Numerous studies have reported compelling evidence that medical male circumcision (MMC) reduces HIV acquisition in men. MMC is now recommended by the World Health Organization (WHO) and UNAIDS as part of HIV prevention strategies in countries with heterosexually-driven HIV epidemics. This research project assesses men's knowledge, understanding and factors influencing their beliefs about male circumcision in rural communities in Northern KwaZulu-Natal, South Africa. The study was conducted a year after the launch of a medical male circumcision programme by the KwaZulu-Natal Department of Health.

Neiserria meningitidis remains an important cause of morbidity and mortality in South Africa (SA). It is the sixth commonest cause of notified disease with a case fatality rate of 11% for the period 1990 1994. Identification of preventable risk factors is critical as no effective vaccine exists for serogroup B, the most prevalent serogroup in SA. A case control study was undertaken to determine the risk factors associated with meningococcal disease. The study population consisted of all children under the age of 14 years who were residents of the Cape Town City Council and Cape Metropolitan Council areas of jurisdiction. Cases were identified from weekly notification reports and from admissions to the City Hospital for Infectious Diseases. Controls were selected from the trauma wards at Red Cross War Memorial Children's Hospital. Data was analyzed using EPI INFO and SAS statistical software. During the period October 1993 to January 1995 70 cases and 210 controls were interviewed. Cases were significantly younger than controls (p = 0.0001). On univariate analysis significant risk factors for meningococcal disease included: a household where 2 or more members smoked (odds ratio (OR) =1.8), recent upper respiratory tract infection (OR= 1.8), poor nutritional status (OR= 3.6), being breastfed for less than 3 months (OR= 2.7) and overcrowding (OR= 2.8). After adjusting for confounders, the main force of passive smoking as a risk factor for meningococcal disease appeared to be in the presence of a recent upper respiratory tract infection. Other factors that remained significant after adjusting for confounders included: being breastfed for less than three months (adjusted OR= 2.4) and being less than 4 years old (adjusted OR= 2.3). This is the first case control study in South Africa examining risk factors associated with meningococcal disease. The study provides further evidence for the reduction of smoking, reduction of overcrowding and the promotion of breast-feeding as important public health measures. It also identifies children under the age of 4 years as an important target group should an effective vaccine become available.

Includes bibliographical references. / In 2003, South Africa's National Department of Health (DoH) initiated the roll out of antiretroviral therapy (ART) for HIV positive individuals in the public health sector. Based on World Health Organization (WHO) guidelines, South Africa's ART programme provides a first line regimen based on a backbone of two nucleoside reverse transcriptase enzyme inhibitors (NRTI) with one non-nucleoside reverse transcriptase inhibitor (NNRTI) while the second line regimen is based on a protease inhibitor (PI) with two NRTIs. Similar to many developing countries, South Africa's NRTI backbone in the first line treatment regimen is stavudine (d4T) combined with lamivudine (3TC), and the NNRTI which is either efavirenz (EFV) or nevirapine (NVP). In some cases, stavudine is replaced with the NRTI zidovudine (AZT) in the first line regimen. Both d4T and AZT have been recognized to contribute to drug related toxicities or side effects, particularly lactic acidosis, lypodystrophy, peripheral neuropathy, and anaemia. However, developing country governments have been limited to these NRTI choices due to the higher cost of alternative treatment options. There is compelling logic that the life long commitment of ART can be made more tolerable, and that adherence among patients and the success of a public sector ART programme can be increased through the provision of ART regimens with the fewest side effects. In addition, the costs and complications associated with treating and managing adverse events associated with d4T and AZT create further burden on the public health sector. By providing tenofovir as an alternative to d4T and AZT in first line ART therapy, the South African government would increase the chance of successful ART therapy for patients and the long-term success of the national ART programme. This cost effectiveness analysis will compare the currently available first line ART options (the status quo) to two alternative options in order to assess the costeffectiveness of the provision of tenofovir in place of d4T/AZT.

Includes bibliographical references (leaves 57-63). / Quantitative Ultrasound (QUS) measurement at the calcaneum is a convenient, cost effective and noninvasive method of determining bone strength well suited to community-based research in countries with limited resources. Although only moderately correlated with dual X-ray absorptiometry (DEXA) measurement of bone mineral density (BMD) at the hip and spine, quantitative ultrasound has shown to be a reliable predictor of osteoporotic fracture. This study aims to evaluate the use of QUS in epidemiological studies in South African settings. To this end, this report determines whether characteristics associated with QUS measures of bone strength in a large sample of premenopausal South African women are similar to those known to be associated with the BMD as measured by DEXA, and compares these associations with those in other populations. This cross-sectional study included 3493 black and mixed race women aged 18 - 44 living in Cape Town. Trained study nurses administered structured interviews on reproductive history and lifestyle factors. In addition they took height, weight and calcaneal QUS measurements using the Sahara device. Adjusted means of QUS measures according to categories of risk factors were obtained using multivariable regression analysis. In both groups associations between QUS measures and age, Body Mass Index (BMI), age at menarche, parity and primary school physical activity were similar to those known to be associated with BMD as measured by DEXA. There were no clear associations between QUS and educational level, alcohol use, cigarette smoking, and current calcium intake. The data give support to the use of QUS as an epidemiological tool in large studies of bone strength in premenopausal women.

Includes bibliographical references. / Generally, sex workers are a socially marginalized group with poor physical health. Within the hierarchy of sex workers, street-based sex workers are at the bottom. Street-based sex workers face different kinds of work experiences and exposure, with varying degrees of health problems. Their health problems are more severe and worse than the other classes of sex workers. Street-based sex workers are subjected to considerable risks of physical abuse, beatings and rape. These impact greatly on their health. This study explored the general health problems of street-based female sex workers. The study was carried out in Cape Town among street-based female sex workers aged 18 years and above. It was cross-sectional, conducted over a period of six months using fifteen (15) in-depth interviews and four (4) focus group discussions. The respondents were non-randomly recruited through the Embrace Dignity Project, whose activities involved sex workers. The study discovered that condom use was inconsistent as a result of financial incentives, condom breakage, violence, rape and non-payment from clients when insisting on condom use. But some respondents were not using condoms at all. The majority of respondents reported stigmatization and discrimination by community members and the police. Most of the respondents do not go for routine and other medical checks. Some respondents were not satisfied with health care provision due to discrimination by providers and long waiting times. Notwithstanding, respondents reported a long list of health problems including: flu, cough, HIV/AIDS, TB, headache, vaginal discharge, itchy vagina, sleeplessness, high blood pressure, fever, heart problems, diarrhoea, sweating at night, arthritis, diabetes, alcoholic problems, bad breath, sore throat, and mouth rash. Physical and psychological problems were also mentioned. Most respondents rated their health status as bad. The illegality of sex work in South Africa pushes sex workers to practice the trade in obscure places making them very vulnerable. Street-based female sex workers have numerous general health problems, but with limited access to health services. The law does not also help the course of street-based female sex workers. There is an urgent need to partially criminalize sex work. Reorientation and education of sex workers and providers is also required. All these will help promote the welfare of sex workers.

Bibliography: leaves 47-49. / Tuberculosis is the leading infectious killer of people living with HIV/AIDS. Millions of tuberculosis deaths could be prevented by the widespread use of the less expensive strategy of directly observed treatment (DOT). The cost-effectiveness of DOT however varies with its method of supervision. This study evaluated the cost-effectiveness of community-based and self-supervision strategies of DOT in Maracha, Arua District, Uganda. Patients', community's and health system's costs were obtained through interviews and expenditure statements. For effectiveness measures, historical follow-up of the cohort belonging to each the tB treatmentt supervison strategy was done. Systematic random sampling was done to identify the 20 patients from each treatment strategy for interviews to estimate their treatment costs. Due to low number of patients in the available TB registers, all the 129 patients were enrolled for the study. The findings showed that community-based supervision of DOT was a more cost-effective TB treatment supervision option than that by self-supervision and was therefore recommended to Maracha HSD and Arua District for more support and expansion. However, the accuracy of this study was limited by method used and generalizability of the results could be affected by the small sample size.

Includes bibliographical references. / Corticosteroids used in addition to anti-tuberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are not consistent, raising doubt as to whether such treatment is worthwhile. Concem also exists regarding the potential adverse effects of steroids, especially in HIV positive patients. An earlier Cochrane review summarized the existing evidence on the effects of steroids in people with tuberculous pleurisy. This review updates the evidence and, for the first time sheds light on the effects of steroids in patients with tuberculous pleurisy co-infected with HIV.

Background Both laparoscopic Heller's myotomy (LHM) and pneumatic balloon dilatation (PBD) are widely used in the management of achalasia, but there is still no clarity as to which of these interventions is the best treatment for patients with the condition. Methods Newly diagnosed achalasia patients were randomised into PBD or LHM. The severity of achalasia symptoms in all participants was documented using the Eckardt score, a clinical symptom score whose components are dysphagia, chest pain, regurgitation and weight loss. The Eckardt score ranges from 0 in those with no symptoms to 12 in patients with pronounced symptoms. The primary outcome, therapeutic success, was defined as a drop in the Eckardt score to <3 or subsequent need for alternative intervention. The secondary outcome was the complication rate, including mortality, in the two treatment arms.

Includes bibliographical references (leaves 19-21). / Transthoracic echocardiography (TTE) plays a crucial role in the care of pediatric patients with heart disease. However, despite numerus recent technological advances, there has been little re-assessment of its accuracy. We sought to systematically assess the diagnostic accuracy of pediatric TTE in the current era.

Includes bibliographical references (leaves 58-60). / Absenteeism is a problem affecting the Public and the Private sector institutions alike. Anecdotal evidence from monthly absenteeism statistics and managers' comments suggest that it is also a problem for Red Cross Children's Hospital (RCCH). This dissertation describes the investigation into absenteeism among nurses at RCCH that was conducted by the writer in the year 2004. The writer reviewed attendance records for the year 2003. The main findings from the investigation and recommendations on management of absenteeism are then presented. The overall objective of the study was to establish the determinants of absenteeism among nursing personnel of RCCH and financial implications thereof. This involved establishing the extent of absenteeism among the nursing personnel, identifying major causes, estimating the financial burden and making recommendations on how to manage this problem. The study followed a descriptive as well as analytic methodology in presentation and discussion of results. The methodology included a review of the literature on absenteeism, motivation and migration of health personnel. The study has a qualitative and a quantitative aspect. Focus groups and in-depth interviews were conducted for collection of primary data from nurses. Two questionnaires were used as interview guides. Secondary data was collected from PERSAL database using the data capture sheet. Attendance records of all nurses were reviewed for the quantitative aspect of the study. A major finding of the study was that absenteeism among nursing personnel at RCCH was above what most writers on the subject regard as acceptable level. Staff turnover was found to be high in the nursing department with staff leaving the service and posts remaining vacant. It was felt that there is difficulty in recruiting nurses especially from the outskirts of the Western Cape and other provinces because of lack of accommodation. It was suggested that Staff Residence policy be enforced to address this problem since it confers power of granting or refusing accommodation to management. Stress was identified as the major cause of absenteeism by all interviewees. The source of stress was identified as both personal and work related problems. The financial burden of nurses' absenteeism was estimated at more than one million rands for the year 2003. Important recommendations that emerged from the study were that absenteeism control should be included in the job descriptions of supervisory positions. Development of institutional absenteeism policy was also recommended. it was also recommended that mechanisms be developed to recognize staff members with good attendance records.