Includes bibliographical references (leaves 77-87). / Also available online. / This study is an evaluation of Support for the Health Sector Devolution Policy in Zambia. The study adopts a stakeholder analytical approach and its central objective is to study characteristics of key stakeholders, analyse how these influence support for implementing the devolution policy in the Zambian Health Sector and recommend strategies for taking forward the decentralisation process.

Both under-nutrition and over-nutrition pose a public health concern, especially for children in South Africa. Several initiatives exist in South Africa in order to promote healthy eating and nutrition at schools. One of them is the Woolworths Making the Difference (MTD) Programme aimed at eliminating barriers to promoting healthy lifestyles that exist at schools, such as the availability of low cost, unhealthy foods either from tuck shops or street vendors. The Healthy Tuck Shop Guide is a recent addition to the MTD programme. The aim of this evaluation is to assess schools’ perceptions of the Woolworths Healthy Tuck Shop Guide as it is being utilized in Woolworths Making the Difference schools.

Exposure to pesticides has been associated with several adverse health effects. When workers who spray pesticides take contaminated Personal Protective Equipment (PPE) and work clothes home, those items pose a risk of cross-contamination. Agriculture employers are recommended to make facilities available for workers to clean and store contaminated items at the workplace to reduce the risk of cross-contamination. However, little research has been conducted on forestry workers, for whom at-work cleaning and storage facilities may be less feasible. Working for Water (WfW) is a South African programme that focuses on removing invasive alien vegetation and alleviating poverty through providing job opportunities to unemployed individuals in low-income settings. WfW forestry workers use herbicides to remove the invasive vegetation. Unlike agricultural workers, WfW forestry workers undertake projects that are transient and tend to be on mountainous or steep terrain. The work environment poses challenges for at-work access to amenities or facilities to clean and store contaminated PPE. Workers have few alternatives but to take contaminated items home. WfW safety protocols do not currently address the risks associated with take-home residues or indicate how workers should clean and store contaminated items. This study is part of a larger project focusing on developing protocols to reduce the risks of cross-contamination and exposure to residues. This dissertation provides baseline data for improved WfW safety protocols through the exploration of workers’ at-home risks of cross-contamination, and the role that worker perceptions and access to amenities have on cleaning and storing behaviors for contaminated items. The Protocol (Part A) describes the methods used to collect and analyze the data. The Literature Review (Part B) presents the risks of take-home residues associated with cross-contamination and the importance of exploring workers’ perceptions and access to amenities to promote safety compliance. The Article (Part C) explores WfW workers’ cleaning and storing behaviors, what contaminated items are taken home, the workers’ access to amenities in the home, and the workers’ perceived risk of exposure. Questionnaires were administered to 27 WfW workers across three excavation sites (Tokai, Citrusdal and Hermanus) that were selected based on convenience sampling. Findings showed that most of the participants took contaminated items home daily. Many participants (55.2%) did not have access to running water. Access to running water and type of housing influenced whether the contaminated items were washed indoors or outdoors, and how they were washed. WfW participants who lived in a shack were more likely to leave contaminated items on the couch or bed or with other clothing items than those living in permanent dwellings. Those workers were more likely to keep them in a non-permeable transport bag, outside, or separate drawers away from clean items. The majority of subjects (65.5%) perceived exposure to herbicides as dangerous to their health. The participants’ perceived risk was associated with whether they took contaminated PPE items home, but not how they were cleaned or stored. WfW Safety protocols should emphasize the importance of keeping contaminated items contained and reducing contact with household surfaces or clean clothes. Workers’ cleaning and storing practices and their associated risk of crosscontamination are largely determined by the amenities they have access to. For new safety protocols to be effective, they need to be realistic and take into account the constraints workers face.

Includes bibliographical references (leaves 55-63). / The benefits of the use of Azathioprine (AZA) and its metabolite 6-mercaptopurine (6-MP) in the treatment of Inflammatory Bowel Disease (IBD) are well established. However, concern regarding the long-term use of these agents in the induction of certain malignancies particularlty lymphoma and skin cancer has been reported in renal transplant and rheumatoid arthritis patients. In IBD patients hoever, several retropsective and prospective studies have been conducted (including two meta-analyses) with divergent results. The primary objective of this study was to compare the incidence of cancer in IBD patients treated with AZA/6BMP with those not treated. Secondary objectives were to assess if skin cancer had a higher incidence of occurrence than other cancers, and to determine the independent risk factors associated with cleveloping any malignancy.

Includes bibliographical references. / The UCT Hospital is a private, fully independent hospital within the buildings of the Groote Schuur Hospital. It has been operational for well over two years. Planning and development began a further four years before this. During the last two years the hospital has changed its name, shareholders and management structures. Since the start of the planning the various stakeholders will too have changed their respective structure and business foci. These changes have added to poor knowledge of all the stakeholders' aims and desires for the hospital. The aims and objectives of this study are to establish what the various stakeholders wish to gain from their relationship with the UCT Hospital. Furthermore, this study investigates the degree of public-private interaction with Groote Schuur Hospital and proposes various possibilities for their future existence and co-operation. A stakeholder analysis indicated that the primary stakeholders wish to expand and grow the hospital. Opponent stakeholders are not satisfied with the structure of and their relations with the UCT Hospital. Key problems in the relationship with Groote Schuur Hospital include tense relations, poor regulation of resource-sharing, and that the two hospitals are vying for comparable markets. These problems are inhibiting growth for both institutions. Communication, improved regulations and specialised market sectors are key needs to help resolve the problems between the two institutions. Various possibilities for future co-existence revolve around the degree of public- private interaction between the two institutions. The most viable option seems to be for the two hospitals to work closely together to form a public-private partnership, where the Groote Schuur Hospital Private Ward is outsourced to the UCT Hospital. This will involve UCT Hospital relinquishing some autonomy and freedom, but result in them having less competition and a greater market base. GSH will have to abandon their own private ward, but can increase risk-sharing, gain in efficiency and effectiveness in the private ward, and get involved in a co-management structure.

Introduction: Discrimination from health workers has been found to be a deterrent for lesbian, gay, bisexual and transgender (LGBTI) people seeking healthcare. Despite these findings, LGBTI-focused healthcare remains understated in medical training and university curricular. Learning about medical students' attitudes can provide useful ways of identifying interventions to capacitate health professionals to address LGBTI health. Methods: This study is a mixed methods study, data were collected using a 25 item homophobia scale with additional questions designed for the South African context, and focus group discussions with semi-structured questions. Results: 157 Medical students in the 5th year class at a university in the Western Cape, South Africa completed the survey, 20 of them formed part of three focus group discussions. Outcomes showed significant gaps in student's curriculum in the area of LGBTI health which influenced their lack of knowledge and preparedness. Considering that homophobia and heterosexism remain widespread in the students' contexts, the findings point to generally favourable views of LGBTI people. In this respect, two thirds of the participants indicated that they are not bothered by seeing same-sex partners together and 64% felt that homosexuality was not immoral and showed support for LGBTI rights. The qualitative findings indicate that a contributing factor in shifting their attitudes based on their own perspectives was a change in environments from their hometowns to university. Students showed a keen interest in early integration of LGBTI health in their curriculum which is encouraging. Conclusion: Medical training needs to be responsive and intentional about addressing student attitudes towards LGBTI people, as this has implications on the students' perceived competency and affects the quality of healthcare they deliver.

Equitable access to, and use of skilled birth attendance during delivery is vital for the achievement of the Sustainable Development Goals (SDGs) in reducing global maternal deaths to 70 deaths per 100, 000. Although several initiatives have been implemented to reduce maternal mortality in Ghana, inequities in the use of skilled birth attendance during delivery still exist among women of different socioeconomic groups. This study assessed the socioeconomic inequalities and the underlying factors related to the inequalities in the use of skilled birth attendants during delivery in Ghana. This study analysed data from the 2014 Ghana Demographic and Health Survey (GDHS) using a decomposable health concentration index. Concentration index (CI) and concentration curves were employed to measure the magnitude of socioeconomic inequality in the use of skilled birth attendants during child delivery. The concentration index was decomposed to identify the underlying factors causing the inequalities. Out of a total of the 1,305 women who gave birth in the year prior to the interview, 28% of the deliveries had no skilled birth attendants of which 60% lives in rural compared to 40% in urban. A concentration index of 0.147 showed a pro-rich utilization of skilled birth attendance during delivery. The decomposition analysis revealed that, wealth, education and location of residence were the major contributors to socioeconomic inequalities in the use of skilled birth attendants during child delivery among Ghanaian women. This study suggests that factors such as wealth, area of residence and education are worthy of increased attention in programmatic efforts, and policy interventions, because they are amenable to the reduction of observed inequality.

Para-occupational 'take-home’ exposure amongst worker’s families in Low-and middle-income countries (LMICs) is not well characterised. This is concerning as research shows the association between long-term low-dose herbicide exposure and the development of adverse health effects. This study explored 'take-home’ herbicide residue exposure risks amongst the families of Working for Water (WfW) forestry workers in the Western Cape, South Africa using aspects of the community-based participatory research (CBPR) approach photovoice. In addition, a documentary review of the existing WfW programme policies and regulations was undertaken to assess whether required practices supported or prevented the risk of 'taking-home’ herbicide residues. The results of the documentary review revealed that workplace policies and regulations did not address 'take-home’ exposure risks. Photovoice findings highlighted low compliance to safety practices (e.g., not adhering to PPE requirements) at worksites, and this was identified as the main risk factor for 'take-home’ exposure amongst worker’s families. It was noted that the transient nature of forestry work impacted on worker’s ability to carry out hygiene practices as decontamination facilities were not available at worksites for worker’s to use before going home. As a result, all workers took their personal protective equipment (PPE) home. Worker’s after work behaviours (e.g., wearing PPE inside the home) and home hygiene practices (e.g., laundering PPE separately from household laundry) varied. That is, some worker’s carried out protective practices whilst others did not. This was largely attributed to the workplace policies and regulations which did not cover 'take-home’ exposure risks as informed by the national legislation which has not established standards and regulations related to 'take-home’ exposure risks. Evidence from this study demonstrated the existence of workers’ 'taking-home’ herbicide residue and exposing their families to potential health risks from low-dose exposures.

Includes bibliographical references (p. 54-60). / The continuum of care for maternal, newborn and child health (MNCH) has recently been highlighted as a systematic approach to integrating health service provision throughout the life-cycle and across levels of service delivery. The continuum provides a framework for delivering high-impact interventions organised in health service packages to deliver high quality reproductive, maternal, newborn and child care services, ensuring appropriate linkages between family and community care, outreach and outpatient services and clinical and the first level facility and the hospital. This study, using data from Demographic and Health Surveys from eight African countries, provides an analysis of the coverage and co-coverage of four essential MNCH packages along the continuum of care, with a particular focus on inequalities in the distribution of services. The analysis of coverage of antenatal care, skilled attendance at childbirth, postnatal care and immunisation packages reveals key gaps, especially during childbirth and the postnatal period. Coverage is especially low for women and children from the poorest households in these countries, with coverage among the richest quintile up to 6 times higher than the poorest quintile. Nigeria emerges as the country with the lowest coverage overall and the largest gap between rich and poor while Malawi has the highest coverage and the most equitable coverage of services Continuity of care between these important packages increases health system efficiency as well as user and provider satisfaction. Co-coverage along the continuum of care was analysed to determine which mothers, newborns and children received all four care packages. While at least three quarters in Nigeria and up to 99% of mothers, newborns and children in Malawi and Tanzania receive at least one package of care, less than half received all four packages. There is greater variation in co-coverage between countries and within countries among the richest and poorest households compared to coverage of single packages alone. The richest quintile in Malawi is twice as likely to receive all four packages compared to the poorest quintile whereas in Nigeria the difference between richest and poorest is 13 fold. The purpose of applying these measures should be seen not as an end in itself but as a tool to describe current patterns and distribution of services and to advance improvements in the continuum of care. This research highlights the importance of integrating MNCH packages in different contexts as well as further improvements in data collection in order to effectively guide and monitor progress towards universal coverage of packages along the continuum of care to save the lives of women and children. Addressing issues of exclusion among families from the poorest households and establishing effective links between these packages is crucial to improving overall coverage. The postnatal period in particular is a notable gap that lacks a systematic package in all these countries. In the meantime, available information can be used to improve MNCH integration and service delivery along the continuum of care in order to reach the highest number of women, newborns and children with effective care.

Includes bibliographical references. / Excellent adherence to antiretroviral therapy (ART) is necessary if HIV-infected children are to experience the dramatically improved outcomes that this treatment affords. However, there is very limited data on adherence to antiretroviral therapy in Africa, with few studies that examine the predictive value of low technology measures of adherence in terms of viral and immune outcomes. In addition there are no long terms studies of adherence in young children in Africa.