HealthKick : evaluating the impact of a school-based intervention on the dietary adequacy of learners from low-income settings in the Western Cape Province, South Africa

HealthKick is a primary school-based nutrition and physical activity intervention programme aimed at promoting the adoption of healthy lifestyle behaviour to reduce diabetes risk factors in disadvantaged communities in South Africa. HealthKick aims to promote and increase learners', teachers' and parents' consumption of healthy food and their participation in health enhancing physical activity. This dissertation sub-study forms part of the evaluation of the greater HealthKick project. The primary objective of the study was to compare the dietary adequacy of learners at intervention and control schools after 18 months of intervention. The subsidiary objective was to identify the determinants of dietary adequacy

Metabolic complications resulting from the use of antiretroviral therapy in HIV-infected patients

While antiretroviral therapy (ART) has extended the life expectancy of those infected with HIV, it is also associated with a number of metabolic complications, such as dysglycaemia, insulin resistance and lipodystrophy. Lipodystrophy is characterised by an increase in trunk fat (lipohypertrophy) and/or a decrease in limb fat (lipoatrophy). This thesis investigates the metabolic complications associated with ART, and develops simple anthropometric cut-points for identifying those with lipodystrophy. Data for this thesis comes from three datasets (a cross sectional study and two longitudinal studies), collected between 2007 and 2013. All datasets consisted of black HIV-infected men and women presenting to ART clinics in Cape Town. The same measurements were collected in all studies: anthropometry, self-reported lipodystrophy, dual-energy X-ray absorptiometry (DXA), blood pressure (BP), cholesterol and glucose. Longitudinal data were used to assess long-term ART exposure on BP, glycaemia, insulin secretion and anthropometric measures in women on ART. We found that weight, waist circumference, and waist-hip ratio increased, limb skinfold thickness decreased, and the proportion of participants with hypertension and diabetes increased. Longitudinal data was used to describe changes in body fat distribution over a 24 month period. We found that women gained more overall weight and more regional fat in all areas compared to men. The risk of lipoatrophy was two-fold greater in men than in women. Simple, objective measures to define lipoatrophy and lipohypertrophy by comparing patient report to anthropometric and DXA-derived variables, were developed using cross sectional data. In women, the best predictors of lipoatrophy were triceps and thigh skinfold thicknesses, and for lipohypertrophy it was waist/hip ratio. Longitudinal data was used to validate the objective measures that were developed by comparing change in limb fat and trunk fat as measured by DXA to anthropometric variables. We showed that the best predictors of lipoatrophy in women were hip and mid-thigh circumference, and mid-arm circumference in men. The thesis findings highlight the importance of early identification of these cardiometabolic risks in Africa. The development of anthropometric measures are of particular relevance in resource limited settings, where health professionals need simple and inexpensive methods for diagnosing patients with lipoatrophy and lipohypertrophy

Perceptions of empowerment: a study of muslim women living in the greater Cape Town Metropole

Magister Artium - MAThis thesis is a small scale in depth exploration into the perceptions of power held by eight Muslim women residing in the Cape Town Metropole area. Using a Qualitative Feminist approach the study aimed to explore and shed light on the multiple ways in which Muslim women negotiate, construct and co-construct agency, power and authority in their everyday lives. This study also sought to explore whether Muslim women who appear independent or empowered actually feel in control of their own lives; and how their ability to make choices is mediated by intersecting identities such as race, class, age, etc. The research highlights a number of emergent themes in which discussion of the women views around education, finance, reproductive responsibilities, patriarchy, etc. takes place and also explores the ways in which the women contest and resist traditional cultural norms in their everyday experiences. Furthermore this study also sought to create a space where the researcher focused and refocused her gaze on the theoretical and epistemological aspects of her chosen method of enquiry in order to interrogate its merits and limits. Upon reflection the researcher also acknowledges that, similar to the participants, she also holds contradictory views on some of the issues discussed.South Afric

Food insecurity and common mental disorders in perinatal women living in low socio-economic settings in Cape Town, South Africa during the COVID-19 pandemic: a cohort study

Abstract Background Common mental disorders (CMDs), i.e. depression and anxiety, are highly prevalent during the perinatal period, and is associated with poverty, food insecurity and domestic violence. We collected data from perinatal women at two time-points during the COVID-19 pandemic to test the hypotheses that (1) socio-economic adversities at baseline would be associated with CMD prevalence at follow-up and (2) worse mental health at baseline would be associated with higher food insecurity prevalence at follow-up. Methods Telephonic interviews with perinatal women attending healthcare facilities in Cape Town, South Africa. Multivariable (multilevel) regression analysis was used to model the associations of baseline risk factors with the prevalence of household food insecurity and probable CMD at 3 months follow-up. Results At baseline 859 women were recruited, of whom 217 (25%) were pregnant, 631 (73%) had given birth in the previous 6 months, 106 (12%) had probable CMD, and 375 (44%) were severely food insecure. At follow-up (n = 634), 22 (4%) were still pregnant, 603 (95%) had given birth, 44 (7%) had probable CMD, and 207 (33%) were severely food insecure. In the multivariable regression model, after controlling for confounders, unemployment [incidence rate ratio (IRR) 1.19 (1.12–2.27); p < 0.001] and had higher scores on the Edinburgh Postnatal Depression Scale [IRR 1.05 (1.03–1.09); p < 0.001] at baseline predicted food insecurity at follow-up; and experiencing domestic violence [OR 2.79 (1.41–5.50); p = 0.003] at baseline predicted CMD at follow-up. Conclusions This study highlights the complex bidirectional relationship between mental health and socio-economic adversity among perinatal women during the COVID-19 pandemic

Validation of a brief mental health screening tool for pregnant women in a low socio-economic setting

Abstract Background In South Africa, the prevalence of symptoms of common mental disorders (CMD), i.e. depression, anxiety and suicidal thoughts are high. This study aimed to use a cognitive interviewing technique to validate the content and structure of a 4-item screening tool, to adapt the tool accordingly, and to use receiver operating curve (ROC) analysis to determine the optimum cut-point for identifying pregnant women with symptoms of CMD. Methods We conducted a mixed method study at a Midwife Obstetric Unit in Cape Town. Women attending the clinic for their first antenatal visit during the recruitment period, whose first language was English, Afrikaans or isiXhosa, were invited to participate. A 4-item screening tool was administered in the first language of the interviewee, after which a cognitive interviewing technique was used to examine the question-response processes and considerations used by respondents as they formed answers to the screening tool questions. The Edinburgh Postnatal Depression Scale (EPDS) was used to identify women with symptoms of CMD. Results A 2-week recall period performed well. Questions about (1) being unable to stop worrying, or thinking too much, (2) feeling down, depressed or hopeless, and (3) having thoughts and plans to harm yourself, were well understood. The question that referred to feeling little interest or pleasure in doing things, was poorly understood across all languages. Using ROC analysis with the EPDS as the reference standard, and a cut-point of ≥13, we showed that a 3-item version of the screening tool was able to correctly classify 91% of the women screened. Conclusions Cognitive interviewing enabled testing and refining of the language and constructs of an ultra-brief screening tool. The shortened, 3-item tool is well understood and effective at identifying pregnant women with symptoms of CMD, across the three most commonly spoken languages and cultures in Cape Town

"HealthKick": Formative assessment of the health environment in low-resource primary schools in the Western Cape Province of South Africa

BACKGROUND: This study evaluated the primary school environment in terms of being conducive to good nutrition practices, sufficient physical activity and prevention of nicotine use, with the view of planning a school-based health intervention. METHODS: A sample of 100 urban and rural disadvantaged schools was randomly selected from two education districts of the Western Cape Education Department, South Africa. A situation analysis, which comprised an interview with the school principal and completion of an observation schedule of the school environment, was done at all schools. RESULTS: Schools, on average, had 560 learners and 16 educators. Principals perceived the top health priorities for learners to be an unhealthy diet (50%) and to far lesser degree, lack of physical activity (24%) and underweight (16%). They cited lack of physical activity (33%) and non-communicable diseases (NCDs; 24%) as the main health priorities for educators, while substance abuse (66%) and tobacco use (31%) were prioritised for parents. Main barriers to health promotion programmes included lack of financial resources and too little time in the time table. The most common items sold at the school tuck shops were crisps (100%), and then sweets (96%), while vendors mainly sold sweets (92%), crisps (89%), and ice lollies (38%). Very few schools (8%) had policies governing the type of food items sold at school. Twenty-six of the 100 schools that were visited had vegetable gardens. All schools reported having physical activity and physical education in their time tables, however, not all of them offered this activity outside the class room. Extramural sport offered at schools mainly included athletics, netball, and rugby, with cricket and soccer being offered less frequently. CONCLUSION: The formative findings of this study contribute to the knowledge of key environmental and policy determinants that may play a role in the health behaviour of learners, their parents and their educators. Evidently, these show that school environments are not always conducive to healthy lifestyles. To address the identified determinants relating to learners it is necessary to intervene on the various levels of influence, i.e. parents, educators, and the support systems for the school environment including the curriculum, food available at school, resources for physical activity as well as appropriate policies in this regard

Developing a task-sharing psychological intervention to treat mild to moderate symptoms of perinatal depression and anxiety in South Africa: a mixed-method formative study

Background Symptoms of depression and anxiety are highly prevalent amongst perinatal women in low-resource settings of South Africa, but there is no access to standardised counselling support for these conditions in public health facilities. The aim of this study is to develop a task-sharing psychological counselling intervention for routine treatment of mild to moderate symptoms of perinatal depression and anxiety in South Africa, as part of the Health Systems Strengthening in sub-Saharan Africa (ASSET) study. Methods We conducted a review of manuals from seven counselling interventions for depression and anxiety in low- and middle-income countries and two local health system training programmes to gather information on delivery format and common counselling components used across task-sharing interventions. Semi-structured interviews were conducted with 20 health workers and 37 pregnant women from four Midwife Obstetric Units in Cape Town to explore perceptions and needs relating to mental health. Stakeholder engagements further informed the intervention design and appropriate service provider. A four-day pilot training with community-based health workers refined the counselling content and training material. Results The manual review identified problem-solving, psychoeducation, basic counselling skills and behavioural activation as common counselling components across interventions using a variety of delivery formats. The interviews found that participants mostly identified symptoms of depression and anxiety in behavioural terms, and lay health workers and pregnant women demonstrated their understanding through a range of local idioms. Perceived causes of symptoms related to interpersonal conflict and challenging social circumstances. Stakeholder engagements identified a three-session counselling model as most feasible for delivery as part of existing health care practices and community health workers in ward-based outreach teams as the best placed delivery agents. Pilot training of a three-session intervention with community-based health workers resulted in minor adaptations of the counselling assessment method. Conclusion Input from health workers and pregnant women is a critical component of adapting existing maternal mental health protocols to the context of routine care in South Africa, providing valuable data to align therapeutic content with contextual needs. Multisector stakeholder engagements is vital to align the intervention design to health system requirements and guidelines

The association between nutrition and physical activity knowledge and weight status of primary school educators

The purpose of this study was to investigate primary school educators' health status, knowledge, perceptions and behaviour regarding nutrition and physical activity.Thus, nutrition and physical activity knowledge, attitudes, behaviour and risk factors for the development of non-communicable diseases of 155 educators were assessed in a cross-sectional survey. Height, weight, waist circumference, blood pressure and random glucose levels were measured. Twenty percent of the sample had normal weight (body mass index (BMI, kg/m2) 25 to 140/90 mmHg: 50.3%), and were inactive (48.7%) with a high waist circumference (> 82 cm: 57.4%). Educators' nutrition and physical activity knowledge was poor. Sixty-nine percent of educators incorrectly believed that eating starchy foods causes weight gain and only 15% knew that one should eat five or more fruit and/or vegetables per day. Aspects of poor nutritional knowledge, misconceptions regarding actual body weight status, and challenges in changing health behaviours, emerged as issues which need to be addressed among educators. Educators' high risk for developing chronic non-communicable diseases (NCDs) may impact on educator absenteeism and subsequently on school functioning. The aspects of poor nutrition and physical activity knowledge along with educators' high risk for NCD development may be particularly significant not merely in relation to their personal health but also the learners they teach

Accessible continued professional development for maternal mental health

Background: Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD. Aim: The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors. Setting: One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study. Methods: Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians’ Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively. Results: Participants’ knowledge showed a statistically significant (p < 0.001) improvement between the pre- and post-test results, for all six chapters of the book. However, participants’ attitudes towards mental illness did not show a statistically significant change between the pre- and post-test results. Conclusion: We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings

Did HealthKick, a randomised controlled trial primary school nutrition intervention improve dietary quality of children in low-income settings in South Africa?

Background: Numerous studies in schools in the Western Cape Province, South Africa have shown that children have an unhealthy diet with poor diversity and which is high in sugar and fat. HealthKick (HK) was a three-year randomised controlled trial aimed at promoting healthy eating habits. Methods: Sixteen schools were selected from two low-income school districts and randomly allocated to intervention (n = 8) or control school (n = 8) status. The HK intervention comprised numerous activities to improve the school nutrition environment such as making healthier food choices available and providing nutrition education support. Dietary intake was measured by using a 24-h recall in 2009 in 500 grade 4 learners at intervention schools and 498 at control schools, and repeated in 2010 and 2011. A dietary diversity score (DDS) was calculated from nine food groups and frequency of snack food consumption was determined. A school level analysis was performed. Results: The mean baseline (2009) DDS was low in both arms 4.55 (SD = 1.29) and 4.54 (1.22) in the intervention and control arms respectively, and 49 % of learners in HK intervention schools had a DDS ≤4 (=low diversity). A small increase in DDS was observed in both arms by 2011: mean score 4.91 (1.17) and 4.83 (1.29) in the intervention and control arms respectively. The estimated DSS intervention effect over the two years was not significant [0 .04 (95 % CI: −0.37 to 0.46)]. Food groups least consumed were eggs, fruit and vegetables. The most commonly eaten snacking items in 2009 were table sugar in beverages and/or cereals (80.5 %); followed by potato crisps (53.1 %); non-carbonated beverages (42.9 %); sweets (26.7 %) and sugar-sweetened carbonated beverages (16 %). Unhealthy snack consumption in terms of frequency of snack items consumed did not improve significantly in intervention or control schools. Discussion: The results of the HK intervention were disappointing in terms of improvement in DDS and a decrease in unhealthy snacking. We attribute this to the finding that the intervention model used by the researchers may not have been the ideal one to use in a setting where many children came from low-income homes and educators have to deal with daily problems associated with poverty.Conclusions: The HK intervention did not significantly improve quality of diet of children