Includes bibliographical references. / Cervical cancer is a public health problem particularly in developing countries where incidence of cervical cancer remains high, either due to a lack of screening or poorly organised screening programmes. Cytology based cervical screening is only beneficial if women with abnormal Papanicolaou (Pap) smears are appropriately investigated. Colposcopy attendance following an abnormal Pap smear is a major problem in South Africa. The aim of this study was to explore barriers and facilitators to colposcopy attendance following an abnormal Pap smear result. A qualitative study was conducted at a public sector tertiary hospital colposcopy service and two primary health care clinics in Cape Town, South Africa. Data collection included 32 semi-structured interviews: 12 face-to-face interviews with colposcopy clinic attendees, 12 telephonic interviews with colposcopy clinic non- attendees and 8 face-to-face interviews with health care providers. Client interviews explored barriers and facilitators to colposcopy attendance; knowledge and experiences of Pap smears, cervical cancer and the colposcopy procedure; scheduling of colposcopy appointments; provider communication; reasons for non-attendance; and community support and beliefs. Provider interviews explored barriers and facilitators to colposcopy attendance from a provider’s perspective, the colposcopy referral process, and provider challenges in the provision of Pap smear or colposcopy services. Results from this study highlighted that the main barriers to colposcopy attendance were: poor levels of knowledge of the importance of a Pap smear and the colposcopy procedure; a lack of awareness of cervical cancer as a disease; a fear of cancer; the asymptomatic nature of the disease; and transport costs. Health system factors that impacted negatively on colposcopy clinic attendance included: the inadequate feedback of Pap smear results – clients were not informed of Pap smear results or colposcopy appointments and therefore did not attend; a disjointed system of colposcopy scheduling; and staff shortages which resulted in less time for client tracking. Factors which promoted colposcopy attendance included experiencing symptoms; a family history of cancer due to the experience with death; colposcopy services situated closer to clients; and social support receive d from family members. Addressing these barriers requires promoting client knowledge with educational materials and improving provider communication with clients. In addition, establishing colposcopy services closer to clients and standardising the system of colposcopy scheduling can improve colposcopy adherence.

Chronic Fatigue Syndrome or Myalgic Encephalomyelitis (CFS/ME) is a relatively unknown disease and is often referred to as a diagnosis of exclusion. Diagnostic tests are not available for this disease because a single empirical cause or marker has yet to be discovered. This means that diagnosis and management is almost solely based on the skill of the health care professional to notice the signs and symptoms of the disease, the subtleties of which often only come with experience. While some studies have assessed the knowledge, attitudes and beliefs of health care professionals (HCP) towards CFS/ME, none have reviewed all the studies focused on health care professionals to aide students and inexperienced professionals to avoid negative behaviours that might lead to a CFS/ME patient not being diagnosed as having CFS/ME. This review contains three parts. Part A is the protocol for the review. This will highlight the background of CFS/ME knowledge and outline the review's methodology. The review will take the form of a qualitative systematic review. Six databases will be searched with the relevant keywords and search terms outlined in the protocol. Appropriate articles will be selected based on the inclusion and exclusion criteria defined in the protocol. Part B is the literature review of the existing research available in the field of CFS/ME, the knowledge of the disease and the attitudes and beliefs of health care professionals about CFS/ME. It will provide a background for the full systematic review in Part C. This review will detail what is known about CFS/ME as a disease, report on potential causal mechanisms for CFS/ME as a disease and report on the scope of the disease in epidemiological terms. Part C is the full systematic review. It follows the previous section in the description of the background as well as outlining the methodology followed. The results of the search are then reviewed and discussed in detail.

Introduction: PCR testing at birth ('birth-testing') is conditionally advised by new World Health Organization guidelines for rapid diagnosis of infants infected with HIV in utero. Prompt diagnosis and early introduction of antiretroviral therapy (ART) can dramatically reduce mortality in HIV-infected infants. However, a negative result at birth must be followed by engagement in subsequent routine early infant diagnosis (EID) services (recommended at 6-10 weeks of age) to rule out intra-partum infection. There are few data on the implementation of this approach in sub-Saharan Africa and whether birth-testing affects the uptake of subsequent routine EID testing is unknown. Methods: We conducted a retrospective cohort study using routine clinical and laboratory data from a large obstetric hospital in Cape Town. All infants suspected to be at high risk of HIV-transmission, underwent birthtesting between July 2013-August 2015. Infants with a negative birth-test were matched to HIV-exposed infants who did not receive birth-testing. Maternal antenatal and obstetric characteristics of neonates were abstracted via folder review. Primary outcome was any subsequent HIV-PCR test before the end of follow-up, ascertained from the National Health Laboratory Service database. Data were analyzed using logistic regression models, examining independent predictors of presentation at follow-up EID testing. Results: Overall, 575 neonates underwent birth-testing, with 22 positive (3.8%) and 551 negative results. At follow-up EID presentation (n=871), 4 infected infants were identified (0.4%). Fewer infants who underwent birth-testing presented for later EID compared to infants who did not receive a birth-test (73% vs 85%), (Odds Ratio, 0.46; 95% confidence interval, 0.34-0.62). Infants who underwent birth-testing, also presented for later EID at a significantly older age (mean age 60 days vs.50 days, p<0.001). The significantly lower rate of EID presentation among birth-tested children persisted in multivariable analyses adjusting for maternal age, nadir CD4 cell count, ART use during pregnancy, gestation, infant sex, birthweight and infant feeding modality (Adjusted odds ratio, 0.60 95% confidence interval, 0.40-0.88). Conclusions: Neonates undergoing HIV testing at birth may be less likely to present for subsequent EID testing than those not birth-tested. Emphasis must be placed on appropriate counseling provided to caregivers on the need for further HIV testing after negative birth-test results.

Access to assistive technologies (AT) is necessary to achieving all 17 sustainable development goals. Yet for most people who need AT in Southern Africa, AT is unaffordable, unavailable, and often inappropriate. My PhD research was guided by the core question: What works to increase access to assistive technology in Southern Africa? Organized into three sub-studies, my research aimed to identify and describe the facilitators and barriers to access AT and develop a theoretical model to inform strategies to increase AT access in Southern Africa. The first two sub-studies listed below were previously published and the full manuscripts are included as separate chapters within the thesis. The three sub-studies included: • Sub-study 1: A scoping review that characterized existing evidence on AT from resource limited environments. Evidence identified was limited in quantity and quality, and primarily focused on mobility and vision types of AT. • Sub-study 2: A secondary analysis (i.e., bivariate regressions) of national survey data from Botswana and Swaziland served to examine factors associated with higher levels of AT access. The type of disability (i.e., mobility vs. non-mobility) was found to be the most important factor in determining AT access in both countries. • Sub-study 3: A regional qualitative sub-study was conducted to increase the understanding of how a multitude of interrelated factors operate to increase the supply of and access to AT. An adapted health systems framework was applied to analyse multiple data sources including stakeholder interviews, documentation review and observations. The thesis is organized into seven chapters. In Chapter 1, I provide background information and conceptual framing of the research topic, assistive technology access within Southern Africa. The research questions and overview of the three sub-studies are included in this introductory chapter. Chapter 2 covers the research methods of all three sub-studies. For the first two sub-studies, a brief overview of data collection and analysis methods are included that reference the more detailed methods presented within each published manuscript. The first two sub-studies are presented as Chapter 3 (scoping review) and Chapter 4 (secondary analysis) within the thesis. The third sub-study (qualitative) provided the most comprehensive data of the three sub-studies and comprises findings presented in Chapter 5 and Chapter 6. In the final chapter, Chapter 7, I synthesize findings from all three sub-studies to identify prominent patterns and present models that aim to explain constraints within the AT sector. The synthesis of evidence showed that AT in Southern Africa does not operate as a sector but as a constellation of uncoordinated parts. The low prioritization of AT and high level of fragmentation within the system emerged as pervasive patterns. The combination of these two patterns result in a wasteful sector. This means that the limited resources invested in funding products and services, and in strengthening the national AT procurement and provision system are not used effectively to increase the supply of and access to appropriate AT. In my further interpretation of data to respond to the core research question: What works to increase access to assistive technology in Southern Africa? I then identify strategic levers to increase AT access. Strategic levers aim to increase resources invested in the AT sector while reducing system-wide inefficiencies. Finally, study limitations and conclusions are presented at the end of this final chapter.

BACKGROUND: Modifiable social needs that include housing security, housing conditions, and food security can impact children’s behavioral health. Boston Children’s Primary Care has entered into an accountable care arrangement that has allotted funds for “flexible services” to direct housing or food intervention at children with mental or behavioral health problems. OBJECTIVE: This cross-sectional study will inform our baseline understanding of our population prior to the roll out of the flexible services program in January 2020. Therefore, among primary care patients we aim to understand the associations between: 1) Behavioral health symptoms and housing status 2) Behavioral health symptoms and food insecurity METHODS: This is a cross-sectional study examining associations between behavioral health symptoms and unmet food and housing needs at Boston Children’s Primary Care. At well-care visits, caregivers completed validated screening questions regarding food and housing insecurity, as well as age-appropriate behavioral health screening forms about their child. We used descriptive statistics to examine the demographics, social needs, and behavioral health problems of our population. Bivariate and multivariate logistic regression analyses were conducted to understand the relationship between social needs and behavioral health problems. RESULTS: Our sample included 125 pediatric patients ages 2-12, 29.6% of whom were Black or African American, 31.2% were Hispanic or Latino, 63.2% were publicly insured, and 76.8% spoke English. In our sample, 12.8% of the sample experienced housing insecurity, 10.4% of the sample experienced problems with housing conditions, 13.6% of the sample experienced food insecurity, and 24.0% experienced any housing or food problem. Our sample showed that 20.0% of children had behavioral health symptoms on screening. In bivariate analyses, those with housing insecurity were more likely to experience behavioral health symptoms (OR 10.444, CI: 3.309-32.969]), those with food insecurity were also likely to experience behavioral health symptoms (OR: 2.350, CI: 1.284-4.302), and those who experienced any food or housing problem were also more likely to experience behavioral health problems (OR: 5.289, CI: 2.061-13.571). In multivariate logistic regression models that included our only significant covariate (insurance), behavioral health symptoms were only associated with housing problem and any housing or food problem.

The aim of this study was to explore and examine the patterns, dynamics and influencing factors of HIV status disclosure among men and women at ARV clinics in low-income area clinics in Cape Town, South Africa and highlight areas for intervention and counselling improvement. The specific objectives were to: * Understand the factors that are associated with disclosure * Explore factors that constrain/promote disclosure of HIV status * Explore who people disclose to and why? * Investigate what impact positive/negative reactions may have had on one's health and hopefulness of living with the virus. * Make recommendations on how to address disclosure in support and treatment programs for people living with HIV. This is a sub-study of a larger study to determine the effectiveness of reproductive health interventions in 4 clinics in Cape Town. This sub-study makes use of the first two sets of interviews out of a total of 3. This was a cohort study design with structured interviews and patient exit interviews. Data were collected between September 2007 and December 2008 in the four clinics. Ethics approval was granted by the Health Sciences Faculty Research Ethics Committee - REC REF: 429/2006. Given the constantly changing nature of HIV in South Africa, tracking changes in the dynamics of disclosure over time is important, rather than relying on 'snapshot' perspectives. Analysis was fore grounded in global and Sub-Saharan African trends to draw out specificities from the South African context. The study concluded by highlighting gaps for further research and practical implications for the future of HIV prevention, support, care and treatment programming.

Part A is a research protocol which describes the background and proposed methodology of this systematic review. This section contains the details of quantitative and qualitative methods to be used when analysing rheumatic heart disease (RHD) prevention and care programmes. Part B is a literature review which expands on the protocol. An in-depth explanation of the disease process is presented in order to understand the multiple opportunities for preventing RHD and its precursors. The importance of this research then is highlighted by contextualising RHD programmes within the health system and integrated care. Part C presents the research as a journal manuscript according the BMJ’s instructions for authors. The manuscript includes a brief introduction to the research followed by a summary of the methods and presentation of the results which are then discussed.

Includes bibliographical references. / Tuberculosis (TB) remains a significant contributor to global morbidity and mortality, and South Africa has one of the highest burdens of TB in the world. Current WHO recommendations include the need for private practitioners to be engaged in national TB strategies. Within Cape Town South Africa, specific strategies are required to effectively involve private practitioners in TB control. This study aimed to investigate private practitioners' perceptions of the enablers and barriers to the effective use of public-private mix (PPM) in TB control in Cape Town. It also explored private provider perspectives on the main components of PPM in TB. Private practitioners included medically trained doctors in private practices, non allopathic medical practitioners, private pharmacists, laboratory technicians and microbiologists. The study employed the convenience sampling method. A total of 50 interviews were conducted with the use of self-administered semi-structured questionnaires. The study found that certain enablers (i.e. direct and indirect incentives), facilitated increased willingness of private providers to participate in PPM initiatives in TB control. The main incentive was financial remuneration. Other incentives included training, the free supply of drugs, private providers improved reputation and the provision of quality assured subsidized microscopy and radiological services. Private providers also identified barriers in both sectors that currently limit their participation in PPM initiatives. The deficiencies of the current system included the need for the development of more effective health promotion campaigns, improving diagnostic services, promoting interaction between the private and public sectors and training. The main recommendations included the facilitation of increased collaboration/communication between the staff in both sectors and strong government stewardship. Further recommendations included the development of a strategy for phased implementation of PPM TB control initiatives, pilot studies with context-specific PPM of TB care in diverse settings and their evaluation in terms of health outcomes, cost-effectiveness, equity and quality of care.

Includes bibliographical references (leaves 57-59). / [Background] Selective non-operative management (SNOM) of abdominal gunshot wounds is a practice that is becoming more common in major urban trauma centres. With increasing levels of violence, SNOM offers a useful method for managing injured patients. Historically, operative management of blunt and penetrating wounds to the abdomen has been the standard of care. This has changed over the past several decades with the advancement of imaging techniques and the realization that many penetrating wounds do not require surgical intervention. However, reticence towards SNOM for the management of abdominal gunshot wounds has remained because of the high probability of visceral organ damage. This study contributes to the growing field of violence prevention and trauma systems management by examining the use ofSNOM for abdominal gunshot wounds. We examined the hypothesis that SNOM does not increase morbidity or mortality in patients and decreases total hospital costs. [Methods] A retrospective cohort study of257 consecutive patients admitted to a level I trauma centre in South Africa for the management of abdominal gunshot wounds over a one year period from I April 2004 to 31 March 2005 was performed. [Results] Ninety-three of257 (36%) of abdominal gunshot wound victims were nonoperatively managed. Of these 93 patients, 5 (5%) later required surgery and were converted to a delayed laparotomy. Of the 164 patients who were treated. with immediate laparotomy, 10 (6%) underwent non-therapeutic laparotomies. There were no deaths within the cohort of patients that were managed non-operatively during the hospital stay compared to 9 deaths in the group of surgically managed patients (p=0.03). On multivariate analysis, there was no statistically significant difference in overall complication rate during the hospital stay between patients who were treated non-operatively compared to those who were treated operatively after adjusting for injury severity (HR 1.25, 95% CI 0.61-2.55). There was also no statistically significant difference in total hospital cost between the two groups (HR 0.40, 95% CI 0.15-1.08). [Conclusion] This study has policy implications for violence prevention and health systems management. It suggests that SNOM can be successfully used in less severely injured abdominal gunshot wounds. The use of SNOM does not increase morbidity or mortality rates during the hospital stay. Thus, it can also be used effectively as a part of cost-containment policies geared towards the redistribution of human and financial resources in the trauma centre.

Includes bibliographical references (leaves 58-61). / In South Africa's public sector maternity services injectible progestogen-only contraceptives (POCs) have typically been administered after delivery to women choosing to use these methods. A series of studies arose in response to the draft South African National Contraceptive Guidelines (1999), which recommended that women wishing to use the POC as their contraception method postnatally be advised to delay use of the POCs until six weeks postpartum. This recommendation followed the international guidelines of the WHO and the IPPF, which were based on theoretical concerns that the early transfer of small amounts of hormones to the infant through breastmilk may affect its growth development. The studies sought to investigate the feasibility of recommending this delay in POC administration, taking into account both the mother's risk of pregnancey in the early postpartum period and her ability to return to a health service at six weeks post-delivery, to initiate a method of contraception.