Thesis submitted in fulfillment of the requirements for the degree of Masters in Technology: Biomedical Sciences in the Faculty of Health and Wellness Sciences at the Cape Peninsula University of Technology 2015 / Background: The Mixed Ancestry population of South Africa has recently been reported to have a higher prevalence of type 2 diabetes (T2DM). However, the genetic risk factors that may contribute to the development of T2DM are currently unknown. We investigated the association of fat mass and obesity-associated gene (FTO), ectonucleotide pyrophosphatase/phosphodiesterase gene (ENPP1) and transcription factor 7-like 2 gene (TCF7L2) with T2DM risk in a community residing in Bellville South, Cape Town. Methods: Five hundred and sixty six participants (11.7% males) who consented to genetic analyses were genotyped for six single nucleotide polymorphisms (SNPs): ENPP1-rs997509 and -rs1044498, FTO-9941349 and -rs3751812, TCF7L2-rs12255372 and -rs7903146. The SNPs were genotyped using their corresponding Taqman genotyping assays, and validated by automated sequencing. Allele and genotype frequencies were determined and regression analyses was conducted to assess the association of the polymorphisms with T2DM and its related,traits. Results: Overall and in subgroups defined by diabetes and obesity statuses, there were present no significant differences in the distribution of alleles and genotypes, except for the polymorphisms observed in the FTO and ENPP1 genes. In logistic regression models adjusted for age, sex, body mass index (BMI) and insulin resistance, minor alleles of ENPP1-rs997509 and ENPP1-rs1044498 were associated with risk for T2DM respectively, 4.55 (1.06-19.49) (p=0.041) and 1.81 (1.09-2.98) (p=0.021) assuming a recessive genetic model. Furthermore, the FTO rs9941349 minor allele was associated with the prevalent T2DM under the log-additive model: 1.40 (1.00 to 1.96) (0.049). The TCF7L2 polymorphisms showed no evidence of association with T2DM and/or insulin sensitivity/resistance indicators. Conclusion: Our results demonstrate that ENPP1 and FTO polymorphisms may contribute to T2DM susceptibility in this population, confirming previous findings that insulin resistance may mediate the development of the disease in the Mixed Ancestry population group of South Africa.

Thesis ((M. A. (Pharm.)) -- University of Limpopo, 2019 / Introduction: Polypharmacy is highly prevalent within the population of patients with diabetes mellitus (DM), with patients being prescribed with four or more medications with mainly preventative medications for cardiovascular complications. The increase in the prevalence of polypharmacy has a major impact on the drug expenditures. Meanwhile, the management of DM is expensive, and the cost affects individuals, families, society, health care providers, and national productivity. The largest component of financial cost is accounted for by medicines. Furthermore, with DM being the second cause of mortality rates in South Africa there is a need for cost of illness studies in order to develop intervention programs to ameliorate or prevent this lifestyle disease Objectives: To identify the medications the patient was taking that were considered as polypharmacy in the management of type 2 diabetes mellitus (T2DM), to calculate and analyse the costs of the medications and to quantify the financial burden of polypharmacy in T2DM patients. Method: This research was a quantitative study, providing the numeric description of the economic cost of polypharmacy. The financial burden of polypharmacy was retrospectively measured using descriptive statistics. The study was conducted using T2DM patient files (n=115) from the outpatient section of the pharmacy as well as from the records department whereby all DM patients’ files were retrieved by aid of a DM register from outpatient department (OPD). The data sheet enabled recording of information that was divided into three sections namely the demographic information, the diagnosis profile, as well as the medications. The cost of drugs was retrieved from the pharmacy purchase invoices for the years 2016 and 2017 as well as Department of Health medicines registry for the retail prices. Data was analysed using statistical Package for Social Sciences (SPSS) version 25 for descriptive analysis and Microsoft Excel TM was used for calculation and quantification of the financial burden. The independent t test was used in Microsoft ExcelTM for statistical significance of differences. Results: The distribution of the population by gender revealed that 68% of females were on polypharmacy as compared to 32% of males. The results also showed that majority of participants accounting 71% of the population were falling within the age xi group of 51-70 years, meanwhile the least number of participants accounting 1% of the population were between the age group of 30-40 years. The total cost of the treatment regimen for the two years of the study period was found to be R179303.50 in hospital (Mean=R35860.80, SD=R58945.15, n=115) and the possible cost of polypharmacy was found to be R1517379.00 in retail (Mean=R303475.76, SD=480115.84, n=115). The difference was statistically significant t (16) = 2.11, p=0.04 (1 tail) at 95% confidence interval. This means that the average cost per patient per year is R1558.18 and R129.93 per month in hospitals but R6597.30 per year and R549.78 per month in retail for the management of T2 DM patients who are on polypharmacy. These numbers are 4 times higher than patients who are on monotherapy. Conclusion: Polypharmacy imposes a high financial burden on the management of T2DM for the government and for patients in cases where medications like insulin which is the most costly component of five out of nine detected regimens are unavailable in hospitals and they therefore have to buy at retail pharmacies. The appreciation and understanding of these costs in real terms by health professionals and decision makers, can add value to processes of budget allocations to pharmaceutical services. Recommendations: Doctors and pharmacists should work together to optimize the quality of care for patients with T2DM but also consider the cost aspect when prescribing and dispensing treatment regimen for a patient. The patient’s prescriptions must be thoroughly reviewed and rationalised according to recent progress of the patient. Non-pharmacological management of T2DM is the mainstay of therapy and prevention so pharmacist and doctors needs to emphasize more on those rather than dispensing a lot of medications to patients that can manage to control their condition with no medications prescribed. Lastly, preventative programs for T2DM needs to be prioritized. / CHIETA and HWSETA

Thesis (M. Pharm) -- University of Limpopo, 2019 / Diabetes mellitus (DM) is a major public health problem, challenging patients, healthcare professionals, health planners and policy makers worldwide. Its prevalence has been on the rise for the past four decades, with this trend expected to continue. With this challenge, the management of DM should be done following evidence-based guidelines to prevent or slow down the development of DM-related complications. According to the Society of Endocrinology Metabolism and Diabetes South Africa (SEMDSA) guidelines, it has been shown that strict glycaemic control and proper clinical monitoring can help with prevention and slowing down development of complications. If left untreated or poorly controlled, DM progresses into an array of complications which may increase morbidity and mortality. The prevalence and management of DM complications was investigated. Objectives: • To determine the prevalence of DM complications at Mankweng Hospital. • To evaluate the management of patients with DM complications at Mankweng Hospital. • To determine the factors contributing to the development of complications. • To determine preventive measures taken on non-complicated patients to prevent them from complicating. Method: A retrospective longitudinal review of 134 randomly selected patient records was conducted for a five-year period spanning from June 2012 to May 2017. A pretested DM complications checklist was used to collect data from the patient records. A cross-sectional study was conducted amongst healthcare professionals caring for patients with DM. A total of 41 healthcare professionals were included in the study where a self-administered questionnaire was used to obtain the data. Both sets of data obtained were analysed using IBM SPSS version 25. xiii Results: Retrospective study The study sample population was entirely consisted of African patients with 70.1% (n=94) females and 29.9% (n=44) males. In the sample, 17.2% were suffering from T1DM while 82.8% were suffering from T2DM. The complications with the highest prevalence were diabetic nephropathy, peripheral neuropathy and diabetic retinopathy with prevalence of 35.8%, 32.1% and 22.4% respectively. Vascular diseases, autonomic neuropathy and diabetic foot ulcer had prevalence of 9.7%, 9% and 6% respectively. The overall prevalence of complications in general was 67.2% which was very high. Cross-sectional study A self-administered questionnaire was distributed amongst 41 healthcare professionals (14 males and 27 females). This sample consisted of 9.8% doctors, 41.5% pharmacists, 17.1% professional nurses, 17.1% physiotherapists, 2.4% podiatrists and 12.2% optometrists. It was discovered that only 92.6% and 84.6% of the participants were compliant with the guidelines in terms of random blood glucose tests and blood pressure (BP) per every visit. Only 50% of the HCPs revealed that HbA1c tests should be done according to the guidelines. Merely 5.6%, 8.3%, 5.3% and 22.7% of the HCPs correctly indicated the frequency of foot examinations, eye examinations, renal function tests and lipogram tests respectively, as per the guidelines. Patient related factors were rated as the most contributory factors (56.4%) to the development of complications. Socio-economic and medication related factors had most of the HCPs (36.1% and 29% respectively) rating them as moderate in terms of how much they contribute to the development of complications. The factors rated the least were healthcare team (32.4%) and health system (33.3%) related factors. Conclusion: There was a high prevalence of overall complications in general, with diabetic nephropathy, peripheral neuropathy and diabetic retinopathy being the three highest individual complications. There was poor monitoring of patients with complications as the compliance with the SEMDSA guidelines was very low. Patient related factors xiv were rated the most contributory factors to the development of complications in patients with DM. Recommendations: There is need to implement patient-centred DM care which makes sure that the patient is involved in decision making so that they take responsibility of their own health. There is need for the development and implementation of institutional quality improvement programs where regular audits of the processes of DM care and outcomes are monitored. Limitations: • The limitations of the study are that the researcher completely relied on patient records. • The sample size for HCPs was very small and therefore the study results cannot be generalised. / HWSETA

Thesis (M. A. (Nursing Science)) -- University of Limpopo, 2019 / Background: Non-attendance of diabetic patients at primary health care facilities for scheduled appointments has been identified as one of the most pressing issues in chronic illness, including diabetes mellitus, management and results into uncontrolled illnesses. Diabetes mellitus has an increased mortality and morbidity rate, thus has been identified as the second most frequent killer disease in South Africa. Aim of the study: The purpose of the study is to determine self-management strategies to maintain a healthy life for diabetic patients under treatment in primary health care facilities in the Sekhukhune District. Methods: A qualitative, phenomenological, explorative and descriptive study design was conducted in 5 clinics of the Sekhukhune District in the Elias Motswaledi Municipality in Limpopo Province. Data were collected through one-to-one interviews using semi-structured guide. An non-probability purposive sampling method was used to select participants until data saturation was reached. Data were analysed using Tech’s coding qualitative data analysis approach. Results: The findings of this research reveal that diabetic patients know the importance of adherence to diet. However, they also elaborated on the challenges they face, like inability to afford proper diet and their stress levels. They are aware of predisposing factors and recommend support structures like food parcels as well as adhering to the prescribed treatment. Conclusion and recommendations: Diabetic patients lack self-management strategies to maintain their quality of life when diagnosed with diabetes. Furthermore, the study concludes that diabetics lack encouragement and empowerment from health care workers and their families. The study recommends that diabetic patients adhere to a prescribed diet and treatment and that they could be offered food parcels and taught how to avoid factors that could trigger stress. Additionally, it is recommended that support structures be developed to assist diabetic patients about self-management strategies that they could use in order to maintain a good quality of v life. It is also recommended that the Department of Health employ Home-Based Carers in the facilities to assist diabetic patients with their day-to-day care.

Thesis (MFamMed)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Background Diabetes is a significant contributor to the burden of disease in South Africa and to the reasons for encounter in primary care. There is little structured and systematic education of patients that supports self-care. This study was a qualitative assessment of a diabetes group education programme in Community Health Centres of the Cape Town Metropolitan District. The programme offered four sessions of group education and was delivered by trained health promoters using motivational interviewing as a communication style. The aim of the study was to evaluate the programme by exploring the experiences of the patients who attended. Methods Thirteen individual in depth interviews were conducted. Each patient had attended the educational programme and came from a different health centre in the intervention arm of a larger randomised controlled trial. The interviews were audiotaped, transcribed and then analyzed using the framework approach. Results Patients expressed that they gained useful new knowledge about diabetes. The use of educational material was experienced positively and enhanced recall and understanding of information. The general experience was that the health promoters were competent, utilised useful communication skills and the structure of sessions was suitable. Patients reported a change in behaviour especially with diet, physical activity, medication and foot care. There were organizational and infrastructural problems experienced specifically with regards to the suitability of the venue and communication of information regarding the timing and location of the sessions. Conclusion This study supports the wider implementation of this programme following consideration of recommendations resulting from patient feedback. However, only patients who attended the educational sessions were interviewed and the results of the larger controlled trial must still be obtained.

The aim of this study was to determine the prevalence and causes as well as the risk factors of visual impairment (VI) and blindness among Black South Africans with diabetes mellitus (DM) aged 40 years and older in Mopani District, Limpopo province, South Africa. This was a cross-sectional study in which Black South Africans with DM aged ≥40 years old were examined for VI and blindness. In addition, anthropometric as well as risk factors for VI and blindness were studied. A total of 225 participants were selected from seven Public Health Facilities in Mopani District. Data was collected using standard optometric instruments, anthropometric instruments and structured interviews. Data analysis was done using the Statistical Analysis System (SAS) and Microsoft Excel software packages. The ages of the participants ranged from 40 to 90 years with a mean of 61.5±10.49 years. There were more females (71.5%) than males (28.4%). The prevalence of uncorrected VI and blindness in the right eyes of the participants was 70.7% and 3.6%, respectively. In the left eyes, it was 72% and 3.1%, respectively. However, following optical correction, the prevalence in right eyes was 41.3% and 3.6%, respectively. In the left eyes, it was 42.2% and 3.1%, respectively. Risk factors that were individually associated with VI and blindness include age, educational qualification, monthly income, knowledge of DM types, oral DM treatment (pills), losing weight, compliance to losing weight, family history of DM, physical activity, and date of last eye examination .When logistic regression was used, knowledge of DM types, pills, and compliance to losing weight, family history of DM, monthly income and physical activity remained associated with VI and blindness. The high prevalence of VI in this diabetes population was not primarily due to DM itself, but due to refractive error and cataract, conditions which have effective and easy treatments. A total of 84% of the participants were visually impaired due to either refractive error or cataract or both and only 3.8% due to diabetes retinopathy. It is therefore recommended that appropriate and affordable refraction and cataract surgical services be made available and accessible to this population / Health Studies / D. Litt. et Phil. (Health Studies)

The aim of this study was to determine the prevalence and causes as well as the risk factors of visual impairment (VI) and blindness among Black South Africans with diabetes mellitus (DM) aged 40 years and older in Mopani District, Limpopo province, South Africa. This was a cross-sectional study in which Black South Africans with DM aged ≥40 years old were examined for VI and blindness. In addition, anthropometric as well as risk factors for VI and blindness were studied. A total of 225 participants were selected from seven Public Health Facilities in Mopani District. Data was collected using standard optometric instruments, anthropometric instruments and structured interviews. Data analysis was done using the Statistical Analysis System (SAS) and Microsoft Excel software packages. The ages of the participants ranged from 40 to 90 years with a mean of 61.5±10.49 years. There were more females (71.5%) than males (28.4%). The prevalence of uncorrected VI and blindness in the right eyes of the participants was 70.7% and 3.6%, respectively. In the left eyes, it was 72% and 3.1%, respectively. However, following optical correction, the prevalence in right eyes was 41.3% and 3.6%, respectively. In the left eyes, it was 42.2% and 3.1%, respectively. Risk factors that were individually associated with VI and blindness include age, educational qualification, monthly income, knowledge of DM types, oral DM treatment (pills), losing weight, compliance to losing weight, family history of DM, physical activity, and date of last eye examination .When logistic regression was used, knowledge of DM types, pills, and compliance to losing weight, family history of DM, monthly income and physical activity remained associated with VI and blindness. The high prevalence of VI in this diabetes population was not primarily due to DM itself, but due to refractive error and cataract, conditions which have effective and easy treatments. A total of 84% of the participants were visually impaired due to either refractive error or cataract or both and only 3.8% due to diabetes retinopathy. It is therefore recommended that appropriate and affordable refraction and cataract surgical services be made available and accessible to this population / Health Studies / D. Litt. et Phil. (Health Studies)