Current Projects

Details of our projects can be accessed under these thematic areas.

Thematic area 1: Maternal, Family, Child Health, Nutrition (MFCHN)

A proof of concept feasibility study of an outreach mentorship approach for disseminating the updated 2016 WHO HIV and Infant feeding guidelines: 2018

PI: Prof. Ameena Goga, Prof Tanya Doherty and Dr Christiane Horwood

Overview
In 2017 HIV and infant feeding guidance was updated in South Africa, in response to the 2016 WHO update..

Aim
We sought to determine whether a participatory mentorship approach to guidelines dissemination increases knowledge, attitude and skills of health workers.

Collaboration
UKZN, WHO, University of Bergen

Project status

Field work has been completed. Two papers have been published and one is in press.

Contact person
Prof. Ameena Goga (ameena.goga@mrc.ac.za),  Prof Tanya Doherty (Tanya.Doherty@mrc.ac.za)

Publications:

  1. Horwood C, Haskins L,Goga A,Doherty T, John V, Engebretsen IMS, Feucht U, Rollins N, Kroon M,Sanders D, Tylleskar T. An educational intervention to update health workers about HIV and infant feeding. Maternal & Child Nutrition. https://doi.org/10.1111/mcn.12922
  2. Doherty T, Horwood C, Magasana V, Goga A, Feucht U, Sanders D, Tylleskar T, Kauchali S, Rollins N, Kroon M, Engebretsen IMS.  Breastfeeding advice for reality: women’s perspectives on infant feeding support received in primary health care settings in South Africa. Accepted by Maternal and Child Nutrition: https://doi.org/10.1111/mcn.12877

Thematic area 2: Adolescent and young adults' health and wellbeing

PREPARE Study: Promoting sexual and reproductive health among adolescents in southern and eastern Africa - mobilizing schools, parents and communities

PI
Dr. Catherine Mathews

Aim
To develop, implement and evaluate an intervention for young adolescents aimed at preventing HIV, pregnancies and sexual risk behavior and reducing intimate partner violence (IPV).

Study methods
This is a cluster RCT in 42 high schools in the Western Cape. The outcomes focus on: sexual debut, condom use, number of sexual partners, IPV, conceptions in female participants.

Collaboration
The partners include: University of Cape Town, Muhimbili University College of Health Sciences, University of Limpopo, Makerere University, Maastricht University, University of Exeter, University of Oslo and the University of Bergen

Project status
Trial complete, primary outcomes published, further writing underway.

Contact person
Catherine Mathews (cathy.mathews@mrc.ac.za)
See also the project homepage: http://prepare.b.uib.no/

Imbumba Study: Enhanced STI/HIV Partner Notification in South Africa

PI Dr. Catherine Mathews and Dr. Sarah Dewing

Aim
To test a theory-based approach to HIV risk reduction with enhanced partner notification counselling tailored for STI clinic patients in South Africa. Our study will test whether the effects of risk reduction counselling on contracting subsequent STI are enhanced by building skills for index patients to self-notify their current and recent sex partners.

Study methods 
This study is a three-arm randomized control trial at one primary healthcare clinic based in Cape Town, South Africa. Approximately 1050 participants will be randomized to receive one of three conditions: 1) 60 minute risk reduction and enhanced partner notification counselling, or 2) 60 minute risk reduction counselling, or 3) 20 minute STI and HIV education counselling.

Primary outcomes are 1) sexually transmitted infections and 2) partner notification. Secondary outcomes are 1) unprotected and protected sexual behaviours and 2) partner notification behaviours.

Collaboration 
This project is a collaboration between the Medical Research Council of South Africa, the University of Connecticut, the University of Cape Town and Cape Town City Health. The study is funded by the National Institutes of Health (NIH).

Project status 
Trial completed, primary outcomes published, further writing underway..

Contact persons
Dr. Catherine Matthews (catherine.mathews@mrc.ac.za)

SMART Africa

PI: Mary McKay
Capacity Development Leads: Arvin Bhana, Inge Petersen

Overview
The goal of this study is to fund an African Center for Collaborative Child mental health implementation Research and an African Regional Trans Disciplinary-Collaborative Center aimed at to reducing child mental health service and research gaps in Uganda, Ghana and Kenya through a population approach to child mental health. SMART Africa is one of 11 NIMH global HUBS.

Aim
To build research capacity in African countries in child mental health implementation research

Collaboration
SAMRC; University of KwaZulu-Natal, New York University, Makerere University

Project Status
Project Status
The project was initiated in May 2016 in Kampala and has held an annual conference since. The last conference was held at the Uganda implementation site focusing on evidence-based practice in child and adolescent well-being and involved capacity-development fellows from the US, Kenya and Ghana. Multiple publications and grant awards have been achieved. The project concludes in 2021.

Contact person
Arvin Bhana (arvin.bhana@mrc.ac.za)
Project webpage

Safe South Africa: Integrated prevention of HIV risk and intimate partner violence among adolescents in South Africa

PI: Catherine Mathews and Caroline Kuo

Overview

South Africa, a country with the largest HIV epidemic and some of the highest rates of IPV perpetration in the world. Few behavioral interventions integrate HIV-IPV prevention and are tailored for the unique age and developmental needs of adolescents. We utilized the insights of adolescent development theory in our school-based preventive intervention strategy by capitalizing on adolescents’ developmental propensities for maximum prevention gains. Adolescence presents an ideal age and developmental transition period for an integrated intervention targeting prevention of HIV behavioral risk reduction and perpetration of IPV including sexual violence. Developmental hallmarks of adolescence – including for example, the role of social norms in motivating behaviors, the importance of peers in shaping behavioral choices, and the desire for increased responsibility – were leveraged for prevention of sexual risk behavior driving acquisition of HIV infection and engagement in IPV. We used positive peer pressure and tapped into adolescents’ desire to be responsible future leaders to motivate adolescents to intervene as bystanders when their peers are involved in HIV risk behaviors or sexual assault and aggression.

Aims
This study investigates the acceptability and feasibility of Safe South Africa, an school-based, theory-driven, developmentally-tailored intervention to prevent adolescent behavioral risk for HIV and perpetration of intimate partner violence (IPV) among adolescent boys 15-17 years of age.

  1. Development aim – to create Safe South Africa, a school-based male adolescent preventive intervention for HIV risk behavior and IPV perpetration;
  2. Acceptability aim – to evaluate the school social ecology of HIV and IPV risk and test the acceptability of Safe South Africa through an open pilot trial in one high school
  3. Feasibility aim – to conduct a randomized controlled pilot trial in one high school to assess the feasibility and acceptability for a future fully powered randomized controlled trial to evaluate efficacy of the intervention

Collaboration

Gender and Health Research Unit, SAMRC; Brown University, USA

Project status

Analysis and report-writing

Contact person

Catherine Mathews (catherine.mathews@mrc.ac.za)

WAYA study: Wellbeing among adolescents and young adults living with and without HIV in SSA- measures, understandings and determinants

PI: Darshini Govindasamy (this study forms the basis of her PhD)

Co-investigators: Prof Catherine Mathews, Dr Giulia Ferrari, Prof Janet Seeley

Background
Young people in SSA, particularly those living with HIV, are at high risk of poor mental health which is likely to compromise their wellbeing. Economic studies have shown that wellbeing during adolescence is a strong predictor of favourable gains in the short (educational attainment) and long-run (good mental health, employment). This suggests that intervening to improve wellbeing among young people might be a viable strategy to consider for enhancing their health and economic outcomes. In line with Sustainable Development Goal 3 (“Ensure healthy lives and promote well-being for all at all ages”), wellbeing has emerged as a major policy outcome for the assessment of social progress. To date, there is a gap in knowledge on appropriate wellbeing measures for young people in this region. If we can robustly measure wellbeing among young people then we could provide more accurate policy guidance on suitable interventions to promote long-run sustainable wellbeing among this population.

Aims
Aim 1
To understand the correlates and lived experiences among young people living with HIV (aged 15-24 yrs.) in sub-Saharan Africa.

Methods: Mixed-methods review.

Publication: Govindasamy, D., Seeley, J., Olaru, I. D., et al. 2020. Informing the measurement of wellbeing among young people living with HIV in sub-Saharan Africa for policy evaluations: a mixed-methods systematic review. Health and quality of life outcomes. 18,1-34. doi:https://doi.org/10.1186/s12955-020-01352-w

Aim 2
To understand the meaning and experiences of wellbeing among young people living with and without HIV in Umlazi, KwaZulu-Natal, South Africa

Methods: Qualitative research (“The Njabulo study”). Data collected via focus-group discussions and in-depth interviews with young people living with and without HIV (aged 15-24 yrs.) and key informant interviews with experts and healthcare workers.

Publication: Govindasamy, D., Ferrari, G., Maruping, K., et al. 2020. A qualitative enquiry into the meaning and experiences of wellbeing among young people living with and without HIV in KwaZulu-Natal, South Africa. Social Science & Medicine. 248,113103. doi:https://doi.org/10.1016/j.socscimed.2020.113103

Aim 3
To understand the relationship between poor mental and physical health on wellbeing among young people in South Africa To understand the impact of ART-scale up on youth (15-34 yrs.) wellbeing in South Africa

Methods: Construction of a panel dataset using data from the National Income Dynamics study (NIDS) and HIV data from the National Health Laboratory Services. Application of econometric techniques - multi-level modelling

Manuscripts in preparation for submission

  1. Govindasamy D, Neuman M, Bärnighausen T, Bodzo P, Mathews C, Seeley J, Ferrari G. The association between mental health and wellbeing among young people in South Africa: evidence from a longitudinal survey.
  2. Govindasamy D, Neuman M, Bärnighausen T, Bodzo P, Mathews C, Seeley J, Ferrari G. BMI and wellbeing among young people in South Africa: evidence from a longitudinal survey.
  3. Govindasamy D, Bärnighausen T, Neuman M, Govender D, Bodzo P, Mathews C, Seeley J, Ferrari G. The association between HIV treatment access and young people’s wellbeing in South Africa: a multi-level modelling approach.

Collaboration 
London School of Hygiene and Tropical Medicine.

Project Status
Write-up.

Contact person
Darshini Govindasamy (darshini.govindasamy@mrc.ac.za)

Funder: Bongani Mayosi National Health PhD Scholarship, National Research Foundation (NRF) Thuthuka grant, SAMRC Intramural MRC award

Yomelela Study

PIs: Dr Catherine Mathews; Prof Seth Kalichman

Overview
Among the factors that impede retention in HIV care, ART adherence and HIV suppression is the social stigmatization of HIV infection. HIV stigmas and behaviors intended to avoid stigma have the adverse consequences of deterring people from seeking care, interfering with clinic attendance, and detracting from taking ART. Interventions to increase HIV care retention and ART adherence have not thus far focused on reducing the adverse effects of stigma in countries where HIV is most prevalent.  

Overall aim
This study will test a theory-based mobile-phone delivered counseling intervention designed to address HIV-stigma concerns in order to improve HIV treatment retention and adherence in South Africa. The intervention is grounded in Behavioral Self-Regulation Theory and the HIV Stigma Framework and was developed in partnership with South African public health agencies.

We will conduct a 3-arm randomised controlled trial in to compare: (a) Behavioral Self-Regulation + Stigma Management Counseling for HIV treatment retention and adherence, vs. (b) Behavioral Self-Regulation Counseling for HIV treatment retention and adherence, vs. (c) Uniform standard of care HIV patient education.

We will enrol 1250 men and women with unsuppressed HIV and receiving HIV treatment and follow them for 15-months post-intervention to assess effects on HIV care retention and HIV suppression (primary outcomes) and ART adherence (secondary outcome).

Collaboration
University of Connecticut

Project status
Data collection will start in October 2020.

Contact person
Dr. Catherine Mathews (catherine.mathews@mrc.ac.za); Ms Ellen Banas (ellen.banas@mrc.ac.za)

HERStory Study: Impact Evaluation of a combination HIV Prevention Intervention for Adolescent Girls and Young Women (AGYW) in Ten South African Districts

PI: Dr Catherine Mathews

Overview

From 2016 to the present day, the Global Fund to Fight AIDS, TB and Malaria has invested in a combination HIV prevention intervention for adolescent girls and young women in South Africa (AGYW), with the aim of reducing HIV incidence, teenage pregnancy, gender-based violence, and increasing retention in school and access to economic opportunities. The intervention is being implemented in several districts with high HIV burden by a range of South African organisations, with the support of the South African National AIDS Council. It is aligned with the She Conquers campaign, and the South African National Strategic Plan for HIV, STI’s and TB (2017-2022).

Combination HIV prevention interventions merge effective biomedical, behavioural and structural interventions for combined delivery. They are one of the key strategies for reaching the UNAIDS 90-90-90 targets and achieving the Sustainable Development Goal (SDG) of ending the HIV epidemic by 2030.

The HERStory Study is an evaluation of the combination HIV prevention intervention for AGYW, conducted by the South African Medical Research Council (SAMRC) and partners.

Aims

The aim of the evaluation is to determine the impact of the Global-Funded AGYW intervention on HIV incidence among AGYW aged 15 to 24 years living in the intervention districts. The study also evaluates the impact of the intervention on the cognitions, behaviours and social environments of AGYW.

Collaboration

  • National Institute for Communicable Diseases
  • Brown University
  • University of Cape Town
  • Centers for Disease Control and Prevention
  • Epicentre AIDS Risk Management (Pty) Limited

Project status

First survey of two consecutive representative household surveys has been completed and published.  Second phase of research is in the planning phase.

Contact person

Dr. Catherine Mathews (Catherine.Mathews@mrc.ac.za)

Tracy McClinton Appollis (tmappollis@mrc.ac.za)

https://www.samrc.ac.za/intramural-research-units/HealthSystems-HERStory

HERStory 2 Study: Process evaluation of the combination HIV prevention intervention for adolescent girls and young women (AGYW), Global Fund grant period 2019 to 2022

PIs: Dr Catherine Mathews, Dr Kim Jonas, and Dr Zoe Duby

Overview

From 2016 to the present day, the Global Fund to Fight AIDS, TB and Malaria has invested in a combination HIV prevention intervention for adolescent girls and young women in South Africa (AGYW), with the aim of reducing HIV incidence, teenage pregnancy, and gender-based violence and increasing retention in school and access to economic opportunities. Combination HIV prevention interventions, which merge effective biomedical, behavioural and structural interventions for combined delivery, are one of the key strategies for reaching the UNAIDS 90-90-90 targets and achieving the Sustainable Development Goal (SDG) of ending the HIV epidemic by 2030.

Scientists in the Health Systems Research Unit have been requested to conduct a process evaluation of the AGYW combination intervention being implemented during the 2019 to 2022 Global Fund grant period.

Aims

To investigate:

  1. Whether the coverage of the intervention is aligned to the theory of change, by conducting “coverage cascades” for HIV prevention and care interventions and for pregnancy prevention interventions.
  2. The extent to which the intervention is acceptable to AGYW and key stakeholders in schools and communities, and why they participate in it, or decline to participate in aspects of the intervention.
  3. The extent to which the context of the intervention is conducive to intervention implementation, and to what extent key gatekeepers in the intervention context are supportive of implementation.
  4. Whether the theory of change is appropriately specified to achieve the intervention goals and to what extent is it being implemented as theorized.

Collaboration

  • Brown University
  • University of Cape Town
  • South African National AIDS Council
  • Data Yarn
  • Stellenbosch University

Project status

Protocol development

Contact person

Dr. Catherine Mathews (Catherine.Mathews@mrc.ac.za)

Dr Kim Jonas (Kim.Jonas@mrc.ac.za)

https://www.samrc.ac.za/intramural-research-units/HealthSystems-HERStory

Thematic area 3: Communicable and Non-Communicable Diseases

What are the maternal treatment outcomes, pregnancy outcomes and infant outcomes in women treated for DR-TB during pregnancy.

PI: Dr. Marian Loveday

Aim
To document the treatment, pregnancy and outcomes of women treated for DR-TB during their pregnancy. 

Study methods
A descriptive cohort analysis

Status
Data collection ongoing

Collaboration

  • Dr. Jennifer Hughes from the Desmond Tutu TB Centre (DTCC)
  • Dr. James Seddon from Imperial College London and the Desmond Tutu TB Centre (DTCC)
  • Clinicians at King Dinuzulu Hospital, eThekweni, KwaZulu-Natal.

Study outcomes

  • Loveday M, Hughes J, Sunkari B, Master I, Hlangu S, Reddy T, Chotoo S, Green N, Seddon JA. Maternal and infant outcomes among pregnant women treated for multidrug/rifampicin-resistant tuberculosis in South Africa. 2020. https://doi.org/10.1093/cid/ciaa189.
  • Presented pregnancy findings as WHO Guideline Development Group meeting. These findings have been included in the latest WHO guidelines on how pregnant women with RR-TB should be managed.

Nested study within the DR-TB during pregnancy study:
Title:
To explore plasma concentrations of second-line TB drugs in pregnant women and their infants

PI: Dr. Marian Loveday

Aim
To explore plasma concentrations of the second-line TB drugs in these women and their infants.

Study methods
All recruited participants who have not yet delivered will be screened for eligibility into the pharmacokinetic (PK) analysis to enhance the understanding of drug exposure in pregnant women on therapy for DR-TB. Two PK sampling occasions will be scheduled, the first will be prior to delivery preferably in the third trimester, on a date, which is convenient for the mother and the second at 6 weeks post-delivery to compare drug levels in the pregnant and non-pregnant state.

Status
Recruitment has started and is ongoing.

Collaboration

Prof Gary Maartens, Prof Helen Mclleron, Dr Richard Court: UCT

Second nested study within the DR-TB during pregnancy study:

PI: Dr. Marian Loveday

Aim

To explore whether microbiomes of mothers (airways, breastmilk, vagina, gut) and babies (gut) are potentially affected by treatment, and if so, are any microbiome changes associated with infant outcomes and drug exposure?

Study methods

All recruited participants who have not yet delivered will be screened for eligibility into the microbiome study. Vaginal, gut, breastmilk and sputum samples will be collected from the mother in the 3rd trimester and 6 weeks, 6 months and 12 months after delivery. Microbiome estimates in each specimen type will be correlated with PK data and clinical outcomes (in mothers and babies).

Status

This study amendment is awaiting ethics approval.

Survival and TB recurrence after successful drug-susceptible- and rifampicin-resistant TB treatment

PI: Dr. Marian Loveday

Aim
To document survival and the recurrence of TB after successful drug-susceptible- and rifampicin-resistant TB treatment

Study methods
A mixed methods cohort study design: We will identify a similar number of patients with TB in Umzinyathi and Khayelitsha, matching for age and gender with MDR-TB patients in the same area.  Patients co-infected with HIV and with co-morbid conditions (eg. Diabetes) will be included.

Status
Data collection has commenced

Collaboration
Mr Johnny Daniels and Dr. Erika Mohr from Medicins san Frontier (Khayelitsha, South Africa)
Dr. Helen Cox and Dr. Andrew Boulle from UCT

Exploring opportunities and models for improved integration and health service delivery at a community and primary health care level in eThekweni metro, KwaZulu-Natal, South Africa

PI: Dr. Marian Loveday

Aims
The aims of the implementation component are:

  • To develop and implement a targeted screening approach for diabetes, hypertension, and other diseases and conditions utilizing existing community-based and facility-based health service infrastructure in eThekwini, using an improved diagnostic algorithm aligned with national guidelines. This builds on existing screening efforts against other diseases such as tuberculosis.
  • To develop an algorithm alongside our partners that is based on peer-reviewed evidence and in line national guidelines. Subsequently, implement it for treatment, support, and education for these patients and their families. Work with public health and where appropriate private health delivery partners to implement and improve this program in subsequent years in a large, targeted area of the municipality.
  • To support the National health services integration initiative by sharing practical operational research in a timely manner, avoiding duplication or parallel, “vertical” disease efforts (HIV, TB, hypertension, diabetes, etc.), improving existing and new health worker capacity in public and private sectors, and implementing a clear sustainability plan at the end of the grant period

The aims of the evaluation component:

  1. Document the opportunities and models for improved integration and health service delivery implemented by AA&D and local partners at PHC facilities, schools and in the community.
  2. Through the lens of a non-communicable disease (NCD) diabetes and an infectious disease TB document the functioning of the different levels of the health system, the interface and relationship between these layers and the inputs needed to optimize health system functionality across all levels.
  3. Document the strategies and interventions required to improve integration and for effective patient-centered services including active case finding, linkage to care, effective education and quality management of both non-communicable and infectious diseases.
  4. Monitor the integration of both non-communicable and infectious disease services at a community level, together with the linkages to PHC facility level care. 
  5. Using the platform created for the Zero TB Cities Initiative, pilot a program of decentralized, community-based screening and referral for diabetes, hypertension and other conditions (as the basis for using this approach for integrated PHC delivery).
  6. Monitor the impact of the introduction of new, complex interventions at a district level and how these impact on and are integrated into existing services. This may include the provision of MDR-TB services, Test and Treat and adolescent HIV prevention.

Study methods
Implementation research

Status
Ongoing

Collaboration
Advance Access & Delivery (AA&D)
eThekweni Metro Health Services
Provincial TB and NCD directorates

Task sharing mental health services within chronic care in South Africa (MHiNT)

PI: Deepa Rao; Inge Petersen
Co-investigators: Arvin Bhana, Lara Fairall, Crick Lund

Overview
In the context of the re‐engineered PHC system, including integrated chronic care in South Africa, the University of KwaZulu-Natal is collaborating with the University of Washington and I‐TECH South Africa to scale up the integration of mental health care into integrated chronic care at primary health care facilities in collaboration with the national and provincial DOH in North West, Mpumalanga and KwaZulu-Natal.

Aim
To scale up integrated mental health care into HIV and chronic care platforms at primary health care level

Collaboration
Department of Global Health, University of Washington, University of KwaZulu-Natal, I-TECH South Africa, University of Cape Town, Medical Research Council, Department of Health (National and Regional)

Project Status
While the project concluded in 2019, many of the learnings from this project have been taken up in a sister project (SMhINT). For example, the Brief Mental Health Screening (BMH) tool was validated for use in a primary care setting and has now been accepted as a standardized tool for screening all patients at a facility level for common mental health disorders.

Funder
United States Centres for Disease Control and Prevention

Contact person
Inge Petersen (peterseni@ukzn.ac.za)

Southern African Research Consortium for Mental Health INTgration (S-MHiNT)

PIs: Arvin Bhana, Inge Petersen, Deepa Rao

Co-Investigators
Max Bachmann, Ruanne V Barnabas, Joy N Baumgartner, Lara Fairall, Sylvia Kaaya, Joȁo L Manuel, James T Pfeiffer, Kenneth Sherr, Jurgen Unutzer, Bradley Wagenaar

Overview
In this project, we will study how to smoothly scale up treatment of mental health issues in primary care settings, by navigating bottlenecks in primary care systems. We will also work to train others in researching these models of scale up. Our work benefits people who live in under resourced settings and suffer from mental health and other chronic health issues.

Aim

Aim 1. To establish and engage a trans-disciplinary research consortium of academics, government representatives and non-governmental organizations in South Africa, Mozambique and Tanzania to address the burden of common mental disorders in primary health care settings.

Aim 2. To examine multi-level influences on the uptake, implementation, effectiveness and sustainability of an existing scale-up of an integrated mental health package for chronic disorders at primary health care level in two different districts in South Africa which have different resource capacities.

Aim 3. To build implementation science and dissemination research (ISDR) capacity in South Africa, Mozambique and Tanzania, recruiting service providers, managers and policy makers as trainees, providing real-world opportunities, mentorship and necessary knowledge to conduct optimal scale-up of evidence-based integrated mental health care.

Collaboration
University of KwaZulu-Natal, University of Washington, Beira Operations Research Center (CIOB), Health Alliance International (HAI), Muhambili University of Health and Allied Sciences, Dar es Salaam, Tanzania.

Project Status
In addition to data collection arising from the implementation of a Brief Mental Health screening tool at a facility level, the project has also completed an acceptability study of a community-based screening and detection tool (CMED) for use by community health workers.

Contact person
Arvin Bhana (arvin.bhana@mrc.ac.za)
Inge Petersen (peterseni@ukzn.ac.za)

SMS-TEXT Adherence Support (STAR): A multi-stage process evaluation of a mobile-phone intervention to enhance adherence to diabetes treatment and care in Lilongwe, Malawi, Cape Town and Johannesburg

PI Dr. Natalie Leon

Aim
The StAR Diabetes (StAR2D) study aims  1. to inform the development of the SMS content and delivery mechanisms of a mobile-phone intervention that will be tested in a randomised controlled trial (RCT), to enhance adherence to diabetes treatment and care and 2. through a multi-stage process evaluation,  to evaluate the implementation of the RCT and the experience of stakeholders in the three sites in order to investigate contextual factors, possible causal pathways of the intervention and requirements for scaling and sustainability. There is also an economic evaluation component of this mHealth trial.

Study methods 
The formative and process evaluations are multi-method, mainly qualitative evaluations using focus groups, individual interviews, document reviews, literature reviews and observational methods.

Collaboration
Nuffield Department of Primary Care Health Sciences, University of Oxford, UK; Chronic Diseases Initiative in Africa, University of Cape Town and Groote Schuur Hospital, Malawi Epidemiology and Intervention Research Unit, University of Witwatersrand, Johannesburg. Funders are MRC UK, SAMRC and Global Alliance for Chronic Disease.

Project status 
The formative and intervention development phase of the research was completed in Dec 2016. The trial and the first phase of the process evaluation is in progress. The economic evaluation, led by Ms Daviaud from SAMRC, is also in progress. The project was concluded June 2020 and there are three publications in submission: The trial results, the formative research and the process evaluation. The costing paper is in progress.

Contact person 
Dr. Natalie Leon  (natalie.leon@mrc.ac.za)
Ms. Emmanuelle Daviaud (Emmanuelle.daviaud@mrc.ac.za)

The Cape Town iALARM Project: Using routine health information to align services and link and retain men in the HIV cascade
In South Africa, men are less likely than women to be tested for HIV and to access HIV prevention, treatment and care. This is due to a complex set of social and health systems factors. The iALARM study, headed by Dr Chris Colvin from UCT and Dr Mark Lurie from Brown University, USA, is a 5-year  NIH-funded, mixed method collaboration with co-investigators from a number of institutions, including Dr Natalie Leon from the Health Systems Research Unit at the SAMRC. The study attempts to address this problem pf poor linkage to care through two aims, to 1) understand the cultural, social and psychological factors that make it difficult for men to get HIV services and stay in care, and 2) help healthcare workers and managers from NGOs, city and provincial facilities work together to better support men in HIV care. iALARM aims to achieve this through a routine health information system intervention that will allow for better coordination between partners in the area working with HIV positive men. The intervention will integrate routine facility-level data with local-level cohort data of men moving through the HIV cascade in our study site. We use this information to better align services to link and retain men in HIV

Thematic area 4: Social and Economic Policy and Health

The Health Economics section of the Health System Research Unit frames its work within a Universal Health Coverage and ultimately National Health Insurance perspective.   It thus focuses on the following areas: human resources planning, development of investment cases, costing and economic evaluation of existing services, private sector research, and more recently applying this work to COVID19 response.

Study 1: A birth cohort assessing the utilisation of the CSG and its link to dietary diversity, and child growth

PI: Dr Wanga Zembe, Dr Vundli Ramokolo, Prof Tanya Doherty, Prof David Sanders, Prof Rina Swart
A longitudinal birth cohort study identifying women during pregnancy and following them up with their children from birth until 2 years to assess the nutritional status and dietary patterns of recipients and non-recipients of the CSG in Langa Township, Western Cape. This study builds upon the qualitative study outlined under Study 3. It is partially funded by the Centre of Excellence for Food Security and will run from 2016-2019.

The birth cohort commenced in March 2016. Fieldwork is in progress with the aim to recruit and follow up 500 mothers and their children.

Collaboration: The Centre of Excellence for Food Security, and UWC School of Public Health,

Contact person
Dr. Wanga Zembe (wanga.zembe@mrc.ac.za)
Dr Vundli Ramokolo (Vundli.ramokolo@mrc.ac.za)

Study 2: Social protection, youth economic empowerment and social support for adolescent girls and young women at risk of poor health and wellbeing

PI: Dr Wanga Zembe

Co-Investigators: Lieve Vanleeuw; Yanga Zembe

A two-year mixed-methods research project that aims to assess (i) the levels of social support, economic empowerment and social protection available to adolescent girls and young women (AGYW), and (ii) the impact thereof on health and wellbeing of AGYW.

The main outcomes of the project are:

  1. Synthesized evidence on best practice models regarding social protection, economic empowerment and social support interventions that can protect and improve the health and wellbeing of AGYW in LMIC settings.
  2. Empirical evidence on the correlation between social protection, economic empowerment, and social support resources, interventions and programmes to proximal indicators associated with vulnerability, poor health and wellbeing among AGYW in South Africa.
  3. Knowledge on gaps, opportunities and acceptability of expanded state-provided social protection and economic empowerment interventions to protect and promote health and wellbeing in AGYW in South Africa.
  4. Recommendations for an integrated package of financial, economic and social support interventions to protect and promote the health and wellbeing of AGYW based on outcomes 1, 2 and 3.

Project status: The rapid review has been completed and a progress report for year 1 has been submitted to funders. The qualitative component of the project was carried out in 2019, as well as secondary analysis of data and engagement with stakeholders. Further analysis of data and writing up of reports and publications from the work have commenced.

Contact person

Wanga Zembe (wanga.zembe@mrc.ac.za)

Study 3: Exploring the experiences of CSG recipients and non-recipients regarding coping, access to social protection, food security, income security, and safety in the time of Covid-19

PI: Dr Wanga Zembe-Mkabile, Dr Vundli Ramokolo, Prof Tanya Doherty

Overview
The advent of the Covid-19 pandemic in South Africa and across the globe, with associated national lockdowns, poses special challenges and implications for household food security, and child health and wellbeing among poor households. It is important to assess how Child Support Grant-eligible but non-recipient, and recipient households are experiencing and coping with the threat of Covid-19 and the accompanying restrictions on movement, as well as potential loss and or reduction of income.

Study Aim

To explore the experiences of Covid-19 among recipients and non-recipients of the CSG in Langa Township, Western Cape

For this qualitative study we are conducting twenty  telephonic qualitative interviews over two time points with participants (mother-child pairs) that we have been following up for two years in a longitudinal cohort study assessing the impact of the CSG on child nutritional status and food security. For this additional piece of research we are exploring  participants’ experiences of accessing social grants in the time of Covid-19; their experiences of securing food for their children and households, experiences of restrictions to movement, loss of earnings due to not working and social distancing while living in informal settlements and or small housing structures with small or no yard space; experiences with safety; perspectives and concerns they might have for themselves and their children and families at this time; and what they see as the role of social grants and the CSG in particular in providing support to impoverished and vulnerable households and communities in the time of Covid-19.

The study will provide learnings and lessons on how poor households reliant on small social grants cope during pandemics such as Covid-19 and the ways in which the social security system in South Africa can better respond to and support children and families from poor households.

Collaboration
SAMRC

Project status
Qualitative interviews are in progress. As part of this study we have published an Op-Ed in the Daily Maverick which communicates emerging results and the implications thereof for policy and practice. Link to the article: https://www.dailymaverick.co.za/article/2020-05-26-covid-19-and-social-grants-relief-measures-welcome-but-not-enough/#gsc.tab=0

Contact person
Dr. Wanga Zembe-Mkabile: wanga.zembe@mrc.ac.za

Study 4: Patient experiences of the burden of TB in the context of syndemic interaction and social protection, in Cape Town South Africa

PIs: Lieve Vanleeuw, Wanga Zembe

Overview

TB remains a major health problem and the number one cause of death in South Africa. While TB is closely associated with poverty, it can also push households into worsening impoverishment through costs associated with the disease such as the cost of food and travel and the loss of income. In addition, household contacts of TB patients have an increased risk of developing TB. Transmission of TB can infect multiple members of the household which in turn can aggravate the social and economic burden of TB and diminish household resilience over time. TB patients frequently also suffer from chronic conditions like HIV and diabetes. The coordination of health and social services for each of these conditions can put an extra burden on the patient. The co-occurrence of TB and chronic conditions, in the context of a broader set of socio-economic factors such as household vulnerability to multiple and recurring transmission of TB, fragmented social and healthcare services, and poverty can have a syndemic effect on the burden of TB for patients.

Aim

The study aims to explore patient experiences of the multiplicative burden of TB caused by the co-occurrence of TB and chronic conditions such as HIV and diabetes, in the context of a broad set of socio-economic factors such as household vulnerability to multiple and recurring transmission of TB, poverty, overcrowding, stigma, and fragmented social and healthcare services. It furthermore aims to explore patient experiences of existing interventions like contact screening, integration of services and the disability grant that can potentially alleviate the syndemic burden of TB in the Western Cape, South Africa.

Project status

Semi-structured interviews have been conducted with TB patients and healthcare workers at 2 clinics and officials from the South African Social Security Agency (SASSA) in Cape Town. Collected data is currently being analysed and written up for publication.

Collaboration

Tampere University Finland

Tampere TB Foundation Finland

Contact person

Lieve Vanleeuw: Lieve.vanLeeuw@mrc.ac.za

Study 5: Patient experiences of the burden of TB before and during the COVID-19 crisis

PIs: Lieve Vanleeuw, Wanga Zembe

Overview

Amid the COVID-19 crisis TB patients face increased vulnerability due to the consequences of the COVID-19 response such as loss of income, challenges to access healthcare services and anti-TB medication, increased stigma, and a loss of social support structures. Many of them are already poor, and many depend on informal work or have lost their jobs. The COVID-19 social and economic response in South Africa, however, might also offer some alleviation to TB patients’ burden by accessing the Covid-19 Social Relief of Distress Grant (SRDG) designed for unemployed working age adults who are destitute because of the virus. Our study will explore how the COVID-19 epidemic and response have affected the social, economic, and health situation of TB patients, as well as how COVID-19 measures to alleviate the social and economic effects of the COVID-19 epidemic and response such as the Social Relief of Distress Grant have affected TB patients’ vulnerability.

Aims

  1. Explore how the COVID-19 epidemic and response, such as the lockdown measures, have affected the health, social and economic burden of TB patients in Cape Town, South Africa.
  2. Explore how COVID-19 measures to alleviate the social and economic effects of the COVID-19 epidemic and response such as the Social Relief of Distress Grant have affected TB patients’ vulnerability.
  3. Explore perceptions of healthcare workers working with TB patients of two primary healthcare clinics in Cape Town on how the COVID-19 crisis has affected TB patients in Cape Town, South Africa.
  4. Explore perceptions of SASSA officials on the Social Relief of Distress grant and other forms of assistance for TB patients in Cape Town, South Africa.

Collaboration

Tampere University Finland

Tampere TB Foundation Finland

Project status

Protocol approved by the SAMRC Ethics Committee. Interviews to start in October 2020.

Contact person

Lieve Vanleeuw: Lieve.vanLeeuw@mrc.ac.za

Study 6: Exploring the links between food and nutrition messaging, local food knowledge systems and food experiences and eating practices in Langa

PI: Prof Yanga Zembe,

Co-PI: Dr Wanga Zembe

Aim: To explore the engagement of poor people with public health policies, interventions and food knowledge systems, including social media, and how these shape their food experiences and eating practices in Langa Township, Cape Town

Objectives

  • To explore the food experiences and eating practices of CSG recipients and non-recipients
  • To examine the kind of nutrition education that CSG recipients and non-recipients, and their sources of health information and knowledge regarding nutrition
  • To explore how the CSG recipients and non-recipients regard these sources of information, including their considerations regarding their accessibility, credibility, usefulness and impact
  • To determine the perceptions CSG recipients and non-recipients have regarding the influence of the food and nutrition messaging and education that they are exposed to, on what and how they eat
  • To explore CSG recipients and non-recipients’ knowledge of and familiarity with policies on nutrition and healthy food practices, and how they interpret and apply these
  • To determine the role of socio-cultural knowledge systems about food on gender-based food practices, as well as the influence of such gender norms on how public health nutrition education and interventions are interpreted and applied by CSG recipients and non-recipients
  • To understand the ways in which Covid-19 has affected the resourcefulness and capabilities of CSG recipients and non-recipients in their quest to ensure adequacy of food in their households

Methods:

For this qualitative study 20 telephonic qualitative interviews will be conducted with participants (primary caregivers) and five with spaza shop owners from a cohort of mother-child pairs that we have been following up for two years in a longitudinal cohort study assessing the impact of the CSG on child nutritional status and food security

Collaborators: CoE for Food Security

Project status: Awaiting ethical approval; data collection soon to commence.

Contact person: yanga.zembe@gmail.com

Human Resource planning

Planning PHC human resources needs for 2025 and 2030

PIs: Emmanuelle Daviaud and Donela Besada

Aim: To develop an incremental needs-based model to estimate PHC HR needs (skill mix and quantity) for 2025 and 2030.

Study methods: Assessment of needs for PHC services based on population structure, burden of disease and NDoH target coverages. Skill mix: Allocation of types of visits based on scope of practice. Staff needs calculated for the country and by 100,000 population. Includes community-based services (WBOTs), clinics, CHCs, school health and environmental health.

Collaboration: Member of the Ministerial Task Team Workstream 1

Project status:   Completed.  Model results included in the HR Strategic Plan for 2025

Contact person:   Emmanuelle Daviaud (Emmanuelle.Daviaud@mrc.ac.za)

Time Analysis to Improve Workforce Planning for HIV Services  

PI: Emmanuelle Daviaud

Co-PI: Donnela Besada

Aim
The purpose of this exercise is to provide additional understanding of HIV service workload requirements to further inform workforce planning, in line with Government of South Africa (GoSA) issuance of PEPFAR Supplemental Staffing Guidelines to all Provinces and adoption of the national Ward Based Primary Health Care Outreach Team (WBPHCOT) policy. In 2018, PEPFAR supported the application of the Prioritization and Optimization Analysis (POA) approach to identify the optimal allocation of PEPFAR supplemental health workers. The POA analysis applied South Africa Workload Indicators of Staffing Need (WISN) model along with PEPFAR programmatic and budget data to generate estimates. The analysis identified the need to better understand workload requirements across cadres and area of HIV service based on actual data. The time and motion analysis will provide up-to-date calculation of staff time by cadre for each area of HIV service delivery.

Methods

The analysis will use a mixed-method approach combining an observational time and motion time study (using a random work sampling approach) with self-administered time-based diaries (time analysis).

Collaboration
PEPFAR, USAID, Open Development, HRH 2030, Chemonics, NDOH

Project status
Study in process

Contact person
Emmanuelle Daviaud: edaviaud@mrc.ac.za

Investment Cases

Development of an Investment Case for Mental Health in South Africa

PI: Professor Crick Lund

Co-PI: Donela Besada (SAMRC) and Sumaiyah Docrat (UCT)

Aim
To develop an investment case for mental health to determine the costs and returns of a prioritized package of system and service-level interventions to reach important targets related to South African mental health services.

Study methods
The study will involve a mixed method approach including qualitative interviews with key stakeholders to identify the priorities on a package of interventions for the South African mental health system, a review of the evidence base for known interventions for mental health, calculating the total budget needed to implement the package of prioritized investments and carrying out an economic evaluation to estimate the returns on these investments linked to key outcomes.

Collaboration
National and Provincial Departments of Health

Project status
Project underway

Contact person
Donela Besada (Donnela.Besada@mrc.ac.za)

Costing and Economic Evaluation of Existing Services

Mobile messaging support to control type 2 diabetes (StAR2D): a multicentre randomized controlled trial

PI:  Prof. Andrew Falmer (Oxford University)

Co-PIs: N. Levitt, MN Nyirenda

Co-Investigators:  KB. Bobrow, N. Leon, E. Daviaud, D. Besada

Aim: The overall aim of this project is to test the effectiveness of sending short message service (SMS) texts in improving health outcomes and supporting medication adherence in patients with type 2 diabetes in the context of implementing a low-cost, mobile-health communication infrastructure in an operational setting .  The cost analysis aims to assess the affordability of such intervention for the provider.  Analysing patients’ costs seeks to identify whether these can constitute a barrier to adherence.

Methods: The cost analysis focussed on both providers and patients’ costs in a PHC site in Cape Town (SA) and an outpatient site in Lilongwe (Malawi).  Actual costing, as different from protocol based modelling, was carried out to obtain per site the routine cost per patient per treatment year and cost of the messaging intervention if scaled-up to country level. Patient costs focused on transport costs and time in facility.  E daviaud and D Besada were responsible for the economic component of the study

Collaboration: University of Cape Town, Malawi College of Medicine, South African Medical Research Council, University of Oxford

Project status: Project completed.

Publications: Publication on cost analysis in process

Contact person: Emmanuelle Daviaud (Edaviaud@mrc.ac.za)

Thematic area 5: Knowledge synthesis for strengthening health systems

Assessing the effects of interventions to improve Health Information Systems (HIS): A systematic Review

PI Dr. Natalie Leon

Aim
To systematically review evidence on effectiveness routine health information interventions aimed at improving health information systems, health systems functioning and health outcomes. The objective is to document the evidence-base on HIS strengthening in order to inform policy and practice in health systems strengthening.

Study methods 
Evidence synthesis approach: EPOC Systematic review.

Collaboration
A project by Alliance for Health Policy and Systems Research and

Project status 
EPOC Protocol published; Report accepted for publication June 2020

Contact person                       
Dr. Natalie Leon  (natalie.leon@mrc.ac.za)

South African Initiative for Systematic Reviews on Health Policies and Systems (SAI)

PI  Dr Simon Lewin and Dr. Natalie Leon

Aim
SAI aims to develop institutional capacity in LMICs to conduct and to promote the translation of evidence syntheses into practice. We focus on health policy and systems issues that are policy-relevant at the national level in South Africa, but that could also be relevant to the needs of other countries in the region or in similar settings in other parts of the world. Our work comprises conducting systematic reviews and producing rapid evidence syntheses to knowledge users across departments of health and civil society. 

Collaboration
SAI is partnering with senior researchers in South Africa from Cochrane South Africa, the University of the Witwatersrand, and the University of Stellenbosch. We also directly and actively engage with policy makers within the South African Department of Health at local government (municipal), provincial and national levels. SAI is funded by the Alliance for Health Policy and Systems Research, based at the World Health Organisation. We also form part of the Global Evidence Synthesis Initiative (GESI) network.

Project status 
This multi-year project started in June 2013, commencing with a priority setting exercise involving leading academics and policy makers, primarily in South Africa but also extending to other countries in sub-Saharan Africa. This exercise resulted in identifying priority health systems and policy research questions, and informed the focus and design of the full systematic reviews that are conducted by the SAI. We also recently began with our rapid evidence synthesis service. Through this service, we directly engage decision makers within Provincial Departments of Health. Our engagement is focused on understanding what urgent health systems’ decisions they are having to take, and how we can support their decision making through producing rapid evidence syntheses. For further information on what rapid evidence syntheses are, see the Rapid reviews to strengthen health policy and systems: a practical guide, 2017 that can be downloaded from: http://www.who.int/alliance-hpsr/resources/publications/rapid-review-guide/en/

Contact person 
Dr Simon Lewin: Simon.Lewin@fhi.no
We welcome interaction and feedback around our work. We also welcome requests to be involved in systematic reviews of health systems and policy questions, and invite knowledge users to make use of our rapid evidence synthesis service.

Healthcare workers' perceptions and experience of primary healthcare integration: a qualitative evidence synthesis

PI Ms Hlengiwe Moloi and Dr Natalie Leon

AIM

We aim to explore healthcare workers' perceptions and experience of Primary health care (PHC) integration interventions. This can help us understand the influence healthcare workers have on the implementation of PHC integration, and the possible impacts this may have on the success or otherwise of PHC integration.

PHC integration has been promoted as a health sector reform tool to promote Universal Health Care, especially in low-resource settings, but the uptake and implementation has been uneven, and the evidence of success remains elusive. Thus, our study will contribute to the knowledge base.

Study methods 
Evidence synthesis approach: EPOC Cochrane Systematic review.

Collaboration
A project by Alliance for Health Policy and Systems Research and SAMRC

Project status 
EPOC Protocol published in March 2020

Contact person                       
Ms Hlengiwe Moloi  (hlengiwe.moloi@mrc.ac.za)

Completed Projects

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