Background: Engagement in the core public health functions and ten essential services remains the standard for measuring local health department (LHD) performance; their role as providers of clinical services remains uncertain, particularly in rural and underserved communities. Purpose: To examine the role of LHDs as clinical service providers and how this role varies among rural and nonrural communities. Methods: The 2013 National Association of County and City Health Officials (NACCHO) Profile was used to examine the geographic distribution of clinical service provision among LHDs. LHDs were coded as urban, large rural, or small rural based on Rural/Urban Commuting Area codes. Bivariate analysis for clinical services was conducted by rural/urban status. For each service, the proportions of LHDs that directly performed the service, contracted with other organizations to provide the service, or reported provision of the service by independent organizations in the community was compared. Results: Analyses show significant differences in patterns of clinical services offered, contracted, or provided by others, based on rurality. LHDs serving rural communities, especially large rural LHDs, tend to provide more direct services than urban LHDs. Among rural LHDs, larger rural LHDs provided a broader array of services and reported more community capacity for delivery than small rural LHDs- particularly maternal and child health services. Implications: There are capacity differences between large and small rural LHDs. Limited capacity within small rural LHDs may result in providing less services, regardless of the availability of other providers within their communities. These findings provide valuable information on clinical service provision among LHDs, particularly in rural and underserved communities.

This study is concerned with the pre-test counselling conversation (as regulated by policy-governing and training documents) that occurs between HIV counsellors and their clients. It attempts to explore and describe some of the assumptions underlying HIV/AIDS pre-test counselling in South Africa, and reflects on how these assumptions determine the content and process of HIV pre-test counselling. This exploration has been done by means of an analysis of a selection of official and non-official documentation on pre-test counselling. The aim of HIV/AIDS counselling in general is to support and educate infected/affected clients about the HI-virus. Pre-test counselling (the conversation that takes place before an HIV-test is administered) forms the entry level to HIV counselling service delivery in South Africa, and it is often the only opportunity a counsellor has to support and educate a client about HIV/AIDS. Policy-governing pre-test counselling and training documents on such counselling confirm the role played by counsellors. The pre-test counselling conversation is based on the assumption that education about the HI-virus will enable clients to make informed decisions about their health which will help them to live long and healthy lives once they are aware of their HIV-status. However, this educational approach does not seem to be successful, as a change in risk behaviour is often not achieved. My recognition of this situation motivated this study and its focus on the conversation that takes place between counsellors and their clients in pre-test counselling. I was curious about what is discussed during pre-test counselling and why, if we acknowledge that counselling plays a major role in infection rate prevention, risk-reducing behaviour is not being achieved. This qualitative study was based on a social constructionist paradigm and document analysis was used as a research method. This study offers an alternative approach to health education – a drive towards client-centred pre-test counselling where the client’s needs become the focus of the pre-test counselling conversation. / Dissertation (MA (Counselling Psychology))--University of Pretoria, 2007. / Psychology / unrestricted