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Background: Achieving universal health coverage (UHC) in the context of limited resources will require prioritising the most vulnerable and ensuring health policies and services are responsive to their needs. One way of addressing this is through the engagement of marginalised voices in the priority setting process. Public engagement approaches that enable group level deliberation as well as individual level preference capturing might be valuable in this regard, but there are limited examples of their practical application, and gaps in understanding their outcomes, especially with rural populations. Objective: To address this gap, we implemented a modified priority setting tool (Choosing All Together—CHAT) that enables individuals and groups to make trade‐offs to demonstrate the type of health services packages that may be acceptable to a rural population. The paper presents the findings from the individual choices as compared to the group choices, as well as the differences among the individual choices using this tool. Methods: Participants worked in groups and as individuals to allocate stickers representing the available budget to different health topics and interventions using the CHAT tool. The allocations were recorded at each stage of the study. We calculated the median and interquartile range across study participants for the topic totals. To examine differences in individual choices, we performed Wilcoxon rank sum tests. Results: The results show that individual interests were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics like age. Discussion: The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and potentially enhance the legitimacy and acceptability of priority setting. Methods that enable group level deliberation and individual level priority setting may be necessary to reconcile plurality. The paper also highlights the importance of capturing the details of public engagement processes and transparently reporting on these details to ensure valuable outcomes. Public Contribution: The facilitator of the CHAT groups was a member from the community and underwent training from the research team. The fieldworkers were also from the community and were trained and paid to capture the data. The participants were all members of the rural community‐ the study represents their priorities. [ABSTRACT FROM AUTHOR]

Introduction: The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of tasksharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC). Methods: The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention. MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas. Results: Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%. Conclusions: The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC. [ABSTRACT FROM AUTHOR]

Societal Impact Statement: Opuntia ficus‐indica, commonly known as prickly pear, is a widely distributed plant originating in central America. Its wide distribution and popularity as a cultivated plant are due to the sweetness of its fruits. Here, the role of O. ficus‐indica in the livelihoods of people in Limpopo Province, South Africa, was investigated. Roadside traders of prickly pear were surveyed 2019–2020 using paper‐based questionnaires and a convenience sampling strategy. Evidence of O. ficus‐indica trading as a means to generate income was uncovered. Notably, none of the traders knew about invasive species. Future studies should seek to understand the motivations of purchasers. The extent to which rural communities use this species for food security and poverty alleviation is not fully understood. Summary: The Opuntia ficus‐indica (whose fruits are traded in South Africa) is a species that is classified according to the National Environmental Management: Biodiversity Act (10/2004) Alien and Invasive Species (NEM:BA A&IS) regulations as an invasive species. This study sought to provide an understanding of the socio‐economic value of O. ficus‐indica and the characteristic profiles of the people who trade with O. ficus‐indica in the Limpopo Province of South Africa.A convenience sampling strategy was conducted along trading roads in Limpopo province, and the data were collected by surveying traders' attitudes toward the prickly pear trade using questionnaires.Our findings show that at the time of sampling 72 traders participated in prickly pear trading along the roadside. Unemployment is cited as the primary reason for their involvement in trading. O. Ficus‐indica is an important fruit for rural communities in Limpopo province. It helps communities living below the poverty line to generate income and to support their livelihoods.Our study highlights the need for the establishment of a Prickly Pear Traders' Agency in order to promote the trade of O. ficus‐indica as a measure to generate income, alleviate poverty, and ensure food security. The paper concludes with recommendations for local government support for O. ficus‐indica traders through the formalization of the trade and through monetary support. [ABSTRACT FROM AUTHOR]

Aim: To better understand the aetiologies of epileptic spasms in infants, as well as the safety and efficacy of high dose corticosteroids in tuberculosis and human immunodeficiency virus (HIV) endemic resource‐limited settings. Method: This was a retrospective analysis of infants with epileptic spasms managed at the tertiary referral centres in the Western Cape, South Africa. Results: Of 175 children with epileptic spasms, the median age at onset was 6 months (interquartile range 4–8 months). Structural aetiologies were most common (115 out of 175 [66%]), with two‐thirds related to perinatal insults. A lead time to treatment (LTTT) of less than 1 month was more likely in the epileptic encephalopathy/developmental and epileptic encephalopathy (DEE) group: 58 out of 92 (63%), compared to 28 out of 76 (37%) of those with developmental encephalopathy (p = 0.001). Failure to recognize preceding developmental delay was common. Ninety‐nine children (57%) received first line hormonal therapy such as adrenocorticotropic hormone. A total of 111 out of 172 children (65%) from the developmental encephalopathy and epileptic encephalopathy/DEE groups had clinical and/or electroencephalogram resolution of spasms within 14 days. In our population, children in whom an aetiology could not be identified were statistically more likely to have moderate to profound developmental delay at 1 year of age: 33 out of 44 (p = 0.001). Based on reported incidence of epileptic spasms, 23 to 58 cases per annum would be expected but a far smaller proportion presented to our centres. Interpretation: Whilst this is the largest cohort of infants with epileptic spasms from sub‐Saharan Africa, the study size is less than expected; this may reflect misdiagnosis and failure of referral pathways. Despite a reported shorter LTTT, infants with DEE had worse developmental outcomes compared to international studies. Hormonal therapy was safe and effective in our setting, despite exposure to high levels of tuberculosis and HIV. What this paper adds: The number of unreferred cases of epileptic spasms in South Africa remains high.Caregivers and health care workers in primary care facilities often fail to recognize developmental delay.The burden of disease from hypoxic‐ischaemic encephalopathy remains high in our resource‐limited setting.Hormonal treatment (e.g. adrenocorticotropic hormone) was safe and effective despite the high prevalence of human immunodeficiency virus and tuberculosis. [ABSTRACT FROM AUTHOR]

South Africa has a documented high prevalence of stunting and increasing obesity in children as well as obesity in adults. The double burden of malnutrition, which can be on an individual‐, household‐ or population level, has implications for both health and the economic development of a community and country. This paper describes a large‐scale survey (N = 774) of infant feeding, growth monitoring and anthropometry among mother and child pairs aged 6 months of age in KwaZulu‐Natal (KZN), South Africa, conducted between January and August 2017. Among children, a large increase in the prevalence of stunting and obesity was seen between birth and 6 months of age increasing from 9.3% to 21.7% and 4.0% to 21.0%, respectively. 32.1% of the mothers were overweight [body mass index (BMI): 25.0–29.9] and 28.4% had obesity grade 1 (BMI: 30–<40). Although most mothers (93%; 563/605) initiated breastfeeding, the introduction of other foods started early with 17.6% (56/319) of the mothers having started giving other fluids or food to their child within the first month. At 6 months 70.6% (427/605) children were still breastfed and 23.5% were exclusively breastfed. In addition, we found that length measurements were done less frequently than weight measurements between birth and 6 months, on average 2.2 (SD: 1.3) versus 5.8 (SD: 1.5) times. Moreover, there is a need for improvement of health worker training and understanding regarding anthropometric measurements when assessing malnutrition in children in the clinics. Early detection and improved infant feeding practices are key in preventing both stunting and obesity in children. Key messages: The double burden of malnutrition is severe in KwaZulu‐Natal with high rates of maternal obesity and increasing prevalence of stunting and obesity among infants in the first 6 months of life.Breastfeeding and complementary feeding practices are suboptimal and additional support for breastfeeding is required in the post‐natal period and in the workplace to address breastfeeding challenges.Growth monitoring is inadequate in health facilities leading to many lost opportunities for early identification of malnutrition. Hence, anthropometric practices and interpretation of findings need to be strengthened. [ABSTRACT FROM AUTHOR]

Industrialization and urbanization processes have challenged deeply held traditional gender norms and facilitated the emergence of modern ideologies in South Africa. This paper seeks to explore the gendered roles of family members on maternal and child nutrition and investigate indications of perceived change in related practices. A qualitative secondary analysis was conducted of data from nine focus group discussions (FGDs) held with men (n = 3) and women (n = 6) aged ≥18. Data from the FGD were coded and thematic analysis conducted. We found that elderly women seem to have a central advisory role with respect to maternal and child nutrition and that men and elderly women upheld patriarchal gender divisions of labour, which entrust mothers with the primarily responsibility for young children's nutrition. Young mothers relied on elderly women for provision of childcare and nutritious foods for children; however, they demonstrated some resistance to traditionally feminized forms of food preparation. We found that men's involvement in children's nutrition was limited, though they expressed a preference to be more involved in maternal and child nutrition and care practices. A gender transformative approach to policy development, which includes elderly women and men, has the potential to promote more gender‐equitable nutrition practices, increase young women's self‐efficacy and support them to overcome barriers that could be limiting their decision making power in achieving optimal nutrition for themselves and their children. [ABSTRACT FROM AUTHOR]