Health Districts In South Africa Research Articles

Community perceptions of community health worker effectiveness: Contributions to health behaviour change in an urban health district in South Africa

Background. Community health worker (CHW) programmes contribute towards strengthening adherence support, improving maternal and child health outcomes and providing support for social services. They play a valuable role in health behaviour change in vulnerable communities. Large-scale, comprehensive CHW programmes at health district level are part of a South African (SA) strategy to re-engineer primary healthcare and take health directly into communities and households, contributing to universal health coverage. Objective. These CHW programmes across health districts were introduced in SA in 2010 - 11. Their overall purpose is to improve access to healthcare and encourage healthy behaviour in vulnerable communities, through community and family engagements, leading to less disease and better population health. Communities therefore need to accept and support these initiatives. There is, however, inadequate local evidence on community perceptions of the effectiveness of such programmes. Methods. A cross-sectional descriptive study to determine community perceptions of the role and contributions of the CHW programme was conducted in the Ekurhuleni health district, an urban metropolis in SA. Members from 417 households supported by CHWs were interviewed in May 2019 by retired nurses used as fieldworkers. Frequencies and descriptive analyses were used to report on the main study outcomes of community acceptance and satisfaction. Results. Nearly all the study households were poor and had at least one vulnerable member, either a child under 5, an elderly person, a pregnant woman or someone with a chronic condition. CHWs had supported these households for 2 years or longer. More than 90% of households were extremely satisfied with their CHW; they found it easy to talk to them within the privacy of their homes and to follow the health education and advice given by the CHWs. The community members highly rated care for chronic conditions (82%), indicated that children were healthier (41%) and had safer pregnancies (6%). Conclusion. As important stakeholders in CHW programmes, exploring community acceptance, appreciation and support is critical in understanding the drivers of programme performance. Community acceptance of the CHWs in the Ekurhuleni health district was high. The perspective of the community was that the CHWs were quite effective. This was demonstrated when they reported changes in household behaviour with regard to improved access to care through early screening, referrals and improved management of chronic and other conditions.

Oral Health Status of Illicit Drug Users in a Health District in South Africa.

The prevalence of illicit drug use and its associated oral health complications have been increasing in South Africa (SA). There has been a paucity of studies to determine the oral health status among illicit drug users in SA. This study aimed to determine the oral health knowledge, practices, and status of illicit drug users at rehabilitation centers in a district in SA. This was a cross-sectional study conducted at four rehabilitation centers in Pretoria, SA. Data were collected using a validated self-administered questionnaire and an oral examination. The questionnaire consisted of three parts: demographics, oral health knowledge, and oral health practices. The oral examination was conducted by a calibrated researcher and included caries, periodontal status, dental erosion, trauma, and soft tissue lesions. The data were analyzed using the Statistical Package for Social Sciences (SPSS) software. The mean age was 25.5 (±7.49) years with 91% being male. The majority (84%) of patients were Black, and almost all (87%) had never received oral health education; 55% were not aware that illicit drugs could have an impact on the oral health status and 40% had never had a prior dental consultation. The caries prevalence was 68% with a mean decayed, missing and filled teeth (DMFT) score of 5.3 (±6.18). More than half (58%) required periodontal treatment and there were minimal soft and hard tissue lesions diagnosed. Those who perceived their teeth to be in a poor condition had a significantly higher Decayed, Missing and Filled Teeth (DMFT) score compared with those who perceived their oral health to be good. Just under half (41.9%) of the participants did not need any periodontal intervention, with the other half presenting with plaque retention or calculus and thus needed oral hygiene intervention inclusive of scaling and polishing. There was minimal evidence of pathological oral lesions with only 1.5% presenting with necrotizing periodontal disease (NPD). Overall, there was generalized poor oral hygiene CONCLUSION: Many of the participants had poor oral hygiene knowledge and practices and a relatively high prevalence of caries. It is imperative that oral health promotion and education is incorporated into the medical interventions provided at rehabilitation centers.

When Pregnancy Coincides with Positive Diagnosis of HIV: Accounts of the Process of Acceptance of Self and Motherhood among Women in South Africa.

Literature has highlighted the unique period of vulnerability following an HIV diagnosis during pregnancy. Despite the high burden of HIV among pregnant women in South Africa, the experiences of women diagnosed with HIV during pregnancy have rarely been explored in isolation from those diagnosed at different times. This paper explored the experiences of women who were diagnosed with HIV when pregnant and assessed their emotional recovery beyond diagnosis. The study used a qualitative descriptive phenomenological approach to conduct interviews with women recruited from ART clinics in a health district in South Africa. Participants included 19 women sampled purposively. The interviews were transcribed verbatim and analysed following the thematic approach. Testing positive during pregnancy and being free of symptoms increased the shock, disbelief, and strong emotions exhibited. For the women, the diagnosis of HIV coincided with pregnancy and transformed pregnancy from excitement to anxiety. Although the transition from being HIV negative to becoming HIV positive and pregnant was overwhelming, with the passage of time, the women transitioned to feelings of acceptance. However, the process of acceptance was slow and varied, with some experiencing non-acceptance for extended periods. Non-acceptance of HIV diagnosis has serious adverse public health consequences for the individual. Integrating continuous HIV counselling and culturally appropriate psychosocial care into practice could foster acceptance for pregnant women with HIV diagnosis.

Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: the experience of an urban health district in South Africa

IntroductionSouth Africa is an upper middle-income country with wide wealth inequality. It faces a quadruple burden of disease and poor health outcomes, with access to appropriate and adequate health care a challenge for millions of South Africans. The introduction of large-scale, comprehensive community health worker (CHW) programs in the country, within the context of implementing universal health coverage, was anticipated to improve population health outcomes. However, there is inadequate local (or global) evidence on whether such programs are effective, especially in urban settings.MethodsThis study is part of a multi-method, quasi-experimental intervention study measuring effectiveness of a large-scale CHW program in a health district in an urban province of South Africa, where CHWs now support approximately one million people in 280,000 households. Using interviewer administered questionnaires, a 2019 cross-sectional survey of 417 vulnerable households with long-term CHW support (intervention households) are compared to 417 households with no CHW support (control households). Households were selected from similar vulnerable areas from all sub-levels of the Ekurhuleni health district.ResultsThe 417 intervention and control households each had good health knowledge. Compared to controls, intervention households with long-term comprehensive CHW support were more likely to access early care, get diagnosed for a chronic condition, be put on treatment and be well controlled on chronic treatment. They were also more likely to receive a social grant, and have a birth certificate or identity document. The differences were statistically significant for social support, health seeking behavior, and health outcomes for maternal, child health and chronic care.ConclusionA large-scale and sustained comprehensive CHW program in an urban setting improved access to social support, chronic and minor acute health services at household and population level through better health-seeking behavior and adherence to treatment. Direct evidence from households illustrated that such community health worker programs are therefore effective and should be part of health systems in low- and middle-income countries.

Intimate Partner Violence and the HIV Care and Treatment Cascade Among Adolescent Girls and Young Women in DREAMS, South Africa.

Intimate partner violence (IPV) may affect the HIV-treatment cascade. Four high HIV-prevalence DREAMS health districts in South Africa. Secondary analysis of cross-sectional data collected March 2017-June 2018, using random household sample of young (12-24 years) girls and women. Face-to-face interviews assessed IPV and HIV-status knowledge, and finger-prick blood draws assessed ART (antiretroviral therapy) uptake and viral suppression. We used logistic regression to estimate crude and adjusted effects of IPV on HIV knowledge, ART uptake, and viral suppression. Of 18,230 adolescent girls and young women, 8413 (46%) reported ever having had sex, of whom 1118 (13%) were HIV positive. The 90:90:90 benchmarks were 61% knew their status, 86% had ART present in their blood sample, and 91% were virally suppressed. Among the entire sample of young women living with HIV, 65.6% were virally suppressed. Past year IPV was reported by 15%. In adjusted models, IPV trended toward increasing the odds that a young woman was aware she was living with HIV [adjusted odds ratios (aOR) = 1.40, 2.00-9.98, P = 0.067]. There was no association between IPV and reduced treatment use (aOR = 0.73, 0.41-1.29). IPV was independently associated with reduced viral suppression (aOR = 0.30, 0.13-0.66). Addressing the role of IPV in undermining the treatment cascade for adolescent and young women is a critical issue for HIV programming.

The HIV care cascade for adolescents initiated on antiretroviral therapy in a health district of South Africa: a retrospective cohort study

BackgroundLittle evidence exists to comprehensively estimate adolescent viral suppression after initiation on antiretroviral therapy in sub-Saharan Africa. This study examines adolescent progression along the HIV care cascade to viral suppression for adolescents initiated on antiretroviral therapy in South Africa.MethodsAll adolescents ever initiated on antiretroviral therapy (n=1080) by 2015 in a health district of the Eastern Cape, South Africa, were interviewed in 2014–2015. Clinical records were extracted from 52 healthcare facilities through January 2018 (including records in multiple facilities). Mortality and loss to follow-up rates were corrected for transfers. Predictors of progression through the HIV care cascade were tested using sequential multivariable logistic regressions. Predicted probabilities for the effects of significant predictors were estimated by sex and mode of infection.ResultsCorrected mortality and loss to follow-up rates were 3.3 and 16.9%, respectively. Among adolescents with clinical records, 92.3% had ≥1 viral load, but only 51.1% of viral loads were from the past 12 months. Adolescents on ART for ≥2 years (AOR 3.42 [95%CI 2.14–5.47], p< 0.001) and who experienced decentralised care (AOR 1.39 [95%CI 1.06–1.83], p=0.018) were more likely to have a recent viral load. The average effect of decentralised care on recent viral load was greater for female (AOR 2.39 [95%CI 1.29–4.43], p=0.006) and sexually infected adolescents (AOR 3.48 [95%CI 1.04–11.65], p=0.043). Of the total cohort, 47.5% were recorded as fully virally suppressed at most recent test. Only 23.2% were recorded as fully virally suppressed within the past 12 months. Younger adolescents (AOR 1.39 [95%CI 1.06–1.82], p=0.017) and those on ART for ≥2 years (AOR 1.70 [95%CI 1.12–2.58], p=0.013) were more likely to be fully viral suppressed.ConclusionsViral load recording and viral suppression rates remain low for ART-initiated adolescents in South Africa. Improved outcomes for this population require stronger engagement in care and viral load monitoring.

Parenting the child with HIV in limited resource communities in South Africa: mothers with HIV’s emotional vulnerability and hope for the future

Introduction:A diagnosis of HIV does not affect the well-being of mothers alone but also affects how they care for their children. The aim of this study was to explore how mothers who were diagnosed with HIV when pregnant or when their children became ill experience raising children living with HIV. The purpose was to understand how a diagnosis of HIV impacts mothering their children at different points on the mothering journey.Methods:Using descriptive phenomenological enquiry, interviews were conducted with 28 mothers recruited via purposeful sampling from clinics in health district in South Africa. The interviews were audiotaped, transcribed verbatim, and analysed following the thematic approach.Results:The mothers found mothering a child living with HIV stressful and associated with constant thoughts of death. The burden of mothering was increased for mothers who had to confront emotions of self-blame and guilt for unintentionally infecting the child. They used secrecy to protect their children from the social consequences of a diagnosis of HIV. The thought of living with HIV weighed on them every day and they expressed their experience of intense feelings of chronic worry, anxiety, and sadness. The findings identified high levels of stress, with the mothers expressing emotions suggestive of depression. With time, they accepted living with HIV and embraced motherhood, and became better mothers.Conclusion:The negative coping strategies used to deal with the child’s HIV diagnosis and high levels of stress and anxiety identified in the study underscore the need to address the psychosocial needs of mothers living with HIV. There is need to provide psychosocial support and continuous counselling for these mothers post diagnosis and upon a positive HIV diagnosis of the child to women enrolled in the prevention of mother to child transmission of HIV programme.

A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa

BackgroundThe KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district.MethodsA packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data.ResultsMkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation.ConclusionsThe packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Clinical and Obstetric Risk Factors for Postnatal Depression in HIV Positive Women: A Cross Sectional Study in Health Facilities in Rural KwaZulu-Natal.

Postnatal depression (PND) remains underdiagnosed and undertreated in different socio-economic backgrounds in South Africa. This study determined the prevalence of and clinical and obstetric risk factors for PND symptoms among HIV positive women in health facilities in a rural health district in South Africa. The Edinburgh Postnatal Depression Scale was used to measure PND from 386 women who had delivered a live infant. More than half (58.5%) tested HIV positive during the current pregnancy. The prevalence of PND symptoms was 42.5%. Logistic regression analysis yielded significant associations between clinical and obstetric variables of pre-term baby (p-value < 0.01), baby health status p-value < 0.01), baby hospitalization, (p-value < 0.01), and knowing the baby’s HIV status (p-value = 0.047). Maternal variables associated with PND were level of education (p-value < 0.01), monthly income (p-value < 0.01), and source of income (p-value = 0.05). At multivariate analysis, none of the clinical and obstetrical risk factors were independently associated with the PND. The high prevalence of PND symptoms underscore the need to integrate routine screening for PND in prevention of mother to child transmission of HIV programmes to enable early diagnosing and treatment of PND.

A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa

BackgroundChronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model.MethodsThis was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically.ResultsThe median age of participants was 36.5 (IQR: 30.8–45.5) years, and they had been in their roles for a median of 4.0 (IQR: 1.0–7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure, adequate staff, and balanced patient caseloads.ConclusionThere are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.

Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa

BackgroundThe Integrated Chronic Disease Management (ICDM) model has been implemented in South Africa to enhance quality of clinical services in Primary Healthcare (PHC) clinics in a context of a high prevalence of chronic conditions and multi-morbidity. This study aimed to assess the implementation fidelity (adherence to guidelines) of the ICDM model.MethodsA cross-sectional study in 16 PHC clinics in two health districts in South Africa: Dr. Kenneth Kaunda (DKK) and West Rand (WR). A fidelity assessment tool with 89 activities and maximum score of 158 was developed from the four interrelated ICDM model components: facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems. Value stream mapping of patient flow was conducted to analyse waiting time and identify operational inefficiencies. ICDM items were scored based on structured observations, facility document reviews and structured questionnaires completed by healthcare workers. Fidelity scores were summarized using medians and proportions and compared by facilities and districts using Chi-Square and Kruskal Wallis test.ResultsThe monthly patient headcount over a six-month period in these 16 PHC clinics was a median of 2430 (IQR: 1685–2942) individuals over 20 years. The DKK district had more newly diagnosed TB patients per month [median 5.5 (IQR: 4.00–9.33) vs 2.0 (IQR: 1.67–2.92)], and fewer medical officers per clinic [median 1 (IQR: 1–1) vs 3.5 (IQR:2–4.5)] compared to WR district. The median fidelity scores in both districts for facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems were 78% [29/37, IQR: 27–31)]; 77% [30/39 (IQR: 27–34)]; 77% [30/39 (IQR: 28–34)]; and 80% [35/44 (IQR: 30–37)], respectively. The overall median implementation fidelity of the ICDM model was 79% (125/158, IQR, 117–132); WR was 80% (126/158, IQR, 123–132) while DKK was 74% (117/158, IQR, 106–130), p = 0.1409. The lowest clinic fidelity score was 66% (104/158), while the highest was 86% (136/158). A patient flow analysis showed long (2–5 h) waiting times and one stream of care for acute and chronic services.ConclusionThere was some variability of scores on components of the ICDM model by PHC clinics. More research is needed on contextual adaptations of the model.

Changing priorities in maternal and perinatal health in Gert Sibande District, South Africa

Gert Sibande District is a predominantly rural district in Mpumalanga Province, South Africa (SA), with a population of just over 1.1 million. It has a high prevalence of HIV infection and pregnancy-related hypertensive disease. In 2010 the district was one of the worst-performing health districts in SA, with a maternal mortality ratio of 328.0 per 100 000 births. Various programmes were introduced between 2010 and 2017 to address major causes of maternal and perinatal morbidity and mortality in the district. The focus has been on HIV-related morbidity, the direct obstetric causes of maternal and perinatal morbidity and mortality, and health systems strengthening. During the period 2010 - 2017, there was a steady decline in institutional maternal mortality with a drop of 71% in maternal deaths over a period of 6 years, from 328.0 per 100 000 births to 95.0. However, the ratio levelled off in 2016 and 2017, mainly as a result of a changing disease profile. The stillbirth rate showed a decline of 24.4% over a period of 8 years. With perseverance, rapid response and evidence-based strategies it was possible to more than halve the institutional maternal mortality ratio within 6 years. However, with the changing disease profile, conditions such as hypertensive disease in pregnancy should be prioritised and new strategies developed to further reduce maternal and perinatal mortality and morbidity.

ImPROving TB outcomes by modifying LIFE-style behaviours through a brief motivational intervention followed by short text messages (ProLife): study protocol for a randomised controlled trial

BackgroundSouth Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes.MethodsThis is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups.DiscussionThis trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings.Trial registrationISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018.

Impact of Xpert MTB/RIF assay on multidrug-resistant tuberculosis treatment outcomes in a health district in South Africa.

Xpert MTB/RIF assay rapidly diagnoses rifampicin resistance, enabling early initiation of second-line tuberculosis (TB) treatment. However, the impact of an earlier multidrug-resistant TB (MDR-TB) diagnosis on treatment outcomes is unknown. To compare MDR-TB treatment outcomes in cases diagnosed with smear/culture and Xpert. This was a retrospective cohort study with cohorts defined by the diagnostic assay used in presumptive TB cases. Data were extracted from a drug-resistant (DR)-TB register including cases from January 2012 to June 2014. Treatment outcomes were assessed at recorded endpoints or after 2 years for those completing treatment. A total of 718 cases were enrolled into the study. Cure rates were 43.4% (n=158) for the smear/culture cohort and 33.5% (n=118) for the Xpert cohort (p&lt;0.01). Xpert diagnosis (adjusted risk ratio (aRR) 0.65; p=0.02) and male gender (aRR 0.66; p=0.04) were associated with cure outcome. Xpert diagnosis increased time to sputum culture conversion from 4 to 5 months (log-rank test p=0.01). Time to treatment initiation was not associated with treatment success in logistic regression analysis. Despite rapid treatment initiation, MDR-TB treatment outcomes were poorer in patients diagnosed with Xpert MTB/RIF assay than in the smear/culture cohort, and they were also poorer in men than in women. Additional studies are required to assess possible factors influencing DR-TB outcomes.

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa

BackgroundIn 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others.MethodsA multiple case study design comprising three cases was conducted. Data collection in 2012 – early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts.ResultsManagers valued the national Minister of Health’s role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved.ConclusionThose driving reform processes from ‘the top’ must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.

Awareness of the Ward Based Outreach Team and the services offered by the programme in the Tshwane health district, South Africa

Background: The Ward Based Outreach Team (WBOT) is an organised team approach to a healthcare system based on the principles of epidemiology, primary health care, preventive medicine and health promotion. Globally, it has become a primary care response to many health challenges such as universal health coverage. The beneficiaries are community members, also referred to as households.Methods: The study assessed the awareness of the WBOT and the services offered by the programme in the Tshwane health district of South Africa. This was a cross-sectional survey conducted in all seven sub-districts of the health district. The health district is further sub-divided into 150 health wards. Eighty-five health wards were randomly selected for the study. Using the sample size calculator, with a confidence interval of 5% and confidence level of 99%, the sample size of participants was 654. However, during the data collection process there was over-sampling of up to 764. Participants were recruited by convenience sampling. Data were collected between October 12 and December 3, 2015, using a pre-piloted, structured questionnaire administered by 14 trained field workers.Results: The study obtained 6 288 responses from the 764 participants. The responses were grouped into two sections, ‘Yes’ and ‘No’. A summary of the responses showed that the number of ‘yes’ responses, the number of participants who were aware of the WBOT and the services offered by the programme were higher than the number of participants who were unaware of the programme. The figures were 5 590 (88.8%) ‘yes’ responses and 698 (11.1%) ‘no’ responses.Conclusion: In summary, the awareness of the WBOT and the services offered by the programme in the Tshwane health district, South Africa is evaluated to be 88.8%.

A Packaged Intervention to Improve Viral Load Monitoring within a Deeply Rural Health District of South Africa

A Packaged Intervention to Improve Viral Load Monitoring within a Deeply Rural Health District of South Africa

Suicidal thoughts and behaviour among South African adolescents living with HIV: Can social support buffer the impact of stigma?

BackgroundAdolescents living with HIV represent a high-risk population for suicidal ideation and attempts, especially in low-income settings. Yet little is known about risk and protective factors for suicide in this population. MethodsA moderated mediation model was employed to test for potential (a) effects of stigma on suicidal ideation and attempts, both direct and mediated through depression and (b) direct and stress-buffering effects of social support resources on depression and suicidal ideation and attempts, among 1053 HIV-positive 10–19-year-old adolescents from a resource-scarce health district in South Africa. The survey data was collected using full community sampling of 53 clinics and tracing to over 180 communities. Effects of two support resources were tested: perceived support availability from the adolescents’ social network and structured clinic support groups. Stigma was measured using the ALHIV-SS scale, depression through the CDI short form and social support through items from the MOS-SS. ResultsStigma was a risk factor for depression (B = 0.295; p < 001) and for suicidal thoughts and behaviour (B = 0.185; p < .001). Only perceived support availability was directly associated with less depression (B = −0.182, p < .001). However, both perceived support availability and support group participation contributed to the overall stress-buffering effects moderating the direct and indirect relationships between stigma and suicidal thoughts and behaviour. LimitationsThe data used in this study was self-reported and cross-sectional. ConclusionsFindings suggest that strengthening multiple social support resources for HIV-positive adolescents, through early clinic and community-based interventions, may protect them from experiencing poor mental health and suicidal tendencies.

Risks of Preterm Labour among Women Who Attend Public Antenatal Care Clinics

Preterm births are the leading cause of perinatal morbidity and mortality worldwide. Complications of prematurity are the single largest cause of neonatal death and the second leading cause of deaths among children under the age of five years. The study aimed to identify the possible causes for preterm labour among women who attend antenatal care clinics in the East London area of the Buffalo City Metropolitan Health District in South Africa. A quantitative, explorative, descriptive, and retrospective design was used. The target population was women who delivered preterm infants in the year 2014. Patient files were used to collect the data and simple random sampling was used to select patient files. The sample only included women who delivered preterm infants who received antenatal care at primary healthcare clinics. An audit tool was developed and used to collect data. The findings suggest that many of the women did not receive quality antenatal care with certain tests and procedures being omitted and underreported by nurses, leading to some conditions being poorly monitored or even undiagnosed. In conclusion, many preterm births could be prevented among women who attend antenatal care clinics, provided that they attend early, adhere to return dates and experience quality basic antenatal care services.

South African health decentralisation: requiring contextually intelligent leaders

Subject area Public Health; Leadership; Organisational Development; Organisational Behaviour; Public Administration Management. Study level/applicability Postgraduate level for honours or masters programmes in courses on public health; executive leadership and management programmes; MBA level. Case overview The case unpacks decentralisation as a means to promote and improve local decision-making and accountability through community participation and engagements. Ayanda Nkele was a programme manager in a health district in South Africa. He was faced with many challenges when trying to implement his programme, most of which were related to local authority, responsibilities and decision-making abilities at his level. This case describes briefly the South African health system. and how it functions. It describes the proposed changes to the health system and its transformation towards Universal Health Coverage. The decision space analysis as discussed in the case illustrates the types of decentralisation in the country and how this also applies to Nkele’s level. Expected learning outcomes Understanding the concepts and principles of decentralisation within the context of strengthening district health services, the re-engineering of primary health care (PHC) and rolling out a National Health Insurance in South Africa. Applying the “decision space” approach to analyse the extent of decentralisation. Grasping the requirement of leaders to be “contextually intelligent” and identify the important contextual variables to take into account when analysing public health care. Supplementary materials Teaching Notes are available for educators only. Please contact your library to gain login details or email support@emeraldinsight.com to request teaching notes. Subject code CSS 7: Management Science.