South African men's perceptions of breast cancer: impact of gender norms on health care accessibility.

Women in low- and middle-income countries (LMICs) often present to the health care system at advanced stages of breast cancer (BC), leading to poor outcomes. A lack of BC awareness and affordability issues are proposed as contributors to the delayed presentation. In many areas of the world, however, women lack the autonomy to deal with their health needs due to restrictive gender norms. The role of gender norms has been relatively underexplored in the BC literature in LMICs and little is known about what men know about BC and how they are involved in women's access to care. To better understand these factors, we conducted a qualitative descriptive study in South Africa. We interviewed 20 low-income Black men with current woman partners who had not experienced BC. Interviewees had limited knowledge and held specific misconceptions about BC symptoms and treatment. Cancer is not commonly discussed within their community and multiple barriers prevent them from reaching care. Interviewees described themselves as having a facilitative role in their partner's access to health care, facets of which could inadvertently prevent their partners from autonomously seeking care. The findings point to the need to better consider the role of the male partner in BC awareness efforts in LMICs to facilitate prevention, earlier diagnosis and treatment.

Women in undeveloped countries are often not diagnosed with breast cancer until the disease is already very severe. Some of the reasons for this include the women's lack of awareness about breast cancer and difficulty affording the costs of health care or the costs of transportation to a hospital or clinic. In many areas of the world, women also do not have the freedom to respond to their own health needs without having a male family member involved. However, we do not know very much about how men may be involved in women's health care. To better understand this, we conducted a research study in which we talked to 20 South African men about what they knew about breast cancer and how they are involved in their partner's health care decisions. Through talking to them, we found out that many did not know about breast cancer or had inaccurate information about it. The men reported that people in their community do not often talk about cancer. The men described themselves as having a positive influence on their partner's health care decisions, but some of the things they reported doing might stop their partners from being able to receive health care independently. Overall, we think that campaigns to raise awareness of breast cancer should consider how women's partners may be involved in their health care.

Health promotion capacity and institutional systems: an assessment of the South African Department of Health.

Health promotion (HP) capacity of staff and institutions is critical for health-promoting programmes to address social determinants of health and effectively contribute to disease prevention. HP capacity mapping initiatives are the first step to identify gaps to guide capacity strengthening and inform resource allocation. In low-and-middle-income countries, there is limited evidence on HP capacity. We assessed collective and institutional capacity to prioritize, plan, deliver, monitor and evaluate HP within the South African Department of Health (DoH). A concurrent mixed methods study that drew on data collected using a participatory HP capacity assessment tool. We held five 1-day workshops (one national, two provincial and two districts) with DoH staff (n = 28). Participants completed self-assessments of collective capacity across three areas: technical, coordinating and systems capacity using a four-point Likert scale. HP capacity scores were analysed and presented as means with standard deviations (SDs). Thematic analysis of verbatim transcripts of audio-recorded group discussions that provided rationale and evidence for scores were conducted using deductive and inductive codes. At all levels, groups revealed that capacity to develop long-term, sustainable HP interventions was limited. We found limited collaboration between national and provincial HP levels. There was limited monitoring of HP indicators in the health information system. Coordination of HP efforts across different sectors was largely absent. Lack of capacity in budgeting emerged as a major challenge, with few resources available to conduct HP activities at any level. Overall, the capacity mean score was 2.08/4.00 (SD = 0.83). There is need to overcome institutional barriers, and strengthen capacity for HP implementation, support and evaluation within the South African DoH.

Implementing without guidelines, learning at the coalface: a case study of health promoters in an era of community health workers in South Africa.

BACKGROUND: Internationally, there has been renewed focus on primary healthcare (PHC). PHC revitalisation is one of the mechanisms to emphasise health promotion and prevention. However, it is not always clear who should lead health promotion activities. In some countries, health promotion practitioners provide health promotion; in others, community health workers (CHWs) are responsible. South Africa, like other countries, has embarked on reforms to strengthen PHC, including a nationwide CHW programme - resulting in an unclear role for pre-existing health promoters. This paper examined the tension between these two cadres in two South African provinces in an era of primary health reform. METHODOLOGY: We used a qualitative case study approach. Participants were recruited from the national, provincial, district and facility levels of the health system. Thirty-seven face-to-face in-depth interviews were conducted with 16 health promotion managers, 12 health promoters and 13 facility managers during a 3-month period (November 2017 to February 2018). Interviews were audio-recorded and transcribed verbatim. Both inductive and deductive thematic content analysis approaches were used, supported by MAXQDA software. RESULTS: Two South African policy documents, one on PHC reform and the other on health promotion, were introduced and implemented without clear guidelines on how health promoter job descriptions should be altered in the context of CHWs. The introduction of CHWs triggered anxiety and uncertainty among some health promoters. However, despite considerable role overlap and the absence of formal re-orientation processes to re-align their roles, some health promoters have carved out a role for themselves, supporting CHWs (for example, providing up-to-date health information, jointly discussing how to assist with health problems in the community, providing advice and household-visit support). CONCLUSIONS: This paper adds to recent literature on the current wave of PHC reforms. It describes how health promoters are 'working it out' on the ground, when the policy or process do not provide adequate guidance or structure. Lessons learnt on how these two cadres could work together are important, especially given the shortage of human resources for health in low- and middle-income settings. This is a missed opportunity, researchers and policy-makers need to think more about how to feed experience/tacit knowledge up the system.

Performance management in times of change: experiences of implementing a performance assessment system in a district in South Africa.

BACKGROUND: Health systems globally are under pressure to ensure value for money, and the people working within the system determine the extent and nature of health services provided. A performance assessment (PA); an important component of a performance management system (PMS) is deemed important at improving the performance of human resources for health. An effective PA motivates and improves staff engagement in their work. The aim of this paper is to describe the experiences of implementing a PA practice at a district in South Africa. It highlights factors that undermine the intention of the process and reflects on factors that can enable implementation to improve the staff performance for an effective and efficient district health service. METHODS: Data was collected through in-depth interviews, observations and reflective engagements with managers at a district in one of the Provinces in South Africa. The study examined the managers' experiences of implementing the PA at the district level. RESULTS: Findings illuminate that a range of factors influence the implementation of the PA system. Most of it is attributed to context and organizational culture including management and leadership capacity. The dominance of autocratic approaches influence management and supervision of front-line managers. Management and leadership capacity is constrained by factors such as insufficient management skills due to lack of training. The established practice of recruiting from local communities facilitates patronage - compromising supervisor-subordinate relationships. In addition, organizational constraints and the constant policy changes and demands have compromised the implementation of the overall Performance Management and Development System (PMDS) - indirectly affecting the assessment component. CONCLUSION: To strengthen district health services, there should be improvement of processes that enhance the performance of the health system. Implementation of the PA system relies on the extent of management skills at the local level. There is a need to develop managers who have the ability to manage in a transforming and complex environment. This means developing both hard skills such as planning, co-ordination and monitoring and soft skills where one is able to focus on relationships and communication, therefore allowing collaborative and shared management as opposed to authoritarian approaches.

Patients' perspectives of acceptability of ART, TB and maternal health services in a subdistrict of Johannesburg, South Africa.

BACKGROUND: The field of acceptability of health services is emerging and growing in coherence. But there are gaps, including relatively little integration of elements of acceptability. This study attempted to analyse collectively three elements of acceptability namely: patient-provider, patient-service organisation and patient-community interactions. METHODS: Mixed methods were used to analyse secondary data collected as part of the Researching Equity in Access to Health Care (REACH) study of access to tuberculosis (TB) treatment, antiretroviral therapy (ART) and maternal health (MH) services in South Africa's public health sector. RESULTS: Provider acceptability was consistently high across all the three tracer services at 97.6% (ART), 96.6% (TB) and 96.4% (MH). Service acceptability was high only for TB tracer (70.1%). Community acceptability was high for both TB (83.6%) and MH (96.8%) tracers. CONCLUSION: Through mixed methods, this paper provides a nuanced view of acceptability of health services.

Evaluating the sub-national fidelity of national Initiatives in decentralized health systems: Integrated Primary Health Care Governance in Nigeria.

BACKGROUND: Policy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria's decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives. METHODS: Having engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach. RESULTS: Contrary to national government's assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of "Office Establishment" and Legislation" respectively, no state was fully compliant to "Human Resource Management" and "Funding" requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives. CONCLUSIONS: Our study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes.

A critical appraisal of guidelines used for management of severe acute malnutrition in South Africa's referral system.

BACKGROUND: Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents (global and national) that guide the country's SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country's lower level and referral healthcare system under-explored. METHODS: To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines (global and national) and conducted complementary expert interviews (n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country's referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents' development process. RESULTS: None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines' formulation processes to be unclear and stakeholder involvement in the process to be minimal. CONCLUSION: In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines.

An epistemic community comes and goes? Local and national expressions of heart health promotion in Canada.

BACKGROUND: The objective of this study is to examine the existence and shape of epistemic communities for (heart) health promotion at the international, national, provincial and regional levels in Canada. Epistemic community may be defined as a network of experts with an authoritative claim to policy relevant knowledge in their area of expertise. METHODS: An interpretive policy analysis was employed using 60 documents (48 provincial, 8 national and 4 international) and 66 interviews (from 5 Canadian provinces). These data were entered into NUD*IST, a qualitative software analysis package, to assist in the development of codes and themes. These codes form the basis of the results. RESULTS: A scientific and policy epistemic community was identified at the international and Canadian federal levels. Provincially and regionally, the community is present as an idea but its implementation varies between jurisdictions. CONCLUSION: The importance of economic, political and cultural factors shapes the presence and shape of the epistemic community in different jurisdictions. The community waxes and wanes but appears robust.

Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa.

INTRODUCTION: In 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs' and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework. METHODS: We conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted. RESULTS: There were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme. CONCLUSION: The implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.

Smoke-free spaces over time: a policy diffusion study of bylaw development in Alberta and Ontario, Canada.

Policy diffusion is a process whereby political bodies 'learn' policy solutions to public health problems by imitating policy from similar jurisdictions. This suggests that diffusion is a critical element in the policy development process, and that its role must be recognised in any examination of policy development. Yet, to date, no systematic work on the diffusion of smoke-free spaces bylaws has been reported. We examined the diffusion of municipal smoke-free bylaws over a 30-year period in the provinces of Alberta and Ontario, Canada, to begin to address this gap and to determine whether spatial patterns could be identified to help explain the nature of policy development. Bylaw adoption and change were analysed within local, regional, and provincial contexts. Geographical models of hierarchical and expansion diffusion in conjunction with the diffusion of innovations framework conceptually guided the analyses. Study findings contribute to a broader understanding of how and why health policies diffuse across time and place. Policy development can be a powerful mechanism for creating environments that support healthy decisions; hence, an understanding of policy diffusion is critical for those interested in policy interventions aimed at improving population health in any jurisdiction.

Exploring the roles and factors influencing community health workers' performance in managing and referring severe acute malnutrition cases in two subdistricts in South Africa.

As primary providers of preventive and curative community case management services in low- and middle-income countries (LMICs), community health workers (CHWs) have emerged as a formalised part of the health system (HS). However, discourses on their practices as formalised cadres of the HS are limited. Therefore, we examined their role in care, referral (to clinics) and rehabilitation of severe acute malnutrition (SAM) cases. Focusing on SAM was essential since it is a global public health problem associated with 30% of all South Africa's (SA's) child deaths in 2015. Guided by a policy analysis framework, a qualitative case study was conducted in two rural subdistricts of North West province. From April to August 2016, data collected from CHW's training manuals and guideline reviews, 20 patient record reviews and 15 in-depth interviews with four CHW leaders and 11 CHWs. Using thematic content analysis which was guided by the Walt and Gilson policy triangle, data was manually analysed to derive emerging themes on case management and administrative structures. The study found that although CHWs were responsible for identifying, referring, and rehabilitating SAM cases, they neglected curative roles of stabilisation before referral and treatment of uncomplicated cases. Such limitations resulted from restrictive CHW policies, inadequate training, lack of supportive supervision and essential resources. Concurrently, the CHW program was based on weak operational and administrative structures which challenged CHWs practices. Poor curative components and weak operational structures in this context compromised the use of CHWs in LMICs to strengthen primary healthcare. If CHWs are to contribute to Sustainable Development Goal (SDG) 3 by reducing SAM mortality, strategies on community management of acute malnutrition coupled with thorough training, supportive supervision, firm operational structures, adequate resources and providers' motivation should be adopted by governments.

Relationships between community characteristics and municipal smoke-free bylaw status and strength.

BACKGROUND: Municipal smoke-free spaces bylaws are a common population-level intervention to address the prominent health risks associated with exposure to second-hand smoke. In Canada, bylaw prevalence is increasing, but inequities in level of protection across communities remain as bylaws vary from place to place. Little is known about the role of place in this policy disparity. To address this gap, this study examined associations between community characteristics and municipal smoke-free spaces policy outcomes to elucidate how ecological conditions are associated with bylaw status and strength. METHOD: Smoke-free public place and workplace bylaws were obtained from all municipalities with a population of >or=5000 in the provinces of Alberta (N=78) and Ontario (N=245), Canada. Bylaws were assigned a strength score (ranging 0-100) rating the degree of bylaw comprehensiveness, restrictiveness and enforcement provisions. These data were then linked to socio-demographic data from the Canadian Census (1996) and the Canadian Community Health Survey Cycle 1.1 (2000/2001). Logistic and multiple linear regression analyses were used to develop models for municipal bylaw status and strength using community factors including: socio-demographics, municipality type, health region smoking rates, and provincial tobacco control environment. CONCLUSIONS: Study findings suggest that community characteristics play a key role in the status and strength of municipal smoke-free bylaws. As smoking bans continue to emerge world-wide under the Framework Convention on Tobacco Control, knowledge about conditions that promote policy success will be critical for those in need of immediate information to maximize policy-making in their own settings. Use of community profiles that consider socio-demographics along with broader contextual factors can aid decision-makers, public health advocates, and researchers in identifying similar jurisdictions with a successful smoke-free spaces policy and communicating with them about their policy-making experiences. Knowledge about the conditions associated with municipal policy-development may be translated to other jurisdictions where information is sparse, or evidence is newly emerging.

From heart health promotion to chronic disease prevention: contributions of the Canadian Heart Health Initiative.

BACKGROUND: The Canadian Heart Health Initiative began in 1987 as an 18-year undertaking to address the epidemic of cardiovascular disease in Canada. There is growing recognition in Canada of the need for an integrated approach to prevention that addresses common risks for many chronic diseases. CONTEXT: Research and intervention activities of the Canadian Heart Health Initiative have shifted toward chronic disease prevention and health promotion. This study explores the contributions of the Canadian Heart Health Initiative to document how single-disease strategies can evolve into integrated chronic disease prevention efforts. METHODS: Key informant interviews were conducted with project researchers and health system stakeholders from seven Canadian Heart Health Initiative provincial projects. A review of provincial health policy documents was also performed. CONSEQUENCES: Findings indicate that the Canadian Heart Health Initiative projects contributed to public health capacity development, including coalition and partnership building, and development of health knowledge and resource infrastructure. The Canadian Heart Health Initiative projects helped put chronic disease prevention issues onto local and provincial health agendas and provided community-based models to help develop public health policies. INTERPRETATION: Experience with the Canadian Heart Health Initiative shows the need for integrated health programs to build on existing infrastructure. Other requirements for integrated chronic disease prevention programs include shared goals, partnerships at various policy levels and in multiple sectors, ongoing information sharing, and funding that is flexible and long-term.

'Reasonable access' to primary care: assessing the role of individual and system characteristics.

Access to health care continues to be an important issue for health policy makers, researchers, service providers and consumers alike. In countries with universal health care coverage, services are generally free at the point of delivery which is intended to provide equitable access to care for all residents regardless of their individual situations. Past studies have pointed to the importance of individual characteristics such as age, gender, and socioeconomic status in shaping access to health care but much less is known about the role of health system characteristics. The purpose of this study is to explore, by means of qualitative research methods, the extent to which individual and system factors shape access to primary health care services for residents living in two contrasting neighbourhoods in Hamilton, Ont., Canada. Semi-structured, in-depth interviews were conducted with 40 men and women. The interviews probed participants about their experiences with primary care, barriers to receiving care and their general perceptions of the health care system. The interviews demonstrated the existence of many system-related barriers to receiving health care (e.g., wait times, geographic inaccessibility and quality of care) and some individual-related barriers (e.g., work or family responsibilities). While the findings revealed little difference between the neighbourhoods in terms of accessibility problems and barriers, differences between men and women were evident.

Deliberations about deliberative methods: issues in the design and evaluation of public participation processes.

A common thread weaving through the current public participation debate is the need for new approaches that emphasize two-way interaction between decision makers and the public as well as deliberation among participants. Increasingly complex decision making processes require a more informed citizenry that has weighed the evidence on the issue, discussed and debated potential decision options and arrived at a mutually agreed upon decision or at least one by which all parties can abide. We explore the recent fascination with deliberative methods for public involvement first by examining their origins within democratic theory, and then by focusing on the experiences with deliberative methods within the health sector. In doing so, we answer the following questions "What are deliberative methods and why have they become so popular? What are their potential contributions to the health sector?" We use this critical review of the literature as the basis for developing general principles that can be used to guide the design and evaluation of public involvement processes for the health-care sector in particular.

Does accessibility to antiretroviral care improve after down-referral of patients from hospitals to health centres in rural South Africa?

We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were 'down-referred' from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p = 0.001) and travel time to an ART facility (p =0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01-0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07-18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07-0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16-65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22-9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86-13.04) and practice self-care (AOR 4.91; 95% CI: 2.37-10.17), resulting in increased health-related expenditure (p = 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and show better adherence levels. However, unintended consequences include increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.

"It all depends": conceptualizing public involvement in the context of health technology assessment agencies.

There have been calls in recent years for greater public involvement in health technology assessment (HTA). Yet the concept of public involvement is poorly articulated and little attention has been paid to the context of HTA agencies. This article investigates how public involvement is conceptualized in the HTA agency environment. Using qualitative concept analysis methods, we reviewed the HTA literature and the websites of HTA agencies and conducted semi-structured interviews with informants in Canada, Denmark, and the United Kingdom. Our analysis reveals that HTA agencies' role as bridges or boundary organizations situated at the frontier of research and policymaking causes the agencies to struggle with the idea of public involvement. The HTA community is concerned with conceptualizing public involvement in such a way as to meet scientific and methodological standards without neglecting its responsibilities to healthcare policymakers. We offer a conceptual tool for analyzing the nature of public involvement across agencies, characterizing different domains, levels of involvement, and types of publics.

Advancing Health Promotion Priorities: Stories of Capacity Building from the Canadian Heart Health Initiative (CHHI).

The purpose of this paper is to explore how public health professionals built capacity to carry out health promotion despite a low level of investment and competition for financial resources with acute-oriented healthcare services. Three data sources are used in this analysis: key-informant interviews with project participants, final reports from three provincial Heart Health projects in Canada (Prince Edward Island, Ontario and Manitoba) and major provincial health policy documents prior to and during each project. We use a narrative policy analysis to identify contextual factors influencing health promotion priority and progress through capacity building. Common capacity building themes emerged from the data despite the different contexts within which the projects were situated: building community trust and support, developing a linking system that promotes provincial partnerships and assisting in sustainability efforts by coordinating resources and efforts towards a common chronic disease prevention strategy. Each of these provincial projects overcame instances of resistance to advancing a health promotion agenda by concentrating on building relationships, by making better use of existing structures and organizations and by developing new productive unions that shared a primary prevention agenda.