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

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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.
Defining early health technology assessment : building consensus using Delphi technique
Grutters, Janneke P.C.; Bouttell, Janet; Abrishami, Payam; Ahmed, Sulafa. Y.M.; Cole, Amanda; Dawoud, Dalia; Fernández-Barceló, Carla; Frederix, Geert W.J.; Hawkins, Neil; Karnon, Jonathan; Leadbitter, Sharon; McCabe, Christopher; Mueller, Jani; Achiaw, Samuel Owusu; Partington, Andrew; Sampietro-Colom, Laura; Seyahian, Abril; Sucu, Rabia; Tew, Michelle; Van Katwyk, Sasha; Verboven, Yves; Wang, Yi; A Working Group of HTAi (Cambridge University Press, 2025-06)
Although early health technology assessment (HTA) is increasingly being used to guide and inform decisions on product development, a consensus definition is currently lacking. A working group under the HTA International Society was established to develop a consensus-based definition of early HTA. The working group developed a definition using an iterative process that comprised five stages of work and included a two-round Delphi survey with 133 respondents in the first and 99 respondents in the second round of the survey, with various backgrounds and levels of expertise. Following this process, the working group reached the first consensus-based definition of early HTA, which is an HTA conducted to inform decisions about subsequent development, research, and/or investment by explicitly evaluating the potential value of a conceptual or actual health technology. In total, 86 (87 percent) of the 99 panelists who participated in the second round of the Delphi survey either strongly agreed or agreed with this definition. This consensus definition represents an important milestone in early HTA. It will enhance the uniformity of terminology, increasing the visibility of research and policy in this field. We also hope that it will act as a catalyst sparkling further research and developments in this discipline.
Towards including environmental sustainability in health technology assessment
Holtorf, Anke-Peggy; Pegg, Melissa; Mueller, Debjani; McMeekin, Nicola (Cambridge University Press, 2025-09)
INTRODUCTION : The life cycle of health technologies contribute to air pollution, ecotoxicity, and resource depletion, impacting the environment and human health. Increasing healthcare resource use globally increases emissions that accelerate climate change and negatively affect the health of current and future generations. Health Technology Assessment (HTA) should inform decision makers to prioritize the adoption of technologies demonstrating value in terms of health benefits, costs, and other relevant dimensions such as environmental sustainability. This paper reports on a multistakeholder approach to guiding an international working group for Environmental Sustainability in Health Technology Assessment (ESHTA) that has been formed by Health Technology Assessment international. METHODS : A multistakeholder online workshop was held with 32 participants in May 2024 to define the critical issues to be considered. The resulting report underwent consultation among the ESHTA members and in a broader group of 90 additional worldwide stakeholder representatives. RESULTS : The workshop participants recognized defining frameworks, mechanisms, and tools for embedding environmental sustainability into HTA as an opportunity to support sustainable development and quality improvement in healthcare. Achieving this requires (1) consensus on what environmental sustainability in healthcare means, (2) reconcilement with other healthcare and environmental policies, and (3) methods that are useful and applicable within HTA frameworks. CONCLUSION : This novel collaboration aims to align the global HTA community on the role of environmental sustainability in HTA. The report provides a path for the way forward for incorporating environmental sustainability into HTA based on broad perspectives from global multi-stakeholders.
Y chromosome variation and prostate cancer ancestral disparities
Soh, Pamela X.Y.; Adams, Alice; Bornman, Maria S. (Riana); Jiang, Jue; Stricker, Phillip D.; Mutambirwa, Shingai B.A.; Jaratlerdsiri, Weerachai; Hayes, Vanessa M. (Elsevier, 2025-05-16)
Prostate cancer (PCa) is marked by significant ancestral bias, with African men disproportionately impacted. However, genome profiling studies have yet to explore the mutational landscape and disparity contribution of the male-determining Y chromosome. Using a cohort of 106 African and 57 European PCa cases, biased toward aggressive presenting primary disease, we performed complete Y chromosome interrogation for inherited and somatic variance. Capturing unexplored early-diverged Y-haplogroup substructure, while European men are 3.1-fold more likely to present with a rare potentially deleterious germline variant, a higher proportion of African patients acquired Y chromosome tumorigenic events (26.4% African, 14% European). While somatic copy number alterations were universally more common to aggressive tumors, besides shared alterations impacting DDX3Y and USP9Y, African derived tumors were prone to somatic losses associated with KDM5D, PCDH11Y, and RBMY. This much-needed African inclusive study alludes to possible Y chromosome contribution, at least in part, to treatment resistance and worsened mortality rates in African men.
Initiation of Dolutegravir versus Efavirenz on viral suppression and retention at 6 months : a regression discontinuity design
Zheng, Amy; Fox, Matthew P.; Greener, Ross; Kileel, Emma M.; Bor, Jacob; Venter, Willem Daniel Francois; Pisa, Pedro Terrence; Brennan, Alana T.; Maskew, Mhairi (Wolters Kluwer Health, 2025-06)
BACKGROUND : In 2019, South Africa's Antiretroviral Therapy (ART) Treatment Guidelines replaced efavirenz with dolutegravir in first-line ART. SETTING : We assessed the impact of this national guideline change on retention and viral suppression in the Themba Lethu Clinical Cohort, Johannesburg, South Africa. We applied a regression discontinuity design in a prospective cohort study of 1654 adults living with HIV initiating first-line ART within 12 months (±12 months) of the guideline change. METHODS : We compared outcomes in individuals presenting just before and after the guideline change and estimated intention-to-treat effects on initiating a dolutegravir- vs efavirenz-based regimen. Primary outcomes were retention and viral suppression. Participants were defined as retained in care if a visit took place within ±3 months of the 6-month end point. Viral suppression was defined as having a viral load ≤1000 copies/mL 3 months before and up to 6 months after the 6-month end point. RESULTS : The 2019 guideline change led to an increase in uptake of dolutegravir. We noted a 26.6 percentage point increase in the proportion initiating dolutegravir [95% Confidence Interval (CI): 14.1 to 38.6]. We saw a small increase in viral suppression [Risk Difference (RD): 7.4 percentage points; 95% CI: -1.6 to 16.5] and no change in retention (RD: -1.7 percentage points; 95% CI: -13.9 to 10.5) at 6 months, though our findings were imprecise. CONCLUSIONS : Our estimates suggest early uptake of the revised treatment guidelines after implementation. Despite this, there was no meaningful change in viral suppression and retention rates at 6 months.
The association between HIV-related stigma, ART adherence, and cardiovascular disease risk in people living with HIV
Shilabye, Patane S.; Scheuermaier, Karine; Vos-Seda, Alinda G.; Barth, Roos E.; Devillé, Walter; Coutinho, Roel A.; Umunnakwe, Chijioke N.; Grobbee, Diederick E.; Venter, Willem Daniel Francois; Tempelman, Hugo; Klipstein-Grobusch, Kerstin (Wolters Kluwer Health, Inc., 2025-06)
INTRODUCTION : HIV/AIDS continues to be a significant health issue in sub-Saharan Africa, with stigma likely affecting ART adherence, and subsequently viremia, inflammation, and cardiovascular disease (CVD). We investigated the association between stigma, ART adherence, and CVD risk among people living with HIV (PLWH). SETTING : A longitudinal study was conducted among 325 PLWH from the Ndlovu Cohort Study, South Africa. METHODS : Stigma was assessed using a 12-item questionnaire (range: 0–44; higher scores indicate greater stigma). Pulse wave velocity (PWV, CVD surrogate marker) and viral load (VL) were assessed at 12 and 36 months. VL was considered a surrogate marker of ART adherence: VL > 1000 copies indicating poor/no adherence, VL 50–1000 copies suboptimal, and VL < 50 copies good adherence. The relationship between stigma, VL, and PWV was assessed by linear regression and changes in PWV overtime by mixed linear models. RESULTS : At baseline, PLWH (n = 325, mean age (SD) = 41.1 (10.2) years, 67% female) had mean PWV of 7.3 min/s. Good, suboptimal, and poor adherence were 78%, 15%, and 7%, respectively. The mean (SD) stigma score was 16.9 (1.4) and was not associated with VL and PWV. Suboptimal and poor adherence were associated with higher PWV [beta = 4.18 (95% confidence interval (CI): 1.79 to 6.57)] at 12 months and between 12 and 36 months [beta = 1.30 (95% CI: 0.06 to 2.55)] in mixed model analyses in PLWH older than 49 years, respectively. PWV increased by 0.21 min/s (95% CI: 0.02 to 0.40; P = 0.03) between 12 and 36 months overall. CONCLUSIONS : In this study, poor ART adherence was associated with higher PWV. The stigma score was low and not associated with ART adherence and PWV.
Predictors of concurrent sexual partnerships and association with recent HIV infection in a large population-based survey in Botswana
Moyo, Sikhulile; Yankinda, Etienne Kadima; Hurwitz, Kathleen E.; Bennett, Kara; Chakalisa, Unoda A.; Gaolathe, Tendani; Okui, Lillian; Leidner, Jean; Kgathi, Coulson; Sekoto, Tumalano; Van Widenfelt, Erik; Melton, M. Lendsey; Lebelonyane, Refeletswe; Gaseitsiwe, Simani; Mmalane, Mompati O.; Novitsky, Vlad; Makhema, Joseph M. (Wolters Kluwer Health, 2025-12)
BACKGROUND : Multiple concurrent sexual partnerships (MCP) may drive new HIV infections. We investigated the association between MCP and recent or incident HIV infection in a cluster-randomized HIV prevention trial that followed a population-based HIV incidence cohort across 30 communities in Botswana. METHODS : We used structured questionnaires to evaluate MCP for prior 12 months, defined as either (1) MCP per UNAIDS definition or (2) concurrent sexual relationship per survey questions. Recent HIV infection was determined using an avidity assay-based algorithm or seroconversion within 2 years, and incident infection was determined through annual HIV testing for up to 3 years. We estimated prevalence ratios (PRs) and 95% confidence intervals (CIs) for MCP predictors using univariate and multivariable Poisson regression with log-link and fixed effects for matched pairs. RESULTS : We included 11,965 (94.9%) of the 12,610 participants in the Botswana Combination Prevention Project with sexual history data. Among 9363 sexually active persons in prior 12 months, 2770 (29.6%) were engaged in MCP. Factors independently associated with MCP included male sex (aPR = 1.57; 95% CI: 1.45 to 1.71), age < 25 years (aPR = 1.25, 95% CI: 1.01 to 1.56), alcohol consumption ≥ 2 times/week (aPR = 1.38, 95% CI: 1.26 to 1.51), transactional sex (aPR = 1.69, 95% CI: 1.49 to 1.92), having a partner with MCP (aPR = 1.82, 95% CI: 1.65 to 2.02), and intergenerational sex (partners 10 years younger: aPR = 1.16, 95% CI: 1.06 to 1.28 or 10 years older: aPR = 1.32, 95% CI: 1.15 to 1.51). Reporting prior MCP was associated with HIV seroconversion during follow-up (aPR= 1.28, 95% CI: 1.05 to 1.57) but not with prevalent or recent HIV infection at baseline. CONCLUSIONS : MCP was common and associated with incident HIV infection. People reporting MCP may benefit from pre-exposure prophylaxis.
The health sector response to gender-based violence and sexual reproductive health programs in the Commonwealth and selected African countries : protocol for a mixed methods systematic review and meta-analysis
Phaswana-Mafuya, Refilwe Nancy; Phalane, Edith; Zungu, Nompumelelo; Musekiwa, Alfred; Ramalepe, Lebogang; Bagg, Kayla; Nyasulu, Peter; Shisana, Olive (JMIR Publications, 2025-09-18)
BACKGROUND : The intertwining nature of gender-based violence (GBV) and violence perpetrated against women and girls (VAWG), as well as sexual and reproductive health rights (SRHR), underlines the urgent need for the health sector to enhance the coordination of services to improve health outcomes. Importantly, GBV and VAWG are intricately linked to a spectrum of SRHR challenges, ranging from unintended pregnancies to severe maternal, gynecological, and mental health outcomes. Cumulative GBV had a more significant effect on abortion risk than associated variables. Recognizing the interplay between GBV, VAWG, and SRHR highlights the necessity for a comprehensive health sector response. A systematic review of the health sector response to GBV, VAWG, and SRHR will be conducted to understand the extent and array of health facility–based coordinated responses to GBV, VAWG, and SRHR; lessons learned; and successes and challenges in the Commonwealth and selected African countries. OBJECTIVE : We aim to understand the context of GBV, VAWG, and SRHR by conducting a comprehensive review of health sector responses in different national, cultural, and socioeconomic contexts, and we aim to share best practices, experiences, and lessons learned. METHODS : A mixed methods systematic review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. The population, intervention, comparison, and outcome framework will be applied to screen and select relevant sources guided by the inclusion and exclusion criteria. The review will include relevant research papers published in the last 15 years and conducted in the 24 Commonwealth and 7 selected African countries. Electronic databases to be searched will include PubMed, Google Scholar, Science Direct, EBSCOhost, Web of Science, Embase, PsycINFO, Cochrane, CINAHL, Index Medicus for the Eastern Mediterranean Region, and POPline. RESULTS : Ethics approval will be waived as the study will use data in the public domain. The project has been commissioned by the Commonwealth Secretariat (2022-2025). The database search, data screening, and data extraction process for the review will be completed by September 2025. A manuscript will be submitted to a peer-reviewed international journal by November 2025. The initial online database searches, citations of eligible studies, and Microsoft Copilot identified 38,200 studies focusing on GBV, VAWG, and SRHR interventions. To date, 60 studies have been found eligible for inclusion in the review. The majority of these studies were conducted in eastern Africa (n=34), South Africa (n=14), and Asia (n=13). Evidence generated from this review will be made available through journal publications, seminars and workshops with key stakeholders, ministries of health, and local and international conferences. CONCLUSIONS : The study will generate evidence to inform recommendations on addressing and mitigating the effects of GBV and VAWG on SRHR outcomes and coordinated services in the health sectors of Commonwealth and selected African countries.
Developing and validating an inclusive and cost-effective prediction algorithm for survival and death among people living with HIV in sub-Saharan Africa : protocol for a meta-analysis and case-control and cost-effectiveness study
Nweke, Martins C.; Pillay, Julian David; Musekiwa, Alfred; Ibeneme, Sam Chidi (JMIR Publications, 2025-08-25)
BACKGROUND : Premature death in people with HIV in sub-Saharan Africa (SSA) is highly preventable. However, the lack of inclusive, cost-effective prognostic tools remains challenging. Most prognostic tools have been developed in high-income economies. The distinct cultural dynamics in HIV-related death epidemiology makes them unsuitable for the region. Additionally, the models lack systematic stratification of death determinants based on clinical relevance, and some included factors are too expensive for people with HIV in SSA. OBJECTIVE : We aimed to create a tailored predictive model that considers the unique context of SSA, including cultural dynamics, cost-effectiveness, and clinical relevance. METHODS : This is a 2-phase study. In the development phase, we will use a combination of evidence synthesis, namely meta-analysis, application epidemiology, biostatistical, and economic paradigms, to develop a prognostic model for people living with HIV in SSA. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) protocol will be followed in the structuring of the meta-analysis. From their creation to the present, we will search African journals (Sabinet) and the PubMed, Scopus, MEDLINE, Academic Search Complete, Directory of Open Access Repository, Cochrane Library, Web of Science, EMBASE, and Cumulative Index for Nursing and Allied Health Literature databases. Only cohort studies with moderate to high quality will be included. The primary outcome variables include the predictors of HIV-related death and their corresponding effect sizes (adjusted relative risk). A random-effect meta-analysis model will be used to synthesize the unbiased estimate of risk (relative risk) per predictor. Epidemiological metrics such as risk responsiveness, geotemporal trend, risk weight (Rw), clinical minimum important difference (CMID), predictors interaction density (PID), critical risk points, and potential cost implication will be computed. A combination of Rw and CMID will be used for risk stratification. The model’s constituent items will be selected based on the combination of Rw, CMID, PID and cost implication. In the validation phase, we will apply the emergent model to classify participants using a secondary data obtained from a cohort of people living with HIV in East and West Africa, with outcomes including sensitivity, specificity, calibration, and area under the receiver operating characteristic curve (AUC). RESULTS : The study is projected to commence in October 2025 and end in September 2026. The expected result will be published in November 2026. The result will be presented using narrative and quantitative synthesis. Indices of causality namely as strength of association, temporality, consistency, biological gradient, and specificity of the predictor-outcome association will be presented in a tabular format. TheAUC will be used to decide the optimal critical risk point for the emergent predictive algorithm. CONCLUSIONS : Effective prognostication coupled with intense monitoring and evaluation, and prioritizing of therapeutic targets could positively turn around the fate of millions of people living with HIV at risk of premature death in SSA.
Optimising insulin use in people living with type 2 diabetes at primary healthcare facilities : the Tshwane insulin project
Rheeder, Paul; Botha, G.; Mohlala, Maryangela G.; Eales, Owen; Van Zyl, Danie G.; Ngassa Piotie, Patrick (South african Medical Association, 2025-07)
BACKGROUND : In South Africa (SA), glucose control for individuals with type 2 diabetes follows a stepwise approach. According to the guidelines, insulin therapy is started after using two oral agents. However, various challenges may delay the initiation of insulin. OBJECTIVES : To implement a nurse-led, telehealth-assisted programme to address these challenges, aiming to transition patients to insulin safely to achieve better glycaemic control. METHODS : From 2021 to 2023, we conducted a single-arm, unblinded before-and-after study in primary care facilities in Tshwane District, Gauteng Province, SA. Participants were on insulin or two oral agents at maximum doses. Study nurses monitored glycated haemoglobin (HbA1c) results, and participants with HbA1c levels of ≥8% (≥10% during the COVID‑19 pandemic) were counselled about insulin use. During an initiation visit, participants received demonstrations and education on using insulin and glucose meters. The participants then tested their glucose levels at home according to a fixed schedule. Over 14 weeks, we implemented monthly clinic visits supplemented by home visits facilitated by community healthcare worker teams. During these visits, glucose results were communicated to the clinic physician via the Vula mobile app, allowing timely adjustments to insulin therapy. RESULTS : Of the 293 participants, 65% (n=192) were women and 35% (n=101) were men. The mean (standard deviation (SD)) age was 53 (10) years, with a baseline mean (SD) HbA1c level of 12.1% (1.7%). Of those initiated, 169 (58%) were on oral agents and 124 (42%) were on insulin. Biphasic mixed human insulin was prescribed to 185 participants (63%) and intermediate human neutral protamine Hagedorn (NPH) insulin to 108 (37%). Immediately after baseline assessment and during the 14-week study period, 72 participants (23%) were lost to follow-up, and seven were hospitalised during the study period. Glucose values decreased over 14 weeks, with approximately one-third of participants having no insulin adjustments, one-third having one adjustment, and one-third having more than one adjustment. The mean (SD) HbA1c level decreased from 12.1% (1.6%) to 8.8% (1.6%) over the 14 weeks in 240 paired samples (p<0.001). Ten percent of these participants achieved HbA1c levels <7%, and 34% had levels <8%. CONCLUSION : The nurse-led, telehealth-supported intervention successfully transitioned participants onto twice-daily mixed insulin or night-time intermediate NPH insulin, resulting in a significant decrease in HbA1c from 12.1% to 8.8%. However, clinics will require additional resources to initiate or intensify insulin therapy in primary care settings.
Weekly azithromycin for 48 weeks impacts nasopharyngeal microbial prevalence and Streptococcus pneumoniae serotypes in children with HIV-associated chronic lung disease
Mushunje, Prince K.; Sovershaeva, Evgeniya; Olwagen, Courtney P.; Madhi, Shabir; Odland, Jon Oyvind; Ferrand, Rashida A.; Nicol, Mark P.; Abotsi, Regina E.; Dube, Felix S. (Nature Research, 2025-11-07)
HIV-associated chronic lung disease (HCLD) accounts for over 50% of deaths in children living with HIV. Azithromycin reduces the risk of respiratory exacerbations in children with HCLD, but its impact on respiratory pathogens and Streptococcus pneumoniae serotypes in HCLD remains partially understood. We investigated the impact of azithromycin on the prevalence and density of respiratory microbes in children enrolled in the BREATHE randomized controlled trial. Nasopharyngeal swabs collected from 287 participants at baseline, 48 and 72 weeks were analysed using nanofluidic qPCR testing for 94 S. pneumoniae serotypes, 12 bacterial species, and eight respiratory viruses. No differences were observed between microbial colonisation in the azithromycin and placebo groups at baseline or 72 weeks. At 48 weeks, overall bacterial colonisation was significantly lower in the azithromycin group compared to placebo (adjusted Odd Ratio [aOR]: 0.45, 95% CI 0.25-0.82; p=0.008), with reduced colonisation of S. pneumoniae (aOR: 0.37; 95% CI: 0.24-0.71; p=0.003) and non-typeable Haemophilus influenzae (aOR: 0.29; 95% CI: 0.14-0.61; p=0.001). The 13-valent pneumococcal conjugate vaccine serotypes (19F and 23F) and non-vaccine type (15A/F) were most commonly observed in both groups at all time points. Findings suggest that azithromycin reduces nasopharyngeal colonisation of certain bacteria in HCLD during treatment but has no long-lasting effects after treatment cessation.
Determinants of chronic malnutrition among under-five children in Ethiopia using simultaneous quantile regression
Warssamo, Birhanu Betela; Belay, Denekew Bitew; Chen, Ding-Geng (Din) (Nature Research, 2025-10-22)
Child malnutrition remains a challenge in Ethiopia despite progress in development goals. Stunting in children under five leads to disease, impaired development, and increased mortality. Earlier studies have used linear and logistic regressions to identify the drivers of stunting. These models overlook variations across outcome distributions. This study employed simultaneous quantile regression to identify the association between chronic malnutrition across different height-for-age z-score (HAZ) quantiles in children under the age of five. Data were drawn from the 2016 Ethiopian Demographic and Health Survey, including 8,592 women aged 15 – 49 years and their under-five children. After cleaning missing variables, HAZ score served as the dependent variable. Simultaneous quantile regression modeled covariates across multiple quantiles. The findings indicated that 34.75% of children were stunted. Significant variables associated with HAZ score included place of residence, shared toilet facility, respondent employed, vaccination, succeeding birth interval in months, frequency of checking antenatal care, literacy, type of toilet facility, anemia level, wealth index of household, twin status, place of delivery, highest level of education of mother and father and age of child. The association of these factors varied across quantiles, with slope differences between the 10th and 90th quantiles. The quantile regression plots for the selected quantiles 10th to 90th revealed significant differences in the association of the covariates across the HAZ quantiles under consideration. Quantile regression revealed that various factors work differently across the HAZ distribution. Findings demonstrate the benefit of quantile regression in revealing differential impacts and guiding targeted policy. Addressing stunting requires coordinated efforts to enhance child nutrition and achieve the Sustainable Development Goals by 2030.
Gender-associated factors on the occurrence and prevalence of zero-dose children in Sub-Saharan Africa : a critical literature review
Musuka, Godfrey; Moyo, Enos; Iradukunda, Patrick Gad; Gashema, Pierre; Madziva, Roda; Herrera, Helena; Dhliwayo, Tapiwa; Mutata, Constantine; Mataruse, Noah; Mano, Oscar; Mbunge, Elliot; Dzinamarira, Tafadzwa (MDPI, 2025-10-06)
BACKGROUND : Immunisation remains one of the most effective and cost-efficient public health interventions for preventing infectious diseases in children. Despite global progress, Sub-Saharan Africa (SSA) continues to face challenges in achieving equitable immunisation coverage. Gender-related disparities, rooted in sociocultural and structural inequalities, significantly influence the prevalence of zero-dose and under-immunised children in the region. This review critically examines the gender-associated barriers to routine childhood immunisation in SSA to inform more inclusive and equitable health interventions. METHODS : A critical literature review was conducted generally following some steps of the PRISMA-P and CRD guidelines. Using the Population–Concept–Context (PCC) framework, studies were selected that examined gender-related barriers to routine immunisation for children under five in Sub-Saharan Africa. Comprehensive searches were performed across PubMed, Google Scholar, and relevant organisational websites, targeting articles published between 2015 and 2025. A total of 3683 articles were retrieved, with 24 studies ultimately meeting the inclusion criteria. Thematic analysis was used to synthesise the findings. RESULTS : Four major themes emerged: (1) women’s empowerment and autonomy, including limited decision-making power, financial control, and the impact of gender-based violence; (2) male involvement and prevailing gender norms, where patriarchal structures and low male engagement negatively influenced vaccine uptake; (3) socioeconomic and structural barriers, such as poverty, geographic inaccessibility, maternal workload, and service availability; and (4) education, awareness, and health system responsiveness. CONCLUSIONS : Gender dynamics have a significant impact on childhood immunisation outcomes in Sub-Saharan Africa. Future policies must integrate these insights to improve immunisation equity and reduce preventable child morbidity and mortality across the region.
The role of mathematical modelling in predicting and controlling infectious disease outbreaks in underserved settings : a systematic review and meta-analysis
Khumbudzo, Mavhunga; Duah, Evans; Grobler, Estelle; Maluleke, Kahlula (Wiley, 2025-09)
BACKGROUND AND AIM : Mathematical modelling plays an important role in public health by enabling the prediction of disease outbreaks, assessment of transmission dynamics and evaluation of intervention strategies. Although widely applied in high-resource settings, its use in underserved contexts remains underexplored. This review aimed to examine and synthesize current evidence on the application of mathematical modelling for predicting and controlling infectious diseases in underserved settings. METHODS : A comprehensive and reproducible search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and population, intervention, comparison and outcome (PICO) frameworks across databases, including PubMed, Scopus, Medline, ScienceDirect and EBSCOhost. Keywords and Medical Subject Headings (MeSH) terms related to mathematical modelling and infectious disease control were applied. Two reviewers independently screened titles, abstracts and full texts, with a third resolving discrepancies. Thematic analysis and meta-analysis were used for synthesis. RESULTS : Out of 838 studies screened, 27 (3.2%) met inclusion criteria. Deterministic models were most used, followed by stochastic and agent-based models. Diseases modelled included COVID-19, malaria, tuberculosis (TB), Ebola, Zika, chikungunya, dengue, diphtheria, respiratory infections, visceral leishmaniasis (VL) and Mpox. Modelling predicted the impact of interventions on transmission, with pooled effect size (Ro) of 1.32 (θ = 1.3, p < 0.0001). However, challenges, such as data underreporting, gaps and inconsistencies, were common, potentially affecting model accuracy and real-world applicability. CONCLUSION : Mathematical modelling has demonstrated value in supporting infectious disease control in underserved settings. However, the predominance of deterministic models limits adaptability across diverse contexts. Poor data quality further constrains reliability. Future work should focus on expanding modelling approaches, strengthening data infrastructure and addressing a broader range of diseases. These findings can guide public health policy by supporting data-driven decision-making, improving resource allocation and integrating modelling into outbreak preparedness and response strategies in underserved settings.
Spatial distribution of COVID-19 diagnostic services in Mopani district, Limpopo Province, South Africa
Maluleke, Kuhlula; Musekiwa, Alfred; Mckelly, David; Baloyi; Mashamba‑Thompson, Tivani Phosa (Wiley, 2025-10)
INTRODUCTION : Access to healthcare facilities in rural areas remains a major challenge, particularly during the coronavirus disease 2019 (COVID-19) pandemic. This study investigated the spatial distribution and accessibility of COVID-19 point-of-care (POC) diagnostic services in Mopani District, Limpopo province, South Africa, using a geographic information system (GIS)-based approach. The aim was to identify areas where healthcare access requires improvement. METHODS : A descriptive cross-sectional study design was used, analysing secondary data through dasymetric mapping to disaggregate and re-aggregate population data into analytical units. Accessibility was measured by distances from residences to the nearest primary healthcare (PHC) clinics (<5 km) and from clinics to the nearest district hospitals (<30 km). Demographic and socio-economic data from Statistics South Africa were included for context. RESULTS : Mopani District had an estimated population of 1,202,916, with 942,801 (78.4%) residing within 5 kmof a PHC clinic. The district had 105 clinics, each serving about 11,456 people, and 72 (68.6%) of these clinics were within 30 km of a district hospital. The district contained both densely and sparsely populated areas, with high unemployment and low-income levels, particularly in rural regions. Limited public transport further constrained access. Ba-Phalaborwa, Maruleng, Greater Tzaneen and Greater Letaba have relatively good access, whereas Greater Giyani faces significant challenges. DISCUSSION : Although a majority of the population lived within 5 km of a clinic, notable gaps in accessibility remain. Improving transport infrastructure, using telemedicine and mobile health units, and implementing socio-economic support strategies, such as subsidized transport, can enhance access. Addressing geographic and structural inequalities in healthcare distribution is critical to promoting equity and improving health outcomes in rural districts like Mopani.
Defining public health transformation : a scoping review
Phooko, Violet; Maluleke, Kuhlula; Ramatsokotla, Sebueng; Serite, Thato; Kgarosi, Kabelo; Sokudela, Funeka Brenda; Mashamba‑Thompson, Tivani Phosa (Wiley, 2025-06)
Public health transformation aims to instigate enduring changes in healthcare services, staff roles and patient involvement, fostering heightened satisfaction among patients and staff while bolstering financial sustainability. Public health transformation is the process of reorganizing and creating a shared vision to ensure the right mindsets, capacity, resources and workforce to deliver equitable Foundational Public Health Services and ultimately promote health, well-being and equity. Such transformation requires a fundamental change in public health systems’ structure, functioning and interactions, supported by continuous quality improvement, innovation, partnerships, community-driven efforts and systems change. This scoping review maps evidence of public health transformation. Searches encompassed databases including EBSCO Host, Academic Search Complete, Africa-Wide Information, Dentistry & Oral Sciences Source, Health Source–Consumer and Academic Edition, PUBMED and Scopus. Abstracts and full-text articles were screened by two independent reviewers against predefined criteria. Inclusion criteria spanned peer-reviewed published between 2013 and 2023. The quality of the included studies was assessed using the 2018 version of the mixed method appraisal tool. Screening results were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Of 9509 articles retrieved, 808 duplicates were excluded, leaving 8692 for title and abstract screening. Following title and abstract screening, 105 articles were relevant and underwent full article screening, which resulted in 20 that became eligible for data extraction. Emergent themes included (1) Transformation in Public Healthcare; (2) Evaluation of Health Transformation Programs; (3) Financial Implications; (4) Public Health Access; and (5) Job Satisfaction. Theme 4 featured a subtheme addressing healthcare access for minority groups. Overall, the review highlights a dearth of evidence guiding policymakers in decision-making on public health transformation, oversight of vulnerable populations, financial implications, and healthcare accessibility. Solutions should prioritize a people-centred approach in both practice and research to effectively address these gaps.
Strategies and responses to the effects of climate change on health systems in Sub-Saharan Africa : a scoping review protocol
Chimatiro, Chancy Skenard; Mianda, Solange; Hajison, Precious L.; Lembani, Martina (Public Library of Science, 2025-08-06)
BACKGROUND : Climate change is recognized as the greatest global health threat of the 21st century. Projections suggest that the Sub-Saharan African region will face more consequences of climate change than any other region globally. The health systems within the region have been affected by the negative effects of climate change. Mapping strategies and responses used in the region to address the effects of climate change on health systems in Sub-Saharan Africa could be a starting point for understanding evidence-based decision-making to inform best practices. METHODS : This scoping review will follow the methodological framework by Arksey & O'Malley. A wide range of databases will be searched to identify articles published on the strategies and responses to the effects of climate change on the health systems in Sub-Saharan Africa. Only peer-reviewed articles (original quantitative and qualitative studies, mixed methods, systematic reviews, editorials, and commentaries) published in English Language between 2010 and 2024 will be reviewed. All Book chapters and the grey literature (dissertations, conference proceedings, abstracts, reports) and publications primarily focusing on climate change strategies and responses without effects on health systems will be excluded. Covidence software will be used during study selection, data extraction, and summary. Deductive thematic analysis will be performed using predetermined themes from the objectives. DISSEMINATION : The results of this scoping review will be disseminated at local and international research conferences. Furthermore, the findings will be published in open-access journals targeting different audiences. The findings will also be shared with the Ministry of Health in Malawi for possible policy considerations.

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