This thesis is a critical examination of directing within the context of devising performance practice. It emanates from my need to make sense of the particular ways in which I work as a theatre director who engages with devising performance coupled with an identified lack in the literature that speaks to directing and devising performance from a Southern African perspective. The notion of the [un]knowing director is posited as the central concept that is evidently plausible for the particular context of devising performance practice argued for in the thesis. The key argument expressed in this thesis is that [un]knowing is a way of knowing realised through intuition and collaboration as co-constitutive or symbiotic aspects applicable to the study's particular contexts of directing and devising performance practice. To be more specific, the study investigates how the [un]knowing director makes artistic discoveries and decisions/choices during the moment-to-moment unfolding of a devising process. The notion of the [un]knowing is conceptually explicated by drawing from Tim Ingold's ideas of wayfaring and wayfinding (2000 & 2011), Henri Bergson's (1907) philosophical conception of time understood as duration, and Leopold Senghor's Africanist philosophy that speaks of rhythmic attitude, reason-eye and reason embrace (Diagne, 2019). This thesis is located within the sphere of nonrepresentational theory and purports for knowledge, within the context of directing and devising performance, as an undertaking that is non-predetermined and emergent in character. In terms of its methodology, this study is generally located within the methodological terrain of qualitative research and specifically employs practice as research. Specifically, its methodology entailed a structured questionnaire responded to by seven Southern African devising performance directors. The questionnaire's general research aim was to identify the plausibility of the [un]knowing director concept based on other director's experiences of devising performance. Thereafter, three creative research projects in the form of devising performance processes, were undertaken. These projects served as related case studies constituting an investigative cycle. The research method of autoethnographical devising session note-taking and reflective accounts was used in generating the necessary data through the creative research projects. Essentially, this thesis concludes that the [un]knowing director knows through intuition and collaboration in ways that are particular to its critical examination of directing and devising performance. These two ways of knowing are complex in their nature and characterised by the elements of initiation, facilitation and decision making during the moment-to-moment unfolding of a devising session. Relatedly, this thesis refers to the [un]knowing director's momentary undertakings as the molecular, micro and macro levels of artistic activity. Ultimately, this thesis concludes that the [un]knowing director has a complex genealogy emanating from the Southern African oral performance tradition. Thus, the [un]knowing director's practice is story-like and significantly affected by time.

Background: The emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic has unravelled a global demand for rapid and reliable guidance at the clinical, systems, and policy levels. Therefore, to equip decision-makers with the appropriate knowledge and tools, organizations have published evidence-informed guidance for its prevention and treatment. Objectives: Various organizations may produce comparable but diverging recommendations for the same intervention or health scope. Diverging recommendations are those that contain varying judgements in their strength, direction, or subgroup consideration associated with the intervention. Nonetheless, the extent of divergence between COVID-19 recommendations remains unknown. Consequently, the primary objectives of this study are to 1) describe the frequency and types of divergence between COVID-19 recommendations for the same intervention and 2) investigate differences in the guideline development process for a selected sample of diverging recommendations. Methods: We screened guidelines for divergence using the digital COVID-19 Recommendations Catalogue (covid19.recmap.org). Diverging recommendations for the same intervention were grouped into clusters, and differences in their formal judgment of strength and direction were appraised. Additionally, we compared any differences between PICO criteria for comparable recommendations addressing the same health scope. Descriptive statistics were performed to assess the frequency and types of divergence. Finally, we applied deductive content analysis to evaluate differences in the methods for a sample of 12 recommendation clusters. Results: Two-hundred twenty-three diverging recommendations resulted in the categorization of 66 clusters. Twenty-nine clusters contained clinical also stated as therapeutic recommendations, and 37 clusters contained public health recommendations. Each cluster had a range of 2-8 individual recommendations in divergence with at least one recommendation for the same intervention. Clinical recommendations were more likely to diverge in formal judgment than public health recommendations (P < 0.001). We identified differences in the date of publication, the interpretation of evidence, and in the judgments of the Evidence-to-Decision framework between comparable recommendations. Consequently, results from our study may have important implications for comparing duplicate recommendations and for making clinical practice decisions. Conclusions: From our study, we have identified diverging recommendations for a range of COVID-19 related interventions. These recommendations may have important implications for clinical practice and public health decisions. / Thesis / Master of Public Health (MPH)

No description available.

Background: Diarrhoea remains one of the leading causes of mortality in young children. After dehydration and malnutrition, electrolytes disturbances are an important complication of diarrhoea. In Cape Town, fluctuation of plasma sodium and potassium has been observed in childhood diarrhoea and were seasonal in their occurrence. A study conducted at Red Cross Children's Hospital found that seasonal fluctuations of plasma sodium and potassium were associated with specific enteropathogens but did not identify associations that suggested potential public health interventions that could target the electrolytes disturbances. It is possible that by identifying association with the enteropathogens directly, one could identify public health interventions to avoid seasonal electrolyte disturbances. Objectives: To identify clinical, nutritional, socio-economic, socio-demographic and seasonal associations with childhood diarrhoea caused by the enteropathogens Shigella, Salmonella, enterotoxigenic E. coli, enteropathogenic E.coli, Cryptosporidium, rotavirus or Campylobacter. Methods: This study was a secondary analysis of a cross-sectional study of infants less than 2 years old admitted to the Rehydration Unit of the Red Cross Children's Hospital with diarrhoea. Data were obtained through routine medical records and a questionnaire. Multiple logistic regression was performed to identify determinants of the diarrhoea-associated electrolytes disturbances. Results: Height for age was negatively associated with enteropathogenic E.coli (OR: 0.82, p-value: 0.039), Campylobacter (OR: 0.87, p-value: 0.082) and Salmonella (OR: 0.79, 0-value: 0.029) in the bi-variate analysis. Weight forheight and height for age were associated respectively to rotavirus (OR: 1.24, p-value: 0.011) and enterotoxigenic E.coli (OR: 1.16, p-value: 0.064 ). Water source was positively associated with Enteropathogenic E. coli, Campylobacter and inversely associated with rotavirus. Toilet was positively associated with enteropathogenic E. coli and Salmonella. Average temperature was positively associated with Enteropathogenic E. coli, Enterotoxigenic E. coli, Salmonella and Shiga/la. In the multivariate analysis breast feeding was negatively associated with Cryptosporidium infection (OR: 0.13; 95% Cl 0.20-0.62) while average humidity was positively associated with Cryptosporidium infection (OR: 1.1 O; 95% Cl 1.05-1.16). Enteropathogenic E. coli infection was positively associated with average ambient temperature (OR: 1.16, 95% Cl 1.03- 1.30).The child's age was a determinant of Campylobacter, (OR: 1.05; 95% Cl 1.00-1.11 ). Formula feeding, (OR: 0.45; 95% Cl 0.20-0.99) average temperature (OR: 0.87; 95% Cl 0.81-0.95) and humidity (OR: 0.91; 95% Cl 0.80-0.94) were all protective of rotavirus infection. None of the socioeconomic variables were associated with specific enteropathogens. Discussion: The only determinant associated with Enteropathogenic E coli identified in this study was average temperature. This concurs with its summer isolation. No significant determinant was identified for Enterotoxigenic E. coli in this analysis. For Cryptosporidium, in the multivariate analyses were duration of diarrhoea, breast-feeding and average humidity were identified as significant determinants. With the exception of breast-feeding, none of these determinants could be amended through public health intervention. For Campylobacter, age and adequacy of drinking were identified as significant determinants during the multivariate analysis. Adequacy of drinking was the only significant determinant associated with Salmonella. Formula feeding, plasma pH, average humidity and average temperature were associated with rotavirus while associations identified with Shiga/la were duration of vomiting, plasma pH and average temperature. As above, none of the identified determinants could be changed to modify the occurrence of these enteropathogenic diarrhoea. Conclusion: Although associations with specific enteropathogens were identified, none of the associations identified suggest public health interventions to avoid seasonal electrolyte disturbances.

BACKGROUND: Recognizing the connection between food insecurity and health, healthcare institutions in the past decade have begun to provide food assistance to patients. Healthcare-based food assistance programs have previously found positive impacts on food security, overall health, and healthcare spending. However, there is a lack of guidance on creating, staffing, and funding of healthcare-based food assistance programs, which is a significant barrier to the availability, accessibility, and continuation of this important resource for food insecure individuals. To address the evidence-practice gap, this dissertation sought to identify barriers and facilitators to implementation and sustainability of these programs. METHODS: First, to understand the landscape of healthcare-based food assistance programs in the United States, a scoping review of the peer-reviewed literature was completed and 42 articles regarding 35 healthcare-based food assistance programs were identified. Content analysis was used to extract programmatic information from each article. Program components were then analyzed using the constant comparative method in order create a typology of programs. Second, to investigate an exemplar healthcare based food assistance program, a sequential mixed methods approach, guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework, was used to evaluate the implementation and uptake of a community health center-based mobile market (MM). Data from semi-structured interviews with MM staff and participants (n=24), direct observations (n=4), and a quantitative dataset containing electronic medical record data with ICD-10 codes and demographic and attendance data collected at the MM (n=3,071 health center patients) were analyzed. Thematic analysis and multiple logistic regression were used to identify barriers and facilitators to MM use. RESULTS: The scoping review and typology indicate that implementation of healthcare-based food insecurity assistance programs is influenced by program goals, staffing, existence of willing community-based partners, and refrigeration and storage space. Participants reported that facilitators to use of a healthcare-based MM include financial need, simple registration processes, a centralized location, and comfort and familiarity with the health center; barriers to use include impaired mobility and lack of communication regarding MM dates. Analysis of medical record and MM attendance data indicate that cardiometabolic disease (e.g., type 2 diabetes and cardiovascular disease) is not associated with use of the MM. CONCLUSION: Investment in healthcare-based food assistance programs can provide patients with needed support to improve food insecurity and maintain health. Healthcare institutions should aim to direct as much funding as possible to providing all food insecure patients, not just those with nutrition-related comorbidities, with either food or an increased ability to purchase food (e.g., financial assistance, food vouchers, and federal food assistance program enrollment). To achieve this goal, healthcare institutions should consider: 1) maximizing benefits to patients while minimizing costs to the institution, 2) minimizing barriers to participation, 3) designing programs in line with their unique patient populations’ needs, and 4) planning with sustainability in mind. / 2025-08-03T00:00:00Z

Background: Intrauterine growth restriction (IUGR) is a major contributory factor of perinatal morbidity and mortality. This suboptimal growth is associated with infants being small-for-gestational age. In addition to genetic and placental factors, maternal factors such as infection are also responsible for IUGR. Numerous studies have shown that HIV infection could increase the risk of IUGR. Given the consequences of IUGR, determining the incidence of IUGR in a high HIV prevalence setting is essential. Screening for foetal growth abnormalities is an essential component of antenatal care, with foetal ultrasound playing a key role. Improving antenatal detection of IUGR in resource limited settings could improve perinatal outcomes. Methods: This research is a secondary analysis of a large prospective observational study conducted among pregnant women, seeking antenatal care at the Gugulethu MOU in South Africa. Pregnancy dating and foetal size was determined by research ultrasound in women ≤24 weeks' gestation. Women from the overall cohort were included if they had a singleton pregnancy, at least one ultrasound and a recorded estimated foetal weight. A subset of HIV-infected women enrolled in a longitudinal component were included for additional analyses. Growth restriction was determined using INTERGROWTH-21ST Project Standards. The incidence of IUGR was compared by HIV status in the overall cohort; while the relationship between estimated foetal weight and birthweight and size for gestational age was explored through regression modelling. Results: 1391 women were included in the overall cohort, and had an ultrasound at a median gestational age of 19 (16-23). The incidence of IUGR was very low (1.3%); with an unexpected difference observed by HIV status. In the nested cohort (n=453), using the ultrasound conducted at median gestational age of 28 weeks (27-28), an association between estimated foetal weight and birthweight was observed (β = 1.16, p <0.01). However, no association observed between estimated foetal weight and size for gestational age. Conclusions: While an unexpected difference was detected in IUGR by HIV status, further research is needed, into the incidence of IUGR in populations with HIV, taking into consideration ART status. Further exploration of the ability of foetal biometry to independently and accurately identify IUGR cases antenatally in resource limited settings is essential.

BACKGROUND: Measles is a leading cause of death among children globally. Nationwide non-selective campaigns together with routine immunization have sharply reduced measles cases and deaths in many low- and middle-income countries (LMICs). However, since 2018, vaccine funders (especially Gavi) are urging countries to consider targeted and selective measles-rubella campaigns. In 2021, Senegal conducted a nationwide selective campaign, with a door-to-door census to identify un- and under-vaccinated children needing a measles-rubella vaccine, followed by a vaccination campaign three weeks later. An evaluation of the selective campaign in Senegal and a scoping review on targeted and selective campaigns were conducted to assess if the evidence supports use of these strategies. METHODS: For the scoping review, publications relevant to LMICs were sourced from key word searches on PubMed and Embase, and through consultation with measles-rubella experts, who also advised on data extraction and synthesis. To evaluate Senegal’s campaign, census and vaccination data were reviewed and 56 key informants were interviewed across national, regional, district, and health facility levels to understand campaign outcomes, barriers, and facilitators. The RE-AIM framework was used to interpret the findings. The scoping review and evaluation findings were presented during a World Health Organization (WHO) consultation in March 2023. OUTCOMES: The scoping review found insufficient published evidence on the relative benefits of targeted and selective campaigns and no evidence-based guidance to consider them. The review proposed definitions for “tailored”, “targeted”, and “selective” campaigns; consensus was reached on the definitions during the WHO consultation. The evaluation in Senegal revealed that only 23% of the estimated 913,445 un- and under-vaccinated children were identified during the census. Several respondents recommended against using a selective campaign in the future due to difficulties with conducting a complete door-to-door census, misallocation of resources for the vaccination campaign based on an incomplete census, and challenges with vaccinating all identified children in a mobile population. CONCLUSION: The selective measles-rubella campaign in Senegal was unsuccessful in vaccinating most un- and under-vaccinated children and suggested that these approaches may not succeed in countries with limited operational capacity and weak information systems. The evaluation and scoping review findings informed WHO’s decision to develop interim guidance on targeted and selective campaigns in 2023. / 2025-07-25T00:00:00Z

The World Health Organization (WHO) recommends antiretroviral therapy (ART) initiation at the time of HIV diagnosis irrespective of immunological criteria – known as Treat-All – aiming at improving individual level health outcomes and reducing HIV transmission. However, concerns were raised about the feasibility of further treatment expansion in already fragile health systems in resource-limited settings (RLS). This thesis evaluates the feasibility of ART expansion under the Treat-All approach in a public sector setting in Eswatini. A wide range of HIV care expansion outcomes were explored at patient, programme, and population level. The studies were conducted in outpatient departments of primary and secondary care facilities of the predominantly rural Shiselweni region of Eswatini, from 2007 to 2016. The study population consisted of people living with HIV (PLHIV) who were offered ART under Treat-All and standard of care (SOC) as well as HIV co-infected tuberculosis (TB) patients. The result section of this thesis presents the findings through submitted and published manuscripts. The first paper describes the feasibility of rapid public sector ART expansion before the Treat-All approach became policy. The active ART cohort and treatment coverage among PLHIV expanded approximately 8-fold. Attrition decreased over time, which was most pronounced in the most recent treatment cohort. Attrition remained high for previously described higher risk socio-demographic (e.g. young age, men), clinical (e.g. higher WHO clinical stage, lower CD4 cell count), and programme factors (e.g. toxic drug regimens). The second paper investigates the feasibility of ART initiation under Treat-All compared with SOC. ART initiation was higher and quicker under Treat-All, mainly because more patients with high baseline CD4 cell count initiated treatment under the policy of universal ART. ART initiation was delayed for patients co-infected with TB disease under Treat-All, but was higher overall after 1 month compared with patients without TB. Patients presenting with advanced HIV disease (CD4 < 200 cells/mm3 and/or WHO III/IV clinical stage) had similar cumulative ART initiation rates with both interventions, although initiation was faster under Treat-All during the first month after care enrolment. The third paper assesses treatment outcomes of patients initiated on ART under Treat-All compared with SOC. Patients under Treat-All initiated ART with a higher median CD4 cell count and were more likely to achieve viral suppression. The risk of an unfavourable treatment outcome and viral failure was similar between both interventions. Under Treat-All, previously described higher risk socio-demographic (e.g. younger age, pregnancy) and clinical factors (e.g. low CD4 cell count, higher WHO clinical staging) increased the risk of the unfavourable outcome. The fourth paper evaluated the effectiveness and efficacy of ART initiation on the day of facility-based HIV care enrolment under Treat-All compared with patients initiated 1 to 14 days after care enrolment. Among patients initiated on treatment, same-day ART initiation increased the risk of an unfavourable outcome. This effect was mainly seen during the first months of ART after HIV care enrolment. The fifth paper describes temporal trends in HIV-associated TB during rapid ART expansion including the time-period of Treat-All. Notifications of TB disease decreased by 5-fold over a period of 8 years, and the decline was most pronounced in HIV-associated TB disease compared with HIV-negative TB. The main population-level predictor of TB disease was HIV disease, and the decline in TB coincided with increased access to ART in PLHIV. The thesis concludes that ART expansion and Treat-All are feasible in this RLS, by achieving favourable HIV care outcomes in terms of ART initiation and treatment, for patients with high CD4 cell counts as well for patients presenting late to HIV care. It also highlights the potential population level impact of rapid ART expansion on reducing the burden of HIV-associated TB disease over time. It cautions however against the assumption that outcomes will be improved through ART initiation on the same day as facility-based HIV care enrolment under the Treat-All approach.

Includes bibliographical references (leaves 47-52). / The aim was to describe the profile and clinical outcomes of all persons attending an HIV -service in a resource-limited setting, in Khayelitsha, Cape Town.

Includes bibliographical references (leaves 44-45). / The aim of the current study was to investigate factors that influence the use of insecticide treated bed nets in a rural community in Mangochi district in Malawi.