Thesis (PhD)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: INTRODUCTION Religion is important in Africa and many churches are involved in HIV ministry. Prevention programmes, however, are less frequent in the church setting and there is little evaluation of them. If an effective model is found, it can contribute to HIV prevention efforts in Sub-Saharan Africa. This study was conducted in the Cape Town Diocese of the Anglican Church. Fikelela, an HIV/AIDS project of the Diocese, developed a 20-session peer education programme (Agents of Change) aimed at changing the risky sexual behaviour of youth. Workshops were also aimed at parents. A literature review was conducted looking at three areas: 'theories of behaviour change', 'adolescent sexual relationships' and 'religion and HIV'. A conceptual framework for the programme was developed by integrating findings from the literature review. The aim of this research was to evaluate the effectiveness and functioning of the programme, to develop a best practice model and to make recommendations for the use of the programme in the wider church. METHODS Outcome mapping was used to integrate an approach to the design, monitoring and evaluation of the programme. Changes in project partners, key project strategies and organisational practices were all monitored. Project partners were defined as peer educators, facilitators, young people, clergy and parents. Monitoring allowed an in-depth understanding of which aspects of the programme worked. Evaluation was designed as a quasi-experimental study that compared non-randomly chosen intervention and control groups. 1352 participants took part at base-line, 176 returned matched questionnaires in the intervention groups and 92 in the control groups. Reported changes in attitudes, knowledge and sexual behaviour were compared between the two groups. RESULTS The main factors leading to the success of the programme were: a well developed curriculum and programme, effective training camps, the support given by facilitators to peer educators, ongoing mentoring and training, role modelling by peer educators, a participatory style of education and positive peer pressure within a strong church based social network. Challenging the church.s negative attitude to condoms was also important. The weakest areas of the programme were amongst clergy and parents and in challenging media messages and norms on gender. The project impact evaluation showed significant differences at baseline between genders in terms of sexual beliefs and behaviour. There was no significant impact of religiosity on sexual activity. The programme was successful at increasing condom usage (Condom use score 3.5 vs. 2.1; p=0.02) and reduced sexual debut (9.6% vs. 22.6%; p=0.04). There was increased abstinence amongst the intervention group, but it did not reach statistical significance (22.5% vs. 12,5%; p=0.25). There was no effect on the number of partners (Mean 1.7 vs. 1.4; p=0.67). CONCLUSIONS Implementation: The programme should be promoted as a youth development programme rather than an HIV prevention programme. Priority should be given to churches in communities with the highest HIV rates. The target group should include younger teens. Peer educators should be selected by peers not by adults. Strategies: The strategies of training camp and quarterly gatherings are effective, but a new strategy needs to be devised to impact the parents. Content: The programme should build self-efficacy amongst the youth, develop a critical consciousness about sexual health, provide positive messages rather than fear-inducing ones, address sexual coercion and persuasion, explore the linking of condom use with trust, address inter-generational sex and promote community outreach and advocacy activities. The programme is effective and meets the threshold of evidence required to be rolled out. It should be rolled out through the Anglican Church with its estimated membership of two million and could be adapted for other denominations as well. / AFRIKAANSE OPSOMMING: INLEIDING Godsdiens is belangrik in Afrika en talle kerke is betrokke by HIV-bediening. Voorkomingsprogramme is egter ongewoon in die kerkomgewing en die evaluering daarvan vind selde plaas. Indien 'n effektiewe voorkomingsprogram model gevind kan word, behoort dit 'n belangrike bydrae te lewer tot HIV infeksie voorkomingspogings in Sub-Sahara Afrika. Hierdie studie is gedoen onder die lidmate van die Kaapstadse Biskoplike gebied van die Anglikaanse Kerk. 'n Bestaande HIV/VIGS projek van die Biskoplike gebied, genaamd Fikelela, het 'n 20-sessie portuurgroepopvoedingsprogram (Agente van Verandering) ontwikkel wat gemik is op die verandering van riskante seksuele gedrag onder die jeug. Daar was ook werkswinkels gemik op ouers. 'n Voorstellingsraamwerk vir die program is ontwikkel deur die integrasie van gedragsveranderingsteorieë met bewyse ten opsigte van verandering van seksuele gedrag onder adolossente en die invloed van godsdiens op adolossente seksualiteit. Die doelwit van hierdie navorsing was om die doeltreffendheid en funksionering van die program te evalueer, 'n optimale praktiese model te ontwikkel en aanbevelings vir die gebruik van die program aan 'n wyer sirkel van kerke te maak. METODES Uitkomskartering is gebruik om 'n benadering tot die ontwerp, waarneming en evaluering van die program te integreer. Alle veranderinge in projekvennote, sleutelprojekstrategieë en organisatoriese handelinge is waargeneem. Projekvennote is gedefinieër as portuurgroepopvoeders, fasiliteerders, jongmense, leraars en ouers. 'n Diepgaande begrip van watter aspekte van die program gewerk het, is bewerkstellig. Die evaluasie was ontwerp as 'n prospektiewe bykans-eksperimentele studie wat nie-lukraak gekose intervensiegroepe en kontrolegroepe vergelyk het. Daar was1352 deelnemers by aanvang, 176 afgepaarde vraelyste is teruggestuur in die intervensiegroepe en 92 in die kontrolegroepe. Veranderings in houdings, kennis en seksuele gedrag wat gerapporteer is, is tussen die twee groepe vergelyk. RESULTATE Die hooffaktore wat tot die sukses van die program gelei het, was: 'n goed ontwikkelde kurrikulum en program, effektiewe opleidingskampe, ondersteuning aan portuurgroepopvoeders deur die fasiliteerders, deurlopende raadgewing en opleiding, portuurgroepopvoeders as rolmodelle, 'n deelnemende styl van opvoeding en positiewe groepsdruk binne 'n sterk kerkgebaseerde sosiale netwerk. Die uitdaging van die kerk se negatiewe houding teenoor kondome was ook belangrik. Die swakste areas van die program was onder die leraars en ouers en in die uitdaging van media boodskappe en norme aangaande geslagskwessies. Die evaluering van die projekimpak het betekenisvolle verskille op grondslag tussen geslagte in terme van seksuele geloof en gedrag getoon. Daar was geen betekenisvolle impak van godsienstigheid op seksuele aktiwiteit nie. Die program was wel suksesvol in die toename van kondoomgebruik (p=0.02) en verhoging in ouderdom van eerste seksuele optrede (p =0.04), maar het geen impak in toename van geheelonthouding onder dié wie alreeds seksueel aktief is (p=0.25) of op die aantal seksmaats (p=0.67) gewys nie. GEVOLGTREKKING Implementering: Die program moet eerder as 'n jeug-ontwikkelingsprogram, as 'n HIV-voorkomingsprogram bemark word. Kerke in gemeenskappe met die hoogste HIV-koers moet voorkeur geniet. Die teikengroep moet jonger tieners insluit. Portuurgroepopvoeders moet deur portuurgroepe self aangewys word en nie deur volwassenes nie. Strategieë: Die strategieë van opleidingskampe en kwartaalikse byeenkomste is effektief, maar nuwe strategieë word benodig om 'n impak op ouers te maak. Inhoud: Die program behoort self-doeltreffendheid onder die jeug te bou, 'n kritiese bewustheid oor seksuele gesondheid te ontwikkel, eerder positiewe as vrees-gebaseerde boodskappe aan te bied, seksuele dwang en oorreding aan te spreek, die verband tussen kondoomgebruik en vertroue te verken, intergenerasie-seks aan te spreek en gemeenskapsuitreik- en aanbevelingsprogramme te bevorder. Die program is effektief en voldoen aan die verlangde bewyse ten einde aangewend te kan word.Met sy geskatte lidmaatskap van twee miljoen behoort die Anglikaanse Kerk dit aan te wend en kan dit ook vir ander denominasies aangepas word.

Thesis (MFamMed)--Stellenbosch University, 2012. / INTRODUCTION: Access to health care, like childhood survival, often depends on where one lives. The infant mortality rate in rural South Africa (SA) is 52.6 per 1000 births, compared to 32.6 per 1000 births in urban areas. Furthermore, three of the four districts in SA with the highest HIV prevalence are rural. These being two commonly used health indicators, it is clear that rural populations have significantly poorer health outcomes than their urban counterparts. About half the world’s population live outside major urban centres, where health services and specialist medical services are concentrated. Rural SA are home to 43.6% of the population, but are served by only 12% of doctors and 19% of nurses. Of the 1200 medical students graduating in the country annually, only about 35 work in rural areas in the long term. There are 30 generalists and 30 specialists/100 000 people in urban areas, compared to an average of 13 generalists and two specialists/100 000 people in rural areas. The question arises whether the poorer access to particularly specialist services is a contributing factor towards poorer outcomes. Specialist outreach to rural communities is one way of improving access to care. In the Eden and Central-Karoo districts of the Western Cape of SA there are one level 2 (regional) hospital and ten level 1 (district) hospitals. All clinical disciplines reach out, with varying frequencies. On average, the four main district hospitals receive 17 specialist outreach visits per month; while the smaller district hospitals receive three specialist visits per month (Appendix 1). A typical outreach visit includes a problem ward round, outpatient session, theatre list for some surgical disciplines and formal/informal educational sessions. In principle, stakeholders agree that specialist outreach and support (O&S) to rural populations is necessary, as it improves access to specialized health care services. In practise however, there are factors that influence whether or not O&S reaches its goals. This in turn affects the sustainability of O&S projects. Understanding these factors would aid recommendations for a suitable model for O&S.

Thesis (MFamMed) -- Stellenbosch University, 2012. / ENGLISH ABSTRACT: Background Sub-Saharan Africa has been hard hit by the HIV/AIDS epidemic with an estimated 22.9 million adults infected in 2010. The advent of antiretroviral therapy (ART) has seen significant reduction in mortality from AIDS related illnesses. With the reduction of mortality and the indisputable positive results seen from the use of Anti-retroviral Treatment (ART), the demand both from people living with HIV and health care providers to phase in less toxic ARVs while maintaining simplified fixed-dose combinations has increased considerably. Botswana like most low-resource countries has adapted the WHO recommendation of daily ART as opposed to the previous twice daily HAART. No evidence from resource limited settings has been found that clearly indicates the superiority of regimens based on AZT, d4T or TDF. Aim The primary aim was to compare treatment response between two cohorts. The secondary aim was to compare any association of regimen to age or gender. Objectives To comparatively determine treatment response at 3 months based on immunological response (shown by an increase in CD4 above pre-therapy levels) and viral load response. Methods The study is a retrospective comparative cohort study. Three ART sites were selected from a total of 6 sites. A sample size of 263 was required to achieve a 90% effect power. An equal number of patient records were reviewed per site and each arm had an equal number of reviewed records. A total of 286 patient record files which fit the inclusion criteria were retrospectively analysed and data entered in Excel before being analysed using Statistica Version 10. A p <0.05 represents statistical significance whilst a 95% confidence interval was used for estimation of unknown variables. Results n=263. The overall sample was predominantly male (75.19%). An overwhelming majority (95.88%) of patients in both arms had undetectable viral loads (VL<400). A significant association was found between the regimen and viral load (p=0.0315-Pearson Chi Test). The difference in CD4 between the two arms was not statistically significant (p=0.655890-ANOVA). A positive association was found between the regimen and gender (p=0.03190-Pearson Chi Test). This was possibly owing to the high numbers of males and no statistical adjustment to gender made. No association was found in the difference in CD4 cell counts for regimen and gender (p=0.612191-Anova). Conclusion Treatment response at 3 months post initiation between once daily and twice daily HAART in Gaborone Botswana by use of virologic and immunologic response has been shown to be comparable. The use of one regimen over the other as first line as recommended by WHO and the subsequent adoption of the current first line regimen by the Botswana Ministry of Health may be justified. This study has therefore reinforced the applicability of previous findings in other settings of this recommendation. As part of the targeted audience and indeed as a partner in the care and management of HIV, the responsibility to ensure applicability of the recommendations set out for resource limited areas has been achieved through this study. However, bigger randomized trials in resource limited settings are needed to justify and accredit these findings as well as add to the evidence obtained in developed countries.

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.