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Background A quality improvement (QI) collaborative approach to enhancing integrated HIV-Tuberculosis (TB) services may be effective in scaling up and improving the quality of service delivery. Little is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives. This study aims to determine which OCFs were associated with improvement in a QI collaborative intervention to enhance integrated HIV-TB services delivery. Methods This is a nested sub-study embedded in a cluster-randomized controlled trial. Sixteen nurse supervisors (clusters) overseeing 40 clinics were randomized (1:1) to receive QI training and mentorship, or standard of care support (SOC). In the QI arm, eight nurse supervisors and 20 clinics formed a “collaborative” which aimed to improve HIV-TB process indicators, namely HIV testing, TB screening, isoniazid preventive therapy (IPT) initiations, viral load testing, and antiretroviral therapy for TB patients. OCFs measured at baseline were physical infrastructure, key staff, flexibility of clinic hours, monitoring data for improvement (MDI), and leadership support. Surveys were administered to clinic staff at baseline and month 12 to assess perceptions of supportiveness of contexts for change, and clinic organization for delivering integrated HIV-TB services. Linear mixed modelling was used to test for associations between OCFs and HIV-TB process indicators. Results A total of 209 clinic staff participated in the study; 97 (46.4%) and 112 (53.6%) from QI and SOC arms, respectively. There were no differences between the QI and SOC arms scores achieved for physical infrastructure (78.9% vs 64.7%; p = 0.058), key staff (95.8 vs 92; p = 0.270), clinic hours (66.9 vs 65.5; p = 0.900), MDI (63.3 vs 65; p = 0.875, leadership support (46.0 vs 57.4; p = 0.265), and perceptions of supportiveness of contexts for change (76.2 vs 79.7; p = 0.128 and clinic organization for delivering integrated HIV-TB services (74.1 vs 80.1; p = 0.916). IPT initiation was the only indicator that was significantly improved in the parent study. MDI was a significantly associated with increasing IPT initiation rates [beta coefficient (β) = 0.004; p = 0.004]. Discussion MDI is a practice that should be fostered in public health facilities to increase the likelihood of success of future QI collaboratives to improve HIV-TB service delivery. Trial registration Clinicaltrials.gov, NCT02654613. Registered 01 June 2015.

Despite being standard of care, gaps in HIV-TB service delivery are present. Quality Improvement methods are effective in uncovering health systems weaknesses that impede efficient delivery of integrated HIV-TB services., Key Findings The quality improvement (QI) intervention was able to guide clinic staff in developing simple but effective change interventions, using resources already available, to improve HIV-TB integrated service delivery.The QI intervention implemented dramatically improved isoniazid preventive therapy initiation rates among eligible HIV patients and resulted in moderate improvements in HIV testing and screening, TB screening, and viral load monitoring. Key Implications Program managers should ensure that all categories of health care workers from all levels of the health care system are included in QI workshops or learning sessions to harness the knowledge and experiences of all role players working within the system.QI implementers should consider adopting a combination approach to improvement interventions, such as QI training combined with mentorship, collaborative learning, and data QI activities.To strengthen and ensure the success of QI interventions, senior-level program managers should consider allocating resources (human, financial, and infrastructure) dedicated to data QI for a sustainable and effective QI program., Introduction: In South Africa, mortality rates among HIV-TB coinfected patients are among the highest in the world. The key to reducing mortality is integrating HIV-TB services, however, a generalizable implementation method and package of tested change ideas to guide the scale-up of integrated HIV-TB services are unavailable. We describe the implementation of a quality improvement (QI) intervention, health systems’ weaknesses, change ideas, and lessons learned in improving integrated HIV-TB services. Methods: Between December 1, 2016, and December 31, 2018, 8 nurse supervisors overseeing 20 primary health care (PHC) clinics formed a learning collaborative to improve a set of HIV-TB process indicators. HIV-TB process indicators comprised: HIV testing services (HTS), TB screening among PHC clinic attendees, isoniazid preventive therapy (IPT) for eligible HIV patients, antiretroviral therapy (ART) for HIV-TB coinfected patients, and viral load (VL) testing at month 12. Routine HIV-TB process data were collected and analyzed. Results: Key change interventions, generated by health care workers, included: patient-flow redesign, daily data quality checks; prior identification of patients eligible for IPT and VL testing. Between baseline and post-QI intervention, IPT initiation rates increased from 15.9% to 76.4% (P=.019), HTS increased from 84.8% to 94.5% (P=.110), TB screening increased from 76.2% to 85.2% (P=.040), and VL testing increased from 61.4% to 74.0% (P=.045). ART initiation decreased from 95.8% to 94.1% (P=.481). Discussion: Although integrating HIV-TB services is standard guidance, existing process gaps to achieve integration can be closed using QI methods. QI interventions can rapidly improve the performance of processes, particularly if baseline performance is low. Improving data quality enhances the success of QI initiatives.

Background Adverse maternal and child health outcomes due to adolescent pregnancy are central to public health research and practice. In addition, public health has emphasised that the care rendered by healthcare providers plays a pivotal role in the health and well-being of pregnant and parenting adolescents. Healthcare providers may differ in the ways they interpret adolescent pregnancy and parenting and consequently, this may have profound implications for healthcare decision making. The aim of this study was to explore the multiple perspectives of a diverse group of healthcare providers' delivering services and engaging with pregnant adolescents and adolescent mothers at a district hospital in Ugu, KwaZulu Natal, South Africa. Methods This descriptive qualitative study used semi-structured interviews (n=33). Healthcare providers rendering care to pregnant and parenting adolescents were recruited from the maternity, antenatal, paediatrics, psychology, dietetics, physiotherapy and social work departments, as well as from the HIV/AIDS, STIs and TB (HAST) programme. The data were analysed using thematic analysis. Results The healthcare providers acknowledged that adolescent pregnancy is a problematic issue in Ugu district. Furthermore, they felt that the postpartum sexual-related and reproductive health of adolescent mothers was not given priority. In the healthcare providers' view, the problems experienced by pregnant and parenting adolescents were school dropout, financial constraints, breakdown of relationships, abandonment, stigmatisation, parenting and child rearing difficulties, and both physical and mental health problems. Conclusion This study highlights that the issue of sexual- and reproductive-related outcomes of adolescent pregnancy and parenting is not given priority. In addition, the findings also highlighted the need for a multidisciplinary approach to the care of pregnant and parenting adolescents. Multidisciplinary communities of practices as interventions can be used to generate and share knowledge, capacitate healthcare providers and improve clinical practice. The training of healthcare providers, provision of non-judgemental counselling and tailored services for pregnant adolescents and adolescent mothers are essential. When appropriately disseminated, the findings will assist relevant healthcare providers, administrators in healthcare institutions, policymakers, and officials of the Department of Health and the Department of Education in South Africa to address the lack of appropriate care for pregnant and parenting adolescents.

Mengistu Meskele,1,2 Nelisiwe Khuzwayo,3 Myra Taylor1 1School of Nursing and Public Health, Discipline of Public Health, Durban, KwaZulu-Natal, South Africa; 2School of Public Health, Wolaita Sodo University, Wolaita Sodo, Ethiopia; 3School of Nursing and Public Health, Discipline of Rural Health, University of KwaZulu-Natal, Durban, South AfricaCorrespondence: Mengistu Meskele Email mengistu77@gmail.comBackground: Intimate partner violence is a crime against humanity. This study aimed to explore the experiences and challenges in screening for intimate partner violence among women who use antiretroviral therapy and other health services in Wolaita Zone in Ethiopia.Methods: A descriptive phenomenological qualitative study design was used, and 16 in-depth interviews were conducted with healthcare workers from 19 health facilities who were providing healthcare services in Wolaita Zone. We selected participants purposively until data saturation was reached. Colaizzi’s descriptive phenomenological method was used for the data analysis, and the Open Code software was used to assist with the data coding. We maintained the scientific rigour of credibility, transferability, dependability, and confirmability.Results: Analysis of the study data identified the following five themes: type of IPV identified by HCWs among women, provider-related barriers, healthcare system barriers, patient-level barriers, and providers’ recommendations for improvements. Issues that emerged from these findings were a gap in medico-legal report provision, absence of a separate record-keeping for IPV cases, lack of client follow-up, absence of routine assessment of violence for women who have injuries, and lack of specific coordination with an external organisation. Moreover, the absence of staff training, weak referral systems, and a shortage of necessary medical equipment challenged IPV screening.Conclusion: This study has shown that there are healthcare provider and health system challenges relating to screening clients for intimate partner violence in Wolaita Zone. Provision of separate record-keeping of intimate partner violence cases in the healthcare facilities, standardising the medico-legal reporting system, improving women’s access to education, and executing more gender-equitable policies, are needed. Moreover, the inclusion of intimate partner violence-specific policy frameworks in national legislation is necessary.Keywords: healthcare workers, intimate partner violence, screening, Wolaita Zone

Background Adolescent pregnancy has been a persistent area of interest and concern in the field of public health. The debate about adolescents’ sexual risk behaviour has also gained prominence due to findings that have demonstrated that adolescent girls between 15 and 19 years of age give birth to 16 million infants and account for 62% of new HIV infections in the Caribbean and African regions. Health compromising behaviours often develop in adolescence, yet the sexual and reproductive health of adolescent mothers is often marginalised in the healthcare field. The aim of this study was to explore adolescent mothers’ understanding of sexual risk behaviour. Methods The study employed a descriptive qualitative design. To collect the data, four focus group discussions were conducted with adolescent mothers aged 16–19 years. The eighteen adolescent mothers were recruited using purposive sampling technique from a hospital in the Ugu district in KwaZulu-Natal, South Africa. Data were analysed using thematic analysis. Results The study revealed that decisions to engage in risky sexual behaviour is influenced by peer pressure, drugs and alcohol, sexual experimentation, myths about contraception, the media, poor parental supervision and power gender dynamics, poverty leading to transactional sex, the vulnerability of young girls, and the fear of partner rejection. Conclusion The findings of this study will contribute to a better understanding of adolescent mothers’ perspectives of sexual risk behaviour. In the subject matter of sexual and reproductive health, adolescents’ autonomy with respect to cultural and social recommendations should not be sidelined. Due to their vulnerability, adolescent women are exposed to transactional sex, and it is particularly due to poverty that adolescent women are driven into sexual relations with older men as a means of survival. Moreover, interventions to curb postpartum sexual risk behaviour are important to protect adolescent women and mothers against HIV/AIDS. The sexual and reproductive education of adolescent women should focus on resilience, negotiating skills, and protective decision making. Collaborative efforts to curb sexual risk taking by young women should be encouraged and should involve relevant agents from the educational, social and clinical fields.

Introduction : Tuberculosis (TB) remains the most common cause of death among people living with HIV. Integrating HIV and TB services reduces mortality but is sub‐optimally implemented. Quality improvement (QI) methods offer a low‐cost and easily implementable approach to strengthening healthcare delivery systems. This trial assessed a QI intervention on key process indicators for delivering integrated HIV‐TB care in rural South African primary healthcare (PHC) clinics. Methods Sixteen nurse supervisors, (each with a cluster of clinics) overseeing 40 PHC clinics, were randomized 1:1 to the intervention or the standard of care (SOC) groups. The QI intervention comprised three key components: clinical and QI skills training, on‐site mentorship of nurse supervisors and clinic staff, and data quality improvement activities to enhance accuracy and completeness of routine clinic data. The SOC comprised monthly supervision and data feedback meetings. From 01 December 2016 to 31 December 2018, data were collected monthly by a team of study‐appointed data capturers from all study clinics. This study's outcomes were HIV testing services (HTS), TB screening, antiretroviral therapy (ART) initiation, isoniazid preventive therapy (IPT) initiation and viral load (VL) testing. Results The QI group (eight clusters) comprised 244 clinic staff who attended to 13,347 patients during the trial compared to the SOC group (eight clusters) with 217 clinic staff who attended to 8141 patients. QI mentors completed 85% (510/600) of expected QI mentorship visits to QI clinics. HTS was 19% higher [94.5% vs. 79.6%; relative risk (RR)=1.19; 95% CI: 1.02–1.38; p=0.029] and IPT initiation was 66% higher (61.2 vs. 36.8; RR=1.66; 95% CI: 1.02–2.72; p=0·044), in the QI group compared to SOC group. The percentage of patients screened for TB (83.4% vs. 79.3%; RR=1.05; p=0.448), initiated on ART (91.7 vs. 95.5; RR=0.96; p=0.172) and VL testing (72.2% vs. 72.8%; RR=0.99; p=0.879) was similar in both groups. Conclusions QI improved HIV testing and IPT initiation compared to SOC. TB screening, ART initiation and VL testing remained similar. Incorporating QI methods into routine supervision and support activities may strengthen integrated HIV‐TB service delivery and increase the success of future QI scale‐up activities.

Background:Identification of the geographical areas with low uptake of HIV testing could assist in spatial targeting of interventions to improve the uptake of HIV testing. Objectives:The objective of this research study was to map the uptake of HIV testing at the district level in South Africa. Method:The secondary analysis used data from the Human Sciences Research Council’s 2017 National HIV Prevalence, Incidence, Behaviour and Communication Survey, where data were collected using a multistage stratified random cluster sampling approach. Descriptive spatial methods were used to assess disparities in the proportion of those ever tested for HIV at the district level in South Africa. Results:The districts with the highest overall coverage of people ever having tested for HIV (> 85%) include West Rand in Gauteng, Lejweleputswa and Thabo Mofutsanyane in Free State, and Ngaka Modiri Molema in North-West. These provinces also had the least variation in HIV testing coverage between their districts. Districts in KwaZulu-Natal had the widest variation in coverage of HIV testing. The districts with the lowest uptake of HIV testing were uMkhanyakude (54.7%) and Ugu (61.4%) in KwaZulu-Natal and Vhembe (61.0%) in Limpopo. Most districts had a higher uptake of HIV testing amongst female than male participants. Conclusion:The uptake of HIV testing across various districts in South Africa seems to be unequal. Intervention programmes must improve the overall uptake of HIV testing, especially in uMkhanyakude and Ugu in KwaZulu-Natal and Vhembe in Limpopo. Interventions must also focus on enhancing uptake of HIV testing amongst male participants in most districts. Strategies that would improve the uptake of HIV testing include HIV self-testing and community HIV testing, specifically home-based testing.

Background: In South Africa, Community Health Workers (CHWs) are a key component of community outreach teams as part of Primary Health Care (PHC) re-engineering. Although the value of CHW programs has been increasingly recognized, published evaluations of CHWs’ training programs are rare. This study documents the training and evaluation of CHWs on maternal and neonatal care towards improved maternal-newborn survival in an impoverished urban setting in KwaZulu-Natal, South Africa. Methods: Using a descriptive study design, CHWs were trained to do home visits, assess and support the mother to settle in well at home post-discharge, check on babies’ warmth, cord care, breastfeeding, basic hygiene, size of the baby if underweight and advise on Kangaroo mother care. They were also trained to check if the mothers were given the Road to Health card and to inquire about the immunization and subsequent follow-up visits to the PHC, and encourage mothers to adhere to their follow up dates at PHC clinics. Pre-and post-test scores, shadow visits, and spot checks were used to evaluate their performance. Results: Generally, CHWs (n=47) from all three PHC clinics performed well. Overall, the highest post-test score among the PHC CHWs was 72% and the lowest was 50%. On average during shadow visits 67% CHWs were rated as good, 2% were rated as poor, and most CHWs received the highest score at 92% during spot checks. Conclusion: CHWs demonstrated social commitment and purpose in the short term observed. The evaluation of the training of CHWs revealed that most demonstrated the necessary skills for referrals to prevent complications, caring for newborns and their mothers at home immediately after discharge from health care centers. CHW upskilling training on maternal-newborn services should be prioritized in the most affected areas.

Background: The Asenze study has the long-term goal of promoting better physical, cognitive and psychosocial functioning of children in a rural area in KwaZulu-Natal, 50 km from Durban, with a view...

Background The first 90 of UNAIDS 90–90–90 targets to have 90% of the people living with HIV know their status is an important entry point to the HIV treatment cascade and care continuum, but evidence shows that there is a large gap between males and females in this regard. It is therefore important to understand barriers and facilitators of achieving the first 90 target. This study examined determinants of the first 90 target among females and males in order to inform strategies aimed at improving the HIV cascade in South Africa. Methods The data used in the analysis were obtained from a 2017 household-based cross-sectional nationally representative survey conducted using a multi-stage stratified cluster random sampling design. A series of hierarchical multiple logistic regression models were fitted to identify the determinants of the first 90 target by gender. Results Overall, 84.8% of HIV-positive individuals aged 15 years and older were aware of their HIV status. Females were significantly more aware of their HIV status compared to males (88.7% vs 78.2%, p Conclusion Significant progress has been made with regards to reaching the UNAIDS first 90 target. In this context achieving the first 90 target is feasible but there is a need for additional interventions to reach the males especially youth including those with no education or low levels of education.

BackgroundThe shortage of healthcare professionals (HCP) negatively affects health services in rural areas in many parts of the world, as is the case in South Africa. Innovative programs designed to improve the recruitment strategies for health system in a rural area are essential. They need support with a scholarship and mentorship programme for young people from rural areas to study for health science degrees, with the aim that they would take up a post at the hospital in their community, once qualified.This paper reports the perceptions and experiences of the students and graduates sponsored by the foundation, and those of managers from the facilities where the students were ultimately placed, in order to gauge whether such a programme can make a sustainable contribution to address the shortage of health personnel in rural areas and to what extent this is happening.MethodsThe authors used qualitative methods, combining semi-structured in-depth interviews and focus groups and the data were analyzed thematically.ResultsThe results provide information on students interviewed who appreciated the financial and socio-emotional support that they received. On the other hand, graduates value the availability of jobs in their home community on completion of their studies. The managers reported the success of the programme in increasing the number of healthcare personnel at the hospitals, and the increased range of available medical services. Since the graduates are familiar with the language and culture of their patients the managers considered that they are better able to assist them.ConclusionsThe system was well thought-out and achieved its goal of improving health services in an underdeveloped rural area of South Africa. More could be achieved if other government services in the area were simultaneously improved and if the system were replicated elsewhere. The students and graduates from rural areas are involved on sustaining health services in rural areas while rural managers support the programme and make suggestions for improvement and to promote the program in other regions.

Background Visualization of the lesions in the lower genital tract is the mainstay for diagnosis of the four lesions found in female genital schistosomiasis (FGS), but colposcopes are generally not available in low‐resource settings. Objective We sought to review handheld devices that could potentially be used for FGS diagnosis. Search strategy We searched Medline and Embase 2015–2019 for handheld devices used in cervical cancer screening and FGS diagnosis. Selection criteria We excluded studies that did not compare the device to standard‐of‐care colposcopes or histopathology. Main results and conclusion In 11 studies, four handheld colposcopes, two smartphones, and one compact digital camera were evaluated. Two handheld colposcopes were found to be potentially adequate for FGS diagnosis, namely Gynocular and Mobile ODT. The smartphones and digital camera did not have sufficient magnification to diagnose grainy sandy patches, one of the FGS lesion types. Customized software should be made to support the diagnosis of both FGS and cervical neoplasia. Real‐time postgraduate training and quality control should be considered in future studies of handheld colposcopes. For patients from schistosomiasis endemic areas, we recommend that handheld devices are used for FGS. Studies are needed to determine which of the two devices is most adequate for FGS diagnosis in schistosomiasis endemic areas., Synopsis Handheld colposcopy for schistosomiasis endemic areas should be adequate for both cervical cancer and genital schistosomiasis diagnoses.

Women with female genital schistosomiasis (FGS) have been found to have genital symptoms and a three-fold higher risk of HIV infection. Despite WHO recommendations, regular antischistosomal mass drug administration (MDA) has not yet been implemented in South Africa possibly because of the lack of updated epidemiological data. To provide data for future prevention efforts against FGS and HIV, this study explored Schistosoma haematobium prevalence in girls and young women and the effects of antischistosomal MDA, respectively. Urinary schistosomiasis and genital symptoms were investigated in 70 randomly selected secondary schools in three districts within KwaZulu-Natal and 18 primary schools. All study participants were treated for schistosomiasis, and schools with the highest urinary prevalence were followed up after 1 and 4 years of MDA. At baseline, urine analysis data showed that most schools were within the moderate-risk prevalence category where biennial antischistosomal MDA is recommended, as per WHO guidelines. Young women had high prevalence of genital symptoms (36%) after correcting for sexually transmitted infections. These symptoms may be caused by infection with schistosomes. However, FGS cannot be diagnosed by urine analysis alone. In KwaZulu-Natal rural schools, this study suggests that antischistosomal MDA with praziquantel could prevent genital symptoms in more than 200,000 young women. Furthermore, it is feasible that more than 5,000 HIV infections could be prevented in adolescent girls and young women by treatment and prevention of FGS.

Background Institutions of higher learning provide education, training, independence and life-long skills for young people. However, for students to achieve their optimal growth and intellectual development they need to be healthy psychologically, mentally and physically. This can be achieved through the development of effective health programs for all university students. This qualitative study was designed to explore Black male students’ perspectives and experiences regarding the utilization of on-campus health services at the University of KwaZulu-Natal. Methods The study population was selected using purposive sampling. Data were collected using four focus group discussions (FGDs) with 36 participants and three key informant interviews. Thematic analysis was conducted to identify the key patterns and themes that emerged from the data. Results Emerging themes included poor knowledge and awareness, negative perceptions and attitudes, fear and lack of privacy, and negative experiences leading to poor access and utilization of campus health services. The findings suggested a need for more advocacy and awareness campaigns especially among first year students, campaigns for normalization of sexual health, addressing HIV stigma and discrimination, providing youth friendly services to improve students’ use of sexual health services, and ultimately, their overall health and well-being. Conclusions The findings give valuable insights from male students on the barriers and potential solutions to campus health services and highlight where improvements can be directed to increase access and use of health services by the study population.

Background Improved understanding of barriers to HIV testing is important for reaching the first of the UNAIDS 90–90-90 targets, which states that 90% of HIV positive individuals ought to know their HIV status. This study examined socio-economic status (SES) differences in HIV testing uptake and associated factors among youth and adults 15 years and older in South Africa. Methods This study used data from a national cross-sectional, population-based household survey conducted in 2017 using a multi-stage sampling design. A composite SES score was created using multiple correspondence analyses of household assets; households were classified into wealth quintiles and dichotomised into low SES/poorest (lowest 3 quintiles) and high SES/less-poor (highest 2 quintiles). Bivariate and multivariate logistic regression models were used to examine factors associated with the uptake of HIV testing in low and high SES households. Results HIV testing uptake was 73.8 and 76.7% among low and high SES households, respectively, both of which were below the first 90 targets. Among both low and high SES households, increased HIV testing uptake was significantly associated with females than males. The decreased likelihood was significantly associated with residing in rural formal areas than urban areas, those with no education or low levels of educational attainment and alcohol drinkers among low SES households. Whites and Indians/Asians had a decreased likelihood than Black Africans in high SES households. Conclusions HIV testing interventions should target males, residents in rural formal areas, those with no or low education and those that consume alcohol in low SES households, including Whites and Indians/Asians from high SES households in order to bridge socio-economic disparities in the uptake of HIV testing. This should entail expanding HIV testing beyond traditional centres for voluntary counselling and testing through outreach efforts, including mobile testing and home-based testing.

Background: Schistosomiasis is a disease caused by parasitic trematode worms of the genus Schistosoma. In 2014, over 258 million people worldwide required treatment for the disease. Schistosomiasis is known to be prevalent in the northern region of KwaZulu-Natal province of South Africa, especially among school-going children but less is known about their knowledge of the disease and their attitude towards being treated for the disease at school.Methods: The study was a descriptive and analytical cross-sectional survey conducted through self-administered questionnaires among grades 5 and 7 learners from 10 randomly selected rural primary schools in iLembe and uThungulu, KwaZulu-Natal. Teachers from the same schools participated during the same period.Results: A total of 730 learners and 78 teachers took part in the study. Among the learners, 73.2% (95% confidence interval [CI]: 69.7% – 76.4%) correctly identified freshwater contact as a risk for schistosomiasis, but only 42.7% (95% CI: 38.8% – 46.8%) knew how to prevent it. Among the teachers, 96.8% (95% CI: 87.8% – 99.4%) knew the risk and 69.0% (95% CI: 55.3%– 80.1%) knew the prevention of schistosomiasis. Almost 70% (95% CI: 65.9% – 72.8%) of the learners and 67.6% (95% CI: 42.1% – 65.6%) of the teachers reported their willingness to receive treatment with praziquantel at school.Conclusion: This study showed that basic knowledge about the risk of schistosomiasis among the participants was high, but the cause and prevention of the disease were less well understood. There is need to include schistosomiasis in health education both at school and through community awareness programmes.

Background: In order to improve health in low- and middle- income countries the basic health infrastructure needs to be upgraded. Part of the problem is the shortage of skilled healthcare professionals (HCP) particularly in rural areas. The Umthombo Youth Development Foundation (UYDF) is a non-profit organisation (NPO) established in 1999 to assist in addressing shortage of HCPs in rural areas. The aim of this study is to measure the success of the UYDF bursary scheme in achieving this goal by calculating the cost of supporting rural students and estimating the benefits in relieving the shortage in terms of the financial return on investment.Methods: The sources of the data were the UYDF organisational records (finance, human resources and procurement), supplemented by the published and unpublished UYDF reports. The return on investment was estimated through the use of an Internal Rate of Return (IRR) calculation.Results: The UYDF database of beneficiaries showed that by the year 2017 a total of 337 HCPs had graduated and a further 254 were still studying. An average of R17 million was spent every year on the students or R102 015 per student per year. The IRR was 63% higher than interest rates on commercial loans. These graduates are expected to generate an estimated R15 billion in lifetime earnings, which would be equal to R4 billion at current prices.Conclusion: The UYDF scheme relieved the shortage of HCPs in rural hospitals, and the hospitals were able to retain the service of many of the locally sourced HCPs. The costs of implementing the bursary scheme were outweighed by the income generated from salaries, and taxes contributed to the country’s economic development.

Background Inadequate water supply and sanitation adversely affects the health and socio-economic development of communities and places them at risk of contracting schistosomiasis and soil-transmitted helminths (STHs). The aim of this study was to quantify the prevalence and intensity of schistosomiasis (bilharzia) and STHs amongst female school-going pupils in Ugu district. Methods A descriptive cross-sectional study was conducted in Ugu district amongst primary school pupils from 18 randomly selected schools in 2010. A structured questionnaire was used to collect information on the history and knowledge of bilharzia of 1057 pupils. One stool and 3 consecutive days of urine samples were collected per participant and screened for helminth ova. Findings were compared with those reported by the parasite control programme, which collected data in the same area in 1998. Results The prevalence of Ascaris lumbricoides and Trichuris trichiura was 25% and 26%, respectively, and their corresponding mean intensities of infection were 21 and 26 eggs per gram. The prevalence of Schistosoma haematobium was 32%, and its mean intensity of infection was 52 eggs per 10 mL urine. Of the pupils, 60% knew about schistosomiasis, 9% reported red urine in the past week and 22% had had dysuria before. Although the prevalence of ascariasis and trichuriasis had decreased since 1998 (62% and 59%, respectively), the prevalence of schistosomiasis had increased to 32% (p < 0.05). Conclusion Female pupils in rural schools remain at risk. A mass treatment campaign, increased public awareness and improved sanitation are required to reduce these infections and sustain a reduction of STHs and schistosomiasis. Keywords prevalence; intensity; schistosomiasis; soil-transmitted helminths; Ascaris lumbricoides; Trichuris trichiura; Schistosoma haematobium; parasite control programme; water contact.

Background In order to improve health in low- and middle- income countries the basic health infrastructure needs to be upgraded. Part of the problem is the shortage of skilled healthcare professionals (HCP) particularly in rural areas. The Umthombo Youth Development Foundation (UYDF) is a non-profit organisation (NPO) established in 1999 to assist in addressing shortage of HCPs in rural areas. The aim of this study is to measure the success of the UYDF bursary scheme in achieving this goal by calculating the cost of supporting rural students and estimating the benefits in relieving the shortage in terms of the financial return on investment.Methods The sources of the data were the UYDF organisational records (finance, human resources and procurement), supplemented by the published and unpublished UYDF reports. The return on investment was estimated through the use of an Internal Rate of Return (IRR) calculation.Results The UYDF database of beneficiaries showed that by the year 2017 a total of 337 HCPs had graduated and a further 254 were still studying. An average of R17 million was spent every year on the students or R102 015 per student per year. The IRR was 63% higher than interest rates on commercial loans. These graduates are expected to generate an estimated R15 billion in lifetime earnings, which would be equal to R4 billion at current prices.Conclusion The UYDF scheme relieved the shortage of HCPs in rural hospitals, and the hospitals were able to retain the service of many of the locally sourced HCPs. The costs of implementing the bursary scheme were outweighed by the income generated from salaries, and taxes contributed to the country’s economic development.

Perinatal HIV infection is associated with delayed neurocognitive development, but less is known about children perinatally HIV-exposed but uninfected (CHEU). We compared cognitive and language outcomes in 4-6-year old CHEU versus children HIV-unexposed and uninfected (CHUU) and children living with HIV (CLHIV). We enrolled 1,581 children (77% of the child population) in five communities in KwaZulu-Natal, South Africa. Children completed: Grover-Counter Scale of cognitive development, sub-scales of the Kaufman Assessment Battery for Children, Reynell Developmental Language Scales. HIV status of children and primary caregivers was determined by repeated rapid tests or report of prior testing. We conducted a cross-sectional multivariable linear regression on 922 dyads with complete data (257 CHEU, 627 CHUU, 38 CLHIV). On all outcome measures, CHEU and CHUU groups had comparable scores; CLHIV scored significantly lower. Emerging global progress toward the elimination of vertical HIV transmission may not only reduce mortality, but also positively impact child development.

Background Community advisory groups (CAGs) have been shown to be catalysts who bridge the gap between communities and primary health care facilities by sustaining good working relationships through community engagement to improve the quality of the health care services. This study aimed to explore the establishment, operation, and accomplishments of a CAG towards building a strong partnership between the health facilities and local communities in support of the Partner Defined Quality (PDQ) process, to improve the delivery of quality maternal and neonatal care in a peri-urban setting in the province of KwaZulu-Natal, South Africa. Methods The study used a qualitative exploratory research design. Recruitment followed a purposive sampling approach. The study targeted leadership representatives from the community, potential beneficiaries, and health care providers in the selected catchment areas. Participants were identified during community mobilization events that took place during the preparatory stage to ensure key stakeholder support. A participatory research approach was used to discuss membership, composition, the selection criteria, including formulation, and agreement on terms of reference of the CAG membership, roles and responsibilities. A rapid assessment method was used for data collection and analysis of establishment of the CAG, its activities and accomplishments. Results The community nominated 24 CAG members during the consultative meetings and the organogram provides clear terms of reference, roles and responsibilities. Immediately after inception, the CAG used four indicators (weaknesses, threats and risks, strengths, and opportunities) to review the community and primary health care challenges that affect their communities. These CAG activities were linked with the phases of the PDQ process. The CAG committed itself going forward to continue to create an enabling environment for all stakeholders working to improve the well-being of the community, especially the PDQ teams working on improving the care of pregnant mothers and their babies pre- and post-delivery. Conclusion This work shows that developing community relationships and infrastructure are critical initial stages before embarking on PDQ planning and implementation. Empowerment, local ownership, funding, technical resources and ongoing support are critical elements for sustainability of CAG activities.

Background Ethiopia is one of the nations which has an enormous burden of intimate partner violence (IPV), and where it is usually difficult to talk about HIV separately from IPV. Objectives This research aimed to explore the lived experience of IPV against women using antiretroviral therapy (ART) and other outpatient services in Wolaita Zone, Ethiopia Methods We used an Interpretive (hermeneutic) Phenomenological Analysis design among purposively selected adult women aged 18–49 years. A total of 43 women participated in this study, of whom 30 were using ART, and 13 women were using other health services. We used an in-depth interview and focus group discussions until data saturation, while conscious of the need to maintain the scientific rigor, dependability, and credibility. The data were transcribed verbatim and translated into English. We read the transcripts repeatedly to understand the content. We used NVivo 11 software to assist with data organisation, and also, we used the framework analysis method. Results We identified five themes, namely: “women's terrifying experiences of violence,” “the effect of violence on women's health,” “support/lack of support /partner’s controlling behaviours,” “women’s feelings about the available services,” and “IPV prevention strategies from the perspective of women.” Interviewees described their violent experiences which included wife-beating, being stigmatised in front of others, having material thrown at the woman’s face, wife’s hand and teeth were broken, forced sex, restriction of movement, name-calling, threats to hurt, being insulted, being left alone, and the withdrawal of finances. The negative health impacts reported included abortion, infection with HIV and other sexually transmitted diseases, disability, child’s death, and depression. The disclosure of HIV test information resulted in violence. Inappropriate punishment of the perpetrator and the lack of a supportive women’s network to avert IPV were perceived as legal limitations. Conclusions IPV is a considerable health burden, varying in its presentation and its negative impact on women’s health. Improved laws should provide justice for all victims. Establishing a women’s network to assist women at risk of violence, should be emphasised. Unwise HIV test result disclosure leads to IPV; hence HIV disclosure should be facilitated through health care providers.

Background South Africa is currently undergoing a nutrition transition, and overweight and obesity is on the increase in South African children. Urbanization and other health determinants have led to reduced physical activity and unhealthy eating that have increased the risk of adverse chronic health conditions. This study aims to provide evidence of the effectiveness of a school-based intervention study that targets diet and physical activity for the prevention of child and adolescent overweight and/or obesity. Methods We will employ a mixed method study design which is divided into two phases. Phase 1, namely the qualitative elicitation research phase will inform the development of the quantitative intervention phase (phase 2), consisting of a cluster-randomized trial, based on input from key stakeholders. The study will be undertaken in 16 government-funded primary schools in the iLembe district of KwaZulu-Natal, South Africa. The study will target learners in Grades 4 and 7, their parents, Life Orientation educators, school principals and members of school governing bodies. Assessment for the primary objective (BMI Z scores), and the secondary objectives (change in knowledge, attitudes and behaviours regarding diet and physical activity) in both study arms will be conducted at baseline in March 2020 and at the end of the study in October 2020. Discussion The study will be a novel combined mixed methods/RCT design that focuses on diet, physical activity school and family-based interventions in the context of rapidly increasing overweight and obesity prevalence in KwaZulu-Natal. To encourage behaviour change and management of malnutrition, education including diet and physical activity, is an important strategy that must be considered. Nutrition education extends beyond the dissemination of food information; it includes addressing the needs of participants, empowers and encourages decision-making and choice of foods, change in nutrition attitudes, beliefs and influences based on resources available and within cultural boundaries. Trial registration Pan African Clinical Trial Registry PACTR201711002699153. Protocol registered on 16 November 2017.

Fruit and vegetable consumption is on the rise as an increasing number of people recognize their health promoting effects, which are mediated through phytochemicals with disease combatting properties. The aim of this paper is to identify the potential benefits of fruits and vegetables in chronic diseases such as diabetes mellitus and hypertension. An electronic search of databases such as Pubmed Central, Science Direct and Web of Science from the last 5 years was conducted. Four commonly consumed edible fruit and vegetables, namely, Hypoxis hemmerocallidea (African potato), Moringa oleifera (Moringa), Persea americana (Avocado) and Psidium guajava (Guava) and their potential role in the prevention and management of metabolic syndrome and other disorders, are presented. In this narrative review plant uses extend beyond traditional medicine and include usage in food preparation, beverages, as part of fragrances, culinary flavouring, as well as cosmetic use, but more importantly have potential in contributing to the amelioration of the deleterious effects of diseases/health conditions. In addressing disease states, including metabolic syndrome and other disorders, the interest in medicinal plants continues to grow with the possibility of novel compounds and/or new drug discovery. Alternative and affordable methods of large scale harvesting of medicinal plants, as well as identification and specificity of bioactive compounds as future therapeutics are essential for sustainability.

Background Schistosomiasis, a neglected tropical disease caused by parasites that infest open water sources such as rivers and dams may increase susceptibility to HIV. Mass-treatment with praziquantel tablets, recommended by the World Health Organization reduces the prevalence of schistosomiasis. The goal in endemic areas is 75% treatment participation in every treatment round (e.g. yearly). However, in rural Ugu district, KwaZulu-Natal, South-Africa there was low participation among pupils in a Department of Health Mass-Treatment Campaign for schistosomiasis. Methods Nested in a large study on schistosomiasis the study was conducted in 2012 over 4 months using qualitative methods with the Health Belief Model as the conceptual framework. Purposive sampling was done. Focus Group Discussions were undertaken at six schools in grades 10–12. Individual in-depth interviews were held with one teacher and two pupils at each school. In addition three traditional healers and a community health worker were interviewed. Results The severity of schistosomiasis was not recognised and neither was the pupils’ susceptibility. Barriers to treatment included confusing S, haematobium symptoms with sexually transmitted infections, teasing and stigma. Conclusions Increased knowledge, health literacy for treatment, and correct understanding about the severity of schistosomiasis may provide cues to action. The study indicates that comprehensive information may increase pupil participation in mass-treatment and decrease schistosomiasis prevalence. Trial registration This study was registered with clinicaltrials.gov registry database and the registration number is NCT01154907 30 June 2011.

Background: HIV and AIDS, sexually transmitted infections (STIs) and tuberculosis (TB) are common co-infections in South Africa, and constitute major public health problems. Nurses have frequent contact with HIV positive and TB co-infected patients, their counselling behaviour being influenced by knowledge about counselling as well as their beliefs, attitudes and perceptions about barriers to counselling.Purpose: The purpose of the survey was to assess the knowledge, attitude and beliefs of nurses about behavioural counselling for HIV and AIDS, STIs and TB (HAST) in three areas of the eThekwini Municipality.Results: This was a quantitative descriptive cross sectional study, with stratified sampling being used to select 87 nurses from 24 PHC facilities who completed self-administered questionnaires. The most significant factors associated with the knowledge, attitude and beliefs of nurses about counselling behaviour were their age and level of education. Nurses were well informed about counselling behaviour (mean scores 4.1/5). However, the potential barriers to implementing effective counselling behaviour included their negative perceptions about counselling in HAST.Conclusion: There is an urgent need for further studies to explore barriers to counselling behaviour and how these can be addressed by the nurses and their managers.Keywords: Counselling behaviour, HCT, PICT, HIV, STIs & TB

Sexual violence, a global concern, has far reaching consequences for individuals and communities. This survey of South African high school students, reported baseline prevalence and factors associated with forced sex. Data collected among 434 adolescents (54.4% boys; 45.6% girls) used a questionnaire developed using the I-Change Model conceptual framework. Forced sex prevalence was 14.2% (95% CI 9.1, 21.5) with a non-significant difference between females (15.0%) and males (13.6%) (p = 0.781). After multivariable adjustment, urban location (39%), low socio-economic status (15%) and discordant mother/father vital status (20%) remained significant risk factors for forced sex. South African high school students are still at risk of experiencing forced sex with a higher prevalence in females. Interventions to address socio-economic and structural constructs contributing to the forced sex prevalence in this population are required.

Schistosoma haematobium infection is reported to facilitate the development of urogenital diseases. Its symptoms include haematuria, dysuria and tiredness, and it may cause cognitive decline in chi...

Background: High-risk human papillomavirus (hr-HPV) infections and low-grade squamous intraepithelial lesions occur frequently in young women. The available vaccines cover up to seven hr-HPV genotypes (HPV16, HPV18, HPV31, HPV33, HPV45, HPV52 and HPV58) and two low-risk HPV types (HPV6 and HPV11). The objective of this study was to describe the hr-HPV genotypes present among HIV-uninfected and HIV-infected young women in rural high schools. Methods: Cervicovaginal lavages were obtained from sexually active young women recruited from high schools in KwaZulu-Natal (n=1223). HPV testing was done by the polymerase chain reaction using GP5+/GP6+primers and enzyme immunoassay. HIV testing was done using rapid test kits. Results: Of the 1223 cervicovaginal lavages, 301 (25%) were positive for hr-HPV. The HPV prevalence was higher in HIV infected (32.20%, 95% CI: 0.27-0.38) than in HIV-uninfected women (22.50%, 95% CI: 0.21-0.26), (p=.001). Similarly, multiple infections were slightly more common in HIV infected (59.32%) than in HIV-uninfected women (53.51%), (p=.37). The nine predominant genotypes in descending order were HPV types 16 (n=99, 22.10%), 51 (n=58, 12.91%), 18 (n=56, 12.50%), 35 (n=50, 11.10%), 33 (n=47, 10.82%), 56 (n=42, 9.31%), 45 (n=34, 7.60%), 52 (n=32, 7.14%) and 59 (n=31, 6.91%). HPV 35, 51, 56 and 59 (40.62%), which are not covered by any vaccine, were among the most prevalent in the schools of KwaZulu-Natal. Conclusion: Four of the most predominant high-risk HPV types in this region are not covered by the new nine-valent HPV vaccine.

Background. Maternal depression is a major public health concern as it affects both mothers and their children. Antenatal depression, which is often underdiagnosed, has been associated with preterm labour, low birth weight, and intrauterine growth restriction. Research has demonstrated that postpartum depression is associated with mother-infant bonding impairment, child abuse, child neglect, maternal substance abuse, and self-harm. Globally, the prevalence of depression in pregnant and postpartum adolescents varies. This paper reports on the findings of the prevalence of depression and its associated risk factors among pregnant and postpartum adolescents in KwaZulu-Natal, South Africa. Methods. Data were generated by means of a descriptive cross-sectional study that was conducted between June and November 2017 utilizing a sample of 326 adolescent females accessing maternal health services in a medium-sized rural peripheral district hospital in Ugu, Southern KwaZulu-Natal. The Edinburgh Postnatal Depression Scale questionnaire was used to screen participating pregnant and postnatal adolescents for depression. A cut-off score of ≥13 was used to identify pregnant and postnatal adolescents with symptoms of depression. The data were analysed using R software. Results. The prevalence of depression among the pregnant participants was 15.9% (21/132), whereas it was 8.8% (17/194) among the postpartum participants. Antenatal depression was associated with physical violence (adjusted odds ratio (aOR) 6.47, 95% CI 1.36-30.53, p=0.01) and verbal abuse (adjusted odds ratio (aOR) 4.8, 95% CI 1.5-15.16, p=0.006). The pregnant participants who indicated they received a lot of support from their partners were 0.93% less likely to have depression. Postnatal depression was associated with physical violence (adjusted odds ratio (aOR) 7.32, 95% CI 1.66-29.44, p=0.005), verbal abuse (adjusted odds ratio (aOR) 4.3, 95% CI 1.03-15.79, p=0.03), and intimate partner violence (adjusted odds ratio (aOR) 9.58, 95% CI 1.58-48.82, p=0.008). Conclusion. The prevalence of antenatal depression was higher than postpartum depression in the study sample. In light of the findings, maternal healthcare professionals are cautioned to consider the mental health of pregnant and postpartum adolescents who seek their services at health facilities.

Background and objectivesThe aim of the current study was to establish the relative prevalences of Female Genital Schistosomiasis (FGS) and sexually transmitted infections (STIs). We hypothesised that due to the use of syndromic management for STIs it is possible that FGS is being misdiagnosed and mismanaged as an STI. We therefore wanted to examine the relationship between FGS and the individual STIs in schistosomiasis endemic areas.MethodsBetween 2011 and 2013, a cross-sectional study was performed in 32 randomly selected secondary schools in rural KwaZulu-Natal, South Africa, where each school had at least 300 pupils. In a research clinic, FGS diagnosis, STI testing, and face-to-face interviews were performed in sexually active, young women aged 16 – 22 years.ResultsFGS was the second most prevalent current genital infection (23%). There were significantly more women who had presented FGS among those who had detectable urinary schistosomiasis (35%), compared to those without (19%, p< 0.001). In the FGS positive group 35% were positive for HPV infection, compared to 24 % in the FGS negative group (p=0.010). In the FGS positive group 37% were sero-positive for HSV infection, compared to 30% in the FGS negative group (p=0.079). There were significantly fewer chlamydia infections amongst women with FGS (20%, p=0.018) compared with those who did not have FGS (28%).ConclusionsFGS was the second most common genital infection after HSV but the two were not significantly associated. HPV infection was significantly associated with FGS. Surprisingly Chlamydia infection were negatively associated with FGS. The results show the importance of the inclusion of FGS in the management protocols for genital infections in areas endemic for urinary schistosomiasis, and highlight the importance for more research on suitable differential diagnostic tools and disease management.Key messages boxFGS was the second most common genital infection in this rural population after HSV.FGS was positively associated with HPV.FGS was negatively associated with genital chlamydia infections.FGS should be included in the syndromic management of genital infections.

Background HIV testing contributes to the prevention and control of the HIV epidemic in the general population. South Africa has made strides to improve HIV testing towards reaching the first of the UNAIDS 90–90–90 targets by 2020. However, to date no nationally representative analysis has examined temporal trends and factors associated with HIV testing among youth and adults in the country. Aim This study aimed to examine the trends and associations with ever having tested for HIV among youth and adults aged 15 years and older in South Africa using the 2005, 2008, 2012 and 2017 nationally representative population-based household surveys. Methods The analysis of the data collected used multi-stage stratified cluster randomised cross-sectional design. P-trend chi-squared test was used to identify any significant changes over the four study periods. Bivariate and multivariate logistic regression analysis was conducted to determine factors associated with HIV testing in each of the survey periods. Results Ever having tested for HIV increased substantially from 2005 (30.6%, n = 16 112), 2008 (50.4%, n = 13 084), 2012 (65.5%, n = 26 381), to 2017 (75.2%, n = 23 190). Those aged 50 years and older were significantly less likely to ever have tested for HIV than those aged 25–49 years. Those residing in rural areas were significantly less likely to have tested for HIV as compared to people from urban areas. There was a change in HIV testing among race groups with Whites, Coloureds and Indian/Asians testing more in 2005 and 2008 and Black Africans in 2017. Marriage, education and employment were significantly associated with increased likelihood of ever testing for HIV. Those who provided a blood specimen for laboratory HIV testing in the survey rounds and were found to have tested positive were more likely to have ever tested for HIV previously. Conclusion The results show that overall there has been an increase in ever having an HIV test in the South African population over time. The findings also suggest that for South Africa to close the testing gap and reach the first of the UNAIDS 90–90–90 targets by 2020, targeted programmes aimed at increasing access and utilization of HIV testing in young people, males, those not married, the less educated, unemployed and those residing in rural areas of South Africa should be prioritised.

Background Adolescent pregnancy and motherhood has been a controversial and much disputed subject within the field of public health. Early childbearing is not only characterized as a physical body experience but also embodies the experiences and perceptions of the social norms, discourses, conflict and moral judgement. There is an increasing concern that the psychosocial challenges facing adolescent mothers remains in the background since research in this field has mainly focused on the medical and physical complications of early childbearing. The aim of this qualitative study was to explore adolescent pregnancy and motherhood in order to understand this phenomenon from the perspective of adolescent mothers and to gain insight into their future aspirations. Methods This descriptive qualitative study was based on data from four focus group discussions with adolescent mothers utilising healthcare services at a district hospital in Ugu district, KwaZulu Natal, South Africa. The data were audio-recorded and transcribed verbatim, then analysed using thematic analysis. Results Some adolescent mothers’ partners were in denial and rejected them and the child while others’ partners were happy and supported them during their pregnancy. Families’ reactions to the pregnancies ranged between anger and disappointment to abandonment, the silent treatment, and acceptance and forgiveness. The psychological issues experienced by some of the adolescent mothers included suicidal ideation, guilt, loneliness, anxiety, and stress. They also experienced financial constraints, difficulty in returning to school, and stigmatisation in society. The participants envisioned completing their education, focusing on their dream careers, and contributing positively to society. Conclusion Experiences of adolescent pregnancy and parenting are multifaceted and the healthcare needs of pregnant and parenting adolescents extend beyond information and knowledge. A multidisciplinary approach is required in the care of adolescent mothers. A key policy priority should encompass the collaboration of different professionals from various healthcare sectors to assist adolescent mothers in achieving better health and psychosocial and socio-economic outcomes as steps to securing a better future for them.

IntroductionAmong women living with HIV, intimate partner violence (IPV) is increasingly recognised worldwide as a serious public health concern. The understanding of the link between IPV and HIV is currently inconclusive and information concerning the IPV experiences of HIV-infected women is insufficient. This protocol aims to map evidence of IPV against women living with HIV/AIDS in Africa.Methods and analysisWe will search and review peer-reviewed and review articles. The comprehensive search will include the electronic databases PubMed, MEDLINE with full text via EBSCO host, Google Scholar, Science Direct and Scopus. The advanced search will use MeSH terms. Grey literature will also be included. The titles of the studies from the database searches will be screened, and duplicates will be removed. The abstract screening will be done independently by two reviewers, followed by the full-text screening which will be based on the eligibility criteria. The six methodological stages in this review will be to: identify the research questions; identify relevant studies; select the studies; chart the data; collate, summarise and report the results; and thereafter undertake consultations. The quality of studies included in the review will be determined by the Mixed Methods Appraisal Tool. NVIVO software V.11 will be used to undertake a thematic analysis of each of the studies and to extract the relevant outcomes.DisseminationThe results of this study will be disseminated through publication, and presented at conferences related to IPV.Scoping review registrationCurrently, a scoping review is not eligible for registration on the International Prospective Register of Systematic Reviews.

Background: Anaemia is a common blood disorder in children and is known to cause complications such as lethargy and stress on bodily organs. Children from disadvantaged communities often fail to achieve their age-related potential with iron deficiency anaemia stated as a risk factor through causing inattentiveness and learning problems. Limited evidence exists for the adverse effects of iron deficiency anaemia on the developing child’s brain from South African studies. Aim: The objective of this study was to determine the local prevalence of anaemia and iron deficiency and to examine their association with psychomotor development and school performance in school-aged children. Setting: This study was conducted in a peri-urban disadvantaged community from KwaZulu-Natal, South Africa. Methods: Children aged 6 to 8 years from KwaZulu-Natal were enrolled ( n = 184). Three parameters of assessment were used: clinical data, biochemical data (haemoglobin levels and iron studies) and school performance (interviews with caregivers, teachers and the children). Anaemia presence and iron deficiency were the hypothesised mediating variables through which growth, development and school performance were influenced. Results: A high point prevalence of anaemia (23.4%), iron deficiency anaemia (4.9%) and helminth infection (27.1%) was identified. Impaired cognitive assessment scores (20.7%) were prevalent in the children sampled. Behavioural problems (4.3%), poor memory function (4.3%) and impaired attention (1.1%) were of low prevalence. Anaemia and iron deficiency were both associated with impaired fine motor skills ( p < 0.05). Anaemia was significantly associated with low cognitive scores ( p = 0.01). Neither anaemia, iron status nor helminth infection significantly predicted school performance in the children sampled. Conclusions: The point prevalence of anaemia and iron deficiency among the sampled children was higher than the national prevalence. The sample size was however inadequate for drawing statistical conclusions about psychomotor development and school performance because of the low prevalence of the different outcomes that were examined. Practical challenges faced in conducting this investigation in rural South African schools were discussed.

Background: Adolescent childbearing has numerous consequences on maternal health, child health and the well-being of society. Because of the high-risk nature of adolescent pregnancy, a multidisciplinary team (MDT) approach is recommended to achieve satisfactory pregnancy outcomes. Aim: The aim of this study was to explore nurses’ perceptions of the MDT approach in the continuum of care for adolescent mothers and their children. Setting: The study was conducted in a local district hospital in Ugu, KwaZulu-Natal. Methods: An explorative and descriptive qualitative study design was used. The first author and hospital staff (clinical midwives and the clinical manager of obstetrics and gynaecology) collaborated on the development of the focus group discussion (FGD) guide to explore nurses’ perception of the MDT approach of care for adolescent mothers and their children. A total of three FGDs were conducted. Data were analysed using thematic analysis. Results: Six overarching themes emerged from the data analysis which included professional benefits of adopting the MDT approach of care for adolescent mothers and their children, barriers to the multidisciplinary collaboration, clinical benefits of adopting the MDT approach of care for parenting adolescent mothers, problems and needs of adolescent mothers, and nurses’ reasons regarding their willingness to participate in a multidisciplinary collaboration in the care of parenting adolescent mothers. Conclusion: In the opinion of nurses, the MDT approach of care for adolescent mothers and their children is an important strategy to improve maternal and child health outcomes. This study has important implications for the design of an intervention.

The research study that informed this article’s discussion, critically interrogates an HIV-infected research team’s positionality whilst conducting a mixed-methods’ study on HIV-positive patients’ experiences of the public ART programme at four ARV clinics in KwaZulu-Natal, South Africa. It primarily utilises the principal investigator’s (PI) narrative to explore insider/outsider positionality, reflexivity, bracketing and participatory action research through exposure of feelings, emotions, challenges, engagements, relationships and observations. The fluid positionality of the HIV-positive research team presented both challenges and opportunities. However, the opportunities for more HIV-infected researchers to engage in HIV-related research to assist with destigmatising HIV, close research gaps and the creation of a trustworthy research environment to achieve an ethical and reliable health science study, far outweigh the challenges. Further, such research can improve patients’ support and healthcare, healthcare workers’ perceptions of patients, and provide a guide for policymakers to better understand the recipients of HIV policies. Lastly, the term ‘HIV reflexivity’ is coined as a result.

ObjectivesThe present study undertakes a scoping review aimed to map the evidence of intimate partner violence (IPV) against women living with HIV/AIDS in Africa.DesignWe used the online database to identify papers published from 1 January 2009 to 1 April 2019, from which we selected 21 articles from Uganda, Nigeria, Kenya, South Africa, Zambia, Ethiopia, Cameroon, Tanzania and Swaziland that used IPV as an outcome variable among women living with HIV/AIDS.Data sourcesPubMed, MEDLINE, EBSCO host, Google Scholar.Eligibility criteriaWe included women who were aged 15 years and above, living with HIV/AIDS in sub-Saharan Africa.Data extraction and synthesisWe conducted the abstract screening with two independent reviewers. We also performed full-text screening. We used the six methodological frameworks proposed by Arksey and O'Malley. The Mixed Method Appraisal Tool was used to determine the quality of the studies. We used NVIVO software V.12 to undertake a thematic analysis.ResultsOf the studies, the majority, 57.1%, reported cross-sectional results. In comparison, 23.8% examined qualitative studies, 9.5% were clinical trials, 4.8% were cohort studies and the remaining 4.8% covered grey literature. This review revealed evidence of IPV experience among women with HIV/AIDS, evidence of how HIV status disclosure influences IPV, proof of the association of sociodemographic characteristics with IPV and implications for practice. Moreover, the review revealed that following the serostatus disclosure, there is evidence of heightened risk for IPV.ConclusionsThis study found evidence of IPV among women living with HIV/AIDS. The HIV-positive women were at considerable risk of IPV after disclosure of their serostatus to a male partner. Therefore, further research is needed to promote action to reduce IPV among HIV-positive and HIV-negative women and to determine healthcare workers’ IPV screening experience.

Background and Objectives Alcohol abuse, a significant health problem in South Africa, affects the ability of adults to care for children. Little is known regarding risky alcohol use among child caregivers there. A large population-based study examined the prevalence of, and factors associated with, risky drinking among caregivers of young children in KwaZulu-Natal, South Africa comparing the use of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-C screens for hazardous or harmful drinking (referred to here as risky drinking). Methods 83 % of child caregivers from five tribal areas were interviewed using the 10-question AUDIT to screen for risky drinking. The AUDIT-C screen, a subset of AUDIT questions, targets alcohol consumption and binge drinking. Factors associated with risky drinking were investigated using logistic regression. Results 1434 caregivers participated, 98 % female. Sixteen percent reported ever drinking alcohol. Based on AUDIT criteria for risky drinking, 13 % of the sample scored as moderate drinkers, 2 % as hazardous users, and 1 % as harmful or dependent users (identifying 3 % as risky drinkers). Using AUDIT-C criteria to identify risky drinking significantly increased the proportion of caregivers identified as risky drinkers to 9 %. In multivariate analyses, factors associated with risky drinking were similar in both screens: partner violence, smoking, HIV-infection, caring for a child with disabilities. Conclusions for Practice Since the AUDIT-C identified risky alcohol use not otherwise detected with the full AUDIT, and since resources for screening in health care settings is limited, the AUDIT-C may be a more appropriate screen in populations where binge drinking is common.

Background In many countries, there is evidence that intimate partner violence is prevalent among young women. This study aimed to determine the prevalence and the factors associated with intimate partner violence in young women (aged 15–24 years) attending secondary schools in Maputo, Mozambique. Method Using a probability proportional sampling strategy, 431 participants were recruited, and the data were collected using a self-administered questionnaire. Binary and multivariate logistic regression analyses were performed to assess the association between IPV and sociodemographic and sociocultural factors. Odds ratio (OR) and 95% confidence intervals (CI) are reported. Results Of the 413 participants, 248 (60%) (95% CI: 55.15–64.61) had experienced at least one form of IPV in their lifetime. Then, of the 293 participants who had a partner in the previous 12 months prior to the data collection, 186 (63.4%) (95% CI: 57.68–69.00) reported IPV in the 12 months prior to data collection. The psychological violence was the predominant type of violence, lifetime prevalence 230 (55.7%), and over the previous 12 months 164 (55.9%). The risk of IPV was associated with young women lacking religious commitment (AOR, 1.596, 95% CI: 1.009–2.525, p = 0.046) and if the head of the young women’s household was unemployed (AOR, 1.642 95% CI: 1.044–2.584, p = 0.032). In the bivariate analysis the odds of being abused remained lower among the younger teenage women (OR, 0.458 95% CI: 0.237–0.888, p = 0.021), and higher, among young women if the partner was employed (OR, 2.247 95% CI: 1.187–4.256, p = 0.013) and among the young women believing that males are superior to females (OR, 2.298 95% CI:1.014–5.210. p = 0.046). Conclusion These findings reveal a high prevalence of IPV among young women. Comprehensive programs should incorporate socioeconomic empowerment strategies to increase women’s autonomy. There is a need to address religious beliefs through cultural perspectives, to improve social interactions that promote violence free relationships, gender egalitarian norms, and physical and emotional wellbeing for young women.

ObjectiveThis study carried out a scoping review of research on intimate partner violence to determine the extent to which studies on sociocultural factors influencing intimate partner violence among young women (15–24 years) have been conducted, and how different geographical areas are represented. It also considered whether the methodologies used were sufficient to describe the risk factors, prevalence and health outcomes associated with intimate partner violence among young women.Study designScoping review.MethodsOnline databases were used to identify studies published between 2008 and 2019. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines by Arksey and O’Malley were used to select studies, and primary studies were assessed using the Mixed Method Appraisal Tool, V.2011. Thematic content analysis was used to summarise the findings of the scoping review.ResultsThe majority of publications eight (61.5%) reported cross-sectional studies, while four (31.5%) were qualitative studies. One of the studies (7%) collected measured data. Overall, 13 (100%) of the publications examined factors influencing intimate partner violence.Using a customised quality assessment instrument, 12 (92.3%) of studies achieved a ‘high’-quality ranking with a score of 100%, and 7.7% of studies achieved an ‘average’ quality ranking with a score of 75%.ConclusionsWhile the quality of the studies is generally high, researches on sociocultural factors influencing intimate partner violence among young women would benefit from a careful selection of methods and reference standards, including direct measures of the violence affecting young women. Prospective cohort studies are required linking early exposure with individual, sociocultural and community factors, and detailing the abuse experienced from childhood, adolescence and youth.PROSPERO registration numberCRD42018116463.Scoping protocol publicationhttps://doi.org/10.1186/s13643-019-1234-y

Background Knowledge and practices of sexual and reproductive healthcare is pivotal to the Safe Motherhood Initiative; however, only a few studies have investigated adolescent mothers’ knowledge of sexual and reproductive health in light of the above initiative. Research should thus focus on the knowledge and attitudes of adolescent girls as well as peer influences related to pregnancy and sexual and reproductive health among adolescents, as the findings may highlight vital health interventions that should be introduced. The aim of this study was thus to determine the knowledge, personal attitudes and peer influences related to pregnancy, sexual and reproductive health among adolescents who attended maternal health services in a district hospital in Ugu, KwaZulu-Natal, South Africa. Methods A cross sectional study was conducted. Data were collected from 326 adolescents who accessed maternal health services in a peri-urban district hospital during June 2017 and November 2017. The questionnaire surveyed the knowledge, personal attitudes and peer influences related to pregnancy, sexual and reproductive health. The questionnaire was administered by fieldworkers using mobile devices powered by the Mobenzi Researcher® technology. The completed surveys were uploaded to the Mobenzi server where it was stored and aggregated. The data was analysed using R software. Results Of the 326 participants, 65 (19.9%) experienced repeat pregnancies in adolescence. Overall, only 143 (43.9%) of the participants answered 50% or more of the knowledge questions on pregnancy and HIV/AIDS and STIs correctly, while 183 (56.1%) answered less than 50% of the knowledge questions correctly. There was no relationship between knowledge of pregnancy and HIV/STIs and repeat adolescent pregnancies. Conclusion Adolescents’ knowledge of pregnancy and sexual and reproductive health was deficient as, even with repeat pregnancies, these adolescents were evidently no better informed about pregnancy and sexual and reproductive health. This suggests that social determinants, modes and platforms regarding the delivery of adolescent sexual and reproductive health education are important. An innovative mode to the delivery of sexual and reproductive health education includes the emerging digital platform. The digital platform encompasses social media, multimedia and mobile phones which is growing popular among young people. Electronic supplementary material The online version of this article (10.1186/s12889-019-7242-y) contains supplementary material, which is available to authorized users.

Background: Patients play a major role in the success of any antiretroviral treatment (ART) programme. Hence, their needs should be articulated on a regular basis for interventional processes to promote adherence, retention and quality care. Aim: This study investigated whether patients’ needs were being met, described which needs were met, which were not and how such needs could be met. Setting: The study took place at four ART clinics in eThekwini district public hospitals. Methods: This study formed part of a larger study that utilised a sequential mixed-methods design. However, only the qualitative component is documented herein. Twelve HIV-infected patients engaged in in-depth interviews (three patients from each of the four hospitals). A socio-ecological framework divided responses into four categories, namely, the individual, interpersonal, institutional and policy. Each category presented (1) patients’ needs that are being met, (2) needs that are not being met, (3) recommendations on how they can be met and (4) researchers’ observations. Results: All 12 patients reported that all their needs were not being met. They further shared their met needs, unmet needs and made recommendations for meeting their unmet needs. These needs varied per antiretroviral clinic because of unique processes at each institution. Conclusion: To adequately address the needs of HIV-infected patients, it is imperative for all stakeholders involved in the public ART programme to gain an understanding of what constitutes ‘patients’ needs’. The results reflect patients’ willingness to be involved in their care, treatment and interventional strategies to adequately meet their needs.

ObjectivesThis study aimed to measure the prevalence and associated factors of Intimate Partner Violence (IPV) among women living with and without HIV in Wolaita Zone, Southern Ethiopia.MethodsA comparative cross-sectional study design was used to interview the 816 women between 18-49 years of age (408 = HIV positive, 408 = HIV negative). Using a multistage sampling technique, participants were recruited from nine health facilities based on probability proportional to the number of clients. After data entry (EpiData version 4.4.2.0) the data were exported to STATA/SE 15 software. Binary and multivariable logistic regression analysis were undertaken and the odds ratio (OR) and 95% confidence interval (CI) are presented.ResultsThe lifetime prevalence of IPV among all women was 59.7%, [95% CI: 56.31%-63.05%]. IPV was slightly higher among women living with HIV, 250(61.3%), than those who were HIV negative, 238(58.1%). Lifetime prevalence of emotional violence 413(50.6%), physical violence 349(42.8%), sexual violence 219(26.8%), and controlling behaviours by husbands/partners 489(59.9%) were reported. Associations were found between IPV and controlling behaviour of husband/partner [AOR = 8.13; 95% CI: 4.93-13.42],income [AOR = 3.97; 95% CI:1.81-8.72], bride price payment [AOR = 3.46; 95% CI:1.74-6.87], women's decision to refuse sex [AOR = 2.99; 95% CI: 1.39-6.41],age group of women [AOR = 2.86; 95% CI:1.67-4.90], partner's family choosing wife [AOR = 2.83; 95% CI:1.70-4.69], alcohol consumption by partner [AOR = 2.36;95% CI:1.36-4.10], number of sexual partners [AOR = 2.35; 95% CI:1.36-4.09], and if partner ever physically fought with another man [AOR = 1.83; 95% CI:1.05-3.19].ConclusionsThere is a high prevalence of IPV against women both living with and without HIV. Policy priorities should therefore involve males in programs of gender-based violence prevention in order to change their violent behaviour, and interventions are required to improve the economic status of women. Both sexes should be advised to have a single partner and marriage arrangements should be by mutual consent rather than being made by parents.

Background: Sexually transmitted infections (STIs) remain a major public health problem globally, with men being the main transmitters of infections. A high prevalence of curable STIs is reported in adults aged between 15 and 49 years, and the delay in seeking treatment has adverse consequences for both the individual and population.Objective: A study was undertaken to assess the factors associated with the health seeking and sexual behaviour of men presenting with STIs at the two primary health care sites in eThekwini metropolitan area.Method: A cross-sectional study design with systematic random sampling was used. Data were collected using an intervieweradministered questionnaire and analysed using STATA.Results: Some 23% of the 134 participants delayed coming to the clinic after noticing the signs and symptoms of an STI. Participants were 5.89 (95% CI 1.49–23.32) times more likely to delay seeking treatment if they sought medical help only when perceiving an illness to be severe, and three times more likely to delay (borderline result) if they only used a condom when sober (OR 3.16; 95% CI 0.99–10.06). Staff stigma and the bad attitude of nurses were factors that delayed men visiting the clinic for STI treatment and this was reported by 76 (56.7%) of the participants.Conclusion: Delayed health seeking behaviour amongst men with STIs remains a major challenge. Appropriate interventions are required to deal with factors associated with delayed health seeking behaviour amongst men with STIs.

Background. Worldwide, suicide affects the most vulnerable populations, including adolescents and young adults. It is estimated that suicide will contribute more than 2% to the global burden of disease by 2020. Information about the prevalence of suicidal behaviour and the sociodemographic characteristics and risk factors associated with suicide in the South African (SA) rural context is important for local and national policy and contributes to global understanding of the phenomenon. Objective. To investigate key demographic factors and behaviours associated with planning and attempting suicide among high-school learners. Methods. In a cross-sectional study, we used stratified random sampling to select 16 schools in uMgungundlovu District, KwaZulu-Natal Province, SA. All grade 10 learners ( N =1 759) at these schools completed a self-administered questionnaire (Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance System). Data analysis was carried out with Stata 13 statistical software using generalised estimating equations. Results. In total, 222 learners (12.6% of the 1 759) had made plans to attempt suicide during the previous 12 months, 261 (14.8%) had actually attempted suicide, and 218 attempts had resulted in the learner being treated by a doctor or nurse (12.4%). The risk of planning suicide increased with age. For male learners, being threatened with a weapon on school property (adjusted odds ratio (AOR) 3.7, 95% confidence interval (CI) 1.9 - 7.1; p

Background: Prevention of youth sexual risk behaviour among the youth in uMgungundlovu District Municipality continues to be a primary challenge for public health and health promotion. Current prevention interventions are targeted at an individual level, whilst youth behaviour is influenced by many social and environmental factors.Aim: The aim of the study was to explore the factors influencing sexual risk behaviours of the youth at different socio-ecological levels in uMgungundlovu District Municipality.Methods: An explorative and descriptive qualitative study design was used, using in-depth interviews and focus group discussions for data collection. A framework analysis was used to develop themes derived from the socio-ecological theory.Results: Four themes were identified that influence youth to engage in sexual risk behaviours: (1) individual factors, related to role modelling behaviour, gender and negative stereotypes towards females; (2) the microsystem in which youth function including the influence of family and peers; (3) the exo-system comprising the disadvantaged socio-economic status of the communities where the youth live; and (4) the macrosystem where negative social norms were reported to influence youth health outcomes.Conclusion: Sexual risk behaviour among youth in uMgungundlovu is influenced by many factors at multiple social levels. Interventions directed at these multiple levels are needed urgently.

Female genital schistosomiasis (FGS) is a highly prevalent waterborne disease in some of the poorest areas of sub-Saharan Africa. Reliable and affordable diagnostics are unavailable. We explored colourimetric image analysis to identify the characteristic, yellow lesions caused by FGS. We found that the method may yield a sensitivity of 83% and a specificity of 73% in colposcopic images. The accuracy was also explored in images of simulated inferior quality, to assess the possibility of implementing such a method in simple, electronic devices. This represents the first step towards developing a safe and affordable aid in clinical diagnosis, allowing for a point-of-care approach.

Background: It has been estimated that 700 million people worldwide and 5.2 million people in South Africa are in need of annual treatment for schistosomiasis. In accordance with the current policy the Department of Health (DoH) in KwaZulu-Natal province, South Africa, aimed to reach 75% treatment coverage in a mass treatment campaign (MTC) of schools in a schistosomiasis-endemic area.Methods: A cross-sectional study was designed to explore the implementation, coverage, challenges and limitations of a DoH MTC in a middle-income country. The study was conducted by exploring nurses’ and research team records, school enrolment lists and parental consent forms.Results: Slightly more than 10 000 learners in 43 primary and high schools were treated, achieving treatment coverage of 44.3%. A median of two schools per day were visited over the course of 39 days. We found that older learners, being male and attending a large school were independent significant predictors for low treatment coverage.Conclusion: Our r...

Background South African young women continue to be vulnerable, with high prevalence of teenage pregnancy, HIV, sexually transmitted infections (STIs) and female genital schistosomiasis (FGS). This study seeks to examine the underlying factors that may be associated with these four adverse reproductive health outcomes. Methods In a cross-sectional study of 1413 sexually active of young women, we explored these four adverse reproductive health outcomes by considering socio-demographic factors, socio-economic factors, sexual risk behaviour, substance abuse and knowledge about reproductive health by using a questionnaire. Consenting participants were asked about previous pregnancies and were tested for HIV, STIs and FGS. Multivariable regression analyses were used to explore the factors associated with these four reproductive health outcomes. Results 1. Early pregnancy: Among the young women, 44.4% had already been pregnant at least once. Associated factors were hormonal contraceptives, (adjusted odds ratio (AOR): 17.94, 95% confidence interval (CI): 12.73–25.29), and sexual debut