diabetes mellitus, 67% (95% CI: 45-89, p < 0.0001) increase in primary healthcare headcounts for clients seen by public medical practitioners, 22% (95% CI: 19-24, p < 0.0001) increase in primary healthcare headcounts for clients on ART, and 155% (95% CI: 118-192, p < 0.0001) increase in primary healthcare headcounts for clients seen by a professional nurse. Fourth, a 10% increase in headcounts for total primary healthcare clients resulted in a 0.4% (95% CI: 0.1-0.8, p < 0.0001) decrease in primary healthcare headcounts for new diabetes clients. Based on these relationships and dependencies, the outpatient department follow-up headcounts would increase from 337 945 in the fourth quarter of 2019 to 534 412 (95% CI: 327 682–741 142) in the fourth quarter of 2025, while the total primary healthcare headcounts would only marginally decrease from 1 345 360 in the fourth quarter of 2019 to 1 166 619 (95% CI: 633 650–1 699 588) in the fourth quarter of 2025. Conclusion: The study findings suggested that improvements in primary health care indicators in National Health Insurance pilot districts could not be attributed to the implementation of contracting private medical practitioners but were likely a result of other co-interventions and transitions in the district. However, it might have resulted in an improved perception of quality of care at primary health care facilities, evidenced by a reduction in the self-referral rate for non-emergency hospital outpatient departments. The study also confirmed the influence of selected primary healthcare and non-emergency outpatient department headcounts on each other by finding four common long-run trends of relationships. Based on these relationships and trends, outpatient department follow-up headcounts are forecasted to increase by two-thirds. Conversely, the total headcount for primary healthcare clients seen by a professional nurse will marginally decrease. Recommendations: Based on the study findings, the bidirectional referral between primary and non-emergency secondary levels of care in the Tshwane district should be strengthened to offset the burden of care at outpatient departments of district hospitals. Thus, the district health information system should include a down-referral indicator to monitor this activity. With the implementation of National Health Insurance, there is a need to improve the perception of quality of care at the primary healthcare level through appropriate training, recruitment, and placement of medical practitioners. Similarly, professional nurses, the core providers of primary healthcare services, should be supported and capacitated in line with the epidemiological transition.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission dynamics and social contact patterns
(University of the Witwatersrand, Johannesburg, 2023-03) Kleynhans, Jacoba Wilhelmina; Cohen, Cheryl; Tempia, Stefano
Background: Understanding the community burden and transmission dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can assist to make informed decisions for prevention policies. Methods: From August through October 2018, before the SARS-CoV-2 pandemic, we performed a cross-sectional contact survey nested in a prospective household cohort in an urban (Jouberton, North West Province) and a rural community (Agincourt, Mpumalanga Province) in South Africa to measure contact rates in 535 study participants. Participants were interviewed to collect details on all contact events (within and outside of the household). During the SARS-CoV-2 pandemic we enrolled 1211 individuals from 232 randomly selected households in the same urban and rural community, and followed the cohort prospectively for 16 months (July 2020 through November 2021), collecting blood every two months to test for SARS-CoV-2 antibodies. Using these longitudinal SARS-CoV-2 seroprevalence estimates and comparing these with reported laboratory-confirmed cases, hospitalizations and deaths, we investigated the community burden and severity of SARS-CoV-2. We also performed a case-ascertained household transmission study of symptomatic SARS-CoV-2 index cases living with HIV (LWH) and not LWH (NLWH) in two urban communities (Jouberton, North West Province and Soweto, Gauteng Province) from October 2020 through September 2021. We enrolled 131 SARS-CoV-2 index cases at primary healthcare clinics. The index cases and their 457 household contacts were followed up for six weeks with thrice weekly visits to collect nasal swabs for SARS-CoV-2 testing on reverse transcription real-time polymerase chain reaction (rRT-PCR), irrespective of symptoms. We assessed household cumulative infection risk (HCIR), duration of virus detection and the interval between index and contact symptom onset (serial interval). By collecting high-resolution household contact patterns in these households using wearable sensors, we assessed the association between contact patterns and SARS-CoV-2 household transmission. Results: During the contact survey, we observed an overall contact rate of 14 (95% confidence interval (CI), 13-15) contacts per day, with higher contact rates in children aged 14-18 years (22, 95%CI 8-35) compared to children <7 years (15, 95%CI 12-17). We found higher contact rates in the rural site (21, 95%CI 14-28) compared to the urban site (12, 95%CI 11-13). When comparing the household cohort seroprevalence estimates to district SARS-CoV-2 laboratory-confirmed infections, we saw that only 5% of SARS-CoV-2 infections were reported to surveillance. Three percent of infections resulted in hospitalization and 0.7% in death. People LWH were not more likely to be seropositive for SARS-CoV-2 (odds ratio [OR] 1.0, 95%CI 0.7–1.5), although the sample size for people LWH was small (159/1131 LWH). During the case-ascertained household transmission study for SARS-CoV-2, we estimated a HCIR of 59% (220/373) in susceptible household members, with similar rates in households with an index LWH and NLWH (60% LWH vs 58% NLWH). We observed a higher risk of transmission from index cases aged 35–59 years (adjusted OR [aOR] 3.4, 95%CI 1.5–7.8) and ≥60 years (aOR 3.1, 95% CI 1.0–10.1) compared with those aged 18–34 years, and index cases with a high SARS-CoV-2 viral load (using cycle threshold values (Ct) <25 as a proxy, aOR 5.3, 95%CI 1.6–17.6). HCIR was also higher in contacts aged 13–17 years (aOR 7.1, 95%CI 1.5–33.9) and 18–34 years (aOR 4.4, 95% CI 1.0–18.4) compared with <5 years. Through the deployment of wearable sensors, we were able to measure high-resolution within-household contact patterns in the same households. We did not find an association between duration (aOR 1.0 95%CI 1.0-1.0) and frequency (aOR 1.0 95%CI 1.0-1.0) of close-proximity contact with SARS CoV-2 index cases and household members and transmission. Conclusion: We found high contact rates in school-going children, and higher contact rates in the rural community compared to the urban community. These contact rates add to the limited literature on measured contact patterns in South Africa. The burden of SARS-CoV-2 is underestimated in national surveillance, highlighting the importance of serological surveys to determine the true burden. Under-ascertainment of cases can hinder containment efforts through isolation and contact tracing. Based on seroprevalence estimates in our study, people LWH did not have higher SARS-CoV-2 community attack rates. In the household transmission study, we observed a high HCIR in households with symptomatic index cases, and that index cases LWH did not infect more household members compared to people NLWH. We found a correlation between age and SARS-CoV-2 transmission and acquisition, as well as between age and contact rates. Although we did not observe an association between household contact patterns and SARS-CoV-2 transmission, we generated SARS-CoV-2 transmission parameters and community and household contact data that can be used to parametrize infectious disease models for both SARS-CoV-2 and other pathogens to assist with forecasting and intervention assessments. The availability of robust data is important in the face of a pandemic where intervention strategies have to be adapted continuously.
Initial loss to follow up among tuberculosis patients: the role of ward-based outreach teams (wbots) and short message service (sms) technology
(University of the Witwatersrand, Johannesburg, 2023-03) Mwansa-Kambafwile, Judith Reegan Mulubwa; Menezes, Colin; Chasela, Charles
Introduction: In South Africa, tuberculosis (TB) is still a serious public health problem with rates of initial loss to follow up (initial LTFU) varying between 14.9% and 22.5%. Poor clinician-patient communication resulting in lack of clarity on next steps, patients not prioritizing their healthcare and patients not knowing that their results are ready at the clinic are some reasons for initial LTFU. This PhD aimed to assess the effectiveness of Ward-based Outreach Teams (WBOTs) or Short Message Service (SMS) technology in reducing TB initial LTFU in Johannesburg, South Africa between 2018 and 2020. Methods: A mixed methods approach comprising two phases (formative and intervention) was employed. In the formative phase, secondary data were analyzed for frequency distributions to determine the rates of initial LTFU in the study area. In addition, in-depth interviews with WBOT Managers and with TB Program Managers were conducted to determine their perceived reasons for TB initial LTFU. In the intervention phase, two interventions (WBOTs/SMS technology) were tested using a 3 arm randomized controlled trial (RCT) comparing each of the interventions to standard of care (SOC). The WBOTs delivered paper slip reminders while SMS intervention entailed sending reminder SMS messages to patients as soon as TB results were available. Chi square statistics, Poisson regression and Kaplan-Meier estimates were used to analyze the data. The RCT was followed by in-depth interviews with WBOT members and with some of the trial participants who had tested TB positive and had received reminder messages. To identify themes in the qualitative studies, both inductive and deductive coding were used in the hybrid analytic approach. Results: From the formative phase, the TB initial LTFU among the 271 patients was found to be 22.5% and the overall time to treatment initiation was 9 days. Interviews with managers revealed that relocation and “shopping around” were the main patient related factors found as the reasons for initial LTFU. Health system related factors for initial LTFU were communication and staff rotations. In terms of TB related work, WBOTs screened household members for TB and referred them for TB testing. The services of the WBOT/TB programs which were found to be integrated were: referral of symptomatic patients for TB testing and adherence monitoring in patients already on TB treatment. There was minimal involvement of the WBOTs in the treatment initiation of patients diagnosed with TB. Findings from the trial were that 11% (314/2850) of the participants tested positive for TB. The 314 TB patients were assigned to one of the 3 arms (SOC=104, WBOTs=105, and SMS=105). Overall, 255 patients (81.2%) were initiated treatment across all study arms. More patients in the SMS arm were initiated TB treatment than in the SOC arm (92/105; 88% and 81/104; 78% respectively; P=0.062). Patients in the SMS arm also had a shorter time to treatment initiation than those in the SOC arm (4 days versus 8 days; P<0.001). A comparison of the WBOTs arm and the SOC arm showed similar proportions initiated on treatment (45/62; 73% and 44/61; 72% respectively) as well as similar times to treatment initiation. Findings from the post-trial interviews showed that delivery of the reminder paper slips by the WBOTs during the trial was something new, but possible to incorporate into their daily schedule. The patient interviews revealed that various emotions (happiness, fear, worry etc.) were experienced upon receipt of the reminder messages. Participants also reported that receiving the reminder message did influence their decision to go back to collect the results. Conclusion: Reminder messages to patients are beneficial in TB treatment initiation. National TB programs can use SMS messaging because it is an affordable and feasible method. Although implementation of the WBOTs intervention was suboptimal, findings show that with proper integration of TB and WBOT programs, WBOTs have the potential to contribute to improved treatment initiation.
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.
The relationship between antenatal food insecurity, maternal depression and birthweight and stunting: results from the National Income Dynamics Study (NIDS)
(University of the Witwatersrand, Johannesburg, 2023-07) Harper, Abigail Joan; Mall, Sumaya; Rothberg, Alan; Chirwa, Esnat
Background: Maternal food insecurity is an important social determinant of health and has been associated with adverse birth and pregnancy outcomes as well as depressive symptoms. Pregnant women and new mothers are vulnerable to both food insecurity and depression. This thesis investigated the relationships between maternal food insecurity, depressive symptoms and low birthweight and stunting using nationally representative longitudinal data from the National Income Dynamics Study (NIDS). In addition, the thesis also examined the association between various food security indicators and adult and child anthropometry. Methods: The NIDS data included three experiential indicators of food security (adult and child hunger in the household in the past twelve months and household food sufficiency in the past 12 months) as well as household dietary diversity in the past thirty days and household food expenditure in the past thirty days. Three of the included studies utilised NIDS data. a) Chapter 4 was a scoping review that examined dietary diversity and maternal depression. b) Chapter 5 gives a broad overview by using cross-sectional data from wave 1 to examine food security indicators in relation to adult and child anthropometry. c) Chapter 6 used maternal data from Wave 1 of NIDS and child data from wave 3 of NIDS to longitudinally examine maternal depression and food insecurity during the periconceptional and antenatal period in relation to a continuous measure of birthweight and children’s height-for-age scores. In this vein, Chapter 6 employs different statistical measures to achieve longitudinal perspectives. d) Chapter 7 used the same dataset as Chapter 6 to examine various maternal exposures in more depth including food security indicators, alcohol use and other maternal characteristics in relation to binary measures of low birthweight and stunting among children born during the reference period. e) The final article used mobile survey data from the MomConnect database, a government database of pregnant and postnatal women. Results: a) For the scoping review, a total of 813 records were screened and 11 articles from 13 different studies met the inclusion criteria. The findings on maternal depression and maternal dietary diversity were mixed; The findings on maternal depression and children’s dietary diversity were also mixed. In the studies that examined maternal depression and dietary diversity as predictor variables for child outcomes, the findings on depression were mixed but dietary diversity was consistently associated with both cognitive and linear growth outcomes among children. b) Among children, the prevalence of stunting was 18.4% and the prevalence of wasting and overweight was 6.8% and 10.4% respectively. Children <5 and adolescents with medium dietary diversity were significantly more likely to be stunted than children with high dietary diversity. None of the indicators were associated with stunting in children aged 5-9. Among stunted children, 70.2% lived with an overweight or obese adult, the double burden of malnutrition. Among adults, increased dietary diversity increased the risk of adult overweight and obesity. c) Maternal food insecurity significantly increased the risk of depression among periconceptional and pregnant women but there was no association between maternal depression, food insecurity and mean birthweight or height-for age scores among children. d) Women who reported a child going hungry in the household in the past 12 months were significantly more likely to give birth to a low birthweight infant during the reference period. Low dietary diversity among periconceptional and pregnant women was associated with stunting among children five years later. Low birthweight significantly increased the risk of stunting among children. e) The prevalence of depression in the sample was 16% and pregnant women and new mothers who reported hunger in the household were significantly more likely to be depressed. The qualitative component of the study revealed that women’s main worries could be broadly divided into three categories; worries about hunger and food insecurity, fears that they or their children would be infected with Covid 19 and concerns about unemployment during the lockdown. Conclusion: The studies included in this PhD study demonstrate that food insecurity is an important social determinant of both physical and mental health and a potentially modifiable risk factor for low birthweight and stunting. In both studies that examined maternal depression, food insecurity significantly increased the risk of depression among periconceptional women as well as pregnant women and new mothers. In addition, food insecurity is associated with adverse child health outcomes (low birthweight, stunting and wasting). However, experiential measures of food insecurity are not associated with stunting among young children or adolescents while dietary diversity is. Dietary diversity consistently emerged as an important indicator for children’s linear growth as well as cognitive development in the scoping review. Holistic interventions that focus on the social determinants of health such as food security may improve maternal depressive symptoms among women in resource poor settings. Dietary diversity tools could be refined to also include a category for processed foods given the nutrition transition occurring in many LMICS. More longitudinal research with repeated measurements is required to elucidate the relationship between maternal depression and child health outcomes.
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.
Occupational Exposure to Chrysotile Asbestos in the Chrysotile Asbestos Cement Manufacturing Industry in Zimbabwe
(University of the Witwatersrand, Johannesburg, 2023-08) Mutetwa, Benjamin; Brouwer, Derk; Moyo, Dingani
Introduction: Asbestos is a generic term for a group of naturally occurring silicates that principally include serpentine variety (white chrysotile asbestos) and the amphibole variety, consisting of crocidolite (blue asbestos), amosite (brown asbestos), anthophyllite, actinolite and tremolite. Asbestos exposure has drawn much international, regional and national attention as it presents significant public and occupational health concerns. All asbestos types are known to cause asbestos related disease. Objectives: The objectives of this PhD were: 1. To analyse trends in airborne chrysotile asbestos fibre exposure data obtained by the chrysotile asbestos cement manufacturing factories for the period 1996 to about 2016. 2. To establish a job exposure matrix (JEM) to estimate occupational exposure levels in the Zimbabwe chrysotile asbestos industry using available exposure data. 3. To predict asbestos related diseases (ARDs) namely lung cancer, mesothelioma, gastrointestinal cancer and asbestosis in the chrysotile asbestos cement manufacturing industry through exposure levels obtained in the factories. 4. To assess amphibole contaminants in the chrysotile asbestos fibre being used by the factories in the manufacture of asbestos cement (AC) products. 5. To examine approaches for prevention of exposure to chrysotile asbestos fibre and some perspectives on the debate on asbestos ban. Methodology: A retrospective cross-sectional study using the factories personal chrysotile exposure data was designed to evaluate exposure patterns over time. Analysis involved close to 3000 personal exposure measurements extracted from paper records in the two-asbestos cement (AC) manufacturing factories in Harare and Bulawayo, covering the period 1996-2020. Exposure trends were characterised according to three to four time periods and calendar years to gain insight into exposure trends over time. Operational areas for which personal exposure data were available were saw cutting, fettling table, kollergang, moulded goods, ground hard waste, laundry room, and pipe making operations in the case of the Bulawayo factory. The standard method of the Asbestos International Association (AIA) Recommended Technical Membrane Filter Reference Method (AIA, 1982) was reported to be used to collect personal chrysotile asbestos fibre in various operational areas over the years. Quantitative personal exposure chrysotile fibre concentration data collected by the two factories over the considered period were used to construct the JEM. Analysis of amphiboles in locally produced and imported raw chrysotile fibre samples used in the manufacturing processes was done using Scanning Electron Microscopy (SEM) and Energy Dispersive Spectroscopy (SEM). Prediction of asbestos related diseases (ARDs) was done by combining the JEM converted to cumulative exposures, with OSHA’s linear dose effect model in which asbestos related cancers was derived using linear regression equations established for lung cancer, mesothelioma and gastrointestinal cancer by plotting estimates of cancer mortality cases versus respective cumulative exposures. The linear regression equations were applied to establish estimates of possible cancer mortality while for asbestosis, the linear in cumulative dose equation, Ra = m(f)(d), where Ra – predicted incidence of asbestosis, m – slope of linear regression taken as 0.055, f – asbestos fibre concentration and d – duration of exposure, was used to estimate possible asbestosis cases over the respective duration of exposure at 1, 10, 20 and 25 years. To examine arguments for approaches used for prevention of exposure to chrysotile asbestos and examine some perspectives on the debate on asbestos ban, a literature search was conducted. Literature materials that advocated for the complete ban of all forms of asbestos including chrysotile as the only means of control of exposure and that, which argues for the controlled use approach, were reviewed. Search words used in literature search were chrysotile asbestos exposure, asbestos-cement, ban asbestos, controlled use, asbestos related disease, mesothelioma, lung cancer and asbestosis. Data analysis was conducted using IBM SPSS version 26. For analysis, monthly averaged personal exposure levels for the factories were used. Mean personal airborne chrysotile fibre concentrations were analysed per operational area per factory and trends in airborne fibre concentrations over the years were displayed graphically. ANOVA was applied with the aim categories and determine whether there was a statistically significant difference in exposure concentrations between four time-periods for various jobs. Additionally, a Tukey Post Hoc Test (Tukey’s Honest Significance Difference test) was run to find out which specific group means of time periods (compared with each other) were different. Results and Discussion: Trends in airborne chrysotile asbestos fibre concentrations in asbestos cement manufacturing factories in Zimbabwe from 1996 to 2016. Mean personal exposure chrysotile asbestos fibre concentrations generally showed a downward trend over the years in both factories. Exposure data showed that over the observed period 57% and 50% of mean personal exposure chrysotile asbestos fibre concentrations in the Harare and Bulawayo factories, respectively, were above the Zimbabwean OEL of 0.1 f/mL, with overexposure generally being exhibited before 2008. Overall, personal exposure asbestos fibre concentrations in the factories dropped from 0.15 f/mL in 1996 to 0.05–0.06 f/mL in 2016, a decrease of 60–67%. Statistically significant relationships were observed over time between exposure levels and calendar year and time periods (p<0.001) for all occupational categories other than fettling table operations in Harare. The general decline in exposure over time from 1996 to 2016 suggests good occupational safety and health (OSH) framework being implemented by the two factories over the years, with the years after 2008 showing much lower exposure levels below the OEL particularly for the Bulawayo factory. However, for the period 2018 to 2020 exposures in the Harare factory were much higher than the proceeding time period of 2009 to 2016 due to movement of trucks within the factory as they come to load concrete tiles and other products making it possible for residual chrysotile fibre left during manufacture of AC products to become airborne. The company reported no clean-up of asbestos in the factory or wetting of the floors to control dust, hence the possible increased levels of chrysotile asbestos fibre for the period 2009 to 2016. The general decreasing trends in exposure to chrysotile asbestos fibre may also be viewed from the fact that industry was responding to anticipated lowering of chrysotile OEL as a result of increased calls to ban all forms asbestos, triggering the scaling up of exposure controls in the factories. Job Exposure Matrix for chrysotile asbestos fibre in the asbestos cement manufacturing (ACM) industry in Zimbabwe. On average, all jobs/occupations in both factories had annual mean personal exposure concentrations exceeding the OEL of 0.1 f/ml, except for the period 2009 to 2016 in the Harare factory and for the time-periods 2009 to 2020 in the Bulawayo factory. Despite Harare factory having no AC manufacturing activity since 2017, personal exposure concentrations showed elevated levels for the period 2018-2020. Amphiboles were detected in almost all presently collected bulk samples of chrysotile asbestos analysed. The established JEM, which was successfully generated from actual local quantitative exposure measurements, can be used in evaluating historical exposure to chrysotile asbestos fibre, to better understand, inform and predict occurrence of ARDs in future. Prediction of Asbestos Related Diseases (ARDs) and chrysotile asbestos exposure concentrations in asbestos-cement (AC) manufacturing factories in Zimbabwe. The results show that more cancer and asbestosis cases were likely to be experienced among those workers exposed before 2008 as exposure levels (0.11-0.19 f/ml) and subsequently cumulative exposures were generally much higher than those experienced after 2008 (0.04-0.10 f/ml). After a possible working exposure period of 25 years, overall cancer cases, i.e., estimates of possible cancer cases in a factory for each respective duration of exposure, predicted in the Harare factory were 325 cases per 100 000 workers while for the Bulawayo factory 347 cancer cases per 100 000 workers exposed may be experienced. Asbestosis cases likely to be detected after 25-years duration of exposure ranged from 50 to 260 cases per 100 000 workers (0.05 to 0.26% incidence of asbestosis) for various jobs. Possible high numbers of ARDs are likely to be associated with specific tasks/job titles, e.g., saw cutting, kollergang, fettling table, ground hard waste and possibly pipe making operations as cumulative exposures though lower than reported in other studies may present higher risk of health impairment. Examining approaches for prevention of exposure to chrysotile asbestos and some perspectives on the debate on ban of asbestos. Different perspectives on approaches to the prevention of exposure to asbestos have been presented. One position argues that there exist major differences in health risk between amphiboles and chrysotile asbestos, that low exposure and risk experienced under today’s workplace conditions are completely different to high-risk exposures experienced in the past where occupational hygiene conditions were very poor and levels of education, awareness and training in the asbestos industry was low compared to the present situation. It is further argued that there are low levels of exposure below which risk of health impairment becomes insignificant, hence controlled use approach as a measure of exposure control can be successfully applied. However, the other position holds that all forms of asbestos including chrysotile are equipotent, that there is no safe level of exposure, that controlled use is not practical and that there is no merit in continuing use of chrysotile asbestos in light of safer alternatives available today. Both positions appear plausible. Banning as a form of control measure occupies a high level in the hierarchy of controls with potential to eliminate the hazard and risk; nonetheless, the banning of chrysotile may imply substitution with materials that have been reported to carry health risk of cancer and other health impairments. On balance, banning may possibly not be the panacea of elimination of ARDs, in view of the fact that some other forms of mining such as diamond and gold mining have been associated with exposure to amphibole asbestos. The controlled use approach may provide real possibilities of prevention of exposure to levels that presents minimal risk to health if effectively implemented as applied to a range of occupational hazards with success. Conclusion: Not much is known about exposure to airborne chrysotile asbestos fibre exposure in Zimbabwe chrysotile asbestos cement (AC) manufacturing industry. This study may constitute the single largest characterisation of personal exposure chrysotile asbestos fibre concentrations data set in Zimbabwe in which about 3000 airborne personal exposure measurements collected from company records spanning a period of about 25 years, were used in assessing exposure trends over time, building a job exposure matrix, and predicting possible ARDs namely lung cancer, mesothelioma, gastrointestinal cancer and asbestosis in Zimbabwe AC manufacturing industry. The study adds considerably to future epidemiological studies, gives insights into possible magnitude of ARDs that may be observed in AC factories and possibly analysis of exposure response relationships that may be linked to exposure episodes in the distant past. The study also gives some insights into possible amphibole contaminants that may be associated with local and imported chrysotile asbestos that is used in the AC manufacturing processes and thus providing support for a more comprehensive investigation into the presence of amphiboles in chrysotile asbestos in Zimbabwe. The study also provides some perspectives on approaches to prevention of exposure to asbestos and some aspects on the call to ban all forms of asbestos including chrysotile. Personal exposure chrysotile fibre concentration data in the two AC manufacturing factories showed a downward trend over the years, and that overexposure as evaluated against the OEL of 0.1 f/ml were being exhibited largely before 2008. The job categories with high exposure levels were saw cutting, fettling, ground hard waste, laundry room and multi-cutter operator and such jobs are likely to be associated with high risk of ARDs particularly for exposures happening before 2008. Moulded goods operators were associated with low exposures as process is generally a wet process. Despite exposure concentrations being high in the earlier time periods of 1996 to 2008, declines over time particularly for Bulawayo factory which has continued to use chrysotile to date, suggests that controlled use approach may yield exposures that may present minimal risk to health of those exposed to chrysotile asbestos. While banning can still be considered as a way to eliminating ARDs, it may not necessarily be the panacea for prevention of ARDs, as controlled use approach may perhaps still present real possibilities of prevention of exposure to levels that may present minimal risk to health impairment if effectively implemented as applied to a range of hazards with some success. Banning would possibly imply substitution by materials reported to be hazardous to health. These results can be used in future epidemiological studies, and in predicting the occurrence of asbestos-related diseases in Zimbabwe.
Occupational exposure to chemicals, and health outcomes, among nail technicians in Johannesburg, South Africa
(University of the Witwatersrand, Johannesburg, 2023-08) Keretetse, Goitsemang; Brouwer, Derk H.; Nelson, Gill
Introduction: Nail technicians are exposed to chemicals emitted from activities performed in nail salons, including simple buffing of nails, basic manicures and pedicures, application of nail polish, and the application and sculpting of artificial nails. The various products used during these processes may contain volatile organic compounds (VOCs), which pose a health risk to both the nail technicians and their clients. Associated health effects include skin, eye, and respiratory irritation, neurologic effects, reproductive effects, and cancer. The aim of this study was to effects within the formal and informal sectors in Johannesburg, South Africa. In this study, informal nail technicians are defined as those working in nail salons that are not licensed or registered with any formal enterprise or establishment, or in their own capacity. The objectives were 1) to estimate the prevalence of self-reported symptoms associated with the use of nail products, 2) to measure exposures to chemicals in nail products used in the formal and informal nail salons, 3) to investigate the feasibility and reliability of self-assessment of exposure as a method of estimating exposure to chemicals, and 4) to investigate the association between respiratory symptoms (chronic and acute) and chemical exposures in both formal and informal nail technicians. Methods: This was a cross-sectional study. A questionnaire, adapted from other studies, was piloted before being administered to the participating nail technicians. Data were collected from 54 formal and 60 informal nail technicians, regarding sociodemographic characteristics, perceptions of working with nail products, and self-reported symptoms of associated health effects. A subset of 20 formal and 20 informal nail technicians was conveniently selected from the 114 participants for the exposure assessment phase. The two groups were further divided into two groups of 10 for the controlled/expert exposure assessment (CAE) and the self-assessment of exposure (SAE). Personal 8-hr exposure measurements were performed using VOC and formaldehyde passive samplers attached to the participant’s breathing zone over three consecutive days. For the SAE approach, participants conducted their own exposure measurements, while the CAE approach was fully conducted by the principal researcher. Task-based measurements were carried out using a photoionization detector (PID) to measure peak concentrations during specific nail application activities. A probabilistic risk assessment was conducted to estimate the carcinogenic and non-carcinogenic life time risks from exposure to VOCs. Chemical analysis was conducted by a SANAS-accredited laboratory. After correcting for their respective evaporation rates, relative to the evaporation rate of d-limonene (the VOC with the lowest evaporation rate), the adjusted total VOC (TVOC) concentrations were calculated using the 13 VOCs that were detected at a frequency of 30% or more. VOC concentration data below the limit of detection (LoD) were imputed, using the regression on order statistic (Robust ROS) approach. The self-reported symptoms were categorised into neurological effects, respiratory effects, eye irritation, and skin irritation. The ACGIH additive effects formula was used to calculate the combined respiratory effect of selected VOCs. Different statistical tools were used to analyse the data for each objective. Results: Formal and informal nail technicians used different nail products, performed different nail applications, serviced different mean numbers of clients, and were exposed to different concentrations of selected VOCs. Acetone concentrations were higher in formal nail salons, due to the soak-off method used for removing existing nail applications, while methyl methacrylate (MMA) concentrations were higher in informal nail salons - related to acrylic methods being used more frequently in the informal than the formal nail salons. All VOC concentrations were below their respective occupational exposure limits, with the exception of formaldehyde (0.21 mg/m3). TVOC levels were higher in formal nail salons, due to the bystander effect from multiple nail technicians performing nail applications simultaneously. Sixty percent of the informal nail technicians reported health-related symptoms, compared to 52% of the formal nail technicians, and informal male nail technicians reported more symptoms than their female counterparts. All nail technicians' median and 95th percentile non-cancer risks exceeded the acceptable risk of 1 for xylene, 2-propanol, and benzene, while the cancer risk estimates (medians and 95th percentiles) for benzene and formaldehyde exceeded the US EPA cancer risk threshold of 1 x 10-6. Conclusion: This is the first study to assess exposures to VOCs in the often-overlooked informal sector and compare these exposures with those in the formal sector of the nail industry. Personal breathing zone concentration data for nail salon workers were generated in this study, including the informal sector, which is always challenging to access for research. Although banned in many countries, MMA is still used in South Africa in the informal nail sector. The SAE study showed that participatory research is feasible and enables a more reliable estimate of the exposure by expanding the amount of data. Using a combination of shift and task-based measurements was particularly effective in creating exposure profiles of employees and identifying activities that require targeted interventions. There is a need for the nail industry, especially the informal salons, to be more closely regulated, concerning the hazardous chemicals frequently encountered in nail products. Nail salons should reduce exposure frequency by regulating working hours, making informed decisions regarding the procurement of nail products, and adopting safe work practices to reduce emissions from harmful chemicals and thus exposure among nail salon workers and their clients.