Arthur, Keshni2021-10-282021-10-282020https://hdl.handle.net/10539/31823A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, 2020Background: South Africa, together with many low-and middle-income countries, is in the midst of a health transition, characterised by the double burden of communicable and non-communicable disease. The obesity epidemic is a key contributor to the rise in non-communicable diseases and, together with HIV/AIDS, is a leading cause of early mortality. Transdisciplinary research approaches that integrate common health issues at an early life-stage into a single intervention directed at both parents and children are very limited in the extant literature. In addition, the need to address the implementation of interventions and to ensure quality has been highlighted as requisite for successful programmes. Researchers have recommended a need for integrated models that re-formulate existing prevention programmes to produce holistic health interventions. Furthermore, engaging the education sector as a participant in health prevention offers a dynamic strategy because of the existing organisational, social and communication structures. A transdisciplinary research approach provides a collaborative opportunity to strengthen an intervention’s infrastructure and improve its organisational functioning. Ensuring widespread translation of integrated, evidence-based practices into real-world settings requires the successful implementation of age- and culture-appropriate interventions. Since pre-adolescence is an important developmental period for prevention efforts – implementing interventions early not only permits lessons learnt early in life to be carried forward into adulthood, but could also influence inter-generational knowledge transmission from child to parent. Aims and objectives: The study was designed to develop, implement and evaluate a transdisciplinary intervention that addresses HIV and obesity prevention, aimed directly at pre-adolescent learners (9 – 12 years old), and indirectly at their parents, to promote knowledge transfer. The four objectives of the study were: a) to develop a transdisciplinary intervention - The CIrCLE of Life Initiative - to address HIV and obesity prevention; b) to assess the level of organisational readiness in schools and to identify organisational facilitators, barriers and contextual factors that might suggest proactive improvements before implementation of the intervention; c) to assess implementation fidelity during a process evaluation of the intervention; and d) to evaluate the effectiveness of the combined HIV and obesity intervention. Methods: The study was based on a mixed-methods approach. Five government-run primary schools in a district located in Gauteng province, South Africa were purposively selected, based on quintile classification and urban-rural classification. Intervention Mapping and implementation science theory facilitated the development of both the intervention and implementation strategies. The formative study involved a scoping review and needs analysis. The scoping review mapped the literature on VI school-based health interventions designed to reduce the risk of HIV and obesity in pre-adolescents and their parents. The needs assessment evaluated the health status at selected schools, the environmental conditions and behaviour/s associated with disease, and the desired programme outcomes. In planning for implementation, an evaluation of organisational readiness at schools was conducted. Implementation climate and organisational readiness for implementing change were evaluated conjointly. Forty-six educators and school management staff answered a self-administered questionnaire and contributed to focus group discussions. Mean scores with standard deviations, or median scores with interquartile ranges, were calculated to determine levels of organisational readiness. Qualitative data were transcribed and analysed thematically. The CIrCLE of Life Initiative was implemented to 537 Grade 6 learners and their parents. Educators delivered the lessons to learners who communicated with parents through shared homework activities. Data were collected on an adapted Proctor’s taxonomy of implementation outcomes to assess process outcomes. Qualitative and quantitative data were collected through educator logbooks, researcher observations and learner parent workbooks. All qualitative data were transcribed and analysed. A pretest-posttest study design, with a three-month follow up, was used to assess effectiveness of the intervention. Both groups completed self-administered questionnaires. Differences in proportions between the two time points were tested using Chi-square or Fisher’s exact tests. Results: Through the needs assessment, it was found that educators perceived that health and lifestyle issues among learners affected classroom learning and saw a need for school-based health curricula. The scoping review shortlisted 11 studies which described successful interventions which informed the intervention-design. The CIrCLE of Life Initiative comprised a learning curriculum, environmental support and activity-based constituents that targeted the learner in the school environment and the parent in the home environment. The intervention was designed to increase knowledge about HIV and obesity, and enhance skills and strengthen self-efficacy in communication. The organisational readiness evaluation showed that the overall implementation climate and organisational readiness for implementing change median scores were acceptable, at 3.6 (IQR 3.2 – 4.1) and 4.3 (IQR 3.8 – 4.9), respectively. Results indicated that educators collectively valued the proposed change highly enough to commit to its implementation; the motivation for the intervention, associated goals and objectives, realisation for change, and the benefits thereof, were well-comprehended. Thirteen barriers and 13 facilitators suggested proactive improvements to the intervention and the implementation strategy. The process evaluation revealed high learner penetration (97.2%) but lower learner and parent exposure (44.3% and 55.5%, respectively). Differentiation between the various school contexts was observed. Results of the outcome evaluation showed that response rates were high for both learners (80.6%) and their parents (83.4%). There were positive changes in outcomes such as HIV knowledge (p<0.001), obesity awareness (p=0.040), and certain related skills and behaviours in both groups. Changes in the perceptions and attitudes of pre-adolescents were, however, limited. Learners VII displayed a high intention to share gained knowledge with parents who also had a high intention to receive it (89.4% and 89.6%, respectively). Conclusion: The transdisciplinary research approach used to facilitate collaboration between the health and education organisations, moved beyond the limitations of any single disciplinary focus to create a new synergistic way of addressing current public health concerns. Even with the complexities of a multi-level intervention, the study showed that through early stakeholder engagement, organisational readiness assessments and needs analysis that this approach can promote stronger forms of involvement and support in the processes needed for effective programme delivery and implementation. The statistically significant differences between pre- and post-test scores in the outcome evaluation confirmed the effectiveness of the intervention in increasing self-assessed HIV related knowledge and obesity-related awareness, showing positive results in outcomes such as knowledge, obesity awareness and certain related skills and behaviours in both groups. As opposed to the conventional view that parents transfer knowledge to children, the study also provided promising findings that an inter-generational transfer of knowledge from pre-adolescent to parent is possible. The conceptual model of implementation research which brought together the four phases of intervention design, implementation strategy, and process and outcome evaluation also included other frameworks, that functioned within this model, to strengthen the overall outcome. The combination of Intervention Mapping and implementation science strategies not only strengthened the intervention and implementation development process but demonstrated the benefits of using implementation science in the early stages of intervention development. Although other models, such as the taxonomy of eight conceptually distinct implementation outcomes proved to be a valuable tool to assess the process evaluation, it lacked the dimension of context. The study also uniquely married organisational readiness for implementing change and implementation climate constructs to ascertain underlying organisational readiness levels and the associated barriers and facilitators. Overall the study also demonstrated how feedback loops between intervention development, implementation science strategies (organisational readiness and adaption) and process and outcome evaluation function to enhance design and implementation. The CIrCLE of Life Initiative has the potential to create an immense impact through the synergy of its combined HIV and obesity health prevention components. Moreover, as it presents new findings in an area of limited research, it broadens the scope of research, particularly in the field of transdisciplinary approaches, targeting pre-adolescents in prevention programmes, and using pre-adolescents as agents of change in inter-generational knowledge transfer mechanisms.enThesis