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Adolescents living with perinatally acquired HIV are among the first generation in South Africa to grow up with anti-retroviral therapy and democratic freedoms. In this article, we explore the biosocial lives of adolescent boys and young men living with HIV in the Eastern Cape Province of South Africa. We conducted qualitative research with 36 adolescent boys and young men in 2016-2018, including life history narratives, semi-structured interviews, and analysis of health facility files. [masculinity, South Africa, HIV, adolescence].

Background Continuity of care remains a challenge for TB patients who are discharged from hospital and referred to primary health care clinics in South Africa. The aim of this study was to explore the experiences and perceptions of patients, health care workers and family members regarding continuity of TB care in a Cape Town health district. Methods We conducted one-on-one interviews, using semi-structured interview guides, with TB patients and their families and health care workers. We also conducted focus group interviews with other health care workers who performed similar duties. Field notes were kept and patients’ home circumstances were also physically observed. Data saturation was achieved after 31 interviews. We used Miles and Huberman’s qualitative data analysis framework to interpret the data. Results Themes identified in the interviews were grouped into two categories: (1) patients’ socio-economic circumstances including complex family relationships, good or lack of family support, inadequate income, and agency; and (2) health system challenges, including inadequate referral links between the clinic and the hospital and negative emotions as a result of poor service delivery experienced by patients. Conclusion Some TB Patients experienced poor continuity of care on discharge from hospitals to primary health clinics and perceived that this resulted from socio-economic conditions and health system-related problems that triggered negative emotions. Proper communication between the hospital and clinic regarding patients’ care, adequate counselling, and patient-centred treatment are required to address poor continuity of care among patients with TB down-referred to clinics.

In this issue of Critical Public Health, we publish a paper from Savona et al. (2021) that documents some of the ways government and commercial actors in the UK have mobilized the discourse of ‘com...

For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012–2013 from ART initiation in 2012–2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)—17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2–21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8–10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83–3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.

South Africa is burdened by twin epidemics of HIV and tuberculosis (TB) in which men are less likely than their female counterparts to engage with prevention, treatment and care. In some Cape Flats communities in Cape Town, South Africa, the challenge to men is compounded by high levels of gang violence. This study investigates the role of gang violence as a barrier to men's entry and retention in the HIV/TB care cascade. Data for this study drew from six weeks of participant observation and eleven in-depth interviews in Hanover Park, a largely Coloured township of Cape Town. Key findings concerned men's restricted mobility due to gang violence as a result of conflict over gang territory. Men both inside and outside gangs are affected by this violence, with men in gangs, in most cases, being totally cut off from healthcare services. Men in gangs are a key risk population group for both HIV and TB programming. Community-based interventions that address the effects of violence on health services should be designed for the communities on the Cape Flats. Findings could potentially be extrapolated to other settings affected by gang violence, both within South Africa and abroad.

In this paper, we explore the gender socialization of adolescent boys in soccer clubs, and ask whether there are opportunities for integrating gender transformative elements into that socialization. This qualitative study involved 11 in-depth interviews and informal conversations with male soccer coaches from Gugulethu township and Mthatha town in the Western Cape and Eastern Cape provinces of South Africa, respectively. Data were analyzed using a thematic analysis approach. We found that the coaches felt that the adolescent boys in their soccer clubs faced serious social and emotional challenges, with the boys’ poor socio-economic backgrounds and fragmented family structures being major contributors to these challenges. Most coaches also gave themselves the responsibility to try to address some of the challenges faced by their club members. To do this, they employed specific strategies, including creating an alliance with parents and professionals. In the process, the coaches engaged the boys on topics around respect, sexual and reproductive health, and avoiding alcohol, drugs, and involvement in criminal gangs. Some coaches also played a social fathering role to club members as a way of helping them to think differently about their lives, redirect risky practices, and reduce the chance for poor health outcomes. These findings highlight the role of soccer clubs and coaches as potential avenues for health- and equity-promoting gender socialization of adolescent boys.

Long-term patient engagement and retention in HIV care is an ongoing challenge in South Africa's strained health system. However, some patients thought to be "lost to follow-up" (LTFU) may have "transferred" clinics to receive care elsewhere. Through semi-structured interviews, we explored the relationship between clinic transfer and long-term patient engagement among 19 treatment-experienced people living with HIV (PLWH) who self-identified as having engaged in a clinic transfer at least once since starting antiretroviral therapy (ART) in Gugulethu, Cape Town. Our findings suggest that patient engagement is often fluid, as PLWH cycle in and out of care multiple times during their lifetime. The linear nature of the HIV care cascade model poorly describes the lived realities of PLWH on established treatment. Further research is needed to explore strategies for reducing unplanned clinic transfers and offer more supportive care to new and returning patients.

The success of health interventions often hinges on complex processes of implementation, the impact of sociopolitical and cultural contexts, resource constraints and opportunity costs, and issues of equity and accountability. Qualitative research offers critical insights for understanding these issues. “Qualitative evidence syntheses” (or QES)—modeled on quantitative systematic reviews—have recently emerged as an important vehicle for integrating insights from qualitative evidence into global health policy. However, it is challenging to integrate QES into policymaking in ways that are bothacceptableto the often-conservative health policy world andconsonantwith social science’s distinctive methodologies and paradigms. Based on my experiences participating in and observing numerous guideline working group meetings and interviews with key informants, this chapter offers an auto-ethnographic account of an effort to integrate QES into the World Health Organization’s global OptimizeMNH guidelines for task shifting in maternal and newborn health (MNH). It is based on my experiences participating in and observing numerous guideline working group meetings as well as interviews with several key informants. Advocates of QES were successful in helping to make a place for qualitative evidence in this global guideline. Their work, however, required a delicate balance between adopting quantitatively inspired methods for evidence synthesis and innovating new methods that would both suit the project needs and be seen as legitimate by qualitative researchers. This case study of the development of one WHO guideline does not signal a revolution in knowledge production, but it does show there remains room—perhaps growing room—for a more expansive vision of what forms of knowledge need to be on the table when developing global health policy.

Background Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage. Methods For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February–March 2018 in South Africa’s KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes. Results Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media. Conclusions Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women’s knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women’s breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.

ObjectivesFor persons living with HIV (PLWH) in long-term care, clinic transfers are common and influence sustained engagement in HIV care, as they are associated with significant time out-of-care, low CD4 count, and unsuppressed viral load on re-entry. Despite the geospatial nature of clinic transfers, there exist limited data on the geospatial trends of clinic transfers to guide intervention development. In this study, we investigate the geospatial characteristics and trends of clinic transfers among PLWH on antiretroviral therapy (ART) in the Western Cape Province of South Africa.DesignRetrospective spatial analysis.SettingPLWH who initiated ART treatment between 2012 and 2016 in South Africa’s Western Cape Province were followed from ART initiation to their last visit prior to 2017. Deidentified electronic medical records from all public clinical, pharmacy, and laboratory visits in the Western Cape were linked across space and time using a unique patient identifier number.Participants4176 ART initiators in South Africa (68% women).MethodsWe defined a clinic transfer as any switch between health facilities that occurred on different days and measured the distance between facilities using geodesic distance. We constructed network flow maps to evaluate geospatial trends in clinic transfers over time, both for individuals’ first transfer and overall.ResultsTwo-thirds of ART initiators transferred health facilities at least once during follow-up. Median distance between all clinic transfer origins and destinations among participants was 8.6 km. Participant transfers were heavily clustered around Cape Town. There was a positive association between time on ART and clinic transfer distance, both among participants’ first transfers and overall.ConclusionThis study is among the first to examine geospatial trends in clinic transfers over time among PLWH. Our results make clear that clinic transfers are common and can cluster in urban areas, necessitating better integrated health information systems and HIV care.

Background: Although many healthcare workers (HCWs) are aware of the protective role that mask-wearing has in reducing transmission of tuberculosis (TB) and other airborne diseases, studies on infection prevention and control (IPC) for TB in South Africa indicate that mask-wearing is often poorly implemented. Mask-wearing practices are influenced by aspects of the environment and organisational culture within which HCWs work. Methods: We draw on 23 interviews and four focus group discussions conducted with 44 HCWs in six primary care facilities in the Western Cape Province of South Africa. Three key dimensions of organisational culture were used to guide a thematic analysis of HCWs’ perceptions of masks and mask-wearing practices in the context of TB infection prevention and control. Results: First, HCW accounts address both the physical experience of wearing masks, as well as how mask-wearing is perceived in social interactions, reflecting visual manifestations of organisational culture in clinics. Second, HCWs expressed shared ways of thinking in their normalisation of TB as an inevitable risk that is inherent to their work and their localization of TB risk in specific areas of the clinic. Third, deeper assumptions about mask-wearing as an individual choice rather than a collective responsibility were embedded in power and accountability relationships among HCWs and clinic managers. These features of organisational culture are underpinned by broader systemic shortcomings, including limited availability of masks, poorly enforced protocols, and a general lack of role modelling around mask-wearing. HCW mask-wearing was thus shaped not only by individual knowledge and motivation but also by the embodied social dimensions of mask-wearing, the perceptions that TB risk was normal and localizable, and a shared underlying tendency to assume that mask-wearing, ultimately, was a matter of individual choice and responsibility. Conclusions: Organisational culture has an important, and under-researched, impact on HCW mask-wearing and other PPE and IPC practices. Consistent mask-wearing might become a more routine feature of IPC in health facilities if facility managers more actively promote engagement with TB-IPC guidelines and develop a sense of collective involvement and ownership of TB-IPC in facilities.

Background Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents’ views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination. Objectives ‐ Explore parents’ and informal caregivers’ views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. ‐ Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. ‐ Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness. Search methods We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020. Selection criteria We included studies that: utilised qualitative methods for data collection and analysis; focused on parents’ or caregivers’ views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided. Data collection and analysis We used a pre‐specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income‐level settings. We extracted contextual and methodological data from each sampled study. We used a meta‐ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE‐CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review. Main results We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South‐East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high‐, middle‐, and low‐income settings. Many complex factors were found to influence parents’ vaccination views and practices, which we divided into four themes. Firstly, parents’ vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents’ vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, ‘neoliberal logic’, suggests that many parents, particularly from high‐income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, ‘social exclusion’, suggests that some parents, particularly from low‐ and middle‐income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness. Authors' conclusions Our review has revealed that parents’ views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users., Plain language summary What factors influence parents’ views and practices around routine childhood vaccines? Review aim This Cochrane synthesis of qualitative evidence aimed to explore the factors that influence parents’ views and practices around routine childhood vaccines. To do this, we searched for and analysed qualitative studies of parents’ views, experiences, and practices. This synthesis complements other Cochrane Reviews assessing the effect of strategies to improve the uptake of childhood vaccination. Key messages Many factors influence parents’ vaccination views and practices, including those related to individual perceptions, social relationships, and the wider context in which parents live. When parents make decisions about vaccination for their children, they are often communicating not just what they think about vaccines, but also who they are, what they value, and with whom they identify. What was studied in this synthesis? Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations. There are several potential reasons for this. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents’ views and practices around childhood vaccination, and why some parents may not accept vaccines for their children is still limited. Qualitative research explores how people perceive and experience the world around them, and is therefore well‐placed for examining these issues. What are the main findings of the review? We included 27 studies in our analysis. Studies were conducted in Africa, the Americas, South‐East Asia, Europe, and the Western Pacific, and included urban and rural settings, as well as high‐, middle‐, and low‐income settings. Many complex factors were found to influence parents’ vaccination views and practices, which we divided into four themes. Firstly, parents’ vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents’ vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turned strengthened their views and practices around vaccination. Thirdly, parent’s vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parent’s vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, ‘neoliberal logic’, suggests that many parents, particularly from high‐income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, ‘social exclusion’, suggests that some parents, particularly from low‐ and middle‐income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. How up‐to‐date is this review? We searched for studies published before 3 June 2020.

Background This is the eighth in our series of 11 papers on “CHWs at the Dawn of a New Era”. Community health worker (CHW) incentives and remuneration are core issues that affect the performance of individual CHWs and the performance of the overall CHW programme. A better understanding of what motivates CHWs and a stronger awareness of the social justice dimensions of remuneration are essential in order to build stronger CHW programmes and to support the professionalization of the CHW workforce. Methods We provide examples of incentives that have been provided to CHWs and identify factors that motivate and demotivate CHWs. We developed our findings in this paper by synthesizing the findings of a recent review of CHW motivation and incentives in a wide variety of CHW programmes with detailed case study data about CHW compensation and incentives in 29 national CHW programmes. Results Incentives can be direct or indirect, and they can be complementary/demand-side incentives. Direct incentives can be financial or nonfinancial. Indirect incentives can be available through the health system or from the community, as can complementary, demand-side incentives. Motivation is sustained when CHWs feel they are a valued member of the health system and have a clear role and set of responsibilities within it. A sense of the “do-ability” of the CHW role is critical in maintaining CHW motivation. CHWs are best motivated by work that provides opportunities for personal growth and professional development, irrespective of the direct remuneration and technical skills obtained. Working and social relationships among CHWs themselves and between CHWs and other healthcare professionals and community members strongly shape CHW motivation. Conclusion Our findings support the recent guidelines for CHWs released by WHO in 2018 that call for CHWs to receive a financial package that corresponds to their job demands, complexity, number of hours worked, training, and the roles they undertake. The guidelines also call for written agreements that specify the CHW’s role and responsibilities, working conditions, remuneration, and workers’ rights.

Summary The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.

Systematic reviews of qualitative evidence-or 'qualitative evidence syntheses' (QES)-have recently become an important form of knowledge production within the broader projects of 'evidence-based medicine' (EBM) and 'evidence-informed policymaking' in global health. Proponents of QES argue that these reviews offer a way to promote 'health systems thinking' and build a better understanding of local process and context in global health policy- and decision-making. EBM's detailed technical procedures for evidence synthesis, however, do not necessarily fit well with conventional qualitative research paradigms and there are concerns that subjecting qualitative research to EBM's logics and practices might fatally compromise both its epistemological integrity and political impact. This article addresses these concerns via a reflective case study of the use of qualitative evidence in the World Health Organization's (WHO) OptimizeMNH guidelines for task shifting in maternal and newborn health programs. When I first joined the team developing the evidence base for these health systems-oriented guidelines, I wondered whether the inclusion of qualitative research would result in a broadening of the forms of reason, experience and judgment that informed global health policy, or instead, be another disheartening example of how modern bureaucratic systems coopt, standardize, and complexity-reduce the alternative logics they encounter. While the integration of qualitative evidence did come at some cost to the depth and critical insights of the evidence we were reviewing, there were also important ways in which the technical procedures of evidence-based medicine were open to adaptation and transformation. The formal inclusion of qualitative evidence syntheses in these global guidelines did not represent-or produce-a dramatic about-turn in global health policy's hegemonic discourses and practices. It did reveal, however, that powerful systems of health governance like the WHO and evidence-based medicine are not inevitably closed, but in fact open to change, in often unpredictable ways.

In South Africa, early fertility and teenage pregnancy have become a central focus of both political and public health concern. In this article, we explore the ways that young men and women have used their fertility and performance of parenthood to navigate the transition from childhood to adulthood. For these young people, the persistent inequities related to income poverty, inadequate education, lack of employment opportunities and a high burden of disease remain significant barriers to achieving this transition. This article draws on ethnographic data collected between 2014 and early 2016 with young adults (17-25 years) in Town Two, Khayelitsha. Participant observation was the primary data collection method. Narratives and experiences of 15 young people are presented here. We argue that in addition to immediate fertility desires, young people's contraceptive decision-making was significantly shaped by gendered ideals and social norms. Young women's fertility operated as both an aspiration and a threat within partnerships. Some couples partially achieved relationship stability or longevity through having a child. Entering parenthood in the context of a seemingly stable relationship was perceived as a movement towards an accepted, albeit tenuous, form of social adulthood. Although living up to the ideal of good parent was challenging, it was partially achieved by young mothers who provided care and young fathers who provided financially for children. In the absence of other accepted markers of transition to adulthood and within a context of deprivation and exclusion, early fertility, though clearly a public health problem, can become a solution to social circumstances.

Responses to COVID-19 have included top-down, command-and-control measures, laissez-faire approaches, and bottom-up, community-driven solidarity and support, reflecting long-standing contradictions around how people and populations are imagined in public health-as a 'problem' to be managed, as 'free agents' who make their own choices, or as a potential 'solution' to be engaged and empowered for comprehensive public health. In this rapid review, we examine community-engaged responses that move beyond risk communication and instead meaningfully integrate communities into decision-making and multi-sectoral action on various dimensions of the response to COVID-19. Based on a rapid, global review of 42 case studies of diverse forms of substantive community engagement in response to COVID-19, this paper identifies promising models of effective community-engaged responses and highlights the factors enabling or disabling these responses. The paper reflects on the ways in which these community-engaged responses contribute to comprehensive approaches and address social determinants and rights, within dynamics of relational power and inequality, and how they are sometimes able to take advantage of the ruptures and uncertainties of a new pandemic to refashion some of these dynamics.

RATIONALE. Adherence to antiretroviral therapy (ART) is a global concern among pregnant and postpartum women living with HIV (WLHIV). Research focusing on peripartum WLHIV and how they balance adherence, engaging in HIV care, and other forms of self-care is limited. Women’s empowerment theories have been applied to myriad health behaviors to understand patterns, establish mechanisms, and develop interventions; yet empowerment theory as applied to ART is under-researched. OBJECTIVE. Seeking deeper insight into peripartum health behaviors, we examine these factors using Naila Kabeer’s (1999) women’s empowerment theory, which denotes resources, agency, and achievements as three primary and interrelated components of empowerment. METHODS. Data were collected in Gugulethu, South Africa, between March and July 2018. Thirty in-depth interviews were conducted with WLHIV at 32-35 weeks of pregnancy, with topics including experiences related to ART adherence and meanings of empowerment in motherhood. Analyses had two phases: (1) inductive open-coding for emergent themes; and (2) classifying themes into Kabeer’s empowerment theory. RESULTS. Participants expressed that resources play a critical role in adherence, ranging from practical support to motivational support provided by both family and partners. Agency is experienced as a desire to be an independent mother in the often-expected event that partners withdraw support. Participants described achievements as time-oriented goals, ranging from having a baby born without HIV to living a long and productive life. CONCLUSIONS. These findings suggest that a promising and innovative approach to improving ART adherence across the peripartum transition would focus on understanding resources as an enabling environment, build on existing feelings of agency, and highlight the lifelong goals achievable with high levels of adherence. A better understanding of how women’s empowerment evolves over the course of pregnancy and into the postpartum period will support intervention development aimed at improving ART adherence and potentially additional peripartum health behaviors.

South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on 'new' evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.

Background Supporting the ability of women living with HIV (WLWH) to avoid unintended pregnancy during the postpartum period decreases the number of new pediatric HIV infections, reduces pregnancy-related morbidity and mortality, and is a cost-effective strategy for the elimination of mother-to-child transmission. However, little is currently known about the contraceptive intentions and experiences of reinitiating family planning use among mothers living with HIV as they transition from pregnancy into postpartum. Study objectives To (1) understand the contraceptive trajectories of women living with HIV during pregnancy and postpartum in Cape Town, South Africa, and (2) identify factors shaping differing contraceptive trajectories during the postpartum period. Methods Thirty pregnant WLWH were interviewed during their eighth month of pregnancy and completed follow-up interviews at 6-8 weeks and 9-12 months postpartum (n = 81 total interviews). Interview topics included postpartum contraception intentions, contraceptive use, and experiences accessing family planning services. Trajectory analysis of contraceptive intentions was applied after initial thematic coding. Results While nearly half of women interviewed during pregnancy expressed an intention to utilize a non-injectable contraceptive option after childbirth (e.g. implant, IUD, sterilization, oral contraceptive pills), all women interviewed at one year postpartum had received at least one injection. Three main contraceptive trajectories were identified. (1) realization of contraceptive intentions postpartum; (2) unrealized contraceptive intentions postpartum; and (3) change in contraceptive intention over time. Provider influence, coordination of services, and low contraceptive inventory were identified as potential factors shaping the contraceptive trajectories of participants enrolled in the study. Conclusion Disparities between contraceptive method intentions articulated by WLWH during pregnancy and methods attained postpartum suggest that significant barriers remain for women who are unsatisfied with injectable contraception. Failing to provide postpartum mothers living with HIV their intended family planning method undermines efforts to prevent unintended pregnancy, a key pillar of elimination of mother-to-child transmission.

Background Data harmonisation (DH) has emerged amongst health managers, information technology specialists and researchers as an important intervention for routine health information systems (RHISs). It is important to understand what DH is, how it is defined and conceptualised, and how it can lead to better health management decision-making. This scoping review identifies a range of definitions for DH, its characteristics (in terms of key components and processes), and common explanations of the relationship between DH and health management decision-making. Methods This scoping review identified relevant studies from 2000 onwards (date filter), written in English and published in PubMed, Web of Science and CINAHL. Two reviewers independently screened records for potential inclusion for the abstract and full-text screening stages. One reviewer did the data extraction, analysis and synthesis, with built-in reliability checks from the rest of the team. We developed a narrative synthesis of definitions and explanations of the relationship between DH and health management decision-making. Results We sampled 61 of 181 included to synthesis definitions and concepts of DH in detail. We identified six common terms for data harmonisation: record linkage, data linkage, data warehousing, data sharing, data interoperability and health information exchange. We also identified nine key components of data harmonisation: DH involves (a) a process of multiple steps; (b) integrating, harmonising and bringing together different databases (c) two or more databases; (d) electronic data; (e) pooling data using unique patient identifiers; and (f) different types of data; (g) data found within and across different departments and institutions at facility, district, regional and national levels; (h) different types of technical activities; (i) has a specific scope. The relationship between DH and health management decision-making is not well-described in the literature. Several studies mentioned health providers’ concerns about data completeness, data quality, terminology and coding of data elements as barriers to data utilisation for clinical decision-making. Conclusion To our knowledge, this scoping review was the first to synthesise definitions and concepts of DH and address the causal relationship between DH and health management decision-making. Future research is required to assess the effectiveness of data harmonisation on health management decision-making.

Infection prevention and control (IPC) measures to reduce transmission of drug-resistant and drug-sensitive tuberculosis (TB) in health facilities are well described but poorly implemented. The implementation of TB IPC has been assessed primarily through quantitative and structured approaches that treat administrative, environmental, and personal protective measures as discrete entities. We present an on-going project entitled Umoya omuhle (“good air”), conducted in two provinces of South Africa, that adopts an interdisciplinary, ‘whole systems’ approach to problem analysis and intervention development for reducing nosocomial transmission of Mycobacterium tuberculosis (Mtb) through improved IPC. We suggest that TB IPC represents a complex intervention that is delivered within a dynamic context shaped by policy guidelines, health facility space, infrastructure, organisation of care, and management culture. Methods drawn from epidemiology, anthropology, and health policy and systems research enable rich contextual analysis of how nosocomial Mtb transmission occurs, as well as opportunities to address the problem holistically. A ‘whole systems’ approach can identify leverage points within the health facility infrastructure and organisation of care that can inform the design of interventions to reduce the risk of nosocomial Mtb transmission.

This paper examines the recently formed Movement for Change and Social Justice (MCSJ) in the township of Gugulethu, in Cape Town, South Africa. MCSJ is a health and social justice movement that has an unusual trajectory—guided by the political principles and strategies of South Africa AIDS activism, inspired but also frustrated by the contemporary progressive public health activism, and catalysed by a university research partnership at the University of Cape Town (UCT) that focused on innovative ways of using health information to spur community and health system action to respond to issues of men, masculinity and HIV.This paper synthesises findings from participant observation, qualitative process evaluations of MCSJ’s work, and reflections from the UCT-based research team to develop a number of lessons about the challenges and opportunities in efforts to foster a healthy public for men and HIV. MCSJ’s approach builds on current modes and models of public health thinking while also pushing for more responsive, more inclusive, more sustained, and more locally rooted forms of practice. The paper identifies a range of enabling conditions for MCSJ’s work, describes the often delicate balancing act MCSJ has to manage in its work, and outlines some of the key strategies of this community–university partnerships that guided efforts to develop a healthy public for men and HIV. Lessons learned from this case study will be helpful for other efforts to promote and sustain engaged and impactful university–community collaborations to support the emergence of healthy publics.

Tuberculosis remains a leading cause of death worldwide. Transmission is the dominant mechanism sustaining the multidrug-resistant tuberculosis epidemic. Tuberculosis infection prevention and control (TBIPC) guidelines for healthcare facilities are poorly implemented. This systematic review aimed to explore the barriers and facilitators of implementation of TBIPC guidelines in low- and middle-income countries from the perspective of healthcare workers. Two separate reviewers carried out an electronic database search to select qualitative and quantitative studies exploring healthcare workers attitudes towards TBIPC. Eligible studies underwent thematic synthesis. Derived themes were further organised into a macro-, meso- and micro-level framework, which allows us to analyse barriers at different levels of the healthcare system. We found that most studies focused on assessing implementation within facilities in accordance with the hierarchy of TBIPC measures—administrative, environmental and respiratory protection controls. TBIPC implementation was over-estimated by self-report compared with what researchers observed within facilities, indicating a knowledge-action gap. Macro-level barriers included the lack of coordination of integrated HIV/tuberculosis care, in the context of an expanding antiretroviral therapy programme and hence increasing opportunity for nosocomial acquisition of tuberculosis; a lack of funding; and ineffective occupational health policies, such as poor systems for screening for tuberculosis amongst healthcare workers. Meso-level barriers included little staff training to implement programmes, and managers not understanding policy sufficiently to translate it into an IPC programme. Most studies reported micro-level barriers including the impact of stigma, work culture, lack of perception of risk, poor supply and use of respirators and difficulty sensitising patients to the need for IPC. Existing literature on healthcare workers’ attitudes to TBIPC focusses on collecting data about poor implementation at facility level. In order to bridge the knowledge-action gap, we need to understand how best to implement policy, taking account of the context.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effectiveness of financial and non-financial incentives for lay health workers in improving performance, increasing retention, and attracting appropriate LHW candidates.