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To achieve the goal of universal health coverage, no one should be left behind. To achieve this goal, refugees and asylum seekers should be prioritised due to their heightened risks. This would improve health outcomes and assist in attaining the Sustainable Development Goals (SDGs) of 2030. In the South African context, numerous studies have been conducted on access to health care services from asylumseekers and refugees' perspectives. It is a complicated problem, however, both the service providers' point of view and that of the patient need to be explored and understood deeply for effective action to be taken. A lack of studies from the service providers (professional and enrolled nurses) lens on asylumseekers and refugees accessing healthcare services, specifically in Musina, Limpopo, South Africa, motivated this study. The study aimed at providing more information on the perceptions and practices of nurses on asylum-seekers and refugees accessing health care services. A qualitative approach was utilised to explore the perceptions and practices of nurses with regards to asylum-seekers and refugees accessing healthcare services. The study was conducted at Nancefield clinic and the Musina hospital in Musina with professional nurses. Semi-structured interviews were utilised to collect data and a thematic analysis approach was utilised to analyse the data. The study provided some insight on the perceptions and practices of healthcare providers. Due to the small sample size, it cannot be concluded that there is no systematic discrimination of asylum-seekers and refugees in South Africa. Nurses were incorrectly classifying asylum-seekers and refugees as economic migrants. Most nurses were of the view that the majority of their patients were migrants, including asylum-seekers and refugees. Nurses said that they apply the law in their practices as expected. Nurses believe in work documents and the hierarchy of power. These two factors guide nurses when interacting with asylum-seekers and refugees accessing their services. The study recommends that stakeholders that are working with refugees and asylum-seekers conduct capacity-building activities with nurses to raise awareness on the relationship between migration and health or government requests training.

Communities are an important part of health systems as they assist in the monitoring of health service quality and providing the end users with a voice. This is particularly important in South Africa where there is a quadruple burden of disease, and a history of social injustice which continues to impact social determinants of health in communities. This presents significant challenges to provide high-quality health services in South Africa. To redress these health challenges, the South African government is relying on community-led mechanisms aimed at enhancing access to and strengthening of health services in communities. By using ethnographic methodologies, this paper explores the role of Street Committees (SC) in strengthening health services in a low-income setting in South Africa. The mini thesis is divided into two parts, a research protocol (Part A) and journal ‘ready' manuscript (Part B). Part A explores the historical, current, and future roles of SC in Gugulethu as well as identifying gaps in literature. Part B focuses on emerging roles from the data collected on SC in strengthening health services in Gugulethu. This thesis shows that although SC do not see themselves as health stakeholders nor are perceived by others as such, they do play a significant role, as they strengthen access to health care services through their numerous roles in the community. SC strengthen access to health services by enhancing physical access to health services, bringing medication to the frail and elderly, informing and educating the community about services and health issues and lastly by advocating for high quality health care in their community. This article also highlights the different roles SC play in strengthening health services through collaboration, advocacy and community education and provides lessons for community engagement in health systems which can be used to provide quality, equitable and people centred health care for all.

The lives of young people in Khayelitsha are characterised by a series of intersecting challenges. These include inadequate access to education, limited opportunities to find gainful employment, exposure to violence and the risk of contracting HIV. Several conventional avenues of transition to adulthood, for example achieving financial independence, moving out of the parental home or getting married, remain unavailable to many. The majority thus find themselves in a situation of waithood, an interminable period between childhood and adulthood characterised by extreme uncertainty. This thesis takes up questions of what it means to be a young man or woman navigating towards adulthood in this context of socioeconomic marginalisation. In particular, it explores the ways that youth negotiate the tensions between the structures that shape their lives and their opportunities for agency within the domains of gendered identities and sexual partnerships. Public health research and intervention with youth tends to rely more heavily on approaches underpinned by individual-level behaviour change theories, with lesser albeit growing attention paid to the structural forces that shape young lives. This thesis aims to balance the reading of individuals' capacity for agency in decision-making, with the broader structural forces that shape their life trajectories. To this end, a longitudinal, ethnographic approach was employed to capture nuances of context and experience as they unfolded and shifted through time and space. The data presented here is drawn from 18 months of ethnographic fieldwork with young people in the neighbourhood of Town Two, Khayelitsha, primarily collected between 2014 and 2015. Youth transition to adulthood is explored in the two interrelated domains of gendered identity and sexual partnerships. Within these domains, living up to individual and social ideals associated with masculinity and femininity is persistently challenging. Faced with these challenges, young people employ creative and dynamic strategies in their endeavours to maximize the precarious gains they make in their transition towards adulthood. Broadly speaking, these strategies include those linked to their physical bodies, sexual and social networks and the ways that they invoke ideas about what it means to be a young South African citizen. The findings highlight that in their transitions to adulthood, youth in Khayelitsha are neither complete victims, nor entirely free agents with the capacity to radically change their circumstances. This thesis ends by offering some recommendations about how public health programming might take into account the lived experiences of youth as they navigate the transition to adulthood in this context.

Men are less vulnerable to HIV acquisition than women, but have poorer HIV-related outcomes. They access HIV services less often and later, and are more likely to die while on antiretroviral therapy (ART). The adolescent HIV epidemic presents further challenges, and AIDS-related illness is the leading cause of death among adolescents in sub-Saharan Africa. Such deaths have tripled since 2000, while declining in all other age groups. There is a clear need to better understand health practices for adolescent boys and young men living with HIV, and the processes through which these practices are formed and sustained. This doctorate explores the biosocial lives of adolescent boys and young men living with HIV in the Eastern Cape Province of South Africa. It engaged health-focused life history narratives (n=36), semi-structured interviews (n=32) and analysis of health facility files (n=43), alongside semi-structured interviews with traditional and biomedical health practitioners (n=14). Young male participants were among the first generation to grow up with access to ART and democratic freedoms. In a context where HIV-positivity and men’s inability to fulfil traditional roles are considered signs of social and moral decay, they felt pressure to be ‘good’ HIV-positive patients and respectable young men. As younger children, they performed to norms of HIVpositive patienthood. As they became older, norms of masculinity, including financial achievement, ulwaluko (traditional initiation/circumcision), ‘moral’ behaviour and engaged fatherhood became more important and began to conflict with performances of ‘good’ patienthood. This was most apparent during and following ulwaluko, where societal norms made it difficult to engage with biomedical treatment and care. Despite this, participants and their families demonstrated agency, creativity and resilience in subverting and re-signifying these norms. Participants did not access traditional products or services for HIV-related issues, a finding that deviates from much of the literature. This study suggests that health practices are mediated not only by gender and culture, but also childhood experiences of growing up deeply embedded in the health system, through which participants forged additional health-seeking tools. Findings affirm the syncretic nature of traditional beliefs, documenting the plural and complementary ways that participants engaged with traditional products and services.

Disclosure of HIV status to children is a challenging process for caregivers, as it involves discussing a highly stigmatised disease, which may cause psychological stress to a child. Despite the benefits of disclosing, rates of HIV disclosure remain low as caregivers face various obstacles preventing them from disclosing, and this can have long-lasting effects on the treatment adherence of HIV-positive children. This qualitative study explored the perspectives and experiences of caregivers, in order to understand their readiness to disclose HIV status to their children, and address the factors that assist and hinder the process. Caregivers of HIV positive children (aged 5-15 years) participated in two focus group discussions (11 in each), and in-depth interviews were conducted with eight additional caregivers. Two healthcare workers and 10 NGO staff were also interviewed. Three key themes emerged from the data: caregivers' avoidance or delay of disclosure, factors related to caregivers' motivations to disclose, and caregiver's perception of child readiness for disclosure. The findings support the view that caregiver readiness is a key element of child disclosure. The research identified how caregivers can be educated about the benefits of disclosure, and be guided to take responsibility for the process. As there is a lack of context-specific and culturally-sensitive recommendations for child disclosure in South Africa, this research can be used to broaden the case base to inform the development of standardised guidelines that will assist caregivers to effectively communicate and manage the process of HIV disclosure with their children.

This project will be completed as a requirement for the Master of Public Health (MPH) degree at the University of Cape Town. This study is linked to an already existing project of Médecins Sans Frontières (MSF), which is called the Welcome Service. The Welcome Service focuses on addressing barriers that HIV+ patients face when they are returning to care after disengagement from treatment. One of the common barriers to re-engaging in treatment that the project seeks to address is the unwelcoming approach that health care workers have towards patients that disengage from treatment. To address this barrier the Welcome Service provides intervention through training packages for health care workers. The training packages seek to address staff behaviour that is unhelpful and unsupportive to patients that intend to reengage with treatment. The Welcome Service was initially implemented at Michael Mapongwana Clinic in Khayelitsha. This Clinic is in a peri-urban settlement in the Western Cape province of South Africa. This was then scaled up to Ubuntu Clinic, also in the same location. To measure the change in the Welcome service project, baseline semi-structured interviews with health facility staff at Ubuntu Clinic were conducted. Health facility staff that were interviewed at baseline will participate in an in-depth interview as a follow-up after attending Welcome Service training. As an MPH project, I will conduct secondary data analysis from baseline interviews of health facility staff at Ubuntu Clinic. The analysis will focus on interviews in which the perceptions and attitudes of health facility staff towards patients who disengage from treatment were gathered. These interviews may also explore health facility staff's perspectives on the reasons for patients disengaging from HIV treatment and reasons that might help patients to reengage with HIV treatment. This current project seeks to address the research question: What are the perspectives of health facilities staff on patients who disengage from HIV care in Khayelitsha, Cape Town, South Africa. This study will use inductive thematic analysis and the analysis will be done in NVivo, a qualitative data management software program. The researcher will identify themes from the trancripts and will not use a predetermined theory to derive themes, but will allow the data to guide theme development. Interviews were conducted by the MSF research team in English. The participants included in the study were doctors, nurses, counsellors, data clerks, security guards, and allied health professionals at Ubuntu Clinic. The respondents were above eighteen years old and were in the capacity to give consent on their own. The MSF research team was responsible for the recruitment of participants. All health facility staff that participated in this study were requested to give written informed consent to participate in the interviews. The findings of the primary study have not been published yet because the project is still in progress. The researcher received the questionnaire that was used in the study and from there the researcher developed a research question for this project. Some of the questions from the questionnaire asked the health facility staff if they feel able to deal with patients who disengage and how they feel when dealing with a patient who is returning to care. A data-sharing agreement was signed by the researcher and MSF before the researcher received the data obtained from MSF's project. The researcher will have access to the transcripts of the interviews, which have already been transcribed. In reporting, the researcher will not include the participants' names or any identifying information to ensure anonymity and confidentiality. This analysis aims to inform current and future health interventions to re-engage people living with HIV (PLWHIV) who have disengaged from care.

South Africa continues to have the highest number of people living with HIV/AIDS in the world. HIV testing remains vital in the prevention and management efforts of the pandemic. Despite the efforts by the government, and local and international organizations to prevent the spread of HIV in men, HIV testing uptake in men continues to remain significantly low in the sub-Saharan Africa, including South Africa. Several factors, including experiences and perceptions of HIV testing services contribute to a low uptake and men's willingness to use HIV testing services in South Africa. This mini-dissertation explores men's experiences and perceptions of HIV testing services from a qualitative perspective. This mini-dissertation is divided in the following three parts. A research protocol (Part A) focuses on understanding men's experiences and perceptions of HIV testing in Gugulethu Township, Cape Town. A literature review (Part B) identifies literature on HIV testing in South Africa, gender norms and their impact on HIV testing uptake, men's perceptions of HIV testing, confidentiality issues, perceived benefits of HIV testing, and gaps in current literature. Lastly, a qualitative journal "ready" manuscript (Part C) focuses on men's experiences and perceptions of HIV testing services in Gugulethu Township, Cape Town. Desirably, this mini-dissertation will inform health interventions that are specific to men's health needs while also aiming to focus on health policies that are inclusive of men. This study will in part address the core issues men encounter when testing for HIV in Gugulethu Township.

What drives variance in wild animals’ ability to acquire, process, store, and utilize information is the key question of cognitive ecology. The intraspecific approach is used to examine this question as it can measure the effects of the environment and sex, while directly measuring potential correlations or trade-offs in cognitive abilities. This thesis seeks to study how cognition varies across environments, among-individuals, and between sexes. The ‘harsh environment’ hypothesis states that food variability and scarcity could drive changes in cognitive abilities that that may aid in foraging. However, this hypothesis is primarily studied in food hoarders, or animals that cache food and retrieve it over winter. In Chapter 1, I compare the serial reversal learning performance of high and low elevation non-food hoarding great tits (Parus major). I report that low elevation great tits performed more accurately on the task than high elevation birds, showing that elevation drove differences in cognitive ability, in a similar way to scatter hoarders but opposite to what was predicted by the ‘harsh environment’ hypothesis. In Chapter 2, I compare the spatial memory accuracy and proactive interference performance of high and low elevation great tits and find no relationship between these two measures and elevation, but I did find the first significant among-individual trade-off between spatial memory accuracy and proactive interference performance. This trade-off suggests that if the environment does increase or decrease spatial memory, we should see a concurrent evolutionary change in proactive interference. My elevation results differ from those observed in food hoarders which exhibited a positive correlation between elevation and spatial memory. In Chapter 3, I performed the second comparison of female and male differences in cognitive variance in a wild animal, by comparing variance in great tits for serial reversal learning and spatial memory. I find that there is no variance difference for serial reversal learning, but greater female variability in spatial memory. These results differ from those found in food hoarders, which found greater male variability in reversal learning, but not spatial memory. This also is the first time greater female variance has been found for a cognitive ability and provides preliminary evidence that spatial memory accuracy may be coded for on the sex chromosome pair in great tits. In Chapter 4, I tested a method to measure motor training and other cognitive abilities and found that black-legged kittiwakes (Rissa tridactyla) could complete the motor training task. With some modifications, this task could measure associative learning performance and be the first to investigate its fitness consequences in a seabird. This thesis shows that the relationships between cognition, elevation, and sex is species specific or at least differs between hoarders and non-hoarders. and future studies should continue to utilize variance partitioning approaches to investigate the inter-relatedness of these relationships within species. Ce qui détermine la variation dans la capacité des animaux sauvages à acquérir, traiter, stocker et utiliser l'information est une question clé en l'écologie cognitive. Une approche intraspécifique est utilisée pour examiner cette question puisqu’elle nous aide à mesurer les effets de l'environnement et du sexe, tout en mesurant directement les corrélations ou les compromis potentiels dans les capacités cognitives. Cette thèse étudie les variations cognitives selon l’environnement, entre les individus et entre les sexes. L'hypothèse « harsh environment » stipule que la variabilité et la rareté de nourriture pourraient entraîner des changements dans les capacités cognitives aidant à la recherche de nourriture. Cependant, cette hypothèse est principalement étudiée chez les espèces qui cachent de la nourriture pour la récupérer plus tard en hiver. Dans le chapitre 1, je compare les performances d'apprentissage inversé en série chez une espèce qui ne cache pas de nourriture, la mésange charbonnière (Parus major), provenant de sites à haute et basse altitude. Je rapporte que les mésanges charbonnières de basse altitude ont exécuté la tâche avec plus de précision que les oiseaux de haute altitude, montrant que l'altitude a entraîné des différences dans les capacités cognitives. Ce résultat est à l'opposé de ce qui était prédit par l'hypothèse « harsh environment ». Dans le chapitre 2, je compare la précision de la mémoire spatiale et les performances d'interférence proactive des mésanges charbonnières provenant de multiples sites à haute et basse altitude. Je ne rapporte aucune relation entre ces deux mesures et l'altitude, mais je démontre pour la première un compromis entre la précision de la mémoire spatiale et la performance de la proactivité d'interférence au niveau inter-individuel. Ce compromis suggère que si l'environnement influence la mémoire spatiale, nous devrions voir un changement évolutif correspondant dans l'interférence proactive. Mes résultats en lien avec l’altitude diffèrent des résultats trouvés pour les espèces qui cachent de la nourriture, chez qui les études antérieures ont rapporté une corrélation positive entre l’altitude et la mémoire spatiale. Dans le chapitre 3, j'ai effectué la deuxième comparaison des différences de variance entre mâles et femelles dans la variance cognitive chez un animal sauvage, en comparant la variance pour l'apprentissage inversé en série et la mémoire spatiale chez les mésanges charbonnières. Je note qu'il n'y a pas de différence de variance pour l'apprentissage inversé en série, mais je remarque que les femelles démontrent une plus grande variabilité que les mâles dans leur mémoire spatiale. Ces résultats diffèrent de ceux trouvés chez les espèces qui cachent de la nourriture. Ils ont trouvé une plus grande variabilité masculine dans l'apprentissage par inversion, mais pas dans la mémoire spatiale. C'est également la première fois que nous constatons une plus grande variabilité par rapport aux capacités cognitives chez les femelles. Ceci suggère que la précision de la mémoire spatiale pourrait être codée au moins en partie sur la paire de chromosomes sexuels chez les mésanges charbonnières. Au chapitre 4, j'ai testé une méthode pour mesurer les performances d'apprentissage moteur et d'autres traits cognitifs chez la mouette tridactyle (Rissa tridactyla). J’ai trouvé que les mouettes pouvaient accomplir la tâche d'apprentissage moteur. Avec quelques modifications, cette tâche pourrait mesurer les performances d'apprentissage par association et devenir la première tâche qui permet d’étudier les conséquences de l’apprentissage par association sur le succès reproducteur chez un oiseau marin. Cette thèse montre que les relations entre la cognition, l'altitude, et le sexe sont spécifiques à l'espèce, ou du moins diffère chez les espèces qui cachent ou non de la nourriture. Dorénavant, nos études devraient continuer à utiliser des approches pour partitionner la variance statistique afin d’étudier l'interdépendance des variables au sein des espèces.