Doctoral Degrees (Health Systems and Public Health)

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    Understanding the influence of the MomConnect programme on antenatal and postnatal care service utilization in two South African provinces : a realist evaluation
    (Stellenbosch : Stellenbosch University, 2023-12) Kabongo, Eveline Muika; Nicol, Edward; Mukumbang, Ferdinand; Delobelle, Peter; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY: Introduction: Improvement of maternal and child health is in the 2030 agenda of the 17 Sustainable Development Goals (SDGs) where health is centrally positioned with one comprehensive goal (SDG 3), of ensuring lives and promoting well-being for all at all ages. A mobile health programme called MomConnect programme was implemented in the nine provinces of South Africa to register pregnant women and mothers, providing them with health information and education on their health and that of their babies to improve the maternal and child health in the country. Some other studies have shown the efficacy of the MomConnect programme in improving health-seeking behaviours among pregnant women and mothers. Nonetheless, there is little understanding of the contextual factors and causal mechanisms that explained these intended outcomes. To this end, a theory-driven approach to evaluate the MomConnect intervention was proposed. Methodology: The realist evaluation approach was adopted to evaluate and describe not only the intervention and its outcomes but to understand how, why, for whom and under which health system conditions, the MomConnect programme improves the health-seeking behaviours of pregnant women and mothers of infants in antenatal (ANC) and post-natal care (PNC) services in Gauteng and Free State Provinces, South Africa. And to inform guidelines on how the MomConnect can be rolled out elsewhere. The study was conducted in three different phases. In Phase one/emergent phase, the initial programme theory (IPT) of the MomConnect programme was developed using the elicitation approach. In Phase two/construction phase, we applied a multi case explanatory theory-building approach and a confirmatory theory testing approach to test the initial programme theory in four healthcare facilities, in Free State and Gauteng provinces. A cross-case analysis/in-case theories comparison was done to obtain some more refined theories. In phase three/confirmatory phase, a discussion was done with MomConnect key informants to confirm and consolidate the refined theories. Retroduction logic of making inferences was applied to configure information obtained from different sources using the intervention-context-actor-mechanism-outcome (ICAMO) heuristic tool. Results: Our initial programme theory (IPT) revealed three plausible hypotheses. The first theory assumed that a good programme designer, and health system, allow for good implementation of the programme in HCPs and increase the uptake of health services among consumers. The second theory assumed that the national department of health (NDoH) support and influence of authorities and leaders motivate healthcare providers and managers to buy-in and engage with the programme to contribute to the success of the programme by improving their performance and delivering quality maternal and child health (MCH) services. The third theory suggested that women become encouraged, empowered, and motivated, through the MomConnect health information and education to change their health-seeking behaviours and improve their health and that of their babies. After testing the initial programme theory, four different theories were refined. The first showed that MomConnect works because of a good collaboration, political clout, healthcare providers (HCPs) and clinic managers’ buy-in and willingness to work and contribute to the success of the programme by improving their performance. The delivery of MCH services is assumed to improve the health-seeking behaviours. The second refined theory showed that the programme did not work in some facilities, due to a lack of training, lack of stewardship, lack of buy-in from HCPs and clinic managers, and lack of understanding of how the MomConnect Help Desk works. The third refined theory showed that when HCPs and clinic managers perceived the NDoH’s support through training on the programme they are empowered, leading to improvement in their self-efficacy, and they become motivated and nudged to improve their performance. In the fourth theory MomConnect encouraged, empowered, and motivated women to improve their health-seeking behaviours. Our refined theories confirmed the IPTs. Conclusion: The effective implementation, sustainability, and rollout of the MomConnect mobile health programme is contingent on some important health system conditions such as availability of funding, public awareness, HCPs, and clinic managers' buy-in and engagement, and facility readiness to provide care. HCPs' workload decreases if they feel that they can get assistance when women are educated on the MCH from the MomConnect platform and get all information needed on their mobile phones from home. This makes HCPs feel less pressured to conform to their work. Also, if HCPs are satisfied with the implementation of the MomConnect programme they will engage with the programme, and their positive attitude will encourage pregnant women and mothers to use healthcare facilities and change their health-seeking behaviours. In the context of the system failure or lack of updated mechanisms, caution must be taken when registering pregnant women by explaining to them how to switch to the baby messages once they give birth, to receive the baby messages and avoid the lack of system mechanism issues.
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    Adolescent mental health in the context of adversity : evidence from a longitudinal intervention study in Khayelitsha, South Africa
    (Stellenbosch : Stellenbosch University, 2023-12) Du Toit, Stefani; Skeen, Sarah; Haag, Katharina; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY: The World Health Organization defines adolescents as individuals between the ages of 10 and 19 years, undergoing transition from childhood to adulthood [1, 2]. Adolescence is a rapid developmental phase during which an individual undergoes major physical and psychological changes [1]. The changes that occur during this period create a vulnerability that is accentuated by exposure to risk factors such as poverty, community violence, and lack of access to basic services [1-5]. Mental health conditions most commonly appear during adolescence [1]. Experiencing mental health conditions during this period can have lasting effects on an individual's health, as it can increase the risk of substance use, violence victimisation and perpetration, and suicidal ideation [6-8]. There is a critical gap in the exploration of mental health conditions among adolescents in low- and middle-income countries, particularly in sub-Saharan African countries, where most adolescents live in the context of widespread poverty [9]. Most of the research on adolescent mental health is conducted in high-income countries, despite nearly 90% of the world's adolescent population living in low- and middle-income countries [9, 10]. There is an urgent need to assess potential risk and protective factors, as well as interventions, to address the mental health of adolescents in these contexts. To design effective preventative initiatives that aim to protect adolescents from the adverse consequences of mental health conditions, it is crucial to understand risk and protective factors at various stages throughout the life course. In addition, a comprehensive understanding of support structures and interventions that can aid in the prevention of mental health conditions and the promotion of positive mental health among adolescents is crucial. This thesis is based on research reported on four articles. The first two articles report on predictors of mental health problems, exploring both early childhood and current environmental factors. The second two articles in this thesis report on potential interventions for adolescent mental health.
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    An exploration of disability experiences and responses of disabled persons and their families within Muslim culture of the community of Strand, South Africa
    (Stellenbosch : Stellenbosch University, 2023-12) Sait, Washeila; Mji, Gubela; Eide, Arne; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY: Introduction: At the core of the study is the researcher’s perception that Muslim persons with disabilities and their families in the community of Strand are not participating in disability rights discourse and developments and activities of daily living within Muslim life. The perception is that they do not have the necessary knowledge and information, resulting in the practice of stifling care/or negatively impacting opportunities to engender participation. This perception required further investigation and validation, which is why this study was conducted. Study aim: This qualitative study aims to explore, understand and describe the disability experience and responses of Muslim persons with disability and their families within the religious socio-cultural constructs of the Muslim community of Strand. Study purpose: The purpose is to lift Muslim persons with disabilities out of uninformed-ness and invisibility into visibility and awareness, to bring their voices out of silence through descriptions of their specific experiences of disability into arenas of disability rights discourse and developments, and to encourage the development of enabling environments for participation and self-actualization. Methodology: The ethnography research method used describes the disability experiences of Muslim persons with disabilities and their families. Twenty-five participants selected through a blend of purposive and convenience sampling informed the study data. Data was collected using open-ended questions with participants in in-depth interviews, focus group discussions and observations. The inductive/deductive analysis and descriptive interpretative narration informed the presentation of the findings. Presentation of findings: The study findings were as follows: • In the absence of disability information and rights-based approaches, the disability context is marred by struggles for participation opportunities to achieve self-actualization, experiences of negative attitudes, discrimination, exclusion and enforced isolation. • Disability ignorance within the community suggests that persons with disabilities and their families experience exclusion from participation in cultural programmes aimed at Muslim persons within the broader community. • The various negative factors that inform the disability context shows that within lived realities, being Muslim, disabled, and that of gender within Muslim religiosity and socio-cultural contexts places Muslim persons with disabilities outside the frame of belonging and of living life on the margins of their own religious, cultural and traditional daily life activities. Conclusion: Further disability research is required to improve the overall situation of Muslim persons with disabilities’ experiences to encourage their participation and self-actualization.
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    Envisioning enabling environments for young women with perinatal infections of Human Immunodeficiency Virus in Africa : a participatory creative new-materialist approach.
    (Stellenbosch : Stellenbosch University, 2023-12) Hendricks, Lynn Avril; Hannes, Karin; Young, Taryn; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY: Background: Targeted due to gender and age in South Africa, young women often must negotiate health and safety in their homes and communities – this is even more challenging for young women living with perinatal infections of Human Immunodeficiency Virus (YWLPHIV). Young people living with perinatal infections face a chronic disease, with treatment including adherence to lifelong Antiretroviral treatment (ART). We set out to learn more about young women perinatally infected with Human Immunodeficiency Virus (HIV) in Cape Town, their experience with HIV, how they negotiated adherence to ART regimens within their environments, and how environments could be enabled to support their adherence. Methods: This study used qualitative evidence synthesis (QES) and multisensory arts-based community participatory research methods, working together with six young women as allies. In phase 1, we synthesised the evidence landscape on adherence to ART. In phase 2, we conceptualised the Adherence Assemblage conceptual model of ART and the methodological approach of the third sphere for allyship. In phase 3, we co-explored with YWLPHIV their experiences and co-produced creative artworks and a research documentary, More than a pill. In phase 4, we focused on recommendations for enabling environments. Our multimodal approach included methods such as QES, artistic co-creations, body mapping, collaborative filmmaking, collecting material objects of meaning, community mapping, individual and group conversations including walking and driving interviews, journalling, multisensory home and clinic interviews, a research camp, and storytelling. Analytically, we used a new materialist lens to develop a new enabling environments framework from the innovative Adherence Assemblage model and applied analysis such as mega-aggregation framework synthesis, synthesis by storyboarding, creative synthesis, and thematic analysis. Results: Drawing on the findings of multiple types of qualitative data, which captured the perspectives of various role players, and amplified the voices of YWLPHIV, while considering the social-material-natural environment context in Africa, this PhD delivers: an innovative method of Mega-Aggregation Framework synthesis, a new qualitative evidence synthesis analytic method called Analysis by Storyboarding, a new conceptual model for adherence – the Adherence Assemblage, advances allyship in qualitative methods with the concept of the third sphere, actualised collaborative film production and creative works as synthesis, had a sustainable impact for both researchers and participants alike, and provides tangible recommendations for enabling environments to support adherence to ART for YWLPHIV. To enable environments for YWLPHIV, recommendations included supportive disclosure practices, self-efficacy and self-acceptance, supportive relationships and caring communities, mitigating violence as a barrier to adherence and safe outdoor spaces, acknowledging the material dimension, integrated and holistic health care, compassionate educational systems, and advancing knowledge systems and research practices. Conclusion: This study is one of the first to go beyond barriers and facilitators to adherence for people living with HIV and explores the role of the socio-natural-material environment in depth. Young women living in challenging communities in Cape Town, South Africa, struggled with adherence due to environmental and community-level factors such as violence, economic inequities, lack of social support, inadequate health systems, and disadvantageous structural community layouts. Risking their lives to travel to clinics in unsafe communities, silencing their voices in their households, and being at high risk for domestic violence and femicide in their romantic relationships demands of us to bring to light their experiences, which is in line with Sustainable Development Goals (SDG) 5 (gender equality) and ending all forms of discrimination against all women and girls in private and public spheres. Working from a multimodal perspective allowed us to venture deeper together and opened the research space for multiple stakeholders for rich engagement throughout the research process. The findings of this PhD contribute to the African evidence that future research and interventions can be built to support young women and their families as they navigate their journeys of adherence to ART.
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    Understanding the influence of the MomConnect programme on antenatal and postnatal care service utilization in two South African Provinces : a realist evaluation
    (Stellenbosch : Stellenbosch University, 2023-03) Kabongo, Eveline Muika; Nicol, Edward; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY: Introduction: Improvement of maternal and child health is in the 2030 agenda of the 17 Sustainable Development Goals (SDGs) where health is centrally positioned with one comprehensive goal (SDG 3), of ensuring lives and promoting well-being for all at all ages. A mobile health programme called MomConnect programme was implemented in the nine provinces of South Africa to register pregnant women and mothers, providing them with health information and education on their health and that of their babies to improve the maternal and child health in the country. Some other studies have shown the efficacy of the MomConnect programme in improving health-seeking behaviours among pregnant women and mothers. Nonetheless, there is little understanding of the contextual factors and causal mechanisms that explained these intended outcomes. To this end, a theory-driven approach to evaluate the MomConnect intervention was proposed. Methodology: The realist evaluation approach was adopted to evaluate and describe not only the intervention and its outcomes but to understand how, why, for whom and under which health system conditions, the MomConnect programme improves the health-seeking behaviours of pregnant women and mothers of infants in antenatal (ANC) and post-natal care (PNC) services in Gauteng and Free State Provinces, South Africa. And to inform guidelines on how the MomConnect can be rolled out elsewhere. The study was conducted in three different phases. In Phase one/emergent phase, the initial programme theory (IPT) of the MomConnect programme was developed using the elicitation approach. In Phase two/construction phase, we applied a multi case explanatory theory-building approach and a confirmatory theory testing approach to test the initial programme theory in four healthcare facilities, in Free State and Gauteng provinces. A cross-case analysis/in-case theories comparison was done to obtain some more refined theories. In phase three/confirmatory phase, a discussion was done with MomConnect key informants to confirm and consolidate the refined theories. Retroduction logic of making inferences was applied to configure information obtained from different sources using the intervention-context-actor-mechanism-outcome (ICAMO) heuristic tool. Results: Our initial programme theory (IPT) revealed three plausible hypotheses. The first theory assumed that a good programme designer, and health system, allow for good implementation of the programme in HCPs and increase the uptake of health services among consumers. The second theory assumed that the national department of health (NDoH) support and influence of authorities and leaders motivate healthcare providers and managers to buy-in and engage with the programme to contribute to the success of the programme by improving their performance and delivering quality maternal and child health (MCH) services. The third theory suggested that women become encouraged, empowered, and motivated, through the MomConnect health information and education to change their health-seeking behaviours and improve their health and that of their babies. After testing the initial programme theory, four different theories were refined. The first showed that MomConnect works because of a good collaboration, political clout, healthcare providers (HCPs) and clinic managers’ buy-in and willingness to work and contribute to the success of the programme by improving their performance. The delivery of MCH services is assumed to improve the health-seeking behaviours. The second refined theory showed that the programme did not work in some facilities, due to a lack of training, lack of stewardship, lack of buy-in from HCPs and clinic managers, and lack of understanding of how the MomConnect Help Desk works. The third refined theory showed that when HCPs and clinic managers perceived the NDoH’s support through training on the programme they are empowered, leading to improvement in their self-efficacy, and they become motivated and nudged to improve their performance. In the fourth theory MomConnect encouraged, empowered, and motivated women to improve their health-seeking behaviours. Our refined theories confirmed the IPTs. Conclusion: The effective implementation, sustainability, and rollout of the MomConnect mobile health programme is contingent on some important health system conditions such as availability of funding, public awareness, HCPs, and clinic managers' buy-in and engagement, and facility readiness to provide care. HCPs' workload decreases if they feel that they can get assistance when women are educated on the MCH from the MomConnect platform and get all information needed on their mobile phones from home. This makes HCPs feel less pressured to conform to their work. Also, if HCPs are satisfied with the implementation of the MomConnect programme they will engage with the programme, and their positive attitude will encourage pregnant women and mothers to use healthcare facilities and change their health-seeking behaviours. In the context of the system failure or lack of updated mechanisms, caution must be taken when registering pregnant women by explaining to them how to switch to the baby messages once they give birth, to receive the baby messages and avoid the lack of system mechanism issues.