Doctoral Degrees (Health Systems and Public Health)

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The adherence to effective vaccine stock management protocols in the government facilities, the availability of vaccines, and the effectiveness of the stock visibility system in OR Tambo District of the Eastern Cape Province of South Africa
(Stellenbosch : Stellenbosch University, 2019-12) Iwu, Chinwe Juliana; Wiysonge, Charles S.; Chikte, Usuf; Ngcobo, Ntombenhle Judith; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems & Public Health.
ENGLISH SUMMARY : Effective vaccine stock management is one of the criteria for a functional vaccine supply chain. It ensures that the quality of vaccines is maintained and that vaccines are continuously available at service delivery points. The continuous availability of vaccines is a vital component of the health system which is required to achieve public health goals such as improved immunisation coverage, and universal health coverage. Reports on vaccine availability and stock management of vaccines in OR Tambo district of the Eastern Cape Province are scarce. Also, since the implementation of the mobile device for stock reporting, stock visibility solution (SVS), no study has explored the experiences of the health care workers in order to identify potential barriers and facilitators to the implementation of the system. This study was therefore aimed at assessing the vaccine stock management status as well as availability of vaccines in the OR Tambo district, in Eastern Cape Province, South Africa. As part of the literature review, we firstly gathered evidence on occurrence of vaccine stock -outs at different levels of the supply chain; the national, district, health facility level in the WHO African region. A systematic search of the literature was conducted to identify studies reporting on vaccine stock-outs at these levels. Furthermore, a cross-sectional study was conducted to assess the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care settings in the Eastern Cape province, South Africa. Data was collected from a total of 64 PHC facilities using a researcher administered questionnaire, record checks and direct observation. This was followed by a qualitative study to explore the perceptions and experiences of the SVS system amongst healthcare workers (HCWs) who are involved with managing stock levels of medicines in primary health care facilities in the Eastern Cape Province. Consequently, a scoping review was conducted to summarise currently available information on interventions for vaccine stock management. Quantitative data was managed using an electronic data capturing tool, REDCap, and descriptive statistics, and Pearson’s chi-squared test, were conducted using STATA® Version 14. The qualitative data was analysed using thematic analysis. Based on the JRF data, approximately 50% of the countries in Africa reported stock-outs of at least one vaccine for at least one month at national and district levels, in 2017. Fourteen (30%) countries reported vaccine stock-outs in 2017 at the national level. BCG vaccine is the most affected vaccine, with an increase from five countries in 2010 to 16 counties in 2015. There is an 86% chance of stock-out at the district level is caused by stock-out at the national level being linked to national level stock-outs and a 62% chance of this leading to interruption of immunisation services at the facility level. At the facility level stock-outs reports from Africa were few. We found a total of eight studies that reported vaccine stock-outs across Africa; South Africa (5); Nigeria (1); Guinea (1) and Kenya (1) and Ethiopia (1). Poor stock management, disease outbreaks, poor supply chain structure, delays in deliveries and lack of trained health personnel are possible causes of facility level stock-outs. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. However, the health care workers were reluctant to fill in the stock cards. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. The ordering system was weak; as only about half 31(49%) of the respondents understood the concept of maximum and minimum stock levels, which are needed for proper quantification of needs. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which could have contributed to stock-outs. Common reasons for delays from the depot include staff shortages at the pharmaceutical depot causing a backlog of orders, delay from the suppliers, procurement delays and possibly lack of proper communication between the depot and the facilities. A total of 49 (77%) health facilities had at least one stockout for at least one vaccine on the day of the visit. Furthermore, BCG and OPV were the most commonly affected vaccines in 37 (58%) and 28 (44%) facilities, respectively. Within the last two years (between February 2017- February 2019), BCG and OPV had the most prolonged median duration of 167 and 103 days, respectively. PCV experienced the most prolonged duration of stock-outs amongst the newer vaccines with a median duration of stock-outs of 85 days. Four studies met our inclusion criteria (three before-after studies and one randomised trial). Three studies were conducted in low- and middle-income countries, while one was conducted in Canada. All the studies had various limitations and were classified as having a high risk of bias. Study findings suggest that use of digital information systems to improve information and stock visibility, coupled with other interventions (such as training of health care workers on the use of innovative tools and redesign of the supply chain to tackle specific bottlenecks) have the potential to increase vaccine availability, reduce response times, and improve the quality of vaccine records. Although more of well-designed studies are needed to strengthen the evidence base. The SVS system was well understood by most HCWs, as a system for reporting stock levels to managers. They also displayed high commitment to ensuring the systems works. However, some factors were identified as potential barriers for efficient usage of the system. This includes staff shortages and high staff turnover, lack of responses from the managers, the extra workload that comes with the system, amongst others. The HCWs made various suggestions for how the system might be improved, most pertinently the need for more pharmacists and pharmacy assistants and for these cadres to be primarily in-charge of stock management and the use of the SVS. The OR Tambo district of South Africa, just like in other countries, suffers from vaccine stock-outs especially BCG, and OPV. Similarly, the lack of proper stock management linked to the use of manual stock cards, long response time from the pharmaceutical depot and inadequate fridge capacity may be responsible for stock-outs in the primary health care facilities in OR Tambo district. Interventions for improving vaccine availability should be considered, especially those focused on the factors highlighted above.
Adolescent mental health in the context of adversity : evidence from a longitudinal intervention study in Khayelitsha, South Africa
(Stellenbosch : Stellenbosch University, 2023-12) Du Toit, Stefani; Skeen, Sarah; Haag, Katharina; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: The World Health Organization defines adolescents as individuals between the ages of 10 and 19 years, undergoing transition from childhood to adulthood [1, 2]. Adolescence is a rapid developmental phase during which an individual undergoes major physical and psychological changes [1]. The changes that occur during this period create a vulnerability that is accentuated by exposure to risk factors such as poverty, community violence, and lack of access to basic services [1-5]. Mental health conditions most commonly appear during adolescence [1]. Experiencing mental health conditions during this period can have lasting effects on an individual's health, as it can increase the risk of substance use, violence victimisation and perpetration, and suicidal ideation [6-8]. There is a critical gap in the exploration of mental health conditions among adolescents in low- and middle-income countries, particularly in sub-Saharan African countries, where most adolescents live in the context of widespread poverty [9]. Most of the research on adolescent mental health is conducted in high-income countries, despite nearly 90% of the world's adolescent population living in low- and middle-income countries [9, 10]. There is an urgent need to assess potential risk and protective factors, as well as interventions, to address the mental health of adolescents in these contexts. To design effective preventative initiatives that aim to protect adolescents from the adverse consequences of mental health conditions, it is crucial to understand risk and protective factors at various stages throughout the life course. In addition, a comprehensive understanding of support structures and interventions that can aid in the prevention of mental health conditions and the promotion of positive mental health among adolescents is crucial. This thesis is based on research reported on four articles. The first two articles report on predictors of mental health problems, exploring both early childhood and current environmental factors. The second two articles in this thesis report on potential interventions for adolescent mental health.
Barrier to cervical cancer screening in Gwanda district, Zimbabwe : a mixed method analysis
(Stellenbosch : Stellenbosch University, 2022-12) Mantula, Fennie; Sewram, Vikash; Toefy, Yoesrie; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: Background: Zimbabwe is among the countries that carry the highest burden of cervical cancer globally. Regular screening has been proved to significantly reduce the disease incidence and mortality if screening coverage is high. Whereas proven and cost-effective strategies for secondary prevention of cervical cancer are available, the national screening rate is low. This justified the need for a study to determine the barriers to uptake of screening in order to develop strategies for addressing them. Aim: This study explored factors that influence the low utilisation of cervical cancer screening services in Gwanda district, Zimbabwe, guided by the socio-ecological conceptual framework. The objectives of the study were to: Analyse socio-demographic factors associated with uptake of screening by local women aged 25-50 years; Assess their knowledge, attitudes and behaviours related to cervical cancer and screening; Identify factors perceived as barriers to screening; Determine factors health providers perceive as barriers to screening, and to examine screening uptake facilitators that could be incorporated into the programme. Methods: An explanatory sequential mixed-method research design was employed in the study. It was conducted in two phases: The first phase was a household-level cross-sectional survey of 609 screening-eligible women selected from 10 of 34 electoral wards in the district using multi-stage random sampling. The quantitative survey informed the content of the second qualitative phase that engaged 36 women, purposively selected from the first phase, in focus group discussions as well as 25 health providers, with different roles in the screening programme, in in-depth interviews. Data analysis utilised the socio-ecological model. Results: The first phase found knowledge about cervical cancer and screening inadequate among women, and screening prevalence among this cohort was 30.05%. Screening uptake was associated with urban and mine residency (p = 0.009), higher educational attainment (p < 0.001), being employed (p = 0.056) marginally, accessing health care from urban clinics and the provincial hospital that provides screening (p = 0.007), and a family history of cervical cancer (p = 0.045). Multivariable log-binomial regression showed the risk of encountering screening barriers to be lower for women who lived in urban and mine settings compared to those who lived in rural areas (p < 0.001). Women with adequate knowledge on cervical cancer were less likely to face barriers than less knowledgeable women (p < 0.001). Factor analysis identified knowledge gaps on screening, inaccessibility of screening services, and socio-cultural beliefs as major barriers to screening. Findings from the second phase confirmed inadequate knowledge, poor access to services and lack of men involvement as key barriers to screening. Screening facilitators were awareness and an adequate understanding of the benefits of screening, availability of services, and male involvement in the planning and implementation of screening programmes. Conclusions: Major barriers to cervical cancer screening were identified at all levels of the socio-ecological model implying that individual, interpersonal, community and health system-related factors contribute to challenges women face in accessing screening. This study’s findings provide policy makers, programme managers and implementers with better insights for developing targeted interventions to improve screening uptake.
Barriers to cervical cancer screening in Gwanda district, Zimbabwe : a mixed method analysis
(Stellenbosch : Stellenbosch University, 2022-12) Mantula, Fennie; Sewram, Vikash; Toefy, Yoesrie; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: Background: Zimbabwe is among the countries that carry the highest burden of cervical cancer globally. Regular screening has been proved to significantly reduce the disease incidence and mortality if screening coverage is high. Whereas proven and cost-effective strategies for secondary prevention of cervical cancer are available, the national screening rate is low. This justified the need for a study to determine the barriers to uptake of screening in order to develop strategies for addressing them. Aim: This study explored factors that influence the low utilisation of cervical cancer screening services in Gwanda district, Zimbabwe, guided by the socio-ecological conceptual framework. The objectives of the study were to: Analyse socio-demographic factors associated with uptake of screening by local women aged 25-50 years; Assess their knowledge, attitudes and behaviours related to cervical cancer and screening; Identify factors perceived as barriers to screening; Determine factors health providers perceive as barriers to screening, and to examine screening uptake facilitators that could be incorporated into the programme. Methods: An explanatory sequential mixed-method research design was employed in the study. It was conducted in two phases: The first phase was a household-level cross-sectional survey of 609 screening-eligible women selected from 10 of 34 electoral wards in the district using multi-stage random sampling. The quantitative survey informed the content of the second qualitative phase that engaged 36 women, purposively selected from the first phase, in focus group discussions as well as 25 health providers, with different roles in the screening programme, in in-depth interviews. Data analysis utilised the socio-ecological model. Results: The first phase found knowledge about cervical cancer and screening inadequate among women, and screening prevalence among this cohort was 30.05%. Screening uptake was associated with urban and mine residency (p = 0.009), higher educational attainment (p < 0.001), being employed (p = 0.056) marginally, accessing health care from urban clinics and the provincial hospital that provides screening (p = 0.007), and a family history of cervical cancer (p = 0.045). Multivariable log-binomial regression showed the risk of encountering screening barriers to be lower for women who lived in urban and mine settings compared to those who lived in rural areas (p < 0.001). Women with adequate knowledge on cervical cancer were less likely to face barriers than less knowledgeable women (p < 0.001). Factor analysis identified knowledge gaps on screening, inaccessibility of screening services, and socio-cultural beliefs as major barriers to screening. Findings from the second phase confirmed inadequate knowledge, poor access to services and lack of men involvement as key barriers to screening. Screening facilitators were awareness and an adequate understanding of the benefits of screening, availability of services, and male involvement in the planning and implementation of screening programmes. Conclusions: Major barriers to cervical cancer screening were identified at all levels of the socio-ecological model implying that individual, interpersonal, community and health system-related factors contribute to challenges women face in accessing screening. This study’s findings provide policy makers, programme managers and implementers with better insights for developing targeted interventions to improve screening uptake.
Continuity of care for tuberculosis patients between hospital and primary health care services in South Africa
(Stellenbosch : Stellenbosch University, 2020-03) Dudley, Lilian Diana; Volmink, Jimmy; Zwarenstein, Merrick; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems & Public Health.
ENGLISH ABSTRACT : Many tuberculosis (TB) patients in South Africa are admitted to acute care hospitals, but large numbers are lost to care after discharge, and few complete their TB treatment. This contributes to ongoing transmission of TB in communities, frequent hospital readmissions, a high mortality rate and avoidable costs to the health system and society. This thesis studied continuity of care for TB patients discharged from hospital in South Africa. It aimed to describe the problem, identify risk factors for poor continuity of care, synthesise evidence to inform, implement and evaluate an intervention, and produce a policy brief to translate the evidence into policy and practice. The research methods included an observational study, research synthesis, qualitative research, participatory action research, a quasi-experimental study as well as knowledge translation methods to address the various research questions. The study found that a third of TB patients discharged from hospital did not continue TB treatment, and that inadequate clinical management of TB patients in hospital showed a significant correlation with poorer continuity of care and an increased mortality rate. Evidence of strategies to improve continuity of care for chronically ill patients was identified in high-income countries, but no such evidence could be found for TB patients in low and middle-income countries. Using the available evidence and participatory action research, a multicomponent discharge planning and support intervention was designed and implemented in collaboration with a referral hospital in the Western Cape. A before-and-after evaluation found that continuity of care for TB patients improved significantly after implementing the intervention. A process assessment revealed that the characteristics of the intervention, the external context, the persons involved and the methods of implementation had a favourable impact on implementation. Yet the internal context of the hospital was unfavourable for implementation, and in-hospital intervention activities were not sustained. In contrast, information linkages and community-based follow-up and support of TB patients continued. More rigorous studies of interventions to improve continuity of care for TB patients discharged from hospital in similar settings are required. This should be complemented by implementation research to understand and address health systems challenges. Both types of research are needed to effectively translate evidence into practice in the health systems of low and middle-income countries.
Determinants of maternal colonization with multidrug-resistant gram-negative bacteria
(Stellenbosch : Stellenbosch University, 2020-03) Bulabula, Andre Nyandwe Hamama; Mehtar, Shaheen; Dramowski, Angela; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH ABSTRACT : This doctoral research explored the topic of maternal colonization with multidrug-resistant Gram-negative bacilli (MDR-GNB) in Africa, using analytical cross-sectional studies to generate novel data and systematic reviews and meta-analyses to synthesize existing data. Maternal colonization is an established risk factor for neonatal colonization, which is a precursor to neonatal infection (the third leading cause of neonatal deaths in Africa). Understanding the factors contributing to maternal colonization with MDR-GNB in Africa, will inform the development of preventive interventions and ultimately contribute to reduction of neonatal infection burden. Through a systematic review and meta-analysis, we underscored the major knowledge gaps regarding the burden of and risk factors for maternal colonization with MDR-GNB in Africa. The meta-analysis allowed us to provide a first estimate of the prevalence of maternal colonization with extended-spectrum beta-lactamases producing Enterobacteriaceae (ESBL-E) among pregnant and postpartum women in Africa (17%), which was 2 to 3-fold higher than that described from high-income countries. Utilizing an analytical cross-sectional study design, we generated unique data describing the prevalence of maternal colonization with antimicrobial resistance (AMR) genes in a South African cohort of 651 peripartum women. Cefotaxime-M15 (CTX-M15) and New Delhi Metallo-beta-lactamase (NDM) genes were isolated from 12.9% and 2.2% of specimens respectively. Communal taps as the primary water source was the only independent predictor of maternal colonization with CTX-M15. Poverty-related factors (lower educational achievement, low income group and rural residence), and a clinical factor (primiparous status), were independent predictors of maternal colonization with carbapenem-resistant pathogens. Comorbidities like HIV infection and diabetes, or exposures such as recent antibiotic use, did not predict maternal colonization with AMR genes. The knowledge, attitudes and practices regarding antibiotic use during pregnancy were assessed in a cohort of 301 pregnant South African women. Women with higher mean knowledge score (K-score) had lower reported proportions of antibiotic self-medication compared to women with lower mean K-scores. High monthly household income was an independent predictor of self-medication with The relationship between the density of hospital environmental contamination with AMR genes and colonization proportions in 180 hospitalized peripartum women and 92 neonates, was prospectively assessed. The level of hospital environmental contamination with AMR genes was low (5.8%); similarly, the number of colonized patients was small (2.8% of the peripartum women and 9.8% of the neonates), limiting the study’s power to determine a clear link between environmental contamination and patient colonization. Finally, in a second systematic review and meta-analysis, we produced a synthesis of molecular evidence linking MDR-GNB transmission from colonized mothers to their neonates. Although limited by the number and quality of studies, molecular evidence supports an overall 27% transmission proportion for MDR- and/or ESBL Enterobacteriaceae from colonized mothers to their infants, resulting in neonatal colonization. Further high-quality research is needed to determine the risk factors that promote mother-to-infant MDR-GNB transmission and evidence to link maternal MDR-GNB colonization and subsequent neonatal infection. This doctoral thesis has produced new findings on the magnitude of and risk factors for maternal colonization with MDR-GNB in an African context. The novel data will inform the development of interventions to prevent colonization with MDR-GNB in mothers and subsequently reduce neonatal infection.
Development and testing of an m-Health platform to reduce post-operative penetrative sex in recipients of voluntary medical male circumcision
(Stellenbosch : Stellenbosch University, 2017-12) Toefy, Mogamat Yoesrie; Skinner, Donald; Thomsen, Sarah; Diwan, Vinod; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY : Background: The widespread roll-out of voluntary medical male circumcision (VMMC) has been accompanied by reports of VMMC recipients, particularly men who are married or cohabiting, resuming sexual intercourse before the recommended healing period of six weeks. This behaviour carries an increased risk of transmission of STIs and HIV, for both partners. At the same time, it is unrealistic to assume that an already over-burdened health system will be able to provide repeated, intense messaging that recent recipients of VMMC may need to help them navigate the postoperative period sexually. There is an urgent need to develop culturally appropriate messages and innovative delivery strategies for behaviour modification in the postoperative period and in the longer term for medically circumcised men. Methods: As a step to better understand the behaviour of the VMMC patients during the six-week recovery period, we conducted nine single-gender focus groups with males who had undergone VMMC in the previous six months and their partners (Study 1). Armed with this information, we strove to create a contextuallyrelevant message regime by using a staggered qualitative methodology: (1) focus group discussions with 52 recently circumcised men and their partners to develop initial voice messages (2) thematic analysis and expert consultation to select the final messages for pilot testing, and (3) cognitive interviews with 12 recent VMMC patients to judge message comprehension and rank the messages. The message content and phasing were guided by the theory of planned behaviour, the health action process approach and the action research approach (Study 2). For the next two years, this intervention was evaluated using a two-armed, randomized, single-blind, controlled design. This sample was collected at 12 clinics in urban area of Cape Town in the Western Cape Province, South Africa. Patients were followed up at 42 days after enrolment (Study 3). As a final measure, the usability of the platform was evaluated. At follow-up, 597 participants completed questionnaires regarding the usability and user experience of the mobile audio platform. Usability was measured with the System Usability Scale (SUS). Five focus groups with a total of 25 patients were also conducted. The scale’s multidimensionality was shown with the emergence of three trends that explained more than 65% of the total variance of the scale (Study 4). Results: The primary motivation to VMMC uptake included religious injunction and hygiene reasons and protection against sexually transmitted infections not necessarily HIV. Both men and women felt that sex was important to maintain the relationship (Study 1). We received 245 messages with 42 themes. Expert review and cognitive interviews with more patients resulted in 42 messages with a clear division in terms of needs and expectations between the initial wound-healing recovery phase (weeks 1–3) and the adjustment phase (weeks 4–6). Participants were more positive and salutogenic than public health experts were (Study 2). The randomised controlled trial found a slightly larger positive effect in the Intervention Group (28.0%) than in the Control Group (32.3%)) but not significant (p=0.071) (Study 3). Participants gave the platform an overall usability score of 62.80 (SD 13.41). Most of them were positive about the messages (Study 4). Conclusions: VMMC counselling needs to take into account the real-life context of the circumcised men. Due to systematic, social and cultural factors, there is a real risk that men in this population may initiate sex before complete healing has occurred (Study 1). Consultation with potential m-Health recipients and using classic behavioural theories are vital to the success of a programme (Study 2). Early resumption of sex after VMMC is common, warranting better counselling. M-Health technology is a potential tool but it should be complemented by other behaviour-change methods (Study 3). The results suggest that the audio messaging system has good usability, user experience and user acceptance (Study 4).
Development of a best practice model for teaching and learning evidence-based health care at Stellenbosch University, South Africa
(Stellenbosch : Stellenbosch University, 2016-03) Young, Taryn; Volmink, Jimmy; Clarke, Mike; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Community Health.
ENGLISH ABSTRACT: This thesis used a mixed-methods approach to investigate how teaching and learning of Evidence-based Health Care (EBHC) could best be integrated in medical student training to enhance student EBHC knowledge, attitude and skills. An overview of systematic reviews assessing the effects of teaching EBHC showed that clinically integrated multifaceted strategies with assessment were more effective than single interventions or no interventions for enhancing knowledge, attitude and skills. Implementation of clinically integrated EBHC teaching and learning was further explored through interviews with programme coordinators from around the world. Informants were requested to provide data on the various approaches used, and on barriers and facilitators encountered with programmes aimed at teaching and learning EBHC in an integrated manner. By far the most common challenges were lack of space in the clinical setting, EBHC misconceptions, resistance of staff and lack of confidence of tutors, time, and negative role modelling. Critical success factors identified were pragmatism and nimbleness in responding to opportunities for engagement and including EBHC learning into the curriculum, patience, and a critical mass of the right teachers who have EBHC knowledge, attitudes and skills and are confident in facilitating learning. In addition, role modelling within the clinical setting and the overall institutional context were found to be important for success. The next phase involved conducting a set of studies to determine the opportunities for, and barriers to, implementing EBHC teaching and learning at Stellenbosch University’s (SU) Faculty of Medicine and Health Sciences. This included a curriculum document review, survey of recent graduates and interviews with faculty. EBHC teaching was found to be fragmented and recent graduates called for more teaching of certain EBHC competencies. Module convenors identified a number of factors that needed to be addressed: contextual factors within the faculty (e.g. recognition for teaching), health sector issues (e.g. clinical workload), access to research evidence, and issues related to educators (e.g. competing priorities) and learners (e.g. motivation). Interviewees also emphasised the importance of educators as facilitators and role models. A cross-sectional study of SU was conducted to assess SU educators’ knowledge of, attitude to and confidence in practicing and teaching EBHC as well as perceived barriers to practicing and teaching EBHC. Limitations to practicing EBHC identified included lack of time, clinical workload, limited access to internet and resources, knowledge and skills. Respondents’ called for reliable internet access, easy point-of-care access to databases and resources, increasing awareness of EBHC, building capacity to practice and facilitate learning of EBHC, and a supportive community of practice. Finally, drawing on the findings of the preceding quantitative and qualitative studies, and taking into account the context of various EBHC initiatives in the African region, an outline proposal is presented for a cluster randomised trial to evaluate alternative options for implementing a clinically integrated EBHC curriculum in an African setting.
Economic support to improve TB treatment outcomes in South Africa : a pragmatic cluster randomized controlled trial
(Stellenbosch : Stellenbosch University, 2013-12) Lutge, Elizabeth Eleanor; Volmink, J. A.; Lewin, S. A.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Division of Community Health.
ENGLISH ABSTRACT: This thesis focused on the provision of economic support to improve the outcomes of patients on TB treatment. Although the association between poverty and tuberculosis is generally acknowledged, there is little evidence to guide the use of economic interventions to improve tuberculosis control. In South Africa, a high burden country with extensive poverty, such evidence is particularly important. The first part of this thesis is a Cochrane systematic review of evidence from randomized controlled trials regarding the effectiveness of economic support among patients with tuberculosis. Eleven trials were included: ten conducted among marginalised groups in the United States on economic support for people on prophylactic treatment for latent TB; and one from Timor-Leste on economic support for patients with active TB. The review found that the use of economic interventions in patients with latent TB may increase the return rate for reading tuberculin skin test results, probably improves clinic re-attendance for initiation or continuation of prophylaxis and may improve completion of prophylaxis, compared to normal care. However, it is uncertain if economic support improves treatment completion in patients with active TB (low quality evidence). The second part of the thesis reports the findings of a pragmatic, cluster randomized controlled trial to evaluate the feasibility and effectiveness of delivering economic support to patients on treatment for active TB in South Africa. Patients with drug sensitive pulmonary TB were offered a monthly voucher valued at ZAR120 until completion of treatment or a maximum of eight months. Patients in control clinics received usual TB care. A parallel process evaluation provided contextual information to explain the trial findings. The qualitative component of this evaluation consisted of in-depth interviews with a sample of trial participants, including patients, nurses and health managers, to assess responses to the voucher and its administration. The quantitative component included a survey of patients’ household expenditure to assess patients’ levels of poverty and the effects of the voucher on these, and an analysis of the goods on which patients spent their vouchers. 4091 patients were included in the trial: 1984 in the control arm (10 clinics) and 2107 in the intervention arm (10 clinics). Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (-1.2; 12.3%), p = 0.107). Fidelity to the intervention was low, partly because nurses preferred to issue vouchers based on perceived financial need, rather than on eligibility. Logistical difficulties in delivering vouchers to clinics also undermined fidelity. The vouchers did not significantly increase patients’ household expenditure, but were experienced by patients as helpful, especially in providing more food with which to take their tablets. Factors related to the administration of economic support may undermine its effectiveness in improving TB treatment outcomes. Further research is needed to explore how best to deliver such economic support to those eligible to receive it, particularly in low and middle income countries where the burden of tuberculosis is highest.
Edentulousness and complete denture care in the Western Cape Province with specific reference to the need for and feasibility of establishing denturists as a new occupational category in the oral health care work force
(Stellenbosch : Stellenbosch University, 1998) Hartshorne, Johannes Enoch; Louw, N. P.; Stellenbosch University. Faculty of Medicine & Health Sciences. Department of Restorative Dentistry.
ENGLISH ABSTRACT: see item for full text.
Envisioning enabling environments for young women with perinatal infections of Human Immunodeficiency Virus in Africa : a participatory creative new-materialist approach.
(Stellenbosch : Stellenbosch University, 2023-12) Hendricks, Lynn Avril; Hannes, Karin; Young, Taryn; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: Background: Targeted due to gender and age in South Africa, young women often must negotiate health and safety in their homes and communities – this is even more challenging for young women living with perinatal infections of Human Immunodeficiency Virus (YWLPHIV). Young people living with perinatal infections face a chronic disease, with treatment including adherence to lifelong Antiretroviral treatment (ART). We set out to learn more about young women perinatally infected with Human Immunodeficiency Virus (HIV) in Cape Town, their experience with HIV, how they negotiated adherence to ART regimens within their environments, and how environments could be enabled to support their adherence. Methods: This study used qualitative evidence synthesis (QES) and multisensory arts-based community participatory research methods, working together with six young women as allies. In phase 1, we synthesised the evidence landscape on adherence to ART. In phase 2, we conceptualised the Adherence Assemblage conceptual model of ART and the methodological approach of the third sphere for allyship. In phase 3, we co-explored with YWLPHIV their experiences and co-produced creative artworks and a research documentary, More than a pill. In phase 4, we focused on recommendations for enabling environments. Our multimodal approach included methods such as QES, artistic co-creations, body mapping, collaborative filmmaking, collecting material objects of meaning, community mapping, individual and group conversations including walking and driving interviews, journalling, multisensory home and clinic interviews, a research camp, and storytelling. Analytically, we used a new materialist lens to develop a new enabling environments framework from the innovative Adherence Assemblage model and applied analysis such as mega-aggregation framework synthesis, synthesis by storyboarding, creative synthesis, and thematic analysis. Results: Drawing on the findings of multiple types of qualitative data, which captured the perspectives of various role players, and amplified the voices of YWLPHIV, while considering the social-material-natural environment context in Africa, this PhD delivers: an innovative method of Mega-Aggregation Framework synthesis, a new qualitative evidence synthesis analytic method called Analysis by Storyboarding, a new conceptual model for adherence – the Adherence Assemblage, advances allyship in qualitative methods with the concept of the third sphere, actualised collaborative film production and creative works as synthesis, had a sustainable impact for both researchers and participants alike, and provides tangible recommendations for enabling environments to support adherence to ART for YWLPHIV. To enable environments for YWLPHIV, recommendations included supportive disclosure practices, self-efficacy and self-acceptance, supportive relationships and caring communities, mitigating violence as a barrier to adherence and safe outdoor spaces, acknowledging the material dimension, integrated and holistic health care, compassionate educational systems, and advancing knowledge systems and research practices. Conclusion: This study is one of the first to go beyond barriers and facilitators to adherence for people living with HIV and explores the role of the socio-natural-material environment in depth. Young women living in challenging communities in Cape Town, South Africa, struggled with adherence due to environmental and community-level factors such as violence, economic inequities, lack of social support, inadequate health systems, and disadvantageous structural community layouts. Risking their lives to travel to clinics in unsafe communities, silencing their voices in their households, and being at high risk for domestic violence and femicide in their romantic relationships demands of us to bring to light their experiences, which is in line with Sustainable Development Goals (SDG) 5 (gender equality) and ending all forms of discrimination against all women and girls in private and public spheres. Working from a multimodal perspective allowed us to venture deeper together and opened the research space for multiple stakeholders for rich engagement throughout the research process. The findings of this PhD contribute to the African evidence that future research and interventions can be built to support young women and their families as they navigate their journeys of adherence to ART.
Epidemiological and laboratory investigations of the hazardous effects of wine on human enamel
(2005-04) Chikte, Usuf M. E.; Grobler, S. R.; Dreyer, W. P.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Community Health.
ENGLISH ABSTRACT: The purpose of this study was to investigate the erosive effect of wine on human permanent teeth. A multidimensional research approach utilising epidemiological investigations, Microhardness tests, Scanning Electron Microscopy and Confocal Laser Scanning Electron Microscopy (CLSM) were employed. The combination of these three scientific methods enabled the researcher to arrive at new concepts about the physical characteristics of the influence wine has on the dentition with special reference to enamel. A difference in erosion between teeth of wine-makers (and/or wine-tasters) and those who are not wine-makers, was clearly demonstrated. It is, however, possible that this difference might partially be attributed to the fact that the two main comparative groups were of opposite genders. In comparative epidemiological studies the design is constructed to have the groups similar with respect to background aetiology and different only to the factor under investigation, in this instance the frequent exposure to wine (high frequency and long duration of contact between wine and the teeth). In all likelihood the continuous, frequent exposure of wine-makers to wine is the major factor in the differences obtained (e.g. tooth surface loss and dentition status) in this study. A strong positive relationship was noted between statistically weighted tooth surface loss and the chronological age of wine-makers. A similar positive relationship could not be demonstrated in the case of years employed in the wine industry and tooth surface loss. All the Microhardness tests and microscopic investigations conducted confirmed the deleterious influence of wine on enamel. A clear 'dose-response' relationship was demonstrated by means of the Microhardness tests. The Scanning Electron Microscope and the Confocal Scanning Laser Electron Microscope (CLSM) work both corroborated the effects determined by the Microhardness tests. Differences were also demonstrated in the surface morphology of enamel with respect to the exposure to the wines investigated in the Scanning Electron Microscope (SEM) (three wines) and CLSM (two wines) studies. Differences with respect to severity were well established by means of the SEM investigations. Surface and subsurface lesions were observed with the aid of CLSM on the enamel exposed to the two wines.
Ergonomic chair design for school computer laboratories in the Cape Metropole, Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2013-03) Van Niekerk, Sjan-Mari; Louw, Quinette A.; Schreve, K.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences.
ENGLISH SUMMARY : Background: Computers have become increasingly accessible in developing countries. Such increased computer usage is also noted in the Western Cape, South Africa. Prolonged posture whilst using computers and a learner‐chair mismatch is associated with spinal pain in adolescents. In South Africa, the prevalence of spinal pain among high school learners has been reported as being about 70%. Consideration of learner anthropometrics and school furniture design is essential to evolving strategies to be adopted to promote adolescent spinal health. Aim: The aim of this project is to determine whether the school computer laboratory chair or a commercially‐available chair matches the anthropometric profile of high school learners and, if not, to develop and test a prototype chair that will also facilitate postural changes, whilst the sitter is using a desktop computer. Methods: This study consisted of two phases. Phase one dealt with the anthropometric match of the learners to their school chair and to commercially‐available chairs. The following body dimensions were measured: stature; popliteal height (PH); buttock‐topopliteal length (BPL) and hip width (HW). These body dimensions were matched with the corresponding chair seat dimensions; and height, depth and width, using standard matching criteria. During Phase two, a prototype chair was designed according to the anthropometric profile of the learners concerned. The chair’s ability to reduce static sitting postures by facilitating postural changes in sitters whilst they are seated at a desktop computer was evaluated. The three‐dimensional (3D) sitting posture of twelve learners was evaluated while they were sitting on the school and the prototype chairs. The anthropometric and 3D data were analysed using descriptive statistics, including means (and standard deviations), medians (and interquartile ranges (IQR)) and ratios. To determine the difference in the number of postural changes between chairs, the Wilcoxon match pair test was used. Results: The sample consisted of 689 male and female learners aged 13 to 18 years, for the anthropometric study (phase 1). Of the learners, 65% to 80% did not match the school chairs’ dimensions. Five commercial chairs offered a good match for the seat height, but neither the seat depth nor the seat width matched 50% of the learners. The prototype chair matched 97% for height, 65% for depth and 60% for seat width. The prototype chair was associated with more postural changes in the frontal and transverse planes for the pelvis (ρ <0.05). Conclusions: This thesis is the first to report on the lower body anthropometric size of high school learners in the Cape Metropole area, Western Cape, South Africa. Neither the school computer laboratory chair nor commercially‐available adjustable computer chairs offered an acceptable fit for the anthropometric profile of the learners. The prototype “Dynamic” chair was consequently developed and provided the best match for the anthropometric profile. The prototype chair was also associated with an increased number of postural changes, particularly of the pelvis. The promising results obtained warrant further exploration of the prototype chair to determine the effect on the musculoskeletal pain experienced by school learners in South Africa.
Evaluating the process and output indicators for maternal, newborn and child survival in South Africa : a comparative study of PMTCT information systems in KwaZulu-Natal and the Western Cape
(Stellenbosch : Stellenbosch University, 2015-04) Nicol, Edward Fredrick; Dudley, Lilian; Bradshaw, Debbie; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Community Health.
ENGLISH ABSTRACT: The prevention of mother-to-child transmission (PMTCT) of HIV is a key maternal and child health intervention in the context of the HIV/AIDS pandemic in South Africa. Accordingly, the PMTCT programme has been incorporated in the District Health Management Information System (DHMIS) that collects monthly facility-based data to support the management of public health services. To date, there has not been a comprehensive evaluation of the PMTCT information system. By comparing the experiences in two health districts, using the Performance of Routine Information System Management (PRISM) framework and tools, this study seeks to evaluate the availability, quality and use of process and output indicators for monitoring PMTCT interventions. A comparative analytical and observational study was undertaken using a multi-method approach which included: a self-administered survey of health information personnel to assess confidence and competence levels for routine health information system (RHIS) tasks, an assessment of the routine PMTCT data for quality, completeness, accuracy, and data use; and a facility survey of RHIS processes and resources. In addition, in-depth interviews with 22 key informants and observations in health facilities were conducted. Data were collected from 57 health facilities in a convenience sample of two health districts, and also from 182 health information personnel in the 57 health facilities, three sub-districts, and two district offices. Descriptive statistics, χ2-test, correlation and multiple regression analyses were conducted using STATA® Version 13. A general inductive approach was also used to analyse the qualitative data, which was used for triangulation. The study revealed considerable data quality concerns for the PMTCT information with an average accuracy between the register and routine monthly report of 51% and between the routine monthly reports and DHMIS database of 84% suggesting that the primary point of departure for accurate transfer of data is during the collation process. The importance of human factors was emphasised by the observation that the average confidence level for performing RHIS-related tasks (69%) was not commensurate with the average competence levels (30%). Education was found to be associated with competence, implying that levels of education may be associated with the level at which RHIS competencies are acquired; and that three years or more of post-matriculation education is necessary. Motivation, on the other hand was not associated Stellenbosch University https://scholar.sun.ac.za iv with competence. The study observed the absence of processes such as data-quality checks and data-analysis in place in facilities. There was a general absence of a culture of information use, as a result of lack of trust in the data, and the inability of programme and facility managers to analyse, interpret and use information. We observed differences in the data accuracy by organisational authority, and multivariate analysis and qualitative information suggested that feedback may be an essential process to ensure quality. Although the PRISM framework has been developed from a multi-disciplinary evidence base, this study has been able to validate some of the internal assumptions but has also found some aspects that were not supported such as motivation and data display. Data collected from a larger number of facilities will be required to investigate this further. Institutional capacity to improve RHIS processes, ensure core competencies for RHIS-related tasks are needed, and in the longer term, measures to tackle problems associated with low pass rates in numeracy subjects among high school learners are needed. Further exploration of the possible factors that may influence data accuracy, such as supervision, training and leadership are needed as well as investigating the relationships between human and institutional agency-related aspects, in particular, how individual actions can bring about changes in institutional routines. Further study is needed to determine how decision for planning and evaluating key programmes such as PMTCT are made, and what informs such decisions if not routine data.
An exploration of disability experiences and responses of disabled persons and their families within Muslim culture of the community of Strand, South Africa
(Stellenbosch : Stellenbosch University, 2023-12) Sait, Washeila; Mji, Gubela; Eide, Arne; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: Introduction: At the core of the study is the researcher’s perception that Muslim persons with disabilities and their families in the community of Strand are not participating in disability rights discourse and developments and activities of daily living within Muslim life. The perception is that they do not have the necessary knowledge and information, resulting in the practice of stifling care/or negatively impacting opportunities to engender participation. This perception required further investigation and validation, which is why this study was conducted. Study aim: This qualitative study aims to explore, understand and describe the disability experience and responses of Muslim persons with disability and their families within the religious socio-cultural constructs of the Muslim community of Strand. Study purpose: The purpose is to lift Muslim persons with disabilities out of uninformed-ness and invisibility into visibility and awareness, to bring their voices out of silence through descriptions of their specific experiences of disability into arenas of disability rights discourse and developments, and to encourage the development of enabling environments for participation and self-actualization. Methodology: The ethnography research method used describes the disability experiences of Muslim persons with disabilities and their families. Twenty-five participants selected through a blend of purposive and convenience sampling informed the study data. Data was collected using open-ended questions with participants in in-depth interviews, focus group discussions and observations. The inductive/deductive analysis and descriptive interpretative narration informed the presentation of the findings. Presentation of findings: The study findings were as follows: • In the absence of disability information and rights-based approaches, the disability context is marred by struggles for participation opportunities to achieve self-actualization, experiences of negative attitudes, discrimination, exclusion and enforced isolation. • Disability ignorance within the community suggests that persons with disabilities and their families experience exclusion from participation in cultural programmes aimed at Muslim persons within the broader community. • The various negative factors that inform the disability context shows that within lived realities, being Muslim, disabled, and that of gender within Muslim religiosity and socio-cultural contexts places Muslim persons with disabilities outside the frame of belonging and of living life on the margins of their own religious, cultural and traditional daily life activities. Conclusion: Further disability research is required to improve the overall situation of Muslim persons with disabilities’ experiences to encourage their participation and self-actualization.
A grounded theory study exploring the participation of persons with disabilities in the Saudi Arabian culture
(Stellenbosch : Stellenbosch University, 2023-03) Misbach, Sadia; Mji, Gubela; Kahonde, Callista; Eide, Arne; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: This study set out to explore the ways that Saudi Arabian persons with acquired disabilities participate in society. In the context of concerns raised about value-based rehabilitation and readmissions of patients with disabilities in Saudi Arabia, suggestions have been made about harnessing indigenous knowledge to address unfulfilled needs for participation. Theoretical frameworks used to explore subjective dimensions of participation embody Western approaches, which when used in contexts other than the West such as Saudi Arabia, may not be suitable. Furthermore, rehabilitation practices have largely been underdeveloped to address the psychosocial dimensions related to participation of persons with acquired physical disabilities. This study explores an indigenous understanding of participation in everyday life to answer the research question of how participation is processed by persons with disabilities in Saudi Arabia. The study’s primary aim was to generate a substantive theory that explained the main processes involved in participation of persons with acquired disabilities in Saudi Arabia; useful for rehabilitation. The study is positioned within an indigenous interpretive paradigm using a grounded theory approach. The strengths of the interpretive indigenous grounded theory research design affirm and legitimises indigenous-based values based on Islamic religious beliefs. This project’s innovation lies in the application of key elements of indigenous research methodology scaffolded onto classical grounded theory, not found in previous studies on participation. The study was conducted at a large rehabilitation hospital in Saudi Arabia. The iterative cyclical data collection and analysis grounded theory methodology was followed. Twenty-eight persons with disabilities were interviewed, following Arab oral traditions of sharing information and lessons learnt. Three focus group discussions were held with Saudi nationals without disabilities to gain perspectives of disability. Persons with disabilities in Saudi Arabia understand participation as a process that involves their relations with others and Allah. Within the context of religious beliefs, their biographical disruption following an acquired disability, is explained as destiny. The process of overcoming is to rework their biographies within the context of religious and spiritual beliefs that provide meaning and purpose to life. Participants in the study experienced multiple tensions over time as they navigated various aspects of their life to reconstruct their identities, reinterpret participation and cultivate dignity of self. The narratives of persons with disabilities draw on their knowledge of Islamic religious beliefs, norms and expected behaviours. The Theory of Cultivating Dignity in Participation Spaces builds on the participants’ lived experiences and conceptualises a culturally embedded social process of multiple interacting transitions. The staged-transition theory describes patterns of behaviour underpinned by relational dignity, relational autonomy and interdependence for meaningful participation. The proposed theory provides a framework that demonstrate the interaction of participation, identity and dignity that can be further developed to extract active ingredients for context-based rehabilitation interventions. The study begins to inform an indigenous holistic approach to participation.
The health and sanitation status of specific low-cost housing communities as contrasted with those occupying backyard dwellings in the city of Cape Town, South Africa
(Stellenbosch : Stellenbosch University, 2011-12) Govender, Thashlin; Barnes, J. M.; Pieper, C. H.; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Community Health.
ENGLISH ABSTRACT: South Africa embarked on an ambitious program to rehouse the informally housed poor. These initiatives were formerly called the RDP and later the BNG programmes. This was aimed at improving the living conditions of the urban poor and consequently their health and poverty status. These low-cost houses were quickly augmented by backyard shacks in almost all settlements. The present study is an epidemiological assessment of the health and sanitation status of inhabitants of specific low cost housing communities in the City of Cape Town as contrasted with those occupying ‘backyard dwellings’ on the same premises. The study was undertaken in four low-cost housing communities identified within the City. A health and housing evaluation, together with dwelling inspections were carried out in 336 randomly selected dwellings accommodating 1080 inhabitants from Tafelsig, Masipumelela, Driftsands and Greenfields. In addition, the microbiological pollution of surface run-off water encountered in these settlements was assessed by means of Escherichia coli levels (as found by ColilertTM Defined Substrate Technology) as an indication of environmental health hazards. The study population was classified as ‘young’ - 43% of the study population was aged 20 years or younger. Almost a third of households were headed by a single-parent female. In all four communities combined, 47.3% of households received one or other form of social grant. At the time of inspection 58% of the toilets on the premises were non-operational, while all the houses showed major structural damage - 99% of homeowners reported not being able to afford repairs to their homes. In 32% of dwellings one or more cases of diarrhoea were reported during the two weeks preceding the survey. Five percent of the participants willingly disclosed that they were HIV positive, while 11% reported being TB positive (one of them Multiple Drug Resistant TB). None of the HIV positive or TB positive persons was on any treatment. The E. coli levels of the water on the premises or sidewalks varied from 750 to 1 580 000 000 organisms per 100 ml of water - thus confirming gross faecal pollution of the environment. Improvements in health intended by the re-housing process did not materialise for the recipients of low-cost housing in this study. The health vulnerability of individuals in these communities has considerable implications for the health services. Sanitation failures, infectious disease pressure and environmental pollution in these communities represent a serious public health risk. The densification caused by backyard shacks also has municipal service implications and needs to be better managed. Policies on low-cost housing for the poor need realignment to cope with the realities of backyard densification so that state-funded housing schemes can deliver the improved health that was envisaged at its inception. This is in fact a national problem affecting almost all of the state funded housing communities in South Africa. Public health and urban planning need to bridge the divide between these two disciplines in order to improve the health inequalities facing the urban poor.
The impact of water pollution from formal and informal urban developments along the Plankenbrug River on water quality and health risk / J.M. Barnes.
(Stellenbosch : Stellenbosch University, 2003-03) Barnes, J. M. (Johanna Maria); De Villiers, B.; Liebowitz, L. D.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Medicine. Community Health.
ENGLISH ABSTRACT: The Plankenbrug River runs past the dense settlement of Kayamandi, on the outskirts of Stellenbosch. This site was chosen to study the impact of water pollution from formal and informal urban developments on water quality and associated health factors. Aims of the study: (1) To determine some basic epidemiological characteristics of the exposed population of Kayamandi, their sanitation problems and reasons for poor hygiene; (2) To determine the microbiological and chemical pollution load patterns in the Plankenbrug River over time; (3) To investigate the spectrum of organisms present in the river (other than the indicator E. coli) and their epidemiological implications for health; (4) To establish the possible presence of organisms resistant to chlorine or to antibiotics in the river below Kayamandi as indicators of environmental hazard. Methods: During the period 5 May 1998 to 10 February 2003 microbiological and chemical analyses have been carried out every 6 weeks on water samples obtained at various points along the Plankenbrug River. Two large surveys (n=2196 persons and n=3568 persons) of the community of Kayamandi have been undertaken and door-to-door education campaigns were carried out with the aid of trained community health workers. Results: Below Kayamandi the river contains dangerously high levels of faecal contamination and it constitutes a health hazard to all persons coming into contact with the water. Up to 13 million Escherichia coli per 100 ml water was recorded (cut-off level as indicator of human safety is 1000 organisms per 100 ml water). Not all the faecal contamination originated from Kayamandi. Substantial amounts of faecal contamination sporadically entered the river at different points below Kayamandi. The pollution load resulting from these intrusions were sometimes larger than that contributed by the whole of Kayamandi. Water samples below Kayamandi were screened to ascertain what other pathogens were present. Amongst the organisms were 0 haemolytic Streptococcus Group A and B, Mycobacterium intracellulare, Staphylococcus spp, Klebsiella spp., Pseudomonas spp. and many others. The list of pathogens found had such serious implications that a confidential health warning was sent out to health care centres and other affected organisations in the area. |3 haemolytic Streptococcus Group A has never before been reported as isolated in viable form from free-flowing natural waters. Signs of increased resistance to chorine were found in organisms isolated from the river water. There were also organisms showing signs of resistance to commonly used antibiotics. The E. coli organisms that survived various levels of chlorine treatment also showed increased resistance to amoxycillin when compared to untreated E. coli organisms sampled from the Plankenbrug River. During the community phase of the project in Kayamandi a reduction in the pollution levels occurred over the summers of 2000 and 2001 (note that "improved" does not yet mean "safe" by any means). This can be ascribed to the multi-pronged approach of the project. Attention was given to service and repair of sanitation facilities, a strong accent on door-todoor community education about better sanitation behaviour, creation of a central reporting point for blockages and breakages, and training of artisans (plumbers, bricklayers, etc) from the community to help with upkeep. The community showed encouraging signs of wanting better sanitation education. The improvement in pollution levels is however in danger of reverting back to the previous dangerous situation if better support and co-operation cannot be obtained from the relevant authorities. There were 16.9% of households who reported one or more cases of diarrhoea during the survey period (5 weeks) - a very high prevalence seeing that the survey was carried out during a wet and cold winter period. Conclusions: Active planning and other steps to cope with the sewage intrusions into the river should be instituted without delay. The water quality of the Plankenbrug River downstream from Kayamandi is extremely poor. The water constitutes a serious health hazard and a threat to downstream economic activities. The settlement of Kayamandi demonstrated that education, when coupled with maintenance and repairs of existing toilet facilities, can bring about a reduction in pollution loads, but that this should be an ongoing process and not be reduced to sporadic attempts.
Improving the quality of care for inpatient management of childhood pneumonia at the first level referral hospital : a country wide programme
(Stellenbosch : Stellenbosch University, 2015-04) Enarson, Penelope Marjorie; Gie, Robert Peter; Cameron, Neil A.; Graham, Stephen Michael; Stellenbosch University. Faculty of Health Sciences. Interdisciplinary Health Sciences. Community Health
ENGLISH ABSTRACT: Pneumonia is the greatest single cause of mortality in children less than five years of age throughout the world causing more deaths than those due to AIDS, malaria and tuberculosis combined. Approximately 50% of all childhood pneumonia deaths occur in sub-Saharan Africa. Children in developing countries being treated for pneumonia frequently have one or more comorbid conditions which increases their risk of dying. The proper management of the child with severe or very severe pneumonia is essential to reduce case fatality. Standard case management (SCM) of pneumonia, has been shown to be an effective intervention to reduce deaths from pneumonia, but what is lacking is a means of delivering it in low-resource/high burden countries. A major barrier to wide application of this intervention in low-income countries is weak health-care systems with insufficient human and financial resources for implementing SCM to a sufficient number of children at a level of quality and coverage that would result in a significant impact. The objective of this dissertation is to address this issue by investigating ways of improving delivery of standard case management of pneumonia in district hospitals throughout Malawi, a high HIV-prevalent country which would result in a decrease in the in-hospital case fatality rates (CFR) from pneumonia in children less than five years of age. We reviewed the evidence base for SCM. Then we evaluated the development and implementation of a national Child Lung Health Programme (CLHP) to deliver SCM of severe and very severe pneumonia and a programme to provide uninterrupted oxygen supply in all paediatric wards at District Hospitals throughout Malawi. We demonstrated that it was feasible to implement and maintain both programmes country-wide. Thirdly we evaluated the trend in case fatality rates in infants and young children (0 to 59 months of age) hospitalized and treated for severe and very severe pneumonia over the course of the implementation of the CLHP. The findings from this study showed that in the majority (64%) of cases, who were aged 2-59 months with severe pneumonia there was a significant effect of the intervention that was sustained over time whereas in the same age group children treated for very severe pneumonia there was no interventional benefit. No benefit was observed for neonates. Fourthly we investigated factors associated with poor outcome reported in the previous study, in a subset of this cohort to determine the individual factors including demographics of the study population, recognised co-morbidities and clinical management that were associated with inpatient death. This study identified a number of factors associated with poor pneumonia-related outcomes in young infants and children with very severe pneumonia. They included co-morbidities of malaria, malnutrition, severe anaemia and HIV infection. The study found that the majority of reported comorbid conditions were based on clinical signs alone indicating a need for more accurate diagnosis and improved management of these comorbidities that may lead to improved outcomes. Other identified factors included a number of potentially modifiable aspects of care where adjustments to the implementation of SCM are indicated. These included enhancing correct classification of the severity of the disease, the use of correct antibiotics according to standard case management, more extensive availability and use of oxygen together with oximetry to guide its use,. Finally recommendations were made to address the identified reasons for poor outcomes and suggested future research.
Innovation and incentives : role of the research funder in knowledge translation and scaling science
(Stellenbosch : Stellenbosch University, 2020-12) McLean, Robert Kenneth Douglas; Volmink, Jimmy; Graham, Ian; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY : Research and innovation are vital to global sustainable development and human prosperity. However, it is well documented that the creation of knowledge does not ensure its effective and ethical application. In fact, studies indicate that knowledge is converted into action in slow, haphazard, and inequitable ways. This dissertation casts new light on this challenge by investigating an understudied component of knowledge translation (KT), the role of the research funder. This dissertation applied a multi-stream study design and mixed-methods data collection and analysis strategy. The research used an Integrated Knowledge Translation (IKT) approach which facilitated a focused and dynamic investigation, at the same time promoting relevance and uptake with the intended research-user, research funders. Stream one, Funders’ KT, initiates the dissertation using a single funder case study to construct a KT-focused evaluation protocol, and an international empirical scan of 26 health research funding agencies resulting in a state-of-the-art overview of how funders support KT. An unexpected and significant finding was the lack of empirical evidence guiding funders’ KT support. From this result, research streams two and three were born. Stream two, Scaling Science, investigates facilitators of research impact using a large multi-project review and in-depth case studies. Results include a typology of pathways to scale and four guiding principles for scaling impact. These innovations are converted into an action-oriented tool that will help researchers build evidenced practices into their research. Stream three, Research Quality Plus (RQ+), describes a novel evaluation framework for assessing research quality with KT in mind. The RQ+ approach is implemented in seven funder-based evaluations and the aggregate evaluation results are synthesized via meta-analysis. Results demonstrate that KT and scientific rigour can be pursued, accomplished, and assessed as equally valued dimensions of research quality. The validation of the RQ+ approach showcases a fresh and practical framework for funders and other science systems actors interested in KT and scaling science. Overall, the results of this dissertation fill a critical knowledge gap related to the role of the funder in research translation and impact. In turn, they demonstrate original and significant contributions to global academic knowledge and understanding of KT theory and practice. To convert this knowledge into action, practical guidance is developed, elaborated, and validated.

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