BackgroundThe obesity epidemic is associated with rising rates of cardiovascular disease (CVD) among adults, particularly in countries undergoing rapid urbanisation and nutrition transition. This study explored the perceptions of body size, obesity risk awareness, and the willingness to lose weight among adults in a resource-limited urban community to inform appropriate community-based interventions for the prevention of obesity.MethodThis is a descriptive qualitative study. Semi-structured focus group discussions were conducted with purposively selected black men and women aged 35–70 years living in an urban South African township. Weight and height measurements were taken, and the participants were classified into optimal weight, overweight and obese groups based on their body mass index (Kg/m2). Participants were asked to discuss on perceived obesity threat and risk of cardiovascular disease. Information on body image perceptions and the willingness to lose excess body weight were also discussed. Discussions were conducted in the local language (isiXhosa), transcribed and translated into English. Data was analysed using the thematic analysis approach.ResultsParticipants generally believed that obesity could lead to health conditions such as heart attack, stroke, diabetes, and hypertension. However, severity of obesity was perceived differently in the groups. Men in all groups and women in the obese and optimal weight groups perceived obesity to be a serious threat to their health, whereas the overweight women did not. Obese participants who had experienced chronic disease conditions indicated strong perceptions of risk of obesity and cardiovascular disease. Obese participants, particularly men, expressed willingness to lose weight, compared to the men and women who were overweight. The belief that overweight is ‘normal’ and not a disease, subjective norms, and inaccessibility to physical activity facilities, negatively influenced participants’ readiness to lose weight.ConclusionLow perception of threat of obesity to health particularly among overweight women in this community indicates a considerable challenge to obesity control. Community health education and promotion programmes that increase awareness about the risk associated with overweight, and improve the motivation for physical activity and maintenance of optimal body weight are needed.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3028-7) contains supplementary material, which is available to authorized users.

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BackgroundThis paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries—Jamaica, India, the Philippines, and South Africa—have historically been “sources” of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa.MethodsThe study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically.ResultsThere has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself.ConclusionsIn the near past, South Africa’s health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa.

BackgroundGlobal Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined.MethodsA multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries’ responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context.ResultsIn all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs.ConclusionSustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.

BackgroundThe Eastern Cape Province reports among the poorest health service indicators in South Africa with some of its districts standing out as worst performing as regards maternal health indicators. To understand key drivers and outcomes of this underperformance and to explore whether a participatory analysis could deepen action-oriented understanding among stakeholders, a study was conducted in one of the chronically poorly performing districts.MethodsThe study used a systems analysis approach to understand the drivers and outcomes affecting maternal health in the district in order to identify key leverage points for addressing the situation. The approach included semi-structured interviews with a total of 24 individuals consisting health system managers at various levels, health facility staff and patients. This was followed by a participatory group model building exercise with 23 key stakeholders to analyze system factors and their interrelationships affecting maternal health in the district using rich pictures and interrelationship diagraphs (IRDs) and finally the development of causal loop diagrams (CLDs).ResultsThe stakeholders were able to unpack the complex ways in which factors were interrelated in contributing to poor maternal health performance and identified the feedback loops which resulted in the situation being intractable, suggesting strategies for sustainable improvement. Quality of leadership was shown to have a pervasive influence on overall system performance by linking to numerous factors and feedback loops, including staff motivation and capacity building. Staff motivation was linked to quality of care in turn influencing patient attendance and feeding back into staff motivation through its impact on workload. Without attention to workload, patient waiting times and satisfaction, the impact of improved leadership and staff support on staff competence and attitudes would be diminished.ConclusionUnderstanding the complex interrelationships of factors in the health system is key to identifying workable solutions especially in the context of chronic health systems challenges. Systems modelling using group model building methods can be an efficient means of supporting stakeholders to recognize valuable resources within the context of a dysfunctional system to strengthen systems performance.

This paper describes the experiences of caregivers in a rural district in Zimbabwe, in caring for pregnant women within a context of changing antenatal care routines. Data were generated using individual interviews with 18 nurses and midwives. The caregivers experienced their working situation as stressful and frustrating due to high staff turnover, inconsistent policies, parallel programmes and limited resources, including time. They also faced difficulties when implementing some of the proposed changes. Furthermore, the caregivers had to deal with the pressure and resistance from the pregnant women, whose reasoning and rationale for using care appeared different from those of the health professionals. In light of the above, we stress the necessity for reflecting on and including the experiences and perspectives of caregivers and the users of care, as well as their contexts and realities, when implementing change.

BackgroundMissed appointments serve as a key indicator for adherence to therapy and as such, identifying patient reasons for this inconsistency could assist in developing programmes to improve health outcomes. In this article, we explore the reasons for missed appointments linked to a centralised dispensing system in South Africa. This system dispenses pre-packed, patient-specific medication parcels for clinically stable patients to health facilities. However, at least 8%–12% of about 300,000 parcels are not collected each month. This article aims to establish whether missed appointments for collection of medicine parcels are indicative of loss-to-follow-up and also to characterise the patient and health system factors linked to missed appointments.MethodsWe applied an exploratory mixed-methods design in two overlapping research phases. This involved in-depth interviews to yield healthcare practitioners’ and patients’ experiences and medical record reviews. Data collection was conducted during the period 2014–2015. Qualitative data were analysed through a hybrid process of inductive and deductive thematic analysis which integrated data-driven and theory-driven codes. Data from medical records (N = 89) were analysed in MS excel using both descriptive statistics and textual descriptions.ResultsReview of medical records suggests that the majority of patients (67%) who missed original appointments later presented voluntarily to obtain medicines. This could indicate a temporal effect of some barriers. The remaining 33% revealed a range of CDU implementation issues resulting from, among others, erroneous classification of patients as defaulters. Interviews with patients revealed the following reasons for missed appointments: temporary migration, forgetting appointments, work commitments and temporary switch to private care. Most healthcare practitioners confirmed these barriers to collection but perceived that some were beyond the scope of health services. In addition, healthcare practitioners also identified a lack of patient responsibility, under-utilisation of medicines and use of plural healthcare sources (e.g. traditional healers) as contributing to missed appointments.ConclusionWe suggest developing a patient care model reflecting the  local context, attention to improving CDU’s implementation processes and strengthening information systems in order to improve patient monitoring. This model presents lessons for other low-and-middle income countries with increasing need for dispensing of medicines for chronic illnesses.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-017-0655-8) contains supplementary material, which is available to authorized users.

Individual interviews with 25 nurses and midwives revealed their experiences with providing maternity care in rural Zimbabwe. These first-hand accounts especially illuminate the complexities of providing maternity care in the context of HIV/AIDS. The caregivers described feeling troubled by knowing statistics about the magnitude and high prevalence of HIV (from official sources and the media) while they witnessed the increase in disease and the deaths of women, children and colleagues around them. They expressed frustration with a lack of information regarding the HIV status of their female patients - a situation exacerbated by HIV stigma and poor healthcare organisation. The social relationships between the caregivers and women in the study area sometimes meant that the caregivers did not effectively apply universal precautions, such as use of gloves during births. The situation described by the caregivers emphasises that contextual factors must be addressed to meet the increased demands and challenges of providing maternal healthcare in endemic HIV/AIDS countries such as Zimbabwe.