Doctoral Degrees (Health Systems and Public Health)
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- 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, 2023-03) Kabongo, Eveline Muika; Nicol, Edward; 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.
- ItemBarriers 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.
- ItemInvestigating vaccine hesitancy in the City of Cape Town Metropolitan District(Stellenbosch : Stellenbosch University, 2022-12) Oduwole, Odunayo Elizabeth; Wiysonge, Charles Shey; Mahomed, Hassan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.ENGLISH SUMMARY: Vaccine hesitancy, previously defined as the delay in acceptance or refusal of vaccination despite availability of vaccination services, and more recently defined as a motivational state of being conflicted about, or opposed to, getting vaccinated, including intentions and willingness; has been a growing challenge to vaccination uptake and coverage over the years. Its negative effects on vaccination, an acclaimed successful public health measure that saves millions of lives annually, reached such high levels of concern that the World Health Organization (WHO) declared it as one of the ten top threats to global health in 2019. This made the earlier recommendation of the WHO that countries should incorporate plans to measure and address vaccine hesitancy into their immunization programs more exigent. To comply with this recommendation, governments and health institutions need to be able to detect early concerns about vaccination in the population, track vaccination attitudes, and monitor changes in vaccination behaviors. To do this effectively, context-specific knowledge of vaccine hesitancy is required. The paucity of such data in South Africa is a major challenge, making investigating vaccine hesitancy in its context an important necessity. Moreover, the advent of the coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which started in late 2019 further aggravated matters. The accelerated rate of development and approval for emergency use of some of the COVID-19 vaccines among other factors heightened public skepticism and contributed to further erosion of confidence in vaccines and vaccination in general; and of COVID-19 vaccines in particular. The devastating effects of the disease on lives, livelihoods, and economies of many countries and the strain exerted on healthcare workers and systems particularly in low and middle income countries (LMICs) turned an important necessity into a critical need. This study, conceptualized, developed and commenced before the outbreak of the pandemic and amended during its first year, aimed to investigate vaccine hesitancy in the City of Cape Town Metropolitan District. This was done by conducting a scoping review of existing vaccine hesitancy measurement tools, a qualitative enquiry into vaccine hesitancy in the City of Cape Town Metropolitan District, and a quantitative assessment of vaccine hesitancy in the district using an adaptation of one of the measurement tools identified in the scoping review. This study is a two-part, three-phase study. The first part consists of the evidence synthesis part (phase 1) while the second part is the primary study part consisting of phase 2 (qualitative) and phase 3 (quantitative) sub-studies. Listed below are the sub studies in the order of appearance. 1. Phase 1: Scoping review of current tools available to measure vaccine hesitancy in a period spanning 2010 to 2019. This included the first 9 years of the decade of vaccines endorsed by the 65th World Health Assembly in May 2012 to be 2011 to 2020. Conceptualized and developed with the protocol published before the outbreak of the COVID-19 pandemic, this review scopes the literature for published tools for measuring vaccine hesitancy in various contexts. Evidence from the review suggests that relatively few tools for measuring vaccine hesitancy existed prior to the pandemic. However, a significant amount of quantitative studies that explored various aspects of vaccine hesitancy were published in the said period. 2. Phase 2: Investigating the major drivers of vaccine hesitancy from the perception of vaccinators in the Cape Metropolitan District. Key informant interviews were conducted with 19 point-of-care vaccinators from 16 selected facilities drawn from the 8 health sub-districts of the Metro. Two qualitative enquiries were conducted simultaneously, the first explored and established the presence of vaccine hesitancy in the Metro; while the second documented other challenges apart from vaccine hesitancy encountered by the vaccinators in the course of their duties. It also documented the creative ways of mitigating them currently employed and recommended by the vaccinators. Findings from both enquiries have been published in international, peer-reviewed journals. 3. Phase 3: Measuring vaccine hesitancy among current staff and students at the Faculty of Medicine and Health Sciences (FMHS), Stellenbosch University (SU). The outbreak of the COVID-19 pandemic and the initial strict containment measures necessitated changes in some aspects of the study. The initially-planned door-to-door survey of mothers and primary caregivers had to be set aside, and a pandemic regulation-compliant, relevant sub-study developed in its place. This sub-study estimated the levels of vaccine confidence among current staff and students of the FMHS. High levels of vaccine confidence were recorded among the study population. The protocol detailing the methodology, and the full results of the sub-study have been published in an international, peer-reviewed journal. Vaccine hesitancy is a threat not only to the success of previous vaccination endeavors, but also to the health and economic wellbeing of millions across the globe as the control and containment of the COVID-19 pandemic largely depends on high vaccination uptake and coverage. Findings from the scoping review indicate that of the limited number of validated tools available to measure vaccine hesitancy in the decade of vaccines (2010-2019), few were developed and validated for use in LMIC contexts. The predominantly positive attitude of the public to vaccination as alluded to by the interviewed point-of-care vaccinators in the Cape Metro, and high levels of vaccine confidence among future healthcare workers and their trainers indicates that the challenge of vaccine hesitancy is still minimal in the Metro. The creative ways employed by the vaccinators and the insightful recommendations proffered by them to mitigate against the challenges of vaccination in the Metro will be invaluable interventions that will further enhance vaccination uptake and coverage not only in the Metro, but wherever they are adapted and/or adopted.
- ItemThe role of genetic and environmental factors in the aetiology of esophageal cancer(Stellenbosch : Stellenbosch University, 2021-12) Simba, Hannah; Sewram, Vikash; Kuivaniemi, Helena; Tromp, Gerard; Abnet, Christian; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.ENGLISH SUMMARY : Esophageal cancer (EC) is an aggressive cancer contributing an estimated 572,034 new cases and 508,585 deaths annually. Because no early detection programs exist, late presentation and high mortality are the rule. Prevalence rates are high in East Asia, Southern Europe, as well as in Eastern and Southern Africa. This peculiar distribution draws attention on the specificity of certain risk factors to particular regions. South Africa is a hotspot for EC; high prevalence has been reported in the Eastern Cape for the past five decades. Little research attention is given to EC in Africa; therefore, the epidemiology, as well as the genetic and environmental basis of EC is not well understood. The high incidence of EC, and the fatal nature of the disease, warrants a dedicated study to understand risk factors and pathobiology to facilitate strategies on prevention and screening. The aim of this study was to assess the role of genetic and environmental factors in the development of EC, and investigate the underlying molecular pathobiology using gene expression. Genetic variants associated with esophageal squamous cell carcinoma (ESCC) in African populations were assessed in 23 studies. Altogether, 25 variants in 20 genes were reported with a statistically significant association. In addition, eight studies identified somatic alterations in 17 genes and evidence of loss of heterozygosity, copy number variation, and microsatellite instability. This was the first genetic systematic review in African populations. A meta-analysis on 27 studies investigating environmental and lifestyle risk factors for ESCC (tobacco, alcohol use, combined tobacco and alcohol use, polycyclic aromatic hydrocarbon exposure, esophageal injury and fruit and vegetable consumption) was carried out. Adverse associations between ESCC risk and all the risk factors were found, whereas fruit and vegetable consumption showed a protective effect. The proportion of ESCC attributable to tobacco (17%), alcohol use (13%), combined tobacco and alcohol use (23%), polycyclic aromatic hydrocarbon exposure (5%), esophageal injury (17%) and fruit and vegetable consumption (-11%) were estimated using population attributable fraction analysis. This study was the most comprehensive systematic review and meta-analysis on African literature. Genes and pathways with differential mRNA expression were identified using datasets on ESCC, esophageal adenocarcinoma (EAC) and Barrett’s esophagus (BE) using the Rank Product Method, and gene set enrichment analysis (SetRank), with the Reactome Annotation Database. A total of 18 publicly available GEO mRNA expression datasets on 906 tissue samples, were analyzed. Overall, 1,107 upregulated genes and 1,537 downregulated genes were outputted for BE, EAC and ESCC. Significantly associated pathways included “Extracellular matrix organisation”, “Collagen chain trimerization”, “TP53 regulates transcription of several additional cell death genes whose specific roles in p53-dependent apoptosis remain uncertain”, and “Cyclin B2 mediated events”. Pathways not previously discussed or interpreted for EC in literature were identified, which warrant further investigation. These results highlight the multifactorial and complex etiology of EC. Comprehensive large-scale studies on the genetic basis and pathobiology of ESCC are still lacking in Africa. Understanding EC requires an integrated approach incorporating different study designs to assess both environmental and genetic factors of EC.
- ItemStrengthening pre-hospital clinical practice guideline development for South Africa(Stellenbosch : Stellenbosch University, 2020-12) McCaul, Michael Gilbert; Clarke, Mike; Young, Taryn; Bruijns, Stevan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.ENGLISH SUMMARY : In 2016, the first evidence-based prehospital clinical practice guideline was developed for South African paramedics, replacing outdated and eminence-based practice protocols. Rather than de novo development, alternative methods were used to develop these guidelines. These methods, however, require further strengthening and there is a modest gap in the literature regarding such methods. This strengthening would make it possible to address issues in current and future guideline development and implementation practices in South Africa and beyond, especially in resourcelimited settings. Issues include poor guideline quality and lack of appropriate methods, especially in prehospital care. In this thesis, I explore how to strengthen prehospital clinical practice guideline (CPG) development and implementation in low-resource settings. Using the African Federation for Emergency Medicine (AFEM) prehospital CPG as a case study, I used various research methods to i) identify, map and appraise global and regional prehospital guidelines (via a descriptive study and a scoping review); ii) describe and strengthen guideline development methods (via a qualitative case study, an expert review and a critical reflection/report); and iii) identify guideline implementation challenges and solutions (via a qualitative implementation research study). I show that overall, both global and regional (African) prehospital guidance quality is poor; however, an existing pool of high-quality CPGs can be adapted to fit national and local settings. I identify guideline development and implementation challenges within the AFEM guideline project and provide solutions and linked priority actions for guideline stakeholders. Considering these results, I have produced an alternative guideline development roadmap for prehospital guideline development in South Africa and beyond. This PhD argues that in order to strengthen existing and future prehospital CPG and end-user products, I suggest developers use existing high-quality guidelines, together with national policy and evidence to support context-specific recommendations. I argue that when developing and implementing guidelines, careful consideration of conflicts of interest during implementation decisions must be considered, together with ensuring wide and open consultation with stakeholders. To support robust development, I provide a critical report and roadmap for guideline development producers in resource-limited settings. This PhD highlights implications for future research, including the need to determine the cost-effectiveness of alternative versus de novo methods, identify prehospital topics with the greatest impact where CPGs are lacking, exploring the roles, need and objectives of policy-makers in prehospital guideline development, and testing and evaluating methods of dealing with consolidating multiple conflicting CPG recommendations and levels of evidence.