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CEBHA+ : Collaboration for Evidence-Based Healthcare and Public Health in Africa

Research team Cape Town: Naomi Levitt, Bob Mash, Taryn Young


The goal of CEBHA+ is to build long-term capacity and infrastructure for evidence-based healthcare (EBHC) and public health in sub-Saharan Africa, including primary research; evidence synthesis; and evidence- based policy-and-practice. CEBHA+ adopts a population perspective, which encompasses both prevention of disease and delivery of care. CEBHA+ aims to:

  • support primary research into  the development, implementation and evaluation of priority health interventions in sub-Saharan Africa;
  • enhance the conduct of systematic reviews of priority health interventions and organisation of care, and their targeted dissemination in sub-Saharan Africa;
  • build capacity for and conduct training in public health, primary research, systematic reviews, guideline development and evidence into policy-and-practice in sub-Saharan Africa;
  • build a lasting research collaboration among partners in the South (South-South) and with EBHC and public health networks in Germany and Europe (South-North); and
  • promote the development of guidelines and the use of contextualised research evidence in decision- making in sub-Saharan Africa through focused long-term continuous engagement with representatives of the policy-and-practice community and specific knowledge translation and exchange activities.

The prevalence of type 2 diabetes mellitus and associated risk factors in women who had gestational diabetes mellitus 5 years previously, in South Africa

Research team:Naomi Levitt, Tawanda Chivese, Krisela Steyn, Shane Norris, Christina Zarowsky


Women with a history of gestational diabetes mellitus (GDM) are at high risk of progressing to type II diabetes mellitus (T2DM) and require frequent screening after delivery for early detection and intervention. In addition, their children may have an increased risk for overweight and obesity during their lifespan. Further, women with previous GDM may have a higher risk for metabolic syndrome, compared to the general population. Such data are not available in South Africa and the sub-Saharan African region, where the potential factors that may increase the risk of progression to T2DM as well as the metabolic syndrome may differ from risk factors in high income countries. These include high rates of food insecurity and obesity co-existing with undernutrition together with a potentially different genotype.

Postpartum screening for T2DM in women with previous GDM can be improved by the use of glycated hemoglobin (HbA1C), instead of the more complicated oral glucose tolerance test (OGTT). However, there are limited data on whether the recommended positive screening result of identifying diabetes of HbA1c level of > 6.5% for T2DM, is appropriate for the South African context. The level of HbA1c may be influenced by population specific variables such as ethnic group. Validation of the HbA1c as a screening tool for T2DM in women with prior GDM in South Africa would greatly simplify any future screening programs as well as improve its utility in clinical settings.

The overall objective of this study is to determine the prevalence of and risk factors for T2DM in postpartum women from low socioeconomic urban settings in South Africa who were diagnosed 5 years earlier with GDM. Additional objectives are to estimate the prevalence of the metabolic syndrome in women with previous GDM, to determine the prevalence of overweight and obesity in their 5 year old children exposed to GDM during pregnancy and to validate the use of the HbA1c test in screening for T2DM in South Africa five years  post-partum.

IINDIAGO (Integrated INtervention for DIAbetes rIsk after GestatiOnal diabetes 

Research team: Naomi Levitt, Christina Zarowsky, Shane Norris, Katherine Murphy, Janetta Harbron, Sharmilah Booley, Krisela Steyn, Carl Lombard.

Students: Lorrein Muhwava, Tawanda Chivese, Jean-Claude Mutabazi, Stephanie Krige, Vimbayi Mafunda

In 2015, the CDIA, in partnership with the University of Montreal and WITS, was awarded a grant from the International Development Research Centre (IDRC) in Canada to undertake a four-year study to develop and evaluate a health system intervention aimed at reducing type 2 diabetes (T2D) risk in women who have had gestational diabetes.


Women with gestational diabetes mellitus (GDM) are a high risk group for developing T2D and represent an important and unique target group for intervention. In South Africa, it is estimated that the prevalence of GDM is over 15%. There is compelling evidence that lifestyle interventions in high risk groups can reduce the progression to T2D. Currently, in the high diabetes burden, urban settings of Cape Town and Soweto, women with GDM receive their antenatal care and are delivered at their nearest tertiary facility. In contrast to their intensive antenatal care, postpartum, these women receive little attention, when they are referred back into primary care for ongoing follow-up and management. Anecdotal reports suggest that only one third of women with recent GDM attend for a postpartum follow-up oral glucose tolerance test (OGTT) and no specific lifestyle advice or support is being delivered.

The IINDIAGO study will take place in urban, public sector health services settings in Cape Town and Soweto where the population is of lower socio-economic status, the diabetes prevalence is high, and there are large hospital-based services for the management of GDM. Study participants will be women diagnosed with GDM who have received antenatal care at Groote Schuur and Mowbray Maternity hospitals in Cape Town and Chris Hani Baragwaneth Hospital in Soweto.

The main objective of the study is to develop and pilot a health system intervention for women with recent GDM that links existing public hospital-based antenatal care with postnatal community-based care. The idea is to leverage scheduled visits for infant immunisation at community based Well Baby clinic as an opportunity to offer the necessary tests and lifestyle interventions to GDM mothers.

H3 Africa Study (Human Hereditary and Health in Africa) - Burden, spectrum and aetiology of type II diabetes in sub-Saharan Africa

Research team Cape Town: Naomi Levitt, Raj Ramesar

Field Team Cape Town: Takalani Tshikovhi; Joy Norman, Malibungwe Majola; Simpiwe Nkepu, Anelisa Mndende, Luyanda Sebe, Lindelwa Duba, Sharon Sibanda


This is a multi-centre study of the prevalence and environmental and genetic determinants of type 2 diabetes in sub-Saharan Africa funded by the Welcome Trust. The burden of T2D, its underlying aetiology, and the relative contribution and spectrum of its risk factors and related metabolic traits, might differ among populations and be influenced by varying environments and underlying susceptibility. These aspects of the epidemiology of T2D have not been reliably clarified in Sub-Saharan Africa (SSA), highlighting the need for comparable, context-specific epidemiological studies with the statistical resolution to reliably assess the burden and epidemiology of T2D, and to inform potential preventative and therapeutic strategies.

The H3 Africa project involves developing multi-country case-series and population based cross-sectional studies using harmonised approaches across the region. A large-scale epidemiological and genomic research resource will be developed comprising up to 6,300 cases of T2D and a population based cross-sectional study of up to 6,300 participants drawn from diverse sampling frames across SSA. It is expected that these data will be of direct relevance to an improved understanding of the molecular and pathophysiological basis of diabetes in African populations, as well as to contribute to more global efforts in these respects. 

StAR2D -  Mobile phone text-messaging to support treatment for people with Type 2 diabetes in Sub-Saharan Africa: A Pragmatic individually randomized trial

Research team: Andrew Farmer; Stephanie Robinson (UK); Moffat Nyirenda (Malawi); Shane Norris (Soweto); Naomi Levitt; Natalie Leon; Kirsty Bobrow; Carmen Delport (Cape Town)


In 2015, members of the CDIA, in collaboration with researchers from the Universities of Cape Town and the Witwatersrand, the Karonga Prevention Study (KPS), the South African Medical Research Council and the team in the Nuffield Department of Primary Care Health Sciences at the University of Oxford, were awarded funding through the Global Alliance for Chronic Disease Initiative (GACD) and UK MRC for a follow up study from the StAR study. Whilst StAR was a trial which tested the efficacy of SMS messaging in enhancing treatment adherence in hypertensive patients, StAR2D will assess the impact of SMS text messages on adherence with people living with type 2 diabetes across a variety of health care settings. This project also contains a formal health economic analysis component and a process evaluation tracing the project though all its phases.

SMART2D - The development of new interventions for addressing T2DM prevention and management for target populations in selected low-, middle- and high-income countries.

Research team: Thandi Puoane, Lungiswa Tsolekile, Peter Delobelle, Kululwa Ndayi, Mark Spires, Tiny Masupe, David Sanders.

PhD Student: Bonaventure Egbujie


The SMART2D project is a European Union-funded research collaboration funded under the EU Horizon 2020 programme. The programme focuses on the development of new interventions for addressing type 2 diabetes mellitus (T2DM) prevention and management for target populations in selected low-, middle- and high-income countries. The study is being conducted in Sweden, South Africa and Uganda.

Ntshembo – Health and well-being of female adolescents: Limiting the inter-generational risk of metabolic disease

Research team: Shane Norris, Vicki Lambert, Lisa Micklesfield, Catherine Draper and others.


This project started in 2007 with collaborating institutions that include the University of the Witwatersrand, University of Cambridge (UK), University of North Carolina at Chapel Hill (USA), University of Oxford (UK), Umea University (Sweden), University of Southampton (UK) and the University of Cape Town (SA). It involves the development and evaluation of a community based intervention aimed at improving adolescent health among females in the rural community of Agincourt, Mpumalanga. The formative phase of research for intervention development has been completed. Much of this research tried to understand adolescent’s beliefs and practices with regard to lifestyle factors and reproductive health.  An Intervention Mapping approach was used in the development of this intervention, with the following four key behavioural objectives: to eat a healthy, balanced diet; increase physical activity; reduce sedentary behaviour and promote reproductive health. The Ntshembo intervention will be community based, involving the use of specialist adolescent community health workers, who will deliver a complex intervention consisting of individual, peer, family and community mobilisation components. The Ntshembo intervention is novel, both in SA and globally, as it is: (1) based on strong evidence, extensive formative work and best practice from evaluated interventions; (2) combines theory with evidence to inform intervention components; (3) includes multiple domains of influence (community through to the individual); (4) focuses on an at-risk target group; and (5) embeds within existing and planned health service priorities in SA.

Evaluation of SALT WATCH media campaign

Prof. Krisela Steyn worked with the research team of the SALT WATCH initiative under the leadership of Prof. Edelweiss Wentzel-Viljoen in evaluating the Heart and Stroke Foundation’s mass media, salt awareness campaign. The campaign used adverts on television and radio stations to raise awareness of the potential risks of high salt consumption. The initial results suggested that the knowledge of the target population (women in LSM class 5-7) about the dangers of a diet high in salt intake increased significantly after the campaign and that the increase of knowledge was related to the content and messaging of the advertising campaign.

Pragmatic cluster randomised controlled trial of a guideline-based intervention to improve the primary care of non-communicable diseases in the Eden and Overberg districts of the Western Cape 

Research team: Lara Fairall, Naomi Levitt, Max Bachmann, Thomas Gaziano, Eric Bateman, Krisela Steyn, Carl Lombard, Merrick Zwarenstein, Beverly Draper, Ruth Cornick, Alan Bryer, Crick Lund and Debbie Bradshaw

PhD student: Naomi Folb


The objective of this trial was to test the effectiveness of a guideline-based training programme (Primary Care 101) for nurses on the processes and outcomes of NCD care across four priority conditions: hypertension, diabetes, chronic respiratory disease and depression.

Development and validation of a non-blood based cardiovascular (CVD) risk assessment tool

Research team: Thomas Gaziano, Krisela Steyn, Debbie Bradshaw, Ankur Panday, Lara Fairall and Naomi Levitt


The overall objective of this study is to develop and validate new and cost-effective non-laboratory-based screening tools for cardiovascular risk prediction in low-resource settings to obviate the high cost of blood assays associated with such screening. Three projects are being conducted to validate this non-laboratory total CVD risk score.

Economic modelling of the impact of preventive and management interventions for chronic diseases

Research team: Thomas Gaziano, Ankur Panday, Debbie Bradshaw, James Irlam, Lara Fairall, Krisela Steyn and Naomi Levitt


The aim is to develop a CVD prevention and management model that will allow the accurate prediction of CVD events and which can be used in cost-effectiveness analyses of screening and intervention strategies.

Lifestyle intervention tools: ichange4health package (previously called the Putting Prevention into Practice package)  

Research team: Katherine Murphy, Zelra Malan, Krisela Steyn, Catherine Draper, Tracy Kolbe-Alexander, Estelle Lambert and Bob Mash


The aim of this project is to develop and evaluate a lifestyle modification training programme for healthcare providers and to develop lifestyle intervention tools for common modifiable CVD lifestyle risk factors.

Community health workers (CHW) project

Research team: Thandi Puoane, Lungiswa Tsoliekile, Naomi Levitt, Krisela Steyn and Helen Schneider


The aim of this project is to review and define the current role of community health workers (CHWs) in caring for patients with chronic diseases. The requirements for the expansion of a CHW’s role will also be defined.

SMS-text adherence support for patients with hypertension (*StAR study)

Research team: Kirsty Bobrow, David Springer, Thomas Brennan, Lionel Tarassenko, Andrew Farmer, Naomi Levitt and Krisela Steyn


The aim of the study is to conduct a pragmatic randomised controlled trial to test the efficacy of an SMS-text-based intervention to support treatment adherence, compared to usual care for adult patients receiving hypertension care in resource-poor primary care settings in Cape Town. The intervention is a structured programme of clinic appointments and medication collection reminders, medication adherence support and hypertension-related education, delivered remotely through informative or interactive SMS-text messages.

An evaluation of community health workers’ screening for CVD in the community in four developing countries using the non-laboratory total CVD risk factor score 

Research team in South Africa: Naomi Levitt, Shafika Abrahams-Gessel, Thandi Puoane, Thomas Gaziano and Jabulisiwe Zulu


This study proposes to train community health workers (CHWs) to use the non-laboratory-based CVD total risk assessment tool described in Project 2 to identify persons at high risk for CVD in community settings in South Africa, Bangladesh, Guatemala and Mexico. The referral pattern for high-risk patients from CHWs to a trained health professional at a community health clinic will also be assessed. CHWs’ knowledge levels and retention of knowledge about CVD and its risk factors will be evaluated, as will the costs of the programme.

A randomised controlled trial to evaluate the effectiveness of a group diabetic education programme using motivational interviewing in under-served communities in South Africa

Research team: Bob Mash, Naomi Levitt, Stephen Rollnick, Katherine Everett-Murphy, Krisela Steyn, Merrick Zwarenstein, Hilary Rhode (co-ordinator), Unita van Vuuren, Buyelwa Majikela-Dlangamandla, Roland Kaukamp and Maureen McRae

The development and evaluation of a training programme for healthcare providers in behaviour change counselling

Research team: Bob Mash, Katherine Murphy

PhD student: Zelra Malan


The aim of this project was to develop and test a training module for primary care providers in brief behaviour change counselling for NCD risk factors. The training course was developed and evaluated among family medicine registrars and primary care nurses at Stellenbosch University in 2014 as part of Dr Zelra Malan’s Phd study. The course is a further component of the iChange4Health project (see above) and the resource package was used as an integral part of the training provided in this study.

A qualitative study of the nutrition patterns of low-income South Africans

Research team: Anniza de Villiers, Katherine Murphy, Debbie Jonathan and Gillian Hill

Background and objectives

The planning of a dietary intervention tool for the iChange4Health lifestyle modification package (described in Project 4) required an understanding of the commonly consumed foods, the food preferences and the inexpensive, healthy options available and acceptable to the lower socio-economic communities of diverse cultures in South Africa. 

What are the effects of blanket screening for hypertension and/or diabetes mellitus compared to other forms of screening or no screening in South Africa?

Research team: Solange Durão, Yemisi Ajumobi, Tamara Kredo, Celeste Naude, Naomi Levitt, Krisela Steyn and Taryn Young


A collaboration between CDIA, the Centre for Evidence-based Health Care and the South African Cochrane Centre has been established (R3 project), which involves the use of systematic reviews to inform CDIA’s work.


To prepare an overview of systematic reviews to assess the effects of blanket screening for hypertension and/or diabetes mellitus (DM) compared to other forms of screening or no screening.

Prospective urban rural epidemiological (PURE) study

Research team: Thandi Puoane, Ehimario Igumbor, Gavin Reagon, Gail Hughes, David Sanders, Vicki Lambert, Naomi Levitt, Andre Kengne and Bongani Mayosi

PhD student: Kufre Okop

Background and objectives

The PURE study is a global prospective study that seeks to identify the population level factors that drive the development of known risk factors for NCDs, so that their distribution in the entire population can be shifted favourably by appropriate societal interventions (primordial prevention). The study is being conducted in 17 countries (including high-income, middle-income and low-income countries and from every major region of the world) and will involve investigations of 150 000 individuals. It also includes investigation of community-level factors (urban-rural differences; the built environment; the policy environment related to tobacco and food; and social factors), household-level factors (family structure; income; housing; and so on) and individual-level factors (lifestyle behaviours and attitudes; and genetic markers). From 2009, the University of the Western Cape School of Public Health has been leading the research collaboration, with researchers from the Medical Research Council, Human Sciences Research Council and the University of Cape Town contributing to the PURE global study. A South African arm of the study was initiated and incorporates urban and rural communities within South Africa’s Western Cape and Eastern Cape provinces into the global study. In 2013, the PURE study researchers chose to link the project to the CDIA network.

Evaluation of point of care testing for HbA1c in primary care

Research team: Bob Mash, Rajiv Erasmus and Megan Rensburg

Master’s students: Cobus Vos and Abimbola Ugoagwu

Background and objectives

The main aim of this study is to investigate if the placement of a point of care (POC) device for glycated haemoglobin (HbA1c) measurement in community healthcare centres in Cape Town for the management and care of diabetic patients would lead to an improvement in the frequency of annual HbA1c, treatment intensification, patient education and glycaemic control. Other objectives included evaluating the technical quality of the POC testing in primary care settings, the experience of the primary care providers in using the POC machine and the incremental costs.

Patterns of HIV, TB, and non-communicable disease multi-morbidity in peri-urban South Africa: A cross-sectional study 

Research team: Tolu Oni, Elizabeth Youngblood, Andrew Boulle, Nuala McGrath, Robert Wilkinson and Naomi Levitt

Background and objectives

To use routine data from a public health programme to explore the distribution of chronic diseases and patterns of HIV, TB, and NCD multi-morbidity (MM) in adults who have received care and treatment in a public community health clinic. 

A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes.

Research team: Tolu Oni (Dept Public Health, University of Cape Town) & Katherine Murphy (CDIA, University of Cape Town).

Masters Student: Rangarirai Matima


With the convergence of communicable and non-communicable diseases in SA, the incidence of co-morbidity continues to increase. Little is currently known about how chronic patients with multi-morbidities experience the demands of treatment and self-management. This study used individual, in depth qualitative interviews to explore the experiences and perspectives of patients in managing the workload of HIV /T2D co-morbidity; and how this impacted on their capacity for effective self-management. Interviews were conducted with a purposive sample of 10 public sector patients who have HIV and type two diabetes (T2D). Six health workers who provided health services to this group of patients at a primary health care facility in Cape Town were also interviewed.

The study was funded by the Pan University Network for Global Health (which includes the Universities of Cape Town, Limpopo, Savitribai Phule Pune in India; Penn State in the US; Freiberg in Germany and the West Indies) as part of a multi-site study on multi-morbidity. Protocols have been shared between the different sites and findings will be compared. 

Findings indicated that there were multiple and significant tasks associated with multi-morbidity: attending separate clinics for HIV and T2D at different times and locations; taking medication and/or injecting insulin on a daily basis; learning about how to manage the conditions, changing lifestyle and negotiating social support from family and employers. Patients reported finding it difficult to adjust to the diagnosis at first, but described that, over time, they had managed to normalise these tasks into their daily routines and had learnt to cope with them. T2D was seen as more difficult to manage than HIV. Adherence to the recommended diet was seen as very challenging because eating differently from the rest of the family was inconvenient, isolating and more expensive. Patients reported that having a positive, accepting attitude; support from family and faith were key to coping with multi-morbidity. Stigma, for both HIV and T2D, was raised as a difficulty. The social support and information offered by the Treatment Action Campaign and Mothers2Mothers programme at the HIV clinic was highly valued. Equivalent support and education was seen as necessary at the Diabetes clinic.

Long waiting periods at the clinic was the single most frustrating issue raised by participants. The HIV clinic was seen to be better organised and more efficient that the T2D clinic (average 2 hours versus 4-7 hours waiting time). The hour-long lunch break taken by health workers and long queues at the pharmacy were particular bones of contention.

Health workers suggested a central, computerised data base for patient records, integrated clinical guidelines for HIV and T2D, greater continuity of care and a more efficient T2D appointment system as means of improving on the current organisation of care. Patients expressed a desire for a one-stop-shop approach, which offered comprehensive, integrated care and a service which could also address mental health issues. This would save them time, effort and transport money and make caring for themselves less of a full time job.

Knowledge and perceptions about cardiovascular disease and its risk factors: Findings of a qualitative investigation from a low-income peri-urban community in the Western Cape, South Africa

Research team: Sam Surka, Krisela Steyn, Thomas Gaziano, Katherine Murphy, Naomi Levitt

Background and objectives

South Africa currently faces an increasing burden of cardiovascular disease (CVD). Few individuals that are identified as high risk during community screening initiatives attend clinics when referred. Low health literacy and risk perception have been identified as possible causes. This qualitative study aimed to deepen understanding of cardiovascular disease risk from a community member’s perspective.

Development of diabetes self-care management strategy targeted at older people with type 2 diabetes mellitus attending community health centres (CHCs)

Research team: Prof. Naomi Levitt (Division of Diabetes and Endocrinology, Department of Medicine, CDIA, University of Cape Town) & Dr. Sebastiana Kalula (Division of Geriatric Medicine, Department of Medicine, University of Cape Town).

PhD student: Mahmoud Werfalli


Despite diabetes becoming an increasingly significant problem in Africa, little emphasis has been placed on research relating to the older person with diabetes on the continent. This research project aims to develop a diabetes self-care management strategy targeted at both older patients and healthcare professionals, with a view to limiting the impact of the disease and improving health-related quality of life (HRQoL) for this group. The project started in 2013.

Neighbourhood Environmental Walkability Survey (NEWS)

Research team: Jim Sallis, Adewale Oyeyemi, Estelle Lambert, Clare Bartels, Tracy Kolbe-Alexander, Sarah Moss and Pasmore Malambo

Background and methods

This project involves the adaptation of an instrument used globally to measure the perceived ‘walkability’ of neighbourhood built environments and to measure this against actual physical activity in different countries. The study will be validating the instrument with Prof. Jim Sallis from San Diego and colleagues from Nigeria, Kenya, Ghana, Uganda, Mozambique, Cameroon and South Africa.