Health Sciences students' experience of COVID-19 case management and contact tracing in Cape Town, South Africa.

BACKGROUND: COVID-19 has challenged health and higher education systems globally. Managing the epidemic in Cape Town, South Africa (SA), required partnerships with universities and setting up of de novo systems for mass case and contact tracing (C&CT). Health sciences, predominantly medical students, as well as social work and psychology students formed the core of this telephone-based work over the 18 months when SARS-CoV-2 caused severe disease. METHODS: This qualitative study aimed to elicit students' motivations for becoming involved in C&CT, their experiences, and recommendations for C&CT and curricula. After Cape Town's first COVID-19 wave, six on-line focus groups comprising 23 students were conducted, and a further four were conducted with 13 students after the second wave. As the researchers were predominantly educators previously involved in undergraduate health sciences education, the study's purpose was to reflect on students' experiences to make educational and health system recommendations. RESULTS: Students were largely motivated to mitigate the impact of the epidemic on society and support people affected by COVID-19, as well as hone their professional skills. While these motivations were realised, students also needed to learn new skills - to autonomously work remotely, using novel communication strategies to engage those affected and use virtual groups to connect with colleagues. They managed responsibilities within the healthcare systems that did not always work smoothly, distressed cases who were financially insecure, difficult employers, and language barriers. They were prepared through training, and supported by virtual, yet effective teamwork and debriefing opportunities. Although the work was sometimes physically and emotionally exhausting, students found the work personally meaningful. They embraced public health's role to protect population and individuals' health. CONCLUSION: New teaching and learning practices adopted due to Covid-19 lockdowns enabled this digital C&CT project. It facilitated students to become confident, work autonomously and navigate challenges they will encounter as young professionals. The programme demonstrated that novel opportunities for rich student learning, such as in telehealth, can be embedded into public health and clinical functions of health services in contexts such as in SA, deepening partnerships between the health services and universities, to mutual benefit.

Reflections of volunteer counselors working remotely during the COVID-19 pandemic-Implications for policy and practice.

PURPOSE: We reflect on our experience of running a remote volunteer counseling service, known as the Counseling Collective, to support patients and their families during the second wave of the COVID-19 pandemic in Cape Town, South Africa, and the learning and implications for practice and policy regarding the effective utilization of volunteers during a crisis or disaster context. BACKGROUND: The Beta SARS-Co-2 variant dominated the second COVID-19 wave which gained momentum in December 2020, as public sector health teams prepared to deescalate services over the South African summer season. The ferocity with which the wave hit the city soon made it clear that volunteers would be needed to assist with counseling services as the Beta variant caused serious disease, resulting in a significant upswing in hospitalisations and deaths. METHODS: Four counselors and a colleague with oversight responsibilities of the volunteers reflected on the service we provided. This was done with the benefit of hindsight a year after the activities of the Counseling Collective were wrapped up. LESSONS LEARNED: Virtual volunteers are a largely untapped resource in the South African health care system. Much is to be gained by using this underutilized resource to deliver patient-centred services, especially in times of crisis. CONCLUSION: Networks of retired and self-employed health professionals, particularly nurses,-skilled volunteers-are a valuable resource and can be deployed for critical work using their versatile skillsets, in public health emergencies. Telephonic consultations are a useful modality for providing quality care and need to be built into the business of health services. Skills to conduct such consultations and for the provision of palliative care services need to be mainstreamed into the skillsets of health professionals. POLICY AND CLINICAL RELEVANCE: Public health disaster plans should include a blueprint for the rapid recruitment and deployment of volunteer counselors to assist permanent staff in providing crucial patient-centred care.

Providers' approaches to contraceptive provision in Cape Town.

Background: Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs. Methods: Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach. Results: Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services. Discussion: Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

Sexual health behavior, health status, and knowledge among queer womxn and trans men in Kenya: An online cross-sectional study.

INTRODUCTION: Little research has been conducted on the sexual health needs and risk behaviors of queer womxn and trans men, making it difficult to identify specific health needs and disparities. This is especially the case in the Global South, where their needs are poorly understood. This study presents findings on demographics, sources of information, sexual (risk) behaviors, and substance use in Kenyan queer womxn and trans men. METHODS: An online survey among 335 Kenyan queer womxn and trans men was used to collect data on sexual health, risk behavior, health information sources, and substance use. The participants needed to have had at least one self-identified female sexual partner. RESULTS: The sample presented young, highly-educated queer womxn and trans men. A high incidence of childhood sexual trauma found was found. Risk behaviors included sexual activities with partners of multiple genders, violence, and low use of barrier methods. One in three participants had been treated for an STD in the previous year. The incidences of smoking and drinking were high, and a quarter of participants indicated having taken drugs at least once a month or more. The internet was either the first or second most important source of sexual health information for 44.1% of the participants, followed by schools (30.9%). DISCUSSION AND CONCLUSION: Our findings indicate that queer womxn and trans men are at risk of negative sexual health outcomes due to a lack of appropriate information, risk behavior, substance use, and low uptake of sexual health services. Kenya's Penal Code still criminalizes consensual same-sex activities and may play a role in perpetuating barriers that prohibit them from making healthier choices. Developing tailored programming and policies require local, national, and global stakeholders to engage with the inclusion of queer womxn and trans men's sexual health needs within strategic planning and healthcare delivery.

Using online spaces to recruit Kenyan queer womxn and trans men in restrictive offline settings.

BACKGROUND: Understanding and addressing healthcare and service delivery inequalities is essential to increase equity and overcome health disparities and service access discrimination. While tremendous progress has been made towards the inclusion of sexual and gender minorities in health and other research, gaps still exist. Innovative methods are needed to close these. This case study describes and reflects on using online-based data collection to ascertain sexual health decision-making and health service utilisation among Kenyan queer womxn and trans men. METHODS: Case study The study used a mixed-methods approach in two phases with triangulated quantitative and qualitative elements. Both elements used web-based technology to gather data. RESULTS: Using online spaces to recruit and collect data from queer womxn and trans men exceeded expectations. A total of 360 queer womxn and trans men responded to the digitally distributed survey, and 33 people, queer womxn and trans men, as well as key informants, participated in the interviews, which were primarily conducted on Zoom and Skype. The case study analyses the risks and benefits of this approach and concludes that online sampling approaches can mitigate risks and enable effective and safe sampling of a marginalised group in a restrictive legal setting: Kenyan queer womxn and trans men. CONCLUSION: Using online spaces when researching marginalised populations could effectively overcome risks around stigma, discrimination and violence. It could be an effective way to understand these populations' healthcare needs better. Factors contributing to success included building trusting relationships with key members of the community, strategic and opportune timing, a nuanced understanding of the mobile landscape, and carefully chosen safety and security measures. However, it should be noted that conducting research online could increase the risk of further marginalising and excluding those without access to web-based technology.

Investigating the disjoint between education and health policy for infant feeding among teenage mothers in South Africa: a case for intersectoral work.

BACKGROUND: Many low-and-middle-income countries, including South Africa, have high rates of teenage pregnancy. Following the World Health Organisation recommendations, South African health policy on infant feeding promotes exclusive breastfeeding until six months of age, with gradual weaning. At the same time, South Africa's education department, in the interest of learners, promotes adolescents' early return to school post-partum. Yet infant feeding at school is currently not perceived as a realistic option. METHODS: Recognising his this policy tension, we aimed to explore how policies are interpreted and implemented by the health and education sectors through interviews with key informants who produce, interpret and implement these policies. Using an interview guide developed for this study, we conducted in-depth interviews with 24 health policy makers, managers in both sectors, school principals and nursing staff who manage adolescent mothers (aged 16-19) and their babies. Data was analysed using thematic analysis. RESULTS: Informants from both sectors expressed discomfort at pregnant learners remaining in school late in pregnancy and were uncertain about policy regarding when to return to school and how long to breast-feed. Educators reported that new mothers typically returned to school within a fortnight after delivery and that breastfeeding was not common. While health professionals highlighted the benefits of extended breastfeeding for infants and mothers, they recognised the potential conflict between the need for the mother to return to school and the recommendation for longer breastfeeding. Additionally, the need for ongoing support of young mothers and their families was highlighted. CONCLUSIONS: Our findings suggest educators should actively encourage school attendance in a healthy pregnant adolescent until delivery with later return to school, and health providers should focus attention on breastfeeding for the initial 4-6 weeks postpartum, followed by guided support of formula-feeding. We encourage the active engagement of adolescents' mothers and extended families who are often involved in infant feeding and care decisions. Education and health departments must engage to facilitate the interests of both the mother and infant: some exclusive infant feeding together with a supported return to school for the adolescent mother.

What happens to misunderstandings of biomedical concepts across a medical curriculum?

Research on the extent and nature of commonly misunderstood fundamental biomedical concepts across a medical curriculum is scarce. These misunderstandings could point toward robust misconceptions. We examined first whether common misunderstandings persist throughout a medical curriculum, followed by a fine-grained analysis to identify their nature. We designed and administered a 2-tier test to 987 medical students across our curriculum, with 8 questions covering the respiratory and cardiovascular systems, cell division, and homeostatic processes. Proportions of incorrect responses were computed. Four questions where misunderstandings persisted were further qualitatively analyzed. A one-way ANOVA showed the proportion of incorrect responses decreased significantly by students' academic year [F(6, 986) = 96.05, P < 0.001]. While novices and end-of -first-year students showed similar proportion of incorrect responses (P > 0.05), incorrect responses decreased significantly between first years and second years (P < 0.001). Thereafter, the proportion of incorrect responses remained stable from second to final year (P > 0.05), with ∼35% of incorrect responses. Five questions showed no decrease of incorrect responses between second and final years, with two questions where final year students performed marginally better than novices. A Chi-square analysis, with Bonferroni post hoc test, showed certain misunderstandings appeared frequently across the curriculum. The qualitative analysis of the open-ended questions yielded 15 categories of common misunderstandings of fundamental biomedical concepts in all years of training. If educators become aware of commonly misunderstood biomedical concepts, preventative measures could be taken to prevent robust misconceptions.

Routine Health Information System (RHIS) improvements for strengthened health system management.

BACKGROUND: A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management. OBJECTIVES: To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed. SELECTION CRITERIA: Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence). AUTHORS' CONCLUSIONS: The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

Career Paths of Public Health Medicine Specialists in South Africa.

Public health (PH) skills are core to building responsive and appropriate health systems, and PH personnel including medical specialists are embedded in many countries' health systems. In South Africa, the medical specialty in PH, Public Health Medicine (PHM), has existed for over 40 years. Four years of accredited training plus success in a single national exit exam allows specialist registration with the Health Professions Council of South Africa (HPCSA). However, there are few posts designated specifically for PHM specialists in SA's health system. In view of uncertain roles, this research was designed to determine specialists' career paths, their work, job satisfaction, and perspectives on the future of the specialty. We combined three databases to generate the study population and invited all specialists to participate in an online or hard-copy survey. We found that in 2010, PHM was a small specialty of less 200 physicians. Of the 151 contactable, eligible physicians, 55.6% completed the questionnaire. Participants represented an aging group (median age = 49) of specialists and recent graduates were increasingly women. They largely worked in academic institutions (as managers, teachers, and researchers) and in the public sector health system; were motivated by a sense of social justice and their training was formative, exposing them to work settings which they later entered; were largely highly satisfied at work, but many worked in non-specialist positions. Indeed, one fifth had not registered with the HPCSA as specialists. They were concerned about the specialty's poor visibility and identity, but did not see other PH professionals as a threat. They believed that the specialty should refine its competencies, demonstrate its value and advocate for service positions at all levels of the public sector health service. PHM has a contribution to make-reorienting services to protect communities, preventing ill health, analyzing disease burdens locally, identifying innovations in a resource-constrained health service, largely preoccupied with curative care services.

Stakeholders' perspectives on Public Health Medicine in South Africa.

South Africa (SA) is reforming its health system in preparation for an anticipated national health insurance (NHI) scheme that aims to improve the delivery of affordable, equitable, accessible health care. Public health (PH) language is explicit in the policy and skilled PH professionals would be expected to play a key role in its implementation. In South Africa, training of doctors as Public Health Medicine (PHM) specialists is funded by the state, yet there are few positions for PHM specialists in the health services. We explored stakeholders' perspectives about this absence, and their views on PHM specialist' roles and contribution in an era of health reform. A qualitative study was conducted in 2012-13, using in-depth interviews with thematic analysis, which elicited perspectives of 31 key stakeholders nationally reflecting diverse employer and institutional backgrounds. While some were surprised by the absence of PH professionals in SA's health system, most agreed the reason was due to factors internal to the profession, such as its low profile and uncertain identity. External factors such as legislation and political preferences for health managers impacted on the employment of PH professionals. However, given the competencies required to implement an ambitious restructuring of the health sector, all believed that PH and PHM personnel were vital. In view of the health system's dominant curative orientation, embedding PH personnel in the services should ensure that health protection, promotion and prevention strategies will inform health priorities. This study, the first known from a low and middle-income country, contributes to the international literature about the identity and roles of PHM physicians, who are versatile professionals with broad skills-sets. In SA, through consultation with health sector employers about potential roles, curricular redesign and trainee recruitment, PHM can graduate fit-for-purpose specialists to work in a range of institutions to address health system reform.

Adolescent girls' perceptions of breastfeeding in two low-income periurban communities in South Africa.

In South Africa, exclusive breastfeeding rates are low, and rates of teenage pregnancy are high. Educational policy enables mothers' return to school, which conflicts with policy emphasizing exclusive breastfeeding. We elicited adolescent women's perceptions and experiences of infant feeding choices, and conducted six focus groups (N = 57) in two periurban settlements. Participants knew arguments in favor of and against breast and formula-feeding, but in practice, mixed feeding occurred early after birth. While completion of high school was emphasized, exclusive breastfeeding was viewed as impractical. Congruent education policies and infant feeding policies/guidelines must address the constraints and contexts of adolescent mothers.

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems.

BACKGROUND: The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries. METHODS: Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature. RESULTS: The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting. CONCLUSION: This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice.

Motivations of South African physicians specialising in public health.

BACKGROUND: South African physicians can specialise in public health through a four-year 'registrar' programme. Despite national health policies that seemingly value public health (PH) approaches, the Public Health Medicine (PHM) speciality is largely invisible in the health services. Nevertheless, many physicians enrol for specialist training. OBJECTIVES: This study investigated physicians' motivations for specialising in PHM, their intended career paths, perceptions of training, and perspectives about the future of the speciality. METHODS: Focus groups and in-depth interviews were conducted with specialists-in-training and newly qualified specialists, and thematic analysis of transcripts was performed. RESULTS: Motivations, often driven by difficult experiences as young physicians in poorly resourced clinical settings, stemmed from a commitment to improving communities' health and desire to impact on perceived failing health systems. Rather than 'exiting' the South African health service, selecting PHM specialist training enacted participants' 'loyalty' to population health. Participants anticipated carving out their own careers due to an absence of public sector career paths. They believed specialists' contribution centred on providing 'public health intelligence' - finding and interpreting information; supporting services through management and leadership; and inputting into policymaking and planning. CONCLUSIONS: Competencies of PHM specialists should be refined to inform and improve management of this scarce human resource for health. This is particularly important given the proposed major health reforms towards universal health coverage in South Africa presently. In addition, findings highlight the importance of physicians' early work experiences where avenues for expressing 'voice', mediated by 'loyalty', could be utilised to improve public sector health systems.

Assessing the impact of a waiting time survey on reducing waiting times in urban primary care clinics in Cape Town, South Africa.

A waiting time survey (WTS) conducted in several clinics in Cape Town, South Africa provided recommendations on how to shorten waiting times (WT). A follow-up study was conducted to assess whether WT had reduced. Using a stratified sample of 22 clinics, a before and after study design assessed changes in WT. The WT was measured and perceptions of clinic managers were elicited, about the previous survey's recommendations. The overall median WT decreased by 21 minutes (95%CI: 11.77-30.23), a 28% decrease from the previous WTS. Although no specific factor was associated with decreases in WT, implementation of recommendations to reduce WT was 2.67 times (95%CI: 1.33-5.40) more likely amongst those who received written recommendations and 2.3 times (95%CI: 1.28-4.19) more likely amongst managers with 5 or more years' experience. The decrease in WT found demonstrates the utility of a WTS in busy urban clinics in developing country contexts. Experienced facility managers who timeously receive customised reports of their clinic's performance are more likely to implement changes that positively impact on reducing WT.

'Why do an MPH?' Motivations and intentions of physicians undertaking postgraduate public health training at the University of Cape Town.

BACKGROUND: Public health (PH) approaches underpin the management and transformation of health systems in low- and middle-income countries. Despite the Master of Public Health (MPH) rarely being a prerequisite for health service employment in South Africa, many physicians pursue MPH qualifications. OBJECTIVES: This study identifies their motivations and career intentions and explored MPH programme strengths and gaps in under- and post-graduate PH training. DESIGN: A cross-sectional study using an online questionnaire was completed by physicians graduating with an MPH between 2000 and 2009 and those enrolled in the programme in 2010 at the University of Cape Town. RESULTS: Nearly a quarter of MPH students were physicians. Of the 65 contactable physicians, 48% responded. They were mid-career physicians who wished to obtain research training (55%), who wished to gain broader perspectives on health (32%), and who used the MPH to advance careers (90%) as researchers, policy-makers, or managers. The MPH widened professional opportunities, with 62% changing jobs. They believed that inadequate undergraduate exposure should be remedied by applying PH approaches to clinical problems in community settings, which would increase the attractiveness of postgraduate PH training. CONCLUSIONS: The MPH allows physicians to transition from pure clinical to research, policy and/or management work, preparing them to innovate changes for effective health systems, responsive to the health needs of populations. Limited local job options and incentives are important constraining factors. Advocacy for positions requiring qualifications and benchmarking exit competencies of programmes nationally may promote enrolment.

Pregnancy intent among a sample of recently diagnosed HIV-positive women and men practicing unprotected sex in Cape Town, South Africa.

BACKGROUND: Sexual and reproductive health (SRH) services for HIV-positive women and men often neglect their fertility desires. We examined factors associated with pregnancy intent among recently diagnosed HIV-positive women (N = 106) and men (N = 91) who reported inconsistent condom use and were enrolled in an SRH intervention conducted in public sector HIV care clinics in Cape Town. METHODS: Participants were recruited when receiving their first CD4 results at the clinic. All reported unprotected sex in the previous 3 months. Logistic regression identified predictors of pregnancy intent for the total sample and by gender. RESULTS: About three fifths of men and one fifth of women reported intent to conceive in the next 6 months. In the full-sample multiple regression analysis, men [adjusted odds ratio (AOR = 6.62)] and those whose main partner shared intent to conceive (AOR = 3.80) had significantly higher odds of pregnancy intent; those with more years of education (AOR = 0.81) and more biological children (AOR = 0.62) had lower odds of intending pregnancy. In gender-specific analyses, partner sharing pregnancy intent was positively associated with intent among both men (AOR = 3.53) and women (AOR = 13.24). Among men, odds were lower among those having more biological children (AOR = 0.71) and those unemployed (AOR = 0.30). Among women, relying on hormonal contraception was negatively associated with intent (AOR = 0.08), and main partner knowing her HIV status (AOR = 5.80) was positively associated with intent to conceive. CONCLUSIONS: Findings underscore the importance of providing integrated SRH services, and we discuss implications for clinical practice and care.

Implementing intimate partner violence care in a rural sub-district of South Africa: a qualitative evaluation.

BACKGROUND: Despite a high burden of disease, in South Africa, intimate partner violence (IPV) is known to be poorly recognised and managed. To address this gap, an innovative intersectoral model for the delivery of comprehensive IPV care was piloted in a rural sub-district. OBJECTIVE: To evaluate the initiative from the perspectives of women using the service, service providers, and managers. DESIGN: A qualitative evaluation was conducted. Service users were interviewed, focus groups were conducted amongst health care workers (HCW), and a focus group and interviews were conducted with the intersectoral implementation team to explore their experiences of the intervention. A thematic analysis approach was used, triangulating the various sources of data. RESULTS: During the pilot, 75 women received the intervention. Study participants described their experience as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For HCW, barriers to inquiry about IPV included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints affected continuity of care, privacy, and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example, high levels of alcohol misuse and socio-economic disempowerment, highlighted the need for a multifaceted approach to addressing IPV. CONCLUSIONS: This evaluation draws attention to the need to take a systems approach and focus on contextual factors when implementing complex interventions. The results will be used to inform decisions about instituting appropriate IPV care in the rest of the province. In addition, there is a pressing need for clear policies and guidelines framing IPV as a health issue.

Health sector responses to intimate partner violence: a literature review.

BACKGROUND: Intimate partner violence (IPV) is a common and serious public health concern, particularly in South Africa, but it is not well managed in primary care. AIM: This review aims to summarise the current state of knowledge regarding health sector-based interventions for IPV, their integration into health systems and services and the perspectives of service users and healthcare workers on IPV care, focusing on the South African context. METHOD: PubMed, CINAHL, PsycINFO and Google Scholar were searched between January 2012 and May 2014. All types of study design were included, critically appraised and summarised. RESULTS: Exposure to IPV leads to wide-ranging and serious health effects. There is sufficient evidence that intervening in IPV in primary care can improve outcomes. Women who have experienced IPV have described an appropriate response by healthcare providers to be non-judgmental, understanding and empathetic. IPV interventions that are complex, comprehensive and utilise systems-wide approaches have been most effective, but system- and society-level barriers hamper implementation. Gender inequities should not be overlooked when responding to IPV. CONCLUSION: Further evaluations of health sector responses to IPV are needed, in order to assist health services to determine the most appropriate models of care, how these can be integrated into current systems and how they can be supported in managing IPV. The need for this research should not prevent health services and healthcare providers from implementing IPV care, but rather should guide the development of rigorous contextually-appropriate evaluations.

General practitioners' perceptions on management of epilepsy in primary care settings in Cape Town, South Africa: an exploratory pilot study.

In a context where there are few neurologists, excellent management of patients with epilepsy at a primary care level is imperative. In South Africa, most uninsured patients suffering from epilepsy and other chronic illnesses are managed by general practitioners in state-provided primary care settings. We conducted a qualitative pilot study to explore perceptions of doctors working in primary care settings in Cape Town regarding the quality of epilepsy management. Our analysis revealed that these clinicians believe that epilepsy is poorly managed. Attributing factors were consistent with those found in literature. Although study findings cannot be generalized, we conclude that lack of attention to factors impacting on management of epilepsy is a serious concern and may lead to violations of health rights. Urgent prioritization, advocacy, collaboration, and empowerment of healthcare professionals, patients, lay carers, and the general public are needed to improve the management and quality of care of PWE.