Coming of age in Khayelitsha: gendered identity, sexual partnerships and the transition to adulthood

The lives of young people in Khayelitsha are characterised by a series of intersecting challenges. These include inadequate access to education, limited opportunities to find gainful employment, exposure to violence and the risk of contracting HIV. Several conventional avenues of transition to adulthood, for example achieving financial independence, moving out of the parental home or getting married, remain unavailable to many. The majority thus find themselves in a situation of waithood, an interminable period between childhood and adulthood characterised by extreme uncertainty. This thesis takes up questions of what it means to be a young man or woman navigating towards adulthood in this context of socioeconomic marginalisation. In particular, it explores the ways that youth negotiate the tensions between the structures that shape their lives and their opportunities for agency within the domains of gendered identities and sexual partnerships. Public health research and intervention with youth tends to rely more heavily on approaches underpinned by individual-level behaviour change theories, with lesser albeit growing attention paid to the structural forces that shape young lives. This thesis aims to balance the reading of individuals' capacity for agency in decision-making, with the broader structural forces that shape their life trajectories. To this end, a longitudinal, ethnographic approach was employed to capture nuances of context and experience as they unfolded and shifted through time and space. The data presented here is drawn from 18 months of ethnographic fieldwork with young people in the neighbourhood of Town Two, Khayelitsha, primarily collected between 2014 and 2015. Youth transition to adulthood is explored in the two interrelated domains of gendered identity and sexual partnerships. Within these domains, living up to individual and social ideals associated with masculinity and femininity is persistently challenging. Faced with these challenges, young people employ creative and dynamic strategies in their endeavours to maximize the precarious gains they make in their transition towards adulthood. Broadly speaking, these strategies include those linked to their physical bodies, sexual and social networks and the ways that they invoke ideas about what it means to be a young South African citizen. The findings highlight that in their transitions to adulthood, youth in Khayelitsha are neither complete victims, nor entirely free agents with the capacity to radically change their circumstances. This thesis ends by offering some recommendations about how public health programming might take into account the lived experiences of youth as they navigate the transition to adulthood in this context

Community health workers in Khayelitsha : motivations and challenges as providers of care and players within the health system

Includes abstract.Includes bibliographical references.Community health workers (CHWs) play an important role in health care in South Africa and similar countries, but relatively little is known about CHW motivations and experiences in the provision of care. This thesis considers these issues in three parts: 1. A protocol for a study of community health work in Khayelitsha, an impoverished peri-urban settlement near Cape Town, which is home to a number of ‘flagship’ public health interventions aimed at HIV/AIDS and TB. 2. A review of literature on community health work exploring naturalistic versus economistic discourses around care work, and the complex intersections of these discourses. 3. An ethnographic account of CHWs who provide a wide range of community-based care work in Khayelitsha

‘It has become everybody’s business and nobody’s business’: Policy actor perspectives on the implementation of TB infection prevention and control (IPC) policies in South African public sector primary care health facilities

Karina Kielmann - ORCID: 0000-0001-5519-1658 https://orcid.org/0000-0001-5519-1658South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on ‘new’ evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.The support of the Economic and Social Research Council (IK) is gratefully acknowledged. The project is partly funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with other funders including support from the GCRF. Grant reference: ES/P008011/1https://doi.org/10.1080/17441692.2020.183993216pubpub1

Treatment at the front end of the criminal justice continuum: the association between arrest and admission into specialty substance abuse treatment

BACKGROUND: To reduce criminal recidivism and drug use, it has been proposed that the substance abuse treatment delivery system cut across different components of the criminal justice continuum. Arrest, at the front end of this continuum, may represent a critical moment to motivate people with substance use disorders (SUD) to seek treatment but is often over looked as an intervention point. We used data from the 2002 National Survey on Drug Use and Health (NSDUH) to compare treatment need and recent treatment admission for participants with no criminal justice (CJ) involvement in the past year, past-year arrest, and CJ supervision (i.e., probation or parole status). RESULTS: Of those arrested, 44.8% met criteria for an SUD. However, only 14% of those arrested with an SUD received treatment in the year of their arrest. In multivariate modelling, arrest was an independent predictor of treatment admission (odds ratio (OR) = 8.74) similar in magnitude to meeting criteria for an SUD (OR = 8.22). Those further along the continuum – under supervision – were most likely to receive treatment (OR = 22.62). CONCLUSION: Arrest involves the largest number of individuals entering the criminal justice system. The NSDUH suggests that nearly 6 million individuals in the US experience an arrest annually and that nearly half meet criteria for an SUD. Although arrest involves the largest number of individuals entering the criminal justice system, it is also the most fleeting point as individuals can move in and out rather quickly. Minimally, arrest imposes contact between the individual and a law enforcement person and can be an opportunity for early intervention strategies such as pre-arraignment diversion into treatment or brief intervention strategies. Using brief intervention at this early point in the continuum may motivate a greater number of individuals to seek treatment or decrease drug and alcohol use. Training and procedural shifts at this point of contact could have important policy implications in reducing the number of subsequent arrests or preventing individuals moving further along the criminal justice continuum, as well as decreasing the fiscal and resource burdens associated with criminal justice processing and confinement

A scoping review of how exposure to urban violence impacts youth access to sexual, reproductive and trauma health care in LMICs

Violence in the community can impact access to health care. This scoping review examines the impact of urban violence upon youth (aged 15–24) access to sexual and reproductive health and trauma care in Low and Middle Income Countries (LMICs). We searched key electronic health and other databases for primary peer-reviewed studies from 2010 through June 2020. Thirty five of 6712 studies extracted met criteria for inclusion. They were diverse in terms of study objective and design but clear themes emerged. First, youth experience the environment and interpersonal relationships to be violent which impacts their access to health care. Second, sexual assault care is often inadequate, and stigma and abuse are sometimes reported in treatment settings. Third is the low rate of health seeking among youth living in a violent environment. Fourth is the paucity of literature focusing on interventions to address these issues. The scoping review suggests urban violence is a structural and systemic issue that, particularly in low-income areas in LMICs, contributes to framing the conditions for accessing health care. There is a gap in evidence about interventions that will support youth to access good quality health care in complex scenarios where violence is endemic

Developing mathematical thinking in the primary classroom: liberating students and teachers as learners of mathematics

This paper reports on a research study conducted with a group of practising primary school teachers (n = 24) in North East Scotland during 2011–2012. The teachers were all participants in a newly developed Masters course that had been designed with the aim of promoting the development of mathematical thinking in the primary classroom as part of project supported by the Scottish Government. The paper presents the background for this initiative within the context of the Scottish Curriculum for Excellence reform. Particular attention is given to the epistemological positioning of the researchers as this influenced both the curriculum design process and also the theoretical framing of the research study which are both described. The project was set up within a design research framework, which aimed to promote classroom-based action research on the part of participants through the course and also research by the university researchers into the process of curriculum development. The research questions focused on the teachers’ confidence, competence, attitudes and beliefs in relation to mathematics and their expectations and experiences of the impact on pupil learning arising from this course. Empirical data were drawn from pre- and post-course surveys, interviews and observations of the discussion forums in the online environment. Findings from this study highlight the way the course had a transformational and emancipatory impact on these teachers. They also highlight ways in which the ‘framing’ of particular aspects of the curriculum had an oppressive impact on learners in the ways that suppressed creativity and limited the exercise of learner autonomy. Furthermore, they highlight the ways in which a number of these teachers had experienced mathematics as a school subject in very negative ways, involving high levels of ‘symbolic violence’ and of being ‘labelled’

Stakeholders’ Understandings of Human Papillomavirus (HPV) Vaccination in Sub-Saharan Africa: A Rapid Qualitative Systematic Review

Cervical cancer rates in Sub-Saharan Africa (SSA) are amongst the highest worldwide. All three of the Human Papillomavirus (HPV) vaccines (9-valent, quadrivalent and bivalent HPV vaccine) provide primary protection against the most common cancer-causing strains of HPV (types 16 and 18) that are known to cause 70% of cervical cancers. Over the last five years, there has been an increase in Sub-Saharan African countries that have introduced the HPV vaccine. The majority of research has been conducted on supply-side barriers and facilitators to HPV vaccination uptake in SSA, yet little research has been conducted on demand-side or end-user perspectives of, and decisions around, HPV vaccination. In order to complement existing research, and inform current and future HPV vaccination implementation approaches, this qualitative systematic review explored Stakeholders’ understandings of HPV vaccination in SSA. This review searched the following databases: Embase (via Scopus), Scopus, MEDLINE (via PubMed), PubMed, EBSCOhost, Academic Search Premier, Africa-Wide Information, CINAHL, PsycARTICLES, PsycINFO, SocINDEX, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) and found a total of 259 articles. Thirty-one studies were found eligible for inclusion and were analyzed thematically using Braun and Clarke’s methods for conducting a thematic analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Three major themes emerged from this analysis; knowledge of HPV vaccination and cervical cancer is intertwined with misinformation; fear has shaped contradictory perceptions about HPV vaccination and gender dynamics are relevant in how stakeholders understand HPV vaccination in SSA

Tuberculosis infection prevention and control: why we need a whole systems approach.

Infection prevention and control (IPC) measures to reduce transmission of drug-resistant and drug-sensitive tuberculosis (TB) in health facilities are well described but poorly implemented. The implementation of TB IPC has been assessed primarily through quantitative and structured approaches that treat administrative, environmental, and personal protective measures as discrete entities. We present an on-going project entitled Umoya omuhle ("good air"), conducted in two provinces of South Africa, that adopts an interdisciplinary, 'whole systems' approach to problem analysis and intervention development for reducing nosocomial transmission of Mycobacterium tuberculosis (Mtb) through improved IPC. We suggest that TB IPC represents a complex intervention that is delivered within a dynamic context shaped by policy guidelines, health facility space, infrastructure, organisation of care, and management culture. Methods drawn from epidemiology, anthropology, and health policy and systems research enable rich contextual analysis of how nosocomial Mtb transmission occurs, as well as opportunities to address the problem holistically. A 'whole systems' approach can identify leverage points within the health facility infrastructure and organisation of care that can inform the design of interventions to reduce the risk of nosocomial Mtb transmission

Identifying Sensitive Windows of Exposure to NO2 and Fetal Growth Trajectories in a Spanish Birth Cohort

Background: We previously identified associations between trimester-specific NO2 exposures and reduced fetal growth in the Spanish INfancia y Medio Ambiente (INMA) project. Here, we use temporally refined exposure estimates to explore the impact of narrow (weekly) windows of exposure on fetal growth. Methods: We included 1,685 women from INMA with serial ultrasounds at 12, 20, and 34 gestational weeks. We measured biparietal diameter (BPD), femur length, and abdominal circumference (AC) and from them calculated estimated fetal weight (EFW). We calculated z-scores describing trajectories of each parameter during early (0-12 weeks), mid (12-20 weeks), and late (20-34 weeks) pregnancy, based on longitudinal growth curves from mixed-effects models. We estimated weekly NO2 exposures at each woman's residence using land-use regression models. We applied distributed lag nonlinear models to identify sensitive windows of exposure. We present effect estimates as the percentage change in fetal growth per 10 mu g/m(3) increase in NO2 exposure, and we calculated cumulative effect estimates by aggregating estimates across adjacent lags. Results: We identified weeks 5-12 as a sensitive window for NO2 exposure on late EFW (cumulative beta = -3.0%; 95% CI = -4.1%, -1.9%). We identified weeks 6-19 as a sensitive window for late growth in BPD (cumulative beta = -2.0%; 95% CI = -2.7%, -1.4%) and weeks 8-13 for AC (cumulative beta = -0.68%; 95% CI = -0.97%, -0.40%). We found suggestive evidence that third trimester NO2 exposure is associated with increased AC, BPD, and EFW growth in late pregnancy. Conclusions: Our findings are consistent with the hypothesis that NO2 exposure is associated with alterations in growth of EFW, BPD, and AC dependent on the specific timing of exposure during gestation.K.W.W. and E.S. were partially supported by the P30 Environmental Health Sciences Core Center grant P30ES030285 from the National Institute

Multiple pathways to scaling up and sustainability: an exploration of digital health solutions in South Africa

Background With the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application). Results A framework integrating complexity and scaling up processes was used to conceptually orient the study. Findings are presented by case in four domains: value proposition, actors, technology and organisational context. The scale and use of PPIP and Child PIP were driven by ‘champions’; clinicians who developed technically simple tools to digitise clinical audit data. Top-down political will at the national level drove the scaling of MomConnect, supported by ongoing financial and technical support from donors and technical partners. Donor preferences played a significant role in the selection of CommCare as the platform to digitise community health worker service information, with a focus on HIV and TB. A key driver of scale across cases is leadership that recognises and advocates for the value of the digital health solution. The technology need not be complex but must navigate the complexity of operating within an overburdened and fragmented South African health system. Inadequate and unsustained investment from donors and government, particularly in human resource capacity and robust monitioring and evaluation, continue to threaten the sustainability of digital health solutions. Conclusions There is no single pathway to achieving scale up or sustainability, and there will be successes and challenges regardless of the configuration of the domains of value proposition, technology, actors and organisational context. While scaling and sustaining digital solutions has its technological challenges, perhaps more complex are the idiosyncratic factors and nature of the relationships between actors involved. Scaling up and sustaining digital solutions need to account for the interplay of the various technical and social dimensions involved in supporting digital solutions to succeed, particularly in health systems that are themselves social and political dynamic systems