Self-inflicted ingestion of harmful chemicals in adolescents and adults: risk factors and characteristics.

BACKGROUND: Injury due to ingestion of harmful chemicals has become an area of concern globally. In South Africa, paraffin has been widely implicated in multiple health outcomes, including severe ingestion injuries. A specific category of such injuries is those that are self-inflicted. A significant proportion of self-inflicted ingestion is reported to be intentional, although intentionality for self-infliction may be difficult to determine. Nonetheless, the identification of key explanatory risks and demographic factors of self-inflicted ingestion may contribute towards a better understanding of self-inflicted and harmful chemical ingestion injuries. METHODS: This study used secondary data that had been collected on burn injuries of all causes, including those due to the ingestion of harmful chemicals, from a sample of South Africans from low-income communities close to major metropolitan centres. The current analysis focused on the risks for self-inflicted ingestion injuries and used logistic regression to determine risks for self-inflicted ingestion as differentiated from ingestion due to the actions of another person (other-inflicted ingestion) by sex and age cohort of the victim, and the presence of alcohol, by examining paraffin ingestion versus that of other chemicals. RESULTS: The overwhelming majority of ingestion injuries (92.1%) were self-inflicted. The current findings indicate that sex (with females almost twice as likely to present with self-inflicted ingestion), age cohort (with those aged 18-29 and 30-44 years old four times more likely affected than older adults), presence of alcohol (twice as likely present than amongst individuals reporting ingestion injuries inflicted by others), and chemicals other than paraffin (three times more likely) are key explanatory factors for an increased risk for self-inflicted ingestion of harmful chemicals. CONCLUSIONS: The study empirically confirms the role of several key risk factors in what remains a relatively unreported and understudied phenomenon, but which appears to align with the demographic and risk profile reported for suicidal injuries through chemical ingestion, i.e. intentional self-inflicted ingestion. The findings may contribute towards improved safety policies on the availability and sale of chemical products and more focussed community interventions for at-risk individuals such as females and young people. It also flags the importance of assessing for alcohol use and alcohol use disorders at hospital admission of self-ingestion injuries.

The influence of type of sexual partnership on male condom use: empirical evidence from the South African construction industry.

There are indications that gender has an effect on individual risk factors and pathways to HIV diagnoses and treatment. Furthermore, there is growing recognition that to improve HIV-related health outcomes for men, it is important to understand their experiences and perspectives. Perhaps because of the physical nature of construction work, the South African construction industry is dominated by men. Given that employed men are a hard-to-reach community population group, the construction workplace offers an ideal environment for data collection and delivery of non-health-facility-based HIV prevention and treatment interventions. Furthermore, workers in the construction industry have been identified as being at a heightened risk of acquiring HIV and AIDS because of work-related travel, the ubiquity of transactional sex around worker hostels and having an increased likelihood of multiple and concurrent sex partnerships. As a consequence, this study examines the association between condom use and sexual partnerships among men working in the construction industry. A purposive cross-sectional survey was used to collect data from 450 workers across 18 construction sites in the Western Cape province of South Africa. The types of sexual partnership had three categories: regular sex partnerships, casual sex partnerships and sex worker partnerships. Frequency of condom use was determined to be highest with casual sex partners (51.2%), followed by sex workers (40.6%) and regular sex partners (25.6%). Hierarchical multiple linear regression analysis was used to examine the demographic, experiential, behavioural and cognitive predictors of condom use across the three categories of sexual partnership. The results indicate that an individual's perception of control over condom use, and the perceived threat posed by HIV and AIDS are significantly associated with consistent condom use, even after accounting for differences in partner type. Implications of the findings are discussed, and directions for future research on the association between sexual partnerships and condom use are offered.

Assault burn injuries in adolescents and adults in South Africa: risk factors and characteristics.

Assault burns comprise a significant subset of burns, with a greater risk of severe injuries. This South African study used a national dataset from major hospitals to identify risks and injury characteristics of assault burns. The analysis sample comprised 2658 adolescent and adult cases and employed logistic regression with bootstrapping to examine the risk of assault compared to unintentional burns. The study indicates that 17.4% of burns were due to assault. Males were 1.5 times more likely than females to be burn assault victims. Compared to adults 55 years and older, young adults 22-39 years were at greatest risk, followed by youth 13-21 years. Assault injuries were five times more likely due to chemical attacks and three times more likely to scalds than to flame burns. The head, neck and trunk were most affected. Where alcohol was indicated, assault burns were five times more likely than unintentional burns. The findings may indicate the need for targeted prevention strategies such as conflict resolution, alcohol use management and the control of corrosive chemicals.

Determinants of HIV testing behaviour among male South African construction workers.

The global trend of poorer outcomes across the HIV treatment cascade for men has drawn attention to the importance of engaging men in prevention and treatment services. The South African construction industry is one of the economic sectors most adversely affected by HIV/AIDS. Previous research on HIV testing behaviour among workers in the industry has revealed that male workers are less likely to be tested than female workers. Given this gender differential, this study employed a field-administered survey to gather data from 450 site-based, male construction workers in Western Cape, South Africa. An integrated model comprising demographic, cognitive, and behavioural factors was then hypothesised to explain HIV testing behaviour. Bivariate analysis and structural equation modelling were then used to test the model. Findings indicate that HIV knowledge, having previously had an STI, and possessing a positive attitude towards HIV testing are terminal predictors of testing behaviour. As a strategy for positively influencing testing behaviour, employers should ensure that effective communication about HIV testing is established with workers across all levels of education and ethnic groups. Interventions relating to risky sexual behaviour need particular attention, and where possible HIV testing should be coupled with general STI screening.

Fatality risk and issues of inequity among vulnerable road users in South Africa.

BACKGROUND: Contextual effects from the physical and social environment contribute to inequitable protection for a large proportion of road users, especially in low- and middle-income countries like South Africa where distorted urban planning and socio-spatial disparities from the apartheid era prevail. OBJECTIVES: This paper examines the differentiated risk of road traffic crashes and injuries to vulnerable road users in South Africa, including pedestrians, females and users of some modes of public transport, in relation to characteristics of the crashes that proxy a range of contextual influences such as rurality and socio-economic deprivation. METHODS: The study is based on a descriptive analysis of 33 659 fatal crashes that occurred in South Africa over a three-year period from 2016-2018. Measures of simple proportion, population-based fatality rate, "impact factor" and crash severity are compared between disaggregated groups using Chi-Square analysis, with the Cramer's V statistic used to assess effect size. RESULTS AND SIGNIFICANCE: Key findings show a higher pedestrian risk in relation to public transport vehicles and area-level influences such as the nature of roads or extent of urbanity; higher passenger risk in relation to public transport vehicles and rurality; and higher risk for female road users in relation to public transport vehicles. The findings have implications for prioritising a range of deprivation-related structural effects. In addition, we present a "User-System-Context" conceptual framework that allows for a holistic approach to addressing vulnerability in the transport system. The findings provide an important avenue for addressing the persistently large burden of road traffic crashes and injuries in the country.

Childhood vulnerability to drowning in the Western Cape, South Africa: Risk differences across age and sex.

INTRODUCTION: Drowning is amongst the leading causes of death of children and young people worldwide, with high concentrations in Southeast Asia and Sub-Saharan Africa. In the Western Cape province in South Africa, drowning mortality rates for children were reported at 3.8 per 100,000 population. Internationally, evidence suggests that unimpeded access to water bodies and containers and lapses in supervision together with the child's limited developmental capacities, place children at greater risk of drowning. This study examined the risk for fatal drowning by age cohort and sex in child and adolescent (0-19 years old) in the Western Cape. METHOD: Demographic and descriptive data for child drowning fatalities from 2010 to 2016 were obtained from the Western Cape Forensic Pathology Service. Descriptive variables included location of drowning incident by body of water, time of day, day of week and season. Data were analysed by age cohorts aligned to child psychosocial developmental stages. Descriptive statistics reported fatality frequencies by age cohort and sex, and logistic regression was conducted to detect differences in drowning risk across these categories. RESULTS: A total of 538 childhood drowning fatalities were analysed, with the highest proportion occurring in children aged 13-19 years (29.6%) and the majority occurring in males (75.8%). Sex, location of drowning incident and season were significant predictors of drowning across the age cohorts. Relative to females, males between ages 0-1 and 2-3 years were less likely to drown when compared with older children. CONCLUSION: This study confirms existing evidence that children younger than five are most at risk of drowning. In contrast to international and local research findings that have indicated a similar or higher risk for drowning amongst boys compared with girls aged 3 years and younger, this study identified that males were less likely to drown between the ages of 0 and 3 years compared with girls.

The role of concomitant alcohol and drug use in increased risk for burn mortality outcomes.

BACKGROUND: Burn injuries are a major cause of mortality and morbidity in low- and middle-income countries, with high rates in Sub-Saharan Africa. The risks may be heightened for persons who present with concomitant use of alcohol and illicit substances, which increase the risk for injury and severely compromise prognosis following injury. METHODS: This study utilised a national dataset on hospitalised burns in South Africa to explore the risk for mortality relative to morbidity. To assess the influence of alcohol and drugs in mortality outcomes, the analysis was restricted to adult cases, 18 years and older (N = 918). The primary statistical procedures used in the analysis were logistic regression models. FINDINGS: The results indicate that burn victims with full thickness and partial thickness burn degree and more than 30% TBSA had a significantly increased risk of mortality. In addition, the risk for mortality was increased ten times when concomitant alcohol and drugs were indicated compared to cases where these were absent. The length of stay in hospital diminished the risk for mortality by about 10%. INTERPRETATION: The findings may be explained by the role of skin as the main barrier against infections and the concurrent increase in risk of infection based on the degree and extent of any damage. The combined presence of both alcohol and drugs may predispose towards more severe burns and greatly compromise liver function with heightened risk for sepsis and death.

South African service users' perceptions of patient-reported outcome and experience measures for adolescent substance use treatment: A qualitative study.

INTRODUCTION AND AIMS: Patient-reported outcome measures (PROM) and experience measures (PREM) for substance use disorder (SUD) treatment exist for adults but have unknown relevance for adolescents. This study aimed to explore adolescents' perceptions of effective SUD treatment and possible barriers to completing PROMs and PREMs to guide efforts to adapt the South African Addiction Treatment Services Assessment (SAATSA) for adolescents. DESIGN AND METHODS: Five focus groups were conducted with 38 adolescent service users recruited from residential and outpatient SUD treatment facilities in South Africa. Group discussions explored perceptions of treatment components necessary for desired SUD treatment outcomes, treatment experiences that support engagement in care, and perceptions of PROM and PREM completion. RESULTS: Participants viewed treatment elements that enhance motivation for change, coping and emotional regulation; provide recreational alternatives to substance use; and improve family relationships and home environments as critical to positive treatment outcomes. They reflected that provider characteristics and developmentally and culturally appropriate services facilitated engagement in treatment. PROM and PREM completion seemed acceptable, with participants suggesting ways to enhance their appeal. DISCUSSION AND CONCLUSION: Findings confirm that adult-oriented PROMs and PREMs require adaptation for adolescents. Service user inputs identified ways to expand the content of the SAATSA to better reflect adolescents' treatment priorities. These inputs have also guided changes to item formulation and administration procedures to enhance the SAATSA's acceptability for adolescents. Ensuring the SAATSA addresses treatment outcomes and experiences that matter to adolescents is vital for generating information to guide improvements to adolescent SUD services.

A Mixed-Methods Evaluation of the Implementation of a Performance Measurement System for South Africa's Substance Use Treatment Services.

OBJECTIVE: Minimal knowledge exists on the factors that affect implementation of performance measurement systems, particularly in low- and middle-income countries (LMICs). To address this, we describe the implementation of a performance measurement system for South Africa's substance abuse treatment services known as the Service Quality Measures (SQM) initiative. METHOD: We conducted a mixed-methods evaluation of system implementation. We surveyed 81 providers about the extent of system implementation within their agencies and the factors that facilitated implementation. We conducted 26 in-depth interviews of providers' perceived barriers and facilitators to implementation. RESULTS: The overall penetration of this system was high. Almost all providers viewed the system as feasible to implement, acceptable, appropriate for use in their context, and useful for guiding service improvements. However, the extent of implementation varied significantly across sites (p < .05). Leadership support (p < .05) was associated with increased implementation in multivariable analyses. Providers reflected that high rates of patient attrition, variability in willingness to implement the system, and limited capacity for interpreting performance feedback affected the extent of system implementation. CONCLUSIONS: It is feasible to implement a performance measurement system in LMICs if the system is acceptable, appropriate, and useful to providers. To ensure the utility of this system for treatment service strengthening, system implementation must be optimized. Efforts to enhance target population coverage, strengthen leadership support for performance measurement, and build capacity for performance feedback utilization may enhance the implementation of this performance measurement system.

Validation of the Schieman and Young measurement scales for work contact, work-family conflict, working conditions, psychological distress and sleep problems in construction industry professionals.

BACKGROUND: This study examined the construct validity and internal consistency of modified versions of the job autonomy and control, job pressure, work contact, work-family conflict, psychological distress, and sleep problems scales developed by Schieman and Young (2013) among construction professionals through confirmatory factor analysis and tests of internal consistency. METHODS: Using a cross-sectional design, survey data were collected from 942 South African construction professionals, of which 630 responses were considered for analysis. Confirmatory factor analysis was used to examine construct validity. Cronbach's coefficient alpha was used to determine the internal consistency, and convergent validity was tested using correlation analysis. RESULTS: The final CFA indicated very good model fit to the data (χ2 /df ratio = 2.11, IFI = .95, CFI = .95, RMSEA = .06, and Hoelter (95%) = 176). The scales demonstrated satisfactory internal consistency: .82; .91; .83; .90; .90; and .73, respectively. Convergent validity was largely demonstrated with respect to direction of association, but not in relation to magnitude. A limitation of the validation study was the lack of available data for a more robust examination of reliability beyond internal consistency, such as test-retest. CONCLUSIONS: The six scales developed by Schieman and Young (2013) hold promise as measures of work contact, work-family conflict, psychological distress, and sleep problems in relation to working conditions of construction professionals.

Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative.

BACKGROUND: Optimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC. METHOD: We explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit. RESULTS: Overall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit. CONCLUSION: Improving rates of outpatient treatment completion will enhance the effectiveness of South Africa's SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.

Burns and fires in South Africa's informal settlements: Have approved kerosene stoves improved safety?

This study is a follow-on to an intervention project that implemented South African Bureau of Standards approved kerosene stoves and safety education in 150 households of a Johannesburg informal settlement. An investigation conducted 12 months later established that 43 stoves had operational defects, yet 23 households continued using the faulty appliances. This study focuses on (1) the psychological and behavioural factors associated with continued use of faulty stoves by the 23 households, and (2), the specific technical failures of these stoves. The study involved one-on-one recall interviews with the households using defective stoves (N=21) and laboratory-based stove tests for seven of the affected appliances. The results indicate that the stoves had defects in critical safety features such as flame control and the self-extinguishing mechanism. Four stove malfunctions of minor burn affect were reported in the study. Continued use of the damaged stoves was significantly associated with the time from receipt of the stove to detection of first failure: stoves that failed later on were more significantly likely to remain in use as compared to those that failed sooner. The findings point to the need for strengthening enforcement of appliance standards, public education on kerosene stove use, and structural change for the energy-poor.

Parental supervision and discomfort with children walking to school in low-income communities in Cape Town, South Africa.

OBJECTIVE: The risk of pedestrian injury is compounded for children living in low-income communities due to factors such as poor road and pedestrian infrastructure, reliance on walking as a means of transport, and compromised supervision. Parents play an important role in child pedestrian safety. The primary objective of this study was to examine the effects of child pedestrian variables on parental discomfort with regard to letting their child walk to and from school and on the frequency of adult supervision. METHODS: A cross-sectional study was conducted using a convenience sample from 3 schools participating in a pedestrian safety school initiative. The schools are situated in low-income, high-risk communities in the City of Cape Town. A parent survey form was translated into isiXhosa and sent home with learners to those parents who had consented to participate. The response rate was 70.4%, and only parents of children who walk to and from school were included in the final sample (n = 359). Child pedestrian variables include the time taken to walk to school, parental rating of the child's ability to safely cross the road, and the frequency of adult supervision. RESULTS: More than half of parents reported that their child walked to and from school without adult supervision. About 56% of children took less than 20 min to walk to school. Most parents (61%) were uncomfortable with their child walking to school, although the majority of parents (55.7%) rated their child's ability to cross the road safely as better or significantly better than average (compared to peers). The parents did not perceive any differences in pedestrian risk factors between boys and girls or between younger (6-9 years) and older (10-15 years) children. The time spent by a child walking to school and parents' perceptions of their child's road-crossing ability were found to be significant predictors of parental discomfort (in letting their child walk). Younger children and children who spent less time walking were more likely to be supervised by an adult. CONCLUSIONS: Many South African schoolchildren have to navigate the roads without adult supervision from a young age. Caregivers, especially in low-income settings, often have limited options with regard to getting their child to school safely. Regardless of the child's age and gender, the time that they spend on the roads is an important factor for parents in terms of pedestrian safety.

HIV infection in the South African construction industry.

South Africa has one of the highest HIV prevalences in the world, and compared with other sectors of the national economy, the construction industry is disproportionately adversely affected. Using data collected nationally from more than 57,000 construction workers, HIV infection among South African construction workers was estimated, together with an assessment of the association between worker HIV serostatus and worker characteristics of gender, age, nature of employment, occupation, and HIV testing history. The HIV infection of construction workers was estimated to be lower than that found in a smaller 2008 sample. All worker characteristics are significantly associated with HIV serostatus. In terms of most at-risk categories: females are more at risk of HIV infection than males; workers in the 30-49 year old age group are more at risk than other age groups; workers employed on a less permanent basis are more at risk; as are workers not having recently tested for HIV. Among occupations in the construction industry, general workers, artisans, and operator/drivers are those most at risk. Besides yielding more up-to-date estimated infection statistics, this research also identifies vulnerable sub-groups as valuable pointers for more targeted workplace interventions by construction firms.

AIDS-related knowledge, stigma and customary beliefs of South African construction workers.

Customary beliefs about the cause/s of AIDS are significantly related to whether or not individuals will undergo HIV testing. This study examined the cultural beliefs of construction workers in terms of their demographic and lifestyle behavioural characteristics, and their AIDS-related knowledge and stigma attitudes, to help inform improved work-based AIDS-education interventions by construction firms. A total of 512 workers drawn from 6 firms operating on 18 construction sites in the Western Cape province participated in the study. Thirty-seven per cent of participants either endorsed customary beliefs/explanations about the cause of AIDS, or were unsure. AIDS-related knowledge proved a significant differentiator of participants endorsing customary beliefs (aOR = 0.8, 95% CI, 0.6-1.0), or being unsure (aOR = 0.5, 95% CI, 0.4-0.6), compared to participants not endorsing such beliefs. Stigma (aOR = 1.3, 95% CI, 1.1-1.7) proved a significant differentiator of participants with more polarized beliefs, namely, those endorsing customary beliefs compared to those not endorsing such beliefs, but was not significant in differentiating these categories from that of being unsure. The challenges to testing behaviour from incorrect AIDS knowledge may be amplified by adherence to customary beliefs that discount scientific explanations about the cause of AIDS. Interventions are required to specifically address misinformation or incorrect knowledge about AIDS derived from traditional beliefs, and should explicitly target persons who either endorse such beliefs or are somewhat equivocal about them. The role of peer educators is highlighted. Traditional healers, given their credibility and status within many traditional cultures, may also have an important role to play in this regard.

Child pedestrian safety knowledge, behaviour and road injury in Cape Town, South Africa.

Pedestrian injuries are a leading cause of death among South African children, and young children residing in low-income communities are more at risk, due to various factors such as inadequate road infrastructure, exposure to traffic due to reliance on walking as a means of transport, and lack of supervision. This study used a cross-sectional, non-randomized self-report survey to assess pedestrian safety knowledge, road-crossing behaviour and pedestrian injuries of primary school children in selected low-income settings in Cape Town. The survey focused on three primary schools that had joined the Safe Kids Worldwide Model School Zone Project and was administered to 536 children aged 6-15 years, in their home language of isiXhosa. Descriptive and bivariate analyses as well as multivariate regression analyses were conducted to investigate potential predictor variables for pedestrian collision severity and unsafe road-crossing behaviour. Walking was the sole form of travel for 81% of the children, with a large proportion regularly walking unsupervised. Children who walk to or from school alone were younger and reported riskier road-crossing behaviour, although children who walk accompanied tended to have higher pedestrian collision severity. "Negligent Behaviour" related to road-crossing was significantly associated with higher pedestrian collision severity, with predictors of "Negligent Behaviour" including the lack of pedestrian safety knowledge and greater exposure to traffic in terms of time spent walking. More than half of the reported pedestrian collisions involved a bicycle, and older boys (10-15 years) were most at risk of experiencing a severe pedestrian injury. The findings substantiate emerging evidence that children in low-income settings are at greater risk for child pedestrian injury, and emphasise the need for evidence-based safety promotion and injury prevention interventions in these settings.

Providers' perceptions of the implementation of a performance measurement system for substance abuse treatment: A process evaluation of the Service Quality Measures initiative.

BACKGROUND: In South Africa, concerns exist about the quality of substance abuse treatment. We developed a performance measurement system, known as the Service Quality Measures (SQM) initiative, to monitor the quality of treatment and assess efforts to improve quality of care. In 2014, the SQM system was implemented at six treatment sites to evaluate how implementation protocols could be improved in preparation for wider roll-out. OBJECTIVE: To describe providers' perceptions of the feasibility and acceptability of implementing the SQM system, including barriers to and facilitators of implementation. METHODS: We conducted 15 in-depth interviews (IDIs) with treatment providers from six treatment sites (two sites in KwaZulu-Natal and four in the Western Cape). Providers were asked about their experiences in implementing the system, the perceived feasibility of the system, and barriers to implementation. All IDIs were audio-recorded and transcribed verbatim. A framework approach was used to analyse the data. RESULTS: Providers reported that the SQM system was feasible to implement and acceptable to patients and providers. Issues identified through the IDIs included a perceived lack of clarity about sequencing of key elements in the implementation of the SQM system, questions on integration of the system into clinical care pathways, difficulties in tracking patients through the system, and concerns about maximising patient participation in the process. CONCLUSION: Findings suggest that the SQM system is feasible to implement and acceptable to providers, but that some refinements to the implementation protocols are needed to maximise patient participation and the likelihood of sustained implementation.

Validating survey measurement scales for AIDS-related knowledge and stigma among construction workers in South Africa.

BACKGROUND: Construction workers in South Africa are regarded as a high-risk group in the context of HIV/AIDS. HIV testing is pivotal to controlling HIV transmission and providing palliative care and AIDS-related knowledge and stigma are key issues in addressing the likelihood of testing behaviour. In exploring these issues, various studies have employed an 11-item AIDS-related knowledge scale (Kalichman and Simbayi, AIDS Care 16:572-580, 2004) and a 9-item stigma scale (Kalichman et al., AIDS Behav 9:135-143, 2005), but little evidence exists confirming the psychometric properties of these scales. METHODS: Using survey data from 512 construction workers in the Western Cape, South Africa, this research examines the validity and reliability of the two scales through exploratory and confirmatory factor analysis and internal consistency tests. RESULTS: From confirmatory factor analysis, a revised 10-item knowledge scale was developed (χ2 /df ratio = 1.675, CFI = 0.982, RMSEA = 0.038, and Hoelter (95 %) = 393). A revised 8-item stigma scale was also developed (χ2 /df ratio = 1.929, CFI = 0.974, RMSEA = 0.045, and Hoelter (95 %) = 380). Both revised scales demonstrated good model fit and all factor loadings were significant (p < 0.01). Reliability analysis demonstrated excellent to good internal consistency, with alpha values of 0.80 and 0.74, respectively. Both revised scales also demonstrated satisfactory convergent and divergent validity. Limitations of the original survey from which the data was obtained include the failure to properly account for respondent selection of language for completion of the survey, use of ethnicity as a proxy for identifying the native language of participants, the limited geographical area from which the survey data was collected, and the limitations associated with the convenience sample. A limitation of the validation study was the lack of available data for a more robust examination of reliability beyond internal consistency, such as test-retest reliability. CONCLUSIONS: The revised knowledge and stigma scales offered here hold considerable promise as measures of AIDS-related knowledge and stigma among South African construction workers.

Development and psychometric validation of a novel patient survey to assess perceived quality of substance abuse treatment in South Africa.

BACKGROUND: A hybrid performance measurement system that combines patient-reported outcome data with administrative data has been developed for South African substance abuse treatment services. This paper describes the development and psychometric validation of one component of this system, the South African Addiction Treatment Services Assessment (SAATSA). METHODS: First, a national steering committee identified five domains and corresponding indicators on which treatment quality should be assessed. A decision was made to develop a patient survey to assess several of these indicators. A stakeholder work group sourced survey items and generated additional items where appropriate. The feasibility and face validity of these items were examined during cognitive response testing with 16 patients. This led to the elimination of several items. Next, we conducted an initial psychometric validation of the SAATSA with 364 patients from residential and outpatient services. Exploratory (EFA) and confirmatory factor analyses (CFA) were conducted to assess the latent structure of the SAATSA. Findings highlighted areas where the SAATSA required revision. Following revision, we conducted another psychometric validation with an additional sample of 285 patients. We used EFA and CFA to assess construct validity and we assessed reliability using Cronbach's measure of internal consistency. RESULTS: The final version of the SAATSA comprised 31 items (rated on a four-point response scale) that correspond to six scales. Four of these scales are patient-reported outcome measures (substance use, quality of life, social connectedness and HIV risk outcomes) that together assess the perceived effectiveness of treatment. The remaining two scales assess patients' perceptions of access to and quality of care. The models for the final revised scales had good fit and the internal reliability of these scales was good to excellent, with Cronbach's α ranging from 0.72 to 0.89. CONCLUSION: A lack of adequate measurement tools hampers efforts to improve the quality of substance abuse treatment. Our preliminary evidence suggests that the SAATSA, a novel patient survey that assesses patients' perceptions of the outcomes and quality of substance abuse treatment, is a psychometrically robust tool that can help fill this void.

Understanding the Impact of Hazardous and Harmful Use of Alcohol and/or Other Drugs on ARV Adherence and Disease Progression.

The objective of this study was to understand the impact of hazardous and harmful use of alcohol and/or other drugs on ARV adherence and disease progression among HIV patients. A cross-sectional study design was used. A total of 1503 patients attending HIV clinics in Cape Town, South Africa were screened for problematic substance use. A sub-sample of 607 patients (303 patients who screened positive for problematic substance use and 304 who did not) participated in this study. Hazardous or harmful alcohol use and problematic drug use predicted missing and stopping ARVs which, in turn, was associated with a decrease in CD4 counts and more rapid HIV-disease progression and poorer health outcomes in people living with HIV/AIDS (PLWHA). The findings of this study underscore the need for an integrated approach to managing substance-use disorders in PLWHA.