Thesis (MCur)--University of Stellenbosch, 2003. / ENGLISH ABSTRACT: Nationally and internationally emphasis is placed on quality care in health services. The researcher identified a need to evaluate a component of primary health care service in the Northern province. A study based on the combination of qualitative and quantitative methods was conducted to formulate and evaluate structure, process and outcome standards for selected clinics in the Northern Province. The most important results are: • The standard relating to the structure was suboptimal. Physical and human resources are of critical importance to the rendering of quality patient care. However this did not comply with the pre-set standard norm of 80%. • Process standards focused on physical examination of patients taking into account the age of the client and the systems involved. Substandard care was found in all these aspects. • Outcome standards determined by the patient questionnaire also revealed negative findings. Recommendations include the development of a quality improvement model for the Northern Province Health Services, formulation of standards for all disciplines of health care, annual evaluation of patient care and the institution of a formal staff development programme. Key words: quality care, formulation of standards, structure, process, outcome / AFRIKAANSE OPSOMMING: Nasionaal en internasionaal word die belang van gehaltesorg in gesondheidsdienste beklemtoon. Die navorser het enbehoefte ge'identifiseer om en component van prirnerre gesondheidsorgdienste in die Noordelike provinsie te evalueer. en Kombinasie van kwalitatiewe en kwantitatiewe metodes is gebruik om struktuur-, proses en uitkomsstandaarde in geselekteerde klinieke in die Noordelike provinsie te formuleer en evalueer. Die belangrikste resultate was: • Die standard ten opsigte van die standard was suboptimal. Fisiese en menslike hulpbronne is van kritiese belang vir gesondheidsdienslewering. Die standaard hiervan het nie voldoen aan die voorafbepaalde norm van 80% wat gestel is nie. • Prosesstandaarde het op fisiese ondersoek van die pasiente gefokus met inagneming van die ouderdom van die klient en die simptome waarmee pasiente presenter. Sub-standaardsorg is ten opsigte van al hierdie aspekte gevind. • Uitkomsstandaarde is deur middel van en pasientevraelys gemeet en he took negatiewe bevindinge opgelewer. Aanbevelings sluit in die ontwikkeling van engehalteversekeringsmodel vir die Noordelike Provinsie se gesondheidsdienste, die formulering van standaarde vir aile dissiplines van gesondheidsorg, jaarlikse evaluering van pasientesorq en die instelling van enformele personeelontwikkelingsprogram. Kernwoorde: Gehaltesorg, formulering van standaarde, struktuur, proses, uitkomsstandaarde.

Background: This study is located within a complex network of paradigmatical methodological, and institutional relationships, and draws concepts from a range of scholastic traditions. The hermeneutical tradition within Sociology, particularly as exemplified in the work of Jurgen Habermas, provides a starting point for exploring and interpreting the experiences of chronic illness and healthcare access. The concept of the lifeworld/ healthworld as a description of the complex of health beliefs and behaviours of individuals in relation to the ailing body is used to describe chronic illness and healthcare access, both as lived experience and as fields for public health intervention. Aim: To understand how women living with chronic illness experience their illness and access healthcare in an urban and rural context. Methods: This study is a mixed-methods comparative case study of the healthcare access experiences of women with chronic illness in an urban and rural area in South Africa. The core of the study methodology is a comparative qualitative case study, with quantitative methods serving to contextualise the findings. The urban component of the study was conducted in Birth to Twenty (Bt20), a birth cohort study located in Johannesburg-Soweto. The rural component of the study was conducted in Agincourt, a sub-district of the Bushbuckridge district in Mpumalanga Province. The quantitative context for the Soweto case study uses secondary data collected by Bt20 to construct a historical overview of the use of formal and informal healthcare services in Soweto. It also uses the findings of a large scale cross sectional survey of the primary caregivers of the Bt20 cohort, conducted between November 2008 and June 2010. The rural case study is contextualised by a detailed review of research conducted in the Agincourt sub-district. For the qualitative case studies I employed a qualitative methodology incorporating serial narrative interviews to present an experience-based overview of concepts of disease causation, self treatment and coping. Results: The cross-sectional survey describes a low resource population with a high prevalence of chronic noncommunicable disease (NCDs). Over one third (37.3%) of the population in Soweto could be categorised as having a low socio-economic status, defined as access to only one or less of 5 socio-economic items. Slightly over half the respondents in Soweto (50.7%) reported having at least one chronic illness. Only around a third (33.3%) of the survey participants with chronic illnesses reported accessing formal healthcare services in the last 6 months. Similar trends were found in the review of research carried out in Agincourt. The qualitative case study in Soweto is characterised by a preoccupation with how the medicine from the clinic interacts with the body. The search for alternative remedies took place not as an attempt to cure disease, but to reach a deeper understanding of the diseased state of the body. The Agincourt qualitative case study highlights the importance of church membership, particularly of African Christian Churches, as the strongest factor motivating against the open use of traditional medicine. In both study sites there is evidence that traditional healers were consulted for social purposes rather than health-related purposes. Discussion: Soweto and Agincourt share similar patterns of healthcare utilisation and healthcare belief. Both study sites were characterised by increasing trends in formalisation. At the same time, only a small portion of individuals in both study sites with chronic illness utilised formal healthcare services. A consideration of the findings suggests five broad themes for further research: (1) Processes of constructing body narratives; (2) Encounters with purposive-rational systems; (3) Encounters with traditional medicine; (4) Encounters with contemporary informal medicine; and (5) Religion and healthcare. These five themes constitute the beginning of a comprehensive map of the lifeworld/ healthworld schema. Such a schema has implications for healthcare policy and practice, particularly with regard to the development of integrative paradigms in South Africa as exemplified by Community Oriented Primary Care (COPC). Conclusion: The aims and objectives of the study were met through the development of an initial lifeworld/ healthworld schema, which suggests that the coexistence of diverse public healthcare concerns of high NCD prevalence and low formal healthcare utilisation is best addressed through the adoption of integrated healthcare approaches based on lifeworld/ healthworld rationalistion.

Thesis (MEng)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Telemedicine is de ned as an electronic exchange of medical information and/or the delivery of clinical health care over a distance, by means of Information and Communication Technology (ICT). South Africa is faced with the problem of providing health care to a population in urban, as well as across vast rural areas. In addition to this, the South African health care system must deal with economical imbalances and a shortage of human resources to provide quality health care. Telemedicine services could provide a solution. Since the introduction of the rst national telemedicine services initiative in the late 1990s, a number of South African telemedicine services have been implemented in the public health care system. The majority of these telemedicine services have been prone to failure and many were prematurely terminated. The circumstances which in uence the failure or success of these services are not unknown. The lack of insight, and the high failure rate of telemedicine services implemented in the South Africa were the reasons for conducting this study. The purpose of the study is to assess telemedicine services implemented in the Western Cape public health care sector. The purpose is also to provide recommendations for improving the current and future telemedicine services in the Western Cape and other provinces. A telemedicine services assessment was conducted on a total of 26 telemedicine services identi ed at 6 health care facilities located in the Western Cape. The assessments were based on the TeleMedicine Services Maturity Model (TMSMM), which was developed speci cally for the purpose of assessing telemedicine services. The TMSMM capability statements were used as a yardstick to assess the maturity of each of the elements of telemedicine services in terms of the three service level groups (micro-,meso- and macro-level) and ve telemedicine domains (man, machine, material, method and money). The assessment process included: (i) the identi cation of telemedicine services at the selected health care facilities; (ii) the gathering of the relevant telemedicine service data by means of structured interviews; (iii) the transformation of the complex ow of information into Data Flow Diagrams (DFDs); (iv) the loading of telemedicine services data into a data warehouse; and (v) the analysis of data by means of On-Line Analytical Processing (OLAP), as well as box-and-whisker plots and statistical correlations. Based on the results of the TMSMM assessment, an electronic questionnaire was developed and administered amongst health care workers throughout the entire Western Cape. The questionnaire con rmed that the ndings from the TMSMM assessment are indeed representative of the entire Western Cape. The assessment of the telemedicine services provides information about the elements which a ect the success or failure of these services. This therefore addresses the initial research problem and ful ls the purpose of the study. These results were used as an input to the analysis of strengths, weaknesses, opportunities and threats (SWOT) of the delivery of telemedicine services in the Western Cape public health sector. For future references and studies, the SWOT analysis provides a point of departure for a strategic telemedicine services framework for a province like the Western Cape. / AFRIKAANSE OPSOMMING: Telegeneeskunde, per de nisie, behels die deel van mediese inligting en/of die lewering van kliniese gesondheidsdienste oor 'n afstand, deur middel van inligting en kommunikasie tegnologie (ICT). Telegeneeskunde dienste is moontlik een van die oplossings vir die lewering van gesondheidsdienste vir 'n bevolking wat versprei is oor 'n groot landelike gebied binne 'n publieke gesondheidsektor wat mense hulpbronne kort om kwaliteit gesondheidsorg te lewer. Die publieke gesondeheidstelsel van Suid Afrika het 'n drie-dubbele las van siektes, ekonomiese wanbalans and 'n tekort aan mediese praktisyns. Sedert die eerste nasionale inisiatief vir telegeneeskunde dienste in die laat 1990s bekend gestel is, is 'n paar telegeneeskunde dienste in die publieke gesondheidsektor van Suid Afrika geïmplementeer. Die meerderheid van hierdie dienste blyk onsuksesvol te wees. The faktore wat die implementeringsukses beïnvloed is nog nie goed nagevors nie. Die doel van hierdie studie is om telegeneeskunde dienste wat in die Wes- Kaap publieke gesondheidsektor geïmplementeer is te ondersoek. Die doel is verdermeer om aanbevelings te maak met die oog op die verbetering van bestaande en toekomstige dienste in die Wes-Kaap asook ander provinsies. Eerstens is 'n telegeneeskunde diens assessering uitgevoer op 'n totaal van 26 dienste 6 fasiliteite. Hierdie assesserings is gebasseer of the Telegeneeskunde Diens Volwassenheidsmodel (TMSMM), wat ontwikkel is spesi ek met die doel om telegeneeskunde dienste te assesseer. Dit word gedoen deur die dienste te meet in terme van drie vlakke (mikro-, meso- en macrovlak) en vyf domeine (man, masjien, materiaal, metode en geld). Die TMSMM vermoeë-stellings word as maatstaaf gebruik. Die assesseringsproses sluit in (i) die identi sering van telegeneeskunde dienste by die aangewese gesondheidsfasiliteite; (ii) die versameling van relevante telegeneeskunde data deur middel van gestruktureerde onderhoude; (iii) die transformasie van komplekse inligtings vloei na data vloeidiagramme (DFDs); (iv) die laai van telegeneeskundige dinste data in 'n databasis; and (v) die analyse van data deur middel van aanlyn analitiese verwerking (OLAP) sowel as boxen- snorbaard gra k en statistiese korrelasies. Gebasseer op die resultate van die TMSMM assesseringsproses, is 'n elektroniese vraelys ontwikkel en geadministreer onder gesondheidswerkers regoor die Wes-Kaap ten einde te bevestig of die gevolgtrekkings van die TMSMM assessering die hele provinsie verteenwoordig. Die assessering van die telegeneeskundige dienste verskaf inligting in terme van die faktore wat die sukses van telegeneeskundie dienste beïnvloed. Sodoende word die aanvanklike navorsingsprobleem aangespreek. Hierdie resultate is toe gebruik as inset vir die analise van die sterk punte, swak punte, geleenthede en bedreigings (SWOT) in die publieke gesondheidsektor van die Wes-Kaap in terme van telegeneeskundige dienste. Hierdie SWOT-analise kan in die toekoms gebruik word as vertrekpunt vir die ontwikkeling van strategiese raamwerk vir die implementering van telegeneeskundige dienste in 'n provinsie soos die Wes-Kaap.

In a descriptive survey, the accessibility of primary healthcare services in Molemole was explored and factors impacting on accessibility were identified. The research sample consisted of 134 community members who visited one of five clinics (one a mobile clinic) in Molemole. Questionnaires, information lists, observations and field notes were used as research instruments. Ethical principles were adhered to, and validity and reliability maintained. Findings indicated that geographical, financial and cultural accessibility were satisfactory. Functional accessibility seemed problematic. The main reasons for dissatisfaction were attitudes, shortages of staff, unavailability of treatment, dysfunctional hours and fragmented services. Recommendations included optimal utilisation of staff and resources, improvements on infrastructure and support systems, community involvement in decision-making, as well as reassessing service point locations and policies on medications, supplies and equipment. / Health Studies / M. A. (Health Studies)

The maternal mortality ratio (MMR) and neonatal mortality rate (NMR) have been persistently high in South Africa, with black, poor, rural women and neonates mostly affected. The MMR and the NMR are indicative of the health of the population and reflect deeper issues such as inequitable distribution of the country’s resources, social exclusion, deprivation, and lack of access to quality public services. The purpose of the study was to develop a model to meet the overall health needs of the socially excluded, the deprived and the vulnerable women by listing those factors that influence maternal and child health outcomes. From the point of view that individual reproduction and health decision-making takes place in a milieu comprising multiple socio-economic and cultural factors, this study attempts to add to the body of knowledge on maternal and child health in order to influence policies and interventions. Data was collected through a multi-staged, qualitative research design. The results show how structural factors result in high risk for poor maternal and child health outcomes, suggesting that the high rates of poor health outcomes are evidence of deprivation of women’s needs due to poverty leading to an inability to cope with pregnancy and childbirth. The results are used to develop a model that proposes pathways for policy action to confront both the structural and intermediary determinants of maternal and child ill health and mortality. These pathways operate through integrative and inter-sectorial mechanisms intended at empowering women and enhancing female reproductive health care activities. / Sociology / D.Litt. et Phil. (Sociology)

Background: Research has shown that men who have sex with men (MSM) experience stigma, discrimination, negative and judgmental attitudes and homophobia when accessing health care services. This has resulted in limited uptake of existing HIV and AIDS services. Further, the experiences serve as barriers to seeking and accessing public primary health care services. Negative psychological outcomes and in unique cases, adverse mental health outcomes have resulted from these experiences. Aim: The study aimed to explore and describe the experiences of a sample of MSM when accessing public health care services in Nelson Mandela Bay Municipality (NMBM). Method: A purposive sample of twenty-one MSM aged 22 to 30+ years, mainly black who lived in NMBM participated in semi-structured in-depth interviews. The study used the exploratory-descriptive qualitative design and thematic analysis was used to summarize findings. Findings: Findings from the study showed that MSM experience internalized stigma, perceived stigma, experienced stigma and HIV related stigma, resulting in minority stress. Experiences with health care services included long waiting time, lack of supplies, being attended to by different health care providers, health care provider insensitivity, comfort with health care provider and a need for integrating health services for MSM with general health services. Effects of stigma expressed by the men were non-disclosure of sexual orientation, reluctance to use public health facilities, negative mental health outcome and conformity to society. Conclusion: The study suggests that MSM public health services need to be improved and barriers to health access among MSM need to be addressed. Lastly, there is a need to address the health, psychological and social effects of stigma suffered by MSM.

This study is an assessment of the quality of sexually transmitted disease (STD) management and control in a rural district of South Africa. A semi-structured questionnaire was administered to 5 nurses from public sector primary health care clinics, 5 doctors from the public district hospital, 5 private general practitioners, 6 traditional healers and 7 STD patients. A patient simulation exercise involving 6 nurses and 6 general practitioners was also conducted. Using routine data collection forms, the spectrum of STD syndromes and the contact tracing rate were assessed. The private sector treated nearly a third of the STDs even though they charge about ten times the price of the public sector services. In general, the clinical skills of all providers were poor. While hypothetical patient histories produced reasonable responses on STD management during the interviews, the patient simulation results showed that health service providers provided STD management that was much poorer than the questionnaires indicated. The private general practitioners did not practice syndromic STD management and often did not use laboratory tests appropriately resulting in incorrect diagnosis and inappropriate treatment for STDs. All health service providers did not counsel, promote condoms or encourage contact notification adequately. All health service providers were keen to participate in continuing medical education that better equip them to manage STDs. Any attempts at improving the quality of care in the district must therefore include private general practitioners as an important and central component of STD policy and planning. Interviews with traditional healers and patients showed the importance of using non-biomedical constructs of health and illness in developing health promotion strategies. There is an urgent need to improve STD management at district level in an attempt to meet the first milestone of ensuring that a patient presenting with an STD to a health service is correctly managed. This can be done through the design of simple quality assurance methods as demonstrated in this paper.

The study aimed to explore and describe factors which impacted on the satisfaction of patients using the curative component of primary health care in the Ekurhuleni Metropolitan area. A qualitative, explorative and contextual design was followed in this study. Focus group interviews were used to collect data from clients, nurse clinicians and community health committee members. Findings indicated that there was lack of facilities, resources and supplies, lack of safety and security measures, negative attitudes of nurse clinicians, lack of community involvement and lack of clinic management involvement. Suggestions were made by the groups on how to improve the curative primary health care service and intervention strategies were identified from the suggestions made. The implementation of these strategies will help with the improvement of the service delivery at the clinic for primary health care. / Health Studies / (M.A. (Health Studies)

Submitted in fulfillment of the Masters degree in Technology: Community Health Nursing, Durban University of Technology, 2013. / Background One of the major challenges for the Department of Health in South Africa today is inequity and the need to provide quality integrated health care for all its citizens. Primary Health Care (PHC) has been declared as the way to achieve this goal, through the District Health System. Standard Treatment Guidelines (STGs) and the Essential Medicines List (EML) have been developed and are used at PHC clinics and hospitals. This study explored the use of STGs and the EML by professional nurses at PHC clinics in the UMgungundlovu District, KwaZulu-Natal, South Africa. Methods A quantitative descriptive research design was used. Questionnaires were used to collect data from respondents at the PHC clinics. A retrospective review of facility registers kept by the respondents on the rational use of drugs was also carried out by the researcher. Results The findings of the study revealed that the respondents had a good understanding of the use of the STGs and the EML. There was no evidence of polypharmacy, and medications were prescribed according to guidelines. Areas that were suboptimal were related to prescription writing in writing of schedules and routes of medication as indicated in facility records. The results further showed that training on the use of the STGs and EML were inadequate, which implies the need for strengthening of training programmes.

Submitted in compliance with the requirements for the Master's Degree in Technology: Nursing, Durban University of Technology, 2014. / Background : Tuberculosis (TB) is a global public health concern and is identified as the leading cause of morbidity and mortality in the population infected with Human Immune Deficiency Virus (HIV). South Africa (SA), particularly the KwaZulu-Natal Province, is burdened with persistently high rates of both TB and HIV infections. In an attempt to improve TB and HIV co-infection outcomes the South African health care system has adopted the World Health Organisation (WHO) guidelines for intensified TB case findings in all HIV positive individuals for regular screening of TB symptoms in order to promptly diagnose and treat active TB disease or to exclude TB for initiation Isoniazid Prophylactic Therapy (IPT). IPT has proven effective in preventing TB disease in People Living with HIV or AIDS (PLWHA). This critical first step of TB symptom screening is regarded as the intervention that could significantly reduce the challenge currently faced with TB-HIV co-infection. The study was conducted in selected eThekwini Municipality Primary Health Care (PHC) facilities with the focus on an investigation to determine the extent of the implementation of the TB symptom screening tool in HIV infected individuals, in addition to identifying treatment initiation or further investigations based on the tool implementation. It has been found during the literature review, that there is a lack of research in SA to show that this critical first step in TB identification has been investigated, yet one in six South African’s is HIV positive and the incidence of TB-HIV co-infection is not declining. Methodology : A quantitative, descriptive approach was utilised to conduct a retrospective patient chart review. A multistage cluster sampling technique comprising three stages was implemented to identify the sample. There was a random selection of clinics, and the required number of client records was obtained through convenience sampling from the selected clinics. Results : The findings of this study revealed there is inadequate implementation of the current national and provincial TB protocols. The study provides varied levels of information about TB symptom screening in HIV infected individuals in the PHC clinics of eThekwini Municipality. It was observed that Health Care Worker’s (HCW) in some facilities carried out TB symptom screening to an extent. However, the inconsistent and partial application of this screening tool warrants improvement to facilitate the broad success of TB-HIV care strategies.