Background: Workers in the wood processing industry are exposed to a heterogeneous mixture of inorganic and organic particles comprising wood fragments, viable and non-viable microorganisms, endotoxins, glucans and allergens, with the potential to cause work-related asthma. While this association has been reported in diverse settings, few studies have comprehensively studied host and environmental risk factors for work-related asthma phenotypes associated with wood dust. The aim of this study was to determine the prevalence and risk factors for work-related asthma among workers in the Mozambiquan wood processing industry. Methods: A cross-sectional study of wood workers was conducted in 21 factories located in three Mozambiquan provinces that processed various indigenous wood species. The environmental exposure assessment component comprised systematic walk-through inspections of all factories and the measurement of inhalable wood dust to determine particulate, (1-3)-β-D-glucan and endotoxin concentrations. A random sample of 30 workers were selected from similarly exposed groups (EGs) working in 9 representative factories for personal environmental sampling using PAS-6 sampling heads connected to Gillian GilAir pumps. A total of 124 of personal inhalable dust samples were collected for analysis. For the health outcome assessment, 450 subjects completed an ECRHS questionnaire adapted for occupational studies and underwent spirometry accompanied with bronchial reversibility and fractional exhaled nitric oxide (FeNO) testing conducted during the work shift. In addition, sera were obtained to determine the atopic status of workers using the Phadiatop test. Multivariate multiple lean and logistic regression was conducted adjusting for known confounders in saturated models using STATA 12 computer software. Results: The environmental exposure assessment demonstrated that the mean inhalable concentrations were 3.29 mg/m3 (GSD: 3.04) dust particulate, 98 endotoxin units (EU)/m3 (GSD: 5.05) and 123 ng/m3 (1-3)-β-D-Glucans (GSD: 5.05). These concentrations are higher compared to international exposure standards, generally ranging between 0.5-5 mg/m3 for dust particulate and 90 EU/m3 for endotoxins. A significant (p<0.05) modest correlation was observed between dust particulate and endotoxin (Pearson r = 0.48) and glucan (r = 0.40) concentrations. In the multivariate models, certain wood species were significantly associated with increased inhalable dust particulate levels - mahogany bean (Afzelia quanzensis Welw) (GM ratio=3.39) and African sandalwood (Spirostachys Africana Sonder) (GM ratio=3.19), as was factory building features (closed and semi-closed buildings, GM ratio=2.14). Additional determinants of elevated endotoxin exposures included African sandalwood (GM ratio=9.21) and working in closed buildings (GM ratio=2.10), while working in semi-closed buildings (GM ratio=2.14) was the main determinant of elevated glucan levels. Damp cloth cleaning methods were associated with lower dust particulate (GM ratio=0.55), endotoxin (GM ratio=0.32) and glucan (GM ratio=0.53) levels. The health outcome assessment of study subjects found the mean age to be 38 years, mostly male (94%), a large proportion non-smokers (76%) and 50% were atopic. The prevalence of current asthma was 7%, with equal proportions of atopic and non-atopic asthma (4%), while 2% had work-related asthma. The main host factors associated with work-related asthma outcomes were age, gender and atopic status. Exposure to Missanda (Erythrophleum suaveolens Brenan), Panga-panga (Millettia Stuhlmannii Taub.) and Mahogany bean (Afzelia quanzensis Welw.) wood species was associated with work-related ocular-nasal symptoms, while Mutondo (Cordyla Africana) species was associated with both work-related ocular-nasal and asthma symptoms. Work-related ocular-nasal symptoms were also associated, in a dose-dependent manner, with EGs categorized according to job titles as well as current dust particulate levels (medium, 4.68-4.71 mg/m3: OR = 3.45, 95% CI: 1.21 – 10.63; high, >4.71 mg/m3: OR = 3.66, 95% CI: 1.19 – 11.26) when compared to the low EG (<4.68 mg/m3) in unadjusted models. A similar trend was observed in the multivariate models adjusted for age, gender and smoking status. A history of work-related asthma symptoms was also positively associated with mean cumulative dust particulate exposure calculated across all jobs in the factory (OR = 1.01, 95% CI: 1.00 – 1.02) in multivariate linear regression models. In both unadjusted and adjusted models, increasing degree of bronchial reversibility was associated with increasing current dust particulate levels (medium, 4.68-4.71 mg/m3: OR = 1.99, 95% CI: 1.25 – 3.22; high, >4.71 mg/m3: OR = 1.73, 95% CI: 1.07 – 2.80) when compared to the low EG (<4.68 mg/m3). Increasing FeNO was associated with cumulative dust exposure quartiles based on current job >10.09 mg/m3-yr in both unadjusted (Q2, OR = 1.23, 95% CI: 1.02 – 1.51; Q3, OR: = 1.11, 95% CI: 0.91 – 1.35, Q4, OR= 1.23, 95% CI: 1.02 – 1.49) and adjusted models. Conclusion: This study demonstrated that exposure to all wood dust components in Mozambiquan wood processing workers were above international standards. The 7% asthma prevalence is consistent with global and specifically African country estimates, while 2% had work-related asthma. Processing of particular indigenous wood species and exposure metrics based on current as well as cumulative inhalable wood dust exposures were associated with an increased risk of work-related ocular-nasal and asthma symptoms, bronchial reversibility and airway inflammation. These risks are modified by host-associated factors of age, gender and atopy.

Background Sub-Saharan Africa is home to >90% of all children living with HIV worldwide. Since 2008, there has been a shift in paediatric HIV treatment towards universal antiretroviral therapy (ART) allowing for immediate initiation of ART, regardless of clinical or immunologic status initially for infants, and subsequently for progressively older, and ultimately all children. Given the scale-up of early infant diagnosis (EID) and early initiation of ART for infants and young children who are especially vulnerable to rapid progression of HIV and mortality, access to paediatric antiretroviral therapy (ART) services has substantially improved across sub-Saharan Africa (SSA). However, with the changing guidelines and practices, the demographic and clinical characteristics of infants and young children infected in recent years may vary from those infected before the widespread uptake of prevention of mother-to-child transmission of HIV (PMTCT) services and universal ART. This study therefore sought to understand the impact of changing guidelines on key metrics of the paediatric HIV care continuum, including timeliness of ART initiation, mortality, program retention and viral load suppression in order to examine effectiveness of ART in infants and young children enrolled in routine ART programs. Methods Using data from the International epidemiologic Databases to Evaluate AIDS Collaboration (IeDEA), this thesis described the temporal trends in the ART initiation characteristics in a total of 1692 infants initiating ART < 1 year of age and 32,220 young children initiating ART < 5 years of age between 2006-2017 in South Africa and SSA respectively. The trends in outcomes including mortality, loss to follow-up (LTFU), viral suppression. Associated determinants were also examined. Findings The result chapters of this thesis are presented in the form of journal papers in different stages of publication. The first paper reports that disease severity characteristics among all children starting ART aged <5 years in sub-Saharan Africa improved over time. Mortality declined substantially, however, LTFU remained unchanged with one in five children continuing to be lost before two years on ART. There was substantial heterogeneity in outcomes across country income groups. The second paper presents data on infants with HIV starting ART ≤3 months of age in South Africa. Findings suggests a that growing proportion of infants started ART at younger ages and with less advanced HIV disease. Mortality was 10.6% (7.8%-14.4%) in 2006- 2009 and decreases progressively to 4.6% (3.1%-6.7%) in 2013-2017 (p< 0.001), with LTFU remaining unchanged across calendar periods (p=0.274). The third paper presents findings on the trends in viral suppression (viral load [VL] < 400 copies/ml) and immunologic response up to 12 months on ART in infants who started treatment at < 3 months of age. By 6 and 12 months on ART, 56% and 65% infants achieved virologic suppression and the median (IQR) CD4 percentages increased slightly to 30% (22-37) and 31% (25-39) respectively, from a median of 27% (18-38) at ART initiation. There was a trend towards poorer viral suppression levels among infants initiating early ART in recent calendar years, despite improvement in CD4% and lower VL at ART initiation. The final paper suggests that good long-term viral suppression (<70%) among infants in routine care is achievable. However, infants staring ART between 0- 3 months vs those starting at 4-12 months of age had the lowest rate of viral suppression at all timepoints during a follow-up period of five years on ART. Conclusions Findings from this thesis suggest an increase in earlier ART initiation for infants and young children, with associated improvement in health status at ART initiation and declines in mortality following universal ART recommendations. However, substantial inequities existed across country income groups and a quarter of children on antiretroviral therapy across SSA continue to experience LTFU. In addition findings highlight suboptimal short and long-term viral suppression in infants acquiring HIV in the era of birth diagnosis and early infant ART. Targeted interventions are therefore urgently required to improve the outcomes of infants and young children living with HIV, especially among infants initiating ART before three months of age and children in low and lower-middle-income countries.

Background It is recognized that healthcare leaders of today would need to not only be responsive to the rapid changes around them, but also plan for the future of healthcare by creating a climate that is sensitive to the context of the organization while responding to the service needs. In the South African public healthcare context, where the service demands outweigh the ability to satisfy these needs with limited resources, leadership and leadership development is required to create more adaptive and resilient leaders and leadership. This PhD therefore aimed to study the implementation of a strategy to improve the leadership of the executive team at the hospital through a leadership development program, specifically analysing whether and how the program facilitated their capacity as leaders and their continuing work, with their respective multidisciplinary teams to implement improvement processes across the hospital. Methodology Given the limited knowledge on implementing a leadership development program (LDP) at a large South African central hospital, this study was comprised of two phases. Phase one of the study used a qualitative exploratory design, to explore the experiences and perspectives of the thirteen executive leaders on the LDP and whether these learnings played any role in developing their capacity. This was done by reviewing 242 documents and 13 one on one interviews with the hospital executive leaders, using purposive sampling. The second phase of this study used the insights of phase one to guide the analysis of four improvement processes initiated at the hospital. This phase explored which factors contributed to the success or failure of the implementation of the improvement processes in the executive leaders' respective areas and how their leadership of the process contributed to these factors. This was done by conducting in-depth case studies through focus group interviews with a total number of 36 participants in the respective teams and six one-on-one interviews with key informants (members of the team who had retired, but were integral to the process) that were involved in the improvement processes. Results The results of the study indicated the need for a context specific, practical LDP that provided benefit to the executive leaders, both as individuals and as team leaders. The executives reflected on their growth as leaders through building relationships, developing themselves through self-awareness and developing multidisciplinary teams. The analysis of the case studies in turn showed that leaders who engaged and supported their teams were more successful in their improvement processes. Concluding remarks This research summarized eight major conclusions drawn from the study as a contribution to what is possible in the public sector. Both the leadership development program and the case studies provided a broad conceptual framework of the Individual, the Team and the System as components that can be used to develop leaders, develop teams and improve overall leadership at a hospital. Based on the study learnings, the bottom-up approach and specific tools developed could serve as a basis for other hospitals to implement a leadership development program (LDP) and improvement processes in similar contexts. Further research on LDPs in a South African context could test the findings of this study and assist in enhancing the development of leaders at public sector hospitals.

This study assessed the perspectives of HIV-positive mothers and family members (i.e., grandmothers and fathers) of infant feeding options for HIV-positive mothers in southern Ghana. This entailed individual interviews with 40 HIV-positive mothers with infants, and 6 focus group discussions with HIV-positive mothers, fathers and grandmothers of unknown status in two urban districts. All infants born to the HIV-positive mothers in both districts had been breastfed. Breastfeeding was initiated any time between three hours and three days following birth. While some of the infants had been exclusively breast-fed, none had been exclusively replacement fed. Early mixed feeding patterns are deeply entrenched and the adoption of either EBF or ERF or both, represents departures from the social norms. Barriers to replacement feeding by HIV-positive mothers' included cultural and familial influences, socio-economic factors (including cost of infant formula, and lack of access to resources (for example, fridges, clean water, fuel and others) which are necessary for the safe preparation and storage of formula milk and fear over stigma and discrimination. Interventions designed to promote safer infant feeding among HIV-infected mothers in these settings need to be mindful of these barriers (socio-economic, cultural and familial) that these women face. Failure by policy makers to incorporate these issues will continue to lead to a gap between well-intended policies and programmes, and actual practices of HIV-positive mothers.

International literature has evidenced that Deaf people have been disadvantaged during the COVID-19 pandemic; however, there is currently no research published within the South African context. Deaf people, as both part of the disability community and a linguistic minority, have faced unique challenges during the COVID-19 pandemic, largely due to the implemented pandemic response measures. Such measures have included mask mandates, social distancing policies, hand hygiene guidelines, and lockdown protocols. This qualitative study investigated the ways in which the COVID-19 pandemic and its consequent response measures impacted Deaf adults in Cape Town. Semi-structured, in-depth interviews were held with fifteen Deaf/Hoh adults, who were recruited through the Deaf Community of Cape Town (DCCT) organisation. The interview schedule guided discussions to explore the perspectives, attitudes, and experiences of Deaf people on the implementation of COVID-19 response measures, assess the impact of response measures of Deaf persons' ability to communicate, access to and quality of health and social services, and access to Covid-19- related information. Professional SASL interpreters were used, and interviews were videotaped to capture the original, signed data and then transcribed by the researcher into English and stored on a password-protected drive. Fieldnotes were used as a complimentary method of data collection. The data were analysed using a thematic analysis approach in the N-Vivo software, firstly through a process of deductive coding, where pre-determined themes were applied to the data to generate codes, followed by inductive coding, which allowed codes and themes to emerge naturally from the content of the data. The findings focus on information provision, the impact of communication barriers on daily life, and how the response measures impacted access to and quality of healthcare. Overall, the findings demonstrate how the needs of the Deaf community were overlooked and their voices disregarded during the planning of the national response, ultimately having detrimental consequences.

Includes bibliographical references. / Woman abuse is now well recognised as a local and international concern that has serious repercussions for women's health and well-being. Little however is known about what it feels like to be abused by someone you love. How does a woman make sense of a life of physical and psychological abuse? Why does she stay in the abusive relationship? To gain more understanding of this complex dynamic, a qualitative study of five women's experiences of violence by an intimate partner was performed. The first part of this paper, a literature review, examines women's accounts of their experiences in abusive relationships by looking at common themes across these studies. The second part details the research process. The knowledge uncovered by the women's stories, can provide family physicians with valuable insights for devising strategies to identify and intervene in domestic violence.

From social media to support groups to learning at a distance, online conversations have long been of interest to qualitative researchers in a variety of fields. Though a majority of research in this area relies on content analysis methods, this two-day course will present a variety of qualitative methods foranalyzing online conversations. We will introduce a research framework for analyzing online conversations, an approach designed to assist researchers in creating conceptually congruent research designs to answer important questions about what is happening in online conversations. More specifically, the framework will help participantslearn how to: Identify an object of interest for investigation Recognize philosophical and theoretical assumptions that impact research design Create focused and relevant research questions Ensure methodological alignment across aspects of the study design Resolve ethical dilemmas surrounding the analysis of online conversations Transform online conversations into a coherent dataset Select appropriate technologies for working with the data Analyze data using thematic, narrative and discursive techniques Establish the quality of the findings Course material will be drawn from Looking for Learning, Insight and Transformation in Online Talk (Routledge, 2019).

Introduction: Young pregnant and postpartum women's suboptimum antiretroviral therapy (ART) adherence and engagement in HIV care remains a global concern despite improvements in prevention of mother-to-child transmission (PMTCT) and general ART services. Various psychosocial risk factors have been individually shown to be associated with HIV infection. However, longitudinal, and quantitative research on the impact of these psychosocial risk factors on HIV treatment outcomes is limited, particularly among young pregnant and postpartum women living with HIV (WLHIV) in low-income countries like South Africa. Furthermore, knowledge on the cumulative impact of these often-co-occurring psychosocial risk factors on HIV treatment outcomes is limited. This analysis examined the prevalence and co-occurrence of four key psychosocial risk factors [unintended pregnancy, depression, hazardous alcohol use and intimate partner violence (IPV)]. Furthermore, the analysis quantitatively examined the cumulative impact (defined as psychosocial burden) of these psychosocial risk factors on HIV treatment outcomes among young pregnant and postpartum WLHIV. Methods: This was a secondary data analysis of a pilot study (“Masibambisane Girls”) that designed and evaluated the role of a peer support intervention to mitigate the negative impact of stigma among young (16 – 24 years old) pregnant and postpartum WLHIV attending antenatal care (ANC) at the Gugulethu midwife obstetric unit (MOU), in Cape Town, South Africa. Participants were followed up to 6 months post enrolment. This analysis includes data collected from 114 of these pregnant (n=55) and postpartum (n=59) women. Psychosocial burden (primary exposure variable) was calculated as a sum score of the four key psychosocial risk factors. Each psychosocial risk factor threshold met scored the participant one point on psychosocial burden such that the minimum score was zero and the maximum was four. The prevalence of each exposure variable was analyzed using descriptive statistics and associations between them and with the outcome variables (engagement in care and HIV viral load <50 copies/mL) were examined using Chi2 tests and Fischer exact tests for sparse data. Poisson regression models were built to examine the association between psychosocial burden and HIV treatment outcomes before and after adjusting for sociodemographic and clinical confounding variables. Results: Overall, data from 114 women who were followed up for 6 months was analyzed (median age: 23 years, median gestation 25 weeks, median days postpartum: 6 days). There was an 88%, 14%, 19% and 32% prevalence of unintended pregnancy, probable depression, hazardous alcohol use and IPV respectively. Furthermore, probable depression and hazardous alcohol use were more prevalent among pregnant versus postpartum women. No statistically significant associations were found among these psychosocial risk factors. However, there was some indication of an association between depression and unintended pregnancy (P=0.095), depression and IPV (p=0.087) and hazardous alcohol use and IPV (p=0.119). The risk factors that most commonly co-occurred were unintended pregnancy and IPV (in 16% of women). Overall, pregnant women had significantly higher psychosocial burden scores than postpartum women. Analysis of HIV treatment outcomes revealed that 60% of women were engaged in care and among the 58 women who had an available viral load result within the window of follow up, 78% were virally suppressed. There was some indication of depression being a potential predictor of engagement in care (p=0.151). However, no statistically significant associations were found between any of the other psychosocial risk factors nor psychosocial burden scores and either HIV treatment outcome, before and after adjusting for potential confounders. Conclusions: This analysis mostly supports the existing body of literature on the prevalence of psychosocial risk factors and HIV treatment outcomes. However, more extensive research is needed to confirm associations among psychosocial risk factors and rigorously assess the cumulative impact of psychosocial risk factors (psychosocial burden) on HIV treatment outcomes.

This thesis used nationally representative data from the 2008 - 2017 National Income Dynamics Study, 1998 and 2016 South African Demographic and Health Surveys and 2005/06 and 2010/11 Income and Expenditure Surveys to examine prevalence, socioeconomic inequality, and determinants of overweight and obesity among non-pregnant women of childbearing age (15 to 49 years) (WCBA) in South Africa over time. It also assessed socioeconomic inequality in the intergenerational transmission of overweight and obesity from mothers to their offsprings among 10,735 mother-offspring pairs and decomposed socioeconomic inequality in household ultra-processed food (UPF) product spending in samples of 16,209 households in 2005/06 and 17,217 households in 2010/11. Overweight and obesity in WCBA in South Africa increased between 1998 and 2017 with factors including increased age, self-identifying with the Black African population group, higher educational attainment, residing in an urban area, and wealth contributing to the rise. Smoking had a protective effect on being overweight and obese. Overweight and obesity were also increasingly prevalent among wealthier than poorer WCBA in South Africa between 1998 and 2016. It was found that UPF expenditure increased between 2005/6 and 2010/11, accounting for a substantial share of poorer households' expenditures than their wealthier counterparts over time. Although factors explaining socioeconomic inequality in the intergenerational transmission of overweight and obesity differed by offspring sex, intergenerational overweight and obesity occur more frequently among wealthier mother-offspring pairs than their poorer counterparts. Key factors explaining inequalities in intergenerational overweight and obesity include the mother's socioeconomic status, education and exercise habits. This study improves the empirical understanding of the burgeoning overweight and obesity challenges among women, especially in South Africa, who are likely to transmit them to their offspring. Policy to address these issues should not only be about health services but also focus on the social determinants of health inequalities.

Introduction A recent systematic review estimated that almost a quarter of patients in low- and middle-income countries are not retained on antiretroviral treatment (ART) beyond one year. Further, it is difficult to determine whether a patient who is not retained in care has interrupted their treatment, transferred to another treatment facility, or died. Previous studies have been deterministic in classifying loss to follow-up and treatment interruption. This study investigates treatment interruption and resumption rates when accounting for uncertainty in the occurrence of interruptions. The primary objective is to estimate the rate at which ART is interrupted and the rate at which ART is resumed after an interruption. Methods We fitted a multi-state model to data from the Khayelitsha cohort of the International Epidemiologic Databases to Evaluate AIDS. Between 2001 and 2012, 6796 adult patients starting ART were included. Potential treatment interruption periods were defined between contact points 3 or more months apart. To aid the model in determining if a patient truly interrupted treatment a CD4 count model was used. CD4 counts were modelled to drop to baseline by 3 months after the start of a treatment interruption. Bayesian estimation and Markov chain Monte Carlo were used to obtain posterior distributions of parameters. Several scenarios were used in sensitivity testing, including varying the threshold used to define potential treatment interruption periods, and either adjusting or excluding the data of those with CD4 counts that drop below baseline. Results The baseline annual rate of treatment interruption had a posterior mean of 0.060 (95% CI 0.038- 0.087) which is significantly lower than the prior distribution that had a mean of 0.145 (95% CI 0.080-0.229). The posterior distribution of the baseline annual rate of treatment resumption (mean 1.09; 95% CI 0.68-1.65) was consistent with the prior distribution (mean 1.46; 95% CI 0.21-3.90). The posterior distributions of the parameters related to treatment interruption and resumption did not change significantly in sensitivity testing. Conclusion This study indicates that treatment interruption rates may be significantly lower than previously estimated. The methodology of this study may be useful to those measuring retention within ART programmes. An important limitation was that the CD4 count model did not allow for CD4 counts to fall below baseline during periods of treatment interruption. This limits the generalisability of the posterior estimates of the parameters of the CD4 count model. Further research may require a more flexible CD4 count model.