Thesis (M.Public Health) -- University of the Western Cape, 2009. / Includes bibliographic references (leaves 118-126).

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The high prevalence of HIV has been a major cause for concern in Lesotho and the clinical course has witnessed some service lapses, complications and deaths. The researcher was therefore motivated to conduct this study with the aim to assess care and outcomes offered to HIV patients at St. Joseph’s Hospital. The objectives were to describe patient socio-demographic and clinical characteristics at initiation of antiretroviral therapy, to describe clinical parameters of haemoglobin, AST, CD4 count levels as outcome proxy of care and to analyze the rate and predictors of patient retention and lost to follow-up. Methods A retrospective cohort study of 1060 patients initiated on ART at the Thusong ART Clinic in St. Joseph’s Hospital, Roma between August 2005 and July 2008 was conducted. Relevant documentation was captured from the patients’ clinical records hard copy files onto the Therapy-Edge (TE) database tool used. Patient confidentiality was respected The dataset was closed on 31st October 2012. Data were analyzed using STATA version 11. Results The total number of patients enrolled during the study period of August 2005 – July 2008 was 1060. The findings on the patients studied showed that 99.5% were Sotho with the majority of 70.2% being female. Patients in the age group of 16-35 years were 22.2%, in the age groups of 36-55 years and >55 years were 58.3% and 19.5% respectively. Median age was 43 years. Employed persons were 24.3%, students were 2.3%, unemployed persons were 44.8% and 28.6% were of unknown employment status. On WHO classification, 18.1% was WHO Stage I, 34.6% was Stage II, 43.4% was Stage III and 3% was Stage IV. Median weight at enrollment was 55.6kg. Baseline CD4 count < 50 cells/mm3 was 13.3%, count of 50 – 199 cells/mm3 was 43.2%, CD4 count ≥ 200 cells was 38.7%. Patients with Hb <10g/dl were 17.3%. On patient retention over a period of about 6 years, 57% of the patients were still alive and in care, 11.3% had been transferred out to the health centers and clinics, 29.5% were lost to follow up. It is noteworthy that only 2.2% were recorded as dead. Conclusion The study showed that more than half of the HIV patients on ART were female, thus suggesting better access to care and health seeking behaviour. Clinical parameters of haemoglobin, AST, CD4 cell counts used to monitor progress over follow-up period showed results comparable with other similar studies. Baseline CD4 count, WHO stage, age, gender and employment status were agreeable with studies in other settings to predict those lost to follow-up (LFTU). The low percentage of documented deaths suggests that some deaths may have been included in LTFU. Better documentation, staff training and retention, decentralization of care and proper follow-up measures are steps in the right direction for better ART monitoring and outcomes.

Doctor of Philosophy(PhD) / This thesis consists of a series of studies of new models of multidisciplinary community health care in four compartments. These compartments are acute, subacute, outpatient and maintenance care. The purpose of the individual studies is to demonstrate the benifits of munltidisciplinary community health care in delivering alternatives to current practice by replacing hospital care or improving traditional community care.

The North-West Province has the fifth highest prevalence of HIV/AIDS in the country and has an estimated HIV prevalence of 22.9%. On the 24th November 1999 cabinet approved a special allocation of funds to finance a National integrated programme in the fight against the HIV/AIDS pandemic. They involved Departments of Social Services, Health, Education and Agriculture. The plan comprised three main components, which included the implementation of Home Community Based Care models for children and youth infected and affected by HIV/AIDS. The North-West Province was one of the provinces identified to pilot the programme and funds were allocated for the establishment of the programme. This study was undertaken with the aim of assessing the quality of services provided by the Home Community Based Care Programme to people infected and affected by HIV/AIDS. An empirical survey as well as a literature study was undertaken to determine whether the caregivers that are part of the Home community based care programme play their set role. Forty-five beneficiaries of the programme were randomly selected as respondents. An evaluative research design was utilised to test the progress of the Programme and check whether the programme is consistent with programme design specifications. A structured self-administered coded questionnaire with descriptive questions was developed and self administered to 45 respondents in Ikageleng Location in Zeerust who were randomly selected from a list of beneficiaries. The findings of the study indicated that caregivers who are part of the Home Community Based Care Programme play their set role. The programme provides good quality services to beneficiaries. The programme provides palliative care services, material support, care and support services, awareness and education and income generation. / Thesis (M.A. (MW))--North-West University, Potchefstroom Campus, 2008.

The North-West Province has the fifth highest prevalence of HIV/AIDS in the country and has an estimated HIV prevalence of 22.9%. On the 24th November 1999 cabinet approved a special allocation of funds to finance a National integrated programme in the fight against the HIV/AIDS pandemic. They involved Departments of Social Services, Health, Education and Agriculture. The plan comprised three main components, which included the implementation of Home Community Based Care models for children and youth infected and affected by HIV/AIDS. The North-West Province was one of the provinces identified to pilot the programme and funds were allocated for the establishment of the programme. This study was undertaken with the aim of assessing the quality of services provided by the Home Community Based Care Programme to people infected and affected by HIV/AIDS. An empirical survey as well as a literature study was undertaken to determine whether the caregivers that are part of the Home community based care programme play their set role. Forty-five beneficiaries of the programme were randomly selected as respondents. An evaluative research design was utilised to test the progress of the Programme and check whether the programme is consistent with programme design specifications. A structured self-administered coded questionnaire with descriptive questions was developed and self administered to 45 respondents in Ikageleng Location in Zeerust who were randomly selected from a list of beneficiaries. The findings of the study indicated that caregivers who are part of the Home Community Based Care Programme play their set role. The programme provides good quality services to beneficiaries. The programme provides palliative care services, material support, care and support services, awareness and education and income generation. / Thesis (M.A. (MW))--North-West University, Potchefstroom Campus, 2008.

Doctor of Philosophy(PhD) / This thesis consists of a series of studies of new models of multidisciplinary community health care in four compartments. These compartments are acute, subacute, outpatient and maintenance care. The purpose of the individual studies is to demonstrate the benifits of munltidisciplinary community health care in delivering alternatives to current practice by replacing hospital care or improving traditional community care.

Background: The role of community matron (CM) was introduced to provide a single point of access to patients living with co-morbid long-term conditions who had, or were at risk of, frequent emergency admissions to hospital. CMs utilised case management as a means of managing this growing population of patients with fragile health. Since its inception, many changes in service delivery have impacted on the role. Aim: The aim was to undertake a mixed methodology study of the factors that have affected embedding of the community matron role in 3 geographical areas. Methodology: A pragmatic mixed methods approach (QUAL quan) was utilised. Settings and participants: The studies were based in health services within 2 cities and a rural area in central England. Participants for the qualitative components of the study were purposefully sampled. The sample comprised professionals: community matrons (n=21), managers (n=4), former commissioners (n=2) and GPs (n=3); and patients (n=10) and their family carers (n=5). Quantitative data for 212 people with long-term conditions were derived from the anonymised Patients at Risk of Rehospitalisation database (PARR data) held by area 1. Methods: Qualitative data were collected from participants using semi-structured interviews and audio diaries. For the quantitative component using PARR, some patient journeys within area 1 were explored. In addition, a sample of patients who were case managed by a CM (n=106) were matched with a set of patients who were not (n=106) and the data was examined. Findings: Participants were largely positive about the role of CM. However, difficulties with role setup had led to numerous changes which affected how the role has embedded. Additionally, this impacted understanding of the role by health care professionals, and caused practical and emotional difficulties for some CMs as they perceived the role to be eroded. The quantitative findings showed that CMs did not make a significant difference to hospital bed days used by patients on their caseload. Evaluating the role and finding an effective means of showing the work undertaken by CMs, which is often invisible, proved difficult. Conclusion: Embedding of the CM role has been affected by numerous changes in service delivery. Invisibility of community nursing rather than autonomy of the community matron role seems to be a key factor in the challenges of embedding the role. The significance of these findings is that using a mixed method approach and Liaschenko and Fisher’s adapted model may help CMs to improve the visibility of their role, and so helping the role to be less prone to the challenges of service redesign.

The purpose of this thesis was threefold – First to investigate the emergence from the existing health system of nurse practitioners as a new occupation. Second to make sense of how nurse practitioners developed as primary care providers in the province of Ontario. Third to understand the nature and development of the intra-professional relationship between primary care nurse practitioners and physicians in local practice settings. I used a case study approach, with both historical (document review) and empirical (ethnography and interview) components. The empirical data was analyzed from an interpretive perspective using thematic analysis. A number of theoretical perspectives were drawn on, including Kingdon’s Agendas, Alternatives and Public Policy model, Abbott’s Occupational Jurisdiction model, Van de Ven et al’s Innovation Journey model, and Closure Theory. The study makes 3 contributions to new knowledge. First it documents the unfolding of events and actions over time, and thus serves as a historical summary. Second it adds an analysis of the case of nurse practitioners as an emergent occupation to the existing body of sociological analyses of professions. Third, it provides insight into how nurse practitioner - physician relationships are impacted at the local level because nurse practitioners are obligated to develop a relationship with a physician in order to be able to deliver comprehensive primary care services. The empirical component of the thesis analyzes and describes the nature of this relationship at a practice level. It also describes the use of ‘workarounds’ to bypass legislated restrictions in nurse practitioners’ scope of practice. It analyzes how structural differences in the manner of regulation, payment, and employment status between nurse practitioners and family physicians contribute to different styles of practice and perpetuate the hierarchical relationships between nurses and physicians. This knowledge has potential generalization to other emerging occupations, such as physician assistants and paramedics.