Background: Undiagnosed chronic obstructive pulmonary disease (COPD) and asthma remain prevalent health issues. The current global and Canadian prevalence reported for obstructive lung disease do not reflect the true prevalence since undiagnosed cases remain missed and uncounted. Spirometry testing is viewed as the current gold standard for diagnosing obstructive lung disease. However, barriers associated with inaccessibility and underuse have contributed to undiagnosed lung disease. While guidelines advise against spirometry for asymptomatic persons, active case-finding for persons at-risk and those presenting with symptoms has been recommended. Given early treatment and management has the potential to improve health-related quality of life and reduce the progression of lung decline, identifying undiagnosed lung disease is critical to preventing adverse health outcomes. To date, this marks the first study to incorporate both obstructive lung diseases into a single-case finding instrument. Objective: To develop and validate a case-finding questionnaire to identify undiagnosed COPD and asthma in community-dwelling adults, and to prospectively evaluate reliability and predictive performance. Methods: This study uses data obtained from the Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population (UCAP) study from June 2017 to March 2020. Eligible participants were >18 years, had a history of chronic respiratory symptoms, and had no previous physician diagnosis of obstructive lung disease. Presence of obstructive lung disease was confirmed with spirometry. Multinomial logistic regression and recursive partitioning were used to develop a case-finding questionnaire. Predictors available from six questionnaires completed during spirometry visit. Diagnostic accuracy of the models was used to evaluate performance. Risk score externally validated in a cohort of participants recruited between October 2020 and January 2021 at study sites open during the COVID-19 pandemic. Results: Derivation cohort included 1615 participants, with 136 ultimately diagnosed with asthma and 195 diagnosed with COPD. A 13-item questionnaire was developed using logistic regression: age, pack-years of cigarette smoking, wheeze, cough, sleep, chest tightness, level of tiredness, physical activity limitation, occupational exposure, primary or second-hand smoke exposure, frequency of chest attacks, and salbutamol medication. Internal validation showed an area under the curve (AUC) of 0.79 (0.70-0.90) for COPD and 0.64 (0.45-0.80) for asthma. At a predicted probability of greater than or equal to 6%, specificity was 17% for no OLD, sensitivity was 91% for asthma, and sensitivity was 96% for COPD. External cohort included 74 subjects, with 8 diagnosed with COPD and 6 diagnosed with asthma. The AUC for COPD was 0.89 (95% CI: 0.62-0.90) and AUC was 0.65 (95% CI: 0.63-0.72) for asthma. Sensitivity was 100% for both asthma and COPD, specificity was 13%, and positive predictive value was 23%. Conclusion: The 13-item case-finding questionnaire was shown to be reliable and with modest predictive ability in identifying COPD and asthma. Prospective evaluation with the UCAP study is still ongoing to recruit a larger sample to re-evaluate predictive performance.

Tuberculosis remains a communicable disease of major public health importance in South Africa. The purpose of this study is to search for trends in management of tuberculosis at Hillbrow Health Centre from 2000 to 2002. Furthermore, to assess completeness of routine records, compare performance of tuberculosis control in this clinic with others in region 8 during 2002 and identify residential areas with high volumes of tuberculosis patients. Data was obtained from tuberculosis documents at the facility. Information provided by the district office was compared with research findings and used to evaluate performance of Hillbrow Health Centre against the other four clinics in the region. The main findings from the study conducted at Hillbrow Health Centre were the large number of patients diagnosed with tuberculosis annually and cure rates below 40% during the study period. In 2002, the clinic reported the highest proportion of TB patients and the lowest cure rate compared to the other four clinics reporting tuberculosis in region 8. “Hot spots” for the disease were identified in Hillbrow and Joubert Park suburbs and this is where Esselen, Hillbrow and Urban Health Clinics are situated. There is room for improvement of tuberculosis control. More research needs to be done to determine factors contributing to the high incidence of TB in Hillbrow and Joubert Park Suburbs.

Master of Public Health - MPH / Background: In South Africa, tuberculosis (TB) detection remains a major problem, as notified cases are estimated to account for only 68% of all incident cases. Health services have relied on passive case finding and this leads to missed or delayed diagnosis. In Cape Town, City Health has embarked on an active surveillance programme to systematically screen all adults seeking health care at PHC facilities for active TB, in order to identify undiagnosed incident TB cases and avert missed opportunities for treating TB. Aim: The aim of this study was to evaluate the effects of an intensified TB screening strategy on changes in facility level TB case finding in City Health PHC facilities in Cape Town.

Background: There is an unacceptable delay in diagnosis of axial Spondyloarthritis (axSpA) especially in its early stages among patients with inflammatory bowel disease (IBD). Objective: to develop a sensible and reliable questionnaire to identify undetected axSpA among IBD patients. Methods: Candidate items for the questionnaire were selected on 3 domains (IBD, inflammatory back symptoms, and extra-axial features). Sensibility of the Toronto axSpA Questionnaire (TASQ) was assessed leading to drafting 18 items. Test-retest reliability study was conducted among 77 patients with established IBD and axSpA and kappa agreement coefficients were calculated for items. Results: The TASQ was developed using multiple steps of sensibility assessment resulting in 16 items. Kappa coefficients ranged from 0.81 to 1.00 for all items indicating almost perfect agreement. Conclusion: TASQ is a newly developed, sensible and reliable questionnaire that should facilitate identification and referral of IBD patients to rheumatologists and should avoid delay in diagnosis of axSpA.

Background: There is an unacceptable delay in diagnosis of axial Spondyloarthritis (axSpA) especially in its early stages among patients with inflammatory bowel disease (IBD). Objective: to develop a sensible and reliable questionnaire to identify undetected axSpA among IBD patients. Methods: Candidate items for the questionnaire were selected on 3 domains (IBD, inflammatory back symptoms, and extra-axial features). Sensibility of the Toronto axSpA Questionnaire (TASQ) was assessed leading to drafting 18 items. Test-retest reliability study was conducted among 77 patients with established IBD and axSpA and kappa agreement coefficients were calculated for items. Results: The TASQ was developed using multiple steps of sensibility assessment resulting in 16 items. Kappa coefficients ranged from 0.81 to 1.00 for all items indicating almost perfect agreement. Conclusion: TASQ is a newly developed, sensible and reliable questionnaire that should facilitate identification and referral of IBD patients to rheumatologists and should avoid delay in diagnosis of axSpA.

Background: The cumulative effect of taking anticholinergic medicines (anticholinergic burden) is associated with adverse outcomes for older people. Prevalence of anticholinergic prescribing is increasing, and there is a need for tools to proactively identify at-risk patients for medication reviews. Aim: To explore the need for, and feasibility of, an integrated case-finding tool that predicts risks using electronic health records (EHRs), facilitating the review of anticholinergic medicines for frail older people. Methods: Mixed methods, adopting a pragmatic approach. A systematic review, prediction modelling of cohort study data, and qualitative interviews were undertaken. Results: The systematic review found anticholinergic exposure was associated with adverse outcomes for the frail; poorer physical function, falls, and mortality, indicating a need for a risk reducing intervention. In the prediction modelling study, predicting risks using composite measures of anticholinergic burden and frailty indicated limited feasibility. Neither enhanced the performance of best subset models using cohort study data. Their predictive utility needs to be investigated using EHR data, to determine their feasibility within primary care. The qualitative study found healthcare professionals needed a proactive tool, supporting risk prediction as a feasible approach. Factors influencing future implementation were; upskilling requirements, deprescribing confidence, patient reluctance, motivation, holistic care, interoperability, trust in risk prediction, remuneration, among other barriers and facilitators. Conclusions: Through identifying a need, and potential feasibility, foundations towards the future developments of a case-finding tool have been provided, informing an early tool prototype (AC-FRAIL). Recommendations for further work suggest a roadmap ahead, to maximise the potential for integrated solutions to proactively reduce anticholinergic risks. / NIHR Yorkshire and Humber Patient Safety Translational Research Centre (NIHR YHPSTRC)

No mundo, mais pessoas morrem de tuberculose que de qualquer outra infecção curável. O Programa Nacional de Controle da Tuberculose (PNCT) tem como propósito fundamental promover o controle da tuberculose no Brasil. Busca a interrupção da transmissão da doença e a conseqüente diminuição dos riscos de adoecer e morrer por ela. Para isso, procura identificar precocemente todos os doentes, garantindo seu tratamento até o final. O Estado de São Paulo, seguindo a política nacional, muito tem investido em treinamentos para implantação da busca ativa do sintomático respiratório. Todos os funcionários de unidades de saúde vêm recebendo treinamentos e todos podem realizar a busca ativa, independente de sua profissão ou função na unidade. Entretanto, em estudo realizado no Município de Guarulhos, em 2005, constatou-se que mais de 90% dos sintomáticos respiratórios deixam de ser identificados pelos serviços de saúde, apesar de que 70% dos profissionais da rede básica de saúde do município receberam treinamento sobre busca ativa em 2004 e a mesma foi implantada em todas as unidades. O objetivo deste estudo foi de conhecer a percepção do profissional de saúde sobre a atividade de busca ativa do sintomático respiratório, no município de Guarulhos, através de entrevistas semi estruturadas e gravadas em fitas magnéticas, utilizando a estratégia metodológica do Discurso do Sujeito Coletivo. Na análise dos discursos ficou evidente que o profissional de saúde sabe o que é fazer busca ativa, a maioria se preocupa com quem está tossindo indo investigar, a atividade é reconhecida como um bom trabalho, é considerada simples apesar de desencadear várias etapas e trazer preocupações e reações tanto do usuário como do profissional de saúde, onde os fatores que inviabilizam a sua execução nas unidades de saúde que fizeram parte deste estudo são: a falta de recursos humanos, excesso de trabalho, falta de interesse e desmotivação aliados à inexistência de uma rotina implantada para que a mesma possa ser realizada. / More people die of tuberculosis than of any other curable infection worldwide. The National Tuberculosis Control Program (NTCP) is involved in the tuberculosis control in Brazil and halting disease transmission and consequently reduce the risk of people getting and dying of tuberculosis. Hence, the early identification is attempted in order to provide complete treatment of all cases. The State of Sao Paulo, in accordance with the National policy, has heavily invested in training professionals to introduce the active case finding of respiratory symptomatics as a routine activity in health care units. All healthcare professionals have been trained and are able to conduct active case findings, independent of their profession or function at the healthcare system. However, in a study conducted in the city of Guarullhos (State of Sao Paulo), in 2005, was observed that more than 90% of respiratory symptomatics are left unidentified in the healthcare units, in spite of 70% of professionals of the whole healthcare system of the municipality having received active case finding training in 2004, when the activity was introduced in all healthcare system. The objective of the present study is to appraise the perception of healthcare workers regarding the active case finding activity in the city of Guarulhos, by means of semistructured tape-recorded interviews, using the methodologic strategy of Speech of Collective Subject. In examining the speeches, it was found out that the healthcare worker is aware of what the active case finding means and most of them are concerned with people coughing and do start the necessary investigations. They recognize that the activity is simple and useful, although comprising several steps. Preoccupations and reactions of both patients and healthcare workers regarding factors that may render the activity not feasible in healthcare units are: lack of personnel, excessive amount of work, lack of interest and motivation added up to non-existing routines that would allow the work to be done.

No mundo, mais pessoas morrem de tuberculose que de qualquer outra infecção curável. O Programa Nacional de Controle da Tuberculose (PNCT) tem como propósito fundamental promover o controle da tuberculose no Brasil. Busca a interrupção da transmissão da doença e a conseqüente diminuição dos riscos de adoecer e morrer por ela. Para isso, procura identificar precocemente todos os doentes, garantindo seu tratamento até o final. O Estado de São Paulo, seguindo a política nacional, muito tem investido em treinamentos para implantação da busca ativa do sintomático respiratório. Todos os funcionários de unidades de saúde vêm recebendo treinamentos e todos podem realizar a busca ativa, independente de sua profissão ou função na unidade. Entretanto, em estudo realizado no Município de Guarulhos, em 2005, constatou-se que mais de 90% dos sintomáticos respiratórios deixam de ser identificados pelos serviços de saúde, apesar de que 70% dos profissionais da rede básica de saúde do município receberam treinamento sobre busca ativa em 2004 e a mesma foi implantada em todas as unidades. O objetivo deste estudo foi de conhecer a percepção do profissional de saúde sobre a atividade de busca ativa do sintomático respiratório, no município de Guarulhos, através de entrevistas semi estruturadas e gravadas em fitas magnéticas, utilizando a estratégia metodológica do Discurso do Sujeito Coletivo. Na análise dos discursos ficou evidente que o profissional de saúde sabe o que é fazer busca ativa, a maioria se preocupa com quem está tossindo indo investigar, a atividade é reconhecida como um bom trabalho, é considerada simples apesar de desencadear várias etapas e trazer preocupações e reações tanto do usuário como do profissional de saúde, onde os fatores que inviabilizam a sua execução nas unidades de saúde que fizeram parte deste estudo são: a falta de recursos humanos, excesso de trabalho, falta de interesse e desmotivação aliados à inexistência de uma rotina implantada para que a mesma possa ser realizada. / More people die of tuberculosis than of any other curable infection worldwide. The National Tuberculosis Control Program (NTCP) is involved in the tuberculosis control in Brazil and halting disease transmission and consequently reduce the risk of people getting and dying of tuberculosis. Hence, the early identification is attempted in order to provide complete treatment of all cases. The State of Sao Paulo, in accordance with the National policy, has heavily invested in training professionals to introduce the active case finding of respiratory symptomatics as a routine activity in health care units. All healthcare professionals have been trained and are able to conduct active case findings, independent of their profession or function at the healthcare system. However, in a study conducted in the city of Guarullhos (State of Sao Paulo), in 2005, was observed that more than 90% of respiratory symptomatics are left unidentified in the healthcare units, in spite of 70% of professionals of the whole healthcare system of the municipality having received active case finding training in 2004, when the activity was introduced in all healthcare system. The objective of the present study is to appraise the perception of healthcare workers regarding the active case finding activity in the city of Guarulhos, by means of semistructured tape-recorded interviews, using the methodologic strategy of Speech of Collective Subject. In examining the speeches, it was found out that the healthcare worker is aware of what the active case finding means and most of them are concerned with people coughing and do start the necessary investigations. They recognize that the activity is simple and useful, although comprising several steps. Preoccupations and reactions of both patients and healthcare workers regarding factors that may render the activity not feasible in healthcare units are: lack of personnel, excessive amount of work, lack of interest and motivation added up to non-existing routines that would allow the work to be done.

Introduction: World Health Organization recommends screening of household contact as a key to improve detection of tuberculosis cases. Ethiopia’s current tuberculosis household contact investigation strategies rely on symptomatic contacts attending health facilities for investigation. This approach has not led to the detection of additional tuberculosis (TB) cases; alternative approaches have to be considered. The purpose of the research was to develop guidelines in endorsing the implementation of a community based household contact investigation program in Addis Ababa. Methods: A mixed method research using sequential exploratory design was conducted in Addis Ababa. In the first phase, qualitative data collection and analysis methods were used to formulate intervention approach and in the second phase, a quantitative random controlled trial was conducted, with the purpose of comparing the proposed intervention measures with routine household contact tuberculosis investigation. Frequencies and logistic regression analyses were used to determine the relative risk and associated factors. Thematic analysis was used for qualitative data analysis. Results: The in-depth interview and focus group discussion findings identified themes namely household contact investigation (HHCI) implementation, misconceptions on HHCI, challenges with HHCI Approaches, opportunities for HHCI provision, contributing factors associated with household involvement, strategies for effective HHCI service and partnerships with health bureau. In phase two, the study reported that the prevalence of TB was 7.1% among the intervention group compared to 1.9% in the control groups at the end of first year follow-up. Nine guidelines were developed to support the household contact investigation system. Conclusion: The passive case detection strategy of contact investigation did not find more cases, and tuberculosis patients and their family contacts were not satisfied with this method. However, the proposed community-based strategy shows that more TB cases can be detected by using existing medical staff. Therefore, an approach that makes the service more accessible is significant and the recommended community based TB household contact tracing approaches needs to be scaled up for its performance towards identified missed cases and enhance patient and their household contacts involvement. / Health Studies / D. Litt. et Phil. (Public Health)

Although the importance of early identification and intervention of infants at risk for communication delays and disorders have been advocated and emphasized in literature, case finding and service delivery in rural areas in South Africa appears to be problematic. The implementation of early communication intervention (ECI) within public service delivery has been proposed in the past. The primary health care (PHC) package had to be considered as a possible vehicle to be utilized for the implementation of ECI functions in rural communities. Against this background the existing identification methods and referral systems, utilized in Ditsobotla sub-district, were described in the current study to determine the limitations in case finding, and the feasibility of the implementation of ECI functions in collaboration with other PHC programmes. A descriptive dominant-less-dominant model provided the design to describe the identification process and teamwork in Ditsobotla sub-district. Data triangulation was utilized to improve reliability and validity of results which entailed a rating scale, face-to-face interviews with PHC personnel (participants in Group 1) and face-to-face interviews with PHC programme managers (participants in group 2). The results indicated that the capacity of facilities and human resources to support the implementation of ECI functions vary within the sub-district. Therefore an incremental implementation of ECI functions is feasible in collaboration with the existing PHC package. The current identification methods and referral systems are limited and a great need for collaboration exists. ECI functions need to be implemented formally within the PHC package and guidelines for such an implementation are provided. Furthermore the identification process to be introduced needs to form part of the incremental implementation of ECI functions. The implications are discussed in terms of ECI service delivery in rural South Africa. The proposed process of incremental implementation of ECI functions in rural areas, i.e. Ditsobotla sub-district, within the PHC package is provided. The need to develop identification methods, referral systems and guidelines for the implementation of ECI in PHC are emphasized. Future practice-based research is recommended in order to improve ECI service delivery in rural areas in South Africa. Copyright / Dissertation (MCommunication Pathology)--University of Pretoria, 2009. / Speech-Language Pathology and Audiology / Unrestricted