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Abstract Background Although South Africa has the largest public-sector anti-retroviral treatment (ART) programme in the world, anti-retroviral coverage in adults was only 40.2% in 2008. However, longitudinal studies of who is accessing the South African public-sector ART programme are scarce. This study therefore had one main research question: who is accessing public-sector ART in the Free State Province, South Africa? The study aimed to extend the current literature by investigating, in a quantitative manner and using a longitudinal study design, the participants enrolled in the public-sector ART programme in the period 2004-2006 in the Free State Province of South Africa. Methods Differences in the demographic (age, sex, population group and marital status) socio-economic (education, income, neo-material indicators), geographic (travel costs, relocation for ART), and medical characteristics (CD4, viral load, time since first diagnosis, treatment status) among 912 patients enrolled in the Free State public-sector ART programme between 2004 and 2006 were assessed with one-way analysis of variance, Bonferroni post-hoc analysis, and cross tabulations with the chi square test. Results The patients accessing treatment tended to be female (71.1%) and unemployed (83.4%). However, although relatively poor, those most likely to access ART services were not the most impoverished patients. The proportion of female patients increased (P < 0.05) and their socio-economic situation improved between 2004 and 2006 (P < 0.05). The increasing mean transport cost (P < 0.05) to visit the facility is worrying, because this cost is an important barrier to ART uptake and adherence. Encouragingly, the study results revealed that the interval between the first HIV-positive diagnosis and ART initiation decreased steadily over time (P < 0.05). This was also reflected in the increasing baseline CD4 cell count at ART initiation (P < 0.05). Conclusions Our analysis showed significant changes in the demographic, socio-economic, geographic, and medical characteristics of the patients during the first three years of the programme. Knowledge of the characteristics of these patients can assist policy makers in developing measures to retain them in care. The information reported here can also be usefully applied to target patient groups that are currently not reached in the implementation of the ART programme.

Abstract Background African and Asian cohort studies have demonstrated the clinical efficacy of antiretroviral treatment (ART) in resource-limited settings. However, reports of the long-term changes in the physical and emotional quality of life (QoL) of patients on ART in these settings are still scarce. In this study, we assessed the physical and emotional QoL after six and 12 months of ART of a sample of 268 patients enrolled in South Africa's public-sector ART programme. The study also tested the impact of the adverse effects of medication on patients' physical and emotional QoL. Methods A stratified random sample of 268 patients undergoing ART was interviewed at baseline (< 6 months ART) and follow-up (< 12 months ART). A model of the relationships between the duration of ART, the adverse effects of medication, and physical and emotional QoL (measured using EUROQOL-5D) was tested using structural equation modelling. Results The improved physical and emotional QoL shown at baseline was sustained over the 12-month study period, because treatment duration was not significantly associated with changes in the patients' QoL. Physical QoL significantly and positively influenced the patients' emotional QoL (subjective well-being [SWB]) (β = 0.33, P < 0.01). Longitudinal data showed that patients reported significantly fewer adverse effects at follow-up than at baseline (β = -0.38, P < 0.001) and that these adverse effects negatively influenced physical (β = -0.27, P < 0.01) and emotional QoL (β = -0.15, P < 0.05). Conclusion This study provides evidence that the South African public-sector ART programme is effective in delivering sustained improvement in patient well-being. However, the results should encourage clinicians and lay health workers to be vigilant regarding the adverse effects of treatment, because they can seriously affect physical and emotional QoL.

As a large international consortium of 26 countries and 110 higher-education institutions (HEIs), we successfully developed and executed an online student survey during or directly after the initial peak of the COVID-19 pandemic. The COVID-19 International Student Well-being Study (C19 ISWS) is a cross-sectional multicountry study that collected data on higher-education students during the COVID-19 outbreak in the spring of 2020. The dataset allows description of: (1) living conditions, financial conditions, and academic workload before and during the COVID-19 outbreak; (2) the current level of mental well-being and effects on healthy lifestyles; (3) perceived stressors; (4) resources (e.g., social support and economic capital); (5) knowledge related to COVID-19; and (6) attitudes toward COVID-19 measures implemented by the government and relevant HEI. The dataset additionally includes information about COVID-19 measures taken by the government and HEI that were in place during the period of data collection. The collected data provide a comprehensive and comparative dataset on student well-being. In this article, we present the rationale for this study, the development and content of the survey, the methodology of data collection and sampling, and the limitations of the study. In addition, we highlight the opportunities that the dataset provides for advancing social science research on student well-being during the COVID-19 pandemic in varying policy contexts. Thus far, this is, to our knowledge, the first cross-country student well-being survey during the COVID-19 pandemic, resulting in a unique dataset that enables high-priority socially relevant research. [ABSTRACT FROM AUTHOR]

Abstract Background The study's first objective was to determine the levels of patient satisfaction with services at antiretroviral treatment (ART) assessment sites. Differences in patient satisfaction with several aspects of service over time and among health districts were measured. The second objective was to examine the association between human resource shortages and levels of patient satisfaction with services. Methods Four cross-sectional waves of data were collected from a random sample of 975 patients enrolled in the Free State's public-sector ART programme. One-way analysis of variance (ANOVA) with the Bonferroni adjustment for multiple comparisons was used to assess the differences in patient satisfaction among the Province's five districts and among the four waves of data. Correlation coefficient analysis using Pearson's r was used to assess the association between ART nurse vacancy rates and patient satisfaction with the services provided by nurses over time. Results With respect to both general services and the services provided by nurses, our results indicate high overall satisfaction among Free State patients receiving public-sector ART. However, our data present a less positive picture of patient satisfaction with waiting times. Patients in Fezile Dabi District were generally slightly dissatisfied with the waiting times at their assessment sites. In fact, waiting times at assessment sites were the most important predictor of discontent among ART patients. Significant geographical (P < 0.001) and temporal differences (P < 0.005) were observed in these three aspects of patient satisfaction. Patients were most satisfied in Thabo Mofutsanyana District and least satisfied in Motheo District. Patients in Fezile Dabi District were generally slightly dissatisfied with the waiting times at their assessment sites. Finally, our analysis revealed a strong negative association (r = -0.438, P < 0.001) between nurse vacancy rates and mean satisfaction levels with services performed by nurses at baseline. Patients attending facilities with high professional nurse vacancy rates reported significantly less satisfaction with nurses' services than did those attending facilities with fewer vacant nursing posts. Conclusion Collectively, our findings show high levels of patient satisfaction with ART-related services, but also confirm claims by other studies, which have identified human resource shortages as the most important obstacle to a successful South African AIDS strategy.

Introduction: Hope is an essential dimension of successful coping in the context of illnesses such as HIV/AIDS, because positive expectations for the future alleviate emotional distress, enhance quality of life and have been linked to the capacity for behavioural change. The social environment (e.g. family, peers) is a regulator of hope for people living with HIV/AIDS (PLWHA). In this regard, the dual aim of this article is (1) to analyze the influence of a peer adherence support (PAS) intervention and the family environment on the state of hope in PLWHA and (2) to investigate the interrelationship between the two determinants. Methods: The Effective AIDS Treatment and Support in the Free State study is a prospective randomized controlled trial. Participants were recruited from 12 public antiretroviral treatment (ART) clinics across five districts in the Free State Province of South Africa. Each of these patients was assigned to one of the following groups: a control group receiving standard care, a group receiving additional biweekly PAS or a group receiving PAS and nutritional support. Latent cross-lagged modelling (Mplus) was used to analyse the impact of PAS and the family environment on the level of hope in PLWHA. Results: The results of the study indicate that neither PAS nor the family environment has a direct effect on the level of hope in PLWHA. Subsequent analysis reveals a positive significant interaction between family functioning and PAS at the second followup, indicating that better family functioning increases the positive effect of PAS on the state of hope in PLWHA. Conclusions: The interplay between well-functioning families and external PAS generates higher levels of hope, which is an essential dimension in the success of lifelong treatment. This study provides additional insight into the important role played by family dynamics in HIV/AIDS care, and it underscores the need for PAS interventions that are sensitive to the contexts in which they are implemented. Keywords: peer adherence support; hope; family functioning; latent cross-lagged modelling; randomized controlled trial; South Africa., Introduction After many years of disappointment, the international community was filled with hope in 1996, when scientists were able to report a significant treatment breakthrough: highly active antiretroviral therapy (HAART) [...]

Introduction: Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. This is also the case in Belgium, which has a complex governing system where both the federal and federated governments have responsibilities concerning health care. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years (the federal care trajectory for diabetes, the joint plan for the chronically ill and the reform of primary care in Flanders), we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view. Methods: 27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Policymakers, public administrators, finance stakeholders, provider organisations, user and patient groups and scientific stakeholders were included. Semi-structured interviews were guided by a timeline of policies and performed by two researchers. The main topics of the interview guide were: stakeholder role, their understanding of integrated chronic care, and the barriers to and facilitators of the development and implementation of integrated care policies. The interviews were transcribed verbatim and an inductive thematic analysis was performed and repeatedly discussed within the team. Results: Stakeholders had diverse interpretations of integrated care, but agreed that implementation of integrated care in Belgium is still suboptimal. Barriers and facilitators were identified on both health care and policy level. A major barriers is the fee-for-service system, which does not stimulate cooperation nor quality of care. Within the topic of data sharing, many strategies have been formulated, but the implementation lacks, which hinders again cooperation. A last major barrier is the fragmentation of responsibilities between different levels of government. It leads to confusion, but mainly it hinders integrated care as different policy-makers head in different directions and so it is difficult to align plans, especially on the long term. Remarkably, these factors strongly interact. Conclusion: The scale-up of integrated care is influenced by multiple factors, which interact with each other. The preparedness to change at both the policy level and health care level will be key to triggering a transformation leading to integrated care. However, important barriers, are hindering a much needed change to the entire Belgian health care system and a shift towards integrated care. Implications: This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. A focus on the financing system seems important in this regard. Political commitment and citizen participation will be crucial. [ABSTRACT FROM AUTHOR]

Introduction: Raised blood pressure (BP) is a major risk factor for cardiovascular disease worldwide. Although effective treatment exists and is widely available, few patients manage to achieve BP control, even in high-income countries such as Belgium. As hypertension (HTN) is a chronic condition, it requires lifelong continuous and coordinated action from healthcare systems along the continuum of care. This raises the need to evaluate the delivery of HTN care accordingly, using a cascade of care (CoC) approach, rather than solely focussing on the outcomes (i.e. BP control). Objectives and methods: The objective of the current study is twofold. First, we use a CoC approach to identify where most patients are lost along the continuum of HTN care. Second, we identify patient characteristics that are associated with the leakages in the CoC. Based on crosssectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Study, we estimate the prevalence of HTN among the Belgian population aged 40-80 and the proportions that reach each stage of the HTN CoC: being screened, diagnosed, linked to care, treated, followed-up and well-controlled. Next, cox regression models are estimated to assess the factors associated with an elevated risk of not being linked to care, treated and followed-up. Results: Our preliminary findings indicate that 44.7% of the Belgian population aged 40-80 has HTN. Of these, 96.7% had their BP measured in the past 3 years, but only 56.1% self-reported having been diagnosed. Furthermore, 52.9% is linked to care, 49.5% is in treatment and 43.1% is followed-up by means of a yearly blood cholesterol measure. Finally, only about a quarter (25.8%) is well controlled. Men diagnosed with HTN are more likely to be unlinked to care, while once they are in treatment, they are more likely to be followed-up appropriately. Age and BMI were positively associated with being linked to care and in treatment, but not with being followed-up. Finally, the results revealed a socio-economic gradient: both perceived financial strain and being lower educated was associated with an increased risk of being diagnosed but unlinked to care. Conclusion: Patients are lost at each stage of the HTN CoC and only about a quarter of the HTN population is well controlled. The largest loss occurs early on in the cascade: less than half of the HTN population reported to be diagnosed. Once diagnosed, the healthcare system retains patients fairly well, but there are differences between population sub-groups. Implications for applicability and limitations: A limitation of the current study is that we were unable to study HTN patients' characteristics that are associated with 'being undiagnosed', due to data limitations. Further research is therefore warranted, as this constitutes the largest drop in the Belgian HTN CoC. Nevertheless, this study is the first to inform Belgian policymakers about where patient retention needs to be improved along the HTN CoC and which high-risk groups require special attention in this regard. [ABSTRACT FROM AUTHOR]

Two types of bivariate models for categorical response variables are introduced to deal with special categories such as ‘unsure’ or ‘unknown’ in combination with other ordinal categories, while taking additional hierarchical data structures into account. The latter is achieved by the use of different covariance structures for a trivariate random effect. The models are applied to data from the INSIDA survey, where interest goes to the effect of covariates on the association between HIV risk perception (quadrinomial with an ‘unknown risk’ category) and HIV infection status (binary). The final model combines continuation-ratio with cumulative link logits for the risk perception, together with partly correlated and partly shared trivariate random effects for the household level. The results indicate that only age has a significant effect on the association between HIV risk perception and infection status. The proposed models may be useful in various fields of application such as social and biomedical sciences, epidemiology and public health. [ABSTRACT FROM AUTHOR]

Optimal family relationships are central to individual well-being. The focus of this paper is on family functioning and how socioeconomic status (SES) explains family functioning. Ecological theory states that a family’s socioeconomic context is determined by macro-systemic factors, thereby influencing individuals’ perceptions of family functioning. Within this context, the social causation hypothesis asserts that social conditions influence family functioning. This paper uses the Family Attachment and Changeability Index as measure of family functioning. SES is viewed as multidimensional and individual-, household-, and subjective SES indices are developed using multiple correspondence analysis. Multivariate regression models suggest that household- and subjective SES are associated with higher levels of perceived flexibility in the family. There is no association between SES and family members’ attachment to each other. In general, the findings support the social causation hypothesis. [ABSTRACT FROM AUTHOR]

The Life Esidimeni tragedy in South Africa showed that, despite significant global gains in recognizing the salience of integrated public mental health care during the past decade, crucial gaps remain. State and non-state mental health service collaboration is a recognized strategy to increase access to care and optimal use of community resources, but little evidence exist about how it unfolds in low- to middle-income countries. South Africa's Mental Health Policy Framework and Strategic Plan 2013-20 (MHPF) underlines the importance of collaborative public mental health care, though it is unclear how and to what extent this happens. The aim of the study was to explore the extent and nature of state and non-state mental health service collaboration in the Mangaung Metropolitan District, Free State, South Africa. The research involved an equal status, sequential mixed methods design, comprised of social network analysis (SNA) and semi-structured interviews. SNA-structured interviews were conducted with collaborating state and non-state mental health service providers. Semi-structured interviews were conducted with collaborating partners and key stake holders. Descriptive network analyses of the SNA data were performed with Gephi, and thematic analysis of the semi-structured interview data were performed in NVivo. SNA results suggested a fragmented, hospital centric network, with low average density and clustering, and high authority and influence of a specialist psychiatric hospital. Several different types of collaborative interactions emerged, of which housing and treatment adherence a key point of collaboration. Proportional interactions between state and non-state services were low. Qualitative data expanded on these findings, highlighting the range of available mental health services, and pointed to power dynamics as an important consideration in the mental health service network. The fostering of a well-integrated system of care as proposed in the MHPF requires inter-institutional arrangements that include both clinical and social facets of care, and improvements in local governance. [ABSTRACT FROM AUTHOR]

Background: Alcohol and drug misuse among college students has been studied extensively and has been clearly identified as a public health problem. Within more general populations alcohol misuse remains one of the leading causes of disease, disability and death worldwide. Conducting research on alcohol misuse requires valid and reliable instruments to measure its consequences. One scale that is often used is the consequences scale in the Core Alcohol and Drug Survey (CADS). However, psychometric studies on the CADS are rare and the ones that do exist report varying results. This article aims to address this imbalance by examining the psychometric properties of a Dutch version of the CADS in a large sample of Flemish university and college students. Methods: The analyses are based on data collected by the inter-university project ‘Head in the clouds’, measuring alcohol use among students. In total, 19,253 students participated (22.1% response rate). The CADS scale was measured using 19 consequences, and participants were asked how often they had experienced these on a 6-point scale. Firstly, the factor structure of the CADS was examined. Two models from literature were compared by performing confirmatory factor analyses (CFA) and were adapted if necessary. Secondly, we assessed the composite reliability as well as the convergent, discriminant and concurrent validity. Results: The two-factor model, identifying personal consequences (had a hangover; got nauseated or vomited; missed a class) and social consequences (got into an argument or fight; been criticized by someone I know; done something I later regretted; been hurt or injured) was indicated to be the best model, having both a good model fit and an acceptable composite reliability. In addition, construct validity was evaluated to be acceptable, with good discriminant validity, although the convergent validity of the factor measuring ‘social consequences’ could be improved. Concurrent validity was evaluated as good. Conclusions: In deciding which model best represents the data, it is crucial that not only the model fit is evaluated, but the importance of factor reliability and validity issues is also taken into account. The two-factor model, identifying personal consequences and social consequences, was concluded to be the best model. This shortened Dutch version of the CADS (CADS_D) is a useful tool to screen alcohol-related consequences among college students. [ABSTRACT FROM AUTHOR]

Risky sexual behaviour in PLWHA on antiretroviral therapy threatens both prevention and treatment efforts, but disclosure promises to support safer sexual practices. This paper investigates the association between HIV self-disclosure and consistent condom use in a cohort of public sector patients on antiretroviral (ARV) treatment. Using data from the FEATS cohort study, logistic regression analysis shows that knowledge of your partner's HIV status is positively associated with consistent condom use (OR 2.73, 95% CI 1.37-5.43, p = 0.004) and so too mutual HIV disclosure (OR 3.38, 95% CI 1.60-7.18, p = 0.001). Prevention and treatment programmes, through couple HIV counselling and testing (CHCT) and other assistance programmes, should focus on supporting the mutual disclosure of HIV status among PLWHA on ARV treatment. [ABSTRACT FROM AUTHOR]