A scoping review of ethics review processes during public health emergencies in Africa.

BACKGROUND: The COVID-19 pandemic forced governments, multilateral public health organisations and research institutions to undertake research quickly to inform their responses to the pandemic. Most COVID-19-related studies required swift approval, creating ethical and practical challenges for regulatory authorities and researchers. In this paper, we examine the landscape of ethics review processes in Africa during public health emergencies (PHEs). METHODS: We searched four electronic databases (Web of Science, PUBMED, MEDLINE Complete, and CINAHL) to identify articles describing ethics review processes during public health emergencies and/or pandemics. We selected and reviewed those articles that were focused on Africa. We charted the data from the retrieved articles including the authors and year of publication, title, country and disease(s) reference, broad areas of (ethical) consideration, paper type, and approach. RESULTS: Of an initial 4536 records retrieved, we screened the titles and abstracts of 1491 articles, and identified 72 articles for full review. Nine articles were selected for inclusion. Of these nine articles, five referenced West African countries including Liberia, Guinea and Sierra Leone, and experiences linked to the Ebola virus disease. Two articles focused on South Africa and Kenya, while the other two articles discussed more general experiences and pitfalls of ethics review during PHEs in Africa more broadly. We found no articles published on ethics review processes in Africa before the 2014 Ebola outbreak, and only a few before the COVID-19 outbreak. Although guidelines on protocol review and approval processes for PHEs were more frequently discussed after the 2014 Ebola outbreak, these did not focus on Africa specifically. CONCLUSIONS: There is a gap in the literature about ethics review processes and preparedness within Africa during PHEs. This paper underscores the importance of these processes to inform practices that facilitate timely, context-relevant research that adequately recognises and reinforces human dignity within the quest to advance scientific knowledge about diseases. This is important to improve fast responses to PHEs, reduce mortality and morbidity, and enhance the quality of care before, during, and after pandemics.

Scoping review on lessons learnt on the promotion and use of drugs and traditional medicine in Africa during COVID-19.

ABSTRACTScientific evidence on the safety and efficacy of pharmaceutical drugs, substances and herbal medicines is important in medical advertising and promotion. Following guidelines for conducting a scoping review, we systematically searched PubMed, SCOPUS and Web of Science to identify in peer reviewed articles medications that were promoted and used widely in Africa during the COVID-19 pandemic. We also searched for information about how safety concerns about untested/or not properly tested drugs were communicated to the public during the pandemic. Of the 2043 articles identified, 41 papers were eligible for inclusion. Most studies were clinical trials (n = 11), systematic reviews (n = 9), quantitative studies (n = 9) the rest were qualitative studies, reviews and reports. We found that following global trends, several drugs, traditional and herbal treatments were used and repurposed for the treatment of respiratory symptoms of COVID-19 in Africa. The results highlighted the value of some herbal medicines for treatment during the COVID-19 pandemic, as well as the risks posed by the unregulated sharing of advice and recommendations on treatments in Africa, and globally.

Making sense of uncertainty: The precarious lives of young migrants from rural Kwazulu-Natal, South Africa.

This study aims to examine the experiences of young migrants and the role of uncertainty in their precarious lives. Drawing on data from individual interviews and a workshop with young migrants aged 16-24 years old in KwaZulu-Natal, South Africa, we use uncertainty as a theoretical lens, to illustrate the ways in which young migrants' experiences provide meaning for them and give them an opportunity to assess, and plan for better opportunities despite the stark outlook. Thematic analysis was used to examine the multidimensionality of socio-spatial identities in young migrants. The findings illustrate how young migrants hustle for opportunities to lead valuable lives in the face of uncertainty. The implications highlight how attending to the complex intersectional nuances of uncertainty can serve as an enabler of aspirations, alongside essential structural factors influencing migration among young people brought up in rural communities. However, in proposing this alternative view of positive uncertainty, the structural violence experienced by these young people should not be overlooked and should be addressed as per their context.

Radiologists' perceptions of knowledge and training required by radiographers in the interpretation of radiographic images: An explorative study in KwaZulu-Natal province, South Africa.

INTRODUCTION: The health sector of South Africa is burdened by the shortage of radiologists leading to the under-reporting of radiographic images and ultimately mismanagement of patients. Previous studies have recommended training of radiographers in radiographic image interpretation in order to improve the reporting. There is paucity of information regarding the knowledge and training required by radiographers to interpret radiographic images. The purpose of this study was therefore to explore the knowledge and training required by diagnostic radiographers, according to radiologists, for the interpretation of radiographs. METHOD: A qualitative descriptive study employing criterion sampling to select qualified radiologists practicing in the eThekwini district of the KwaZulu Natal province, was conducted. One-on-one and in-depth, semi-structured interviews were used to collect data from three participants. The interviews were not carried out face to face as a result of the Covid 19 pandemic and the regulation of social distancing. This did not permit engagement with research communities. The data from the interviews were analysed using Tesch's eight steps for analysing qualitative data. RESULTS: Findings revealed that radiologists supported the interpretation of radiographic images by radiographers in rural settings, and for the radiographer's scope of practice to be restructured to include the reporting of chest and the musculoskeletal system images. The themes that emerged from the analysis included knowledge, training, clinical competencies and medico-legal responsibilities required by radiographers in the interpretation of radiographic images. CONCLUSION: Although the radiologists support the training of radiographers in the interpretation of radiographic images, radiologists think that the scope of practice should be limited to the interpretation of the chest and musculoskeletal systems in rural areas only.

Respecting relational agency in the context of vulnerability: What can research ethics learn from the social sciences?

Despite advances in theory, often driven by feminist ethicists, research ethics struggles in practice to adequately account for and respond to the agency and autonomy of people considered vulnerable in the research context. We argue that shifts within feminist research ethics scholarship to better characterise and respond to autonomy and agency can be bolstered by further grounding in discourses from the social sciences, in work that confirms the complex nature of human agency in contexts of structural and other sources of vulnerability. We discuss some of the core concepts and critiques emerging from the literature on women and children's agency in under-resourced settings, highlighting calls to move from individualistic to relational models of agency, and to recognise the ambiguous, value-laden, and heterogeneous nature of the concept. We then draw out what these conceptual shifts might mean for research ethics obligations and guidance, illustrating our analysis using a case vignette based on research ethics work conducted in South Africa. We conclude that if research practices are to be supportive of agency, it will be crucial to scrutinise the moral judgements which underpin accounts of agency, derive more situated definitions of and responses to agency, and enable people and participants to influence these based on their own experiences and self-perceptions.

Policy and Guideline Review of Vaccine Safety for COVID-19 in Pregnant Women in Southern Africa, with a Particular Focus on South Africa.

Pregnant and lactating mothers have historically been excluded from clinical trials. To understand the shift from excluding to including this population in COVID-19 vaccine trials, we conducted a review of guidance issued by countries in southern Africa over the last three years. We conducted a review of documents and official statements recorded on Ministries of Health websites, and social media platforms, the World Health Organisation website, the COVID-19 Maternal Immunisation tracker and the African Union official webpage. Search terms included COVID-19 vaccination policies, guidelines for pregnant and lactating women, COVID-19 vaccination trials and pregnant women. We retrieved and reviewed policies, guidelines, and official statements from 12 countries. We found inconsistencies and incomplete guidance in respect to the inclusion of pregnant and lactating mothers in COVID-19 vaccine trials from the selected countries. Of the twelve countries reviewed, Namibia and South Africa had clear guidance on vaccination plans and implementation for pregnant women, and their inclusion in COVID-19 vaccine trials. Explicit and clear guidelines are critical in communicating changes in policy towards those deemed vulnerable for them to participate in vaccine trials. This review provides lessons for future pandemics on managing changes in guidance towards those groups historically excluded from vaccine and clinical trials.

'Labouring' on the frontlines of global health research: mapping challenges experienced by frontline workers in Africa and Asia.

Drawing on the reflections and discussions from a special session at the 2021 Global Health Bioethics Network summer school, this paper has summarised the key challenges faced by Frontline Workers (FWs) across research sites in Africa and Asia in performing the everyday 'body work' entailed in operationalising global health research. Using a 'body work' lens, we specifically explore and map key challenges that FWs face in Africa and Asia and the physical, social, ethical, emotional, and political labour involved in operationalising global health in these settings. The research encounter links with wider social and economic structures, and spatial dimensions and impacts on the FWs' performance and well-being. Yet, FWs' 'body-work' and the embedded emotions during the research encounter remain hidden and undervalued.

The sexual and reproductive health needs of school-going young people in the context of COVID-19 in rural KwaZulu-Natal, South Africa.

Background: The impact of school closures due to COVID-19 raised widespread concerns about children's health and well-being. We examine the impact on the sexual health needs of learners in the context of COVID-19 related lockdowns in rural KwaZulu-Natal, South Africa.Methods: In july-November 2020 and August-November 2021 we conducted 24 in-depth interviews and 8 group discussions with teachers and learners from 4 schools, community members and key education stakeholders. All interviews were conducted by telephone. We used a thematic analysis approach and Nvivo 12 software to manage the data.Results: Four main themes related to the COVID-19 pandemic emerged from the data: the sexual and reproductive health (SRH) of learners in the lead-up to the pandemic; the impact of COVID-19 on learners' SRH and wellbeing; the opportunities schools provided to support sexual well-being of learners during the pandemic; and the role of schools in supporting SRH for learners during the pandemic. Learners and stakeholders reported that the SRH of young people was affected by alcohol misuse, poor SRH knowledge and few pathways to link learners with services. Stakeholders working with schools reported that a lack of access to biomedical interventions (e.g., contraception) increased learner pregnancies. Gender-based violence in learners' households was reported to have increased during the COVID-19 pandemic related to loss of income. School closures disrupted the provision of a safe space to provide SRH and HIV-education through Life Orientation lessons and school nurse talks. This loss of a safe space also left learners vulnerable to sexual and physical violence. However, once schools re-opened, daily COVID-19 screening in schools provided the opportunity to identify and support vulnerable children who had other social needs (food and uniforms).Conclusion: The COVID-19 pandemic may have increased SRH needs and vulnerability of school-going children in a high HIV-burden rural setting. School shutdowns reduced the opportunity for schools to provide a vital safe space and information to enhance SRH for adolescents. Schools play a vital health promotion and social protection role.

Disruptive behaviours involving radiographers that impede a safe work environment. Survey at central hospitals in Harare Metropolitan Province, Zimbabwe.

Background: Understanding disruptive behaviours from the perspective of radiographers is important, as this professional group uses hazardous radiation in the execution of their duties, making patient safety of utmost concern. Objective: Determine the disruptive behaviours involving radiographers at central hospitals in Harare Metropolitan Province, Zimbabwe. Methods: A descriptive cross-sectional quantitative study was carried out at central hospitals in Harare Metropolitan Province, Zimbabwe, where 100 radiographers were randomly selected. Results: Overall, 83% of radiographers had been exposed to an incident of DB in the preceding 12 months. Reported types of disruptive behaviour included: Verbal abuse (81%), sexual abuse (21%) and physical abuse (4%). Of the 21 radiographers that suffered sexual abuse, the majority 71 % (n=15) were female while 29% (n=6) were males. Prevalence odds ratio revealed that female radiographers were 1.8 times more likely than their male counterparts to be victims of the workplace sexual abuse (95% C.I.: 0 - 3.04). A significant 69% were abused by patients and their families/escorts, p=.001. Conclusion: More than 8 out of 10 radiographers in this study were exposed to disruptive behaviours, mostly from the patients and patient's family or escorts. A framework to increases awareness and address these behaviours is recommended.

A network of empirical ethics teams embedded in research programmes across multiple sites: opportunities and challenges in contributing to COVID-19 research and responses.

Covid-19 continues to teach the global community important lessons about preparedness for research and effective action to respond to emerging health threats. We share the COVID-19 experiences of a pre-existing cross-site ethics network-the Global Health Bioethics Network-which brings together researchers and practitioners from Africa, Europe, and Southeast Asia. We describe the network and its members and activities, and the work-related opportunities and challenges we faced over a one-year period during the pandemic. We highlight the value of having strong and long-term empirical ethics networks embedded across diverse research institutions to be able to: 1) identify and share relevant ethics challenges and research questions and ways of 'doing research'; 2) work with key stakeholders to identify appropriate ways to contribute to the emerging health issue response - e.g., through ethics oversight, community engagement, and advisory roles at different levels; and 3) learn from each other and from diverse contexts to advocate for positive change at multiple levels. It is our view that being embedded and long term offers opportunities in terms of deep institutional and contextual knowledge, existing relationships and access to a wide range of stakeholders. Being networked offers opportunities to draw upon a wide range of expertise and perspectives, and to bring together internal and external insights (i.e.drawing on different positionalities). Long term funding means that the people and resources are in place and ready to respond in a timely way. However, many tensions and challenges remain, including difficulties in negotiating power and politics in the roles that researchers and research institutions can and should play in an emergency, and the position of empirical ethics within research programmes. We discuss some of these tensions and challenges and consider the implications for our own and similar networks in future.

Factors motivating intent to leave amongst radiographers employed by public tertiary hospitals in the Gauteng Province, South Africa.

Background: The elements of job satisfaction can be categorized into intrinsic and extrinsic factors. The presence of a higher level of intrinsic factors will result in increased motivation amongst employees, whilst extrinsic factors will result in job dissatisfaction. Decreased job satisfaction levels amongst healthcare professionals are known to create an intent to leave. Hence the need to explore these factors amongst radiographers employed by tertiary hospitals in the Gauteng province of South Africa. Objective: To determine the influence of intrinsic and extrinsic factors of job satisfaction on intent to leave amongst radiographers employed by public tertiary hospitals in the Gauteng province. Methods: A quantitative cross-sectional survey guided the study, and a self-administered questionnaire was used to collect data. The sampling technique used for this study was disproportional stratified sampling. Results: The study had a response rate of 62%. A significant number of the participants (50%) were between the ages of 21-33 years. Also, worth noting that 51% of the participants were newly qualified, 28% were employed for a period of 10-20 years and only 20% were employed for a period greater than 20 years. Diagnostic radiography had the most number of participants at 55%, followed by radiation therapist at 24%, nuclear medicine radiographers at 13%, mammography radiographers at 5% and only 3% were sonographers. Pearson's correlation showed a significant negative correlation with the following extrinsic factors: supervision, r= -.344, p=.000; satisfaction with PMDS, r=-.302, p=.000; human resources processes, r=-.249, p=.001; infrastructure, r=-.236, p=.001; the OSD policy, r=-.233, p=.002; satisfaction with remuneration, r=-.202, p=.006; satisfaction with CPD activities, r=-.201, p=.007; and satisfaction with equipment, r=-.163, p=.029. Conclusion: Both intrinsic and extrinsic factors are associated with an intent to leave amongst radiographers employed by public tertiary hospitals in the Gauteng province.

The ethical-legal requirements for adolescent self-consent to research in sub-Saharan Africa: A scoping review.

Support for the enrolment of adolescents in research has been constrained by uncertainties in parental involvement, and the lack of clarity in the ethical and legal frameworks. We conducted a scoping review to examine articles that explored the opinion of scholars on the question of adolescent consent and conditions for parental waivers in research in sub-Saharan Africa (SSA). Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) tool, we searched electronic databases (PubMed, EMBASSE, EBSCOHOST) and also reviewed the references of articles identified for additional relevant literature. We included full text English articles focusing on adolescent consent and parental waivers in SSA that were published between 2004 and 2020. We excluded studies focusing on healthcare, theses, and reviews. We reviewed a total of 21 publications from South Africa (n = 12), Kenya (n = 4) and Botswana, Malawi, Nigeria, Uganda and Zimbabwe (n = 1 each). We identified four broad thematic issues: the current position regarding parental waivers and self-consent; parental involvement in the consent process; the role of community approval or consent when adolescent self-consent approaches were used; and complexities and ambiguities in legal requirements and ethical guidelines on adolescent consent. Our findings show inconsistencies and ambiguities in the existing legal and ethical frameworks within and across different countries, and underscore the need for consistent and clearer guidance on parental waivers and adolescent self-consent. Harmonization of the legal and ethical frameworks taking into account varying contexts is critically important to ensure research on adolescents in SSA meets adolescents' specific unmet needs.

Factors motivating intent to leave amongst radiographers employed by public tertiary hospitals in the Gauteng Province, South Africa

Background: The elements of job satisfaction can be categorized into intrinsic and extrinsic factors. The presence of a higher level of intrinsic factors will result in increased motivation amongst employees, whilst extrinsic factors will result in job dissatisfaction. Decreased job satisfaction levels amongst healthcare professionals are known to create an intent to leave. Hence the need to explore these factors amongst radiographers employed by tertiary hospitals in the Gauteng province of South Africa. Objective: To determine the influence of intrinsic and extrinsic factors of job satisfaction on intent to leave amongst radiographers employed by public tertiary hospitals in the Gauteng province. Methods: A quantitative cross-sectional survey guided the study, and a self-administered questionnaire was used to collect data. The sampling technique used for this study was disproportional stratified sampling. Results: The study had a response rate of 62%. A significant number of the participants (50%) were between the ages of 21-33 years. Also, worth noting that 51% of the participants were newly qualified, 28% were employed for a period of 10-20 years and only 20% were employed for a period greater than 20 years. Diagnostic radiography had the most number of participants at 55%, followed by radiation therapist at 24%, nuclear medicine radiographers at 13%, mammography radiographers at 5% and only 3% were sonographers. Pearson's correlation showed a significant negative correlation with the following extrinsic factors: supervision, r= -.344, p=.000; satisfaction with PMDS, r=-.302, p=.000; human resources processes, r=-.249, p=.001; infrastructure, r=-.236, p=.001; the OSD policy, r=-.233, p=.002; satisfaction with remuneration, r=-.202, p=.006; satisfaction with CPD activities, r=-.201, p=.007; and satisfaction with equipment, r=-.163, p=.029. Conclusion: Both intrinsic and extrinsic factors are associated with an intent to leave amongst radiographers employed by public tertiary hospitals in the Gauteng province

Managing ancillary care in resource-constrained settings: Dilemmas faced by frontline HIV prevention researchers in a rural area in South Africa.

BACKGROUND: We describe the findings from a research ethics case study, linked with a team evaluating a package of intervention services to prevent HIV infection in adolescent girls and young women (AGYW) living in a rural and poor setting of KwaZulu-Natal, South Africa. METHODS: We conducted qualitative interviews (n=77) with members of the linked research team evaluating the intervention programme, programme implementing staff, AGYW enrolled in the intervention programme, caregivers, ethics committee members, Public Engagement officers, community advisory board members and community stakeholders. Data were analysed iteratively using thematic framework analysis. Themes were determined by the study aims combined with an inductive development of codes emerging from the data. RESULTS: The findings show that the burden of providing ancillary care fell primarily on the shoulders of frontline researchers and programme staff. Dilemmas around responding to gender-based violence illustrated the limits of 'referral to services' as a solution for meeting ancillary care obligations in contexts with barriers to basic health and social services. CONCLUSION: Our findings show important gaps in meeting ancillary care needs. Participants' needs required social and economic support which frontline researchers and implementing partners were not able to meet, causing moral distress.

Participant understanding of informed consent in a multidisease community-based health screening and biobank platform in rural South Africa.

BACKGROUND: In low- and middle-income settings, obtaining informed consent for biobanking may be complicated by socio-economic vulnerability and context-specific power dynamics. We explored participants experiences and perceptions of the research objectives in a community-based multidisease screening and biospecimen collection platform in rural KwaZulu-Natal, South Africa. METHODS: We undertook semi-structured in-depth interviews to assess participant understanding of the informed consent, research objectives and motivation for participation. RESULTS: Thirty-nine people participated (individuals who participated in screening/biospecimen collection and those who did not and members of the research team). Some participants said they understood the information shared with them. Some said they participated due to the perceived benefits of the reimbursement and convenience of free healthcare. Most who did not participate said it was due to logistical rather than ethical concerns. None of the participants recalled aspects of biobanking and genetics from the consent process. CONCLUSIONS: Although most people understood the study objectives, we observed challenges to identifying language appropriate to explain biobanking and genetic testing to our target population. Engagement with communities to adopt contextually relevant terminologies that participants can understand is crucial. Researchers need to be mindful of the impact of communities' socio-economic status and how compensation can be potentially coercive.

"They have this not care - don't care attitude:" A Mixed Methods Study Evaluating Community Readiness for Oral PrEP in Adolescent Girls and Young Women in a Rural Area of South Africa.

INTRODUCTION: Adolescent girls and young women (AGYW) remain disproportionately affected by HIV. In a rural area of South Africa with an annual incidence (2011-2015) of 5 and 7% per annum for 15-19 and 20-24-year olds respectively, oral pre-exposure prophylaxis (PrEP) could provide AGYW with a form of HIV prevention they can more easily control. Using quantitative and qualitative methods, we describe findings from a study conducted in 2017 that assessed knowledge of and attitudes toward PrEP to better understand community readiness for an AGYW PrEP rollout. METHODS: We used descriptive analysis of a quantitative demographic survey (n = 8,414 ages 15-86) to identify population awareness and early PrEP adopters. We also conducted semi-structured, in-depth interviews with a purposive sample of 52 potential PrEP gatekeepers (health care workers, community leaders) to assess their potential influence in an AGYW PrEP rollout and describe the current sexual health landscape. Interviews were recorded, transcribed, and iteratively coded to identify major themes. RESULTS: PrEP knowledge in the general population, measured through a demographic survey, was low (n = 125/8,414, 1.49% had heard of the drug). Medicalized delivery pathways created hostility to AGYW PrEP use. Key informants had higher levels of knowledge about PrEP and saw it as a needed intervention. Community norms around adolescent sexuality, which painted sexually active youth as irresponsible and disengaged from their own health, made many ambivalent towards a PrEP rollout to AGYW. Health care workers discussed ways to shame AGYW if they tried to access PrEP as they feared the drug would encourage promiscuity and "risky" behaviour. Others interviewed opposed provision on the basis of health care equity and feared PrEP would divert both drug and human resources from treatment programs. CONCLUSIONS: The health system in this poor, high-HIV incidence area had multiple barriers to a PrEP rollout to AGYW. Norms around adolescent sexuality and gatekeeper concerns that PrEP could divert health resources from treatment to prevention could create barriers to PrEP roll-out in this setting. Alternate modes of delivery, particularly those which are youth-led and demedicalize PrEP, must be explored.

Behavioural and socio-ecological factors that influence access and utilisation of health services by young people living in rural KwaZulu-Natal, South Africa: Implications for intervention.

BACKGROUND: Young people's health service utilisation (the number accessing a facility) has been the focus of guidelines and health systems strengthening policies. This is due to young people being at an increased health risk because of inequitable access and utilisation of health services, which is more pronounced in rural settings with limited service availability. This is a major concern as globally, youth constitute a considerable and increasing part of the population in Sub-Saharan Africa. OBJECTIVE: The objective of this paper is to present a comprehensive approach for the exploration of health service utilisation by young people in rural KwaZulu-Natal, South Africa. We examined barriers and facilitators conceptualised by the constructs of the Theory of Planned Behaviour, framed within a socio-ecological model. METHODS: Data were collected in January to June 2017 from two sites using in-depth interviews, spiral transect walks and community mapping with young people (aged 10 to 24 years), primary care health providers, school health professionals, community stakeholders and young people's parents. RESULTS: Socio-ecological and behavioural factors influenced young people's intention to use services. Barriers included perceived negative attitudes of health providers and perceived poor staff competencies. Facilitators included an appreciation of receiving health education and assumed improved health. At social and community levels, normative beliefs hindered young people from utilising services as they feared stigmatisation and gossip. At a public policy level, structural elements had a disempowering effect as the physical layout of the clinics hindered utilisation, limited resources influenced staffing, and facility opening times were not convenient for school goers. CONCLUSION: We suggest that to fully appreciate the complexity of health service utilisation, it is necessary to not only consider factors and processes relevant to the individual, but also acknowledge and act upon, the disjuncture between community level cultural values, norms and national policies.

Challenges of developing a district child welfare plan in South Africa: lessons from a community-engaged HIV/AIDS research project.

The Amajuba Child Health and Wellbeing Research Project measured the impact of orphaning due to HIV/AIDS on South African households between 2004 and 2007. Community engagement was a central component of the project and extended through 2010. We describe researcher engagement with the community to recruit participants, build local buy-in, stimulate interest in study findings, and promote integration of government social welfare services for families and children affected by HIV/AIDS. This narrative documents the experience of researchers, drawing also on project reports, public documents, and published articles, with the objective of documenting lessons learned in this collaboration between researchers from two universities and a community in South Africa during a period that spanned seven years. This experience is then analyzed within the context of an applied research, community-engagement framework.

'We must treat them like all the other people': Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa.

BACKGROUND: Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The 'Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa' aimed to improve access to appropriate and non-judgemental health services for 'key populations', specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers. OBJECTIVES: The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa. METHODS: This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex. RESULTS: The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes. CONCLUSION: The findings suggest that sensitisation training increases healthcare workers' knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services.

Exploring adolescents and young people's candidacy for utilising health services in a rural district, South Africa.

BACKGROUND: We use the 'candidacy framework' to describe adolescents' and young people's (AYP) experiences of health services in a rural KwaZulu-Natal district, South Africa. METHODS: A qualitative approach was used including group discussions, in-depth and key informant interviews with a purposive sample of AYP (n = 70), community leaders (n = 15), school health teams (n = 10), and health service providers (n = 6). RESULTS: Findings indicate tacit understanding among AYP that they are candidates for general health services. However, HIV stigma, apprehensions and misconceptions about sexual and reproductive health, and socio-cultural views which disapprove of AYP pre-marital sex undermine their candidacy for sexual and reproductive services. CONCLUSION: Consideration and understanding of the vulnerabilities and reasons AYP exclude themselves will inform interventions to address their health needs. AYP's participation in the design of health services will increase their acceptability and encourage uptake of services.