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UBC Theses and Dissertations

The influence of upstream forces on health : a multi-method investigation of tuberculosis among healthcare workers in South Africa Adu, Prince Asumadu


Empirical evidence is lacking on the degree to which structural or upstream forces contribute to tuberculosis (TB) incidence in the general population, and in healthcare workers, a group known to be at high-risk for this disease, let alone on how these forces are addressed in policy. This dissertation used a multi-method design to examine the link between upstream forces and TB. First, it utilized a linear mixed-effects regression to investigate the association between globalizing processes and TB incidence in the 22 high burden countries. Secondly, semi-structured in-depth interviews were conducted in South Africa to explore how macro-level determinants of TB incidence in the general population and among healthcare workers are perceived by key stakeholders, identifying barriers and facilitators to the implementation of effective prevention and control measures. South Africa’s current National Strategic Plan was then examined to ascertain how these factors were being addressed. The World Health Organization (WHO) Health Systems Building Blocks framework was also applied to assess interventions for protecting healthcare workers. Globalization was found to be associated with higher TB incidence in high burden countries. In the South African context, a history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be the major drivers of the epidemic. Although South Africa’s current National Strategic Plan makes a firm discursive commitment to addressing the structural drivers of TB, analysis from this dissertation revealed that this commitment was not clearly reflected in projected budgetary allocations. As many low and middle-income countries continue to integrate their economies into the global market, there is a need to consider ways to address unintended inequities that accompany this integration. In South Africa, while funding allocation to improve diagnostic procedures and investment in more efficacious drugs are laudable, attention to structural drivers of TB is deficient. Although a national TB policy for healthcare workers will soon be launched, it is perceived that implementation and adherence to such policies may well remain problematic unless the policy explicitly addresses the drivers of this scourge.

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