Projects Collaborative projects with UWC’s Department of Dietetics

This is a listing of projects undertaken in 2019 and 2020 – many of which have resulted in substantial publications listed at the end of this report. They were implemented by the staff of the School of Public Health (SOPH), often in collaboration with partners whose organisations are named wherever this is the case. Only the names of the SOPH staff, students (both current and alumni), NRF interns, post-doctoral fellows and the School’s extraordinary professors are named here, however.

COVID-19 PROJECTS

A number of projects were undertaken in 2020, following the advent of the COVID-19 pandemic. These were all parts of larger international studies and included topics such as food and cooking, mental health of students and of the general population, the experiences of community health workers and the use of cloth masks.

• Cloth face mask use during COVID-19 crisis: A multi-country on-line cross-sectional study among adult runners

Anam Nyembezi, Zandile Mchiza, Sunday Onagbiye,

Timothy Makubuya This multi-country study was conducted between July and September 2020 in the United States and South Africa. These countries were selected as COVID-19 community transmission was still occurring and there were still active cases at the time.

Undertaken in collaboration with the University of Missouri-St. Louis (USA) and the UWC Department of Sport, Recreation and Exercise Science, the aim was to assess adult runners’ knowledge, attitudes, and practices regarding the use of cloth face masks/ coverings to prevent the spread of COVID-19. A total of 372 participants were conveniently invited using Facebook and WhatsApp, 294 being from South Africa and 78 from the USA. The majority (78%) belonged to a running club and 91% cited fitness as the reason for running/jogging. More than half (53%) were screened, 24% were tested and 15% tested positive for COVID-19. The study showed 94% of the participants had accurate knowledge and 86% positive attitudes regarding COVID-19. 61% reported always wearing a mask when running, with 60% often using buffs. The percentage of those who incorrectly used the mask was low; never covered mouth (12%) and nose (16%), lowered mask (13%), never washed mask (3%) and hands after removing mask (4%). The majority (67%) reported that sometimes they saw other runners not wearing a mask, not covering mouth (66%) and nose (64%). The perceived risk of contracting COVID-19 among the general population was higher (47%) compared with doing so from other runners (31%).

• Corona cooking

Zandile Mchiza A partnership between UWC, the University of Antwerp and Katholieke Universiteit (KU) Leuven, this project explored the changes in shopping, cooking and food consumption that have occurred globally during the COVID-19 lockdown crisis. Forced to stay home, with restaurants in many countries closed, some people have resorted to ordering in prepared foods while others embarked on learning how to cook for the first time. Anecdotal evidence that many people have engaged in cooking less healthy meals has resulted in a major concern that overconsumption of these foods may affect the health of people globally. The project produced a report - Impact of the COVID-19 pandemic on Food Literacy: A multicountry observational study in 38 countries (De Backer et al., 2021) – and four webinar presentations: COVID 19 lockdown mental health consequences and changes with respect to shopping, food preparation and consumption among South Africans: Facebook survey. These were organised by the SASUF (South Africa Sweden University Forum) consortium, the University of Johannesburg’s Food Evolution Research Lab, UWC’s Health Sciences and the South African Association of Family Ecology and Consumer Science (SAAFECS). The project was undertaken with financial support from the Research Foundation Flanders, Flanders Innovation & Entrepreneurship.

• The impact of the COVID-19 pandemic on the mental health and wellbeing of the South African population

Hanani Tabana In May 2020 an on-line survey was administered to adults 18 years and older living in South Africa. The study measured the prevalence and severity of psychological distress among the general population during COVID-19 containment measures, and aimed to establish longitudinal estimates of the impact on mental health and psychological distress of COVID-19 and the different containment measures applied during various phases of the pandemic.

The study was undertaken in partnership with the UWC Division for Postgraduate Studies, the

University of Cape Town and the University of Antwerp (Belgium).

• The experiences of community health workers affected by COVID-19 during the outbreak in

South Africa: A qualitative study

Lungiswa Tsolekile, Uta Lehmann

In 2020 SOPH began a review of the role of community-based services during the COVID-19 pandemic in the Western Cape Province, as part of a wider review of public health responses led by the provincial health department. Linked to the SAMRC HSSU Research Unit, this work will be part of a larger study to be conducted in 2021 with community

health workers (CHWs) who are employed by nongovernmental organisations in Cape Town, as well as the nurse co-ordinators and managers who work with them. Based on the lived experiences of CHWs working as frontline healthcare workers during the COVID-19 outbreak in Cape Town, the larger study will explore the meaning and impact of COVID-19 and its care and outbreak control measures. The CHW study is part of a larger project – led by the University of Cape Town in collaboration with Stellenbosch University and the Western Cape Department of Health – that seeks to obtain data on the plurality of experiences, practices, and ideas. These will be captured through an in-depth inquiry with four key stakeholder groups, each comprising a broad spectrum of participants, namely public health responders, frontline healthcare workers, community action networks and people with COVID-19.

• An examination of the impact of the COVID-19 outbreak on wellbeing in higher education students

Lucia Knight, Anton Delport A survey was conducted in mid-2020 with a view to understanding the wellbeing of higher education students in various countries. It focused on changes resulting from the COVID-19 outbreak and the measures that were implemented by governments and higher education institutions in response to the epidemic; the effects of different institutional and national policy contexts were also investigated. The study included an assessment of how students’ living conditions and workloads had changed and how these related to stress levels and impacts on mental health, and health behaviour during the COVID-19 outbreak; it also looked at the various mediating roles of other stressors, social support, and COVID-19 knowledge.

This research was undertaken in collaboration with the University of Antwerp (Belgium) and was part of a global study. The final report will be available in late 2021.

Demographic profiling of postgraduate students in the SOPH

Verona Mathews, Corinne Carolissen To date, no investigation has been conducted to determine the profile of students enrolling in the postgraduate programmes of the SOPH. The aim of this study was, therefore, to determine the demographic profile of the postgraduate public health students and their motivations for pursuing a distance learning postgraduate qualification in public health. It sought to contribute to the body of knowledge of lifelong learning and adult education.

Strengthening capacity for research, education, policy support, advocacy and networking of the partners in the field of human and animal health

Helen Schneider, Woldekidan Amde, Asha George, Uta Lehmann, Hazel Bradley, Ziyanda Mwanda, Carnita Ernest, Teresa de Lima In 2017 the SOPH renewed its partnership with the Institute of Tropical Medicine (ITM), Antwerp in collaboration with the universities of Pretoria and Cape Town. The partnership secured a new five-year grant from the Belgian Development Co-operation to strengthen the partners’ capacity for research, education, policy support, advocacy and networking. SOPH’s key focus with ITM has been on strengthening South-based knowledge generation based on ‘embedded country’ health policy and systems research (HPSR) and education. The project involves a focus on three synergistic strategies, namely • doctoral and post-doctoral level training and curriculum development; • South-South networking; and • collaborative HPSR and supervision. In 2019 and 2020 the School consolidated our predoctoral, doctoral and post-doctoral programmes, providing for a range of flexible modalities of support to enhance student and supervisor capacity and experience through the various phases of the PhD. We also intensified peer support and networking opportunities through bi-monthly webinars, established an on-line writing camp and ran an induction programme for 13 new enrolees during the course of 2020. (See page 7 on the School’s PhD Programme.) We have also been able to deepen the collaboration (teaching, research, supervision) between ITM and UWC in a few critical areas: health system governance, pharmaceutical public health and short course development. We launched a jointly run ITM-UWC on-line module in Pharmaceutical Public Health and Management, which constitutes a third MPH module in the Pharmaceutical Public Health area of specialisation at SOPH.

Academic literacies embedded within the Public Health curricula at the School of Public Health, University of the Western Cape

Nikki Schaay, Hazel Bradley, Arona Dison, Jenny Birkett Initiated in 2018, this project is being undertaken in collaboration with the UWC Writing Centre (Directorate of Teaching and Learning) with the aim of identifying academic literacies required by public health professionals, both as public health postgraduate students and in relation to their professional practice. It has included analysing how academic literacies are embedded in, and aligned within, the curriculum of the SOPH’s Postgraduate Diploma (PGD) and Master of

Public Health (MPH) qualifications, as well as exploring the roles played by the various supports offered by the School in developing the academic literacies of these students. Rich data from participatory workshops and qualitative interviews with SOPH students and academics will inform the School’s future e-learning and teaching practices.

Human Resources for Health Leadership and Management course

Uta Lehmann, Woldekidan Amde SOPH is one of four academic institutions in an academic consortium contracted by the WHO Workforce Department to develop prototype curricula for training in Human Resources for Health (HRH) leadership which will contribute to the implementation of the Global Health Workforce Strategy. This comprises developing a Master programme, a one-month Diploma course and a two-week executive course, plus associated training materials, to be used internationally. The design will allow for the inclusion of individual modules into postgraduate training programmes and continuing education courses. Co-ordinated by Universidade Nova de Lisboa (Portugal), the consortium comprises the • Instituto de Higiene e Medicina Tropical(Portugal),

WHO Collaborating Centre on Health Workforce Policy and Planning; • Semmelweis University (Hungary) - Health Services Management Training Centre, WHO Collaborating Centre on Human Resources for Health Development; • Universidade do Estado do Rio de Janeiro (Brazil) - Instituto de Medicina Social, WHO Collaborating

Centre for Health Workforce Planning and Information; and • SOPH which is the WHO Collaborating Centre for Research and Training in Human Resources.

Supporting community health workers through interprofessional learning

Thandi Puoane, Lungiswa Tsolekile, Peter Delobelle This project aims to develops a strategy of interprofessional learning which will support and strengthen community health workers (CHWs) in preventing non-communicable diseases (NCDs) in South Africa. While most CHWs are volunteers with limited training, they are becoming an important part of interdisciplinary healthcare teams in the community. Universities have a prominent and important task in supporting CHWs by sharing knowledge and expertise and contributing to their training and empowerment. This project therefore focuses on developing an overall model to provide standardised training for CHWs, resulting in betterprepared health workers. This is being undertaken through a mutual approach in which universities and CHWs may learn with, from and about each other – focussing on the design of an interprofessional model for co-operation between CHWs and students, researchers, lecturers and other stakeholders. The project is funded by VLIR-UOS (Belgium) and is being undertaken in collaboration with the VIVES University of Applied Sciences, Department of Health Care (Belgium), and four South African universities: UWC Interprofessional Education Unit; University of Venda School of Health Sciences, Department of Public Health; University of Free State, Faculty of Health Sciences, School of Nursing; and University of Cape Town, Chronic Diseases Initiative for Africa.

Monitoring and evaluating the Human Resources for Health – challenges and requirements for an information system

Verona Mathews, Calsey Carolissen There is a dearth of reliable and up-to-date information on monitoring and evaluating human resources for health (HRH) in low- and middle-income countries, especially in South Africa. This study is identifying the challenges in monitoring and evaluating HRH, and is assessing the types of evidence produced, with a view to providing a baseline for the development of a monitoring and evaluation framework for the country’s national health system. This project has been supported by UWC Senate Research Funding.

Scholarly health informatics learning

Verona Mathews, Corinne Carolissen The Millennium Development Goals, and now the Sustainable Development Goals – as well as the WHO’s efforts to promote measurement of country-level health indicators – has underscored the need for students of public health, information systems and information technology to be able to manage and interpret large data sets. The main goal of this project was to increase the quality and relevance of education in health information systems at the universities of Oslo and the Western Cape, and at Nelson Mandela University. This was done through developing joint educational material on global health information systems, supporting student mobility and fostering collaboration between academic institutions. The project was supported through a four-year grant from the Norwegian Centre for International Co-operation in Education (SIU), and was undertaken in collaboration with the Norwegian Institute of Public Health and the Health Information Systems Program, South Africa (HISP-SA).

A people-centred approach through self-management and reciprocal learning for the prevention and management of type 2 diabetes (SMART2D)

Thandi Puoane, David Sanders, Peter Delobelle, Lungiswa Tsolekile, Mark Spires, Mariam Hassen, Kululwa Ndayi, Tshilidzi Manuga, Boniswa Mphiti, Khumbula Ndibaza, Kholiswa Mphiti, Sandile Luke, Sunday Onagbiye Launched in 2015, SMART2D explored new interventions for addressing the growing burden of type 2 diabetes in high-, middle- and low income countries. Based on reports from the formative research (led by SOPH), an intervention design was implemented. During 2017 and 2018, 584 study participants were enrolled, of whom half were recruited for the intervention arm and half for the control arm. Study participants in the intervention arm were assigned to community health workers for individual follow-up and attended structured peer-led support groups as part of the intervention. Participants in the control group received usual care. In 2019, process and end-line evaluations were conducted. To date, key outputs have included two site-specific (South African) articles based on formative research; and six consortium-based articles published in peerreviewed journals; several oral / poster presentations at local and international conferences; and one PhD graduation (Mark Spires – who now works at the City University of London). SMART2D is an EU H2020-funded multi-centre study. The South African research has been supported through close collaboration with The Caring Network in Khayelitsha and the Chronic Diseases Initiative for Africa (CDIA) at the University of Cape Town.

Sivile Senza: Adapting the Diabetes Prevention Programme for a developing world context

Thandi Puoane, Lungiswa Tsolekile, Mariam Hassen, Asiphe Ketelo, Kenneth Mulalo, Cynthia Paka, Rivalani Derrick Chauke, Smart Mabweazara, Hanani Tabana The overall purpose of the Sivile Senza Lifestyle Africa project is to adapt the Diabetes Prevention Programme (DPP) – a lifestyle modification intervention used in many countries – for delivery in a developing world setting and to evaluate its feasibility and effectiveness in an urban community in South Africa. The project’s official launch in 2018 followed an initial phase in 2017 during which materials were adapted for local use through collaborative work with the Children’s Mercy Hospital (USA), the University of Cape Town and the South African Christian Leadership Association Health Project (SACLA). A significant adaptation was to shift the mode of delivery to support groups, known as health clubs, run by community health workers. In what is effectively the third year of Sivile Senza – meaning ‘We have heard, now we can do’ – the project undertook a randomised trial with about 60 existing health clubs, taking baseline measurements and starting the intervention. In early 2019 data from the first group of clubs, along with baseline data for the control group of clubs, were collected to assess the effect of the intervention. The National Institutes of Health (NIH) funds the project through the Children’s Mercy Hospital.

SINAKO: Households in HIV care. Developing and testing an intervention to capitalise on the intermediate role of the household in community support for chronic HIV care

Lucia Knight, Kenneth Mulalo, Anton Delport, Neo Sematlane, Tanyaradzwa Dube, Anathi Qina with fieldstaff: Nceba Phike, Esihle Nyalambisa, Boniswa Jwili, Eleanore Francis, Sandile Luke, Kholiswa Mphiti Michelle Odendaal Current research on support for people living with HIV has focused on community-level (community health workers - CHWs) and the individual (the patient), leaving out the family/household level to which the individual is closely connected, especially in the South African context. Working closely with colleagues at the University of Antwerp, this four-year project, begun in 2018, is investigating the potential mediating role of the household in chronic HIV care in South Africa. The study is framed within the Individual-HouseholdCommunity model for comprehensive HIV research in high prevalence, resource-limited settings. It includes developing and testing – in a cluster randomised controlled trial (RCT) – a household intervention to stimulate HIV competence levels and create HIV competent households. The intention is that this optimises the impact of CHWs’ support on individual antiretroviral treatment (ART) outcomes. In addition, a qualitative study to assess the acceptability of the intervention is being undertaken. As the RCT was halted in 2020 due to COVID-19, telephonic follow-up was conducted to collect both quantitative and qualitative data to explore the impacts of COVID-19, lockdown and the situation in 2020 on the HIV-positive respondents enrolled in the original study.

Data are being analysed and will be published in late 2021, when we also hope to start the RCT component of the project again. The project is being undertaken in collaboration with TB/HIV Care and the University of Antwerp (with joint supervision of participating PhD students). It is supported by a number of donors including the Flemish Interuniversity Council (VLIR-UOS), Research Foundation-Flanders (Belgium) and the South African National Research Foundation.

Improving adherence, retention in care and treatment outcomes for adolescents in the Western Cape Metropole

Brian van Wyk, Ebrahim Kriel, Zaida Orth, Ferdinand Mukumbang, Shelley Vickerman, Shabaana Osman With respect to adherence and retention in care, adolescents (10-19 years) on antiretroviral therapy (ART) are doing comparably worse than adults and children. Within this study, it is hypothesised that, in addition to the well-known challenges with long-term adherence related to chronic conditions, the particular reasons for poor treatment outcomes for adolescents may be related to a lack of psycho-social support and transition guidance from paediatric to adult HIV programmes. The primary aim of the study is to develop guidelines to support adolescents living with HIV (ALHIV) to achieve and sustain improved treatment outcomes (viral load suppression). Our quantitative analysis found low rates of viral load suppression and diminishing retention in care during the first two years after being initiated on ART. Qualitative findings from three research sites indicate that adherence and retention in care remain challenges for ALHIV as well as health care providers. Current interventions to promote adherence – youth clubs and family clinic – hold promise, but at present fall short of meeting the psychosocial needs of ALHIV. Begun in 2018, this three-year project is undertaken in partnership with the Western Cape Provincial Government Department of Health and the University of Missouri-Columbia. It is supported through grants from UWC Senate Research Funding, a self-initiated research grant from the South African Medical Research Council and Cape Higher Education Consortium/Western Cape Government Innovation fund, as well as the University of Missouri-South Africa Education Program and a University of Missouri Catalyst research grant.

The effects of violence and crime on youth access to HIV and sexual and reproductive health care delivery in violence- and crime-vulnerable suburbs in Cape Town

Di Cooper, Nomazizi Cishe, Nomfundo Cishe, Ntobeko Ngwagi, Michelle Odendaal Completed in 2020, this project sought to understand the mechanisms employed by youth and public sector primary healthcare providers to cope with the impact of endemic violence on youth access to HIV services in violence-andcrime vulnerable suburbs in Cape Town. It also explored which initiatives may be helpful in addressing these challenges, relevant for both South Africa as well as other contexts with endemic urban violence. The in-depth interviews with healthcare providers revealed that the effects of crime and violence impacted on providers at the level of their workplace and within the surrounding communities; and identified levels of resilience. Findings from interviews with youth attending health services revealed fear of encountering crime and violence on their way to visit health services as hindering their access. Despite this, most youth reported devising strategies to access health service when they needed to. The project resulted in a number of publications – like an article in the Journal for Advanced Nursing – and engagements with stakeholders to share findings. The project was funded by the South African Medical Research Council and a small seed grant from the University of Essex.

Collaborative partnerships addressing the effects of urban violence on youth access to health services in South Africa and Brazil

Di Cooper, Asha George The aim of the project was to improve understandings of the effects that urban violence may have on hindering or delaying youth access to sexual and reproductive healthcare and trauma services. Possible context-specific health system interventions to address barriers were identified through stakeholder engagement. This project built on previous exploratory research conducted in two suburbs of Cape Town with high levels of violence that had focused on the impact of violence on youth access to HIV care (see above). Continuing this work with the University of Essex, this project expands its focus geographically by collaborating with colleagues at Universidade Estadual de Campinas (UNICAMP) São Paulo at the Universidade Federal do Rio Grande do Sul (UFRGS) in Brazil. It has broadened the healthcare focus to explore the impact of violence on youth access to sexual and reproductive healthcare and trauma services. It is supported through an NIHR (UK) Global HPSR Development Award.

Improving adolescent sexual and reproductive health (SRH): The influence of early adolescent gender socialisation on later SRH. A South AfricanFlemish study

Di Cooper, Lucia Knight, Suraya Mohamed, Hanani Tabana, Ntobeko Ngwagi, Michelle Odendaal, Mamothena Mothupi This cross-sectional research study sought to understand how gender norms – including those related to sexual and gender diversity – evolve and develop during the first years of adolescence (12-14 years); and to assess the influence of gender norms on adolescents’ sexual and reproductive health (SRH) and access to health services. By early March 2020, a survey had been completed by 569 of an intended sample of 900 learners (aged 12-14 years) in 12 sampled public sector schools in the greater Cape Town – after which data collection had to be stopped due to the COVID-19 pandemic. Initial findings indicate that

they will contribute to improved understanding of the links between adolescent gender norms and SRH. Our ability to directly disseminate information on the findings has been severely constrained by the closure of schools. Nonetheless in early 2020 we disseminated briefing documents of the study’s interim results to stakeholders – including policy makers and managers in the departments of Education and Health; to teachers and learners in schools and to parents /caregivers. Findings are being published in the Journal of Adolescent Health in 2021 and further articles are being prepared for submission to peer-reviewed journals. This has been a collaborative study with the International Centre for Reproductive Health at Ghent University, Belgium. In addition, the project links to the 15-country Global Early Adolescent Study led by Johns Hopkins University, and has research arms in Cape Town and urban areas of Flanders, Belgium. The team has also participated actively in the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER). The SOPH component of this study was supported by a grant from the South African National Research Foundation awarded as part of a Flemish (FWO)/South African Research Collaboration Programme.

Understanding the intersections between mental health wellbeing, HIV and adolescent pregnancy: A knowledge production and systems study

Hanani Tabana, Martina Lembani, Suraya Mohamed, Di Cooper The overall aim of this research was to explore the understandings and experiences of pregnant and postpartum adolescents aged 15-19 in selected facilities in Mpumalanga and the Western Cape with regards to mental health wellbeing and HIV. It also sought to understand the perspectives of those in the adolescents’ social environments. Ultimately it aimed to develop relevant intervention(s) to address any identified needs and supportive mechanisms related to the intersections between adolescent pregnancy/postpartum, mental health wellbeing and HIV. A mixed methods approach was used and the study was exploratory in nature. Comprising two phases, the first phase used qualitative interviews and narratives of life histories to explore the understandings and experiences of various groups of individuals – namely pregnant and post-partum adolescents and their peers, partners and parents/caregivers, as well as frontline health providers and teachers – with regards to adolescent pregnancy, HIV and mental health. The second phase is quantitative, comprising a crosssectional survey that will lead to the development of a quantitative instrument for assessing the intersections between adolescent pregnancy, HIV and mental health. The questionnaire will be developed based on phase 1 outcomes. The project is funded by the National Research Foundation.

Understanding the mental health disorders among males who have been traditionally circumcised in the Eastern Cape province

Anam Nyembezi Initiation and traditional male circumcision have become a matter of significant public health concern in recent years, following an increase in the morbidity and mortality rates resulting from botched circumcisions. As little is known about the mental health problems of traditionally initiated and circumcised men who are hospitalised, the aim of this study is to understand these problems among those admitted to a public hospital in the Eastern Cape province. The study comprised a two-phased mixed method design. Phase 1 was a formative qualitative study intended to gain deeper knowledge of health worker insights into the mental health of traditionally initiated and circumcised men – to better understand the surveillance systems and strategies for monitoring mental health disorders like depression, anxiety, post-traumatic stress. In mid2019 in-depth interviews were conducted with five participants (two doctors, a nurse, a counsellor and an administrator) during which three broad reasons for hospital admissions by these young men were identified: debridement, assault and dehydration. Reported mental health symptoms were anxiety, post-traumatic stress, psychosis and depression. Challenges faced during the admission were the lack of mental health services, staff, assessment tools and privacy. Phase 2 will seek to ascertain the utilisation of mental health care services by traditionally initiated and circumcised men, to identify contextual factors that enable or prevent their use and implementation of the systems and strategies that are needed. The project is a partnership with Walter Sisulu University and the Nelson Mandela Academic Hospital and is supported by funds from the South African Medical Research Council.

African Men for Culture & Education (AM4CE): An explorative cultural comparison of male success with traditional initiation

Anam Nyembezi An additional scoping project to explore comparative experiences of traditional initiation and male circumcision in South Africa and in the African diaspora in the United States is being supported through the University of Missouri-South Africa Education Program (UMSAEP). This qualitative study will be conducted in four countries: South Africa, Uganda, Kenya and United States. Using in-depth interviews, participants will be asked to share their knowledge, attitudes, beliefs and mental health issues related to traditional initiation and circumcision. In 2020 this project was stalled due to COVID-19; the intention is to resume in the second half of 2021.

Barriers to exclusive breastfeeding in women

Di Cooper, Hanani Tabana, Erin Roberts This research project has described and explored a range of factors – individual, interpersonal, community, social and health care and health systems – that have shaped South African women’s lived experience and their capacity to exclusively breastfeed. The aim was to identify potential solutions and improved implementation of infant feeding policies and programmes. Qualitative interviews were conducted with women at two Cape Town public sector primary healthcare sites to identify barriers to effective exclusive breastfeeding. Healthcare providers at three public sector primary healthcare sites in Khayelitsha, Cape Town were also interviewed, to explore their attitudes towards different infant feeding options, especially for HIV positive mothers. This was against the background of their understanding of the changes in revised 2013 Infant and Young Child Feeding policy guidelines. The project was undertaken in collaboration with the University of Massachusetts (USA). It was funded through an award from the DST/NRF Centre of Excellence in Food Security at UWC.

Food insecurity and ART adherence among older people living with HIV in the Western Cape

Lucia Knight South Africa has one of the highest HIV prevalence rates in the world and, given the widespread rollout of antiretroviral treatment (ART), is seeing increasing numbers of older persons (aged 50 and over) living with HIV (OPLWH). Older Africans are an understudied and underserviced population with regards to HIV, health and social support. A formative qualitative study conducted with OPLWH and with health care providers in and near Khayelitsha, Cape Town, found that older people tested late for HIV; that women in particular were shocked to hear they were HIV-positive (they had not seen themselves as ‘at risk’); and that testing and treatment for HIV and noncommunicable diseases were siloed, causing OPLWHs to experience barriers to integrated holistic care. A secondary study looked at food insecurity and ART adherence among OPLWH in the Western Cape. The initial findings highlighted the need to explore the messaging older people are receiving about food and the interaction/need for food; and whether messaging is adequately tailored to their ability to access sufficient food. It also demonstrated the vital roles played by the state-funded old age pension and, in some cases, the disability grant, both in ensuring food security as well as supporting their families more broadly. Completed in 2019, this study was was conducted in collaboration with University of Missouri-Columbia and funded by the DST/NRF Centre of Excellence in Food Security.

Street food vending model

Zandile Mchiza The main aim of this ongoing multi-year project was to implement the newly developed, sustainable street food vending business model (SFVBM) for selling healthy and safe foods in the streets of Cape Town and surrounding areas – while enabling street food vendors to make a decent living and consumers to make healthy food choices. The secondary aim was to investigate the metabolic profile, blood pressure, body size and behaviours of taxi drivers who operate at selected locations around Cape Town and who consume street foods daily. Other aims were to explore various issues like the types and nutritional value of street foods, the regulatory environment governing street food vending, and the knowledge and intentions of consumers to purchase healthy street food. Initial findings have been integrated within a socioecological framework to develop the four components of the SFVBM: a business component, food and nutrition component, hygiene component, and a mobile street food vending cart. This model has been piloted, evaluated, adapted and is now ready for implementation in all South African provinces to test its effectiveness. This project was undertaken in partnership with the South African Medical Research Council, the Cape Peninsula University of Technology and the University of Cape Town, and has been supported financially by the National Research Foundation.

Body size, mental health, and inequality: A life course approach

Zandile Mchiza This research project, conducted between 2018 and early 2021, investigated the social and developmental origins and consequences of overweight and obesity, negative body image, disordered eating, and impaired psychological wellbeing. It did so across the life course, and across generations, of parents and children in South Africa and Sweden. In focussing on improving understandings of the role psychological wellbeing plays in the development of overweight and obesity, special attention was paid to identifying modifiable risk factors and social determinants of health, such as socio-demographic characteristics, family and social environment and social mobility – identified as possible factors in mediating and/ or moderating the relationship between body mass index and psychological wellbeing across life courses. Substudies included: • investigating the socio-demographic and early life determinants of overweight and obesity among men and women across a range of different policy and social contexts; • quantifying the social and health consequences of overweight and obesity among men and women from different socio-economic groups;

• investigating the role of body image and poor psychological health for body size trajectories across different stages of the life course; • exploring the long-term health and reproductive outcomes of disordered eating; and • testing whether effects on body size and mental health of social or health disadvantage and social mobility are transmitted differentially through maternal and paternal lines. The project used existing complementary information from surveys, cohort studies and register data linkages in South Africa, Sweden and Australia, and applied methods from life course and social epidemiology. Preliminary findings were presented at the 2018 National Nutrition Congress. The project was undertaken in partnership with the South African Human Sciences Research Council and two Swedish educational institutes: Stockholm University and the Karolinska Institutet. It was jointly financed by the South African Medical Research Council and the Swedish Research Council for Health, Working Life and Welfare (FORTE).

Researching the obesogenic food environment, its drivers and potential policy levers in South Africa and Ghana

David Sanders, Rina Swart, Florian Kroll, Mariam Hassen Funded by the Canadian International Development Research Centre (IDRC), this four-year study sought to better understand the changing nature of food acquired and consumed in poor communities in South Africa and Ghana; it also enquired into the drivers of these changes, and the potential policy levers available to improve the healthfulness of the local food environment. Data collection entailed research on individual and household consumption, mapping and surveying the local food geography in two South African and two Ghanaian research sites, tracing key foods up value chains, and exploring policy options and the political economy of food governance. The study also explored, and made recommendations on, the policy and regulatory environments in South Africa and Ghana. A special supplement of Public Health Nutrition is being prepared to share the various findings. At least three other articles have been published – two by Ghanain colleagues and another on Achieving the right to food for South Africa: Justice, security, sovereignty and the politics of malnutrition published in World Nutrition. In collaboration with UWC’s NRF/DST Centre of Excellence (COE) in Food Security, the project also nurtured short stories by participants from Khayelitsha. These have been featured in several places including at the Southern Africa Food Lab workshop in Pretoria in 2019. The project was undertaken in partnership with UWC’s NRF/DST COE in Food Security and the Institute for Poverty, Land and Agrarian Studies (PLAAS) as well as with Kwame Nkrumah University of Science and Technology in Ghana and in collaboration with the University of Sydney, Australia and the Southern Africa Food Lab at the University of Stellenbosch.

Using a multi-media entertainment-education programme as a tool to prevent obesity in black South African women

Zandile Mchiza, Asiphe Ketelo, Hlolisiso Nonkeneza Completed in 2019 this project developed a multimedia education-entertainment (MM-EE) programme to improve the food and nutrition literacy, as well as body image, of South African women who lived in the poorly-resourced communities of Gugulethu, Nyanga and Kensington in Cape Town. Focusing on the development and validation of the approach/methodology, the project worked with 96 conveniently sampled female community health workers (CHWs) who operated community health clubs in these townships. The MM-EE programme instruments included 30 video clips, and accompanying written materials in the form of two-page comics, which were co-scripted with the CHWs, as well as researchers, health professionals and local media producers. The intervention used media platforms including text messages and WhatsApp to share the educational materials. The post-intervention data are being analysed. This project was undertaken in partnership with the University of Antwerp and the Katholieke Universiteit (KU) Leuven, with financial support from VLIR-UOS (Belgium).

Prospective Urban and Rural Epidemiology (PURE) study: A prospective cohort study to track changing lifestyles, risk factors and chronic disease

Rina Swart, Lungiswa Tsolekile, Thandi Puoane, Derrick Chauke, David Sanders SOPH continues to be a research partner in this international project which aims to track the changing lifestyles, risk factors and chronic disease among 225,000 people over 15 years (from 2009-2024) across 27 high- to low-income countries from every major region of the world. In so doing, the Prospective Urban and Rural Epidemiological (PURE) study intends to identify the factors that drive the development of risk for chronic noncommunicable diseases (NCDs), with a view to reducing their prevalence in the entire population. Households are visited every year to determine any life changes that may have occurred over the past year; medical measurements collected at baseline are repeated every three to five years. As the PURE populations are ageing, the future focus will be on healthy ageing, fragility and dementia. A nested study – on the costs of chronic diseases – is described below. The Cape Town and Eastern Cape research sites are managed by SOPH, collaborating with researchers from the South African Medical Research Council, Human Sciences Research Council and the University of Cape Town. This research is funded by Hamilton Health Sciences, Canada.

• PURE: Cost of chronic diseases: Measuring the impact of CVD costs on equity and impoverishment

This project aims to adapt, develop and implement a standardised methodology to capture health care costs for households of patient with cardiovascular disease (CVD) – and to assess the impact these costs have on health care utilisation and risk of impoverishment. It builds specifically on the initial findings from PURE which showed the large gap in treatment for common CVDs in low- and middleincome countries (LMICs). The study seeks to answer two questions: • how costs associated with health care for CVD affect the care-seeking decisions of households in LMICs; and • among those who do seek care, whether health care costs increase short- and long-term risk of impoverishment. Using a mixed-methods approach, the study concentrated on five conditions that comprise a large share of the total burden of disability related to CVD, namely hypertension, hypercholesterolaemia, angina, heart failure and secondary prevention following myocardial infarction (heart attack). Detection, treatment and long-term management of these conditions is essential to avoiding more costly and often life-threatening, acute CVD events, including heart attack and stroke. Initiated in 2017, the project is being undertaken in collaboration with the London School of Hygiene and Tropical Medicine with funding support from Wellcome Trust.

Support to the implementation of the East African Community Regional Centre of Excellence for Vaccines, Immunisation and Health Supply Management

Hazel Bradley, Jenny Birkett, Ziyanda Mwanda Between 2016 and 2019 the SOPH provided expertise to assist the University of Rwanda establish the EAC (East African Community) Regional Centre of Excellence for Vaccines, Immunisation and Health Supply Chain Management (RCE-VIHSCM). The vision of the Centre is to become an autonomous, well-recognised, top-class, regional ‘knowledge hub’, providing high-quality pre- and in-service training, disseminating best practices regarding vaccines, immunisation and health supply chain management. Key areas of support provided by SOPH were • the development and co-ordination of short-course training; and • continuous development of training support for the Master programme, focussing especially on learning management systems and open source e-learning platforms. Four members of the University of Rwanda team attended an SOPH Winter School short course on Medicines Supply Chain Management (MSCM), also learning about UWC’s learning management system and being introduced to several e-learning tools at the School. The SOPH team’s visits to Rwanda focussed on building capacity and transferring skills regarding the development of on-line learning materials, and mentoring on-line teaching and support staff. The first cohort for the Master degree in MSCM graduated in 2019 and included participants from all six EAC member states (Burundi, Kenya, Rwanda, South Sudan, Tanzania, and Uganda). The Regional Centre is funded by the German Development Bank (KfW) through Health Research for Action (hera). KfW has agreed to support a second cycle during which the RCE will be established as a centre for digital teaching and learning for the EAC and beyond in health supply chain management.

Availability of essential medicines and human resources for contraception and medical abortion in different health districts of Cape Town

Lucia Knight, Jessica Dutton This project is an initial phase in producing new insights about the real-world restrictions to contraception and medical abortion in an urban, liberal legal setting (South Africa). The first aim is to investigate the availability and affordability of essential medicines and trained healthcare providers for contraception and medical abortion in public health facilities in various geographical locations of Cape Town. The second aim is to understand the barriers women experience in accessing contraception and medical abortions. The study is a collaboration with Ghent University.

Respectful maternal care and the barriers to quality of care among providers across the continuum of maternal care in South Africa

Lucia Knight, Jessica Dutton, Stephanie Gormley In the MDG era, South Africa partially improved maternal health by increasing antenatal care coverage and the proportion of births attended by skilled health personnel. The goal to reduce the maternal mortality ratio (MMR) to 37.5 per 100,000 live births (or less) was not met, however. The current MMR is approximately 147 per 100,000 live births, which is still far from the current SDG target which is to reduce MMR to 70 per 100,000 live births or less. Research shows that 60% of maternal deaths in South Africa are preventable through improved care. If preventable maternal deaths were realised, the country could reach the SDG target. The aim of this research was to better understand the context of respectful maternal care and the barriers to quality of care throughout the continuum of maternal health care in South Africa. It aimed to synthesise existing evidence about respectful maternal care; to explore the drivers of disrespect and abuse from the perspective of providers in urban Western Cape (especially nurses and midwives); and to understand the health system and structural factors that contribute to norms of midwifery practice and barriers to quality of care in urban Western Cape. The ultimate purpose of the research was to develop a conceptual framework for the analysis of barriers to quality of care and drivers of disrespect and abuse, in order to inform the implementation of new maternal health guidelines. Data collection for the project is completed and analysis is underway. The project was funded by the South African Medical Research Council.

An assessment of a toy-based intervention aimed at promoting cognitive development for children aged 2-5 years old in Cape Town, South Africa

Emma Chademana, Brian van Wyk The Bright Start programme aims to support caregivers of young children (2-5 years) to begin to develop cognitive skills from early childhood. Implemented in Crossroads, Cape Town, in 2019, it is based on the cognitive development module/intervention developed by colleagues at University College London. 115 caregivers were divided into six groups for 2-3 year olds and six groups for 4-5 year olds. Sessions were held at two-week intervals to allow carers to repeatedly implement each toy activity with their children. At each session, carers were taught a toy-based activity and were each given a toy to take home and play with their children. Quantitative data were collected at the start of each subsequent session to assess how caregivers and their children experienced play with the last toy introduced. In addition, post-intervention qualitative assessments were conducted comprising 20 individual interviews, three focus group discussions with carers and a focus group discussion with facilitators. The pilot study found that the toy activities increased the children’s knowledge of colours, shapes, animals and counting. Caregivers also reported that playing with their children helped them to better understand them and bond with them. The sessions also offered some respite for many caregivers who indicated that when they were at the sessions they could forget about problems at home. Caregivers also established social networks. The study was undertaken in collaboration with Oneto-One Africa Children’s Fund and the University College London.

An evaluation of process and contextual factors in the implementation of the National Department of Health-led Mphatlalatsane quality improvement initiative in three provinces of South Africa

Helen Schneider, Solange Mianda The Mphatlalatsane Initiative is a multi-partner collaboration spearheaded by the National Department of Health (NDoH) which aims to improve maternal and newborn health in three provinces - Limpopo, Mpumalanga and the Eastern Cape. The SoPH is working with the South African Medical Research Council (SAMRC) in an evaluation of Mphtlalatsane. The SOPH team is specifically identifying the key elements of an enabling sub-district, district, regional and national environment for improved quality and outcomes of maternal and newborn healthcare. In particular this entails exploring what macro- (regional/national), meso- (sub-district/district), and micro- (facility) level processes and contextual factors explain variations in the uptake and outcomes of the Mphatlalatsane quality improvement interventions, and the implications for scale-up and spread.

In 2020 a scoping review of approaches to service delivery strengthening interventions for maternal and newborn health was undertaken - the protocol for which has been published.

Health policy and systems research: Strengthening community-based health systems

Helen Schneider, Nelisiwe Maleka Completed in 2020, this three-year project sought to enhance research capacity and competence for designing and conducting health policy and systems research with a focus on community-based health systems (CHS). It also sought to understand how, for whom and under what circumstances, innovations in community-based delivery achieve gains in access to healthcare and strengthens health systems. Undertaken with Umeå University (Sweden) the Umeå-UWC collaboration (known as the ‘U2U collaboration’) enabled the School to leverage a wider (South-South-North) network and set of collaborative arrangements on CHS. This network includes the universities of Cape Town and of Zambia, Muhimbili University (Tanzania), Makerere University (Uganda), and the Centre for Health Equity and Governance in Health Systems (Guatemala). The project culminated in a two-workshop series in Lusaka, Zambia, the first of which (in June 2019) was attended by 33 participants from seven institutions in the U2U wider network as well as frontline workers, managers and senior policy makers from the Zambian Ministry of Health. The workshop explored the multiple lenses on CHS, and developed research priorities which were captured in Chaminuka workshop report. In a follow-up writing workshop held in March 2020, a smaller group of participants planned a special issue of the International Journal on Health Policy and Management on CHS – to be co-edited by UWC, Umeå and University of Zambia. This project was funded by the Swedish Foundation for International Co-operation in Research and Higher Education (STINT) and the South African National Research Foundation. In late 2020, the Swedish Research Council awarded the network (now referred to as CHS Connect) a further three years funding (2020-2022) to consolidate and advance its activities.

Countdown to 2030

Asha George, Tanya Jacobs, Mary Kinney, Ulla Walmisley, Amnesty LeFevre (consultant) The main aims of the ‘Countdown to 2030’ programme are to improve the monitoring and measurement of women’s, children’s and adolescents’ health. SOPH holds sub-grants from UNICEF USA to support the health policy and systems-related work of the Countdown to 2030 programme, including Phase 1 activities (the Drivers Technical Working Group [Drivers TWG]) and Phase 2 activities (the Maternal and Newborn Health Exemplar project and the Data & Analysis Centers (DAC) for the Countdown country collaborations). For Phase 1 activities, the Drivers TWG, co-chaired by SOPH’s Asha George, has focused on four main work streams: digital health tools; quality improvement; adolescent health; and gender mainstreaming. Outputs related to this work have included engagement on four supplements, 20 publications, four conference presentations, representation on multiple technical working groups, establishment of one national community of practice, and engagement in the WHO–UNICEF–Lancet Commission ‘A future for the world’s children?’. The Drivers TWG has also supported the revision of Countdown 2030 indicators. For Phase 2 activities, SOPH has led the Data & Analysis Center for Health Policy and Systems, which aims to provide technical guidance and tools that support the reviews of the RMNCAH-N national plans and programmes / investment cases. Future research will focus on understanding the content of health system and policy levers in the Global Financing Facility’s country investment cases.

Gender and Health Hub

Asha George, Mamothena Mothupi, Ulla Walmisely In 2019 UWC entered into a memorandum of understanding (MoU) with United Nations University International Institute for Global Health (UNU-IIGH) to work together on advancing research and policy on gender and health from a global South perspective. SOPH’s Asha George is a member of the Core Working Group for the Gender and Health Hub funded by the Bill and Melinda Gates Foundation. Under this MoU, SOPH will support gender and health activities in sub-Saharan Africa and undertake gender analysis in health systems (primary health care, human resources for health). As a part of this collaboration, Asha George led the analysis on violence against women health workers as a part of the BMJ Series on Women’s Health and Gender Inequalities co-edited by WHO and UNU-IIGH. UWC has been co-convening an open and consultative process to set research priorities on Gender and COVID19. Since September 2020, over 400 participants, mostly from low- and middle-income country settings have been engaged, a research protocol finalised and five thematic reports drafted.

Children in All Policies 2030

Asha George, Ida Okeyo, Ulla Walmisely, Tanya Doherty While children should be at the centre of the concept of sustainability that underlies the Sustainable Development Goals (SDGs), agreed upon by all countries as the framework to guide development efforts, no country is adequately protecting children’s health, their environment and their future. A global collaboration between the WHO, UNICEF, The Lancet, and University College London (UCL) has brought together researchers, policy makers, advocates, political leaders and, most importantly, children to drive policy change. They have been using the evidence, assembling coalitions, and producing powerful advocacy for children’s current and future health and wellbeing, building on the recommendations of the WHO-UNICEFLancet Commission report published in February 2020. The UCL Secretariat of the ‘Children + SDGs 2030 Initiative’ supports and co-ordinates this global collaboration. Crosssectoral activities have emphasised the building of lasting partnerships for children at global, regional, and country level – beginning in three to five countries. The SOPH, in partnership with the Health Systems Unit at the South African Medical Research Council and Mark Tomlinson from the Department of Global Health at Stellenbosch University, will play a central role in promoting this agenda, notably leading work on community and multi-sectoral approaches to addressing alcohol as a determinant of children’s and adolescent’s health and wellbeing in South Africa.

Strengthening health system responsiveness to citizen feedback about health services in South Africa and Kenya

Nikki Schaay, Helen Schneider While responsiveness to citizen rights, needs, expectations and values is understood to be an essential quality of health systems, there is a limited understanding of the architecture, implementation and effectiveness of feedback and response mechanisms in health system settings in low- and middle-income countries. This embedded health policy and systems research study undertaken in South Africa and Kenya seeks to answer two questions: • What policies and mechanisms (formal and informal) work for receiving and responding to citizen feedback on health systems? • How can health systems responsiveness be strengthened towards the development of learning, equitable health systems? Begun in 2018, this three-year project has involved policy mapping and in-depth, multiple case studies of feedback mechanisms in each country, with an explicit strategy for cross-country analysis and embedding the research in policy processes to inform future improvements. The project is a partnership between the SOPH, Kenya Medical Research Institute (KEMRI) and the universities of Oxford and Cape Town (which also plays the co-ordinator role); an advisory role is undertaken by the Public Health Foundation of India. It is supported by the UK Medical Research Council’s Joint Health Systems Research Initiative.

Punching above their weight: Building capacity for research on why some countries have better life expectancies than predicted by national income

David Sanders, Fran Baum, Nikki Schaay The Punching Above their Weight (PAW) Network brings together academics, public servants, policy makers and civil society activists from 14 countries in order to design and undertake research to better understand why some countries are able to ‘punch above their weight’ in terms of producing good health outcomes relative to other countries with similar levels of economic development. To this end the Network has developed a series of research questions related to the complex interplay of political factors, governance regimes, civil society action, and specific policies that are thought to potentially contribute to the ability of a country to ‘punch above its weight’. Using the framework developed by the Network, case studies of three countries were conducted: Ethiopia, Brazil, and the United States. In February 2019, 16 participants from 8 countries met in Cape Town. Established in 2017 in Bellagio, Italy, The PAW Network was chaired by Prof David Sanders of SOPH, Prof Fran Baum of Flinders University, Australia and Prof Jennie Popay of Lancaster University, UK. Activities have been supported through a Global Challenges Research Fund Networking Grant, part of the UK’s Official Development Assistance (ODA).