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Background: Sex workers in South Africa face various forms of structural and interpersonal violence, including police violence, exclusion from health services, and stigmatization and marginalization within their communities. In an attempt to counteract the harmful health effects of criminalization and exclusion, risk-reduction workshops are a key component of HIV prevention programs globally. This paper offers a critical investigation of Creative Space workshops – a South African model of risk-reduction workshops for sex workers – taking place in Soweto, Johannesburg. Drawing on Paulo Freire's work, the paper explores the potential of these workshops to contribute to the empowerment, health and well-being of sex workers. Objectives: The aim of this paper is to investigate the social and psychological effects of peer-led risk-reduction workshops for sex workers in Soweto, South Africa, with a particular focus on the ways in which they might contribute to community empowerment. Methods: This paper is based on in-depth interviews and focus group discussions with 32 sex workers conducted as part of a 20-month ethnographic study (December 2015 to July 2017). Data was analyzed combining inductive thematic analysis with a theoretical frame based on Freire's theory of community empowerment. Results: Peer-led risk-reduction workshops can serve as a 'safe space' for sex workers and distribute empowering forms of knowledge, particularly regarding health issues and rights. However, divisions between different groups of sex workers and between sex workers and non-sex workers counteract the potential benefits of the workshops. Conclusions: Peer-led sex worker programs are likely to be more empowering when they are committed to raising critical consciousness and creating solidarity, and embedded in community action, focusing on common issues such as institutionalized racism, livelihood insecurity, and lack of access to safe and secure housing. Such actions would have positive outcomes on health and well-being. [ABSTRACT FROM AUTHOR]

Background: It is becoming increasingly important for researchers to critically reflect on approaches that can have a positive impact on the health outcomes of indigenous people. Such issues are of great importance and perhaps of special relevance to researchers in the Global South, and to the African context in which we work. Objective:To share some lessons learned from our fieldwork to contribute to current knowledge and conversations on decolonising research process. Methods: We used an African lens to critically reflect upon some issues raised from individual interviews and focus group discussions with our participants which we deem to be important for consideration in a decolonising research process. Results: The major issues that we raise are about important structures such as power, trust, cultural competence, respectful and legitimate research practice and recognition of individual and communities' health assets in a decolonising research process. Conclusions: Our paper argues for alternative approaches which are culturally appropriate for health research and for improved health outcomes of marginalised groups. In addition, we argue that participatory and transformative research methods which recognises individual and communities' assets are needed. We hope that the lessons that we share in this paper can contribute towards a respectful and good research practice among the marginalised population groups in our context. [ABSTRACT FROM AUTHOR]

Although evidence indicates that task-shared psychological interventions can reduce mental health treatment gaps in resource-constrained settings, systemic barriers have limited their widespread implementation. Evidence on how to sustain and scale such approaches is scant. This study responds to this gap by examining the experiences of South African health managers involved in the implementation of a task-shared counselling service for Project MIND. To qualitatively describe managers' experiences of implementing the MIND programme and their insights into potential strategies for supporting sustained implementation. Two focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with managers of urban and rural primary care facilities in the Western Cape province. All managers were female and 30–50 years old. FGDs and IDIs used an identical semi-structured topic guide to explore the experiences of the MIND programme and perceived barriers to sustained implementation. Normalisation process theory (NPT) guided the thematic analysis. Four themes emerged that mapped onto the NPT constructs. First, managers noted that their relational work with staff to promote support for the intervention and reduce resistance was key to facilitating implementation. Second, managers emphasised the need for staff reorientation and upskilling to foster openness to mental health practice and for adequate time for quality counselling. Third, managers underscored the importance of strengthening linkages between the health and social service sectors to facilitate delivery of comprehensive mental health services. Finally, managers recommended ongoing monitoring of the service and communication about its impacts as strategies for supporting integration into routine practice. Findings contribute to the emerging literature on strategies to support implementation of task-shared interventions in low- and middle-income countries. The findings highlight the leadership role of managers in identifying and actioning these strategies. Investing in managers' capacity to support implementation of psychological interventions is critical for scale-up of these mental health innovations. [ABSTRACT FROM AUTHOR]

Health education and self-management are among key strategies for managing diabetes and hypertension to reduce morbidity and mortality. Inappropriate self-management support can potentially worsen chronic diseases outcomes if relevant barriers are not identified and self-management solutions are not contextualised. Few studies deliberately solicit suggestions for enhancing self-management from patients and their providers. This qualitative study aimed to unravel experiences, identify self-management barriers, and solicit solutions for enhancing self-management from patients and their healthcare providers. Eight in-depth interviews were conducted with healthcare providers. These were followed by four focus group discussions among patients with type-2- diabetes and or hypertension receiving chronic disease care from two health facilities in a peri-urban township in Cape Town, South Africa. The Self-Management framework described by Lorig and Holman, based on work done by Corbin and Strauss was used to analyse the data. Patients experienced challenges across all three self-management tasks of behavioural/medical management, role management, and emotional management. Main challenges included poor patient self-control towards lifestyle modification, sub-optimal patient-provider and family partnerships, and post-diagnosis grief-reactions by patients. Barriers experienced were stigma, socio-economic and cultural influences, provider-patient communication gaps, disconnect between facility-based services and patients' lived experiences, and inadequate community care services. Patients suggested empowering community-based solutions to strengthen their disease self-management, including dedicated multidisciplinary diabetes services, counselling services; strengthened family support; patient buddies; patient-led community projects, and advocacy. Providers suggested contextualised communication using audio-visual technologies and patient-centred provider consultations. Community-based dedicated multidisciplinary chronic disease healthcare teams, chronic disease counselling services, patient-driven projects and advocacy are needed to improve patient self-management. [ABSTRACT FROM AUTHOR]

Despite South Africa being an upper middle-income country producing enough food to sustain its population, and having an advanced social welfare system, it has high levels of food insecurity at the household-level. Food insecurity is linked to malnutrition and undernutrition in children. This manuscript addresses gaps in knowledge about food choices and practices of primary caregivers of children in receipt of South Africa's largest cash transfer programme, the Child Support Grant (CSG). The main objective of the study was to explore CSG caregivers' foodways and the choices they made about what food to buy, where to buy it and for what reasons, in Langa in the Western Cape and Mt Frere in the Eastern Cape. We conducted a total of 40 in-depth interviews and 5 focus group discussions with primary caregivers of Child Support Grant recipients younger than 5 years in the Eastern and Western Cape provinces. Caregivers' food choices were less influenced by cultural practices and personal preferences, than by financial and physical constraints in terms of what and where to access food. Constraints in food choices were chiefly a consequence of the small amount of the grant, as well as a food environment that only availed foods of a certain quality and type in these low-income communities The foodways of recipients of social assistance can only be better aligned with nutrition messaging and policy if there are changes in the monetary value of cash transfers, and the food environments of low-income households which determine access to, availability and affordability of nutritious food. Local informal food enterprises play an important role in the food system of CSG recipients and need to be considered in any strategies that seek to reform the food system of low-income communities in South Africa and similar settings [ABSTRACT FROM AUTHOR]

Levels of obesity are rising in South Africa, notably among adolescent females. Excessive energy-dense diets and physical inactivity are among the factors contributing to this increase. Given that these factors are largely behavioural, understanding young people's views of obesity can contribute to more targeted behavioural interventions. Yet little is known of how rural South African adolescents view obesity. The aim of this study was to explore rural South African adolescents' views of obesity, including their understanding of its causes, consequences, and solutions. This qualitative study took place within the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) study area, in rural northeast South Africa. Three focus group discussions were held with male (n = 16) and female adolescents (n = 15), aged 14–19 years in 2018. Data were analysed using thematic analysis and the Social Cognitive Theory used to frame the findings. Participants presented conflicting views of obesity, with both positive and negative opinions expressed. Causes of obesity were seen to be multifactorial, including genetics, diet, lack of physical activity, and HIV treatment. Adolescents proposed medication and hospitalisation as ways to address obesity. When discussing interventions to address obesity, adolescents expressed the need for more information, suggesting that providing information to both themselves and their family members as part of interventions would be important. Rural South African adolescents have a complex perspective of obesity, likely driven in part by the current nutrition transition underway and do not inherently see individual behaviour as a driver or mitigator of obesity. Complex interventions including the involvement of other household members are needed to change adolescents' views on the role of the individual, and ultimately, change both individual and household behaviour to prevent obesity. [ABSTRACT FROM AUTHOR]

Background: HIV/AIDS has had a significant impact on maternal and child health in South Africa. It is thus of vital importance to implement interventions to prevent mother-to-child transmission of HIV (PMTCT) as early as possible during pregnancy. Negative interactions between patients and health care providers (HCPs) can be an important barrier to antenatal care, PMTCT use and PMTCT adherence. Research about respectful maternity care has focused more on the patient perspective. We therefore compared the patient and HCP perspectives and reflected on how interactions between HCPs and patients can be improved. Objective: To obtain insights into the attitudes of HCPs in the context of HIV and PMTCT-related care, by studying patient and HCP perceptions of their interactions, in a peri-urban hospital setting in Gauteng province, South Africa. Methods: A qualitative study was conducted in a public tertiary-level hospital. Fourteen semi-structured in-depth interviews were conducted with nurses and doctors in the antenatal clinic and postnatal ward. Thirty-one semi-structured in-depth interviews and two focus group discussions were conducted with HIV positive and negative women on the postnatal ward. Results: HCPs experienced a difficult work environment due to a high workload. This was combined with frustrations when they felt that patients did not take responsibility for their own or their child's health. They were motivated by the need to help the child. Patients experienced judging comments by HCPs especially towards younger, older and foreign women. They expressed fear to ask questions and self-blame, which in some cases delayed health care seeking. No discrimination or isolation of HIV infected patients was reported by patients and HCPs. Conclusion: We hypothesize that more humane working conditions for obstetric HCPs and a caring, personalised approach to patient management can improve patient-provider interactions and access to respectful care. These are critical to preventing mother-to-child transmission of HIV. [ABSTRACT FROM AUTHOR]

Background: Major national primary healthcare reforms are seldom implemented, and few studies have explored the benefits of primary healthcare outreach teams to rural households, a knowledge gap we sought to address with this study. Objective: The objective of this study was to explore the community benefits in the context of PHC services delivered in rural households by outreach teams. Methods: The study was conducted in the iLembe District on the east coast of KwaZulu-Natal, South Africa between July 2015 and January 2017. In-depth, explorative and semi-structured qualitative interviews were conducted as part of a mixed-method study. A total of 21 in-depth interviews with key informants and four focus group discussions (n = 28) were conducted with purposefully sampled households and outreach team members. Content analysis was used to explore and understand the households' experiences of primary healthcare services provided by outreach teams. Results: Household members benefited from outreach team services tailored to specific households and individuals, which improved the efficiency of healthcare services, access to appropriate health information and the overall experience of healthcare, particularly among those who are physically unwell, on chronic treatment, default treatment or immunisation, or who need referrals for clinical and social services. The benefits to household members included personalised care in the home, improved referral pathways, awareness of health events, improved adherence to treatment and reduction in opportunity costs of healthcare. Conclusion: It is perceived that participants have benefitted from the model of PHC service delivery by outreach teams through improved access to healthcare services, and by allowing community members to receive services that are responsive to their needs since the outreach team members' advocate and negotiate to deliver services on behalf of community members. These stated benefits, as perceived by household members, have the potential to improve health outcomes and increase satisfaction levels amongst household members. [ABSTRACT FROM AUTHOR]

Background: South African physicians can specialise in public health through a four-year 'registrar' programme. Despite national health policies that seemingly value public health (PH) approaches, the Public Health Medicine (PHM) speciality is largely invisible in the health services. Nevertheless, many physicians enrol for specialist training. Objectives: This study investigated physicians' motivations for specialising in PHM, their intended career paths, perceptions of training, and perspectives about the future of the speciality. Methods: Focus groups and in-depth interviews were conducted with specialists-in-training and newly qualified specialists, and thematic analysis of transcripts was performed. Results: Motivations, often driven by difficult experiences as young physicians in poorly resourced clinical settings, stemmed from a commitment to improving communities' health and desire to impact on perceived failing health systems. Rather than 'exiting' the South African health service, selecting PHM specialist training enacted participants' 'loyalty' to population health. Participants anticipated carving out their own careers due to an absence of public sector career paths. They believed specialists' contribution centred on providing 'public health intelligence' - finding and interpreting information; supporting services through management and leadership; and inputting into policymaking and planning. Conclusions: Competencies of PHM specialists should be refined to inform and improve management of this scarce human resource for health. This is particularly important given the proposed major health reforms towards universal health coverage in South Africa presently. In addition, findings highlight the importance of physicians' early work experiences where avenues for expressing 'voice', mediated by 'loyalty', could be utilised to improve public sector health systems. [ABSTRACT FROM AUTHOR]