Integrative Summary In 1997 the Minister of Public Service and Administration of South Africa, Zola Skweyiya, introduced the White Paper on Transforming Public Service Delivery(Department of Public Service and Administration(DPSA,1997: 1). It was premised on what was called Batho Pele (DPSA, 1997: 9), giving effect to Section 197 of the Constitution, Act 108 of 1996 as amended. A linkage to performance management can be found from the assertion made in the White Paper that in future the Batho Pele would form the basis of any assessment of the performance of individual staff and that would contribute to improving the delivery of service (DPSA, 1997:16). Another factor that contributed to the utilisation of a performance management system was the recommendation put forward by the Public Service Commission of South Africa( PSC,2004: 16),that called for public institutions to adopt a clear, comprehensive performance management and evaluation framework for the delivery of public service. That was expected to turn around the ailing public institutions whose record of serving the public with pride and dignity was on the decline. The research aim was to evaluate the effectiveness of the performance management system in creating and resolving role conflict with health professionals employed by the Buffalo City sub-district. The research goal was divided into three objectives, namely: evaluation of the effectiveness of the performance management system as a managerial tool for health managers to manage their subordinates including both professional and support staff, evaluation of the effectiveness of the performance system from the perspective of the health professional as a subordinate and to analyze the functioning and effectiveness of the system in creating and resolving role conflict between professional conduct and organisational requirements. The respondents noted that the implementation of the system was not matched with appointment at managerial level with officials having relevant managerial capacity. Further to that resources at the coal face of service delivery continued to deteriorate and became very scarce and there is no documented proof that has been found of an effort made to check the compatibility of the system to health professionals. The literature identified negative effects that have emanated from the implementation of the performance management system. The study was conducted by interviewing health professionals from the entry level to the management level within the Buffalo City sub-district from three mini hospitals or Health Care Centres. The respondents indicated that there are positives that have been achieved by the implementation of the system, such as the skills gap identification as well as specific targets contained in annual performance contracts. These targets help motivate health professional to focus on that particular direction of activities. Unfortunately it has been clearly documented that the performance management system has also contributed to the development of role conflict in a number of professionals. It has been documented that the system has not been crafted with a health professional in mind and, as such, appears to favour quantity rather than quality of health services as advocated by the codes of practice of different health professionals. There are a number of recommendations that were put forward by the respondents to try to salvage the system and in mitigation of the identified negative factors. For the improvement of the system, the Eastern Cape Provincial Department of Health has to firstly customise the annual contracts to contain only the fundamental information. Secondly need to improve the transparency pertaining to financial pressures facing the Health Department. Thirdly the provision of essential enablers, need to be prioritised. Fourthly there is a need to upgrade the system to incorporate 360 degree feedback. Further research recommendations include a bigger sample incorporating different research methods and to also incorporate searches for measures that can be implemented to improve the system to be more relevant to health professionals. This document is organised and presented in three sections. The first section is the evaluation report with a review of literature, research methodology, findings, discussion and conclusion. The second section is where an indepth literature review is located and the last section details the research methodology.

This project examines the role of immunization registries and their effect on a health care delivery system. Recent efforts to attain coverage of child populations by recommended vaccines have included initiatives by federal and state agencies, as well as private foundations, to develop and implement statewide community-based childhood immunization registries.

The purpose of this research is to explore students’ on-line interactivity in an Open Distance Learning institution with other students, educators, study materials and Unisa as the sampled prototypical research subject. A mixed-method of research encompassing both explorative and descriptive aspects was used. Data was collected through myUnisa discussion forum, focus group interviews and an on-line questionnaire from second and third year Health Services Management students at the University of South Africa (Unisa). Although the findings indicated that 84.9% of students owned computers, and 100% owned cellular phones, only 3.8% participated in the discussion forum. On-line discussion forum are critical in Open Distance Learning (ODL) because it allows people who cannot physically attend the educational institution to interact with each other. Almost 40% of these sampled students agreed that the discussion forum allowed them to study with their peers. However, only 53 of the 1,379 students registered for both second and third year studies during the first semester participated in the discussion forum. This indicates that very few students benefit from on-line interaction. Most of the students who are enrolled in Health Services Management course are from 21 to above 50 years of age. This age factor can have an impact on computer literacy. Some of them indicated that they struggled with the utilisation of technology. The majority of these students do not utilise the prescribed on-line interactive tools effectively. Students’ need support cognitively, academically, administratively, institutionally and affectively. The findings suggest that although students are aware of the benefits of using online technologies, they do not have the support from the institution to enable them to better their skills in using these technologies. The other challenge that they have raised is that educators also interact minimally on-line. Therefore, they do not receive the necessary feedback they require. The university systems are sometimes offline, which becomes worse during registration and submission of assignments. The recommendations emanating from the study warrants various interventions of multiple stakeholders to resolve the students’ challenges. / Health Studies / D.Litt. et Phil. (Health Studies)

Indiana University-Purdue University Indianapolis (IUPUI) / Consistent under-reporting of autism cases by Indiana physicians to the Indiana Birth Defects and Problems Registry (IBDPR) has made quality autism-related data very difficult to obtain (Indiana Birth Defects and Problems Registry [IBDPR], 2011). As a result, the Indiana State Department of Health (ISDH) currently also utilizes data from billing information that it receives from hospital discharges. However, such cases must be investigated further because autism is often merely suspected as a possibility in the discharge data. A chart auditor must therefore review the child’s chart to determine if the condition is confirmed. Meanwhile, the Indiana Department of Education (IDOE) has a different diagnostic procedure from physicians for determining whether a student has an Autism Spectrum Disorder (ASD), which qualifies him or her for special education. A physician diagnosis of autism does not guarantee that a child will receive special education from public schools. With all of these current complications surrounding autism, announced changes in the definition of autism by the American Psychiatric Association (APA) will likely have effects on both the special education field and the public health field. There is a possibility that children who had previously received special education could cease to maintain their eligibility and may find it difficult to obtain benefits. The IDOE may find it necessary to reevaluate their criteria for determining special education eligibility. Additionally, public health officials may see the definition changes affect the number of autism cases they perceive their populations to have, thus impacting community and policy decisions. This study was performed as an attempt to investigate and compare the sources used by the IBDPR to obtain autism data, and determine whether or not the resulting data creates an accurate depiction of the autistic population of Indiana. It was also performed to speculate whether a stricter definition of autism will result in a higher quality of data for the IBDPR and a more consistent view on the disorder between the ISDH and the IDOE. Perhaps from such consistency and simpler definitions, future recorded data will more closely resemble that of reality, enabling the ISDH to utilize the IBDPR to its full extent. Using current definitions for an exploratory analysis of data from the past five years, a discrepancy clearly exists between the IBDPR and the reality of the population of Indiana.

Background Iron deficiency (ID) is the world‟s most prevalent micronutrient deficiency and predominantly affects developing countries, also South Africa. In areas with low fish consumption and high n-6 PUFA vegetable oil intake, there is a risk for having inadequate n-3 PUFA status. Both iron and n-3 PUFA play important roles in the immune response, and supplementation is a strategy to alleviate deficiencies. However, little is known about potential interactive effects between concurrent iron and n-3 PUFA supplementation on the immune system. This is also important in the context that iron supplementation may be unsafe and may increase morbidity and mortality. Aim The overall aim of this thesis was to assess the effects of iron and docosahexaenoic (DHA)/eicosapentaenoic acid (EPA) supplementation, alone and in combination, on the immune system of ID children. More specifically, these effects were investigated on the occurrence and duration of illness and school-absenteeism due to illness, peripheral blood mononuclear cell (PBMC), red blood cell (RBC) and plasma total phospholipid fatty acid composition, iron status, fatty acid-derived immune modulators and targeted PBMC gene expression. Furthermore, association of PBMC, RBC and plasma total phospholipid fatty acid composition with allergic disease, were also examined. Design In a 2-by-2 factorial, randomised, double-blind, placebo-controlled trial, South African children (n = 321, aged 6–11 y) were randomly assigned to receive oral supplements of either 1) iron (50 mg as ferrous sulphate) plus placebo; 2) DHA/EPA (420/80 mg) plus placebo; 3) iron plus DHA/EPA (420/80 mg); or 4) placebo plus placebo for 8.5 mo, four times per week. Absenteeism and illness symptoms were recorded and biochemical parameters for compliance as well as parameters fundamental to immune function were assessed at baseline and endpoint. Furthermore, in a cross-sectional design, associations of allergic disease with baseline fatty acid composition of PBMC, RBC and plasma were examined. Results The combination of iron and DHA/EPA significantly attenuated respiratory illness caused by iron supplementation. DHA/EPA supplementation alone improved respiratory symptoms at school, but increased headache-related absenteeism. DHA/EPA and iron supplementation individually tended to increase and decrease anti-inflammatory DHA and EPA-derived mediators, respectively. Furthermore the anti-inflammatory DHA-derived immune mediator, 17HDHA was higher in the DHA/EPA plus placebo and iron plus DHA/EPA groups than in the iron plus placebo group. Also, the pro-inflammatory arachidonic acid (AA)-derived modulators (5- and 15-hydroxyeicosapentaenoic acid) were significantly lower in the iron plus DHA/EPA group compared to the placebo plus placebo groups. In the study population, 27.2% of the children had allergic disease and AA in PBMC phospholipids was significantly lower in the allergic children than in the non-allergic children. In RBC phospholipids dihomo-gamma-linolenic acid (DGLA) and the ratio of DGLA: linoleic acid (LA) correlated negatively and the n-6:n-3 PUFA ratio positively with total immunoglobulin E (tIgE). Furthermore, trans-C18:1n-9, tended to be higher in the allergic group. Conclusion DHA/EPA prevented respiratory illness caused by iron supplementation and although DHA/EPA on its own reduced respiratory morbidity when the children were present at school, surprisingly it increased the likelihood of being absent with headache and fever. The biochemical findings compliment the clinical results and support previous observations about DHA/EPA supplementation to reduce inflammation, but add to the current knowledge base that a relatively high oral dose of non-haem iron modulates circulating lipid-derived immune modulators and related gene expression. Furthermore, when supplementing with iron and DHA/EPA combined, in this ID population with low fish intake, the anti-inflammatory effect of DHA/EPA is maintained concurrently with attenuation of respiratory morbidity. This finding support the notion that excess iron (probably as non-transferrin bound iron) becomes available for pathogens and is probably why we found that iron increased respiratory infectious morbidity. The improved clinical outcome with combined supplementation seems to be related to increased lipid-mediator synthesis gene expression and the availability of DHA/EPA, leading to a more pro-resolving profile and enhanced immune competence. Overall these results give better insight into immune function and infectious morbidity in relation to n-3 PUFA and iron status and treatment, as well as the possible association of fatty acid status with allergic disease in young South-African school children. / PhD (Nutrition), North-West University, Potchefstroom Campus, 2015

Background Iron deficiency (ID) is the world‟s most prevalent micronutrient deficiency and predominantly affects developing countries, also South Africa. In areas with low fish consumption and high n-6 PUFA vegetable oil intake, there is a risk for having inadequate n-3 PUFA status. Both iron and n-3 PUFA play important roles in the immune response, and supplementation is a strategy to alleviate deficiencies. However, little is known about potential interactive effects between concurrent iron and n-3 PUFA supplementation on the immune system. This is also important in the context that iron supplementation may be unsafe and may increase morbidity and mortality. Aim The overall aim of this thesis was to assess the effects of iron and docosahexaenoic (DHA)/eicosapentaenoic acid (EPA) supplementation, alone and in combination, on the immune system of ID children. More specifically, these effects were investigated on the occurrence and duration of illness and school-absenteeism due to illness, peripheral blood mononuclear cell (PBMC), red blood cell (RBC) and plasma total phospholipid fatty acid composition, iron status, fatty acid-derived immune modulators and targeted PBMC gene expression. Furthermore, association of PBMC, RBC and plasma total phospholipid fatty acid composition with allergic disease, were also examined. Design In a 2-by-2 factorial, randomised, double-blind, placebo-controlled trial, South African children (n = 321, aged 6–11 y) were randomly assigned to receive oral supplements of either 1) iron (50 mg as ferrous sulphate) plus placebo; 2) DHA/EPA (420/80 mg) plus placebo; 3) iron plus DHA/EPA (420/80 mg); or 4) placebo plus placebo for 8.5 mo, four times per week. Absenteeism and illness symptoms were recorded and biochemical parameters for compliance as well as parameters fundamental to immune function were assessed at baseline and endpoint. Furthermore, in a cross-sectional design, associations of allergic disease with baseline fatty acid composition of PBMC, RBC and plasma were examined. Results The combination of iron and DHA/EPA significantly attenuated respiratory illness caused by iron supplementation. DHA/EPA supplementation alone improved respiratory symptoms at school, but increased headache-related absenteeism. DHA/EPA and iron supplementation individually tended to increase and decrease anti-inflammatory DHA and EPA-derived mediators, respectively. Furthermore the anti-inflammatory DHA-derived immune mediator, 17HDHA was higher in the DHA/EPA plus placebo and iron plus DHA/EPA groups than in the iron plus placebo group. Also, the pro-inflammatory arachidonic acid (AA)-derived modulators (5- and 15-hydroxyeicosapentaenoic acid) were significantly lower in the iron plus DHA/EPA group compared to the placebo plus placebo groups. In the study population, 27.2% of the children had allergic disease and AA in PBMC phospholipids was significantly lower in the allergic children than in the non-allergic children. In RBC phospholipids dihomo-gamma-linolenic acid (DGLA) and the ratio of DGLA: linoleic acid (LA) correlated negatively and the n-6:n-3 PUFA ratio positively with total immunoglobulin E (tIgE). Furthermore, trans-C18:1n-9, tended to be higher in the allergic group. Conclusion DHA/EPA prevented respiratory illness caused by iron supplementation and although DHA/EPA on its own reduced respiratory morbidity when the children were present at school, surprisingly it increased the likelihood of being absent with headache and fever. The biochemical findings compliment the clinical results and support previous observations about DHA/EPA supplementation to reduce inflammation, but add to the current knowledge base that a relatively high oral dose of non-haem iron modulates circulating lipid-derived immune modulators and related gene expression. Furthermore, when supplementing with iron and DHA/EPA combined, in this ID population with low fish intake, the anti-inflammatory effect of DHA/EPA is maintained concurrently with attenuation of respiratory morbidity. This finding support the notion that excess iron (probably as non-transferrin bound iron) becomes available for pathogens and is probably why we found that iron increased respiratory infectious morbidity. The improved clinical outcome with combined supplementation seems to be related to increased lipid-mediator synthesis gene expression and the availability of DHA/EPA, leading to a more pro-resolving profile and enhanced immune competence. Overall these results give better insight into immune function and infectious morbidity in relation to n-3 PUFA and iron status and treatment, as well as the possible association of fatty acid status with allergic disease in young South-African school children. / PhD (Nutrition), North-West University, Potchefstroom Campus, 2015

The primary aim of this study is to describe and explain the extent of which school managers and primary healthcare facility managers possess knowledge and awareness of their roles in the implementation of the Integrated School Health Policy in Region C in the Gauteng Provincial Department of Basic Education. The study used a qualitative research method by which semi-structured interviews were conducted using a descriptive and explanative design. A sample of ten respondents was elected using a purposive sampling strategy and conventional or content analysis was utilised in the interpretation and analysis of data. The main findings of the study revealed that managers know their role in the implementation of the policy. Although managers are aware of their important roles; they are unable to fulfil them due to a lack of skills. Therefore, the study recommends that the Department of Health and the Department of Basic Education should ensure that managers are skilled and more knowledgeable in implementing the policy objectives. / Public Administration and Operations Management / M. Admin. (Public Admiistration)

Climate change is regarded as the greatest threat facing the world today. The Intergovernmental Panel on Climate Change (IPCC) concluded that climate change is caused by human activities, as a result of greenhouse gases (GHGs) being emitted into the atmosphere. Scientific literature on the impact of climate change is well documented, especially for the health sector. The mission of the Gauteng Department of Health (GDoH) is to “contribute towards the reduction of the burden of diseases in all the communities in Gauteng”. Ekurhuleni Health District is part of GDoH and shares a similar mission. However, this mission is under threat due to the direct and indirect impact of climate change on the public health sector. Therefore, it is essential for Ekurhuleni Health District and Provincial Clinics to take measures to reduce their contribution to climate change in the light of improving the health of their constituent. This study estimates the carbon footprint of the employees of Ekurhuleni Health District and Provincial Clinics and determines the knowledge and perception of climate change among managers and operational employees. The methodologies of the Greenhouse Gas Protocol (GHGP) and the Department of Environmental Forestry and Rural Affairs (DEFRA) were used to quantify the carbon footprints of the employees of the Ekurhuleni Health District and Provincial Clinics. A content analysis was applied to determine the knowledge and perception of climate change. The study revealed that Scope 2, indirect emissions (electricity), accounts for 92% (35150 t CO2e) of the total carbon footprints for the period of five years, 2010-2014. Scope 1, direct emission (vehicles), is responsible for 4% (1362 t CO2e) and Scope 3, indirect emissions for ICT, for 2% (862 t CO2e), office paper 1% (181 t CO2e) and air conditioners 1% (458 t CO2e). The majority of employees demonstrated basic knowledge of climate change. However, the concept of GHGs was unfamiliar to most of the employees. In terms of perceptions of climate change, the majority of employees were concerned about the future of the planet and climate change and believed that climate change will impact their job description. The study recommends the following mitigation measures, among others, to reduce carbon footprints: (1) electrical vehicles; (2) substituting personal desktops with laptops; and (3) substituting HFC-23 air conditioner refrigerant with R410A. These recommendations have the potential to reduce the carbon emissions by 2445 t CO2e for the period of five (5) years and save R7 875 089 from fuel and power consumption. Furthermore, the District Office and Provincial Clinics can generate a revenue of R293 400 by registering for a CMD project for five years or R1 173 600 for the duration of the project (20 years). / Environmental Sciences / M. Sc. (Environmental Management)

Indiana University-Purdue University Indianapolis (IUPUI) / Oral health is crucial to overall health and a focus of the U.S. Health Center program, which provides preventive dental services in medically underserved communities. Dental hygiene is an oral health profession whose practice is focused on dental disease prevention and oral health promotion. Variations in the practice and regulation of dental hygiene has been demonstrated to influence access to dental care at a state level; restrictive policies are associated lower rates of access to care. Understanding whether and to what extent policy variations affect availability and access to dental care and the oral health of medically underserved communities served by grantees of the U.S. Health Center program is the focus of this study. This longitudinal study examines dental service utilization at 1,135 health center grantees that received community health center funding from 2004 to 2011. The Dental Hygiene Professional Practice Index (DHPPI) was used as an indicator of the state policy environment. The influence of grantee and state level characteristics are also considered. Mixed effects models were used to account for correlations introduced by the multiple hierarchical structure of the data. Key findings of this study demonstrate that state policy environment is a predictor of the availability and access to dental care and the oral health status of medically underserved communities that received care at a grantee of the U.S. Health Center program. Grantees located in states with highly restrictive policy environments were 73% less likely to deliver dental services and, those that do, provided care to 7% fewer patients than those grantees located in states with the most supportive policy environments. Population’s served by grantees from the most restrictive states received less preventive care and had greater restorative and emergency dental care needs. State policy environment is a predictor of availability and access to dental care and the oral health status of medically underserved communities. This study has important implications for policy at the federal, state, and local levels. Findings demonstrate the need for policy and advocacy efforts at all levels, especially within states with restrictive policy environments.