4. Electronic Theses and Dissertations (ETDs) - Faculties submissions

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Engaging the public in priority setting for health in rural South Africa
(University of the Witwatersrand, Johannesburg, 2023-10) Tugendhaft, Aviva Chana; Hofman, Karen; Kahn, Kathleen; Christofides, Nicola
Introduction: The importance of public engagement in health priority setting is widely recognised as a means to promote more inclusive, fair, and legitimate decision-making processes. This is particularly critical in the context of Universal Health Coverage, where there is often an imbalance between the demands for and the available health resources. In South Africa, public engagement is protected in the Constitution and entrenched in policy documents; yet context specific tools and applications to enable this are lacking. Where public engagement initiatives do occur, marginalised voices are frequently excluded, and the process and outcomes of these initiatives are not fully evaluated. This hampers our understanding of public engagement approaches and how to meaningfully include important voices in the priority setting agenda. The aim of this doctoral (PhD) research was to investigate the feasibility and practicality of including the public in resource allocation and priority setting for health in a rural setting in South Africa using an adapted deliberative engagement tool called CHAT (Choosing All Together). Methods: The PhD involved the modification and implementation of the CHAT tool with seven groups in a rural community in South Africa to determine priorities for a health services package. For the modification of CHAT, desktop review of published literature and policy documents was conducted, as well as three focus group discussions, with policy makers and implementers at national and local levels of the health system and the community, and modified Delphi method to identify health topics/issues and related interventions appropriate for a rural setting in South Africa. Cost information was drawn from various national sources and an existing actuarial model used in previous CHAT exercises was employed to create the board. The iterative participatory modification process was documented in detail. The implementation process was analysed in terms of the negotiations that took place within the groups and what types of deliberations and engagement with trade-offs the participants faced when resources were constrained. In terms of the outcomes, the study focused on what priorities were most important to the rural community within a constrained budget and the values driving these priorities, but also how priorities might differ amongst individuals within the same community and the characteristics associated with these choices. Qualitative data were analysed from the seven group deliberations using the engagement tool. Content analysis was conducted, and inductive and deductive coding was used. Descriptive statistics was used to describe the study participants using the data from a demographic questionnaire and to show the group choices from the stickers allocated on the boards from the groups rounds. The investment level (sticker allocation) of all study participants was recorded at each stage of the study. From these the number of stickers allocated to each topic by the participants was calculated by adding up the number of stickers across interventions selected by the participant by topic. The median and interquartile range across study participants was calculated for the topic totals. To examine differences in sticker allocations, Wilcoxon rank sum tests were performed for differences across participant categories and sticker allocations in the final round of CHAT. Findings: Based on the outcomes, seven areas of health need and related interventions specific for a rural community context were identified and costed for inclusion in the CHAT board. These include maternal, new-born and reproductive health; child health; woman and child abuse; HIV/AIDS and TB; lifestyle diseases; quality/access; and malaria. The CHAT SA board reflects both priority options of policymakers/ experts and of community members and demonstrates some of the context specific coverage decisions that will need to be made under NHI. The CHAT implementation shows that the rural communities mostly prioritised curative services over primary prevention due to perceived inefficacy of existing health education and prevention programmes. The exercise fostered strong debates and deliberations. Specifically, the groups engaged deeply with trade-offs between costly treatment for HIV/AIDS and those for non-communicable disease. Barriers to healthcare access were of particular concern and some priorities included investing in more mobile clinic. The individual level priorities were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics such as age. The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and enhance the legitimacy and acceptability of the decision-making process. In terms of reconciling plurality in priority setting for health, group deliberative approaches help to identify social values and reconcile some of the differences, but additional individual voices may also need to be considered alongside group processes, especially among the most vulnerable. Conclusion: This research marks the first instance of modifying and implementing a deliberative tool for priority setting in a South African rural context. The findings shed light on the process and some of the outcomes of this approach within a vulnerable community, offering insights into public engagement in priority setting more broadly. The study demonstrates that participatory methods are feasible in modifying public engagement tools such as CHAT and can be adapted to different country contexts, potentially enhancing the priority setting process. Regarding the implementation of CHAT, the study provides an example of how a rural community grappled with resource allocation decisions, considered different perspectives and societal implications, and set priorities together. The research also highlights the priorities of this rural community, the social values driving their choices, and individual characteristics that are important to consider when setting priorities. The work demonstrates that meaningful public engagement includes various factors that interrelate and impact one another and that could inform a dynamic and cyclical approach going forward, as well as the importance of transparency during all stages of the process.
Role of novel biomarkers in predicting chronic kidney disease progression among black patients attending a tertiary hospital in Johannesburg, South Africa
(University of the Witwatersrand, Johannesburg, 2023) Meremo, Alfred Jackson; Naicker, Saraladevi; Duarte, Raquel; Paget, Graham; Dickens, Caroline
Background: Chronic kidney disease (CKD) is a leading health issue and its magnitude has been increasing globally; where the developing countries are the most affected and they are the least equipped to deal with its associated consequences. Chronic kidney disease can rapidly and quietly progress to late CKD stages in impoverished environments. Early recognition of patients who are likely to develop end-stage kidney disease (ESKD) is important. Methodology: A prospective longitudinal study was conducted on CKD patients of black ethnicity attending at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) renal outpatient clinic in South Africa, as from September 2019 to March 2022. Patients provided blood and urine samples for investigations in the laboratory at study enrolment (0) and at the 24 months follow up. The concentrations of the transforming growth factor isoforms [(TGF)-β1, TGF-β2 and TGF-β3) were determined in serum and urine at baseline using the Human TGF-β duoset ELISA. Data were descriptively and inferentially processed by the REDcap and analyzed using STATA version 17 and multivariable logistic regression analysis was applied to find out the predictors of CKD progression. Results: A total of 312 patients were recruited into the study; the median age was 58 (IQR 46 -67) years and 162 (51.9 %) were male. Hypertension was present in majority (96.7 %) of the patients. Diabetes mellitus was present in 38.7 % of patients and 38.1 % of the study patients had both hypertension and diabetes mellitus. A total of 297 (95.2%) patients completed the study. Death was reported in 5 (1.6%) patients and 10 (3.2%) of patients were lost to follow up. The prevalence of CKD progression was 49.5%, 33% had CKD remission and 17.5% had CKD regression while the prevalence of CKD progression by change in uPCR > 30% was 51.9%. Almost half (47.8 %) had a sustained decline in eGFR of > 4 ml/min/1.73 m2 /year or more, 35.0% of the patients moved to a more severe stage of CKD and 19.9% had more than 30% 6 decline in eGFR in two years. For patients with CKD progression, 54.9% patients were men and at baseline, their median age was 59 (46 - 67) years, urine protein creatinine ratio (uPCR) increased at 0.039 (0.015-0.085) g/mmol, eGFR was 37 (32 -51) mL/min/1.73 m2; the median serum TGF-β1 was 21210 (15915 – 25745) ng/L and the median urine TGF-β3 was 17.5 (5.4 –76.2) ng/L. For those who had CKD progression, hypertension was present in the majority (95.2%) of the patients. Diabetes mellitus was present in 59 (40.1%) patients and 58 (39.5%) patients had both hypertension and diabetes mellitus; 48.3% had severely increased proteinuria, 45.6% patients had anaemia, 34.0% had hyperuricemia and 17.7% had hypocalcaemia at baseline. For those patients with CKD progression vs those without CKD progression, the baseline median serum TGF-β1 was 21210 (15915 – 25745) ng/L vs 24200 (17570 – 29560) ng/L, the baseline median urine TGF-β3 was 17.5 (5.4 – 76.2) ng/L vs 2.8 (1.8 – 15.3) ng/L; however, baseline serum and urine TGF-β isoforms did not predict progression of CKD on univariate and multivariable analyses. Regarding use of medications among patients with CKD progression, calcium channel blockers (amlodipine) were used by majority (85.2 %) of the patients. Diuretics were used by 63.4% of the patients and 31.7 % of the patients were using insulin. Variables associated with CKD progression after multivariable logistic regression analysis were moderately elevated proteinuria (OR 2.1, 95% CI (1.1 – 3.9), P= 0.019), severely elevated proteinuria (OR 6.1, 95 % CI (3.2 – 11.6), P = 0.001), hyponatraemia (OR 4.5, 95% CI 1.8 - 23.6, P= 0.042), hypocalcaemia (OR 3.8, 95 % CI 1.0 - 14.8, P = 0.047), anaemia (OR 2.1, 95% CI 1.0 - 4.3, P= 0.048), elevated HbA1c (OR 1.8, 95 % CI 1.2 - 2.8, P = 0.007), diabetes mellitus (OR 1.8, 95 % CI 1.9 - 3.6, P = 0.047), current smoking (OR 2.8, 95 % CI 1.9 - 8.6, P = 0.049), medications which were calcium channel blockers (OR 2.07, 95 % CI 1.04 – 4.12, P = 0.038), diuretics (OR 2.35, 95 % CI 1.37 – 4.00, P = 0.002), insulin (OR 1.96, 95 % CI 1.01 – 3.84, P = 0.048) and baseline serum calcium levels (OR 0.06, 95 % CI 0.01 -0.64, P = 0.019). An increase in uPCR > 30% at two years identified most patients with CKD progression; clinicians and nephrologists should utilize change in uPCR > 30% at two years to identify those patients with CKD who are likely to progress more rapidly, who require closer surveillance and monitoring with emphasis on slowing or stopping progression of the CKD. Conclusion: Our study has demonstrated a higher prevalence of CKD progression in a prospective longitudinal study among black patients than that reported in previous studies. CKD progression was associated with current smoking, hyponatremia, hypocalcemia, anaemia, elevated HbA1c, diabetes mellitus, and proteinuria. While patients with CKD progression had lower baseline concentrations of serum TGF-β1 and increased baseline urinary TGF-β3 concentrations, baseline serum and urine TGF-β isoforms did not predict progression of CKD. The roles of the various serum and urine TGF-β isoforms in CKD progression at baseline are still unclear and highlight the importance of further studies to determine their isoform specific effects.
Could Not Sing in the Dead Heat: Liner Notes Under the Sun
(University of the Witwatersrand, Johannesburg, 2022) Ramphalile, Molemo Karabo; Schuhmann, Antje
On the one hand we place blackness as a historical if inconsistent category inextricable with morbidity, disfavour, depravity, mystery, wretchedness, penumbra, opacity or absence of light, and the abyssal – in both secular and religious metaphysical symbolism. On the other hand we place space as a historical and physical category denoting area, range, clearance, scope, volume, expanse, lacunae, aperture, margin, and in its instance as verb – opening, arranging, ordering, placing, separating, and locating; which in cosmography, geography and cartography finds its varied imaginative and applied interpretation. We coalesce what is in both hands in order to envisage how blackness persistently becomes and comes to be the extractable property of sub-Saharan Africans. Through various ontological-cosmographic- geographic designations such as Torrid Zone, ‘land of the blacks’ or even terra nullius, we encounter visualisations of a territory and expanse that is always either completely devoid of people or inadequately peopled, that is, the territory whence blackness as inextricably embodied (or fleshened) exists and is cultivated. Blackness: not only does it determine our modes of being, or non-being, in this world, but for us in this study, it is also an experiential, experimental and analytical lens permitting the suggestion and scribing of historical narratives and discourses that centre the inveterate decentring of blacks. In the tradition of liner notes, this study is written in a performative relation to the subject or object at hand; there under the sun, in the dead heat.
Voiding cystourethrography in the renal pre-transplantation workup: an essential investigation?
(University of the Witwatersrand, Johannesburg, 2022-10) Sofianos, Zelia; Rajkumar, Leisha; Lucas, Susan
INTRODUCTION: Due to resource constraints in the South African public healthcare sector, patients with End-Stage Renal Disease (ESRD) are eligible for renal replacement therapy only if they are also found to be eligible for renal transplant. AIM: The aim of this study is to document Voiding Cystourethrogram (VCUG) findings in potential renal transplant candidates to assess the contribution of the VCUG as a standard investigation in the renal transplant workup. METHODS: Of the patients who underwent VCUG in Klerksdorp/Tshepong Hospital Complex (North West province, South Africa) from 1 January 2019 to 31 March 2020, 85 patients were included in the study and their VCUG findings retrospectively analysed. RESULTS: The mean age was 40.0 years (range 21-62 years), with males constituting 57.7% of patients and females 42.3%. Lower urinary tract abnormalities were identified in 24.7% of patients, some of whom had more than one abnormality. Of the total abnormalities, VUR (vesicoureteral reflux) accounted for 15.3%, bladder diverticula for 5.9%, urethral strictures for 3.5% and a significant post-void residual volume for 4.7%. No comorbidities were found to have a statistically significant association with the presence of VCUG abnormalities. CONCLUSIONS: To ensure that patients with End-Stage Renal Disease are adequately prepared for renal dialysis and potential renal transplant, and that their comorbidities and lower urinary tract are optimised should abnormalities be identified on VCUG, the VCUG remains an essential investigation in the renal transplant workup.
Maternal death at Leratong Regional Hospital: a six-year retrospective review, South Africa
(University of the Witwatersrand, Johannesburg, 2021-11) Motau, Tumelo Ngaka; Chauke, Lawrence
Background: The aim of the study was to systematically examine the main causes of maternal deaths and contributing factors at Leratong Regional Hospital in order to recommend strategies that can assist in reducing maternal mortality at this level of healthcare. Objectives: The objectives of the study were to: determine the institutional maternal mortality rate at Leratong Regional Hospital between 2012 to 2017, compare the trend (year on year) in the iMMR over the study period, describe the profile of women who died during the period under study, describe the clinical and surgical management of the women who died, and to determine the leading causes of maternal deaths, contributing factors and avoidable factors. Methods: A hospital based retrospective study based on patient clinical records at Leratong hospital. It included all the maternal deaths that occurred at Leratong Regional Hospital during the six-year study period (2012-2017). Results: There was a total of 78 maternal deaths with 32441 live births giving the MMR of 240 per 100 000 live births. However only 74 files could be analysed. The results showed that there was a rise in the maternal mortality rate over a six years period. The majority (70, 94.5%) of the women who died were African, aged between 20-35 years (56, 76%), multigravida (54,73%) with a parity of three or more (23, 31%). Obstetric haemorrhage was the leading cause of maternal death particularly postpartum haemorrhage (11.14%) followed by non-pregnancy related infections, sepsis and eclampsia. Conclusion: Maternal mortality has decreased according to recent confidential enquiry into maternal death in South Africa (2017-2019) However our study did not demonstrate a decline but rather an increase in the maternal mortality rate at Leratong. It showed that most of the maternal deaths were avoidable and the need for urgent interventions in terms of education, improving access to health care facilities, intensifying health care worker skills training and better transport systems between health care facilities is important.
Financial inclusion in South Africa: An analysis of the financial sector regulatory framework and proposals for reform
(2018-09) Duma, Amanda; Kawadza, Herbert
Abstract Not Available.
Adherence to the Standard Treatment Guidelines in managing patients with hypertension at Chiawelo Community Health Centre, Gauteng, South Africa
(University of the Witwatersrand, Johannesburg, 2022-04) Dawduth, Nikkeeta; Torlutter, Michele
Background: Hypertension is a highly prevalent chronic disease, causing significant morbidity and mortality and is poorly managed and controlled in primary care, with only 24.5 to 56% of patients being controlled. Aim: The aim of the study was to determine health care worker adherence to the Standard Treatment Guidelines in managing hypertensive patients in primary care. Methods: The study was conducted at Chiawelo Community Practice Johannesburg. A retrospective file review was done on 261 hypertensive patients and information extracted to determine whether health care workers performed correct baseline tests at diagnosis; correct investigations were done on ongoing basis; lifestyle modification was addressed; and correct pharmacological therapy was prescribed and titrated. Data analysis included descriptive statistics and bivariate analysis. Results: A total of 77% of participants were female and 23% were male of which 80.5% participants had co-morbidities. Patients were treated by a doctor in 97% of cases; 84.3% by clinical associate, and 0.6% by a nurse only over time. Baseline findings recorded in the file at diagnosis were: weight 65.9%, height 73.2%, potassium 32.2%, BMI 50.2%, abdominal circumference 51.7%, and urine dipsticks 47.9%. Vitals and investigations recorded in the file: BP 99.6%, weight 19.5%, blood glucose 86.6%, creatinine 95.4%, eGFR 94.3% and urine protein 3.4%. Lifestyle modification was recorded for 23.7% and medication adherence was checked and recorded for 36.4% of patients. The correct antihypertensive medications were prescribed in 96.5% of patients but titrated correctly in only 73.5% of patients. 52.8% of patients were controlled on treatment. Conclusion: Adherence to guidelines by health care workers was suboptimal and several aspects of care warrants quality improvement processes.
COVID-19 and health care worker exposure at Chris Hani Baragwanath Academic Hospital
(University of the Witwatersrand, Johannesburg, 2021-12-05) Glatt, Sara Chaya; Menezes, Colin; Winchow, Lai ling; Tsitsi, Merika
Background: Health care workers (HCWs) are at an increased risk of acquiring coronavirus disease 2019 (COVID-19). Appropriate risk assessments and testing are essential to reduce transmission and avoid workforce depletion. Objective: Investigate the risk of COVID-19 infection among HCWs at Chris Hani Baragwanath Academic Hospital who fulfil the Person Under Investigation (PUI) case definition or had exposure to a confirmed COVID-19 contact. Methods: A retrospective review of HCW records was conducted over a two month period. Data collected included demographics, exposure type, risk level, and COVID-19 test result. Frequency distribution tables, bivariate analyses and univariate and multivariate analyses were conducted. Results: Among the 1111 HCWs reviewed, 643 were tested with 35.6% positive results. PUI’s accounted for 62.4% of positive cases. Symptomatic HCWs with no known contact were at a greater risk of infection than those with a patient exposure (p=0.000). Risk of testing positive was higher after a patient exposure (p=0.000) compared to a co-worker contact. Conclusion: There is a higher positivity rate among HCWs than the general population. The presence of symptoms warrants testing. Nosocomial transmission was derived from patient more than co-worker contacts.
Surgical aortopulmonary shunts - a thirty-seven year experience in a South African tertiary institution
(University of the Witwatersrand, Johannesburg, 2019-11) Dladla-Mukansi, Nontobeko Charity; Cilliers, Antoinette; Mammen, Vijay; Vanderdonk, Kathy
Introduction: The surgical aortopulmonary shunt is a valuable palliative procedure in the management of congenital heart diseases. There is a paucity of data regarding aortopulmonary shunts in the developing world, including South Africa. Objectives: The primary objective was to describe the demographic, clinical and echocardiographic characteristics of children between ages 0 and 14 years that underwent surgical aortopulmonary shunts. The secondary objectives were to describe trends in aortopulmonary shunt designs, outcomes in terms of morbidity and mortality, progression to definitive surgery and to assess patency of shunts. Material and Methods: A retrospective clinical audit of patient files who underwent an aortopulmonary shunt between 01 January 1980 to 30 December 2016 was undertaken at Chris Hani Baragwanath Academic Hospital (CHBAH) in Soweto, Johannesburg. The study period was divided into 3 stages and for descriptive purposes as follows: 1980-1991 refers to period 1, 1992-2003 refers to period 2 and 2004-2016 refers to period 3. Results: A total of 177 aortopulmonary shunts were done over the 37-year study period. Of these 177 patients, 165 (93.2%) patient files were available. Fifty-six percent of the patients included in the study were male. The majority of patients were from the Gauteng Province (76.8%). The four most common diagnoses across the entire study period were tricuspid atresia (26.0%), pulmonary atresia with VSD (23.7%), tetralogy of Fallot (23.2%) and complex cardiac lesions (16.9%), with no particular trend in the proportion of these diagnoses presenting across this study period. There was no statistical difference between period 1 and 2 (p-value a=0,328) and between period 1 and 3 (p-value b=0,548). The total number of all surgeries done over the entire study period was 2145, of which 8.3% were aortopulmonary shunts. Period 1 had the highest percentage [35 (10.9%)] of aortopulmonary shunts compared to the total number of surgeries performed. There was a decline in the number of aortopulmonary shunts performed over the study periods 1-3. With no statistical difference across periods as shown in table 1 with p-value a and b. Of the different types of aortopulmonary shunts, most patients [157 (88.7%)] had a modified Blalock-Taussig shunt (BTS). The remainder of the shunts included 3 (1.7%) classic BTS, 12 (6.8%) central shunts and 5 (2.8%) unknown BTS. The percentage of modified BTS done increased from 80% in period 1 to 87.3% in period 2 and to 95.2% in period 3. Period 1 had the most complications (28.6%) compared to 11.4% in period 2 and 19.1% in period 3. Sepsis as a complication following surgery increased over the study period from 2.9% in period 1 to 3.8% and 7.9% in periods 2 and 3 respectively. Early mortality was 17.1%, 26.6% and 25.4% from periods 1-3 respectively. Late mortality declined from 17.0% in period 1 to 11.4% and 0% in periods 2 and 3 respectively. Only 37 (20.9%) patients were documented to have further surgery after the initial aortopulmonary shunt. Across all three study periods, no blocked shunts were documented. Conclusions: This study describes the characteristics and outcomes of aortopulmonary shunts over a 37-year period in a tertiary care resource limited low to middle income country setting. The commonest cardiac lesions for which aortopulmonary shunts are performed are tricuspid atresia, pulmonary atresia with VSD, tetralogy of Fallot and other complex cyanotic cardiac lesions. The frequency of aortopulmonary shunts compared to total surgeries has corrective surgery for these cardiac lesions. The modified BTS is the most frequently performed aortopulmonary shunt used for palliative surgery in our setting, which is a similar trend in developed countries. The morbidity and mortality in this study is higher than developed countries, with sepsis being the most common complication. Attention to infection control practises need to be emphasized peri- and post-operatively in our hospitals.
Challenges and opportunities faced by social entrepreneurs in Sekhukhune District Municipality, Limpopo
(University of the Witwatersrand, Johannesburg, 2023) Moipane, Phasha Pharane
Background: Social entrepreneurship is increasingly recognised as a powerful means to address pressing societal issues. However, a substantial gap exists in the literature regarding the challenges and opportunities faced by social entrepreneurs in the Sekhukhune District Municipality (SDM) in Limpopo. This study aims to fill this gap by investigating the specific hurdles and prospects encountered by social entrepreneurs within this geographically isolated context. Significance: Social entrepreneurs play a pivotal role in mitigating socio-economic challenges and fostering community development. Their contributions are especially significant in underserved areas like the SDM. Population and Sample Framework: Data for this study was collected through interviews, articles, reports, and websites. Out of 50 social entrepreneurs approached, 26 accepted to be interviewed, constituting the study's sample. Method of Data Collection and Analysis: Qualitative research methods were employed to conduct interviews with the 26 social entrepreneurs operating in the SDM of Limpopo Province, South Africa. The data collected was analysed to uncover the challenges and opportunities faced by these social entrepreneurs. Highlights of Results: The study's findings underscore the substantial obstacles faced by social entrepreneurs in this region, which include insufficient funding, restricted access to networks, and inadequate training. These challenges hinder their project financing and sustainability efforts. Conclusions and Recommendations: This study recommends expanding local economic development and municipal procurement policies to provide interest-free grants to emerging entrepreneurs in the region. Furthermore, it suggests that social entrepreneurs can overcome some of these challenges by harnessing support from customers and leveraging tender opportunities provided by the SDM and other entities

4. Electronic Theses and Dissertations (ETDs) - Faculties submissions

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