Stephen Tollman

Aim: Community participation is essential for equitable primary health care but remains inconsistently implemented, particularly in rural settings. This study evaluates a participatory learning intervention designed to strengthen community health workers’ community mobilisation competencies as a pathway for supporting community participation and institutionalisation within primary health care. Method: The Verbal Autopsy with Participatory Action Research programme, in partnership with Mpumalanga Department of Health, delivered structured community mobilisation training across all provincial health districts in 2024. Using a training-of-trainers model and learning cycles combining facilitated sessions with field application, trainees applied participatory tools to priorities including HIV/TB treatment adherence, stigma, and loss to follow-up. A cross-sectional evaluation triangulated project outputs, semi-structured interviews with trainees, and a policy/strategy desk review. Findings: Key informants described the intervention as practical, relevant, and confidence building. Reported changes included improved facilitation and problem solving, stronger collaboration between community health workers, outreach team leaders and facility teams, and greater capacity to engage patients and community actors around locally identified service challenges. The training strengthened community health worker-led mobilisation capabilities by helping frontline workers surface local concerns, organise them through participatory tools, and link them to primary health care action. A key finding was rapid peer-to-peer diffusion of tools and learning beyond primary trainees, suggesting a potential multiplier effect. There were also clear signals of institutional uptake by provincial leadership, and movement towards aligning the programme with regional training requirements. Operational constraints included transport and equipment gaps, uneven foundational skills/literacy, workload pressures, and limited formal recognition. Conclusion: Participatory learning can support relational and community-oriented primary health care strengthening by building community health worker capabilities to convene actors, surface local concerns, and translate tacit community and service knowledge into collective problem solving across communities and facilities. Scaling will require supervision, mentoring, minimum resources, and systems to document and quality-assure peer diffusion.

Type 2 diabetes is rising globally, with sub-Saharan Africa facing the steepest projected increase. In low-resource settings, limited screening contributes to high rates of undiagnosed disease, delaying intervention. Traditional risk models often rely on single-factor thresholds or population averages, which can miss combinations of demographic, anthropometric, and lifestyle factors relevant in African contexts. However, emerging evidence suggests that interactions between multiple risk factors provide more accurate, region-specific characterizations of risk. We applied a multidimensional subgroup discovery algorithm to cross-sectional data from three African populations and identified combinations of risk factor cutoffs that define high-risk subgroups. The most consistent profile, such as waist-to-hip ratio greater than 0.9, physical activity less than or equal to 2448 metabolic equivalent-minutes per week, and family history, shows elevated risk across regions and outperforms guideline-based definitions. Here we show that core anthropometric and familial factors are stable across populations, while others are region-specific, improving predictive performance for screening.

Returning individualized microbiome results in ways that are ethical, comprehensible, and useful remains under-explored in African settings. We nested a multi-site, mixed-methods study within the AWI-Gen Wave 2 gut microbiome sub-study of 1,801 women aged 42 – 86 years to engage the participants and provide feedback. All (1,001) participants from Agincourt and Soweto (South Africa) and Nairobi (Kenya) were invited to feedback meetings: 496 from Agincourt, 87 from Soweto, and 195 from Nairobi responded. Engagement strategies were tailored by site (small-group and home-based sessions, visual metaphors, Foldscopes, and local-language delivery). Using semi-structured discussions and structured observations analysed thematically in MAXQDA under COREQ, five cross-cutting themes emerged: (1) understanding of microbiome reports, (2) emotional responses to feedback, (3) perceived health relevance, (4) trust in research institutions, and (5) suggestions for improving engagement. Culturally grounded explanations and local-language facilitation enhanced comprehension and perceived relevance; English-heavy sessions were associated with more confusion. Most participants expressed satisfaction and described planned or enacted dietary and lifestyle changes, while frustration centred on long delays between sampling and feedback. Trust increased with transparency and individualized return of results but was often conditional on minimizing burdensome procedures such as repeat blood sampling (phlebotomy) and ensuring timely feedback. Engagement was feasible and low-cost (approximately USD 29-59 per participant) with site-specific resource needs. Limitations included constrained generalizability beyond the three study sites. Returning individualized microbiome findings in community settings in Africa is acceptable, feasible, and can motivate health-promoting behaviours when delivered promptly and in culturally and linguistically appropriate ways. IMPORTANCE: Microbiome studies rarely return individualized results in low-resource settings due to concerns about appropriate feedback and associated costs. This gap risks eroding trust and diminishing research impact. In three African communities, tailored feedback on gut microbiome profiles was provided to 778 women. By documenting a costed, multi-site engagement model and the themes influencing acceptance and actionability, this work offers a practical framework for ethically returning complex -omics results at scale in underrepresented populations - advancing scientific equity and strengthening community trust in microbiome research.

Background Learning platforms can strengthen primary healthcare (PHC) by integrating community knowledge with system decision-making, but evidence on how they work in low-resource settings is limited. This study presents a realist evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) learning platform in rural Mpumalanga, South Africa (2015–25). VAPAR aimed to embed participatory evidence generation and shared learning within routine district processes to support more equitable, community-linked PHC. Methods A realist design was used to synthesise data from five action-learning cycles (2017–23), a preceding pilot (2015–16), and an engagement and uptake phase (2023–25). Data included cycle reports, participatory outputs, verbal autopsy (VA) analyses, 22 endline interviews, policy, strategy and planning documents. Using a co-developed theory of change, qualitative data were coded to examine context-mechanism-outcome patterns. Mechanisms were identified and refined through cross-cycle comparison, triangulation, and stakeholder validation. Results VAPAR was contextually responsive, adapting to shocks such as COVID-19 and progressively embedding within the district health system. Through regular dialogue, the platform activated generative mechanisms of trust-building, role clarity and recognition, collective sense-making, and strengthened agency, particularly among Community Health Workers (CHWs), whose skills, confidence and legitimacy expanded. These mechanisms operated within an enabling structural context shaped by PHC reforms that strengthened the District Health System and Ward-Based Primary Health Care Outreach Teams, alongside trade-union action for CHW absorption into public service. Institutionalisation followed through Mpumalanga’s revitalised Health Promotion Programme, with adaptation to additional provinces and for outbreak response and emergency obstetric care. Outcomes were interpreted through context-mechanism-outcome patterns, illustrating how participatory learning becomes embedded in decentralised health systems. Conclusions Over a decade, VAPAR demonstrated how structured, participatory learning can reshape relationships, strengthen community-linked PHC, and support institutionalisation of routine, evidence-informed practice in decentralised health systems. The findings offer transferable lessons for sustaining learning platforms in resource-constrained settings.

Despite repeated calls from international governing bodies for benefit sharing in biomedical research as a means of promoting mutual trust and reciprocity, real-world examples of benefit sharing are lacking. Here, we discuss benefit-sharing initiatives instituted as part of human genomics research projects carried out in both semi-rural and urban settings in South Africa. We explore lessons learned from applying different approaches to benefit sharing, as well as recommendations for ways to enhance success for future initiatives. Ultimately, we advocate for the adoption of flexible benefit-sharing models that take into consideration community representation and engagement, benefit management mechanisms, and long-term sustainability.

Sub-Saharan Africa (SSA) is experiencing an epidemiological transition where non-communicable diseases are becoming the leading cause of disability and mortality alongside infectious diseases such as HIV/AIDS. Multimorbidity, the coexistence of two or more long-term conditions, is increasing in SSA. However, the cost of managing multimorbidity is largely unknown. This study aimed to estimate the economic cost of public outpatient primary care for adults with multimorbidity (HIV, hypertension, and/or diabetes, and their associated conditions: cardiovascular disease, and TB) in rural South Africa. This study used a cross-sectional, retrospective cost-of-illness approach to estimate the direct and indirect costs of multimorbidity management in Bushbuckridge, Mpumalanga, in 2022. Data were synthesized from patient-level data from eight public primary healthcare facilities within the Agincourt study site—a rapidly transitioning rural South African setting. Additionally, government reports and an existing study on transport costs and productivity losses conducted within the Agincourt study site were used to estimate the costs of managing patients in the primary care facilities. Results showed that patients with multimorbidity had higher average economic costs per patient compared to those with single conditions. Overall, patients with multimorbidity increase costs above the baseline of a patient with a single condition (R4 900/annum) by between 42% and 83%. Patients with multimorbidity also incur slightly higher costs associated with accessing primary care services compared to those with a single condition. However, our model shows that the additive cost of managing multiple conditions in separate consultations is higher than managing all conditions in one visit. This shows that managing patients within an integrated care model seems to have a cost-limiting effect. However, treatment guidelines for managing multimorbidity in South Africa should be developed to ensure standardized care.

Rapid social, population and health transitions characterize much of rural Africa today. Integral to the complexity of change are rising life expectancy coupled with premature onset of multimorbidity, coupling infectious and non‐communicable conditions. Understanding and awareness of Alzheimer's Disease and Related Dementias (ADRD) in such contexts is weak to non‐existent. In consequence, scientific and policy communities, and the public at large, risk falling far behind the curve of evidence needed to mount effective, community‐sensitive responses. Investment in population‐based cohorts including health and socio‐demographic surveillance platforms are critical instruments in these environments. Such capability is needed to generate the necessary data, support the required analyses, provide foundations for intervention‐evaluation, and contribute to public understanding. This contribution to a session on Perspectives will draw on data and analyses from 10‐plus years of the HAALSI cohort: Health and Aging in Africa: longitudinal studies in South Africa which is based in the country's rural northeast adjacent to southern Mozambique. HAALSI is nested within the long‐running Agincourt health and socio‐demographic surveillance system (HDSS) – a whole population cohort of ∼120,000 people in 22,000 households that together make up 31 village communities. The breadth of findings from this community‐representative cohort will be shared – providing an acute insight into dementia prevalence, cognitive trajectories, behavioral and social drivers of positive/negative cognitive change, mortality transition including cause‐of‐death, and community responses. In this rapidly transitioning, high HIV context with escalating cardiometabolic risk, the scope for preventive and promotive responses is high with potential for marked impact on dementias, their cognitive antecedents, and underlying clinical, behavioral and social risk factors manifesting along the life course. Altogether, the HAALSI experience is an exemplar of the contributions possible by capitalizing on longitudinal population‐based platforms responsive to communities and other stakeholders. Such in‐depth, community representative platforms can provide invaluable testbeds for the questionnaire sets, screening tests, sample collection, field research methods, and community engagement necessary to

Functional genomics resources are critical for interpreting human genetic studies, but currently they are predominantly from European-ancestry individuals. Here we present the South African Blood Regulatory (SABR) resource, a map of blood regulatory variation that includes three South Eastern Bantu-speaking groups. Using paired whole-genome and blood transcriptome data from over 600 individuals, we map the genetic architecture of 40 blood cell traits derived from deconvolution analysis, as well as expression, splice and cell-type interaction quantitative trait loci. We comprehensively compare SABR to the Genotype Tissue Expression Project and characterize thousands of regulatory variants only observed in African-ancestry individuals. Finally, we demonstrate the increased utility of SABR for interpreting African-ancestry association studies by identifying putatively causal genes and molecular mechanisms through colocalization analysis of blood-relevant traits from the Pan-UK Biobank. Importantly, we make full SABR summary statistics publicly available to support the African genomics community.