Hanani Tabana - Academia.edu (original) (raw)

Papers by Hanani Tabana

Background Implementation frameworks and theories acknowledge the role of power as a factor in th... more Background Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa. Methods A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’...

BMJ Open

The COVID-19 pandemic has led to an explosion of online research using rating scales. While this ... more The COVID-19 pandemic has led to an explosion of online research using rating scales. While this approach can be useful, two of the major challenges affecting the quality of this type of research include selection bias and the use of non-validated scales. Online research is prone to various forms of selection bias, including self-selection bias, non-response bias or only reaching specific subgroups. The use of rating scales requires contextually validated scales that meet psychometrical properties such as validity, reliability and—for cross-country comparisons—invariance across settings. We discuss options to prevent or tackle these challenges. Researchers, readers, editors and reviewers need to take a critical stance towards research using this type of methodology.

International Journal of Environmental Research and Public Health

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people l... more Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH’s ART adherence. Gender norms affected the type...

Health Research Policy and Systems

Background: The continuum of care is a key strategy for ensuring comprehensive service delivery f... more Background: The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low-and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context. Methods: We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4. Results: Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges. Conclusion: Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low-and middle-income countries using the continuum of care framework and locally available indicators.

BMC Research Notes

Objective This study uses health and non-health sector data sources to select and assess availabl... more Objective This study uses health and non-health sector data sources to select and assess available indicators for service provision along the continuum of care for maternal health at subnational levels in South Africa. It applies the adequacy approach established in another study to assess the multi-dimensionality of available indicators. Using adequacy and the process of assessment in the study, the comprehensiveness of the continuum of care for improving maternal health outcomes can be assessed. Results We found 27 indicators of care utilization and access, linkages of care, and quality of care from the routine district health information system. The General Household Survey contained 11 indicators for the social determinants of health on the continuum of care framework. Indicator gaps include health promotion during and after pregnancy, maternal nutrition, empowerment and quality of care. At present, the available indicators measure about 74% of the interventions on the continuum...

Objective : This study uses health and non-health sector data sources to select and assess availa... more Objective : This study uses health and non-health sector data sources to select and assess available indicators for service provision along the continuum of care for maternal health at subnational levels in South Africa. It applies the adequacy approach established in another study to assess the multi-dimensionality of available indicators. Using adequacy and the process of assessment in the study, the comprehensiveness of the continuum of care for improving maternal health outcomes can be assessed. Results: We found 27 indicators of care utilization and access, linkages of care, and quality of care from the routine district health information system. The General Household Survey contained 11 indicators for the social determinants of health on the continuum of care framework. Indicator gaps include health promotion during and after pregnancy, maternal nutrition, empowerment and quality of care. At present, the available indicators measure about 74% of the interventions on the contin...

Health Systems & Reform

District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not... more District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.

Behaviour Research and Therapy

If citing, it is advised that you check and use the publisher's definitive version for pagination... more If citing, it is advised that you check and use the publisher's definitive version for pagination, volume/issue, and date of publication details. And where the final published version is provided on the Research Portal, if citing you are again advised to check the publisher's website for any subsequent corrections.

BMC Health Services Research

Background: Global strategies recommend a continuum of care for maternal health to improve outcom... more Background: Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context. Methods: We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps. Results: We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa. Conclusions: Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources.

The Lancet Psychiatry

Background: The Thinking Healthy Programme (THP) is a psychological intervention recommended for ... more Background: The Thinking Healthy Programme (THP) is a psychological intervention recommended for the treatment of perinatal depression. We assessed the effectiveness and cost-effectiveness of THP delivered by peers (THPP) in Goa, India. Methods: In this single-blind, individually-randomised controlled trial, we recruited pregnant women aged ≥18 years attending antenatal clinics, who scored ≥10 on the Patient Health Questionnaire (PHQ-9). Participants were randomly allocated (1:1) to THPP plus enhanced usual care (EUC), or to EUC alone in randomly-sized blocks, stratified by area of residence. Allocation was concealed using sequentiallynumbered opaque envelopes. Primary outcomes were severity of depressive symptoms (PHQ-9 score) and remission (PHQ-9 score <5) 6 months post-birth assessed by researchers masked to the treatment allocation. Analyses were by intention to treat, adjusting for covariates defined a priori or that showed imbalance at baseline. The trial is registered with ClinicalTrials.gov (NCT02104232). Findings: 280 women were enrolled between 24th October 2014 and 22nd June 2016 (140 per group). At 6 months, 122 (87%) and 129 (92%) women in the THPP plus EUC, and EUC alone groups, respectively, contributed primary outcome data. There was evidence of higher prevalence of remission at 6 months in the THPP plus EUC versus EUC alone group (n=89 (73%) versus n=77 (60%), respectively; prevalence ratio (PR)=1•21; 95% confidence interval (CI) 1•01 to 1•45, p=0•04), but weaker evidence for lower symptom severity (mean 3•47, standard deviation (SD) 4•49 versus 4•48 (SD=5•11), respectively; standardised mean difference (SMD)=-0•18; 95% CI-0•43 to 0•07, p=0•16).Repeated measures analyses over the duration of the trial (measured at 3 and 6 months post-birth) showed beneficial effects on symptom severity (SMD-0•37, 95% CI-0•88 to-0•24, p=0•01), remission (PR=1•21, 95% CI 1•01 to 1•41, p=0•02), WHO-Disability Assessment Schedule (WHO-DAS) scores (SMD=-0•32, 95% CI-0•76 to-0•21, p=0•02) and Multidimensional Scale of Perceived Social Support (MSPSS) scores (SMD=0•51, 95% CI 0•43 to 1•20, p=0•02).. The incremental societal cost per unit improvement on PHQ-9 was-US$ 29•64 (95% CI-32•88 to-26•41) at 3 months, and-US$93•53 (95% CI-180•21 to-6•84) for the whole duration of the trial, with a 87% likelihood of being costsaving in the study setting. The mean cost of providing THPP was US$ 1•36 per beneficiary (95% CI 1•32 to 1•39). There was no evidence of differences in serious adverse events by group, except stigmatisation was more often reported in the EUC alone (9%) versus the THPP plus EUC group (4%; p=0•08). Interpretation: THPP had a moderate effect on symptom severity and remission from perinatal depression over the 6 month post-natal period. THPP is relatively cheap to deliver and pays for itself through reduced health care, time and productivity costs.

The Lancet Psychiatry

Background: The Thinking Healthy Programme (THP), endorsed by WHO, is an evidence-based intervent... more Background: The Thinking Healthy Programme (THP), endorsed by WHO, is an evidence-based intervention for perinatal depression. We adapted THP for delivery by volunteer peers (THPP)-lay women from the community-and assessed its effectiveness and cost-effectiveness in Rawalpindi, Pakistan. Methods: In this cluster randomised controlled trial, 40 village-clusters were equally randomised to intervention (THPP plus Enhanced Usual Care (EUC)) or to EUC-alone. Consenting pregnant women aged ≥18 years who scored >10 on the nine-item Patient Health Questionnaire (PHQ-9) were eligible. Follow-up visits were at 3 and 6 months post childbirth. Primary outcomes were depressive symptoms score and remission at 6 months post-childbirth. Secondary outcomes included recovery from depression, levels of disability and perceived social support and child outcomes. All assessors were masked, and analyses were modified intention-to-treat. The trial was registered with ClinicalTrials.gov (NCT02111915). Findings: Of the 570 women enrolled between 15 th October 2014 and 25 th February 2016, 227/283 (80%) and 226/287 (79%) women in the THPP plus EUC and EUC-alone groups, respectively, contributed primary outcome data. Compared to women in the EUC-alone group, those in the THPP plus EUC group at 6 months had lower PHQ-9 scores and better proportions of remission, but neither reached statistical significance (standardised mean difference, SMD=-0•13, 95% CI-0•31 to 0•06, p=0•07; 49% vs 45%; Prevalence Ratio PR=1•12, 95% CI 0•95 to 1•29, p=0.14 respectively). Repeated measures analyses over the 6 months post childbirth showed beneficial intervention effects on both PHQ-9 scores (SMD=-0•22, 95%CI-0•35 to-0•09, p=<0•001) and remission (PR=1•15 95% CI 1•02 to 1•28, p=0•02), disability scores (SMD=-0•12, 95% CI-0•25 to 0•01, p=0•03) and perceived social support scores (SMD=0•16, 95%CI 0•03 to 0•29, p=0•01). THPP was associated with slightly higher costs than EUC-alone but significantly better outcome, thereby rendering it a cost-effective intervention; total societal cost per unit improvement on PHQ-9 was US$ 2•65 (95% CI 1•82 to 3•49) at 3 months post childbirth, US$ 1•17 (95% CI-0•53 to 2•88) for the 3-6-month post-childbirth period and US$ 15•50 (95% CI 9•59 to 21•61) over the study period as a whole. There was no evidence of differences in serious adverse events by group. Interpretation: THPP showed moderate effects on symptom severity and remission from perinatal depression over the 6-month postnatal period among women caring for infants and was also costeffective. Our intervention delivered by lay peers can be a potential step towards using an untapped human resource to address the treatment gap of perinatal depression.

Health Research Policy and Systems

Background: The uptake of findings from sexual and reproductive health and rights research into p... more Background: The uptake of findings from sexual and reproductive health and rights research into policy-making remains a complex and non-linear process. Different models of research utilisation and guidelines to maximise this in policy-making exist, however, challenges still remain for researchers to improve uptake of their research findings and for policy-makers to use research evidence in their work. Methods: A participatory workshop with researchers was organised in November 2017 by the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER) to address this gap. ANSER is a consortium of experienced researchers, some of whom have policy-making experience, working on sexual and reproductive health and rights issues across 16 countries and 5 continents. The experiential learning cycle was used to guide the workshop discussions based on case studies and to encourage participants to focus on key lessons learned. Workshop findings were thematically analysed using specific stages from Hanney et al.'s (Health Res Policy Syst 1:2, 2003) framework on the place of policy-making in the stages of assessment of research utilisation and outcomes. Results: The workshop identified key strategies for translating research into policy, including joint agenda-setting between researchers and policy-makers, as well as building trust and partnerships with different stakeholders. These were linked to stages within Hanney et al.'s framework as opportunities for engaging with policy-makers to ensure uptake of research findings. Conclusion: The engagement of stakeholders during the research development and implementation phases, especially at strategic moments, has a positive impact on uptake of research findings. The strategies and stages described in this paper can be applied to improve utilisation of research findings into policy development and implementation globally.

AIDS and behavior, Mar 22, 2017

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, c... more To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and ...

BMC Public Health, 2016

Background: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and... more Background: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa. Methods: A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions. Results: The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators' care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs. Conclusions: We found high acceptance by caregivers and vaccinators of three injections. Caregivers' poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants' pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI's expansion in resource-limited countries.

SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2016

HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV... more HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV/AIDS, and promoted as an essential tool in scaling up and improving access to treatment, care and support especially in community settings. Home-based HCT (HBHCT) is a model that has consistently been found to be highly acceptable and has improved HCT coverage and uptake in low-and middle-income countries since 2002. It involves trained lay counselors going door-todoor offering pre-test counseling and providing HCT services to consenting eligible household members. Currently, there are few studies reporting on the quality of HBHCT services offered by lay counselors especially in Sub-Saharan Africa, including South Africa. This is a quantitative descriptive sub-study of a community randomized trial (Good Start HBHCT trial) which describes the quality of HBHCT provided by lay counselors. Quality of HBHCT was measured as scores comparing observed practice to prescribed protocols using direct observation. Data were collected through periodic observations of HCT sessions and exit interviews with clients. Counselor quality scores for pre-test counseling and post-test counseling sessions were created to determine the level of quality. For the client exit interviews a continuous score was created to assess how satisfied the clients were with the counseling session. A total of 196 (3%) observational assessments and 406 (6%) client exit interviews were completed. Overall, median scores for quality of counseling and testing were high for both HIV-negative and HIV-positive clients. For exit interviews all 406 (100%) clients had overall satisfaction with the counseling and testing services they received, however 11% were concerned about the counselor keeping their discussion confidential. Of all 406 clients, 393 (96.8%) intended to recommend the service to other people. In ensuring good quality HCT services, ongoing quality assessments are important to monitor quality of HCT after training.

Background: Despite the introduction of HIV counselling and testing (HCT) methods about 30 years ... more Background: Despite the introduction of HIV counselling and testing (HCT) methods about 30 years ago, HIV testing uptake remains low in most high HIV prevalence settings. To date, knowledge of status still remains a critical approach in the fight against HIV and a first step to prevention, access to care, treatment, and support. Home-based HIV counselling and testing (HBHCT) is a novel approach that may complement the long-standing approaches for delivering HIV testing. Main Aim: To assess the impact of an HBHCT intervention on the uptake of HIV testing in a rural community in KwaZulu-Natal province, South Africa, using a pragmatic cluster randomised control trial design. Methods: All 4 research studies (Paper I-IV) were sub-studies of a cluster randomised control trial called Good Start HBHCT. The studies were conducted in rural Umzimkhulu sub-district. The intervention was HBHCT offered by trained lay counsellors to all adults residing in the intervention clusters (8 communities). In the control arm (8 communities) people accessed the standard of care (mainly clinic based HIV testing). The primary outcome measured in the trial was uptake of HIV testing. A baseline survey was conducted prior to the intervention in all 16 community clusters to measure uptake of HIV testing using an interviewer administered questionnaire (Paper I). Post-intervention, the same questionnaire (with additional questions on secondary outcomes) was administered (Paper II). In-depth qualitative interviews were conducted with couples who tested and received results together during the intervention (Paper III). We also conducted a cost-effectiveness analysis to compare the HBHCT approach versus clinic HCT (Paper IV). Results: The reported uptake of previous HIV testing among 5821 participants in 16 community clusters was 32% at baseline. Women reported higher testing rates than men, 39% versus 17% respectively (Paper I). The HBHCT intervention increased testing rates from 32% to 69% in the intervention arm, while a smaller increase was observed in the control arm, from 31% to 47% (Paper II). People who received HBHCT had a higher likelihood of having tested compared to those in the control arm, (PR 1.54, 95% CI: 1.32-1.81). The prevalence of couple HIV counselling and testing was about twice as high in the intervention arm as it was in the control arm (PR 2.24, 95% CI: 1.49-3.03). The intervention had a significant effect on some secondary outcomes; notably, a protective effect against having more than one sexual partner in the past three months, which was 55% lower in the intervention arm (Paper II). For couples tested together, mutual knowledge of status challenged their relationships in different ways, depending on HIV status and gender. For discordant and concordant positive couples, the HIV status confirmed suspicions of infidelity, while negative couples were happy and regained trust. Concordant positive couples expected their positive status. Men reported that knowledge of status was an incentive to change their behaviour (Paper III). The economic evaluation demonstrated that HBHCT was more cost-effective in increasing uptake of HCT. The average cost per client was 29forHBHCTcomparedto29 for HBHCT compared to 29forHBHCTcomparedto38 for HCT in the clinic (Paper IV). Conclusions: HBHCT increased HIV counselling and testing and encouraged couple HCT. In addition to increasing HCT uptake, HBHCT was more cost-effective. The intervention also had protective effects on HIV risk behaviour. Thus, the findings provided evidence for wider implementation of the HBHCT approach.

PLOS ONE, 2015

Conclusions HBHCT was less costly and more effective. Home-based HCT could present a cost-effecti... more Conclusions HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural 'hard to reach' populations depending on affordability by the health system, and should be considered as part of community outreach programs.

Low rates of HIV testing in health facilities suggests that expansion of HIV counselling and test... more Low rates of HIV testing in health facilities suggests that expansion of HIV counselling and testing (HCT) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. As such, due consideration must be given to the ability of lay counsellors to perform HCT in community settings. As part of a community randomized controlled trial, we implemented a home-based HCT intervention. Using the same rapid HIV test kits used by district health facilities, trained lay counsellors conducted door-to-door HIV testing in the Sisonke District of South Africa. To monitor test quality and counsellor skill, additional dry blood spots were sent for laboratory-based ELISA testing. Cross tabulations were done to assess result correspondence. Sensitivity and specificity were also calculated using the laboratory test as the gold standard and 95% confidence intervals were calculated using the Wilson method. From a total of 3,861 samples, the counselor and lab...

Journal of the International AIDS Society, 2015

Efforts to increase awareness of HIV status have led to growing interest in community-based model... more Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up. This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics. We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three month...

BMC Health Services Research, 2014

Background: Whole-system interventions are those that entail system wide changes in goals, servic... more Background: Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes. Methods: Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province. Results: Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of 'community dialogues' and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation. Conclusions: These features resonate with the deliberative, multi-level and context sensitive approaches described as the "simple rules" of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.

Background Implementation frameworks and theories acknowledge the role of power as a factor in th... more Background Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa. Methods A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’...

BMJ Open

The COVID-19 pandemic has led to an explosion of online research using rating scales. While this ... more The COVID-19 pandemic has led to an explosion of online research using rating scales. While this approach can be useful, two of the major challenges affecting the quality of this type of research include selection bias and the use of non-validated scales. Online research is prone to various forms of selection bias, including self-selection bias, non-response bias or only reaching specific subgroups. The use of rating scales requires contextually validated scales that meet psychometrical properties such as validity, reliability and—for cross-country comparisons—invariance across settings. We discuss options to prevent or tackle these challenges. Researchers, readers, editors and reviewers need to take a critical stance towards research using this type of methodology.

International Journal of Environmental Research and Public Health

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people l... more Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH’s ART adherence. Gender norms affected the type...

Health Research Policy and Systems

Background: The continuum of care is a key strategy for ensuring comprehensive service delivery f... more Background: The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low-and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context. Methods: We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4. Results: Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges. Conclusion: Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low-and middle-income countries using the continuum of care framework and locally available indicators.

BMC Research Notes

Objective This study uses health and non-health sector data sources to select and assess availabl... more Objective This study uses health and non-health sector data sources to select and assess available indicators for service provision along the continuum of care for maternal health at subnational levels in South Africa. It applies the adequacy approach established in another study to assess the multi-dimensionality of available indicators. Using adequacy and the process of assessment in the study, the comprehensiveness of the continuum of care for improving maternal health outcomes can be assessed. Results We found 27 indicators of care utilization and access, linkages of care, and quality of care from the routine district health information system. The General Household Survey contained 11 indicators for the social determinants of health on the continuum of care framework. Indicator gaps include health promotion during and after pregnancy, maternal nutrition, empowerment and quality of care. At present, the available indicators measure about 74% of the interventions on the continuum...

Objective : This study uses health and non-health sector data sources to select and assess availa... more Objective : This study uses health and non-health sector data sources to select and assess available indicators for service provision along the continuum of care for maternal health at subnational levels in South Africa. It applies the adequacy approach established in another study to assess the multi-dimensionality of available indicators. Using adequacy and the process of assessment in the study, the comprehensiveness of the continuum of care for improving maternal health outcomes can be assessed. Results: We found 27 indicators of care utilization and access, linkages of care, and quality of care from the routine district health information system. The General Household Survey contained 11 indicators for the social determinants of health on the continuum of care framework. Indicator gaps include health promotion during and after pregnancy, maternal nutrition, empowerment and quality of care. At present, the available indicators measure about 74% of the interventions on the contin...

Health Systems & Reform

District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not... more District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.

Behaviour Research and Therapy

If citing, it is advised that you check and use the publisher's definitive version for pagination... more If citing, it is advised that you check and use the publisher's definitive version for pagination, volume/issue, and date of publication details. And where the final published version is provided on the Research Portal, if citing you are again advised to check the publisher's website for any subsequent corrections.

BMC Health Services Research

Background: Global strategies recommend a continuum of care for maternal health to improve outcom... more Background: Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context. Methods: We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps. Results: We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa. Conclusions: Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources.

The Lancet Psychiatry

Background: The Thinking Healthy Programme (THP) is a psychological intervention recommended for ... more Background: The Thinking Healthy Programme (THP) is a psychological intervention recommended for the treatment of perinatal depression. We assessed the effectiveness and cost-effectiveness of THP delivered by peers (THPP) in Goa, India. Methods: In this single-blind, individually-randomised controlled trial, we recruited pregnant women aged ≥18 years attending antenatal clinics, who scored ≥10 on the Patient Health Questionnaire (PHQ-9). Participants were randomly allocated (1:1) to THPP plus enhanced usual care (EUC), or to EUC alone in randomly-sized blocks, stratified by area of residence. Allocation was concealed using sequentiallynumbered opaque envelopes. Primary outcomes were severity of depressive symptoms (PHQ-9 score) and remission (PHQ-9 score <5) 6 months post-birth assessed by researchers masked to the treatment allocation. Analyses were by intention to treat, adjusting for covariates defined a priori or that showed imbalance at baseline. The trial is registered with ClinicalTrials.gov (NCT02104232). Findings: 280 women were enrolled between 24th October 2014 and 22nd June 2016 (140 per group). At 6 months, 122 (87%) and 129 (92%) women in the THPP plus EUC, and EUC alone groups, respectively, contributed primary outcome data. There was evidence of higher prevalence of remission at 6 months in the THPP plus EUC versus EUC alone group (n=89 (73%) versus n=77 (60%), respectively; prevalence ratio (PR)=1•21; 95% confidence interval (CI) 1•01 to 1•45, p=0•04), but weaker evidence for lower symptom severity (mean 3•47, standard deviation (SD) 4•49 versus 4•48 (SD=5•11), respectively; standardised mean difference (SMD)=-0•18; 95% CI-0•43 to 0•07, p=0•16).Repeated measures analyses over the duration of the trial (measured at 3 and 6 months post-birth) showed beneficial effects on symptom severity (SMD-0•37, 95% CI-0•88 to-0•24, p=0•01), remission (PR=1•21, 95% CI 1•01 to 1•41, p=0•02), WHO-Disability Assessment Schedule (WHO-DAS) scores (SMD=-0•32, 95% CI-0•76 to-0•21, p=0•02) and Multidimensional Scale of Perceived Social Support (MSPSS) scores (SMD=0•51, 95% CI 0•43 to 1•20, p=0•02).. The incremental societal cost per unit improvement on PHQ-9 was-US$ 29•64 (95% CI-32•88 to-26•41) at 3 months, and-US$93•53 (95% CI-180•21 to-6•84) for the whole duration of the trial, with a 87% likelihood of being costsaving in the study setting. The mean cost of providing THPP was US$ 1•36 per beneficiary (95% CI 1•32 to 1•39). There was no evidence of differences in serious adverse events by group, except stigmatisation was more often reported in the EUC alone (9%) versus the THPP plus EUC group (4%; p=0•08). Interpretation: THPP had a moderate effect on symptom severity and remission from perinatal depression over the 6 month post-natal period. THPP is relatively cheap to deliver and pays for itself through reduced health care, time and productivity costs.

The Lancet Psychiatry

Background: The Thinking Healthy Programme (THP), endorsed by WHO, is an evidence-based intervent... more Background: The Thinking Healthy Programme (THP), endorsed by WHO, is an evidence-based intervention for perinatal depression. We adapted THP for delivery by volunteer peers (THPP)-lay women from the community-and assessed its effectiveness and cost-effectiveness in Rawalpindi, Pakistan. Methods: In this cluster randomised controlled trial, 40 village-clusters were equally randomised to intervention (THPP plus Enhanced Usual Care (EUC)) or to EUC-alone. Consenting pregnant women aged ≥18 years who scored >10 on the nine-item Patient Health Questionnaire (PHQ-9) were eligible. Follow-up visits were at 3 and 6 months post childbirth. Primary outcomes were depressive symptoms score and remission at 6 months post-childbirth. Secondary outcomes included recovery from depression, levels of disability and perceived social support and child outcomes. All assessors were masked, and analyses were modified intention-to-treat. The trial was registered with ClinicalTrials.gov (NCT02111915). Findings: Of the 570 women enrolled between 15 th October 2014 and 25 th February 2016, 227/283 (80%) and 226/287 (79%) women in the THPP plus EUC and EUC-alone groups, respectively, contributed primary outcome data. Compared to women in the EUC-alone group, those in the THPP plus EUC group at 6 months had lower PHQ-9 scores and better proportions of remission, but neither reached statistical significance (standardised mean difference, SMD=-0•13, 95% CI-0•31 to 0•06, p=0•07; 49% vs 45%; Prevalence Ratio PR=1•12, 95% CI 0•95 to 1•29, p=0.14 respectively). Repeated measures analyses over the 6 months post childbirth showed beneficial intervention effects on both PHQ-9 scores (SMD=-0•22, 95%CI-0•35 to-0•09, p=<0•001) and remission (PR=1•15 95% CI 1•02 to 1•28, p=0•02), disability scores (SMD=-0•12, 95% CI-0•25 to 0•01, p=0•03) and perceived social support scores (SMD=0•16, 95%CI 0•03 to 0•29, p=0•01). THPP was associated with slightly higher costs than EUC-alone but significantly better outcome, thereby rendering it a cost-effective intervention; total societal cost per unit improvement on PHQ-9 was US$ 2•65 (95% CI 1•82 to 3•49) at 3 months post childbirth, US$ 1•17 (95% CI-0•53 to 2•88) for the 3-6-month post-childbirth period and US$ 15•50 (95% CI 9•59 to 21•61) over the study period as a whole. There was no evidence of differences in serious adverse events by group. Interpretation: THPP showed moderate effects on symptom severity and remission from perinatal depression over the 6-month postnatal period among women caring for infants and was also costeffective. Our intervention delivered by lay peers can be a potential step towards using an untapped human resource to address the treatment gap of perinatal depression.

Health Research Policy and Systems

Background: The uptake of findings from sexual and reproductive health and rights research into p... more Background: The uptake of findings from sexual and reproductive health and rights research into policy-making remains a complex and non-linear process. Different models of research utilisation and guidelines to maximise this in policy-making exist, however, challenges still remain for researchers to improve uptake of their research findings and for policy-makers to use research evidence in their work. Methods: A participatory workshop with researchers was organised in November 2017 by the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER) to address this gap. ANSER is a consortium of experienced researchers, some of whom have policy-making experience, working on sexual and reproductive health and rights issues across 16 countries and 5 continents. The experiential learning cycle was used to guide the workshop discussions based on case studies and to encourage participants to focus on key lessons learned. Workshop findings were thematically analysed using specific stages from Hanney et al.'s (Health Res Policy Syst 1:2, 2003) framework on the place of policy-making in the stages of assessment of research utilisation and outcomes. Results: The workshop identified key strategies for translating research into policy, including joint agenda-setting between researchers and policy-makers, as well as building trust and partnerships with different stakeholders. These were linked to stages within Hanney et al.'s framework as opportunities for engaging with policy-makers to ensure uptake of research findings. Conclusion: The engagement of stakeholders during the research development and implementation phases, especially at strategic moments, has a positive impact on uptake of research findings. The strategies and stages described in this paper can be applied to improve utilisation of research findings into policy development and implementation globally.

AIDS and behavior, Mar 22, 2017

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, c... more To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and ...

BMC Public Health, 2016

Background: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and... more Background: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa. Methods: A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions. Results: The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators' care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs. Conclusions: We found high acceptance by caregivers and vaccinators of three injections. Caregivers' poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants' pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI's expansion in resource-limited countries.

SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2016

HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV... more HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV/AIDS, and promoted as an essential tool in scaling up and improving access to treatment, care and support especially in community settings. Home-based HCT (HBHCT) is a model that has consistently been found to be highly acceptable and has improved HCT coverage and uptake in low-and middle-income countries since 2002. It involves trained lay counselors going door-todoor offering pre-test counseling and providing HCT services to consenting eligible household members. Currently, there are few studies reporting on the quality of HBHCT services offered by lay counselors especially in Sub-Saharan Africa, including South Africa. This is a quantitative descriptive sub-study of a community randomized trial (Good Start HBHCT trial) which describes the quality of HBHCT provided by lay counselors. Quality of HBHCT was measured as scores comparing observed practice to prescribed protocols using direct observation. Data were collected through periodic observations of HCT sessions and exit interviews with clients. Counselor quality scores for pre-test counseling and post-test counseling sessions were created to determine the level of quality. For the client exit interviews a continuous score was created to assess how satisfied the clients were with the counseling session. A total of 196 (3%) observational assessments and 406 (6%) client exit interviews were completed. Overall, median scores for quality of counseling and testing were high for both HIV-negative and HIV-positive clients. For exit interviews all 406 (100%) clients had overall satisfaction with the counseling and testing services they received, however 11% were concerned about the counselor keeping their discussion confidential. Of all 406 clients, 393 (96.8%) intended to recommend the service to other people. In ensuring good quality HCT services, ongoing quality assessments are important to monitor quality of HCT after training.

Background: Despite the introduction of HIV counselling and testing (HCT) methods about 30 years ... more Background: Despite the introduction of HIV counselling and testing (HCT) methods about 30 years ago, HIV testing uptake remains low in most high HIV prevalence settings. To date, knowledge of status still remains a critical approach in the fight against HIV and a first step to prevention, access to care, treatment, and support. Home-based HIV counselling and testing (HBHCT) is a novel approach that may complement the long-standing approaches for delivering HIV testing. Main Aim: To assess the impact of an HBHCT intervention on the uptake of HIV testing in a rural community in KwaZulu-Natal province, South Africa, using a pragmatic cluster randomised control trial design. Methods: All 4 research studies (Paper I-IV) were sub-studies of a cluster randomised control trial called Good Start HBHCT. The studies were conducted in rural Umzimkhulu sub-district. The intervention was HBHCT offered by trained lay counsellors to all adults residing in the intervention clusters (8 communities). In the control arm (8 communities) people accessed the standard of care (mainly clinic based HIV testing). The primary outcome measured in the trial was uptake of HIV testing. A baseline survey was conducted prior to the intervention in all 16 community clusters to measure uptake of HIV testing using an interviewer administered questionnaire (Paper I). Post-intervention, the same questionnaire (with additional questions on secondary outcomes) was administered (Paper II). In-depth qualitative interviews were conducted with couples who tested and received results together during the intervention (Paper III). We also conducted a cost-effectiveness analysis to compare the HBHCT approach versus clinic HCT (Paper IV). Results: The reported uptake of previous HIV testing among 5821 participants in 16 community clusters was 32% at baseline. Women reported higher testing rates than men, 39% versus 17% respectively (Paper I). The HBHCT intervention increased testing rates from 32% to 69% in the intervention arm, while a smaller increase was observed in the control arm, from 31% to 47% (Paper II). People who received HBHCT had a higher likelihood of having tested compared to those in the control arm, (PR 1.54, 95% CI: 1.32-1.81). The prevalence of couple HIV counselling and testing was about twice as high in the intervention arm as it was in the control arm (PR 2.24, 95% CI: 1.49-3.03). The intervention had a significant effect on some secondary outcomes; notably, a protective effect against having more than one sexual partner in the past three months, which was 55% lower in the intervention arm (Paper II). For couples tested together, mutual knowledge of status challenged their relationships in different ways, depending on HIV status and gender. For discordant and concordant positive couples, the HIV status confirmed suspicions of infidelity, while negative couples were happy and regained trust. Concordant positive couples expected their positive status. Men reported that knowledge of status was an incentive to change their behaviour (Paper III). The economic evaluation demonstrated that HBHCT was more cost-effective in increasing uptake of HCT. The average cost per client was 29forHBHCTcomparedto29 for HBHCT compared to 29forHBHCTcomparedto38 for HCT in the clinic (Paper IV). Conclusions: HBHCT increased HIV counselling and testing and encouraged couple HCT. In addition to increasing HCT uptake, HBHCT was more cost-effective. The intervention also had protective effects on HIV risk behaviour. Thus, the findings provided evidence for wider implementation of the HBHCT approach.

PLOS ONE, 2015

Conclusions HBHCT was less costly and more effective. Home-based HCT could present a cost-effecti... more Conclusions HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural 'hard to reach' populations depending on affordability by the health system, and should be considered as part of community outreach programs.

Low rates of HIV testing in health facilities suggests that expansion of HIV counselling and test... more Low rates of HIV testing in health facilities suggests that expansion of HIV counselling and testing (HCT) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. As such, due consideration must be given to the ability of lay counsellors to perform HCT in community settings. As part of a community randomized controlled trial, we implemented a home-based HCT intervention. Using the same rapid HIV test kits used by district health facilities, trained lay counsellors conducted door-to-door HIV testing in the Sisonke District of South Africa. To monitor test quality and counsellor skill, additional dry blood spots were sent for laboratory-based ELISA testing. Cross tabulations were done to assess result correspondence. Sensitivity and specificity were also calculated using the laboratory test as the gold standard and 95% confidence intervals were calculated using the Wilson method. From a total of 3,861 samples, the counselor and lab...

Journal of the International AIDS Society, 2015

Efforts to increase awareness of HIV status have led to growing interest in community-based model... more Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up. This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics. We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three month...

BMC Health Services Research, 2014

Background: Whole-system interventions are those that entail system wide changes in goals, servic... more Background: Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes. Methods: Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province. Results: Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of 'community dialogues' and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation. Conclusions: These features resonate with the deliberative, multi-level and context sensitive approaches described as the "simple rules" of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.