1. Academic Wits Research Publications (Faculties submissions)
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Item Associations between sleep parameters, non-communicable diseases, HIV status and medications in older, rural South Africans(Nature Research, 2018-11) Gómez-Olivé, F. Xavier; Rohr, Julia K.; Roden, Laura C.; Rae, Dale E.; von Schantz, MalcolmAs part of the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we investigated sleep habits and their interactions with HIV or non-communicable diseases (NCDs) in 5059 participants (median age: 61, interquartile range: 52—71, 54% females). Selfreported sleep duration was 8.2±1.6h, and bed and rise times were 20:48±1:15 and 05:31±1:05 respectively. Ratings of insufcient sleep were associated with older age, lack of formal education, unemployment, and obesity (p<0.05). Ratings of restless sleep were associated with being older, female, having more education, being unemployed, and single. Hypertension was associated with shorter self-reported sleep duration, poor sleep quality, restless sleep, and periods of stopping breathing during the night (p<0.05). HIV positive individuals not on antiretroviral treatment (ART) reported more nocturnal awakenings than those on ART (p=0.029) and HIV negative individuals (p=0.024), suggesting a negative net efect of untreated infection, but not of ART, on sleep quality. In this cohort, shorter, poor-quality sleep was associated with hypertension, but average self-reported sleep duration was longer than reported in other regions globally. It remains to be determined whether this is particular to this cohort, South Africa in general, or low- to middle-income countries undergoing transition.Item Developing a model for integrating sexual and reproductive health services with HIV prevention and care in KwaZulu-Natal, South Africa(BioMed Central, 2018-11) Milford, Cecilia; Scorgie, Fiona; Greener, Letitia Rambally; Mabude, Zonke; Beksinska, Mags; Harrison, Abigail; Smit, JenniferBackground: There are few rigorous studies evaluating the benefits of vertical versus integrated delivery of healthcare services, and limited published studies describing conceptual models of integration at service-delivery level in public healthcare facilities. This article seeks to fill this gap, by describing the development of a district-based model for integrating sexual and reproductive health (SRH) and HIV services in KwaZulu-Natal, South Africa. Methods: Baseline data were collected from seven urban public healthcare facilities through client and provider interviews, and a facility inventory was completed to assess current service integration practices. Feedback sessions were held with health providers from participating facilities to share data collected and explore appropriate integration scenarios. A conceptual model of potential service integration was then designed, and subsequently implemented and evaluated in the research sites. Results: Key principles of the model included a focus on health system strengthening and strong community input and involvement. The model was designed primarily to support the integration of family planning into HIV services, and included measures to improve client and commodity monitoring; capacity building through training and mentorship; and a ‘health navigation’ strategy to strengthen referrals within and between public healthcare facilities. Endline evaluation data were collected in the same facilities following implementation of the model. Conclusions: This manuscript demonstrates the utility of the conceptual model. It shows that service integration can be accomplished in a phased manner with support of community and healthcare providers. In addition, local context must be taken into account and the components of the model should be flexible to suit the needs of the health system.Item Death of preceding child and maternal healthcare services utilisation in Nigeria: investigation using lagged logit models(BioMed Central, 2018-11) Akinyemi, Joshua O.; Bolajoko, Izzatullah; Gbadebo, Babatunde M.Background: One of the factors responsible for high level of childhood mortality in Nigeria is poor utilization of maternal healthcare (MHC) services. Another important perspective which has been rarely explored is the influence of childhood death on MHC service utilization. In this study, we examined the relationship between death of preceding child and MHC services utilization [antenatal care (ANC), skilled attendant at birth (SAB), and postnatal care (PNC)] among Nigerian women and across the six geo-political zones of the country. Methodology: We analyzed reproductive history dataset for 16,747 index births extracted from the 2013 Nigeria Demographic and Health Survey. The main explanatory variable was survival status of preceding child; therefore, only second or higher order births were considered. Analysis involved the use of descriptive statistics and lagged logit models fitted for each measure of MHC utilization. Association and statistical significance were expressed as adjusted odds ratio (AOR) with 95% confidence interval. Results: The use of MCH services for most recent births in the 2013 Nigeria DHS were ANC (56.0%), SAB (34.7%), and PNC (27.3%). Univariate models revealed that the death of preceding child was associated with lesser likelihood of ANC (OR = 0.64, CI 0.57–0.71), SAB (OR = 0.56, CI 0.50–0.63), and PNC (OR = 0.65, CI 0.55–0.69). Following adjustment for maternal socio-economic and bio-demographic variables, statistical significance in the relationship disappeared for the three MHC indicators: ANC (AOR = 1.00, CI 0.88–1.14), SAB (AOR = 0.97, CI 0.81–1.15), and PNC (AOR = 0.95, CI 0.83–1.11). There were no significant variations across the six geo-political regions in Nigeria. The likelihood of ANC utilization was higher when the preceding child died in Northcentral (AOR = 1.19, CI 0.84–1.70), Northeast (AOR = 1.26, CI 0.99–1.59), and South-south (AOR = 1.19, CI 0.72–1.99) regions while the reverse is the case in Southeast (AOR = 0.39, CI 0.23–0.60). For the Southeast, similar result was obtained for ANC, SAB, and PNC. Conclusion: Death of a preceding child does not predict MHC services use in Nigeria especially when maternal socio-economic characteristics are controlled. Variations across the Northern and Southern regions did not attain statistical significance. Interventions are needed to reverse the pattern such that greater MHC utilization is recorded among women who have experienced child death.Item Use of contraceptives, high risk births and under-five mortality in Sub Saharan Africa: evidence from Kenyan (2014) and Zimbabwean (2011) demographic health surveys(BioMed Central, 2018-10) Chikandiwa, Admire; Burgess, Emma; Otwombe, Kennedy; Chimoyi, LucyBackground: Increasing uptake of modern contraception is done to alleviate maternal and infant mortality in poor countries. We describe prevalence of contraceptive use, high risk births, under-five mortality and their risk factors in Kenya and Zimbabwe. Methods: This was a cross-sectional analysis on DHS data from Kenya (2014) and Zimbabwe (2011) for women aged 15–49. Geospatial mapping was used to compare the proportions of the following outcomes: current use of contraceptives, high-risk births, and under-5 mortality at regional levels after applying sample weights to account for disproportionate sampling and non-responses. Multivariate risk factors for the outcomes were evaluated by multilevel logistic regression and reported as adjusted odds ratios (aOR). Results: A total of 40,250 (31,079 Kenya vs. 9171 Zimbabwe) women were included in this analysis. Majority were aged 18–30 years (47%), married/cohabiting (61%) and unemployed (60%). Less than half were using contraceptives (36% Kenya vs. 41% Zimbabwe). Spatial maps, especially in the Kenyan North-eastern region, showed an inverse correlation in the current use of contraceptives with high risk births and under-5 mortality. At individual level, women that had experienced high risk births were likely to have attained secondary education in both Kenya (aOR = 5.20, 95% CI: 3.86–7.01) and Zimbabwe (aOR = 1.63, 95% CI: 1.08–2.25). In Kenya, high household wealth was associated with higher contraceptive use among both women who had high risk births (aOR: 1.72, 95% CI: 1.41–2.11) and under-5 mortality (aOR: 1.66, 95% CI: 1.27–2.16). Contraceptive use was protective against high risk births in Zimbabwe only (aOR: 0.79, 95% CI: 0.68–0.92) and under-five mortality in both Kenya (aOR: 0.79, 95% CI: 0.70–0.89) and Zimbabwe (aOR: 0.71, 95% CI: 0.61–0.83). Overall, community levels factors were not strong predictors of the three main outcomes. Conclusions: There is a high unmet need of contraception services. Geospatial mapping might be useful to policy makers in identifying areas of greatest need. Increasing educational opportunities and economic empowerment for women could yield better health outcomes.Item HIV testing and counselling experiences: a qualitative study of older adults living with HIV in western Kenya(BioMed Central, 2018-10) Kiplagat, Jepchirchir; Huschke, SusannBackground: Finding HIV infected persons and engaging them in care is crucial in achieving UNAIDS 90–90-90 targets; diagnosing 90% of those infected with HIV, initiating 90% of the diagnosed on ART and achieving viral suppression in 90% of those on ART. To achieve the first target, no person should be left behind in their access to HIV testing services. In Kenya, HIV prevention and testing services give less emphasis on older adults. This article describes HIV testing experiences of older adults living with HIV and how their age shaped their interaction and treatment received during HIV testing and diagnosis. Methods: We conducted a qualitative study in two HIV clinics (rural and urban) in western Kenya, and recruited 57 HIV infected persons aged ≥50 years. We conducted in depth interviews (IDIs) with 25 participants and 4 focus group discussions (FGDs) with a total of 32 participants and audio recorded all the sessions. Participants recruited were aged between 54 and 79 years with 43% being females. We transcribed audio records and analyzed the data using thematic content analysis method. Results: Older persons’ experiences with HIV testing depended on where they tested (hospital or community setting); whether they actively sought the testing or not; and the age and gender of the healthcare provider who conducted the test. Participants expressed concerns with ageist discrimination when actively seeking HIV care testing services in hospital settings, characterized by providers’ reluctance or refusal to test. The testing and counseling sessions were described as short and hurried within the hospital settings, whereas the interactions with service providers in home-based testing were experienced as appropriate and supportive. Participants in this study expressed preference for healthcare providers who were older and of similar gender. Conclusion: HIV testing services are still not tailored to target older adults’ needs in our setting resulting in late diagnosis among older persons. We argue that a scale-up of community level testing services that provide adequate testing and counselling time and actively reach out to older adults is key to attaining the UNAIDS targets of having 90% of PLWH know their status.Item Neurodevelopmental outcome of late preterm infants in Johannesburg, South Africa(BioMed Central, 2018-10) Ramdin, Tanusha; Ballot, DayniaBackground: Late preterm infants, previously considered low risk, have been identified to be at risk of developmental problems in infancy and early childhood. There is limited information on the outcome of these infants in low and middle income countries. Methods: Bayley scales of infant and toddler development, version III, were done on a group of late preterm infants in Johannesburg, South Africa. The mean composite cognitive, language and motor sub-scales were compared to those obtained from a group of typically developed control infants. Infants were considered to be “at risk” if the composite subscale score was below 85 and “disabled” if the composite subscale score was below 70. Infants identified with cerebral palsy were also reported. Results: 56 of 73 (76.7%) late preterm infants enrolled in the study had at least one Bayley assessment at a mean age of 16.5 months (95% CI 15.2–17.6). The mean birth weight was 1.9 kg (95%CI 1.8–2.0) and mean gestational age 33.0 weeks (95% CI 32.56–33.51). There was no difference in the mean cognitive subscales between late preterm infants and controls (95.4 9, 95% CI 91.2–99.5 vs 91.9.95% CI 87.7–96.0). There was similarly no difference in mean language subscales (94.5, 95% CI 91.3–97.7 vs 95.9, 95% CI 92.9–99.0) or motor subscales (96.2, 95% CI 91.8–100.7 vs 97.6, 95% CI 94.7–100.5). There were four late preterm infants who were classified as disabled, two of whom had cerebral palsy. None of the control group was disabled Conclusions: This study demonstrates that overall developmental outcome, as assessed by the Bayley scales of infant and toddler development, was not different between late preterm infants and a group of normal controls. However, 7.1% of the late preterm infants, had evidence of developmental disability. Thus late preterm infants in low and middle income countries require long term follow up to monitor developmental outcome. In a resource limited setting, this may best be achieved by including a parental screening questionnaire, such as the Ages and Stages Questionnaire, in the routine well baby clinic visits.Item A survey of knowledge and attitudes relating to cervical and breast cancer among women in Ethiopia(BioMed Central, 2018-08) Chaka, Bekele; Sayed, Abdul-Rauf; Goeieman, Bridgette; Rayne, SarahBackground: Breast cancer and cervical cancer are the two leading cancers among women in Ethiopia. This study investigated knowledge and attitudes related to these two types of cancer among women in 4 zones of Ethiopia. This is the first study employing a validated questionnaire to investigate knowledge and attitudes relating to breast and cervical cancer in Ethiopia. Methods: A community based cross-sectional study was conducted from September to November 2015 in the North Shewa zone (Amhara region), Gamo Gofa zone (Southern Nations, Nationalities and Peoples’ region) and zones 1 and 3 (Afar region) of Ethiopia. A total of 799 women aged 18 years and older participated in the survey. Multiple logistic regression analysis was used to investigate the association of possible predictors with breast and cervical cancer knowledge. Results: A total of 799 women aged 18 years and older participated in the survey. Of the women interviewed, 63.0% had heard of breast cancer and 42.2% had heard of cervical cancer. Among those who had heard of breast cancer, 21.3% (107/503) had heard of breast cancer screening and 1.4% of women aged 40 years and older had undergone at least one breast screening examination. Fewer than half of the participants provided the correct response to questions related to risk factors for breast and cervical cancer. Among those who had heard of cervical cancer, 41.5% (140/337) had heard of cervical cancer screening and 3.3% had undergone at least one cervical cancer screening examination. Women with primary and higher levels of education were more likely to have heard of breast cancers (OR = 3.0; 95% CI: 2.1–4.2; p < 0.001) and cervical cancer (OR = 1.9; 95% CI: 1.4–2.6; p < 0.001). From the overall attitude score, the majority of the women were found to have negative attitudes towards breast cancer (67.4%) and cervical cancer (70.6%). Conclusions: This study found that the overall knowledge of risk factors for breast cancer and cervical cancer among women was low. Lack of cancer awareness, and lack of education in general, are the most potent barriers to access and care, and should be addressed through multi-faceted strategies including peer-education, mass media and other community-based interventions.Item Oppression, liberation, wellbeing, and ecology: organizing metaphors for understanding health workforce migration and other social determinants of health(BioMed Central, 2018-08) Tankwanchi, Akhenaten Benjamin SiankamBackground: The Commission on Social Determinants of Health (CSDH) identifies the maldistribution of power, money, and resources as main drivers of health inequities. The CSDH further observes that tackling these drivers effectively requires interventions to focus at local, national, and global levels. Consistent with the CSDH’s observation, this paper describes the eco-psychopolitical validity (EPV) paradigm, a multilevel and transdisciplinary model for research and action, thus far insufficiently tapped, but with the potential to systematize the exploration of the social determinants of health. Results: Using the physician migration from Sub-Saharan Africa (SSA) to the United States as illustration, this paper articulates how the EPV model can be applied to the systematic analysis of a complex social problem with health inequity implications. To help explore potential determinants of physician migration, a comprehensive coding matrix is developed; with the organizing metaphors of the EPV model–namely oppression, liberation, and wellbeing–serving as analytical categories. Through the lens of the EPV model, migrating physicians are revealed as both ecological subjects enmeshed in a vast web of transnational processes linking source and destination countries, and potential change agents pursuing liberation and wellbeing. While migration may expand the opportunities of émigré physicians, it is argued that, the pursuit of wellbeing by way of migration cannot fully materialize abroad without some efforts to return home, physically or socially. Conclusion: Clarifying the relationship between various social determinants of health and health inequities at different levels of analysis is a more complex but essential endeavor to knowledge generation than using a one-dimensional frame. With its roots in interdisciplinary thinking and its emphasis on both individual and contextual factors, the EPV paradigm holds promise as a model for examining the social determinants of health.Item Liver cancer mortality trends in South Africa: 1999–2015(BioMed Central, 2018-08) Daniel Mak, Daniel; Sengayi, Mazvita; Chen, Wenlong C.; de Villiers, Chantal Babb; Singh, Elvira; Kramvis, AnnaBackground: In South Africa (SA), liver cancer (LC) is a public health problem and information is limited. Methods: Joinpoint regression analysis was computed for the most recent LC mortality data from Statistics South Africa (StatsSA), by age group, sex and population group. The mortality-to-incidence ratios (MIRs) were calculated as the age-adjusted mortality rate divided by the age-adjusted incidence rate. Results: From 1999 to 2015, the overall LC mortality significantly decreased in men (− 4.9%) and women (− 2.7%). Overall a significant decrease was noted in black African men aged 20–29 and 40–49 years, and white women older than 60 years but mortality rates increased among 50–59 and 60–69 year old black African men (from 2010/2009–2015) and women (from 2004/2009–2015). The mortality rates increased with age, and were higher among blacks Africans compared to whites in all age groups - with a peak black African-to-white mortality rate ratio of six in men and three in women at ages 30–39 years. The average MIR for black African men and women was 4 and 3.3 respectively, and 2.2 and 1.8 in their white counterparts. Moreover, decreasing LC mortality rates among younger and the increase in rates in older black Africans suggest that the nadir of the disease may be near or may have passed. Conclusions: Findings of population-age subgroup variations in LC mortality and the number of underdiagnosed cases can inform surveillance efforts, while more extensive investigations of the aetiological risk factors are needed. Impact: There was a large race, sex and age differences in trends of LC mortality in SA. These findings should inform more extensive evaluation of the aetiology and risk factors of LC in the country in order to guide control efforts.Item Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system(2018-08) Oboirien, Kafayat; Harris, Bronwyn; Goudge, Jane; Eyles, JohnBackground: Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role. Methods: Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts. Results: We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors’ expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery. Conclusion: Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.