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Parental decision-making in infant and child male circumcision is influenced by complex, interrelated factors on many levels. Several studies have highlighted reasons for the acceptance and non-acceptance of child male circumcision. This study investigates the factors that influence parental decision-making in this matter and proposes a parental decision-making framework. The study was conducted in the townships of Diepsloot and Diepkloof in Gauteng, South Africa, using 48 in-depth interviews with parents, grandparents and uncles of the boys, as well as government officials and members of civil society as part of an explorative case study. Purposive and snowball sampling were used to select the participants. Thematic analysis was used to analyse the data by applying the conceptual framework of Bronfenbrenner's ecological systems theory. Three main themes emerged from the data: microsystem factors related to health and hygiene, the father's circumcision status, cultural expectations, pain, the child's autonomy and the extended family; mesosystem factors related to early childhood development centres; and exosystem factors related to circumcision policies and financial considerations.

Grief over companion animals is prevalent but few studies provide empirical comparisons to grief over people. The aim of the current study was to extend previous findings by (1) asking identical questions to participants bereaved of a person or a pet, respectively, and (2) correlating grief level with an improved measure of closeness to the deceased.Method: Two standardized grief scales were reworded to be applicable across species, and closeness was measured by 8 items representing two dimensions of attachment. An open invitation from the study elicited 366 participants, of whom 58% had lost a person and 42% a pet. Results: Measures proved reliable (chr α = .89-.94). For neither grief measure did level of grief significantly differ between those having lost a person and those having lost at pet (t-tests, ps > .4). Attachment consistently correlated with level of grief across species and across grief measures (rs =39-53, ps < .001).Limitations: Convenience sample and few male participants.Conclusion: Attachment seems a better predictor of grief than whether the deceased was a person or a pet. This deserves further study. The revised grief measures and the derived attachment measure are useful.

Vaccine hesitancy, long considered a global health threat, poses a major barrier to effective roll-out of COVID-19 vaccination. With less than half (45%) of adult South Africans currently fully vaccinated, we identified factors affecting non-uptake of vaccination and vaccine hesitancy in order to identify key groups to be targeted when embarking upon COVID-19 vaccine promotion campaigns. A cross-sectional, anonymous online survey was undertaken among the South African adult population in September 2021. Our research identified race, interactive–critical vaccine literacy, trust in the government’s ability to roll out the COVID-19 vaccination programme, flu vaccination status and risk perception for COVID-19 infection as key factors influencing the uptake of COVID-19 vaccination. Respondents who did not trust in the government’s ability to roll out vaccination were almost 13 times more likely to be vaccine-hesitant compared to those respondents who did trust the government. Reliable, easy-to-understand information regarding the safety of COVID-19 vaccines is needed, but it is also important that vaccination promotion and communication strategies include broader trust-building measures to enhance South Africans’ trust in the government’s ability to roll out vaccination effectively and safely. This may also be the case in other countries where distrust in governments’ ability prevails.

IntroductionTuberculosis (TB) has become an occupational health hazard in South African hospitals where healthcare workers (HCWs) are additionally confronted daily with HIV and its associated stigma, causing asyndemic. Early TB diagnosis and treatment are vital, but the uptake of these services through occupational healthcare units (OHUs) is low. The current study hypothesises that (1) the link between HIV and TB and (2) the perceived HIV stigmatisation by colleagues create (3) a double HIV–TB stigma which increases (4) internalised TB stigma and leads to (5) a lower willingness to use OHU services for TB screening and treatment.DesignA cross-sectional study using the baseline data from the HIV and TB Stigma among Healthcare workers Study (HaTSaH Study).SettingSix hospitals in the Free State province of South Africa.Participants820 HCWs of the six selected hospitals.ResultsThe study results demonstrate that the co-epidemic (β=0.399 (screening model) and β=0.345 (treatment model)) combined (interaction effect: β=0.133 (screening) and β=0.132 (treatment)) with the persistent stigmatisation of HIV is altering the attitudes towards TB (β=0.345 (screening) and β=0.400 (treatment)), where the stigmatising views of HIV are transferred to TB—illustrating the syndemic impact. Our model demonstrated that this syndemic not only leads to higher levels of internal TB stigma (β=0.421 (screening) and β=0.426 (treatment)), but also to a lower willingness to use the OHU for TB screening (probit coefficient=−0.216) and treatment (probit coefficient=−0.160). Confidentiality consistently emerged as a contextual correlate of OHU use.ConclusionsTheoretically, our results confirm HIV as a ‘syndemic generator’ which changes the social meaning of TB in the hospital context. Practically, the study demonstrated that the syndemic of TB and HIV in a highly endemic context with stigma impacts the intended use of occupational TB services.Trial registration numberPre-results of the trial registered at the South African National Clinical Trials Register, registration ID: DOH-27-1115-5204.

The UFS Faculty of the Humanities held a research webinar on research data management focusing on: • What is data management and why should research data be managed? • Keeping your data safe, and destruction of data: When is it time? • Safety of data during COVID-19. Chaired by Prof TS Petrus, presententations were made by Prof MC Engelbrecht, Prof IP Khumalo, and Dr SI Brokensha.

South Africa has the highest number of people living with HIV in the world, and health care workers (HCWs) are as likely to be infected as the general population. Stigma in health care settings has severe implications for HCWs and health facilities when HCWs with HIV delay or avoid seeking care, causing increased morbidity and mortality. We explored factors associated with HIV stigma toward colleagues. A representative sample of 882 HCWs from 8 hospitals was surveyed in the Free State, South Africa. We applied multigroup structural equation modeling to compare effects between 3 professional categories. In all 3 groups, there was a significant negative relationship between stigmatizing attitudes against other co-workers and knowing a colleague living with HIV, having a colleague who worked to reduce stigma in the workplace, and having basic HIV knowledge. Our results have implications for understanding and crafting interventions to reduce HIV stigma among HCWs.

Prior to the 2019 novel coronavirus (COVID-19) outbreak, the South African healthcare system was already under severe strain due to amongst others, a lack of human resources, poor governance and management, and an unequal distribution of resources among provinces and between the public and private healthcare sectors. At the center of these challenges are nurses, the backbone of the healthcare system, and the first point of call for most patients in the country. This research investigated post-traumatic stress and coping strategies of nurses during the second wave of COVID-19 in the country. A structured self-administered questionnaire captured the biographic characteristics, perceived risk factors for COVID-19, and views on infection control of 286 nurses Data were subjected to descriptive and binomial logistic regression analyses. More than four in every 10 nurses screened positive for higher levels of post-traumatic disorder (PTSD). Self-reported risk for contracting COVID-19 mainly centered on being a health worker and patients’ non-adherence to infection prevention guidelines. Unpreparedness to manage COVID-19 patients, poorer health, and avoidant coping were associated with PTSD. Nurses voiced a need for emotional support and empathy from managers. Emotional, psychological, and debriefing intervention sessions that focus on positive coping strategies to actively address stress are recommended.

Background HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. Methods Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. Results The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. Conclusions This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences. Trial registration South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Background: Insufficient training in infection control and occupational health among healthcare workers (HCWs) in countries with high human immunodeficiency virus (HIV) and tuberculosis (TB) burdens requires attention. We examined the effectiveness of a 1-year Certificate Program in Occupational Health and Infection Control conducted in Free State Province, South Africa in an international partnership to empower HCWs to become change agents to promote workplace-based HIV and TB prevention. Methods: Questionnaires assessing reactions to the program and Knowledge, Attitudes, Skills, and Practices were collected pre-, mid-, and postprogram. Individual interviews, group project evaluations, and participant observation were also conducted. Quantitative data were analyzed using Wilcoxon signed-rank test. Qualitative data were thematically coded and analyzed using the Kirkpatrick framework. Results: Participants recruited (n = 32) were mostly female (81%) and nurses (56%). Pre-to-post-program mean scores improved in knowledge (+12%, p = 0.002) and skills/practices (+14%, p = 0.002). Pre-program attitude scores were high but did not change. Participants felt empowered and demonstrated attitudinal improvements regarding HIV, TB, infection control, and occupational health. Successful projects were indeed implemented. However, participants encountered considerable difficulties in trying to sustain improvement, due largely to lack of pre-existing knowledge and experience, combined with inadequate staffing and insufficient management support. Conclusion: Training is essential to strengthen HCWs' occupational health and infection control knowledge, attitudes, skills, and practices, and workplace-based training programs such as this can yield impressive results. However, the considerable mentorship resources required for such programs and the substantial infrastructural supports needed for implementation and sustainability of improvements in settings without pre-existing experience in such endeavors should not be underestimated. Keywords: capacity building, healthcare workers, HIV infection control, occupational health, tuberculosis

Rationale The HIV and TB co-epidemic has a severe impact on the South African healthcare workforce and health system. HIV- and TB- stigma directed from healthcare workers (HCWs) towards colleagues not only has a negative impact on the mental health and well-being of the HCWs, but has been identified as a barrier to their own health-seeking behaviour. It also increases the strain on the health system due to absenteeism. Objective This cluster-randomised trial tested an intervention to reduce HIV- and TB-stigma among HCWs. The intervention, based on the theory of Diffusion of Innovations consisted of training healthcare workers as change agents in a Social and Behavioural Change Communication workshop to help them change stigmatising attitudes in the workplace. This was supported by a social marketing campaign. Methods Eight hospitals in the Free State province were randomised into intervention and control group in a stratified study design. 652 respondents randomly drawn from the hospitals were surveyed on aspects of HIV and TB stigma once in 2016 and again in 2018. Since the study only used four hospitals per intervention arm, cluster-based summaries were compared when analysing the intervention effect, using the nonparametric Mann-Whitney test. To explore how the intervention worked, 24 qualitative focus groups were conducted following the intervention. Results The quantitative test did not show a significant intervention effect on stigma between intervention and control groups. Qualitative evidence reported new awareness and changed behaviour related to HIV- and TB-stigma among individual HCWs, but a combination of factors including strong social hierarchies in the workplace and the down-scaling of the original version of the intervention seemed to reduce the impact. Conclusion The findings did not indicate a significant intervention effect, but show the potential of using HCWs as change agents to reduce HIV and TB stigma in their local communities.

BACKGROUND AND AIM Given the myriad occupational stressors of nursing itself, plus the challenges of moonlighting, we aimed to investigate the emotional well-being of moonlighting nurses and their work engagement. Well-being was defined by levels of general health, mental health, emotional exhaustion, personal accomplishment, compassion satisfaction and compassion fatigue. DESIGN A cross-sectional descriptive survey (December 2017 to March 2018) at private health care facilities in a Metropolitan Municipality, South Africa. METHODS Two hundred and fifty-one nurses completed self-administered questionnaires, which comprised of validated scales. RESULTS Nurses were at low risk for emotional exhaustion (M=12.8; SD=11.23) and scored high on compassion satisfaction (M=42.34; SD=7.22) and work engagement (M=4.87, SD=1.18). Personal accomplishment (t= 2.535; P

Background Systematic household contact investigation (SHCI) is recommended as an active-case-finding (ACF) strategy to identify individuals at high risk of tuberculosis (TB) infection, in order to enable early detection and treatment. Reluctance to implement SHCI in sub-Saharan African and South African high-burden contexts may stem from uncertainty about the potential yield of this strategy when targeting specific categories of TB index cases. In order to inform and motivate scale-up, this pilot study investigated the effectiveness of SHCI when targeting the World Health Organization’s (WHO) recommended categories of infectious index cases. Method Data were gathered in September and October 2016. Household contacts of infectious TB cases who attended 40 primary health care facilities in Mangaung Metropolitan District were recruited. The categories of TB index cases included 1) children

Background Fear of TB infection is rooted in historical and social memories of the disease, marked by stigma, segregation and exclusion. Healthcare workers (HCWs) face these same fears today, and even seek to hide their TB status when infected. This study sought to investigate factors associated with HCWs fears of acquiring TB while at work, including selected biographic characteristics, TB knowledge, infection control and perceptions that their colleagues stigmatise co-workers with TB/ presumed to have TB. Methods In the Free State Province, South Africa, a representative sample of 882 HCWs from eight hospitals completed self-administered questionnaires on issues related to fear of occupationally acquired TB, infection control, TB knowledge and workplace TB stigma. The data were analysed using descriptive statistics as well as binomial logistic regression. Results Most of the HCWs (67.2%) were concerned about contracting TB at work. Support staff were less likely to worry about acquiring TB than clinical staff (OR = 0.657, P = 0.041). Respondents who indicated that there were inadequate numbers of disposable respirators at work, were 1.6 times more likely to be afraid of contracting TB at work (P = 0.040). With every unit increase on the TB stigma scale, respondents were 1.1 times more likely to fear acquiring TB at work (P = 0.000). Conclusions Being a professional clinical HCW, not having adequate disposable respirators available and seeing/perceiving co-workers stigmatise colleagues with (presumptive) TB were all significantly associated with the fear of occupationally-acquired TB. It is recommended that campaigns to destigmatise TB, as well as appropriate TB infection control education and measures, are necessary to alleviate HCWs fears of acquiring the disease in the workplace. Ultimately this should create a health-enabling working environment, where HCWs are not afraid to function and are free to seek treatment and support when necessary.

Background: Tuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines. Aim: To describe the state of implementation of TB infection control measures in a high-burden metro in South Africa. Setting: The research was undertaken in a high TB- and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), thatamong other services also diagnosed TB. Methods: A cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa. Results: Tuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and noncoughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation ( n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment ( n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers ( n = 18; 33.3%). Conclusion: All levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection.

Background South Africa's protracted battle with the dual epidemic of HIV and TB is well-documented. TB patients who smoke tobacco are often faced by low socio-economic status and alcohol dependence, with poor TB treatment outcomes. This paper reports on findings that inform the feasibility of scaling an intervention based on motivational interviewing and mhealth, delivered by lay health workers (LHWs), towards achieving tobacco and alcohol cessation and improving TB and HIV treatment adherence. Methods A theory-driven, qualitative feasibility study was conducted in the Free State, North-West and Gauteng provinces of South Africa. Thirteen semi-structured interviews were conducted with district, provincial and national TB managers, and nine focus group discussions were conducted with LHWs and TB patients at the study sites. Transcribed data was thematically analysed in NVivo 11 and guided by Normalisation Process Theory. Results The intervention package and its importance were generally understood among participants, though some had difficulty differentiating it from past and current government initiatives (Coherence). The intervention package does not require extensive re-alignment in terms of work roles, and participants were well-aligned to the introduction of LHWs in existing work spaces (Cognitive Participation). Little difficulties were foreseen in different stakeholders working together in adopting new practices, and the intervention was perceived to align well with government policies. It was noted that the LHWs would require extensive training and support (Collective Action). Measuring the effects post-intervention was perceived to possibly be hampered by fragmented health information systems (Reflexive Monitoring). Conclusions The intervention package was suggested to have a fairly high level of feasibility, being well-supported by stakeholders and aligning well with key health system elements. The findings also illustrate the precarious nature of the challenge under focus, and suggest the necessity of a fair amount of sustained support, dynamism and flexibility in different sites for intervention success.

The Life Esidimeni tragedy in South Africa showed that, despite significant global gains in recognizing the salience of integrated public mental health care during the past decade, crucial gaps remain. State and non-state mental health service collaboration is a recognized strategy to increase access to care and optimal use of community resources, but little evidence exist about how it unfolds in low-to middle-income countries. South Africa's Mental Health Policy Framework and Strategic Plan 2013-20 (MHPF) underlines the importance of collaborative public mental health care, though it is unclear how and to what extent this happens. The aim of the study was to explore the extent and nature of state and non-state mental health service collaboration in the Mangaung Metropolitan District, Free State, South Africa. The research involved an equal status, sequential mixed methods design, comprised of social network analysis (SNA) and semi-structured interviews. SNA-structured interviews were conducted with collaborating state and non-state mental health service providers. Semi-structured interviews were conducted with collaborating partners and key stake holders. Descriptive network analyses of the SNA data were performed with Gephi, and thematic analysis of the semi-structured interview data were performed in NVivo. SNA results suggested a fragmented, hospital centric network, with low average density and clustering, and high authority and influence of a specialist psychiatric hospital. Several different types of collaborative interactions emerged, of which housing and treatment adherence a key point of collaboration. Proportional interactions between state and non-state services were low. Qualitative data expanded on these findings, highlighting the range of available mental health services, and pointed to power dynamics as an important consideration in the mental health service network. The fostering of a well-integrated system of care as proposed in the MHPF requires inter-institutional arrangements that include both clinical and social facets of care, and improvements in local governance.

Healthcare workers (HCWs) have increased risks due to continued exposure to patients with infectious diseases, particularly tuberculosis and hepatitis B. This study assessed workplace conditions and practices regarding air- and blood-borne infections in public hospitals in the Free State. Workplace audits were conducted in intensive care, medical wards and casualty departments at three Free State public hospitals. A questionnaire survey was also administered to a targeted 20% stratified quota sample at these facilities. Of the 513 HCWs surveyed, 21.2% reported needle-stick injuries and other body fluid exposure and 19.1% were not adequately protected against hepatitis B. Additionally, 68.3% were never screened for tuberculosis, 54.8% did not wear N95® respirators when needed, only 28.5% washed their gloves and 19.8% did not always wash their hands between caring for different patients. Physicians were at highest risk of needle-stick injuries, were less compliant with hand hygiene, and associated with lowe...

SETTING: Tuberculosis (TB) is the leading cause of death in South Africa, and health care workers (HCWs) are disproportionally affected. The resulting absenteeism strains the already overburdened health system. Although hospital occupational health care units (OHUs) are cost-effective and of crucial importance in tackling the TB epidemic, the fear of being stigmatised by other colleagues might lead HCWs to avoid using OHUs. OBJECTIVE : To investigate whether the perception of TB stigma among colleagues has a negative effect on the willingness to use OHUs for TB services. DESIGN: In the Free State Province, South Africa, a representative sample of 804 HCWs from six hospitals were surveyed on workplace stigma as a predictor for the use of OHUs for TB services. Applying structural equation modelling, we also controlled for exogenous variables. RESULTS : There was a significant negative relationship between the perception of stigmatising attitudes and behaviours among co-workers and the use of OHUs for TB screening (beta - 0.21, P = 0.000), treatment (beta - 0.16, P = 0.001) and isoniazid preventive therapy (beta - 0.17, P = 0.000). CONCLUSION: The negative effect of TB stigma on OHU use among HCWs can impact upon their health and increase hospital costs. This needs to be addressed by interventions combating TB stigma among HCWs in the workplace.

SETTING: Recent evidence indicates that human immunodeficiency virus (HIV) and tuberculosis (TB) related stigma act as a key barrier to the utilisation of associated occupational health services by South African health care workers (HCWs). It also highlights a dearth of appropriate tools to measure HIV and TB stigma among HCWs. OBJECTIVE: To test four scales measuring different aspects of stigma: respondent's external stigma (RES) and others' external stigma (OES) towards TB as well as HIV across different professional categories of HCWs. DESIGN: The current study employs data from a study on HIV and TB stigma among HCWs, a cluster randomised controlled trial for the collection of data among 882 HCWs in the Free State Province of South Africa. Confirmatory factor analyses and structural equation modelling were used to assess the validity and reliability of the scales. RESULTS: All four scales displayed adequate internal construct validity. Subsequent analysis demonstrated that all four scales were metric-invariant, and that the OES scales were even scalar-invariant across patient and support staff groups. The scales displayed good reliability and external construct validity. CONCLUSION: Our results support the use of the scales developed to measure TB and HIV stigma among HCWs. Further research is, however, needed to fine tune the instruments and test them across different resource-limited countries.

Background Health education is important to empower patients and encourage their contribution towards tuberculosis (TB) control. In South Africa, health education activities are integrated into services provided at the primary health care (PHC) level. This study was conducted in a high TB burden metropolitan area in South Africa. The objective was to assess TB-related knowledge, attitudes and infection control practices of patients attending PHC facilities. Methods In September and October 2015, a cross-sectional survey using fieldworker-administered questionnaires was conducted among patients older than 17 years attending 40 PHC facilities in the Mangaung Metropolitan. Convenience sampling was used to select patients. Participation in the study was voluntary. Descriptive, inferential and multivariate logistic regression analyses were performed. Statistical significance was considered at alpha

Background South Africa did not meet the MDG targets to reduce TB prevalence and mortality by 50% by 2015, and the TB cure rate remains below the WHO target of 85%. TB incidence in the country is largely fuelled by the HIV epidemic, and co-infected patients are more likely to have unsuccessful TB treatment outcomes. This paper analyses the demographic and clinical characteristics of new TB patients with unsuccessful treatment outcomes, as well as factors associated with unsuccessful treatment outcomes for HIV co-infected patients. Methods A cross-sectional retrospective record review of routinely collected data for new TB cases registered in the Free State provincial electronic TB database between 2009 and 2012. The outcome variable, unsuccessful treatment, was defined as cases ≥15 years that ‘died’, ‘failed’ or ‘defaulted’ as the recorded treatment outcome. The data were subjected to descriptive and logistic regression analyses. Results From 2009 to 2012 there were 66,940 new TB cases among persons ≥15 years (with a recorded TB treatment outcome), of these 61% were co-infected with HIV. Unsuccessful TB treatment outcomes were recorded for 24.5% of co-infected cases and 15.3% of HIV-negative cases. In 2009, co-infected cases were 2.35 times more at risk for an unsuccessful TB treatment outcome (OR: 2.35; CI: 2.06-2.69); this figure decreased to 1.8 times by 2012 (OR: 1.80; CI: 1.63-1.99). Among the co-infected cases, main risk factors for unsuccessful treatment outcomes were: ≥ 65 years (AOR: 1.71; CI: 1.25-2.35); receiving treatment in healthcare facilities in District D (AOR: 1.15; CI 1.05-1.28); and taking CPT (and not ART) (AOR: 1.28; CI: 1.05-1.57). Females (AOR: 0.93; CI: 0.88-0.99) and cases with a CD4 count >350 (AOR: 0.40; CI: 0.36-0.44) were less likely to have an unsuccessful treatment outcome. Conclusions The importance of TB-HIV/AIDS treatment integration is evident as co-infected patients on both ART and CPT, and those who have a higher CD4 count are less likely to have an unsuccessful TB treatment outcome. Furthermore, co-infected patients who require more programmatic attention are older people and males. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2406-x) contains supplementary material, which is available to authorized users.

Tuberculosis (TB) continues to challenge global health systems, especially in South Africa. Nurses are especially vulnerable to TB exposure, because of their prolonged front-line contact with infected patients-especially in primary health care (PHC) clinics. Their infection control practices, influenced by key factors such as knowledge and attitudes towards TB prevention, become an important consideration. The aim of the study was to (1) describe the TB prevention knowledge, attitudes, and practices of PHC nurses in a South African district and (2) explore moderating factors on TB prevention practices.A cross-sectional survey was undertaken at all 41 PHC facilities in Mangaung Metropolitan district, Free State province, South Africa, using self-administered questionnaires. Captured data were analysed to yield descriptive and multivariate statistics.Results suggest several instances of inadequate TB prevention knowledge, attitudes, and practices. Good TB practice was predicted by TB attitudes and knowledge, and the relationship between TB prevention knowledge and practices was not moderated by training, attitudes, or nurse category.Results echo previous indications that nurses often do not exhibit the desired knowledge, attitudes, and practices required to adequately protect themselves and others against TB and suggest further exploration towards understanding the influences on TB prevention practice among nurses.

Setting Twenty-eight public hospitals in the Free State Province, South Africa. Objective To examine the association between tuberculosis (TB) infection control (IC) scores in Free State hospitals and the incidence of TB disease among health care workers (HCWs) in 2012. Design A cross-sectional survey and mixed-methods analysis of TB IC policies, practices and infrastructure using a comprehensive, 83-item IC audit and observation tool. Results As the total IC score increased, the probability of TB in an HCW at that hospital decreased. When adjusted for other covariates in multivariate analysis, if the total score of a hospital increased by one unit, the odds of an HCW having TB decreased by 4.9% (95%CI 0.9-8.8). Significant associations were also seen for the personal protective equipment (PPE) score, where odds decreased by 11.5% (95%CI 1.8-20.1) for each unit increase in score. Administrative score, environmental score and miscellaneous score were not statistically significant in the multivariate model. Conclusions These findings reaffirm that overall IC and PPE are essential to protect HCWs from acquiring TB. More attention to TB IC is required to protect the health care workforce and to stop the South African TB epidemic.

Recent WHO/ILO/UNAIDS guidelines recommend priority access to HIV services for health care workers (HCWs), in order to retain and support HCWs, especially those at risk of occupationally acquired tuberculosis (TB). The purpose of this study was to identify barriers to uptake of HIV counselling and testing (HCT) services for HCWs receiving HCT within occupational health units (OHUs). Questions were included within a larger occupational health survey of a 20% quota sample of HCWs from three public hospitals in Free State Province, South Africa. Of the 978 respondents, nearly 65% believed that their co-workers would not want to know their HIV status. Barriers to accessing HCT at the OHU included ambiguity over whether antiretroviral treatment was available at the OHU (only 51.1% knew), or whether TB treatment was available (55.5% knew). Nearly 40% of respondents perceived that stigma as a barrier. When controlling for age and race, the odds of perceiving HIV stigma in the workplace among patient-care health care workers (PCHWs) were 2.4 times that for non-PCHWs [95% confidence interval (CI): 1.80-3.15]. Of the 692 survey respondents who indicated a reason for not using HIV services at the OHU, 38.9% felt that confidentiality was the reason cited. Among PCHWs, the adjusted odds of expressing concern that confidentiality may not be maintained in the OHU were 2.4 times (95% CI: 1.8-3.2) that of non-PCHWs and were higher among Black [odds ratio (OR): 2.7, CI: 1.7-4.2] and Coloured HCWs (OR: 3.0, 95% CI: 1.6-5.6) as compared to White HCWs, suggesting that stigma and confidentiality concerns are still barriers to uptake of HCT. Campaigns to improve awareness of HCT and TB services offered in the OHUs, address stigma and ensure that the workforce is aware of the confidentiality provisions that are in place are warranted.

Background : Community-based cluster-randomized controlled trials (RCTs) are increasingly being conducted to address pressing global health concerns. Preparations for clinical trials are well-described, as are the steps for multi-component health service trials. However, guidance is lacking for addressing the ethical and logistic challenges in (cluster) RCTs of population health interventions in low- and middle-income countries. Objective : We aimed to identify the factors that population health researchers must explicitly consider when planning RCTs within North–South partnerships. Design : We reviewed our experiences and identified key ethical and logistic issues encountered during the pre-trial phase of a recently implemented RCT. This trial aimed to improve tuberculosis (TB) and Human Immunodeficiency Virus (HIV) prevention and care for health workers by enhancing workplace assessment capability, addressing concerns about confidentiality and stigma, and providing onsite counseling, testing, and treatment. An iterative framework was used to synthesize this analysis with lessons taken from other studies. Results : The checklist of critical factors was grouped into eight categories: 1) Building trust and shared ownership; 2) Conducting feasibility studies throughout the process; 3) Building capacity; 4) Creating an appropriate information system; 5) Conducting pilot studies; 6) Securing stakeholder support, with a view to scale-up; 7) Continuously refining methodological rigor; and 8) Explicitly addressing all ethical issues both at the start and continuously as they arise. Conclusion : Researchers should allow for the significant investment of time and resources required for successful implementation of population health RCTs within North–South collaborations, recognize the iterative nature of the process, and be prepared to revise protocols as challenges emerge. Keywords : cluster-randomized controlled trials; population health; pre-trial considerations; receptor capacity; feasibility studies; pilot testing; building relationships; ethical issues; iterative process ( Published: 2 May 2014) Citation : Glob Health Action 2014, 7 : 23594 - http://dx.doi.org/10.3402/gha.v7.23594

South Africa has one of the highest incidence of tuberculosis in the world, which can partly be attributed to poor infection control in public healthcare (PHC) facilities. The aim of the study was to explore the extent of tuberculosis and infection control training, as well as facility-level managerial, administrative, environmental and personal protection, infection control measures, at PHC facilities. Cross-sectional surveys were conducted at 127 PHC facilities across three districts of South Africa. Data collection was achieved through interviews with tuberculosis nurses, observations of infection control practices and a review of the clinic records. Univariate analysis was performed using SPSS® version 17. Limited implementation of World Health Organization infection control measures was identifed. In terms of facility controls, 43.3% of the clinics did not have an infection control committee and 40.9% did not have a clinic specifc infection control plan. In terms of administrative controls, 94.5% of...

Background. The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting. Methods. The current pilot study aimed to develop and test a range of scales measuring different aspects of stigmainternal and external stigma toward tuberculosis as well as HIVin a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa. Results. Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity. Conclusions. The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

There is good progress with the implementation of South Africa's antiretroviral treatment program. The country, however, faces human resource shortages that could be addressed through appropriate task shifting. During 2009, we studied task shifting from nurses to community health workers (CHWs) for HIV treatment and care at 12 primary health-care clinics in Free State Province, South Africa. We found inefficiency in nurse deployment, and nurses spent considerable time on training, counseling, and administrative tasks that could be shifted to CHWs. Such a shift will require the South African Ministry of Health to recognize CHWs formally in the health system.

Christo Heunis, PhD, is an Associate Professor, Centre for Health Systems ResearchD and Research Associate, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Gladys Kigozi, MSc, is a Junior Researcher and Doctoral Student, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Michelle Engelbrecht, PhD, is a Senior Researcher, Centre for Health Systems Research&Development, University of the Free State, Bloemfontein. Yolisa Tsibolane, BA Cur, is a Senior Manager, TB Management Programme, Free State Department of Health, Bloemfontein. Sonja van der Merwe, B Soc Sc, is an Assistant Director, TB Programme Surveillance, Free State Department of Health, Bloemfontein. Seipati Motlhanke, BA Cur, is an Assistant Director, TB-HIV/AIDS Programme Integration, Free State Department of Health, Bloemfontein. Reliable data are a prerequisite for evidence-based decision making in health care policy (AbouZahr & Boerma, 2005). Accurate measurement is crucial in evaluating epidemic trends, as well as in planning and monitoring disease-specific service provision. On the basis of a systematic review of descriptive and comparative studies and previous reviews of health information technologies, Chaudhry et al. (2006) demonstrated the efficacy of information gathered using health information technologies, such as electronic health records, to improve both quality and efficiency of health care. Sound data are especially vital for the success of large-scale public sector health programs in developing countries where limited human and financial resources require their optimal use (Fraser et al., 2005). Lippeveld (in AbouZahr & Boerma, 2005) defined a health information system (HIS) as an “integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research” (p. 579). HISs are especially important when responses need to be urgent, as in the case of epidemic diseases such as

Aim Tuberculosis (TB) continues to challenge global health systems, especially in South Africa. Nurses are especially vulnerable to TB exposure, because of their prolonged front-line contact with infected patients-especially in primary health care (PHC) clinics. Their infection control practices, influenced by key factors such as knowledge and attitudes towards TB prevention, become an important consideration. The aim of the study was to (1) describe the TB prevention knowledge, attitudes, and practices of PHC nurses in a South African district and (2) explore moderating factors on TB prevention practices. Methods A cross-sectional survey was undertaken at all 41 PHC facilities in Mangaung Metropolitan district, Free State province, South Africa, using self-administered questionnaires. Captured data were analysed to yield descriptive and multivariate statistics. Results Results suggest several instances of inadequate TB prevention knowledge, attitudes, and practices. Good TB practice was predicted by TB attitudes and knowledge, and the relationship between TB prevention knowledge and practices was not moderated by training, attitudes, or nurse category. Conclusion Results echo previous indications that nurses often do not exhibit the desired knowledge, attitudes, and practices required to adequately protect themselves and others against TB and suggest further exploration towards understanding the influences on TB prevention practice among nurses.

This article describes the distribution and management of drugs and supplies in scaling up access to public sector antiretroviral treatment (ART) in a middle-income country. More specifically, a case study of the Free State Province of South Africa is presented focusing on: the mobilisation and training of pharmaceutical staff for ART, processes related to the ordering, distribution and storage of medicines, continuity of ART supplies and the impact of ART delivery on other drugs and supplies. Data were obtained from longitudinal research conducted between April 2004 and July 2006 comprising three surveys of the first 20 health facilities providing ART in the province, key informant interviews and observations made of provincial ART Task Team meetings. The supply of ART in the Province was managed through the existing drug supply system but with special mechanisms to ensure integrity of ART supplies and security of stock within the existing supply system. Initial hiccups in the procurement of antiretroviral (ARV) drugs for South Africa (a national function) caused delays in putting patients on ART, although these supply problems were short-lived. At provincial level, not all pharmacist posts created for the programme were filled, and pharmacists working in the rest of the health system were subsequently trained to take on ART programme functions. Electronic systems were not established at all service sites, which in part contributed to delays in the delivery of drugs and supplies to more peripheral units. Adequate space to safely store ARV drugs remained problematic. The introduction of the ART programme did not create disruptions in the supply of non-ART essential drugs, which in fact improved over the period of observation. It is concluded that despite some process, human resource and infrastructural challenges, the drug management system in the Free State succeeded in incorporating public sector ART within its existing drug distribution network and functions, at least in the initial phase of scale up.

In South Africa, nurses form the backbone of the primary health care (PHC) system. Their well-being is, therefore, of paramount importance in the effective provisioning of health services. This paper explores predictors and levels of burnout experienced by professional nurses working in PHC facilities in the Free State. The sample comprised 182 nurses working in facilities rendering antiretroviral treatment (ART) services and 361 nurses working in facilities not rendering ART. Respondents completed a series of standardised instruments. Descriptive statistics were calculated and stepwise regression analysis performed to investigate the relative contribution of various stressors to the variance in burnout. High levels of burnout were identified. Availability of resources, workload and conflict at work explain 21% of the variance in the level of emotional exhaustion reported by the professional nurses. To a large degree, the results indicate that the well-being of professional nurses is significantly affected by chronic work overload and occupational stress.

Fear of stigma and discrimination among health care workers (HCWs) in South African hospitals is thought to be a major factor in the high rates of HIV and tuberculosis infection experienced in the health care workforce. The aim of the current study is to inform the development of a stigma reduction intervention in the context of a large multicomponent trial. We analysed relevant results of four feasibility studies conducted in the lead up to the trial. Our findings suggest that a stigma reduction campaign must address community and structural level drivers of stigma, in addition to individual level concerns, through a participatory and iterative approach. Importantly, stigma reduction must not only be embedded in the institutional management of HCWs but also be attentive to the localised needs of HCWs themselves.

Africa is a vast continent, divided into the sub-Saharan south and the Arab north. The diverse geographic, cultural, and societal makeup explains the varying morbidity and mortality patterns, and shapes the health-related beliefs, behaviors, and practices of Africans. Socioeconomically, the least developed countries in the world are in Africa, implying huge backlogs in living standards and a widespread lack of health services. Consequently, Africans generally fare poorly on core health indicators (infant, under-5, and maternal mortality), and are heavily burdened by communicable diseases. Increasing globalization, Westernization, and urbanization have changed the living conditions and lifestyles of Africans, with concomitant increases in non-communicable and lifestyle diseases. Over centuries, African health systems have been shaped by multiple factors. Western-type health care was introduced by waves of Europeans settlers and missionaries. However, Africans strongly maintained traditional ways of explaining, diagnosing, and treating disease. From this emerged mixed health systems, variably containing elements of traditional and allopathic care, and delivered in free-market (private) and state-provided settings. Western-type care remains in many African countries weakly developed and urban-concentrated. Amid chronic shortages of resources, new care models are emerging. The general availability of African traditional healers means that large proportions of Africans prefer African traditional healing over allopathic medicine. Keywords: Africa; disease; health; health care