Background: Men’s perpetration of intimate partner violence (IPV) limits gains in health and wellbeing for populations globally. Largely informal, rapidly expanding peri-urban settlements, with limited basic services such as electricity, have high prevalence rates of IPV. Evidence on how to reduce men’s perpetration, change social norms and patriarchal attitudes within these settings is limited. Our cluster randomised controlled trial aimed to determine the effectiveness of the Sonke CHANGE intervention in reducing use of sexual and/or physical IPV and severity of perpetration by men aged 18–40 years over 2 years. Methodology: The theory-based intervention delivered activities to bolster community action, including door-to-door discussions, workshops, drawing on the CHANGE curriculum, and deploying community action teams over 18 months. In 2016 and 2018, we collected data from a cohort of men, recruited from 18 clusters; nine were randomised to receive the intervention, while the nine control clusters received no intervention. A self-administered questionnaire, using audio-computer assisted software, asked about sociodemographics, gender attitudes, mental health, and the use and severity of IPV. We conducted an intention-to-treat analysis at the cluster level comparing the expected risk to observed risk of using IPV while controlling for baseline characteristics. A secondary analysis used latent classes (LCA) of men to see whether there were differential effects of the intervention for subgroups of men. Results: Of 2406 men recruited, 1458 (63%) were followed to 2 years. Overall, we saw a reduction in men’s reports of physical, sexual and severe IPV from baseline to endpoint (40.2% to 25.4%, 31.8% to 15.8%, and 33.4% to 18.2%, respectively). Intention-to-treat analysis showed no measurable differences between intervention and control clusters for primary IPV outcomes. Difference in the cluster-level proportion of physical IPV perpetration was 0.002 (95% confidence interval [CI] − 0.07 to 0.08). Similarly, differences between arms for sexual IPV was 0.01 (95% CI − 0.04 to 0.06), while severe IPV followed a similar pattern (Diff = 0.01; 95% CI − 0.05 to 0.07). A secondary analysis using LCA suggests that among the men living in intervention communities, there was a greater reduction in IPV among less violent and more law abiding men than among more highly violent men, although the differences did not reach statistical significance. Conclusion: The intervention, when implemented in a peri-urban settlement, had limited effect in reducing IPV perpetrated by male residents. Further analysis showed it was unable to transform entrenched gender attitudes and use of IPV by those men who use the most violence, but the intervention showed promise for men who use violence less. Trial registration: ClinicalTrials.gov, NCT02823288. Registered on 30 June 2016.

Children spend a significant proportion of their time at school and in school buildings. A healthy learning environment that supports children should be thermally conducive for learning and working. Here, we aimed to study the relations between indoor classroom temperatures and learner absenteeism as a proxy for children’s health and well-being. This one-year prospective study that spanned two calendar years (from June 2017 to May 2018) entailed measurement of indoor classroom temperature and relative humidity, calculated as apparent temperature (Tapp) and collection of daily absenteeism records for each classroom in schools in and around King Williams Town, Eastern Cape province, South Africa. Classroom characteristics were collected using a standardized observation checklist. Mean indoor classroom temperature ranged from 11 to 30 °C, while mean outdoor temperature ranged from 6 °C to 31 °C during the sample period. Indoor classroom temperatures typically exceeded outdoor temperatures by 5 °C for 90% of the study period. While multiple factors may influence absenteeism, we found absenteeism was highest at low indoor classroom Tapp (i.e., below 15 °C). Absenteeism decreased as indoor Tapp increased to about 25 °C before showing another increase in absenteeism. Classroom characteristics differed among schools. Analyses of indoor classroom temperature and absenteeism in relation to classroom characteristics showed few statistically significant relations—although not exceptionally strong ones—likely because of the multiple factors that influence absenteeism. However, given the possible relationship between indoor temperature and absenteeism, there is a learning imperative to consider thermal comfort as a fundamental element of school planning and design. Furthermore, additional research on factors besides temperature that affect learner absenteeism is needed, especially in rural areas.

Exposure to heatwaves may result in adverse human health impacts. Heat alerts in South Africa are currently based on defined temperature-fixed threshold values for large towns and cities. However, heat-health warning systems (HHWS) should incorporate metrics that have been shown to be effective predictors of negative heat-related health outcomes. This study contributes to the development of a HHWS for South Africa that can potentially minimize heat-related mortality. Distributed lag nonlinear models (DLNM) were used to assess the association between maximum and minimum temperature and diurnal temperature range (DTR) and population-adjusted mortality during summer months, and the effects were presented as incidence rate ratios (IRR). District-level thresholds for the best predictor from these three metrics were estimated with threshold regression. The mortality dataset contained records of daily registered deaths (n = 8,476,532) from 1997 to 2013 and data for the temperature indices were for the same period. Maximum temperature appeared to be the most statistically significant predictor of all-cause mortality with strong associations observed in 40 out of 52 districts. Maximum temperature was associated with increased risk of mortality in all but three of the districts. Our results also found that heat-related mortality was influenced by regional climate because the spatial distribution of the thresholds varied according to the climate zones across the country. On average, districts located in the hot, arid interior provinces of the Northern Cape and North West experienced some of the highest thresholds compared to districts located in temperate interior or coastal provinces. As the effects of climate change become more significant, population exposure to heat is increasing. Therefore, evidence-based HHWS are required to reduce heat-related mortality and morbidity. The exceedance of the maximum temperature thresholds provided in this study could be used to issue heat alerts as part of effective heat health action plans.

South Africa is experiencing an increasing burden of cardiovascular diseases, including coronary heart disease (CHD) and stroke. We aimed to obtain overall national prevalence estimates of CHD and stroke in South Africa. Methods: Studies conducted in South Africa were systematically reviewed from PubMed, Scopus and Web of Science from January 1990 to July 2017. Random-effects meta-analyses were conducted on the selected studies to determine the overall prevalence of CHD and stroke. Studies conducted in South Africa were systematically reviewed from PubMed, Scopus and Web of Science from January 1990 to July 2017. Random-effects meta-analyses were conducted on the selected studies to determine the overall prevalence of CHD and stroke. Out of 2 466 studies, only 12 covering 75 140 participants reported the national prevalence of CHD and stroke. All 12 studies estimated the national prevalence of both diseases based on self-reported disease status. The overall national prevalence was 1.29 (95% CI = 0.83; 1.75) and 4.29 (95% CI = 3.13; 5.45) for CHD and stroke, respectively. Only one study reported incidence rates so we did not perform any meta-analysis of incidence rates. There are very few studies on national prevalence of CHD and stroke in South Africa. Well-structured registries for CHD and stroke are required to accurately identify the disease burden and enable adequate resources to be allocated for the implementation of appropriate prevention and management programmes.

Background: The COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels. Objective: Our evaluation aims to determine the effect of various exposures, including the COVID-19 pandemic, and a system-level, complex, patient-centered quality improvement (QI) intervention (the Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected South African facilities. The objectives are to determine whether Mphatlalatsane reduces the institutional maternal mortality ratio, neonatal mortality rate, and stillbirth rate (objective 1) and improves patients’ experiences (objective 2) and quality of care (objective 3). Objective 4 assesses the contextual and implementation process factors, including the COVID-19 pandemic, that shape Mphatlalatsane uptake and variation. Methods: This study is an implementation science type 2 hybrid effectiveness, controlled before-and-after design with quantitative and qualitative components. The Mphatlalatsane intervention commenced at the end of 2019. For objective 1, intervention and control facility-level data from the District Health Information System are compared for changes in institutional maternal and neonatal mortality and stillbirth rates and associations with QI, the COVID-19 pandemic, and both. This first analysis includes data from 18 facilities, regardless of their allocation to intervention or comparison, to obtain a general idea of the effect of the COVID-19 pandemic. For objectives 2 to 3, data collectors abstract data from maternal and neonatal records, interview participants, and conduct neonatal facility assessments. For objective 4, interviews, program documentation, surveys, and observations are used to assess how contextual factors at the macro-, meso-, and microlevels explain variation in intervention uptake and outcome. The intervention dose is measured at the microlevel only in the intervention facilities. The study assesses the Mphatlalatsane Initiative from 2020 to 2022. Results: From preliminary analysis, across the 3 provinces, maternal and neonatal deaths increased during the COVID-19 pandemic, whereas stillbirths remained unchanged. Maternal satisfaction with quality of care was >90%. The COVID-19 pandemic severely disrupted the QI teams functioning. However, the QI teams regained their pre–COVID-19 momentum by adapting the QI model, with advisers providing mentoring and support. Variation in adoption at the mesolevel was related to stable and motivated leadership (particularly at the facility level), poor integration into routine processes, and buy-in from senior district managers who were affected by competing priorities. Varying referral and specialist outreach systems, staff availability and development, and service delivery infrastructure are plausible factors in variable outcomes. Conclusions: Few evaluations rigorously evaluated the effect of health system interventions on improving health services and outcomes. Results will inform the scaling up of successful intervention components and strategies to mitigate the effects of the COVID-19 pandemic or similar emerging epidemics on maternal and neonatal mortality. International Registered Report Identifier (IRRID): DERR1-10.2196/42041

Working with men to prevent their perpetration of intimate partner violence and non-partner sexual violence is increasingly recognised as effective. However, in any given context there are a multiplicity of masculinities, each of which has a different association with violence perpetration. There remains lack of clarity about whether such interventions impact all men and masculinities equally. We undertook a post-hoc analysis of men involved in the successful Stepping Stones and Creating Futures cluster randomized control trial in Durban, South Africa, to assess: i) whether there were different groups of men, ii) the factors associated with group allocation, and iii) whether the intervention had a differential impact on these groups in terms of violence perpetration. We used Latent Class Analysis (LCA) to identify masculinity classes, based on fit statistics and theoretical plausibility, and then used descriptive statistics (numbers, percentages, means) and p-values and multinomial models (95% confidence intervals, p-values) to assess factors associated with allocation to each class. To assess intervention impact by group, we used an intention-to-treat analysis, comparing men in each masculinity class, by intervention and control arm, using generalized estimating equations reporting unadjusted and adjusted odds ratios (aORs). In total 674 were recruited at baseline, and the LCA identified three classes of men: high violence (29% of men), medium violence (50% of men) and low violence (21% of men). Multinomial models showed those in more violent classes were more supportive of violence, had more adverse experiences, more depression and had worked more. By masculinity class, the impact of SS-CF showed reductions among the most violent men, with significant reductions in past year physical IPV (aOR0.59, p = 0.014), emotional IPV (aOR0.44, p = 0.044) and economic IPV (aOR0.35, p = 0.004), with non-significant reductions among other classes of men. This analysis suggests intensive group-based interventions can have significant impacts on the most violent men in communities.