Decision makers perceptions and experiences of developing population-level interventions targeting risk factors for hypertension and diabetes in South Africa: a qualitative study.

BACKGROUND: People in low- and middle-income countries are disproportionately affected by Noncommunicable diseases (NCDs). NCD's such as heart disease, cancer, chronic respiratory disease, and diabetes, are the leading cause of premature death worldwide and represent an emerging global health threat. The purpose of this qualitative study was to explore decision makers perceptions of developing population-level interventions (policies and programmes), targeting risk factors for hypertension and diabetes, in South Africa. METHODS: Using purposive sampling we recruited fifteen participants, who were well informed about the policies, programs or supportive environment for prevention and management of diabetes and hypertension in South Africa. We conducted 12 individual interviews and 1 group interview (consisting of 3 participants). Data was analysed thematically in NVivo. The results were shared and discussed in two consultative stakeholder workshops, with participants, as part of a member validation process in qualitative research. All communication with participants was done virtually using MS Teams or ZOOM. RESULTS: For development of population-level interventions, key enablers included, stakeholders' engagement and collaboration, contextualization of policies and programs, and evaluation and organic growth. Challenges for supportive policy and program formulation, and to enable supportive environments, included the lack of time and resources, lack of consultation with stakeholders, regulations and competing priorities, and ineffective monitoring and evaluation. The main drivers of population-level interventions for diabetes and hypertension were perceived as the current contextual realities, costs, organizational reasons, and communication between various stakeholders. CONCLUSION: To address the risk factors for hypertension and diabetes in South Africa, policies and programs must account for the needs of the public and the historical and socio-economic climate. Feasibility and sustainability of programs can only be ensured when the resources are provided, and environments enabled to promote behavior change on a population-level. A holistic public health approach, which is contextually relevant, and evidence informed, is considered best practice in the formulation of population-level interventions.

Storyboarding HIV Infected Young People's Adherence to Antiretroviral Therapy in Lower- to Upper Middle-Income Countries: A New-Materialist Qualitative Evidence Synthesis.

Young people living with perinatal infections of Human Immunodeficiency Virus (YLPHIV) face a chronic disease, with treatment including adherence to lifelong antiretroviral treatment (ART). The aim of this QES was to explore adherence to ART for YLPHIV as an assemblage within the framework of the biopsychosocial model with a new materialist perspective. We searched up to November 2021 and followed the ENTREQ and Cochrane guidelines for QES. All screening, data extraction, and critical appraisal were done in duplicate. We analysed and interpreted the findings innovatively by creating images of meaning, a storyboard, and storylines. We then reported the findings in a first-person narrative story. We included 47 studies and identified 9 storylines. We found that treatment adherence has less to do with humans' preferences, motivations, needs, and dispositions and more to do with how bodies, viruses, things, ideas, institutions, environments, social processes, and social structures assemble. This QES highlights that adherence to ART for YLPHIV is a multisensorial experience in a multi-agentic world. Future research into rethinking the linear and casual inferences we are accustomed to in evidence-based health care is needed if we are to adopt multidisciplinary approaches to address pressing issues such as adherence to ART.

Challenges and enablers for implementation of WHO 'Best buys' interventions targeting risk factors of diabetes and hypertension in South Africa: a mixed methods study.

Introduction: World Health Organization (WHO) recommends the implementation of 'Best buys', cost-effective interventions that address risk factors of non-communicable diseases (NCDs). However, country responses to the implementation of these have been slow and undocumented. The aim of this study was to identify and understand challenges and enablers for the implementation of WHO 'Best buys' for risk factors of diabetes and hypertension in South Africa (SA). Methods: a mixed methods research with a sequential dominant status design was used starting with a document review to take stock of WHO 'Best buys' in policy in SA. A qualitative study using key informant interviews was then done to identify and understand challenges and enablers for implementation. A triangulation approach for the analysis of both document review and qualitative data was used. Results: SA has made good progress in including the WHO 'Best buys' in the policy. However, several challenges hamper the successful implementation. Most challenges were related to upstream policy implementation processes such as competing interests of actors, lack of balance between economic vs health gains, and lack of funding. Enabling factors included multi-sectoral engagement and collaboration; community ownership and empowerment; building partnerships for co-creation of enabling environments; leveraging on the existing infrastructure of other health programs; contextualization of policies and programs; and political will and leadership. Conclusion: SA has made good progress in including WHO 'Best buys' targeting risk factors of diabetes and hypertension in policy, however, various contextual barriers influence effective implementation. Hence, there is a need to leverage enabling factors to foster the implementation of WHO 'Best buys' interventions targeting risk factors of diabetes and hypertension in South Africa.

The impact of faith-based organizations on maternal and child health care outcomes in Africa: taking stock of research evidence.

This evidence synthesis aimed at assessing the effectiveness of Faith-Based Organisations (FBOs) on Maternal and Child Health (MCH) outcomes; and explore the perceptions and experiences of the users and providers of MCH services delivered by FBOs in Africa. This review considered studies from African countries only. Both reviews and primary studies focusing on MCH services provided by FBOs were considered. Quantitative, qualitative, and mixed methods reviews were included with no restriction on the date and language. Primary outcomes included maternal mortality ratio, neonatal mortality, infant mortality, child mortality, quality of care, views, experiences, and perceptions of users of FBOs. We searched up to November 2020 in the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PROSPERO register, PDQ-evidence, Health Systems Evidence, CINAHL, EMBASE, and PubMed. We searched references cited by similar studies that may be potentially eligible for inclusion. We then updated the search for primary studies from December 2009 - October 2020. One systematic review and six primary studies met the eligibility criteria for inclusion. Methodological quality varied. These observational and qualitative studies found that FBOs offered the following MCH services - training of healthcare workers, obstetric services, health promotion, sexual education, immunization services, and intermittent preventive therapy for malaria. Maternal and Child Health (MCH) services provided by FBO suggest a reduction in maternal morbidity and mortality. Increased uptake of maternal healthcare services, and increased satisfaction were reported by users of care. However, costs of providing these services varied across the studies and users. This review shows that FBOs play an important role in improving access and delivery of MCH services and have the potential of strengthening the health system at large. Rigorous research is needed to ascertain the effectiveness of FBO-based interventions in strengthening the health systems in Africa.

Population-level interventions targeting risk factors of diabetes and hypertension in South Africa: a document review.

BACKGROUND: South Africa bears an increasing burden of non-communicable diseases (NCDs), particularly diabetes, cardiovascular diseases, and cancer. The objective of this study was to identify which population-level interventions, implemented at the level of governmental or political jurisdictions only, targeting risk factors of diabetes and hypertension were included in policies in South Africa. We also looked at whether these have been implemented or not. METHODS: A review of relevant reports, journal articles, and policy documents was conducted. Documentation from government reports that contains information regarding the planning, implementation and evaluation of population-level interventions targeting diabetes and hypertension were considered, and various databases were searched. The identified population-level interventions were categorized as supportive policies, supportive programs and enabling environments according to the major risk factors of NCDs i.e., tobacco use, harmful consumption of alcohol, unhealthy diet/nutrition and physical inactivity, in accordance with the WHO 'Best buys'. A content document analysis was conducted. RESULTS: The source documents reviewed included Acts and laws, regulations, policy documents, strategic plans, case studies, government reports and editorials. South Africa has a plethora of policies and regulations targeting major risk factors for diabetes and hypertension implemented in line with WHO 'Best buys' since 1990. A total of 28 policies, legislations, strategic plans, and regulations were identified - 8 on tobacco use; 7 on harmful consumption of alcohol; 8 on unhealthy diet and 5 on physical inactivity - as well as 12 case studies, government reports and editorials. There is good progress in policy formulation in line with the 'Best buys'. However, there are some gaps in the implementation of these policies and programs. CONCLUSION: Curbing the rising burden of NCDs requires comprehensive strategies which include population-level interventions targeting risk factors for diabetes and hypertension and effective implementation with robust evaluation to identify successes and ways to overcome challenges.

Testing for saturation in qualitative evidence syntheses: An update of HIV adherence in Africa.

BACKGROUND: A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant. METHODS: We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as 'rich' or 'sparse', coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model. RESULTS: After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory. CONCLUSIONS: Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.

A mega-aggregation framework synthesis of the barriers and facilitators to linkage, adherence to ART and retention in care among people living with HIV.

BACKGROUND: People living with human immunodeficiency virus (PLHIV) struggle with the challenges of living with a chronic disease and integrating antiretroviral treatment (ART) and care into their daily lives. The aims of this study were as follows: (1) to undertake the first mega-aggregation of qualitative evidence syntheses using the methods of framework synthesis and (2) make sense of existing qualitative evidence syntheses that explore the barriers and facilitators of adherence to antiretroviral treatment, linkage to care and retention in care for PLHIV to identify research gaps. METHODS: We conducted a comprehensive search and did all screening, data extraction and critical appraisal independently and in duplicate. We used the Kaufman HIV Behaviour Change model (Kaufman et al., 2014) as a framework to synthesise the findings using the mega-aggregative framework synthesis approach, which consists of 8 steps: (1) identify a clearly defined review question and objectives, (2) identify a theoretical framework or model, (3) decide on criteria for considering reviews for inclusion, (4) conduct searching and screening, (5) conduct quality appraisal of the included studies, (6) data extraction and categorisation, (7) present and synthesise the findings, and (8) transparent reporting. We evaluated systematic reviews up to July 2018 and assessed methodological quality, across reviews, using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews. RESULTS: We included 33 systematic reviews from low, middle- and high-income countries, which reported on 1,111,964 PLHIV. The methodological quality of included reviews varied considerably. We identified 544 unique third-order concepts from the included systematic reviews, which were reclassified into 45 fourth-order themes within the individual, interpersonal, community, institutional and structural levels of the Kaufman HIV Behaviour Change model. We found that the main influencers of linkage, adherence and retention behaviours were psychosocial and personal characteristics-perceptions of ART, desires, fears, experiences of HIV and ART, coping strategies and mental health issues-interwoven with other factors on the interpersonal, community, institutional and structural level. Using this approach, we found interdependence between factors influencing ART linkage, retention and adherence and identified the need for qualitative evidence that explores, in greater depth, the complex relationships between structural factors and adherence, sociodemographic factors such as community violence and retention, and the experiences of growing up with HIV in low- and middle-income countries-specifically in children, youth, women and key populations. CONCLUSIONS: This is the first mega-aggregation framework synthesis, or synthesis of qualitative evidence syntheses using the methods of framework synthesis at the overview level. We found the novel method to be a transparent and efficient method for assessing the quality and making sense of existing qualitative systematic reviews. SYSTEMATIC REVIEW REGISTRATION: The protocol of this overview was registered on PROSPERO ( CRD42017078155 ) on 17 December 2017.

University Curricula in Evidence-Informed Decision Making and Knowledge Translation: Integrating Best Practice, Innovation, and Experience for Effective Teaching and Learning.

As attention to Evidence Informed Decision Making (EIDM) and Knowledge Translation (KT) in research, policy and practice grows, so does a need for capacity enhancement in amongst evidence producers and evidence users. Recognizing that most researchers enter the professional sphere with little or no appreciation of the importance and power of EIDM, the Centre for Evidence-based Health Care at Stellenbosch University, South Africa, spearheaded the development and accreditation of a foundational course titled Evidence-Informed Decision making: The Art, Science and Complexity of knowledge translation. The curriculum draws on the principles of adult learning and effective teaching that includes integrating seven key aspects: (1) extraction of intuitive and tacit knowledge (2) autonomous knowledge generation (3) diverse perspectives (4) learning by doing (5) peer-support and critique (6) facilitator coaching and (7) constant reflection. In this paper, we reflect on these techniques in enhancing understanding and utilization of KT in advancing EIDM. The in-person short course has been offered 5 times since its launch in September 2017 with attendance by ~85 senior researchers and government officials-each of whom left the workshop with three completed outputs: a stakeholder matrix, an engagement strategy for their chosen stakeholder and a plan for evaluating the impact of their KT strategy. Interest in the course has grown considerably: (a) Requests from local institutes of research for dedicated training to their staff; (b) Incorporation into international program partner capacity enhancing strategies; (c) Publication of a book chapter designed using course content; (d) Adaptation and utilization of the templates and tools as teaching resources (e) Informing organizational stakeholder engagement strategies (f) Adaptation of the modules for conference capacity building workshops. In summary, designing courses that take into consideration adult principles of learning is not a new concept. However, effective delivery of such courses is still nascent. We found that integrating the seven aspects mentioned above, including researchers together with decision-makers in the workshops, and having an experienced facilitator is critical for effective learning. Enhancing knowledge and skills "just in time" rather than "just in case" has demonstrated increased potential for immediate relevance, uptake and sustainability.

Prehospital providers' perspectives for clinical practice guideline implementation and dissemination: Strengthening guideline uptake in South Africa.

BACKGROUND: In 2016 the first African emergency care clinical practice guideline (CPG) was developed for national uptake in the prehospital sector in South Africa, with implementation starting in 2018. Comprehensive uptake of CPGs post development is not a given, as this requires effective and efficient dissemination and implementation strategies that take into account the perceptions, barriers and facilitators of the local end-users. This study aimed to identify prehospital end-users' perceptions of the emergency care guidelines, including barriers and facilitators for national decision makers, to strengthen CPG uptake in South Africa. METHODS: Our study employed a descriptive qualitative research design, including nine focus groups with 56 operational emergency care providers across four major provinces in South Africa. Data was analysed using thematic analysis in ATLAS.ti. Ethics approval was provided by Stellenbosch University. RESULTS: Themes related to provider perceptions, expectations and guideline uptake emerging from the data was unofficial and unclear communication, broadening versus limiting guideline expectations, conflicted personal reactions and spreading the word. Challenges to dissemination and implementation included poor communication, changes to scope of practice, and limited capacity to upskill existing providers. Facilitators included using technology for end-user documents, local champions to support change, establishing online and modular training, and implementation by independent decision makers. CONCLUSION: This study provides an overview of the perceptions of operational emergency care providers and how their experiences of hearing about and engaging with the guidelines, in their industry, can contribute to the dissemination, implementation and uptake of emergency care guidelines. In order to disseminate and implement an emergency care CPG, decision makers must take into account the perceptions, barriers, and facilitators of local end-users.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model.

BACKGROUND: Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS: We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS: We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION: This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

'One Man Can': shifts in fatherhood beliefs and parenting practices following a gender-transformative programme in Eastern Cape, South Africa.

'One Man Can' (OMC) is a rights-based gender equality and health programme implemented by Sonke Gender Justice in South Africa. It has been featured as an example of best practice by the World Health Organization, UNAIDS, and the UN Population Fund, and translated into nearly a dozen languages and implemented all across Africa. South Africa has strong gender and HIV-related policies, but the highest documented level of men's violence against women in the world, and the largest number of people living with HIV. In this context, OMC seeks to improve men's relationships with their partners, children, and families, reduce the spread and impact of HIV and AIDS, and reduce violence against women, men, and children. To understand whether and how OMC workshops brought about changes in men's attitudes and practices related to parenting, an academic-non-government organisation partnership was carried out with the University of California at San Francisco, the University of Cape Town, and Sonke. The workshops appear to have contributed powerfully to improved parenting and more involved and responsible fathering. This article shares our findings in more detail and discusses the promises and challenges of gender-transformative work with men, underscoring the implications of this work for the health and well-being of women, children, and men.