Annalee Yassi


Relevant Thesis-Based Degree Programs


Graduate Student Supervision

Doctoral Student Supervision

Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.

Promoting the occupational health and safety of health workers: enabling factors and barriers to the local implementation of internationally designed tools (2021)

Recognizing a global shortage of health workers (HWs), particularly in low- and middle-income countries (LMICs), persistent calls to increase retention and recruitment of this essential workforce have been made. Attrition of HWs is driven in part by unsafe working conditions. To help promote and improve the occupational health and safety (OHS) of HWs, the International Labour Organization (ILO) and World Health Organization (WHO), two specialized agencies of the United Nations, developed HealthWISE. This quality improvement tool helps health facilities identify workplace hazards and develop and apply low-cost solutions. This dissertation examines the overriding question: ‘What are the enabling factors and barriers to the effective local implementation of internationally designed tools, to improve the OHS of HWs in high-risk areas?’ To achieve this, it first explores the roles of the ILO and WHO in promoting the OHS of HWs through 17 semi-structured expert interviews supplemented by a literature and document review. Second, it examines the enabling factors and barriers to the implementation of HealthWISE in seven hospitals in Mozambique, South Africa, and Zimbabwe using a multiple-case study and applying the i-PARIHS framework. Finally, it develops theories about how HealthWISE works to improve the OHS of HWs through a realist evaluation. Roles identified as appropriate for international organizations included raising awareness and advocating (for OHS improvements) as well as developing and supporting the application of tools (like HealthWISE). Factors that enabled efficacious implementation of HealthWISE included dedicated local team members who adapted HealthWISE to workers’ OHS knowledge and skill levels and to the cultures and needs of their workplaces. Initial program theories suggested that HealthWISE works by increasing HWs’ feelings of value, empowerment, and ownership over their personal health and safety, and by emphasizing the need to work with available resources – based on content developed by two recognized and trusted organizations. Reflecting on the roles of international organizations, the experience implementing HealthWISE, and the mechanisms underlying how HealthWISE works suggest that international organizations focus beyond the identification and development of strategies and tools to emphasize increased support from and strengthened engagement with stakeholders to contribute to and critically assess effective implementation processes.

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Incidence and determinants of tuberculosis among healthcare workers in Free State, South Africa: a historical prospective cohort study and evaluation of infection control (2016)

Healthcare workers (HCWs) are at high-risk of exposure to tuberculosis (TB) at work, yet the incidence rate of TB disease among HCWs in South Africa, and other high-burden countries, is unknown. The effectiveness of TB infection control (IC) measures in South African hospitals remains unclear and evidence examining the relationship between IC and TB among HCWs is lacking. Objective 1: Estimate the incidence rate of TB among HCWs in Free State, South Africa from 2002-2012; andObjective 2: Examine the association between TB IC scores in Free State hospitals and the incidence of TB among HCWs in 2012. A record linkage was conducted to identify HCWs who were registered as TB patients. A historical prospective cohort study was conducted to obtain incidence rate ratios (IRR) of TB among HCWs in Free State from 2002-2012 and to compare patient characteristics. A mixed-effects poisson regression was used to model the association between facility type, occupation, duration of employment, and the rate of TB. A TB IC workplace assessment tool was used in 28 public hospitals. A generalized linear mixed-effects regression was used to assess the association between TB IC scores and incidence of TB among HCWs in 2012. There were 231,834 people diagnosed with TB in Free State from 2002-2012. Among HCWs, 2,677 cases of TB were diagnosed and 1,280 were expected. IRR ranged from 1.14 in 2012 to 3.12 in 2005. HCWs who were older, male, black, coloured and employed less than 20 years had higher risk of TB. There is a large variability in TB IC in Free State. As total IC score, environmental and personal protective equipment (PPE) score increased, the probability of TB among HCWs in that hospital decreased. This study objectively estimates the rate of TB among HCWs in South Africa. The findings confirm that HCWs are at high risk of TB - as much as three-times higher than the population they serve. These findings re-affirm that overall IC and PPE are essential to prevent HCWs from acquiring TB. More attention to TB IC is warranted to protect HCWs and to stop the TB epidemic.

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Integration of HIV Care into Primary Health Care: A Health System Approach in Free State South Africa (2015)

Improving access to antiretroviral therapy (ART) for HIV has improved life expectancy and reduced HIV transmission. The integration or decentralisation of HIV care into primary health care (PHC) clinics is a widely promoted strategy to expand access to ART. In South Africa, a national policy to integrate HIV care into PHC services was implemented in April 2010. Comprehensive HIV care, from testing to the initiation and management of ART, was provided largely by nurses in PHC clinics. Little evidence exists on the impact of integration on: 1) patients 2) health care workers and 3) PHC clinic function and service delivery. By examining this question in Free State, South Africa through a health systems approach, I aimed to understand the benefits and challenges of integrating HIV care into PHC services.A mixed methods approach was employed utilising quantitative (i.e. patient surveys and longitudinal analysis of administrative data across 4 years) and qualitative (i.e. key informant interviews and focus group discussions) methods. Statistical analysis included t-tests and linear regressions (patient survey data) and interrupted times series analysis and linear mixed effect modelling (longitudinal data). Qualitative data were inductively and deductively thematically coded, and applied to a health systems framework. Concerning patients, advantages of integration were the provision of comprehensive care at PHC clinics (including HIV care), maintaining quality of care (QoC) as integration progressed, improved care across the continuum, family and community engagement. However, increased wait times, decreased QoC for chronic disease patients and concerns about retention were identified. For health care workers, despite increased workload with staff shortages, integration positively influenced job satisfaction, morale, the promotion of teamwork and mentoring. Concerning PHC service delivery, notwithstanding an increase of nearly 60, 000 patients on ART in the 131 PHC clinics in our four year study, service delivery was mostly unchanged, except for decreased immunisation coverages. In conclusion, expansion of ART through integration to PHC clinics is a viable strategy with wide health system benefits. However, care must be taken to provide adequate support for health systems to ensure the provision of equitable patient-centred PHC, especially in highly HIV prevalent contexts.

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Primary Care, Public Health and the Intersectoral Management of Health Determinants: A Realist Inquiry (2014)

Problem: International bodies such as the World Health Organization call on nation-states to more adequately address health determinants (HD) and strengthen primary healthcare through intersectoral action for health (IAH). Despite many leaders expressing the desire to strengthen IAH, in many countries, practitioners and policy-makers struggle to succeed. This study aims to deepen the understanding of how to maximize the impact on health and HD through collaborations between primary care providers (PCP), public health professionals (PHP), and representatives of sectors other than the health sector (ROS). Method: This research includes a supplementary analysis of a mixed-methods case study on Cuban IAH to clarify and compare the roles of the various actors of interest (PCP, PHP, ROS) in managing HD, including the contexts, mechanisms, and outcomes (CMO) in which IAH occurs in Cuba when involving those particular actors. This is followed by a knowledge synthesis of IAH interventions internationally, providing a variety of different contexts, which enables systematic comparison of the various CMO configurations extracted from those interventions, following a method inspired by realist synthesis. Data for the final CMO analysis and demi-regularity are drawn from both the Cuban case study and the other examples of IAH from around the world that involved PCP, PHP, and ROS.Conclusions: IAH involving PHP, PCP, and ROS can lead to significant, positive health outcomes through the management of HD. A key context in which significant improvement in HD and health outcome occurs is when the IAH are carefully planned based on prior evidence and best practices related to partnership building and public health. Key mechanisms of those interventions include: 1) systematic attention to infrastructures, and activities that successfully increase social capital; 2) which in turn supports the negotiation of complementary and synergistic roles between PCP, PHP and ROS, and 3) using cycles of adjustment based on best practices of quality improvement which enable cumulative and reinforcing synergies over time (years and decades), as projects unfold in complex changing policy and practice environments, and as the multiple actors increase their social capital and experience in dealing with health determinants.

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Master's Student Supervision

Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.

"It will be everyone's secret; he won't tell, and I won't tell": the impact of HIV diagnosis on serodiscordant couples (2021)

Anti-retroviral therapy (ART) and oral pre-exposure (PrEP) have proven effective in the prevention of HIV. As Tanzania begins a nationwide scale-up of pre-exposure prophylaxis (PrEP) with a focus on key populations including couples with different HIV status, described as serodiscordant, we seek to understand the perceived effects of PrEP and early ART on facets of serodiscordant relationships. Additionally, given the gender disparities that contribute to women’s increased risk of HIV infection, this paper will also examine female partners’ decision-making related to HIV testing and partner dynamics post-testing. Using a social constructivist grounded theory paradigm, 44 in-depth interviews conducted during the Dyadic-based Diagnosis, Care and Prevention (DDCP) study in Kisarawe, Tanzania were analysed. Content analysis was employed alongside metaphor analysis and case study analysis to create a contextual, animated yet distinctive, and holistic understanding of the experiences of serodiscordant couples. The findings of the study reveal that when there is disclosure of HIV status to the partner, there is a general feeling of closeness by both partners; however, most participants indicated being more comfortable disclosing to specific family members than partners. Analyses also found that participants were interested in PrEP as a substitute for condom use; some having expressed that PrEP will return their sexual interactions to a semblance of normality. Case study analysis showed that most female participants, regardless of their HIV status, would get tested alone if their partner refused to get tested together. There was also a general consensus on the unfaithfulness of male partners, and for some female participants this led to the breakdown of the relationship whilst others chose to live in peace. The study shows that couples testing is a crucial intervention that may promote better quality of serodiscordant relationships. Including family members and communities in conversations about HIV testing, care and treatment, can engender a more informed support network that promote early ART/PrEP adherence and more stable serodiscordant relationships. Better guidelines that are informed by and accommodate the interests and experiences of serodiscordant couples need to be developed to improve and inform patient-centred care.

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Health impacts of consuming shellfish contaminated with polycyclic aromatic hydrocarbons (PAHs), harvested from waters polluted by petroleum and industrial activities (2021)

Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous toxic chemicals in the environment. Human activities have resulted in water pollution and seafood contamination with PAHs. PAHs bioaccumulate in shellfish, and their ingestion leads to several health outcomes. However, the extent of contamination and actual risk to shellfish consumers is not widely known. Therefore, the primary goal of this thesis is to highlight the health impacts of this consumption by synthesizing the evidence related to the health impacts of PAHs oral exposure, shellfish contamination across the world, and the degree of risk imposed on consumers. Two Cochrane-style systematic reviews were conducted: a review on the health effects of oral exposure to PAHs; another review on shellfish PAH contaminations, and risk assessments globally; and methodological reflections from collaborative research in Burrard Inlet assessing shellfish contamination and health risk to consumers from the Tsleil-Waututh Nation. The first systematic review confirmed cancer, developmental defects, toxicities in the nervous system, immune system, endocrine system, reproductive system, heart, and liver, following PAHs oral exposure. The second review showed different ranges of shellfish contamination worldwide. Based on the risk assessments, shellfish harvested from 40% of the studied areas imposed considerable risks on consumers. In Burrard Inlet, PAH levels were measured in several samples that suggested elevated risk while identifying methodological complexities in defining the implications of these findings. This review showed high risks for consumers due to shellfish PAH contamination across many countries, which may be associated with serious health impacts. In addition to using more rigorous methodological approaches in evaluating contamination, unique characteristics of each population need to be acknowledged in risk assessments.

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Improving well-being through food sovereignty: a meta-narrative literature review (2021)

Industrialized agriculture and food security interventions have failed to eliminate global hunger, while creating complex environmental, health, and well-being challenges. The food sovereignty movement, which recognizes the power imbalances and social inequities in the global food system, presents a new lens through which to design interventions to improve how agricultural practices impact individual and community well-being. This thesis project answered the following research question: how can food sovereignty frameworks incorporate assessments of health and well-being? This research contributes to the gap in our understanding of the importance of food sovereignty practices to health and well-being through a meta-narrative literature review. Four well-being narratives (environmental, physical, cultural-spiritual, and social-political-economic) were identified from the literature and used to develop a novel framework demonstrating the relationship between food sovereignty practices and multi-dimensional well-being outcomes. A set of n=37 indicators were developed and organized into four themes of environmental, physical, cultural-spiritual, and social-political-economic wellbeing, to assess the relationship between food sovereignty practices and multiple forms of well-being. This study demonstrates how the application of food sovereignty practices can influence the well-being of individuals, their environments, and communities. As well, the results of this work emphasize the importance of defining well-being holistically, rather than viewing well-being outcomes from a purely biomedical health perspective. This framework presents a way for future researchers, farmers, and agricultural organizations to begin measuring well-being outcomes that result from their food production practices.

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Mental health and happiness of healthcare workers: narrative review, realist review, and proposed study design (2020)

Introduction: Healthcare workers experience high rates of mental ill health such as burnout, stress and depression, due to workplace conditions including excessive workloads, workplace violence and bullying. Based on the significant burden of mental ill health in the healthcare workforce as well as the recognized need for research on how to promote mental health in the workplace, this thesis aims to synthesize the state of knowledge in this area and chart future research that would be useful to provide further evidence-based insight on ways to promote mental health of healthcare workers.Methods: This thesis comprises three components needed to advance knowledge in this field: a narrative review on the mental health of healthcare workers, a realist review on workplace-based interventions to promote mental wellbeing among healthcare workers, and a detailed proposal for a three-phased cluster randomized controlled trial to develop and evaluate workplace-based interventions to promote mental wellbeing among healthcare workers in Gauteng, South Africa.Results: The narrative review affirmed the significant burden of mental ill health among healthcare workers and the need for workplace-based solutions to improve the current situation. In addition, the narrative review highlighted the growing recognition and adoption of positive mental health constructs such as happiness while also highlighting the complexity and challenges involved in workplace-based health promotion. Similarly, the realist review highlighted the complexities of both mental health in the workplace and the implementation and evaluation of workplace-based interventions, as well as issues of sustainability, the importance of employee engagement, and challenges around aligning organizational-level factors to affect change in individuals’ mental health. Lastly, the proposed study presents a comprehensive approach to designing, developing, implementing, and evaluating workplace-based interventions to promote mental wellbeing among a diverse and distributed healthcare workforce.Discussion: With healthcare workers experiencing significant mental ill health in various professions, countries and settings around the world, there is an urgent need to test and evaluate workplace-based interventions to promote mental wellbeing within this sector. In particular, more research from low- and middle-income countries is needed, as well as more research on organizational-level changes that can be done to improve healthcare workers’ mental wellbeing.

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If you build it, will they be protected? The evaluation of an occupational health and infection control capacity building program for healthcare workers in Free State, South Africa (2016)

Infection control and occupational health training among healthcare workers (HCWs) is insufficient in under-resourced systems. This is especially concerning in systems with high HIV and tuberculosis (TB) burdens where HCW exposure risk can be considerable. There is an urgent need to understand how to best develop and deliver effective capacity building programs for healthcare workers in these fields. This research examined a one-year certificate program in Free State, South Africa that aimed to empower HCWs to act as agents of change by building their capacity to conduct workplace-based HIV and TB prevention interventions. A mixed method approach was utilized. First, quantitative data were collected from self-reported Likert-style questionnaires administered to HCWs pre, mid, and post enrolment in the program. Questionnaire components included reactions to the program, and learning assessments (i.e., Knowledge, Attitudes, Skills, and Practices [KASPs]). Additionally, individual interviews, participant observations, and group project evaluations were used in the analysis. Questionnaire data were analyzed using the Wilcoxon signed-rank test. Interview data were thematically coded and analyzed based on the Kirkpatrick framework. Projects were descriptively analyzed. Participatory observations supplemented and contextualized these data. Participants (n=32) were mostly female (81%) nurses (56%). Findings from the questionnaires demonstrated that pre to post mean scores improved in Knowledge (+12%,Z=3.1,p=0.002) and Skills/Practices (+14%,Z=-3.1,p=0.002). Attitudes scores did not change. Interview data revealed that participants had been empowered and showed attitudinal improvements regarding HIV, TB, infection control and occupational health. Project evaluations, however, showed that participants had acquired only moderate-low proficiency in applying the subject matter to their interventions, although the projects did affect meaningful improvements in some workplaces. Participatory observations and interviews highlighted the resource-intensive nature of the program. Workplace training can strengthen HCWs’ occupational health and infection control KASPs. This capacity building initiative did result in the implementation of positive changes in workplaces, and empowered participants to be agents of change within their communities. However, the resources needed for this program, coupled with the low baseline skill levels of participants were challenges. When designing an intervention, baseline educational levels, institutional politics, sustainability, and resource effectiveness are important determinants of success.

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Stigma and confidentiality as barriers to uptake of HIV counseling and testing for health workers in 3 public hospitals in Free State province, South Africa : a mixed-methods study (2013)

Background: The HIV and AIDS epidemic has created a human resource crisis that “has replaced financial issues as the most serious obstacle to implementing national treatment plans” (WHO 2006a: 20). To retain the existing health workforce, international guidelines promote priority access to health services for health workers (HWs) through occupationally-based HIV counseling and testing (HCT) services. Such services have been implemented in South Africa (RSA), however recent evidence suggests their uptake is low.Objective: To identify barriers and facilitators to uptake of HCT services by HWs in three hospitals in Free State province, RSA. Methods: This mixed-methods study analyzed a portion of a self-administered survey and focus groups interviews (FGIs) to explore participants’ attitudes and behaviours related to HIV in the workplace, why HIV services may be underutilized and participants’ recommendations to improve the service.Results: In total, 978 HWs participated in the survey and 38 participated in the FGIs. Among survey respondents, 38.9% indicated a fear that confidentiality will not be maintained as the reason for not using OHS-based HIV services. 38.5% HWs perceive there is HIV stigma in the workplace. Six themes were identified from the FGIs, including location for testing, privacy, confidentiality, gossip, stigma and facilitators. FG participants perceived doctors’ and nurses’ experience with HIV in the workplace differs from other HWs, supported by multivariate analyses indicating patient-care HWs (PCHWs) have higher odds of perceiving confidentiality is not maintained in the OHS (adjusted ORs = 2.3; 95% CI 1.8-3.2) and perceiving HIV stigma in the workplace (adjusted OR = 2.4; 95% CI 1.8-3.2) when compared to non-PCHWs. FG participants also identified the need for in-service training on a range of topics related to HIV and expressed a desire to form HIV support groups to address negative attitudes toward HIV/AIDS in the workplace. Conclusions: Fear of breaches in confidentiality and HIV stigma were identified as the primary barriers to uptake of occupationally-based HCT by HWs. Overcoming these barriers require educating HWs on policies and guidelines that govern HIV in the workplace, implement measures to ensure confidentiality is maintained and addressing HIV stigma through stigma reduction interventions.

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