Includes bibliographical references (leaves 90-93). / There are few studies on the impact of African traditional healing on HIV/AIDS care and treatment in South Africa. There is a need for concrete data on the subject as many people across the African continent are thought to be accessing these kinds of healing services. This study which consists of three inter-related sub studies, investigated the impact of African traditional healers on Antiretroviral (ARV) treatment in South Africa. Each of the sub studies focused on the insights and opinions of three different populations, i.e. health care workers, traditional healers (who were affiliated with HIV/AIDS care services) and HIV positive patients. The first of the sub studies used in- depth interviews to explore the attitudes and approaches often health care professionals (nurses, doctors, ARV counsellors and a pharmacy assistant) working in ARV roll out sites in South Africa to their patients taking traditional medicine and accessing traditional healing paradigms. The sub study also probed their opinions of collaborating with traditional healers to strengthen ARV care. Furthermore, this sub study included two focus group discussions with lay health workers at two ARV sites (i.e. ARV counsellors and patient advocates). On the whole the study showed that health care professionals are concerned about the possibility of traditional healers undermining an ARV roll out programme. These perceptions are based on concerns that traditional healers may provide untested substances to HIV positive patients that could interact adversely with ARV drugs. They also believed that traditional healers could discourage patients from adhering to their ARV regimen. However, despite these concerns, most of the health care professionals were willing to collaborate with traditional healers but the partnership would have to be formed on the basis of the principles of the biomedical paradigm of healing. Health care professionals preferred to be solely in charge of the ARV drug regimen with (biomedically) trained traditional healers supporting them. They preferred traditional healers to concentrate solely on symbolic rituals. The focus groups with the ARV counsellors and patient advocates show that these lay health workers support an ARV roll out process that effectively underplays the role of traditional healers and therefore actively discourage their patients from using traditional healing services while taking ARV treatment. The second sub study complements the first and used in-depth interviews to explore the attitudes and approaches of five female traditional healers (working in HIV/AIDS organizations in the Western Cape) towards the use of ARV treatment by their clients. This study also explored their attitudes towards a partnership with the formal public health sector with regard to HIV/ AIDS care. The sub study showed that traditional healers are concerned about the wellbeing of HIV positive people. All of the traditional healers who were recruited into this study were in favour of a partnership with health care workers as long as such a partnership is based on mutual collaboration and respect. The third sub study was a study of HIV positive patients attending health facilities that provide ARV care. A semi structured questionnaire was adapted from instruments used in previous studies and was complemented by in depth interviews with patients who reported use of traditional healing systems in the past year. This sub study explored the attitudes of the respondents towards African traditional healers and their practices. The responses of the patients show that the majority of respondents have never accessed a traditional healing service. Some of the patients recruited in the study said they had accessed a traditional healing service before they had begun ARV treatment or before they were recruited into this study. They expressed the reasons for their choice. Only two patients were found to be actively crossing between ARV treatment facilities and traditional healing services at the time of their interview. A public health and human rights analysis suggests means of incorporating a traditional healer in ARV care, whereby an ARV treatment policy can respect cultural rights of patients and traditional healers while simultaneously improving ARV treatment infrastructure. Limitations encountered in the study such as location of the research sites, nature of the respondents and the ways in which the questions were worded to the respondents were addressed through efforts by the researcher. The study concludes that a partnership between traditional healers and the formal public health sector is feasible but must incorporate respect for cultural rights.

Includes abstract. / Includes bibliographical references (leaves 89-92). / The aim of this mini-dissertation was to assess whether sexual coercion at first sex predicts risk behaviours in a sample of school going adolescents by reviewing existing literature and examining a study of youth in Cape Town, South Africa. ... The systematic review appraised literature which aimed to assess the influence of sexual coercion on risk behaviours. The selection criteria included quantitative observational studies and studies with subjects that were sexually active males and females between 10 and 25 years of age. ... A secondary statistical analysis of data from the SATZ project was carried out to further assess the extent to which coercion at first sex predicts; sexual risk behaviour, experience or perpetration of physical abuse and substance use.

Includes abstract. / Includes bibliographical references. / Globally, there are major shifts taking place in health care provision to achieve universal health coverage. In 2011, the South African Department of Health released a Green Paper outlining its vision for implementing a National Health Insurance (NHI). The NHI wants to improve the service provision and promote equity and efficiency to ensure that all South Africans have access to affordable quality health care services. Public participation is important to raise public awareness, consult the public and promote major programs of change. This research aims to analyze the gaps between the everyday lived reality of publicly provided health care consumers and intended health policy reform.

Background: In South Africa the burden of common perinatal mental disorders, is approximately three times higher than in high-income countries, with negative consequences for maternal and child health. The high prevalence and 80% treatment gap may be attributable to multiple contextual risk factors that women encounter as well as health care system barriers. This thesis sought to establish the diagnostic prevalence and psychosocial predictors for Common Perinatal Mental Disorders (CPMD) amongst women living in adversity and to develop a brief screening tool to detect such disorders in low-resource settings. Methods: This cross-sectional study was conducted at a primary level, midwife-run obstetric unit in Hanover Park, Cape Town. The data from 376 pregnant women attending their antenatal, “booking” visit were included. These data were collected using a diagnostic interview and self-reporting screening questionnaires. Logistic regression models explored demographic and socio-economic characteristics, psychosocial risk factors and psychiatric comorbidity as predictors for CPMD. The Area Under the Curve (AUC) from Receiver Operator Characteristic (ROC) curve analysis compared screening tool performance. Bestperforming items from screening tools were analysed against diagnostic data using multiple logistic regression and ROC analysis to develop a novel screening tool. Findings: Prevalence of diagnosable major depressive episode (MDE) and anxiety disorders were 22% and 23% respectively, 50% of depressed women expressed suicidality. CPMD diagnosis was significantly associated with multiple risk factors, including a history of mental health problems, food insecurity, traumatic life events and lower perceived social support. Multigravidity, unintended and unwanted pregnancy and pregnancy loss were strongly associated with antenatal anxiety. The Edinburgh Postnatal Depression Scale (EPDS) and Whooley questions were the best performing screening instruments. Multiple logistic regression identified four items independently predictive of CPMD. At a cut-off of 2, the combined items yielded an AUC of 0.83, with a sensitivity of 78% and specificity of 82%, comparable to the EPDS. Conclusions: These findings confirm the high prevalence of antenatal CPMD in low- and middle-income country (LMIC) settings, where women experience multiple risk factors. Ultrashort screening tools adequately detect CPMD, and a novel, four-item screening tool may be useful for the early identification of mental health symptoms in pregnancy, as part of collaborative stepped care. This is the first measure of its kind developed in South Africa, further novelty is that it is a combined depression and anxiety tool, and includes screening for suicidal ideation.

Background The Cardiff model purports that the true burden of violence within a community can only be quantified by the addition of violence-related data from health services to violence data reported to the police. This thesis describes the conceptualisation, development and implementation of a violence and injury observatory for the routine collection of violence-related data for the City of Cape Town. The observatory model, which was conceptualised in the early 1990s in Colombia, has gone through various iterations as a municipality-level research tool, to a city-level tool and thereafter as a national and transnational tool. Aims of this thesis The thesis aimed to assess the utility of clinical and non-clinical data sources in constituting a prevention-oriented violence and injury observatory (VIO) in urban Cape Town, South Africa. The specific objectives of each study component were as follows: • To describe the objectives of the pilot VIO, potential violence-related datasets for collection, data analysis and research dissemination plan (Study One) • To assess the validity and utility of VIOs in reducing violence and violencerelated harms in adult populations (Study Two) • To identify the optimal data elements for inclusion in a VIO according to expert consensus (Study Three) • To determine the concordance between violent crimes reported to the police with violence-related injuries presenting at health facilities in Khayelitsha (Study Four). Methods The systematic review method was used to determine whether the introduction of violence and injury observatories was associated with a reduction in violence in adult populations (Study Two). A modified two-round Delphi study (Study Three) determined the optimal data elements (including violence and injury indicators, datasets and research priorities) for inclusion in a pilot violence and injury observatory in Cape Town. The Delphi panel of 21 participants included one Provincial Head of Emergency Medicine, one Provincial Head of Disaster Medicine, several Heads of Department of Emergency Medicine across hospitals in Cape Town, and representatives from relevant data stakeholders, including the Forensic Pathology Services (FPS), South African Police Services (SAPS), Health Systems Trust (HST) and the Violence Prevention through Urban Upgrading (VPUU). This was to ensure that decisions were made by persons in senior posts to facilitate subsequent implementation of the recommendations. Khayelitsha, a peri-urban mixed informal township of Cape Town, was the setting for the final study (Study Four), which included a retrospective analysis of secondary cross-sectional health and police data, from three health facilities and three police stations in the community of Khayelitsha, Cape Town. A case-matching study, using personal identifier matching, was employed to determine the concordance between reports of violent crimes to police stations with reports of injuries arising from interpersonal violence at health facilities within the community of Khayelitsha in Cape Town, South Africa. Results and Discussion Subgroup analyses according to the two types of models implemented in the systematic review (Study Two), namely, the VIO and the injury surveillance system (ISS), provided evidence for an association between the implementation of the VIO model and a reduction in homicide count in high-violence settings (incidence rate ratio [IRR]=0.06; 95% CI 0.02 to 0.19; four studies), while the introduction of ISS showed significant results in reducing assault (IRR=0.80; 95% CI 0.71 to 0.91; three studies). Following expert consultation through a Delphi process (Study Three), this study identified 14 violence and injury indicators and 12 violence-related datasets for inclusion in the pilot VIO. Additionally, research priorities within 16 research themes across five different types of violence were identified including: elder abuse, youth violence, intimate partner violence, sexual violence, and armed violence. Key findings from these thematic priorities included: (1) formal methods to define and measure violence, identification of violence-related risk factors; (2) evaluation of the effectiveness of promising programmes that target violence-related risk factors; and (3) evidence-based recommendations on scaling up programmes that were shown to be effective in reducing interpersonal violence. With regard to the key findings around data sharing, the majority of the panelists (>55%) thought that: (1) violence-related data from health services should be shared with Policing Services; (2) the data model employed should go beyond the Cardiff model (policing and health data) and also include violence-related data from the Fire and Rescue Services (FARS) and the Emergency Medical Services (EMS); and (3) the functions of a local observatory should include a civilian spatial data observatory, an information technology division, a predictive analytics division, a historical data repository and a systematic review repository. The expert-identified violence and injury indicators, datasets and research priorities provide a research framework for interpersonal violence and injury prevention work within South Africa. The findings have theoretical implications and build up evidence-based data for the general field, and they have a practical outcome in recommendations that are both general and specific for implementation in South Africa. They may also serve to guide the development of additional VIOs locally. In the final study (Study Four), with regard to concordance between the datasets, among the 708 patients being treated for violence-related injuries at health facilities, only 104 reported the incident to the police which equates to a matching ratio of 14.7%. Combining health and police data revealed an 81.7% increase in potential total violent crimes over the reporting period. Compared to incidents reported to the police, those not reported were more likely to involve male patients (difference: +47.0%; p< 0.001), and sharp object injuries (difference: +24.7%; p< 0.001) and less likely to report blunt trauma i.e., push/kick/punch injuries (difference: -17.5%; p< 0.001). These findings suggest that the majority of injuries arising from interpersonal violence presenting at health facilities in Khayelitsha are not reported to the police. Conclusion This research provides an evidence-based model for the development and implementation of a VIO, and the Cardiff model, to reduce interpersonal violence. It is supported by the evidence from the systematic review of the effectiveness of VIOs in reducing violence outcomes among adults in high-violence settings. This pilot VIO represents the first attempt to collect contemporary and comprehensive data on violence and injury in the Western Cape Province and South Africa. The implementation of VIOs should be considered in high-violence communities where the collation and integration of violence-related data and violence stakeholders, may guide violence reduction. The Delphi study provided indicators, datasets and research priorities to (1) inform the basic research infrastructure of a VIO, and (2) serve as part of a regional standardised data collection framework to guide the development of other local violence and injury observatories. This is consistent with the aims of the South African National Development Plan 2030 to ‘improve the health information system; to prevent and reduce the disease burden and promote health and to improve quality by using evidence'. Finally, the research further shows a clear benefit in combining data on violence from different settings as demonstrated in our analysis of data in the Cape Town suburb of Khayelitsha, where the overwhelming majority of injuries arising from interpersonal violence presenting at health facilities in Khayelitsha are not reported to the police. This study has broader implications regionally and nationally for the surveillance of injuries arising from interpersonal violence, for the police definition and surveillance of community interpersonal violence, for community policing intelligence development (improving the configuration of violence heat maps on a real time basis) and finally for police resource utilisation and distribution, which should, in turn, impact positively on reducing crime and violence in the community, and reduce the burden on the health services. The Western Cape Safety Plan, a policy document developed by the Western Cape Government, advocates the use of data and technology to understand violent crime patterns to inform the deployment of law enforcement resources and investigators accordingly and furthermore acknowledges research and analysis as an important component of its evidence-based policing (EBP) strategy. The policy document and study findings provide support to the implementation of the Cardiff Model locally.

Background: The death of a patient can be a stressful event for doctors, but not many studies have been conducted in South Africa. The rationale for this study is to see whether our participants (junior doctors) would have similar experiences and coping mechanisms as described in the literature. A better understanding of these stressful experiences could guide management to better assist future doctors. This study included doctors with five years or less experience since qualification and included interns, medical officers and registrars working at a District Hospital in the Cape Metro Region i.e. Mitchell's Plain District Hospital. Aim: The aim of the study is to describe the experiences and coping mechanisms of doctors after the death of a patient and to assess the effects on their personal, emotional and family life. Methods: An exploratory or phenomenological descriptive qualitative study was conducted using semi-structured one-on-one interviews conducted by the primary investigator. Fifteen doctors employed at a District Hospital were included, each with less than five years work experience. Results: The core theme identified was that dealing with death is stressful for young doctors. The themes contributing to the stress included: Inexperience of doctors; sudden unexpected deaths of patients; poor coping mechanisms used; and lack of support structures. This had negative effects on their family and personal life. Conclusion: The study found that the stress of patients' deaths negatively affects young doctors and it is recommended that debriefing sessions be available and better coping mechanisms taught. This may prevent future anxiety disorders, depression and less burnout amongst young doctors. Future studies are needed to assess the effectiveness of debriefing sessions once implemented at Mitchell's Plain District Hospital.

Introduction: South Africa, like many other low- and middle-income countries (LMIC), is currently undergoing an epidemiological transition with a growing burden of noncommunicable diseases (NCDs) co-occurring with an existent burden of infectious diseases like human immunodeficiency virus (HIV). South Africa continues to have the biggest HIV epidemic globally, and adolescents and young people, especially young women, bear a disproportionate burden of HIV in the country. Adolescents and youth living with HIV (AYLHIV) face an elevated NCD risk resulting from chronic immune activation, psychosocial factors and the complications of long-term antiretroviral therapy (ART). However, there is data paucity on the intersection of NCDs and HIV in adolescents in South Africa and Africa. This thesis aims to contribute to the limited evidence base in LMIC settings by investigating NCD multimorbidity and risk factors in AYLHIV within a context of epidemiological transition and urbanisation. Objectives: This aim is achieved by fulfilling the following research objectives: 1. To investigate the extent to which NCD comorbidity (prevention, screening and management) is incorporated within existing adolescent HIV primary healthcare services in Cape Town, South Africa. 2. To estimate the prevalence of common NCDs and their known cardiometabolic, respiratory and behavioural risk factors in AYLHIV residing in peri-urban Cape Town. 3. To determine individual, household, social and neighbourhood level factors associated with obesity in AYLHIV. Methods: I conducted a narrative literature review to inform the development of a conceptual framework for investigating the intersection of adolescence developmental theory with NCDs and HIV. The emergent concepts were explored from an over-arching socioecological viewpoint, drawing on life course epidemiology and epidemiological transition theories. I conducted a cross-sectional quantitative study in nine primary care facilities across peri-urban Cape Town. The study was conducted in two parts. The first part of the study was comprised of data collected from 491 medical records of AYLHIV accessing HIV care in these facilities. The second part of the study sought to investigate the epidemiology of NCDs and NCD risk factors and to assess multilevel factors associated with abdominal obesity (the primary outcome). I recruited 176 eligible AYLHIV to participate in the study with primary data (on NCDs and NCD risk factors) collected from 92 participants during routine clinic visits between March and December 2019. Results: The findings from the 491 patient medical records reviewed demonstrated limited attention to NCD comorbidity prevention, screening and treatment within adolescent HIV primary care services. Only 62% of patient folders had documented anthropometric measurements, 59% had documented blood pressure measurements, and less than 11% of patient folders reviewed had any NCD health promotion documented. Among the 92 participants recruited for primary data collection, 76% were female. More than a quarter (27%) were not in education, employment or training; 70% lived in food-insecure households, and 44% were multidimensionally poor. At the individual level, a high prevalence of NCDs was found, particularly elevated blood pressure and hypertension (20% and 5% respectively), overweight/obesity (36%), central obesity (37%), and depressive symptoms (43%). With respect to NCD risk factors, 69% reported engaging in sufficient physical activity (79% of males and 66% of females), and 49% reported three or more hours of sedentary behaviour per day. However, unhealthy dietary practices were common, with only 27% eating fresh fruit, 52% eating vegetables and 33% eating whole grains daily. On the other hand, 29% drank sugar-sweetened beverages, and 33% ate sweets and cakes daily, while 42% skipped breakfast regularly. Furthermore, nutritional knowledge was low, especially with respect to healthy food choices and dietdisease relationships. Risky behaviours were also prevalent with 30% current smokers (48% males and 25% females) and 41% alcohol use in the past month (58% males versus 36% females), with binge drinking most commonly reported in the youngest age group < 18 years (55%). Significantly more malesreported lifetime use of any illicitsubstances(53% versus 30% for females), with cannabis the most frequently reported substance used (23% lifetime prevalence). Beyond individual-level risk factors, household-level factors were also explored. More than half (58%) reported the death of one or both parents, while 47% reported a biological parent as their primary caregiver. Parental level factors were largely positive, with participants reporting high levels of positive parenting and parental supervision. However, 35% lived in informal dwellings, 38% did not have access to piped water inside their dwelling and 62% experienced thermal discomfort in winter. Community experiences revealed a mixed picture, with 61% of participants exposed to high levels of community violence, while participants largely reported high neighbourhood belonging and low levels of stigma. Multilevel regression was conducted to investigate the factors associated with abdominal obesity at different socio-ecological levels. All models were adjusted for sex and age. Statistically significant individual-level risk factors that were associated with higher odds of abdominal obesity were skipping breakfast (OR= 5.42; 95% confidence interval (CI): 1.32 – 22.25) and absence from school or work (OR= 3.06; 95% CI: 1.11 – 8.40), while daily whole grain consumption (OR= 0.20; 95% CI: 0.05 – 0.71) and weekly moderate-intensity physical activity (OR = 0.24; 95% CI: 0.06 – 0.92) were associated with lower odds of abdominal obesity. At the household- and community levels, experiencing thermal discomfort was associated with increased odds of obesity (OR= 4.42; 95% CI: 1.43 – 13.73), while higher anticipated stigma was associated with reduced odds of obesity (OR= 0.58; 95% CI: 0.33 – 1.00). The features of the built and food environment that were associated with reduced odds of abdominal obesity in AYLHIV were land-use mix diversity (OR= 0.52; 95% CI: 0.27 – 0.97), access to recreational places (OR= 0.37; 95% CI: 0.18 – 0.74), higher perceived pedestrian and traffic safety (OR= 0.20; 95% CI: 0.05 – 0.80), and having a non-fast-food restaurant within walking distance (OR= 0.30; 95% CI: 0.10 – 0.93). Conclusion: These results indicate an existent burden of NCDs and NCD risk factors in urban AYLHIV. Beyond the NCD risk attributable to HIV and ART, these multiple risk factors coupled with early initiation of high-risk behaviours like smoking and harmful alcohol use further increase NCD risk. Despite high NCD comorbidity and risk, evidence shows little to no integration of health services and limited responsiveness with regards to NCD health promotion. These findings underscore a missed opportunity in multimorbidity prevention. Overall, these findings highlight the need for a comprehensive, integrated approach for AYLHIV to both prevent and manage NCD multimorbidity within primary care. This integrated approach should include mental health assessment and screening for weight status, abdominal obesity and blood pressure to identify comorbid NCDs early and intervene to improve NCD outcomes. Additionally, risk factor screening should be incorporated into HIV care to prevent NCD multimorbidity. Screening should include early identification of the most common NCD risk factors (insufficient physical activity, poor dietary practices, smoking, alcohol use and binge drinking, particularly in male adolescents and younger age groups). These findings also highlight the need for intervention at various levels of the socio-ecological framework through multisectoral interventions in the social and built environments. Finally, this thesis contributes an evidence base to inform the development of integrated and intersectoral models of care to address the colliding epidemics of HIV and NCDs in young people in LMIC settings.

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.