Annalee Yassi

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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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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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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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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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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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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