Evaluation of a Cape Town Safety Intervention as a Model for Good Practice: A Partnership between Researchers, Community and Implementing Agency

VPUU has a wealth of experience to share and is engaged with broader national and international policymakers and implementing agencies. Researchers are grappling with the difficulty of providing a rigorous project evaluation for these collaborations which could identify project elements that work with a view to their replication. This paper traces the evolution of an evidence-based approach to violence prevention in the Western Cape Province of South Africa. The Violence Prevention through Urban Upgrading (VPUU) project in Cape Town uses such an approach, and relies on a 'whole-of-society' methodology as well. The project and the difficulty of its evaluation are discussed. A partnership between VPUU, researchers, the community and local government has revealed both opportunities and obstacles, which are the subjects of a case study described here

Violence, alcohol and symptoms of depression and in Cape Town's poorest communities: results of a community survey

Introduction This paper summarises key findings from the first of three household surveys conducted in three high-violence areas in the Cape Town, investigating community members’ experiences of alcohol use, their built environment, violence and symptoms of depression, together with their views on alcohol and other interventions. Methods A stratified random sample of 1500 dwellings, 1200 in Khayelitsha and 300 in Gugulethu and Nyanga (“Gunya”) was selected using GIS address data for formal areas and aerial photography for informal areas. Fieldwork took place from July to November 2013. Responses to questions were summarized by area, gender, age and formal vs. informal settlement type. Results After substitution and data cleaning, 1213 Khayelitsha households and 286 Gunya households were included. In Gunya, 29% of respondents reported that they or their family members had been affected by at least one violent crime (murder, assault, domestic violence, rape) in the past year, compared with 12% in Khayelitsha. Using a CES-D-10 cut-off of 10, 44% of respondents were classified as depressed. More than half the respondents reported having experienced some form of alcohol nuisance. Respondents were supportive of alcohol interventions such as increased taxes and police regulation of outlets, particularly in Gunya (87%) and amongst female respondents (76%). Satisfaction with infrastructure such as street lighting and drainage was generally low. Conclusions The results describe the co-occurring burdens of alcohol and drug use, violence, depression and deprivation in our study populations

Antenatal health promotion via short message service at a Midwife Obstetrics Unit in South Africa: a mixed methods study

Abstract Background Adequate antenatal care is important to both the health of a pregnant woman and her unborn baby. Given South Africa’s high rate of cellphone penetration, mobile health interventions have been touted as a potentially powerful means to disseminate health information. This study aimed to increase antenatal health knowledge and awareness by disseminating text messages about clinic procedures at antenatal visits, and how to be healthy during pregnancy. Methods Participants recruited were pregnant women attending a primary health care facility in Cape Town. A controlled clinical trial was carried out where the intervention group (n = 102) received text messages staggered according to the week of pregnancy at the time of recruitment. The control group (n = 104) received no text messages. These text messages contained antenatal health information, and were delivered in English, Xhosa or Afrikaans, according to the preference of each participant. A baseline knowledge questionnaire with nine questions was administered prior to the intervention. The same questionnaire was used with added health-related behaviour questions for the intervention group at exit. A modified intention-to-treat analysis was done. To compare the control and intervention group’s knowledge, Fisher’s exact tests and two-sample t-tests tests were carried out for binary and continuous outcomes, respectively. A focus group of seven participants from the intervention group was then conducted to gain more insight into how the text messages were perceived. Results There was substantial loss to follow-up during the study with only 57% of the participants retained at exit. No statistically significant difference was detected between the control and intervention group in any of the nine knowledge questions at exit (all p > 0.05). Responses from the focus group indicated that the text messages acted as a welcome reminder and a source of positive motivation, and were perceived as extended care from the health care provider. Conclusions While the intervention failed to improve antenatal health knowledge, evidence from self-reported behaviour and the focus group suggests that text messages have the potential to motivate change in health-seeking behaviour. One should be mindful of loss to follow-up when rolling out mobile health interventions in developing country settings. Trial registration Pan African Clinical Trials Registry PACTR201406000841188 . Registered 3 June 2014

Between empathy and anger: healthcare workers’ perspectives on patient disengagement from antiretroviral treatment in Khayelitsha, South Africa - a qualitative study

Background & objectives The benefits of long-term adherence to antiretroviral treatment (ART) are countered by interruptions in care or disengagement from care. Healthcare workers (HCWs) play an important role in patient engagement and negative or authoritarian attitudes can drive patients to disengage. However, little is known about HCW perspectives on disengagement. We explored HCWs’ perspectives on ART disengagement in Khayelitsha, a peri-urban area in South Africa with a high HIV burden. Method Semi-structured interviews were conducted in English with 30 HCWs in a primary care HIV clinic to explore their perspectives of patients who disengage from ART. Participants included doctors, nurses, counsellors, social workers, data clerks, security guards, and allied health professionals. The interview guide included questions that asked HCWs to give examples of patients who interrupt treatment, their perceptions of people who disengage from care and their feelings when dealing with a patient who is returning to care. All transcripts were audio-recorded, transcribed, and analysed using an inductive thematic analysis approach. Results Most staff were knowledgeable about the complexities of disengagement and highlighted potential barriers to sustaining adherence on ART, including mental health challenges and non-disclosure to family and partners. Participants expressed empathy for patients who interrupted treatment, particularly when discussing potential barriers to continued engagement in care. However, many also expressed feelings of anger and frustration towards these patients, partly because they reported these patients increase workload. Some staff, mainly those taking chronic medication themselves, perceived that patient who disengage from ART do not take adequate responsibility for their health. Conclusion Lifelong engagement with HIV care is influenced by many factors, including HCW interactions. Findings from this study show that staff had contradictory feelings towards disengaged patients, experiencing both empathy and anger. This understanding could contribute to the development of more nuanced interventions to support staff and encourage true person-centred care, to improve patient outcomes

Knowledge, attitudes and practices on adolescent vaccination among parents, teachers and adolescents in Africa: a systematic review protocol

Background: Vaccines are the most successful and cost-effective public health interventions available to avert vaccine-preventable diseases and deaths. Despite progress in the field of adolescent health, many young people in Africa still get sick and die from vaccine-preventable diseases due to lack of vaccination. Parents, adolescents and teachers are key players with regard to implementation of adolescent vaccination policies. Therefore, understanding their knowledge, attitudes and practices towards adolescent vaccination may provide clues on what can be done to improve vaccine uptake among adolescents. The aim of this study is to conduct a qualitative and quantitative systematic review on knowledge, attitudes and practices on adolescent vaccination among parents, teachers and adolescents in Africa. Methods: We will include both quantitative and qualitative primary studies. Eligible quantitative studies include both intervention and observational studies. Qualitative studies to be included are focus group discussions, direct observations, in-depth interviews and case ethnographic studies. We will search PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, WHOLIS, Africa Wide and CINAHL for eligible studies with no time and language limits. We will also check reference lists of included studies for other eligible reports. Two authors will independently screen the search output, select studies and extract data, resolving discrepancies by consensus and discussion. We will analyse qualitative data using thematic analysis where applicable, and quantitative studies findings will be presented in a narrative synthesis form based on the outcomes. Discussion: The findings from this systematic review will guide the identification of gaps on knowledge, attitudes and practices among the key role players on adolescent vaccination. We anticipate that our findings will guide the development of adolescent-focused vaccination policy in Africa, which is virtually non-existent at present. Systematic review registration: This review is registered with PROSPERO, registration number CRD42014010395.

An analysis of the HIV testing cascade of a group of HIV-exposed infants from birth to 18 months in peri-urban Khayelitsha, South Africa

BACKGROUND: Despite the reduction of HIV mother-to-child transmission, there are concerns regarding transmission rate in the breastfeeding period. We describe the routine uptake of 6 or 10 (6/10) weeks, 9 months and 18 months testing, with and without tracing, in a cohort of infants who received HIV PCR testing at birth (birth PCR) (with and without point of care (POC) testing) in a peri-urban primary health care setting in Khayelitsha, South Africa. METHODS: In this cohort study conducted between November 2014 and February 2018, HIV-positive mothers and their HIV-exposed babies were recruited at birth and all babies were tested with birth PCR. Results of routine 6/10 weeks PCR, 9 months and 18 months testing were followed up by a patient tracer. We compared testing at 6/10 weeks with a subgroup from historical cohort who was not tested with birth PCR. RESULTS: We found that the uptake of 6/10 weeks testing was 77%, compared to 82% with tracing. When including all infants in the cascade and comparing to a historical cohort without birth testing, we found that infants who tested a birth were 22% more likely to have a 6/10 weeks test compared to those not tested at birth. There was no significant difference between the uptake of 6/10 weeks testing after birth PCR POC versus birth PCR testing without POC. Uptake of 9 months and 18 months testing was 39% and 24% respectively. With intense tracing efforts, uptake increased to 45% and 34% respectively. CONCLUSION: Uptake of HIV testing for HIV-exposed uninfected infants in the first 18 months of life shows good completion of the 6/10 weeks PCR but suboptimal uptake of HIV testing at 9 months and 18 months, despite tracing efforts. Birth PCR testing did not negatively affect uptake of the 6/10 weeks HIV test compared to no birth PCR testing

Experiences of a community-based lymphedema management program for lymphatic filariasis in Odisha State, India: An analysis of focus group discussions with patients, families, community members and program volunteers

Author Summary Around the world 68 million people are infected with lymphatic filariasis (LF), a mosquito-borne disease caused by filarial worms. The parasite can damage patients' lymphatic systems causing pain, infections and swollen limbs, known as lymphedema or, in more advanced stages, elephantiasis. Lymphedema management programs can help patients to deal with the physical and emotional effects of lymphedema and elephantiasis. We held a total of 24 focus groups to discuss the experiences of people with lymphedema in Odisha State, India who participate in such a program. Discussions were held with patients, family members of patients, community members and program volunteers. Significant social, physical and economic difficulties were described by patients and family members, including marriage-related issues, social stigma, and lost workdays. However, the positive impacts of the lymphedema management program were also emphasized, and many family and community members indicated that community members were accepting of patients and had some improved understanding of the cause of the disease. People were able to hold both a 'scientific' and a 'traditional' understanding of LF at the same time. The financial hardships that people described highlight the need for improved economic opportunities for lymphedema-affected patients. Support programs based in the community also have clear social and emotional benefits. There is an urgent need to scale up LF management programs to reduce the suffering of people affected by LF

Patient experiences of ART adherence clubs in Khayelitsha and Gugulethu, Cape Town, South Africa: A qualitative study.

BackgroundGlobally, 37 million people are in need of lifelong antiretroviral treatment (ART). With the continual increase in the number of people living with HIV starting ART and the need for life-long retention and adherence, increasing attention is being paid to differentiated service delivery (DSD), such as adherence clubs. Adherence clubs are groups of 25-30 stable ART patients who meet five times per year at their clinic or a community location and are facilitated by a lay health-care worker who distributes pre-packed ART. This qualitative study explores patient experiences of clubs in two sites in Cape Town, South Africa.MethodsA total of 144 participants took part in 11 focus group discussions (FGDs) and 56 in-depth interviews in the informal settlements of Khayelitsha and Gugulethu in Cape Town, South Africa. Participants included current club members, stable patients who had never joined a club and club members referred back to clinician-led facility-based standard care. FGDs and interviews were conducted in isiXhosa, translated and transcribed into English, entered into NVivo, coded and thematically analysed.ResultsThe main themes were 1) understanding and knowledge of clubs; 2) understanding of and barriers to enrolment; 3) perceived benefits and 4) perceived disadvantages of the clubs. Participants viewed membership as an achievement and considered returning to clinician-led care a 'failure'. Moving between clubs and the clinic created frustration and broke down trust in the health-care system.ConclusionsAdherence clubs were appreciated by patients, particularly time-saving in relation to flexible ART collection. Improved patient understanding of enrolment processes, eligibility and referral criteria and the role of clinical oversight is essential for building relationships with health-care workers and trust in the health-care system

A cluster randomized controlled trial of extending ART refill intervals to six-monthly for anti-retroviral adherence clubs

Abstract Background The antiretroviral therapy (ART) adherence club (AC) differentiated service delivery model, where clinically stable ART patients receive their ART refills and psychosocial support in groups has supported clinically stable patients’ retention and viral suppression. Patients and health systems could benefit further by reducing visit frequency and increasing ART refills. We designed a cluster-randomized control trial comparing standard of care (SoC) ACs and six-month ART refill (Intervention) ACs in a large primary care facility in Khayelitsha, South Africa. Methods Existing ACs were randomized to either the control (SOC ACs) or intervention (Intervention ACs) arm. SoC ACs meet five times annually, receiving two-month ART refills with a four-month ART refill over year-end. Blood is drawn at the AC visit ahead of the clinical assessment visit. Intervention ACs meet twice annually receiving six-month ART refills, with a third individual visit for routine blood collection anytime two-four weeks before the annual clinical assessment AC visit. Primary outcomes will be retention in care, annual viral load assessment completion and viral load suppression. (<400copies/mL) after 2 years. Ethics approval has been granted by the University of Cape Town (HREC 652/2016) and the Medecins Sans Frontieres (MSF) Ethics Review Board (#1639). Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents. Discussion Evaluation of an extended ART refill interval in adherence clubs will provide evidence towards novel model adaptions that can be made to further improve convenience for patients and leverage health system efficiencies. Trial registration Registered with the Pan African Clinical Trial Registry: PACTR201810631281009. Registered 11 September 2018