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    Host immune responses to plasmodium berhei ANKA and trichinella Zimbabwenisis infection in balb/c mice.
    (2015) Nyamongo, Onkoba Wycliffe.; Chimbari, Moses John.; Mukaratirwa, Samson.
    Four objectives were pursued in this study; (i) metabolic and adaptive immune responses induced in BALB/c mice infected with a tissue-dwelling nematode, Trichinella zimbabwensis were measured, (ii) differential cytokine and antibody responses induced in mice infected with T. zimbabwensis were determined, (iii) cytokines, anti-Trichinella and anti-Plasmodium antibody responses in mice mono- and co-infected with Trichinella zimbabwensis and Plasmodium berghei ANKA were determined and (iv) the effect of antihelminthic treatment against T. zimbabwensis on immunity and malaria disease outcomes was determined. Groups of BALB/c mice were mono- or co-infected with a crocodilederived T. zimbabwensis (Code 1SS1209) and P. berghei ANKA parasites. At various time points, metabolic parameters such as levels of water and food intake, glucose and insulin were measured. Cytokine and antibody responses were also measured by ELISA. Parasite burden and survival rates were used to determine malaria disease outcomes. The results showed that primary T. zimbabwensis infection was characterised by significantly elevated levels of insulin (p < 0.001) that were accompanied with hypophagia, weight loss, altered host compensatory feeding mechanisms. Parasite specific antibodies and Th1/Th2/Th17 and T-regulatory immune responses were elevated. In co-infection, it was observed that T. zimbabwensis induced immunomodulation that conferred protection against Plasmodium growth and early death. Anti-helminthic treatment enhanced antibody and cytokine production in mono- and co-infection mice (p < 0.001) and negatively affected malaria parasite multiplication by improving survivorship of co-infected mice by 42.85% (p < 0.001). From the study, it was concluded that T. zimbabwensis parasites induce mixed Th1/Th2/Th17 immune responses, alter host glucose metabolism and trigger immunomodulation that ameliorated malaria disease outcome. Anti-helminthic treatment acted as an immunomodulator for cytokine and antibody production, ameliorated malaria infection and improved survivorship of co-infected mice. The study shows that malaria coinfection with T. zimbabwensis and anti-helminthic treatment improves survival, enhances immunity and ameliorates malaria. It further shows that deworming may be used as an integrated control measure in areas where malaria and helminths are co-endemic.
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    Acceptability and effectiveness of rapid ART initiation: patients’ and healthcare workers’ perspectives.
    (2022) Govere, Sabina May.; Chimbari, Moses John.
    The Joint United Nations Programme on HIV/AIDS is leading the global effort to end AIDS as a public health threat by 2030. In achieving these goals, emphasis has been on the 95–95–95 targets that by 2030, 95% of people living with HIV know their HIV status. However, the focus is on achieving the second 95 and third 95; having 95% of people diagnosed with HIV initiating on treatment within the expected timeframe and 95% of those on treatment obtaining a suppressed viral load. Commendable efforts have been made in increasing HIV testing numbers however, same day initiation on treatment and achieving viral load suppression remains a challenge. According to the WHO recommendations; same day (ART) initiation should be offered to all people living with HIV following a confirmed diagnosis. This study determined the factors influencing the acceptability and implementation of Universal Test and Treat by both patients and healthcare workers. Universal Test and Treat is a prevention strategy encourages that if a person tests HIV positive, irrespective of the persons CD4 count and clinical staging at the time of testing they will have to begin treatment immediately. Furthermore, patient’s clinical outcomes following test and treat in eThekwini municipality in KwaZulu-Natal were determined. This study was cross-sectional and used prospective - mixed methodology to collect data from 403 patients who either accepted or deferred same day ART initiation from June 2020 to May 2021. A structured questionnaire was used to collect demographic information, sexual behaviour, acceptance of same day ART initiation and knowledge of Universal Test and Treat on the day of HIV diagnosis. Key informant in-depth interviews were conducted with healthcare workers and patients were followed up at 6 months after HIV diagnosis to determine clinical outcomes for both groups, rapid and deferred ART initiators using medical charts and electronic databases. Two different analysis univariate and multivariate logistic regression were performed to examine associations between same day ART initiation and several explanatory factors. Logistic regression was performed to examine associations between same day ART initiation and several explanatory factors, retention in care, clinical outcomes and facility related factors. Thematic analysis was used to assess experiences, knowledge and observations of healthcare workers in implementing the Universal Test and Treat policy. Among the 403 participants same-day initiation was 69.2% (n=279). In an adjusted analysis (age, gender, level of education were adjusted at 0.5 significance level in univariate level) number of sexual partners (aOR: 0.35; 95% CI: 0.15-0.81), HIV status of the partner (aOR: 5.03; 95% CI: 2.74-9.26), knowledge of universal test and treat (aOR: 1.97; 95% CI: 1.34-2.90), support from non-governmental organizations (chi-square = 10.18; p-value= 0.015 and provision of clinic staff (chi-square = 7.51; p value = 0.006) were identified as major factors influencing uptake of same-day ART initiation. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002–2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07–4.061), age (OR: 0.941; 95% CI: 0.734–2.791), ART start date (OR: 0.078; 95% CI: 0.042–0.141) and partner HIV status (OR: 0.621; 95% CI: 0.387–0.995) were significantly associated with viral load detection and retention in care. (All variables that were significant at e.g. 0.5 level in univariate). Our results suggest a steady increase in uptake of same day ART initiation with poor retention in care. The results also emphasise a vital need to not only streamline processes to increase immediate ART uptake further but also ensure retention in care in order to meet the 95-95-95 targets. The findings of the study contribute to knowledge useful for strengthening rapid ART initiation implementation by considering individual patient factors, healthcare workers’ perspectives and facility level factors. The qualitative findings revealed variations in UTT knowledge, experiences and observations among diverse healthcare workers from the four clinics in different geographical settings. While training on UTT and SDI of ART initiation was conducted at the inception of the implementation phase, the understanding and interpretation varied especially between clinicians and non-clinical healthcare providers. Denial, feeling healthy, fear of disclosure, limited knowledge about ART, fear of ART side effects, fear of stigma and discrimination were some of the factors HCW observed as hindering uptake of SDI. These findings relate to some of the reasons given by patients with fear of disclosure frequently mentioned by those who deferred SDI of ART.
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    Non-communicable diseases among people living with HIV at Chitungwiza central hospital in Zimbabwe.
    (2022) Cheza, Alexander May.; Tlou , Boikhutso.
    Background The incidence of non-communicable diseases (NCDs) has been reported to be on the rise in the years preceding 2010. Over the years, NCDs have become a global public health burden and a leading cause of premature death, mainly in low to middle-income countries (LMICs). Additionally, sub-Saharan Africa has shown a rise in morbidity and mortality due to NCDs. In Zimbabwe, only a few studies have been conducted to examine the incidence of NCDs in people living with HIV (PLHIV). The study objectives included determining the incidence of NCDs in PLHIV on ART over a ten-year period and the associated risk factors. Furthermore, the study explored physicians’ perceptions on the availability and quality of clinical care for the management of NCDs, in addition to evaluating the knowledge and perceptions of PLHIV towards NCDs. Methods The study encompassed a mixed methods approach using both quantitative and qualitative methods. The thesis is based on three different articles each built from a different study design. Reliability of the questionnaire and the data collection sheet were determined by calculating the Cronbach alpha which exceeded 0.8 in both cases. In addition validity of the tools went through a panel of experts before being approved and also pilot studies were conducted to validate the tools before actual data collection. The title of the first article was: Incidence of non-communicable diseases (NCDs) in HIV patients on ART in a developing country: Case of Zimbabwe’s Chitungwiza Central Hospital—A retrospective cohort study (2010–2019) and it addresses the first two objectives of the thesis. This was a retrospective analysis of data from ongoing longitudinal population-based cohorts from Chitungwiza Central Hospital (CCH) in Zimbabwe, focusing on PLHIV receiving antiretroviral therapy (ART) at the opportunistic infections clinic (OIC) housed at CCH, covering the period 2010-2019. This was crucial for long-term follow-ups and determining the associated risk factors. The intention was to first establish the incidence of NCDs in PLHIV, as well as the association of the incidence with several factors such as age, geographic location of residence of the study participants and their gender. The incidences of NCDs namely cancers, cardiovascular diseases, diabetes mellitus and hypertension were determined and generalized estimating equations (GEE) were used to estimate the association between NCDs and the selected risk factors. Article 2 which addresses objective 3 was published in the Globalization and Health Journal and was entitled: A qualitative exploratory study of selected physicians’ perceptions of the management of non-communicable diseases at a referral hospital in Zimbabwe. This was a qualitative exploratory study meant to obtain expert perceptions of care delivery for NCDs in one Zimbabwean referral hospital setting. Data was collected from participants who consented. A four-point Likert scale was used to categorize different levels of perceived satisfaction and analysis was done using Stata version 13. The third article making up the thesis and addresses objective 4 is entitled: Knowledge and Perceptions about Non-Communicable Diseases by people living with HIV: A descriptive cross-sectional study from Chitungwiza Central Hospital Zimbabwe. The article has been accepted by the African Health Sciences Journal and is pending publication. This was a cross-sectional explanatory study using a mixed methods approach to describe-the participants’ responses. The study explores and descriptively documents the perceptions and knowledge of PLHIV on their exposure to the NCDs burden. Results Data collected at the study’s baseline (2010) showed that the most prevalent NCD was hypertension, found in 8.9% (18/203) of the study participants, followed by diabetes (6.9%), then cardiovascular diseases (CVD) (3.9%). The least common NCD was cancer (1.9%). Incidences of all of these NCDs showed an increasing trend as the time of follow-up progressed. The associated risk factors found to be significantly associated with the development of NCDs were gender, with females being 2 times more likely than males to develop NCD (p = 0.002) and follow-up time (p<0.001). Moreover, geographical location was a significant risk factor as urban patients were more likely to develop hypertension as compared to peri-urban patients (p = 0.001). Nineteen of the doctors were general practitioners, whilst four were specialists. The findings indicated that both general and specialists perceived some shortfalls in clinical care for NCDs. Moreover, the perceptions of general practitioners and specialists were not significantly different. Doctors perceived cancer care to be lagging far behind the other three NCDs under study. Care for cardiovascular diseases (CVDs) and diabetes showed mixed perceptions amongst participants, with positive perceptions almost equalling negative perceptions. Furthermore, hypertension was perceived to be clinically cared for better than the other NCDs under study. Reasons for the gaps in NCD clinical care were attributed by 33% of the participants to financial challenges; a further 27% to patient behavioural challenges; and 21% to communication challenges. The study also found a moderately good level of knowledge (65%) and very high levels of positive perceptions (81%) on NCDs. Participants <40 years of age were more knowledgeable (p=0.003) and a history of NCD in the family had a positive influence on knowledge (p=0.001). Females showed a more positive perception (p=0.043), whilst both increasing age and low education negatively impacted perceptions (p<0.001) as well as knowledge (p=0.020). Conclusion The study concluded that NCDs and HIV comorbidity is common with women, who are more likely than men to develop NCDs as they advance in age. There is need to devise targeted intervention approaches to the respective NCDs and risk factors since they diversely affect people with different demographic characteristics. Moreover, the care delivery for the selected NCDs under study at CCH need to be improved. It is crucial to diagnose NCDs before patients show clinical symptoms. This helps disease prognosis to yield better care results. The evaluation of doctors’ perceptions indicates the need to improve NCD care at CCH in order to control NCD co-morbidities that may increase mortality. Patients’ knowledge and perceptions were moderately high but reduced with decreasing levels of education and increasing age. The study recommends educational campaigns to disseminate information about NCDs in PLHIV, targeting the least educated population groups and those older than 40 years of age.
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    Contraceptive use among adolescent girls in Zambia: a study on adolescents’ needs, preferences and perspectives on contraception methods=Ukusetshenziswa kwezivimbelakukhulelwa ngamantombazane angamatshitshi eZambia: Ucwaningo ngezidingo zamatshitshi, okukhethwayo nemibomo kwezindlela zezivimbelakukhulelwa.
    (2023) Chola, Mumbi.; Ginindza, Themba Geoffrey.; Hlongwana, Khumbulani Welcome.
    The fertility rate in Africa is among the highest in the world, and this trend is projected to continue unless drastic interventions are put in place to avert the situation. Contraceptive use among adolescents in sub-Saharan Africa remains very low despite various interventions to improve the uptake. The study aimed to examine the key determinants of contraceptive use among adolescent girls in Zambia; specifically, i) examining patterns, trends and factors that drive poor usage of contraceptives; ii) exploring the motivators and influencers of decision-making regarding contraceptive use among adolescent girls; and finally, iii) understanding their perspectives on existing contraceptive methods. The study examined patterns, trends and factors associated with contraceptive use among adolescents in Zambia, using data from 1996, 2001/2, 2007 and 2013/14 Zambia Demographic and Health Surveys. Qualitative data was collected through focus group discussions and analysed using thematic analysis. Permission to conduct the study was obtained from the Ministry of Health and the National Health Research Authority. Ethical approvals were provided by the Biomedical Research Ethics Committees (BRECs) of the University of Zambia and the University of KwaZulu-Natal in South Africa. Results revealed that contraceptive use among adolescent girls in Zambia remained low over the 18 years and increased by only 3%, particularly among younger, uneducated, and unmarried sexually active adolescent girls. Marriage or living with a partner contributed the most to the change in contraceptive use (44%), while living in a rural area accounted for approximately 20%. Adolescent girls' experience with contraceptives was affected by various factors such as knowledge of contraceptives, including sources of information and contraceptives, experience with using contraceptives, challenges with access to contraceptives, and misconceptions about contraceptives. The interaction of factors related to their personal experience, their community and the environment in which they access contraceptive services all contribute to the overall patient experience and influence the adolescent girls’ contraceptive decision. Most of the motivators for the use and/or non-use of contraceptives are intrapersonal and interpersonal. Contraceptive use among adolescent girls remains low and is determined by various factors. Key influencers and motivators for contraceptive use involve people in their lives, such as partners, family and community members. Interventions targeting increasing demand, access and use of contraceptives among adolescents must be innovative, participatory and implemented within the context of local cultural norms. IQOQA Izinga lokuvunda e-Afrika libalelwa kweliphezulu emhlabeni wonke, futhi le nkombamvama ihlelelwe ukuqhubeka ngaphandle uma kunokungenelela okunamandla okumele kufakwe ukuze kugwenywe isimo. Izimvimbelakukhulelwa ezisetshenziswa phakathi kwamatshitshi ase-Saharan Africa ziyohlala ziphansi ngale kokungenelela okwahlukene ukuze kuthuthukiswe lokho okukhona okuzosetshenziswa. Ucwaningo lwaluhlose ukuhlola izinkombamthelela ezisemqoka zokusetshenziswa kwezivimbelakukhulelwa phakathi kwamantombazane eZambia; ngokucacile i) ukuhlola izinhlelo, izinkombamvama noma izinto eziqhuba ukusetshenziswa kabi kwezivimbelakukhulelwa; ii) ukuhlola abagqugquzeli nabanomthelela ekuthathweni kwezinqumo ezimayelana nokusetshenziswa kwezivimbelakukhulelwa phakathi kwamantombazane angamatshitshi; ekugcineni, iii) ukuqonda imicabango yabo mayelana nezindlela ezikhona zezivimbelakukhulelwa. Ucwaningo lwahlola izinhlelo, izinkombamvama nezici ezihlobene nezivimbelakukhulelwa ezisetshenziswa phakathi kwamantombazane eZambia, lusebenzisa imininingo esukela onyakeni wowe-1996, 2001/2, 2007 kanye nowezi-2013/14 eZambia Demographic and Health Surveys. Kwaqoqwa imininingo yocwaningo lobunjalo botho kugxilwe ezingxoxweni zeqoqo okwakucwaningwa ngalo lahlaziywa kusetshenziswa uhlaziyongqikithi. Imvume yokwenza ucwaningo yatholakala kuNgqongqoshe WeZempilo kanye NeZiphathimandla Zocwaningo LweZempilo KuZwelonke. Isiqinisekiso SeNqubonhle sanikezelwa Amakomidi eBiomedical Research Ethics (BRECs) aseNyuvesi yaseZambia kanye neNyuvesi YakwaZulu-Natali eNingizimu Afrika. Imiphumela yocwaningo yaveza ukuthi ukusetshenziswa kwezivimbelakukhulelwa phakathi kwamantombazane angamatshitshi aseZambia kwahlala kuphansi esikhathini esingaphezu kweminyaka eyi-18 kwase kukhula ngama-3%, kwabancane, abangafundile kanye nakumantombazane abangamatshitshi angaganile kodwa alwenzayo ucansi. Umshado noma ukuhlala nomlingani wakho kube neqhaza elikhulu ezinguqukweni ezisetshenziswayo zokuvimbela ukukhulelwa (44%), ngenkathi ukuhlala endaweni yasemakhaya kubalelwa esilinganisweni esingama-20%. Lokho amantombazane asengamatshitshi aseke edlula kukho mayelana nokusetshenziswa kwezivimbelakukhulelwa kwaphazanyiswa yizinto eziningi njengolwazi lwezivimbelakukhulelwa kubandakanya nemithombo yolwazi nezivimbelakukhulelwa, odlula kukho uma usebenzisa izivikelakukhelwa, izingqinamaba zokusebenzisa izivimbelakukhulelwa kanye nemibono engemihle ngezivimbelakukhulelwa. Ukuxhumanakunikezelana kwezinto ezihlobene kulokho umuntu nomuntu adlule kukho, umphakathi wabantu kanye nendawo lapho abakwazi ukuthola khona izivimbelakukhulelwa konke kunomthelela kukho lokho isiguli esedlule kukho nalokho okuthinta izinqumo zokuvimbela ukukhulelwa ezithathwa ngamantombazane angamatshitshi. Abagqugquzeli abaningi bokusetshenziswa nokungasetshenziswa kwezivimbelakukhulelwa banobudlelwane bomuntu kanye nobudlelwane kubantu. Ukusetshenziswa kwezivimbelakukhulelwa amantombazane angamatshitshi kuhlale kuphansi futhi lokhu kudalwa yizinto ezahlukene. Abagqugquzeli nabakhuthaza ukusetshenziswa kwezivikelakukhulelwa basemqoka kufaka abantu ezimpilweni zabo, njengabalingani, umndeni namalunga omphakathi. Ukungenelela okuqonde ekukhuliseni isidingo, ukufinyelela nokusetshenziswa kwezivimbelakukhulelwa phakathi kwamatshitshi kumele kufake izindlela ezintsha, kubambe iqhaza futhi kuqaliswe engqikithini yenkambisonqubo yokuyisiko endaweni.
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    The effects of a lung cancer awareness intervention in KwaZulu-Natal (KZN): a stratified cluster based study in five representative communities=Imithelela yokungenelela ngokuqwashisa mayelana nomdlavuza wamaphaphu KwaZulu-Natali (KZN):Ucwaningo lwamaqoqo ngokohlelomikhakha emiphakathini emihlanu eqokelwe ucwaningo.
    (2022) Dlamini, Siyabonga Blessing.; Ginindza, Bonginkosi Mfundza.
    Abstract Background Lung cancer is the leading cause of cancer mortality worldwide, accounting for approximately 1.8 million cancer deaths in 2020. In South Africa, lung cancer is among the top four ranking cancers in terms of morbidity and mortality after breast, prostate, and cervical cancers. The objective of the study was, therefore, to investigate the level of awareness about lung cancer and its screening among communities in KZN, in an attempt to increase awareness of this disease across the province. Methodology A quasi-experiment study was conducted among the selected communities in KZN. In total, forty out of 879 clusters were selected, where a comparison between two cross-sectional surveys was done. An intervention employing community health workers aimed at raising awareness of lung cancer was developed, implemented and evaluated in these communities. A binary logistic regression model was used to measure the effects of the intervention. Results At baseline, approximately 59.9% (95% CI 52.0 - 67.3) of the participants had heard of lung cancer. About 5.7% (95% CI 3.9 - 8.1) were screened for lung cancer at the time. Coughing up blood was the most recognised symptom (61.0%, 95% CI 52.1 - 69.1). Post-intervention, the mean knowledge score increased to 59.9 (95% CI 53.8 – 66.0) (p<0.001). There was a reduction in the number of cigarettes smoked per day (p<0.001) and the number of packs smoked per week (p=0.026). However, the prevalence of smoking remained relatively the same before and after the intervention, at approximately 18% (p=0.958). The intervention had a statistically significant effect (aOR 4.370, 95% CI 1.477-12.928) on lung cancer knowledge in these communities (p<0.001). Conclusion The intervention in this study demonstrated the ability to raise awareness of lung cancer at a community level. It also reduced the number of cigarettes smoked among smokers. Therefore, integration into smoking cessation programmes should be explored. A national lung cancer screening programme should be introduced to encourage health-seeking behaviour. The integration of a lung cancer awareness intervention into the already existing community health worker programmes, such as the tuberculosis response strategy, is recommended. Iqoqa Isendlalelo Umdlavuza wamaphaphu ungenye yezimbangela eziphambili zokubulawa umdlavuza emhlabeni wonke jikelele. Kubantu ababulawa umdlavuza ngonyaka wezi-2020, bayi-1.8 wezigidi zabantu ababulawa umdlavuza wamaphaphu. ENingizimu Afrika umdlavuza wamaphaphu ungolunye lwezinhlobo ezine zomdlavuza ezihamba phambili eziphatha abantu futhi zibabulale emva komdlavuza webele, umdlavuza wamankwahlwa (iprostate), kanye nowesibeletho. Inhloso yalolu cwaningo kwakunguphenya ngamazinga olwazi mayelana nomdlavuza wamaphaphu kanye nokuhlolwa kwawo emiphakathini yaKwaZulu-Natali ngenjongo yokuqwashisa kabanzi ngalesi sifo esifundazweni jikelele. Indlelakwenza Kwenziwa ucwaningo oluyisingalinge emiphakathini eqokelwe ucwaningo KwaZulu-Natali. Esewonke kwakhethwa amaqoqwana angama-879 lapho kwaqhathaniswa khona amasaveyi amabili across-sectional. Kwathuthukiswa, kwasetshenziswa kwaphinda kwahlolwa ukungenelela konompilo ngenhloso yokuqwashisa ngomdlavuza wamaphaphu kule miphakathi. Kwasetshenziswa imodeli yesilinganisobudlelwane ukulinganisa imithelela yalokhu kungenelela. Imiphumela Ukusuka phansi, bangacishe babe ngama-59.9% (95% CI 52.0 - 67.3)kubabambiqhaza abake bezwa ngomdlavuza wamaphaphu. Okungenani u-5.7% (95% CI 3.9 - 8.1) wahlolwa umdlavuza wamaphaphu ngaleso sikhathi. Ukukhwehlela igazi yikhona okwakuyinkomba eyaziwayo (61.0%, 95% CI 52.1 - 69.1). Emva kokungenelela, imini yobungako bolwazi yanyukela ku-59.9% (95% CI 53.8 – 66.0) (p<0.001). Kwaba nokuncipha kwesibalo sosikilidi ababhenywa ngosuku (p<0.001) kanye namaphakethe abhenywa ngesonto (p=0.026). Kodwa-ke, ukuvama kokubhema akuzange kwehle ngaphambi kanye nasemuva kokungenelela; kwakumi ku-18% (p=0.958). Ukungenelela kwaba nomthelela omkhulu ngokwezibalomidanti (aOR 4.370, 95% CI 1.477-12.928)maqondana nolwazi ngomdlavuza wamaphaphu kule miphakathi (p<0.001). Isiphetho Ukungenelela kulolu cwaningo kwakhombisa okungenzeka uma kuqwashiswa abantu ngomdlavuza wamaphaphu ezigabeni semiphakathi. Kwaphinda kwanciphisa isibalo sikasikilidi obhenywayo kubantu ababhemayo. Ngakho-ke kumele kuhlolwe izindlela zokuhlanganiswa kwezinhlelo zokuyekiswa ukubhema. Kumele kuqaliswe ngohlelo lukazwelonke lokuhlola umdlavuza wamaphaphu kubantu ukuze kukhuthazwe umkhuba wokufuna usizo lwezempilo. Kuphakanyiswa ukuthi kuhlanganiswe ukungenelela ngokuqwashisa abantu ngomdlavuza wamaphaphu ezinhlelweni zonompilo ezikhona emiphakathini ezifana namaqhinga okuhlangabezana nesifo sofuba.
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    Effective coverage of emergency obstetric and newborn care services in Wolaita Zone, Southern Ethiopia.
    (2023) Arba, Mihiretu Alemayehu.; Khuzwayo, Nelisiwe.; Yota, Bereket Yakob.
    Background: Despite the significant improvement in the availability and access of facilities in low and middle-income countries, a considerable burden of maternal and child morbidity and mortality exists, further suggesting the need for effective coverage of EmONC services. Understanding the extent to which the health system delivers quality service and the factors that predict the gap in providing the services are vital to evidence-based decisions at the local, national, and global levels. However, evidence is lacking on the effective coverage of EmONC services and factors influencing quality service provision. Objective: This study aimed to understand, explore, and describe the contexts, correlates, and levels of effective coverage of EmONC services in the Wolaita Zone, southern Ethiopia, and develop a model for effective coverage of EmONC services. Methods: After mapping the evidence for effective coverage of EmONC services in Africa, the study employed an explanatory sequential mixed-method approach. The quantitative study applied a cross148 sectional design, including 414 (facility-based survey) and 402 (house-to-house survey) study participants. The quantitative data were collected using an Open Data Kit (ODK) tablet phone software and exported to Stata version 17 for analysis. Simple and multiple linear regressions, along with p151 values, coefficients, and 95% confidence intervals, were used to declare the statistical significance and strength of the association. The qualitative study employed a case-study research design including 37 participants (selected using maximum variation sampling) to explore the barriers and enablers of EmONC services utilization. The coding and thematic analysis of the qualitative study were assisted by NVIVO version 12 software. The qualitative study assured trustworthiness by establishing credibility, transferability, conformability, and dependability. Result: The scoping review showed a paucity of evidence on the effective coverage of EmONC services in Africa. It also provided a summary of existing evidence on the crude coverage, quality of EmONC services assessed through diverse indicators, and factors linked with the quality of EmONC services. The household survey identified 72.1% crude coverage of EmONC services. The facility-based survey of EmONC services revealed that the indices of structural, process, and output quality were 74.2%, 69.4%, and 79.6%, respectively. Overall, 59.2% of women with EmONC service-need received poor quality services. Women’s education grade 1–8 (B=5.35, 95% C.I: 0.56, 10.14), and grade 9–12 viii (B=8.38, 95% C.I: 2.92, 13.85), age (B= 3.86, 95% C.I: 0.39, 7.33), length of stay at health facility (B= 3.58, 95% C.I: 2.66, 4.9), crowding in the delivery room (B= -4.14, 95% C.I: -6.14, -2.13), and health professional’s experience (B= 1.26, 95% C.I: 0.83, 1.69) were statistically significant predictors of observed EmONC service quality. Overall, the effective coverage (the crude coverage adjusted by the observed quality of care) of EmONC services in the Wolaita Zone was 50%, indicating half of the potential health gain loss in EmONC services. The qualitative study of barriers and facilitators of EmONC services utilization identified five themes that interacted at different levels. Theme one was women’s perceptions and experiences with EmONC services, including their knowledge and awareness of the availability of services, perception of the quality of care, reputation, respectful care, and care providers’ gender. Theme two was community-related factors encompassing misconceptions, traditional management of obstetric complications, the role of traditional birth attendants, and family and peer influence on EmONC services utilization. Theme three was the accessibility and availability of EmONC services, including infrastructure and delays in transportation. Theme four was healthcare financing which focused on drugs and supplies, out-of-pocket expenses, and service fee exemption. Theme five was the health facility-related factors related to the care provider, referral system, waiting time, and leadership. Conclusion: The study showed that the effective coverage of EmONC services in the Wolaita Zone (Southern Ethiopia) was low, where half of the potential health gain was lost due to barriers centered on the women, community, access and accessibility, healthcare financing, and health facility linked factors. The quality of EmONC services was sub-optimal, where women and newborns received inadequate services, and the care providers poorly adhered to the standard clinical actions. The study also underlined that the care providers’ adherence to the standard clinical actions was poor and is significantly associated with the age and education of women, length of stay in the facility, crowding of the delivery room, and health professionals’ experience. The inequitable effective coverage of EmONC services implied loose emphasis and suggested an urgent need for the health system’s intervention. Therefore, interventions directed at the identified bottlenecks can improve the utilization and quality of care, ultimately enhancing effective coverage. Furthermore, the model developed by the study can be utilized to enhance maternal and newborn health.
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    Barriers and facilitators to the implementation of the collaborative framework for the care and control of tuberculosis and diabetes in Ghana.
    (2021) Salifu, Rita Suhuyini.; Hlongwana, Khumbulani Welcome.
    Background: The rising tuberculosis -diabetes mellitus co-epidemic is threatening the advances made by global policy to reduce tuberculosis and diabetes mellitus prevalence. In 2011, the World Health Organization (WHO) and International Union Against Lung Disease (Union) launched the Collaborative Framework for Care and Control of Tuberculosis and Diabetes. The recommendations provided by the framework have been adopted by many countries, globally. The overall aim of this research was to explore the barriers and facilitators to the implementation of the WHO-Union collaborative framework in Ghana, from the perspectives of the policymakers, program managers, health facility managers, and front-line implementers (healthcare workers). Methods: Using an explorative qualitative study design, data was generated by employing a scoping review, documents review, in-depth interviews, and non-participant observation. In-depth interviews were conducted with 27 participants from Accra and Tamale in Ghana. All interviews were audio recorded (with participants’ permission) and transcribed verbatim, except for two interviews, whereby participants requested the interview not to be audio-recorded. Non-participant observation was guided by a checklist of sensitising concepts. Analysis was guided by the grounded theory to identify recurrent ideas which were coded and further grouped to develop themes. Results: This thesis presents key findings from research on the implementation of the framework in Ghana. The major outputs of this study included: 1) a scoping review to map evidence on the implementation of the framework, globally. 2) paper one examines the systems and structures in place for implementing the collaboration of TB-DM management in the selected health facilities. 3) paper two explores the mechanisms of collaboration between the National Tuberculosis Control Program and the Non-Communicable Disease Control Program at the national, regional, and local (health facility) levels of the health care system. 4) paper three addresses the experiences of frontline healthcare workers through the lens of Lipsky’s theoretical framework of street-level bureaucracy. Conclusion: The findings of this research support the implementation of the framework in Ghana. This has been enhanced by the increased staff capacity and institutionalization of screening. However, gaps still exist which require increased awareness about TB-DM comorbidity, and increased support for inservice training to curb the rising TB-DM comorbidity.
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    Factors influencing contraceptive use and sexual behaviour among women of reproductive age in Umlazi township, KwaZulu-Natal province, South Africa.
    (2021) Hlongwa, Mbuzeleni Ndabayakhe.; Hlongwana, Khumbulani Welcome.
    Access to safe and effective contraceptive methods is one of the cornerstones of reproductive health, worldwide. However, the degree to which women manage various aspects of their sexual lives, including the prevention of unplanned or unwanted pregnancies, infant and maternal mortality, and exposure to HIV and AIDS, continues to raise questions relating to health promotion concerns. Despite the implementation of various government interventions, unplanned pregnancies, termination of pregnancies, and maternal mortality remain relatively high in South Africa. While HIV infection has been well documented in South Africa, the risky sexual behaviour of South Africans remains a concern. The aim of this study was to examine the factors that influence contraceptive use and sexual behaviour among women of reproductive age in Umlazi Township, KwaZulu-Natal Province, South Africa. The specific research objectives were as follows: 1. To map evidence on factors influencing contraceptive use and sexual behaviour in South Africa through a systematic scoping review. 2. To determine the proportion of women of reproductive age using contraceptives in Umlazi Township, KwaZulu-Natal, South Africa. 3. To examine women’s knowledge of different contraceptive methods in Umlazi Township, KwaZulu-Natal province, South Africa. 4. To determine contraceptive methods used by women in Umlazi Township, KwaZulu- Natal province, South Africa. 5. To identify factors influencing contraceptive use and sexual behaviour among women of reproductive age in Umlazi Township, both from a user and provider perspective. 6. To explore the experiences of women of reproductive age regarding contraceptive use and risky sexual behaviours in Umlazi Township, South Africa. Methods The was a mixed-methods study, which utilised primary level data to answer objectives two to six. A systematic scoping review was conducted to address the first study objective. The study was conducted in a clinic-based setting among women of reproductive age in Umlazi Township under eThekwini Municipality in KwaZulu-Natal. The healthcare providers from the selected clinics and women of reproductive age attending the selected facilities, participated in the study. For quantitative study, data were collected through a structured questionnaire, coded and entered into Epi data manager (version 4.6). Stata version 15 was used to conduct quantitative data analysis. Multivariable logistic regression model was used to assess the level of the association between the predictor and outcome variables and the p-value < 0.05 was considered statistically significant. For qualitative study, women from four primary health care facilities were recruited through a combination of convenience and criterion-based sampling techniques. Using NVivo version 11, two skilled researchers independently conducted thematic data analysis, as a mechanism for quality assurance, before the results were collated and reconciled. Results Overall, 471 eligible women and 35 healthcare workers participated in the quantitative study. Fifteen women participated in the qualitative study. The quantitative study found that more than half (51.8%) of the women were aged 18–24 years, and only a handful (18.3%) had a tertiary qualification. The majority were single (89.0%) and unemployed participants accounted for 54.0% of the total sample. This study found that women who had talked about condoms with their partner/s in the past 12 months were more likely (p=< 0.0001) to have used condoms during their last sexual intercourse. Older women (aged 35-49 years) were more likely (p=0.035) to have used a condom during their last sexual encounter, compared to their younger counterparts. However, women who were exposed to physical partner violence (hitting and/or slapping), those who had been diagnosed with HIV and those whose sexual partners were diagnosed with HIV, did not show a significant association with condom use at last sex. This study showed a high proportion (84.1%) of women using contraception in the sample. This study further indicated that women with a secondary level of education (p=0.053) or a tertiary level of education (p=0.040), were more likely to use contraceptive methods compared to women with a lower education status. Older women aged 25-49 years who experienced pregnancy, whether planned (p=0.038) or unplanned (p=0.001), were more likely to use a contraceptive method. Furthermore, more than a third of healthcare providers (37.1%) were unsure whether modern contraceptives cause users to become promiscuous, and more than half (57%) had negative attitudes toward adolescent girls exploring contraceptive methods. Poor working conditions, long queues, and contraceptive stock-outs were cited by health care providers as deterrents to providing quality sexual behaviour counselling and modern contraceptive education to users. The qualitative study found that women were concerned about unpleasant contraceptive side effects such as prolonged or irregular menstrual periods, bleeding, weight gain, and/or severe pains. Some women stopped using their preferred contraceptive method or opted for a different contraceptive method due to undesirable side effects and/or contraceptive stock outs. Women also raised concerns that they were not adequately counselled or informed on the use or potential negative effects of various contraceptive methods available at health care facilities. Furthermore, perceived negative attitudes towards young women by health care providers, long waiting times and concerns over contraceptive efficacy, contributed to reduced contraceptive uptake. Conclusion This study adds to our knowledge of women's concerns and issues related to contraception access and use in Umlazi Township, KwaZulu-Natal. This study found that numerous factors influence contraceptive use and sexual behaviour. The amount to which women engage in unprotected sexual activities highlights the urgent need for a comprehensive, integrative, and adaptive educational approach to altering women's sexual behaviours. It is vital to make concerted educational efforts to eliminate existing hurdles that prevent young women from using contraception. Family planning strategies tailored to the needs of different groups of women should be targeted, including prioritising education opportunities, given the many benefits associated with these. The availability of comprehensive counselling services to support women who are experiencing short-term side effects is critical in order to ensure that they are able to cope with side effects or switch to a different method rather than completely discontinuing contraceptive use in order to avoid unintended pregnancy.
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    The association of organizational contextual factors and HIV-Tuberculosis service integration following exposure to quality improvement interventions in primary healthcare clinics in rural KwaZulu-Natal.
    (2021) Gengiah, Santhanalakshmi.; Loveday, Marian Patricia.; Taylor, Myra.
    A key strategy to reduce Tuberculosis (TB)-related mortality among people living with HIV is integrating HIV and TB diagnostic and treatment services. In South Africa, integrated HIV-TB service provision is standard of care, however, there is evidence that patients accessing primary healthcare clinics (PHC) are missed for HIV and TB testing and screening, diagnosis, linkage to treatment, and preventive services. Gaps in the HIV-TB care cascade are indicative of weaknesses in healthcare systems at the frontline. Quality Improvement (QI) collaboratives are a widely adopted approach to facilitating improvement among multiple clinics and scaling up best practices to improve on a given health topic. Little is known of the effectiveness of QI collaboratives and less is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives to improve integrated HIV-TB services. Scaling up TB/HIV Integration (SUTHI) was a cluster-randomised trial designed to test the effectiveness of a QI intervention to enhance integrated HIV-TB services on mortality in HIV, TB, and HIV-TB patients. The study was from 01 December 2016-31 December 2018. Sixteen nurse supervisors (clusters) overseeing 40 PHC clinics were randomized (1:1) to receive either a structured QI intervention (QI group), which comprised, clinical training, three QI workshops timed at 6-month intervals, and in-person mentorship visits; or standard of care (SOC group) supervision and support for HIV-TB service delivery. This PhD project was a nested sub-study embedded in the SUTHI trial which aimed to describe and assess the influence of OCFs on the QI intervention to improve process indicators of HIV-TB services. A description of the QI intervention, including change ideas generated and lessons learned from practical application of the intervention in 20 QI clinics are presented in Paper I. Baseline performance of indicators was highlighted as important in influencing the size of improvements. OCFs that undermined the QI process were poor data quality, data capturing backlogs, lack of data analytic skills among clinic staff, poor transfer of training knowledge to peers, low clinic staff motivation to consistently track performance and limited involvement of the clinic management team in QI activities due to heavy workloads. A comparison between the QI and SOC group clinics showed that the QI intervention was only effective in improving two of five HIV-TB indicators, HIV testing services (HTS) andIsoniazid Preventive Therapy (IPT) initiation rates in new antiretroviral therapy patients. HTS was 19% higher (94.5% versus (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 the SOC group. Small clusters showed larger improvements in IPT initiation rates compared to big clusters, likely due to better coordination of efforts (Paper II). Several OCFs were quantitatively assessed and inserted into a linear mixed model to determine which factors likely influenced the improvement observed in the IPT initiation rates (Paper III). The practice of monitoring data for improvement was significantly associated with higher IPT initiation rates (Beta coefficient (β)=0.004; p=0.004). The main recommendations made from the PhD project are to encourage the practice of monitoring data for improvement among clinic teams; provision of widespread QI training for all levels of staff, different staff categories and leadership; to ensure good quality of routine data, and provision of regular performance feedback from upper management to the clinics.
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    Evaluation of health promotion roles and services offered by health workers in the Nelson Mandela Bay Municipality of Eastern Cape, South Africa.
    (2022) Melariri, Herbert Ikechukwu.  ; Chimbari, Moses John.
    Background: Various factors affect the role of healthcare workers (HCWs) in health promotion (HP). The Nelson Mandela Bay Municipality (NMBM) public health service is overstretched and there is minimal evidence of health promoting healthcare services. This research project evaluated the roles and services of HCWs on HP as well as the views of patients regarding the HP services they received from HCWs in the municipality. Methods: A phased quantitative cross-sectional study was conducted to address the study aim and objectives. In phase one, 495 HCWs randomly sampled from 23 healthcare facilities in NMBM completed a structured questionnaire. In phase two, 500 patients completed a structured questionnaire regarding the quality of HP services received using the interview method. Descriptive and inferential analyses were conducted using StataIC 15. Results: Three groups of indicators classified as facility related indicators (FRI), healthcare workers’ related indicators (HRI), and outcome related indicators (ORI) emerged for measuring HP. The study identified thirteen categories of enablers and eight categories of hindrances. Eleven enablers and six hindrances were associated with tertiary hospitals, and none was recorded for the other health care levels. Collaboration among disciplines and organizations (Coeff: 2.16, 95% CI: 1.28 - 3.66) and programme planning (Coeff: 0.375, 95% CI: 0.23 - 0.62) were the predictors of HP and disease prevention (DP) enablers among medical doctors. On the other hand, ‘healthcare facilities promoting treatment more than DP’ (Coeff: 2.03, 95% CI: 1.30-3.14) and ‘absence of practice guidelines incorporating HP’ (Coeff: 2.79, 95% CI: 1.66-4.70) were the predictors of HP and DP hindrances among medical doctors and allied health workers (AHWs), respectively. Furthermore, most of the HCWs (75.78%; n=363) reported absence of coordinated HP training for staff in their facilities. Similarly, the attitude that ‘HP is a waste of time’ (adjusted Coeff 0.51, 95% CI 0.31 - 0.83) influenced the practice for AHWs. Results of the second phase study were categorized into three phases namely - pre-admission phase (PAP), admission phase (ADP), and post admission phase (POP). The ADP showed that patients’ health behaviours improved by 1.54 times by their interactions with nurses compared to their interactions with medical doctors. Conclusion: This study shows that the healthcare system is more committed to biomedical care as against health promotion services at all levels of healthcare. The implementation of HP services requires changes in HCWs behaviour, patients’ attitude and very importantly, structural reorganization and reprioritization.
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    Female Genital Schistosomiasis (FGS) as a risk factor for squamous cell atypia in an epidemiological longitudinal cohort of young women in KwaZulu-Natal.
    (2016) Pillay, Pavitra.; Tylor, Myra M.; Kjetland, Eyrun Floerecke.; Van Leishout, Lisette.; Roald, Borghild.
    Abstract available in PDF file.
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    Paternal roles in promoting child well-being: what are the challenges facing paternal involvement in child healthcare in rural South Coast Kenya?
    (2015) Songola, Kennedy Munyambu.; Taylor, Myra.
    Introduction While it has long been accepted that mothers play a key role in child health outcomes, the role of the father is less well understood. The proposed study was nested in another study investigating the relationship between the social environment and child health, growth and development. The work took place in South Coast Kenya, Kwale County, an area characterized by low income, restricted health resources, and exposure to multiple infections, including malaria. Child health clinics are largely contained within Mother and Child Health programmes [1, 2]. This has excluded the fathers who rarely visit the health facilities. This observation made during previous studies in the area was a clear indication of little paternal involvement with their children. Through previous studies carried out in this region, community consultation groups have consistently made recommendations on how to improve the existing situation[2]. It clearly emerged that other family members, particularly fathers, need to be included in the process of addressing child health and development. Therefore, this study aimed to investigate how paternal involvement in child health services can affect child wellbeing in collectivist rural communities in South Coast Kenya. It has also highlighted their attitudes and beliefs towards parenting and how they affect child health outcomes. Objectives This study had three main objectives to investigate parenting in a rural low income setting. They included describing and comparing the maternal and paternal attitudes and perceived parenting roles and responsibilities in managing infant health, investigation of the relationship between parental psychosocial factors and child health outcomes in the two main communities (Mijikenda vs. Non-Mijikenda communities) within the study area and finally, to summarize the key factors affecting paternal inclusion or involvement in child health programmes. Methodology Two types of interviews were administered to both parents (fathers and mothers) to find out their roles, attitudes and beliefs towards parenting. The first type of interview used was a quantitative structured interview and it investigated their parenting stress. The second was a qualitative semi-structured in-depth interview and investigated the parents’ roles, beliefs, and attitudes towards parenting. Data analysis was carried out using SPSS21 Software for quantitative data and NVivo10 Software for qualitative data. The information has been used to explain the existing pattern of parental involvement in child health care programmes. Study findings The results suggested that both mothers and fathers were very happy to be parents and were willing to be involved with their child or children in promoting their well-being. Nevertheless, although the mothers agreed with the fathers’ reports that they were practically involved in supporting their children financially, decision making and providing their daily needs, they disagreed with paternal reports that fathers participated in taking their children to the hospital when sick. None of the parental characteristics was significantly associated with the child health variables measured. The extra challenges parents experience in parenting and their inability to handle their children well were associated with poor parenting styles. Their low household income and health care system factors preventing working fathers from attending clinic were also associated with low paternal involvement with their children and in the management of their children’s health. Conclusion Financial constraints and the design of the healthcare system, biased in favour of the mothers are major obstacles affecting paternal involvement with their children. The fathers in the study area are willing to take part in any activity undertaken to promote the well-being of their children and generally happy to be parents. Increased paternal involvement in the healthcare programmes may improve the wellbeing of their children and the public at large.
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    Access to higher education in the health sciences : a policy implementation analysis.
    (2014) Orton, Penelope M.; Brysiewicz, Petra.; Essack, Sabiha Yusuf.
    Access to health sciences education in South Africa is a challenging and contested area of higher education seeped in politics and history within a context of transformation. There are a large number of students wanting to study health science courses but there are limited places. The first democratically elected government in South Africa issued White Paper 3: A Programme for the Transformation of Higher Education with a vision of transforming the higher education system to one that was more representative of the country`s demographic profile. However in the absence of any guidelines for the implementation of this White Paper 3, higher education in many instances has not been transformed as the government envisaged. The aim of this study was to identify the factors affecting access to health sciences education at universities in South Africa and to develop guidelines to broaden access for social redress. This study was conducted within a pragmatic paradigm using a mixed methods sequential exploratory design in the complementarity genre. Universities offering traditional health science courses` including medicine were included in the study. The research consisted of 3 Phases – Phase 1 reviewed existing policies and practices through the review of relevant documents; Phase 2 assessed existing practices through one-on-one interviews and Policy Delphi and Phase 3 developed policy implementation guidelines and two policy briefs to broaden access using the information gathered from the literature reviewed and data collected from stakeholders. The Policy Delphi questionnaire was developed following the analysis of qualitative data collected in Phase 2 and the instrument was subjected to 2 cycles of item content validity index (I-CVI). The results indicated that achieving equity of access is multi-factorial and has diverse and complex challenges. Some of these challenges are ingrained in South Africa`s apartheid history, some are rooted in the process of access and some in the mind-set of the actors involved in access. The research identified eight categories, promotion of health science disciplines; challenges to transformation; competitiveness; health sciences sets the “bar”; alternative access; reason for choosing a health sciences profession; innovation in teaching and learning and retention and throughput rates which were related to access to health sciences education in universities. The data indicated that the student demographic has changed substantially in Health Science programmes but more could be done. Faculties of Health Sciences need to implement some strategies to reach out to the eligible students in rural and remote areas. Student success in Health science courses is relatively good as would be expected as the selection and admission criteria, is generally higher. Health Sciences at many of the universities are committed to the imperative of transformation for social redress but there are others who are caught between facilitating transformation and overwhelming demand for their programmes. Guidelines for the Implementation of the Access Policy in Health Sciences Education and the Access for Success in Health Sciences Education in Universities Policy briefs were informed by the results. Universities have implemented a number of initiatives to address the past injustice in higher education access however the issue of enabling access for those who are socio-economically disadvantaged is very much more complex and challenging to address. Transformation of health sciences education in universities is essential to the transformation of the health service to reflect a health service that is accessible, available, affordable and agreeable, something that every South African citizen.
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    Epidemiological and clinical status of South African primary school children : investing in the future.
    (2001) Jinabhai, Champaklal Chhaganlal.; Coovadia, Hoosen Mahomed.
    The physical, psychological and social development of school children has been neglected - partly because they were seen as healthy "survivors" of the ravages of childhood illnesses, and partly because of the way in which health services are organized (such as the traditional under-five maternal and child health (MCH) services and the curative PHC clinic services). From the age of five years children undergo rapid and profound bio-psycho-social development, to emerge in adolescence as the next generation of leaders and workers. Securing their future growth and development is vital for any society to be economically and socially productive. A substantial body of national and intemational literature has recognised the detrimental impact of helminthic infections and micronutrient deficiencies on the physical and psychological health and development of school children; which requires appropriate nutritional interventions. Concern has been expressed that these adverse biological, physical and social deprivations have a cumulative impact on several dimensions of children's growth. Most important, apart from stunting physical growth, is the inhibition of educational development of school children. Recent evidence strongly suggests a powerful interaction between physical and psychosocial growth and development of children. Inhibition of either component of a child's well-being has adverse implications. Conversely, investments in the physical and psychological development of children are likely to generate substantial health and educational benefits and are a worthy investment to secure a healthy future generation. In summary, there are a number of reasons for, and benefits of, investing in school-based health and nutrition interventions. They are likely to improve learning at school and enhance educational outcomes; create new opportunities to meet unfulfilled needs; redress inequity; build on investments in early child development and promote and protect youth and adolescent development. Health and nutrition interventions such as school feeding programmes, micronutrient supplementation and deworming aim to improve primary outcomes of macro and micro-nutrient deficiencies, parasitic and cognitive status; as well as secondary outcomes of developing integrated comprehensive school health policies and programmes. This rationale served as the conceptual framework for this study. This theoretical framework views improvements of the health, nutritional, cognitive and scholastic development status of school children as the primary focus of policies, strategies and programmes in the health and education sector. This focus constitutes the central core of this thesis. Optimum social development requires investments in both the health and educational development of school children, so as to maximise the synergies inherent in each sector and to operationalise national and international strategies and programmes. As part of the larger RCT study a comprehensive nutritional, health and psychological profile of rural school children was established through a community-based cross-sectional study. Eleven schools were randomly selected from the Vulamehlo Magisterial District in southern KwaZulu-Natal (KZN). Within each school, all Standard 1 pupils, aged between 8 - 10 years, were selected giving a final study sample of 579 children. Some of the observed prevalence's were stunting (7.3%), wasting (0.7%), anaemia (16.5%) (as measured by haemoglobin below 12 g/dl), vitamin A deficiency (34.7%) (as measured by serum retinol below 20 ug/dl) and serum ferritin below 12ng/ml (28.1%). This study established that micronutrient deficiency, parasitic infestations and stunting remain significant public health problems among school-aged children in South Africa. Combining micronutrient supplementation and deworming are likely to produce significant health and educational gains. To determine the impact of single and combined interventions (anthelminthic treatment and micronutrient supplements) on nutritional status and scholastic and cognitive performance of school children, a double-blind randomised placebo controlled trial was undertaken among 579 children 8-10 years of age. There was a significant treatment effect of vitamin A on serum retinol (P<0.01), and the suggestion of an additive effect between vitamin A fortification and deworming. Vitamin A and iron fortification also produced a significant treatment effect on transferrin saturation (P<0.05). Among the dewormed group, anthelminthic treatment produced a significant decrease in the prevalence of helminthic infections (P<0.02), but with no significant between-group treatment effect (P>0.40). Scholastic and cognitive scores and anthropometric indicators were no different among the treated or the untreated children. Fortified biscuits improved micronutrient status among rural primary school children; vitamin A combined with deworming had a greater impact on micronutrient status than vitamin A fortification on its own; while anthelminthic treatment produced a significant reduction in the overall prevalence of parasite infection. The prevalence's of Ascaris lumbricoides, Trichuris trichiura and Schistosoma haematobium declined significantly sixteen weeks post-treatment. The levels of both prevalence and intensity in the untreated group remained constant. The cure rates over the first two weeks of the study were 94.4% for Ascaris lumbricoides, 40% for Trichuris trichiura, and 72.2% for Schistosoma haematobium. The benefits of targeted school-based treatment in reducing the prevalence and intensity of infection supports the South African government's focus of using school-based interventions as part of an integrated parasite control programme. These strategies and programmes were found to be consistent with the recommendations of WHO and UNICEF. The nutritional transition facing developing and middle-income countries also has important implications for preventive strategies to control chronic degenerative diseases (Popkin B, 1994; WHO 1998; Monyeki KO, 1999). This descriptive study, comparing BMI data of school children over three time periods, found a rising prevalence of overweight and obesity among South African school children. Obesity as a public health problem requires to be addressed from a population or community perspective for its prevention and management. Environmental risk factors such as exposure to atmospheric pollution remain significant hazards for children. Lead poisoning is a significant, preventable risk factor affecting cognitive and scholastic development among children. The prevalence of elevated blood lead (PbB) levels in rural and semi-urban areas of KwaZulu-Natal (KZN) as well as the risk factors for elevation of PbB among children in informal settlements were examined. This study investigated over 1200 rural and urban children in two age groups: 3-5 and 8-10 years old. Average PbB level in peri-urban Besters, an informal settlement in the Durban metropolitan region, was 10 ug/dl with 5% of the children showing PbB level of greater than 25 ug/dl. By comparison, average PbB value in Vulamehlo, a rural area located 90-120 km from Durban, was 3.8 ug/dl and 2% of the children's PbB levels were greater than 10 ug/dl. Since the cognitive and scholastic performance of school children was a primary outcome measure in this study, it was important to explore other factors that influenced this variable. The performance scores of all four tests in the battery, among the cohort of a thousand rural and urban children, were in the lower range. The educational deficit identified in this test battery clearly indicates the impact of the inferior "Bantu" educational system that African children have experienced in South Africa. Aspects of the School Health Services that were investigated in this descriptive study included the services provided and their distribution; assessment of health inspection; health education and referral processes undertaken by the School Health Teams; perceptions of managers, providers and recipients of the service; as well as the costs of the provision of the service in KwaZulu-Natal. In KwaZulu-Natal, there were School Health Teams In all the 8 health and education regions in the province. In total, there were 95 teams in the province, consisting of nearly 300 staff members. The School Health Teams were involved in a wide range of activities - 74% of all teams were involved in health inspection and 80% were involved in health education. The total annual cost of delivering School Health Services in the province in 1995 was estimated to be approximately R8 750 000. Given the rise of HIV and AIDS in the province, School Health Services need to play a central role not only in prevention, but also in assisting with the acceptance of HIV-positive children within schools. It is recommended that the current and future draft SHS policy guidelines be approved by the relevant authorities for immediate implementation. Districts should consider developing "Health Promoting Schools", with School Health Teams being a central resource. This thesis has explored several aspects of the epidemiological profile of school children in rural and urban settings in KwaZulu-Natal. It has established that school children are exposed to a range of risk factors ranging from nutritional deficits, parasitic infections, atmospheric lead poisoning and a rising prevalence of overweight. All of these risk factors may compromise their physical, psychological and social development. A number of health interventions have been identified, which have the potential to address these problems. Such investments are essential to secure the health of future generations.
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    Evaluation of the clinical and drug management of HIV/AIDS patients in the private health care sector of the eThekwini Metro of KwaZulu-Natal : sharing models and lessons for application in the public health care sector.
    (2010) Naidoo, Panjasaram.; Jinabhai, Champaklal Chhaganlal.; Taylor, Myra.
    Introduction: South Africa is currently experiencing one of the most severe AIDS epidemics in the world with South Africa‘s public sector under great stress and under-resourced whilst there exists a vibrant private healthcare sector. Private healthcare sector doctors have a pivotal role to play in the management of HIV and AIDS infection. However not much is known about the extent of private healthcare sector doctor involvement in the management of HIV and AIDS patients. In addition these doctors need to have an accurate knowledge of the management of the infection, and a positive attitude towards the treatment of persons with HIV and AIDS. With the availability of antiretroviral drugs only since around 1996, many of the doctors who were trained prior to 1996 would not have received any formal training in the management of HIV and AIDS patients, further it is very important that these doctors constantly update their knowledge and obtain information in order to practise high-quality medicine. Although private sector doctors are the backbone of treatment service in many countries, caring for patients with HIV brings a whole new set of challenges and difficulties. The few studies done on the quality of care of HIV patients, in the private sector in developing countries, have highlighted some problems with management thus it becomes important to ascertain these doctors‘ training needs together with where these doctors source information on HIV/AIDS to stay updated. In South Africa two thirds of the doctors work in the private sector. To address some of the resource and personnel shortages facing the public sector in South Africa, partnerships between the public and private sectors are slowly being forged. However, little is known about the willingness on the part of private sector doctors in the eThekwini Metro of KwaZulu-Natal, to manage public sector HIV and AIDS patients. Though many studies have been undertaken on HIV/AIDS, fewer have been done in the private sector in terms of the management of this disease which includes doctors‘ adherence monitoring practices, their training needs and sources of information and their willingness to manage public sector patients. A study was therefore undertaken to assess the involvement of private sector doctors in the management of HIV, their training needs and sources of HIV information, the quality of HIV clinical management that they provided, together with their strategies for improving adherence in patients. Further the study assessed factors that affect adherence in patients attending private healthcare, and finally investigated whether private sector doctors are willing to manage public sector HIV infected patients. A literature review of the barriers that prevent doctors from managing HIV/AIDS patients was also undertaken. Method: A descriptive cross sectional study was undertaken using structured self reported questionnaires. All private sector doctors practising in the eThekwini Metro were included in the study. The study was divided into different phases. After exclusions a valid sample of 931 participants was obtained in Phase 1. However only 235 of these doctors indicated that they managed HIV infected patients, of which only 190 consented to be part of Phase 2 of the study. In Phase 2 the questionnaires were administered by trained field workers to the doctors after confirming doctors‘ consent. The questionnaires were thereafter collected, the data captured and analysed using SP55 version 15. Results: Although 235 (71.6%) doctors managed HIV and AIDS patients, 93 (28.4%) doctors did not, and of the latter 48 (51.61%) had not encountered HIV and AIDS patients, twenty five (26.88%) referred such patients to specialists, six (6.45%) cited cost factors as reasons for not treating such patients, whilst twelve (12.90%) doctors, though they indicated that there were other reasons for not managing HIV infected patients, did not specify their reasons. Two doctors (2.15%) indicated that due to inadequate knowledge they did not manage HIV and AIDS patients. Significantly younger (recently qualified) doctors rather than older (qualified for more years) doctors treated HIV/AIDS patients (p<0.001). Most doctors (76.3%) expressed a need for more training/knowledge on the management of HIV patients. Eighty five doctors (54.5%) always measured the CD4 count and viral load levels at diagnosis. Both CD4 counts and viral load were always used by 76 doctors (61.8%) to initiate therapy. Of the doctors 134 (78.5%) initiated therapy at CD4 count < 200cells/mm3. The majority of doctors prescribed triple therapy regimens using the 2 NRTI +1 NNRTI combination. Doctors who used CD4 counts tended to also use viral load (VL) to assess effectiveness and change therapy (p<0.001). At initiation of treatment 68.5% of the doctors saw their patients monthly and 64.3% saw them 3-6 monthly when stable. The majority of the doctors (92.4%) obtained information on HIV and AIDS from journals. Continuing Medical Education (CME), textbooks, pharmaceutical representatives, workshops, colleagues and conferences were identified as other sources of information, while only 35.7% of doctors were found to use the internet for information. GPs and specialists differed significantly with regard to their reliance on colleagues (52.9% versus 72.7%; p < 0.05) and conferences (48.6% versus 78.8%; p < 0.05) as sources of HIV information. Of the respondents, 78.9% indicated that they monitor for adherence. Comparison of GPs and specialists found that 82.6% of the GPs monitor for adherence compared to 63.6% of the specialists. (p=0.016). Doctors used several approaches with 60.6% reporting the use of patient self reports and 18.3% pill counts. Doctors (68.7%) indicated that their adherence monitoring is reliable, whilst 19.7% stated they did not test the reliability of their monitoring tool. The most common strategy used to improve adherence of their patients was by counseling. Other strategies included alarm clocks, SMS, telephoning the patient, encouraging family support and the use of medical aid programmes. One hundred and thirty three (77.8%) doctors were willing to manage public sector HIV and AIDS patients, with 105 (78.9%) reporting adequate knowledge, 99 (74.4%) adequate time, and 83 (62.4%) adequate infrastructure. Of the 38 (22.2%) that were unwilling to manage these patients, more than 80% cited a lack of time, knowledge and infrastructure to manage them. Another reason cited by five doctors (3.8%) who were unwilling was the distance from public sector facilities. Of the 33 specialist doctors, 14 (42.4%) indicated that they would not be willing to manage public sector HIV and AIDS patients, compared with only 24 (17.4%) of the 138 GPs (p < 0.01). There was no statistical difference between adherence to treatment and demographics of the respondent patient such as age, gender and marital status. In this study 89.1% of patients were classified as non-adherent and reasons for non-adherence included difficulty in swallowing medicines (67.3%) (p = 0.01); side effects (61.8%) (p = 0.03); forgetting to take medication (58.2%) (p = 0.003); and not wanting to reveal their HIV status (41.8%) (p = 0.03). Common side effects experienced were nausea, dizziness, insomnia, tiredness or weakness. Reasons for taking their medicines included that tablets would save their lives (83.6%); they understood how to take the medication (81.8%); tablets would help them feel better (80.0%); and that they were educated about their illness (78.2%). All participants that were on a regimen that comprised protease inhibitors and two NRTIs were found to be non-adherent. Conclusion: All doctors in the private healthcare sector were not involved in the management of HIV/AIDS patients. Doctors indicated that they required more training in the management of HIV/AIDS patients. However private sector doctors in the eThekwini Metro do obtain information on HIV from reliable sources in order to have up-to-date knowledge on the management of HIV-infected patients, with the majority of private sector doctors being compliant with the current guidelines, hence maintaining an acceptable quality of clinical health care. These doctors do monitor for adherence and employ strategies to improve adherence in their patients who do have problems adhering to their treatment due to various factors. Many private sector doctors are willing to manage public sector HIV and AIDS patients in the eThekwini Metro, potentially removing some of the current burden on the public health sector.
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    Patterns of disclosure : an investigation into the dynamics of disclosure among HIV-positive women in two PMTCT settings in an urban context, KwaZulu-Natal, South Africa.
    (2011) Crankshaw, Tarmaryn Lee.; Voce, Anna Silvia.
    Introduction: Little guidance is given to health professionals over how to deal with HIV disclosure complexities in the biomedical setting. Given the paucity of related research in this context, there is also little consideration of the actual effect of HIV disclosure in a given context. Social constructionist theory is an important contribution to disclosure research because it shifts the focus from a biomedical perspective to one that incorporates an individual's experience with HIV infection in a specific context. The task of this study was to develop substantive theory, with the aim of providing a theoretical framework for public health and health care practitioners to better understand HIV disclosure dynamics in the PMTCT setting. Methods: This was a qualitative study which explored the experience of disclosure amongst HIV positive pregnant women in the PMTCT context. Between 5 June – 31 November 2008, a total of 62 participants were recruited from two urban-based PMTCT programmes located within the eThekwini District, KwaZulu-Natal, South Africa. Results: Participants disclosed to two main groups: sexual partners, and family/others. Structural and relationship network factors shaped transmission risk behaviour, subsequent disclosure behaviour and outcomes. The circumstances which placed participants at risk for HIV acquisition also affected the likelihood of disclosure and health behaviour change. HIV and pregnancy diagnoses often occurred concurrently which profoundly impacted on participant's social identities and disclosure behaviour. Current HIV testing protocols within PMTCT settings often recommend disclosure to sexual partners under the assumption that couples will engage in safer behaviours, yet findings from this study indicate that this assumption should be challenged. Discussion: The study findings are synthesized in a conceptual model which offers substantive new theory over the concepts and interrelated factors that were identified to shape HIV disclosure and outcomes in the PMTCT context. The model identifies the following domains: 1) social networks and social support; 2) identity; 3) risk behaviour; 4) HIV and pregnancy diagnoses; and 5) HIV disclosure process to partners and others. Recommendations: Assumed pathways to risk reduction and HIV prevention need to be relooked and reconsidered. The conceptual model provides a proposed framework for future research, intervention design and implementation planning in the PMTCT setting.
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    An HIV/AIDS prevention intervention among high school learners in South Africa.
    (2008) Frank, Serena V.; Taylor, Myra.; Jinabhai, Champaklal Chhaganlal.
    Introduction Nearly half of all new HIV infections worldwide occur in young people aged 15-24 years. Risky sexual behaviours may lead to the development of lifelong negative habits like having multiple partners, thereby placing young people at risk of a broad range of health problems, including HIV/AIDS. Prevention is therefore critical and includes changing behaviours that are risky, such as the early age of sexual initiation, having many sexual partners and non-use of condoms. The study aimed to evaluate whether a theory based HIV/AIDS intervention, 'Be A Responsible Teenager' (B.A.R.T.), could produce behaviour change among high school learners in South Africa. Methods A pre-test /multiple post-test intervention study was undertaken. All Grade 10 learners (n = 805) from all three public high schools in Wentworth were included in the study. Eleven teachers were interviewed from these schools. Learners completed a questionnaire at baseline (Tl), immediately post intervention 1 (T2), post intervention 2 (T3) and after a period of seven months (T4). The B.A.R.T.intervention was implemented in the intervention schools while the control group did not receive any intervention. Qualitative data was analyzed according to themes, while quantitative data was analyzed cross sectionally and longitudinally. Results Teachers reported many obstacles in implementing the HIV/AIDS Life Skills' curriculum, including the poor quality of training and inadequate resources in schools. Further, learners practised high-risk sexual behaviours. Gender differences in sexual behaviour were reported with males predominately practising higher risk behaviours than females.The B.A.R.T. intervention did show changes in behaviour for alcohol use at last sex and for the determinants knowledge, attitudes, beliefs, self-efficacy and intentions to practise safer sex respectively, over time. However, the intervention didnot positively impact abstinence behaviours, condom use and the reduction in partners. Further, subjective norms did not change. Conclusion The major obstacles to AIDS prevention include the current practices of risky sexual behaviours including age mixing, early sexual initiation, multiple partners, forced sex and receiving money or gifts for sex among others. Social norms as potrayed by parents, peers and religious groups play a pivotal role in promoting protective sexual behaviours. The role of gender and the gaps in LHAP (Life Skills' HIV/AIDS programme) also require urgent attention.
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    Analyzing the relationship between leadership style, organisational factors and retention of professional nurses in public health care facilities in KwaZulu-Natal.
    (2009) Nkosi, Zethu Zerish.
    BACKGROUND : Many professional nurses have left the employment to work in developed countries. Quality patient care is declining because the few PNs that are rendering care have limited expertise. Literature review showed that nurse managers have a role to play in retention of staff. PURPOSE : The study aims to analyze the leadership styles and organizational factors toward the retention of professional nurses working in public health facilities. POPULATION : Professional nurses in four public hospitals, four union managers, twelve professional nurses working abroad and representative from SANe. A total of 188 participated in the study which formed part of the 70% of the sample. DESIGN : A Case study design which included both quantitative and qualitative approaches. Observations in the wards and document analysis were done guided by a case protocol. INSTRUMENTS : Revised Nursing Work Index and Revised Conditions of work effectiveness was administered among the professional nurse and chief professional nurses. Chief nursing service managers and union managers were interviewed using interview guides. Focus groups among professional nurses who had overseas experiences were conducted. Reliability was maintained by having a Cronbachs alpha of above 0.70 in all variables except leadership. RESULTS : Cases presented differently in all aspects, except Case C who was consistent in all the variables. The professional nurses in Case C viewed their CNSM as being visible and accessible. Case A and B were similar in terms of the organizational factors. All CNSM verbalized that they were willing to send PNs for educational programmes but the DOH policy was allowing nurses to work anywhere in the province. PNs had little access to resources on time to do tasks and paperwork as compared to access to support and opportunity.CONCLUSION : PNs are willing to stay in their organizations provided they will be given educational and promotional opportunities. There was a relationship between organizational factors and retention. Leadership factors showed a weak negative relationship with other variables.