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Early motherhood can negatively impact health, educational, and socio-economic outcomes for adolescent mothers and their children. Supporting adolescent mothers' educational attainment, and timely return to school, may be key to interrupting intergenerational cycles of adversity. Yet, there remains a paucity of evidence on the factors that are associated with mothers' postpartum return to school and the mediators of this process, particularly across sub-Saharan Africa where adolescent pregnancy rates remain high. This paper is based on interviews with 1,046 adolescent mothers from South Africa. Mothers who had returned to school after birth showed lower poverty, fewer repeated grades preceding the pregnancy, continued schooling during pregnancy, higher daycare/crèche use, more family childcare support, and lower engagement in exclusive breastfeeding within six months postpartum. Mediation analyses showed that lower poverty was directly associated with school return and via two indirect pathways: continued schooling during pregnancy and using daycare/crèche services. This study demonstrates that lacking childcare constitutes a major hurdle to mothers' school return which needs to be addressed in addition to socioeconomic and individual-level barriers. Policy makers and practitioners should consider supporting young mothers with combination interventions which include services supporting school retention during pregnancy and access to, and financial supplements for, daycare. [ABSTRACT FROM AUTHOR]

In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services. This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery. [ABSTRACT FROM AUTHOR]

Purpose: Healthiness is constructed, in Western culture, as a moral ideal or supervalue. This paper will interrogate the assumption that health and the pursuit of healthiness is always and unquestionably positive, by exploring how discourses of health and freedom interact to reinforce the current inequalities and detract from social transformation. Method: Twenty young South African adults were interviewed about their understandings and experiences of health. These discussions were analysed using Foucauldian discourse analysis. Results: Participants constructed healthiness as facilitating the experience of freedom, while at the same time being dependent on a personal orientation towards freedom (as opposed to merely submitting to dominant health authorities). Freedom discourses also played a role in connecting health to neoliberal discourses idealizing economic productivity and hard work. Participants were able to construct a self that is active, productive, valuable, hopeful, and self-assured when talking about health using discourses of freedom. However, these discourses also functioned to moralise and idealise healthiness, which contributed to blaming poor health on its sufferers. Conclusion: Health/freedom discourses can further reinforce the neoliberal value of individual responsibility by constructing self-improvement and self-work as the solution to ill-health, thereby contributing to victim-blaming and weakening support for public health interventions. [ABSTRACT FROM AUTHOR]

Young people, particularly adolescent girls and young women, represent a growing proportion of those living with HIV. Edutainment programmes have been widely used throughout the world to "educate" and "entertain" audiences and tackle serious social issues in bold and engaging ways. This paper examines the extent to which an edutainment programme, MTV-Shuga, was reported to influence young people's engagement with sexual and reproductive health (SRH) information in rural KwaZulu-Natal, South Africa. In 2019 we conducted eight community-based screenings of MTV-Shuga episodes followed by 25 individual in-depth interviews and 13 focus group discussions with young people aged between 15 and 30. Interviews were audio recorded and transcribed verbatim. Data analysis was thematic and complemented by constant comparison and deviant case analysis techniques. In this rural and poor setting with a high burden of HIV, young people exhibited high levels of awareness of SRH and HIV but had constrained access to services, and limited ability to engage with parents or guardians on SRH matters. MTV Shuga provided an entertaining guide of ways to navigate the risks that they faced in a way that resonated with them. The findings highlight the importance of enabling young people in rural areas to watch MTV Shuga with peers in a safe space in which discussion of the content is facilitated. There is also value in encouraging parents to watch MTV Shuga as a means of enabling discussions between children and adults in their lives about SRH matters. [ABSTRACT FROM AUTHOR]

The aim of this study was to explore how participants and physicians experienced a plant-based dietary approach to type 2 diabetes mellitus (T2DM) in South Africa. A multiple-case study was undertaken. The pilot 'Diabetes Reversal Challenge' was initiated and led by UBUNTU Wellness Institute. Participants with T2DM consume a whole-food plant-based diet for 21 days and are assigned to private physicians for clinical monitoring of health outcomes. South African adults with T2DM (n = 10) and physicians (n = 4) participated in the challenge between April 2021 and May 2022. Participants' health outcomes and contextual factors influencing how participants and physicians experienced the plant-based dietary approach in South Africa were the measures used. The plant-based dietary approach resulted in positive health outcomes for South African adults with T2DM, such as improved glycaemic control, weight loss, reduced need for medication and psychological benefits. Multiple layers of contextual factors influenced the plant-based dietary approach to T2DM in South Africa, mapped into a socio-ecological framework that includes (1) individual, (2) interpersonal, (3) organisational, (4) community and (5) healthcare system factors. These results encourage healthcare systems to explore plant-based dietary approaches as an option in the management of T2DM in South Africa. [ABSTRACT FROM AUTHOR]

Background: The incidence and prevalence of COVID-19 continues to escalate globally, with the consequence to quality of life, the economies of nations and various sectors of society. While there is substantial research on the impact and experiences of the COVID-19 pandemic, little remains known about the perceptions and lived experiences of families living with people diagnosed with COVID-19, particularly within the South African context. Purpose: To explore the perceptions and lived experiences of family members living with people diagnosed with COVID-19 in South Africa. Methods: A descriptive phenomenological design was used. Data were collected from 15 participants who were family members of people diagnosed with COVID-19 in South Africa. Purposive snowball sampling was used to identify and recruit participants, and data were collected at community level in KwaZulu-Natal, Western Cape and Gauteng, South Africa. Individual in-depth interviews were used to collect the data, and an audio tape was used to record all interviews. Data were transcribed verbatim and analysed using a phenomenological data analysis processes. Ethical approval to conduct the study was obtained from the University of KwaZulu-Natal Research Ethics Committee--reference number: BREC00003228/ 2021. Results: Four super-ordinate themes emerged in relation to the perceptions and lived experiences of family members living with people diagnosed with COVID-19 in South Africa. The superordinate themes were: (1) sources of information about COVID-19, (2) pandemic perceptions and experiences, (3) impact of diagnosis and related burden and (4) aftermath of living with a family member diagnosed with COVID-19. Discussion and conclusion: Family members' perceptions and lived experiences of COVID-19 are largely influenced by media, moreover, the impact of diagnosis has consequences for the physical, mental and emotional well-being of family members. Diagnosis disrupts family dynamics by depleting financial resources due to the caregiver burden experienced. The findings thus imply that provision of psychosocial support is imperative for families living with persons diagnosed with COVID-19. [ABSTRACT FROM AUTHOR]

Objective: A study was undertaken to explore the differences in nutrition knowledge, attitudes, beliefs and practices and their correlations among adults in both urban and rural communities in the Free State province of South Africa. Design: This study forms part of the cross-sectional Assuring Health for All in the Free-State (AHA-FS) study. Setting: The AHA-FS study is conducted in urban and rural parts of the Free State province of South Africa. The rural and urban stages of the study were conducted in 2007 and 2009, respectively. Subjects: The sample included 846 adult household members, aged between 25 and 65 years, from both rural and urban areas of the Free State province. Outcome measures: Nutrition knowledge, attitudes, beliefs and practices were measured. Results: The sample included predominantly females (78.2%). Rural adults had significantly better nutrition knowledge (p < 0.001), positive attitudes (p < 0.001) and positive beliefs (p < 0.001) and their nutrition knowledge and attitudes (r = 0.27, p < 0.001), nutrition knowledge and beliefs (r = 0.16, p < 0.001), and nutrition attitudes and beliefs (r = 0.38, p < 0.001) were significantly correlated with each other. However, nutrition knowledge, attitudes and beliefs were not correlated with nutrition practices among our sample in either the urban or rural setting. Conclusion and implication: The results of the current study confirm that relevant and culturally acceptable nutrition education interventions for translating nutrition-related knowledge, attitudes and beliefs into practices are required. [ABSTRACT FROM AUTHOR]

A study was undertaken to determine the energy and nutrient contribution of different food groups to the dietary intake of 6- to <9-month-old infants. An observational study was conducted using baseline data of a preliminary randomised controlled trial that aimed to determine the effect of egg consumption on infant growth. Participants resided in a peri-urban community (Jouberton) in North West province, South Africa. The study included 6- to <9-month-old infants (n = 155); 24-hour dietary recall data were available for n = 144. Most infants consumed either two (29.2%) or three (42.4%) out of eight food groups. The grains/roots/tubers group was consumed by 95.8% of infants; for consumers thereof, it contributed 75.5% of iron, 53.0% of thiamine and 42.5% of folate. Breast milk and dairy were consumed respectively by 64.4% of infants. For breastfed infants, breast milk was the major contributor of energy and fat, and some micronutrients (calcium, zinc, vitamin A, vitamin C, niacin and riboflavin); but they had lower intakes (p < 0.05) for all micronutrients except vitamin A compared with non-breastfed infants. For consumers (16.7%) of animal-source foods (ASFs), these contributed 42.8% for vitamin B12 and 33.4% for protein; and intake of protein, riboflavin and vitamin B12 was higher (p < 0.05) for consumers compared with non-consumers. The least consumed food groups were legumes (0.7%), flesh foods (6.9%) and eggs (10.4%). Grains/roots/tubers, dairy and breast milk made a major contribution to the intake of key nutrients. Animal-source foods were not consumed frequently, but for consumers thereof made a substantial contribution as well. Strategies to improve dietary diversity should encourage continued breastfeeding, aim to increase intake of food groups not frequently consumed and promote locally available food. [ABSTRACT FROM AUTHOR]

Objective: To describe the dietary intake and its quality of patients with poorly controlled type 2 diabetes mellitus (T2DM) by assessing the dietary variety (DVS), dietary diversity (DDS), nutrient adequacy ratio (NAR) and mean nutrient adequacy ratio (MAR). Design: This was a descriptive, cross-sectional study. Setting: Diabetes outpatient clinic at a tertiary hospital in Tshwane district, Gauteng province, South Africa. Subjects: Adults, aged 40–70 years, with poorly controlled T2DM (HbA1c ≥ 8%). Outcome measures: Dietary intake data were obtained through two, multi-pass, 24-hour recalls. Individual food items were used to determine the DVS and DDS. The SAMRC FoodFinder III software was used to analyse the macro- and micronutrients, from which the NAR and MAR scores were determined. Descriptive statistics were used to analyse the data. Results: Seventy-seven patients (60 females) participated. Their mean age was 57.2 (±6.6) years. The DDS was adequate at 4.99 (out of a possible 7 food groups); however, the DVS was low (16%) as well as the consumption of vegetables, fruits and legumes. Mean NAR scores indicated insufficient energy intake. Intakes of vitamin D, calcium, folate and iron were below 50% of the recommended daily intake. MAR scores indicated unsatisfactory micronutrient intake at 0.63 (ideal ≥ 1). Conclusions: In this tertiary healthcare setting, T2DM patients with poor glycaemic control had sub-optimal dietary quality. Interventions such as nutrition education programmes that provide simple and factual information on the benefits of healthy eating and practical ways of achieving healthy diets among people with T2DM are needed. [ABSTRACT FROM AUTHOR]

Background: Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights. Objectives: This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making. Methods: A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps. Results: Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems. Conclusion: China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic. [ABSTRACT FROM AUTHOR]

Complementary foods are required to be given timeously, in adequate amounts, prepared safely and must be nutritious. Caregivers play a vital role in ensuring that the complementary feeding transition and beyond happens optimally to achieve normal growth and development in their children. The aim was to explore what factors influenced the primary caregivers' choices during the complementary feeding transition period. A cross-sectional qualitative study was conducted using focus-group discussions and interviews with caregivers of children enrolled in the Optimal Child Growth and Development (OrCHID) study, which included participants from the Mother and Child in Environment (MACE) cohort and SONKE mother and child cohort. During the analysis of the focus-group discussions (FGDs) and interviews, nine themes were identified including: (i) starting complementary feeding; (ii) food choices; (iii) family meals; (iv) food preparation methods; (v) meal composition; (vi) texture; (vii) education source; (viii) food source; and (ix) nutrition knowledge. These themes and the key concepts associated with them were categorised into timing and transition, meal preparation, and knowledge and choices. The caregivers relied largely on advice from family members who advised on their customs and cultural belief systems, which then impacted when the caregivers started complementary foods, food choices, texture, meal composition and transition to family meals. The caregivers sourced complementary foods based on accessibility, convenience and affordability. The caregivers described having a responsive feeding style, where their decisions were influenced by their sensitivity to how their child was responding emotionally and/or physically to the foods they were receiving. focus group discussion, complementary feeding practices, caregivers [ABSTRACT FROM AUTHOR]

COVID-19 prevention measures including lockdowns, school closures, and restricted movement disrupted young people's lives. This longitudinal qualitative study conducted in Soweto, South Africa aimed to explore young people's knowledge and perceptions of COVID-19, vaccination, and the impact of infections. A convenience sample of 30 young black people (n = 15 men; n = 15 women, aged 16–21 years) from Soweto participated in 24 focus group discussions (FGDs), conducted in six phases – each phase had four FGDs stratified by gender and age. Young people's understanding of COVID-19 deepened throughout the study, however, did not always translate into adherence (following the government's COVID-19 prevention measures). Although deemed inadequate, TV and radio were preferred over internet COVID-19 information. Parents, teachers, and schools were trusted sources of information. Vaccines and limited access to information attributed to low-risk perception, while new COVID-19 variants attributed to high-risk perception. A low-risk perception and conspiracy theories contributed to non-adherence (disregarding COVID-19 preventative measures provided by the government), particularly among young men. Accessing reliable information that considers young people's lives and their living context is important. Communities, scientists, and policymakers must learn from the COVID-19 experience and implement localised preventive strategies for education, awareness, and economic support in future emergencies. [ABSTRACT FROM AUTHOR]

Universal health coverage (UHC) aims to ensure people have access to the health services they need. Sixteen tracer indicators were developed for implementation by countries to measure UHC in the health system. South Africa uses 15 of the proposed 16 indicators. Operational managers in the public health care sector collect data and report on these indicators at a primary health clinic level. This qualitative study explored the knowledge and attitudes of managers toward data and UHC service indicators in a sub-district in Ugu, KwaZulu-Natal, South Africa. Operational managers saw data collection as information gathering, measuring performance and driving action. They understood UHC indicators as 'health for all' linking them to National Department of Health Strategic plans and saw the value of indicators for health promotion. They found the lack of training, inadequate numeracy skills, requests for data from multiple spheres of government and the indicator targets that they had to reach as challenging and untenable. While operational managers made the link between data, measuring performance and action, the limited training, skills gaps and pressures from higher levels of government may impede their ability to use data for local level planning and decision making. [ABSTRACT FROM AUTHOR]

Adolescent mothers face numerous challenges. This study aimed to address the operationalisation of the new South African national policy for young mothers by testing the associations of potential protective provisions with three policy goals: School return, grade promotion, and pregnancy/HIV prevention. Adolescent mothers aged 12–24 from rural and urban communities of South Africa's Eastern Cape completed study questionnaires between 2017–2019. Using multivariate multi-level analysis, we simultaneously estimated associations between hypothesized provisions and protective variables and all policy-aligned goals. School return was associated with using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Grade promotion was associated with greater exposure to friendly and respectful health staff, using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Pregnancy/HIV prevention (condom use) was moderately associated with greater exposure to friendly and respectful health staff. There was evidence of synergies of provisions whereby a combination of protective characteristics showed larger positive effects than receipt of any single factor alone. This study provides essential evidence for operationalising South Africa's new policy on the Prevention and Management of Learner Pregnancy in Schools, and points to implementation strategies that provide low-cost opportunities to promote educational and health outcomes for adolescent mothers. [ABSTRACT FROM AUTHOR]

Men are less vulnerable to HIV acquisition than women, but have poorer HIV-related health outcomes. They access HIV services less, and are more likely to die on antiretroviral therapy. The adolescent epidemic presents further challenges, and AIDS-related illness is the leading cause of death among adolescents in sub-Saharan Africa. We explored the health practices of adolescent boys and young men (aged 13–22) living with perinatally-acquired HIV and the processes through which these practices are formed and sustained. We engaged health-focused life history narratives (n = 35), semi-structured interviews (n = 32) and analysis of health facility files (n = 41), alongside semi-structured interviews with traditional and biomedical health practitioners (n = 14) in the Eastern Cape, South Africa. Participants did not access traditional products and services for HIV, a finding that deviates from much of the literature. Findings suggest that health practices are mediated not only by gender and culture, but also childhood experiences of growing up deeply embedded in the biomedical health system. [ABSTRACT FROM AUTHOR]

We explore how organisations working on parenting programmes and other types of family support and violence prevention in low-resource settings experienced the pandemic. In August 2020–May 2021, we interviewed (1) staff from three community-based organisations delivering evidence-informed parenting interventions and other psychosocial services for families in Cape Town, South Africa, (2) staff from a parenting programme training organisation and (3) staff from two international organisations supporting psychosocial services in South Africa. Interviews (22) were thematically analysed, with findings in three areas. First, respondents noted changes in the context, including the job losses, food insecurity, and stress experienced by local communities, and reductions in organisational funding. Second, we found that in response to these context changes, the organisations shifted their focus to food provision and COVID prevention. Parenting and psychosocial programmes were adapted – e.g. by changing the physical delivery settings, reducing group sizes, and taking up digital and phone implementation. Participants reported improved perceptions of remote delivery as a feasible approach for working with families – but internet and phone access remained challenging. Third, the pandemic brought new responsibilities for staff, and both the challenges of working from home and the health risks of in-person work. [ABSTRACT FROM AUTHOR]

The South African national cause of death validation (NCODV 2017/18) project collected a national sample of verbal autopsies (VA) with cause of death (COD) assignment by physician-coded VA (PCVA) and computer-coded VA (CCVA). The performance of three CCVA algorithms (InterVA-5, InSilicoVA and Tariff 2.0) in assigning a COD was compared with PCVA (reference standard). Seven performance metrics assessed individual and population level agreement of COD assignment by age, sex and place of death subgroups. Positive predictive value (PPV), sensitivity, overall agreement, kappa, and chance corrected concordance (CCC) assessed individual level agreement. Cause-specific mortality fraction (CSMF) accuracy and Spearman's rank correlation assessed population level agreement. A total of 5386 VA records were analysed. PCVA and CCVAs all identified HIV/AIDS as the leading COD. CCVA PPV and sensitivity, based on confidence intervals, were comparable except for HIV/AIDS, TB, maternal, diabetes mellitus, other cancers, and some injuries. CCVAs performed well for identifying perinatal deaths, road traffic accidents, suicide and homicide but poorly for pneumonia, other infectious diseases and renal failure. Overall agreement between CCVAs and PCVA for the top single cause (48.2–51.6) indicated comparable weak agreement between methods. Overall agreement, for the top three causes showed moderate agreement for InterVA (70.9) and InSilicoVA (73.8). Agreement based on kappa (−0.05–0.49)and CCC (0.06–0.43) was weak to none for all algorithms and groups. CCVAs had moderate to strong agreement for CSMF accuracy, with InterVA-5 highest for neonates (0.90), Tariff 2.0 highest for adults (0.89) and males (0.84), and InSilicoVA highest for females (0.88), elders (0.83) and out-of-facility deaths (0.85). Rank correlation indicated moderate agreement for adults (0.75–0.79). Whilst CCVAs identified HIV/AIDS as the leading COD, consistent with PCVA, there is scope for improving the algorithms for use in South Africa. [ABSTRACT FROM AUTHOR]

Harnessing of private sector resources could play an important role in efforts to promote universal access to safe obstetric care including caesarean delivery in low- and middle-income countries especially in rural contexts but any such attempt would need to ensure that the care provided is appropriate and patterns of inappropriate care, such as high caesarean delivery rates, are not reproduced for the entire population. To examine the contracting arrangements for using private general practitioners to provide caesarean delivery services in rural district hospitals in South Africa. We utilised a mixed-method study design to examine the contracting models adopted by five rural district hospitals in the Western Cape, South Africa. Between April 2021 and March 2022, we collected routine data from delivery and theatre registers to capture the profile of deliveries and utilisation of contracted private GPs. We also conducted 23 semi-structured qualitative interviews with key stakeholders to explore perceptions of the contracting arrangements. All five hospitals varied in the level of use of private general practitioners and the contracting models (three private in-sourcing models – via locum agencies, sessional contracts, and tender contracts) used to engage them. Qualitative interviews revealed insights related to the need for flexibility in the use of contractual models to meet local contextual needs, cost implications and administrative burden. Structured appropriately, private public partnerships can fill important gaps in human resources in rural district hospitals. Policy makers should look to developing a 'contracting framework' which requires compliance with a set of underlying principles but allows for flexibility in developing context specific contracting arrangements. These underlying principles should include a 'risk' based delivery model, adherence to public sector- evidence-based protocols, time-based rather than per delivery/type of delivery remuneration models, group liability arrangements, and processes to monitor outcomes. [ABSTRACT FROM AUTHOR]

The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls' and young women's (AGYW; aged 15–24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini's electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW's SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period. [ABSTRACT FROM AUTHOR]

Lifestyle Africa is an adapted version of the Diabetes Prevention Program designed for delivery by community health workers to socioeconomically disadvantaged populations in low- and middle-income countries (LMICs). Results from the Lifestyle Africa trial conducted in an under-resourced community in South Africa indicated that the programme had a significant effect on reducing haemoglobin A1c (HbA1c). To estimate the cost of implementation and the cost-effectiveness (in cost per point reduction in HbA1c) of the Lifestyle Africa programme to inform decision-makers of the resources required and the value of this intervention. Interviews were held with project administrators to identify the activities and resources required to implement the intervention. A direct-measure micro-costing approach was used to determine the number of units and unit cost for each resource. The incremental cost per one point improvement in HbA1c was calculated. The intervention equated to 71 United States dollars (USD) in implementation costs per participant and a 0.26 improvement in HbA1c per participant. Lifestyle Africa reduced HbA1c for relatively little cost and holds promise for addressing chronic disease in LMIC. Decision-makers should consider the comparative clinical effectiveness and cost-effectiveness of this intervention when making resource allocation decisions. Trial registration is at ClinicalTrials.gov (NCT03342274). [ABSTRACT FROM AUTHOR]

Partner engagement in antenatal care can improve care for pregnant people living with HIV. However, concerns about engaging unsupportive non-pregnant partners warrant further study to avoid engaging partners who pressure their pregnant partner to refuse testing or treatment and/or perpetuate intimate partner violence. We adapted established relationship functioning and partner behaviour questionnaires among pregnant people living with HIV initiating antenatal care in rural South Africa. We identified 13 previously validated psychometric scales with 255 items that assess relationship functioning and partner behaviour, but, to our knowledge, had not been used in Southern Africa. After item translation and cognitive interviewing with 30 pregnant people, we recruited an additional 208 pregnant people living with HIV receiving antenatal care. We conducted an exploratory factor analysis with maximum-likelihood extraction and oblique promax rotation with the 58 items and 10 scales that remained after translation and cognitive interviewing. We used parallel analysis, scree plots, and the Kaiser criterion to guide factor retention and assessed internal factor consistency via Cronbach's alpha. Of the 208 participants recruited, 197 (95%) answered each question and were included in the analysis. Exploratory factor analysis revealed 7 factors that assessed partner social support, sexual relationship power, emotional intimacy, threatened or enacted violence, sexual intimacy, violence in relationships, and partner engagement in pregnancy care via 37 items. Factor absolute Spearman correlations ranged from 0.012 to 0.518 and Cronbach's alpha ranged from 0.84 to 0.92. This preliminary analysis will guide further scale development. Future developments will also include relevant clinical outcomes to assess the predictive validity of the resulting measures. These steps will further refine these questions into a succinct screening tool to assess relationship functioning and partner behaviour. This screening tool may eventually guide the selection of partner-based interventions during pregnancy to improve outcomes for pregnant people and their partners. [ABSTRACT FROM AUTHOR]

Sugar-sweetened beverage (SSB) taxes are recognised as an effective intervention to prevent obesity. More countries are adopting SSB taxes, but the process of the adoption is politically complex. This study aimed to analyse how public participation processes influenced the South African tax. We conducted a content analysis of documents associated with the process of adopting the tax. Records were identified utilising the Parliamentary Monitoring Group database, including draft bills, meeting minutes and written submissions. The records were categorised and then inductively coded to identify themes and arguments. We identified six cross-cutting themes advanced by stakeholders: economic considerations, impact on the vulnerable, responsiveness of an SSB tax to the problem of obesity, appropriateness of an SSB tax in South Africa, procedural concerns, and structure of the tax. Stakeholder views and arguments about the tax diverged based on their vested interests. The primary policymaker was most responsive to arguments concerning the economic impact of a tax, procedural concerns and the structure of the tax, reducing the effective rate to address industry concerns. Both supportive and opposing stakeholders influenced the tax. Economic arguments had a significant impact. Arguments in South Africa broadly echoed arguments advanced in many other jurisdictions. [ABSTRACT FROM AUTHOR]

The unfinished burden of poor maternal and child health contributes to the quadruple burden of disease in South Africa with the direct and indirect effects of the COVID-19 pandemic yet to be fully documented. To investigate the indirect effects of COVID-19 on maternal and child health in different geographical regions and relative wealth quintiles. We estimated the effects of COVID-19 on maternal and child health from April 2020 to June 2021. We estimated this by calculating mean changes across facilities, relative wealth index (RWI) quintiles, geographical areas and provinces. To account for confounding by underlying seasonal or linear trends, we subsequently fitted a segmented fixed effect panel model. A total of 4956 public sector facilities were included in the analysis. Between April and September 2020, full immunisation and first dose of measles declined by 6.99% and 2.44%, respectively. In the follow-up months, measles first dose increased by 4.88% while full immunisation remained negative (−0.65%) especially in poorer quintiles. At facility level, the mean change in incidence and mortality due to pneumonia, diarrhoea and severe acute malnutrition was negative. Change in first antenatal visits, delivery by 15–19-year olds, delivery by C-section and maternal mortality was positive but not significant. COVID-19 disrupted utilisation of child health services. While reduction in child health services at the start of the pandemic was followed by an increase in subsequent months, the recovery was not uniform across different quintiles and geographical areas. This study highlights the disproportionate impact of the pandemic and the need for targeted interventions to improve utilisation of health services. [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]

Regulating the marketing of commercial formula products is a long-term commitment required to protect breastfeeding. Marketing strategies of formula manufacturers, retailers and distributors evolve at a rapid rate. The aim of this research was to describe exposure of pregnant women and mothers of young children in South Africa to marketing of commercial formula products, compared to international recommendations and national legislation. Using mobile phone marketing diaries twenty participants in Cape Town and Johannesburg documented the formula marketing they were exposed to for one week. Ten mothers were interviewed to explore their perceptions towards marketing exposure in more depth. Women reported limited infant formula advertising, but an abundance of strategies used to market growing-up formula and powdered drinks for children over 36 months. Strategies included product packaging, in-store displays, online distribution channels and educational material about product ranges. Online strategies were reported, namely social media marketing (sponsored adverts and support groups), websites and mobile phone applications providing infant and young child feeding information and price discounts, print and TV advertisements, and competitions. Products for children over 36 months are cross-promoted with products prohibited to be advertised by national legislation. South African women are being exposed to covert marketing of infant, follow-up, and growing-up formula. Explicit marketing of products for children over 36 months of age allows formula companies to provide messages about branding and use of commercial formula products to mothers. National legislation should be updated and effectively implemented to address changing marketing strategies. [ABSTRACT FROM AUTHOR]

Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa. [ABSTRACT FROM AUTHOR]

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage. The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis. Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts' image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth. Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy. Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients. [ABSTRACT FROM AUTHOR]

Overweight and obesity are major risk factors for noncommunicable diseases. This presents a major burden to health systems and to society in South Africa. Collectively, these conditions are overwhelming public healthcare. This is happening when the country has embarked on a journey to universal health coverage, hence the need to estimate the cost of overweight and obesity. Our objective was to estimate the healthcare cost associated with treatment of weight-related conditions from the perspective of the South African public sector payer. Using a bottom-up gross costing approach, this study draws data from multiple sources to estimate the direct healthcare cost of overweight and obesity in South Africa. Population Attributable Fractions (PAF) were calculated and multiplied by each disease's total treatment cost to apportion costs to overweight and obesity. Annual costs were estimated for 2020. The total cost of overweight and obesity is estimated to be ZAR33,194 million in 2020. This represents 15.38% of government health expenditure and is equivalent to 0.67% of GDP. Annual per person cost of overweight and obesity is ZAR2,769. The overweight and obesity cost is disaggregated as follows: cancers (ZAR352 million), cardiovascular diseases (ZAR8,874 million), diabetes (ZAR19,861 million), musculoskeletal disorders (ZAR3,353 million), respiratory diseases (ZAR360 million) and digestive diseases (ZAR395 million). Sensitivity analyses show that the total overweight and obesity cost is between ZAR30,369 million and ZAR36,207 million. This analysis has demonstrated that overweight and obesity impose a huge financial burden on the public health care system in South Africa. It suggests an urgent need for preventive, population-level interventions to reduce overweight and obesity rates. The reduction will lower the incidence, prevalence, and healthcare spending on noncommunicable diseases. [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]

Community knowledge is a critical input for relevant health programmes and strategies. How community perceptions of risk reflect the burden of mortality is poorly understood. To determine the burden of mortality reflecting community-nominated health risk factors in rural South Africa, where a complex health transition is underway. Three discussion groups (total 48 participants) representing a cross-section of the community nominated health priorities through a Participatory Action Research process. A secondary analysis of Verbal Autopsy (VA) data was performed for deaths in the same community from 1993 to 2015 (n = 14,430). Using population attributable fractions (PAFs) extracted from Global Burden of Disease data for South Africa, deaths were categorised as 'attributable at least in part' to community-nominated risk factors if the PAF of the risk factor to the cause of death was >0. We also calculated 'reducible mortality fractions' (RMFs), defined as the proportions of each and all community-nominated risk factor(s) relative to all possible risk factors for deaths in the population. Three risk factors were nominated as the most important health concerns locally: alcohol abuse, drug abuse, and lack of safe water. Of all causes of deaths 1993–2015, over 77% (n = 11,143) were attributable at least in part to at least one community-nominated risk factor. Causes of attributable deaths, at least in part, to alcohol abuse were most common (52.6%, n = 7,591), followed by drug abuse (29.3%, n = 4,223), and lack of safe water (11.4%, n = 1,652). In terms of the RMF, alcohol use contributed the largest percentage of all possible risk factors leading to death (13.6%), then lack of safe water (7.0%), and drug abuse (1.3%). A substantial proportion of deaths are linked to community-nominated risk factors. Community knowledge is a critical input to understand local health risks. [ABSTRACT FROM AUTHOR]

Retention of patients in HIV care is a critical barrier to reaching the UNAIDS 90–90-90 goals in South Africa. In January 2019, Anova Health Institute launched a campaign to encourage patients who had interrupted antiretroviral therapy to return to care. The Welcome Back campaign included training of health care workers and implementation of Médecins Sans Frontiers Welcome Services principles. The aim of this study was to explore the experiences of healthcare workers managing patients reinitiating antiretroviral therapy following training, including barriers and facilitators to implementation. Data were collected from six clinics. This study consisted of three components: 1) surveys; 2) semi-structured interviews and 3) reflexive feedback sessions. Each component covered staff attitudes and facility management of patients reinitiating antiretroviral therapy. A descriptive analysis was conducted of survey responses. A thematic approach was used to analyze interviews. Thirty-six healthcare workers completed the survey and interview. Following analysis, feedback sessions were conducted with 99 healthcare workers. Twenty-two (61%) participants were lay counsellors. The majority of healthcare workers reported managing patients returning to care appropriately. However, barriers persisted: 9 (25%) responded that patients were sent to the back of the queue and that service providers continued to insist on transfer letters. Twenty-five (69%) responded they had seen/heard other healthcare workers act poorly towards returning patients after training. Many poor behaviours from healthcare workers stemmed from frustration with the clinical flow and their overburdened work environment. Many participants (78%) believed that the Welcome Back approach helped improve client-provider relationships. The Welcome Back approach supported healthcare workers to improve service provision for patients reinitiating antiretroviral therapy. Further support is needed to help providers consistently deliver services in line with the Welcome Back approach. Institutional level changes are required to implement patient-centred and trust-based models of care. [ABSTRACT FROM AUTHOR]

Purpose: Adolescents may be known to take risks, but they may also conform to societal norms if they are given proper guidance, implying that there is a need for proper monitoring. This qualitative study explores the influence of family dynamics on adolescents sexual risk behaviour within a migration affected community.Method: Using thematic analysis, we processed data collected from 13 adolescents and 10 parents.Results: The themes generated from our data include the following, "Household poverty", "Family conflicts", "Lack of discipline", "Parent-child closeness", "Generational gap between adolescents and their parents" and "Lack of sex education". Our study found that financial constrain was a major problem in this community, the impact of this was worse felt among adolescents who lived by themselves. In addition, some parents were delinquent, distant or detached from their adolescents. We also found evidence to suggest that couple conflict was a common occurrence, and this had negative influence on adolescent well-being and there sexual behaviour.Conclusion: In view of the deepening crisis of early sexual engagement among adolescents and the accompanying risk of unplanned pregnancy and sexually transmitted infections, it is imperative to foster adolescent friendly households where the parents/caregivers are empowered to support their adolescents. [ABSTRACT FROM AUTHOR]

Background: Alcohol abuse remains one of the most serious substance abuse disorders in South African society, resulting in inordinately large social, economic and health problems at all levels of society. Alcohol consumers in South Africa are estimated to drink 16.6 l per annum, with a per capita consumption of 7.1 l. South Africa has one of the highest rates of deaths attributable to crime, violence, traffic accidents and HIV/AIDS in the world. These rates relate directly to the high prevalence of alcohol abuse and risky drinking patterns. A food-based dietary guideline that appears to encourage alcohol consumption is not in the nation’s best interest. Method: A search was conducted of websites supported by the World Health Organization to find published literature on substance abuse in South Africa. The website of the Medical Research Council of South Africa for studies on the social impact of alcohol abuse on humans was also reviewed. The search terms “alcohol guidelines”, “alcohol abuse”, “noncommunicable diseases”, “health benefits of alcohol”, “moderate drinking”, “alcohol” and “intake patterns” were used. Studies published between 2002 and the present were reviewed. Results: Based on evidence of the past two decades, messages that convey the positive health benefits of moderate alcohol consumption (e.g. increased levels of high-density cholesterol) should be promoted and even encouraged in moderate drinkers (i.e. one alcoholic drink per day for women and a maximum of two drinks per day for men). Moderate drinking is not encouraged in those who do not consume alcohol at all. Nutrition educators should emphasise the negative consequences of alcohol abuse. Conclusion: The current food-based dietary guideline “If you drink alcohol, drink sensibly”, issued by the South African Department of Health, should not remain as is. [ABSTRACT FROM AUTHOR]

Background: Verbal autopsy (VA) is the only available approach for determining the cause of many deaths,where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHOVA instrument as a new standard, intended both as a research tool and for routine registration of deaths.Objective: A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument.Design: The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths.Results: The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration data set from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4.Conclusions: InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration.Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data. [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]

The aim of the study was to explore children’s representations and perceptions of natural spaces using photovoice and community mapping. The sample consisted of 28 children aged 12–14 years residing in urban and rural communities in the Western Cape, South Africa. Data were collected by means of a series of six focus groups interviews (three photovoice discussion groups and three community mapping discussion groups). For the photovoice missions, children were provided with a 28-exposure disposable camera and given 1 week to complete their missions. Thematic analysis was employed to analyse the data. Three key themes emerged, namely: safe spaces in nature, unsafe spaces in nature, and children’s favourite places in nature. Socio-economic status (SES) was found to be a determining factor in how children make sense of natural spaces. Children from low SES communities indicated being more constricted in their mobility, and were unable to access to safe natural spaces compared to the children from the middle SES community. It is recommended that an expedient starting point would be to work towards and build environmentally and child-friendly communities for children, with children as key contributors in the planning process using a child participation framework. [ABSTRACT FROM PUBLISHER]