Health and social responses

Theme leader: Steve Tollman

PHIRST – A Prospective Household observational cohort study of Influenza, Respiratory Syncytial virus and other respiratory pathogens community burden and Transmission dynamics in South Africa Dec 2015
Cheryl Cohen from the Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, South Africa
The aims of this study are to estimate the community burden of influenza and RSV, and to assess the transmission dynamics of influenza and RSV infections in the community.  This is a household-level community cohort study, with the pilot phase currently underway, which will run for 3 consecutive studies in 50 households in each site.  We are collect baseline data on household composition and medical histories from all members of household, each member of the household will be followed up twice weekly throughout the RSV and influenza season and annually thereafter.  Details on respiratory illness symptoms that occur, hospitalisations and deaths from respiratory illness and monthly TB symptom data will also be collected.   The data should assist policy makers to understand how many people get infected with these various pathogens, understand why and how they are passed from person to person, use this data to plan interventions like vaccines to special groups of people who are at risk of becoming very ill and to make changes to programmes, like the TB programme to improve TB control.


e/mHealth – Vutivi Project (Knowledge) PhD project June, 2015
Collaboration with MRC/Wits Health Policy Research Group and Warwick Medical School UK, funded by the ESRC and GE Healthcare ltd. (Principle investigator: Jocelyn Watkins)

Copyright J Watkins

Introduction: South Africa presents a relevant case study to examine where and how e/mHealth may play a role within the care cycle and assist rural communities in the barriers faced by accessing healthcare. Semi-structured interviews, focus groups and non-participant observations in clinics and in the community with n=256 people including patients with chronic diseases (aged 18-90), pregnant women (18-36), nurses, doctors, clinical associate students, home-based carers, optometrists, traditional healers, community members, key e/mHealth experts and Government policy makers (district, provincial and national Department of Health).
Preliminary Results: Findings are presented in four case studies:
Case Study 1: Landscape of e/mHealth in rural South Africa to identify the different players/stakeholders involved.
E.g. Digital providers, Front-end users, Mobile operators, Policy advocates, Designers etc.
Case Study 2: Mobile health communication between Patients and Health Worker
E.g. a) MomConnect (DOH national mHealth programme) to register all pregnant women at their first ANC booking and receive staged-based messaging on educational pregnancy advice to their cell phones.
b) Nkateko Phone call reminders from lay health workers to hypertensive patients to remind them to come to their clinic appointment
Case Study 3: Mobile health communication between Health Worker (at the coal face) and Other (Health Worker/Specialist clinician/Website/App)
E.g. a) Stop Stockouts Campaign – patients or health workers send a SMS or call a number to alert the DOH when there is a drug shortage at the clinic or hospital.
b) Web literacy of nurses using search engines such as Google
c) Patient referrals made by district doctors to tertiary doctors via Whatsapp (image or text)
Cast Study 4: Use of Portable Ultrasound for pregnant women
E.g. a) How pregnant women feel about either having an ultrasound or wanting to have one
Tentative conclusion: e/mHealth is feasible and acceptable and to some degree already in use but usually in a ad-hoc informal way. Enhancing healthcare through the use of digital communication has potential where its implementation is integrated within this normalisation

PEECHi (Programme for the Economic Evaluation for Maternal and Child Health interventions)
Collaboration with PRICELESS, Health Systems Trust and the MRC Burden of Disease Unit

This project will use economic evaluation to provide evidence for priority setting to guide investments for better maternal, newborn and child health. One focus is to identify and assess the most affordable, effective and scalable interventions to improve maternal and child health in Ehlanzeni district, Mpumalanga Province. The MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), which includes an established population-based research centre with a longitudinal health and socio-demographic information platform, will contribute to this by providing empirical data on rural communities in northeast South Africa.

Vunene team

Integrated Chronic Disease Management model – Vunene (Goodwill) study July, 2015
Principal investigator: Dr. Soter Ameh
Co-investigators: Dr. Francesc Xavier Gómez-Olivé, Prof. Kathleen Kahn, Prof. Stephen M. Tollman and Prof. Kerstin Klipstein-Grobusch
South Africa faces a dual burden of chronic communicable (e.g., HIV) and non-communicable (e.g., hypertension) diseases. In a response, the National Department of Health initiated the Integrated Chronic Disease Management (ICDM) model as a pilot (on-going) programme in selected primary health care (PHC) facilities in Mpumalanga, North West and Gauteng Provinces in South Africa. The overall goal of the ICDM model is to leverage the positive lessons learned from the use of the tools and systems in HIV programme to scale up services for NCDs; improve the quality of chronic disease care for better health outcomes; reduce chronic disease mortality and morbidity; and more efficiently meet patients’ health needs. The aim of the Vunene study was to contribute to understanding the effectiveness of the ICDM model in improving the quality of chronic disease care and patients’ health outcomes.

A four-year longitudinal study was conducted from January 2011 to December 2014 [two and half years retrospective records review (January 2011 to June 2013) and one and half years prospective study (July 2013 to December 2014)] in 12 PHC facilities in Bushbuckridge sub-district of Mpumalanga Province, north-east South Africa. To better understand the effectiveness of the ICDM model in improving patients’ health outcomes, seven PHC facilities were categorised into the ICDM model facilities (n=435) where the ICDM model was implemented and five comparison facilities (n=443) where the ICDM model was not implemented.

The preliminary result of the structural equation modelling in the ICDM model facilities showed there was regular supply of critical drugs as well as better coherence in HIV and NCD services. However, services in the priority areas of hospital referral, defaulter tracing, pre-packing of medicines, clinic appointment and patient waiting time were not significantly associated with good quality of care; hence the need to strengthen services in these areas in the study setting. The segmented regression analysis showed that the ICDM model had an effect on the month-to-month increase in the percentage of HIV/AIDS patients on antiretroviral treatment with CD4 counts ≥ 350 cells/μl in the ICDM model facilities, but had no effect on the month-to-month changes in hypertension control (blood pressure<140/90 mmHg) for hypertensive patients on antihypertensive treatment in both study arms. This implies that the purpose for which the ICDM model was initiated – to leverage HIV programmes, tools and systems to scale up services for NCDs – is yet to be achieved in the study setting.

The Vunene study was funded by the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) South Africa, through the Wellcome Trust, UK; African Doctoral Dissertation Research Fellowship Programme, Nairobi, Kenya; and Fogarty International Center of the National Institutes of Health

Please download this award winning poster….Facility Feedback 2015… to find results from this study.

Engaging Traditional Healers in Agincourt, South Africa June 2015
Collaboration with Carolyn Audet, Vanderbilt University
In both rural and urban sub-Saharan Africa, traditional healers typically hold positions of authority within their communities. Unlike physicians, traditional healers are thought to be able to diagnose and treat physical and emotional ailments resulting from 

Traditional healers meeting in Welverdiend village

such sources as social transgressions, spirits, curses, and sorcery. People seek care from traditional healers due to social acceptability, perceived source of illness, personal relationships between healers and their patients, as well as the perceived fit of a healer’s explanation of illness with patient expectations. Healers often outnumber clinicians, especially in rural or peri-urban areas. In sub- Saharan Africa, it is estimated that 80% of the population have visited a traditional healer. When experiencing illness, it is common for patients to Ping-Pong back and forth between the allopathic health system and the traditional health system, potentially leading to delays in care, interruptions or abandonment of treatment, and herb-drug interactions.

Given this complex, plural-seeking behaviour, this work seeks to create a matrix to identify and link traditional and allopathic illness diagnoses with the goal of identifying disease-specific traditional treatments (frequency and duration), expected prognoses and direct treatment costs. With a particular focus on schizophrenia, epilepsy, HIV, and TB we are learning about traditional illnesses associated with these allopathic diagnoses, modes of transmission and acquisition, traditional treatment offered in the Bushbuckridge area, and the costs associated with traditional healer services. With 10 qualitative interviews of traditional healers and 10 with nurses already complete, we have refined a quantitative survey to gather data from 160 healers in the area. Our long-term goal is to establish a sustainable and acceptable system for healer integration into the health system to improve chronic and acute health outcomes among people living in the Agincourt area.

Epidemiology and treatment of epilepsy in sub-Saharan Africa (SEEDS)
Collaboration with KEMRI/Wellcome Trust, Kilifi and and World Health Organization (Geneva)

samples from nitrogen

The aim of epilepsy work in Agincourt is to measure the burden of epilepsy in rural South Africa, and identify cost-effective interventions aimed at reducing the burden through decreasing the treatment gap and improving the quality of life of people with epilepsy. Work will result in the development of a package of tools for economic evaluation applicable to other conditions (such as cardiometabolic diseases) in a range of African settings. This research will provide insight into management of a non-infectious chronic illness that spans all age groups and has been undertaken with close collaboration from health care service providers.

Gender, pensions and social wellbeing in rural South Africa June, 2015
Collaboration with INDEPTH, Colorado at Boulder and Missouri Univs, USA

Pension day

Pension day, photo by L Hunter

This study aims to describe impact of old age pension on self-perceived health, well being and quality of life in older people and will explore gender differences and explain how policy changes in South Africa (reducing age eligibility of government pensions for men from 65 to 60 years) have influenced men’s perspective of health, wellbeing and quality of life.