Learner mobility in Johannesburg-Soweto, South Africa : dimensions and determinants.

Many South African school children are known to travel fairly long distances to school each day, in pursuit of the best possible educational opportunities in a schooling system that is known to vary greatly in quality. This thesis documents the dimensions and determinants of the daily, education-related travel of primary school aged children in Johannesburg-Soweto, South Africa. It uses data on a sample of 1428 children drawn from the Birth to Twenty cohort study to provide the first population-based data on the extent of learner mobility in contemporary urban South Africa. Learner mobility is measured in three different ways: firstly by the straight line distance between a child‘s home and his or her school; secondly by whether the child‘s school falls into the same geographical area as his or her home; and thirdly by whether the child attends his or her nearest, grade-appropriate school. The thesis provides clear evidence for extensive mobility using all three of these approaches to measurement. Over 25% of children were found to be travelling more than 5km each way to school and back on a daily basis. Almost 60% of children attended a school outside of the Census 2001 Sub-Place (roughly equivalent to a suburb) in which they lived, and fewer than 20% of children attended the grade-appropriate school nearest to their home. Counter to expectations, these figures were fairly stable over time, suggesting that educational mobility does not increase substantially as children age or transition to high school. Mobile children attended significantly more well-resourced and well-performing schools than their non-mobile peers, and the quality of schools attended increased with distance travelled. This substantiates the assumption that children and families make use of educational mobility to improve the quality of education that they are able to access. The analyses presented in the thesis suggest that two distinct patterns of mobility, with different determinants, are in use in the Johannesburg-Soweto area. The first relates primarily to travel from townships to historically advantaged schools in suburban Johannesburg, and typically requires substantial economic investment and extensive parental involvement. The second form of mobility operates at a more local level, and relates to children and families making choices between a number of relatively local schools. This form of mobility is less resource intensive. Children engaging in the first form of mobility were more likely to attend a particularly advantaged school, and to have a well-educated mother. By contrast, children engaged in the second form of mobility were more likely to live in a disadvantaged area, and come from households with moderate SES levels. iv The findings of this thesis provide important insights into the nature of school choice in South Africa, which have implications for educational policy, and the understanding of the nature of urban poverty as experienced by South African children. They also contribute to the international school choice literature, by providing novel information about the implications of relatively unregulated school choice for educational inequality and segregation in the South African context

Integrating community health workers into the formal health system to improve performance : a qualitative study on the role of on-site supervision in the South African programme

To explore the role of on-site supervision in community health worker (CHW) programmes and CHW integration into the health system. We compared the functioning of CHW teams reporting to a clinic-based nurse with teams supervised by a community-based nurse. We also consider whether a junior nurse can provide adequate supervision, given the shortage of senior nurses. A case study approach to study six CHW teams with different configurations of supervision and location. We used a range of qualitative methods: observation of CHW and their supervisors (126 days), focus group discussions (12) and interviews (117). South Africa where a national CHW programme is being implemented with on-site supervision. CHWs, their supervisors, clinic managers and staff, district managers, key informants from the community and CHW clients. Effective supervisors supported CHWs through household visits, on-the-job training, debriefing, reviewing CHWs' daily logs and assistance with compiling reports. CHWs led by senior nurses were motivated and performed a greater range of tasks; junior nurses in these teams could better fulfil their role. Clinic-based teams with senior supervisors were better integrated and more able to ensure continuity of care. In contrast, teams with only junior supervisors, or based in the community, had less engagement with clinic staff, and were less able to ensure necessary care for patients, resulting in lower levels of trust from clients. Senior supervisors raised CHW skills, and successfully negotiated a place for CHWs in the health system. Collaboration with clinic staff reduced CHWs' marginalisation and increased motivation. Despite being clinic-based, teams without senior supervisors had lower skill levels and were less integrated into the health system

Depressive symptoms and violence exposure in a population-based sample of adult women in South Africa

Depressive symptoms are a major burden of disease globally and is associated with violence and poverty. However, much of the research linking these conditions is from resource-rich settings and among smaller, clinical samples. Secondary data from a household survey in Gauteng Province of South Africa examines the cross-sectional association between adult women’s elevated depressive symptoms and markers of violence. Using tablet computers, participants self-completed interview modules to screen for depressive symptoms (Patient Health Questionnaire 2-item screener), childhood exposure to physical and sexual abuse (Childhood Trauma Questionnaire 4-item index), as well as past-year exposure to sexual or intimate partner violence (SIPV; WHO Multicountry Study instrument 4-item index). Socio-economic status, food security, education, and income were self-reported. Representative data at the ward level allows for modeling of results using survey commands and mixed-level modeling. Of the 7,276 adult women participating in the household survey, 42.1% reported elevated depressive symptoms. A total of 63.9% reported childhood violence exposure and 5.3% had past-year SIPV. Multi-level modeling suggests that violence is a strong predictor of depressive symptoms. Childhood abuse alone increases the odds of high depressive symptomology, after controlling for individual-level markers of poverty and neighborhood of residence (aOR 1.31, 95%, CI 1.17–1.37). Combined exposure to childhood abuse and past-year SIPV increased odds of reporting elevated depressive symptoms (aOR 2.05, 95%, CI 1.54–2.71). Ward characteristics account for 6% of the variance in depressive symptoms, over and above the contributions of household food security and socio-economic status. Exposure to violence in childhood and past-year SIPV were associated with depressive symptoms among women. These associations persist after controlling for socio-economic markers and latent neighborhood characteristics, which also had significant association with elevated depressive symptoms. These data suggest that efforts to reduce the burden of depressive symptoms may benefit from approaches that prevent violence against women and children

Children's daily travel to school in Johannesburg-Soweto, South Africa: geography and school choice in the Birth to Twenty cohort study

This paper has two aims: to explore approaches to the measurement of children’s daily travel to school in a context of limited geospatial data availability, and to provide data regarding school choice and distance travelled to school in Soweto-Johannesburg, South Africa. The paper makes use of data from the Birth to Twenty cohort study (n=1428) to explore three different approaches to estimating school choice and travel to school. Firstly, straight-line distance between home and school is calculated. Secondly, census geography is used to determine whether a child's home and school fall in the same area. Thirdly, distance data are used to determine whether a child attends the nearest school. Each of these approaches highlights a different aspect of mobility, and all provide valuable data. Overall, primary school aged children in Soweto-Johannesburg are shown to be travelling substantial distances to school on a daily basis. Over a third travel more than 3km, one-way, to school, 60% attend schools outside of the suburb in which they live, and only 18% attend their nearest school. These data provide evidence for high levels of school choice in Johannesburg-Soweto, and that families and children are making substantial investments in pursuit of high quality educational opportunities. Additionally, these data suggest that two patterns of school choice are evident: one pattern involving travel of substantial distances and requiring a higher level of financial investment, and a second pattern, involving choice between more local schools, requiring less travel and a more limited financial investment

Household coverage, quality and costs of care provided by community health worker teams and the determining factors : findings from a mixed methods study in South Africa

Objective: Community health workers (CHWs) are undertaking more complex tasks as part of the move towards universal health coverage in South Africa. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle with insufficient supervision. In this paper, we assess coverage (proportion of households visited by a CHW in the past year and month), quality of care and costs of the service provided by CHW teams with differing configurations of supervisors, some based in formal clinics and some in community health posts. Participants: CHW, their supervisors, clinic staff, CHW clients. Methods: We used mixed methods (a random household survey, focus group discussions, interviews and observations of the CHW at work) to examine the performance of six CHW teams in vulnerable communities in Sedibeng, South Africa. Results: A CHW had visited 17% of households in the last year, and we estimated they were conducting one to two visits per day. At household registration visits, the CHW asked half of the questions required. Respondents remembered 20%–25% of the health messages that CHW delivered from a visit in the last month, and half of the respondents took the action recommended by the CHW. Training, supervision and motivation of the CHW, and collaboration with other clinic staff, were better with a senior nurse supervisor. We estimated that if CHW carried out four visits a day, coverage would increase to 30%–90% of households, suggesting that some teams need more CHW, as well as better supervision. Conclusion: Household coverage was low, and the service was limited. Support from the local facility was key to providing a quality service, and a senior supervisor facilitated this collaboration. Greater investment in numbers of CHW, supervisors, training and equipment is required for the potential benefits of the programme to be delivered

Project Masihambisane: a cluster randomised controlled trial with peer mentors to improve outcomes for pregnant mothers living with HIV

Abstract Background Pregnant women living with HIV (WLH) face daily challenges maintaining their own and their babies' health and mental health. Standard Prevention of Maternal to Child Transmission (PMTCT) programs are not designed to address these challenges. Methods/Design As part of a cluster randomized controlled trial, WLH are invited to attend four antenatal and four postnatal small group sessions led by a peer WLH (a Peer Mentor). The WLH and their babies are assessed during pregnancy and at one week, six months, and twelve months post-birth. Mobile phones are used to collect routine information, complete questionnaires and remain in contact with participants over time. Pregnant WLH (N = 1200) are randomly assigned by clinic (N = 8 clinics) to an intervention program, called Masihambisane (n = 4 clinics, n = 600 WLH) or a standard care PMTCT control condition (n = 4 clinics; n = 600 WLH). Discussion Data collection with cellular phones are innovative and effective in low-resource settings. Standard PMTCT programs are not designed to address the daily challenges faced by WLH; Peer Mentors may be useful in supporting WLH to cope with these challenges. Trial registration ClinicalTrials.gov registration # NCT0097269

Correlates of children’s travel to school in Johannesburg-Soweto—Evidence from the Birth to Twenty Plus (Bt20+) study, South Africa

Prior work on data obtained from the urban Johannesburg-Soweto based Birth to Twenty Plus (Bt20+) cohort has documented extensive levels of travel to school in the early post-apartheid era (1997–2003), with fewer than 20% of children attending the age-appropriate school closest to their home (de Kadt et al., 2014). These extremely high levels of schooling mobility impose costs on children and families, as well as the educational system more broadly, and have contributed to the evolution of contemporary enrolment patterns. This paper analyses the relationship between travel to school and potentially related variables at the individual, family and community level. Our analysis indicates that Black children, children attending higher quality schools, and those living in relatively poor areas were most likely to travel to school. However, while travel to school has a strong and positive univariate relationship with both maternal education and family socio-economic status (SES), this fades out in a multivariate analysis. Our findings highlight the significant costs incurred in the pursuit of high quality education by many Black children and families, as well as those living in poorer areas, in the early post-apartheid era. This is despite post-apartheid educational policy with an explicit aim of redress. The paper contributes to understanding the challenges of apartheid’s inequitable geographical legacy in ensuring equitable access to high quality education for all in South Africa, as well as to the growing literatures on the geography of education and school choice in low and middle income countries

Infant feeding and school attainment in five cohorts from low- and middle-income countries

Performance in intelligence tests tends to be higher among individuals breastfed as infants, but little is known about the association between breastfeeding and achieved schooling. We assessed the association of infant feeding with school achievement in five cohorts from low- and middle-income countries. Unlike high-income country settings where most previous studies come from, breastfeeding is not positively associated with socioeconomic position in our cohorts, thus reducing the likelihood of a spurious positive association.Methodology and Principal FindingsParticipants included 10,082 young adults from five birth cohorts (Brazil, India, Guatemala, the Philippines, and South Africa). The exposures variables were whether the subject was ever breastfed, total duration of breastfeeding, and age at introduction of complementary foods. We adjusted the estimates for age at follow up, sex, maternal age, smoking during pregnancy, birthweight and socioeconomic position at birth. The key outcome was the highest grade achieved at school. In unadjusted analyses, the association between ever breastfeeding and schooling was positive in Brazil, inverse in the Philippines, and null in South Africa; in adjusted analyses, these associations were attenuated. In Brazil, schooling was highest among individuals breastfed for 3–12 months whereas in the Philippines duration of breastfeeding was inversely associated with schooling; and null associations were observed in South Africa and Guatemala. These associations were attenuated in adjusted models. Late introduction of solid foods was associated with lower schooling achievement in Brazil and South Africa.ConclusionMeasures of breastfeeding are not consistently related to schooling achievement in contemporary cohorts of young adults in lower and middle-income countries.<br/

Development of a tool for assessing quality of comprehensive care provided by community health workers in a Community-Based Care programme in South Africa

Objective To develop a tool for use by non-clinical fieldworkers for assessing the quality of care delivered by community health workers providing comprehensive care in households in low- and middle-income countries. Design We determined the content of the tool using multiple sources of information, including interactions with district managers, national training manuals and an exploratory study that included observations of 70 community health workers undertaking 518 household visits collected as part of a wider study. We also reviewed relevant literature, selecting relevant domains and quality markers. To refine the tool and manual we worked with the fieldworkers who had undertaken the observations. We constructed two scores summarising key aspects of care: (1) delivering messages and actions during household visit, and (2) communicating with the household; we also collected contextual data. The fieldworkers used the tool with community health workers in a different area to test feasibility. Setting South Africa, where community health workers have been brought into the public health system to address the shortage of healthcare workers and limited access to healthcare. It was embedded in an intervention study to improve quality of community health worker supervision. Primary and secondary outcomes Our primary outcome was the completion of a tool and user manual. Results The tool consists of four sections, completed at different stages during community health worker household visits: before setting out, at entry to a household, during the household visit and after leaving the household. Following tool refinement, we found no problems on field-testing the tool. Conclusions We have developed a tool for assessing quality of care delivered by community health workers at home visits, often an unobserved part of their role. The tool was developed for evaluating an intervention but could also be used to support training and management of community health workers

Pre/post evaluation of a pilot prevention with positives training program for healthcare providers in North West Province, Republic of South Africa

Abstract Background Prevention interventions for people living with HIV/AIDS are an important component of HIV programs. We report the results of a pilot evaluation of a four-hour, clinic-based training for healthcare providers in South Africa on HIV prevention assessments and messages. This pre/post pilot evaluation examined whether the training was associated with providers delivering more prevention messages. Methods Seventy providers were trained at four public primary care clinics with a high volume of HIV patients. Pre- and post-training patient exit surveys were conducted using Audio-Computer Assisted Structured Interviews. Seven provider appropriate messaging outcomes and one summary provider outcome were compared pre- and post-training using Poisson regression. Results Four hundred fifty-nine patients pre-training and 405 post-training with known HIV status were interviewed, including 175 and 176 HIV positive patients respectively. Among HIV positive patients, delivery of all appropriate messages by providers declined post-training. The summary outcome decreased from 56 to 50%; adjusted rate ratio 0.92 (95% CI = 0.87–0.97). Sensitivity analyses adjusting for training coverage and time since training detected fewer declines. Among HIV negative patients the summary score was stable at 32% pre- and post-training; adjusted rate ratio 1.05 (95% CI = 0.98–1.12). Conclusions Surprisingly, this training was associated with a decrease in prevention messages delivered to HIV positive patients by providers. Limited training coverage and delays between training and post-training survey may partially account for this apparent decrease. A more targeted approach to prevention messages may be more effective