Research Articles (School of Health Systems and Public Health (SHSPH))

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Enhancing public health education through smart learning environments : integrating technology and pedagogy
Patrick, Sean Mark; Nicholas, Noel; Maritz, Melissa; Wolvaardt, Jacqueline Elizabeth (Liz) (Springer, 2025-08)
The landscape of public health education is transforming, and online learning technologies are rapidly being adopted. This narrative review examines how public health education has evolved by comparing traditional and online learning environments, focusing on how smart learning environments can enhance educational outcomes. The analysis is grounded in the community of inquiry framework, Gardner's theory on multiple intelligences, and the theory of self-regulated learning. This review first outlines the key competencies required by public health professionals, including epidemiology, health policy, and biostatistics, and then discusses how these competencies are taught traditionally. This description is followed by an exploration of online learning environments and the unique challenges faced by learners, such as the need for self-regulation and motivation. Smart learning environments should integrate adaptive learning technologies and personalized learning pathways to address these challenges and provide a more engaging and supportive learning experience. These technologies enable real-time feedback and customization of learning materials, allowing students to monitor their progress and adjust their learning strategies. Smart learning environments can also contribute to community and collaborative learning in online environments. Integrating smart learning environments into public health curricula can enhance student learning outcomes and prepare future public health professionals to navigate a rapidly changing digital world. The purpose of this review is to contribute to the ongoing discourse on the modernization of public health education by proposing a conceptual community of inquiry framework for smart learning environments, suggesting a balanced approach that leverages the strengths of traditional and online learning methods.
Breast milk bisphenol concentrations in Canada and South Africa and associations with body size among South African infants
Elsiwi, Basant; Bayen, Stephane; Chi, Zhi Hao; Goodyer, Cynthia G.; Hales, Barbara F.; Robaire, Bernard; Bornman, Maria S. (Riana); Obida, Muvhulawa; Moodie, Erica E.M.; Chevrier, Jonathan (Elsevier, 2025-11)
OBJECTIVE : Infants may be exposed to bisphenols (BP) via breastfeeding. These chemicals are known endocrine disruptors and may interfere with infant growth. However, their presence in breast milk and their associations with infant size remain unexplored in South Africa, where infants may be especially vulnerable to toxic effects. METHODS : We measured BPA, BPS, and BPAF in breast milk samples obtained 4–8 weeks postpartum from mothers residing in rural (Vhembe district; n = 193) and urban (Pretoria; n = 189) areas of South Africa and compared them to samples from Montreal, Canada (n = 206). Infant length and head circumference were measured in South Africa, with z-scores computed based on World Health Organization (WHO) growth charts. Random forest plots were used to identify top-ranked BP predictors, and linear marginal structural models were used to estimate associations between BP concentrations and infant size. RESULTS : BP concentrations were highest in Vhembe relative to Pretoria; in Montreal, only BPS was detected. Microwaving food in plastic containers and maternal diet were important determinants of exposure. In the combined South African sites, total BPAF detection was associated with greater infant length (β = 0.38 SD, 95 % CI: 0.09, 0.68) and head circumference (β = 0.52 SD, 95 % CI: 0.23, 0.81). Associations were strongest in Pretoria. In contrast, a tenfold increase in total BPA concentration was associated with a 0.20 SD decrease in head circumference (95 % CI: −0.39, −0.01) in Vhembe. CONCLUSION : Findings point to high BP exposure in rural Africa and suggest that exposure to BPA and BPAF may be related to altered growth among South African infants. HIGHLIGHTS • BPA, BPS and BPAF breastmilk levels were higher in Vhembe vs Pretoria and Montreal • Microwaving plastics and diet were associated with higher concentrations • Free and total BPAF were associated with greater length and head circumference • Total BPA was associated with smaller head circumference
Community interventions to prevent violence against women must follow best practice
Jewkes, Rachel; Ramsoomar, Leane (Elsevier, 2025-12)
Violence against women is preventable, but there is much to learn about how to do this. The evidence base largely comprises evaluations of interventions, which have multiplied in the last two decades. Many funded evaluations are small studies, but community-wide impact requires policy change and interventions delivered at scale. Violence against women practitioners have developed a range of approaches to community-wide interventions, with mixed results. These are often influenced by the SASA! Intervention of Raising Voices in Uganda, which was the first such study to show promise when evaluated, but there have been many subsequent variations, some adaptations, some substantially different in design. In India, a large-scale rigorous evaluation of such an intervention has not previously been undertaken. Nayreen Daruwalla and colleagues’ study represents a bold attempt to test their community-wide intervention delivered at scale in a large study conducted in the slums of Mumbai. The findings provide important lessons for the violence against women prevention evidence base.
Association between alcohol use and femicide in South Africa during the COVID-19 pandemic : a cross-sectional study
Abrahams, Naeemah; Mhlongo, Shibe; Dekel, Bianca; Ketelo, Asiphe; Lombard, Carl; Shai, Nwabisa; Ramsoomar, Leane; Mathews, Shanaaz; Labuschagne, Gérard; Matzopoulos, Richard; Prinsloo, Megan; Martin, Lorna J.; Jewkes, Rachel; Chirwa, Esnat; Mhlongo, S.; Ketelo, A.; Shai, N.; Ramsoomar, Leane; Jewkes, R.; Chirwa, E.; Dekel , B.; Abrahams, N.; Lombard, C.; Mathews, S.; Labuschagne, G.; Matzopoulos, R.; Prinsloo, M.; Martin , L.J. (Elsevier, 2025-07)
BACKGROUND : Alcohol use has previously been associated with femicide, the most extreme form of gender-based violence, but research on femicide from low-income and middle-income countries is scarce. We aimed to examine the role of alcohol restrictions during South Africa's COVID-19 lockdowns on femicide rates in the country. METHODS : In this cross-sectional study, we compared estimates of overall femicide, intimate partner femicide, and non-intimate partner femicide from two retrospective national surveys of female individuals aged 14 years and older killed in 2017 and during nine COVID-19 lockdown periods in 2020–21. Both surveys used multistage, stratified cluster sampling with mortuaries or medico-legal laboratories as the primary sampling unit. Sampling frames that listed all mortuaries operating in the country in each study year were developed and mortuaries were stratified by size on the basis of the number of autopsies they performed per year. Mortuary data were supplemented with investigative data extracted from police dockets during interviews with police members. Cases in which age and sex were unknown and in which the cause of death was undetermined were excluded from data collection. Linearisation was used to obtain robust variance estimators for parameter estimates. Female population estimates were derived from the Thembisa mathematical model to calculate age-standardised rates, and the WHO world standard population distribution was used to normalise weightings for age-standardised rate calculations. We used Poisson regression and incidence rate ratios (IRRs) with 95% CIs to compare femicide estimates for periods of complete and partial alcohol sales and curfews with periods of no restrictions and to compare data from corresponding calendar periods in 2017 and 2020–21. FINDINGS : We found no evidence of a significant change in age-standardised rates of overall femicide between 2017 and 2020–21 (IRR 0·95, 95% CI 0·88–1·03). Our Poisson regression results for 2020–21 showed no evidence of a significant difference in the average number of overall femicide cases between the first two lockdown periods, both periods with no alcohol sales but differing curfew levels (1·16, 0·88–1·54), but we found a significant increase in the average number of cases between periods 2 and 3, when alcohol sale restrictions were relaxed (2·14, 1·70–2·69). When combining periods with similar alcohol and curfew restrictions, we found a significant decrease in overall femicide cases between periods of no restriction and periods of restricted alcohol sales and night and late-night curfews (0·57, 0·49–0·66). Similarly, the average number of femicide cases during the period with a complete ban on both movement and alcohol sales was 63% lower than during periods of no restriction (0·37, 0·30–0·47). A similar significant difference was observed for both cases of intimate partner femicide (0·39, 0·28–0·53) and non-intimate partner femicide (0·39, 0·27–0·55). This pattern was not seen during the corresponding calendar periods in 2017. INTERPRETATION : The COVID-19 lockdown presented an opportunity to study the association between alcohol use and femicide in South Africa. We found a decrease in overall femicide, intimate partner femicide, and non-intimate partner femicide during periods of complete alcohol prohibition compared with periods of partial or no alcohol sale bans. This analysis supports alcohol use as a risk factor for severe gender-based violence and emphasises the importance of implementing evidence-based alcohol harm reduction interventions and policies as part of gender-based violence prevention strategies.
Prostate cancer clinicopathological presentation in South-East Africa during the 2010 decade
Patrick, Sean Mark; Ombuki, Winstar Mokua; Ndambuki, Joan; Oyaro, Micah O.; Bida, Meshack; Soh, Pamela X.Y.; Prins, Gail S.; Argos, Maria; Barnhoorn, Irene; Brewer, Daniel S.; Campbell, Raymond; Craddock, Jenna; Eeles, Rosalind A.; Jaratlerdsiri, Weerachai; Lebelo, Maphuti Tebogo; Loda, Massimo; Louw, Melanie; Lutsik, Pavlo; Madueke, Ikenna C.; Mbeke, Tumisang M.N.; Moreira, Daniel M.; Mutambirwa, Shingai B.A.; Nyaga, Muriuki Elias; Obida, Martin; Obida, Muvhulawa; Oyieko, Willis; Radzuma, Mulalo B; Shirinde, Joyce; Walker, Douglas I.; Walong, Edwin O.O.; Wanjiku, Githui Sheila; Wedge, David C.; Yienya, Allan; Hayes, Vanessa M.; Bornman, Maria S. (Riana); Ngugi, Peter Mungai (Oxford University Press, 2025-12)
Prostate cancer is the leading cause of cancer-associated death among men across Sub-Saharan Africa, with Southern and East Africa ranking first and fifth globally. However, lack of coordinated national cancer registries has biased data toward single-sourced, averaged, or model estimates. Here, our retrospective study included 8634 South-East African patients diagnosed between 2010 and 2019, which when compared with 71 694 Black and 322 356 White period-matched American men, were over threefold more likely to present with aggressive disease (International Society of Urological Pathology grade groups ≥4: 45.38% vs 21.22% and 21.05%; prostate-specific antigen ≥20 ng/mL: 62.04% vs 17.29% and 11.17%, respectively; all 2-sided P < .0001). East over Southern African men are 1.5 times more likely to present with advanced disease, however, age was not a confounder. Supporting prostate cancer as a major health concern for Africa, our data suggest underestimation in East Africa, while highlighting the need for accurate monitoring, increased awareness, and tailored screening criteria.
Men's knowledge, attitudes, practices, cultural beliefs, and perceived risk and susceptibility regarding prostate cancer in the Vhembe district, Limpopo province, South Africa
Patrick, Sean Mark; Shirinde, Joyce; Obida, Muvhulawa; Zikalala, Zazi; Hayes, Vanessa M.; Bornman, Maria S. (Riana) (Springer, 2026)
BACKGROUND : Prostate cancer (PCa) awareness and knowledge among men in Vhembe District, Limpopo Province, South Africa, remain inadequately studied despite the high local burden of the disease. This study investigates the knowledge, attitudes, practices, cultural beliefs, and perceived risk of PCa among men aged 40 and above in selected villages under the Mphaphuli and Niani tribal authorities. METHODS : A quantitative survey was conducted with 431 men, utilizing a questionnaire adapted from the African Women Awareness of Cancer (AWACAN) tool. The questionnaire, translated into Tshivenda, assessed socio-demographic data, awareness, knowledge of risk factors and symptoms, health-seeking behavior, and barriers to seeking medical help. RESULTS : The study revealed that 51.3% of participants had heard of PCa, while 48.7% had not. Awareness varied significantly with age, relationship status, education level, and language. Older men and those with higher education levels were more knowledgeable about PCa. Clinics, hospitals, and media were the primary sources of information. Misconceptions about risk factors were prevalent, with 24.0% of men indicating a preference for traditional healers for PCa symptoms. Barriers to medical help included fear of the disease, procedural fears, and cultural taboos. Multivariate analysis identified significant factors associated with PCa knowledge, including age, language, access to tap water, and cell phone ownership. CONCLUSION : These findings underscore the importance of targeted educational interventions considering sociodemographic and cultural contexts. Future public health initiatives should focus on bridging the gap between traditional and modern medical practices to enhance health outcomes in the Vhembe District and similar settings.
Determinants of household community based health insurance membership and healthcare expenditures in rural Awi Zone, Ethiopia : a bivariate logistic regression approach
Wolde, Zelalem Meraf; Getahun, Kefale Tilahun; Birhan, Nigussie Adam; Mitiku, Habtamu Dessie; Hailu, Kahsay Kiros; Belay, Denekew Bitew; Sheferaw, Wegayehu Enbeyle; Musekiwa, Alfred (Springer, 2025-12-11)
INTRODUCTION : In many developing countries, including Ethiopia, out-of-pocket expenditures for healthcare at the point of service delivery often hinder access to necessary health services, particularly in rural areas where poverty prevails. The purpose of this study was to assess the factors associated with healthcare expenditure and Community Based Health Insurance (CBHI) membership in rural areas of the Awi Zone, Northwest Ethiopia. METHODS : A community-based cross-sectional study on 2939 heads of household was conducted using a multistage sampling technique. The data were edited and cleaned using STATA 18 and analyzed in SAS 9.4. Bivariate logistic regression analyses were used to identify factors associated with healthcare expenditure and CBHI membership. RESULTS : Out of the 2939 participants, 1740 (59.2%) were members of the CBHI, and 1757 (59.8%) incurred healthcare expenses, Disability was a significant predictor for both CBHI membership (AOR = 1.45; 95% CI: 1.23, 2.86) and healthcare expenditure (AOR = 1.53; 95% CI: 1.07, 2.19). income with 5001–10,000Birr also a significant predictor for both CBHI membership (AOR = 0.43; 95% CI: 0.31, 0.58) and healthcare expenditure ( AOR = 1.69; 95% CI: 1.27, 2.24). no chronic illness also other significant predictor for both CBHI membership (AOR = 1.53; 95% CI: 1.23, 1.86) and healthcare expenditure (AOR = 1.3; 95% CI: 1.07, 1.58). In addition, gender, family size for health care expenditures, and place of residence for CBHI membership were significant predictors. CONCLUSION : These findings highlight the need for targeted interventions to improve the understanding and perception of CBHI among rural households, with a focus on these key determinants. Policies should aim to increase CBHI membership and minimize healthcare expenditure, and awareness campaigns should be enhanced, with a focus on vulnerable groups such as females, people with disabilities, those with chronic illnesses, and low-income households.
Modern contraception utilization and associated factors among adolescent girls and young women (AGYW) who participated in the Namibia DREAMS program
Moyo, Enos; Melese, Endalkachew; Mangwana, Hadrian; Takawira, Simon; Harases, Bernadette; Indongo, Rosalia; Moyo, Perseverance; Nyoni, Ntombizodwa Makurira; Dzinamarira, Tafadzwa (Springer, 2025-12-04)
OBJECTIVE : A significant gap exists in modern contraception utilization among adolescent girls and young women (AGYW) in Namibia, contributing to a high incidence of teenage pregnancies. This study assessed the utilization of modern contraceptive methods and related factors. STUDY DESIGN : We conducted a retrospective analysis of programmatic data from AGYW aged 15–24 who received clinical services through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program, implemented by Project HOPE Namibia, between 2018 and 2024. Data were analyzed using IBM SPSS version 29, employing Chi-squared tests and bivariate and multivariate logistic regression. RESULTS : Among the 28,945 participants in this analysis, 8420 (29.1%) used a modern contraceptive method. The most used method was the injectable (n = 5,205; 61.8%). Participants who had a higher likelihood of using a modern contraceptive method included those aged 15–19 years (AOR = 1.13, 95% CI (1.06–1.19)), with children (AOR = 2.20, 95% CI (2.04–2.37)), who were breastfeeding (AOR = 2.18, 95% CI (1.30–3.66)), and those who perceived themselves at risk of HIV (AOR = 1.15, 95% CI (1.08–1.22)). Participants less likely to utilize a modern contraceptive method included those who had recent or recurrent sexually transmitted infections (COR = 0.56, 95% CI (0.41–0.77)) and those who attended safe space HIV interventions (AOR = 0.85, 95% CI (0.78–0.93)). CONCLUSION : AGYW aged 20–24 years, those who do not consider themselves at risk of HIV, and those who participate in safe space interventions should be prioritized for initiatives aimed at improving contraception use. IMPLICATION : Several interventions, such as ensuring commodity security of preferred methods, enhancing education on SRH, and providing services on school premises to reduce health system and structural barriers, are required to ensure that AGYW in Namibia utilise modern contraceptive methods to reduce unwanted pregnancies and the risk of contracting HIV.
Impact of COVID-19 on household hunger and socio-economic inequality in South Africa: a comparative analysis using NIDS-CRAM (2020-2021) and NFNSS 2022 data
Lukwa, Akim Tafadzwa; Chiwire, Plaxcedes; Akinsolu, Folahanmi Tomiwa; Bodzo, Paidamoyo; Okova, Denis; Maseko, Sikelela Charles; Mokhele, Tholang; Parker, Whadi-ah; Mjimba, Vuyo; Simelani, Thokozani; Hongoro, Charles (Frontiers Media, 2026-01)
BACKGROUND : Food insecurity is a persistent socio-economic challenge in South Africa that was sharply exacerbated by the COVID-19 pandemic. This study compares household hunger during the acute pandemic period and the early recovery phase and examines how socio-economic inequalities in food security evolved. METHODS : We analyzed five waves of the National Income Dynamics Study-Coronavirus Rapid Mobile Survey (NIDS-CRAM, 2020-2021) and the National Food and Nutrition Security Survey (NFNSS, 2022). A harmonized 7-day household hunger indicator was recoded as "no household hunger" and modeled using survey-weighted logistic regression. Socio-economic-related inequality in being hunger-free was assessed using the Erreygers Concentration Index and decomposition analysis, with sensitivity checks for alternative socio-economic status (SES) specifications and model diagnostics. RESULTS : Hunger peaked at 26.47% in Wave 1 of NIDS-CRAM and declined to 16.07% by Wave 5, before falling to 8.19% in NFNSS. Improvements were uneven; several provinces, notably the Northern Cape, Free State and North West, remained comparatively food insecure. Across all waves and NFNSS, higher SES was strongly associated with a lower risk of hunger, and living in informal or traditional dwellings and larger household size were consistently associated with a higher risk of hunger. Erreygers indices were positive in all periods, indicating pro-rich inequality in food security that intensified during the pandemic and narrowed only modestly post-pandemic, with SES the dominant contributor. CONCLUSION : Although household hunger declined below pandemic peaks, the recovery in food security has been unequal and remains strongly patterned by socio-economic status and place, underscoring the need for structural, equity-focused policy responses.
Washed microbiota transplantation for ribotype 027 Clostridioides difficile infection in a pregnant woman with a two-year follow-up : a case report
He, Xinyi; Luthuli, Sibusiso; Wen, Quan; Wang, Chuan; Ding, Jinli; Cui, Bota; Zhang, Faming (Nanjing Medical University, 2026-01)
Clostridioides difficile (C. difficile) is one of the major causes of nosocomial infections. Pregnant women, who are generally considered at low risk for C. difficile infection (CDI), have attracted attention because of an increasing number of reports. Oral vancomycin, the only first-line treatment for pregnant women infected with C. difficile, has been associated with increasing strain resistance, leading to decreased efficacy. Fecal microbiota transplantation (FMT) is recommended for severe, fulminant, and recurrent CDI; however, it is generally avoided in pregnant women because of safety concerns. We report a case of a pregnant woman with a primary ribotype 027 CDI who experienced a successful outcome with washed microbiota transplantation (WMT), an improved form of FMT, via enema. The specific strain of ribotype 027 is related to severe outcomes but has not previously been reported in pregnant women. The follow-up lasted for two years, during which the patient's diarrhea was fully alleviated without recurrence. The baby showed normal growth and development, and no adverse events were recorded for either. This case provides evidence for the efficacy and safety of WMT in pregnant women infected with C. difficile, indicating that WMT via enema may be a viable therapeutic strategy for this population for treating CDI.
Undetected rifampicin-resistant tuberculosis associated with rpoB I491F and V170F mutations in Botswana : diagnostic implications
Mogashoa, Tuelo; Ngom, Justice T.; Loubser, Johannes; Seru, Kedumetse; Molefi, Tuduetso; Stephen, One; Musonda, Rosemary M.; Gaseitsiwe, Simani; Warren, Robin M.; Dippenaar, Anzaan; Streicher, Elizabeth M.; Moyo, Sikhulile (Elsevier, 2026-01)
BACKGROUND : Undetected rifampicin resistance is a threat to global tuberculosis (TB) control efforts by delaying effective treatment. In different studies, non-canonical rpoB mutations outside the rifampicin resistance-determining region have been reported at varying prevalences by country. Here, we report cases of rifampicin resistance in Botswana that were missed by the routine molecular diagnostic assays. METHODS : Individuals were tested under routine programme conditions, in accordance with national guidelines, at four designated drug-resistant TB clinics from 2017 to 2022. Initial testing at the facilities included GeneXpert MTB/RIF ultra and later phenotypic drug susceptibility testing (pDST), as well as the Hain MTBDRsl line probe assay, at the National Tuberculosis Reference Laboratory. A total of nine isolates were subsequently sequenced on the Illumina NextSeq 2000 instrument. RESULTS : At the point of care, routine molecular tests classified all nine individuals as susceptible to rifampicin. Subsequent culture and phenotypic drug susceptibility testing confirmed rifampicin resistance. Whole-genome sequencing identified non-canonical rpoB mutations outside the rifampicin resistance-determining region I49F and V170F, which are associated with low-level rifampicin resistance. Of the nine isolates sequenced, 4 (44%) harboured the rpoB V170F mutation, while 5 (56%) harboured the rpoB I491F mutation. CONCLUSIONS : These results highlight a diagnostic gap within the current algorithms and show the value of sequencing-based approaches for accurately detecting drug resistance. Incorporating sequencing into routine clinical practice could help guide the selection of TB treatment and improve treatment outcomes in patients who do not respond to first-line therapy. HIGHLIGHTS • Non-canonical rpoB mutations I491F and V170F detection in rifampicin-resistant isolates in Botswana. • These variants have low-level rifampicin resistance near MIC breakpoints. • Routine molecular tests, such as Gene Xpert or line probe assays, may miss these variants with mutations outside the rifampicin resistance-determining region. • Whole genome sequencing and minimum inhibitory concentration (MIC) testing may improve the detection of these variants.
Unsupervised machine learning to investigate the joint effects of SO2, NO2, O3, PM2.5 and PM10 on respiratory and cardiovascular hospital admissions in the Vaal Triangle Airshed Priority Area, South Africa
Mwase, Nandi Sisasenkosi; Kebalepile, Moses; Junger, Washington; Wichmann, Janine (Elsevier, 2026-01)
Please read abstract in the article. HIGHLIGHTS • Unsupervised machine learning can be used as a dimension-reduction tool in air epidemiology. • Clustering methods allow to investigate multiple air pollutants (5≤) effects on hospital admissions. • There are noticeable limitations in using unsupervised machine learning in air pollution epidemiology studies.
Implementation strategy for data-driven surgical systems : a South African perspective
Kluyts, Hyla-Louise; Biccard, Bruce M.; Chu, Kathryn; Maswime, Salome; Crisp, Nicholas (BMJ Publishing Group, 2026-01)
Surgical care is essential to achieving universal health coverage, yet many African low-income, lower-middle-income countries (LMICs) and upper-middle-income countries - including South Africa-struggle to harness healthcare data for surgical system strengthening. Despite global advocacy efforts and the adoption of surgical indicators such as perioperative mortality rate and surgical volume, fragmented routine health information systems, limited human resource capacity and siloed data architecture hinder effective, data-informed planning and policy. Drawing on a South African case study, this high-level perspective highlights institutional momentum for integrating routine perioperative data into strategic health planning, while also identifying key technical and operational challenges. The study demonstrated the inability of clinician-led initiatives to generate routine perioperative health information to guide practice at an institutional level. To close the implementation gap, a context-adapted approach, that includes participatory network weaving, stakeholder-driven data use cases and collaborative planning for interoperable data systems, is proposed. These elements are positioned within an implementation framework designed to support policy development, guide clinical practice and improve access to safe, high-quality surgical care across African countries. We propose taking advantage of opportunities for concurrent implementation assessment and adaptation of a clinical health information system module for South African surgical patients.
The role of welfare regimes on socioeconomic inequalities in edentulism : a cross-national analysis of 40 countries
Celeste, Roger Keller; Guarnizo-Herreño, Carol C.; Fritzell, Johan; Costa, Francine S.; Ayo-Yusuf, Olalekan Abdulwahab; Barros, Aluisio J.D.; Li, Huihua; Hariyani, Ninuk; Hackley, Donna M.; Blanco, Silvana; Gamonal, Jorge A.; Maupomé, Gerardo; Watt, Richard Geddie; Peres, Marco Aurélio De A. (Elsevier, 2026-04)
BACKGROUND : We aim to evaluate the association between welfare regimes and edentulism (total tooth loss) and to investigate whether welfare regimes modify the magnitude of socioeconomic inequalities in edentulism. METHODS : The Lancet Commission on Oral Health gathered and analysed nationally representative available data from 40 high, middle- and low-income countries, collected between 2007 and 2018. The study included 117,397 individuals 20 years or older. The outcome was edentulism, defined as the absence of all natural teeth. We categorised countries into seven welfare regimes, which served as both the primary exposure and an effect modifier. Individual-level variables included sex, age and a composite measure of socioeconomic position: “wealth” measured in quintiles. Inverse probability of treatment weight and multilevel logistic regression were employed to estimate the odds of being edentulous, and cross–level interaction terms between wealth and country factors. FINDINGS : Individuals at the lowest wealth quintile had the highest prevalence of edentulism in all regimes. The highest age-sex standardised prevalence was found in Eastern European countries (8.4%, 95% Confidence Interval: 7.6–9.3), followed by Corporative (8.1%, 95% CI: 7.0–9.3), while the lowest was among the Insecurity regime (0.8%, 95% CI: 0.4–1.5), followed by the Scandinavian regime (4.7%, 95% CI: 3.5–6.1). Liberal countries presented the highest magnitude of absolute and relative inequalities, where the lowest quintile had OR = 20.6 (95% CI: 15.3–27.8) times higher likelihood of being edentulous and 17.3 percentage points (pp) higher prevalence. Low-income countries in the Insecurity regime presented the lowest level of inequality. Among high- and upper-middle income countries, the Scandinavian regime had the lowest absolute inequalities (5.5 pp difference between highest and lowest quintiles). The Informal Security regime had the lowest relative differences between the highest and lowest quintiles (OR = 2.20, 95% CI: 1.06–4.59). INTERPRETATION : Our findings indicate that some welfare regime policies may enhance oral health while decreasing socioeconomic inequalities. Higher prevalence and inequalities among industrialised countries may reflect higher levels of oral health hazards.
Prevalence and determinants of full immunization among children under five in sub-Saharan Africa : a systematic review and meta-analysis (2013–2025)
Dzinamarira, Tafadzwa; Mano, Oscar; Musuka, Godfrey N.; Madziva, Roda; Mataruse, Noah; Mbunge, Elliot; Nkambule, Sphamandla Josias; Moyo, Enos (Elsevier, 2026-03)
BACKGROUND : Despite global progress in childhood immunization, Sub-Saharan Africa (SSA) continues to report suboptimal coverage and high under-five mortality. This systematic review and meta-analysis assessed the prevalence and determinants of full immunization among children under five in SSA between 2013 and 2025. METHODS : We systematically searched six electronic databases for studies published between January 2013 and May 2025 that reported the prevalence and/or determinants of full immunization in SSA. Eligible studies were original, peer-reviewed quantitative research. Data were analysed using random-effects meta-analysis, with subgroup and sensitivity analyses conducted to explore heterogeneity. Determinants were synthesised using pooled odds ratios (ORs) where applicable. RESULTS : Thirty-one studies comprising 299,898 children were included. The pooled prevalence of full immunization was 51% (95% CI: 45%–58%), with substantial heterogeneity (I2 = 100%). Prevalence varied widely across studies from 6% to 96%. Subgroup analyses revealed lower coverage in recent years and in studies with larger sample sizes. Key positive determinants of full immunization included maternal education (OR = 2.70), paternal education (OR = 2.48), antenatal care attendance (OR = 0.23 for non-attendance), institutional delivery (OR = 2.99), and household wealth (OR = 2.45). Children in rural areas (OR = 0.55) and those with mothers of higher parity (OR = 0.67) were less likely to be fully immunised. CONCLUSION : Full immunization coverage in SSA remains well below global targets, with wide disparities by country, socioeconomic status, and maternal healthcare utilization. Strengthening maternal health services, improving education, and addressing health system barriers are critical to improving coverage and reducing preventable child deaths in the region.
Progress toward the second and third UNAIDS 95-95-95 targets among adolescents and young adults in the Ekurhuleni district, South Africa
Silinda, Patricia; Yah, Clarence S.; Musekiwa, Alfred (Taylor and Francis, 2026)
We investigated the progress towards the second and third 95-95-95 UNAIDS targets among adolescents and young adults (AYA) living with HIV in the Ekurhuleni district, South Africa. A total of 39,038 AYA were tested for HIV in 2018, 17.0% (95% CI: 16.6%-17.4%) tested positive, 79.5% (95% CI: 78.5%-80.5%) were aged 20-24, and the majority were females 86.8% (95% CI: 86.0%-87.6%) and of these females 33.8% (95%CI: 32.6%-35.1%) were pregnant. Antiretroviral therapy (ART) initiation rate was 81.9%(95% CI: 81.0%-82.9%) and 63% were initiated on the same day. Viral load suppression had an upward trajectory of 63%, 66%, 71%, 73%, 81%, while retention rate regressed from 67%, 63%, 62%, 60%, 56% over 12, 24, 36, 48 and 60 months. Compared to males, females achieved greater proportions while when comparing the three-agebands, AYA aged 20-24 achieved better outcomes than AYA aged 10-14 and 15-19.These findings underscore the importance of interventions focused on targeted testing and diagnosis, linkage to treatment, retention to care and viral load suppression of younger adolescents (10-14 years) and male AYA and implementation of age and gender disaggregated HIV cascade indicators tracking for this subpopulation.
Poor sleep quality, low physical activity and low-to-moderate diet quality in South African first-year medical students
Borresen, Jill; Celie, Bert; Laubscher, R.; Bac, Martin; Wood, Paola Silvia; Camacho, Tanya Chantelle de Sousa; Nolte, Kim; Schwellnus, Marianne; Schwellnus, Martin Peter (South african Medical Association, 2025-03)
BACKGROUND : The personal health behaviours and lifestyle habits of health professionals influence their counselling practices related to non-communicable diseases (NCDs). There is limited evidence on the prevalence of modifiable NCD risk factors among medical students in South Africa (SA). Objectives. To determine the prevalence of modifiable behavioural and metabolic NCD risk factors in first-year medical students at a SA university. METHODS : This cross-sectional observational study included 256 first-year students. Participants completed five online questionnaires regarding lifestyle behaviours (physical activity, dietary habits, smoking, alcohol consumption and sleep quality). NCD-related metabolic markers including body composition, blood pressure, total cholesterol and random glucose concentrations, were measured. The prevalence of risk factors was calculated using internationally accepted criteria, and sex differences were reported using one-way ANOVA or χ2 test (p<0.05). RESULTS : The prevalence of poor sleep quality was 79.7%, followed by low-to-moderate diet quality (66.8%), low levels of physical activity (64.1%), overweight/obesity (26.2%), current/past smoking (13.3%) and harmful use of alcohol (12.5%). Most (88.3%) participants had two or more NCD-related risk factors. The prevalence of multiple NCD risk factors differed significantly between male and female participants, with more male participants having ≥2. CONCLUSIONS : This study found that first-year medical students at a South African university have a high prevalence of lifestyle-related risk factors, specifically poor sleep quality, low levels of physical activity and low-to-moderate diet quality. Sleep hygiene, regular activity and good nutrition should be promoted, and interventions focusing on nutrition, smoking cessation and alcohol consumption could be targeted by sex.
External factors affecting the efficacy of the Albertina Sisulu executive leadership programme in health fellowship in South Africa : a 360° qualitative assessment
Van der Berg-Cloete, S.E. (Sophy); Tosh, Cheryl A.; Buch, Eric (South African Medical Association, 2025-09)
BACKGROUND : In South Africa (SA), concerns have been expressed that the leadership is not ready for the implementation of National Health Insurance (NHI). The health minister has therefore advocated leadership development and training to equip leaders with the skills to perform optimally. The Albertina Sisulu Executive Leadership Programme in Health (ASELPH) Fellowship, a postgraduate qualification offered in SA, was developed for this purpose and was proven to improve the leadership skills of executive leaders. OBJECTIVES : To identify the various factors influencing the efficacy of the ASELPH Fellowship. Methods. A quasi-experimental study design was used to determine the factors affecting the ASELPH Fellowship. Data were collected from healthcare leaders (n=42) by means of a questionnaire before and after training. It included post-training and retrospective assessments from their assessors and their module daily assessments and reflective essays. Descriptive analysis and thematic content analysis were used for the qualitative reflections. The perceptions of participants, including students and assessors, regarding external barriers to implementing their newfound skills and competencies were assessed. RESULTS : Participants found it difficult to implement their training owing to a lack of leadership skills and knowledge, shortage of human and financial resources, political pressure, poor governance and policy implementation. Despite these barriers, participants who attended the course were still able to improve their leadership skills and performance in the workplace. CONCLUSION : Leadership training and development programmes such as the ASELPH Fellowship bode well for the future implementation of public health because much-needed leadership skills are injected into the currently beleaguered public health system
Person-centred HIV care and prevention for youth in rural South Africa : preliminary implementation findings from Thetha Nami ngithethe nawe stepped-wedge trial of peer-navigator mobilization into mobile sexual health services
Busang, Jacob; Ngoma, Nqobile; Zuma, Thembelihle; Herbst, Carina; Okesola, Nonhlanhla; Chimbindi, Natsayi; Dreyer, Jaco; Smit, Theresa; Bird, Kristien; Mtolo, Lucky; Behuhuma, Osee; Hanekom, Willem; Herbst, Kobus; Lebina, Limakatso; Seeley, Janet; Copas, Andrew; Baisley, Kathy; Shahmanesh, Maryam (Wiley, 2025-10)
INTRODUCTION : Despite the efficacy of antiretroviral therapy (ART)-based prevention, population-level impact remains limited because those at high risk of HIV acquisition are not reached by conventional services. We investigated whether youth-centred and tailored HIV prevention, delivered by community-based peer navigators alongside sexual and reproductive health (SRH) services, can mobilize demand for HIV pre-exposure prophylaxis (PrEP) and ART among adolescents and young adults (AYA) in KwaZulu-Natal, South Africa. METHODS : Thetha Nami ngithethe nawe is a cluster-randomized stepped-wedge trial (SWT) in 40 clusters within a rural health and demographic surveillance site. Clusters were randomized to receive the intervention in period 1 (early) or period 2 (delayed). Trained area-based peer navigators conducted needs assessments with youth aged 15-30 years to tailor health promotion, psychosocial support and referrals into nurse-led mobile SRH clinics that also provided HIV testing, and status-neutral ART and oral PrEP. Standard of care was PrEP delivered through primary health clinics. We report SRH service uptake from the 20 intervention clusters during the first period of the SWT (NCT05405582). RESULTS : Between June 2022 and September 2023, peer-navigators reached 9742 (74.9%) of the 13,000 youth in the target population, 46.8% males. Among 9576 individuals with needs assessment, peer-navigators identified 141 (1.5%) with social needs, and 4138 (43.5%) had medium to high health needs. These individuals were referred to mobile clinics, with 2269 (54.8%) attending, including 959 (42.3%) males. HIV testing uptake was high (92.7%; 2103/2269), with 10.1% (212/2103) testing positive for HIV, 62 (29.2%) of whom started ART for the first time. The prevalence of HIV was higher among females compared to males (15.1% vs. 3.3%; p < 0.001). Among clinic attendees, 96.8% were screened for PrEP eligibility, with 38.5% deemed eligible and offered PrEP. Of the 1433 (63.2%) individuals tested for sexually transmitted infections (STIs), 418 (29.2%) tested positive, with females having higher STI prevalence (37.2% vs. 17.9%; p < 0.001). Of these, 385 (92.1%) received STI treatment. Among 1310 females, 769 (58.7%) reported not using any contraception at their initial visit, and 275/769 (35.8%) started contraception during the trial. CONCLUSIONS : Community-based and person-centred approaches delivered through trained peer-navigators can link AYA with SRH and HIV prevention/care needs with mobile SRH services.
REPRIEVE final results : what does it mean for guidelines in low- and middle-income countries?
Sokhela, Simiso; Manne-Goehler, Jennifer M.; Lalla-Edward, Samanta; Siedner, Mark J.; Ali, Mohammed K.; Hill, Andrew; Mody, Aaloke; Pozniak, Anton; Nel, Jeremy; Venter, Willem Daniel Francois (Wiley, 2025-06)
INTRODUCTION : The REPRIEVE study demonstrated significant reductions in major adverse cardiovascular events (MACE) with pitavastatin among people living with HIV (PWH) with low to moderate cardiovascular risk. Most MACE events occurred in higher-income countries, raising important considerations for similar primary prevention interventions within HIV programmes in low- and middle-income countries (LMICs) as antiretrovirals become safer and as PWH age. DISCUSSION : Limited data from Africa and within REPRIEVE suggests that MACE may not be as prevalent among PWH as within other geographies. Consequently, there remain questions about the appropriateness of extrapolating REPRIEVE data to the region and whether it should motivate programmatic implementation on the continent. Moreover, glucose and lipid screening used in REPRIEVE raise concerns about additional resources for similar screening, where there is little existing infrastructure and subsequent treatment. Similarly, questions around funding priorities, and health worker resource allocation for MACE prevention, particularly in the context of competing health priorities and limited health financing, need to be addressed. Newer cardiovascular medications, with cardiac, renal, hepatic, diabetes and weight loss benefits, may have greater promise, although cost remains a major concern. Finally, successful implementation with statins or other proven interventions will be unlikely, unless systemic change within non-communicable disease health system delivery programmes occurs first. However, HIV programmes and public health systems more generally have shown themselves to be poor at screening and treating other cardiovascular risk factors, including aspects as simple as raised blood pressure, even in high-income countries, and statins remain grossly under-prescribed for primary and secondary prevention internationally. CONCLUSIONS : REPRIEVE turned a spotlight on how ill-prepared current HIV programmes are to implement the simplest and safest primary care prevention interventions for cardiometabolic disease within LMICs. As data for existing and new interventions become available, HIV delivery systems will need to raise their standard beyond simply prescribing antiretrovirals and taking viral loads.

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