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Introduction: Innovative interventions are needed to address the growing burden of breast cancer globally, especially among vulnerable patient populations. Given the success of Community Health Workers (CHWs) in addressing communicable diseases and non-communicable diseases, this scoping review will investigate the roles and impacts of CHWs in breast cancer screening programs. This paper also seeks to determine the effectiveness and feasibility of these programs, with particular attention paid to differences between CHW-led interventions in low- and middle-income countries (LMICs) and high-income countries (HICs).Methods: A scoping review was performed using six databases with dates ranging from 1978 to 2019. Comprehensive definitions and search terms were established for 'Community Health Workers' and 'breast cancer screening', and studies were extracted using the World Bank definition of LMIC. Screening and data extraction were protocolized using multiple independent reviewers. Chi-square test of independence was used for statistical analysis of the incidence of themes in HICs and LMICs.Results: Of the 1,551 papers screened, 33 were included based on inclusion and exclusion criteria. Study locations included the United States (n=27), Bangladesh (n=1), Peru (n=1), Malawi (n=2), Rwanda (n=1), and South Africa (n=1). Three primary roles for CHWs in breast cancer screening were identified: education (n=30), direct assistance or performance of breast cancer screening (n=7), and navigational services (n=6). In these roles, CHWs improved rates of breast cancer screening (n=23) and overall community member knowledge (n=21). Two studies performed cost-analyses of CHW-led interventions.Conclusion: This review extends our understanding of CHW effectiveness to breast cancer screening. It illustrates how CHW involvement in screening programs can have a significant impact in LMICs and HICs, and highlights the three CHW roles of education, direct performance of screening, and navigational services that emerge as useful pillars around which governments and NGOs can design effective programs in this area. [ABSTRACT FROM AUTHOR]

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: Action on the social determinants of health (SDH) is relevant for reducing health inequalities. This is particularly the case for South Africa (SA) with its very high level of income inequality and inequalities in health and health outcomes. This paper provides evidence on the key SDH for reducing health inequalities in the country using a framework initially developed by the World Health Organization. Objective: This paper assesses health inequalities in SA and explains the factors (i.e. SDH and other individual level factors) that account for large disparities in health. The relative contribution of different SDH to health inequality is also assessed. Design: A cross-sectional design is used. Data come from the third wave of the nationally representative National Income Dynamics Study. A subsample of adults (18 years and older) is used. The main variable of interest is dichotomised good versus bad self-assessed health (SAH). Income-related health inequality is assessed using the standard concentration index (CI).ApositiveCI means that the rich report better health than the poor. A negative value signifies the opposite. The paper also decomposes the CI to assess its contributing factors. Results: Good SAH is significantly concentrated among the rich rather than the poor (CI=0.008; pB0.01). Decomposition of this result shows that social protection and employment (contribution=0.012; p>0.01), knowledge and education (0.005; p<0.01), and housing and infrastructure (_0.003; p<0.01) contribute significantly to the disparities in good SAH in SA. After accounting for these other variables, the contribution of income and poverty is negligible. Conclusions: Addressing health inequalities inter alia requires an increased government commitment in terms of budgetary allocations to key sectors (i.e. employment, social protection, education, housing, and other appropriate infrastructure). Attention should also be paid to equity in benefits from government expenditure. In addition, the health sector needs to play its role in providing a broad range of health services to reduce the burden of disease. [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]

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]

Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water. This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa. We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process. Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved. Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented that discusses articles published within the issue on themes that are relevant to a global audience of nurses and health policymakers such as nursing education reforms, use of agency nurses in hospitals and its costs to the health sector and quality of care.

Background: Since the publication of the reports by the Commission on Social Determinants of Health (CSDH), many research papers have documented inequities, explaining causal pathways in order to inform policy and programmatic decision-making. At the international level, the sustainable development goals (SDGs) reflect an attempt to bring together these themes and the complexities involved in defining a comprehensive development framework. However, to date, much less has been done to address the monitoring challenges, that is, how data generation, analysis and use are to become routine tasks. Objective: To test proposed indicators of social determinants of health (SDH), gender, equity, and human rights with respect to their relevance in tracking progress in universal health coverage and population health (level and distribution). Design: In an attempt to explore these monitoring challenges, indicators covering a wide range of social determinants were tested in four country case studies (Bangladesh, Brazil, South Africa, and Vietnam) for their technical feasibility, reliability, and validity, and their communicability and usefulness to policy-makers. Twelve thematic domains with 20 core indicators covering different aspects of equity, human rights, gender, and SDH were tested through a review of data sources, descriptive analyses, key informant interviews, and focus group discussions. To test the communicability and usefulness of the domains, domain narratives that explained the causal pathways were presented to policy-makers, managers, the media, and civil society leaders. Results: For most countries, monitoring is possible, as some data were available for most of the core indicators. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and effectively communicating links to health and ways in which the information could improve decision-making. Conclusions: This exercise revealed that for monitoring to produce reliable data collection, analysis, and discourse, it will need to be adapted to each national context and institutionalised into national systems. This will require that capacities and resources for this and subsequent communication of results are increased across countries for both national and international monitoring, including the successful implementation of the SDGs. [ABSTRACT FROM AUTHOR]

Background: Occupational tuberculosis (TB) continues to plague the healthcare workforce in South Africa. A 2-year cluster randomized controlled trial was therefore launched in 27 public hospitals in Free State province, to better understand how a combined workforce and workplace program can improve health of the healthcare workforce. Objective: This mid-term evaluation aimed to analyze how well the intervention was being implemented, seek evidence of impact or harm, and draw lessons. Methods: Both intervention and comparison sites had been instructed to conduct bi-annual and issue-based infection control assessments (when healthcare workers [HCW] are diagnosed with TB) and offer HCWs confidential TB and HIV counseling and testing, TB treatment and prophylaxis for HIV-positive HCWs. Intervention sites were additionally instructed to conduct quarterly workplace assessments, and also offer HCWs HIV treatment at their occupational health units (OHUs). Trends in HCW mortality, sick-time, and turnover rates (2005-2014) were analyzed from the personnel salary database ('PERSAL'). Data submitted by the OHUs were also analyzed. Open-ended questionnaires were then distributed to OHU HCWs and indepth interviews conducted at 17 of the sites to investigate challenges encountered. Results: OHUs reported identifying and treating 23 new HCW cases of TB amongst the 1,372 workers who used the OHU for HIV and/or TB services; 39 new cases of HIV were also identified and 108 known- HIV-positive HCWs serviced. Although intervention-site workforces used these services significantly more than comparison-site healthcare staff (p < 0.001), the data recorded were incomplete for both the intervention and comparison OHUs. An overall significant decline in mortality and turnover rates was documented over this period, but no significant differences between intervention and comparison sites; sick-time data proved unreliable. Severe OHU workload as well as residual confidentiality concerns prevented the proper implementation of protocols, especially workplace assessments and data recording. Particularly, the failure to implement computerized data collection required OHU staff to duplicate their operational data collection duties by also entering research paper forms. The study was therefore halted pending the implementation of a computerized system. Conclusions: The significant differences in OHU use documented cannot be attributable to the intervention due to incomplete data reporting; unreliable sick-time data further precluded ascertaining the benefit potentially attributable to the intervention. Computerized data collection is essential to facilitate operational monitoring while conducting real-world intervention research. The digital divide still requires the attention of researchers along with overall infrastructural constraints. [ABSTRACT FROM AUTHOR]

Background: Worldwide, there is an increased reliance on casual staff in the health sector. Recent policy attention in South Africa has focused on the interrelated challenges of agency nursing and moonlighting in the health sector. Objective: This paper examines the potential health system consequences of agency nursing and moonlighting among South African nurses. Methods: During 2010, a cluster random sample of 80 hospitals was selected in four South African provinces. On the survey day, all nurses providing clinical care completed a self-administered questionnaire after giving informed consent. The questionnaire obtained information on socio-demographics, involvement in agency nursing and moonlighting, and self-reported indicators of potential health system consequences of agency nursing and moonlighting. A weighted analysis was done using STATA® 13. Results: In the survey, 40.7% of nurses reported moonlighting or working for an agency in the preceding year. Of all participants, 51.5% reported feeling too tired to work, 11.5% paid less attention to nursing work on duty, and 10.9% took sick leave when not actually sick in the preceding year. Among the moonlighters, 11.9% had taken vacation leave to do agency work or moonlighting, and 9.8% reported conflicting schedules between their primary and secondary jobs. In the bivariate analysis, moonlighting nurses were significantly more likely than non-moonlighters to take sick leave when not sick (p=0.011) and to pay less attention to nursing work on duty (p=0.035). However, in a multiple logistic regression analysis, the differences between moonlighters and non-moonlighters did not remain statistically significant after adjusting for other sociodemographic variables. Conclusion: Although moonlighting did not emerge as a statistically significant predictor, the reported health system consequences are serious. A combination of strong nursing leadership, effective management, and consultation with and buy-in from front-line nurses is needed to counteract the potential negative health system consequences of agency nursing and moonlighting. [ABSTRACT FROM AUTHOR]

Background: There is global emphasis on transforming health workforce education in support of universal health coverage. Objective: This paper uses a social accountability framework, specifically the World Health Organization's six building blocks for transformative education, to explore key informants' perspectives on nursing education in South Africa. Methods: Using a snowballing sampling technique, 44 key informants were selected purposively on the basis of their expertise or knowledge of the research area. Semi-structured interviews were conducted with the key informants after informed consent had been obtained. The interviews were analysed using template analysis. Results: South Africa has strategic plans on human resources for health and nursing education, training, and practice and has a well-established system of regulation and accreditation of nursing education through the South African Nursing Council (SANC). Key informants criticised the following: the lack of national staffing norms; sub-optimal governance by both the SANC and the Department of Health; outdated curricula that are unresponsive to population and health system needs; lack of preparedness of nurse educators; and the unsuitability of the majority of nursing students. These problems are exacerbated by a perceived lack of prioritisation of nursing, resource constraints in both the nursing education institutions and the health training facilities, and general implementation inertia. Conclusion: Social accountability, which is an essential component of transformative education, necessitates that attention be paid to the issues of governance, responsive curricula, educator preparedness, and appropriate student recruitment and selection. [ABSTRACT FROM AUTHOR]

Background: Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. Objective: This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. Methods: During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semistructured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. Results: The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers' recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. Conclusion: The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care. [ABSTRACT FROM AUTHOR]

Background: There has been increased emphasis globally on nurses' involvement in health policy and systems development. However, there has been limited scholarly attention on nurses' participation in policy-making in South Africa. Objective: This paper analyses the dynamics, strengths, and weaknesses of nurses' participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. Design: Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 frontline nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software. Results: The study found that nurses' participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses' participation in nursing policies. There was a disjuncture between nursing leadership and frontline nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses' views and inputs were considered and incorporated. Conclusions: The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing association. [ABSTRACT FROM AUTHOR]

Background: Staff retention and turnover have risen in prominence in the global discourse on the health workforce. Moonlighting, having a second job in addition to a primary job, has not featured in debates on turnover. Objective: This paper examines whether moonlighting is a determinant of South African nurses' intention to leave their primary jobs. Design: During 2010, a one-stage cluster random sample of 80 hospitals was selected in four South African provinces. On the survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire after giving informed consent. In addition to demographic information and information on moonlighting, the questionnaire obtained information on the participants' intention to leave their primary jobs in the 12 months following the survey. A weighted analysis of the survey data was done using STATA® 13. Results: Survey participants (n=3,784) were predominantly middle-aged with a mean age of 41.5 (SD±10.4) years. Almost one-third of survey participants (30.9%) indicated that they planned to leave their jobs within 12 months. Intention to leave was higher among the moonlighters (39.5%) compared to non-moonlighters (27.9%; p<0.001). Predictors of intention to leave in a multiple logistic regression were moonlighting in the preceding year, nursing category, sector of primary employment, period working at the primary job, and number of children. The odds of intention to leave was 1.40 (95% CI: 1.16-1.69) times higher for moonlighters than for non-moonlighters. The odds ratio of intention to leave was 0.53 (95% CI: 0.42-0.66) for nursing assistants compared to professional nurses and 2.09 (95% CI: 1.49-2.94) for nurses working for a commercial nursing agency compared to those working in the public sector. Conclusions: Moonlighting is a predictor of intention to leave. Both individual and organisational strategies are needed to manage moonlighting and to enhance retention among South African nurses. [ABSTRACT FROM AUTHOR]

Background: Urban informal settlements remain sites of high HIV incidence and prevalence, as well as violence. Increasing attention is paid on how configurations of young men's masculinities shape these practices through exploring how men build respect and identity. In this paper, we explore how young Black South Africans in two urban informal settlements construct respect and a masculine identity. Methods: Data are drawn from three focus groups and 19 in-depth interviews. Results: We suggest that while young men aspire to a 'traditional' masculinity, prioritising economic power and control over the household, we suggest that a youth masculinity emerges which, in lieu of alternative ways to display power, prioritises violence and control over men's sexual partners, men seeking multiple sexual partners and men's violence to other men. This functions as a way of demonstrating masculinity and their position within a public gender order. Discussion: We suggest there are three implications of the findings for working with men on violence and HIV-risk reduction. First, there exist a number of contradictions in men's discourses about masculinity that may provide spaces and opportunities for change. Second, it is important to work on multiple issues at once given the way violence, alcohol use, and sexual risk are interlinked in youth masculinity. Finally, engaging with men's exclusion from the capitalist system may provide an important way to reduce violence. [ABSTRACT FROM AUTHOR]

Background: Lay health workers (LHWs) are critical in linking communities and primary healthcare (PHC) facilities. Effective communication between facilities and LHWs is key to this role. We implemented a mobile health (mHealth) system to improve communication and continuity of care for chronically ill clients. The system focused on requests from facility staff to LHWs to follow up clients and LHW referrals of people who needed care at a facility. We implemented the system in two rural and semi-rural sub-districts in South Africa. Objective: To assess the feasibility of the mHealth system in improving continuity of care for clients in PHC in South Africa. Method: We implemented the intervention in 15 PHC facilities. The clerks issued recalls to LHWs using a tablet computer. LHWs used smartphones to receive these requests, communicate with clerks and refer people to a facility. We undertook a mixed-methods evaluation to assess the feasibility of the mHealth system. We analysed recall and referral data using descriptive statistics. We used thematic content analysis to analyse qualitative data from semi-structured interviews with facility staff and a researcher fieldwork journal. Results: Across the sub-districts, 2,204 clients were recalled and 628 (28%) of these recalls were successful. LHWs made 1,085 referrals of which 485 (45%) were successful. The main client group referred and recalled were children under 5 years. Qualitative data showed the impacts of facility conditions and interpersonal relationships on the mHealth system. Conclusion: Using mHealth for recalls and referrals is probably feasible and can improve communication between LHWs and facility staff. However, the low success rates highlight the need to assess facility capacity beforehand and to integrate mHealth with existing health information systems. mHealth may improve communication between LHWs and facility staff, but its success depends on the health system capacity to incorporate these interventions. [ABSTRACT FROM AUTHOR]

There is an alarming tide of cardiovascular and metabolic disease (CMD) sweeping across Africa. This may be a result of an increasingly urbanized lifestyle characterized by the growing consumption of processed and calorie-dense food, combined with physical inactivity and more sedentary behaviour. While the link between lifestyle and public health has been extensively studied in Caucasian and African American populations, few studies have been conducted in Africa. This paper describes the detailed methods for Phase 1 of the AWI-Gen study that were used to capture phenotype data and assess the associated risk factors and end points for CMD in persons over the age of 40 years in sub-Saharan Africa (SSA). We developed a population-based cross-sectional study of disease burden and phenotype in Africans, across six centres in SSA. These centres are in West Africa (Nanoro, Burkina Faso, and Navrongo, Ghana), in East Africa (Nairobi, Kenya) and in South Africa (Agincourt, Dikgale and Soweto). A total of 10,702 individuals between the ages of 40 and 60 years were recruited into the study across the six centres, plus an additional 1021 participants over the age of 60 years from the Agincourt centre. We collected socio-demographic, anthropometric, medical history, diet, physical activity, fat distribution and alcohol/tobacco consumption data from participants. Blood samples were collected for disease-related biomarker assays, and genomic DNA extraction for genome-wide association studies. Urine samples were collected to assess kidney function. The study provides base-line data for the development of a series of cohorts with a second wave of data collection in Phase 2 of the study. These data will provide valuable insights into the genetic and environmental influences on CMD on the African continent. [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]

In this paper, the current situation regarding rural mental health in South Africa is explored. The current status is presented, followed by an attempt to provide approaches and ideas to improve the situation in order to make it more context appropriate and relevant. Issues of staffing, task shifting or sharing, and formal vs informal health care systems are considered and discussed as possible future approaches to improve rural mental health care in South Africa. [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]

Stepping Stones and Creating Futures (SS/CF) is a gender transformative and economic empowerment intervention that has effectively reduced the perpetration of intimate partner violence (IPV) by young men living in informal settlements in South Africa. This study examines whether depression mediated the association between SS/CF intervention and decreased IPV. Data from a two-arm cluster randomised community-based controlled trial that evaluated the effectiveness of SS/CF in lowering IPV were obtained from 674 young men aged 18–30 within urban informal settlements in South Africa. After being randomly assigned to either the experimental arm (SS/CF) or the control arm, the participants were followed up for 24 months. Logistic regression using mediation analysis was conducted to see whether changes in depressive symptoms mediated the association between the intervention and reduced IPV perpetration. Findings from the mediation analysis indicated that those assigned to the SS/CF experimental group reported lower depression (β = -0.42, p < 0.05) at 12 months, and this was subsequently associated with reduced IPV (β = 0.43, p < 0.05) at 24 months. The direct path from SS/CF to IPV was originally (β = -0.46, p < 0.01), but reduced in the mediation model to (β = -0.13, p = 0.50). Depressive symptoms mediated the association between the SS/CF intervention and decreased IPV perpetration. These findings suggest that one pathway through which SS/CF decreased IPV was through improvement in mental health (i.e. depression). Future IPV prevention interventions may consider incorporating components that focus on improving mental health as a way of also reducing IPV perpetration in disadvantaged settings. [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]

Men who have sex with men (MSM) represent an increasing number of new HIV infections in Botswana. Many in Botswana still hold discriminatory views against people who engage in same-sex practices. While it is well documented that stigma and discrimination undermine efforts to prevent HIV, the literature about the perception and experiences of discrimination against MSM in accessing HIV services in Botswana is scant. In this study, we sought to explore the perception and experiences of discrimination against MSM to improve access to HIV services and reduce discrimination against this marginalised population. We employed a descriptive qualitative design using purposive sampling to recruit 20 MSM and 12 stakeholders (six policy-makers and six service providers) involved in implementing HIV/AIDS interventions in Botswana. We conducted semi-structured interviews with participants. All data were audio-recorded, transcribed, translated into English and analysed using thematic analysis. The findings of this study show that MSM experience discrimination at the policy, healthcare system and community levels, which undermines their ability to seek HIV services. The participants reported that MSM are excluded from HIV policies and targeted HIV services. They reported a scarcity of trained personnel, poor access to HIV information, condoms, lack of treatment services targeted at MSM and negative attitudes directed towards MSM by service providers and other users. The participants also reported that they are excluded from community interventions and experience negative attitudes from community and family members. Discrimination against MSM undermines the ability of HIV interventions to address MSM sexual health needs. The findings indicate the importance of enabling MSM to overcome discrimination to seek HIV services. Also, there is a need to further explore discrimination against MSM by service providers within the healthcare settings and ways to improve their understanding of male same-sex practices. [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]

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]

There is a rising noncommunicable disease (NCD) burden in low- and middle-income countries. Sub-Saharan Africa (SSA) bears a higher burden than the global average with South Africa (SA) enduring the highest regional burden. SA among other southern African countries also bears a high prevalence of HIV and other chronic communicable diseases. Having a perspective on common chronic diseases in the ever-increasing numbers of adult cancer patients in SA will inform our understanding of approaches to better manage them. This commentary reviews regional and national studies and data of low- and middle-income countries and particularly SA on the chronic infectious and NCD multimorbidity burden among adult cancer patients. It also reflects on the considerable health system challenges of managing discordant multimorbidity among adult cancer patients within the SA Public Health System. Despite the critical need to better manage the growing MM burden in general and particularly the high prevalence of discordant multimorbidity among cancer patients, there is a dearth of research into MM management generally and in LMICs particularly. [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]

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]

South Africa's effort to eliminate malaria is significantly challenged by a large number of imported malaria cases, especially from neighbouring Mozambique. The country has a funding gap to achieve its malaria elimination goals (prior to 2019) and is ineligible to receive a national allocation from the Global Fund. The findings of an IC were utilised to successfully mobilise resources for malaria elimination in South Africa in 2018. A five-step resource mobilisation strategy was implemented to highlight financing challenges and leverage the economic evidence from an IC for malaria elimination in South Africa. South Africa's malaria programme implements control and elimination activities in three malaria-endemic provinces (KwaZulu Natal, Limpopo, and Mpumalanga). Driven by the IC findings, the South African government took an unprecedented step and increased total domestic malaria financing by approximately 36%, from the 2018/19 to the 2019/20 financial years through the creation of a new conditional grant for malaria. The IC findings predicted that malaria control in southern Mozambique is a prerequisite to eliminate malaria in South Africa. Based on this, the South African government also allocated funding towards a co-financing mechanism to support malaria control efforts in southern Mozambique. The IC findings assisted the South African National Department of Health to make a convincing case to key government decision-makers to invest in national malaria elimination and maximise economic returns in the long run. The South African government is the first in Southern Africa to mobilise a significant increase in domestic malaria financing to address the financial sustainability of both national and regional malaria elimination efforts. Continued surveillance activities will be required to prevent the re-establishment of malaria transmission even after malaria elimination is achieved in South Africa. Information sharing and close collaboration with provincial and national government officials were key to the successful outcome. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) continues to be a public health issue of concern in South Africa. Workers in the agricultural sector are generally at increased risk of TB due to multiple interacting factors such as exposure to silica dust, co-worker infection, and occupations falling within the lower socio-economic sectors. This study investigates factors associated with TB screening uptake for agricultural workers in Limpopo Province, South Africa. This cross-sectional study targeted a study population of 16,787 agricultural workers across 96 agricultural worksites in South Africa. A two-stage cluster random sampling design identified 24 agricultural worksites and a potential 2500 participants. The outcome variable was self-reported TB screening. Descriptive statistics and unadjusted and adjusted logistic regression analyses were performed to determine factors associated with TB screening. A literature review informed the selection of covariates as possible confounders. The final study sample comprised 2144 workers across 24 sites, with 55% being women. TB screening uptake was 1155 (56.3%). Factors such as living with human immunodeficiency virus (HIV) (AOR 3.16, 95% CI: 2.44–4.09), accessing health services in the workplace (AOR 1.94, 95% CI: 1.09–3.46), and having prior TB knowledge (AOR 18.45, 95% CI: 9.8–34.74) were positively associated with TB screening. Participants in the age group 36–49 years had significantly higher odds of self-reporting TB screening, compared with those aged 18–25 years (AOR 1.37, 95% CI 1.07–1.77). Migrant workers from Mozambique (OR 0.52, 95% CI: 0.34–0.79) and Zimbabwe (OR 0.71, 95% CI 0.57–0.89) were significantly less likely to self-report TB screening compared to their South African counterparts. The findings underscore the importance of workplace health services in achieving end-TB targets. We recommend programs and interventions for preventing TB in South Africa that target the agricultural sector in general, and in particular migrant workers. [ABSTRACT FROM AUTHOR]

Background: When developing intervention research, it is important to explore issues from the community perspective. Interventions that promote adolescent health in South Africa are urgently needed, and Project Ntshembo ('hope') aims to improve the health of young women and their offspring in the Agincourt sub-district of rural northeast South Africa, actively using stakeholder involvement throughout the research process. Objective: This study aimed to determine adolescent health priorities according to key stakeholders, to align stakeholder and researcher priorities, and to form a stakeholder forum, which would be active throughout the intervention. Design: Thirty-two stakeholders were purposefully identified as community members interested in the health of adolescents. An adapted Delphi incorporating face-to-face discussions, as well as participatory visualisation, was used in a series of three workshops. Consensus was determined through non-parametric analysis. Results: Stakeholders and researchers agreed that peer pressure and lack of information, or having information but not acting on it, were the root causes of adolescent health problems. Pregnancy, HIV, school dropout, alcohol and drug abuse, not accessing health services, and unhealthy lifestyle (leading to obesity) were identified as priority adolescent health issues. A diagram was developed showing how these eight priorities relate to one another, which was useful in the development of the intervention. A stakeholder forum was founded, comprising 12 of the stakeholders involved in the stakeholder involvement process. Conclusions: The process brought researchers and stakeholders to consensus on the most important health issues facing adolescents, and a stakeholder forum was developed within which to address the issues. Stakeholder involvement as part of a research engagement strategy can be of mutual benefit to the researchers and the community in which the research is taking place. [ABSTRACT FROM AUTHOR]

South Africa has a significant violence problem. The exposure of girls and women to interpersonal violence is widespread, and the victimization of men, especially to severe and homicidal forms of aggression, is of considerable concern, with male homicide eight times the global rate. In the last two decades, there have been a plethora of South African policies to promote safety. However, indications suggest that the policy response to violence is not coherently formulated, comprehensive, or evenly implemented. This study examines selected South African national legislative instruments in terms of their framing and definition of violence and its typology, vulnerable populations, and prevention. This study comprises a directed content analysis of selected legislative documents from South African ministries mandated to prevent violence and its consequences or tasked with the prevention of key contributors to violence. Documents were selected using an electronic keyword search method and analyzed independently by two researchers. The legislative documents recognized the high levels of violence, confirmed the prioritization of selected vulnerable groups, especially women, children, disabled persons, and rural populations, and above all drew on criminological perspectives to emphasize tertiary prevention interventions. There is a policy focus on the protection and support of victims and the prosecution of perpetrators, but near absent recognition of men as victims. There is a need to broaden the policy framework from primarily criminological and prosecutorial perspectives to include public health contributions. It is likewise important to enlarge the conceptions of vulnerability to include men alongside other vulnerable groups. These measures are important for shaping and resourcing prevention decisions and strengthening primary prevention approaches to violence. [ABSTRACT FROM AUTHOR]

Background: The study was conducted in the Dikgale Health and Demographic Surveillance System (DHDSS) site where we have observed increasing obesity levels, particularly in women, despite evidence of high physical activity (PA) and a relatively low daily energy intake. Objective: This study aimed to assess the socio-demographic, behavioural and biological determinants of body mass index (BMI) in adult residents permanently residing in the DHDSS. Methods: A cross-sectional study was conducted in which socio-demographic, behavioural and biological characteristics from 1143 participants (aged 40–60 years) were collected using a paper questionnaire and standard anthropometric measures. Human immunodeficiency virus (HIV) testing was performed on all participants except those who indicated that they had tested positive. Chi-square and Mann-Whitney tests were used to analyze categorical and continuous variables, respectively, while hierarchical multivariate regression was used to analyze predictors of BMI. Results: The median age of women and men was 51 (46–56) and 50 (45–55) years, respectively. The prevalence of overweight-obesity was 76% in women and 21% in men. A significant negative association of BMI with HIV and smoking and a significant positive association with socio-economic status (SES) was observed in both sexes. In women, BMI was negatively associated with sleep duration (p = 0.015) and age (p = 0.012), but positively associated with sugar-sweetened beverages (SSBs) (p = 0.08). In men, BMI was negatively associated with alcohol use (p = 0.016) and positively associated with being married (p < 0.001). PA was not associated with BMI in either sexes. Full models explained 9.2% and 20% of the variance in BMI in women and men, respectively. Conclusion: BMI in DHDSS adults is not associated with physical inactivity but is associated wealth, marital status, sleep, smoking, alcohol use, and HIV status. Future studies should explore the contribution of nutrition, stunting, psycho-social and genetic factors to overweight and obesity in DHDSS. [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]

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]

Preconception care (PCC) is necessary to identify and deal with all the risk factors before conception. Some aspects of PCC, like folic acid supplementation, would be relevant to people desiring a pregnancy. Alternatively, PCC could provide contraceptive support to those with no pregnancy intention. In South Africa, primary healthcare nurses provide a comprehensive package of essential services in public health facilities to about 90% of the population at no cost. Therefore, they are the key providers of promotive, preventive, and curative services, including PCC. This study aimed to determine the level of PCC practice among primary healthcare nurses and identify determinants of effective practice. This cross-sectional descriptive survey was conducted among 196 nurses undertaking a specialisation Primary HealthCare program in a selected higher education institution. A pretested questionnaire was used to collect data that were analysed with SPSS version 27 software. The overall practice of PCC was 87.8%. Older participants were significantly less likely to exhibit good PCC practice than their younger counterparts. Female participants were also less likely to have good PCC practices than their male counterparts. Married participants were significantly more likely to practice PCC than their unmarried counterparts. Participants practicing in rural areas were also less likely to have good PCC practices than their urban counterparts. The PCC practice of most primary healthcare nurses in the study is relatively high. The study also identified the determinants of good PCC practice that can enhance its practice. There is a need to revisit the PCC training of healthcare workers, as most indicated the need for further training. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has interrupted the prevention of mother-to-child transmission of HIV (PMTCT) programming in South Africa. In 2020, it was estimated that there were 4 million cross-border migrants in South Africa, some of whom are women living with HIV (WLWH), who are highly mobile and located within peripheral and urban areas of Johannesburg. Little is known about the mobility typologies of these women associated with different movement patterns, the impact of the COVID-19 pandemic on mobility typologies of women utilising PMTCT services and on how changes to services might have affected adherence. To qualitatively explore experiences of different mobility typologies of migrant women utilising PMTCT services in a high mobility context of Johannesburg and how belonging to a specific typology might have affected the health care received and their overall experiences during the COVID-19 pandemic. Qualitative semi-structured interviews with 40 pregnant migrant WLWH were conducted from June 2020-June 2021. Participants were recruited through purposive sampling at a public hospital in Johannesburg. A thematic approach was used to analyse interviews. Forty interviews were conducted with 22 cross-border and 18 internal migrants. Women in cross-border migration patterns compared to interprovincial and intraregional mobility experienced barriers of documentation, language availability, mistreatment, education and counselling. Due to border closures, they were unable to receive ART interrupting adherence and relied on SMS reminders to adhere to ART during the pandemic. All 40 women struggled to understand the importance of adherence because of the lack of infrastructure to support social distancing protocols and to provide PMTCT education. COVID-19 amplified existing challenges for cross-border migrant women to utilise PMTCT services. Future pandemic preparedness should be addressed with differentiated service delivery including multi-month dispensing of ARVs, virtual educational care, and language-sensitive information, responsive to the needs of mobile women to alleviate the burden on the healthcare system. [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]

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]

Early life is important for later health outcomes, yet there are few studies which adequately address all of the potential early life insults that may affect later life health and growth trajectories. This is particularly evident in low- to middle-income countries such as South Africa, where women of childbearing age are particularly vulnerable to high levels of physical inactivity, malnutrition, and obesity. Pregnancy may therefore be an opportune time to change behaviours and improve maternal and offspring health outcomes, and decrease the inter-generational transfer of risk. We show clear evidence that physical activity and nutrition are important target areas for intervention during pregnancy and in the early years of life, yet that current literature in Africa, and specifically South Africa, is limited. We have outlined the available literature concerning the impact of maternal and early life nutrition and physical activity on the health status of South African children, and have provided some recommendations for future research and policy. [ABSTRACT FROM PUBLISHER]

Health workforce cohort studies are uncommon in low-and middle-income countries (LMICs), especially those in sub-Saharan Africa. Describe the methodology and lessons learned from establishing and maintaining the WiSDOM (Wits longitudinal Study to Determine the Operation of the labour Market among its health professional graduates) health professional cohort study in South Africa. WiSDOM is a prospective longitudinal cohort study that commenced in 2017. The cohort focuses on the eight professional groups of clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists and physiotherapists. Annual, electronic follow-up surveys have been conducted in 2018, 2019 and 2020 with informed consent. Key steps in establishing the WiSDOM cohort include consultation, communication and marketing, stakeholder feedback, resources and infrastructure. Retention strategies consist of an electronic database, detailed cohort contact information, cohort engagement, communication and feedback, short survey tools, and appropriate incentives. We obtained an overall response rate of 89.5% at baseline in 2017, 79.6% in 2018, 68.3% in 2019 and 72.8% in 2020. The largest decline in response rates is for medical doctors: 66.0% response rate in 2018, 53.2% in 2019 and 58.2% in 2020. However, for each of the three follow-up surveys, we have obtained response rates in excess of 80% for clinical associates, dentists, nurses, oral hygienists, pharmacists and physiotherapists. Since baseline, the outright refusals have remained very low at 4.7%. The multiple logistic regression analysis showed that self-identified race was the only significant socio-demographic difference between medical doctor respondents and non-respondents. Black African doctors and Indian doctors were 2.0 and 2.6 times more likely respectively to respond than White doctors (p < 0.05). Other LMICs can learn from WiSDOM's lessons of establishing and maintaining a health professional cohort that aims to generate new knowledge for health system transformation. [ABSTRACT FROM AUTHOR]

Despite extensive rollout of tuberculosis preventive therapy (TPT) in South Africa to reduce the incidence of tuberculosis among people living with HIV (PWH), rates of initiation and completion have remained suboptimal. This study aimed to identify factors associated with low TPT prescription rates among health care workers (HCWs) in rural South Africa. A cross-sectional study was conducted using an anonymous 39-item questionnaire guided by the Consolidated Framework for Implementation Research (CFIR). HCWs from a government district hospital and 14 primary healthcare clinics (PHCs) in the rural Msinga sub-district of KwaZulu-Natal were surveyed from November 2019 to January 2020. Self-reported data on prescription rates as well as knowledge, attitudes, beliefs, and practices regarding isoniazid preventative therapy, the current TPT regimen, were obtained. Factor analysis and logistic regression were used to determine associations with low prescription rates (< 50% of PWH) for TPT prescribers, and results were placed within CFIR-driven context. Among 160 HCWs, the median (IQR) age was 39 (33–46) years, 76% were women, 78% worked at a PHC, and 44% had experience prescribing TPT. On multivariable analysis, prescribers (n = 71) who believed their patients would not disclose TPT use to others were significantly less likely to prescribe TPT (aOR 4.19 95% CI 1.35–13.00; p = 0.01). Inadequate isoniazid supplies trended towards significance (aOR 10.10 95% CI 0.95–106.92; p = 0.06) in association with low prescription rates. Strengthening HCW training to emphasize TPT prescription to all eligible PWH regardless of beliefs about patient disclosure and ensuring a consistent isoniazid supply at the health systems-level are both critical steps to enhancing TPT implementation in rural South Africa. [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]

In South Africa, female sex workers (FSWs) are perceived to play a pivotal role in the country's HIV epidemic. Understanding their health status and risk factors for adverse health outcomes is foundational for developing evidence-based health care for this population. Describe the methodology used to successfully implement a community-led study of social and employment circumstances, HIV and associated factors amongst FSWs in South Africa. A community-centric, cross-sectional, survey of 3,005 adult FSWs was conducted (January–July 2019) on 12 Sex Work (SW) programme sites across nine provinces of South Africa. Sites had existing SW networks and support programmes providing peer education and HIV services. FSWs were involved in the study design, questionnaire development, and data collection. Questions included: demographic, sexual behaviour, HIV testing and treatment/PrEP history, and violence exposure. HIV rapid testing, viral load, CD4 count, HIV recency, and HIV drug resistance genotypic testing were undertaken. Partner organisations provided follow-up services. HIV Prevalence was 61.96%, the median length of selling sex was 6 years, and inconsistent condom use was reported by 81.6% of participants, 88.4% reported childhood trauma, 46.2% reported physical or sexual abuse by an intimate partner and 57.4% by a client. More than half of participants had depression and post-traumatic stress disorder (52.7% and 54.1%, respectively). This is the first national survey of HIV prevalence amongst FSWs in programmes in South Africa. The data highlight the vulnerability of this population to HIV, violence and mental ill health, suggesting the need for urgent law reform. Based on the unique methodology and the successful implementation alongside study partners, the outcomes will inform tailored interventions. Our rapid rate of enrolment, low rate of screening failure and low proportion of missing data showed the feasibility and importance of community-centric research with marginalised, highly vulnerable populations. [ABSTRACT FROM AUTHOR]