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    A nexus of student food (in)security, common mental disorders, and academic success in the midst of the covid-19 pandemic
    (University of the Witwatersrand, Johannesburg, 2024) Wagner, Fezile
    Background: South African Higher Education Institutions (HEIs), akin to their global counterparts, grapple with the challenge of low throughput and dropout rates, as students often extend beyond the minimum required duration to complete their academic programmes. Research has identified the first year of study as the period carrying the highest risk for student failure and attrition. Factors such as prior academic performance, family background, and the student's ability to integrate into various aspects of university life emerge as significant determinants of academic success. Notably absent from these determinants are considerations pertaining to student wellbeing, encompassing mental health and food security status. These aspects assumed heightened awareness during the coronavirus disease of 2019 (COVID-19) pandemic, which posed threats to social, economic physical, and psychological wellbeing. For university students, the pandemic necessitated a swift adoption of a new pedagogical approach - Emergency Remote Teaching and Learning (ERTL) – along with most students being forced to relocate home, while simultaneously facing the harsh realities of mass job loss, illness, and grief brought on by the pandemic. Objective: This PhD aims to measure the impact of the COVID-19 pandemic on first time, first year university students’ food insecurity and mental health status (specifically, the common mental disorders (CMDs): anxiety, depression and mental distress symptoms), as well as to understand the implications of this on academic success. Methods: Taking place at a large, urban South African university, this research made use of a concurrent triangulation research design. Two cross-sectional surveys were administered in the years 2019 (before the pandemic) and 2020 (during the COVID-19 pandemic). Included in the surveys were validated tools used to measure depression (Patient Health Questionnaire 9-item (PHQ 9)), anxiety (Generalized Anxiety Disorder 7-item (GAD-7)), and mental distress symptoms. The Household Food Insecurity Access Scale (HFIAS) was also included in the two cross-sectional surveys to measure food insecurity levels. This tool was validated before being administered. Academic success was evaluated through two distinct approaches: i) the first method involved scrutinizing student failure rates and progress; ii) the second method focused on assessing retention and dropout rates. Qualitative data collection took place in 2020 and took the form of in-depth interviews (IDIs) and focus group discussions (FGDs). ii Results: Due to the lockdown directive, students living at home during studies increased from 29% in 2019 to 88% in 2020. In terms of the student failure rate, a reduction was noted from 23.4% (95% CI: 20.7- 26.3) in 2019 to 14.6% (95% CI: 12.0- 17.7) in 2020. Teaching staff acknowledged that students seemed to have a better grasp of complex content during ERTL, and feedback from students themselves indicated the benefits of being able to access and replay lecture recordings as well as the flexibility introduced by ERTL. Increased dropout levels were found - increasing from 5.5% (95% CI 4.2- 7.2) in 2020 to 10.5% (95% CI 8.2- 13.2) in 2021. Moderate food insecurity status (OR= 2.50; 95% CI: 1.12- 5.55; p=0.025), and severe mental distress symptoms (OR= 7.08; 95% CI: 2.67- 18.81; p<0.001) increased the odds of student dropout. The adjusted prevalence of food security was found to be better during the later time point - 30.3% (95% CI: 27.4- 33.4) in 2019 before the COVID-19 pandemic, to 37.9% (95% CI: 34.1- 41.9) 2020 during the COVID-19 pandemic. While the prevalence of CMD symptoms worsened over time; the prevalence of severe anxiety symptoms increased from 17.5% (95% CI: 15.2- 20.1) in 2019 to 25.4% (95% CI: 22.0- 29.1) in 2020. Conclusions: The study found an increase in student dropout and a decrease in failure rates during the pandemic, findings corroborated by other studies. Analyses suggest mental distress symptoms and food insecurity were important drivers of student dropout during the pandemic. Findings highlighted a clear decline of food insecurity when compared to figures before the pandemic. Literature highlighted how food and eating practices change when students are at home; this may have reduced food insecurity levels. A significant increase in the prevalence of CMD symptoms during the COVID-19 pandemic was observed and is believed to have been influenced by various intricate factors including grief, job loss and confinement. These findings provide important insights to HEIs in the event of future disruptions and as they embrace hybrid teaching and learning approaches post COVID-19. Although the reduction in failure rates may have been possibly due to changing the delivery of content (ERTL), HEIs must consider economic, social and mental health factors that may exclude certain groups of students when designing these approaches. It is crucial to explore ways to facilitate remote learning for students that address epistemological access challenges while maintaining inclusivity and connectedness as this is likely to contribute positively to academic success.
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    Utilisation of maternal, newborn and child healthcare services in three sub-Saharan African countries (DRC, Kenya, and Tanzania) using Demographic Health Surveys data from 2007-2016: Application of Generalised Structural Equation and Machine Learning Models
    (University of the Witwatersrand, Johannesburg, 2024) Mlandu, Chenai; Musenge, Eustasius
    Background: The risk of child deaths within the first month of life is elevated than the later stages of childhood. Globally, Sub-Saharan Africa (SSA) has the highest neonatal mortality. Majority of the countries in SSA including the DRC, Kenya and Tanzania are struggling to meet Sustainable Development Goal (SDG) 3.2 of reducing the neonatal mortality rate to 12 deaths per 1,000 live births by 2030 (2). Most causes of neonatal deaths are preventable and treatable. Universal coverage, timely and effective utilisation of maternal, newborn, and child healthcare (MNCH) services during pregnancy, delivery, and postpartum has the potential to save many lives of newborns in high-burden countries. vii Antenatal care (ANC) is the first service offered to pregnant women in MNCH. The timing and frequency of ANC visits is critical for the mother and her unborn child. The WHO recommends that women initiate ANC within 16 weeks of pregnancy and attend a minimum of four ANC visits for timely and optimum care before delivery (3, 4). The WHO also recommends that pregnant women receive assistance from a skilled worker during delivery and get postnatal checks with their newborns within 6 weeks of delivery (5, 6). Furthermore, utilising the Continuum of Care (CoC) for MNCH could significantly reduce maternal and newborn deaths in SSA. In the context of MNCH, the CoC is an approach that ensures continuous care from the period of pregnancy, through to childbirth, postnatal period, infancy, and the childhood period (7). Despite the recognition of the use of vital services in MNCH, timely and adequate uptake of MNCH services remains poor and the coverage of MNCH is far from universal in SSA. Most pregnant women initiate ANC after 16 weeks and hence fail to receive timely ANC interventions (8). Uptake of ANC visits, skilled birth attendance (SBA) and postnatal care (PNC) is suboptimal (8-11). Studies in SSA have explored various factors associated with MNCH services utilisation, however, our understanding of MNCH services utilisation in SSA is still limited. Trends in utilisation of MNCH services over time such as late ANC uptake have not been thoroughly assessed. Late uptake of ANC is still a common problem in SSA. Tracking women’s progress in the timing of ANC will ascertain if they are any changes in women’s late uptake of ANC and the contributing factors. This information will guide future policies and programmes which focus on improving the timely uptake of ANC in the SGD era. There is also a dearth of empirical evidence on the factors associated with the utilisation of ANC, skilled delivery and postnatal care in the CoC using nationally representative data. The CoC views both the mother and child as a collective rather than as separate/ individual entities. Understanding factors that viii contribute to the full utilisation of drop out from the CoC is essential for the formulation of interventions than enhance the CoC. Furthermore, studies which investigated either the individual utilisation of MNCH services such as timing of ANC, ANC visits, SBA and PNC services or the CoC have tended to use more of the traditional analysis methods such as the logistic regression. The application of more versatile analysis methods such as Machine Learning is not common. Machine Learning methods are capable of extracting information that commonly used methods (logistic regression) fail to do by uncovering hidden patterns and relationships, particularly in large data sets (12). The application of Machine Learning methods can offer opportunities of enhancing existing methods (conventional regression methods) for predicting and classifying MNCH utilisation leading to more effective interventions to improve MNCH utilisation. There is also a limited understanding on the interrelationships between MNCH services utilisation and neonatal outcomes. The associations between MNCH services utilisation and newborn outcomes such as neonatal mortality are commonly assessed using traditional approaches that assume direct associations. Specific analytical methods, such as Generalised Structural Equation Modeling (GSEM) can be used to model complex relationships such as interrelated links between utilisation of different MNCH services and neonatal outcomes. GSEM gives a clear understanding of how different services of MNCH are related to one another with neonatal outcomes by estimating both direct and indirect paths associations for more effective targeted interventions. Given the critical role of MNCH in ending preventable neonatal mortality, the overarching aim of this study was to describe the utilisation of MNCH services and their associations with neonatal mortality using GSEM and Machine Learning models in three sub-Saharan African countries: the DRC, Kenya, and Tanzania. ix Methods: The study utilised cross-sectional secondary data of reproductive-age women from the Democratic Republic of Congo (DRC) (2007-2013/14), Kenya (2008-2014) and Tanzania (2010-2015/16) Demographic Health Surveys. Firstly, the multivariate logistic regression analysed factors associated with late ANC initiation accounting for clusters, survey weights and stratification for the different rounds of the Demographic Health Surveys. Trends in late initiation of ANC over time in each country were assessed by comparing the earlier and later surveys using differences in prediction scores (prediction probabilities generated after running the multivariate logistic regression models). Secondly, the study assessed the main predictors of non-utilisation of PNC using the Decision Tree. The model performance of the Decision Tree was compared to the Logistic Regression using Accuracy, Sensitivity, Specificity and area under the Receiver Operating Characteristics. Thirdly, factors associated with the drop out from the MNCH continuum, defined as not fully utilising either ANC, SBA, or PNC services, were analysed using multivariate logistic regression accounting for clusters, survey weights and stratification. Machine Learning analysis was used to predict the drop out from the MNCH continuum using features (predictors) that were found significant in the multivariate logistic regression. Five classification Machine Learning models were built and developed including the Artificial Neural Network, Decision Tree, Logistic Regression, Random Forest and Support Vector Machine to predict the drop out from the MNCH continuum. The prediction accuracies of the models were then compared using parameters including Accuracy, Precision, Recall, Specificity, F1 score and area under the Receiver Operating Characteristics. Fourthly, the Generalised Structural Equation Modeling (GSEM) was used to assess the mediatory role of MNCH services utilisation on neonatal mortality. The endogenous variables x were ANC attendance, SBA and PNC attendance, low birth weight and neonatal mortality. The GSEM analysis also accounted for survey weights and considered cluster random effects. Results: The findings showed a reduction in late ANC initiation (67.8%-60.5%) between 2008-2014 in Kenya as well as in Tanzania (60.9%-49.8%) between 2010-2016, but an increase was observed in the DRC (56.8%-61.0%) between 2007-2014. In the DRC, higher birth order was associated with ANC initiation delays from 2007-2014, whilst rural residency, lower maternal education and household income was linked to ANC initiation delays in 2014. In Kenya, lower maternal education and household income was associated with ANC initiation delays from 2008-2014, whilst rural residency and increased birth order were linked to ANC initiation delays in 2014. In Tanzania, higher birth order and larger households were linked to ANC delays from 2010-2016, whilst ANC initiation delays were associated with lower maternal education in 2010 and lower-income households in 2016. The results also showed that the Decision Tree models had higher prediction accuracy of non- utilisation of PNC than the Logistic Regression models. Using the Decision Tree, low quality of ANC, home deliveries and unemployment were associated with the highest probability of not utilising PNC (92.0%) in the DRC. In Kenya, home deliveries, unemployment and lack of access to mass media were associated the highest likelihood of not utilising PNC (87.0%). In Tanzania, home deliveries, low quality of ANC and unwanted pregnancies exhibited the highest likelihood of not utilising PNC (100.0%). The results also revealed very high rates of dropping out from the MNCH continuum in the DRC (91.0%), in Kenya (72.3%) and Tanzania (93.7%). Rural residence, lower maternal education and non-exposure to mass media were common predictors of dropping out from the MNCH continuum across the three countries. Further, the influence of factors such as xi household wealth, household size, access to money for medication, travel distance to health facilities, and parity and maternal age varied by country. Results from the Machine Learning analysis showed that the Logistic Regression had the least prediction accuracy, while the Random Forest exhibited the highest prediction accuracy. Using the Random Forest, the study further ranked the most important predictors of the drop out from the MNCH continuum. Household wealth, place of residence, maternal education and exposure to mass media were the top four most important predictors. The results also showed direct and indirect associations between MNCH services utilisation and neonatal mortality. ANC attendance mediated the total effects of PNC attendance on neonatal mortality by 8.8% in Kenya and 5.5% in Tanzania. ANC attendance and SBA also sequentially mediated the total effects of PNC attendance on neonatal mortality by 1.9% in Kenya and 1.0% in Tanzania. The results in Tanzania also showed ANC attendance mediated 2.8% of the total effects of LBW on neonatal mortality. No presence of mediation was observed in the DRC; however, ANC attendance moderated the relationship between parity and neonatal mortality. Conclusions: The study found that late uptake of ANC decreased between the two survey rounds in Kenya and Tanzania but increased in the DRC. Women from various geographic, educational, parity, and economic groups showed varying levels of late ANC uptake. Increasing women’s access to information platforms and strengthening initiatives that enhance female education, household incomes, and localise services may enhance early ANC uptake. The Decision Tree models showed higher prediction accuracy of non-utilisation of PNC than the Logistic Regression models in the DRC, Kenya and Tanzania. Using the Decision Tree, women who had poor quality of ANC, home deliveries, unemployment, unplanned pregnancies, and no mass media access were identified as high-risk subpopulations of non- xii utilisation of PNC. Improving access and quality of care, incorporation of TBAs into the formal health systems, government health financing, increasing access to mass media and integrating maternal healthcare services with family planning services should be considered as top priority interventions to improving the utilisation of PNC. Most women and children drop out of the MNCH continuum in the DRC, Kenya and Tanzania. Rural residence, lower maternal education and non-exposure to mass media were common factors linked to the high dropout in the MNCH continuum. The use of Machine Learning can help support evidence-based decisions in MNCH interventions. Rapid response mechanisms such as web-based applications can also be developed through the use Machine Learning whereby a pregnant woman’s future utilisation of the services in CoC is assessed and monitored in real-time. The GSEM findings showed interconnections between MNCH services utilisation such as timing of ANC, ANC visits, SBA, PNC and neonatal mortality. This suggests that more than direct and indirect factors are accountable for the associations between MNCH services utilisation and neonatal mortality. The mediation role of MNCH services on neonatal mortality indicates critical areas for targeted interventions to reduce neonatal mortality. Overall, the study aimed to describe the utilisation of the MNCH services and associations with neonatal mortality in the DRC, Kenya and Tanzania. The study showed declines in late ANC uptake in two countries, however, early uptake of ANC is far is still not universal. The study also showed very low levels of retention in the CoC, and most women and children drop out in the CoC at postpartum period. The findings also showed the existence of social, health system and individual inequalities in MNCH and their impact on early childhood survival. Women who are vulnerable to unequal and poor MNCH services utilisation are characterised by poverty, rural residence, long travel distances to health facilities, unaffordable medical expenses, home deliveries, low quality of xiii care, low education, high parity, younger age, unemployment, limited exposure to mass media, and unplanned pregnancies. Context-specific intervention programs such as female education, government health financing, MNCH promotion programs through mass media and improved accessibility and quality of care in health facilities, particularly for the most vulnerable groups of the populations such as women of low socioeconomic status and women from underserved rural areas are essential to improve the overall health of mothers and children and meeting the SDG-3 goals. Modern biostatistical models like Machine Learning provide essential tools to understand public health problems. These techniques should be applied to complement the conventional statistical methods, particularly the tree-based models like the Decision Tree and Random Forest for predicting and classifying the utilisation of MNCH services. The GSEM established interconnections between timing of ANC, ANC visits, SBA and PNC and neonatal mortality. The timing of the first ANC contact is an important starting point to a continuation through the COC. It makes women better informed about pregnancy and the subsequent use of MNCH services. All stakeholders should work more on promoting early uptake of ANC by setting up initiatives that increase women’s access to information platforms, enhance female education, improve household incomes, and bring services closer to communities.
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    The Role and Role Activities of Professional Nurses Practicing in Child and Adolescent Psychiatric Inpatient Units in Gauteng, South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Coetzee, Rebecca Adelle; Nkosi, Nokuthula
    Background: In South Africa’s healthcare system, the rise in mental health challenges among children and adolescents underscores the need for effective, specialized services. Central to psychiatric care are multidisciplinary teams, with child and adolescent professional nurses playing crucial roles in supporting positive health outcomes. However, the specific roles and activities of these nurses remain unclear within the South African context. Purpose: This study aims to fill this gap by investigating the roles and activities of child and adolescent professional nurse practitioners in South Africa. Through semi- structured interviews, the study explores the various dimensions of their roles. Research Methods: This qualitative descriptive study used semi structured interviews and thematic analysis to gather and analyse data, 17 interviews were conducted and analysed. A scoping literature review was also conducted, following Arksey and O'Malley’s (2005) framework, to map the role of child and adolescent professional nurses internationally over the past decade. The review, conducted across databases including Ebsco Host, Scopus, and ProQuest, resulted in six articles after applying inclusion and exclusion criteria. Findings: Interview data revealed that nurses’ roles include patient support, crisis management, independent admission processes, medication administration, and therapy sessions. Their responsibilities span ensuring safety, collaborating in multidisciplinary teams, managing high-risk patients, and maintaining records. Administrative duties involve delegation, supervision, training, advocacy, and referrals. The main challenges identified were training gaps in psychology, burnout, resource limitations, and facility constraints. The scoping review echoed similar themes, including professional roles, patient care, therapeutic interventions, safety measures, collaborative practices, training needs, and skills development for CAMH nurses. Conclusion: This study illuminates the diverse and essential roles of child and adolescent professional nurses within the healthcare team, underscoring the need to integrate these responsibilities into training curricula. By synthesising literature and xii empirical data, the study offers a comprehensive view of these nurses’ roles and challenges, contributing valuable insights for future practice and education in the field.
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    The Development of an Environmental Hygiene Management Audit Tool for Operating Rooms
    (University of the Witwatersrand, Johannesburg, 2024) Mahlangu, Patience; Engelbrecht , Linette
    Background: The operating theatre environment is as complex as surgical and anaesthetic practices combined. The intra-operative environment may be one of the most contaminated areas in a hospital. Effective operating room environmental management is an important measure to prevent the spread of Surgical Site Infections (SSIs). Environmental cleaning teams require clear instructions and training, and simple methods of assessing cleanliness, which cannot be done by visual assessment. Despite the abovementioned recommendations, incorrect cleaning practices continue to occur for multiple reasons. Aim: The aim of this study is to contribute to a safe operating room environmental cleaning practices and management through the development of an environmental hygiene audit tool that could enhance the quality care of all patients in the operating room. Methods: An exploratory three- phase sequential mixed-methods design was conducted to meet the research objectives. 1) In Phase 1, a scoping review of literature was conducted guided by a framework proposed by Johanna Briggs Institute. Five data bases were searched for primary studies published in English between 2010 and 2020. 2) In-depth interviews were conducted with four purposively selected experts in the field of Infection Prevention and Control in the operating theatre, to gather multiple viewpoints on the intraoperative environmental cleaning practices and management in phase 2. 3) In Phase 3, an audit tool of an an environmental hygiene management was developed, based on the findings of phase 1 and 2. The development was guided by the Donabedian framework. Data analysis: Data were analysed following the thematic analysis in Phase 1 and Phase 2. Following data analysis, 5 major themes emerged in phase 1 and 4 themes in phase 2 of the study. Data from the 2 phases informed the development of the environmental hygiene management audit tool in phase 3. Summary of findings: The findings of this study indicated that the environmental hygiene in the operating room should be managed through specific cleaning practices, specific cleaning methods and cleaning intervals. It is also indicated that there are different types of chemicals/products with different strength that should be used for surfaces, equipment and floors. The equipment such as mops and cloths should also be cared for and handled in a 6 certain manner. This was backed up by the participants during the in-depth interviews and they even added on the aspect of cleaner safety, risks, training and responsibility. Conclusion: Operating theatre environment is a secondary reservoir for organisms with the potential for infecting patients undergoing surgery. This study recommends that thorough and frequent disinfection of surfaces with higher frequency of hand contact be done after each patient procedure.
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    Worker’s Knowledge and Practices on Factors Influencing the Risk of Silica Dust Exposure in Lesotho Mines
    (University of the Witwatersrand, Johannesburg, 2024) Langwana, Vuyiseka; Masekameni, M.D
    Background Exposure to respirable crystalline silica (RCS) dust is a major occupational hazard linked to serious lung diseases, including silicosis, lung cancer, and pneumoconiosis, with mining accounting for a significant portion of these illnesses. Despite awareness of silica's health risks and efforts to control exposure, hazardous levels persist in industries like mining, quarrying, and mineral processing, where silica is found in materials such as quartzite, sandstone, and granite. Silicosis, an irreversible lung-scarring disease, remains prevalent among workers, particularly miners in Lesotho, where cases have slightly increased, underscoring the need for improved silica dust control measures. Although preventive controls exist, there is an urgent need to enhance silica exposure management in these high-risk environments. Aim This study aims to evaluate mine workers' knowledge, attitudes and practices regarding factors that increase the risk of silica dust exposure in selected mines in Lesotho. Methods The study employed a descriptive retrospective cross-sectional design with a quantitative approach. A record review guide was used to gather secondary data from the Southern Africa Tuberculosis and Health Systems Support (SATBHSS) project. This data was entered into Microsoft Excel, cleaned for accuracy, and analyzed in STATA software, version 17, using both descriptive and inferential statistics. The study focused on a sample of workers from 5 selected mines, chosen from 11 active mines in Lesotho, which extract various minerals. The selected mines were those engaged in mining diamonds, sandstone, and quarry materials. The study aimed to assess the knowledge, attitudes, and practices of mine workers regarding factors that elevate the risk of silica dust exposure in these mines. vi Results The study found that mine workers had good knowledge about certain Occupational Health and Safety (OHS) hazards, with high awareness of lung cancer (91%), noise levels (99%), and safety stressors (96%). However, 90% of workers lacked adequate knowledge on physical stressors in their workplaces. The average knowledge score was 13.43 (SD = 2.99), with scores ranging from 6 to 19 and a median of 14. Regarding preventive practices, 55% of workers reported the presence of health and safety strategies, 60% held regular safety meetings, and only 40% indicated regular dust and noise monitoring by employers. Additionally, 56% had health and safety representatives at work. Notably, 15% viewed the work as suitable only for the "brave," and 65% considered minor accidents a normal part of the job. The workforce was predominantly male (91%) with most having secondary education (79%), which may impact their understanding of training resources on crystalline silica exposure. Conclusion This study reveals that, while health and safety programs exist within mines to prevent exposure to respirable crystalline silica (RCS) dust, gaps in program implementation leave workers at risk for silicosis and other respiratory diseases. Mine workers generally had limited knowledge about managing RCS dust exposure, which leads to poor practices in dust control. The findings emphasize that engineering controls alone are insufficient, underscoring the need for a broader hierarchy of controls and improved administrative measures, including training and best practices. Only 46% of participants recognized air measurements as beneficial for controlling dust exposure. This study, the first of its kind in Lesotho, could inform national policies on silica dust exposure control. However, its findings may be less generalizable to similar mining contexts across Africa due to its retrospective, questionnaire-based design, which may introduce response bias. The study suggests that greater emphasis on knowledge, attitudes, and practices is essential to effectively reduce silica dust exposure in mines.
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    A comparative assessment of the legislative and regulatory frameworks for local manufacture of vaccines in South Africa and Egypt
    (University of the Witwatersrand, Johannesburg, 2024) Naidoo, Thevendran
    Healthcare systems in low-and middle-income countries in Africa are highly dependent on immunisation programmes and the availability of vaccines to manage infectious disease outbreaks and, together with clean water and access to health care, serve as the cornerstone of prevention. A dependable supply of quality vaccines is crucial in maintaining a country’s health care needs. Local manufacture of vaccines in Africa is vastly inadequate to meet the healthcare needs of the continent. South Africa, like most low-and middle-income countries, is highly reliant on external supplies of vaccines to meet its healthcare needs. This makes the health care system extremely vulnerable during public health emergencies and pandemics. A well-developed policy, legislative and regulatory framework is crucial in supporting local vaccine manufacturing activities. The study investigated the framework that currently exists for local vaccine manufacturing in South Africa in comparison to Egypt as a similar middle- income country with a rapidly advancing local vaccine manufacturing industry. The comparative analysis enabled the formulation of strategies and recommendations to overcome barriers to local manufacturing of vaccines in South Africa. A qualitative study utilising comparative content analysis, was used to compare the policy, legislative and regulatory frameworks in South Africa with that of Egypt. The study found that South Africa and Egypt have adopted vaccine policies of the African Union. South African legislation is well developed with the relevant regulations to support local vaccine manufacturing. Detailed guidelines for vaccine manufacturing activities are present in South Africa and Egypt that are aligned with international regulatory bodies. The South African Health Products Regulatory Authority has established itself as the frontrunner for regulatory harmonisation in Africa. Strong collaboration between national regulators and vaccine manufacturers is needed. National Regulatory Authority harmonisation on the African continent is the cornerstone for supporting the local vaccine manufacturing industry.
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    A retrospective study of isokinetic dynamometry parameters in patients diagnosed with unilateral Achilles tendinopathy
    (University of the Witwatersrand, Johannesburg, 2024) Lloyd, Rohan; Gradidge , Philippe; Constantinou, Demitri
    Introduction: The Achilles tendon, the strongest tendon in the human body, is vital for locomotive activities like walking and running. Despite its strength, it is prone to Achilles tendinopathy (AT), a debilitating condition characterised by pain, swelling, and decreased performance. As a common foot and ankle disorder, AT’s prevalence spans across athletes, recreational exercisers, and the sedentary population, with incidences up to 52% in former elite athletes with a lifetime incidence of six percent in the general population. The aetiology of AT involves both extrinsic- and intrinsic risk factors, including overuse, biomechanical irregularities, and muscular dysfunction, particularly in the gastrocnemius-soleus muscles. Research indicates that plantar flexor weakness often occurs before Achilles tendon pain develops. Weakness in the plantar flexor muscles is a key modifiable risk factor for AT issues. Conventional research on AT has primarily focused on peak torque (PT) derived from isokinetic dynamometry evaluations, leaving a gap in understanding the full spectrum of muscle performance affected by AT. Isokinetic dynamometry, with its versatile protocols and advanced software, can comprehensively evaluate muscle performance from both strength and endurance perspectives, addressing this gap. Aim of study: This study aimed to investigate the effects of unilateral AT on various isokinetic dynamometry parameters, including torque, position, and time, in individuals diagnosed with this condition. The objectives were to determine the extent of dysfunction and weakness in the gastrocnemius-soleus muscles and to compare these parameters between symptomatic and asymptomatic extremities, thus enhancing the understanding of AT's unilateral nature. By expanding the analysis beyond PT, the study addresses the gap in current research, exploring a more comprehensive scope of muscle performance in AT. Method: This retrospective study investigated the impact of unilateral AT on isokinetic dynamometry parameters. Participants were males and females, aged 18 years or older, diagnosed with unilateral AT. Initial isokinetic dynamometry evaluation reports from 2015 to 2022 were collected from a private biokinetics practice in South Africa. Although data on 54 participants initially met the inclusion criteria, the exclusion criteria, which required evaluations to be performed at an angular velocity of 60 degrees per second, reduced the number of suitable reports. Consequently, only the evaluations of n=21 participants (n=18 males and n=3 females, with a total sample mean age of 53.1 years) were included in the study. Isokinetic dynamometry evaluation, conducted by registered biokineticists, followed standardised protocols with the Humac Norm Cybex Testing and Rehabilitation System. Parameters analysed included torque, position, and time measures. Statistical analysis 4 involved paired t-Tests and Wilcoxon tests for normally and non-normally distributed data, respectively, with a significance level set at p<0.05. Results: The analysis of PT between symptomatic- and asymptomatic extremities revealed no statistically significant difference, with symptomatic extremities demonstrating a mean PT of 38.81 foot-pounds (SD: ±10.97) compared to 40.91 foot-pounds (SD: ±11.48) for asymptomatic extremities (p = 0.24). However, a significant difference was noted in the joint angle at PT (JAPT), as determined by the Wilcoxon signed-rank test. Symptomatic extremities exhibited a lower mean joint angle of 1.8 degrees (SD: ±5.11) compared to 2.24 degrees (SD: ±3.89) in asymptomatic extremities (p = 0.0001). Time to PT (TPT) did not differ significantly between symptomatic- (0.20 seconds; SD: ±0.13) and asymptomatic (0.21 seconds; SD: ±0.11) extremities (p = 0.16). Similarly, time PT held (TPTH) showed no significant difference between symptomatic- (0.36 seconds; SD: ±0.33) and asymptomatic (0.34 seconds; SD: ±0.39) extremities (p = 0.49). The analysis of work per repetition (WPR) revealed marginal differences between symptomatic- (17.57 foot-pounds; SD: ±5.48) and asymptomatic (18.91 foot-pounds; SD: ±5.90) extremities, but these differences did not reach statistical significance (p = 0.16). The average power per repetition (APR) differed between symptomatic- (35.48 watts; SD: ±11.71) and asymptomatic (39.05 watts; SD: ±13.14) extremities, with a paired t-Test indicating a trend toward statistical significance (p = 0.06), though this did not meet the conventional threshold for significance in this sample. Conclusion: The study provides an understanding of unilateral AT's impact on isokinetic dynamometry parameters. The study highlighted bilateral muscle dysfunction and weakness in individuals with unilateral AT. This was evidenced through the comparative analysis of PT, PT percentage body weight (PT%BW) and PT ratio (PTR) parameters against established norms. Achilles tendinopathy does not significantly affect the speed of muscle contraction or endurance in maintaining PT. This questions the notion of unilateral impairment in AT and highlights the necessity of a comprehensive approach in rehabilitation, focusing on strength, endurance, and biomechanics. The findings also suggest the need for further research with larger cohorts and varied isokinetic dynamometry parameters to validate these conclusions and enhance rehabilitation protocols in AT.
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    Antibacterial resistance patterns found in urine samples obtained from the elderly in Gauteng
    (University of the Witwatersrand, Johannesburg, 2024) Labuschagne, Olivia; Leigh-De Rapper, Stephanie; Williams, Christopher David
    Background: Elderly are frequent users of healthcare services and may have complex needs related to frailty and multimorbidity. Urinary tract infection (UTI) is often diagnosed in this cohort (often based on non-specific or atypical symptoms) leading to antimicrobial therapy, often chosen empirically. This presents a poorly understood risk of antimicrobial resistance. More accurate data on antimicrobial resistance (AMR) of urinary pathogens in older people, including LTCF residents, is needed. This study aims to determine if samples obtained from LTCF-dwelling individuals show different rates of in vitro AMR compared to samples obtained from community dwelling older people (aged 60 years). Methodology: The study used computerised microbiology laboratory records of urinary samples analysed by Ampath Laboratories in South Africa. 𝜒2 analyses were used to detect differences in resistance patterns between LTCF and community-dwelling individuals. Sub-group analyses and multivariable logistic regression were undertaken for gender, age, in-patient and out-patient samples, and year of collection. Results: Microbiological results from urine samples in Gauteng where analysed (n=50,704). Three cultured bacteria (Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis) showed significant differences in AMR between the two study cohorts. The adjusted odd ratios for Escherichia coli and Proteus mirabilis indicated increased AMR amongst LTCF residents. Conclusion: Urine samples from LTCF-dwelling people have higher rates of in vitro resistance to common antimicrobials used to treat UTI. Greater focus on antimicrobial stewardship in LTCFs is recommended extending to diagnostic approach, empirical antibiotic choice and bacteriological confirmation of antimicrobial choice.
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    Community profiling of water sources and uses in a rural setting in Northwest Province, South Africa
    (University of the Witwatersrand, Johannesburg, 2024) Xulu, Nqobile Thabisile; Mmereki, Daniel
    Background Access to sustainable and potable water remains a constitutional right for all citizens regardless of their demographic, level of educational, or socioeconomic status. Rural communities are vulnerable to inadequate water supply and lack access to potable water, increasing their vulnerability to waterborne diseases and a lack of personal and environmental hygiene. The majority of residents in rural communities often resort to alternative water sources. Those water sources are often susceptible to contamination. The water contamination has been attributed to a lack of norms and monitoring plans aimed at protecting and preserving the quality of these water sources. Many studies have focused on identifying factors that influence water demand in urban and semi-urban areas to improve water resource planning and development. However, there have been limited studies focused on water use patterns and water profiling in rural areas, particularly where water is sourced from surface sources. Purpose The purpose of the study was to describe the socio-economic characteristics, water sources, water uses, and consumption patterns in Ganyesa village, Northwest Province. Methods A quantitative cross-sectional study design was employed to profile water sources and uses in a rural setting in the Northwest. A total of 175 households were randomly selected to participate in the study. A semi-structured questionnaire comprising of Section A: Household socio-economic data, Section B: Water sources, and Section C: Water consumption. Furthermore, water consumption daily activity diaries were used to collect information on water activity usage for seven (7) days. Results A total of 175 participants aged 18 to 65 years were included in this study. Most of the participants were females (78.28%, n = 137), and males accounted for (21.72%, n = 38). The majority of the study participants (37.17%, n = 65) were between the ages of 41 to 50 years, and the majority (58.5%) had a secondary education. v Participants use different water sources, such as communal taps, boreholes, bottled water, rainwater, water tankers, and rainwater, to meet their daily water needs. The water needs included activities such as bathing, cooking, and outdoor activities. Most of the participants (78,29%, n = 137) depend on communal taps as their primary water supply, followed by boreholes (19.4%, n = 34), and a small group of participants used both boreholes and communal taps (2.22%, n = 4). Participants used variety of alternative water sources to meet their daily water needs during water shortage from their primary water sources. Boreholes were the most used alternative water source (65,71% n=115), communal tap (20%, n=35), borehole and water tanker (7,43%, n=13), borehole and rainwater (2,86%, n=5), borehole and communal tap (2,29%, n=4). The average daily water consumption of one to three occupants was estimated to be 26.62 L/day per person. The average water consumption of males and females was estimated to be 29.6 L/day and 25 L/day, respectively. Several socio- demographic covariates were independently associated with water consumption. In terms of income, i.e., those earning R 5001-R 10000 per month had a statistically significant negative association with water consumption (p = 0.01), with a coefficient of -8.00. Similarly, the distance to the source of water was significant (p < 0.001), with a negative coefficient of -5.82, suggesting that as the distance from the water source increases, the average water consumption at the household level decreases. Gender disparity in water consumption was observed, male participants had a statistically significant reduction in water usage compared to their female counterparts (p = 0.02), with a coefficient of -3.84. Conclusion The study hypothesized that residents residing in rural settings use various water sources improved or unimproved to meet their water daily needs. Therefore, the hypothesis of this study is confirmed, meaning that rural dwellers of (Ganyesa) use both improved and unimproved water sources. Residents use both communal taps and boreholes as their primary water sources. The most used alternative source is borehole, indicating water unsustainability by Kagisano Molopo Local municipality. The alternative water sources used by residents are unimproved and unmonitored as per SANS 241. Groundwater was acknowledged as a remedy to water shortage. To prevent contamination to this groundwater sources the sustainability and preservation of this resource, effective management strategies and policies must be vi implemented. From the study, a conclusion can be made that most of the community members utilized communal taps for both indoor and outdoor activities. It was also found that water consumption at the household level is affected by various sociodemographic factors including household income, sex and distance to water source, the type of water source and number of occupants. This study provides scientific evidence that would help policy and decision makers to take these factors into consideration when addressing water scarcity and improving service delivery challenges to rural communities.
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    Ethical Implications of Adopting Value-Based Healthcare in Africa
    (University of the Witwatersrand, Johannesburg, 2024) Khabela, Sithandile Nomfundo
    Value-based healthcare (VBHC) is purported to be the solution to address the issues that are present within fee-for-service (FFS) healthcare reimbursement. As the global discourse around adopting VBHC gains momentum, the body of knowledge on the topic is growing. Conversely, the literature on VBHC's ethical implications is still sparse. Nonetheless, a few ethical issues have emerged from existing literature and will be detailed below. Civil society and the healthcare fraternity ought to be concerned about the ethical implications of the shift in reimbursement models. This is particularly important in Africa, where economic disparities are glaring and extend into the healthcare sector. Some literature highlights issues of justice, equity, and solidarity as requiring attention with adopting VBHC. They are concerned with how VBHC disproportionately benefits certain populations at the expense of vulnerable populations. Secondly, concerns about the VBHC’s impact on patient autonomy are also emphasised as posing a risk of incentivizing providers to under-treat as a means of maximising revenue. Also, the extensive IT system integration required to underpin VBHC means that patient medical records and treatment history will be stored in a centralised location, accessible to a wider team of providers to monitor population-based patient outcomes statistics. This raises a critical issue of how patient confidentiality will be preserved within VBHC. Ⅲ The concept of “value” in healthcare is unclear and thus poses the real risk of measurement metrics being skewed towards cost containment vs patient outcomes and quality. Thus, providers would potentially use patients for financial gain. Additionally, the lack of cost transparency by providers also makes it challenging for patients to understand how their treatment is priced, how their care is evaluated and how treatment decisions are being made, ultimately potentially resulting in a mistrust of the healthcare system. Finally, VBHC does not make provisions for traditional or alternative medicine providers, who are an essential component of the healthcare system in most LMIC countries (especially in Africa). The oversight of this cultural nuance risks alienating large segments of populations, thus posing a real threat to patient dignity. This paper seeks to consolidate and describe the emerging ethical issues based on globally available literature. In light of the ethical issues raised in the previous chapter, I will argue that adopting VBHC in Africa is morally justified. I hinge my thesis on the Afro-communitarian tenets of shared identity, solidarity and goodwill. However, South Africa’s NHI (which is the most explicit national VBHC in Africa) as spelt out in the National Health Insurance (NHI) Bill of 2019, omits to include Traditional African Healers as part of the care team, thus potentially alienating a significant portion of the population. Secondly, the NHI Bill of 2019 does not provide clarity on how confidentiality will be maintained under the NHI. Until these two issues have been satisfied, I argue that VBHC in Africa is conditionally morally justified. My argument is supported by the Utilitarian ideological basis that actions provide the greatest benefit ought to be pursued. Kantian ethics adds that limiting the citizen’s choices under the NHI is an assault to their autonomy and therefore also deems adopting VBHC in Africa as being conditionally morally justifiable.