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D'Ambruoso L, Abruquah NA, Mabetha D, van der Merwe M, Goosen G, Sigudla J, Witter S. Correction: Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district. Hum Resour Health 2023; 21:78. [PMID: 37798749 PMCID: PMC10552429 DOI: 10.1186/s12960-023-00863-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Affiliation(s)
- Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Public Health, National Health Service (NHS) Grampian, Aberdeen, Scotland, UK.
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
| | - Nana Akua Abruquah
- The University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Denny Mabetha
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Maria Van Der Merwe Consulting, White River, South Africa
| | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, Scotland, UK
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D'Ambruoso L, Abruquah NA, Mabetha D, van der Merwe M, Goosen G, Sigudla J, Witter S. Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district. Hum Resour Health 2023; 21:66. [PMID: 37596628 PMCID: PMC10439531 DOI: 10.1186/s12960-023-00853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. METHODS CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. RESULTS CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. CONCLUSIONS Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.
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Affiliation(s)
- Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Public Health, National Health Service (NHS) Grampian, Aberdeen, Scotland, UK.
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
| | - Nana Akua Abruquah
- The University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Denny Mabetha
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Maria Van Der Merwe Consulting, White River, South Africa
| | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, Scotland, UK
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Hove J, Mabetha D, van der Merwe M, Twine R, Kahn K, Witter S, D'Ambruoso L. Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa. PLoS One 2023; 18:e0288524. [PMID: 37498863 PMCID: PMC10374036 DOI: 10.1371/journal.pone.0288524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Despite international evidence supporting community participation in health for improved health outcomes and more responsive and equitable health systems there is little practical evidence on how to do this. This work sought to understand the process involved in collective implementation of a health-related local action plan developed by multiple stakeholders. METHODS Communities, government departments and non-government stakeholders convened in three iterative phases of a participatory action research (PAR) learning cycle. Stakeholders were involved in problem identification, development, and implementation of a local action plan, reflection on action, and reiteration of the process. Participants engaged in reflective exercises, exploring how factors such as power and interest impacted success or failure. RESULTS The local action plan was partially successful, with three out of seven action items achieved. High levels of both power and interest were key factors in the achievement of action items. For the achieved items, stakeholders reported that continuous interactions with one another created a shift in both power and interest through ownership of implementation processes. Participants who possessed significant power and influence were able to leverage resources and connections to overcome obstacles and barriers to progress the plan. Lack of financial support, shifting priorities and insufficient buy-in from stakeholders hindered implementation. CONCLUSION The process offered new ways of thinking and stakeholders were supported to generate local evidence for action and learning. The process also enabled exploration of how different stakeholders with different levels of power and interest coalesce to design, plan, and act on evidence. Creation of safe spaces was achievable, meanwhile changing stakeholders' level of power and interest was possible but challenging. This study suggests that when researchers, service providers and communities are connected as legitimate participants in a learning platform with access to information and decision-making, a shift in power and interest may be feasible.
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Affiliation(s)
- Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
- Institute of Applied Health Sciences, Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
| | - Denny Mabetha
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
| | | | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Scotland, United Kingdom
| | - Lucia D'Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
- Institute of Applied Health Sciences, Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health, National Health Service (NHS) Grampian, Scotland, United Kingdom
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
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D'Ambruoso L, Mabetha D, Twine R, van der Merwe M, Hove J, Goosen G, Sigudla J, Witter S. Correction: 'Voice needs teeth to have bite'! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa. PLOS Glob Public Health 2023; 3:e0002187. [PMID: 37437006 DOI: 10.1371/journal.pgph.0002187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0000323.].
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Mabetha D, Ojewola T, van der Merwe M, Mabika R, Goosen G, Sigudla J, Hove J, Witter S, D'Ambruoso L. Realising radical potential: building community power in primary health care through Participatory Action Research. Int J Equity Health 2023; 22:94. [PMID: 37198678 DOI: 10.1186/s12939-023-01894-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/14/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component. METHODS Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks. RESULTS Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district. CONCLUSIONS Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.
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Affiliation(s)
- Denny Mabetha
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
| | - Temitope Ojewola
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- Health Education England, Northwest, Manchester, England, UK
| | - Maria van der Merwe
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- Maria Van Der Merwe Consulting, White River, South Africa
| | | | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, UK
| | - Lucia D'Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, UK.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Public Health, National Health Service (NHS) Grampian, Aberdeen, Scotland, UK.
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
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D’Ambruoso L, Mabetha D, Twine R, van der Merwe M, Hove J, Goosen G, Sigudla J, Witter S. 'Voice needs teeth to have bite'! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa. PLOS Glob Public Health 2022; 2:e0000323. [PMID: 36962488 PMCID: PMC10022044 DOI: 10.1371/journal.pgph.0000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 07/01/2022] [Indexed: 03/26/2023]
Abstract
There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community 'voice' and initiating dialogue with the authorities, giving the voice 'teeth'. Achieving 'bite', however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative.
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Affiliation(s)
- Lucia D’Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
- Department of Epidemiology and Global Health, Umeå University, Sweden
- Public Health, National Health Service (NHS) Grampian, Scotland, United Kingdom
| | - Denny Mabetha
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
- Maria van der Merwe Consulting, White River, South Africa
| | - Jennifer Hove
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Scotland, United Kingdom
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Hove J, D’Ambruoso L, Kahn K, Witter S, van der Merwe M, Mabetha D, Tembo K, Twine R. Lessons from community participation in primary health care and water resource governance in South Africa: a narrative review. Glob Health Action 2022; 15:2004730. [PMID: 34994680 PMCID: PMC8745361 DOI: 10.1080/16549716.2021.2004730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services. OBJECTIVE This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). METHODS Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. RESULTS There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. CONCLUSION Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery.
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Affiliation(s)
- Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | - Lucia D’Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health/Health Protection, National Health Service (NHS) Grampian, Scotland, UK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- International Network for the Demographic Evaluation of Populations and Their Health (Indepth), Accra, Ghana
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Maria van der Merwe
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
- Independent Consultant, White river, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | | | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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D'Ambruoso L, Price J, Cowan E, Goosen G, Fottrell E, Herbst K, van der Merwe M, Sigudla J, Davies J, Kahn K. Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making. Glob Health Action 2021; 14:2000091. [PMID: 35377291 PMCID: PMC8986216 DOI: 10.1080/16549716.2021.2000091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Recognising that the causes of over half the world's deaths pass unrecorded, the World Health Organization (WHO) leads development of Verbal Autopsy (VA): a method to understand causes of death in otherwise unregistered populations. Recently, VA has been developed for use outside research environments, supporting countries and communities to recognise and act on their own health priorities. We developed the Circumstances of Mortality Categories (COMCATs) system within VA to provide complementary circumstantial categorisations of deaths. OBJECTIVES Refine the COMCAT system to (a) support large-scale population assessment and (b) inform public health decision-making. METHODS We analysed VA data for 7,980 deaths from two South African Health and Socio-Demographic Surveillance Systems (HDSS) from 2012 to 2019: the Agincourt HDSS in Mpumalanga and the Africa Health Research Institute HDSS in KwaZulu-Natal. We assessed the COMCAT system's reliability (consistency over time and similar conditions), validity (the extent to which COMCATs capture a sufficient range of key circumstances and events at and around time of death) and relevance (for public health decision-making). RESULTS Plausible results were reliably produced, with 'emergencies', 'recognition, 'accessing care' and 'perceived quality' characterising the majority of avoidable deaths. We identified gaps and developed an additional COMCAT 'referral', which accounted for a significant proportion of deaths in sub-group analysis. To support decision-making, data that establish an impetus for action, that can be operationalised into interventions and that capture deaths outside facilities are important. CONCLUSIONS COMCAT is a pragmatic, scalable approach enhancing functionality of VA providing basic information, not available from other sources, on care seeking and utilisation at and around time of death. Continued development with stakeholders in health systems, civil registration, community and research environments will further strengthen the tool to capture social and health systems drivers of avoidable deaths and promote use in practice settings.
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Affiliation(s)
- Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science (ACHDS), Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland.,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Public Healtlh, National Health Service (NHS), Scotland
| | - Jessica Price
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eilidh Cowan
- Aberdeen Centre for Health Data Science (ACHDS), Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland.,School of Geosciences, College of Science and Engineering, University of Edinburgh, Scotland
| | | | | | - Kobus Herbst
- Africa Health Research Institute, Durban, South Africa.,DSI-MRC South African Population Research Infrastructure Network (SAPRIN), South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science (ACHDS), Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Independent Consultant, South Africa
| | | | - Justine Davies
- Institute for Applied Health Research, University of Birmingham, UK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,International Network for the Demographic Evaluation of Populations and Their Health (Indepth), Accra, Ghana
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Cowan E, D'Ambruoso L, van der Merwe M, Witter S, Byass P, Ameh S, Wagner RG, Twine R. Understanding non-communicable diseases: combining health surveillance with local knowledge to improve rural primary health care in South Africa. Glob Health Action 2021; 14:1852781. [PMID: 33357074 PMCID: PMC7782313 DOI: 10.1080/16549716.2020.1852781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: NCDs are non-infectious, long-term conditions that account for 40 million deaths per annum. 87% of premature NCD mortality occurs in low- and middle-income countries. Objective: The aims were:develop methods to provide integrated biosocial accounts of NCD mortality; and explore the practical utility of extended mortality data for the primary health care system. Methods: We drew on data from research programmes in the study area. Data were analysed in three steps: [a]analysis of levels, causes and circumstances of NCD mortality [n = 4,166] from routine census updates including Verbal Autopsy and of qualitative data on lived experiences of NCDs in rural villages from participatory research; [b] identifying areas of convergence and divergence between the analyses; and [c]exploration of the practical relevance of the data drawing on engagements with health systems stakeholders. Results: NCDs constituted a significant proportion of mortality in this setting [36%]. VA data revealed multiple barriers to access in end-of-life care. Many deaths were attributed to problems with resources and health systems [21%;19% respectively]. The qualitative research provided rich complementary detail on the processes through which risk originates, accumulates and is expressed in access to end-of-life care, related to chronic poverty and perceptions of poor quality care in clinics. The exploration of practical relevance revealed chronic under-funding for NCD services, and an acute need for robust, timely data on the NCD burden. Conclusions: VA data allowed a significant burden of NCD mortality to be quantified and revealed barriers to access at and around the time of death. Qualitative research contextualised these barriers, providing explanations of how and why they exist and persist. Health systems analysis revealed shortages of resources allocated to NCDs and a need for robust research to provide locally relevant evidence to organise and deliver care. Pragmatic interdisciplinary and mixed method analysis provides relevant renditions of complex problems to inform more effective responses.
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Affiliation(s)
- Eilidh Cowan
- School of Geosciences, University of Edinburgh , Edinburgh, UK
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, University of Aberdeen , Aberdeen, UK.,Umeå Centre for Global Health Research, Department of Epidemiology and Global Health, Umeå University , Umeå, Sweden.,MRC/Wits Rural Public Health and Health Transitions Research Unit [Agincourt], School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa.,National Health Service , Grampian, UK
| | - Maria van der Merwe
- Independent Public Health and Nutrition Consultant , Nelspruit, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University Edinburgh , Musselburgh, UK
| | - Peter Byass
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, University of Aberdeen , Aberdeen, UK.,Umeå Centre for Global Health Research, Department of Epidemiology and Global Health, Umeå University , Umeå, Sweden.,MRC/Wits Rural Public Health and Health Transitions Research Unit [Agincourt], School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Soter Ameh
- Department of Community Medicine, College of Medical Sciences, University of Calabar , Calabar, Nigeria.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University , Boston, MA, USA
| | - Ryan G Wagner
- Umeå Centre for Global Health Research, Department of Epidemiology and Global Health, Umeå University , Umeå, Sweden.,MRC/Wits Rural Public Health and Health Transitions Research Unit [Agincourt], School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa.,Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) - INDEPTH Network , Accra, Ghana
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit [Agincourt], School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
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van der Merwe M, D'Ambruoso L, Witter S, Twine R, Mabetha D, Hove J, Byass P, Tollman S, Kahn K. Collective reflections on the first cycle of a collaborative learning platform to strengthen rural primary healthcare in Mpumalanga, South Africa. Health Res Policy Syst 2021; 19:66. [PMID: 33874951 PMCID: PMC8054125 DOI: 10.1186/s12961-021-00716-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme-a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa-for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance. METHODS Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017-19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts. RESULTS Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the VAPAR process. Findings were collated into a revised theory of change. CONCLUSIONS The VAPAR learning platform was regarded as a feasible, acceptable and relevant approach to facilitate cooperative learning and community participation in health systems. The evaluation provides support for a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research.
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Affiliation(s)
- Maria van der Merwe
- , White River, South Africa.
- Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland.
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- National Health Service (NHS) Grampian, Aberdeen, Scotland
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Byass
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Tollman
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
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Hove J, D'Ambruoso L, Twine R, Mabetha D, van der Merwe M, Mtungwa I, Khoza S, Kahn K, Witter S. Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa. Glob Health Action 2021; 14:1973715. [PMID: 34538225 PMCID: PMC8462876 DOI: 10.1080/16549716.2021.1973715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water. OBJECTIVE This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa. METHOD We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process. RESULTS Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved. CONCLUSION Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation.
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Affiliation(s)
- Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | - Lucia D'Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK.,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,National Health Service (NHS) Grampian, Scotland, UK
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | - Maria van der Merwe
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK.,Independent Consultant, South Africa
| | - Ishmael Mtungwa
- Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa
| | - Sonto Khoza
- Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,International Network for the Demographic Evaluation of Populations and Their Health (Indepth), Accra, Ghana
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Scotland, UK
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D’Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, Masinga S, Mokoena V, Spies B, Tollman S, Witter S, Twine R. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-429. [PMID: 31243457 PMCID: PMC6736195 DOI: 10.1093/heapol/czz047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2019] [Indexed: 01/08/2023] Open
Abstract
Following 50 years of apartheid, South Africa introduced visionary health policy committing to the right to health as part of a primary health care (PHC) approach. Implementation is seriously challenged, however, in an often-dysfunctional health system with scarce resources and a complex burden of avoidable mortality persists. Our aim was to develop a process generating evidence of practical relevance on implementation processes among people excluded from access to health systems. Informed by health policy and systems research, we developed a collaborative learning platform in which we worked as co-researchers with health authorities in a rural province. This article reports on the process and insights brought by health systems stakeholders. Evidence gaps on under-five mortality were identified with a provincial Directorate after which we collected quantitative and qualitative data. We applied verbal autopsy to quantify levels, causes and circumstances of deaths and participatory action research to gain community perspectives on the problem and priorities for action. We then re-convened health systems stakeholders to analyse and interpret these data through which several systems issues were identified as contributory to under-five deaths: staff availability and performance; service organization and infrastructure; multiple parallel initiatives; and capacity to address social determinants. Recommendations were developed ranging from immediate low- and no-cost re-organization of services to those where responses from higher levels of the system or outside were required. The process was viewed as acceptable and relevant for an overburdened system operating 'in the dark' in the absence of local data. Institutional infrastructure for evidence-based decision-making does not exist in many health systems. We developed a process connecting research evidence on rural health priorities with the means for action and enabled new partnerships between communities, authorities and researchers. Further development is planned to understand potential in deliberative processes for rural PHC.
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Affiliation(s)
- Lucia D’Ambruoso
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Maria van der Merwe
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Oghenebrume Wariri
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Medical Research Council (MRC) Unit, The Gambia at London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Peter Byass
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Gerhard Goosen
- Mpumalanga Department of Health, Nelspruit, South Africa
| | - Kathleen Kahn
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | | | | | - Barry Spies
- Mpumalanga Department of Health, Nelspruit, South Africa
| | - Stephen Tollman
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
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Schneider H, van der Merwe M, Marutla B, Cupido J, Kauchali S. The whole is more than the sum of the parts: establishing an enabling health system environment for reducing acute child malnutrition in a rural South African district. Health Policy Plan 2019; 34:430-439. [PMID: 31280321 PMCID: PMC6735808 DOI: 10.1093/heapol/czz060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 11/29/2022] Open
Abstract
There is a gap in understanding of how national commitments to child nutrition are translated into sub-national implementation. This article is a mixed methods case study of a rural South African health district which achieved accelerated declines in morbidity and mortality from severe acute malnutrition (SAM) in young children, following a district health system strengthening (HSS) initiative centred on real-time death reporting, analysis and response. Drawing on routine audit data, the declining trends in under-five admissions and in-hospital mortality for SAM over a 5-year period are presented, comparing the district with two others in the same province. Adapting Gillespie et al.'s typology of 'enabling environments' for Maternal and Child Nutrition, and based on 41 in-depth interviews and a follow-up workshop, the article then presents an analysis of how an enabling local health system environment for maternal-child health was established, creating the conditions for achievement of the SAM outcomes. Embedded in supportive policy and processes at national and provincial levels, the district HSS interventions and the manner in which they were implemented produced three kinds of system-level change: knowledge and use of evidence by providers and managers ('ways of thinking'), leadership, participation and coordination ('ways of governing') and inputs and capacity ('ways of resourcing'). These processes mainstreamed responsibility, deepened accountability and triggered new service delivery and organizational practices and mindsets. The article concludes that it is possible to foster enabling district environments for the prevention and management of acute malnutrition, emphasizing the multilevel and simultaneous nature of system actions, where action on system 'software' complements the 'hardware' of HSS interventions, and where the whole is more than the sum of the parts.
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Affiliation(s)
- Helen Schneider
- School of Public Health and SAMRC Health Services to Systems Unit, University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa
| | - Maria van der Merwe
- Mpumalanga Department of Health, No 7 Government Boulevard, Mbombela, South Africa
| | - Beauty Marutla
- Mpumalanga Department of Health, No 7 Government Boulevard, Mbombela, South Africa
| | - Joseph Cupido
- National Department of Health, Civitas Building, 222, Thabo Sehume St, Pretoria, South Africa
| | - Shuaib Kauchali
- National Department of Health, Civitas Building, 222, Thabo Sehume St, Pretoria, South Africa
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Hove J, D'Ambruoso L, Mabetha D, van der Merwe M, Byass P, Kahn K, Khosa S, Witter S, Twine R. 'Water is life': developing community participation for clean water in rural South Africa. BMJ Glob Health 2019; 4:e001377. [PMID: 31263583 PMCID: PMC6570987 DOI: 10.1136/bmjgh-2018-001377] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background South Africa is a semiarid country where 5 million people, mainly in rural areas, lack access to water. Despite legislative and policy commitments to the right to water, cooperative governance and public participation, many authorities lack the means to engage with and respond to community needs. The objectives were to develop local knowledge on health priorities in a rural province as part of a programme developing community evidence for policy and planning. Methods We engaged 24 participants across three villages in the Agincourt Health and Socio-Demographic Surveillance System and codesigned the study. This paper reports on lack of clean, safe water, which was nominated in one village (n=8 participants) and in which women of reproductive age were nominated as a group whose voices are excluded from attention to the issue. On this basis, additional participants were recruited (n=8). We then held a series of consensus-building workshops to develop accounts of the problem and actions to address it using Photovoice to document lived realities. Thematic analysis of narrative and visual data was performed. Results Repeated and prolonged periods when piped water is unavailable were reported, as was unreliable infrastructure, inadequate service delivery, empty reservoirs and poor supply exacerbated by droughts. Interconnected social, behavioural and health impacts were documented combined with lack of understanding, cooperation and trust between communities and authorities. There was unanimity among participants for taps in houses as an overarching goal and strategies to build an evidence base for planning and advocacy were developed. Conclusion In this setting, there is willingness among community stakeholders to improve water security and there are existing community assemblies to support this. Health and Socio-Demographic Surveillance Systems provide important opportunities to routinely connect communities to resource management and service delivery. Developing learning platforms with government and non-government organisations may offer a means to enable more effective public participation in decentralised water governance.
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Affiliation(s)
- Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lucia D'Ambruoso
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria van der Merwe
- Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
| | - Peter Byass
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sonto Khosa
- Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, Scotland, UK
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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15
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Wariri O, D’Ambruoso L, Twine R, Ngobeni S, van der Merwe M, Spies B, Kahn K, Tollman S, Wagner RG, Byass P. Initiating a participatory action research process in the Agincourt health and socio-demographic surveillance site. J Glob Health 2017; 7:010413. [PMID: 28685035 PMCID: PMC5475314 DOI: 10.7189/jogh.07.010413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite progressive health policy, disease burdens in South Africa remain patterned by deeply entrenched social inequalities. Accounting for the relationships between context, health and risk can provide important information for equitable service delivery. The aims of the research were to initiate a participatory research process with communities in a low income setting and produce evidence of practical relevance. METHODS We initiated a participatory action research (PAR) process in the Agincourt health and socio-demographic surveillance site (HDSS) in rural north-east South Africa. Three village-based discussion groups were convened and consulted about conditions to examine, one of which was under-5 mortality. A series of discussions followed in which routine HDSS data were presented and participants' subjective perspectives were elicited and systematized into collective forms of knowledge using ranking, diagramming and participatory photography. The process concluded with a priority setting exercise. Visual and narrative data were thematically analyzed to complement the participants' analysis. RESULTS A range of social and structural root causes of under-5 mortality were identified: poverty, unemployment, inadequate housing, unsafe environments and shortages of clean water. Despite these constraints, single mothers were often viewed as negligent. A series of mid-level contributory factors in clinics were also identified: overcrowding, poor staffing, delays in treatment and shortages of medications. In a similar sense, pronounced blame and negativity were directed toward clinic nurses in spite of the systems constraints identified. Actions to address these issues were prioritized as: expanding clinics, improving accountability and responsiveness of health workers, improving employment, providing clean water, and expanding community engagement for health promotion. CONCLUSIONS We initiated a PAR process to gain local knowledge and prioritize actions. The process was acceptable to those involved, and there was willingness and commitment to continue. The study provided a basis from which to gain support to develop fuller forms of participatory research in this setting. The next steps are to build deeper involvement of participants in the process, expand to include the perspectives of those most marginalized, and engage in the health system at different levels to move toward an ongoing process of action and learning from action.
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Affiliation(s)
- Oghenebrume Wariri
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Department of Paediatrics, Federal Teaching Hospital Gombe, Gombe, Nigeria
| | - Lucia D’Ambruoso
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH, Accra, Ghana
| | - Sizzy Ngobeni
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH, Accra, Ghana
| | - Maria van der Merwe
- Directorate for Maternal, Child, Women and Youth Health and Nutrition, Mpumalanga Department of Health, South Africa
| | - Barry Spies
- Directorate for Maternal, Child, Women and Youth Health and Nutrition, Mpumalanga Department of Health, South Africa
| | - Kathleen Kahn
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH, Accra, Ghana
| | - Stephen Tollman
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH, Accra, Ghana
| | - Ryan G Wagner
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH, Accra, Ghana
| | - Peter Byass
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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D’Ambruoso L, Kahn K, Wagner RG, Twine R, Spies B, van der Merwe M, Gómez-Olivé FX, Tollman S, Byass P. Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality. Glob Health Res Policy 2016; 1:2. [PMID: 29202052 PMCID: PMC5675065 DOI: 10.1186/s41256-016-0002-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Verbal autopsy (VA) is a health surveillance technique used in low and middle-income countries to establish medical causes of death (CODs) for people who die outside hospitals and/or without registration. By virtue of the deaths it investigates, VA is also an opportunity to examine social exclusion from access to health systems. The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA. METHODS A short set of questions on care pathways, circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA (SF-VA). Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site (HDSS), South Africa in 2012 and 2013 where the SF-VA had been applied. InterVA and descriptive analysis were used to calculate cause-specific mortality fractions (CSMFs), and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex sub-groups. RESULTS One thousand two hundred forty-nine deaths were recorded in the Agincourt HDSS censuses in 2012-13 of which 1,196 (96 %) had complete VA data. Infectious and non-communicable conditions accounted for the majority of deaths (47 % and 39 % respectively) with smaller proportions attributed to external, neonatal and maternal causes (5 %, 2 % and 1 % respectively). 5 % of deaths were of indeterminable cause. The new indicators revealed multiple problems with access to care at the time of death: 39 % of deaths did not call for help, 36 % found care unaffordable overall, and 33 % did not go to a facility. These problems were reported consistently across age and sex sub-groups. Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility. An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting. CONCLUSIONS Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning. Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.
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Affiliation(s)
- Lucia D’Ambruoso
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana
| | - Ryan G. Wagner
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Barry Spies
- Directorate for Maternal, Child, Women and Youth Health and Nutrition, Mpumalanga Department of Health, Nelspruit, Mpumalanga South Africa
| | - Maria van der Merwe
- Directorate for Maternal, Child, Women and Youth Health and Nutrition, Mpumalanga Department of Health, Nelspruit, Mpumalanga South Africa
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana
| | - Stephen Tollman
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana
| | - Peter Byass
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Bingham J, van der Merwe M. Distribution of rabies antigen in infected brain material: determining the reliability of different regions of the brain for the rabies fluorescent antibody test. J Virol Methods 2002; 101:85-94. [PMID: 11849687 DOI: 10.1016/s0166-0934(01)00423-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To assist in making recommendations for sampling of brains for the fluorescent antibody test (FAT), a study was conducted to determine the regions of the brain where rabies antigen is found most reliably. Each identifiable part of 252 rabies-positive brains of various species was re-tested using routine FA tests. It was found that there was frequent variation in the quantity of antigen between regions of the brain. The thalamus, pons and medulla were the most reliable parts of the brain as they were positive in all specimens tested. The cerebellum, hippocampus and different parts of the cerebrum were negative in, respectively, 4.5, 4.9 and 3.9-11.1% of positive brains. It is recommended that specimens for rabies diagnosis must include the brain stem. The structure of choice would be the thalamus as it was positive in all specimens and had the most frequent prevalence (97.8%) of abundant antigen. These findings contradict many old studies that state that the hippocampus should be the structure of choice for rabies diagnosis. The current data demonstrate that the reason for the old recommendations is that the hippocampus has the highest frequency of large inclusion bodies, as the reliability of the histological tests used previously depended on inclusion body size.
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Affiliation(s)
- John Bingham
- Rabies Unit, Onderstepoort Veterinary Institute, 0110, Onderstepoort, South Africa.
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