Mental health has a long history of proving to be a tough concept to define. Multiple forms of knowledge and representation seek to inform as to the nature of mental health, all contributing to the production of immense complexity as to the experience of living with mental health difficulties. This thesis sets out to explore this, by getting as close as possible to mental health service users' actual experiences. A range of forms of knowledge that pertain to inform as to service users' experiences are explored, prior to analysing a corpus of interviews with service users. These are analysed through the development of a Deleuzian Discourse Analysis. Service users' experiences are analysed in terms of the relation between discursive and non-discursive factors, which include forms of mainstream psychiatric discursive practice, such as the application of diagnostic criteria and administration of treatments, along with how such practices are experienced in non-discursive dimensions of service user embodiment and space. The challenges facing service users are seen to operate around identity and control in relation to forms of psychiatric knowledge, along with presenting particular problems with regard to how user embodiment is felt, primarily in relation to psychiatric medication, and how these are driven into the production of service user spaces, i.e. day centres. Finally, a politics of affectivity is offered, as a way to unfold the complexity of service user experience, and to emphasise the existence and potential for change that can be gained through deterritorialising mental health.

Introduction There is concern that C-section rates are increasing in the public health sector in South Africa and wide variation has been reported between districts, provinces and hospitals. This study is a comprehensive analysis of C-section rates in all public sector hospitals during 2000/01- 2008/09 by facility, district and province. It aims to inform decision makers in maternal health services of the trends and patterns occurring in C-section rates in South African public sector hospitals. Variation in C-section rates is described to highlight the differences in care that pregnant women receive in different parts of the country and to illustrate where inequity of resource allocation is occurring, as well as highlighting possible data quality problems. Methodology This is a descriptive study using quantitative methods of analysis on secondary data obtained from the National Department of Health’s routinely collected data specific to Caesarean sections in the DHIS. C-section averages are weighted by taking the number of deliveries per facility and level into consideration. Results 1. Wide variation is noted between individual facilities, between and within provinces and districts and within the different levels of hospitals in 2008/09. The mean weighted C-section rate ranges from 17.2% in District Hospitals to 40.7% in Specialised Maternity Hospitals. A 3.7 fold difference between the highest and lowest district average C-section rates is seen for District Hospitals. Within provinces, average District Hospital C-section rates vary by as much as 3.5 fold between districts. Interdistrict variation in Regional Hospitals shows a 3.3 fold difference between the lowest and highest average district rates. Among the eight National Central Hospitals there is a 2.5 fold difference between the highest (79.7%) and lowest (31.7%) facility C-section rates. Nationally a total of 23 District Hospitals had C-section rates below 5% and nine hospitals of varying levels had rates of over 50% 2. Caesarean Section rate trends, 2000/01 – 2008/09 are increasing. Nationally the average C-section rate in South Africa increased by 6.3 percentage points from 18.1% in 2000/01 to 24.4% in 2008/09, with an average annual compounded growth rate of 3.8%. Bivariate linear regression analysis confirms there is a positive linear relationship between time (year) and C-section rate (p<0.001). All levels of hospitals showed an increasing trend over the nine years, (p<0.001), with the rate in Provincial Hospitals having increased by the highest amount (1.40%) year on year and District Hospitals, the least (0.48%). Trends within certain districts and individual hospitals however, show a decline. 3. A strong relationship between level of deprivation and C-section rate exists when adjusting data for provincial variation Bivariate linear regression analysis revealed no association between the level of deprivation of the population at district level and the mean C-sections rate per district (p=0.130). Multiple regression analysis adjusted for the effect of province, reveals a significant association (p=0.044). A negative association between the DI (p=0.006) and Csection rate is seen in eight out of nine provinces. 4. Data quality of C-sections and deliveries in the DHIS needs improving Data quality in the DHIS leaves uncertainty in some instances whether C-section rate trends are a true reflection or not. The C-section rate indicator on its own is unable to inform on the full spectrum of emergency obstetric care. The definition of C-section rate for primary health care currently only considers deliveries in District Hospitals. The national C-section rate for primary health care in the country however, reduces from 17.2% to 13.2% when including the deliveries which take place in CHCs. Conclusions The quality of data relating to C-sections (number of births, C-sections and hospital categorisation) in the DHIS needs to be improved in order to enable accurate monitoring and should include deliveries and C-sections which take place in Community Health Centres to allow for a more accurate reflection of C-section rate in primary health care. The C-section rate indicator on its own is insufficient to adequately inform on the full spectrum and quality of the provision of emergency obstetric care in South Africa. Including additional indicators to the DHIS, such as the UN process indicators, could improve on the current knowledge and monitoring of the provision of emergency obstetric care in South Africa. The wide variation in C-section rates seen among District Hospitals and the C-section rates between and within districts and provinces, suggest inequity in resource allocation and irregular service delivery patterns. Reasons and solutions for these wide differences need to be found, which are likely to be unique to each district and province. Further studies are needed to investigate the access of poorer women, especially those in remote rural areas to emergency obstetric care services.

Background: Long waiting times and the quality of care are sometimes compromised by the ineffective systems caused among others by the bottlenecks at the reception and the treatment areas. The Hospital management of the Kopanong Hospital was concerned about the long queues and waiting times in the Hospital’s out-patient department. Therefore, the Hospital management would like to reduce the long queues and the length of the waiting times. The information from the customer care system showed that the average waiting times in the out-patient department was about five hours and that much of this time was spent at reception area waiting for files. However no study was done to systematically measure the waiting time in the OPD and the factors that might have influence on it. This study was planned in this setting to assist the Hospital management in setting the baseline that could be used in benchmarking for monitoring the situation. Aims: To evaluate factors affecting waiting times at the Out-patient department (OPD) of Kopanong Hospital Methodology: The setting of this study was Kopanong Hospital, in the Sedibeng District in the Gauteng Province. This was a cross-sectional study that looked at broad issues pertaining to the waiting time at the Out-patient Department of Kopanong Hospital, a district hospital in a the rural district in the Gauteng Province during three-year study period. The OPD has three sections: General OPD, Paediatric OPD and Antenatal Clinic (ANC). The MS excel software based data extraction tool was designed to obtain data from Hospital Information System. Results: The majority of the patients came from poor socio-economic class and had no medical aid. Therefore, these patients are dependent on public health facilities for their health care and would not be able to pay for their health care. The majority of the patients were self referred except ANC. This might be due to a well-functioning referral system for maternity patients in the District. The majority of the patients attended the General OPD and Paediatric OPD for medical reasons. The analysis of data showed that the patients spent a significant amount of time in the system before they were seen by the nurses and doctors. However, they were also spending a significant amount of time in the Pharmacy. The reasons for efficient record keeping for ANC and Paediatric OPD patients might be due to the fact patients caries their own cards (ANC cards and Road to Health cards). Similar system should be introduced for General OPD patients. Further study is necessary to identify the cause for delay in the Pharmacy. Conclusion: This study was the first of its kind to be done in this Hospital and the Sedibeng Health District. The study identified the areas where patients spent time in the OPD. This would assist the Hospital Management to develop appropriate measures to reduce waiting time in the Hospital OPD. In addition, further study is necessary at the PHC facilities in the District to identify reasons for high self-referral.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Community Health Johannesburg, November 2015 / Introduction: One of the aims of the re-engineering of primary health care in South Africa is to strengthen the health system and improve accessibility of health services through ward based outreach teams (WBOTs) comprising of nurses and community health workers. Aim: To evaluate the implementation of WBOTs against national guidelines and identify Community Health Worker (CHW) characteristics that influence adherence to guidelines regarding the referral and follow up of maternal and child health clients. Methodology: This cross-sectional study was conducted during 2013. All 9 WBOTs at the time were included in the study. Data were collected through: a questionnaire survey; key informant interviews and a review of records of pregnant, post-natal women and unimmunized children under five. A process evaluation was conducted to describe inputs (training, team composition, resources, and knowledge); processes (service delivery, referral linkages, support and supervision) and outputs (number of clients referred and followed up). Logistic regression was performed to identify CHW characteristics (Age, education, experience, training, and knowledge) associated with adherence to national guidelines. Results: WBOT had sufficient numbers of CHWs within the team; however lacked sufficient knowledge and resources required to conduct household visits. CHWs adhered to the guidelines regarding the follow up of maternal clients with 85% of CHW having conducted the required number of follow up visits for pregnant and postnatal women. However, only 29% of unimmunized children were appropriately followed up. Challenges identified included: lack of supervision, limited resources, and poor knowledge. There was no statistically significant association between CHW characteristics and adherence to guidelines. Conclusion and recommendations: This study highlights the challenges that need to be addressed around the WBOT implementation. It is recommended that there is improvement in resource availability, CHW supervision, capacity and training to improve the implementation process of future teams. Key words: Ward Based Outreach Teams, Primary Health Care re-engineering, Community Health Worker

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016 / Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (<140/90 mmHg) and CD4 counts (>350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs. / MT2017

Background: South Africa has a high Maternal Mortality Ratio (MMR) and is not on track to meet Millennium Development Goal (MDG) 5, target 5A (to reduce by three quarters between 1990 and 2015 the MMR). Along with gathering crucial information about maternal deaths, it is also important to understand the experiences and opinions of those who have almost died during their pregnancy or delivery - termed near-misses in maternal health services - to recommend relevant interventions aimed at bringing down South Africa's MMR. Aim: The overall aim of the study was to explore patient experiences and perspectives of maternal near-misses and their opinions of how these could have been prevented. Methods: Using a case study design, where the case was women who had experienced severe acute maternal morbidity (a near-miss event), in-depth interviews were conducted with nearmisses until a point of saturation was reached after the ninth woman. Each woman was interviewed twice on two separate occasions between 1st April and 30th September 2009 about their experiences and opinions of the near-miss event, and access to reproductive health services and the health system more broadly. Their social and economic circumstances were also explored.MAXqda was used for data management and a thematic analysis was carried out on the interview data. Results: Bureaucracy in accessing reproductive health services, lengthy referral processes, lack of transport and resources in clinics were seen as major health system barriers that contributed in women being near-misses. Inadequate knowledge about reproductive health and warning signs of serious morbidity; although seen as patient factors, were also be attributed to health system factors. The desire to or not to fall pregnant was not the only factor that influenced contraceptive use. Power relations between women and their partners affected most women who were in lower positions of power. Cessation of menstruation as a side effect of contraception resulted in failure to recognize absence of menstruation during pregnancy. Lack of service integration affected women irrespective of their demographic characteristics. Patients are at risk of abuse in health facilities although this is not the norm. Little attention was given to postnatal care of women. Conclusion: Health systems' issue which according to the AAAQ framework were not satisfactory contributed in women being near-misses. Women's limited knowledge on reproductive health issues which might be as a result of inadequate information offered at the clinic affected use of reproductive health services. Educating women and their families about obstetric emergencies may result in early recognition of warning signs of obstetric emergencies and prevention of near-misses.

A thesis submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy April 2017. / Introduction The number of maternal deaths from bleeding during and after caesarean section (BDACS) has increased dramatically in South Africa in recent years. Four studies were conducted to gain insight on measures to reduce maternal deaths from BDACS. The aim was to identify clinical and health system factors associated with near-miss and maternal death from BDACS. Methods A systematic review was done on near-miss from postpartum haemorrhage, with a sub-analysis on BDACS. The field research, done in southern Gauteng, included: 1) a six-month prospective near-miss audit of women with BDACS in 13 hospitals; 2) a two-year retrospective maternal death audit in seven hospitals; and 3) a health systems audit in 15 hospitals. Results The systematic review on near-miss from PPH found two studies that described near-miss from BDACS, with a mortality index of 0-11%. In the near-miss and maternal death audits, the main risk factors for BDACS were pre-operative anaemia and previous caesarean section. Atonic uterus was the main cause of haemorrhage, with associated failure to use second line uterotonic drugs. Failure to diagnose and treat shock was the main reason why women died. Most maternal deaths from BDACS occurred in regional hospitals. The hospital systems audit identified shortages of second line uterotonic drugs and surgical skills availability as contributors to near-miss and maternal death from BDACS. Conclusion Although bleeding may be arrested through obstetric surgical techniques and easily available drugs, severe BDACS is a complex disease that requires a multi-disciplinary approach in a functional health system, especially regarding the detection and management of hypovolaemic shock. Measures to reduce maternal morbidity and mortality from BDACS include health system strengthening, with high care and critical care facilities, and improving the availability of drugs and surgical skills at district and regional hospitals / MT2017

The purpose of this study was to elicit how mental health care users from a mixed ancestry group, otherwise called “Coloureds” at a Mental Health Clinic in an urban South African context, understood mental illness. “Coloured” peoples perceptions about mental illness in not well documented as few studies have addressed the needs of this population group in South Africa. The purpose was addressed within a closed questionnaire schedule using the Illness Perception Questionnaire - Mental Health, which was administered over a two month period, from 3rd June 2011 to 29th July 2011, using a non experimental, prospective, descriptive research design survey method. Data were collected by means of a self administered questionnaire and analysed by means of descriptive statistics. According to the statistician no confidence level was necessary as the instrument used was already tested to be valid and reliable. Since the study was descriptive, no comparative statistics were necessary.The analysed data revealed evidence of poor identification of mental illnesses. This could be a contributory factor to the inadequate adherence to treatment strategies and high re-hospitalization rates in this community. There was also a lack of collaboration between health workers and mental health care users and inadequate imparting of mental illness information by the mental health care practitioners. The positive results that have become evident in this study of good community support, good personal control of illness, a belief in the importance of taking medication and low stress levels, may be utilized effectively to empower this community with knowledge about mental illness. This may allow this community to assume responsibility and be supportive in the efforts to destigmatise mental illness and to ensure that community mental health care services move efficiently and effectively.

BACKGROUND: The Tokollo/Mafube District (TMD) Hospital Complex located in the rural area of Fezile Dabi District within the Free State Province has reported a high number of adverse events (AE) from the maternity units. Although the information linked to AE occurring in the hospitals is routinely collected and reported to the hospital management in accordance with the Provincial policy, no study has been done to systematically analyse the available information and to explore the current situation. AIM: To describe the patient-related AE in the maternity units of TMD Hospital Complex, related individual and health system factors, and the functioning of the reporting system used for these AE during the two year study period. METHODOLOGY: A descriptive cross-sectional study design was used, based on a retrospective review of routinely collected hospital data from the health records of patients, the AE Committee meeting minutes, and other relevant hospital documents. The study was conducted at the maternity units of TMD Hospital Complex which consists of two hospitals in the Fezile Dabi District within the Free State Province. Data was collected in the following categories of variables: the types of AE (in terms of levels of seriousness), the profiles of patients who experienced such AE (e.g. age, gravidity, marital status, residence, and socio-economic status), the related health system factors identified during the adverse events committees meetings (such as personnel, transport, equipment, environment and management) and reporting of these AE. RESULTS: This study revealed that a total of 88 patients, comprising 0.8% of the total number of admissions to the maternity units, experienced AE. Maternal AE occurred more commonly than perinatal AE. The majority of women experiencing AE were unemployed (93%), between the ages of 19-34 (81%), unmarried (79%) and resided in towns (88.6%). In addition, most of these women belonged to the groups of primigravida and multigravida (85%), attended between one and three antenatal visits (42%), and delivered via normal vaginal deliveries (76%) with a high number of stillborns (77.2%). Overall, the majority of maternal AE occurred during the intrapartum stage. Another significant finding was that majority of AE reported were classified as the most serious being SAC 1, which accounted for 93% of the maternal AE and 84% of perinatal AE. The early perinatal AE accounted for 100% of the reported perinatal AE. Although majority of AE reported at the institution were within the prescribed period, reporting time to the Complex AE Committee (CAEC) and District AE Committee (DAEC) was exceeded in the majority of cases. In addition, all AE that required investigation complied with the provincial policy but exceeded the required investigation period. The findings regarding health systems related factors as determined by root cause analysis performed by the AE committee revealed that clinical governance issues accounted for 43% of both maternal and perinatal AE, followed by patient transport issues as provided by the Emergency Medical Services (EMS) which also accounted for a significant percentage (33%). CONCLUSION: This study has demonstrated that specific health system related factors played a significant role on the occurrence of AE at the maternity units of TMD Hospital Complex and that the majority of the reported AE were very serious (SAC 1). It is important that these preventable, contributory factors are addressed by management at both the complex and district levels. Furthermore the results suggest that patients’ profiles, to a certain extent, do have an influence on the occurrence of AE in maternity units of TMD hospital Complex and it is important that patients’ profiles be taken into consideration when adverse incidents are analysed.

"The purpose of this study was to ascertain whether there were differences between a sample of 93 reopened cases at the Leon County Mental Health Clinic in Tallahassee, Florida, during a two-year period, and a sample of 100 cases-not-reopened during that period of time. The period used in the selection of cases was from July 1, 1955 through June 30, 1957. A schedule of eighteen items was utilized to gather information from 193 case records. The comparison of the two samples was done by an analysis of the information thus obtained"--Introduction. / Typescript. / "May, 1958." / "Submitted to the Graduate Council of Florida State University in partial fulfillment of the requirements for the degree of Master of Social Work." / Advisor: Vernon Fox, Professor Directing Study. / Includes bibliographical references.