Acceptability, feasibility and appropriateness of intensified health education, SMS/phone tracing and transport reimbursement for uptake of voluntary medical male circumcision in a sexually transmitted infections clinic in Malawi: a mixed methods study.

Introduction: Uptake of voluntary medical male circumcision (VMMC) remains a challenge in many settings. Innovative implementation strategies are required to scale-up VMMC uptake. Methodology: RITe was a multi-faceted intervention comprising transport reimbursement (R), intensified health education (IHE) and SMS/Telephone tracing (Te), which increased the uptake of VMMC among uncircumcised men with sexually transmitted infections (STIs) in Malawi. Using a concurrent exploratory mixed-method approach, we assessed the intervention's acceptability, feasibility and appropriateness among men with STIs and healthcare workers (HCWs) at Bwaila District Hospital. Participants completed Likert scale surveys and participated in-depth interviews (IDIs) and focus group discussions (FGDs). We calculated percentages of responses to survey items and summarized common themes using thematic analysis. Median scores and interquartile ranges (IQR) were calculated for acceptability, feasibility and appropriateness of each strategy at baseline and end-line and compared using the Wilcoxon signed rank test. Results: A total of 300 surveys, 17 IDIs and 4 FGDs were conducted with men and HCWs between baseline and end-line. The mean age for men in the survey was 29 years (SD ±8) and most were married/cohabiting (59.3%). Mean age for HCWs was 38.5 years (SD ±7), and most were female (59.1%). For acceptability, participants agreed that RITe was welcome, approvable, and likable. Despite participants agreeing that RITe was a good idea, culture and religion influenced appropriateness, particularly at baseline, which improved at end-line for Te and R. For feasibility, HCWs agreed that RITe was easy to implement, but expressed concerns that R (end-line median = 4, IQR: 2, 4) and Te (end-line median = 4, IQR: 4, 4), were resource intensive, hence unsustainable. Interviews corroborated the survey results. Participants reported that IHE provided important information, Te was a good reminder and R was attractive, but they reported barriers to R and Te such as electricity, limited access to phones and distrust in the government. Conclusions: The RITe intervention was acceptable, feasible and appropriate. However, culture/religion and structural barriers affected perceptions of appropriateness and feasibility, respectively. Continued awareness raising on VMMC and addressing setting-specific structural factors are required to overcome barriers that impede demand-creation interventions for VMMC. Study registration: ClinicalTrials.gov identifier: NCT04677374. Registered on December 18, 2020.

Correction: Exploring reasons why South African dental therapists are leaving their profession: A theory-informed qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0293039.].

Social Determinants of Health: Healthcare managers' COVID-19 experiences of poor governance, poverty and social media on health interventions.

Objectives: The COVID-19 pandemic has highlighted many barriers to healthcare including structural factors like poverty and governance, and intermediary factors such as service delivery, especially in low and middle-income countries where resources are limited. Social Determinants of Health like poverty, governance and access to basic services significantly affect the effectiveness of health interventions. This study aimed to explore healthcare managers' experiences of delivering health interventions during the COVID-19 pandemic in Gauteng Province, South Africa, using the Social Determinant of Health lens. Study design: Exploratory qualitative study. Methods: Online in-depth interviews were conducted with senior healthcare managers at the Gauteng Department of Health, to explore their experiences during COVID-19, using open-ended questions. The data was saturated with 13 respondents and was analyzed thematically and inductively in NVivo 10. Results: We identified four interrelated themes that adversely impacted health interventions from the manager's COVID-19 experiences: poor governance through non-service delivery, government distrust, poverty within communities and the influence of social media on societal values. Conclusion: The failure of the government to deliver community services leads to public distrust and in turn has a spill-over effect which constitutes a barrier to healthcare. COVID-19 has reaffirmed that poverty, poor governance and societal values (influenced by social media) are structural Social Determinants of Health that exacerbates the vulnerability of the poor during outbreaks. Poor governance and poverty limit behavioral options, trust and the effectiveness of health interventions. Social support is needed to assist the poor and vulnerable during outbreak. Finally, while social media messages negatively influenced health-seeking behaviors during COVID-19, they are also a potential tool to counter disease infodemics.

Effectiveness of an intervention to increase uptake of voluntary medical male circumcision among men with sexually transmitted infections in Malawi: a preinterventional and postinterventional study.

OBJECTIVE: To evaluate the effect a multistrategy demand-creation and linkage intervention on voluntary medical male circumcision (VMMC) uptake, time to VMMC and predictors of VMMC uptake among men with sexually transmitted infections (STIs). DESIGN: Pragmatic preinterventional and postinterventional quasi-experimental study combined with a prospective observational design. SETTING: A public and specialised STI clinic in Lilongwe, Malawi. POPULATION: Uncircumcised men who presented to the STI clinic. METHODS AND INTERVENTION: The intervention consisted of transport reimbursement ('R'), intensified health education ('I') and short-messaging services/telephonic tracing ('Te'), abbreviated (RITe). A preintervention phase was conducted at baseline while RITe was rolled-out in the intervention phase in a sequential manner called implementation blocks: 'I' only-block 1; 'I+Te'-block 2 and RITe-block 3. MAIN OUTCOME MEASURES: Primary: VMMC uptake and time to VMMC for the full intervention and for each block. Secondary: predictors of VMMC uptake. RESULTS: A total of 2230 uncircumcised men presented to the STI clinic. The mean age was 29 years (SD±9), 58% were married/cohabiting, HIV prevalence was 6.4% and 43% had urethral discharge. Compared with standard of care (8/514, 1.6%), uptake increased by 100% during the intervention period (55/1716, 3.2%) (p=0.048). 'I' (25/731, 113%, p=0.044) and RITe (17/477, 125%, p=0.044) significantly increased VMMC uptake. The median time to VMMC was shorter during the intervention period (6 days, IQR: 0, 13) compared with standard of care (15 days, IQR: 9, 18). There was no significant incremental effect on VMMC uptake and time to VMMC between blocks. Men with genital warts were 18 times more likely to receive VMMC (adjusted relative risk=18.74, 95% CI: 2.041 to 172.453). CONCLUSIONS: Our intervention addressing barriers to VMMC improved VMMC uptake and time to VMMC among uncircumcised men with STIs, an important subpopulation for VMMC prioritisation. TRIAL REGISTRATION NUMBER: NCT04677374.

Exploring reasons why South African dental therapists are leaving their profession: A theory-informed qualitative study.

BACKGROUND: Dental therapy is a category of mid-level oral health professional that was introduced to address inequities in oral health service provision in South Africa within a constrained human resource for health context. However, low numbers of registered dental therapists and attrition threaten this strategy. AIM: This study explored reasons for this attrition, building on the Hertzberg Two-Factor Theory. METHODS: Through a qualitative exploratory study design, in-depth interviews were conducted with former dental therapists to explore their reasons for leaving the profession. They were recruited using snowball sampling. All interviews were audio recorded, transcribed verbatim, and coded in NVIVO12. A team of researchers applied thematic analysis to agree on themes and sub-themes, guided by Hertzberg's ideas of intrinsic and extrinsic factors. FINDINGS: All 14 former dental therapists interviewed expressed their passion for the profession, even though their motivations to join the profession varied. Many of their reasons for leaving aligned with extrinsic and intrinsic factors defined in Hertzberg's Two-Factor Theory. However, they also spoke about a desire for a professional identity that was recognized and respected within the oral health profession, health system, and communities. This is a novel study contribution. CONCLUSION: Dental therapist attrition in South Africa is mainly caused by job dissatisfaction and motivation issues resulting from health system level factors. While the Hertzberg Two-Factor Theory helped identify extrinsic and intrinsic factors at an individual level, we used the Human Resources for Health System Development Analytical Framework to identify solutions for dental therapist production, deployment, and retention. Addressing these issues will enhance retention and accessibility to oral health services in the country.

Risk, lifestyle and non-communicable diseases of poverty.

Common discourse in public health and preventive medicine frames non-communicable diseases, including cardiovascular and metabolic diseases, as diseases of 'lifestyle'; the choice of terminology implies that their prevention, control and management are amenable to individual action. In drawing attention to global increases in the incidence and prevalence of non-communicable disease, however, we increasingly observe that these are non-communicable diseases of poverty. In this article, we call for the reframing of discourse to emphasize the underlying social and commercial determinants of health, including poverty and the manipulation of food markets. We demonstrate this by analysing trends in disease, which indicate that diabetes- and cardiovascular-related DALYS and deaths are increasing particularly in countries categorized as low-middle to middle levels of development. In contrast, countries with very low levels of development contribute least to diabetes and document low levels of CVDs. Although this might suggest that NCDs track increased national wealth, the metrics obscure the ways in which the populations most affected by these diseases are among the poorest in many countries, and hence, disease incidence is a marker of poverty not wealth. We also illustrate variations in five countries - Mexico, Brazil, South Africa, India and Nigeria - by gender, and argue that these differences are associated with gender norms that vary by context rather than sex-specific biological pathways.We tie these trends to shifts in food consumption from whole foods to ultra-processed foods, under colonialism and with continued globalization. Industrialization and the manipulation of global food markets influence food choice in the context of limited household income, time, and household and community resources. Other factors that constitute risk factors for NCDs are likewise constrained by low household income and the poverty of the environment for people with low income, including the capacity of individuals in sedentary occupations to engage in physical activity. These contextual factors highlight extremely limited personal power over diet and exercise. In acknowledging the importance of poverty in shaping diet and activity, we argue the merit in using the term non-communicable diseases of poverty and the acronym NCDP. In doing so, we call for greater attention and interventions to address structural determinants of NCDs.

The infant feeding methods promoted by South African Instagram influencers in relation to crying and sleeping, 2018-2020: a retrospective digital ethnography.

BACKGROUND: Globally, there has been a decline in breastfeeding rates. This has resulted in increased infant mortality due to infectious diseases and inappropriate feeding practices. The aggressive marketing of breastmilk substitutes (BMS) by manufacturers has contributed, in part, to these declines. With the progressive use of social media, marketing has shifted from traditional methods to the use of influencers, who command a huge following on their social media accounts and influence the daily decisions of their followers. This study investigates the infant feeding methods and associated products promoted by South African influencers in relation to crying and sleeping and their followers' responses. METHODS: This was a retrospective study, which used a mixed methods digital ethnographic approach to analyse posts related to infant feeding methods that were made by seven South African Instagram influencers between the period of January 2018 to December 2020. Framing analysis was used to analyse qualitative data and quantitative data were analysed descriptively. RESULTS: From the 62 posts that were analysed, 27 were sponsored advertisements (some violating local regulations) and 35 posts promoted breastfeeding. The 18,333 follower comments and 918,299 likes in response to the posts were also analysed. We found that influencers presented BMS products as a solution for a child who cries a lot and has trouble sleeping. BMS were framed as helpful for children who are seemingly always hungry and dissatisfied with breastmilk alone. The study also found that some influencers promoted breastfeeding on their Instagram pages. Unlike BMS posts, breastfeeding posts were not sponsored. With a few exceptions, followers tended to support and reinforce the framing of influencers. CONCLUSION: Stiffer regulations should be enforced against companies using influencers to promote infant formula and other BMS products, with proactive monitoring of social media. Professionals giving advice contrary to the guidelines from the WHO should be reported according to Regulation 991 and made accountable. Proactive engagement with Instagram influencers to promote breastfeeding should be considered.

Prevalence and Correlates of Stunting among Children Aged 6-23 Months from Poor Households in Rwanda.

Stunted linear growth continues to be a public health problem that overwhelms the entire world and, particularly, developing countries. Despite several interventions designed and implemented to reduce stunting, the rate of 33.1% is still high for the proposed target of 19% in 2024. This study investigated the prevalence and associated factors of stunting among children aged 6-23 months from poor households in Rwanda. A cross-sectional study was conducted among 817 mother-child dyads (two individuals from one home) living in low-income families in five districts with a high prevalence of stunting. Descriptive statistics were used to determine the prevalence of stunting. In addition, we used bivariate analysis and a multivariate logistic regression model to measure the strength of the association between childhood stunting and exposure variables. The prevalence of stunting was 34.1%. Children from households without a vegetable garden (AOR = 2.165, p-value < 0.01), children aged 19-23 months (AOR = 4.410, p-value = 0.01), and children aged 13-18 months (AOR = 2.788, p-value = 0.08) showed increased likelihood of stunting. On the other hand, children whose mothers were not exposed to physical violence (AOR = 0.145, p-value < 0.001), those whose fathers were working (AOR = 0.036, p-value = 0.001), those whose parents were both working (AOR = 0.208, p-value = 0.029), and children whose mothers demonstrated good hand washing practice (AOR = 0.181, p-value < 0.001) were less likely to be stunted. Our findings underscore the importance of integrating the promotion of handwashing practices, owning vegetable gardens, and intimate partner violence prevention in the interventions to fight child stunting.

Attrition of dental therapists in South Africa-A 42-year review.

INTRODUCTION: Dental therapists are mid-level oral healthcare providers introduced in 1977 to the South African health system to improve access to oral health services. There has, however, been anecdotal evidence of their unusually high rate of attrition that is cause for concern. AIM AND OBJECTIVES: This study aimed to determine the demographic profile and attrition rate among members of the South African Dental Therapy profession. METHODS: A retrospective time series review of records of all dental therapists who were previously registered and who are still registered with the Health Professions Council of South Africa (HPCSA) between 1977 and 2019 was conducted. RESULTS: A total of 1232 dental therapists were registered from 1977 to 2019. The majority (64%) were Africans. Most practicing dental therapists were based in KwaZulu-Natal (44%) and Gauteng (27%), which are the provinces where dental therapists are trained. The overall attrition rate between 1977 and 2019 was 40%, with a figure of 9% for the last 10 years of the study (2010 to 2019). CONCLUSION: This study has provided the first evidence of the high attrition rate of dental therapists in South Africa. The high attrition warrants further investigation to address the loss of valuable human resources from an already overburdened and under-resourced public oral health sector.

(Non)Marketing of Breastmilk Substitutes in South African Parenting Magazines: How Marketing Regulations May Be Working.

Although exclusive breastfeeding (EBF) for the first six months is optimal for child health, it remains low globally. Breastmilk substitutes (BMS) marketing undermines breastfeeding. In 2012, South Africa introduced Regulation 991, which prohibits marketing BMS products for infants below 6 months. Our study aimed to explore if and how BMS products were presented in South African parenting magazines post-R991. We applied a mixed-methods cross-sectional content analysis design, analyzing all 2018 issues of two popular parenting magazines. We descriptively analyzed quantitative codes, derived from an a priori framework, and conducted qualitative content analysis on a subset of texts and images. We found there was no overt marketing of BMS to parents with infants below 6 months. However, BMS advertisements were placed next to articles about young infants, and vague wording and images were ways by which BMS companies may indirectly benefit. Medical experts in both magazines promoted the introduction of solids before six months. To conclude, while BMS companies in South Africa were abiding by R991 by not overtly advertising BMS in parental print media, their influence persists. Continued monitoring of print media as well as other channels is advisable. This study may be of interest to countries considering stronger regulations of BMS advertising.

Uptake of voluntary medical male circumcision among men with sexually transmitted infections in Lilongwe, Malawi: a protocol for a pre-interventional and post-interventional study.

INTRODUCTION: Voluntary medical male circumcision (VMMC) is one of the key interventions for HIV prevention. However, its uptake among men in Malawi is low. Implementation science strategies for demand creation of VMMC increase uptake. We designed an implementation science demand-creation intervention to increase the uptake of VMMC among men with sexually transmitted infections (STIs). METHODS AND ANALYSIS: We designed a pragmatic pre-interventional and post-interventional quasi-experimental study combined with a prospective observational design to determine the uptake, acceptability, appropriateness and feasibility of a multifaceted intervention for scale up of uptake of VMMC among men with STIs at Bwaila STI clinic in Lilongwe, Malawi. The intervention includes transport reimbursement (R), intensified health education (I) and short messaging service (SMS)/telephonic tracing (Te) (RITe). The intervention will be implemented in phases: pre-implementation and implementation. Pre-implementation phase will be used for collecting baseline data, while the RITe intervention will be rolled-out in the implementation phase. The RITe intervention will be implemented in a sequential and incremental manner called implementation blocks: block 1: intensified health education; block 2: intensified health education and SMS/telephonic tracing; and block 3: intensified health education, SMS/telephonic tracing and transport reimbursement. The target sample size is 80 uncircumcised men for each intervention block, including the pre-implementation sample, making a total of 320 men (280 total, 70 per block will be surveyed). The primary outcome is uptake of VMMC during the implementation period. Mixed methods assessments will be conducted to evaluate the acceptability, appropriateness and feasibility of the RITe intervention. ETHICS AND DISSEMINATION: The study protocol was approved by the Malawi's National Health Sciences Research Ethics Committee (approval number: 19/10/2412), University of North Carolina at Chapel Hill's Institutional Review Board (approval number: 19-2559) and University of the Witwatersrand's Health Research Ethics Committee (approval number: M200328). Results will be disseminated via publication in a peer-reviewed journal and presentations at relevant scientific conferences and meetings. TRIAL REGISTRATION NUMBER: NCT04677374.

"Maskandi experience": exploring the use of a cultural song for community engagement in preparation for a pilot Sterile Insect Technique release programme for malaria vector control in KwaZulu-Natal Province, South Africa 2019.

BACKGROUND: An assessment of the Sterile Insect Technique (SIT) as a complementary malaria vector control tool, is at an advanced stage in South Africa. The technique involves the release of laboratory-reared sterilized male mosquitoes of the major malaria vector Anopheles arabiensis, raising social, ethical and regulatory concerns. Therefore, its implementation largely depends on community participation and acceptance. Against this background, it is critical that robust and effective community strategies are developed. This study describes the development of a cultural song to engage the community and increase awareness on SIT and malaria control in KwaZulu-Natal, South Africa. METHODS: An exploratory concurrent mixed-methods study was conducted to get opinions about the effectiveness of a cultural song developed to engage communities and increase acceptability of the SIT technology. Two self-administered surveys (expert and community) were conducted. Additionally, more in depth opinions of the song and its effectiveness in conveying the intended information were investigated through three community dialogue sessions with community members in the study area. RESULTS: A total of 40 experts and 54 community members participated in the survey. Four themes were identified in relation to the appropriateness and effectiveness of the song, with a fifth theme focused on recommendations for adaptations. Overall, the song was well received with the audience finding it entertaining and informative. Responses to unstructured questions posed after the song showed an increase in the knowledge on malaria transmission and SIT technology. In particular, the explanation that male mosquitoes do not bite allayed anxiety and fears about the SIT technology. CONCLUSION: The song was deemed both culturally appropriate and informative in engaging community members about the SIT technology. It proved useful in promoting health messages and conveying SIT technology as a complementary malaria vector control tool. With minor adaptations, the song has potential as an area-wide community engagement tool in areas targeted for sterile male releases.

Effects of HIV voluntary medical male circumcision programs on sexually transmitted infections.

PURPOSE OF REVIEW: Evidence of the protective effect of voluntary medical male circumcision (VMMC) against HIV is well established. However, evidence of the protective effect of VMMC against other sexually transmitted infections (STIs) has been inconsistent or scarce across different populations and settings. This review summarizes the current evidence on the effect of VMMC for HIV prevention on acquisition and transmission of other STIs in heterosexual men, women, and men who have sex with men (MSM). RECENT FINDINGS: Recent findings continue to strongly support the protective effect of male medical circumcision against acquisition and transmission of herpes simplex virus type 2 (HSV-2), human papillomavirus (HPV) and syphilis infections in heterosexual men and women, and bacterial vaginosis and trichomoniasis in women. There is emerging evidence on the protective effect of VMMC against acquisition of hepatitis B and Mycoplasma genitalium infections in heterosexual men, and HSV-2, HPV, and syphilis in MSM. SUMMARY: Evidence on the protective effect of VMMC against acquisition and transmission of common STIs is available for heterosexual men and women but more evidence is required for MSM. This review supports policy recommendations for the protective benefits of VMMC against STIs.

Reported infant feeding practices and contextual influences on breastfeeding: qualitative interviews with women registered to MomConnect in three South African provinces.

BACKGROUND: Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage. METHODS: For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February-March 2018 in South Africa's KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes. RESULTS: Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media. CONCLUSIONS: Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women's knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women's breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.

Initial loss to follow up of tuberculosis patients in South Africa: perspectives of program managers.

BACKGROUND: Tuberculosis (TB) remains a serious public health problem in South Africa. Initial loss to follow up (LTFU) rates among TB patients are high, varying between 14.9 and 22.5%. From the perspective of patients, documented reasons for this include poor communication between patient and staff after testing, not being aware that results are ready and other competing priorities such as preference to go to work as opposed to seeking healthcare. Ward-based Outreach Teams (WBOTs) routinely conduct home visits to ensure adherence to medication for various conditions including TB. We explored reasons for TB initial loss to follow up from the perspectives of TB program managers and WBOT program managers, with a focus on the WBOT's (potential) role in reducing initial LTFU, in particular. METHODS: Key informant interviews with five WBOT program managers and four TB program managers were conducted. The interviews were audio-recorded, then transcribed and exported to NVivo 11 software for coding. A hybrid analytic approach consisting of both inductive and deductive coding was used to identify themes. RESULTS: The age of the nine managers ranged between 28 and 52 years old, of which two were male. They had been in their current position for between 2 to 12 years. Prior to treatment initiation, WBOTs screen household members for TB and refer them for TB testing if need be, but integration of the two programs is emphasized only after TB treatment has been initiated. Counseling of patients testing for TB is not guaranteed due to frequent staff rotations and staff shortages. Participants reported that possible dissatisfaction with services as well as stigma associated with the TB diagnosis could explain loss to follow up prior to treatment initiation. CONCLUSION: Program managers view health system related factors such as staff rotations, poor communication with patients and lack of counseling as contributing to the problem of initial LTFU among TB patients. The integration of the WBOT and TB programs is limited to referring suspected cases for testing and patients already on treatment.