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.

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.

Background: Cervical cancer is a common cause of death among women in developing countries, including South Africa. In 2000, the South African National Department of Health introduced the national cervical cancer screening policy, which states that every woman is entitled to three free Papanicolaou (Pap) smears in her lifetime, at 1 0-year intervals starting at the age of 30 years. A number of studies have indicated that the uptake of cervical cancer screening is dependent on the targeted population's knowledge, attitudes and practices (KAP) related to health-seeking behaviours. The aim of the study is to determine the baseline KAP to Pap smears and cervical cancer of women aged 25 years and older in Mitchell's Plain, Western Cape Province. Methods: A cross-sectional survey was undertaken among clients attending primary health care facilities in the Mitchell's Plain district, Cape Town, Western Cape Province. The study population consisted of women aged 25 years and older who presented at the public health care facilities in Mitchell's Plain between 1 April and 31 July 2002 and who consented to participate in the study. The data were analysed using the STAT A version 8 statistical package. Results: A total of 445 women were interviewed, most of whom were above the age of 30 years (72%), married (68%) and unemployed (68%). Ninety-five per cent said they had heard of a Pap smear; however, when asked what part of the body was examined during a Pap smear, only 4% correctly answered. Only 13% of the women knew that a Pap smear was a test for cancer of the cervix, although 52% recognised it as a test for cancer. Of the women interviewed, 73% had heard of cancer of the cervix. A total of 78% of women had had a Pap smear. The results indicated no significant association between ever hearing of a pap smear and the following predictors: age, educational level, marital status, pregnancy and the use of contraception. Women who were significantly more likely to have had a Pap smear included: older women, those who were in a relationship, owned a radio, were employed, had ever been pregnant or had heard of a Pap smear before. Main sources of information regarding Pap smears were reported to be posters (17%) and the radio (16%). Conclusions: The data suggest that although a very high proportion of the women (95%) had heard of Pap smears, a smaller proportion (78%) had actually had a Pap smear. This study showed that there were missed opportunities that the health workers could possibly have utilised to encourage women in the targeted age group to have a Pap smear while at the health facilities for reasons other than reproductive health. Women who had not been afforded the opportunity to have a Pap smear by the health provider reported a great interest in having a Pap smear, showing willingness to improve their health if afforded the opportunity. In order to reduce the high morbidity and mortality from cervical cancer in South Africa, very large numbers of women in the target age group need to be recruited to the screening programme. To be able to achieve an increase in the cervical cancer screening uptake, huge efforts have to be made to actively recruit women who are within reach of the health services, particularly any women who present at the health facilities.

Antiretroviral therapy (ART) first became available in the public sector in the Western Cape Province in Khayelitsha in 2001. This thesis describes the effectiveness of ART in Khayelitsha and the Province, following adult patients for up to five years on ART, and examining temporal trends over seven years during which time the availability of ART in the Province increased dramatically. Associations are explored with a range of clinical outcomes, and regimen durability and tolerability are described, together with regimen effectiveness when ART is administered to patients co-infected with tuberculosis. The results chapters of the thesis are presented in the form of published or submitted papers. The first paper corrects for under-ascertainment of mortality through linkages with the death registry. After five years on ART, four out of five patients were still alive. Survival did not deteriorate in more recent years despite the large increase in patient numbers. Patients who remained virologically suppressed experienced on average continued CD4 count recovery throughout follow-up to five years. The second paper describes the tolerability of each commonly used first-line antiretroviral drug in two townships in the Western Cape. Treatment-limiting toxicities were frequent and continued throughout follow-up in patients on stavudine (21% by 3 years on ART). Symptomatic hyperlactataemia or lactic acidosis as well as lipodystrophy were strongly associated with women initiating ART with a high initial body mass. The third paper explores the effectiveness of ART when co-administered with tuberculosis treatment, identifying that co-infected patients initiating nevirapinebased ART may be at a higher risk of virological failure, but that concurrent tuberculosis treatment did not otherwise compromise ART outcomes. The fourth paper, based on a household survey, provides an in-depth description of the Khayelitsha population demonstrating comparability with many of the urban settings in which ART is provided in the region. The final paper demonstrates that outcomes have not been compromised by the wider availability of ART in the Western Cape Province. The thesis concludes that the Khayelitsha and Provincial analyses provide considerable reassurance that the anticipated benefits of ART have not to date been eroded by health system weaknesses or contextual challenges.

Emerging as a global health crisis, the novel Coronavirus disease 2019 (COVID-19) pandemic has become a great threat to the stability and prosperity of economies and households worldwide. With the World Health Organization (WHO) declaring COVID-19 a Public Health Emergency of International Concern (PHEIC) in the earlier months of 2020 (WHO, 2020), COVID-19 has spread rapidly throughout the world- at a pace that has demanded an understanding of COVID-19 that goes beyond the clinical and pharmacological interventions that have since been put in place. COVID-19 has demanded a need for robust study and implementation of public policy, as well as, personal interventions that would work to contain the spread of the virus. COVID-19 has not only adversely affected the health of individuals- it has also adversely affected the economic standing of households worldwide. These adverse effects show that without active means of rapid mitigation, households in LMICs especially, will continue to experience great economic distress. Now, mitigation cannot start without a well-grounded understanding of the problem at hand. This is what this systematic review aims to address. This study aims to locate, appraise and synthesize the best available evidence relating to the economic impact of COVID-19 on households in low- and middle-income countries, through a mixed-methods narrative systematic review. Evidence from both qualitative and quantitative papers will be combined in a single synthesis. This will be done by adopting an “integrated” mixed-method synthesis methodology, whereby both forms of data- quantitative and qualitative-have been combined into a single mixed-methods synthesis. The quantitative data will be grouped into themes and then presented alongside the qualitative findings (which fall under similar themes) in a mixed-methods synthesis. Upon completing the review, it was found that the COVID-19 pandemic has reduced household income for households in LMICs, whilst also introducing an increased degree of volatility to it as well. The pandemic has also led to disruptions to education and employment, thereby disproportionately affecting the poor more than the well-off, as the former, due to structural constraints, failed to transition to online means of education and employment. There was also an increase in household food insecurity, as well as, female poverty. In order to cope, households have since reduced their consumption, and tapped into some of their savings and investments, amongst other forms of coping mechanisms. In response to this economic shock, many governments across LMICs have offered aid in the form of water and food parcels, as well as, cash transfers. It can therefore be said that households in LMICs have been hard-hit and left in worser economic conditions than they were in prior to the COVID-19 pandemic. This is mainly due to the loss of household income as a result of the lockdown measures that were introducedwhich made it difficult for many informal workers to have means of generating income during the period of the pandemic. The fall in remittances also contributed to the loss of total household income. In response to this, policy-makers and practitioners in LMICs need to tailor their social protection policies in a way that prioritises the implementation of pro-poor policies that work to “soften the (economic) blow” of the COVID-19 pandemic, particularly for the (economically) vulnerable. They also need to put in place policies which support and protect the incomes of existing informal forms of employment.

Includes bibliographical references (leaves 79-84). / [Motivation] A high prevalence of alcohol consumption and the negative impact of alcohol on rural communities in the Western Cape have been linked to coercive labour practices and the ease of availability of cheap, low quality white wine, typically packaged in foil bags (papsakke). A process is underway to regulate papsakke out of the market. However, limited research has been conducted on the use and impact of papsakke. [Aims and objectives] This study aims to determine the prevalence of, and risk factors for papsak consumption and problem amongst farm workers in the rural Western Cape. It also explores the attitudes of drinkers with respect to their choice of alcohol type and the practices of papsak drinkers, in order to identify target groups for community level interventions and to inform the consent and monitoring of developmental and/or restrictive interventions. [Study design] A cross sectional analytical study performed as a post hoc analysis of data obtained from a larger study on papsakke which included a farm worker survey. [Subjects] 461 female and male farm workers resident on predominantly wine grape producing farms in Stellenbosch, Franschoek and Vredendal in the rural Western Cape Province from February to May of 2004.

Includes bibliographical references (leaves 75-82). / The study was undertaken at a village called Ramotswa in Botswana. Botswana is a small country in Southern Africa with a population of 1.7 million people (Botswana Housing and Population Census, 2001). The study explores HIV/AIDS clients' and caregivers' perceptions of the Community Home-Based Care support programme. The people involved in the community home-based care programme included nurses, family welfare educators (FWEs), social workers, community volunteers, and drivers. An exploratory qualitative design was used. Collection of data was through in-depth interviews, as well as a focus-group discussion. The sample was obtained through purposeful sampling, and there were nine HIV/AIDS clients, and seven caregivers who participated in the study. Results of the study were analysed themeativally. Resulst showed that many caregivers are women, and that they perform the task of care-giving under very difficult situations of poverty, social isolation, fear and stigma. They needed financial, material spiritual, as well as professional support from the home-based care team and community members.