Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned.

Includes bibliographical references. / Tenofovir disoproxil fumarate (TDF) is used worldwide for the treatment of HIV-1 infection. Tenofovir has been found to be associated with declines in renal function and chronic kidney disease in HIV-infected patients. There are limited data on how soon after antiretroviral therapy (ART) initiation any loss of renal function can be detected. We studied a cohort of HIV-infected adults initiating TDF-containing ART regimens at the Hannan Crusaid Antiretroviral Treatment Centre in Gugulethu. The centre provides ART to the residents of the Gugulethu and Nyanga districts situated on the outskirts of Cape Town. We described the prevalence and incidence of renal dysfunction in this cohort, the patterns of change in their renal function in the first 12 months on therapy and factors associated with renal dysfunction. We also examined the diagnostic value of early serum creatinine tests in identifying incident renal dysfunction after 12 months.

Includes bibliographical references. / AIM OF THIS STUDY: To describe how doctors are prescribing low dose antidepressants at Heideveld Community Health Centre. OBJECTIVES: 1. To determine how many patients are being prescribed low dose antidepressants at Heideveld Community Health Centre. 2. To see what sort of dosages are being prescribed as low dose most frequently. 3. To see if indications for the use of low dose tricyclic antidepressants are being recorded. 4. To identify the indications for the use of low dose tricyclic antidepressant. METHOD: A total of 500 patient folders were reviewed. 50 patient folders, (10 folders each from five medical officers), were systematically sampled, per day, for ten days over a two week period. Records were reviewed and data was captured on a data capture sheet. Demographic data: age and gender was recorded. The dose of the antidepressant per patient was recorded. The indication for its use was recorded. Where the indication of its use was not recorded, this was also documented. RESULTS: 1. Of the 500 folders reviewed, a total of 153 (30,6%) of the patients were prescribed low dose tricyclic antidepressants at the consultation, during the time that the study took place. 2. The minimum dose used was 10mg and the maximum dose used was 75mg of tricyclic antidepressant. The median dose used was 25mg. 3. 83% of the folders had reasons for the use of low dose tricyclic antidepressant recorded. 17% of the folders had no reason recorded. 4. The reasons for using low dose tricyclic antidepressants, were for chronic pain syndromes, insomnia, somatic symptoms and for psychological or psychiatric reasons (anxiety or depression related symptoms). CONCLUSION: Low dose tricyclic antidepressants were justifiably prescribed for the many non-psychiatric and psychiatric conditions that respond to it, at Heideveld Community Health Centre.

HIV testing during pregnancy is the gateway to the HIV-related services that are part of the prevention of mother-to-child transmission (PMTCT) cascade. The virtual elimination of vertical HIV transmission cannot be achieved without universal antenatal care (ANC) HIV testing. Furthermore, women are at an increased risk of HIV infection and subsequent mother-to-child transmission (MTCT) during pregnancy. Emphasis has thus been placed on repeat testing during pregnancy among women who have a HIV-negative result at their first ANC test. Very little has been published on the current uptake and adherence to antenatal and repeat HIV testing in sub-Saharan Africa (SSA) countries. In line with the World Health Organization Guidelines, the Western Cape Prevention of Mother-to-Child Transmission of HIV (PMTCT) Clinical Guidelines in 2014 recommended a repeat HIV test between 32 - 34 weeks gestation and again at delivery in addition to testing at “booking” (< 20 weeks gestation), meaning that there were three “testing windows” during which pregnant women not previously diagnosed as HIV-infected should undergo testing. Between 2013 and 2016 the Closing the Gaps study established an electronic PMTCT register (e-register) that consolidated routine care data from a primary healthcare facility and its secondary and tertiary referral sites in Cape Town, South Africa. This provided a single longitudinal record, from antenatal care to delivery, for each pregnant woman which enabled the longitudinal assessment of maternal HIV testing uptake and treatment. Utilizing these data, we conducted a retrospective sub-analysis investigating the implementation of PMTCT HIV testing guidelines (until delivery), in Cape Town, for the period 1 July 2014 - 31 December 2016. The main objectives of the study were to assess the coverage and timing of initial HIV testing during pregnancy, the completion of HIV testing at “booking” and within the recommended testing windows (including delivery), HIV prevalence and incidence at the recommended testing windows, and the predictors of missed testing opportunities. The research protocol (Part A) was designed to describe the proposed significance, objectives and methodology of the study. The literature review (Part B) critically evaluated available literature on: antenatal and repeat HIV testing proportions, HIV positivity, the feasibility and acceptability of repeat iv testing, and the predictors of testing completeness within different SSA countries, for the period 2010 - June 2018. Its aim was to inform this study. The need for post-Option B+ implementation, longitudinal studies that analyze antenatal and repeat HIV testing coverage and implementation within SSA was identified. In Part C I present the methods, results and interpretation thereof for the analysis of individual-level, longitudinal, maternal HIV-testing patient data from the Closing the Gaps study e-register as a manuscript to be submitted for publication. Among 8558 women who delivered at either the primary care facility or its referral sites, 7213 were not diagnosed HIV-positive prior to their first visit and thus eligible for testing in pregnancy. Among these women, 91% received ≥1 HIV test and 85% “booked” >5 days before delivery with 98% testing completeness at “booking”. Only 49% of women eligible for testing “booked” ≤22 weeks gestation. Among women that “booked” ≤22 weeks gestation who weren’t diagnosed HIV-positive before delivery and delivered >5 days after the start of the third trimester, 10% received tests in all three recommended windows. Thirty-one percent of women that had not been diagnosed HIV-positive before delivery had an uncertain (i.e. last tested ≥3 months before delivery) or unknown (i.e. never tested) HIV status after delivery. Out of the women that had a known HIV status at delivery, 21% were HIV-positive of whom 95% were known HIV-positive before current pregnancy and 4% were diagnosed at “booking”. Overall, HIV incidence in those with ≥2 HIV tests during pregnancy/at delivery was estimated to be 0.2% between “booking” and delivery. Women who enrolled after 2014 were less likely to miss ≥1 of the three recommended tests (aOR: 0.70; CI: 0.55 - 0.90) and not test at delivery (aOR: 0.63; CI: 0.55 - 0.71) compared to those who enrolled in 2014. Conclusion: In our study, HIV testing completion at “booking” was high, but women tended to “book” late during pregnancy resulting in late initial testing and missed opportunities for early HIV diagnosis. Implementation of repeat HIV testing is poor, particularly at delivery. HIV incidence between first negative ANC test and delivery is very low and therefore future studies to assess the most cost-effective number and timing of HIV tests, and feasibility of implementation, should be considered. Overall, maternal HIV testing within the PMTCT programme in Cape Town has matured post 2014 with improved implementation over time.

Includes summary. / Booth Memorial Hospital (BMH), situated at the foot of Table Mountain in urban Cape Town, South Africa, is an NGO-run hospital in a Public- Private Partnership with the Western Cape Department of Health. The essential service being offered is sub-acute health care, with state hospitals referring patients needing terminal, rehabilitation or convalescent care for a variety of illnesses. Post-acute stroke rehabilitation forms an integral part of the general service being offered by BMH. This dovetails with the state-run rehabilitation hospital in the sense that younger patients able to undergo intense rehabilitation are sent to the state-run hospital, while BMH generally cares for those patients who may not be able to withstand the rigours of an intense rehabilitation program. In our setting, this means that most of the patients seen at BMH for post-stroke rehabilitation are elderly. The elderly patient who has suffered a stroke is vulnerable in many respects. The most obvious vulnerability refers to the physical, emotional and psychological derangements that follow strokes in this age group. In addition, due to rampant poverty prevalent in the community we serve, social and economic factors place this group of patients at an even greater disadvantage. It is an imperative for social survival and an acceptable quality of life that this group of patients retain as much of their independence and empowerment after the stroke as is possible. The current situation of overflowing old-age homes, increasing prevalence of elder abuse and neglect, and the deficiency of community structures to care for the elderly compel health care providers to ensure that a post-stroke rehabilitation service operates with maximal efficiency, given the paucity of resources endemic in our health system. The above factors provided an impetus for this study. A need arose to assess the quality of the stroke rehabilitation services at BMH, as the starting point to what is hoped will be a continuous Quality Improvement Cycle. An additional factor compelling the examination of the quality of service being offered is that the Geriatric population is underserved in the present health system, competing for scarce resources with other vulnerable groups such as children, Cancer patients, and people living with HIV/AIDS. By focussing on a service that is almost exclusively aimed at the elderly, we hope to be able to advocate for greater resource allocation to this age group, given that receiving good health care is essential to the quality of life of the ageing population. This assessment of the current services looked at the Structure, Process of care and Clinical Outcomes of stroke rehabilitation services being given to patients over the age of 65 years. The findings were evaluated against internationally accepted norms of post-acute stroke care, and are presented in this study.

Includes bibliographical references. / Multi-drug resistant tuberculosis (MDR-TB) was first recognized in the 1990s with an increase in caseload of eighty-two percent between 2000 and 2007. Extensively drug-resistant tuberculosis (XDR-TB), a more difficult and more expensive form of TB to treat with poorer outcomes, emerged in South Africa in 2006. The prevalence of XDR-TB is likely to be underestimated in South Africa as a result of incomplete detection and notification. In peri-urban areas like Khayelitsha where there are high rates of HIV, TB and poverty, the prevalence of MDR-TB is estimated at 51/100 000. A significant proportion of these cases are indeed undetected pre-XDR-TB (MDR and resistance to either a fluoroquinolone or a 2nd line injectable drug) and XDR (MDR and resistance to both fluoroquinolones and any one of the 2nd line injectable drugs) cases with inadequate access to drug sensitivity testing. Treatment outcomes of XDR-TB have been variable with countries like Peru showing a 60% overall cure (or completed treatment) rate, and studies in KwaZulu Natal in South Africa showing much poorer outcomes. The reasons for the poor outcomes in XDR-TB remain unclear. We are continuing to investigate the role of strain-type and several other factors including nutritional status, degree of drug resistance, HIV status and drug regimens in determining outcomes. There is a paucity of literature describing the chest X-ray (CXR) findings in patients with XDR-TB, and whether disease extent is related to treatment outcomes and the evolution of resistance remains unclear. It has been shown that patients with radiological extensive drug-sensitive TB have higher initial sputum mycobacterial loads and take a longer time to sputum conversion than those without . The extent of disease on the CXR at baseline has been used as a tool to inform and predict the need for infection control measures, treatment duration, and outcomes. The time-to-positivity (TTP) of mycobacterium tuberculosis in a liquid medium culture has become a validated indicator of bacterial sputum load and indeed a surrogate bio-marker of treatment response to anti-tuberculosis drugs. The relationships between mycobacterial sputum load, radiological disease and treatment outcomes have been studied in drug-sensitive TB, but little is known about XDR-TB.

Background: Primary care practitioners are at the forefront of the health service and therefore have an opportunity to promote oral health, manage certain oral conditions, or refer appropriately to the closest dental service. In under-resourced areas, patients are more likely to present initially to a primary health care nurse or doctor, with oral or dental needs. Studies abroad have revealed that general practitioners do not always examine the oral cavity, enquire about oral health, or manage oral disease particularly well and have expressed an interest to learn more about oral health. A literature search for similar South African studies did not yield results. This study aims to describe current oral health care practice provided by primary care practitioners in Cape Town and to assess whether this level of service might benefit from interventions to improve the quality of care. Methods: The Nominal Group technique (NGT) was used to identify and achieve consensus among 8 community health centre primary care practitioners regarding the main challenges to providing oral health care and offer suggestions for strengthening oral health care. This assisted the development of a questionnaire, which was then distributed to practitioners at five Community Health Centres in the Cape Town Metropole. The questionnaire aimed to assess the knowledge, attitudes and current practices of practitioners in the area of oral health. Results: The NGT yielded valuable information to inform the questionnaire; two main topics were discussed which helped inform two sections of the 9-part questionnaire. A total of 53 doctors and clinical nurse practitioners completed the questionnaire. Only 17% of participants reported routinely examining the oral cavity, others examined it on request of the patient or suspicion of an abnormality. A minority (13.2%) stated that they routinely promote oral health in the consultation and reported limiting factors to include: insufficient time during consultations, forgetting to include oral health promotion, a limited knowledge of oral disease, and limited access to Oral Health Services. Suggestions for strengthening the oral health care included training clinicians in oral health, motivating clinicians to provide better oral health care, improving patient education on the importance of oral health care, and improving the integration of Primary Care services with Oral Health services. Limitations of this study include a small sample size, studying only urban community health centres in Cape Town, the absence of input from oral health experts, the absence of input from patients and missing data. Conclusion: It is apparent from this study that oral health is inadequately managed, for a number of reasons; including time constraints, limited knowledge of treating clinicians, and limited available oral health services. Possible interventions to improve this clinical area can be posed to relevant authorities and may include examining undergraduate curricula (medicine and nursing) to assess the content and quality of oral health education, provide in-house training to CHC staff by local dentists and oral hygienists, provide information sessions for staff at CHC about the local Oral Health Service available in their areas, and offering education to patients in the waiting room on the topic of good oral health.

Introduction Deaf people experience significant barriers in access to health care as well as poorer health outcomes. While there are many international and South African studies describing the difficulties deaf patients experience when accessing health care, only anecdotal evidence suggests that health care workers (HCW) also experience challenges at these encounters. These difficulties are significant as they may results in errors in medical management with significant impact on mortality and morbidity of the patient as well impacting on future encounters. This study was intended to further the understanding of the dynamics of the encounters between HCW and deaf patient by examining the HCWs experience. In this way we may identify the intrinsic and extrinsic factors contributing to the success of failure of the task, establish if the HCW has the competencies and training to achieve the objectives, how working conditions impact on success and how HCWs adapt their communication strategies. These findings could advocate for changes to formal training HCWs receive and the planning and adaptation of services offered to give deaf patients access to appropriate and effective health care. Methods The study design is a qualitative, descriptive case study. Data was collected using interviews and focus groups of invited staff members at Retreat Community Health Centre (RCHC) in Cape Town. Convenience sampling was used to select participants, and interviews were conducted until saturation was reached. Data was studied and analysed using the phenomenological method. Results HCWs reported that they serve very few Deaf or HI clients. However, themes of language barriers; resilience; preconceptions; improvisation and innovation: interpreters and recommendations emerged. Difficulties in communication were acknowledged, but HCWs insisted that these barriers are not insurmountable. Discussion and conclusion A few preconceptions and gaps in knowledge and awareness were revealed. HCWs also tended to rely on escorts and other interpreters. The dominant recommendations are that HCWs should receive training in sign language (SL) and/or that SL Interpreters be available at facilities. Despite using words and phrases such as “frustrating” and “more effort”, participants concluding remarks reiterate that their experiences are positive, suggesting a notable resilience.

Includes bibliographical references (leaves 65-67). / This study explores the experience of people suffering from chronic pain post surgical interventions. Cases are selected from those patients currently attending a pain clinic. By means of five in-depth, unstructured interviews this research seeks to understand how these patients view their pain. Recurrent themes arising emanating from these interviews are identified and then examined. These include: the breakdown in the doctor-patient relationship, and the all pervasive nature and effect of pain on the lives of those suffering from chronic pain. This research recommends that doctors should begin to examine the part they may play in the aeitiology of chronic pain. A practical aspect of this might be the rotation of student doctors through chronic pain clinics.

No description available.