Toward a conceptual model of ‘the act’; an exercise in theory generation in the problematic space of school-based HIV prevention through behaviour change intervention.

Doctoral Degree. University of KwaZulu-Natal, Pietermaritzburg.Health outcomes, whether due to infectious disease vectors or so-called diseases of lifestyle, appear to be the consequence of human behaviour. Simple behaviours such as wearing a condom, eating a balanced diet, or regular health screening appear to hold the key to drastically reducing global mortality and morbidity. And yet health interventions premised on behaviour change often fail to demonstrate significant effect on health outcomes. Perhaps we do not understand what behaviour is in the first place. I aimed to posit a conceptual model of ‘the act’, a unit through which to re-understand human behaviour, as a first step toward more effective interventions. The overall design was theory-generative research, including: (a) a critical review of three prominent cognitive behaviour change theories, (b) an applied exploration of the research philosophical implications of theory generative research, (c) a discourse analysis of assumptions about behaviour in school-based HIV prevention in Africa, (d) a critical analysis of assumptions about young people’s sexual behaviour in two school-communities in rural KwaZulu-Natal, South Arica, and (e) a comparative description of a normative and an alternative model of ‘the act’. I described the symphonic model of ‘the act’ for behaviour change intervention design. The symphonic model is premised on five assumptions about the ontology of behaviour: (1) intention follows the act, (2) the act is a synthesis of possibility, not a derivative eventuality, (3) the act is marginally predictable through imposing narratives of intentionality, (4) time is a necessary frame for imposing narrative intentionality onto the act, and (5) consummation of the act is always dialogically interpersonal. I demonstrated how these assumptions could be represented in a graphic model of the components of the act and the interaction of these components with each other. Finally, I presented how the symphonic model of the act could be applied to school-based HIV prevention in Africa. The symphonic model of the act is a viable avenue for further research. This should include practical demonstrations of its application. Future development should also include the expansion of the conceptual model into a theoretical framework – integrated with existing theories of behaviour and psychology

Prosaic intertexting : a methodological enquiry into human be-ing.

Thesis (M.Soc.Sc.)-University of KwaZulu-Natal, Pietermaritzburg, 2009.The thesis is the rhetorical development of a model of the utterance (principally) and of narrative (secondarily). The utterance is treated as the basic unit of human be-ing and therefore the basic analytic unit for social science. The starting motivation for the thesis is to provide a philosophical and methodological foundation upon which persons and people can be re-conceived in multiple and constructive renderings. The thesis draws on the collective works of Mikhail Bakhtin to generate new diction with which to characterize the model. First the model is stated, then six arguments to which the model is in answer are developed, finally the model is put into practice in nine analytics of data. Data from 65 editions of ‘letters to the editor’ of the Daily News newspaper are used as prototypes to demonstrate prosaic intertexting as an analytic model. Each letter to the editor is treated as representing a possible unit of the writer’s be-ing. Prosaic intertexting is demonstrated in creating these ‘letters to the editor’ as data (utterances) as a unit of analysis for social science. What is achieved is a model of how, not what, social science should do, though there are immediate implications for the ethics of research, therapy and peace-building

HIV prevention for South African youth: which interventions work? A systematic review of current evidence

In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest. Given the urgent need to identify effective HIV prevention approaches, this review assesses the evidence base for youth HIV prevention in South Africa

Process evaluation for the FEeding Support Team (FEST) randomised controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas

OBJECTIVE: To assess the feasibility, acceptability and fidelity of a feeding team intervention with an embedded randomised controlled trial of team-initiated (proactive) and woman-initiated (reactive) telephone support after hospital discharge. DESIGN: Participatory approach to the design and implementation of a pilot trial embedded within a before-and-after study, with mixed-method process evaluation. SETTING: A postnatal ward in Scotland. SAMPLE: Women initiating breast feeding and living in disadvantaged areas. METHODS: Quantitative data: telephone call log and workload diaries. Qualitative data: interviews with women (n=40) with follow-up (n=11) and staff (n=17); ward observations 2 weeks before and after the intervention; recorded telephone calls (n=16) and steering group meetings (n=9); trial case notes (n=69); open question in a telephone interview (n=372). The Framework approach to analysis was applied to mixed-method data. MAIN OUTCOME MEASURES: Quantitative: telephone call characteristics (number, frequency, duration); workload activity. Qualitative: experiences and perspectives of women and staff. RESULTS: A median of eight proactive calls per woman (n=35) with a median duration of 5 min occurred in the 14 days following hospital discharge. Only one of 34 control women initiated a call to the feeding team, with women undervaluing their own needs compared to others, and breast feeding as a reason to call. Proactive calls providing continuity of care increased women's confidence and were highly valued. Data demonstrated intervention fidelity for woman-centred care; however, observing an entire breast feed was not well implemented due to short hospital stays, ward routines and staff-team-woman communication issues. Staff pragmatically recognised that dedicated feeding teams help meet women's breastfeeding support needs in the context of overstretched and variable postnatal services. CONCLUSIONS: Implementing and integrating the FEeding Support Team (FEST) trial within routine postnatal care was feasible and acceptable to women and staff from a research and practice perspective and shows promise for addressing health inequalities

Community narratives about women and HIV risk in 21 high-burden communities in Zambia and South Africa.

Public health researchers repeatedly represent women as a group vulnerable to ill health. This has been particularly true in the field of HIV research, where women are disproportionately affected by HIV in terms of disease burden and the social effects of the epidemic. Although women have been the focus of many prevention and treatment programs, structural barriers to implementation of these targeted programs persist. In this article we explore how high HIV-burden communities in South Africa and Zambia engage with the concepts of "woman" and "HIV risk". The data are drawn from participatory storytelling activities completed with 604 participants across 78 group discussions between December 2012 and May 2013. During discussions we found that participants made use of the core archetypal caricatures of "goodness," "badness," and "vulnerability" when describing women's HIV risk. Community members shifted between these categories in their characterizations of women, as they acknowledged the multiple roles women play, internalized different stories about women, and sometimes shifted register in the same stories. Findings suggest that health implementers, in consultation with community members, should consider the multiple positions women occupy and how this impacts the wider community's understandings of women and "risk". This approach of taking on board community understandings of the complexity of HIV risk can inform the design and implementation of HIV prevention and care programs by rendering programs more focused and in-line with community needs

Good Health and Moral Responsibility: Key Concepts Underlying the Interpretation of Treatment as Prevention in South Africa and Zambia Before Rolling Out Universal HIV Testing and Treatment.

Gauging community responses to the WHO 2015 recommendation to provide antiretroviral treatment (ART) to all people living with HIV (PLHIV) is critical. There is limited qualitative evidence on the acceptability of this Universal Test and Treat (UTT) strategy or community understanding of the impact of ART on reducing HIV transmission, promoted as Treatment as Prevention (TasP). This article explores early understanding of UTT and TasP in 21 urban communities in South Africa and Zambia in 2013 before a community randomized trial of combination prevention-HPTN 071 (PopART). It draws on participatory research conducted in each community, which carried out group discussions and interviews with 1202 respondents and 203 structured observations. Participants were largely unfamiliar with the concepts of UTT and TasP. They were concerned about an accompanying de-emphasis on sexual behavior change. Treatment and prevention seemed, at first glance, to be experienced separately. With the exception of the prevention of mother-to-child transmission, prevention seldom came into discussions about ART. This was partly because this science had not yet been explained to many and also because it was not an easy fit. Contemplating the link between treatment and prevention, participants emphasized both PLHIV taking care of themselves through good health and preventing disease progression and the moral responsibility of PLHIV to prevent HIV transmission. To avoid igniting moralizing and blaming when introducing UTT and TasP, we should capitalize on the "taking care of yourself" legacy while boosting public responsibility through broad antistigma education and patient empowerment efforts

A narrative analysis positioning HIV relative to personal (sexual) relationship challenges in an agony aunt column in the Western Cape, South Africa - Aunty Mona's "love advice".

HIV prevalence and incidence in South Africa remain high, making HIV a part of everyday life. Community narratives on HIV treatment and prevention are important and influence official and unofficial health messaging and community perceptions and understandings of HIV. We explore how contributors and the columnist of an agony aunt column position HIV relative to choices made about love, partnership, and sex over three years. We analysed all columns of an agony aunt series (Antie Mona) published between December 2012 and November 2015. The column is published in a South African, Afrikaans-language newspaper "Son", prioritising sensationalist news items. Trends were identified through narrative analysis. Data were managed in ATLAS.ti and inductive, iterative coding conducted. It was found that letters to the agony aunt rarely refer to HIV directly (less than 7%). Euphemisms such as diseases of the flesh and the great flu were more commonly used instead of HIV or AIDS. Letters addressed HIV in three ways: direct references to experiences living with HIV; direct questions about HIV prevention; and scenarios where HIV could (from a public health perspective) have been the main concern, but everyday issues took precedence. The majority of letters fell into this latter category where the writers focused on the immediate concerns of good sexual relations, problems related to love and romantic relationships, good moral behaviour of others, and issues of oppressive life conditions rather than on HIV directly. The findings illustrate that informal, public contributions to health information, such as agony aunts, are important narratives that inform popular perspectives on HIV and health. A better appreciation of this context would allow health implementers to ensure that these role players receive updated health messaging to avoid the risk of HIV-related stigma where HIV is used as a moral rod to punish perceived moral transgressions

Breast pumps as an incentive for breastfeeding: a mixed methods study of acceptability

Increasing breastfeeding rates would improve maternal and child health, but multiple barriers to breastfeeding persist. Breast pump provision has been used as an incentive for breastfeeding, although effectiveness is unclear. Women's use of breast pumps is increasing and a high proportion of mothers express breastmilk. No research has yet reported women's and health professionals' perspectives on breast pumps as an incentive for breastfeeding. In the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study, mixed methods research explored women's and professionals' views of breast pumps as an incentive for breastfeeding. A survey of health professionals across Scotland and North West England measured agreement with ‘a breast pump costing around£40 provided for free on the NHS’ as an incentive strategy. Qualitative interviews and focus groups were conducted in two UK regions with a total of 68 participants (pregnant women, new mothers, and their significant others and health professionals) and thematic analysis undertaken. The survey of 497 health professionals found net agreement of 67.8% (337/497) with the breast pump incentive strategy, with no predictors of agreement shown by a multiple ordered logistic regression model. Qualitative research found interrelated themes of the ‘appeal and value of breast pumps’, ‘sharing the load’, ‘perceived benefits’, ‘perceived risks’ and issues related to ‘timing’. Qualitative participants expressed mixed views on the acceptability of breast pumps as an incentive for breastfeeding. Understanding the mechanisms of action for pump type, timing and additional support required for effectiveness is required to underpin trials of breast pump provision as an incentive for improving breastfeeding outcomes

The FEeding Support Team (FEST) randomised, controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas

Peer reviewedPublisher PD

Process evaluation for the FEeding Support Team (FEST) randomised controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas

PMID: 22535794 [PubMed] PMCID: PMC3341595 Free PMC ArticlePeer reviewe