Aim: This is a study of the extent to which clinical associate students learn person-centred practice (PcP) as well as the curricular elements that may facilitate such learning. Methods: A quality improvement intervention by students on their own medical consultations was explored in focus group discussions. The learning of PcP were analysed using the capability approach framework. PcP was measured in consultations during Objective Structured Clinical Examinations (OSCEs) before and after the intervention in both intervention and control groups. Results: Disruptions to students’ abilities, knowledge, identity and relationships triggered learning. The quality improvement process functioned as a learning cycle scaffolded by peer feedback and assessment tools during which students reviewed disruptions and developed improvement plans. Even though students articulated their passion for PcP in focus groups, few actually demonstrated these skills during OSCE consultations with simulated patients. An increase in PcP was observed but the difference between intervention and control groups was not significant. Students’ sense of self was disturbed when they were unable to help patients. In response, self-directed students devised learning strategies involving relationships with peers and facilitators. Relationships are thus both triggers for learning and a means to learning. Conclusion and recommendations: The significantly better improvement in third year students, compared to those in second year, suggest that learning PcP is grounded in increased confidence in biomedical knowledge and skills, motivation and sense of self-efficacy. Students learn and practice PcP best in authentic encounters with real patients. Therefore, student learning and practice of PcP should be evaluated in such encounters and, to achieve PcP, the student-patient relationship needs to be given primacy in professional identity formation as patients and their needs transform student apprentices into caring, solution-seeking clinicians who engage with rather than other patients in the therapeutic alliance. / Thesis (PhD)--University of Pretoria, 2019. / Scholarship of Teaching and Learning (SoTL) fund of the Faculty of Health Sciences, University of Pretoria / Family Medicine / PhD Family Medicine / Unrestricted

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Background: The prevalence of HIV was greater than 30% in the Free State province in South Africa and PMTCT services were widely available at the time the guidelines recommended nevirapine in labour and to the child postpartum. Aim: The aim was to determine the effectiveness of the PMTCT program in the Free State by measuring HIV transmission and HIV-free survival in children less than two years of age. Variables associated with HIV transmission and HIV-free survival including PMTCT uptake by mother, demographic characteristics, type of delivery and breastfeeding status were investigated. Methods: This was a secondary analysis of data collected from a cross sectional community household survey, using multistage cluster sampling. The population was all women who had given birth to a child in the two years prior to the study in the catchment area of three sub-districts that were randomly selected in Free State. All mothers were anonymously tested for HIV and if infected the child was also tested. Trained field workers interviewed mothers, identified children who had died and collected data on variables that could be related to transmission and survival. Logistic regression was used to determine risk factors.

Background: Diabetes is now the most common non-communicable disease globally and complications are resulting in increased disability, reduced life expectancy and enormous health costs for virtually every society. Medical Nutrition Therapy is important for the prevention, treatment, self-management of diabetes and the prevention or delay in onset of diabetes-related complications. The current nutritional guidelines for DM states that carbohydrates should make up 45-60% of the total nutritional intake and that low carbohydrate or high protein diets offer no long term success over healthy eating plans. Recent studies suggest that there may be merit in using low carbohydrate diets in diabetic patients. Aim and Objectives: The study aimed to implement and evaluate a program for weight loss in Diabetes Mellitus type 2 patients by comparing a Low carbohydrate diet to the conventional low fat diet. Changes in weight, waist circumference, blood pressure and blood parameters (creatinine, lipids and HbA1c) were recorded in both groups. Methods: The study design was that of a two group randomised parallel design, with one group following a low fat diet and the other a low carbohydrate diet. Both groups received advice on exercise and behaviour change. Clinical parameters were recorded at week 0 (baseline) and week 12 of the program. Patients were invited to participate in the study using leaflets, posters and via staff. A total of 10 patients per group were identified and followed. Results: Significant reductions were seen in weight loss and Hba1c in the Low Carbohydrate diet group which was not evident in the Low fat diet group. No significant change was seen in other parameters including BP, total cholesterol and serum creatinine for either group. Conclusion: Low Carbohydrate diets are effective in promoting weight loss and glucose control in diabetic patients. More research is recommended to assess patient's experience of following a low carbohydrate diet. Recommendations include training staff at facilities in our Sub-District on understanding and implementing Low Carbohydrate diets.

Includes bibliographical references / OPurpose: The purpose of this study is to investigate the impact of the revised Women Infant and Children (WIC) programme on whole grain consumption among WIC participating children. In addition, this study aims to investigate how knowledge on whole grain consumption and/or perceptions on cost of whole grain contribute to consumption. Background: The WIC programme is a supplementary nutrition programme for women, infants and children which seeks to promote the health of women who are pregnant, postpartium and lactating and children up to the age of 5 years. The WIC programme is aimed at low-income women and children facing nutritional risk. This nutritional risk is classified by a number of factors that include anaemia, underweight, overweight, history of pregnancy complication or poor pregnancy outcomes. Women and children facing nutritional risk are provided with services that include supplementary foods, nutrition and education counselling, screening and referral to other health, welfare and social services. Methods: This study is a secondary analysis of the Phase II Emory WIC study that investigated the impact of the new WIC programme on fruit and vegetable consumption among participating women. In addition to this, the primary study also investigated the consumption of whole grain foods. The study population consisted of 77 women and their children that attended routine visits in two Metro-Atlanta WIC clinics. In order to meet the aims of this secondary analysis, this study will firstly undertake a univariate analysis and thereafter simple bivariate analysis intended to determine any associations between exposure/risk factors (i.e. old and new WIC Emory Voucher package) and response variables. In addition to the above analysis, paired-tests will be conducted to determine if there is any statistical significant increase in whole grain consumption between; (a.) baseline and week 1 and (b.) baseline and 4 week. Finally, in order to account for possible confounding not taken into consideration by the aforementioned analysis, this study will use General Estimating Equation (GEE) approach to model the change in whole grain consumption over time (from baseline to 4 weeks). It is anticipated that the above methodology will help answer the objectives of this research. Conclusion: It is hoped that the results of the study will highlight possible socio-economic factors that may lead to greater consumption of whole grain foods and provide recommendations on how to best improve the WIC programme with regard to Whole Grain Foods (WGFs) among participating children.

Includes bibliographical references. / Malaria is an important public health problem with a high morbidity and mortality in more than 90 malaria endemic countries in the world. The burden of malaria is quite high especially among pregnant women and children under five years of age. There has been little focus on the factors that influence women's responses to malaria control strategies, It is important to establish whether the control measures, health education and the treatment options are available to and utilised by women. They are the caretakers of young children who are particularly vulnerable to severe malaria, and in need of prompt response to the illness, while women themselves are at great risk of severe anaemia and other complications during pregnancy. The purpose of the study is to better understand the role of women in the control and management of malaria at the household level, particularly with respect to women's awareness of transmission, prophylaxis, symptoms, complications, treatment and control of the disease and to provide recommendations to make malaria control programs more gender sensitive and therefore more effective.

A ruptured abdominal aortic aneurysm (AAA) has a mortality of 80 percent. The majority of these cases present as medical emergencies, with 50 percent dying before they reach hospital. Twenty percent are not operated on because of an incorrect diagnosis and of the surviving 30 percent, there will be a peri-operative mortality of 40 percent. Thus only 20 percent of patients survive this condition. It is important to state that the long-term survival reported for patients undergoing AAA surgery approximates that of age-matched populations. This is in contrast to patients undergoing a coronary bypass procedure, where the long-term survival is affected by factors such as hypertension, angina and peripheral vascular disease. If the condition is diagnosed electively, the mortality rate is reduced to less than 5 percent. The researcher obtained the records of 18 patients who had presented to the vascular service at the New Kingsbury Hospital with a diagnosis of a ruptured or acute symptomatic AAA. He interviewed the referring family doctor and also obtained information from the case records to determine whether there were missed opportunities for the detection of such aneurysms. The results of the research showed that 12 general practitioners (GP's) out of a group of 13, were unaware that abdominal ultrasound is a highly specific and sensitive method for detecting AAA's. Only one of the group of 13 GP's regularly screens for AAA. The diagnosis of AAA was missed in 12 of the 18 patients. In this series the mean diameter of the aorta was 7,67 cm which is considered to be easily palpable. Five of the patients were referred to specialists for incidental reasons and they all failed to detect the AAA. The majority of patients with AAA's have at least 2 associated risk factors. The patients consulted their GP at least 5 times over the 24 month period. The GP's are not aware of the different modes of presentation, associated risk factors nor the value of screening for AAA's. Ten of the group of 13 GP's profess to engage in some form of Continuing Medical Education (CME). I have suggested a few guidelines to encourage family physicians to screen for AAA in all males over the age of 60, especially if they have risk factors, such as hypertension, a current or former cigarette smoker, coronary artery disease, peripheral vascular disease and a family history of AAA. The examination should include a thorough abdominal palpation and referral for an abdominal ultrasound examination to obtain the precise diameter of the AAA as treatment depends on the size of the AAA.

Tubal sterilization is the world's most popular contraceptive method. The possibility of subsequent menstrual dysfunction has been a cause for concern. This study was conducted to examine whether post-sterilisation menstrual dysfunction was measurable in a group of women attending a general practice, by means of a case-control study. Biopsychosocial factors, such as health status, social support, psychological and medical history, and reasons for sterilisation were investigated to see whether any of these factors could be predictive of post-sterilisation menstrual problems. Sterilised women attending a general practice over an eight-month period were invited to participate in the study. 143 out of 144 patients completed a highly structured interview (questionnaire) administered by two interviewers. Forty-nine cases were identified and compared to ninety-four controls. The results showed that women with menstrual dysfunction differed from a comparison group in that; those with menstrual dysfunction were generally less satisfied with their quality of life, had significantly more fears about sterilisation, felt that the quality of their social support was inferior, and suffered from depression and tension headaches more often than controls. Menstrual dysfunction was also more common during the first two years after tubal ligation. These results could point to factors other than biological factors involved in menstrual dysfunction following tubal ligation.

Includes abstract. / Includes bibliographical references. / As perinatally infected adolescents living with HIV (ADLHIV) grow older and gain a greater sense of independence, disclosure issues and adherence to antiretroviral treatment (ART) have become major concerns. However, research on how adolescents view and cope with these challenges remains limited, especially in Sub-Saharan Africa. We explored ADLHIV's understanding of their infection and its perceived effects on their well-being, and ultimately, on their attitude towards life-long adherence to ART.

Introduction Wheezing is common in young children. By the age of six, approximately 50% of children in high-income countries will have experienced at least one episode of wheezing in their life. Furthermore, childhood wheezing may be associated with reduced lung function and increased risk of asthma in later life. Determining the epidemiology of wheeze is complex given that the risk factors vary based on the age of the child and the phenotype of wheeze. Little is known regarding the recurrent nature of childhood wheezing in low- and middle-income contexts. This study aimed to use multi-state models to estimate the rate of transition among various states of wheeze in children from birth to the age of three years. This study also aimed to investigate the association between possible risk factors for childhood wheezing and the estimated transition intensities. Methods The rationale for conducting the study, as well as the objectives of the study, methods and data analysis plan are outlined in the study protocol (Part A). A summary of what is currently known about childhood wheezing is presented as part of the literature review (Part B). The aim of the literature review was to identify known risk factors for childhood wheeze and the methods used to analyse recurrent childhood wheezing, as well as identify the limitations of the current methods used to analyse recurrent childhood wheezing. A manuscript presenting the results of the study is included as Part C. This study was a secondary analysis of data from 1086 children from birth to three years, born to mothers in the Drakenstein area of the Western Cape, South Africa, enrolled at one of two pri- mary care clinics. The data were collected as part of a prospective birth cohort, the Drakenstein Child Health Study. Cox proportional hazards models were used to investigate the association of risk factors with time to first wheezing event and time to recurrent wheezing. Two multistate models investigating the progression of childhood wheezing were constructed. Multiple definitions of childhood wheeze as an outcome were investigated for all constructed models. A simple unidirectional multi-state model and a complex multi-state model with three states (never wheeze, wheeze not associated with lower respiratory tract infection (LRTI), and, lower respiratory tract infection associated wheeze) were constructed. The multi-state model allowed four possible transitions: 1) from “never wheeze” to “wheeze not associated with LRTI” or from 2) “never wheeze” to “LRTI-associated wheeze” or from 3) “wheeze not associated with LRTI” to “LRTI-associated wheeze” and from 4) “LRTI-associated wheeze” to “wheeze not associated with LRTI”. Transition intensities between wheeze states were estimated using discrete time multi-state models. The association of risk factors with transition intensities were estimated using multivariable proportional hazards models. Results Of the 1086 children included in the study, 476 (44%) experienced at least one episode of wheezing, and 227 (21%) experienced more than one episode of wheezing in the first three years of life. A total of 951 episodes of wheezing were recorded in the 36 months of follow-up time. In the multi-state analysis, LRTI-associated wheeze and wheeze not associated with LRTI were equally likely to be the first wheeze event. However, recurrent wheezing events were more likely to follow LRTI-associated wheeze as the first event (0.0020033 vs 8.6683754 × 10−4 ). Male children were at significantly higher risk of experiencing wheeze associated with an LRTI as the first wheezing event and at significantly higher risk of subsequent recurrent wheezing. Children exposed to maternal smoking prenatally had a significantly higher risk of transition to the wheeze state compared to unexposed children. Conclusion Multi-state models provide a novel method for the analysis of wheezing and recurrent wheezing in a cohort of children in South Africa. Multi-state models successfully predicted the progression of children through discrete states of wheeze and produced results consistent with existing literature on childhood wheeze, while accounting for recurrent events and interval-censored data.