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.

Early fertility remains a public health concern in South Africa, with teenage pregnancy rates remaining high, and more significantly among black adolescent girls of low socioeconomic status. This indicates the unmet need of contraception for adolescent girls. Contraceptive use and non-use by young women of low socioeconomic status is a complex issue that reveals a range of political and socio-economic injustices. Barriers to contraceptive access and use have been identified to include: health care access, interaction with healthcare providers, genders norms, knowledge gaps, reproductive choices, socio-cultural attitudes and policing, intimate partner relationship dynamics, parental judgement, and side effects. To address this public health concern there has been an increase in the provision of contraceptives through the introduction of long-acting reversible contraceptive (LARC) methods. However, young women's response to LARC methods has been characterized by low and declining uptake and early removals. A tension exists between the way public health practitioners imagine meeting the contraceptive needs of young women of low-socio economic status and what it is acceptable as contraception by young women. This mini-dissertation aims to examine young women's perceptions of long-term contraception and LARC methods; specifically, the implant and intrauterine device (IUD) contraceptive methods in how they reveal young women's fertility attitudes and how it shapes their contraceptive decision-making. This examination foregrounds the individual, interpersonal relationships and social contexts that shape sexual and reproductive choices of young women. The mini dissertation is structured in two parts: the research protocol (Part A) and a manuscript for a journal article prepared for publication (Part B). Part A explores the factors that influence young women's contraceptive decision-making at three different levels, namely: the individual level, interpersonal relationship level and social and structural context level. For the aim of further understanding young women's contraceptive decision-making, PART B focusses on examining the tensions in the acceptability and uptake of LARC methods and long-term contraception use to explain low and ineffective contraceptive use by young women, which often result in unwanted pregnancies. The findings from this mini dissertation can add to the existing literature that examines why current contraceptive provision has been inadequate in meeting the contraceptive needs of young women of low socioeconomic status and significantly curbing early fertility. Additionally, they can provide valuable information to public health practitioners on how particular factors influence the acceptability of contraceptive methods and as well as the root causes of behaviors that result in ineffective contraceptive use resulting in early fertility. Therefore, providing clear points for public health intervention.

This study explores factors that influence condom use decision-making of adolescents from two schools in the Western Cape, South Africa. Thematic analysis was used to analyse the data generated from 16 individual semi-structured interviews. When exploring the factors that influence adolescent’s condom use decision-making, sexual debut and the role that emotion plays in the decision-making process were frequently discussed. The themes which emerged for sexual debut included relationships were about displaying true love which was equated with having sex and respecting parents’ expectations and rules informing decisions not to have sex at this age. When exploring the themes which emerged for condom use decision-making, the adolescents spoke about their concerns for the future and organising their lives. In addition, anticipated fear about falling pregnant, becoming parents and being infected with a disease emerged when exploring adolescent condom use decision-making. Understanding adolescent condom use can assist in aligning sexual and reproductive health (SRH) interventions and supporting healthy SRH decision-making and healthy relationships for adolescents.

Behavioural research studies often include a data acquisition process, during which subjects are observed, and the displayed behaviours recorded, and a subsequent analysis process, during which the observed behaviours are analysed. In addition the data acquisition process could occur in real-time, or at a later stage, by referring to a recording of the original session. This dissertation addresses the latter approach through the use of computer based digital video technology. A windows based video analysis system, called VAS, that was developed to assist with the acquisition of observed behaviours from the video, and the analysis thereof is discussed. This is followed by a discussion of the implementation of VAS. Finally the directions for further research are identified, and discussed. / Thesis (M.Sc.)-University of Natal, Pietermaritzburg, 1996.