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Doctoral Degrees (Health Promotion).

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    Caring for adolescents by older carers in the context of HIV combination prevention interventions in rural KwaZulu-Natal: an ethnographic approach.
    (2021) Gumede, Dumile Olivia.; Meyer-Weitz, Anna.
    In South Africa and in many other developing countries, grandparents/older carers have taken the role of caring for children, even where the older carers themselves have no steady source of income and are suffering from chronic illnesses. While previous studies have documented the experiences of older carers who are raising young children, few researchers have examined the caring of adolescents and the care relationships from the perspectives of both the older carers and adolescents in South Africa. The study examined the caring of adolescents by older carers in a rural KwaZulu-Natal district in which HIV prevention interventions called DREAMS were implemented. Following an ethnographic approach, this study used repeat in-depth interviews, key informant interviews, and observations to elicit information from six adolescents aged 13 to 19, six older carers aged 50 and above, and two HIV programme facilitators (n=14) over 12 months, from October 2017 to September 2018, in the uMkhanyakude district, KwaZulu-Natal. Written informed consent was obtained from all individuals before participation. All data were collected in isiZulu and audio-recorded, transcribed, and translated into English. The researcher combined both thematic and dyadic analysis approaches to understand care relationships and the lives of adolescents and their older carers in order to add a deeper understanding of the data. A multitheoretical approach including the life course perspective, the social-ecological model, and the self-management framework was applied to examine and interpret data. The findings of the study indicated a dynamic process which influenced how older carers ended up taking the primary care responsibility of their grandchildren. The factors that positively or negatively affected the quality of relationships between adolescents and their older carers were adolescents’ difficult behaviours and carers’ behaviours (positive and negative). Gender was also used to frame the labels ascribed to the adolescents. The consequences of stigmatised labelling of adolescents negatively affected the adolescents in older carer families. Additionally, generational perspectives between adolescents and their older carers of romantic sexual viii relationships were highlighted. Further, the motivators and barriers to participation in DREAMS interventions of adolescents in older carer families were influenced by the four levels of the socio-ecological model namely individual, interpersonal, organisational, and community levels. The motivating factors included obtaining HIV and sexual and reproductive health information, perceived changes in risky behaviours, and improved care relationships and communication between adolescents and the older carers. The barriers to participation in DREAMS interventions included internalized stigma, negative peer pressure, and caregivers’ lack of information about the HIV prevention interventions as well as challenges related to the organisation responsible for implementing DREAMS interventions. Lastly, the older carers employed a range of self-management practices for chronic conditions to promote health and well-being; while, sometimes, putting their lives at risk. In conclusion, the adolescents and their older carers were emotionally distressed, thereby impacting their well-being and the quality of the care relationships. Furthermore, adolescents faced challenges as they explored their sexuality and transit to adulthood. The strenuous relationships with the adolescents, rather than chronic conditions, were the main stressors that undermined the older carers’ ability to selfmanage chronic illnesses. Further studies are required to understand the impact of COVID-19 on older carer families and its influence on self-management of chronic illnesses and caring for adolescents.
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    Physical and mental health challenges of migrant female head porters (Kayayei) in Ghana: guidelines for health promotion interventions.
    (2021) Komesuor, Joyce.; Meyer -Weitz, Anna.
    Background: While internal migrants (Kayayei) in Ghana have been perceived as a vulnerable group faced with mental and physical health challenges, there has not been enough research on the impact of the trade on their health. Grounded on the broad bioecological framework of Bronfenbrenner and Morris, this study investigated the lived experiences, prevalence of physical and mental health challenges, risk factors for mental health challenges, protective factors that mitigate the effects of the daily lived experiences on mental health. Methods: The study adopted a sequential exploratory mixed method design whereby qualitative data were collected and analysed first to get in-depth understanding of the physical and mental health of Kayayei, followed by the quantitative survey. For the qualitative study, the study employed a purposive sampling technique to select 31 Kayayei from the Agbogbloshie market. The study utilised Interpretive Phenomenology Analysis (IPA) to analyse the transcripts from the qualitative study interviews. The quantitative aspect of the study undertook a cross-sectional survey using an interviewer-administered questionnaire to collect data from 352 participants. On the other hand, the quantitative study used exploratory factor analysis, Chi-Square test, mean test, and binary logistic regression for the analysis. Results: Results for the qualitative study showed that the main reasons for migrating to Accra are economic and cultural restrictions and oppression. The findings also revealed that the Kayayei were often maltreated, lacked decent accommodation, and were involved in accidents. To cope with the situation, they used religion, social support, and distractions such as entertainment. The quantitative results indicated that participants had low level of education. Only 6.2 per cent (n=21) had Senior High education, and the majority suffered from poor physical (59.9%) and mental health, [anxiety a94.4 per cent, followed by depression 86.6 per cent, and stress at 42.4 per cent] challenges. The difficult nature of their work context coupled with maltreatment by their clients contributed to poor mental health outcomes. The results showed participants adopted various coping strategies to deal with their situation. However, apart from humour, which helped mitigate stress (OR=0.358, 95% CI=0.169, 0.757, p= 0 007), all other coping strategies used by the Kayayei increased mental health distress. The use of denial coping strategy predicted depression (95% CI=2.428, 27.038, p=0.001), stress (95% CI=0.988, 3.323, p=0.005, p=0.005), and anxiety (95% CI= 2.37, 54.088, p= 0.002). The results also showed that participants received low to medium social support overall, while support from family and friends helped mitigate mental health distress. Conclusion: The results of the present study indicated that even though the work of Kayayei exposes them to physical and mental health challenges, the coping strategies they adopt create more rather than less mental health concerns. However, social support from family and friends helped to buffer the impact of the challenges. The findings of the present study were used to develop a multilevel prevention intervention aimed at training the Kayayei on the appropriate coping strategies to adopt to improve mental health outcomes. It is recommended that at the personal level, the Kayayei should have access to psychological counselling that will teach them how to adopt better coping strategies that could enhance their mental health outcomes. At the interpersonal level, the Kayayei should be assisted to form cooperatives that could facilitate social networks, proper integration, and social support for its members. At the structural level, relevant governmental and non-profit organisations should address the determinants of health including access to physical and mental health care services, employment opportunities, skills training, and affordable housing for the Kayayei. Finally, there should be structural change and interventions that target the mental health of the vulnerable in society, particularly women.
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    Let’s talk about pre-exposure prophylaxis: a participatory HIV prevention intervention with and for female sex workers in Durban, South Africa.
    (2021) Makhakhe, Nosipho Faith.; Sliep, Yvonne.; Meyer-Weitz, Anna.
    Introduction: Since the discovery of HIV/AIDS in the early 1980s, scientists have been in search of a cure. Significant scientific efforts have so far led to the discovery of antiretroviral treatment that suppresses the replication of HIV that leads to AIDS. Recently, Tenofovir or Tenofovir-emtricitabine as antiretroviral treatment for HIV-positive persons can now be used as prevention in the form of oral pre-exposure prophylaxis (PrEP). This HIV prevention therapy is currently being administered to people considered at high risk of HIV, such as men who have sex with men, intravenous drug users and serodiscordant couples. In 2015, the WHO expanded its oral PrEP guidelines to include female sex workers (FSWs) who are a high-risk group for HIV worldwide. In response to these WHO guidelines, the South African government approved oral PrEP distribution among FSWs in 2016, as part of combination prevention with the expectation that FSWs would take up PrEP and this will reduce the rate of new HIV infections. However, the response to PrEP was underwhelming. Identifying the reasons for the low uptake of PrEP among FSWs is the primary objective of this study. This was followed with engaging FSW peer educators in a participatory intervention mapping process to design an intervention plan to address these challenges to uptake and potentially inform PrEP programming in Durban in the KwaZulu-Natal province which is a high HIV prevalence area in South Africa. Methods: This study was a participatory action intervention research that was conducted in two phases. The first phase was a qualitative needs analysis conducted from May to November 2018 to identify the challenges associated with PrEP uptake and retention, as well as to ascertain the motivating factors for PrEP use among FSWs. Interviews were conducted with 39 participants, 30 individual participants, and nine focus group participants. Eleven participants were FSW peer educators including one health worker and one researcher from sex work and PrEP distributing organisations (13 in total); the rest of the participants were FSWs (n=26). Consent was obtained from all participants. Data were analysed thematically. The second phase of this study was an intervention mapping phase during which a PrEP intervention plan was developed with eight FSW peer educators who were at the forefront of PrEP promotion among FSWs. This intervention plan was informed by data obtained from the needs analysis. A total of six meetings took place in which the individual, interpersonal and environmental determinants that have an impact on PrEP uptake, adherence, and retention were discussed. This resulted in the performance and change objectives, including a theory of change logic framework that systematically depicted the process of change. Furthermore, theory-based methods and activities were established which culminated into a PrEP intervention workshop programme. Additionally, the implementation and evaluation plans were also formulated. Results: The needs analysis showed that the majority of the participants could not distinguish between PrEP and antiretrovirals. This inability contributed to the stigma against PrEP. Another challenge was that distribution was fragmented with the research organisations distributing PrEP to FSWs through peer education and yet, PrEP was not well understood or promoted by health care providers from public health facilities. This resulted in the mistrust of PrEP efficacy among FSWs and delayed uptake and lessened retention. The FSWs taking PrEP were met with hostility from their friends who failed to understand that PrEP as an antiretroviral can be taken to prevent HIV. This resulted in HIV positive FSWs on antiretrovirals accusing PrEP users of deception, and HIV denialism. They also experienced similar reactions from intimate partners. These accusations were believed to arise because of lack of knowledge and competition for clients, given the preferred market for HIV-negative FSWs. PrEP users reported feeling stigmatised and thrust into interpersonal conflicts with their peers, which caused broken relationships, this led some FSWs to discontinue PrEP, while others took it secretly. The FSWs who remained on PrEP mentioned various motivating factors for adherence, such as PrEP being an empowering tool that gives them agency to prevent HIV and bodily autonomy as well as a sense of hope for the future, because HIV was no longer a consequence of sex work. The PrEP intervention mapping process which resulted in a workshop programme showed how FSWs can engage in reflexive dialogues that help promote agency, power, self-efficacy, hope and responsibility to the self and others, to encourage effective engagement in HIV prevention. Conclusion: This study recommends for a wider promotion and dissemination of PrEP through public health care facilities. This will encourage the normalisation of PrEP and curb the stigma associated with PrEP being for high-risk groups. Biomedical interventions should be coupled with behavioural strategies that engage users on the personal, interpersonal, and environmental challenges that have an impact on behavioural change. FSWs should be involved in the design and implementation of their own interventions to ensure effective approaches and to create a sense of responsibility, power and ownership. It is important for future interventions to realise that simply promoting a prevention method because it is medically effective will not warrant uptake and adherence on the part of end users; therefore, interventions need to engage with the complexity of human behaviour. This makes it imperative for practitioners to invest in understanding the patient’s deeper motivations that encourage or discourage behavioural change.
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    Policy and practice of health care waste management in community-based care in South Africa.
    (2016) Hangulu, Lydia.; Akintola, Olagoke.
    Health care waste management (HCWM) is a growing concern more especially in the low- and middle-income countries (LMICs). Improper management of health care waste (HCW) has negative effects on the environment and on the health of the people. Unfortunately, no study has been found so far that addresses policy and practice of HCWM in community-based care (CBC) in South Africa. This thesis begins to address HCWM issues through five manuscripts that use various methods and approaches to develop an understanding of HCWM in CBC. The main scripts in this thesis present: 1) a scoping review that highlights the terminologies of HCW, definitions, categories and its classifications; 2) analysis of international and national policies that govern HCW in South Africa; 3) media analysis which explains how the South African media frames the issue of HCWM; 4) results from interviews with policy makers and stakeholders regarding their opinions on the practices of HCW in CBC; 5) results from focus group discussions, informal interviews and participant observations from the community health workers (CHWs) indicating their experiences about HCWM practices. This study is the first to be conducted in CBC. The methodologies used in this study provide useful insights into HCWM and the findings are an addition to the body of literature on HCWM in CBC, environmental health and public health.