Doctoral Degrees (Health Systems and Public Health)
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- ItemHealth workers’ perceptions and experiences of the role that teams, leadership, and health facility context play in the implementation of a quality improvement programme for maternal, neonatal and child health in three South African provinces(Stellenbosch : Stellenbosch University , 2024-12) Odendaal, Willem Adriaan; Hunt, Xanthe; Chetty, Terusha; Tomlinson, Mark (Mark R.); Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.ENGLISH SUMMARY: Background: Quality improvement (QI) methodologies can reduce avoidable maternal and neonatal deaths and stillbirths, through small scale solutions that address service delivery problems. The methodologies propose healthcare workers organise in QI teams who then develop and implement these changes. Despite inroads, maternal and neonatal mortalities remain high in South Africa. This study evaluated Mphatlalatsane, a National Department of Health QI programme to improve maternal and neonatal healthcare in the country. The programme was implemented in 21 public health facilities across three provinces, seven per participating province, between 2018 and 2022. Aim: This study aimed to explore the perceptions and experiences of the Mphatlalatsane QI team leaders, team members, and advisors (who provided technical support to the teams), of how leaders, members, implementation processes, and facility contexts, shaped variation in QI uptake and team performance across the teams. Methods: This longitudinal, qualitative process evaluation was conducted in 14 purposively selected ‘Mphatlalatsane facilities’. The research comprised interviewing 17 team leaders and 47 team members over three time points; monthly debriefings with the advisors; reviewing programme documentation; and participant observations of the Mphatlalatsane management meetings. All the data were thematically analysed. Results: Paper 1 details that the eight high uptake teams had more training than low uptake teams; advisors who were technically more skilled; leaders with high intrinsic motivation towards QI; better teamwork; and district support. The COVID-19 pandemic resulted in teams introducing major adaptations to the methodology. Paper 2 explains how the intrinsic motivation of the leaders of the six well-performing teams were associated with their aptitude to use routine data and them experiencing how the methodology improved services. The paper also highlights how these leaders nurtured a learning culture in their teams and embedded the methodology in standard care practices. Paper 3 reports that each of the six well-performing teams had a core team with a second-in-charge leader; the members had a good understanding of the methodology; and there was a positive work culture in the existing service teams from whom the core team was recruited. Paper 4 proposes eight good practices to set up and manage a QI team. Conclusion: The performance of a QI team is influenced by configurations of the contextual and implementation process variables identified in this study. However, success starts off with a focus on the ‘hearts and minds’ of healthcare workers by recruiting those who have QI specific attributes as leaders and members.
- ItemPre-treatment loss to follow-up in adults with pulmonary tuberculosis in Kenya - contributing factors and evidence-based interventions(Stellenbosch : Stellenbosch University, 2024-03) Mulaku, Mercy Namuma; Young, Taryn; Ochodo, Eleanor; Steingart, Karen R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.ENGLISH SUMMARY: Background: Tuberculosis incidence and mortality are not falling fast enough to meet global targets. Pre-treatment loss to follow-up (PTLFU), when people who are diagnosed with tuberculosis are lost to care before starting treatment, has been shown to contribute substantially to patient losses in the tuberculosis care cascade with subsequent high mortality rates and ongoing community transmission. A systematic review found a high proportion (up to 38%) of PTLFU in Africa. With Kenya having limited evidence on PTLFU, I aimed to describe the scope of, associated factors, and strategies to reduce PTLFU in adults with pulmonary tuberculosis. Methods: I achieved these objectives by conducting: (i) a qualitative evidence synthesis (QES) of patient and healthcare worker (HCW) perspectives on PTLFU; (ii) a retrospective review of laboratory and treatment registers of people with pulmonary tuberculosis to determine the proportion of people experiencing PTLFU and associated patient factors; (iii) key informant interviews to explore the experiences and perspectives of HCWs on PTLFU; and (iv) a scoping review of studies with quantitative data to map evidence on interventions to reduce PTLFU, identify gaps in existing knowledge, and develop a conceptual framework to guide intervention implementation.I categorized the interventions according to patient, HCW, and healthcare system levels. Results: (i) QES identified five studies describing multiple factors contributing to PTLFU: insufficient knowledge about tuberculosis and its management; poor HCW attitudes toward people with tuberculosis; communication challenges between HCWs and patients; difficulty accessing care; and weakness in tuberculosis program management. (ii) the retrospective review of laboratory and treatment registers found that, of 476 people with pulmonary tuberculosis (verified by Xpert MTB/RIF and smear microscopy), 42.4%, (95% confidence interval 38.1 to 46.9) experienced PTLFU. Age 55 and older and providing only an address or telephone number were associated with PTLFU while sex, HIV status, history of tuberculosis treatment, and residence were not. (iii) 19 key informant interviews highlighted multiple challenges leading to PTLFU: misconceptions about tuberculosis, stigma, hesitancy of HCWs to work in the tuberculosis clinic, and unclear linkage between laboratory and clinician. (iv) I identified seven interventions that reduced PTLFU: treatment support groups; mobile notifications; community health workers; integrated HIV/TB services; Xpert MTB/RIF as the initial diagnostic test; computer-aided detection with chest radiography screening; and multi-component strategies incorporating health education, home visits, and counselling. Intervention barriers included stigma and inadequate human and financial resources; enablers included mobile phones and TB testing and results on the same day. Key implementation considerations were the availability, accessibility, and acceptability of the interventions, political commitment, resources, and infrastructure. Conclusion: PTLFU affects a high proportion of people with tuberculosis in western Kenya. Multiple factors relating to patients, HCWs, and the healthcare system contribute to PTLFU. Interventions to reduce PTLFU involve providing people-centred care and strengthening healthcare systems by use of multi-component packages and community health workers. Improving systems for documenting patient information and timely delivery of test results are needed. Future research should be people-centred and consider perspectives of people with tuberculosis, as well as the social and economic factors affecting PTLFU.
- ItemUnderstanding the influence of the MomConnect programme on antenatal and postnatal care service utilization in two South African provinces : a realist evaluation(Stellenbosch : Stellenbosch University, 2023-12) Kabongo, Eveline Muika; Nicol, Edward; Mukumbang, Ferdinand; Delobelle, Peter; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.ENGLISH SUMMARY: Introduction: Improvement of maternal and child health is in the 2030 agenda of the 17 Sustainable Development Goals (SDGs) where health is centrally positioned with one comprehensive goal (SDG 3), of ensuring lives and promoting well-being for all at all ages. A mobile health programme called MomConnect programme was implemented in the nine provinces of South Africa to register pregnant women and mothers, providing them with health information and education on their health and that of their babies to improve the maternal and child health in the country. Some other studies have shown the efficacy of the MomConnect programme in improving health-seeking behaviours among pregnant women and mothers. Nonetheless, there is little understanding of the contextual factors and causal mechanisms that explained these intended outcomes. To this end, a theory-driven approach to evaluate the MomConnect intervention was proposed. Methodology: The realist evaluation approach was adopted to evaluate and describe not only the intervention and its outcomes but to understand how, why, for whom and under which health system conditions, the MomConnect programme improves the health-seeking behaviours of pregnant women and mothers of infants in antenatal (ANC) and post-natal care (PNC) services in Gauteng and Free State Provinces, South Africa. And to inform guidelines on how the MomConnect can be rolled out elsewhere. The study was conducted in three different phases. In Phase one/emergent phase, the initial programme theory (IPT) of the MomConnect programme was developed using the elicitation approach. In Phase two/construction phase, we applied a multi case explanatory theory-building approach and a confirmatory theory testing approach to test the initial programme theory in four healthcare facilities, in Free State and Gauteng provinces. A cross-case analysis/in-case theories comparison was done to obtain some more refined theories. In phase three/confirmatory phase, a discussion was done with MomConnect key informants to confirm and consolidate the refined theories. Retroduction logic of making inferences was applied to configure information obtained from different sources using the intervention-context-actor-mechanism-outcome (ICAMO) heuristic tool. Results: Our initial programme theory (IPT) revealed three plausible hypotheses. The first theory assumed that a good programme designer, and health system, allow for good implementation of the programme in HCPs and increase the uptake of health services among consumers. The second theory assumed that the national department of health (NDoH) support and influence of authorities and leaders motivate healthcare providers and managers to buy-in and engage with the programme to contribute to the success of the programme by improving their performance and delivering quality maternal and child health (MCH) services. The third theory suggested that women become encouraged, empowered, and motivated, through the MomConnect health information and education to change their health-seeking behaviours and improve their health and that of their babies. After testing the initial programme theory, four different theories were refined. The first showed that MomConnect works because of a good collaboration, political clout, healthcare providers (HCPs) and clinic managers’ buy-in and willingness to work and contribute to the success of the programme by improving their performance. The delivery of MCH services is assumed to improve the health-seeking behaviours. The second refined theory showed that the programme did not work in some facilities, due to a lack of training, lack of stewardship, lack of buy-in from HCPs and clinic managers, and lack of understanding of how the MomConnect Help Desk works. The third refined theory showed that when HCPs and clinic managers perceived the NDoH’s support through training on the programme they are empowered, leading to improvement in their self-efficacy, and they become motivated and nudged to improve their performance. In the fourth theory MomConnect encouraged, empowered, and motivated women to improve their health-seeking behaviours. Our refined theories confirmed the IPTs. Conclusion: The effective implementation, sustainability, and rollout of the MomConnect mobile health programme is contingent on some important health system conditions such as availability of funding, public awareness, HCPs, and clinic managers' buy-in and engagement, and facility readiness to provide care. HCPs' workload decreases if they feel that they can get assistance when women are educated on the MCH from the MomConnect platform and get all information needed on their mobile phones from home. This makes HCPs feel less pressured to conform to their work. Also, if HCPs are satisfied with the implementation of the MomConnect programme they will engage with the programme, and their positive attitude will encourage pregnant women and mothers to use healthcare facilities and change their health-seeking behaviours. In the context of the system failure or lack of updated mechanisms, caution must be taken when registering pregnant women by explaining to them how to switch to the baby messages once they give birth, to receive the baby messages and avoid the lack of system mechanism issues.
- ItemAdolescent 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.
- ItemAn 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.