Impact of COVID-19 on selected essential public health services - lessons learned from a retrospective record review in the Free State, South Africa.

BACKGROUND: In an attempt to discern lessons to improve future pandemic responses, this study measured the effects of the COVID-19 pandemic on essential public health services (EPHSs) related to primary health care (PHC) and outpatient department (OPD) utilisation, antiretroviral treatment (ART) commencement, drug-susceptible tuberculosis (DS-TB) confirmation and treatment commencement, and Bacillus Calmette-Guérin (BCG) coverage, in the Free State province of South Africa during January 2019 to March 2021. METHODS: A pre-post study design comparing EPHS performance between 2019 and 2020/21 was employed. Routinely collected data were analysed. An interrupted time series analysis was used to measure changes in service use and outcomes from January 2019 to March 2021. Median changes were compared using Wilcoxon rank-sum tests. A 5% statistical significance level was considered. RESULTS: Over the study period, the median values for the annual number of PHC visits was 1.80, 55.30% for non-referred OPD visits, 69.40% for ART commencement, 95.10% and 18.70% for DS-TB confirmation and treatment commencement respectively, and 93.70% for BCG coverage. While BCG coverage increased by 5.85% (p = 0.010), significant declines were observed in PHC utilisation (10.53%; p = 0.001), non-referred OPD visits (12.05%; p < 0.001), and ART commencement (9.53%; p = 0.017) rates. Given the importance of PHC in addressing a new pandemic, along with the existing HIV and TB epidemics - as well as the entire quadruple burden of disease - in South Africa, the finding that the PHC utilisation rate statistically significantly decreased in the Free State post-COVID-19 commencement is particularly concerning. CONCLUSIONS: The lessons learned from this retrospective review attest to a measure of resilience in EPHS delivery in the Free State in as far as a significant hike in BCG vaccination over the study period, 2019-2020/21 was observed. As evidenced by a decline in PHC service utilisation and the decreased numbers of new patients commencing ART, we also learned that EPHS delivery in the province was fragile.

Black Women's Perceptions Towards Infant and Child Male Circumcision.

OBJECTIVE: The objective of this article was to analyse women's perceptions of ICMC and to propose a framework for ICMC decision-making that can inform ICMC policies. METHOD: Using qualitative interviews, this study investigated twenty-five Black women's perceptions of ICMC decisionmaking in South Africa. Black women who had opted not to circumcise their sons, were selected through purposive and snowball sampling. Underpinned by the Social Norms Theory, their responses were analysed through in-depth interviews and a framework analysis. We conducted the study in the townships of Diepsloot and Diepkloof, Gauteng, South Africa. RESULTS: Three major themes emerged: medical mistrust, inaccurate knowledge leading to myths and misconceptions, and cultural practices related to traditional male circumcision. Building Black women's trust in the public health system is important for ICMC decision-making. CONCLUSIONS FOR PRACTICE: Policies should address misinformation through platforms that Black women share. There should be an acknowledgement of the role that cultural differences play in the decision-making process. This study developed an ICMC perception framework to inform policy.

Primary health care nurses' mental health knowledge and attitudes towards patients and mental health care in a South African metropolitan municipality.

BACKGROUND: In South Africa, there are on-going calls to integrate mental health services into existing primary health care (PHC) programmes such as Tuberculosis (TB). Successful service integration and quality service delivery partially depend on healthcare providers' mental health-related knowledge and attitudes. The aim of this study was to assess PHC nurses' mental health knowledge and attitudes towards mental health patients and mental health care. METHODS: This was a cross-sectional survey involving the distribution of self-administered questionnaires among PHC nurses across 47 clinics. Data on socio-demographics, stigma-related mental health knowledge, and nurses' attitudes towards people with mental health problems and mental health care were subjected to descriptive and multiple regression analyses. RESULTS: Out of 205 respondents, the majority were female (n = 178, 86.8%). The nurses' median age was 50 (interquartile range: 39-56). Their mean mental health knowledge score was 23.0 (standard deviation [sd]: 3.07) out of 30. Nurses were less knowledgeable about the employment (n = 95, 46.3%), recovery (n = 112, 54.6%), and help-seeking behaviour (n = 119, 58.0%) of people with mental health problems. Professional nurses had a significantly higher mean mental health knowledge score than enrolled/assistant nurses (22.8 vs. 21.1, t203 = 4.775, p < 0.001). Regarding attitudes, the nurses' mean attitude score was 40.68 (sd: 9.70) out of 96. Two in every five nurses (n = 91, 44.4%) scored above the mean attitude score, implying that they were inclined to have negative (stigmatising) attitudes towards people with mental problems and mental health care. Age (p = 0.048), job category (p < 0.001), and prior in-service mental health training (p = 0.029) made a unique contribution to predicting nurses' attitudes. CONCLUSION: Gaps were established in PHC nurses' stigma-related mental health knowledge. A significant proportion of nurses had a propensity for negative (stigmatising) attitudes towards mental health patients and mental health care. Efforts towards integration of mental health into TB services in this metropolitan and similar settings should address mental health knowledge deficits and factors influencing nurses' negative attitudes. In-service training on mental health should be optimised, with attention to older nurses and enrolled/nursing assistants.

Parental decision-making in infant and child male circumcision: a case study in two townships in Gauteng, South Africa.

Parental decision-making in infant and child male circumcision is influenced by complex, interrelated factors on many levels. Several studies have highlighted reasons for the acceptance and non-acceptance of child male circumcision. This study investigates the factors that influence parental decision-making in this matter and proposes a parental decision-making framework. The study was conducted in the townships of Diepsloot and Diepkloof in Gauteng, South Africa, using 48 in-depth interviews with parents, grandparents and uncles of the boys, as well as government officials and members of civil society as part of an explorative case study. Purposive and snowball sampling were used to select the participants. Thematic analysis was used to analyse the data by applying the conceptual framework of Bronfenbrenner's ecological systems theory. Three main themes emerged from the data: microsystem factors related to health and hygiene, the father's circumcision status, cultural expectations, pain, the child's autonomy and the extended family; mesosystem factors related to early childhood development centres; and exosystem factors related to circumcision policies and financial considerations.

Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers.

BACKGROUND: HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. METHODS: Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. RESULTS: The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. CONCLUSIONS: This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences. TRIAL REGISTRATION: South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa.

BACKGROUND: South Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs' motivation to deliver systematic household contact tuberculosis (TB) investigation (SHCI). METHODS: In 2017, a cross-sectional survey was conducted among CHWs in the Mangaung Metropolitan District, Free State Province. Exploratory factor analysis was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used to investigate the determinants of CHW motivation. RESULTS: Out of 235 participants, 89.2% were female. Participants' median age was 39 (inter-quartile range: 33-45) years. CHW motivation was defined by 16 items across three dimensions - intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived scale showed satisfactory internal consistency (Cronbach's alpha: 0.81), with a mean motivation score of 52.26 (standard deviation [sd]: 5.86) out of 64. Statistically significant differences were observed between formal CHWs - those with at least phase 1 standardised accredited training, and informal CHWs - those without such accredited training regarding team commitment scores (17.82 [sd: 2.48] vs. 17.07 [sd: 2.82]; t(233) = 2.157; p = 0.013). CHW age (ß = 0.118, p = 0.029), location (ß = 1.737, p = 0.041), length of service (ß = - 0.495, p < 0.001), attendance of TB SHCI training (ß = 1.809, p = 0.036), and TB SHCI competence (ß = 0.706, p < 0.001), contributed statistically significantly to CHW motivation. CONCLUSION: CHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, programme managers in the Free State and similar settings could potentially use the tool derived from this study to monitor and inform CHW motivation interventions. Interventions should pay close attention to the CHWs' formalisation, competence and training.

Emotional well-being and work engagement of nurses who moonlight (dual employment) in private hospitals.

BACKGROUND AND AIM: Given the myriad occupational stressors of nursing itself, plus the challenges of moonlighting, we aimed to investigate the emotional well-being of moonlighting nurses and their work engagement. Well-being was defined by levels of general health, mental health, emotional exhaustion, personal accomplishment, compassion satisfaction and compassion fatigue. DESIGN: A cross-sectional descriptive survey (December 2017 to March 2018) at private health care facilities in a Metropolitan Municipality, South Africa. METHODS: Two hundred and fifty-one nurses completed self-administered questionnaires, which comprised of validated scales. RESULTS: Nurses were at low risk for emotional exhaustion (M=12.8; SD=11.23) and scored high on compassion satisfaction (M=42.34; SD=7.22) and work engagement (M=4.87, SD=1.18). Personal accomplishment (t= 2.535; P<.05) compassion satisfaction (t= 6.790; P=.000) and mental health (t=3.206; P<.05) made a statistically significant unique contribution to the prediction of work engagement. Nurses who had considered leaving the profession scored significantly higher on emotional exhaustion and compassion fatigue. CONCLUSION: Nurses who moonlighted in private health care facilities reported low risk for burnout and high levels of compassion satisfaction and work engagement. Further research is needed to explore the reasons for these findings. Attention must be given to ensuring the occupational well-being of nurses in order to retain them in the profession.

Waiting to inhale: factors associated with healthcare workers' fears of occupationally-acquired tuberculosis (TB).

BACKGROUND: Fear of TB infection is rooted in historical and social memories of the disease, marked by stigma, segregation and exclusion. Healthcare workers (HCWs) face these same fears today, and even seek to hide their TB status when infected. This study sought to investigate factors associated with HCWs fears of acquiring TB while at work, including selected biographic characteristics, TB knowledge, infection control and perceptions that their colleagues stigmatise co-workers with TB/ presumed to have TB. METHODS: In the Free State Province, South Africa, a representative sample of 882 HCWs from eight hospitals completed self-administered questionnaires on issues related to fear of occupationally acquired TB, infection control, TB knowledge and workplace TB stigma. The data were analysed using descriptive statistics as well as binomial logistic regression. RESULTS: Most of the HCWs (67.2%) were concerned about contracting TB at work. Support staff were less likely to worry about acquiring TB than clinical staff (OR = 0.657, P = 0.041). Respondents who indicated that there were inadequate numbers of disposable respirators at work, were 1.6 times more likely to be afraid of contracting TB at work (P = 0.040). With every unit increase on the TB stigma scale, respondents were 1.1 times more likely to fear acquiring TB at work (P = 0.000). CONCLUSIONS: Being a professional clinical HCW, not having adequate disposable respirators available and seeing/perceiving co-workers stigmatise colleagues with (presumptive) TB were all significantly associated with the fear of occupationally-acquired TB. It is recommended that campaigns to destigmatise TB, as well as appropriate TB infection control education and measures, are necessary to alleviate HCWs fears of acquiring the disease in the workplace. Ultimately this should create a health-enabling working environment, where HCWs are not afraid to function and are free to seek treatment and support when necessary.

Yield of systematic household contact investigation for tuberculosis in a high-burden metropolitan district of South Africa.

BACKGROUND: Systematic household contact investigation (SHCI) is recommended as an active-case-finding (ACF) strategy to identify individuals at high risk of tuberculosis (TB) infection, in order to enable early detection and treatment. Reluctance to implement SHCI in sub-Saharan African and South African high-burden contexts may stem from uncertainty about the potential yield of this strategy when targeting specific categories of TB index cases. In order to inform and motivate scale-up, this pilot study investigated the effectiveness of SHCI when targeting the World Health Organization's (WHO) recommended categories of infectious index cases. METHOD: Data were gathered in September and October 2016. Household contacts of infectious TB cases who attended 40 primary health care facilities in Mangaung Metropolitan District were recruited. The categories of TB index cases included 1) children <5 years, 2) HIV co-infected pulmonary TB (PTB) cases (≥5 years), 3) HIV-negative PTB cases (≥5 years), and 4) multidrug-resistant (MDR) TB cases. Contacts were screened for TB symptoms and symptomatic individuals and all children <5 years were referred for clinical evaluation. Data were analysed to establish the yield and factors associated with new TB diagnosis. RESULTS: Of 259 contacts screened, just under half (47.1%) underwent TB clinical investigation, during which 17 (6.6%) new TB cases were diagnosed, which represents a prevalence rate of 6564 per 100,000 population. Fifteen contacts needed to be screened to detect one new TB case. The proportion of new TB cases was the highest among contacts of HIV-negative PTB index cases (47.9%). The likelihood of TB diagnosis was higher among male contacts (odds ratio [OR]: 4.8; 95% confidence interval [CI]: 1.54-14.97) and those reporting coughing (OR: 4.3; 95% CI: 1.11-16.43). CONCLUSION: The high yield of new TB observed in this pilot study demonstrates that targeted SHCI may be an effective ACF strategy in Mangaung and similar high-burden settings in South Africa. Targeting different index case categories produced variable yield - the highest among contacts of HIV-negative TB index cases. SHCI among household contacts of all four the WHO-recommended categories of infectious TB index cases - and male and coughing contacts, in particular - should be maximised.

Fighting stigma, promoting care: a study on the use of occupationally-based HIV services in the Free State Province of South Africa.

Fear of breaches in confidentiality and HIV-related stigma in the workplace have been shown to be primary concerns and potential barriers to uptake of HIV testing and treatment by health care workers (HCWs) at the Occupational Health Unit (OHU). In a context of human resource shortages, it is essential to investigate potential ways of reducing HIV-related stigma and promoting confidentially in the workplace. Using Structural Equation Modelling (SEM), baseline data of the "HIV and TB Stigma among Health Care Workers Study" (HaTSaH Study) for 818 respondents has been analysed to investigate (1) whether bottom-up stigma-reduction activities already occur; and (2) whether such grassroots actions can reduce the fear of breaches in confidentiality and HIV-related stigma - and thus indirectly stimulate the uptake of HIV services at the OHU. Results (aim 1) illustrate the occurrence of existing activities aiming to reduce HIV-related stigma, such as HCWs giving extra support to HIV positive co-workers and educating co-workers who stigmatise HIV. Furthermore, results of the SEM analysis (aim 2) show that the Fighting-stigma factor has a significant negative effect on HIV-related stigma and a significant positive effect on Confidentiality. Results show that the latent fighting-stigma factor has a significant positive total indirect effect on the use of HIV testing, CD4 cell count and HIV-treatment at the OHU. The findings reveal that the fear of breaches in confidentiality and HIV-related stigma can be potential barriers to the uptake of occupationally-based HIV services. However, results also show that a bottom-up climate of fighting HIV-related stigma can stimulate confidentiality in the workplace and diminish the negative effect of HIV-related stigma - resulting in an overall positive effect on the reported willingness to access occupationally-based HIV services.

Household contact non-attendance of clinical evaluation for tuberculosis: a pilot study in a high burden district in South Africa.

BACKGROUND: In 2012, the World Health Organization launched guidelines for systematically investigating contacts of persons with infectious tuberculosis (TB) in low- and middle-income countries. As such, it is necessary to understand factors that would influence successful scale-up. This study targeted household contacts of newly-diagnosed infectious TB patients in the Mangaung Metropolitan district to explore factors associated with non-attendance of clinical evaluation. METHOD: In September-October 2016, a pilot study of household contacts was conducted. At each of the 40 primary health care (PHC) facilities in the district, at least one out of four types of TB index cases were purposefully selected. These included children <5 years, smear-positive cases, HIV co-infected cases, and multidrug-resistant TB (MDR-TB) cases. Trained fieldworkers administered questionnaires and screened contacts for TB symptoms. Those with TB symptoms as well as children <5 years were referred for clinical evaluation at the nearest PHC facility. Contacts' socio-demographic and clinical characteristics, TB knowledge and perception about TB-related discrimination are described. Logistic regression analysis was used to investigate factors associated with non-attendance of clinical evaluation. RESULTS: Out of the 259 participants, approximately three in every five (59.5%) were female. The median age was 20 (interquartile range: 8-41) years. While the large majority (87.3%) of adult contacts correctly described TB aetiology, almost three in every five (59.9%) thought that it was hereditary, and almost two-thirds (65.5%) believed that it could be cured by herbal medicine. About one-fifth (22.9%) of contacts believed that TB patients were subjected to discrimination. Two in every five (39.4%) contacts were referred for clinical evaluation of whom more than half (52.9%) did not attend the clinic. Non-attendance was significantly associated with inter alia male gender (AOR: 3.4; CI: 1.11-10.24), prior TB diagnosis (AOR: 5.6; CI: 1.13-27.90) and sharing of a bedroom with the index case (AOR: 3.4: CI: 1.07-10.59). CONCLUSION: The pilot study identified gaps in household contacts' knowledge of TB. Further research on important individual, clinical and structural factors that can influence and should be considered in the planning, implementation and scale-up of household contact TB investigation is warranted.

Voices from the frontline: barriers and strategies to improve tuberculosis infection control in primary health care facilities in South Africa.

BACKGROUND: Tuberculosis (TB) infection control at primary healthcare (PHC) level remains problematic, especially in South Africa. Improvements are significantly dependent on healthcare workers' (HCWs) behaviours, underwriting an urgent need for behaviour change. This study sought to 1) identify factors influencing TB infection control behaviour at PHC level within a high TB burden district and 2) in a participatory manner elicit recommendations from HCWs for improved TB infection control. METHOD: A qualitative case study was employed. TB nurses and facility managers in the Mangaung Metropolitan District, South Africa, participated in five focus group and nominal group discussions. Data was thematically analysed. RESULTS: Utilising the Information Motivation and Behaviour (IMB) Model, major barriers to TB infection control information included poor training and conflicting policy guidelines. Low levels of motivation were observed among participants, linked to feelings of powerlessness, negative attitudes of HCWs, poor district health support, and general health system challenges. With a few exceptions, most behaviours necessary to achieve TB risk-reduction, were generally regarded as easy to accomplish. CONCLUSIONS: Strategies for improved TB infection control included: training for comprehensive TB infection control for all HCWs; clarity on TB infection control policy guidelines; improved patient education and awareness of TB infection control measures; emphasis on the active role HCWs can play in infection control as change agents; improved social support; practical, hands-on training or role playing to improve behavioural skills; and the destigmatisation of TB/HIV among HCWs and patients.

Tuberculosis prevention knowledge, attitudes, and practices of primary health care nurses.

AIM: Tuberculosis (TB) continues to challenge global health systems, especially in South Africa. Nurses are especially vulnerable to TB exposure, because of their prolonged front-line contact with infected patients-especially in primary health care (PHC) clinics. Their infection control practices, influenced by key factors such as knowledge and attitudes towards TB prevention, become an important consideration. The aim of the study was to (1) describe the TB prevention knowledge, attitudes, and practices of PHC nurses in a South African district and (2) explore moderating factors on TB prevention practices. METHODS: A cross-sectional survey was undertaken at all 41 PHC facilities in Mangaung Metropolitan district, Free State province, South Africa, using self-administered questionnaires. Captured data were analysed to yield descriptive and multivariate statistics. RESULTS: Results suggest several instances of inadequate TB prevention knowledge, attitudes, and practices. Good TB practice was predicted by TB attitudes and knowledge, and the relationship between TB prevention knowledge and practices was not moderated by training, attitudes, or nurse category. CONCLUSION: Results echo previous indications that nurses often do not exhibit the desired knowledge, attitudes, and practices required to adequately protect themselves and others against TB and suggest further exploration towards understanding the influences on TB prevention practice among nurses.

Tuberculosis knowledge, attitudes and practices of patients at primary health care facilities in a South African metropolitan: research towards improved health education.

BACKGROUND: Health education is important to empower patients and encourage their contribution towards tuberculosis (TB) control. In South Africa, health education activities are integrated into services provided at the primary health care (PHC) level. This study was conducted in a high TB burden metropolitan area in South Africa. The objective was to assess TB-related knowledge, attitudes and infection control practices of patients attending PHC facilities. METHODS: In September and October 2015, a cross-sectional survey using fieldworker-administered questionnaires was conducted among patients older than 17 years attending 40 PHC facilities in the Mangaung Metropolitan. Convenience sampling was used to select patients. Participation in the study was voluntary. Descriptive, inferential and multivariate logistic regression analyses were performed. Statistical significance was considered at alpha <0.05 and 95% confidence interval. RESULTS: A total of 507 patients' data were included in the analysis. Most of the patients knew that TB transmission is facilitated by crowded conditions (84.6%) and that pulmonary TB is contagious (73.0%). Surprisingly, the majority of patients also believed that one can get TB from sharing toothbrushes (85.0%) or kissing (65.0%). An overwhelming majority of patients perceived TB to be serious (89.7%), and concurred that taking treatment (97.2%) and opening windows to prevent transmission in PHC facilities (97.0%) are important. Being employed (AOR: 11.5; CI: 4.8-27.6), having received TB infection control information from a PHC facility (AOR: 2.2; CI: 1.5-3.4), and being a TB patient (AOR: 1.6; CI: 1.02-2.46) increased the likelihood of adopting good infection control practices. CONCLUSION: These findings highlight the need for health education efforts to strengthen accurate information dissemination to promote sound TB knowledge and attitudes among patients attending PHC facilities. Health education efforts should also capitalise on the positive finding of this study that information dissemination at PHC facilities increases good infection control practices.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa.

BACKGROUND: The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting. METHODS: The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa. RESULTS: Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity. CONCLUSIONS: The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

Factors associated with good TB infection control practices among primary healthcare workers in the Free State Province, South Africa.

BACKGROUND: Despite the availability of TB infection control guidelines, and good levels of healthcare worker knowledge about infection control, often these measures are not well implemented. This study sought to determine the factors associated with healthcare workers' good TB infection control practices in primary health care facilities in the Free State Province, South Africa. METHODS: A cross-sectional self-administered survey among nurses (n = 202) and facility-based community healthcare workers (n = 34) as well as facility observations were undertaken at all 41 primary health care facilities in a selected district of the Free State Province. RESULTS: The majority of respondents were female (n = 200; 87.7 %) and the average age was 44.19 years (standard deviation ±10.82). Good levels of knowledge were recorded, with 42.8 % (n = 101) having an average score (i.e. 65-79 %) and 31.8 % (n = 75) a good score (i.e. ≥ 80 %). Most respondents (n = 189; 80.4 %) had positive attitudes towards TB infection control practices (i.e. ≥ 80 %). While good TB infection control practices were reported by 72.9 % (n = 161) of the respondents (i.e. ≥75 %), observations revealed this to not necessarily be the case. For every unit increase in attitudes, good practices increased 1.090 times (CI:1.016-1.169). Respondents with high levels of knowledge (≥80 %) were 4.029 (CI: 1.550-10.469) times more likely to have good practices when compared to respondents with poor levels of knowledge (<65 %). The study did not find TB/HIV-related training to be a predictor of good practices. CONCLUSIONS: Positive attitudes and good levels of knowledge regarding TB infection control were the main factors associated with good infection control practices. Although many respondents reported good infection control practices - which was somewhat countered by the observations - there are areas that require attention, particularly those related to administrative controls and the use of personal protective equipment.

Barriers to HIV counseling and testing uptake by health workers in three public hospitals in Free State Province, South Africa.

Recent WHO/ILO/UNAIDS guidelines recommend priority access to HIV services for health care workers (HCWs), in order to retain and support HCWs, especially those at risk of occupationally acquired tuberculosis (TB). The purpose of this study was to identify barriers to uptake of HIV counselling and testing (HCT) services for HCWs receiving HCT within occupational health units (OHUs). Questions were included within a larger occupational health survey of a 20% quota sample of HCWs from three public hospitals in Free State Province, South Africa. Of the 978 respondents, nearly 65% believed that their co-workers would not want to know their HIV status. Barriers to accessing HCT at the OHU included ambiguity over whether antiretroviral treatment was available at the OHU (only 51.1% knew), or whether TB treatment was available (55.5% knew). Nearly 40% of respondents perceived that stigma as a barrier. When controlling for age and race, the odds of perceiving HIV stigma in the workplace among patient-care health care workers (PCHWs) were 2.4 times that for non-PCHWs [95% confidence interval (CI): 1.80-3.15]. Of the 692 survey respondents who indicated a reason for not using HIV services at the OHU, 38.9% felt that confidentiality was the reason cited. Among PCHWs, the adjusted odds of expressing concern that confidentiality may not be maintained in the OHU were 2.4 times (95% CI: 1.8-3.2) that of non-PCHWs and were higher among Black [odds ratio (OR): 2.7, CI: 1.7-4.2] and Coloured HCWs (OR: 3.0, 95% CI: 1.6-5.6) as compared to White HCWs, suggesting that stigma and confidentiality concerns are still barriers to uptake of HCT. Campaigns to improve awareness of HCT and TB services offered in the OHUs, address stigma and ensure that the workforce is aware of the confidentiality provisions that are in place are warranted.

Factors Associated with COVID-19-Related Stress among Female Primary Caregivers in Vulnerable Families in South Africa.

Inequality in South Africa is deeply rooted, and COVID-19 glaringly brought inequalities between families to the forefront. This study aimed to investigate factors associated with the above average stress levels of female primary caregivers in vulnerable families during the COVID-19 pandemic. A cross-sectional survey was undertaken among vulnerable families from October 2021 to February 2022. Above average scores were reported by approximately half of the respondents regarding stress from children/partners and stress related to financial issues. Fear of COVID-19, feeling depressed, COVID-19's impact on daily life, lower education levels, being in a relationship and living together, and perceiving an increase in domestic violence were statistically significantly associated with above average stress from children/partners. Age, impact of COVID-19 on daily life, being in a relationship and living with a husband/partner, and running out of food during the past 30 days were statistically significantly associated with above average stress concerning finances. These results provide new insights that can assist policy makers and practitioners in supporting low-income families during times of crisis. Support should not just focus on practical aspects, such as the provision of food, but equally importantly, on emotional support and protection for female primary caregivers and their families. Future research should delve more deeply into causes of COVID-19-related stress in vulnerable families.

Construct validity and reliability of the perceived stress scale for nursing students in South Africa.

BACKGROUND:  Increased levels of stress in nursing students are negatively related to caring behaviours and also result in poorer job proficiency and nurses who are more inclined to leave the profession. The Perceived Stress Scale (PSS), developed by Sheu and colleagues, is one of the most cited instruments for measuring stress and sources of stress amongst nursing students in international studies. However, it has not been widely validated for this purpose. OBJECTIVES:  This research aimed to test the construct validity and reliability of the PSS for South African nursing students. METHOD:  A cross-sectional survey was conducted at a Central South African University, and 471 of the 685 registered nursing students (68.8% response rate) participated in the study. Questionnaires were distributed and collected during classes. Confirmatory factor analysis was performed to test the hypothesised six-factor latent structure and determine the construct validity of the PSS. The internal consistency of the PSS was measured using Cronbach's alpha. RESULTS:  The model fit was a good fit and supported the six-factor latent structure as stress from (1) taking care of patients, (2) teachers and nursing staff, (3) assignments and workload, (4) peers and daily life, (5) lack of professional knowledge and skills and (6) clinical environment. Overall the PSS had a Cronbach's alpha of 0.93. CONCLUSION:  The results confirm the construct validity and the internal consistency of the PSS for South African nursing students.

COVID-19 Vaccine Hesitancy in South Africa: Lessons for Future Pandemics.

Vaccine hesitancy, long considered a global health threat, poses a major barrier to effective roll-out of COVID-19 vaccination. With less than half (45%) of adult South Africans currently fully vaccinated, we identified factors affecting non-uptake of vaccination and vaccine hesitancy in order to identify key groups to be targeted when embarking upon COVID-19 vaccine promotion campaigns. A cross-sectional, anonymous online survey was undertaken among the South African adult population in September 2021. Our research identified race, interactive-critical vaccine literacy, trust in the government's ability to roll out the COVID-19 vaccination programme, flu vaccination status and risk perception for COVID-19 infection as key factors influencing the uptake of COVID-19 vaccination. Respondents who did not trust in the government's ability to roll out vaccination were almost 13 times more likely to be vaccine-hesitant compared to those respondents who did trust the government. Reliable, easy-to-understand information regarding the safety of COVID-19 vaccines is needed, but it is also important that vaccination promotion and communication strategies include broader trust-building measures to enhance South Africans' trust in the government's ability to roll out vaccination effectively and safely. This may also be the case in other countries where distrust in governments' ability prevails.