Smoking cigarettes has a negative impact on the population’s health and on the economy. To reduce the burdens associated with smoking, many workplaces have adopted anti-smoking initiatives (i.e., smoking policies and smoking cessation activities). Unfortunately, smaller workplaces are less likely to have implemented these initiatives, with the likelihood of adoption increasing as the size of the workplace increases. Two characteristics hypothesized to influence anti-smoking initiative adoption are organizational culture and workplace health climate. Culture refers to the values, assumptions, and subconscious norms that operate within an organization, while workplace health climate refers to the shared perceptions of an organization’s practices and priorities for health. The first study of this dissertation used a qualitative approach to describe and compare the smoking policies and smoking cessation activities at small (20-99 employees) and very small (< 20 employees) workplaces (specific aim 1). Key informants coming from small and very small workplaces (N=32) completed telephone interviews, with data analyzed using content and thematic analysis. Almost all participants (97%, n=31) described a smoking policy at their workplace. A lower proportion of workplaces offered activities to help employees quit smoking (66%, n=21). Reasons for anti-smoking initiative adoption included the implementation of a statewide smoking ban, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed adopting and implementing these activities. Facilitators to adoption and implementation included the passing of a statewide smoking ban, no issues with compliance among employees, and support from others (e.g., management). Compared to small workplaces, very small workplaces were less likely to offer cessation activities. Reasons cited for this lack of adoption included having no current smokers within the organization (i.e., activities not needed) and a lack of interest in quitting among current smokers. The second study in this dissertation examined the association between organizational culture types and smoking policy strength and smoking cessation activities (specific aim 2), and the associations between organizational culture, workplace health climate, and employee smoking (i.e., smoking status, smoking intensity, and intention to quit smoking) (specific aim 3) at small (20-99 employees) and very small workplaces (< 20 employees). This study conceptualized organizational culture with the Competing Values Framework, which theorizes that four cultural archetypes represent two major dimensions of organizational effectiveness: clan, adhocracy, hierarchical, and market. Executives coming from small and very small workplaces first participated in a brief questionnaire related to their workplace’s anti-smoking initiatives. Executives then sent a link to a separate survey to their employees, which asked questions about organizational culture, workplace health climate, and their smoking behavior. This study used regression analysis to examine associations. The final sample size for analysis was 259 executives and 280 employees coming from 68 workplaces. Culture was not significantly related to smoking policy strength. An increase in clan culture was associated with lower odds of offering smoking cessation activities (OR=0.09; 95% CI: 0.01, 0.65). Workplaces strong in clan culture did not have a significantly better workplace health climate. A better workplace health climate was associated with lower odds of being a current smoker (OR=0.10; 95% CI: 0.02, 0.57), but was not related to smoking intensity or quit intention. In consideration of the findings from both studies, the following conclusions were made: 1) the smallest workplaces offer the least protection in relation to tobacco control; 2) state and federal policies are needed to advance tobacco control; 3) organizational characteristics play an important role in shaping behaviors and outcomes related to smoking; 4) integrating organizational change strategies into comprehensive tobacco control initiatives may produce the greatest changes in employee smoking. Action is needed to increase smoking policies and programs at very small workplaces, with strategies designed to change the culture and climate of the workplace implemented.

Employee assistance was initiated early in the 19th century in the United States of America to assist employees with alcohol abuse in the workplace. During the 1970s, the concept of an employee assistance programme (EAP) was adapted to assist employees not only with alcohol-related problems, but also with personal and other work-related problems resulting in poor work performance. It is evident from the literature that no EAP is the same and that researchers have developed the seven EAP core technologies to promote uniformity within the field of employee assistance. The aim of this study was to establish a framework for a best-practice EAP for the health care sector and the quality management thereof. As background to the study, the researcher conducted an extensive literature review to investigate the current situation on the utilisation of EAPs in various industries worldwide. The literature review was used as a guide during the empirical phase of the study in order to gain more in-depth knowledge with regard to employee assistance in the health care sector. A case study design as a qualitative research approach was applied. Five focus group discussions were held with supervisors from various levels in several health care institutions as a data-gathering method. Several criteria for the bestpractice EAP were identified during the data gathering and a six-round Delphi survey was conducted to achieve consensus with regard to the criteria to be included in the best-practice EAP. Accordingly, a framework for a best-practice EAP and the quality management thereof was developed. The management of health care institutions should realise that their health care workers are their most valuable resource and that there is a need to assist them with personal and work-related problems. The framework was developed specifically for a health care institution with the option to adapt it in order to suit the unique requirements of each individual health care institution. This proposed framework could be used to develop an institution-unique EAP. The establishment of a workplaceunique EAP will show employees that they are regarded as the most valuable resource in the health care institution. The overall goal and objectives, as set out for the research study, were addressed and realised, and meaningful recommendations in the field of employee assistance have been made. The framework for a best-practice EAP is in line with the core technologies of EAPs, the needs of supervisors in health care institutions and the EAPs used internationally. The proposed framework includes the following main aspects, namely the need for an EAP in a health care institution, the strategic approach for the development of such a programme, the structure and processes of an EAP, and the evaluation of an EAP in terms of its effectiveness. The framework will contribute significantly to the management of human resources in the health care industry and provide a supportive work environment for health care workers to ensure healthy and productive employees.

The setting for the research is the urban areas of Cape Town, South Africa where the notification rate of tuberculosis is the highest in the world. Despite the availability of modern drugs, the cure rate is low and approximately 40% of diagnosed patients do not adhere to treatment. This has serious implications for the spread of multiple drug-resistant tuberculosis. The relationship between the patient and health care providers is one of the main determinants of compliance to medical treatment. The main aim of the thesis is to develop an understanding of how nurses experience their work with patients who have pulmonary tuberculosis. The research explores how nurses interact with patients, how nurses perceive their relationship with patients and the processes and organisational arrangements which contribute to the patterns of nurse-patient interaction. The interpretive research design was largely informed by an ethnographic approach. The iterative research process led to several sub-studies; the analysis of each sub-study led to a further cycle of data collection. Data collection techniques include participant observation of nurse-patient interaction and depth interviews with nurses and key informants. An exploration of opportunities to change the prevailing work patterns yielded data on nurses' responses to change. The data were captured as field notes or audio taped and analysed thematically by using qualitative methods and by the application of psychodynamic theory. The research identifies task orientation and patient-centredness as the main patterns of nurse-patient interaction. Task orientation was found to be the dominant work pattern. Its origins are traced to the colonial history and to the influence of Taylorist labour practices. Task orientated work patterns are maintained because of complex mechanisms which operate at both intrapersonal and interpersonal levels. It is argued that the history of racial politics and racial identity has influenced the ways in which nurses manage the degree of distance between themselves and patients. The findings suggest that the closer the nurses identify with patients in terms of ethnic background, the more the nurses may feel the need to distance themselves from the patients. The notion of tuberculosis as a stigmatised disease, the concept of compliance, and the implementation of control measures such as directly observed therapy are critically examined. An exploration of the illness experiences of nurses who become infected with tuberculosis, provides an opportunity to explore how nurses perceive the role of the caregiver when they are in the unfamiliar position of being patients. The findings have implications for public health interventions aimed at transforming nurse-patient interaction. It is recommended that change management processes explicitly acknowledge the consequences of decades of apartheid policies and practices on the behaviour of health professionals and the users of health services. In the years to come change agents will need to address the emotional pain of the past, as well as the more well-known sources of organisational resistance to change.

Objectives: The primary objective of this study was to assess whether active tuberculosis (TB) accelerates the course of HIV-1 infection by measuring progression to AIDS and mortality in HIV-infected patients. Secondary objectives were to evaluate whether TB should be considered an AIDS-defining illness in an area with a high prevalence of TB, and to assess the risk factors for developing TB in HIV-1 infected patients. Setting: New Somerset and Groote Schuur Hospital adult HIV clinics, Department of Medicine, Faculty of Health Sciences, University of Cape Town. Design: Prospective patient cohort study with five years of follow-up. Sample: Adult HIV-infected patients presenting to the two HIV clinics between 1992 and 1996. Methods: The TB case definition was a positive culture or a compatible clinical picture combined with a positive smear or a histologic diagnosis. TB patients were treated with 6-month short course regimens. The Kaplan-Meier method was used to estimate the overall survival times of tuberculosis and non-tuberculosis patients. The generalized log rank test was used to compare the survival curves of these two groups. The Cox proportional hazards regression method was used to determine the risk of death associated with tuberculosis while adjusting for potential confounding variables (i.e. age, CD4+ count, history of an AIDS-defining illness, use of co-trimoxazole prophylaxis, and antiretroviral therapy, etc.). The Kaplan-Meier method was used to evaluate the prognosis of HIV-infected patients with TB vs the prognosis of HIV-infected with other HIV ( or AIDS, as defined by the WHO or the CDC staging systems) related diseases at baseline. The generalized log rank test was used to compare the survival curves of the TB group vs the other groups. Predictors of active TB in HIV-infected patients were assessed using univariate and multivariate logistic regression models.

Includes bibliographical references. / Health Departments across South Africa face increasing financing constraints comparable to other developing countries and reported internationally. During the 1997/98 financial year, the Department of Health (DOH), Provincial Administration of the Western Cape (PAWC) faced huge cuts in its financial resource allocation from the National Department as policy shifted to wards addressing past inequity between the provinces. In the Western Cape Province, 200 regional hospital beds have already been closed with a further 500 beds located in academic health centres earmarked for closure. Hospitals in the province consume over 73% of the health care budge at PAWC and faced with budget cuts, research teams were approached to evaluate the supply of acute care hospital beds focusing on efficiency and equity in order to guide rational policy decisions to achieve savings from hospitals.

Various financial models were developed in the process of planning for the restructuring of academic health services in the Western Cape. In an attempt to inform and assist this process, these models are described, critically analysed and in certain cases further developed. Since most of these models are dynamic and have been developed within computer spreadsheet applications, the relevant files are included here on computer disk and form an integral part of this submission. The background to restructuring is first explored, the models are examined, and then the implications for policy, resource allocation and academic health services are discussed.

Background. When available, chest radiography is widely used in acute lower respiratory infections in children. Its impact on clinical outcome is unknown. Methods. A randomised controlled trial was performed of 522 children aged 2 to 59 months who met the World Health Organisation case definition for pneumonia. The main outcome was time to recovery, measured in a subset of 398 participants who offered a telephone number. Subsidiary outcomes included diagnosis, elements of clinical management and subsequent use of health facilities. Findings. There was a marginal improvement in time to recovery, which was not clinically significant. The median time to recovery was seven days in both groups, 95% CI 6-8 days and 6-9 days in the radiograph and control groups respectively (p=0.50, log rank test). The hazard ratio for recovery was 1.08 (95% CI 0.85 to 1.34). This lack of effect was not modified by clinicians' experience and no sub-groups of children were identified in whom the radiograph had an effect. Pneumonia was diagnosed more often in the radiograph group (14.4% vs. 8.8%, p=0.03) and bronchiolitis less often ( 44% vs. 56%, p=0.005). Antibiotic usage was higher in the radiograph group (60.8% vs. 52.2%, p=0,05). There were no differences in subsequent health facility usage. Interpretation. Despite a net change in diagnosis and an increase in antibiotic usage, chest radiography did not affect clinical outcome in outpatient children with acute lower respiratory infection. This lack of effect was independent of clinicians' experience. There were no clinically identifiable sub-groups of children within the World Health Organisation case definition of pneumonia who benefited from radiography. It is concluded that routine use of chest radiography is not beneficial in ambulatory children over two months of age with acute lower respiratory infection.

Part I of this study has highlighted certain aspects pertaining to the patients admitted to the Spinal Cord Unit at the Conradie Hospital, Pinelands, with Spinal Cord Injury (s.c.i.). The main points of interest are as follows: 0 The majority of victims of s.c.i. in this series are young men, mainly Black or Coloured, with a low educational and poor employment status, with little in the way of pension or sick leave benefits. 0 Post injury employment opportunities are very limited, as are vocational training facilities. 0 The main causes of injury are examined, and while Motor Vehicle Accidents, Falls and Gunshot wounds are commonly described in the literature as causes of s.c.i., what is unique at the Conradie Hospital is the high percentage of stab wounds (29,6%) causing spinal cord lesions. 0 The method of injury in patients coming from Cape Town is compared and contrasted with the methods of injury in other areas. 0 The levels of the cord lesions and the clinical sequelae are analysed, and while Tetraplegia and Paraplegia are well described in all series on spinal cord injuries, this series is unique in the large number of Brown-Sequard type lesions (36, or 12,7% of all patients) that exist, associated with the large number of stab wounds.

Thesis (Ed. D.)--Illinois State University, 2007. / Title from title page screen, viewed on March 11, 2008. Dissertation Committee: Thomas P. Crumpler, Ellen A. Spycher (co-chairs), Anita P. Bohn, Nancy J. Bragg. Includes bibliographical references (leaves 209-218) and abstract. Also available in print.

Thesis (Ph. D.)--University of Adelaide, Dept. of Clinical Nursing, 1998. / Includes bibliographical references (leaves 251-260).