The Transformative Impact of Community-Led Monitoring in the South African Health System: A Comprehensive Analysis.

Objectives: Community-led monitoring (CLM) is an emerging approach that empowers local communities to actively participate in data collection and decision-making processes within the health system. The research aimed to explore stakeholder perceptions of CLM data and establish a CLM Data Value Chain, covering data collection and its impact. Methods: Qualitative data were collected from stakeholders engaged in health programs in South Africa. Data analysis involved a collaborative workshop that integrated elements of affinity diagramming, thematic analysis, and the systematic coding process outlined in Giorgi's method. The workshop fostered joint identification, co-creation of knowledge, and collaborative analysis in developing the data value chain. Results: The findings showed that CLM data enabled community-level analysis, fostering program advocacy and local collaboration. It enhanced program redesign, operational efficiency, and rapid response capabilities. Context-specific solutions emerged through the CLM Data Value Chain, promoting sustainable and efficient program implementation. Conclusion: CLM is a powerful tool for improving program implementation, quality, and advocacy in South African healthcare. It strengthens accountability, trust, and transparency by involving local communities in data-driven decision-making. CLM addresses context-specific challenges and tailors interventions to local needs.

Understanding health outcome drivers among adherence club patients in clinics of Gauteng, South Africa: a structural equation modelling (SEM) approach.

BACKGROUND: There has been growing interest in understanding the drivers of health outcomes, both in developed and developing countries. The drivers of health outcomes, on the other hand, are the factors that influence the likelihood of experiencing positive or negative health outcomes. Human Immunodeficiency Virus (HIV) continues to be a significant global public health challenge, with an estimated 38 million people living with the aim of this study was therefore to develop and empirically test a conceptual research model using SEM, aimed at explaining the magnitude of various factors influencing HIV and other health outcomes among patients attending Adherence Clubs. METHOD: This was a cross sectional survey study design conducted in 16 health facilities in the City of Ekurhuleni in Gauteng Province, South Africa. A total of 730 adherence club patients were systematically sampled to participate in a closed ended questionnaire survey. The questionnaire was assessed by Cronbach's alpha coefficient for internal consistency. The proposed model was tested using structural equation modelling (AMOS software: ADC, Chicago, IL, USA). RESULTS: A total of 730 adherence club members participated in the study. Of these, 425 (58.2%) were female and 305 (41.8%) were male. The overall results indicated a good reliability of all the scale involved in this study as Cronbach alphas ranged from 0.706 to 0.874, and composite reliability from 0.735 to 0.874. The structural model showed that the constructs health seeking behavior (ß = 0.267, p = 0.000), health care services (ß = 0.416, p = 0.000), stigma and discrimination (ß = 0.135, p = 0.022) significantly predicted health outcomes and explained 45% of its variance. The construct healthcare service was the highest predictor of health outcomes among patients in adherence clubs. CONCLUSION: Patient health seeking behaviour, healthcare services, stigma and discrimination were associated with perceived health outcomes. Since adherence clubs have been found to have a significant impact in improving patient outcomes and quality of life, there is a need to ensure replication of this model.

Patient satisfaction with chronic disease care and its associated factors in primary health care facilities in Johannesburg, South Africa.

Background: Patient satisfaction is a widely used indicator of assessing health care quality and has been used by policymakers to consider the needs of patients when developing suitable strategies for safe and high-quality care. However, in South Africa, the dual burden of HIV and NCDs has implications for the health system, whereby the factors influencing the quality of care and patient satisfaction may be unique to this context. Thus, this study examined the predictors affecting chronic disease patients' levels of satisfaction with care in Johannesburg, South Africa. Methods: A cross-sectional study was conducted among 2,429 chronic disease patients at 80 primary healthcare facilities in Johannesburg, South Africa. A questionnaire derived from existing literature and patient satisfaction frameworks was used to measure the level of satisfaction of patients when receiving care. Patients' overall satisfaction was categorized into not satisfied and satisfied. Cronbach's alpha was used to assess scale reliability. Factor analysis was used as a data dimension reduction approach and the Kaiser-Meyer-Olkin and the Bartlett test of sphericity were used to test the sampling adequacy and to examine the inter-independence of the items. Logistic regression was used to determine factors associated with being satisfied. Significance was set at 5%. Results: The majority of chronic disease patients 65.5% (n = 1,592) were aged 18-30 years; 63.8% (n = 1,549) were females, 55.1% (n = 1,339) were married and 2,032 (83.7%) were satisfied with care. The factor analysis results were in five sub-scales namely improving values and attitudes, cleanliness of the clinic, safe and effective care, infection control, and on the availability of medicines. In adjusted models, patients aged >51years had an increased odds of 3.18 (95% CI:1.31-7.75) of being satisfied compared to those aged 18-30 years and patients who had visited the clinic at least 6 times had 51% increased odds of being satisfied (AOR = 1.51,95% CI:1.13-2.03). The odds of being satisfied increased by 28% (AOR = 1.28,95% CI:1.07-1.53), 45% (AOR = 1.45,95% CI:1.2-1.75), 34% (AOR = 1.34,95% CI:1.13-1.59) and 4.31 (95% CI:3.55-5.23) for every score increase in the factors like improving values and attitudes, cleanliness of clinic safe and effective care and availability of medicine, respectively. Conclusions: Key predictors of patient satisfaction were found to be sociodemographic factors including age, distance to the clinic, number of visits and waiting times as well as factors such as improving values and attitudes, cleanliness of the clinic, waiting time, safety and effective care and availability of medicines. Adjustment of existing frameworks for addressing context-specific improvement of patient experiences such as security and safety is recommended to ensure healthcare quality and service utilization for better chronic disease outcomes in South Africa.

Factors associated with high HIV-related stigma among commuter populations in Johannesburg, South Africa.

Stigma remains an important barrier to seeking and staying in care among individuals infected with Human Immunodeficiency Virus (HIV). Despite continued widespread information, education and communication campaigns to raise awareness about the infection. The aim of the study was to identify factors related to HIV stigma among a commuter population in the inner-city Johannesburg. A self-administered closed-ended questionnaire was loaded onto personal tablet computers during a community outreach campaign. The outcome was measured by asking the respondents to rate their perceptions of stigma as 'high or low'. About 1146 participants were enrolled in the study of which 585 (51.0%) reported high stigma levels. Overall, being married/cohabiting (Adjusted Prevalence Ratio (APR): 1.14 95%CI: 1.02-1.28), divorced (APR: 1.38 95%CI: 1.07-1.78), were associated with high levels of stigma; while being aware of HCT services (APR: 0.85 95%CI: 0.75-0.97) and employment status (APR: 0.78 95%CI: 0.71-0.87) were less likely associated with a high level of stigma. High HIV stigma still exists among those affected in our communities. Enhancement of health promotion intervention and reinforcing the benefits of knowing HIV status is essential to mitigate factors shown to influence stigma in the commuter population. Such an approach would help overcome stigma, an obstacle for expanding access to HIV testing and counselling.

Acceptability of Mobile Health Interventions to Increase Diabetic Risk Factor Awareness Among the Commuter Population in Johannesburg: Descriptive Cross-Sectional Study.

BACKGROUND: Developing countries are experiencing a shift from infectious diseases such as HIV and tuberculosis to noncommunicable diseases (NCDs) such as diabetes. Diabetes accounts for more disability-adjusted life years than any other NCD in South Africa, and research has identified a number of preventable risk factors; however, there is not enough evidence from lower resource settings as to how best to disseminate this information to the population. Today, 90% of the world's population lives in mobile phone coverage areas, and this provides a unique opportunity to reach large populations with health information. OBJECTIVE: This study aimed to investigate how potential mobile health (mHealth) platforms should be paired with diabetes risk factor education so that at-risk communities are empowered with information to prevent and manage diabetes. METHODS: A Likert-style survey was distributed to commuters in the City of Johannesburg in July 2018 that explored participants' background characteristics as well as their knowledge and awareness surrounding diabetic risk factors (such as exercise, smoking, and hypertension) and their comfort level with various information delivery methods (such as WhatsApp, short message service, and email). The grouped variables from diabetic risk factors and information delivery methods were described with mean Likert scores and then investigated for relationships with Spearman Rho correlation coefficients. RESULTS: Background characteristics revealed that the self-reported prevalence of diabetes was twice as high in this studied commuter population than the national average. WhatsApp was the most favorable mHealth information delivery method and had a moderate correlation coefficient with diet and nutrition (0.338; P<.001) as well as a weaker correlation with physical activity (0.243; P<.001). Although not as robust as the WhatsApp correlations, each of the other information delivery methods also showed weaker, yet statistically significant, relationships with one or more of the risk factors. CONCLUSIONS: The elevated self-reported diabetes prevalence reinforces the need for diabetes risk factor education in the studied commuter population of Johannesburg. The most feasible mHealth intervention for diabetic risk factor education should focus on WhatsApp messaging while also offering content across other mHealth and traditional platforms to remove barriers to access and enhance the user experience. The content should emphasize diet and nutrition as well as physical activity while also incorporating information on secondary risk factors.

Application of machine learning models in predicting length of stay among healthcare workers in underserved communities in South Africa.

BACKGROUND: Human resource planning in healthcare can employ machine learning to effectively predict length of stay of recruited health workers who are stationed in rural areas. While prior studies have identified a number of demographic factors related to general health practitioners' decision to stay in public health practice, recruitment agencies have no validated methods to predict how long these health workers will commit to their placement. We aim to use machine learning methods to predict health professional's length of practice in the rural public healthcare sector based on their demographic information. METHODS: Recruitment and retention data from Africa Health Placements was used to develop machine-learning models to predict health workers' length of practice. A cross-validation technique was used to validate the models, and to evaluate which model performs better, based on their respective aggregated error rates of prediction. Length of stay was categorized into four groups for classification (less than 1 year, less than 2 years, less than 3 years, and more than 3 years). R, a statistical computing language, was used to train three machine learning models and apply 10-fold cross validation techniques in order to attain evaluative statistics. RESULTS: The three models attain almost identical results, with negligible difference in accuracy. The "best"-performing model (Multinomial logistic classifier) achieved a 47.34% [SD 1.63] classification accuracy while the decision tree model achieved an almost comparable 45.82% [SD 1.69]. The three models achieved an average AUC of approximately 0.66 suggesting sufficient predictive signal at the four categorical variables selected. CONCLUSIONS: Machine-learning models give us a demonstrably effective tool to predict the recruited health workers' length of practice. These models can be adapted in future studies to incorporate other information beside demographic details such as information about placement location and income. Beyond the scope of predicting length of practice, this modelling technique will also allow strategic planning and optimization of public healthcare recruitment.

Acceptability of community-based adherence clubs among health facility staff in South Africa: a qualitative study.

BACKGROUND: Patient retention in care for HIV/AIDS is a critical challenge for antiretroviral treatment programs. Community-based adherence programs (CBAPs) as compared to health care facility-based adherence programs have been considered as one of the options to provide treatment maintenance support for groups of patients on antiretroviral therapy. Such an approach provides a way of enhancing self-management of the patient's condition. In addition, CBAPs have been implemented to support antiretroviral treatment expansion in resource-limited settings. CBAPs involve 30 patients that are allocated to a group and meet at either a facility or a community venue for less than an hour every 2 or 3 months depending on the supply of medication. Our study aimed to establish perceived challenges in moving adherence clubs from health facilities to communities. METHODS: A qualitative study was conducted in 39 clinics in Mpumalanga and Gauteng Provinces in South Africa between December 2015 and January 2016. Purposive sampling method was used to identify nurses, club managers, data capturers, pharmacists and pharmacy assistants who had been involved in facility-based treatment adherence clubs. Key-informant interviews were conducted. Also, semi-structured interviews were used and thematic content analysis was done. RESULTS: A total of 53 health care workers, 12 (22.6%) males and 41 (77.4%) females, participated in the study. Most of them 49 (92.5%) indicated that participating in community adherence clubs were a good idea. Reduction in waiting time at the health facilities, in defaulter rate, improvement in adherence to treatment as well as reduction in stigma were some of the perceived benefits. However, security of medication, storage conditions and transportation of the prepacked medication to the distribution sites were the areas of concern. CONCLUSION: Health care workers were agreeable to idea of the moving adherence clubs from health facilities to communities. Although some challenges were identified, these could be addressed by the key stakeholders. However, government and nongovernmental organizations need to exercise caution when transitioning to community-based adherence clubs.

Health Information Needs and Reliability of Sources Among Nondegree Health Sciences Students: A Prerequisite for Designing eHealth Literacy.

BACKGROUND: Understanding health information needs and health-seeking behavior is a prerequisite for developing an electronic health information literacy (EHIL) or eHealth literacy program for nondegree health sciences students. At present, interest in researching health information needs and reliable sources paradigms has gained momentum in many countries. However, most studies focus on health professionals and students in higher education institutions. OBJECTIVE: The present study was aimed at providing new insight and filling the existing gap by examining health information needs and reliability of sources among nondegree health sciences students in Tanzania. METHOD: A cross-sectional study was conducted in 15 conveniently selected health training institutions, where 403 health sciences students were participated. Thirty health sciences students were both purposely and conveniently chosen from each health-training institution. The selected students were pursuing nursing and midwifery, clinical medicine, dentistry, environmental health sciences, pharmacy, and medical laboratory sciences courses. Involved students were either in their first year, second year, or third year of study. RESULTS: Health sciences students' health information needs focus on their educational requirements, clinical practice, and personal information. They use print, human, and electronic health information. They lack eHealth research skills in navigating health information resources and have insufficient facilities for accessing eHealth information, a lack of specialists in health information, high costs for subscription electronic information, and unawareness of the availability of free Internet and other online health-related databases. CONCLUSION: This study found that nondegree health sciences students have limited skills in EHIL. Thus, designing and incorporating EHIL skills programs into the curriculum of nondegree health sciences students is vital. EHIL is a requirement common to all health settings, learning environments, and levels of study. Our future intention is to design EHIL to support nondegree health sciences students to retrieve and use available health information resources on the Internet.

The mediating role of self-efficacy in the relationship between premotivational cognitions and engagement in multiple health behaviors: a theory-based cross-sectional study among township residents in South Africa.

BACKGROUND: Noncommunicable diseases (NCDs) are one of the major global health challenges in developed countries and are rapidly increasing globally. Perception of self-efficacy is important for complex activities and long-term changes in health behavior. This study aimed to determine whether self-efficacy mediates the effect of individual beliefs (perceived severity, susceptibility, benefits and barriers) among informal settlement residents' health behavior in relation to the prevention and management of NCDs. METHODS: A cross-sectional survey was conducted using a closed-ended questionnaire among informal settlement residents in Diepsloot, Johannesburg. The proposed model was tested using structural equation modeling (AMOS software). RESULTS: A total of 2,277 participants were interviewed during this survey, consisting of 1,236 (54.3%) females, with the majority of them aged between 20 and 29 years. All constructs in the questionnaire had a good reliability with a Cronbach's alpha of >0.7. Perceived benefits and perceived barriers were the strongest predictors of self-efficacy, with the highest beta values of 0.14 and 0.15, respectively. Once associated with perceived self-efficacy, the direct effect of perceived susceptibility and perceived benefits on health behavior was statistically nonsignificant (P=0.0894 and P=0.2839, respectively). Perceived benefits and perceived susceptibility were totally mediated by self-efficacy. The indirect effects of perceived severity and perceived barriers (through self-efficacy) on health behavior were significant. Thus, perceived severity and perceived barriers were partially mediated by self-efficacy. CONCLUSION: Perceived susceptibility and perceived benefits did not affect health behavior unless associated with self-efficacy. In contrast, individual perception of the seriousness of NCDs and perceived barriers might still have a direct influence on health behavior even if the person does not feel able to prevent NCDs. However, this influence would be more significant when perceived severity and perceived barriers of NCDs are associated with self-efficacy.

HIV-related knowledge, perceptions, attitudes, and utilisation of HIV counselling and testing: a venue-based intercept commuter population survey in the inner city of Johannesburg, South Africa.

BACKGROUND: HIV counselling and testing (HCT) and knowledge about HIV have been key strategies utilised in the prevention and control of HIV/AIDS worldwide. HIV knowledge and uptake of HCT services in sub-Saharan Africa are still low. This study was conducted to determine factors associated with HCT and HIV/AIDS knowledge levels among a commuter population in Johannesburg, South Africa. OBJECTIVE: To identify the factors associated with HCT uptake among the commuter population. DESIGN: A simple random sampling method was used to select participants in a venue-based intercept survey at a taxi rank in the Johannesburg Central Business District. Data were collected using an electronic questionnaire. Logistic regression analysis assessed factors associated with HIV testing stratified by gender. RESULTS: 1,146 respondents were interviewed, the maority (n=579, 50.5%) were females and (n=780, 68.1%) were over 25 years of age. Overall HCT knowledge was high (n=951, 83%) with more females utilising HCT facilities. There was a significant difference in HIV testing for respondents living closer to and further away from health facilities. Slightly more than half of the respondents indicated stigma as one of the barriers for testing (n=594, 52%, p-value=0.001). For males, living with a partner (aOR: 1.68, 95% CI: 1.02-2.78, p-value: 0.041) and possessing a post-primary education were positively associated with testing (aOR: 2.00, 95% CI: 1.15-3.47, p-value: 0.014), whereas stigma and discrimination reduced the likelihood of testing (aOR: 0.40, 95% CI: 0.31-0.62, p-value: <0.001). For females, having one sexual partner (aOR: 2.65, 95% CI: 1.19-5.90, p-value: 0.017) and a low perceived benefit for HIV testing (aOR: 0.54, 95% CI: 0.30-0.96, p-value: 0.035) were associated with HIV testing. CONCLUSION: The overall HIV/AIDS knowledge was generally high. Gender-specific health education and HIV intervention programmes are needed for improved access to HCT services. One favourable intervention would be the use of home-based HCT programmes.

Potential barriers to rapid testing for human immunodeficiency virus among a commuter population in Johannesburg, South Africa.

BACKGROUND: This study aimed to determine barriers to accessing human immunodeficiency virus (HIV) counseling and testing (HCT) services among a commuter population. METHODS: A cross-sectional, venue-based intercept survey was conducted. Participants were recruited during a 2-day community campaign at the Noord Street taxi rank in Johannesburg, South Africa. Data were collected using a self-administered questionnaire loaded onto an electronic data collection system and analyzed using Stata software. Factors contributing to barriers for HCT were modeled using multivariate logistic regression. RESULTS: A total of 1,146 (567 male and 579 female) individuals were interviewed; of these, 51.4% were females. The majority (59.5%) were aged 25-35 years. Significant factors were age group (15-19 years), marital status (married), educational level (high school), distance to the nearest clinic (>30 km), area of employment/residence (outside inner city), and number of sexual partners (more than one). Participants aged 15-19 years were more likely to report low-risk perception of HIV as a barrier to HCT (odds ratio [OR] 1.62; 95% confidence interval [CI] 1.01-2.59), the married were more likely to report low-risk perception of HIV as a barrier to HCT (OR 1.49; 95% CI 1.13-1.96), and those living outside the inner city were more likely to report lack of partner support as a potential barrier (OR 1.94; 95% CI 1.34-2.80), while those with a high school education were more likely to report poor health worker attitude as a potential barrier to HIV testing (OR 2.17; 95% CI 1.36-3.45). CONCLUSION: Age, marital status, occupation, educational level, area of employment and residence, distance to the nearest clinic, and number of sexual partners were factors significantly associated with barriers to HIV testing in the study population. Future HIV intervention targeting this population need to be reinforced in order to enhance HIV testing while taking cognizance of these factors.

Factors contributing to home-based acceptability of rapid testing for HIV infection among the inner city commuter population in Johannesburg, South Africa.

BACKGROUND: The study aimed to determine factors contributing to the acceptability of home-based HIV counselling and testing (HBHCT) among commuters in Johannesburg inner city. METHODS: Simple random sampling was used to select participants in a venue based intercept survey at Noord Street taxi rank in Johannesburg central business district. A total of 1146 individuals were interviewed and logistic regression analysis assessed factors associated with HBHCT acceptability. RESULTS: HBHCT acceptability was 64%. Home testing was preferred as an alternative to testing at a health facility. High school education (adjusted odds ratio [aOR] 0.61, CI: 0.46-0.85), inner city residence aOR 0.70, CI: 0.52-0.94), previous HIV testing in the hospital (aOR 0.22, CI: 0.15-0.32) and at home (aOR 0.18, CI: 0.11-0.27) were significantly less likely associated with HBHCT acceptability. Being married (aOR 1.64, CI: 1.15-2.32), recent HIV testing (aOR 1.85, CI: 1.15-2.99) and having experienced negative health worker attitude (aOR 2.41, CI: 1.66-3.48) were significantly more likely associated with HBHCT acceptability. CONCLUSIONS: High acceptability of HBHCT among urban-based commuters plus factors that would deter HBHCT acceptability were identified. Further research to identify strategies to improve HBHCT acceptability among commuter populations is needed.