Implementing intimate partner violence care in a rural sub-district of South Africa: a qualitative evaluation

Background: Despite a high burden of disease, in South Africa, intimate partner violence (IPV) is known to be poorly recognised and managed. To address this gap, an innovative intersectoral model for the delivery of comprehensive IPV care was piloted in a rural sub-district. Objective: To evaluate the initiative from the perspectives of women using the service, service providers, and managers. Design: A qualitative evaluation was conducted. Service users were interviewed, focus groups were conducted amongst health care workers (HCW), and a focus group and interviews were conducted with the intersectoral implementation team to explore their experiences of the intervention. A thematic analysis approach was used, triangulating the various sources of data. Results: During the pilot, 75 women received the intervention. Study participants described their experience as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For HCW, barriers to inquiry about IPV included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints affected continuity of care, privacy, and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example, high levels of alcohol misuse and socio-economic disempowerment, highlighted the need for a multifaceted approach to addressing IPV. Conclusions: This evaluation draws attention to the need to take a systems approach and focus on contextual factors when implementing complex interventions. The results will be used to inform decisions about instituting appropriate IPV care in the rest of the province. In addition, there is a pressing need for clear policies and guidelines framing IPV as a health issue

Developing lay health worker policy in South Africa: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Over the past half decade South Africa has been developing, implementing and redeveloping its Lay Health Worker (LHW) policies. Research during this period has highlighted challenges with LHW programme implementation. These challenges have included an increased burden of care for female LHWs. The aim of this study was to explore contemporary LHW policy development processes and the extent to which issues of gender are taken up within this process.</p> <p>Methods</p> <p>The study adopted a qualitative approach to exploring policy development from the perspective of policy actors. Eleven policy actors (policy makers and policy commentators) were interviewed individually. Data from the interviews were analysed thematically.</p> <p>Results</p> <p>Considerations of LHW working conditions drove policy redevelopment. From the interviews it seems that gender as an issue never reached the policy making agenda. Although there was strong recognition that the working conditions of LHWs needed to be improved, poor working conditions were not necessarily seen as a gender concern. Our data suggests that in the process of defining the problem which the redeveloped policy had to address, gender was not included. There was no group or body who brought the issue of gender to the attention of policy developers. As such the issue of gender never entered the policy debates. These debates focused on whether it was appropriate to have LHWs, what LHW programme model should be adopted and whether or not LHWs should be incorporated into the formal health system.</p> <p>Conclusion</p> <p>LHW policy redevelopment focused on resolving issues of LHW working conditions through an active process involving many actors and strong debates. Within this process the issue of gender had no champion and never reached the LHW policy agenda. Future research may consider how to incorporate the voices of ordinary women into the policy making process.</p

Interpersonal violence: an important risk factor for disease and injury in South Africa

<p>Abstract</p> <p>Background</p> <p>Burden of disease estimates for South Africa have highlighted the particularly high rates of injuries related to interpersonal violence compared with other regions of the world, but these figures tell only part of the story. In addition to direct physical injury, violence survivors are at an increased risk of a wide range of psychological and behavioral problems. This study aimed to comprehensively quantify the excess disease burden attributable to exposure to interpersonal violence as a risk factor for disease and injury in South Africa.</p> <p>Methods</p> <p>The World Health Organization framework of interpersonal violence was adapted. Physical injury mortality and disability were categorically attributed to interpersonal violence. In addition, exposure to child sexual abuse and intimate partner violence, subcategories of interpersonal violence, were treated as risk factors for disease and injury using counterfactual estimation and comparative risk assessment methods. Adjustments were made to account for the combined exposure state of having experienced both child sexual abuse and intimate partner violence.</p> <p>Results</p> <p>Of the 17 risk factors included in the South African Comparative Risk Assessment study, interpersonal violence was the second leading cause of healthy years of life lost, after unsafe sex, accounting for 1.7 million disability-adjusted life years (DALYs) or 10.5% of all DALYs (95% uncertainty interval: 8.5%-12.5%) in 2000. In women, intimate partner violence accounted for 50% and child sexual abuse for 32% of the total attributable DALYs.</p> <p>Conclusions</p> <p>The implications of our findings are that estimates that include only the direct injury burden seriously underrepresent the full health impact of interpersonal violence. Violence is an important direct and indirect cause of health loss and should be recognized as a priority health problem as well as a human rights and social issue. This study highlights the difficulties in measuring the disease burden from interpersonal violence as a risk factor and the need to improve the epidemiological data on the prevalence and risks for the different forms of interpersonal violence to complete the picture. Given the extent of the burden, it is essential that innovative research be supported to identify social policy and other interventions that address both the individual and societal aspects of violence.</p

Trends in soil carbon and nutrients of hill-country pastures receiving different phosphorus fertilizer loadings for 20 years

There are few records of long-term trends in soil C and N in grazed pasture systems but recent measurements have demonstrated unexplained losses on New Zealand lowlands. To determine whether losses were also occurring in hill country pastures, we analyzed archived soil samples collected between 1983 and 2006 from two slope classes (steep and easy) at the Whatawhata Research Centre. Soils were Ultic Hapludand and Typic Haplohumult on the easy slopes (10–20°), and Typic Haplohumult on the steeper slopes (30–40°). Soil samples (0–75 mm) had been collected from paddocks that were fertilized with six different loading rates of P (ranging from 0 to 100 kg P ha⁻¹ year⁻¹ since 1985). This range of P loadings allowed us to determine whether P inputs would regulate trends in soil C and N. While there were significant temporal trends in C and N (P < 0.05), these were not unidirectional and trends were not dependent on P loading rate. On average, soil C initially increased during the first 6 years of the trial at 0.270% C year⁻¹ (1.56 t ha⁻¹ year⁻¹) and 0.156% C year⁻¹ (1.06 t ha⁻¹ year⁻¹) on easy and steep slopes, respectively. Subsequently, there was no significant trend in soil C on the easy slopes but soil C declined at −0.066% year⁻¹ (0.45 t ha⁻¹ year⁻¹) on the steep slopes. Similarly, soil N increased between 1983 and 1989 at 0.025% N year⁻¹ (144 kg ha⁻¹ year⁻¹) and 0.012% N year⁻¹ (82 kg ha⁻¹ year⁻¹) on easy and steep slopes, respectively. Post-1989, small but significant losses of total N were measured on the steep slopes of 0.004% year⁻¹ (27 kg N ha⁻¹ year⁻¹) (P < 0.05) with no trend on the easy slopes. Two potential causal factors for these decadal-scale patterns were identified, operating via changes in primary productivity. These were lower S inputs from 1989 due to a change in fertilizer type, and a series of relatively dry summers during the 1990s. These significant inter-annual trends in soil C and N complicate attempts to measure long-term changes in soil organic matter associated with land use change and management practices. This study has demonstrated the potential error associated with infrequent soil sampling to determine long-term trends in soil C and N; large gains or losses could have been detected at Whatawhata depending on when sampling started and finished. Understanding these long-term trends in soil organic matter dynamics and driving factors requires more long-term sampling trials