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Abstract Background Comprehensive sexuality education (CSE) is critical in addressing negative sexual and reproductive health (SRH) outcomes among adolescents. Yet in many low- and middle-income countries (LMICs) including Zambia, little is known about the impact, realities of CSE implementation, the quality of teaching and the comprehensiveness of the content covered. Methods Our approach was informed by a process evaluation incorporating recommendations by the European Expert Group guidance on evaluating sexuality education programmes and the Medical Research Council (MRC) guidelines on process evaluation. The development process and quality of CSE implementation were assessed using eight and six quality criteria respectively. In-depth interviews (IDIs), focus group discussions (FGDs), document analysis and classroom observation were employed to assess contextual factors, implementation process and mechanisms of impact of CSE. In-depth interviews (50) and focus group discussions (2) with seven pupils in each group were conducted among 64 purposefully selected participants. The sample comprised pupils (35), parents (4) and teachers (17) from nine secondary schools (four peri-urban, four urban and one rural), policymakers (4), and religious leaders (4). We employed deductive content analysis to analyse the data. Results Contextual factors that influenced the implementation of CSE included: (1) piecemeal funding for the CSE programme; (2) lack of monitoring programmes in schools; (3) lack of community engagement; (4) religious and socio-cultural barriers; (5) lack of skills and competency to teach CSE; and (6) insufficient time allocation for CSE. The assessment of the quality of the development of CSE revealed: (1) a lack of sexual diversity; (2) no meaningful participation of pupils in programme implementation; (3) a lack of stakeholder engagement during programme implementation; (4) lack of gender sensitivity; and (5) lack of human rights approach. Assessment of the quality of the implementation of CSE revealed: (1) no evidence of skill-based CSE teaching; (2) no linkage between CSE and SRH services in the communities; and (3) a lack of incorporation of multiple delivery methods during CSE teaching. The mechanisms of impact of CSE were related to the acceptability and positive changes in pupils’ SRH practices. Conclusion The complex influences of contextual factors during CSE implementation highlight the need for contextual analysis during the interventional design. Co-creation of the CSE programme through stakeholder participation could reduce social opposition and enable a culturally sensitive CSE. Comprehensive teacher training, a guiding curriculum as well as setting of appropriate monitoring tools and indicators are likely to enhance the quality of CSE implementation.

Background: Adolescents’ risky sexual behaviours (RSB) are detrimental to their sexual and reproductive health (SRH) well-being and present a serious public health threat, particularly in low- and middle-income countries (LMICs). Aim: This study aims to assess RSB among Grade 12 school-going adolescents after exposure to comprehensive sexuality education (CSE). Setting: This study was conducted in Kitwe district, Zambia. Methods: This cross-sectional study included 807 Grade 12 pupils at 13 selected secondary schools. Data were collected using a structured questionnaire. Proportionate probability sampling involving 13 schools was employed. Risky sexual behaviours binary outcome variables were based on transactional sex, sex while drunk, multiple sexual partners, age-disparate sexual relationships, and condomless sex. We conducted univariate and bivariate analyses to summarise sociodemographic factors and fitted binary and multivariable logistic regression models. Results: The prevalence of RSB was 40.4%. Drinking alcohol (adjusted odds ratio [AOR] = 20.825; 95% CI [6.7–64.489]); ever had sex (AOR = 9.024; 95% CI [1.953–41.704]); school location (AOR = 6.50; 95% CI [1.61–26.24]); living with mother only (AOR = 4.820; 95% CI [1.328–17.493]); sex (male) (AOR = 2.632; 95% CI [1.469–4.713]), watching pornography (AOR = 1.745; 95% CI [1008–3.021]); religion (AOR = 0.472; 95% CI [0.250–0.891]) and attending religious functions (AOR = 0.317; 95% CI [0.118–0.848]) were significantly associated with RSB. Of the sexually active pupils, 221 (67.7%), 64 (19.6%) and 41 (12.5%) were in the low, medium and high-risk categories, respectively. Conclusion: Close to half of the respondents engaged in RSB. This is a significant number that needs intervention. The CSE programme needs to be linked with structural programmes that address the social drivers of RSB among adolescents. Contribution: The study provides a backdrop for evaluating current CSE strategies in LMICs.

Intimate partner violence (IPV) among young women is of serious concern due to the early age of occurrence. This study explored young women's views about IPV in Maputo City, Mozambique. An explorative, qualitative study design was employed using purposive sampling. The themes were developed in line with the socio-ecological model and the data were analyzed using a thematic content approach. Four themes emerged: (1) Individual level, related to the knowledge of young women about IPV; (2) Relationship level, related to the influence of friends; (3) Community level, related to the religious beliefs; and (4) Societal level, related to factors promoting acceptance of IPV. There is need for an integrated approach to address the individual, relationship, community and societal concerns about IPV among young women in Mozambique to improve skills to challenge the dominant male norms and enhance their autonomy to manage and end violent relationships.

IntroductionFemale genital schistosomiasis is a common but neglected disease, which results in symptoms similar to sexually transmitted infections in Schistosoma haematobium-endemic areas of Africa and Middle East. In primary healthcare of low-income countries, healthcare professionals use syndromic management protocols for guidance when treating symptoms of genital infection, due to lack of laboratory resources. These protocols do not include treatment for female genital schistosomiasis, despite the overlap of symptoms. Women are at risk of not receiving the appropriate treatment. The aim of this study was to investigate challenges and missed opportunities when using syndromic management protocols for sexually transmitted infections in female genital schistosomiasis-endemic areas.MethodsThis is a secondary analysis of data from a large cross-sectional prevalence study conducted in 2011 in KwaZulu-Natal, South Africa. Young women in schistosomiasis-endemic areas were asked about genital symptoms and underwent laboratory testing and gynecological examinations to look for common genital infections including female genital schistosomiasis. We used the current South African syndromic management protocols as the basis and analyzed the associations between the reported genital symptoms and the differential diagnoses with logistic regression.ResultsBy use of the syndromic approach the conditions gonorrhea, trichomoniasis and herpes could be identified. The symptom “lower abdominal pain” was significantly associated with documented female genital schistosomiasis. However, the same association was not found with gonorrhea or chlamydia. We found no significant association between reported vaginal discharge syndrome and female genital schistosomiasis or between genital ulcer syndrome and female genital schistosomiasis.DiscussionFemale genital schistosomiasis frequently co-exists with, and mimics other genital infections in rural areas of Sub-Saharan Africa. The management protocols in schistosomiasis endemic countries should include advice on how to diagnose and manage this chronic, waterborne genital condition. There is an urgent need to upscale laboratory and diagnostic resources in low-and middle-income countries and specifically schistosomiasis-endemic areas, to diagnose these common genital infections more accurately and to treat affected women accordingly.

ObjectiveFemale Genital Schistosomiasis (FGS) causes intravaginal lesions and symptoms that could be mistaken for sexually transmitted diseases or cancer. In adults, FGS lesions [grainy sandy patches (GSP), homogenous yellow patches (HYP), abnormal blood vessels and rubbery papules] are refractory to treatment. The effect of treatment has never been explored in young women; it is unclear if gynaecological investigation will be possible in this young age group (16-23 years). We explored the predictors for accepting anti-schistosomal treatment and/or gynaecological reinvestigation in young women, and the effects of anti-schistosomal mass-treatment (praziquantel) on the clinical manifestations of FGS at an adolescent age.MethodThe study was conducted between 2011 and 2013 in randomly selected, rural, high schools in Ilembe, uThungulu and Ugu Districts, KwaZulu-Natal Province, East Coast of South Africa. At baseline, gynaecological investigations were conducted in female learners in grades 8 to 12, aged 16-23 years (n = 2293). Mass-treatment was offered in the low-transmission season between May and August (a few in September, n = 48), in accordance with WHO recommendations. Reinvestigation was offered after a median of 9 months (range 5-14 months). Univariate, multivariable and logistic regression analysis were used to measure the association between variables.ResultsPrevalence: Of the 2293 learners who came for baseline gynaecological investigations, 1045 (46%) had FGS lesions and/or schistosomiasis, 209/1045 (20%) had GSP; 208/1045 (20%) HYP; 772/1045 (74%) had abnormal blood vessels; and 404/1045 (39%) were urine positive. Overall participation rate for mass treatment and gynaecological investigation: Only 26% (587/2293) learners participated in the mass treatment and 17% (401/2293) participated in the follow up gynaecological reinvestigations. Loss to follow-up among those with FGS: More than 70% of learners with FGS lesions at baseline were lost to follow-up for gynaecological investigations: 156/209 (75%) GSP; 154/208 (74%) HYP; 539/722 (75%) abnormal blood vessels; 238/404 (59%) urine positive. The grade 12 pupil had left school and did not participate in the reinvestigations (n = 375; 16%). Follow-up findings: Amongst those with lesions who came for both treatment and reinvestigation, 12/19 still had GSP, 8/28 had HYP, and 54/90 had abnormal blood vessels. Only 3/55 remained positive for S. haematobium ova. Factors influencing treatment and follow-up gynaecological investigation: HIV, current water contact, water contact as a toddler and urinary schistosomiasis influenced participation in mass treatment. Grainy sandy patches, abnormal blood vessels, HYP, previous pregnancy, current water contact, water contact as a toddler and father present in the family were strongly associated with coming back for follow-up gynaecological investigation. Challenges in sample size for follow-up analysis of the effect of treatment: The low mass treatment uptake and loss to follow up among those who had baseline FGS reduced the chances of a larger sample size at follow up investigation. However, multivariable analysis showed that treatment had effect on the abnormal blood vessels (adjusted odds ratio = 2.1, 95% CI 1.1-3.9 and p = 0.018).ConclusionCompliance to treatment and gynaecological reinvestigation was very low. There is need to embark on large scale awareness and advocacy in schools and communities before implementing mass-treatment and investigation studies. Despite challenges in sample size and significant loss to follow-up, limiting the ability to fully understand the treatment's effect, multivariable analysis demonstrated a significant treatment effect on abnormal blood vessels.

Up to 56 million young and adult women of African origin suffer from Female Genital Schistosomiasis (FGS). The transmission of schistosomiasis happens through contact with schistosomiasis infested fresh water in rivers and lakes. The transmission vector is the snail that releases immature worms capable of penetrating the human skin. The worm then matures and mates in the blood vessels and deposits its eggs in tissues, causing urogenital disease. There is currently no gold standard for FGS diagnosis. Reliable diagnostics are challenging due to the lack of appropriate instruments and clinical skills. The World Health Organisation (WHO) recommends "screen-and-treat" cervical cancer management, by means of visual inspection of characteristic lesions on the cervix and point-of-care treatment as per the findings. FGS may be mistaken for cervical cancer or sexually transmitted diseases. Misdiagnosis may lead to the wrong treatment, increased risk of exposure to other infectious diseases (human immunodeficiency virus and human papilloma virus), infertility and stigmatisation. The necessary clinical knowledge is only available to a few experts in the world. For an appropriate diagnosis, this knowledge needs to be transferred to health professionals who have minimal or non-existing laboratory support. Co-design workshops were held with stakeholders (WHO representative, national health authority, FGS experts and researchers, gynaecologists, nurses, medical doctors, public health experts, technical experts, and members of the public) to make prototypes for the WHO Pocket Atlas for FGS, a mobile diagnostic support tool and an e-learning tool for health professionals. The dissemination targeted health facilities, including remote areas across the 51 anglophone, francophone and lusophone African countries. Outcomes were endorsed by the WHO and comprise a practical diagnostic guide for FGS in low-resource environments.

Abstract Background The South African public antiretroviral therapy (ART) programme is considered one of the largest and most successful ART programmes worldwide. Hence, a study exploring the patients’ experiences of the public antiretroviral therapy (ART) programme in the second decade of the programme is relevant as no study has been published on patients’ experiences at these sites. Objectives To explore patients’ experiences of care in the public ART programme at four ARV clinics within the eThekwini District, KwaZulu-Natal. Method A mixed-methods study design with 12 in-depth patient interviews, non-participatory observation, and a stratified random sample of 400 patients completed questionnaires. Qualitative data were thematically analysed. Quantitative data were analysed using a SPSS 24 package to determine frequencies and differences in patients’ responses (p

Female Genital Schistosomiasis (FGS) is a neglected tropical disease that affects the lives of millions of women living in endemic areas. The aim of this study was to identify South African healthcare professionals' perceptions and experiences of Female Genital schistosomiasis. This qualitative study took place in Ugu District, KwaZulu-Natal, South Africa, in one Community Health Centre and two Primary Health Care clinics. The purpose was to explore local healthcare professionals' views and knowledge on FGS in an area endemic for Schistosoma haematobium, referred to as bilharzia, or isichenene in isiZulu. The empirical findings collected through interviews and observations are discussed in relation to the well-established research on FGS. This project also took cognizance of the United Nations (UN) sustainability development goals (SDGs) with a focus on gender and sanitation, as well as control programmes to prevent schistosomiasis. The study showed that there was a multi-faceted gap in knowledge between local midwives and professional nurses’ work-related knowledge and the medical research team. Among the main causes are skewed power relations, whereby the women affected by FGS often have low socioeconomic status in society while the higher power structures do not prioritize FGS. This leads to health professionals being in a “middle position” where they are responsible for community health but are governed by their training and the guidelines of the institution in which they are a part. Furthermore, the study showed the importance of culture since nurses and midwives consult with patients, as they are part of a framework where their role is constrained due to governmental policies, protocols for patient care and the local culture. To provide adequate health services for FGS patients, this study indicates that policy, female patient management protocols, curricula, post graduate training, clinical practice and schistosomiasis prevention programs should include FGS.

The Covid-19 pandemic and resultant disruptions to schooling presented significant challenges for many families. Well organised families have been shown to have a protective effect on adolescent wellbeing in periods of shock. At the onset of the Covid-19 pandemic, Asenze, a population-based cohort study, was conducting a third wave of data collection in peri-urban South Africa, examining risk and protective factors during adolescence. By March 2020, n = 272 adolescents and their caregivers (n = 241) in the cohort had been assessed when in-person data collection was halted by lockdown measures countrywide. During this cessation we undertook a brief telephonic qualitative sub-study to explore whether families enrolled in the cohort were able to cohabit cohesively and undertake distance learning during lockdown. A purposeful sample of 20 families (caregivers n = 20, adolescents n = 24) recently assessed in the Wave 3 of the main study, participated in semi-structured interviews. Quantitative data from Waves 1-3 of the main study was used to measure family function, adolescent cognitive function, and profile adolescent and caregivers. The quantitative and qualitative data were integrated to illustrate the dynamics of the participants' lives before and during lockdown. We found that families classified as well-organized before lockdown, were more likely to report co-operation during lockdown. Adolescents who were self-motivated, had access to smartphones or the internet, and were supported by both family and educators, were well-placed to continue their education without much disruption. However, few schools instituted distance learning. Of the adolescents who were not assisted- some studied on their own or with peers, but others did no schoolwork, hindered by a lack of digital connectivity, and poor service delivery. The experience of adolescence and caregivers in the Asenze Cohort during lockdown highlight the importance of family functioning for adolescent wellbeing in crisis, as well as the need for access to health, mental health, and social services, communication upgrades, and enhancements to the education system during peaceful times, to make a difference to young lives in times of crisis.

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

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

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

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

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

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

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

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

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

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

The university period provides a critical developmental transition from adolescence to adulthood. During this period, young people establish patterns of behaviors and make lifestyle choices that affect their current and future health. Using the social constructionist paradigm that examines the development of masculinities as a mutual construct of individual, social, cultural, and historical context, this article explores the interactions between masculinities and sexual behaviors of young men at the University of KwaZulu-Natal, South Africa. The study used a qualitative approach and employed purposive sampling to recruit 36 young Black male students aged between 18 and 30 years. Four focus group discussions consisting of 8 to 10 participants were conducted according to the current year of study of male students. Data were transcribed, coded, and analyzed thematically. Our results show that the freedom and independence acquired from being away from home enabled students to enact their masculinities freely. Our findings further reveal that an individual has multiple masculinities which are often exerted to suit the present discourse they are in at any given point.

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

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

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

Objective This study carried out a scoping review of research on intimate partner violence to determine the extent to which studies on sociocultural factors influencing intimate partner violence among young women (15–24 years) have been conducted, and how different geographical areas are represented. It also considered whether the methodologies used were sufficient to describe the risk factors, prevalence and health outcomes associated with intimate partner violence among young women.Study design Scoping review.Methods Online databases were used to identify studies published between 2008 and 2019. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines by Arksey and O’Malley were used to select studies, and primary studies were assessed using the Mixed Method Appraisal Tool, V.2011. Thematic content analysis was used to summarise the findings of the scoping review.Results The majority of publications eight (61.5%) reported cross-sectional studies, while four (31.5%) were qualitative studies. One of the studies (7%) collected measured data. Overall, 13 (100%) of the publications examined factors influencing intimate partner violence.Using a customised quality assessment instrument, 12 (92.3%) of studies achieved a ‘high’-quality ranking with a score of 100%, and 7.7% of studies achieved an ‘average’ quality ranking with a score of 75%.Conclusions While the quality of the studies is generally high, researches on sociocultural factors influencing intimate partner violence among young women would benefit from a careful selection of methods and reference standards, including direct measures of the violence affecting young women. Prospective cohort studies are required linking early exposure with individual, sociocultural and community factors, and detailing the abuse experienced from childhood, adolescence and youth.PROSPERO registration number CRD42018116463.Scoping protocol publication https://doi.org/10.1186/s13643-019-1234-y

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

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

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

Abstract Background Child and youth care workers (CYCWs) are a crucial and growing component of South Africa’s national response to HIV and AIDS and other issues affecting children and families. CYCWs use the community-centred Isibindi model of care to reach the most vulnerable with key services including psychosocial, health, economic and education support. Like others in similar professions, they may be at risk for occupational challenges affecting retention. Methods This study uses data from the first nationally representative survey of CYCWs in South Africa to identify factors associated with workers’ retention intentions. Data were collected in 2015 as part of a formative evaluation conducted around the mid-point of a nationwide Isibindi programme expansion. A total of 1158 CYCWs from 78 sites participated. The response rate for the sample was 87%. Questions addressed demographics, work history, retention intentions, training, mentorship and supervision experiences, workload and remuneration. Mixed effects regression models with random intercepts for project site and mentor were used to estimate factors associated with retention intentions. Results High-quality mentorship and frequent supervision support retention intentions among CYCWs. Respondents who indicated that wanting to help children or the community was their primary motivator for seeking work as a CYCW were also more likely to report intending to continue working as a CYCW. High perceived workloads and feeling threatened or unsafe on the job were negatively associated with retention intentions. As CYCWs gained experience, they were also less likely to intend to stay. Conclusions Understanding the factors affecting retention in the CYCW workforce is vital to helping vulnerable children and families across South Africa access key social and health services. Findings highlight the importance of mentoring and supervision as part of the Isibindi model and the value of support for manageable workloads, workplace safety, and career advancement opportunities for promoting worker retention.

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

Schistosoma haematobium infection is reported to facilitate the development of urogenital diseases. Its symptoms include haematuria, dysuria and tiredness, and it may cause cognitive decline in children. The prevalence of S. haematobium infection needs to be known in endemic areas and a mass treatment programme against the disease implemented. The aim of this study was to investigate the prevalence and intensity of S. haematobium infection in ILembe and uThungulu health districts, using the major symptom, haematuria, as an indicator. A total of 6 265 urine samples, from 96 rural schools, was collected for analysis using dipsticks. The prevalence of haematuria in the ILembe health district was 37% (95% CI, 35–39%) for boys and 39% (95% CI, 37–41%) for girls. The prevalence of haematuria in the uThungulu health district was 56% (95% CI, 53– 59%) and 53% (95% CI, 50–56%) for girls and boys, respectively. Light-intensity infection was the most common infection level in both health districts. A negative relationship was observed between prevalence and altitude (r = −0.262, p = 0.009); whereas, we found a slight, though significant, positive association with mid-summer temperatures (r = 0.234, p = 0.021). Associations between prevalence and distance of school to the nearest river were non-significant.

Abstract Background Anaemia is one of the world’s most prevalent child health problems. Its control in Africa and other developing nations has been hindered by uncertainty regarding its cause. Anaemia control has been particularly problematic in regions where the non-iron deficiency causes of anaemia, are projected to be substantial. The implementation of effective interventions to reduce the anaemia prevalence, requires improved documentation on iron status and other causes of anaemia for target populations. Methods This cross-sectional study enrolled n = 184 children, aged 6–8 years from Kwazulu-Natal, South Africa. Tests of haemoglobin, serum ferritin, soluble transferrin receptor and C-reactive protein were performed. These conventional measures of iron status were used to calculate body iron and to categorize the children into different groups of anaemia profiles. Results Anaemia prevalence was high, 43/184 (23.4%). Iron deficiency anaemia contributed 7/43 (16.3%) to the anaemia prevalence compared to non-iron deficiency anaemia 34/43 (79.1%) and mixed anaemia 2/43 (4.7%). In total 47/184 (25.5%) of the sampled children had either iron deficiency or anaemia. Information about the presence of inflammation was used to adjust serum ferritin concentrations, resulting in improved diagnosis of iron deficiency. Conclusion Appropriate investigations for iron status and inflammation/infection screening, need to be integral in the evaluation of anaemia and its causes before anaemia control interventions are implemented. Interventions that target the multifactorial nature of anaemia in school-aged children need to be strengthened. Additionally, regular screening of anaemia in school-aged children from disadvantaged communities is recommended.

Objectives: The objective of this study was to compare mid upper arm circumference (MUAC) and weight for height (W/H) as indices of acute malnutrition in children aged 0–59 months in South Africa. Design: A cross-sectional weighted survey of households was performed. Subjects and setting: Children aged 0–59 months and their mothers/caregivers were included in the study in iLembe district conducted between April and September 2014. Outcome measures: W/H and MUAC were measured and z-scores were calculated using the 2006 World Health Organisation (WHO) child growth standards. Results: Of the 572 child participants, 44 were malnourished (7.7%) using W/H measurements in comparison to 38 children (6.6%) using MUAC. There was ~54.0% agreement between the two indices when categorised in standard deviation (SD) bands and the significant Kappa statistic value of 0.27 constituted fair agreement. Similar percentages of male (1.1%) and female (1.1%) children under five years of age were detected with severe acute malnutrition (SAM) using W/H. In children aged 0–6 months W/H identified ten children as malnourished compared to only one child identified as malnourished using MUAC. Conclusions: The study found W/H to be a more sensitive measure. At a facility level W/H is considered the anthropometric measure of choice in children aged 0–59 months as nurses are trained in obtaining this measure. At the household level MUAC is preferred as a quick and easy measuring tool. In South Africa, the Road to Health Card, given at the clinics, records the W/H of children up to five years of age to assist in the prevention of childhood malnutrition. Future studies are recommended using both indicators in community settings in children particularly during 0–6 months as it is during this critical age period that moderate acute malnutrition (MAM) and SAM can be detected for timeous treatment and management of malnutrition.

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

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

Background: Youth behaviour in South Africa continues to be a public health concern. Primary prevention interventions remain a pre-requisite for promotion of improved social and health outcomes. Aim: The aim of the study was to assess the impact of a behavioural youth risk reduction intervention among grade 10 learners. Setting: The Study was conducted in KwaZulu-Natal high schools, at UMgungundlovu District Municipality. Methods: We conducted a cluster randomised controlled trial at 16 KwaZulu-Natal high schools where learners completed a self- administered questionnaire assessing youth risk behaviours. Schools were divided into two arms, intervention and a control arms. Results: The intervention reduced learners’ reports of carrying of a weapon to school in the past 30 days, but did not significantly reduce other assessed risk behaviours. Although the intervention appeared more likely to reduce learners’ risk behaviours when compared to the control group, such as carrying weapons, risky sexual behaviour and alcohol and drug abuse. Conclusion: This study was unable to show statistical significance for these outcomes.

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

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

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

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

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

Background: Adolescent repeat pregnancy is of importance in public health because the birth of a second child to an adolescent mother compounds the adverse medical, educational, socioeconomic and parenting outcomes. Repeat pregnancy in adolescence is not only an international phenomenon but also a local concern as it also occurs in South Africa. The prevalence of adolescent repeat pregnancy in Durban, KwaZulu-Natal, was reported as 17.6% in 2013. Aim: This review aimed to gather relevant information from national and international sources to inform practice and to provide an understanding of what is known about the risk factors of and the interventions for adolescent repeat pregnancy. Methods: A scoping review was undertaken using the Arksey and O’Malley framework. An electronic search was conducted using PubMed, Medline, Science Direct, Ebscohost, Sage and Wiley Online and Google Scholar. Results: The search identified 3032 citations. After a review of the full text articles, 26 articles met the inclusion criteria. Risk factors pertaining to adolescent repeat pregnancy are categorised according to individual factors, partner relationship factors, family factors, peer factors, and social and community factors. Interventions to reduce adolescent repeat pregnancy have been largely influenced by the ecological framework. Across studies, adolescent mothers who received medical, psychosocial, educational, and family planning support experienced lower rates of repeat pregnancy. Conclusion: A single ‘one-size-fits-all’ intervention for adolescent repeat pregnancy prevention is unlikely as different strategies were employed by the intervention programmes in this scoping review.

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

Urine microscopy is the standard diagnostic method for urogenital S. haematobium infection. However, this may lead to under-diagnosis of urogenital schistosomiasis, as the disease may present itself with genital symptoms in the absence of ova in the urine. Currently there is no single reliable and affordable diagnostic method to diagnose the full spectrum of urogenital S. haematobium infection. In this study we explore the classic indicators in the diagnosis of urogenital S. haematobium infection, with focus on young women.In a cross-sectional study of 1237 sexually active young women in rural South Africa, we assessed four diagnostic indicators of urogenital S. haematobium infection: microscopy of urine, polymerase chain reaction (PCR) of cervicovaginal lavage (CVL), urogenital symptoms, and sandy patches detected clinically in combination with computerised image analysis of photocolposcopic images. We estimated the accuracy of these diagnostic indicators through the following analyses: 1) cross tabulation (assumed empirical gold standard) of the tests against the combined findings of sandy patches and/or computerized image analysis and 2) a latent class model of the four indicators without assuming any gold standard.The empirical approach showed that urine microscopy had a sensitivity of 34.7% and specificity of 75.2% while the latent class analysis approach (LCA) suggested a sensitivity of 81.0% and specificity of 85.6%. The empirical approach and LCA showed that Schistosoma PCR in CVL had low sensitivity (14.1% and 52.4%, respectively) and high specificity (93.0% and 98.0, respectively). Using LCA, the presence of sandy patches showed a sensitivity of 81.6 and specificity of 42.4%. The empirical approach and LCA showed that urogenital symptoms had a high sensitivity (89.4% and 100.0%, respectively), whereas specificity was low (10.6% and 12.3%, respectively).All the diagnostic indicators used in the study had limited accuracy. Using urine microscopy or Schistosoma PCR in CVL would only confirm a fraction of the sandy patches found by colposcopic examination.

BACKGROUND:While neurodevelopmental abnormalities are common in children with HIV infection, their detection can be challenging in settings with limited availability of health professionals. The aim of this study was to assess the ability to identify developmental disability among HIV positive and HIV negative children living in South Africa with an internationally used screen. METHODS AND FINDINGS:This analysis uses a sample of 1,330 4-6 year old children and 1,231 of their caregivers in KwaZulu-Natal, South Africa, including administration of the Ten Questions (TQ) screen, a standardized medical history and physical examination conducted by a medical doctor, with hearing and vision screening, psychological assessment for cognition and language delay, and voluntary HIV testing. There was a high prevalence of disability among the sample. Compared to HIV negative children, HIV positive children were more likely to screen positive on at least one TQ item (59.3 vs 42.8%, p = 0.01), be delayed in sitting, standing or walking (OR 3.89, 95% CI = 2.1-7.2) and have difficulty walking or weakness in the arms or legs (OR = 2.7, 95%CI = 0.8-9.37). By medical doctor assessment, HIV positive children were more likely to be diagnosed with gross motor disability (OR = 3.5, 95%CI = 1.3-9.2) and hearing disability (OR = 2.5, 95%CI = 1.2-5.3). By independent psychological assessment, HIV positive children were more likely to have cognitive delay (OR = 2.2, 95%CI = 1.2-3.9) and language delay (OR = 4.3, 95%CI = 2.2-8.4). Among HIV positive children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 100% and 51.2%, respectively. Among HIV-negative children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 90.2% and 63.9%, respectively. CONCLUSIONS:In this first report of the use of the TQ screen in the isiZulu language, it was found to have high sensitivity for detecting serious developmental disabilities in children, especially HIV positive children. The performance of the TQ in this sample indicates utility for making best use of limited neurodevelopmental resources by screening HIV positive children.

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

A recent study based on a sample of 1,580 children from five adjacent geographical locations in KwaZulu-Natal, South Africa, was carried out to examine the association of nutrition, family influence, preschool education, and disadvantages in geographical location with the cognitive development of school children. Data were collected on the children from 2009 to 2011 for this developmental study and included cognitive scores and information on the health and nutrition of the children. The current study analyzed the association of demographic variables (geographical location (site)), child variables (sex, preschool education and socioeconomic status), parental level of education (maternal and paternal), child’s health (HIV status and hemoglobin level) and anthropometric measures of nutritional status (height-for-age) with children’s cognitive outcomes. The hypothesis is that the nutritional status of children is a pathway through which the indirect effects of the variables of interest exert influence on their cognitive outcomes. Factor analysis based on principal components was used to create a variable based on the cognitive measures, correlations were used to examine the bivariate association between the variables of interest in the preliminary analysis and a path analysis was constructed, which was used for the disaggregation of the direct and indirect effects of the predictors for each cognitive test in a structural equation model. The results revealed that nutritional status directly predicts cognitive test scores and is a path through which other variables indirectly influence children’s cognitive outcome and development.