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.
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.
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).
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.
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).
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
Determinants of sub-optimal glycaemic control among patients enrolled in a medicine dispensing programme in Kwazulu-Natal: A cohort study, 2018 – 2021
(University of the Witwatersrand, Johannesburg, 2023) Johnston, Leigh Clare
Background: In South Africa, type 2 diabetes mellitus (T2DM) is a growing public health problem, thus, by 2030, 50% of T2DM patients, receiving treatment, must achieve optimal glycaemic control (haemoglobin A1c (HbA1c) ≤7%). The CCMDD (Central Chronic Medicines Dispensing and Distribution) programme allows glycaemically-stable patients to collect their medication from community-based pick-up points. While the CCMDD is a large public health programme, there is a paucity in stakeholder’s knowledge of T2DM patients glycaemic control over time. We determined glycaemic control for CCMDD-enrolled T2DM patients in eThekwini, South Africa from 2018-2021, as well as the rate and predictors of becoming sub-optimally controlled. Methods: We performed a cohort study, linking HbA1c data from the National Health Laboratory Service to CCMDD-enrolled patients in eThekwini, South Africa from 2018–2021. We included patients optimally controlled at their baseline HbA1c, and having ≥1 repeat test available. We used Kaplan Meier analysis to assess survival rates and Cox regression to determine associations between time to sub-optimal control (HbA1c > 7%) and several factors. Adjusted hazard ratios (aHR), 95% confidence interval (95% CI), and p-values are reported. Results: Of 41145 T2DM patients enrolled in the CCMDD, 7960 (19%) had an available HbA1c result over the study period. A quarter of patients (2147/7960; 27%) were optimally controlled at their baseline HbA1c. Of those controlled at baseline, 695 (32%) patients had a repeat test available, with 35% (242/695) changing their status to sub-optimal control. Patients prescribed dual-therapy had a higher risk of sub-optimal glycaemic control (aHR: 1.503; 95% CI: 1.16–1.95; p-value=0.002) compared to those on monotherapy. HbA1c testing frequency per national guidelines (aHR: 0.46; 95% CI: 0.24–0.91; p-value=0.024) was associated with a lower hazard of sub-optimal glycaemic control. Conclusions: HbA1c monitoring, in line with testing frequency guidelines, is needed to flag sub- optimally controlled patients who become ineligible for CCMDD enrolment. Patients receiving dual-therapy may require special consideration. Addressing these shortfalls can assist planning and implementation to achieve 2030 targets.
The burden of severe Hepatitis A disease in South Africa’s public sector: A cross sectional study using routine laboratory data from 2016 to 2021
(University of the Witwatersrand, Johannesburg, 2023) Khoza, Mariana Makhanani; Mazanderani, Ahmad Haeri; Somaroo, Harsha
Background Hepatitis A virus (HAV) is a common cause of acute viral hepatitis in South Africa, however, there is limited data on the burden of severe HAV disease in the South African population. Objective To describe the burden of severe HAV disease in South Africa’s public sector by describing the prevalence of laboratory diagnosed acute liver failure (ALF) in patients with HAV infection, during the period January 2016 to December 2021. Methods This was a cross-sectional study using retrospective secondary data from the National Health Laboratory Service (NHLS), from January 2016 to December 2021. Laboratory patient records that were positive for HAV IgM were extracted and merged with International Normalised Ratio (INR) test records, using the NHLS Corporate Data Warehouse (CDW) record linking algorithm. All patients with a positive HAV IgM result linked to an INR result >1.5 were reported as having laboratory diagnosed ALF. Descriptive statistics and regression analyses were conducted using STATA 17 SE. Results A total of 15 261 laboratory patient records were positive for HAV infection. Of the patients with HAV infection a total of 7 824 (51.27%) were linked with an INR test result, and of those a total of 1 420 (18.15%) patients had ALF. The average annual burden of patients with ALF was 237 patients per year (range: 136–333). Children <10 years had the highest number of HAV infections (n= 6 227, 40.80%) and ALF (n=576, 40.56%) for the study period. Patients 50-59 years with HAV infection were most likely to have ALF compared to children <10 years (OR 2.95, 95% CI 2.207 - 3.935, p<0.000). Conclusion Whereas adults with acute HAV infection are more likely to develop ALF, severe HAV disease is predominantly a childhood disease in South Africa. This study emphasises the need to strengthen HAV prevention strategies to limit the incidence and burden of severe HAV disease
The 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
Surveillance of gastrointestinal infections in individuals over the age of 5 years in South Africa
(2024) Johnstone, Siobhan Lindsay
Gastrointestinal infections cause significant mortality and morbidity, especially in Africa. While children ≤5 years of age bear the brunt of diarrhoeal disease, there is a significant burden in older age groups. Limited data on aetiology in these older age groups limits appropriate interventions. Diarrhoeal surveillance is important for monitoring disease trends in a population and should inform testing and treatment guidelines, and interventions. This body of work evaluated the epidemiology of diarrhoea at each level of the surveillance pyramid to assist in interpretation of routine health data and identify gaps in surveillance. A household survey was conducted in Soweto to estimate community diarrhoeal prevalence, associated risk factors and healthcare seeking behaviors. An analysis of diagnostic testing practices for diarrhoeal diseases was done, using a doctors’ survey, at three public hospitals in South Africa. Routine diagnostic data and enhanced surveillance data were compared to evaluate patient-related factors associated with requests for diagnostic investigation, type of diagnostic testing offered and the efficiency of available tests. A hospital surveillance study investigated the infectious causes of diarrhoea in hospitalised patients >5 years. Results indicated a high diarrhoeal burden across all age groups in South Africa (5.3% of respondents reported an episode in the preceding 2 weeks). While the majority of infections were mild, 40% required healthcare. Many of those requiring healthcare (34%), specifically adults, were unable to access the required care. Those that did access healthcare were treated empirically and seldom had stool samples collected for diagnostic investigations (approximately 10% of admitted cases). Available diagnostics in public health laboratories detected pathogens in only 13.7% of these submitted stools due to pre-analytical and analytical issues including not testing for all relevant pathogens. Diarrhoeal prevalence was particularly high among HIV-infected patients (67.5% of patients >5 years admitted for diarrhoea were HIV-infected) and these patients presented with a unique aetiology. This research highlights the need for diarrhoeal testing and treatment guidelines based on local epidemiological data with a focus on HIV-infected patients. Current diagnostics require optimisation including specimen collection, standardisation, pathogens included in routine testing panels, turnaround time and methods of detection. This will guide decisions on future public health interventions including vaccines.
The relationship between traumatic events and quality of sleep in older adults in rural South Africa
(University of the Witwatersrand, Johannesburg, 2024) Dzimbanhete, Tsitsi Cherry; Mall, Sumaya; Redman, Kirsten N.
Introduction: A number of factors are associated with the quality of sleep, a broad measure that includes sleep duration and disturbance. There are many factors associated with quality of sleep including communicable and non-communicable diseases and life course traumatic events (TE). Older adults who have experienced life course TE and the onset of comorbidities may be at risk of fluctuations in their quality of sleep. However, there are limited data on the African continent examining these relationships. Therefore, this study aimed to bridge the aforementioned gap and 1. examine the prevalence of traumatic events (TE), 2. examined the prevalence of poor quality of sleep in adults in the Health and Aging in Africa: a longitudinal study (HAALSI) cohort 3. examine the relationship between the TEs and quality of sleep in the HAALSI cohort in the Mpumalanga Province of South Africa. Methods: A cross sectional analysis using data from the second of four waves of the HAALSI cohort was undertaken. The second wave which recruited 4176 participants was conducted between 2018 and 2019. Measures include the English Longitudinal Study of Aging life history data to estimate prevalence of TE, brief version of Pittsburgh Sleep Quality Index (B-PSQI) to estimate the prevalence of poor sleep quality and the relationship between TE and poor sleep quality. Descriptive analysis, bivariate and multivariate analysis of the data was conducted in Stata 17. Results: The mean age of the participants was 65 years (SD=13). The majority of the sample were of South African origin (70%). With regard to education status, less than half (43%) had not completed a formal education (i.e., primary school). Poor quality of sleep was reported by 27% of the participants. With regards to TEs 66% of the sample reported caregiving trauma, 58% accident and disaster TEs, 30% childhood trauma, 15% war related TEs and 22% community violence. The multivariate analysis suggested that participants with history of exposure to childhood TEs and war related TEs had higher risk of poor sleep quality (OR 1.5 (CI1.2-1.8)) and (OR 1.5(CI 1.2-2.0)) respectively. The other variables associated with higher risk of poor sleep quality were being married (OR=1.2 (CI 1.0-1.4)) history of smoking (OR=1.6 (CI 1.2-3.1)), mild to moderate (OR=1.7 (CI 1.3-2.1)) and major depression symptoms (OR=2.1 (CI 1.8- 2.7)), being obese (OR =1.3 (CI 1.0-1.6)) and being HIV negative (OR= 1.4 (1.0-1.6)). Conclusion: Exposure to war related and childhood TEs were found to be associated with poor sleep quality in the older adults in rural South Africa. While a cross-sectional analysis is valuable, an examination of the full cohort of the trauma at baseline and quality of sleep would inform trauma focused interventions that seek to improve quality of sleep in older adults
Occupational noise exposure among groundskeepers at a public university in Gauteng, South Africa
(2024) Mokone, Moses
Background- There is sufficient scientific evidence indicating that excessive and prolonged exposure to noise causes noise-induced hearing loss (NIHL), also known as permanent hearing loss and other non-auditory effects such as sleep disturbance, hypertension, and interference with the nervous and cardiovascular systems. The World Health Organization (WHO) estimated that NIHL costs approximately 0.2% to 2% of the gross domestic product (GDP) of the developed nations in terms of compensation and economic burden on society. It also estimated that more than 16% of the NIHL in adults is attributable to occupational noise exposure. Although preventable, NIHL is one of the most widespread irreversible occupational disease worldwide and thus was declared as a serious occupational hazard. Worldwide, occupational noise exposure is widely regulated and most countries, including South Africa, use 85 dBA as the occupational exposure limit for noise exposure and has adopted the 3-dB exchange rate, with the exception of the US and Brazil, amongst others, which use the 5-dB exchange rate rule. Exchange Rate is the increase in noise level that corresponds to a doubling of the noise level. A few countries around the world such as the US, Japan and India use 90 dBA as a regulated limit for noise exposure. Acute hearing loss can also occur suddenly if a person is exposed to very high impact noise (above 140 dBC) for a short duration such as explosion and gun shots. Research shows that 8-hour average daily noise exposure levels between 75 dBA and 80 dBA are unlikely to cause hearing loss. The International Organization for Standardization (ISO 1999) “Acoustics - Determination of Occupational Noise Exposure and Estimation of Noise-Induced Hearing Impairment” provides damage risk criterion information that enable the prediction of NIHL at various audiometric frequencies and for varying exposure durations. Attempts to limit human exposure to noise are based on damage risk criterion. For example, the National Institute for Occupational Safety and Health (NIOSH) estimates a risk of NIHL after a 40-year working lifetime of 1% at 80 dBA, 8% at 85 dBA, and 25% at 90 dBA. This shows that the 85 dBA limit does not guarantee safety, since 85 dBA is already indication 8% excess risk. The WHO has indicated that workers employed in sectors such as manufacturing, transportation, construction, mining, utility, agriculture and military have the highest risk of 2 | P a g e NIHL. In the Services sector, which include Garden and Landscaping services, the extensive use of powered lawn maintenance machines results in widespread exposure to high levels of noise. The employees employed in the garden and landscaping sector such as groundskeepers, are in charge of maintaining general landscape of public and private areas such as sporting grounds, community parks and learning institutions grounds. Their main tasks involve a variety of outdoor activities such as clearing leaves, mowing lawns, cutting trees, trimming hedges, applying fertilizer, removing dead or unwanted plants and other general garden maintenance work. Noise exposure, which is one of the main health hazards that severely affect the health of these employees during operation of powered lawn maintenance machines such as leaf blowers, riding and push lawnmowers, brush-cutters and chainsaws can be a significant source of workplace noise exposure among groundskeepers. Although the literature on occupational noise exposure has concentrated on large industrial sectors (mining, construction, manufacturing and transportation), the problem extends to smaller operations such as lawn maintenance. Recent literature suggests that noise generating activities in small-scale operations, such as lawn maintenance, use high noise emitting machinery. Purpose- The purpose of this study was to evaluate occupational noise exposure levels of groundskeepers who operate different types of powered lawn maintenance machines at three campuses of a public university in Gauteng and estimate their risk of NIHL. Methods- A quantitative, cross-sectional study design conducted among groundskeepers following a nonprobability convenience sampling strategy was used. Personal and area noise exposure levels were evaluated in accordance with the South African National Standard (SANS) Code of Practice 10083:2013. The measurements for personal noise were conducted using a type 2 Casella dBbadges (personal noise dosimeters), which were placed on the groundskeepers’ shoulders, close to the ear adjudged as receiving the highest noise levels covering sufficient time representative of daily (task-based) exposure. Area noise measurements were performed using a type 1 Quest integrating sound level meter (SLM), which was mounted on a tripod stand and placed at approximately 1.5 meters above the floor and 1 m from the noise generating machine. In each measurement position, one-minute measurements were completed, and Aweighted equivalent noise levels (LAeq) were recorded. To ensure accuracy of measurements, the noise measuring instruments were calibrated before and after each series of measurements v using a calibrated portable acoustic calibrator as per the manufacturer’s instructions. The SLM and personal noise dosimeters (PNDs) were calibrated using a type 1 acoustic calibrator (Model QC-10, Quest Technologies, USA) and type 2 acoustic calibrator (Casella CEL 110/2, Regent House, Bedford, U.K) respectively. No significant shift in calibration was detected for any individual measurement. All the noise measuring instruments were externally calibrated by a South African National Accreditation System (SANAS) 17025 accredited laboratory. A questionnaire constructed by the primary researcher was utilized to record groundskeepers’ demographic information, work processes pertaining to tasks performed and noise exposure levels, including certain elements of hearing conservation practices such as information and training, audiometric testing, and use of hearing protective devices (HPDs). A total of 18 PND measurements and 17 area noise measurements were conducted at three university campuses i.e. Campus A, Campus B and Campus C. The noise measurements were conducted over a period of five (5) days (1-3 September 2021 and 3-4 November 2021). Data/ readings from the noise monitoring instruments were manually recorded on predesigned field sheets and manually entered onto Microsoft Excel spreadsheet. Thereafter, a statistical analysis using a one-way analysis of variance (ANOVA) was carried out to determine whether a significant difference existed between the mean personal and area noise exposure levels measured at three university campuses. Formulas from the SANS 10083 standard were used to calculate measured noise levels for comparison with the regulated noise rating limit of 85 dBA using Microsoft Excel spreadsheet Results- The results of this study showed that majority, 78% (14 out 18), of groundskeepers’ personal noise exposure levels (task-based) in the three campuses exceeded the legislated noise rating limit of 85 dBA, thus increasing groundskeepers’ risk to NIHL. Groundskeepers in campus A were exposed to the highest eight-hour equivalent continuous A-weighted sound pressure level (LAeq, 8h) with mean noise levels of 91.5 dBA ±4.7, followed by campus B and C with mean noise levels of 89.1 dBA ±4.0 and 86.9 dBA ±2.9 respectively. Peak noise exposure levels (LCpeak) measured as part of personal noise exposure in the three campuses ranged from 115.6 dB to 140.0 dB. These excessive peak noise exposures are attributed to the types of machines used during lawn maintenance activities. The overall statistical difference in the mean personal noise exposure levels (LAeq, 8h) and peak levels (LCpeak) between the three campuses were found to be not significant for both the LAeq, 8h (P = 0.304) and LCpeak (P = 0.607). vi Furthermore, majority, 71% (12 out 17), of area noise levels measured on specific lawn maintenance machines had equivalent continous A-weigted sound pressure level (LAeq) above the noise rating limit of 85 dBA. Machines measured in campus A had the highest area noise levels (LAeq) with mean noise levels of 98.8 dBA ±6.9, followed by campus B and C with mean noise levels of 92.9 dBA ±8.3 and 91.6 dBA ±5.1 respectively. The overall statistical difference in the mean area noise levels (LAeq) between the three campuses were found to be not significant (P = 0.135). The findings of this study demonstrated that the study participants comprised a total of 18 males across the 3 campuses, with mean working experience in the current job of five (5) years (ranging 2 – 11 years). Majority (9 out of 18 or 50%) of the participants were aged between 36–45, while only 16% (3 out of 18) were above the age of 56. The distribution of the participants according to their education was 100% secondary school. This may have positive implications for understanding of information and training material used for noise exposure awareness. The results of groundskeepers’ awareness to certain elements of hearing conservation program, with specific focus to information and training, audiometric testing, and use of hearing protection devices (HPDs) revealed that majority (95%) of groundskeepers were not trained about the noise rating limit and its meaning as required by Regulation 4 of the NIHL Regulations. Furthermore, it was found that, 50% of groundskeepers indicated that they never received information and training on the health effects of noise exposure while working at the university. In terms of audiometric testing, 78% of groundskeepers indicated that they were given audiometric testing while employed at the university. The study further indicated that majority (63%) of groundskeepers reported that, they use hearing protection devices (HPDs) while operating noisy machines. Notably, 90% of groundskeepers reported that, there is no one who is checking and supervising if they wore HPDs while operating lawn maintenance machines. The analysis further shows that, 47% of groundskeepers reported that, their HDPs were not comfortable when worn. Conclusion- The findings of this study have highlighted that, although the university had hearing conservation programs in place, there were shortcomings in the implementation of some elements of the program, in particular with regard to information and training, noise exposure monitoring and use of hearing protection devices. Most groundskeepers were exposed to noise vii levels exceeding the noise rating limit of 85 dBA and were at risk of acquiring NIHL. When considering the peak noise levels, the results of the study showed that there was only one groundskeeper from campus A who was exposed to noise levels exceeding the peak limit of 140 dBC. In all cases, employees should never be exposed to peak noise levels in excess of 140 dBC. Prevention, by reducing the noise exposure via engineering measures should be prioritized. The peak noise exposure limit of 140 dBC is regulated in the European Union Physical Agents (noise) Directive 2003/10/EC (2003) as an upper exposure action value. This EU noise directive is adopted by most European countries. Currently in the South African NIHL Regulations and SANS 10083 standard, peak noise exposure levels are not regulated. No significant differences were found in the mean area and personal noise levels measured in the three campuses. However, the use of certain machines such as backpack leaf blower and chainsaw were shown to be associated high noise exposure levels. Therefore, it is essential to ensure that noise levels on the lawn maintanance machines are significantly reduced by implementing good maintenance practices and buy quiet program. Information and training interventions should be aligned to target potentially exposed groundskeepers to modify their perceptions, noise control adherence approaches and continual motivation to sustain and improve an implemented hearing conservation program. This is the first study in South Africa to evalaute occupational noise exposure among groundskeepers in a public univeristy. Findings from this study may contribute to existing knowledge on occupational noise exposure among groundskeepers and may be investigated by other universities where lawn mainteance machines are used. However, the findings of this study may not be generalized to other universities because the study was only conducted in one university. Lessons drawn from this study are that there is a greater need to enhance hearing conservation measures in gardening and landscaping services within the universities.
Prevalence of Group B Streptococcus colonization and serotype distribution among pregnant women in South Asian and African countries
(University of the Witwatersrand, Johannesburg, 2024) Kwatra, Gaurav; Madhi, Shabir A.
Background: Recto-vaginal Group B Streptococcus (GBS) colonization in pregnant women at the time of labour is the major risk-factor for developing invasive GBS disease within 7 days of age (early onset disease; EOD). We investigated prevalence of GBS recto-vaginal colonization at the time of labour among pregnant women and vertical transmission to their newborns across six African and two south-Asian countries. Methods: This multi-country prospective, observational cross-sectional study was undertaken in six African [(Ethiopia (Adama city), Kenya (Kilifi), Mozambique (Manhica), Nigeria (Gwagwalada), Mali (Bamako) and South Africa (Johannesburg) and two Southeast Asian countries (Bangladesh (Mirzapur) and India (Vellore)]. Inclusion criteria included pregnant women 18 to 45 years of age, delivery at ≥37 weeks gestation and documented to be HIV-uninfected prior to study-enrolment. Lower vaginal swabs, rectal swabs and urine were collected from the mothers and separate skin surface swabs of the umbilicus, outer ear and axillary fold; and rectal and throat swabs were obtained from the newborn for GBS culture. Standardized sampling and culture using direct plating and selective broth media for detection of GBS colonization in the mother-newborn dyads was undertaken across the sites. Serotyping of GBS isolates was done in South Africa. Results: Overall, 6,922 pregnant women were enrolled from January 10th , 2016 to December 11th , 2018. Of 6922 women who were enrolled, 6514 (94.1%; 759 to 892 per site) were included in the analysis. Overall, the prevalence of maternal GBS colonization was 24.1% (95%CI 23.1- 25.2; 1572/6514) being highest in Mali (41.1%, 95%CI: 37.7-44.6; 314/764) and lowest in Ethiopia (11.6%, 95%CI:9.5-14.1; 88/759). The overall rate of vertical transmission of GBS was 72.3% (95%CI 70.0-74.4; 1132/1566); being highest in Mozambique (79.2%, 95%CI 73.3-84.2); 168/212) and lowest in Bangladesh (55.8%, 95%CI 47.5-63.8; 77/138). The five most common GBS colonizing serotypes were Ia (37.3%; 586/1572), V (28.5%; 448/1572), III (25.1%; 394/1572), II (9.2%; 144/1572) and Ib (6.5%; 102/1572). There was geographic variability in serotype proportion distribution. Serotype VII was the third most common serotype in India (8.5%, n=15/176) and serotype VI was mainly identified in Bangladesh (5.8%) and India (5.7%). Conclusion: Our study reported high prevalence of GBS colonization in most settings, with some geographic variability even within African countries. Our findings suggests that there is likely to be a significant burden of EOD across the study sites. Post-licensure vaccine effectiveness studies should also focus on maternal GBS serotype distribution as non-vaccine serotype replacement could occur due to vaccine immune pressure
Occupational characteristics and economic activities of health workers in the quarterly labour force survey: 2008-2017
(University of the Witwatersrand, Johannesburg, 2024) Dinga, Aphiwe; Blaauw, Duane
ackground There is global emphasis on the importance of research and analyses of health labour markets. The latter is defined as dynamic systems consisting of the demand and supply of health workers, influenced by a country’s regulations and institutions. However, there is limited national data to inform a health labour market analysis. Aim The aim of the study was to analyse the demographic, occupational characteristics and the economic activities of health workers who were surveyed in the Quarterly Labour Force Survey (QLFS) from 1 January 2008 to 31 December 2017. Methodology This study was a cross-sectional secondary data analysis of the health workers captured in the QLFS, a household survey that is conducted every three months by Statistics South Africa. The survey focuses on the labour market activities of individuals aged 15 to 64 years who live in South Africa. The sample analysed for this study was all health workers surveyed in the QLFS during the study period. Both the South African Standard Classification of Occupations (SASCO) and the Standard Industry Classification (SIC) codes were used to extract data on all health occupations to ensure that the entire health workforce in the QLFS was included in the current study. To identify predictors of employment a multiple logistic regression was carried out. STATA ® 15 was used for the statistical analysis. Results The study sample comprised a total of 5 502 health workers. Nurses constituted the highest proportion of health workers in the survey (60.1%) while medical doctors and dentists represented 10.0%. Nurses were older than the other categories of health workers with a mean age of 43.6 years (SD±10.3), compared to the mean age of 41.8 (SD±10.8) for doctors, 38.6 (SD±10.4) for mid-level health workers and 37.8 (±10.8) for allied health workers. The majority (59.0%) of health workers were employed in the public sector, and in urban areas (83.8%). Only 4.6% of doctors and 7.0% of allied health workers were employed in rural areas. Overall, the study found that fewer than 1% of health workers reported more than one job during the 10-year period. The results of the logistic regression showed that the odds of employment were approximately two times higher for health workers between the ages of 36-45 and 46-55 years old and 1.8 times higher for health workers between the ages of 26-35. There were 0.5 odds of employment for health workers aged 56-64 years compared to the reference age group of 18–25-year-olds. Females were less (0R=0.56) likely to be employed as compared to males. Compared to health workers in urban areas, those in rural areas were less (0.47) likely to be employed. Health workers were 0.53 times less likely to be employed outside the health industry as compared to being employed in the health industry. Conclusion Although the QLFS provides useful information on the health workforce in South Africa, the results highlight the need for investment in a robust human resources for health information system
Community-orientated primary health care: Exploring the interface between community health workers, the healthcare system and communities in South Africa
(University of the Witwatersrand, Johannesburg, 2024) Malatji, Hlologelo; Goudge, Jane; Griffiths, Frances
Background: To achieve universal health coverage, low and middle income countries (LMICs) are extending primary health care (PHC) services using community health worker (CHW) programmes. However, CHWs are marginalized within the healthcare system. Community-orientated primary health care (COPC) and supportive supervision are two interventions being used to strengthen CHW programmes. Primary aim: To understand whether and how the COPC and supportive supervision approaches strengthen CHW programmes in South Africa. Methods: Data was collected between 2016 and 2019 using qualitative methods in nine PHC facilities in rural and semi-urban areas of Mpumalanga and Gauteng provinces, South Africa. Purposive and snowball sampling techniques were used to recruit participants. The participants included: CHWs, supervisors, facility staff members and community members. Data was collected using focus group discussions, individual interviews and observations, and was analysed thematically. Findings: In line with the COPC approach, there were efforts to engage communities in the implementation of the CHW programmes but community members prioritised other challenges such as lack of housing and running water. In some facilities, in-service training increased CHWs knowledge and skills but challenges such as lack of supervision, lack of resources and outsourced employment without benefits demotivated the CHWs (Paper 1 / Objective 1, Published). In response to challenges, in the semi-urban sites, CHWs unionised to present their grievances to government. This resulted in an increase in stipend but not permanent government employment. During the height of the COVID-19 pandemic, when decision- makers recognised the essential role of CHWs higher remuneration was secured. CHWs in rural areas were not active in demanding permanent employment (Paper 2 / Objective 2, Published). Supportive supervision provided by a nurse mentor over 14 months, (1) trained CHWs and their supervisors resulting in increased knowledge and new skills, (2) addressed their fears of learning and failing and (3) established operational systems to address inefficiencies in CHW core activities (household registration and medication delivery). The intervention was disrupted by union activities. The communities’ demonstrated little interest in the functioning of CHW programmes (Paper/ Objective 3, Published). Conclusion: Both the COPC approach and supportive supervision can reduce marginalisation of CHW within the health system
Understanding the roles and experiences of key stakeholders involved in the design of the novel imagine social outcomes-based contract in South Africa
(2024) Moodley, Gillian Pryadarshini
The Imagine Social Outcomes-Based Contract (SOBC) is an innovative health financing mechanism in South Africa applied to sexual and reproductive health outcomes of adolescent girls and young women. The Imagine SOBC is led by the South African Medical Research Council (SAMRC) and supported by other stakeholders. Its uniqueness stems from the role played by the SAMRC, as an intermediary on behalf of the South African government. Eleven semi-structured interviews were held with stakeholders who played intermediary, technical advisor, and implementation service provider roles during the Imagine SOBC design phase. Interviews were transcribed and analysed using the six steps of thematic analysis. The thematic findings of this study are the dynamics of working together, politics and processes, challenges and looking to the future. Despite internal collaboration and alignment among interviewees, the biggest challenge during the design phase of the Imagine SOBC was obtaining approvals from the government departments due to complex approval processes in the public sector. The lessons generated are important as the SAMRC intends to replicate the outcomes-based contract model for other disease priorities. These findings are valuable for policymakers and future outcomes-based contract practitioners who are considering a transaction of this nature and its application to public health. The findings will also assist in the development of a guiding practice note for policymakers and government officials who grant approvals.
The association between intermittent preventive treatment uptake and anaemia amongst pregnant women in Zambia in 2018: a spatial analysis
(University of the Witwatersrand, Johannesburg, 2024) Chisiba, Charlotte; Musenge, Eustasius; Mapuroma, Relebogile
Background: This study investigated the association between Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine (IPTp-SP) uptake and anaemia among Zambian pregnant women aged 15-49 in 2018. Despite WHO's endorsement of IPTp-SP to combat malaria-related anaemia, its prevalence continued to rise, significantly impacting maternal health. Methodology: Using Zambia Demographic Health Survey 2018 data, 665 pregnant women receiving IPTp-SP were analysed for haemoglobin levels, determining anaemia through blood tests. Statistical methods included survey-adjusted proportions, means, bivariate analysis, multiple linear regression, and multi-level ordinal logistic models with spatial random effects. Spatial analyses used ArcMap for coverage analysis, ordinary least squares, and geographically weighted regression maps (GWR) techniques in R and Stata. Results: Optimal IPTp-SP doses resulted in 36.98% anaemia prevalence (124/369), and suboptimal doses led to 42.85% (112/296). Factors associated with anaemia included household size, rich wealth index, high parity, and employment during pregnancy. Associations between IPTp-SP uptake and anaemia were identified: household size (four to six: AOR= 0.53; 95% CI 0.34 to 0.80; seven or more: AOR=0.57; 95% CI 0.35 to 0.91), adequate antenatal visits (AOR=0.68; 95% CI 0.48 to 0.97), and rich wealth index (AOR= 0.68; 95% CI 0.34 to 0.98). Spatial analysis revealed anaemia hotspots in Southern, Luapula, and Eastern provinces, with iron supplements and household size identified as influential factors. Conclusion: Despite IPTp-SP use, overall anaemia prevalence was 40%, with the highest rates in Southern, Luapula, and Western provinces. Targeted strategies focusing on improving iron tablet access, antenatal care attendance, and utilising spatial maps are crucial for mitigating adverse anaemia outcomes in these region
Predictors of resilience among adolescents living in rural Mpumalanga in 2018: a cross sectional study
(2024) Snijder, Michelle
Literature suggests that resilience can be reached by practicing behaviours, thoughts and attitudes that promote resilience. To understand which behaviours, thoughts and attitudes foster resilience, predictors of resilience should be studied. This study aimed to examine predictors of resilience among adolescents living in the rural Mpumalanga Province, South Africa. Data were collected using a questionnaire from a sample of 245 adolescents between 13.1 and 15.2 years (median age 14.1 (13.1- 15.2); sex 52.7% female and 47.4% male). The questionnaire included questions from depression, stress and resilience scales as well as additional questions relating to communication with parents, and socio-demographic characteristics. The 20 question Centre for Epidemiological Studies Depression Scale (CES-D) measured depression, the 10-item Perceived Stress Scale (PPS-10) measured stress while the 25-item Connor Davidson Resilience Scale (CD-RISC-25) measured resilience. The prevalence of resilience was estimated at 46.1%. The findings suggest that perceptions of stress did not significantly predict resilience. Experiencing depressive symptoms and healthy interpersonal relationships significantly predicted high resilience. Although healthy relationships with parents predicted high resilience, adolescents relied more on relationships with friends to build resilience. However, regularly meeting with friends predicted low resilience, while always meeting with friends decreased the chances of low resilience. Thus, the study suggests that healthy relationships with both parents and friends may predict high resilience. However, when relationships with friends replaces that of parents, low resilience results. Finally, this study supports the need for further studies on the validity and acceptability of the PPS-10 and CES-D scales in the South African context.