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The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study.

ABSTRACT: OBJECTIVE:To assess whether decentralising colposcopy services to a primary care facility in inner-city Johannesburg, South Africa raises access to colposcopy. DESIGN:Before-after study comparing 2?years before and 2 years after decentralisation, using clinical records and laboratory data on cervical cytology and histology. PRIMARY OUTCOME:The proportion of all women attending Hillbrow Community Health Centre (HCHC) with an abnormal Papanikolaou (Pap) smear who had a colposcopy post-decentralisation. SETTING:Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) has provided colposcopy services for several decades. HCHC, located about 3?km away, began colposcopy services in 2014. PARTICIPANTS:Women, aged above 18 years, who had a colposcopy for diagnosis and treatment of precancerous cervical lesions following a Pap smear, from 2012 to 2016 at CMJAH or HCHC. RESULTS:Pre-decentralisation at CMJAH, 910 women had colposcopy (2012-2014). Post-decentralisation (2014-2016), 721 had colposcopy at CMJAH and 399 at HCHC, the decentralised facility. The number who had a Pap smear at HCHC and then a colposcopy rose threefold post-decentralisation (114 vs 350). Post-decentralisation, 43 women at HCHC were referred to CMJAH for colposcopy, compared with 114 pre-decentralisation. Post-decentralisation, 47.3% of women at CMJAH waited >6 months for colposcopy, while 35.5% did at HCHC (p<0.001). Across all three groups, 26.9%-30.3% of women had cervical intraepithelial neoplasia III lesions or carcinoma on colposcopy. The proportion of invalid specimens was similar at CMJAH and HCHC (1.8%-2.8%). Of 401 women who had an abnormal Pap smear at HCHC post-decentralisation, 267 had colposcopy (66.6%). CONCLUSION:Decentralisation can decrease the time to colposcopy and reduce the workload of tertiary hospitals. Overall, more women accessed services. Colposcopy coverage at HCHC is higher than other sites, but could be further improved. Decentralisation did not appear to undermine the quality of services and this model could be extended to similar settings in South Africa and elsewhere.

SUBMITTER: Maimela G

PROVIDER: S-EPMC6475219 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study.

Maimela Gloria G Nene Xolisile X Mvundla Nontuthuko N Sawry Shobna S Smith Trudy T Rees Helen H Kachingwe Elizabeth E Chersich Matthew M

BMJ open 20190330 3

<h4>Objective</h4>To assess whether decentralising colposcopy services to a primary care facility in inner-city Johannesburg, South Africa raises access to colposcopy.<h4>Design</h4>Before-after study comparing 2 years before and 2 years after decentralisation, using clinical records and laboratory data on cervical cytology and histology.<h4>Primary outcome</h4>The proportion of all women attending Hillbrow Community Health Centre (HCHC) with an abnormal Papanikolaou (Pap) smear who had a colpos ...[more]

PMID: 30928936

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Project description:For adolescents growing up in poor urban South African settings, violence is often a part of daily life and has lasting effects on physical and mental health outcomes in adulthood. We conducted a qualitative study to document and understand the forms of interpersonal violence experienced by adolescents living in Hillbrow, Johannesburg. In this article, we explore how violence is experienced differently by adolescent boys and girls, how they conceptualise 'dangerous' and 'safe' spaces in their neighbourhood and what gaps exist in available services for youth in Hillbrow.The article draws on data collected in the formative phase of the 'Wellbeing of Adolescents in Vulnerable Environments' (WAVE) Study of challenges faced by adolescents (15-19 years) growing up in impoverished parts of five cities. This article reports on analysis using only data from the Johannesburg site. Using both purposive and snowball sampling to select participants, we conducted in-depth interviews (n = 20) and community mapping exercises with female (n = 19) and male (n = 20) adolescents living in Hillbrow, as well as key informant interviews with representatives of residential shelters, CBOs, and NGOs working with youth (n = 17). Transcripts were coded manually and analysed using an inductive thematic analysis approach.Both girls and boys reported high exposure to witnessing violence and crime. For girls, the threat of sexual harassment and violence was pervasive, while boys feared local gangs, the threat of physical violence, and being drawn into substance-abuse. Home was largely a safe haven for boys, whereas for girls it was often a space of sexual violence, abuse and neglect. Some adolescents developed coping mechanisms, such as actively seeking out community theatres, churches and other places of sanctuary from violence. Community-based services and shelters that support adolescents reported a lack of resources, overall instability and difficulties networking effectively.Adolescents in Hillbrow commonly witnessed and had direct experience of many forms of violence in their environment, and these experiences differed markedly by gender. Interventions that build young peoples' social capital and resilience are essential for reducing violence-related trauma and long-term health and social consequences for adolescents in this community.

Project description:Alcohol misuse is a key factor underlying the remarkable vulnerability to HIV infection among men and women in sub-Saharan Africa, especially within urban settings. Its effects, however, vary by type of drinking, population group and are modified by socio-cultural co-factors.We interviewed a random sample of 1465 men living in single-sex hostels and 1008 women in adjacent informal settlements in inner-city, Johannesburg, South Africa. Being drunk in the past week was used as an indicator of heavy episodic drinking, and frequency of drinking and number of alcohol units/week used as measures of volume. Associations between dimensions of alcohol use (current drinking, volume of alcohol consumed and heavy episodic drinking patterns) and sexual behaviours were assessed using multivariate logistic regression.Most participants were internal migrants from KwaZulu Natal province. About half of men were current drinkers, as were 13% of women. Of current male drinkers, 18% drank daily and 23% were drunk in the past week (women: 14% and 29% respectively). Among men, associations between heavy episodic drinking and sexual behaviour were especially pronounced. Compared with non-drinkers, episodic ones were 2.6 fold more likely to have transactional sex (95%CI = 1.7-4.1) and 2.2 fold more likely to have a concurrent partner (95%CI = 1.5-3.2). Alcohol use in men, regardless of measure, was strongly associated with having used physical force to have sex. Overall effects of alcohol on sexual behaviour were larger in women than men, and associations were detected between all alcohol measures in women, and concurrency, transactional sex and having been forced to have sex.Alcohol use and sexual behaviours are strongly linked among male and female migrant populations in inner-city Johannesburg. More rigorous interventions at both local and macro level are needed to alleviate alcohol harms and mitigate the alcohol-HIV nexus, especially among already vulnerable groups. These should target the specific dimensions of alcohol use that are harmful, assist women who drink to do so more safely and address the linkages between alcohol and sexual violence.

Project description:The overall unemployment rate in South Africa was impacted by the coronavirus (COVID-19) pandemic, which led many people to resort to informal work such as street trading opportunities in big cities. However, this work is located in the same cities where air pollution is of concern. Furthermore, literature has indicated the lack of regulation of the informal trading sector as compared to the formal sector. An analytical cross-sectional study is proposed to be conducted amongst all of the informal food street vendors (indoor/inside buildings and outdoor/street pavements stalls) in the inner city of Johannesburg, South Africa. By adopting a total sampling method of 746 vendor stalls, this study's key focus is on inhalation as an occupational exposure. In addition, the study aims to assess the respiratory risk factors amongst informal food street vendors' stalls and their impact on vendors' respiratory health. The risk factors to be assessed include the five common air pollutants: street vendor's infrastructure; socioeconomic factors; personal behavior such as tobacco smoking and handwashing practices; wearing of respiratory protective equipment; and vendors' exposure duration. The data collection will follow three phases using quantitative methods. In the pre-assessment phase, it will include a pilot study to test the walkthrough survey checklist and the respiratory symptoms and diseases questionnaire. The assessment phase includes a total of eight area samples, which will be taken in a 1-day event over four yearly seasons, as well as thirty personal samples taken in winter over an 8-h work shift. The post-assessment phase will be the development of a risk impact assessment and a risk management model. The study is essential for healthy occupational conditions as indicated in the Occupational Health and Safety (OHS) Act (no. 85 of 1993) and the Regulations governing general hygiene requirements for food premises, the transport of food, and related matters (no. R638 of 22 June 2018).

Project description:Developing an effective HIV vaccine is the overriding priority for HIV prevention research. Enrolling and maintaining cohorts of men into HIV vaccine efficacy trials is a necessary prerequisite for the development and licensure of a safe and efficacious vaccine.One hundred-fifty consenting HIV-negative men were enrolled into a pilot 1:1 randomised controlled trial of immediate vaccination with a three-dose hepatitis B vaccine compared to deferred vaccination (at 12 months) to investigate feasibility and acceptability of a future HIV vaccine trial in this population. Adverse events, changes in risk behaviour, acceptability of trial procedures and motivations for participation in future trials were assessed.Men were a median 25 years old (inter-quartile range?=?23-29), 53% were employed, 90% secondary school educated and 67% uncircumcised. Of the 900 scheduled study visits, 90% were completed in the immediate vaccination arm (405/450) and 88% (396/450) in the delayed arm (P?=?0.338). Acceptability of trial procedures and services was very high overall. However, only 65% of the deferred group strongly liked being randomised compared to 90% in the immediate group (P?=?0.001). Informed consent processes were viewed favourably by 92% of the delayed and 82% of the immediate group (P?=?0.080). Good quality health services, especially if provided by a male nurse, were rated highly. Even though almost all participants had some concern about the safety of a future HIV vaccine (98%), the majority were willing to participate in a future trial. Future trial participation would be motivated mainly by the potential for accessing an effective vaccine (81%) and altruism (75%), rather than by reimbursement incentives (2%).Recruitment and retention of men into vaccine trials is feasible and acceptable in our setting. Findings from this surrogate vaccine trial show a high willingness to participate in future HIV vaccine trials. While access to potentially effective vaccines is important, quality health services are an equally compelling incentive for enrolment.

Project description:BackgroundAntenatal care (ANC) clinics serve as key gateways to screening and treatment interventions that improve pregnancy outcomes, and are especially important for HIV-infected women. By disaggregating data on access to ANC, we aimed to identify variation in ANC attendance by level of care and across vulnerable groups in inner-city Johannesburg, and document the impact of non-attendance on birth outcomes.MethodsThis record review of routine health service data involved manual extraction of 2 years of data from birth registers at a primary-, secondary- and tertiary-level facility within inner-city Johannesburg. Information was gathered on ANC attendance, HIV testing and status, pregnancy duration, delivery mode and birth outcomes. Women with an unknown attendance status were considered as not having attended clinic, but effects of this assumption were tested in sensitivity analyses. Multiple logistic regression was used to identify associations between ANC attendance and birth outcomes.ResultsOf 31,179 women who delivered, 88.7% (27,651) had attended ANC (95% CI = 88.3-89.0). Attendance was only 77% at primary care (5813/7543), compared to 89% at secondary (3661/4113) and 93% at tertiary level (18,177/19,523). Adolescents had lower ANC attendance than adults (85%, 1951/2295 versus 89%, 22,039/24,771). Only 37% of women not attending ANC had an HIV test (1308/3528), compared with 93% of ANC attenders (25,756/27,651). Caesarean section rates were considerably higher in women who had attended ANC (40%, 10,866/27,344) than non-attenders (13%, 422/3360). Compared to those who had attended ANC, non-attenders were 1.6 fold more likely to have a preterm delivery (95% CI adjusted odds ratio [aOR] = 1.4-1.8) and 1.4 fold more likely to have a stillbirth (aOR 95% CI = 1.1-1.9). Similar results were seen in analyses where missing data on ANC attendance was classified in different ways.ConclusionInner-city Johannesburg has an almost 5% lower ANC attendance rate than national levels. Attendance is particularly concerning in the primary care clinic that serves a predominantly migrant population. Adolescents had especially low rates, perhaps owing to stigma when seeking care. Interventions to raise ANC attendance, especially among adolescents, may help improve birth outcomes and HIV testing rates, bringing the country closer to achieving maternal and child health targets and eliminating HIV in children.

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Dataset Information

The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study.

Publications

The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study.

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