This thesis examines the challenges to and opportunities for comprehensive (primary and secondary) prevention of cervical cancer in South Africa (SA), a middle-income country.

Includes bibliographical references. / This thesis describes the conceptualisation, development and implementation of a mortuary-based system for the routine collection of information about homicide. It traces the evolution of the system from its conceptualisation in 1994, through various iterations as a city-level research tool, to a national sentinel system pilot, as a multicity all-injury surveillance system, and finally its institutionalisation as a provincial injury mortality surveillance system in the Western Cape. In so doing, it demonstrates that the data arising from medico-legal post-mortem investigations described in this thesis were an important source of descriptive epidemiological information on homicide. The 37,037 homicide records described in the thesis were drawn from Cape Town, Durban, Johannesburg, Port Elizabeth and Pretoria, for which the surveillance system maintained full coverage from 2001 to 2005. The aim was to apply more complex statistical analysis and modelling than had been applied previously.

Lack of coordination and integration between routine electronic databases can limit effective data production and utilisation to support health management decision-making. There is currently a need to strengthen data support structures through the harmonisation of multiple databases across different types of health services and organisations. Data harmonisation (DH) is an innovative process of copying existing electronic data captured in various databases into a centralised data repository where the data is integrated and then transformed into useable formats for data users. However, there is limited evidence about the wide range of factors (especially social factors) that impact on DH innovations, such as historical factors, stakeholder relationships and institutional terrain. This doctoral research aimed to identify and explore the factors affecting a DH initiative currently underway in the Western Cape Province of South Africa. The research was conducted using three methodological approaches, namely a historical analysis and synthesis, a scoping review and an ethnographic case study. For the historical analysis, relevant articles were identified through literature searches and data were collected through document reviews and interviews with two key informants. Data were first organised chronologically according to key events that took place in the health information system (HIS). Text from websites, journal articles, internal documents, standard operating procedures and interview notes were then synthesised according to key themes related to HIS interventions. For the scoping review, systematic literature searches were conducted to identify studies that met the eligibility criteria of the review. Two review authors (one being the doctoral student) screened titles, abstracts and full-texts and then sampled studies based on the range, variation and similarities or differences in definitions and concepts and intervention descriptions. Manual coding and the filter option in Excel were used to provide (a) numerical analysis of the characteristics of included studies; (b) narrative synthesis of the different DH definitions, components and processes, as well as intentions, suggestions and/or explanations of how DH may lead to improved health management decision-making. For the ethnographic case study, data were collected using participant observation (including conversations, meeting attendance and telephone and email communication), document reviews and in-depth interviews. Participants included data clerks, facility managers, health information staff and managers, DH innovators, researchers, public health specialists and database managers. Raw data were collected in the form of meeting minutes, field notes, interview notes and document extracts. Data analysis was conducted using thematic data analysis. The doctoral student manually coded data by highlighting recurring themes and evidence, and by extracting prominent themes from the various sources of data. As a strategy for testing the validity of emerging themes, the doctoral student used triangulation of different data sources; including looking for consistencies or inconsistencies between data sources. Five main findings emerged from the doctoral research. The first finding affirms that DH is a multi-faceted intervention. In the literature, it is defined and described using different terms for similar aims and activities (such as record linkage, data warehousing, health information exchange). Key characteristics emerging from a synthesis of DH studies include: a process of multiple steps to integrate electronic data; different types of databases, institutions and technical activities; integrating data involves using unique patient identifiers; and framing interventions or activities around a specific scope or purpose (such as geographic area, disease surveillance and treatment management). DH interventions contributed to three levels of health management decision-making, namely clinical support, operational and strategic management, and populationlevel disease surveillance. The second finding relates to the concept of ‘cultivation’. Cultivation is an ongoing and iterative social process to deal with problems between people, institutions and technology as they engage with each other in the context of an emerging innovation. The third finding is about striking a balance between the role of champions in designing and piloting innovations and the role of institutions in operationalising innovations and incorporating them into the broader health system for acceptance amongst implementers and users and for sustainability in the future. The fourth finding is about the motivations and opportunities that contributed to the emergence of a DH initiative in the Western Cape Province of South Africa. Opportunities for the new DH initiative include well-developed individual electronic databases, a government-university collaboration, and the positive attitude of frontline health workers towards DH projects. The new initiative faced design and operational challenges such as difficulty to access data from different health authorities and the incompleteness of electronic data. However, new data access and transfer procedures and existing social relationships were important for dealing with the changes that occurred as DH projects were being operationalised. The last finding highlights tensions that emerged between DH innovators and other health information technology (HIT) stakeholders because of institutional and conceptual differences (such as different approaches to data access and governance, differences in conceptualisations of the value of data, and misunderstandings about the purpose of formal data procedures). DH innovators were able to navigate conflicts emerging from institutional and conceptual differences because of their strong leadership and team setup, institutional positioning and stakeholder engagement activities, to become institutionalised within the health system. These findings provide health system, information technology and research stakeholders with a broader understanding of the range of social factors that impact on DH innovations. This research promotes a more comprehensive approach in designing, implementing and evaluating DH innovations to limit poor outcomes of innovations and wasted resources.

Includes bibliographical references (leaves 236-251). / This thesis develops a methodology for measuring equity in access to health care. The thesis deconstructs the concept of access into dimensions that represent the supply and demand side of health care and tests each of these dimensions by using the example of access to malaria services in the Kassena-Nankana district of northern Ghana. An innovative framework and a disadvantage index are developed herein, and are used to analyse the primary factors of access and to measure inequities in such access. A cross-sectional survey of 1880 household heads, focus group discussions, in-depth and key informant interviews with community members and health providers were used to explore issues in respect of malaria management, health care access and perceptions of poverty. The principal component and factor analysis statistical methods were then applied to estimate access factors and to compile a disadvantaged index of access. The key findings indicate that the dimensions, availability, affordability, information and acceptability primarily determine access to health care. On the availability dimension, physical distance to health care, provision of primary and inpatient are and travel distance are significant factors. The primary factors of affordability are associated more with the socio-economic characteristics of the household than with direct user costs. The information dimension is determined primarily by knowledge to treat levels of severity of malaria and the source of information for treatment. The acceptability of health care is related to methods and services for managing severity of levels of malaria at home as well as using qualified health care providers. The disadvantage index and poverty maps show significant disparities in health care access between geographic areas and socio-economic groups', with areas in the outskirts of the Kassena district being the most disadvantaged in terms of availability, acceptability and information. These areas are however not economically disadvantaged. The poorest households have the lowest accessibility scores across all dimensions.

Includes bibliographical references. / Widespread under-reporting of acute pesticide poisoning (APP) in developing countries, such as Tanzania, leads to under-estimation of the burden from APP. This thesis aimed to characterize the health consequences of APP in rural agricultural areas in Tanzania with a view to developing an effective surveillance system for APP. Several sub-studies comprise this thesis: A household survey of farmers; A hospital data review for APP, both retrospective, covering a 6-year period, and prospective for 12 months;Health care providers' knowledge and practices relating to APP and notification;Pesticide retailers' knowledge, distribution and handling practices; Stakeholder views regarding APP, notification and risk reduction strategies; and an assessment of APP data from sources other than the hospital system. The study found that major agents responsible for poisoning included Organophosphates and highly or moderately hazardous products and the age group 20 - 30 years was most affected. The majority of health care providers lacked skills for diagnosis of APP. The most problematic circumstances of poisoning in hospital data review was suicide but was occupational with pesticide stakeholders and in household surveys. Prospective data collection in the hospital review reduced the amount of missing data, suggesting that with proper training and support, hospital-based reporting can provide better surveillance data. Many farmers and pesticide retailers had unsafe practices likely to result in exposure and risk for poisoning. Modelling suggested that the Incidence Rate for occupational poisoning ranged from 11.3 to 279.8 cases per million people with a medium estimate of 32.4 cases per million people. The study identified a high burden from APP in Tanzania, largely unreported, particularly from occupational poisonings, and proposes an APP surveillance system for Tanzania aimed at addressing both workplace and non-workplace settings. The system is expected to identify poisoning outbreaks, circumstances and outcomes, agents, poisoning patterns by gender, age, population and geographical areas most affected. Data sources for the system will include health care facilities and other government Institutions, media and community members through community self-monitoring. The system is expected to generate rate estimates and trends for pesticide poisoning, identify opportunities for prevention, further research needs and, ultimately, assist in reducing health risks arising from pesticide exposure.

Includes bibliographical references (leaves 184-200). / To effectively support the primary health care transformation of the South African health system, human resource development is needed. Nurses, at the forefront of primary care service delivery, urgently need support and advancement to fulfill their role. This study aimed to investigate the impact of core competency training on primary care nurse competence. To begin this investigation, a framework or core competencies was generated through two reference group meetings. This work was followed by a Delphi study to further define core competence in primary care nursing and how best to measure such competence. Nine core competencies were defined which led to the development and piloting of a core competency evaluation tool including a self-lest and observation tool. This early work was followed by the implementation and evaluation of a novel core-competency training program. This program was implemented within district health systems with working clinic nurses. It involved tour distinct sites in three different provinces. A total of 162 nurses took part in the study, including an intervention and reference group. The goal was to assess the impact of training in a real world setting. Using the self-lest and observation tools, this study showed that competence does improve with this type of training. Additionally, competence is most reliably assessed through observation since test familiarity and possible contamination decrease the usefulness of repeated self-test measures. Further assessment or this novel training program and ref1nement of the measurement tool are recommended. This study can serve to inform health policies, particularly regarding human resource development within emerging district health systems. It provides a practical and effective training approach for increasing nurse performance of primary care core competencies.

Includes bibliographical references (p. 212-244). / [Objectives] There is a paucity of data regarding paediatric adherence in resource-limited settings (RLS) especially among the very young age groups (<7yrs). The study investigated the rates of adherence, the identification of the adherence measurement, amongst four, which best correlates with viral load suppression; as well as correlates of adherence amongst a cohort of children younger than 7 years on antiretroviral HIV treatment. Design: A Prospective cohort study with 6 months follow-up [ Methods ] Measures of adherence used: caregiver self-report (CSR), medicine measure/pill count, pharmacy refill and clinic attendance. Child, caregiver, socio-economic and health service characteristics were assessed for impact on adherence. Bivariate and multivariate analyses were used to determine agreement between measures and viral load outcome and to determine correlates of adherence. [ Results ] Mean age of children enrolled into the study was 27.08 months with a cohort mean adherence rate of 85% and mean viral load suppression of 74% at 6 months. Biological mothers were the majority primary caregivers (85%) and the majority (76%) of caregivers were unemployed with 60% receiving some form of social welfare grant. Results showed that caregiver selfreported adherence (CSR) was significantly correlated with viral load at 6 months (p=0.004). Correlations were found between clinic visits and pharmacy refill (highest values 0.35; p=0.000) and between medicine measure and clinic visits (highest value -0.21; p=0.04) but none of these measures were significantly correlated with viral load. Sensitivity and specificity analysis for CGSR showed that >95% adherence ensured a good viral load outcome. Four factors were significantly associated with adherence in bivariate analyses. These were: access to social welfare grants (OR=2.7; p=0.05); being counselled for initiation of ARV treatment by a counsellor vs. a doctor or nurse (OR 3.2, p=0.03); having another person in the household other than the index child infected with HIV (OR = 0.34, p=0.05) and caregiver depression (OR=0.07, p=0.01). However, in multivariate analyses certain other child, caregiver, socio-economic and health system characteristics as well as the abovementioned variables emerged as significant. [ Conclusion ] Key findings indicate that adherence rates are relatively high in this cohort and CGSR is valid in a resource-poor setting but medicine measure was problematic as a paediatric HAART adherence measure. Certain child, caregiver, socio-economic and health system characteristics have a significant impact on adherence.

Includes abstract. / Includes bibliographical references. / Since 2004, increasing numbers of children in sub-Saharan Africa have commenced antiretroviral therapy (ART). This thesis reviews the outcomes of published studies of paediatric ART cohorts in Africa, describes outcomes for children receiving ART in South Africa and examines determinants of mortality and generalizability across the Southern African region. Temporal trends in characteristics at ART initiation are also examined. The measurement of treatment success in resource-limited settings is reviewed, by examining virological failure, and assessing the diagnostic accuracy of immunological criteria for identifying virological failure.The results chapter is presented in the form of published or submitted papers based on data from the International epidemiologic Databases to Evaluate AIDS-Southern Africa (IeDEASA) collaboration. The first paper reviews paediatric ART studies from Africa published before 2008. Together with the literature review in chapter 1, it provides the background to this thesis. The second paper reports on mortality (8%) and retention in care (81%) by 3 years after ART start for > 6,000 children who initiated ART in South Africa. The generalizable prognostic models in the third paper suggest that mortality during the first year on ART ranges from <2% to >45%, with the majority of children being in the group with the best prognosis. The fourth paper reports that 1 in 5 children meet criteria for confirmed virological failure by 3 years on ART. The risk is greater with triple ART containing nevirapine or unboosted ritonavir (in comparison with lopinavir/ritonavir or efavirenz). The fifth and sixth papers demonstrate that immunological criteria have low sensitivity and positive predictive value for virological failure. Targeted viral load measurement reduces the number of false positive virological failure diagnoses. The final paper shows that increasing numbers of children have initiated ART with a decline in disease severity at therapy start from 2005-2010. However, even in 2010 a substantial number of children started ART with advanced disease. The thesis concludes that access to ART for children has increased, with good outcomes. HIV cohort research is important in evaluating the safety and effectiveness of different models of care, treatment and monitoring strategies.

Includes bibliographical references. / The effectiveness of prevention of mother-to-child of HIV (PMTCT) programmes depends on the successful coverage of a series of interventions through pregnancy, intrapartum and postpartum. Routine monitoring systems based on service data and limited to women on the PMTCT programme may overestimate intervention coverage at multiple points along this cascade. Methods: Cord blood specimens with individually linked anonymous demographic and pregnancy data were collected from three delivery services in the Western Cape Province, South Africa, and screened for HIV. Seropositive specimens were tested for the presence of antiretrovirals.

High intake of sugar has been recognised as a contributing factor to diet-related overweight and obesity, and as a determinant for non-communicable disease (NCD) emergence in LMICs. In 2015, the World Health Organization (WHO) released a guideline giving specific advice on limiting sugar intake in adults and children. Policy guidance has also been provided to promote healthy diets and/or restrict unhealthy eating habits at country-level. The study explored the extent to which global policy recommendations and directives on reducing sugar intake to prevent and control NCDs have found expression in policies issued at the Africa region, South African national or sub-national Western Cape provincial level. A systematic policy document review was conducted to identify policies between 2000 and 2020, at different levels of government using search terms related to sugar, sugar sweetened beverages (SSBs) and NCDs. NVivo 12 software was used to code and thematically analyse the data. A policy transfer conceptual framework was applied for the policy analysis to assess what ideas were transferred, including why and to what extent transfer occurred. Forty-eight policy documents were included in this review. Most were global or national level policies. It was evident that several global policy ideas on unhealthy diets and reduction of sugar intake had found expression in South African health policies, as well in the education and finance sectors. Global recommendations for effectively tackling unhealthy diets and NCDs are to implement a mix of cost-effective policy options employing a multisectoral approach. Local policy action has followed the explicit guidance from international agencies, and ideas on reducing sugar intake have found expression in sectors outside of health, to a limited extent. Together with the adoption of the sugar-sweetened beverages (SSBs) health tax, South Africa's experience offers learnings for other LMICs.