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BackgroundAntenatal care (ANC) is an essential platform to improve maternal and newborn health (MNH). While several articles have described the content of ANC in low- and middle-income countries (LMICs), few have investigated the quality of detection and management of pregnancy risk factors during ANC. It remains unclear whether women with pregnancy risk factors receive targeted management and additional ANC.Methods and findingsThis observational study uses baseline data from the MNH eCohort study conducted in 8 sites in Ethiopia, India, Kenya, and South Africa from April 2023 to January 2024. A total of 4,068 pregnant women seeking ANC for the first time in their pregnancy were surveyed. We built country-specific ANC completeness indices that measured provision of 16 to 22 recommended clinical actions in 5 domains: physical examinations, diagnostic tests, history taking and screening, counselling, and treatment and prevention. We investigated whether women with pregnancy risks tended to receive higher quality care and we assessed the quality of detection and management of 7 concurrent illnesses and pregnancy risk factors (anemia, undernutrition, obesity, chronic illnesses, depression, prior obstetric complications, and danger signs). ANC completeness ranged from 43% in Ethiopia, 66% in Kenya, 73% in India, and 76% in South Africa, with large gaps in history taking, screening, and counselling. Most women in Ethiopia, Kenya, and South Africa initiated ANC in second or third trimesters. We used country-specific multivariable mixed-effects linear regression models to investigate factors associated with ANC completeness. Models included individual demographics, health status, presence of risk factors, health facility characteristics, and fixed effects for the study site. We found that some facility characteristics (staffing, patient volume, structural readiness) were associated with variation in ANC completeness. In contrast, pregnancy risk factors were only associated with a 1.7 percentage points increase in ANC completeness (95% confidence interval 0.3, 3.0, p-value 0.014) in Kenya only. Poor self-reported health was associated with higher ANC completeness in India and South Africa and with lower ANC completeness in Ethiopia. Some concurrent illnesses and risk factors were overlooked during the ANC visit. Between 0% and 6% of undernourished women were prescribed food supplementation and only 1% to 3% of women with depression were referred to a mental health provider or prescribed antidepressants. Only 36% to 73% of women who had previously experienced an obstetric complication (a miscarriage, preterm birth, stillbirth, or newborn death) discussed their obstetric history with the provider during the first ANC visit. Although we aimed to validate self-reported information on health status and content of care with data from health cards, our findings may be affected by recall or other information biases.ConclusionsIn this study, we observed gaps in adherence to ANC standards, particularly for women in need of specialized management. Strategies to maximize the potential health benefits of ANC should target women at risk of poor pregnancy outcomes and improve early initiation of ANC in the first trimester.

BackgroundIn 1978, the World Health Organization (WHO) adopted primary health care (PHC) as the most effective strategy to meet the healthcare needs of communities. This raises the question as to the extent and nature of the training that undergraduate (UG) medical students receive in medical schools regarding PHC, following this statement.AimThe study aim was to explore the experiences of UG medical students and their trainers regarding training in PHC in their institutions.MethodsA qualitative study was conducted among UG medical students (MBChB 4-6) and their trainers at four conveniently selected South African medical schools. A total of 16 focus group discussions (FGDs) and 27 in-depth interviews were conducted among students and their trainers, respectively. The MAXQDA 2020 (Analytics Pro) software program was used to arrange the data, resulting in 2,179 data segments, from which categories, sub-themes and themes were derived.ResultsBoth the UG medical students and their trainers regarded PHC as mainly an approach to health rather than a level of care. Students were trained by specialists and generalists, received training in the undifferentiated patient, coordinated, comprehensive and continuity of care. The training in tertiary centers, conducted mainly by specialists, the implicitness of the training and the inadequacy of trainers at the PHC settings presented challenges.ConclusionStudents and their trainers experienced UG student training in PHC in line with the internationally recognized principles on the subject. The view by students and their trainers that PHC is an approach rather than a level of care enhanced its training across disciplines. The implicitness of the training and the tertiary learning platforms were the main challenges experienced. For optimum PHC training, more time should be dedicated to distributed training platforms with supportive specialist outreach programs in the South African medical schools.

Background: In South Africa, medical students are expected to have acquired a generalist competence in medical practice on completion of their training. However, what the students and their preceptors understand by ‘generalist medical practice’ has not been established in South African medical schools. Aim: This study aimed to explore what the students and their preceptors understood by ‘generalist medical practice’. Setting: Four South African medical schools: Sefako Makgatho Health Sciences University, University of KwaZulu-Natal, Walter Sisulu University and the University of the Witwatersrand. Methods: The exploratory descriptive qualitative design was used. Sixteen focus group discussions (FGDs) and 27 one-on-one interviews were conducted among students and their preceptors, respectively. Participants were recruited through purposive sampling. The inductive and deductive data analysis methods were used. The MAXQDA 2020 (Analytics Pro) software was used to arrange data, yielding 2179 data segments. Results: Ten themes were identified: (1) basic knowledge of medicine, (2) first point of contact with all patients regardless of their presenting problems, (3) broad field of common conditions prevalent in the community, (4) dealing with the undifferentiated patient without a diagnosis, (5) stabilising emergencies before referral, (6) continuity, (7) coordinated and (8) holistic patient care, necessitating nurturance of doctor–patient relationship, (9) health promotion and disease prevention, and (10) operating mainly in primary health care settings. Conclusion: The understanding of ‘generalist medical practice’ in accordance with internationally accepted principles augurs well in training undergraduate medical students on the subject. However, interdepartmental collaboration on the subject needs further exploration. Contribution: The study’s findings can be used as a guide upon which the students’ preceptors and their students can reflect during the training in generalist medical practice.

Background Adolescent malnutrition is a significant public health challenge in low-income and middle-income countries (LMICs), with long-term consequences for health and development. Community-based interventions have the potential to address multiple forms of malnutrition and improve the health outcomes of adolescents. However, there is a limited understanding of the content, implementation and effectiveness of these interventions. This scoping review aims to synthesise evidence on community-based interventions targeting multiple forms of malnutrition among adolescents in LMICs and describe their effects on nutrition and health.Methods and analysis A comprehensive search strategy will be implemented in multiple databases including MEDLINE (through PubMed), Embase, CENTRAL (through Cochrane Library) and grey literature, covering the period from 1 January 2000 to 14 July 2023. We will follow the Participants, Concept and Context model to design the search strategy. The inclusion criteria encompass randomised controlled trials and quasi-experimental studies focusing on adolescents aged 10–19 years. Various types of interventions, such as micronutrient supplementation, nutrition education, feeding interventions, physical activity and community environment interventions, will be considered. Two reviewers will perform data extraction independently, and, where relevant, risk of bias assessment will be conducted using standard Cochrane risk-of-bias tools. We will follow the PRISMA Extension for Scoping Reviews checklist while reporting results.Ethics and dissemination The scope of this scoping review is restricted to publicly accessible databases that do not require prior ethical approval for access. The findings of this review will be shared through publications in peer-reviewed journals, and presentations at international and regional conferences and stakeholder meetings in LMICs.Scoping review registration The final protocol was registered prospectively with the Open Science Framework on 19 July 2023 (https://osf.io/t2d78).

Abstract Background The definition of Primary Health Care (PHC) issued by the World Health Organisation in 1978 indicated that essential health care should be made accessible to individuals and their communities close to where they live and work. In 1992 Starfield articulated the four pillars of PHC: the patient’s first contact with healthcare, comprehensive care, coordinated care and continuous care. Using this literature guidance, this study sought to explore what undergraduate medical students and their clinical preceptors understood by PHC in four South African medical schools. Methods A qualitative study using the phenomenological design was conducted among undergraduate medical students and their clinical preceptors. The setting was four medical schools in South Africa (Sefako Makgatho Health Sciences University, Walter Sisulu University and the University of KwaZulu-Natal and the Witwatersrand University). A total of 27 in-depth interviews were conducted among the clinical preceptors and 16 focus group discussions among the students who were in their clinical years of training (MBChB 4–6). Interviews were digitally recorded and transcribed verbatim, followed by thematic data analysis using the MAXQDA 2020 (Analytics Pro) software. Results Four themes were identified in which there were similarities between the students and their preceptors regarding their understanding of PHC: (1) PHC as the patient’s first contact with the healthcare system; (2) comprehensive care; (3) coordination of care and (4) continuity of care. A further two themes were identified in which these two groups were not of similar understanding: (5) PHC as a level or an approach to healthcare and (6) the role of specialist clinical preceptors in PHC. Conclusions Medical students and their clinical preceptors displayed an understanding of PHC in line with four pillars articulated by Starfield and the WHO definition of PHC. However, there remains areas of divergence, on which the medical schools should follow the guidance provided by the WHO and Starfield for a holistic understanding of PHC.

Multimorbidity is an emerging challenge for health systems globally. It is commonly defined as the co-occurrence of two or more chronic conditions in one person, but its meaning remains a lively area of academic debate, and the utility of the concept beyond high-income settings is uncertain. This article presents the findings from an interdisciplinary research initiative that drew together 60 academic and applied partners working in 10 African countries to answer the questions: how useful is the concept of multimorbidity within Africa? Can the concept be adapted to context to optimise its transformative potentials? During a three-day concept-building workshop, we investigated how the definition of multimorbidity was understood across diverse disciplinary and regional perspectives, evaluated the utility and limitations of existing concepts and definitions, and considered how to build a more context-sensitive, cross-cutting description of multimorbidity. This iterative process was guided by the principles of grounded theory and involved focus- and whole-group discussions during the workshop, thematic coding of workshop discussions, and further post-workshop development and refinement. Three thematic domains emerged from workshop discussions: the current focus of multimorbidity on constituent diseases; the potential for revised concepts to centre the priorities, needs, and social context of people living with multimorbidity (PLWMM); and the need for revised concepts to respond to varied conceptual priorities amongst stakeholders. These themes fed into the development of an expanded conceptual model that centres the catastrophic impacts multimorbidity can have for PLWMM, families and support structures, service providers, and health systems.

Summary: Population confidence is essential to a well functioning health system. Using data from the People's Voice Survey—a novel population survey conducted in 15 low-income, middle-income, and high-income countries—we report health system confidence among the general population and analyse its associated factors. Across the 15 countries, fewer than half of respondents were health secure and reported being somewhat or very confident that they could get and afford good-quality care if very sick. Only a quarter of respondents endorsed their current health system, deeming it to work well with no need for major reform. The lowest support was in Peru, the UK, and Greece—countries experiencing substantial health system challenges. Wealthy, more educated, young, and female respondents were less likely to endorse the health system in many countries, portending future challenges for maintaining social solidarity for publicly financed health systems. In pooled analyses, the perceived quality of the public health system and government responsiveness to public input were strongly associated with all confidence measures. These results provide a post-COVID-19 pandemic baseline of public confidence in the health system. The survey should be repeated regularly to inform policy and improve health system accountability.

Summary: Primary health care (PHC) is central to attainment of the Sustainable Development Goals, yet comparable cross-country data on key aspects of primary care have not been widely available. This study analysed data from the People's Voice Survey, which was conducted in 2022 and 2023 in 14 countries. We documented usual source of care across countries and examined associations of usual source of care with core PHC services, quality ratings, and health system confidence. We found that 75% of respondents had a usual source of care, and that 40% of respondents accessed usual care in the public sector at primary level. 44% rated their usual source of care as very good or excellent. Access to PHC-linked screenings and treatments varied widely within and across countries. Having any usual source of care was associated with higher take-up of preventive services, greater access to treatment including mental health services, and greater health system endorsement. Strengthening links between health system users and primary care providers could improve take-up of preventive care and increase user satisfaction with health system performance.

Objectives Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB.Design A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements.Participants and setting People identified with MDR/RR-TB from 13 high-burden districts within South Africa.Outcome measures Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined.Results Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0–281 days), average patient distance travelled (12–198 km) and number of health facilities involved in care (1–5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district.Conclusions Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.

Todd Lewis and co-authors discuss development and use of the People's Voice Survey for health system assessment.

Abstract Background The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to multiple factors (viz. poverty, stigma, lack of access to social support services) which have been exacerbated by the COVID-19 pandemic. Economic incentives, such as cash incentives combined with SMS reminders, have been shown to improve wellbeing. However, there is a lack of preliminary evidence on the potential of economic incentives to promote caregiver wellbeing in this setting, particularly in the context of a pandemic. This protocol outlines the design of a parallel-group pilot randomised trial comparing the feasibility and preliminary effectiveness of an economic incentive package versus a control for improving caregiver wellbeing. Methods Caregivers of ALHIV will be recruited from public-sector HIV clinics in the south of the eThekwini municipality, KwaZulu-Natal, South Africa. Participants will be randomly assigned to one of the following groups: (i) the intervention group (n = 50) will receive three cash payments (of ZAR 350, approximately 23 USD), coupled with a positive wellbeing message over a 3-month period; (ii) the control group (n = 50) will receive a standard message encouraging linkage to health services. Participants will be interviewed at baseline and at endline (12 weeks) to collect socio-demographic, food insecurity, health status, mental health (stigma, depressive symptoms) and wellbeing data. The primary outcome measure, caregiver wellbeing, will be measured using the CarerQoL instrument. A qualitative study will be conducted alongside the main trial to understand participant views on participation in the trial and their feedback on study activities. Discussion This study will provide scientific direction for the design of a larger randomised controlled trial exploring the effects of an economic incentive for improving caregiver wellbeing. The feasibility of conducting study activities and delivering the intervention remotely in the context of a pandemic will also be provided. Trial registration PACTR202203585402090. Registry name: Pan African Clinical Trials Registry (PACTR); URL: https://pactr.samrc.ac.za/ ; Registration. date: 24 March 2022 (retrospectively registered); Date first participant enrolled: 03 November 2021

BackgroundWe evaluated continuous quality improvement (CQI) targeting antenatal HIV care quality in rural South Africa using a stepped-wedge cluster-randomised controlled trial (Management and Optimisation of Nutrition, Antenatal, Reproductive, Child health, MONARCH) and an embedded process evaluation. Here, we present results of the process evaluation examining determinants of CQI practice and ‘normalisation.’ MethodsA team of CQI mentors supported public-sector health workers in seven primary care clinics to (1) identify root causes of poor HIV viral load (VL) monitoring among pregnant women living with HIV and repeat HIV testing among pregnant women not living with HIV, and (2) design and iteratively test their own solutions. We used a mixed methods evaluation with field notes from CQI mentors (‘dose’ and ‘reach’ of CQI, causes of poor HIV care testing rates, implemented change ideas); patient medical records (HIV care testing by clinic and time step); and semi-structured interviews with available health workers. We analysed field notes and semi-structured interviews for determinants of CQI implementation and ‘normalisation’ using Normalisation Process Theory (NPT) and Tailored Implementation of Chronic Diseases (TICD) frameworks. ResultsAll interviewed health workers found the CQI mentors and methodology helpful for quality improvement. Total administered ‘dose’ was higher than planned but ‘reach’ was limited by resource constraints, particularly staffing shortages. Simple workable improvements to identified root causes were implemented, such as a patient tracking notebook and results filing system. VL monitoring improved over time, but not repeat HIV testing. Besides resource constraints, gaps in knowledge of guidelines, lack of leadership, poor clinical documentation, and data quality gaps reduced CQI implementation fidelity and normalisation. ConclusionWhile CQI holds promise, we identified several health system challenges. Priorities for policy makers include improving staffing and strategies to improve clinical documentation. Additional support with implementing clinical guidelines and improving routine data quality are needed. Normalising CQI may be challenging without concurrent health system improvements. Trial RegistrationClinicaltrials.gov, identifier: NCT02626351

Objective Champions are recognised as important to driving organisational change in healthcare quality improvement initiatives in high-income settings. In low-income and middle-income countries with a high disease burden and constrained human resources, their role is highly relevant yet understudied. Within a broader study on policy implementation for decentralised drug-resistant tuberculosis care in South Africa, we characterised the role, strategies and organisational context of emergent policy champions.Design Interviews with 34 healthcare workers in three South African provinces identified the presence of individuals who had a strong influence on driving policy implementation forward. Additional interviews were conducted with 13 participants who were either identified as champions in phase II or were healthcare workers in facilities in which the champions operated. Thematic analyses using a socio-ecological framework further explored their strategies and the factors enabling or obstructing their agency.Results All champions occupied senior managerial posts and were accorded legitimacy and authority by their communities. ‘Disease-centred’ champions had a high level of clinical expertise and placed emphasis on clinical governance and clinical outcomes, while ‘patient-centred’ champions promoted pathways of care that would optimise patients’ recovery while minimising disruption in other spheres of their lives. Both types of champions displayed high levels of resourcefulness and flexibility to adapt strategies to the resource-constrained organisational context.Conclusion Policymakers can learn from champions’ experiences regarding barriers and enablers to implementation to adapt policy. Research is needed to understand what factors can promote the sustainability of champion-led policy implementation, and to explore best management practices to support their initiatives.

Abstract We use a regression discontinuity design to estimate the causal effect of antiretroviral therapy (ART) eligibility according to national treatment guidelines of South Africa on two risk factors for cardiovascular disease, body mass index (BMI) and blood pressure. We combine survey data collected in 2010 in KwaZulu-Natal, South Africa, with clinical data on ART. We find that early ART eligibility significantly reduces systolic and diastolic blood pressure. We do not find any significant effects on BMI. The effect on blood pressure can be detected up to three years after becoming eligible for ART.

# Background Widespread use of traditional medicine (TM), the issue of their safety, combined with progressive lobbying from both practitioner groups and the public have made regulation of traditional health practitioners (THPs) an important issue. While there are questions on whether the regulation of THPs are worthwhile endeavour, literature continues to offer limited empirical evidence for clear answers. It is essential to synthesize the available literature in relation to this quest using a scoping study methodology. # Methods This scoping review included publications from PubMed, Sabinet and Web of Science databases and included grey literature, primary research, journal reviews, published reports, as well as available policy articles. A methodological framework set out by Arksey and O’Malley was utilized. # Results Out of 8040 searched publications, 25 met the criteria for full review. Regulation of THPs proved essential, but ways of regulating them showed many inconsistencies and challenges. The issues of recognition, integration, and colonization effects and the idea of viewing TM through a scientific lens dominated the themes arising from the 25 publications. # Conclusion Evidence depicted that regulating THPs would be an arduous task, but the existing literature proved insufficient on the use of such regulations. However, the review calls for more studies looking at THP regulatory mechanisms, especially in developing countries, to learn best practices that embrace indigenous knowledges and promote a decolonized health system.

Abstract Background Suboptimal HIV testing rates through available testing approaches such as HIV counselling and testing have directed research efforts toward recognizing the potential of HIV self-testing as an additional testing method. However, HIV self-testing is not readily available within HIV testing facilities and data on how HIV self-testing and HIV counselling and testing will co-exist within HIV testing facilities is limited. Therefore, this study sought to fill this knowledge gap. Methods Forty consenting adults were exposed to HIV counselling and testing and HIV self-testing using a cross-over study design between February 2016 and February 2017 resulting in 80 (20,20) interviews. Participants were randomly exposed to HIV counselling and testing first, followed by self-testing, or HIV self-testing first, followed by counselling and testing. In-depth interviews were conducted at baseline, and after each testing exposure, using a semi-structured interview guide. Interviews were transcribed and translated prior to doing the framework analysis. Results Support through counselling played a central role in the HIV testing process for some participants who desired support or were not confident to perform unsupervised HIV self-testing. The complementary relationship between HIV self-testing and HIV counselling and testing requires a combination of benefits such as availability of counselling, confidence, convenience and confidentiality (4 Cs) derived from HIV self-testing and HIV counselling and testing. Implementation of the 4 Cs will depend on the availability of unsupervised HIV self-testing and/or supervised self-testing with support from HIV counselling and testing. Conclusions As treatment and prevention efforts expand, the reasons for and frequency of testing is changing and there is a need to develop differentiated models for providing HIV testing services to meet client’s needs. HIV self-testing is an important addition to enhance HIV testing efforts and should be offered in combination with HCT.

COVID-19 vaccine hesitancy poses a threat to the success of vaccination programmes currently being implemented. Concerns regarding vaccine effectiveness and vaccine-related adverse events are potential barriers to vaccination; however, it remains unclear whether tailored messaging and vaccination programmes can influence uptake. Understanding the preferences of key groups, including students, could guide the implementation of youth-targeted COVID-19 vaccination programmes, ensuring optimal uptake. This study examined university staff and students’ perspectives, preferences, and drivers of hesitancy regarding COVID-19 vaccines. A multi-methods approach was used—an online convenience sample survey and discrete choice experiment (DCE)—targeting staff and students at the University of KwaZulu-Natal, South Africa. The survey and DCE were available for staff and students, and data were collected from 18 November to 24 December 2021. The survey captured demographic characteristics as well as attitudes and perspectives of COVID-19 and available vaccines using modified Likert rating questions adapted from previously used tools. The DCE was embedded within the survey tool and varied critical COVID-19 vaccine programme characteristics to calculate relative utilities (preferences) and determine trade-offs. A total of 1836 staff and students participated in the study (541 staff, 1262 students, 33 undisclosed). A total of 1145 (62%) respondents reported that they had been vaccinated against COVID-19. Vaccination against COVID-19 was less prevalent among students compared with staff (79% of staff vs. 57% of students). The vaccine’s effectiveness (22%), and its safety (21%), ranked as the two dominant reasons for not getting vaccinated. These concerns were also evident from the DCE, with staff and students being significantly influenced by vaccine effectiveness, with participants preferring highly effective vaccines (90% effective) as compared with those listed as being 70% or 50% effective (β = −3.72, 95% CI = −4.39 to −3.04); this characteristic had the strongest effect on preferences of any attribute. The frequency of vaccination doses was also found to have a significant effect on preferences with participants deriving less utility from choice alternatives requiring two initial vaccine doses compared with one dose (β = −1.00, 95% CI = −1.42 to −0.58) or annual boosters compared with none (β = −2.35, 95% CI = −2.85 to −1.86). Notably, an incentive of ZAR 350 (USD 23.28) did have a positive utility (β = 1.14, 95% CI = 0.76 to 1.53) as compared with no incentive. Given the slow take-up of vaccination among youth in South Africa, this study offers valuable insights into the factors that drive hesitancy among this population. Concerns have been raised around the safety and effectiveness of vaccines, although there remains a predilection for efficient services. Respondents were not enthusiastic about the prospect of having to take boosters, and this has played out in the roll-out data. Financial incentives may increase both the uptake of the initial dose of vaccines and see a more favourable response to subsequent boosters. Universities should consider tailored messaging regarding vaccine effectiveness and facilitate access to vaccines, to align services with the stated preferences of staff and students.

# Background Regulations could create benefits and opportunities for traditional health practitioners (THPs) and traditional medicine (TM) users in this new era of traditional medicine systems (TMS) as the growing international popularity propels this. The 1978 International Conference on Primary Health Care played a significant role in recognising THPs. To date, millions of people across the globe continue to utilise THPs. The issues of safety and scientific validation led the WHO to recommend regulations of TM. This was also supported by pressures from the realisation that culture and spiritual life is associated with traditional healing. This paper seeks to understand barriers and facilitators surrounding THP regulation implementation. # Methods The qualitative research approach involved five focus group discussions sampled from five Kwazulu-Natal district municipalities (one in each district). Participants were selected using district THP councils and a snowballing technique to recruit non-functional THP councils. Data collection tools included case summaries and a focus group discussion guide. Data was analyzed using Braun & Clarke’s (2017) six-phase thematic analysis framework. # Results Themes identified included purposes of being registered with the THP council; registration being viewed as a tax collection instrument; and recognition and legitimacy of THPs. Most THPs were uncertain about why they should be registered and therefore struggled to identify benefits of being registered. Moreover, several THPs viewed registration as tactic to oppress and squeeze them to contribute towards the countries taxation system. Recognition and legitimacy were the only benefits identified, as THPs saw registration as a gateway into mainstream health and believed it would separate them from charlatans. # Conclusions THPs generally had mixed feelings about being registered; most saw very little, if any, potential benefits in being registered, except for recognition and legitimacy. THPs who found registration beneficial, remained sceptical about how it would impact their intellectual property and belief systems. Further exploration of the role of THP associations, their history and evolution and the influence they could have in driving THP regulation implementation process is warranted, especially since THPs found registering with such associations to be beneficial.

Background: Adequate information and knowledge about COVID-19 has been shown to induce the confidence and positive performance among healthcare workers (HCWs). Therefore, assessing the relationship between confidence in knowledge and associated factors among HCWs is vital in the fight against COVID-19. This paper investigates factors associated with HCWs' confidence in their overall knowledge about COVID-19 in South Africa in the early stages of the epidemic.Methods: Data utilized in this paper were from an online survey conducted among HCWs using a structured questionnaire on a data free online platform. The study population were all the medical fraternity in South Africa including medical and nurse practitioners as well as other healthcare professionals. Bivariate and multivariate logistic regression models were performed to examine the factors associated with confidence in HCWs' overall knowledge about COVID-19.Results: Overall, just below half (47.4%) of respondents indicated that they had confidence in their overall knowledge about COVID-19. Increased odds of having confidence in the knowledge about COVID-19 were significantly associated with being male [aOR = 1.31 95% CI (1.03–1.65), p < 0.05], having a doctorate degree [aOR = 2.01 (1.23–3.28), p < 0.05], being satisfied with the information about COVID-19 guidelines [aOR = 6.01 (4.89–7.39), p < 0.001], having received training in 6–8 areas [aOR = 2.54 (1.89–3.43), p < 0.001] and having received training in 9–11 areas [aOR = 5.33 (3.81–7.47), p < 0.001], and having already treated COVID-19 patients [aOR = 1.43 (1.08–1.90), p < 0.001]. Those who were highly concerned with the levels of training of HCWs [aOR = 0.47 (0.24–0.92), p < 0.05] had decreased odds of having confidence in their overall knowledge about COVID-19.Conclusion: This study sheds light on the importance of capacitating HCWs with knowledge and adequate relevant training as part of infection prevention control measures during pandemics. Future training and information sharing should be sensitive to knowledge gaps by age, gender, qualifications, professional categories, and experience.

There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional ‘injections’, in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer’s place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.

BackgroundEvidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa.Methods and findingsWe conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention.ConclusionsWe found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success.Trial registrationThis trial is registered at ClinicalTrials.gov under registration number NCT02626351.

Abstract Background While focused antenatal care (ANC) has served as an entry point in the continuum of care for both mothers and children, fewer than a third of pregnant women in the most remote and poorest communities of Zambia achieve the four ANC visits recommended by the World Health Organization. Current evidence suggests that attending ANC provided by a skilled healthcare worker at least once is common and associated with skilled birth attendance. The aim of this study was to explain why one ANC visit with a skilled provider seemed more common than four ANC visits among women in the remote and poorest districts of Zambia. Methods A qualitative case study design was conducted in 2012 among 84 participants in the selected remote and poorest districts of Zambia. Focus group discussions were conducted with mothers and community health volunteers, while key informant interviews were conducted with healthcare providers. Thematic analysis was conducted. Results Most women delayed starting antenatal care visits due to uncertainties about the timing for initiation of ANC and due to waiting for confirmation of the pregnancy by an elderly woman. Attendance of ANC once with a skilled provider was due to the need to assess their health status and that of their baby. In some facilities, attendance of ANC at least once was enforced by financial charges imposed on women for late ANC initiation, and/or incentives provided by nongovernmental organisations. Unavailability of services at health posts closest to these remote communities led to failure to return for subsequent ANC visits. Women’s livelihoods such as nomadic lifestyles made it harder for them to initiate and make additional ANC visits. Conclusion The popularity of ANC attendance once by a skilled provider among the remote and poorest women of Zambia was explained through perceived unavoidable social and economic barriers to care, and the punitive and incentive procedures implemented by health services. Maximising comprehensive care by skilled healthcare workers in the one visit a woman makes at the health facility, may lead to optimal utilisation of quality focused ANC. Enhancing community-based interventions may increase the potential to reach the vulnerable populations.

Abstract Background A community-based intervention known as Safe Motherhood Action Groups (SMAGs) was implemented to increase coverage of maternal and neonatal health (MNH) services among the poorest and most remote populations in Zambia. While the outcome evaluation demonstrated statistically significant improvement in the MNH indicators, targets for key indicators were not achieved, and reasons for this shortfall were not known. This study was aimed at understanding why the targeted key indicators for MNH services were not achieved. Methods A process evaluation, in accordance with the Medical Research Council (MRC) framework, was conducted in two selected rural districts of Zambia using qualitative approaches. Focus group discussions were conducted with SMAGs, volunteer community health workers, and mothers and in-depth interviews with healthcare providers. Content analysis was done. Results We found that SMAGs implemented much of the intervention as was intended, particularly in the area of women’s education and referral to health facilities for skilled MNH services. The SMAGs went beyond their prescribed roles to assist women with household chores and personal problems and used their own resources to enhance the success of the intervention. Deficiencies in the intervention were reported and included poor ongoing support, inadequate supplies and lack of effective transportation such as bicycles needed for the SMAGs to facilitate their work. Factors external to the intervention, such as inadequacy of health services and skilled healthcare providers in facilities where SMAGs referred mothers and poor geographical access, may have led SMAGs to engage in the unintended role of conducting deliveries, thus compromising the outcome of the intervention. Conclusion We found evidence suggesting that although SMAGs continue to play pivotal roles in contribution towards accelerated coverage of MNH services among hard-to-reach populations, they are unable to meet some of the critical sets of MNH service-targeted indicators. The complexities of the implementation mechanisms coupled with the presence of setting specific socio-cultural and geographical contextual factors could partially explain this failure. This suggests a need for innovating existing implementation strategies so as to help SMAGs and any other community health system champions to effectively respond to MNH needs of most-at-risk women and promote universal health coverage targeting hard-to-reach groups.

Repeat HIV testing is important in high HIV burden communities to enable sustainability of prevention initiatives; however, an understanding of repeat testing practices is limited. Additional HIV testing approaches may be required to increase testing. HIV self-testing is an additional testing approach, but knowledge on its potential for repeat testing is limited. This study explored repeat HIV testing practices and uptake of HIV self-testing among repeat testers, following exposure to HIV self-testing. HIV testing practices were explored at two time points. During Phase 1, eighty in-depth interviews were conducted among 40 consenting adults, and 30 telephonic contacts were completed during Phase 2. Framework analysis was used to analyse the transcripts from the in-depth interviews. The practice of repeat HIV testing is primarily influenced by HIV status awareness and risk exposure. Thirteen regular testers and one HIV naïve tester at baseline had undergone repeat testing through the use of a traditional testing approach such as HIV counselling and testing as reported in Phase 2. HIV self-testing has a role among repeat testers, but affordability and access are barriers.

Background: Community care workers (CCWs) in rural South Africa provide medical, personal, household, educational, and social care services to their clients. However, little understanding exists on how provision of services is approached within a household, taking into account available social support networks. Objective: The aim of this study was to generate an understanding of the processes that underpin the provision of care by CCWs in rural households and their engagement with clients, primary caregivers (PCGs), and other members of the social support network. Design: We analysed in-depth interviews conducted in a triad of participants involved in a home-based care (HBC) encounter – 32 clients, 32 PCGs, and 17 CCWs. For each triad, a purposefully selected CCW was linked with a purposefully selected client and the corresponding PCG using maximum variation sampling. Three coders used an inductive content analysis method to describe participants’ references to the nuances of processes followed by CCWs in servicing HBC clients. Written informed consent was obtained from all participants. Findings: The results suggest that, by intuition and prior knowledge, CCWs treated each household uniquely, depending on the clients’ care needs, cooperation, availability of a social network, and the reliability and resilience of the social support system for the client. Four distinct processes took place in rural households: needs assessment for care, rationing of care, appraisal of care, and reinforcement of a social support system. However, there was no particular order or sequence established for these processes, and caregivers followed no prescribed or shared standards. Conclusions: CCWs bring a basket of services to a household, but engage in a constant, dynamic, and cyclical process of weighing needs against services provided. The service package is uniquely crafted and tailored for each household, depending on the absorptive capacity of the social support network available to the client, and preferences of the clients remain central to the process of negotiating care.

Background: Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency screening test is essential for malaria treatment, control, and elimination programs. G6PD deficient individuals are at high risk of severe hemolysis when given anti-malarial drugs such as primaquine, quinine, other sulphonamide-containing medicines, and chloroquine, which has recently been shown to be potent for the treatment of coronavirus disease (COVID-19). We evaluated the geographical accessibility to POC testing for G6PD deficiency in Ghana, a malaria-endemic country. Methods: We obtained the geographic information of 100 randomly sampled clinics previously included in a cross-sectional survey. We also obtained the geolocated data of all public hospitals providing G6PD deficiency testing services in the region. Using ArcGIS 10.5, we quantified geographical access to G6PD deficiency screening test and identified clinics as well as visualize locations with poor access for targeted improvement. The travel time was estimated using an assumed speed of 20 km per hour. Findings: Of the 100 clinics, 58% were Community-based Health Planning and Services facilities, and 42% were sub-district health centers. The majority (92%) were Ghana Health Service facilities, and the remaining 8% were Christian Health Association of Ghana facilities. Access to G6PD deficiency screening test was varied across the districts, and G6PD deficiency screening test was available in all eight public hospitals. This implies that the health facility-to-population ratio for G6PD deficiency testing service was approximately 1:159,210 (8/1,273,677) population. The spatial analysis quantified the current mean distance to a G6PD deficiency testing service from all locations in the region to be 34 ± 14 km, and travel time (68 ± 27 min). The estimated mean distance from a clinic to a district hospital for G6PD deficiency testing services was 15 ± 11 km, and travel time (46 ± 33 min). Conclusion: Access to POC testing for G6PD deficiency in Ghana was poor. Given the challenges associated with G6PD deficiency, it would be essential to improve access to G6PD deficiency POC testing to facilitate administration of sulphadoxine-pyrimethamine to pregnant women, full implementation of the malaria control program in Ghana, and treatment of COVID-19 patients with chloroquine in malaria-endemic countries. To enable the World Health Organization include appropriate G6PD POC diagnostic tests in its list of essential in-vitro diagnostics for use in resource-limited settings, we recommend a wider evaluation of available POC diagnostic tests for G6PD deficiency, particularly in malaria-endemic countries.

BackgroundSouth Africa introduced the world’s largest antiretroviral treatment (ART) program in 2004 and since 2016 the Department of Health implemented a universal Treatment as Prevention (TasP) strategy. However, some studies have shown that increasing the availability of ART is insufficient for the comprehensive treatment of HIV, since many people still use traditional health practitioners (THPs) to avoid being identified as HIV positive, and for reasons unrelated to HIV/AIDS. This qualitative study explored the factors influencing how both HIV-negative and HIV-positive people choose amongst multiple sources of healing and how they engage with them, in the context of HIV/AIDS and wide availability of ART.MethodsData were collected as part of a larger TasP trial at the Africa Health Research Institute, KwaZulu-Natal. Repeat in-depth individual interviews were conducted with 10 participants. Repeat group discussions were conducted with 42 participants. Group discussion data were triangulated using community walks and photo-voice techniques to give more insight into the perceptions of community members. All data were collected over 18 months. Thematic analysis was used to analyze participants’ narratives from both individual interviews and group discussions.FindingsIn the context of HIV/AIDS and wide availability of ART, use of biomedical and traditional healing systems seemed to be common in this locality. People used THPs to meet family expectations, particularly those of authoritative heads of households such as parents or grandparents. Most participants believed that THPs could address specific types of illnesses, especially those understood to be spiritually caused and which could not be addressed or cured by biomedical practitioners. However, it was not easy for participants to separate some spiritually caused illnesses from biological illnesses in the context of HIV/AIDS. These data demonstrate that in this context, the use of THPs continues regardless of the wide availability of ART. To meet the health care needs of those patients requiring a health care system which combines biomedical and traditional approaches, collaboration and integration of biomedical and traditional health care should be considered.

BACKGROUND:A community-based intervention comprising both men and women, known as Safe Motherhood Action Groups (SMAGs), was implemented in four of Zambia's poorest and most remote districts to improve coverage of selected maternal and neonatal health interventions. This paper reports on outcomes in the coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) in the study areas. METHODOLOGY:Three serial cross-sectional surveys were conducted between 2012 and 2015 among 1,652 mothers of children 0-5 months of age using a 'before-and-after' evaluation design with multi-stage sampling, combining probability proportional to size and simple random sampling. Logistic regression and chi-square test for trend were used to assess effect size and changes in measures of coverage for ANC, SBA and PNC during the intervention. RESULTS:Mothers' mean age and educational status were non-differentially comparable at all the three-time points. The odds of attending ANC at least four times (aOR 1.63; 95% CI 1.38-1.99) and SBA (aOR 1.72; 95% CI 1.38-1.99) were at least 60% higher at endline than baseline surveillance. A two-fold and four-fold increase in the odds of mothers receiving PNC from an appropriate skilled provider (aOR 2.13; 95% CI 1.62-2.79) and a SMAG (aOR 4.87; 95% CI 3.14-7.54), respectively, were observed at endline. Receiving birth preparedness messages from a SMAG during pregnancy (aOR 1.76; 95% CI, 1.20-2.19) and receiving ANC from a skilled provider (aOR 4.01; 95% CI, 2.88-5.75) were significant predictors for SBA at delivery and PNC. CONCLUSIONS:Strengthening community-based action groups in poor and remote districts through the support of mothers by SMAGs was associated with increased coverage of maternal and newborn health interventions, measured through ANC, SBA and PNC. In remote and marginalised settings, where the need is greatest, context-specific and innovative task-sharing strategies using community health volunteers can be effective in improving coverage of maternal and neonatal services and hold promise for better maternal and child survival in poorly-resourced parts of sub-Saharan Africa.

Background: Major national primary healthcare reforms are seldom implemented, and few studies have explored the benefits of primary healthcare outreach teams to rural households, a knowledge gap we sought to address with this study. Objective: The objective of this study was to explore the community benefits in the context of PHC services delivered in rural households by outreach teams. Methods: The study was conducted in the iLembe District on the east coast of KwaZulu-Natal, South Africa between July 2015 and January 2017. In-depth, explorative and semi-structured qualitative interviews were conducted as part of a mixed-method study. A total of 21 in-depth interviews with key informants and four focus group discussions (n = 28) were conducted with purposefully sampled households and outreach team members. Content analysis was used to explore and understand the households’ experiences of primary healthcare services provided by outreach teams. Results: Household members benefited from outreach team services tailored to specific households and individuals, which improved the efficiency of healthcare services, access to appropriate health information and the overall experience of healthcare, particularly among those who are physically unwell, on chronic treatment, default treatment or immunisation, or who need referrals for clinical and social services. The benefits to household members included personalised care in the home, improved referral pathways, awareness of health events, improved adherence to treatment and reduction in opportunity costs of healthcare. Conclusion: It is perceived that participants have benefitted from the model of PHC service delivery by outreach teams through improved access to healthcare services, and by allowing community members to receive services that are responsive to their needs since the outreach team members’ advocate and negotiate to deliver services on behalf of community members. These stated benefits, as perceived by household members, have the potential to improve health outcomes and increase satisfaction levels amongst household members.

[This corrects the article DOI: 10.1371/journal.pone.0190145.].

Background: Community health workers (CHWs) are an integral resource in many health systems, particularly in resource-poor settings. Their identities – ‘who’ they are – play an important role in their hiring, training, and retention. We explore the perceptions, experiences, and identities of CHWs as they adopt a CHW role in rural South Africa, using ‘role identity theory’. Design: From April to December 2010, we conducted 18 semi-structured interviews with CHWs volunteering in non-governmental home-based care (HBC) organisations in one rural sub-district in South Africa. The role identity theory framework was used to understand the work of CHWs within their communities, addressing themes, such as entry into, and nature of, caring roles, organisational support, state resourcing, and community acceptability. A thematic content analysis was used to analyse the collected data. Results: The study found that CHWs usually begin their ‘caring work’ before they formally join HBC organisations, by caring for children, neighbours, mothers, fathers, friends, and the community in some way. CHWs felt that becoming a health worker provided an elevated status within the community, but that it often led community members to believe they were able to control resources. The key role identities assumed by CHWs, as they sought to meet patients’ and their own needs, were a complex mix of community ‘insider’, ‘outsider’, and ‘broker’. Each of these role identities served as a unique way to position, from the CHW's perspective, themselves and the community, given the diversity of needs and expectations. Conclusions: These role identities reveal the tensions CHWs face as ‘insider’ members of the community and yet at times being treated as ‘outsiders’, who might be regarded with suspicion, and at the same time, appreciated for the resources that they might possess. Understanding role identities, and how best to support them, may contribute to strategies of retention and sustainability of CHW programmes, as their formalisation in different contexts continues to grow.

Background: The aim of ward-based outreach teams (WBOTs) is to improve access to primary healthcare (PHC) services including health promotion and disease prevention in South Africa. Limited information is available in South Africa on user perceptions of services provided by WBOTs in rural households. Aim: The study aimed to explore community awareness and perception of WBOTs, as well people’s motivation to engage and use WBOT services. Setting: The study was conducted between July and September 2015 in iLembe district, KwaZulu-Natal. Methods: This was exploratory-descriptive qualitative research. Purposive sampling technique was used in this study. A total of 16 key informant interviews and 4 focus group discussions were conducted. The voice recordings were transcribed in isiZulu and translated into English. Results: Four themes emerged from the data analysis, namely bringing services closer, organising services, expanding services and forming bridges. Respondents demonstrated insightful knowledge and understanding of services provided by WBOTs. They expressed an appreciation of the way WBOT services brought healthcare closer to people and serve to bridge the gap between the community and local healthcare facilities. Respondents identified unclear WBOT work schedules and the failure to carry medication other than vitamin A as the main challenges. However, WBOTs did deliver medication for controlled chronic patients in their households. Conclusion: The study suggests that WBOTs provide a commendable service, but need to expand their service package to further increase access to PHC services and cater for community health needs.

Background: The community-based medical education curriculum is growing in popularity as a strategy to bring universal health coverage to underserved communities by providing medical students with hands-on training in primary health care. Accommodation and immersion of medical students within the community will become increasingly important to the success of community-based curricula. In the context of tourism, homestays, where local families host guests, have shown to provide an immersive accommodation experience. Objective: By exploring homestays in the educational context, this scoping study investigates their role in providing an immersive pedagogical experience for medical students. Design: A scoping review was performed using the online databases ScienceDirect and the Duke University Library Database, which searches Academic Search Complete, JSTOR, LexisNexis Academic, Web of Science, Proquest, PubMed and WorldCat. Using the inclusion term ‘homestays’ and excluding the term ‘tourism’, 181 results were returned. AClose assessment using inclusion criteria narrowed this to 14 relevant articles. Results: There is very little published research specific to the experience of medical students in community homestays, indicating a gap in the literature. However, the existing educational outcomes suggest homestays may have the potential to serve a significant role in medical education, especially as a component of decentralised or community-based programmes. The literature reveals that educational homestays influence language learning, cultural immersion, and the development of professional skills for health science careers. These outcomes relate to the level of engagement between students and hosts, including the catalytic role of community liaisons. Conclusions: Homestays offer a unique depth of experience that has the potential to enrich the education of participating students, and require further research, particularly in the context of distributed and decentralised training platforms for medical and health sciences students. Future studies should explore the potential for homestays as a pedagogical component of community-based medical curriculum. Abbreviations: CBME: Community-based medical education

Background: Traditional health practitioners (THPs) have been identified as a key local resource in the fight against human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in South Africa. However, their approaches to the treatment of people living with HIV (PLHIV) have been met with scepticism by some biomedical practitioners amid increasing access to antiretroviral therapy (ART). Objective: In light of this ambivalence, this study aims to document and identify treatment approaches of THPs to the management of illness among PLHIV in the current era of widespread access to ART. Methods: The study was conducted as part of a larger trial of Treatment as Prevention (TasP) in rural northern Kwa-Zulu Natal, intended to treat PLHIV regardless of CD4 count. Nine THPs were enrolled using purposive and snowballing techniques. Repeat group discussions, triangulated with community walks and photovoice techniques, were conducted. A thematic analysis approach was used to analyse the data. Results: Eight of the nine THPs had received training in biomedical aspects of HIV. THPs showed a multilayered decision-making process in managing illness among PLHIV, influenced by the attributes and choices of the THPs. THPs assessed and managed illness among PLHIV based on THP training in HIV/AIDS, THP type, as well as knowledge and experience in the traditional healing practice. Management of illness depended on the patients’ report of their HIV status or willingness to test for HIV. Conclusions: THPs’ approaches to illness in PLHIV appear to be shifting in light of increasing exposure to HIV/AIDS-related information. Importantly, disclosure of HIV status plays a major role in THPs’ management of illness among PLHIV, as well as linkage to HIV testing and care for their patients. Therefore, THPs can potentially enhance the success of ART for PLHIV when HIV status is known.

Although home-based care (HBC) programs are widely implemented throughout Africa, their success depends on the existence of an enabling environment, including a referral system and supply of essential commodities. The objective of this study was to explore the current state of client referral patterns and practices by community care workers (CCWs), in an evolving environment of one rural South African sub-district. Using a participant triangulation approach, in-depth qualitative interviews were conducted with 17 CCWs, 32 HBC clients and 32 primary caregivers (PCGs). An open-ended interview guide was used for data collection. Participants were selected from comprehensive lists of CCWs and their clients, using a diversified criterion-based sampling method. Three independent researchers coded three sets of data - CCWs, Clients and PCGs, for referral patterns and practices of CCWs. Referrals from clinics and hospitals to HBC occurred infrequently, as only eight (25%) of the 32 clients interviewed were formally referred. Community care workers showed high levels of commitment and personal investment in supporting their clients to use the formal health care system. They went to the extent of using their own personal resources. Seven CCWs used their own money to ensure client access to clinics, and eight gave their own food to ensure treatment adherence. Community care workers are essential in linking clients to clinics and hospitals and to promote the appropriate use of medical services, although this effort frequently necessitated consumption of their own personal resources. Therefore, risk protection strategies are urgently needed so as to ensure sustainability of the current work performed by HBC organizations and the CCW volunteers.

IntroductionIn an effort to increase understanding of formation of the community and home-based care economy in South Africa, we investigated the origin and development of non-profit organisations (NPOs) providing home- and community-based care for health and social services in a remote rural area of South Africa.MethodsOver a three-year period (2010-12), we identified and tracked all NPOs providing health care and social services in Bushbuckridge sub-district through the use of local government records, snowballing techniques, and attendance at NPO networking meetings--recording both existing and new NPOs. NPO founders and managers were interviewed in face-to-face in-depth interviews, and their organisational records were reviewed.ResultsForty-seven NPOs were formed prior to the study period, and 14 during the study period--six in 2010, six in 2011 and two in 2012, while four ceased operation, representing a 22% growth in the number of NPOs during the study period. Histories of NPOs showed a steady rise in the NPO formation over a 20-year period, from one (1991-1995) to 12 (1996-2000), 16 (2001-2005) and 24 (2006-2010) new organisations formed in each period. Furthermore, the histories of formation revealed three predominant milestones--loose association, formal formation and finally registration. Just over one quarter (28%) of NPOs emerged from a long-standing community based programme of 'care groups' of women. Founders of NPOs were mostly women (62%), with either a religious motivation or a nursing background, but occasionally had an entrepreneurial profile.ConclusionWe observed rapid growth of the NPO sector providing community based health and social services. Women dominated the rural NPO sector, which is being seen as creating occupation and employment opportunities. The implications of this growth in the NPO sector providing community based health and social services needs to be further explored and suggests the need for greater coordination and possibly regulation.

Background. Delay in pulmonary tuberculosis (PTB) diagnosis is one of the major factors that affect outcome and threatens continued spread of tuberculosis. This study aimed at determining factors associated with delayed PTB diagnosis among human immunodeficiency virus (HIV) infected individuals. Methods. A retrospective observational study was done using clinic records of HIV-infected PTB suspects attending an HIV/AIDS clinic at Tintswalo rural hospital in South Africa (SA) between January 2006 and December 2007. Using routine clinic registers, 480 records were identified. Results. PTB diagnosis delay was found among 77/176 (43.8%) of the patients diagnosed with PTB. The mean delay of PTB diagnosis was 170.6 days; diagnosis delay ranged 1–30 days in 27 (35.1%) patients, 31–180 days in 24 (33.8%) patients; 24 (31.2%) patients remained undiagnosed for ≥180 days. Independent factors associated with delayed diagnosis were: older age >40 years (Odds Ratio (OR) 3.43, 95% CI 1.45–8.08) and virological failure (OR 2.72, 95% CI 1.09–6.74). Conclusion. There is a considerable delayed PTB diagnosis among HIV-infected patients in rural SA. Older patients as well as patients with high viral load are at a higher risk of PTB diagnosis delay. Therefore efforts to reduce PTB diagnosis delay need to emphasised.