Current international guidelines recommend that a cranial computed tomography (CT) be performed, on all HIV positive patients presenting with new onset seizures, before a lumbar puncture (LP) is performed. In the South African setting, however, this delay could be life threatening. This study sought to measure the number of cranial CTs that contraindicate an LP and to predict which clinical signs and symptoms are likely to pose an increased risk from LP. Methods: The study was performed at a district level hospital in the Western Cape. Data was collected retrospectively from October 2013 to October 2014. Associations between categorical variables were analysed using Pearson's Chi-squared test. Generalised linear regression was used to estimate prevalence ratios. Results 100 out of 132 patients were studied. Brain shift contraindicated an LP in 5% of patients. Patients with brain shift presented with: decreased level of consciousness, focal signs, head ache and neck stiffness. 25% of patients had a space occupying lesion (defined as a discreet lesion that has a measurable volume) or cerebral oedema. Multivariate analysis showed a CD4 count < 50 (p=0.033) to be a statistically significant predictor of patients with a space occupying lesion (SOL) and cerebral oedema. Univariate analysis showed focal signs (p=0.0001), neck stiffness (p=0.05), vomiting (p=0.018) and a GCS<15 (0.002) to be predictors of SOL and cerebral oedema.

Includes bibliographical references (leaves 93-97). / African traditional healers are themselves "patients" in the modern bio-psycho-social health system. Their "frameworks of meaning" of biomedical diseases provides a glimpse of the "voice of the lifeworld" of the patients who interact both with them and the modern allopathic health services. The main objective of this study was to ascertain African traditional healers' understanding of and beliefs about the medical conditions under discussion in the doctor-patient interaction to which they silently listen.

Includes bibliographical references (leaves 97-102). / To determine if a basic Xhosa course for non-Xhosa-speaking Health Care Workers, working in Primary Health Care Centres in Cape Town improves patient satisfaction for Xhosa-speaking patients, their perceived ability to communicate effectively with Xhosa-speaking patients, and job satisfaction levels.

Background: Globally, type 2 diabetes (T2D) is a significant cause of avoidable mortality and morbidity. It is a major risk factor for cardiovascular disease (CVD). Evidence-based guidelines lower cardiovascular risk in diabetics. Adherence to clinical guidelines for the prevention of CVD in South African primary care public sector facilities is unknown. Aim: This study determined adherence of Cape Town primary care clinicians to recommended clinical guidelines for the prevention of cardiovascular disease in T2D. Methods: This 2013 cross-sectional study extracted data from 300 folders of known T2D patients sampled from three Community Health Centres (CHCs). Compliance with guidelines, and patient demographic factors were analysed. Results: Most (71% or 194/273) hypertensive diabetics were appropriately managed with first-line- medication - an Angiotensin Converting Enzyme Inhibitor (ACEI). There was appropriate supporting documentation for only 39% not on first line therapy. A fifth (22%) with drug intolerance received the recommended alternative. Most were appropriately prescribed a statin (74%) and aspirin (69%). Other cardiovascular risk factors were poorly controlled: mean weights were in the obese range (BMI=31.3 [SD: 5.7]); the mean total cholesterol level was 5.5 (SD: 1.4); there was incomplete data for smoking (19% had no record) and 93% had no record of a family history of CVD. Conclusions: Whilst pharmacological interventions for the prevention of CVD were moderately implemented, patient factors – such as obesity and smoking were poorly addressed. Improving documentation, adherence to recommended clinical guidelines and, health promotion to address modifiable risks are required to improve quality of care for T2D.

Objectives: This study aimed to research efficacy and safety of procedural sedation and analgesia (PSA) administered by medical officers (MOs), without formal anaesthetic training, in a South African district hospital. Design: This is a retrospective descriptive study. Setting: The study took place in the Emergency Department (ED) of False Bay Hospital (FBH), a level one hospital in the Southern suburbs of the Cape Town Metro health district.

Includes bibliographical references. / Continuity of care (COC) is a fundamental concept in Family Medicine. The rollout of antiretrovirals in the primary care setting of the public health care system in South Africa was 'vertically' isolated from the other clinics. This isolation provides a rich environment to research COC. The present project describes the longitudinal COC in the Ubuntu ART/TB Clinic in Site B, Khayelitsha, which is one of the oldest clinics with a total of 6000 patients on ARVs since May 2001. An observational period of the last five visits of patients to the clinic was used to measure the COC as a simple Continuity Fraction (CF)(alternatively called the Usual Provider Continuity/UPC), which was compared with more complex formulas for measuring COC including the K-index, SECON, COC-index and Alpha-index. The nature of the appointments was also explored, in terms of whether the patient was attended to by a nurse or a doctor and whether it was a proxy visit. Since viral loads are a very good indicator of adherence, they were compared to the COC over the observation period of the last five visits. The data showed a nurse-driven clinic achieved a CF below 50% (0.5). The 0.5 COC score seems to be a benchmark for good COC, yet it is difficult to statistically verify. The CF scored higher than the other COC formula scores, yet correlated well with other COC formulae. The CF scores with nurses were more positively related to better virological outcomes than the other COC formulae, though none were statistically significant. Unscheduled and proxy visits were not associated with higher VLs. The statistical test of General Linear Modelling with Poisson Regression with robust error variance could be an alternative way of proving that better COC has a measure of impact on the outcomes. Due to the different role of doctors, doctor visit(s) resulted in higher sequentiality scores, but a decrease in suppressed VL. These COC scores also do not completely explain the good virological outcomes in this clinic, which is considered a well managed public sector clinic in Khayelitsha. The CF places a simple tool in the hands of a clinician at the primary level to measure individual provider continuity; however there is need to test its reproducibility in other contexts of chronic care in order to develop standards. The K-index emerged as a simple measure of the dispersion of the longitudinal COC within the nurse team managing the stable chronic patient. In a broader perspective, this study has put the measuring of COC onto the 'radar' of the public health system in South Africa.

Globally, Tuberculosis remains a devastating disease, despite the availability of treatment. The disease is associated with poverty, and those with the disease incur a high cost of accessing care, while simultaneously experiencing income loss due to a loss in productivity. A key challenge in TB programmes remains the accurate diagnosis of the disease, especially in people who are HIV positive. Diagnosing TB can be very resource intensive and the accuracy of diagnosis is dependent on a range of disease, health service organisation and provider behaviour factors. This thesis seeks to enhance understanding of how the behaviour of healthcare workers mediates the value of TB diagnostic algorithms, and how this may affect the costs, outcomes as well as the economic burden associated with the disease in South Africa. The work presented is based on empirical work done alongside a pragmatic cluster randomized control trial. Empirically, it examines the longitudinal economic burden of TB diagnosis and treatment in South Africa. The discrepancies between the time at which patients incur the greatest cost and income loss, and the available social protection are highlighted. Based on empirical work, a purpose-built state-transition mathematical model of TB diagnosis and treatment was developed to estimate the cost-effectiveness, from the perspective of the health service and the patient, of health systems interventions to strengthen TB diagnosis. Recognising healthcare workers as those who ultimately express policies, the behaviour of healthcare workers was included in the cost-effectiveness analysis by 1) using data from a pragmatic trial reflecting routine practice and clinical decision-making at the time of the study; 2) developing a conceptual framework of the relationship between behaviour at decision points and disease outcomes; and 3) investigating how these interactions may influence the value of the diagnostic algorithm. Possible public policy levers to improve TB diagnosis in healthcare facilities, as well as the potential mediators of costs and effects were explored. The thesis concludes with recommendations for further methodological work to expand on the approach explored in this thesis to improve how heterogeneity in estimates of cost-effectiveness is presented to decision-makers.

Introduction: Over the past few years, the capacity of the government of Mozambique to sustain the cost of payment of salaries to operationalize the Indoor Residual Spray (IRS), a widely recommended tool to control and prevent malaria, is facing numerous challenges. This is due to recent restrictions of the Official Development Assistance (ODA), an external aid scheme and the main source of financing of the Mozambican government budget. Objective: The objective of this study was to estimate the cost of IRS operationalization activities in Matutuine and Namaacha districts health directorates, in Maputo Province, Mozambique. Methods: A cost analysis using an approach from the provider’s perspective was conducted in two district health directorates in the Maputo province, Matutuine and Namaacha. The institutions were purposely selected since in 2014 in both districts the expenditure on salaries to operationalize IRS was funded by the government budget. Cost information was collected retrospectively and both economic and financial costs were calculated. Uncertainty of results was tested using “one-way” deterministic sensitivity analysis. Results: The average total annual economic cost was 117,351.34 US$. The average economic cost per households sprayed totalled 16.35 US$. On average the economic costs per person protected is 4.09 US$ in total. In the financial analysis, the average total annual financial costs totalled 69,174.83 US$. The average financial cost per household sprayed and per person protected were 9.84 US$ and 2.46 US$ respectively. Vehicles, personnel salaries and consumables were the major substantial cost components. Conclusion: Setting aside the ODA restriction and focusing on the aim of implementing IRS within the existing resources, the study makessuggestions for improving efficiency by focusing on areas with a higher need and pays attention to cost drivers in order to reduce the costs.

Introduction Despite the unprecedented efforts of national governments along with various NGOs to achieve the third SDG, which is to reduce global maternal mortality to less than 70 per 100 000 live births by 2030, developing countries seem to be lagging far behind in reaching this goal (UNDP, 2016). This paper focuses on socioeconomic inequalities in the use of ANC services as an important aspect of MHC in SADC countries. Methods The data used in this study are obtained from the Demographic and Health Survey (DHS). Three mutually exclusive variables were created to assess ANC inequality, namely, 1) No ANC visits 2) Less than four ANC visits and 3) At least four ANC visits. A fourth variable that assesses the actual number of ANC visits that a pregnant woman had received was created and called 'Intensity’. ANC and SES using the wealth index were used to construct the concentration curves and indices to determine whether health care utilization is concentrated among the poor or the rich. Results Over 70% of all who lived in rural areas had '0 ANC’, with Namibia and Tanzania as the only exception to this finding. In four of the eleven countries, over 58.36% of women were married and were likely to make an adequate number of ANC visits. Namibia and Lesotho are two of the eleven countries that had a great majority of women educated up to the secondary level, 65.61% and 49.90% of which attained at least 4 ANC visits, respectively. Women who worked in agricultural settings had the least likelihood of attaining any ANC visits. Discussions and conclusion ANC use was consistently lower in women with no education, doing agricultural work and those residing in rural areas in the SADC region. Overall, marriage is inconclusive in determining ANC use. Inequality in wealth makes ANC utilization more predominant among the rich. Saving mothers and babies is ultimately saving the population and knowledge of the patterns of maternal health usage is imperative to draw relevant policies that are evidence based.

It is important to understand the experiences and perceptions of HIV research from the perspectives of persons who have either participated in or worked on HIV research in lowresource settings. Obtaining such information is important because research in low-resource settings presents several ethical challenges that result in the vulnerability of participants due to factors such as low literacy levels, high rates of food insecurity and unemployment. Conducting research on the aforementioned can help researchers to design studies that mitigate some of the ethical challenges associated with conducting HIV research in lowresource communities. This dissertation adds on to existing literature on the experiences and perceptions of HIV research participants and staff involved in HIV research in low-resource settings. This dissertation is divided into three parts. Part A (Research protocol) discusses the importance of evaluating research participants’ experiences and perceptions of HIV studies conducted in lowresource settings. The section also outlines the purpose of the study, research questions, methodology, ethical considerations, rigour, reimbursement and dissemination of results. Part B (Literature review) presents an overview of the literature on HIV research in low-resource settings, with a specific focus on: ethical challenges, factors that contribute to participants’ decisions to participate in HIV research and findings from other studies which examined experiences and perceptions of HIV research in low-resource settings. The section also identifies gaps in the existing literature. Part C (Journal article) presents the findings of the study and the implications thereof.