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Background: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. Methods: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. Results: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. Conclusions: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) Clinical trials registration: Clinicaltrials.gov ID: BFC157/19, August 2019. [ABSTRACT FROM AUTHOR]

Background: Low-resource settings are often less capable of responding to and implementing available quality research evidence for public healthcare practice and policy development due to various factors. In most low-resource settings, limited empirical evidence is available to help deal with localised factors that contribute to low public health research uptake, particularly from the perspective of key research stakeholders. Methods: Although the study initially employed a two-phase exploratory sequential approach, this paper focuses on the results generated from a quantitative approach. Considering the determining factors that affect research uptake in the context of low-resource settings, a measuring instrument was developed and its reliability and validity were assessed using an exploratory factor analysis approach. Results: A total of 212 respondents, according to their job roles and titles, were identified as researchers, front-line workers, programme managers, and directors/senior managers of higher learning institutions, indicating that the three constructs applied in the questionnaire, namely (1) individual factors, (2) organisational factors, and (3) research characteristics, demonstrated relatively high reliability with a Cronbach's alpha of greater than 0.791. Conclusion: The study concludes that the instrument can potentially be used to measure factors that affect research uptake in low-resource settings. [ABSTRACT FROM AUTHOR]

Background: South Africa presents one of the riskiest patterns of alcohol consumption, with per capita consumption above the African regional average. Globally, there has been an increased focus on the potential of appointing lay counsellors to administer alcohol intervention strategies in resource-limited contexts. Given the increasing need for relevant and efficient intervention strategies in response to high-risk alcohol consumption, screening instruments such as the AUDIT-C have gained increased attention. Methods: This paper explores the experiences of 15 lay counsellors in response to the training received on how to administer the AUDIT-C instrument, as well as provide interventions such as brief advice or an appropriate referral, in the resource-limited South African township of Alexandra, Johannesburg. A focus group was facilitated for this purpose and, thereafter, a thematic content analysis was applied to identify the themes most central to the lay counsellors' experiences. Results: The research findings suggest that the lay counsellors perceived the training to be adequate in preparing them for administrating the AUDIT-C and for providing any relevant interventions, and that their confidence in administering the instrument developed as the project progressed. However, recruitment and administration challenges were experienced in primary healthcare and community settings, and lay counsellors perceived home visits to be more appropriate with respect to issues related to confidentiality and stigmatisation. Conclusion: Overall, while lay counsellors feel that the training they received on the tool and the tool itself is useful for effectively implementing the AUDIT-C in low-resource communities, the availability and efficiency of alcohol treatment services in Alexandra Township need to be improved. [ABSTRACT FROM AUTHOR]

Research studies as well as anecdotal evidence suggest that there are challenges regarding the NHI plan implementation. These include problems such as an increase in illnesses and a shortage of personnel to drive the project in South African public hospitals. This is exacerbated by the existing situation of most government-funded healthcare institutions, which are characterized by bad administration, insufficient budget, inadequate infrastructure, and insufficient drug supply, as highlighted in several studies. The hospital under investigation is one such facility, with a history of patients sleeping on the floor and people being turned away owing to a shortage of experts and an overburdened staff. This situation is concerning, given that the government claims to be providing appropriate funds to the institution. The hospital under research is highly regarded by the surrounding community. However, a visit by the Health MEC in 2014 revealed that the facility had insufficient sanitary standards and a high complaint rate. Based on the foregoing, as well as the difficulties that both employees and patients are confronted with at the  selected hospital, the question that emerges is whether the hospital is fit for the implementation of the NHI.Aim: The aim of this study was to assess the preparation for the launch of the national health insurance scheme at a Johannesburg hospital.Setting: The study was conducted at a hospital situated in eastern suburbs of Johannesburg, Gauteng, South Africa.Method: The study employed a qualitative method with an explorative, descriptive, qualitative study design. The population consisted of selected hospital employees, such as doctors, dispensary officers, hospital managers, human resources workers, facility managers, and administration record officials who were employed at the selected hospital. Purposive sampling was used to select participants.Sample Size: Category saturation was used to determine the sample size. The participants for the study were chosen using purposeful sampling, with the researcher aiming for those who were familiar with the NHI scheme at the institution. Semi structured interviews and a focus group discussion were used to gather data. The data from the focus group discussion and semi-structured interviews were analysed using thematic analysis.Results: The investigation found that the hospital was preparing to for the NHI implementation, but that was riddled with lack of resources, poor infrastructure, lack of training, delays in development and poor technological advances.Recommendations: The paper suggests that human resources be increased, infrastructure be upgraded, medicines and equipment be increased, and enough training on NHI implementation be provided.Contribution: The paper adds to the body of knowledge regarding the NHI in South Africa. [ABSTRACT FROM AUTHOR]

Background: Despite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022. Methods: We conducted a qualitative process evaluation of the contextual and implementation process factors' influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces. Results: Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders' intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools. Conclusions: Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed. [ABSTRACT FROM AUTHOR]

Objective: Community health workers (CHW) are undertaking more complex tasks as part of the move towards universal health coverage in many low- and middle-income settings. They are expected to provide promotive and preventative care, make referrals to the local clinic, and follow up on non-attendees for a range of health conditions. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle due to inadequate supervision, low levels of CHW literacy, and the marginalized status of CHW in the health system. In this paper, we assess the effect of a roving nurse mentor on the coverage and quality of care of the CHW service in two vulnerable communities in South Africa. Participants: CHW, their supervisors, household members. Intervention: Roving professional nurse mentor to build skills of supervisors and CHW teams. Methods: Three household surveys to assess household coverage of the CHW service (baseline, end of the intervention, and 6 months after end of intervention); structured observations of CHW working in households to assess quality of care. Results: The intervention led to a sustained 50% increase in the number of households visited by a CHW in the last year. While the proportion of appropriate health messages given to household members by CHW remained constant at approximately 50%, CHW performed a greater range of more complex tasks. They were more likely to visit new households to assess health needs and register the household in the programme, to provide care to pregnant women, children and people who had withdrawn from care. CHW were more likely to discuss with clients the barriers they were facing in accessing care and take notes during a visit. Conclusion: A nurse mentor can have a significant effect both on the quantity and quality of CHW work, allowing them to achieve their potential despite their marginalised status in the health system and their limited prior educational achievement. Supportive supervision is important in enabling the benefit of having a health cadre embedded in marginalised communities to be realised. [ABSTRACT FROM AUTHOR]

Introduction: A task-sharing collaborative care model for integrated depression care for South Africa's burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges. Methods: The Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of 'modifications made' and 'actual implementation' introduced in the 'Getting messier with TIDieR' framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts. Results: In the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger. Conclusion: The need for in-country co-designed collaborative care models, and 'implementation heavy' implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted. [ABSTRACT FROM AUTHOR]

Background: One of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. Evidence on effective approaches to CHW supervision is limited and intervention research has up to now focused primarily on outcomes and less on intervention development processes. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a co-produced district level supportive supervision framework for Ward Based Outreach Teams in a South African district.Methods: Drawing on a conceptual framework of domains of co-production, the paper reflects on the implications of the research process adopted for participants, generation of research knowledge and recommendations for practice, as well as lessons for research on the supervision of CHWs.Results: Through the research process, participants reflected and engaged meaningfully, honestly and productively across hierarchies, and were able to forge new, dialogic relationships. The iterative, back forth feedback, involving a core group of participants across phases, enabled additions and validations, and informed further data collection. The culmination of the process was consensus on the key issues facing the programme and the generation of a set of recommendations for a local, context-specific framework of supportive supervision. The process of engagement, relationships built and consensus forged proved to be more significant than the framework itself.Conclusion: The co-production approach can enable local impact of research findings by providing a bottom-up collaborative platform of active participation, iterative feedback, knowledge generation and mutual learning that can complement guidance and frameworks from above. Although time consuming and not without its limitations, this approach to research has much to offer in advancing understanding of CHW supervision. [ABSTRACT FROM AUTHOR]

Background: HIV diagnosis in South Africa is based on a point-of-care testing (PoCT) algorithm with paper-based record-keeping. Aggregated testing data are reported routinely. To facilitate improved HIV case-based surveillance, the Western Cape Province implemented a unique pilot intervention to digitise PoCT results, at an individual level, and generate an electronic register using the newly developed Provincial Health Data Centre (PHDC). We describe the intervention (phased) and present an evaluation of the operational feasibility of the intervention. We also offer implementation insights into establishing electronic capture of individual level testing data.Methods: Cross-sectional analyses were conducted on records of all patients attending a local Community Health Centre who had an HIV-PoCT during the study period. Data from the intervention were linked to the PHDC using a unique identifier and compared with aggregate data from the paper-based register. Correlation coefficients were calculated to quantify the correlation between the two monthly datasets. To support an understanding of the findings, the Department of Health project management team generated reflections on the implementation process, which were then grouped thematically into implementation lessons.Results: In total, 11,337 PoCT records were digitised (70% (7954) during Phase I; and 30% (3383) during Phase II). Linkage of forms to the PHDC was 96% in Phase I and 98% in Phase II. Comparison with aggregate data showed high correlation during Phase I, but notable divergence during Phase II. Divergence in Phase II was due to stringent data quality requirements and high clinical staff turnover. Factors supporting implementation success in Phase I included direct oversight of data capturing by a manager with clinical and operational insight. Implementation challenges included operational, health system, and high cost-related issues.Conclusions: We demonstrate that rapid digitisation of HIV PoCT data, without compromising currently collected aggregate data, is operationally feasible, and can contribute to person-level longitudinal HIV case-based surveillance. To take to scale, we will need to improve PoCT platforms and clerical and administrative systems. Although we highlight challenges, we demonstrate that electronic HIV testing registers can successfully replace manual registers and improve efforts to monitor and evaluate HIV testing strategies. [ABSTRACT FROM AUTHOR]

Background: Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa.Methods: A retrospective qualitative case study based on interviews with 34 actors in three 'implementation units' - a district hospital and surrounding primary health care services - of the district, selected as purposefully representing full, moderate and low implementation of the intervention, some three years after it was first introduced. Data are analysed using Veneklasen and Miller's typology of the forms of power - namely 'power over', 'power to', 'power within' and 'power with'.Results: Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. As expected, a degree of buy-in of managers (with power over) in implementation units was necessary for the intervention to proceed. Beyond this, the ability to mobilise collective action (power with), combined with support from champions with agency (power within) were key to successful implementation. However, local empowerment may pose a threat to hierarchical power (power over) at higher levels (district and provincial) of the system, potentially affecting sustainability.Conclusions: A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems. [ABSTRACT FROM AUTHOR]

Background: Many people diagnosed with Mycobacterium tuberculosis (TB) in tertiary and district hospitals in South Africa do not arrive at their primary care clinic for continued care after they are discharged from the hospital. This loss to follow up is a major, ongoing problem for public health in South Africa, and contributes to drug-resistant TB strains. The objective of this paper was to explore patients' experiences and perceptions of diagnosis and treatment before their discharge from hospital. We use a framework known as patient-centred care to illustrate how these patient narratives point to lapses in these principles within the hospital system, and to show how such lapses may contribute to loss to follow up and inconsistent TB care.Methods: We employed a qualitative study using semi-structured interviews to investigate patient and healthcare workers' experiences and perceptions of TB care in two Western Cape hospitals. We purposefully sampled 17 patients, 10 healthcare workers, and two key informant policy makers, all of whom had relevant experiences and insights. Data collection was done between October 2015 and February 2017. Data were analysed using Miles and Huberman's qualitative analysis framework.Results: Hospitals did not achieve patient-centred care. Newly diagnosed patients were provided with inadequate TB education, diseased-focused approaches were favoured over patient-focused approaches, and there was limited engagement with patients to understand their needs and feelings during the critical period between diagnosis and discharge. Consequently, some patients felt anxious prior to their discharge from hospital. Coupled with their overwhelming socio-economic barriers and complex family situations, some patients felt hopeless and powerless as they prepared for discharge. Finally, there was a lack of patient-provider partnership due to problems including healthcare workers' time constraints and heavy workloads, which detracted from a focus on patients' needs and feelings.Conclusions: Improving the three intersecting elements of patient-centred care (health education, engaging with patients' needs and feelings, and shared decision-making) has the potential to positively influence patients' continuity of care for TB in South Africa. It would be helpful to also proactively address how patients plan to stay connected to care, on treatment, and supported, in light of their family situation or socio-economic circumstances. Detailed and unique pre-discharge counselling for each patient may be valuable in this regard. [ABSTRACT FROM AUTHOR]

Background: Appropriate health-seeking practices may have a positive influence on child survival, particularly when practiced by kin caregivers of children who are below the age of 5 years. While literature has shown that children who are raised in kinship care often present with poor health outcomes and often have unmet healthcare needs, the health-seeking behaviours and practices of the children's kin caregivers that ultimately influence these health outcomes remain largely unknown. In this paper, we explored the healthcare beliefs and practices of kin caregivers in South Africa on child survival.Methods: Overall, 12 structured interviews were conducted with all the participants. Six [6] interviews were conducted in the Eastern Cape province and 6 were conducted in the KwaZulu-Natal province. The sample of participants was obtained by seeking permission from the child welfare authorities in the KwaZulu-Natal and Eastern Cape Department of Social Development (DSD) to assist in identifying a sample of the kin-caregivers who have provided primary care to children below the age of 5. The structured interviews were transcribed and analysed using thematic content analysis. After thematic content analysis was carried out, transcripts were given case numbers and then imported into NViVo version 11 for analysis and interpretation of the findings.Results: The healthcare seeking behaviours and poor use of healthcare services of the caregivers were largely influenced by their notions and perceptions of health and illness. The notions and perceptions that the caregivers hold about the health statuses of the children placed under their care and illness were found to be largely culturally determined and largely influenced by preconceptions and certain healthcare beliefs. Increased reliance on traditional herbs, Notion of witchcraft and Faith healing emerged as key factors that influence health-seeking practices and beliefs of kin caregivers, thus influencing under-five mortality.Conclusion: Kin caregivers should be equipped with the necessary guidance, resources and training that facilitate the successful fulfilment of the caregiving role, given the number of unmet needs and challenges that they face. This will in turn translate into positive child health outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Traditional healers are frequently exposed to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) through the widespread practice of traditional "injections", in which the healer performs dozens of subcutaneous incisions using a razor blade to rub herbs directly into bloodied tissue. An average healer in Agincourt, a rural northeastern sub-district in Mpumalanga province, South Africa, experiences approximately 1500 occupational blood exposures over the course of their lifetime. Healers in Agincourt have an HIV prevalence of 30% compared to 19% in the general population, and healers who report exposure to patient blood have an adjusted 2.4-fold higher odds of being HIV-positive than those with no exposure. Although research on appropriate PPE use has been well documented for allopathic care providers, little is known about the practices of traditional healers.Methods: This qualitative study was conducted with 30 traditional healers who practice in the rural Bushbuckridge sub-district of Mpumalanga province, northeastern South Africa. We elicited traditional healer attitudes towards glove use during traditional treatments - including patient baths, injections, or other treatments that exposed healers to patient blood or open sores.Results: While 90% of healers reported using latex gloves during some treatments, the majority do not use them regularly. Most employ a combination of gloves, plastic shopping bags, bread bags, paper, and sticks to prevent blood exposure. Healers reported plastic bags slipping or breaking during procedures, exposing them to patient blood. Only three healers consistently used gloves, regardless of the cost.Conclusions: Inadequate PPE use and high HIV prevalence make traditional healers particularly susceptible to contracting HIV in rural South Africa. Despite positive attitudes, consistent glove use remains low due to financial constraints and glove availability. Addressing issues of accessibility and cost of gloves for traditional healers could have a significant impact on the adherence to PPE and, in turn, reduce new HIV infections among this high-risk group. [ABSTRACT FROM AUTHOR]

Background: Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, research into alternative methods of CPG development using existing CPG documents (CPG adaptation) - a specific issue for guideline development groups in low- and middle-income countries - is sparse. There are only a few examples showcasing the pragmatic application of such alternative approaches in settings with time and budget constraints, especially in the prehospital setting. This paper aims to describe and strengthen the methods of developing prehospital CPGs using alternative guideline development methods through a case study design.Methods: We qualitatively explored a CPG development project conducted in 2016 for prehospital providers in South Africa as a case study. Key stakeholders, involved in various processes of the guideline project, were purposefully sampled. Data were collected from one focus group and six in-depth interviews and analysed using thematic analysis. Overarching themes and sub-themes were inductively developed and categorised as challenges and recommendations and further transformed into action points.Results: Key challenges revolved around guideline implementation as opposed to development. These included the unavoidable effect of interest and beliefs on implementing recommendations, the local evidence void, a shifting implementation context, and opposing end-user needs. Guideline development and implementation strengthening priority actions included: i) developing a national end-user document; ii) aligning recommendations with local practice; iii) communicating a clear and consistent message; iv) addressing controversial recommendations; v) managing the impact of interests, beliefs and intellectual conflicts; and vi) transparently reporting implementation decisions.Conclusion: The cornerstone of a successful guideline development process is the translation and implementation of CPG recommendations into clinical practice. We highlight key priority actions for prehospital guideline development teams with limited resources to strengthen guideline development, dissemination, and implementation by drawing from lessons learnt from a prehospital guideline project conducted in South Africa. [ABSTRACT FROM AUTHOR]

Background: Interventions targeting community health workers (CHWs) aim to optimise the delivery of health services to underserved rural areas. Whilst interventions are evaluated against their objectives, there remains limited evidence on the economic costs of these interventions, and the practicality and value of scale up. The aim of this paper is to undertake a cost analysis on a CHW training and supervision intervention using exclusive breastfeeding rates amongst mothers as an outcome measure.Methods: This is a retrospective cost analysis, from an implementer's perspective, of a cluster randomised controlled trial investigating the effectiveness of a continuous quality improvement (CQI) intervention aimed at CHWs providing care and support to pregnant women and women with babies aged < 1 year in South Africa.Results: One of the outcomes of the RCT revealed that the prevalence of exclusive breastfeeding (EBF) significantly improved, with the cost per mother EBF in the control and intervention arm calculated at US$760,13 and US$1705,28 respectively. The cost per additional mother practicing EBF was calculated to be US$7647, 88, with the supervision component of the intervention constituting 64% of the trial costs. In addition, women served by the intervention CHWs were more likely to have received a CHW visit and had significantly better knowledge of childcare practices.Conclusion: Whilst the cost of this intervention is high, adapted interventions could potentially offer an economical alternative for achieving selected maternal and child health (MCH) outcomes. The results of this study should inform future programmes aimed at providing adapted training and supervision to CHWs with the objective of improving community-level health outcomes. [ABSTRACT FROM AUTHOR]

Background: Point of care testing promises to reduce delays in diagnosing and initiating treatment for infectious diseases such as Human Immuno-deficiency Virus (HIV). In South Africa, decentralized HIV testing with rapid tests offers important lessons for point of care testing programs. Yet, little is known about the strategies of providers and clients to make HIV testing successful in settings short of equipment, human resources and space. We aimed at examining these strategies.Methods: This paper is based on a larger qualitative study of diagnostic practices across major diseases and actors in homes, clinics, communities, hospitals and laboratories in South Africa. We conducted 101 semi-structured interviews and 7 focus group discussions with doctors, nurses, community health workers, patients, laboratory technicians, policymakers, hospital managers and manufacturers between September 2012 and June 2013 in Durban, Cape Town and Eastern Cape. The topics explored included diagnostic processes and challenges, understanding of diagnosis, and visions of ideal tests. For this paper, the data on HIV testing processes in clinics, communities and hospitals was used.Results: Strategies to make HIV testing work at point of care involve overcoming constraints in equipment, spaces, human resources and workload and actively managing diagnostic processes. We grouped these strategies into subthemes: maintaining relationships, adapting testing guidelines and practices to stock-outs, to physical space, and to different clients, turning the test into a tool to reach another aim and turning the testing process into a tool to enhance adherence. These adaptive strategies are locally negotiated solutions, often ad-hoc, depending on personal commitment, relationships, human resources, physical space and referral systems. In the process, testing is redefined and repurposed. Not all of these repurposing acts are successful in ensuring a timely diagnosis. Some lead to disruptions, unnecessary testing or delays with at times unclear implications for quality of diagnosis.Conclusion: Tests shape relationships, professional roles and practices of users at point of care. At the same time, testing processes are dynamic and test results and processes take on new meanings for clients and providers. These insights are crucial for understanding the contexts within which diagnostic devices and policies need to function. [ABSTRACT FROM AUTHOR]

Background: Rehabilitation medicine plays an integral part in attainment of optimal functioning after injury or disease. The National Rehabilitation Policy of South Africa (NRP) (2000) highlights the need for access to professional health care services, redistribution and optimal utilisation of resources and research in the field of disability and rehabilitation. The government further ratified the Convention on the Rights of Persons with Disabilities (CRPD) (2007), which validate the urgency in advancing the agenda of persons with disabilities. This paper outlines the methodological plan for evaluating rehabilitation services in the Western Cape, South Africa against the aims and objectives of the NRP as well as its principles and concepts. The evaluation process further focused on specific articles in the CRPD that were aligned with disability, health and rehabilitation.Methods/design: A mixed-method design was used to evaluate the alignment of rehabilitation services with the NRP in the Western Cape. Four rehabilitation study settings were selected to ensure that both inpatient and outpatient rehabilitation levels of care were covered at different contexts (rural and peri-urban). The sites were checked for the most prevalent rehabilitation-related conditions to ensure the identification of suitable instruments for measuring rehabilitation outcomes. Each study setting was linked to two researchers with one exploring the rehabilitation organizational structure of the sites and the other exploring the client outcomes after receiving rehabilitation services. Patients were evaluated at baseline and discharge, within seven days after admission and seven days prior to discharge. The evaluation was based on the rehabilitation organizational capacity to provide patient-oriented rehabilitation and the measurement of rehabilitation outcomes. Kaplan's framework of organisational capacity was used in the context of each study setting. For the measurement of service users' outcomes, the International Classification of Functioning, Disability and Health was used (ICF). Standardised outcome measures were adopted for the domains of impairment, activity and participation. The World Health Organisation Community-Based Rehabilitation guidelines were used as guiding principles and concepts as suggested in the NRP.Discussion: This is a groundbreaking methodological exploration that offers both study methods and instruments to measure rehabilitation services at both in-patient and out-patient rehabilitation services. [ABSTRACT FROM AUTHOR]

Introduction: A task-sharing collaborative care model for integrated depression care for South Africa's burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges.Methods: The Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of 'modifications made' and 'actual implementation' introduced in the 'Getting messier with TIDieR' framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts.Results: In the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger.Conclusion: The need for in-country co-designed collaborative care models, and 'implementation heavy' implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted. [ABSTRACT FROM AUTHOR]

Background: Similar to other countries in the region, South Africa is currently reorienting a loosely structured and highly diverse community care system that evolved around HIV and TB, into a formalized, comprehensive and integrated primary health care outreach programme, based on community health workers (CHWs). While the difficulties of establishing national CHW programmes are well described, the reshaping of disease specific and care oriented community services, based outside the formal health system, poses particular challenges. This paper is an in-depth case study of the challenges of implementing reforms to community based services (CBS) in one province of South Africa.Methods: A multi-method situation appraisal of CBS in the Western Cape Province was conducted over eight months in close collaboration with provincial stakeholders. The appraisal mapped the roles and service delivery, human resource, financing and governance arrangements of an extensive non-governmental organisation (NGO) contracted and CHW based service delivery infrastructure that emerged over 15-20 years in this province. It also gathered the perspectives of a wide range of actors - including communities, users, NGOs, PHC providers and managers - on the current state and future visions of CBS.Results: While there was wide support for new approaches to CBS, there are a number of challenges to achieving this. Although largely government funded, the community based delivery platform remains marginal to the formal public primary health care (PHC) and district health systems. CHW roles evolved from a system of home based care and are limited in scope. There is a high turnover of cadres, and support systems (supervision, monitoring, financing, training), coordination between CHWs, NGOs and PHC facilities, and sub-district capacity for planning and management of CBS are all poorly developed.Conclusions: Reorienting community based services that have their origins in care responses to HIV and TB presents an inter-related set of resource mobilisation, system design and governance challenges. These include not only formalising community based teams themselves, but also the forging of new roles, relationships and mind-sets within the primary health care system, and creating greater capacity for contracting and engaging a plural set of actors - government, NGO and community - at district and sub-district level. [ABSTRACT FROM AUTHOR]

Background: The provision of rehabilitation differs between developed and developing countries, this could impact on the outcomes of post stroke rehabilitation. The aim of this paper is to present provision of in-patient stroke rehabilitation. In addition the challenges experienced by the individuals with participation post discharge are also presented. Methods: Qualitative and quantitative research methods were used to collect data. The quantitative data was collected using a retrospective survey of stroke patients admitted to hospitals over a three- to five-year period. Quantitative data was captured on a validated data capture sheet and analysed descriptively. The qualitative data was collected using interviews from a purposively and conveniently selected sample, audio-taped and analysed thematically. The qualitative data was presented within the participation model. Results: A total of 168 medical folders were reviewed for a South African sample, 139 for a Rwandan sample and 145 for a Tanzanian sample. The mean age ranged from 62.6 (13.78) years in the South African sample to 56.0 (17.4) in the Rwandan sample. While a total of 98 % of South African stroke patients received physiotherapy, only 39.4 % of Rwandan patients received physiotherapy. From the qualitative interviews, it became clear that the stroke patients had participation restrictions. When conceptualised within the Participation Model participation restrictions experienced by the stroke patients were a lack of accomplishment, inability to engage in previous roles and a perception of having health problems. Discussion: With the exception of Rwanda, stroke patients in the countries studied are admitted to settings early post stroke allowing for implementation of effective acute interventions. The participants were experiencing challenges which included a lack of transport and the physical geographic surroundings in the rural settings not being conducive to wheelchair use. Conclusion: Stroke patients admitted to hospitals in certain African countries could receive limited in-patient therapeutic interventions. With the exception of barriers in the physical environment, stroke patients in developing countries where resources are limited experience the same participation restrictions as their counterparts in developed countries where resources are more freely available. Rehabilitation interventions in these developing countries should therefore be community-based focussing on intervening in the physical environment. [ABSTRACT FROM AUTHOR]

Background: Youth in South Africa have been identified as a high-risk group for contracting HIV. In response, the South African Integrated School Health Policy (ISHP) has been developed with the aim of guiding the provision of comprehensive healthcare services within South African schools. Accordingly, the scale-up of HIV counselling and testing (HCT) in high schools is a priority. This study examines the factors affecting the utilisation of HCT services amongst learners in high schools in the KwaZulu-Natal province of South Africa. Methods: Focus group discussions were conducted in 12 rural schools in the Vulindlela sub-district of uMgungundlovu in KwaZulu-Natal. A total of 158 randomly selected learners took part, aged 16 years and older from grades 10, 11 and 12. Qualitative analysis was conducted using the framework approach, providing a systematic structure allowing for a priori and emergent codes, with social cognitive theory as a theoretical framework. Results: The stigma and discrimination attached to testing, along with the inherent fear of a positive result were the biggest barriers to HCT uptake. Fear and the subsequent negative beliefs around HCT were borne out of insufficient knowledge. These fears were exacerbated by the perceived or real attitudes of peers, partners and family towards HIV. The prospect of a positive result and the possible resultant societal backlash hinders high and regular uptake of HCT. Stigma and discrimination remain the foremost barriers to HIV testing despite the presence of localised and convenient testing. Interventions aimed at addressing these challenges could increase the demand for HIV testing amongst adolescents. Conclusions: Increasing education about the importance of HCT and creating awareness about available HCT services will not be enough to increase uptake in schools in South Africa. Efforts to decrease stigma around HIV and HCT by integrating testing into general and sexual reproductive health services offered to youth, and normalising the epidemic within the community could go some way to allaying the fears shrouding testing, if such services are designed with the specific needs of youth in mind. This paper adds to the body of literature informing the design of policy in South Africa aimed at integrating HCT into school health services. [ABSTRACT FROM AUTHOR]

Background In 2006, the South African Department of Health adopted and scaled-up loveLife's Youth Friendly Services (YFS) initiative to a national policy to improve youth utilization of health programmes by strengthening community sensitisation and counselling services. As these services roll-out, alternative services to target young people are also becoming more popular. Success of any of these services, however, is dependent upon young people's perceptions of these health services as a whole. This paper aims to examine the knowledge and perceptions of current health services oriented towards young people and examine potential alternative approaches to health service delivery. Methods The study was conducted in urban Soweto, South Africa. Twenty-five in-depth interviews were conducted between May-July 2012. Twenty-three of these were analysed according to modified grounded theory. Results Knowledge of YFS was very low with no thorough knowledge of the programme's purpose or activities. In general, young people were dissatisfied with the current health services in Soweto citing a lack of resources, long waiting times, and poor quality of care heightened by an underlying lack of choice and perceived inequity. When compared to alternative models of service delivery, no particular model was preferred over another. Conclusions Greater knowledge of whether and to what extent local clinics in Soweto are implementing YFS standards is needed. If implemented, improved outreach and advertisement is suggested. In-service training of nurses should be prioritized with a focus on sensitivity and equitable treatment to all. [ABSTRACT FROM AUTHOR]

Background Front-line health providers have a unique role as brokers (patient advocates) between the health system and patients in ensuring access to medicines (ATM). ATM is a fundamental component of health systems. This paper examines in a South African context supply- and demand- ATM barriers from the provider perspective using a five dimensional framework: availability (fit between existing resources and clients' needs); accessibility (fit between physical location of healthcare and location of clients); accommodation (fit between the organisation of services and clients' practical circumstances); acceptability (fit between clients' and providers' mutual expectations and appropriateness of care) and affordability (fit between cost of care and ability to pay). Methods This cross-sectional, qualitative study uses semi-structured interviews with nurses, pharmacy personnel and doctors. Thirty-six providers were purposively recruited from six public sector Community Health Centres in two districts in the Eastern Cape Province representing both rural and urban settings. Content analysis combined structured coding and grounded theory approaches. Finally, the five dimensional framework was applied to illustrate the interconnected facets of the issue. Results Factors perceived to affect ATM were identified. Availability of medicines was hampered by logistical bottlenecks in the medicines supply chain; poor public transport networks affected accessibility. Organization of disease programmes meshed poorly with the needs of patients with comorbidities and circular migrants who move between provinces searching for economic opportunities, proximity to services such as social grants and shopping centres influenced where patients obtain medicines. Acceptability was affected by, for example, HIV related stigma leading patients to seek distant services. Travel costs exacerbated by the interplay of several ATM barriers influenced affordability. Providers play a brokerage role by adopting flexible prescribing and dispensing for 'stable' patients and aligning clinic and social grant appointments to minimise clients' routine costs. Occasionally they reported assisting patients with transport money. Conclusion All five ATM barriers are important and they interact in complex ways. Context-sensitive responses which minimise treatment interruption are needed. While broad-based changes encompassing all disease programmes to improve ATM are needed, a beginning could be to assess the appropriateness, feasibility and sustainability of existing brokerage mechanisms. [ABSTRACT FROM AUTHOR]

Background: In South Africa, providers are trained on post-rape care by a multitude of organisations, resulting in varied knowledge and skills. In 2007, a national training curriculum was developed and piloted in the country. The objectives of this paper are to identify the factors associated with higher knowledge and confidence in providers at the commencement of the training and to reflect on the implications of this for training and other efforts being made to improve services. Methods: A cross-sectional study using questionnaires was conducted. Providers who attended the training provided information on socio-demographic background, service provision, training, attitudes, and confidence. Knowledge was measured through multiple choice questions. Bi-variable analysis was carried out in order to test for factors associated with high knowledge and confidence. Variables with a p value of <0.20 were then included in backward selection to develop the final multivariable models. Results: Of the 124 providers, 70% were female and 68% were nurses. The mean age of the providers was 41.7 (24 – 64) years. About 60% of providers were trained in providing post-rape care. The median percentage knowledge score was 37.3% (0% - 65.3%) and the median percentage confidence score was 75.4% (10% - 100%). Having a more appropriate attitude towards rape was associated with higher knowledge, while older providers and nurses had lower odds of having high knowledge levels. Working in a crisis centre in the facility, having examined a survivor in the last 3 months, and seeing more than 60% of survivors who came to the facility were associated with higher confidence. Higher confidence was not associated with greater knowledge. Conclusion: The study indicated that although confidence was high, there was poor knowledge in providers, even in those who were previously trained. Knowledge seems to be critically dependant on attitude, which highlights the need for educating providers on rape and the seriousness of the problem. There is a need to train more providers in post-rape care in country, and to ensure that training is comprehensive, and that providers who are trained remain knowledgeable and skilled in current best practices. [ABSTRACT FROM AUTHOR]

Background: Despite concerns about affordability and sustainability, many models of the lifetime costs of antiretroviral therapy (ART) used in resource limited settings are based on data from small research cohorts, together with pragmatic assumptions about life-expectancy. This paper revisits these modelling assumptions in order to provide input to future attempts to model the lifetime costs and the costs of scaling up ART. Methods: We analysed the determinants of costs and outcomes in patients receiving ART in line with standard World Health Organization (WHO) guidelines for resource poor settings in a private sector managed ART programme in South Africa. The cohort included over 5,000 patients with up to 4 years (median 19 months) on ART. Generalized linear and Cox proportional hazards regression models were used to establish cost and outcome determinants respectively. Results: The key variables associated with changes in mean monthly costs were: being on the second line regimen; receiving ART from 4 months prior to 4 months post treatment initiation; having a recent or current CD4 count <50 cells/μL or 50-199 cells/μl; having mean ART adherence <75% as determined by monthly pharmacy refill data; and having a current or recent viral load >100,000 copies/mL. In terms of the likelihood of dying, the key variables were: baseline CD4 count<50 cells/μl (particularly during the first 4 months on treatment); current CD4 count <50 cells/μl and 50-199 cells/μl (particularly during later periods on treatment); and being on the second line regimen. Being poorly adherent and having an unsuppressed viral load was also associated with a higher likelihood of dying. Conclusions: While there are many unknowns associated with modelling the resources needed to scale-up ART, our analysis has suggested a number of key variables which can be used to improve the state of the art of modelling ART. While the magnitude of the effects associated with these variables would be likely to differ in other settings, the variables influencing costs and survival are likely to be generalizable. This is of direct relevance to those concerned about assessing the long-term costs and sustainability of expanded access to ART. [ABSTRACT FROM AUTHOR]

Background: While South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020. Methods: The costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider's perspective reflected in real 2007 prices. Results: The annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget. Conclusions: Responding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a "resource for democracy" or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans. [ABSTRACT FROM AUTHOR]

Background: South Africa's antiretroviral programme is governed by defined national plans, establishing treatment targets and providing funding through ring-fenced conditional grants. However, in terms of the country's quasifederal constitution, provincial governments bear the main responsibility for provision of health care, and have a certain amount of autonomy and therefore choice in the way their HIV/AIDS programmes are implemented. Methods: The paper is a comparative case study of the early management of ART scale up in three South African provincial governments - Western Cape, Gauteng and Free State - focusing on both operational and strategic dimensions. Drawing on surveys of models of ART care and analyses of the policy process conducted in the three provinces between 2005 and 2007, as well as a considerable body of grey and indexed literature on ART scale up in South Africa, it draws links between implementation processes and variations in provincial ART coverage (low, medium and high) achieved in the three provinces. Results: While they adopted similar chronic disease care approaches, the provinces differed with respect to political and managerial leadership of the programme, programme design, the balance between central standardisation and local flexibility, the effectiveness of monitoring and evaluation systems, and the nature and extent of external support and programme partnerships. Conclusions: This case study points to the importance of sub-national programme processes and the influence of factors other than financing or human resource capacity, in understanding intervention scale up. [ABSTRACT FROM AUTHOR]

Background: There is an increasing burden of chronic illness in low and middle income countries, driven by TB/HIV, as well as non-communicable diseases. Few health systems are organized to meet the needs of chronically ill patients, and patients' perspectives on the difficulties of accessing care need to be better understood, particularly in poor resourced settings, to achieve this end. This paper describes the experience of poor households attempting to access chronic care in a rural area of South Africa. Methods: A household survey (n = 1446 individuals) was combined with qualitative longitudinal research that followed 30 case study households over 10 months. Illness narratives and diaries provided descriptive textual data of household interactions with the health system. Results: In the survey 74% of reported health problems were 'chronic', 48% of which had no treatment action taken in the previous month. Amongst the case study households, of the 34 cases of chronic illness, only 21 (62%) cases had an allopathic diagnosis and only 12 (35%) were receiving regular treatment. Livelihoods exhausted from previous illness and death, low income, and limited social networks, prevented consultation with monthly expenditure for repeated consultations as high as 60% of income. Interrupted drug supplies, insufficient clinical services at the clinic level necessitating referral, and a lack of ambulances further hampered access to care. Poor provider-patient interaction led to inadequate understanding of illness, inappropriate treatment action, 'healer shopping', and at times a break down in cooperation, with the patient 'giving up' on the public health system. However, productive patient-provider interactions not only facilitated appropriate treatment action but enabled patients to justify their need for financial assistance to family and neighbours, and so access care. In addition, patients and their families with understanding of a disease became a community resource drawn on to assist others. Conclusion: In strengthening the public sector it is important not only to improve drug supply chains, ambulance services, referral systems and clinical capacity at public clinics, and to address the financial constraints faced by the socially disadvantaged, but also to think through how providers can engage with patients in a way that strengthens the therapeutic alliance. [ABSTRACT FROM AUTHOR]

Background: Eye examinations are recommended for all persons throughout life. However, there is disparity in the uptake of eye care services in different populations. Using data from a nationally representative population-based cross-sectional study (the South African National Health and Nutrition Examination Survey, [SANHANES-1]), this paper investigates the utilization of eye care services and its associated factors in South Africa.Methods: Participants aged 15 years and older who participated in interviews and clinical examination were enrolled in the SANHANES from 2011 to 2012. Eye care utilization was assessed from participants' responses to whether they had their eyes examined by a medical professional and when they were last examined. Data were analysed using multiple logistic regression models employing a hierarchical approach to add predisposing (e.g. age, sex), enabling (e.g. health insurance) and need (e.g. hypertension) factors sequentially.Results: The study sampled 3320 participants, with 64.9% being females. 73.4% (95% CI [69.7-76.7]) of participants had never had an eye examination. After statistical adjustment, age groups (compared with 15-29 years: 30-44 years Odds Ratio [OR] = 1.76; 45-59 years OR = 2.13; 60-74 years OR = 2.74; ≥75 years OR = 3.22), ethnicity (compared with African descent: white OR = 4.71; mixed-race OR = 1.87; Indian OR = 7.67), high risk alcohol use (OR = 1.83), wealth index (compared with lowest quintile: third quintile OR = 1.75; fourth quintile OR = 2.23; fifth quintile OR = 2.49), health insurance (OR = 2.19), diabetes (OR = 1.75), high cholesterol (OR = 2.51), having assessed healthcare in the past 5 years (OR = 2.42), and self-reported vision problems (OR = 1.51) were significantly associated with eye care utilization.Conclusion: Almost three-quarters of South Africans sampled were not utilizing eye care services. It is imperative to strengthen current public health measures (including eye health promotion programs) to address the alarmingly low uptake of eye care services as well as the disparities in eye care utilization in South Africa. [ABSTRACT FROM AUTHOR]

Background: Low- and middle-income countries often lack the fiscal, infrastructural and human resources to conduct evidence-based research; similar constraints may also hinder the application of good clinical practice guidelines based on research findings from high-income countries. While the context of health organizations is increasingly recognized as an important consideration when such guidelines are implemented, there is a paucity of studies that have considered local contexts of resource-scarcity against recommended clinical guidelines.Methods: This paper sets out to explore the implementation of the NICE Guideline 11 on family interventions when working with persons with intellectual disability and challenging behavior by a group of psychologists employed in a government health facility in Cape Town, South Africa.Results: In the absence of evidence-based South African research, we argue that aspects of the guidelines, in particular those that informed our ethos and conceptual thinking, could be applied by clinical psychologists in a meaningful manner notwithstanding the relative scarcity of resources.Conclusion: We have argued that where guidelines such as the NICE Guidelines do not apply contextually throughout, it remains important to retain the principles behind these guidelines in local contexts. Limitations of this study exist in that the data were drawn only from the clinical experience of authors. Some of the implications for future research in resource-constrained contexts such as ours are discussed. Smaller descriptive, qualitative studies are necessary to explore the contextual limitations and resource strengths that exist in low- and middle-income settings, and these studies should be more systematic than drawing only on the clinical experience of authors, as has been done in this study. [ABSTRACT FROM AUTHOR]

Background: Health services for adolescents are increasingly recognised as a priority in low- and middle-income countries (LMICs). The Adolescent and Youth Friendly Service (AYFS) approach has been promoted in South Africa by the National Department of Health and partners, as a means of standardising the quality of adolescent health services in the country. The objective of this paper is to detail the evaluation of AYFS against defined standards to inform initiatives for strengthening these services.Methods: A cross-sectional assessment of AYFS was carried out in 14 healthcare facilities in a sub-district of Gauteng Province and 16 in a sub-district in North West Province, South Africa. Data on adolescent care and service management systems were collected through interviews with healthcare providers, non-clinical staff and document review. Responses were scored using a tool based on national and World Health Organisation criteria for ten AYFS standards.Results: Mean scores for the ten standards showed substantial variation across facilities in the two sub-Districts, with Gauteng Province scoring lower than the North West for 9 standards. The sub-district median for Gauteng was 38% and the North West 48%. In both provinces standards related to the general service delivery, such as Standards 4 and 5, scored above 75%. Assessment of services specifically addressing sexual, reproductive and mental health (Standard 3) showed that almost all these services were scored above 50%. Exploration of services related to psycho-social and physical assessments (Standard 8) demonstrated differences in the healthcare facilities' management of adolescents' presenting complaints and their comprehensive management including psycho-social status and risk profile. Additionally, none of the facilities in either sub-district was able to meet the minimum criteria for the five standards required for AYFS recognition.Conclusion: Facilities had the essential components for general service delivery in place, but adolescent-specific service provision was lacking. AYFS is a government priority, but additional support for facilities is needed to achieve the agreed standards. Meeting these standards could make a major contribution to securing adolescents' health, especially in preventing unintended pregnancies and HIV as well as improving psycho-social management. [ABSTRACT FROM AUTHOR]

Background: The South African public health sector embarked on a National Telemedicine System implementation program in 1999 and although unsuccessful, the Province of KwaZulu-Natal subsequently implemented teledermatology in 2003, with two currently active services (synchronous and asynchronous). Although sustained these have not been scaled-up to meet the needs of all hospitals in the Province. A recent teledermatology scale-up design requirements elicitation process within KwaZulu-Natal confirmed the need for a framework, and identified requirements through key stakeholders, programme observations, the literature, and experts. This study aimed to identify and characterise existing teledermatology or related eHealth scale-up frameworks, determine whether any met the previously elicited scale-up framework requirements, and were suitable for use in the KwaZulu-Natal public health sector.Methods: A structured literature search was performed of electronic databases (Scopus, Science Direct, IEEE, PubMed, and Google Scholar) seeking proposed or developed teledermatology or related scale-up frameworks. Global public health publications were also hand-searched. The teledermatology or telemedicine, telehealth or eHealth related scale-up frameworks identified were critiqued against the previously elicited teledermatology scale-up framework requirements to determine their suitability for use.Results: No specific teledermatology scale-up framework was found. Seven related scale-up frameworks were identified, although none met all the previously identified teledermatology scale-up framework requirements. The identified frameworks were designed for specific scale-up phases and lacked a more holistic and comprehensive approach.Conclusions: There is an evidenced-based need for the development of a health sector aligned, holistic framework that meets the identified teledermatology scale-up framework requirements. The findings of this paper will inform development of such a framework. [ABSTRACT FROM AUTHOR]

Background: Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.Methods: Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.Results: We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.Conclusion: Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines. [ABSTRACT FROM AUTHOR]

Background: Integration of family planning services into HIV care was implemented in South Africa as a core strategy aimed at reducing unintended pregnancies among childbearing women living with HIV. However, it is unclear whether this strategy has made any significant impact at the population level. This paper describes the prevalence and correlates of self-reported unplanned pregnancy among HIV-infected parturient women attending three large maternity centres in the Eastern Cape, South Africa. We also compare unplanned pregnancy rates between HIV-infected parturient women already in care (who have benefitted from services' integration) and newly diagnosed parturient women (who have not benefitted from services' integration).Methods: Drawing from the baseline data of the East London Prospective Cohort Study (ELPCS), data of 594 parturient women living with HIV in the Eastern Cape were included. Chi-square statistics and binary logistics regression were employed to determine the correlates of unplanned pregnancy among the cohort.Results: The prevalence of unplanned pregnancy was 71% (n = 422) with a higher rate among parturient women newly diagnosed during the index pregnancy (87%). Unplanned pregnancy was significantly associated with younger age, single status, HIV diagnosis at booking, high parity and previous abortion. Women who reported unplanned pregnancy were more likely to book late and have lower CD4 counts. After adjusting for confounding variables, having one child and five to seven children (AOR = 2.2; CI = 1.3-3.1), age less than 21 years (AOR = 3.3; CI = 1.1-9.8), late booking after 27 weeks (AOR = 2.7; CI = 1.5-5.0), not married (AOR = 4.3; CI = 2.7-6.8) and HIV diagnosis at booking (AOR = 3.0; CI = 1.6-5.8) were the significant correlates of unplanned pregnancy in the cohort.Conclusion: Unplanned pregnancy remains high overall among parturient women living with HIV in the region, however, with significant reduction among those who were exposed to integrated services. The study confirms that integration of HIV care and family planning services is an important strategy to reduce unplanned pregnancy among women living with HIV. The study's findings have significant implications for the elimination of mother-to-child transmission of HIV in South Africa. Innovative interventions are needed to further consolidate and maximise the benefit of the integration of family planning services with HIV care. [ABSTRACT FROM AUTHOR]