Allanise Cloete

Background: South Africa is committed to achieving Sustainable Development Goal 3 (SDG 3), which aims to ensure health and well-being for all. However, in rural provinces like KwaZulu-Natal, structural inequalities, socio-cultural challenges, and environmental stressors hinder progress. This study synthesises findings from qualitative research conducted at the Africa Health Research Institute (AHRI) to explore the challenges and opportunities in meeting SDG 3 targets. Methods: An integrative literature review was conducted, analysing studies from 2015 to 2024 that focused on SDG 3related topics, including HIV/AIDS, tuberculosis, maternal and child health, sexual and reproductive health, and the impact of climate change. A framework analysis approach was applied to identify common themes, opportunities and challenges to achieving SDG 3 in rural KwaZulu-Natal. Results and discussion: Key challenges to achieving SDG 3 include limited access to healthcare, socio-cultural norms that influence health-seeking behaviours, climate-related stressors, and gender disparities. Studies highlighted poor maternal immunisation uptake due to traditional beliefs, stigma-related challenges in HIV prevention, and climate-induced economic hardships affecting treatment adherence. Gendered challenges were prominent, with men’s healthcare engagement being hindered by masculinity norms and adolescent girls facing restricted access to sexual health services. The COVID-19 pandemic further disrupted access to healthcare, particularly for older adults. Despite these challenges, opportunities exist for progress. Community-driven interventions such as DREAMS and MTV-Shuga improved adolescent engagement with sexual health education. Male-focused interventions like Stepping Stones and Creating Futures increased men’s involvement in HIV care. Additionally, integration of climate adaptation strategies into health systems could mitigate environmental health risks. Conclusion: This study provides critical insights for policymakers to enhance the progress towards achieving SDG 3. To do so policymakers should focus on addressing systemic healthcare challenges, integrating gender-responsive interventions, and strengthening community-based health initiatives. Climate-resilient healthcare infrastructure and policies are crucial to ensuring sustained progress. Future efforts should focus on expanding youth-friendly services, enhancing male engagement in healthcare, and leveraging local partnerships to improve health outcomes in rural communities.

Epidemiological data show that transgender women are disproportionately affected by Human Immunodeficiency Virus (HIV). Data in South Africa on the HIV vulnerabilities of transgender women are sparse. This paper qualitatively explores the structural, personal, and economic factors that contribute to making South African transgender women vulnerable to HIV and other sexually transmitted infections (STIs). We conducted a rapid qualitative assessment in the Cape Town, Johannesburg, and Buffalo City metropolitan municipalities to frame the HIV risk vulnerabilities of transgender women. Purposive sampling was used to recruit study participants. We conducted 25 key informant interviews, five focus group discussions, and 26 in-depth interviews with transgender women. Atlas.ti.8 was used to facilitate qualitative data analysis. These data illustrate a pervasive theme of social rejection, discrimination, and everyday victimization among transgender women. The ubiquitous presence of stigma and rejection leads to internalized stigmatization, which affects the social and mental well-being of transgender women, who often turn to alcohol and illicit drug use to alleviate negative emotions. We found that transgender women may engage in high-risk sexual activities like sex work where they can express and affirm their gender identity. In this context, transgender women engaging in high-risk sexual activities found it challenging to access pre-exposure prophylaxis (PrEP). Stigma also leads to reluctance to use public healthcare services. Despite experiencing stigma and discrimination, qualitative data highlights the resilience of transgender women in the study. Qualitative data demonstrate that HIV risk for transgender women is complex. Multi-level community-led interventions grounded in empowerment are also required to address interpersonal, biological, structural, and community risk. Successful interventions should address stigma and draw upon the resilience of transgender women. Peer-driven interventions may motivate personal responsibility to use high-impact HIV prevention and treatment services.

Adolescents continue to face challenges to their sexual and reproductive health (SRH) both locally and internationally. Digital technologies such as the Internet, text messaging, and social media are often viewed as valuable tools for disseminating information on SRH. Mobile health, also known as mHealth, is a medical and public health practise that uses these digital technologies to communicate information. The literature has revealed that mHealth interventions have a positive outcome in delivering SRH information to adolescents. This review aimed to synthesise empirical studies that evaluate mHealth interventions and assess the extent to which these mHealth interventions promote sexual and reproductive health outcomes among young people. This scoping review reviewed the literature across four databases, including EBSCOhost, Scopus, Proquest, and Cochrane, and included 12 articles. The findings have shown that mHealth interventions are effective in enhancing sexual and reproductive health (SRH) knowledge and attitudes among young people in both low-middle and high-income countries. However, comprehensive longitudinal studies are necessary to measure the sustainability and long-term influence of mHealth interventions on behaviour. It is recommended that with artificial intelligence (AI) improvements, there is a possible path to bolstering mHealth interventions.

The Botshelo Ba Trans study was the first HIV bio-behavioral survey conducted with transgender women in South Africa. Engaging research with marginalized communities requires clear points of entry, reference points for understanding the internal culture, and establishing trust and understanding. The community-based participatory research approach guided the development and implementation of this study. We conducted a rapid qualitative and pre-surveillance formative assessment between August 2017 to January 2018 and a bio-behavioral survey between July 2018 and March 2019. At the start, a Steering Committee, comprising primarily of transgender women, was established and subsequently provided substantial input into the mixed methods study conducted in Buffalo City, Cape Town, and Johannesburg. Key to the study's success was building trust and establishing ownership of the survey by transgender women recognized as expert knowledge holders. Thus, a community-based participatory research-informed approach enhanced the validity of the data and ensured that we addressed relevant issues.

In this paper, we explored how vulnerable, immunocompromised groups and caregivers of the elderly experienced and perceived the onset of the Covid-19 pandemic in South Africa. Semi-structured interviews were conducted remotely between the 5th andthe 18th of April 2020 in the three South African provinces hardest hit by Covid-19, namely Gauteng, KwaZulu-Natal and the Western Cape. In total, 60 qualitative key informant interviews and one focus group discussion were conducted. Study participants expressed concerns for elderly people and people with underlying health conditions because of their increased vulnerability to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). People living with HIV expressed an increased fear of infection following the advent of the Covid-19 pandemic in South Africa. The sidelining of healthcare services and stock-outs of medication proved to be an added concern in particular for vulnerable and immunocompromised groups. Overall, the data suggest that the fear of infection is ubiquitous for people who live in unstable environments such as overcrowded townships and informal settlements. Given the increased fears of infection brought on by the Covid-19 pandemic, the mental health of vulnerable communities and those caring for them becomes an added burden for people living in unstable environments.

The Botshelo Ba Trans study was the first HIV bio-behavioural survey conducted amongst transgender women in South Africa. Engaging research with marginalised communities requires clear points of entry, reference points for understanding the internal culture, and the establishment of trust and understanding. The community-based participatory research approach guided the development and implementation of this study. At the start, a Steering Committee, comprising primarily of transgender women was established and subsequently provided substantial input into the mixed methods study conducted in Buffalo City, Cape Town, and Johannesburg. Key to the success of the study was building trust and establishing ownership of the study by transgender women who were recognized as expert knowledge holders. Thus, a community-based participatory research-informed approach enhanced the validity of the data and ensured that relevant issues were addressed.

Social distancing behaviour is a primary preventive measure for reducing COVID-19 transmission. Improved understanding of factors associated with adherence to social distancing is vital for mitigating the impact of COVID-19 in South Africa. The study assessed adherence to social distancing and its associated factors during the state-implemented lockdown in South Africa. Data was analysed from a large-scale public survey conducted in South Africa from 8 to 29 April 2020, which was administered online and telephonically. Invitations to participate were distributed widely on local websites and social media networks, including on a data-free platform. Adherence to social distancing was measured by self-report of having engaged in close physical contact with someone outside the home. Simple and multiple logistic regression models examined the association between social distancing and potential explanatory variables. Of the 17,586 participants, 9.2% came into close physical contact with a person outside their home by hugging, kissing, or shaking hands during the past 7 days. The odds of coming into close physical contact with other people were significantly higher for males, students, and those with incorrect knowledge on physical distancing, angry attitudes about the lockdown, lack of confidence in the government response, high-risk perception, movement out of the local area, travelling to shops using public transport, households with communal water facilities and higher household size. The 25–59-year olds compared to 18–24-year olds, and the White and Indian/Asian compared to the African population groups had significantly lower odds of close physical contact with others outside the home. The study identifies subgroups of individuals for whom public health interventions to improve adherence to social distancing should be prioritised and tailored. Interventions and policies should take cognisance of the social determinants of health as well as culturally accepted greeting practices like hand shaking.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities’ misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19.