South African Programme Research Articles

Strengthening primary care mental health services - lessons from the South African HIV programme.

Strengthening primary care mental health services - lessons from the South African HIV programme.

Courier delivery of antiretroviral therapy: a cohort study of a South African private-sector HIV programme.

Courier delivery has become a popular antiretroviral therapy (ART) distribution method in some HIV care settings, yet data on ART courier delivery and how it relates to ART outcomes are scarce. We studied the differences in viral suppression rates between individuals from a South African private sector HIV programme receiving ART by courier delivery and those receiving ART through traditional retail dispensing. Individuals aged 15 years or older who were actively enrolled in the Aid for AIDS programme between January 2011 and July 2022 were eligible for the analysis. The outcome of interest was viral suppression defined as a viral load (VL) <400 copies per ml. We calculated adjusted odds ratios (OR) for the association between the ART distribution method and viral suppression, comparing those receiving refills through courier pharmacies versus retail dispensing at the time of the VL testing. We used generalized estimating equations to account for repeated VL testing of the same individual. The models were adjusted for age, sex, calendar year, ART regimen, history of mental illness and medical insurance scheme. We computed adjusted ORs for the calendar periods 2011-2013, 2014-2016, 2017-2019, 2020-2022 and overall. We extracted 442,619 VL measurements from 68,720 eligible individuals, 39,406 (57.3%) were women. The median number of VL measurements per individual was 6 (IQR 3-10). VL suppression was detected in 398,901 (90.1%) tests, and 185,701 (42.0%) of the tests were taken while the individual was receiving ART by courier delivery. Overall, courier delivery was associated with 5% higher odds of viral suppression than retail dispensing (adjusted OR 1.05, 95% CI 1.02-1.08). The strength and direction of this association varied by calendar period, with an adjusted OR of 1.37 (95% CI 1.27-1.48) in 2011-2013 and 1.02 (95% CI 0.97-1.07) in 2020-2022. Courier delivery of ART is a viable alternative to retail dispensing in the South African private sector, as it was associated with higher viral suppression until 2016 and similar suppression rates in recent years. Further research is needed to investigate the potential benefits and drawbacks of courier delivery of ART in both private and public healthcare settings.

A South African case study on anatomical embalming for human body donation programmes with toxicological considerations

Body embalming, a practice with deep historical roots across various cultures, forms the backbone of contemporary human body donation educational programmes. In this study, we explored current embalming practices within six South African human anatomical dissection programmes, focusing on the use and volumes of key chemicals—formalin, phenol, and alcohol—and their associated health risks and potential toxicity. We measured and compared aspects of embalming practices such as the duration of body preservation and the annual intake of bodies. Variations in embalming practices and chemical ratios across different South African universities were found. However, the consistent use of formalin, phenol and alcohol were observed across all six programmes. Formaldehyde concentrations used in South African dissection programmes were within the generally acceptable international range. Regarding arterial embalming, South African dissection programmes showed widespread adherence to international embalming practices, with one programme using a substantially lower concentration of formalin. The dual nature of formaldehyde as both an effective preservative and a recognised carcinogen was underscored in relation to human health regarding chemical toxicity. Phenol, like formaldehyde, was consistently used as it is important for the inhibition of bacterial and fungal growth. Alcohol was also consistently used, but there was much greater variation in its volume across South African institutions. Our data showed a slight positive relationship between storage duration and the volumes of formalin and phenol in human embalming fluid. South African regulators enforce stricter exposure limits than those set by the World Health Organisation and various European agencies. While South African institutions operate within internationally acceptable ranges of chemical use that both maximise preservation and minimise toxicity, we acknowledge that these data are preliminary. Further investigation is encouraged to ensure embalming practices effectively protect all those involved and support the educational goals of human anatomical dissection programmes in South Africa.

Cycles of antibiotic use and emergent antimicrobial resistance in the South African tuberculosis programme (1950-2021): A scoping review and critical reflections on stewardship

ABSTRACT The emergent threat of antimicrobial resistance (AMR) has resulted in debates around the use and preservation of effective antimicrobials. Concerns around AMR reflect a history of increasing dependence on antibiotics to address disease epidemics rooted in profound structural and systemic challenges. In the context of global health, this process, often referred to as pharmaceuticalisation, has commonly occurred within disease programmes, of which lessons are vital for adding nuance to conversations around antimicrobial stewardship. Tuberculosis (TB) is a notable example. A disease which accounts for one-third of AMR globally and remains the leading cause of death from a single infectious agent in many low – and middle-income countries, including South Africa. In this scoping review, we chart TB science in South Africa over 70 years of programming. We reviewed published manuscripts about the programme and critically reflected on the implications of our findings for stewardship. We identified cycles of programmatic responses to new drug availability and the emergence of drug resistance, which intersected with cycles of pharmaceuticalisation. These cycles reflect the political, economic, and social factors influencing programmatic decision-making. Our analysis offers a starting point for research exploring these cycles and drawing out implications for stewardship across the TB and AMR communities.

Compact Housing for Incremental Growth: The K206 RDP Project in Alexandra, Johannesburg

The South African Reconstruction and Development Programme (RDP) was initiated to provide subsidised housing for low-income families. However, the programme faced challenges in establishing adequate technical guidelines and standards, resulting in subpar housing quality. This article discusses the multifaceted nature of subsidised housing design, emphasising the importance of incorporating technical housing standards as well as the spatial needs of residents based on their context (at both domestic and neighbourhood scales). The article focuses on the K206 housing RDP project in Alexandra, Johannesburg, as a case study that transitioned from generic technical standards to a resident-responsive design scheme that was inspired by the backyard room incremental expansions that were already prevalent in the Alexandra context. A critical review of South Africa’s RDP housing design technical standards and policy is explored. The article also examines the density standards and allowances for incremental expansions introduced by the K206 project, analysing data derived from fieldwork observations, interviews, and the spatial analysis of 26 dwelling units. The study’s findings underscore the significance of maintaining an equilibrium between technical standards and resident-responsive design decisions. The results demonstrate that tailoring the RDP housing design solutions to unique contextual needs can significantly elevate the quality of life of residents concerning income generation and flexibility for incremental expansion. However, this balance is delicate and disparities between the RDP technical standards and user-initiated development over time also have the potential to ultimately impair residents’ living spaces.

Treatment of Multidrug-resistant or Rifampicin-resistant Tuberculosis With an All-oral 9-month Regimen Containing Linezolid or Ethionamide in South Africa: A Retrospective Cohort Study.

In 2019, the South African tuberculosis program replaced ethionamide with linezolid as part of an all-oral 9-month regimen. We evaluated treatment outcomes for patients assigned to regimens including linezolid in 2019 and ethionamide in 2017. This retrospective cohort study included patients treated for multidrug-resistant/rifampicin-resistant tuberculosis throughout South Africa between 1 January and 31 December 2017 and 1 January to 31 December 2019. The cohort treated with a 9-month regimen containing ethionamide for four months, was compared with a cohort treated with a 9-month regimen containing linezolid for 2 months. The regimens were otherwise identical. Inverse probability weighting of propensity scores was used to adjust for potential confounding. A log-binomial regression model was used to estimate adjusted relative risk (aRR) comparing 24-month outcomes between cohorts including treatment success, death, loss to follow up, and treatment failure. Adverse event data were available for the linezolid cohort. In total, 817 patients were included in the cohort receiving ethionamide and 4244 in the cohort receiving linezolid. No evidence for a difference was observed between linezolid and ethionamide regimens for treatment success (aRR = 0.96, 95% confidence interval [CI] .91-1.01), death (aRR = 1.01, 95% CI .87-1.17) or treatment failure (aRR = 0.87, 95% CI .44-1.75). Loss to follow-up was more common in the linezolid group, although estimates were imprecise (aRR = 1.22, 95% CI .99-1.50). No significant differences in treatment success and survival were observed with substitution of linezolid for ethionamide as a part of an all-oral 9-month regimen. Linezolid is an acceptable alternative to ethionamide in this shorter regimen for treatment of multidrug-resistant/rifampicin-resistant tuberculosis.

Emerging Trends in South African Higher Education: A Critical Analysis of Distance Learning Modalities in Music

This study addresses the dynamic shifts in South African higher education, focusing on integrating distance learning into music education. The proliferation of digital platforms has redefined educational paradigms, necessitating a critical examination of its impact on music pedagogy within the South African context. Employing a qualitative critical analysis methodology, this research leverages existing scientific literature to discern patterns, challenges, and opportunities presented by distance learning modalities. Anchored in Jack Mezirow's Transformative Learning Theory, this study investigates emerging trends in distance learning modalities within South African higher education music programmes. Two significant findings emerge: firstly, distance learning fosters student autonomy, enabling self-directed exploration of musical concepts. Secondly, collaborative online environments facilitate cross-cultural musical exchanges, enriching students' cultural understanding and musical proficiency. This study underscores the imperative of harnessing technology for music education in South Africa, emphasising its capacity to democratise access and broaden cultural understanding. The findings contribute to a growing body of literature on transformative learning experiences in music education, offering practical insights for educators and policymakers. As South Africa's educational landscape continues to evolve, this research lays a foundation for the innovative integration of digital platforms, ushering in a new era of inclusive and culturally enriched music education.

Exploring students’ views and experiences of an acupuncture programme at a South African university: Case study

&lt;p align="justify"&gt;Curriculum transformation for 21st-century skills in higher education is gaining much attention nationally and internationally. The African continent is becoming acutely aware of strengthening the curriculum to improve teaching and learning. In this study, the focus is on transforming the acupuncture programme to align with international standards. Streamlining and aligning the South Africa (SA) curriculum programme to international standards will improve patients’ health.&lt;strong&gt; &lt;/strong&gt;The reason is that higher education institutions are responsible for ensuring that their students are competent in the world of work through quality educational programmes. There is an increasing demand for quality acupuncture services for the public. According to the World Health Organization, acupuncture is one of the most popular alternative medicines worldwide. However, there is a lack of research to explore contextualised acupuncture programmes on the African continent. This study aimed to explore the content of the South African acupuncture programme and align it with international standards. To undertake this study, the author employed a qualitative, single-case study by interviewing the students of the programme using a semi-structured interview schedule. The findings of this study revealed that students shared positive views towards the acupuncture programme. They had a clear and accurate understanding of the outcome of the programme. However, participants reported that there was limited clinical exposure in the acupuncture programme, which negatively affected students’ competencies in the working world. This study concluded that there was a need to ensure the contextualised acupuncture programme was benchmarked against international standards. Furthermore, there was a need to improve the infrastructure at the university to ensure adequate training facilities. This study is of profound significance since the identified higher education institution is the only university that provides an acupuncture programme in South Africa.&lt;/p&gt;

An Analysis of the Efficacy of South African MBA Programmes in relation to the 4th Industrial Revolution

Background: MBA programmes are considered flagship business programmes for business individuals. Business schools are often revered for being cutting-edge and critical business thought centres. However, over the years, programmes such as the MBA have been criticised due to their relevance. Changes such as the Covid-19 pandemic, the 4th Industrial Revolution, and increasing global political instability have resulted in harsher trading environments for business. As the business landscape evolves, so too are business schools’ programmes, such as the MBA, required to evolve. Purpose: This study explored the efficacy of a sample of South African MBA programmes concerning their perceived efficacy in developing leaders fit for the 4th Industrial Revolution. Methodology: The study conducted a series of semi-structured qualitative interviews with identified stakeholders relating to the business school ecosystem to explore perceived opinions of the efficacy of business schools in programmes such as the MBA. Findings: The analysis from the interviews revealed that MBA programmes in South Africa need to enhance their focus on aspects such as technology-linked technical skills, as this is a key driver that continues to shape the business landscape.

Fake-talk and the Spaza Shop: A Fake Food Furore and the Spectre of Public Health Emergencies in South Africa

At the end of August 2018, a controversy erupted in South Africa. Accusations of potentially poisonous ‘fake food’ had been circulating on social media for a month or so, and by early September reports were common on South African news programmes. Accusations fell at the door of foreign-run spaza shops (convenience stores), some of which were looted and their shopkeepers harmed. Many commentators read these events as another outbreak of the xenophobic violence that has flared up across South African townships for more than a decade. Our reading is different. In this Research Article, rather than dismissing accusations of fake-ness as merely a pretext for popular protest and violence, we tackle the question of what work ‘fake-talk’ does. We show that in this instance, accusations of fake-ness brought a distinctive urgency to events, framing what might otherwise have been seen as concerns about inequality in the language of a public health crisis. In response, a state normally hesitant to act on citizens’ long-standing complaints about ‘the duplicity of foreigners’ intervened with a new speed and decisiveness. ‘Fake-talk’, we conclude, is an important site of inquiry because of how it may enable certain actions, regardless of whether suspicions are founded.

Surgical training and capacity development in the South African internship programme.

Medical practitioners in South Africa manage a quadruple burden of disease. Junior doctors, who contribute significantly to the health workforce, must complete 2 years of internship training and 1 year of community service work in state health facilities after graduation to register as an independent medical practitioner. The aim of this article is to give a critical appraisal of the current national internship programme and why it was implemented, and outline suggestions for future changes. There is a compelling need to train competent, confident doctors while ensuring that the requirements and demands of our health system remain a central concern.

The evolution of a cooperative mentoring community: developing research leadership in early career (healthcare) faculty

ABSTRACT Mentoring (healthcare) research from low-to-middle-income countries is critical for developing evidence-based healthcare solutions. This paper presents findings from a study of the mentoring and supervisory relationships embedded in a South African fellowship program for early career healthcare researchers. The findings demonstrate how, rather than relying only on formally assigned mentors and supervisors, the fellows chose to establish a mentoring community. This mentoring community included a network of mentoring relationships which involved sharing career advice, establishing professional networks and cooperation opportunities, and creating a reciprocal psychosocial support community. We conceptualize these findings from a developmental network and mentoring community perspective.

Costs Comparison of Teaching and Learning Strategies in a South African University Fashion Design Programme

The use of manual teaching and learning (T&amp;L) strategies for creative design, as well as technical drawing modules, continues in South African university fashion design programmes with few computer-aided design (CAD) T&amp;L strategies being employed. Given the global developments in technological T&amp;L strategies using CAD approach, this comparative study assessed the cost-effectiveness of manual T&amp;L strategies against CAD T&amp;L strategies for Creative Design and Technical drawing modules in a South African fashion design programme. A case study design was used to collect data (documents) on manual and CAD T&amp;L strategies from procurement, budget documents and the in-house university printing department. The results showed that manual T&amp;L strategies expenditure was over 70% to 318% compared to the budget, while CAD T&amp;L strategies were below 60% compared to the budget for creative design ii, creative design iii, technical drawing ii, and technical drawing iii. The findings indicated that CAD T&amp;L strategies are sustainable for the implicated university and the South African government as they fund free higher education with decreasing budgets. The paper concluded that technologically driven T&amp;L strategies like CAD can reduce tuition fees for the programme, improve the sustainability of the university, widen access to government funding for free higher education, as well as improve the contribution of fashion design education programmes towards Sustainable Development Goals 8, 9, and 12. This paper contributes to the ongoing research on developing and implementing sustainable strategies to support the constitutional mandate and the #FeesMustFall campaign and the funding sustainability of South African higher education. This paper’s contribution is a comparison of the cost-effectiveness of manual and CAD T&amp;L strategies. Keywords: Computer-aided Design, clothing industry, fashion design education programme, technology in universities.

‘We should not have to choose between hunger and death’: exploring the experiences of primary caregivers of recipients of a South African child cash transfer programme during COVID-19 lockdown in Cape Town, South Africa

Background:The advent of the COVID-19 pandemic in South Africa and across the globe posed special challenges and implications for low-income families with children. In this study we explored the experiences of primary caregivers of children receiving a South African social assistance programme, the Child Support Grant (CSG), during lockdown in Cape Town, South Africa, and sought to understand whether and to what extent the underlying logic of cash transfers such as the CSG speaks to the pitfalls of the social protection paradigm and the potential for moving closer to a transformative social policy approach. Methods:We conducted 26 telephonic qualitative interviews with primary caregivers of recipients of South Africa’s CSG that were part of a longitudinal cohort study assessing the impact of the CSG on child nutritional status and food security. Results:Even though primary caregivers of the CSG and their children and households were already living in precarity before the pandemic, COVID-19, and particularly the hard lockdown, worsened their social, economic and living conditions, especially as regards hunger and food insecurity. Conclusion:Low-income women bore the brunt of the pandemic in their roles as mothers, providers and homemakers. The pandemic has highlighted the inadequacies of the social protection paradigm that underlies the design of cash transfers such as the CSG, which has a narrowed focus on chronic poverty and vulnerability. It has also highlighted opportunities to shift to a transformative social policy framework that incorporates production, redistribution, social cohesion, adequacy and protection.

Streptococcus pneumoniae and other bacterial nasopharyngeal colonization seven years post-introduction of 13-valent pneumococcal conjugate vaccine in South African children

Pneumococcal Conjugate Vaccines (PCVs) reduce pneumococcal-associated disease by reducing vaccine-serotype (VT) acquisition in vaccinated children, thereby interrupting VT transmission. The 7-valent-PCV was introduced in the South African immunisation program since 2009 (13-valent-PCV since 2011) using a 2+1 schedule (6-, 14- and 40-weeks age). We aimed to evaluate temporal changes in VT and non-vaccine-serotype (NVT) colonisation after nine years of childhood PCV immunisation in South Africa. Nasopharyngeal swabs were collected from healthy children <60-months-old (n=571) in 2018 (Period-2) and compared with samples (n=1135) collected during early PCV7-introduction (Period-1, 2010-11) in an urban low-income setting (Soweto). Pneumococci were tested for using a multiplex quantitative-PCR serotyping reaction-set. Overall pneumococcal colonisation in Period-2 (49.4%; 282/571) was 27.5% lower than Period-1 (68.1%; 773/1135; aOR:0.66; 95%CI:0.54-0.88). Colonisation by VT was reduced by 54.5% in Period-2 (18.6%; 106/571) compared with Period-1 (40.9%; 465/1135; aOR:0.41; 95%CI:0.3-0.56). Nevertheless, serotype 19F carriage prevalence was higher (8.1%; 46/571) in Period-2 compared with Period-1 (6.6%; 75/1135; aOR:2.0; 95%CI:1.09-3.56). NVT colonisation prevalence was similar in Period-2 and Period-1 (37.8%; 216/571 and 42.4%; 481/1135). There remains a high residual prevalence of VT, particularly 19F, colonisation nine years post introduction of PCV in the South African childhood immunisation program.

Transformation of Higher Learning in South Africa: Perceptions and Understanding of Speech-Language Therapy and Audiology Undergraduate Students

The professions of speech-language therapy and audiology in South Africa developed under apartheid and historically consisted of and catered to a predominantly white English- or Afrikaans-speaking minority population. Over 25 years into democracy, there continues to be a stark incongruence between the demographic profile of the South African population and the speech-language and hearing (SLH) professions in terms of “race”, linguistic, and cultural diversity, and this has implications for training as well as clinical service provision within the South African context. This article explores undergraduate students’ perceptions and experiences of transformation within South African SLH university training programmes through a cross-sectional descriptive survey research design. A self-developed questionnaire was used to collect data from students enrolled in SLH programmes at South African universities. Thematic analysis identified two themes: 1) progress towards attainment of transformation and, 2) visibility of transformation. These findings highlight the need for diversity through inclusivity, redressing past injustices and incorporating local knowledge into current training and practice. These findings have global relevance for transformation in higher education, not just in the field of SLH. Implications for translation of theory and/or knowledge into practice, with more visible and deliberate application of policy in curriculum reform and institutional culture, are raised.

Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities.

Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities.

Medicine and the Law

The South African (SA) medical internship training programme model was recently revised to extend training into the primary care platform. In this article, we reflect on the experiences of training under the new model from an intern perspective. We use these reflections to make recommendations to the Health Professions Council of SA on how to further improve the training model by implementing systems that guide and empower the intern doctor practising at a primary level of care.

Hepatitis B virus immunity prior to and after administration of a ‘booster’ dose of vaccine among health-care students at a South African university

BackgroundHealth-care students (HCSs) are at risk of occupational exposure to hepatitis B virus (HBV) infection despite an effective hepatitis B vaccine (HepB) being available. The majority of current HCSs are born after HepB was introduced into the South African Expanded Programme on Immunisation in 1995. Thus, it is assumed that having received HepB in infancy, a single ‘booster’ dose would suffice. This study aimed to investigate HBV immunity prior to and after administration of a HepB ‘booster’ dose. MethodsHepatitis B surface antibody (anti-HBs) levels were determined in first year HCSs at the University of the Witwatersrand, before and after receiving the ‘booster’. Participant demographics and HepB history were captured using a structured questionnaire. ResultsBefore receiving the ‘booster’, 56% (101/180) had anti-HBs < 10 mIU/mL and were non-immune. A further 35% had anti-HBs levels of 10 – 99 mIU/mL, and 9% had ≥100 mIU/mL. <30% of HCSs self-reported completion of a three-dose primary series, which was significantly associated with higher baseline anti-HBs levels compared to those with a partial schedule (p = 0.045). Following vaccination, 39% (71/180) returned for follow-up with a significant median (IQR) increase of 476 (151 – 966) mIU/mL (p < 0.001). Of the 45 students who had non-immune baseline levels, 73% (33/45) responded with ≥100 mIU/mL, 16% (7/45) with 10 – 99 mIU/mL and 11% (5/45) remained non-immune. Levels of ≥100 mIU/mL were achieved by 100% of students with baseline levels ≥10 mIU/mL (n = 26). ConclusionMore than half of the HCSs were not immune to HBV prior to receiving the recommended ‘booster’ vaccine. Following vaccination, 7% (5/71) remained unprotected. This study highlights that in the absence of vaccination records and without confirming the immune status of HCSs, it cannot be assumed that HCSs will be protected following a ‘booster’. Policy reform and inclusion of serological tests for immunity prior to HCSs initiating clinical exposure are recommended.

Community-orientated primary health care: Exploring the interface between community health worker programmes, the health system and communities in South Africa.

Due to insufficient number of health workers and the evidence of the benefits of community health workers (CHWs), CHWs are being deployed to provide health care services to under-served communities. In this article, we explore to what extent the South African CHW programmes introduced between 2009 and 2011 are attuned to community needs, integrated into the healthcare system and community structures, and also implemented in accordance with community-orientated primary health care principles. Using a case study approach, we studied CHW teams in seven primary healthcare facilities located in semi-urban and rural areas of Gauteng and Mpumalanga provinces, South Africa. We collected data using in-depth interviews involving facility managers, CHW supervisors, community representatives and key informants, and focus groups and observations of CHWs. The implementation of community-orientated health interventions remains complex. In the different sites, there were efforts to integrate the views of stakeholders (e.g., political leaders) into the implementation of the CHW programmes. However, many residents were more concerned about access to housing than health services. The CHWs services' were found to be generally comprehensive, however inefficient training, supervision and mentorship limited their effectiveness. The multidisciplinary approach to care, as introduced by some sites, helped enhance the knowledge and skills of some of the CHWs on complex health topics. The roll out of community orientated primary health care services is crucial in a resource-constrained setting like South Africa. However, significant socio-economic issues disrupt community involvement and the effective provision of services. Governments need to provide sufficient funds for training, supervision, supplies and remuneration to help overcome these barriers.