Health Systems and Public Health

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The 17th International Congress on Infectious Diseases workshop on developing infection prevention and control resources for low - and middle-income countries
(Published by Elsevier on behalf of International Society for Infectious Diseases, 2017) Sastry, Sangeeta; Masroor, Nadia; Bearman, Gonzalo; Hajjeh, Rana; Holmes, Alison; Memish, Ziad; Lassmann, Britta; Pittet, Didier; Macnab, Fiona; Kamau, Rachel; Wesangula, Evelyn; Pokhare, Paras; Brown, Paul; Daily, Frances; Amer, Fatma; Torres, Jaime; O’Ryan, Miguel; Gunturu, Revathi; Bulabula, Andre; Mehtarp, Shaheen
Hospital-acquired infections (HAIs) are a major concern to healthcare systems around the world. They are associated with significant morbidity and mortality, in addition to increased hospitalization costs. Recent outbreaks, including those caused by the Middle East respiratory syndrome coronavirus and Ebola virus, have highlighted the importance of infection control. Moreover, HAIs, especially those caused by multidrug-resistant Gram-negative rods, have become a top global priority. Although adequate approaches and guidelines have been in existence for many years and have often proven effective in some countries, the implementation of such approaches in low- and middle-income countries (LMICs) is often restricted due to limited resources and underdeveloped infrastructure. While evidence-based infection prevention and control (IPC) principles and practices are universal, studies are needed to evaluate simplified approaches that can be better adapted to LMIC needs, in order to guide IPC in practice. A group of experts from around the world attended a workshop held at the 17th International Congress on Infectious Diseases in Hyderabad, India in March 2016, to discuss the existing IPC practices in LMICs, and how best these can be improved within the local context.
Acceptability and accessibility of pre-exposure prophylaxis modalities for HIV prevention (oral daily PrEP, dapivirine vaginal ring and long-acting cabotegravir injectable) among female sex workers in Salt River, Cape Town : a cross-sectional study
(Stellenbosch : Stellenbosch University, 2022-12) Mbuyamba, Rachel; Cois, Annibale; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
ENGLISH SUMMARY: Background: Female sex workers (FSWs) are at high risk of contracting HIV and have poor access to health care. Evidence is being collected in real world settings on the acceptability and accessibility of pre-exposure prophylaxis (PrEP) amongst FSWs. We explored oral PrEP accessibility, associated factors and acceptability of alternative PrEP modalities. Methods: This cross-sectional study involved 100 HIV-negative FSWs aged >18 years receiving services at the Wits RHI Sex Worker Clinic in Salt River. We tested the association between oral PrEP uptake status and independent variables using logistic regression models. Poisson regression models were used to identify factors associated with oral PrEP accessibility levels. Linear regression was used to identify factors associated with acceptability of alternative PrEP modalities. Results: FSWs with median age 32.6 years (interquartile range 11.7 years) participated in this study, with 97% indicating that they were at risk for HIV infection. Oral PrEP uptake was 33%. Condom use with the main partner (OR = 0.2, 95% CI: 0.0-0.9, sometimes vs. never) was negatively associated with oral PrEP uptake and no previous experience with long-acting drugs (OR = 5.4, 95% CI: 2.2-13.4) was positively associated with oral PrEP uptake. Accessibility of oral PrEP was lower among FSWs for whom sex work was their secondary source of income compared to those for whom sex work was a primary source of income (aIRR for accessibility score = 0.8, 95% CI: 0.7 – 0.9). Acceptability of alternative PrEP modalities was lower among FSWs with previous treatment for sexually transmitted diseases (differences in acceptability scores -5.1, 95% CI: -14.9– 4.6). Long waiting times (72% of participants), PrEP unavailability (27%), PrEP side effects (38%), limited privacy (31%) and nurse unavailability were the main barriers to PrEP uptake. The perceived risk of HIV infection, and the availability (43%) and cost (71%) of PrEP uptake were PrEP uptake facilitators. Conclusions: Oral PrEP uptake among FSWs is currently low. Limited privacy and side effects were the main barriers to PrEP uptake. FSWs were willing to use the new PrEP modalities when available. This study provides valuable lessons for a successful introduction of new PrEP modalities.
The acceptability of three vaccine injections given to infants during a single clinic visit in South Africa
(BioMed Central, 2016) Tabana, Hanani; Dudley, Lilian; Knight, Stephen; Cameron, Neil; Mahomed, Hassan; Goliath, Charlyn; Eggers, Rudolf; Wiysonge, Charles S.
ENGLISH SUMMARY : Background: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa. Methods: A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions. Results: The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators’ care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs. Conclusions: We found high acceptance by caregivers and vaccinators of three injections. Caregivers’ poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants’ pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI’s expansion in resource-limited countries.
Accommodation of accessibility survey in primary care clinics of a rural Alberta community
(Stellenbosch : Stellenbosch University, 2014-12) Van der Linde, Erich; Pather, Michael; Stellenbosch University. Faculty of Health Sciences. Department of Interdisciplinary Health Sciences.
ABSTRACT Introduction: According to the Society of Rural Physicians of Canada’s National Rural Health Strategy, 21% of Canadian residents are rural but only 9.4% of Canadian physicians live in rural areas.1,2 Aim: To evaluate patient experience and the accommodation of accessibility to four primary care clinics in Brooks, Alberta. Objectives were to: • measure and compare the actual versus expected waiting times in the physician’s office. • assess patient satisfaction with the current organization of access and quality of care. • elicit ideas from patients on how to improve the accommodation of access. • elicit feedback from patients regarding the employment of alternative practitioners in the clinics. Methods: Design: cross-sectional survey. Setting: Four primary care clinics in the city of Brooks. Subjects: The study sample (n=391) included registered patients including emergency walk-in consultations, consultations for office procedures, short visits for prescription refills as well as annual physical examinations. Results: The mean perceived waiting room time was 12.35 minutes versus 5-15 minutes actual waiting room time for 60.5% of the participants. The mean perceived exam room waiting time was 10.58 minutes versus 5-15 minutes actual exam room waiting times for 81.4 % of the participants. Mean perceived time spent with the physician was 11.65 minutes versus 5-15 minutes actual time spent with the physician for 67.1 % of the participants. Patients who felt that they can get a timely appointment were 8.4 times more likely to be happy with the quality of care received. Patients who got prompt return of their calls are 10.4 times more likely to be happy with access to primary care clinics. Patients who felt that the clinic hours of operation were acceptable were 15.6 times more likely to agree that they received adequate health care. Patients who felt that the waiting time for an appointment at the clinic were acceptable to them were 8.1 times happier with the quality of care. Conclusion No major differences exist between perceived and actual waiting times in the physician’s offices. The waiting time for scheduled appointments is generally too long. The most satisfied patient appears to be someone whom waits no longer than 5-15 minutes in the waiting room, then no longer than 5-15 minutes in exam room for a 5 -15 minute consultation. The shorter the waiting times for an appointment and the shorter the different waiting times during a consultation in the clinic the more satisfied the patient.
Accuracy and completeness of notification of tuberculosis in two high incident communities in Cape Town, South Africa
(Stellenbosch : Stellenbosch University, 2011-12) Dunbar, Rory; Barnes, J. M.; Beyers, Nulda; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Community Health.
ENGLISH ABSTRACT: Introduction: Tuberculosis (TB) treatment registers and laboratory records are essential recording and reporting tools in TB control programmes. Reliable data are essential for any TB control programme but under-registration of TB cases has been well documented internationally, due to under-reporting of patients on treatment or failure to initiate treatment. The accuracy and completeness of routinely collected data are seldom monitored. Aim: This study used record linking to assess the accuracy and completeness of TB treatment register data and the feasibility of estimating the completeness of bacteriological confirmed pulmonary TB registration in two high incident communities in South Africa with capturerecapture methods. Methods: All cases of bacteriologically confirmed TB defined as 2 smear-positive results and/or at least one culture-positive result were included. Record linking was performed between three data sources: (1) TB treatment registers; and (2) all smear and culture results from (a) the nearest central laboratory, and (b) the referral hospital laboratory. To estimate the completeness of TB treatment recording three-source log-linear capture-recapture models were used, with internal validity analysis. Results: The TB treatment registers had 435 TB cases recorded of which 204 (47%) were bacteriologically confirmed cases. An additional 39 cases that were recorded as nonbacteriological cases in the TB treatment register, were reclassified as bacteriologically confirmed. In addition, there were 63 bacteriologically confirmed cases identified from the laboratory databases which were not recorded in the TB treatment register. The final total number of bacteriologically confirmed TB cases across all 3 databases was 306, an increase of 50% over what had initially been recorded in the TB treatment register. The log-linear capture-recapture model estimated the number of bacteriologically confirmed TB cases not found in any of the data sources at 20, resulting in a total number of bacteriologically confirmed TB cases of 326 (95% CI 314-355). The completeness of registration of bacteriologically confirmed pulmonary TB cases was 79% after record linking and 75% after the capture-recapture estimate. Conclusions: The results presented in this thesis highlighted the concern regarding the accuracy and completeness of routinely collected TB recording and reporting data. A high percentage of bacteriologically confirmed cases from both laboratories were not recorded in the TB treatment registers. Capture-recapture can be useful, but not essential, for evaluation of TB control programmes, also in resource-limited settings, but methodology and results should be carefully assessed. The present study estimated the extent of the problem of underreporting of TB in South Africa and identified challenges in the process. Interventions to reduce underreporting of TB are urgently needed.
Achieving the millennium development goals in sub-Saharan Africa
(Health and Medical Publishing Group (HMPG), 2007-09) Wiysonge, Charles S.; Young, T.; Volmink, J.
To the Editor: The UN has released a mid-term report on progress towards achieving the Millennium Development Goals (MDG), eight pro-poor goals contained in the Millennium Declaration of 2000, to be achieved by 2015. It paints a gloomy picture of health in sub-Saharan Africa. Child mortality rates declined globally, but the improvement was uneven, with sub-Saharan Africa recording the highest rate and the slowest pace of progress. In 1990 and 2005 in sub-Saharan Africa, 185 and 166 children respectively died, mainly from preventable causes, before their 5th birthday for every 1 000 live births, a mere 10% reduction in 16 years.
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.
African HIV/AIDS trials are more likely to report adequate allocation concealment and random generation than North American trials
(Public Library of Science (PLOS), 2008-10) Siegfried, Nandi; Clarke, Michael; Volmink, Jimmy; Van der Merwe, Lize
Background: Adherence to good methodological quality is necessary to minimise bias in randomised conrolled trials (RCTs). Specific trial characteristics are associated with better trial quality, but no studies to date are specific to HIV/AIDS or African trials. We postulated that location may negatively impact on trial quality in regions where resources are scarce. Methods: 1) To compare the methodological quality of all HIV/AIDS RCTs conducted in Africa with a random sample of similar trials conducted in North America; 2) To assess whether location is predictive of trial quality. We searched MEDLINE, EMBASE, CENTRAL and LILACS. Eligible trials were 1) randomized, 2) evaluations of preventive or treatment interventions for HIV/AIDS, 3) reported before 2004, and 4) conducted wholly or partly (if multi-centred) in Africa or North America. We assessed adequacy of random generation, allocation concealment and masking of assessors. Using univariate and multivariate logistic regression analyses we evaluated the association between location (Africa versus North America) and these domains. Findings: The African search yielded 12,815 records, from which 80 trials were identified. The North American search yielded 13,158 records from which 785 trials were identified and a random sample of 114 selected for analysis. African trials were three times more likely than North American trials to report adequate allocation concealment (OR = 3.24; 95%CI: 1.59 to 6.59; p<0.01) and twice as likely to report adequate generation of the sequence (OR = 2.36; 95%CI: 1.20 to 4.67; p = 0.01), after adjusting for other confounding factors. Additional significant factors positively associated with quality were an a priori sample size power calculation, restricted randomization and inclusion of a flow diagram detailing attrition. We did not detect an association between location and outcome assessor masking. Conclusions: The higher quality of reporting of methodology in African trials is noteworthy. Most African trials are externally funded, and it is possible that stricter agency requirements when leading trials in other countries and greater experience and training of principal investigators of an international stature, may account for this difference. © 2008 Siegfried et al.
An analysis of DTP-associated reactions by manufacturer, batch, vaccinator, series number and infant weight
(Health & Medical Publishing Group, 1996-10) Benade, J. G.
Objectives. To determine whether two commonly used DTP batches manufactured by Rhone-Poulenc Rorer were more reactogenic than two commonly used batches manufactured by the South African Institute of Medical Research. Design. Prospective study. Setting. Six community clinics. Patients. Infants routinely scheduled for their first three DTP immunisations. Main outcome measures. Local and systemic adverse reactions following immunisation with DTP. Results. Local reactions were significantly more common with both Rhone-Poulenc Rorer products. Conclusion. All adverse reaction rates compared favourably with those reported by the Centers for Disease Control.
Antibiotic prescribing practice and adherence to guidelines in primary care in the Cape Town Metro District, South Africa
(Health & Medical Publishing Group, 2018) Gasson, J.; Blockman, M.; Willems, B.
Background. Knowledge of antibiotic prescribing practice in primary care in South Africa is limited. As 80% of human antibiotic use is in primary care, this knowledge is important in view of the global problem of antibiotic resistance. Objectives. To assess antibiotic prescribing in primary care facilities in the Cape Town Metro District and compare it with current national guidelines, and to assess the reasons why prescriptions were not adherent to guidelines. Methods. A retrospective medical record review was performed in April/May 2016. Records of all patients seen over 2 days in each of eight representative primary care facilities in the Cape Town Metro District were reviewed. The treatment of any patient who raised a new complaint on either of those days was recorded. Prophylactic antibiotic courses, tuberculosis treatment and patients with a non-infection diagnosis were excluded. Treatment was compared with the Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2014 edition. Results. Of 654 records included, 68.7% indicated that an antibiotic had been prescribed. Overall guideline adherence was 45.1%. Adherence differed significantly between facilities and according to the physiological system being treated, whether the prescription was for an adult or paediatric patient, and the antibiotic prescribed. Healthcare professional type and patient gender had no significant effect on adherence. The main reasons for non-adherence were an undocumented diagnosis (30.5%), antibiotic not required (21.6%), incorrect dose (12.9%), incorrect drug (11.5%), and incorrect duration of therapy (9.5%). Conclusions. This study demonstrates poor adherence to guidelines. Irrational use of antibiotics is associated with increased antibiotic resistance. There is an urgent need to improve antibiotic prescribing practice in primary care in the Cape Town Metro District.
Are central hospitals ready for national health insurance? ICD coding quality from an electronic patient discharge record for clinicians
(Health & Medical Publishing Group, 2016-02) Dyers, Robin E.; Evans, Juliet; Ward, Grant Alex; Du Plooy, Shane; Mahomed, Hassan
ENGLISH SUMMARY : Background. South Africa (SA)’s planned National Health Insurance reforms require the use of International Statistical Classification of Diseases (ICD) codes for hospitals to purchase services from the proposed National Health Authority. However, compliance with coding at public hospitals in the Western Cape Province has been challenging. A computer application was developed to aid clinicians in integrating ICD coding into the patient hospital discharge process.Objective. To evaluate the quality of ICD codes captured using the application and predictors thereof in a single hospital department.Methods. After 6 months, the quality of ICD codes was determined by comparing ICD code descriptors with medical concepts in a random sample of original patient records selected over a 6-week period. Patient and personnel characteristics influencing quality of coding, derived from a theoretical framework, were collected.Results. Of 223 patient records, 45.3% (95% confidence interval (CI) 38.8 - 51.9) had complete ICD codes. Primary ICD code accuracy was 74.0% (95% CI 67.8 - 79.5). Patient characteristics such as female gender, younger age group and fewer comorbidities, as well as seniority of clinician rank, were significantly associated with ICD coding being complete on adjusted analysis.Conclusion. The results of this study describe ICD coding quality at a central hospital in SA supported by a computer application and the factors influencing this. More interventions are required to achieve reliable coding data, such as additional ICD coding validation tools, training and oversight of junior clinicians.
An assessment of a training-of-trainers programme for clinic committees in a South African district : a qualitative exploratory study
(BMC (part of Springer Nature), 2020-11-30) Esau, Natasha; English, Rene; Shung-King, Maylene
Background: In South Africa (SA), clinics and community health centres are the predominant primary level health care facilities in the public health sector. As part of legislated health governance requirements, clinic committees (referring to those for clinics and community health centres) were established to provide management oversight and bring to bear the perspectives and participation of communities at Primary Health Care (PHC) facilities. Clinic committees need training in order to better understand their roles. Facilitators in a district of SA were trained through a designated programme, called the ‘PHC Facility Governance Structures Trainer-of-Facilitator (ToF) Learning Programme‘, in preparation for the training of clinic committees. This paper explores how the programme had evolved and was experienced by the trained facilitators, in a district in SA. Methods: We employed a retrospective qualitative case study design, guided by the Illuminative Evaluation Framework, with the training programme in the selected district as the case. The study assessed whether the intended aims of the training programme were clearly conveyed by the trainers, and how participants understood and subsequently conveyed the training programme intentions to the clinic committees. Key informant interviews and focus group discussions were conducted with trainers and managers, complemented by a review of relevant policy and legislative documents, and published literature. Study participants were purposively selected based on their involvement in the development, facilitation or training of the programme. Thirteen individuals participated in the study, and 23 (national, provincial and partner) documents were reviewed. Results: Despite the different perceptions and understandings of the ToF Learning Programme, its overall aims were achieved. Trainers’ capacity was strengthened and clinic committees were trained accordingly. The training programme holds promise for possible national scale-up. The high quality of the interactive posters can be considered equally valuable as a training tool as the training manuals. Conclusions: Trainers’ capacity was strengthened and clinic committees were trained accordingly, despite deviations in implementation of the original training approach and plan.
An assessment of user satisfaction with outpatient mental health consultation services from rural and urban areas in southern Malawi
(Stellenbosch : Stellenbosch University, 2018-12) Chikasema, Blessings; Tomlinson, Mark; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems & Public Health.
ENGLISH SUMMARY : Background: The assessment of user satisfaction with outpatient mental health services is essential in mental health service. It influences the mental health care that addresses the unmet needs of patients living with mental health problems. In developing countries such as Malawi there is a dearth of mental health studies to assist in evidence based mental health practices. Aim: To evaluate user satisfaction with outpatient mental health consultation services in southern Malawi and to assess social demographic variables that predict user satisfaction. Methods: The study used a quantitative descriptive cross-sectional study design. The assessment was conducted in Malawi at (Blantyre) and (Thyolo) outpatient psychiatric clinics. The study included randomly sampled participants who met the inclusion criteria and consented to be recruited. A total of 216 exit interviews were conducted using Charlestone Psychiatric Outpatient Satisfaction Scale (CPOSS). Results: Of the participants, 57.4% were males and 42.6% were females, with 55.1% being 29 years and older. Of all the study participants, 80% were satisfied with the outpatient mental health services. Participants presenting to the rural clinic were less likely to be satisfied than participants presenting at the urban clinic (AOR = 0.31; 95% CI: 0.13-0.76; p<0.05). Any admission due to mental illness significantly predicted user satisfaction at the rural (Thyolo) study site (AOR = 0.11; 95% CI 0.02-0.54; p< 0.05). Conclusion: The study reveals high satisfaction levels with outpatient psychiatric services, and that participants presenting at the rural facility were less likely to be satisfied with outpatient psychiatric services as compared to the urban facility. Any admission due to mental illness significantly predicted user satisfaction at the rural facility. There is need for policy makers to formulate guidelines to strengthen mental health practices and education at all health levels as well as the need for further studies in patient satisfaction with psychiatric services.
Association of neighbourhood and individual social capital, neighourhood economic deprivation and self-rated health in South Africa - a multi-level analysis
(Public Library of Science, 2013-07-29) Chola, Lumbwe; Alaba, Olufunke
Introduction: Social capital is said to influence health, mostly in research undertaken in high income countries' settings. Because social capital may differ from one setting to another, it is suggested that its measurement be context specific. We examine the association of individual and neighbourhood level social capital, and neighbourhood deprivation to self-rated health using a multi-level analysis. Methods: Data are taken from the 2008 South Africa National Income Dynamic Survey. Health was self-reported on a scale from 1 (excellent) to 5 (poor). Two measures of social capital were used: individual, measured by two variables denoting trust and civic participation; and neighbourhood social capital, denoting support, association, behaviour and safety in a community. Results: Compared to males, females were less likely to report good health (Odds Ratio 0.82: Confidence Interval 0.73, 0.91). There were variations in association of individual social capital and self-rated health among the provinces. In Western Cape (1.37: 0.98, 1.91) and North West (1.39: 1.13, 1.71), trust was positively associated with reporting good health, while the reverse was true in Limpopo (0.56: 0.38, 0.84) and Free State (0.70: 0.48, 1.02). In Western Cape (0.60: 0.44, 0.82) and Mpumalanga (0.72: 0.55, 0.94), neighbourhood social capital was negatively associated with reporting good health. In North West (1.59: 1.27, 1.99) and Gauteng (1.90: 1.21, 2.97), increased neighbourhood social capital was positively associated with reporting good health. Conclusion: Our study demonstrated the importance of considering contextual factors when analysing the relationship between social capital and health. Analysis by province showed variations in the way in which social capital affected health in different contexts. Further studies should be undertaken to understand the mechanisms through which social capital impacts on health in South Africa.
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.
The Cameroon Mobile Phone SMS (CAMPS) trial : a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy
(BioMed Central, 2011-01) Mbuagbaw, Lawrence; Thabane, Lahana; Ongolo-Zogo, Pierre; Lester, Richard T.; Mills, Edward; Volmink, Jimmy; Yondo, David; Essi, Marie Jose; Bonono-Momnougui, Renee-Cecile; Mba, Robert; Ndongo, Jean Serge; Nkoa, Francois C.; Ondoa, Henri Atangana
Background: This trial aims at testing the efficacy of weekly reminder and motivational text messages, compared to usual care in improving adherence to Highly Active Antiretroviral Treatment in patients attending a clinic in Yaoundé, Cameroon. Methods and Design: This is a single-centered randomized controlled single-blinded trial. A central computer generated randomization list will be generated using random block sizes. Allocation will be determined by sequentially numbered sealed opaque envelopes. 198 participants will either receive the mobile phone text message or usual care. Our hypothesis is that weekly motivational text messages can improve adherence to Highly Active Antiretroviral Treatment and other clinical outcomes in the control group by acting as a reminder, a cue to action and opening communication channels. Data will be collected at baseline, three months and six months. A blinded program secretary will send out text messages and record delivery. Our primary outcomes are adherence measured by the visual analogue scale, self report, and pharmacy refill data. Our secondary outcomes are clinical: weight, body mass index, opportunistic infections, all cause mortality and retention; biological: Cluster Designation 4 count and viral load; and quality of life. Analysis will be by intention-to-treat. Covariates and subgroups will be taken into account. Discussion: This trial investigates the potential of SMS motivational reminders to improve adherence to Highly Active Antiretroviral Treatment in Cameroon. The intervention targets non-adherence due to forgetfulness and other forms of non-adherence. Trial Registration: Pan-African Clinical Trials Registry PACTR201011000261458 http://clinicaltrials.gov/ NCT01247181
The candidate TB vaccine, MVA85A, induces highly durable Th1 responses
(PLoS, 2014-02) Tameris, Michele; Geldenhuys, Hennie; Luabeya, Angelique KanyKany; Smit, Erica; Hughes, Jane E.; Vermaak, Samantha; Hanekom, Willem A.; Hatherill, Mark; Mahomed, Hassan; McShane, Helen; Scriba, Thomas J.
Background: Vaccination against tuberculosis (TB) should provide long-term protective immunity against Mycobacterium tuberculosis (M.tb). The current TB vaccine, Bacille Calmette-Guerin (BCG), protects against disseminated childhood TB, but protection against lung TB in adolescents and adults is variable and mostly poor. One potential reason for the limited durability of protection may be waning of immunity through gradual attrition of BCG-induced T cells. We determined if a MVA85A viral-vector boost could enhance the durability of mycobacteria-specific T cell responses above those induced by BCG alone. Methods: We describe a long-term follow-up study of persons previously vaccinated with MVA85A. We performed a medical history and clinical examination, a tuberculin skin test and measured vaccine-specific T cell responses in persons previously enrolled as adults, adolescents, children or infants into three different Phase II trials, between 2005 and 2011. Results: Of 252 potential participants, 183 (72.6%) consented and completed the study visit. Vaccine-induced Ag85A-specific CD4+ T cell responses were remarkably persistent in healthy, HIV-uninfected adults, adolescents, children and infants, up to 6 years after MVA85A vaccination. Specific CD4+ T cells expressed surface markers consistent with either CD45RA−CCR7+ central memory or CD45RA−CCR7− effector memory T cells. Similarly durable Ag85A-specific CD4+ T cell responses were detected in HIV-infected persons who were on successful antiretroviral therapy when MVA85A was administered. By contrast, Ag85A-specific CD4+ T cell frequencies in untreated MVA85A-vaccinated HIV-infected persons were mostly undetectable 3–5 years after vaccination. Conclusion: MVA85A induces remarkably durable T cell responses in immunocompetent persons. However, results from a recent phase IIb trial of MVA85A, conducted in infants from the same geographic area and study population, showed no vaccine efficacy, suggesting that these durable T cell responses do not enhance BCG-induced protection against TB in infants.
Capacity-building needs assessment of rural health managers : the what and the how ...
(Health and Medical Publishing Group, 2015-07) Goliath, C.; Mukinda, Fidele K.; Dudley, Lilian
ENGLISH SUMMARY : Background: There has been a renewed focus on leadership and governance within the South African health workforce as a key to strengthening the health system. Several studies have highlighted that managers feel poorly prepared for their role and responsibilities and argue for support and development for healthcare managers. This study describes a ‘training’ need assessment conducted for health managers in a rural district which has informed Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) continuing professional development activities. Objective: To determine the capacity-building needs and preferred approaches to capacity building for health managers in a rural district. Methods: The study used a mixed method design. A survey was conducted among healthcare managers followed by structured interviews with randomly selected participants. Results were discussed at a workshop and meetings with the district management, which allowed for triangulation and verification of results. Results: Thirty-two (68%) of the 47 health managers in the district completed the questionnaires. Training needs for competencies related to: leadership; communication and knowledge management; infection prevention and control; community/public health and health systems research and strengthening were slightly higher than other areas. Facility managers were prioritised as a target group for leadership and management capacity development. The preferred learning approach was for more practice-based learning in the workplace, supported by e-learning rather than didactic classroom-based teaching. Conclusion: Innovative approaches to capacity development and work-based support in developing intrinsic management competencies for front-line managers were highlighted in this needs assessment.

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