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Background Lung cancer is the highest incident cancer globally and is associated with significant morbidity and mortality particularly if identified at a late stage. Poor patient outcomes in low- and middle-income countries (LMIC’s) might reflect contextual patient and health system constraints at multiple levels, that act as barriers to prevention, disease recognition, diagnosis, and treatment. Lung cancer screening, even for high-risk patients, is not available in the public health sector in South Africa (SA), where the current HIV and tuberculosis (TB) epidemics often take precedence. Yet, there has been no formal assessment of the individual and health-system related barriers that may delay patients with lung cancer from seeking and accessing help within the public health care system and receiving the appropriate and effective diagnosis and treatment. This study aimed to derive consensus from health-system stakeholders in the urban Gauteng Province of SA on the most important challenges faced by the health services and patients in achieving optimum lung cancer management and to identify potential solutions. Methods The study was undertaken among 27 participant stakeholders representing clinical managers, clinicians, opinion leaders from the public health sector and non-governmental organisation (NGO) representatives. The study compromised two components: consensus and engagement. For the consensus component, the Delphi Technique was employed with open-ended questions and item ranking from five rounds of consensus-seeking, to achieve collective agreement on the most important challenges faced by patients and the health services in achieving optimal lung cancer management. For the engagement component, the Nominal Group Technique was used to articulate ideas and reach an agreement on the group’s recommendations for solution strategies and approaches. Results Public health sector stakeholders suggested that a lack of knowledge and awareness of lung cancer, and the apparent stigma associated with the disease and its risk factors, as well as symptoms and signs, are critical to treatment delay. Furthermore, delays in up-referral of patients with suspected lung cancer from district health care level were attributed to inadequate knowledge arising from a lack of in-service training of nurses and doctors regarding oncologic symptoms, risk factors, need for further investigation, interpretation of x-rays and available treatments. At a tertiary level, participants suggested that insufficient availability of specialised diagnostic resources (imaging, cytological and pathological services including biomolecular assessment of lung cancer), theatres, cardiothoracic surgeons, and appropriate therapeutic modalities (chemotherapeutic agents and radiation oncology) are the main barriers to the provision of optimal care. It was suggested that a primary prevention programme initiated by the government that involves private-public partnerships may improve lung cancer management nationally. Conclusions Considerable barriers to the early identification and treatment of lung cancer exist. Finding solutions to overcome both individual and health-system level obstacles to lung cancer screening and management are vital to facilitate early identification and treatment, and to improve survival. Furthermore, research on inexpensive biomarkers for asymptomatic disease detection, the introduction of diagnostic imaging tools that utilise artificial intelligence to compensate for inadequate human resources and improving clinical integration across all levels of the healthcare system are essential.

Food insecurity impacts childhood nutritional status, physical and cognitive development, and increases lifetime risk for chronic disease. Previous South African studies have examined hunger at the sub-national level without a specific focus on children and adolescents. This study determines the national prevalence of childhood food insecurity, from birth to adolescence, and identifies factors associated with hunger within the household. Individual and household-level data were extracted from the South African National Health and Nutrition Examination Survey (SANHANES-1). Prevalence of food insecurity was assessed using the Community Childhood Hunger Identification Project (CCHIP) index. Multinomial logistic regression analyses were conducted on all households (with and without children) to determine the predictors of food insecurity, with additional analyses adjusting for child dependency and sociodemographic characteristics of household heads in households with children. Of 5 098 households surveyed, 68.6% had children and adolescents present (0–19 years). Of these households, 32.5% (95% Confidence Interval [CI]: 29.5–35.7) were experiencing hunger and 26.3% (95% CI: 23.9–28.8) were at risk of hunger. Among all the households, significant associations for experiencing hunger were the presence of children and adolescents: Adjusted Odds Ratio (AOR) = 1.68 (95% CI: 1.12–2.53); being female-headed: AOR = 1.53 (95% CI: 1.21–1.94) and informally-located; AOR = 1.6 (95% CI: 1.07–2.43). Of the racial groups, having a non-African household head, Coloured: AOR = 0.29 (95% CI: 0.19–0.44) and White/Indian/Asian: AOR = 0.12 (95% CI: 0.04–0.33) conferred lower odds of experiencing hunger; and, the household head having secondary/tertiary education conferred lower odds of experiencing hunger; AOR = 0.40 (95% CI: 0.28–0.56) as well as being at risk of hunger; AOR = 0.69 (95% CI: 0.52–0.92). Receiving social grants, pensions, or remittances more than doubled the odds of experiencing hunger; AOR = 2.15 (95% CI: 1.49–3.09). After adjusting for child dependency in households with children, having at least one older child (age 15–19 years old) did not change the odds of food insecurity. In summary, only 41% of South African households with children and adolescents were food secure. The associations between household head sociodemographics, household location and size on household food insecurity indicate a need for multi-sectoral interventions to bolster sustainable food systems for households with children and adolescents and to improve public protections for female-headed, African-headed and informally-located households dependent on social grants.

Background. Workplace bullying and other negative workplace behaviours are problems that need to be addressed across many work settings, including at universities. Objectives. To examine the prevalence of bullying among academics, and factors associated with bullying, in a faculty of health sciences (FHS) of a South African university. Methods. All academic staff, except senior managers, were invited to participate by completing a self-administered, web-based questionnaire hosted on REDCap. In adition to sociodemographic information, the survey collected information on bullying, and the factors associated with experiences of workplace bullying. Survey data were exported to Stata 13 for analysis. The data were weighted to take account of the distribution of staff in the FHS. Chi-square tests and a multiple logistic regression model for bullying were utilised. Results. The majority of study participants were white (52%), female (70%) and South African (85%). Bullying in the workplace was experienced by 58% of respondents, of whom 44% experienced bullying more than once, and 64% of participants had witnessed bullying. Being female (adjusted odds ratio (aOR) 1.83; 95% confidence interval (CI) 1.14 - 2.93; p

PURPOSE Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system. METHODS We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size. RESULTS Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02). CONCLUSIONS In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level.

Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems. Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes. Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities. Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems’ performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2018; DOI: 10.1080/20786190.2017.1348047

Central to South Africa's democratic transformation have been attempts to understand how and why human rights abuses were common under apartheid. In testimony to the Truth and Reconciliation Commission evidence has emerged of a wide range of past complicity in human rights abuses by health professionals and their organisations. This has presented a major challenge to the health sector to develop ways to operationalize a commitment to human rights in the future. This paper argues that only after a process of self-reflection, both personal and institutional, which enables a thorough and accurate analysis of why things went so wrong, can the health sector effectively move forward. The authors' perspective draws on the submission to the TRC Health Sector Hearings by the Health and Human Rights Project in 1997, which provides a systemic and case-based analysis of the health sector's role in human rights abuses under apartheid. However, human rights responses have to take account of a changing national and global terrain in which human rights issues are no longer as morally absolute as previously encountered, and in which seemingly insuperable resource constraints, inimical economic policies, and the demobilization of civil society, are serious obstacles. Moreover, the politics of transformation has generated expediencies that threaten to rewrite history in ways that fundamentally cheapen human rights. To address this contradiction, the authors propose a set of objectives that places accountability of health professionals in a human rights framework. These objectives are intended to give substance to the main tasks facing the health sector--to develop and infuse the capacity to recognise and integrate both the 'new' and traditional human rights dilemmas, and to effect personal and institutional transformation. A matrix is presented, linking these objectives to key role players in the health sector and identifying activities specific for each role player. As the health sector in South Africa grapples with the challenges framed in this model, key lessons for the international community may emerge that further our understanding of the complex relationship between health and human rights and how best to implement strategies for the attainment of human rights in health.

Background The complicity of the South African health sector in apartheid and the international relevance of human rights as a professional obligation prompted moves to include human rights competencies in the curricula of health professionals in South Africa. A Train-the-Trainers course in Health and Human Rights was established in 1998 to equip faculty members from health sciences institutions nationwide with the necessary skills, attitudes and knowledge to teach human rights to their students. This study followed up participants to determine the extent of curriculum implementation, support needed as well as barriers encountered in integrating human rights into health sciences teaching and learning. Methods A survey including both quantitative and qualitative components was distributed in 2007 to past course participants from 1998-2006 via telephone, fax and electronic communication. Results Out of 162 past participants, 46 (28%) completed the survey, the majority of whom were still employed in academic settings (67%). Twenty-two respondents (48%) implemented a total of 33 formal human rights courses into the curricula at their institutions. Respondents were nine times more likely (relative risk 9.26; 95% CI 5.14-16.66) to implement human rights education after completing the training. Seventy-two extracurricular activities were offered by 21 respondents, many of whom had successfully implemented formal curricula. Enabling factors for implementation included: prior teaching experience in human rights, general institutional support and the presence of allies - most commonly coworkers as well as deans. Frequently cited barriers to implementation included: budget restrictions, time constraints and perceived apathy of colleagues or students. Overall, respondents noted personal enrichment and optimism in teaching human rights. Conclusion This Train-the-Trainer course provides the historical context, educational tools, and collective motivation to incorporate human rights educational initiatives at health sciences institutions. Increased implementation of human rights instruction, both formally and extracurricularly, has demonstrated the training's significance not only within academic institutions but more broadly across the health sector. Coworkers are vital allies in teaching human rights to health sciences students, helping to alleviate institutional barriers. Training fellow staff members and those in key leadership roles is noted as vital to the sustainability of human rights education.

The need for health professionals to address their human rights obligations has emerged in the last decade both internationally as well as nationally following the findings of South Africa’s Truth and Reconciliation Commission. Support for human rights norms has become a priority for institutions as well as practitioners within the health sector. Training plays a crucial role in shaping health professional practice. In addition to creating a clear understanding of the linkages between human rights and health, educators can role-model how health professionals should act to support human rights. This article explores human rights derived from the South African Constitution in relation to the obligation on health professionals to respect, protect, promote and fulfill human rights. The implications of this commitment to human rights training of nurses are discussed, drawing on the authors’ nine years of experience in running courses for South African health professional educators. Themes include: developing core competencies for human rights in health professional curricula, identifying appropriate instructional methodologies and assessment tools suited to the content and context of human rights, and engaging the institutional environment for human rights teaching, at both the level of institutional culture and strategic implementation. At a time when there are increasing demands on the nursing profession to assume greater responsibility and develop versatility in its scope of practice, key challenges are posed for teaching and realising human rights.

Point:Wars must be won if our country … is to be protected from unthinkable outcomes, as the events on September 11th most recently illustrated…. This best protection unequivocally requires armed forces having military physicians committed to doing what is required to secure victory…. As opposed to needing neutral physicians, we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs of the mission.Counterpoint:We believe the role of the “physician–soldier” to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the “fighting strength” and … “national security.”This paper is based on the Dual Loyalty Project (1998–2000), which was funded by the Greenwall Foundation to develop guidelines that protect the human rights of patients in situations where health professionals face dual loyalty conflicts. The intellectual contributions of the International Dual Loyalty Working Group, as well as the assistance of Ms. Kathy Mallinson and Dr. Joanne Stevens in preparing this manuscript are gratefully acknowledged.

Examining the work of scientists and health professionals during colonial and apartheid South Africa reveals complex interconnections between science, gender, “race,”1 and nation-building. We explore the complicity of health professionals in the abuse of the reproductive rights of South African women through participation in a system that constructed women primarily as reproductive bodies and manipulated their reproduction for oppressive political purposes. If a culture of respect for human rights is to supplant one of complicity with abuse, this history must first be acknowledged, accountability accepted, and systematic mechanisms put in place to address training, monitoring for human rights abuses and transformation in institutions and organizations. While challenging and perhaps time-consuming to tackle issues of the past, it is imperative to undertake such critical self-study so that current attempts to transform health services in post-apartheid South Africa will be successful.

Documenting, quantifying, intervening in and preventing interpersonal violence is a leading global public health challenge of this decade. Apart from HIV/AIDS, TB and malaria - where violence arguably plays an exacerbating role - what other disease process claims more than half a million lives annually, generating a burden of 'approximately 1400 deaths a day, the equivalent of three long-haul commercial aircraft crashing every single day'? Yet even death may not be the most sensitive measure of the profound impact of interpersonal violence on the lives of individuals, communities, societies, nations, regions and our very humanity. With interpersonal violence occurring anywhere that humans function, both publicly and privately - at home, at work, in the streets, markets and cinemas, and on the battlefield - this social problem poses an increasing threat to the quality of our lives and the planet. The urgency of confronting this issue cannot be clearer.