Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa

Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot study was developed to see whether PMTCT services provided by the South African Government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the USA. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n=160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa

Factors associated with uptake of Isoniazid Preventive Therapy among Human Immunodeficiency Virus-infected clients in Zimbabwe.

Magister Public Health - MPH (Public Health)BACKGROUND: HIV continues to be the single greatest risk factor for developing Tuberculosis (TB) both globally and in sub-Saharan Africa. Zimbabwe is a country that has featured prominently on lists developed by the World Health Organisation (WHO) of countries with a high burden of HIV, of TB, and of TB among people living with HIV. The WHO has developed normative guidance for helping to reduce the burden of TB among people living with HIV, including Isoniazid Preventive Therapy (IPT). Zimbabwe adopted this policy in 2013 as a pilot that has since been rapidly rolled out nationally. METHODOLOGY: This study is based on an analytical cross-sectional study done as a secondary analysis of the electronic Patient Monitoring System (ePMS) data for HIV services currently operational in selected facilities in the country. The overall aim of the study was to establish the uptake of the IPT policy among IPT-eligible PLHIV at facilities with the ePMS. The specific objectives were to establish the uptake of IPT among eligible PLHIV in Zimbabwe; to identify patient factors associated with implementation of IPT; and to identify facility factors associated with implementation of IPT. Data on 345,414 people living with HIV from 205 public health facilities across the country providing HIV services were extracted from the ePMS to establish the uptake of IPT among eligible PLHIV. Bivariate analysis, followed by simple binary and multivariable logistic regression analyses were used to identify both patient and facility factors associated with uptake of IPT. RESULTS: This study showed that uptake of IPT, across all of the 205 facilities implementing IPT was 0.4%, due to the study being carried out soon after a rapid rollout of the programme. The following patient factors were associated with uptake of IPT- age of 0- 14 years (AOR 0.16; 95% CI: 0.06-0.44); age 15- 19 years (AOR 0.23; 95% CI: 0.08- 0.63); age 20- 29 years (AOR 0.62; 95% CI: 0.46-0.82); Not pregnant (AOR 2.50; 95% CI: 1.54- 4.00); WHO Clinical Stage 1 and 2 (AOR 1.14; 95% CI:1.05-1.23); clients between 4 – 7 years since enrolment into HIV care (AOR 1.21; 95% CI: 1.12-1.30); and clients that have been at least eight years since enrolment into HIV care (AOR 1.32; 95% CI: 1.16-1.50). Facility factors that were associated with IPT uptake, referral facility- secondary level or higher-(AOR 0.46; 95% CI: 0.43-0.51); facilities with HIV caseloads of less than 1000 patients in care (AOR 0.49; 95% CI: 0.44-0.54); facilities in Harare province (AOR 0.30; 95% CI: 0.26-0.34); Manicaland (AOR 0.52; 95% CI: 0.43-0.63); Mashonaland Central (AOR 0.13; 95% CI: 0.10-0.18); Mashonaland East (AOR 0.71; 95% CI: 0.58-0.87); Masvingo (AOR 0.06; 95% CI: 0.04-0.08); Matabeleland South (AOR 0.07; 95% CI: 0.05-0.10); Midlands (AOR 0.68; 95% CI : 0.56-0.81); urban setting (AOR 1.66; 95% CI: 1.47-1.87) CONCLUSION: Uptake of IPT is very low, partly due to inclusion of facilities that had only recently begun implementing the IPT policy due to a phased approach to the rollout. In spite of this, patient and facility factors identified in this study need to be used to target interventions aimed at reducing the huge burden of TB on people living with HIV. Another evaluation of this nature is recommended in future to assess the impact of any targeted interventions identified through this study on IPT uptake

Understanding mental distress, coping, help-seeking behaviours and substance abuse of Psychology students.

Masters Degrees. University of KwaZulu-Natal, Durban.Mental distress and substance use among university students is a global concern, with many using ineffective coping strategies and showing reluctance to help-seeking. There is however a paucity of research on mental distress and substance use among adolescents and young adults, within the context of South Africa. The aim of this study was to understand the mental distress, coping, help-seeking behaviours, and substance use of psychology students. This study consisted of 200 psychology students within the University of Kwa-Zulu Natal, using a convenience sampling method to recruit all participants. Various statistical analyses such as frequency analyses, reliability analyses, descriptive statistics, a One-Way ANOVA analysis, a T-test analysis, Chi-square analyses, correlation analyses, and backward multiple regression analyses were performed. The results from the analyses indicated that there was a high prevalence of mental distress and alcohol use among these students. Peer and parental alcohol use were found to be related to student’s alcohol use. Students were also found to use negative coping behaviours in dealing with their distress. Students who used substances were also more likely to employ negative coping behaviours, with current cigarette use, current alcohol use, and current drug use being associated with negative coping. Male students reported more self-stigma of seeking help for their distress. Most of the results were consistent with the results obtained from past research. The findings from this study are useful in creating awareness on the prevalence of mental distress and substance use among South African university students being a great concern. It also creates awareness on the types of coping and help-seeking behaviours (governed by self-stigma of seeking help) employed by these students. These findings not only aid our understanding of mental distress, coping, help-seeking and substance use among university students in South Africa, but also aims to alter the trajectory of mental distress, substance use, coping and help-seeking among South African university students. The findings of this study are also useful in assisting in future preventative measures and interventions that could be useful in curbing this growing burden of mental distress and substance use and promoting effective coping and help-seeking behaviours among South African university students

Exploring the knowledge, attitudes and practices of pregnant women on infant feeding methods for prevention of mother to child transmission of HIV in a regional hospital of eThekwini district.

Master of Nursing in Maternal and Child Health. University of KwaZulu-Natal, Howard College 2015.Background: HIV-infected mothers in high income countries are advised not to breast-feed and are family oriented regarding the decision of the choice of feeding method for their infants. In contrast, in low and middle income countries (LMIC) the responsibility of making an informed choice on feeding practice rests primarily on the woman herself. The choice of infant feeding method is important for HIV-positive mothers in order to optimize the chance of survival for their infants and to minimize the risk of HIV transmission. Purpose of the study The purpose of this study was to assess knowledge, attitudes, and practices of pregnant women with regard to the infant feeding method for prevention of mother to child transmission of HIV. Methodology This study used a quantitative and descriptive design. It was conducted at a regional hospital of eThekwini District. Systematic sampling was used to select 250 respondents. Data was collected data using semi-structured questions in a questionnaire. The data was analysed using simple descriptive statistics using SPSS version 19. Results of the study All 104 (100%) respondents infected with the HIV virus strongly agreed that transmission of the HIV virus occurred from mother to child at the time of pregnancy, during delivery or through breastfeeding. All 104 (100%) of the HIV infected women strongly agreed that formula feeding had no role in the transmission of the HIV virus and they were familiar with modes of transmission of the HIV virus. Forty eight (46%) of the HIV infected respondents stated that they will exclusively breastfeed their infants; 34 (33%) will adopt the mixed feeding method that is breastfeeding and the utilization of formula, while 22 (21%) will use the replacement feeding method milk that the government supplies. Conclusion The choice of feeding practices among the HIV infected and HIV uninfected respondents was varied. The majority 145 (58%) of the respondents selected exclusive breastfeeding as their choice of infant feeding method, while 38 (15.2%) selected replacement and 67 (26.8%) chose mixed feeding. Several factors influenced the mother’s preferred feeding method for their infants. Recommendations Following the results from this study, the recommendations include: Health educate all the pregnant mothers and their relatives on the importance of PMTCT programs with an emphasis on adequate feeding practices, and provide the most recent feeding guidelines. Support to the HIV positive mothers with limited resources, in particular these breastfeeding

The theory, process, and outcomes of culturally adapted psychotherapy and psychosocial interventions

Massive demographic changes have coincided with rise of the importance of evidence-based treatment among the health sciences and widespread awareness of the failure of psychology to address and serve the mental health needs of historically underrepresented groups. Researchers, theorists, and clinicians demand that empirically supported treatments be adapted to better address and better fit clinical needs. Based on existing approaches in the literature, this dissertation presents a four-part model of cultural adaptation of psychological interventions and reviews 101 current culturally adapted empirically supported treatments through the lens of this model. The dissertation project comprehensively describes the current state of the field in terms of the theoretical bases, processes, and outcomes of culturally adapted psychotherapy and psychosocial interventions in the context of evidence-based practice, provides suggestions, and illuminates implications for future research and practice

Exploring health systems integration in urban South Africa : from integrating prevention of mother-to-child transmission of HIV to prevention of type 2 diabetes after gestational diabetes

L'intégration du traitement et de la prévention des maladies chroniques non transmissibles (MNT) au sein des soins de santé primaires représente le principal défi à venir pour la santé publique et les systèmes de santé dans les pays à faible et moyen revenu comme l’Afrique du Sud. Il constitue le principal objectif de cette thèse. L’expérience de l'intégration de la prévention de la transmission du VIH de la mère à l'enfant (PTME) dans les soins de santé primaires (SSP) peut apporter des leçons importantes pour l'intégration de la prévention du diabète chez les femmes souffrant de diabète gestationnel récent (DSG) dans les SSP. Il a été estimé que le DSG touche plus de 9,1 % des grossesses en 2018 en Afrique du Sud. Le DSG augmente le risque de développer ultérieurement du diabète de type 2 (DT2). Le DSG multiplie par plus de 7 le risque de développer un DT2 ainsi que les risques de troubles métaboliques pour les bébés des femmes qui en sont atteintes. Cette thèse explore comment appliquer les leçons tirées de l’intégration de la PTME pour intégrer le dépistage du DSG et les initiatives de prévention du DT2 dans les soins de santé primaires de routine en Afrique du Sud. Le cadre conceptuel adapté pour cette thèse permet ainsi de comprendre les aspects de l’intégration au niveau du patient et du système de santé, englobant les contextes, les mécanismes et la mise en œuvre de l’intégration d’interventions préventives dans les services existants. L'étude s'inscrit dans le cadre du projet IINDIAGO, « Intervention intégrée du système de santé visant à réduire les risques de diabète de type 2 chez les femmes défavorisées après un diabète gestationnel en Afrique du Sud ». La thèse présente d’abord une revue narrative de l’impact de la PTME sur les services et les systèmes de soins de santé en Afrique subsaharienne (Article 1). Les résultats de cette revue montrent que la PTME a eu l’impact positif et négatif sur d’autres services de soins de santé et que son intégration dans les systèmes de santé est de plus en plus privilégiée. L’article 2 est une étude qualitative analysant l’histoire et l’expérience locales de l’intégration de la PTME dans les SSP de routine en Afrique du Sud de différents points de vue. Bien qu’elle ait constaté un fort soutien en faveur de l’intégration parmi tous les répondants, cette étude a fait état de multiples obstacles à la pleine intégration de la PTME dans les SSP, le post-partum en particulier. Les articles 3 et 4 ont utilisé les méthodes mixtes et révélé que l’intégration des services dans les SSP de routine, à base communautaire, pour dépister universellement le DSG et pour prévenir ou retarder le DT2 après le DSG, était perçue comme faisable, acceptable et nécessaire de toute urgence en Afrique du Sud. L’article 6 (dont le protocole est l’article 5) présentait une revue systématique et une méta-analyse sur la prise en charge intégrée du DSG et du DT2 dans le contexte de la multimorbidité en Afrique. Les 13 études incluses dans cette étude ont montré que la gestion intégrée du DSG et du DT2 dans le cadre de la multimorbidité était mise en œuvre avec succès, mais qu’elle nécessitait une formation et une supervision adéquates des infirmières, et la fourniture d’équipements et de médicaments additionnels au sein des systèmes de santé nationaux en Afrique. Les conclusions de cette thèse suggèrent que, bien qu’elle n’ait pas toujours été retenue, en raison de défis structurels et opérationnels, l’intégration complète plutôt que partielle des services de santé est considérée comme souhaitable et réalisable par les femmes, les travailleurs de la santé, les gestionnaires et les experts. L’intégration complète pourrait être idéale pour dépister, diagnostiquer et soigner les maladies chroniques, y compris le DSG et le DT2, au sein des SSP de routine et selon l’approche de la PTME dont les leçons d’intégration n’ont pas été adaptées à ce prochain défi de santé publique.Integrating chronic, non-communicable diseases (NCDs) and their prevention into primary health care is the next major challenge for public health and health systems in low and middle-income countries like South Africa and is the primary focus of this thesis. The experience of integration of Prevention of Mother-to-Child Transmission (PMTCT) of HIV into primary health care (PHC) may have important lessons for integrating prevention of diabetes among women with recent gestational diabetes (GDM) into PHC. GDM was estimated to affect more than 9.1% of pregnancies in 2018 in South Africa. GDM increases the risk of developing subsequent type 2 diabetes (T2DM) more than 7-fold as well as increasing the risks of metabolic disorders for the babies of women who had GDM. This thesis conducted a systematised narrative synthesis, a systematic review and a convergent mixed methods study using primarily qualitative methods in South Africa (focus on Cape Town, Western Cape) to explore how to apply lessons from PMTCT integration in order to integrate GDM screening and T2DM prevention initiatives into routine PHC in South Africa. The adapted conceptual framework for this thesis enables to understand both patient-level and health system-level aspects of integration and encompassing the contexts, mechanisms and implementation for integrating preventive interventions in the existing services. The study was nested in the IINDIAGO project, “Integrated health system intervention aimed at reducing type 2 diabetes risks in disadvantaged women after gestational diabetes in South Africa”. The thesis first presents a narrative review of the impact of PMTCT on health care services and systems in sub-Saharan Africa (Paper 1). This review findings show that PMTCT has had positive and negative impacts on other health care services and that its integration into health systems is increasingly favored. Paper 2 qualitatively documented the local history and experience of PMTCT integration into routine PHC in South Africa from different perspectives. Though it found strong support for integration among all respondents (N=20), this study reported multiple barriers for the full integration of PMTCT into PHC, especially in postpartum. Papers 3 and 4 used mixed methods and highlighted that integrating services within routine, community-based PHC to universally screen GDM and to prevent or delay of T2DM after GDM, was perceived as feasible, acceptable and urgently needed in South Africa – but that it is not currently occurring at a satisfactory level, despite international and national guidelines. The fifth article is a published protocol for Paper 6, a systematic review and meta-analysis on the integrated management of GDM and T2DM in the context of multimorbidity in Africa. This was a study in which all 13 included studies showed that integrated management of GDM and T2DM within multimorbidity was successfully implemented but it required adequate training and supervision of nurses, provision of additional equipment and drugs to the existing resources within national health systems in Africa. This thesis concludes that although not always opted for, due to structural and operational challenges, the full instead of partial integration of health services to screen, diagnose and care for chronic diseases including GDM and T2DM into routine PHC, following the PMTCT approach, was seen as both desirable and feasible by women, health workers, managers, and experts. However, the lessons learned through the history of PMTCT and its integration have not been adapted to this next public health challenge

Acceptance and commitment therapy in the prevention of mother to child transmission of HIV program among pregnant women living with HIV in South Western States of Nigeria

Philosophiae Doctor - PhDThe objective of this study was to determine if introducing acceptance and commitment therapy in the prevention of mother to child HIV transmission (PMTCT) program using weekly mobile phone messages would result in improved mental health status of HIV-positive, pregnant women in Nigeria. The study used a quantitative approach using a Solomon four-group (two intervention and two control groups) randomised design to evaluate the impact of an acceptance and commitment therapy program. The study population was 132 randomly selected (33 per site), HIV-positive pregnant women attending four randomly selected PMTCT centres in Nigeria. Two were Intervention and two were Control sites which functioned as Intervention and Control groups. The intervention groups were exposed to one session of acceptance and commitment therapy with weekly value-based health messages sent by mobile phone for three months during pregnancy. The control groups received only post-HIV test counselling