Cape Town Research Articles

Dialysis for paediatric acute kidney injury in Cape Town, South Africa.

Dialysis is lifesaving for acute kidney injury (AKI), but access is poor in less resourced settings. A "peritoneal dialysis (PD) first" policy for paediatric AKI is more feasible than haemodialysis in low-resource settings. Retrospective review of modalities and outcomes of children dialysed acutely at Red Cross War Memorial Children's Hospital between 1998 and 2020. Of the 593 children with AKI who received dialysis, 463 (78.1%) received PD first. Median age was 9.0 (range 0.03-219.3; IQR 13.0-69.6) months; 57.6% were < 1year old. Weights ranged from 0.9 to 2.0kg (median 7.0kg, IQR 3.0-16.0kg); 38.6% were < 5kg. PD was used more in younger children compared to extracorporeal dialysis (ECD), with median ages 6.4 (IQR 0.9-30.4) vs. 73.9 (IQR 17.5-113.9) months, respectively (p = 0.001). PD was performed with Seldinger soft catheters (n = 480/578, 83%), predominantly inserted by paediatricians at the bedside (n = 412/490, 84.1%). Complications occurred in 127/560 (22.7%) children receiving PD. Overall, 314/542 (57.8%) children survived. Survival was significantly lower in neonates (< 1month old, 47.5%) and infants (1-12months old, 49.2%) compared with older children (> 1year old, 70.4%, p < 0.0001). Survival was superior in the ECD (75.4%) than in the PD group (55.6%, p = 0.002). "PD First for Paediatric AKI" is a valuable therapeutic approach for children with AKI. It is feasible in low-resourced settings where bedside PD catheter insertion can be safely taught and is an acceptable dialysis modality, especially in settings where children with AKI would otherwise not survive.

Pain in head and neck cancer survivors in South Africa: A cross-sectional study

Background: Pain is often a significant symptom in patients with head and neck cancer (HNC). The objective of this study was to determine the prevalence of pain, factors limiting effective pain management, and whether differences in pain management exist between the public and private health sectors in South Africa in HNC patients after they have completed treatment.Methods: A cross-sectional survey using the Brief Pain Inventory was performed on adults over the age of 18 years treated for HNC of any subsite in both a public and private hospital in Cape Town, South Africa.Results: Overall pain scores indicated mild levels of pain and impact on daily activities. The domains of life most affected by pain were general activity, sleep and mood. There was no difference in pain scores between public hospital patients versus those with private insurance. Less than half of the patients reported receiving all their necessary medications. Most of the postoperative pain was managed with paracetamol, tramadol and ibuprofen, with only 12.8% of patients using morphine.Conclusion: This study provides a survey of pain experiences in HNC patients in a middle-income country. Insurance status did not significantly impact pain experiences, indicating equitable access to pain management resources. However, the overall utilisation of morphine and medications used to treat neuropathic pain is low. Further research is needed into the complex factors associated with pain in HNC patients.Contribution: This article is an example of a standard clinical study on patient-reported outcome measures.

Musculoskeletal Discomfort and Musculoskeletal Injuries in Firefighters of the City of Cape Town Fire and Rescue Service

Objective The prevalence of work-related musculoskeletal injuries is reported to be noticeably high amongst firefighters, which augments the dangers of the job and the difficulties that firefighters must face daily. Therefore, this study aimed to firstly determine the prevalence and characteristics of work-related musculoskeletal injuries (MSIs) and musculoskeletal discomfort (MSD) and, secondly, to determine the relationship between MSD and MSIs in firefighters. Methods Using random systematic sampling, 309 firefighters from the City of Cape Town Fire and Rescue Service were recruited to participate. A researcher-generated questionnaire was used to retrieve data on musculoskeletal injuries and musculoskeletal discomfort. Data was analysed using the T-tests, Cochran-Armitage trend test, Jonckheere-Terpstra test, and Binary logistic regression. A p-value of less than 0.05 was used to indicate statistical significance. Results Male (p = 0.036) and older firefighters (p&lt;0.001) with more years of experience (p = 0.002) were most likely to report a musculoskeletal injury. Falls, jumps, slips, and trips were the most common injuries (39.7%), which most often occurred on the fireground (41.1%). Most firefighters (73.3%) reported experiencing discomfort 1-2 times a week of moderate (60.1%) severity that interfered slightly with their ability to work (58.2%). Multivariable analysis showed that the age groups of 40-49 years and 50-65 years and the rank of station commander increased the risk for MSIs by a factor of 2.39, 2.67, and 3.83, respectively. In addition, MSD was associated with an increase in the likelihood of firefighters reporting MSIs (p &lt;0.001). Conclusion Older male firefighters with more years in service were most likely to experience MSIs. Regular physical activity and work-related training should be implemented to increase the fitness for duty and to reduce the prevalence of injuries in firefighters.

EcoSonicML: Harnessing Machine Learning for Biodiversity Monitoring in South African Wetlands

Biodiversity monitoring, particularly in a country as diverse as South Africa with its extensive migratory bird population, presents significant challenges. This challenge becomes even more pronounced in environments with a multitude of coexisting bird species, notably wetlands, which serve as crucial breeding and feeding grounds for various avian species. This research will address this challenge by designing a cost-effective sound-based sensor system capable of deployment in diverse wetland ecosystems. The primary aim is to aid in the monitoring of bird species by detecting their presence and distribution and then transmitting this valuable data to a central base station. To assess the system’s feasibility and performance, a series of experiments were conducted at the Rondevlei Nature Reserve in Cape Town, South Africa. These experiments focused on the sensor’s capacity to accurately identify avian species while maintaining robustness in varying environmental conditions. The results yielded promising outcomes, demonstrating the successful identification of bird species. Furthermore, the system exhibited reliability across different weather conditions, positioning it as a viable choice for long-term deployment in wetland environments. Beyond species detection, this project also delved into practical aspects of data transfer and storage efficiency, ensuring the system’s suitability for real-world applications. Modularity was another crucial consideration, simplifying maintenance and upgrades. Moreover, a preliminary cost analysis indicated the cost-effectiveness of the system compared to commercial alternatives. The integration of climate sensors into the monitoring system was explored as a future direction. This addition holds the potential to provide a more comprehensive approach to environmental monitoring by incorporating climate data into the analysis. Such a holistic approach can further enrich our understanding of bird behaviour in relation to changing environmental conditions. The findings of this research have significant implications for avian conservation and ecological studies, particularly in the unique context of South Africa. This project introduces an affordable and practical tool for monitoring bird species in wetland habitats, offering valuable insights into the preservation and management of these critical ecosystems.

Exploring adolescent girls and young women's PrEP-user profiles: qualitative insights into differentiated PrEP delivery platform selection and engagement in Cape Town, South Africa.

Adolescent girls and young women (AGYW), a priority population for HIV prevention in Africa, show high interest but difficulty in sustained effective use of pre-exposure prophylaxis (PrEP). With ongoing PrEP scale-up focused on increasing access, it is important to understand what influences AGYW's choice of PrEP delivery platforms. The POWER implementation study in Cape Town provided PrEP between 2017 and 2020 to AGYW (16-25 years) from four differentiated delivery platforms: mobile clinic, government facility, courier delivery or community-based youth club. Healthcare providers at government and mobile clinics provided PrEP (initiation and refills) as part of comprehensive, integrated sexual and reproductive health services. Courier and youth club platforms provided light-touch PrEP refill services incorporating rapid HIV self-testing. We conducted in-depth interviews with a purposive sample of AGYW who had ≥3 months of PrEP-use and accessed ≥2 PrEP delivery platforms. The thematic analysis explored AGYW's preferences, decision-making and habits related to PrEP access to inform market segmentation. We interviewed 26 AGYW (median age 20) PrEP-users between November 2020 and March 2021. AGYW PrEP-users reported accessing different services with, 24 accessing mobile clinics, 17 courier delivery, 9 government health facilities and 6 youth clubs for their PrEP refills. Qualitative findings highlighted four potential behavioural profiles. The "Social PrEP-user" preferred PrEP delivery in peer spaces, such as youth clubs or adolescent-friendly mobile clinics, seeking affirmation and social support for continued PrEP use. The "Convenient PrEP-user" favoured PrEP delivery at easily accessible locations, providing quick (courier) or integrated contraception-PrEP refill visits (mobile and government clinic). The "Independent PrEP-user" preferred PrEP delivery that offered control over delivery times that fit into their schedule, such as the courier service. The "Discreet PrEP-user" highly valued privacy regarding their PrEP use (courier delivery) and avoided delivery options where unintentional disclosure was evident (youth club). Comfort with HIV self-testing had minimal influence on PrEP delivery choice. Market segmentation of AGYW characterizes different types of PrEP-users and has the potential to enhance tailored messaging and campaigns to reach specific segments, with the aim of improving sustained PrEP use and HIV prevention benefits.

Challenges experienced by grandparents caring for AIDS orphans in the Western Cape province, South Africa.

There is limited understanding of the difficulties and experiences faced by grandparents who assume the responsibility of caring for AIDS orphans. The objective of the study was to investigate and depict the difficulties encountered by grandparents who provide care for AIDS orphans in the Western Cape province of South Africa. The study was conducted in the City of Cape Town Metropolitan and the Overberg Municipality. The study used qualitative approach with an exploratory-descriptive design. A purposive sampling technique was utilised to select 25 grandparents. Semi-structured interviews were conducted, audio-recorded, transcribed verbatim, and analysed thematically using ATLAS.ti, version 7. Financial difficulties, a lack of support, HIV and/or AIDS stigma, and dealing with rebellious teenagers were primary challenges affecting the well-being of grandparents. The study found that while financial challenges were significant, other factors such as poor family support contributed to the decline in the well-being of grandparents caring for AIDS orphans. The study's results can lead to improved public health programmes that address the identified challenges and health needs of grandparents providing care to AIDS orphans and the orphans under their care.

Two Lineages of Papillomaviruses Identified from Caracals (Caracal caracal) in South Africa

Papillomaviruses (PV) infect epithelial cells and can cause hyperplastic or neoplastic lesions. In felids, most described PVs are from domestic cats (Felis catus; n = 7 types), with one type identified in each of the five wild felid species studied to date (Panthera uncia, Puma concolor, Leopardus wiedii, Panthera leo persica and Lynx rufus). PVs from domestic cats are highly diverse and are currently classified into three genera (Lambdapapillomavirus, Dyothetapapillomavirus, and Taupapillomavirus), whereas those from wild felids, although diverse, are all classified into the Lambdapapillomavirus genus. In this study, we used a metagenomic approach to identify ten novel PV genomes from rectal swabs of five deceased caracals (Caracal caracal) living in the greater Cape Town area, South Africa. These are the first PVs to be described from caracals, and represent six new PV types, i.e., Caracal caracal papillomavirus (CcarPV) 1–6. These CcarPV fall into two phylogenetically distinct genera: Lambdapapillomavirus, and Treisetapapillomavirus. Two or more PV types were identified in a single individual for three of the five caracals, and four caracals shared at least one of the same PV types with another caracal. This study broadens our understanding of wild felid PVs and provides evidence that there may be several wild felid PV lineages.

Negative clinic experiences as a barrier to care for people with HIV and their impact on patient preferences for intervention support: a qualitative study in Cape Town, South Africa

ABSTRACT We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH’s negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..

‘Botha Cake’ and ‘Belgian Onion Soup:’ Gendered Patriotism Through Three South African, First World War, Community Cookbooks

ABSTRACT This article considers three South African community cookbooks – including The Overseas Contingent Fund Recipe Book (Turffontein, 1915) and the Paarl Cookery Book in Aid of War Funds (Paarl, 1918) alongside Wartime Cookery (Cape Town, 1915) – as expressions of gendered patriotism. These community-created cookbooks enabled contributors to participate meaningfully in the First World War by drawing together two established gendered practices: philanthropic fundraising and food and household management. This ‘domesticity in action’ enabled participants to contribute to, and feel connected to, both local and trans-empire causes. These values of philanthropy, economy and patriotism are revealed in the constitutive components of the texts – the titles, aims, prefaces and even the recipes themselves. Apart from supporting specific funds, the call for economy in the cookbooks reflected both experiences and perceptions of wartime material hardship in South Africa. A further consideration of the contributors involved with the books’ compilations highlights the intersection of local and trans-empire networks, and wartime (white) identity politics within urban South Africa. The networks suggest locally-grounded loyalisms, many marked by personal connections to men serving, as well as friend and family networks with overseas reach. Lastly, the article is a reminder of the importance of cookbooks as neglected sources in the writing of history.

Emerging contaminants as unintentional substances in paper and board: A case of unexpected pharmaceuticals detection in the paper recycling chain

The contamination of paper products by various chemicals has been reported on a global level, but to date, no published research has investigated pharmaceutical contamination of paper-based products. In this study, pharmaceutical analysis was conducted on 42 samples collected from various points of the recycled paper value chain in Cape Town, South Africa, which included the various grades that may be included in the manufacturing of recycled paperboard. The analysis was achieved by ultrasonic-assisted extraction of paper samples before detection by UHPLC-Q Orbitrap. Quantification limits ranged from 1.15 pg/g for ketoprofen to 46.07 pg/g for methocarbamol. Pharmaceuticals identified in newspaper samples were dexamethasone, ketoprofen, and 17β-estradiol. The latter was also detected in paper shopping bags (up to 697.49 ng/g), infant bathtub packaging (280.62 ng/g), battery packaging (137.43 ng/g), and an egg carton (170.47 ng/g). Carbamazepine was also prominent with its concentration reaching 13.02 ng/g in a vegetable box. Suspect screening tentatively identified 14 additional pharmaceuticals in paper samples, with minocycline, prazepam, and anabolic steroids appearing more prominently. This pioneering study indicated that unintentional pharmaceutical exposure had expanded beyond environmental media to consumer products.

Necrotising enterocolitis in a middle-income country: Early onset and risk factors for mortality.

There is limited literature available about necrotising enterocolitis (NEC) in low- and middle-income countries. This study sought to determine the proportion, pattern and risk factors for mortality among very low birth weight (VLBW) neonates with NEC in a middle-income setting. A retrospective observational cohort study was conducted on all infants with birth weights less than 1501 g admitted from 2018 to 2020 at Groote Schuur Hospital, Cape Town, South Africa. Data were obtained from the Vermont Oxford Network and hospital folders. A total of 104/1582 (6.6%) neonates were diagnosed with NEC with a median onset of 8 days of life. The mortality rate was 39.0%, compared to the all-cause mortality rate of 18.7% for VLBW neonates. Thirty-two (32.0%) neonates with NEC were transferred for surgery of whom 10 (31.3%) died. Small for gestational age (p = 0.13), NEC stage 2B or above (p = 0,002), a positive blood culture (p = 0.018), a raised C-reactive protein (p = 0.013), hyponatraemia (p = 0.004), anaemia requiring blood transfusion (p = 0.003) and thrombocytopenia requiring platelet transfusion (p = 0.033) were associated with mortality. A positive blood culture was found in 37.0% with a predominance of Klebsiella pneumoniae isolates. NEC has an early onset and a high mortality rate in our setting.

Multilingual education: medical interns perceptions regarding the usefulness of non-mother tongue communications skills taught during the undergraduate curriculum

BackgroundThis paper investigates the perceptions of medical interns regarding the usefulness of non-mother tongue communication skills taught during the undergraduate curriculum at the University of Cape Town in South Africa. In 2003, the university decided to incorporate Afrikaans and IsiXhosa communication skills into the new MBChB curriculum in order to meet the Faculty of Health Sciences goals to promote quality and equity in healthcare, and to prepare graduating health practitioners for multilingual communities where they would be serving. Despite annual internal evaluations and reviews of the languages courses, the usefulness, if any, of the additional languages in the working clinical environment had not been determined.MethodsData were collected during the second year of medical internship across a five-year period through survey questionnaires, as well as focus group interviews conducted in the Western Cape, South Africa. Surveys were conducted from 2009 to 2013.ResultsThe study shows that the usefulness of each of the probed categories was not consistent across both languages. The interns expressed a need for an overall improvement of the isiXhosa course offering, while the outcomes for the Afrikaans language were more positive across all categories except for cultural understanding.ConclusionThe study indicates a positive trend amongst the interns towards developing usefulness in communication skills in Afrikaans and isiXhosa to communicate with their patients.

Cultivating leaders for primary health care: A revised approach for transformative development.

Family physicians require leadership skills to strengthen team-based primary care services. Interviews with South African district managers confirmed the need to develop leadership skills in family physicians. The updated national programmatic learning outcomes for South African family physician training were published in 2021. They sparked the need for curriculum renewal at the University of Cape Town's Division of Family Medicine. A review of the leadership and governance module during registrar training showed that the sessions were perceived to be content heavy with insufficient opportunities for reflection. Following a series of stakeholder engagements, the module convenors co-designed a revised module that was blueprinted on the updated learning outcomes. The module incorporates a group coaching style, facilitating learning through reflection on one's experiences. The revised module was implemented in 2022. It aims to provide a transformative learning experience centred on students' perceptions of themselves as leaders, as well as professional identity formation and resilience building. This short report describes preliminary insights from the revised module's developmental phase and forms part of an ongoing iterative evaluation process.Contribution:Family physicians should lead across all their defined roles. Formal and informal learning opportunities are needed to facilitate their growth as leaders and help them to meet the health needs of communities served by an evolving health care system. This short report describes an example of a revised postgraduate module on leadership and governance, which may be of value to clinician educators and academic departments exploring innovative methods for the African region.

Every loaf of bread is political – Reflections on collective care responses to Covid-19 in Cape Town

Feminist perspectives on care have demonstrated how capitalism undervalues care work. The Covid-19 pandemic highlighted this further, as systems of production and social reproduction became destabilized globally. In many countries, the formal pandemic response fell short of attending to the daily, fundamental care needs of people living through the crisis, especially those compromised by the socio-economic effects of the pandemic. These needs were often attended to at the community level. This article explores a community-led network of care, known as CANs, that emerged in response to the pandemic in Cape Town. It makes three overarching observations. The first is that community-led responses were characterised by a push towards the collectivisation of care work. The second is that this enabled emergent strategies and relational practices of care, centring notions of solidarity, inter-dependence and horizontal exchange of resources and knowledge. Finally, we observed that, although the devaluation of care work limited the recognition and material support extended to CANs, opportunities to re-politicise care work as resistance work emerged. These represent a prefigurative moment in which alternative logics and strategies can transform the vision of our health and care systems, and the notion of community participation in and ownership of those systems.

Experiences and Perceptions of Menstrual Hygiene Management (MHM) Among Homeless Women in Cape Town

This study qualitatively explored the experiences and perceptions of period poverty among homeless women in Cape Town, South Africa, using the Capability Approach. The study was guided by a qualitative research design and non-probability sampling was used in recruiting participants. In-depth interviews were conducted with 16 homeless women who experienced period poverty. The individual interviews were done mainly in English and in IsiZulu and isiXhosa. The interviews lasted for a minimum of 45 minutes and were voice-recorded using a phone. A semi-structed interview schedule with 33 open-ended questions was used during the data collection process. The data analysis aspect of this study relied on the work of Creswell (2012) and Tesch (1990). The findings revealed that homeless women experience period poverty due to a lack of sanitary products and poor Menstrual Hygiene Management (MHM). Sen (1999) identified five ‘instrumental freedoms’ that, according to him, play a role in the general capability of a person to live more freely. Of the five instrumental freedoms, the third freedom,’ social opportunities,’ resonates deeply with this study. This freedom refers to facilities and arrangements available to uplift society. Examples of this would be access to quality education and healthcare. Homeless women lack access to quality healthcare and therefore experience obstacles to achieve effective MHM. The lack of sanitary products causes homeless women to resort to the unhygienic use of items such as rags, old socks, tissue paper, paper towels, torn pieces of clothing, or diapers, to satisfy their menstrual needs. Alternatively, they go about life without any menstrual protection and bleed through their undergarments and clothing. This results in them wearing blood-soaked items for days, or even weeks. Additionally, homeless women do not have access to safe water and sanitation facilities that are required to effectively manage their period. The paper serves as a means of highlighting how life, government policy, funding, etc. are still restricted to issues that relate to men. As a result, a multifaceted and holistic approach to addressing period poverty amongst homeless women is encouraged and provision should be made for the type of sanitary products and facilities that homeless women are most comfortable using.

Research ethics and artificial intelligence for global health: perspectives from the global forum on bioethics in research

BackgroundThe ethical governance of Artificial Intelligence (AI) in health care and public health continues to be an urgent issue for attention in policy, research, and practice. In this paper we report on central themes related to challenges and strategies for promoting ethics in research involving AI in global health, arising from the Global Forum on Bioethics in Research (GFBR), held in Cape Town, South Africa in November 2022.MethodsThe GFBR is an annual meeting organized by the World Health Organization and supported by the Wellcome Trust, the US National Institutes of Health, the UK Medical Research Council (MRC) and the South African MRC. The forum aims to bring together ethicists, researchers, policymakers, research ethics committee members and other actors to engage with challenges and opportunities specifically related to research ethics. In 2022 the focus of the GFBR was “Ethics of AI in Global Health Research”. The forum consisted of 6 case study presentations, 16 governance presentations, and a series of small group and large group discussions. A total of 87 participants attended the forum from 31 countries around the world, representing disciplines of bioethics, AI, health policy, health professional practice, research funding, and bioinformatics. In this paper, we highlight central insights arising from GFBR 2022.ResultsWe describe the significance of four thematic insights arising from the forum: (1) Appropriateness of building AI, (2) Transferability of AI systems, (3) Accountability for AI decision-making and outcomes, and (4) Individual consent. We then describe eight recommendations for governance leaders to enhance the ethical governance of AI in global health research, addressing issues such as AI impact assessments, environmental values, and fair partnerships.ConclusionsThe 2022 Global Forum on Bioethics in Research illustrated several innovations in ethical governance of AI for global health research, as well as several areas in need of urgent attention internationally. This summary is intended to inform international and domestic efforts to strengthen research ethics and support the evolution of governance leadership to meet the demands of AI in global health research.

Rhodes Must Fall and the incongruence of academic freedom and decoloniality

ABSTRACT This study explores the rise of decolonial-styled politics within the University of Cape Town and the University of Oxford and the natural limitations of this form of politics within the ambit of academic freedom as understood by both universities. Leveraging the Rhodes Must Fall movement as a case study of translocal student activism which emerged at both institutions, the paper underscores the necessity of delineating the pursuit of decoloniality within the university into two constitutive components: decolonial thought and decolonial action. The paper argues that without this delineation, the decolonial projects within universities will remain inept.

A comparative analysis of responses to the COVID-19 tourism disruptions among small, medium and micro enterprises in coastal locations: Case studies of Cape Town and Durban, South Africa

ABSTRACT Tourism businesses at coastal locations contribute to job creation and local economic development. There is limited research on COVID-19 and Coastal and Marine Tourism (CMT) Small, Medium and Micro Enterprises (SMMEs) that adopts a comparative approach. The stakeholder theory and diffusion theory frame the research. In total, 446 surveys were conducted with SMMEs at purposively selected coastal tourism locations in Cape Town (219) and Durban (227), key CMT destinations in South Africa, enabling a comparative analysis to be undertaken using descriptive (frequency and percentages) and inferential (chi-squared tests) statistics. The primary findings indicate significant differences in the profiles and COVID-19 responses of SMMEs, with Cape Town SMMEs adopting more strategies. SMMEs adopted diverse tools and measures to deal with the pandemic. The study recommends that interventions need to consider locality-specific aspects and funding and training should be provided to better position tourism SMMEs to be resilient in a world where disruptions are likely to be experienced more regularly.

Leveraging healthcare standards-based improvement initiatives to support learning and continuous improvement: lessons from implementing the Ideal Clinic programme in Cape Town, South Africa

Abstract This paper draws on the experiences of a group of health system leaders and researchers in leading and supporting, respectively, the implementation of the Ideal Clinic Realisation and Maintenance Framework (ICRMF) in Cape Town, South Africa. The ICRMF is a national standards-based quality improvement initiative that seeks to improve the quality of care in public primary healthcare (PHC) facilities. We share lessons learned on how efforts to improve healthcare standards can be leveraged for learning and meaningful system change. A three-pronged approach to improving the implementation of the ICRMF was used in 15 PHC facilities across two sub-districts. The approach included i) nurturing trust, ii) changing the ICRMF assessment strategy and iii) promoting a collaborative and collective sense-making approach to understanding performance and addressing gaps. Routine ICRMF quantitative data and qualitative feedback from both the ICRMF assessment process and routine management meetings were used to reflect on the experience of using this approach and to draw lessons. The results and conclusions were further confirmed through member-checking. We found that using the three-pronged approach, the ICRMF assessments were able to facilitate deep and reflexive conversations about everyday health system challenges facing healthcare delivery in the sub-districts, while encouraging collective sensemaking and collaboration. The ICRMF was often perceived as a compliance-driven exercise with limited value on the actual quality of care. The three-pronged approach helped shift some of these perceptions and improved the experiences of facility managers in implementing the programme. However, it became clear that leveraging the full potential of the ICRMF requires health system leaders to recognise and consider the on-the-ground realities of health system change and the micropolitics of QI. Failure to recognise these issues and intentionally tackle them can result in negative unintended consequences and undermine improvement efforts.

Investigating the effect of ambient light conditions on road traffic crashes: The case of Cape Town, South Africa

Investigating the risk of road crashes associated with ambient light is often challenged by bias resulting from confounding effects of other risk factors. The study used the odds ratio and the risk ratio methods to isolate the effect of ambient light from other risk factors. This was possible in this research using the ‘whole-year’ approach adopted in previous research and utilising seasonal variations in ambient light in Cape Town. The analysis was based on crash and ambient light data collected between 2014 and 2018 in Cape Town. A total of 361 452 crashes were reported during this period. With only minor exceptions, the results confirm a higher crash risk in both twilight and dark conditions. The increase in the risk was different depending on the ambient light level, the crash type (total and pedestrian crashes) and the time of the day (morning and evening times). The results suggest that more efforts need to be made to assist road users to travel safely under twilight and dark conditions.