Thesis (MPH)University of Limpopo (Medunsa Campus), 2011. / INTRODUCTION: Antiretroviral therapy (ART) has been proven to significantly improve the quality and quantity of lives of patients infected with HIV. However, several barriers exist that prevent children from being initiated on treatment on time. Studies in adults have shown that the timing of treatment influence outcomes of ART; but little is known about this in children. Hence, the need for this study. The purpose of this study was to characterize the outcomes of late initiation of ART in HIV- positive children seen at the Mildmay Jajja Home center. METHODOLOGY: The study was a cross-sectional survey involving all children who were initiated at the Mildmay Jajja Home in 2005 and had had been on ART for at least 18 months. Two sets of data were collected, for the children on ART: their age and sex were recorded. In addition, based on the Ugandan clinical guidelines for ART, children were grouped into two groups; those 6 six years and below; and those above 6 years. Clinical variables recorded were baseline and repeated measurements of bodyweights, and CD4 counts; weight and CD4 counts at the time of initiation of ART, at 12 months and at 18 months. For the care providers: their age, gender, education level, relationship to the child was recorded. Three outcomes of treatment were assessed, adherence level by the 12th month on treatment; hospitalisation by the 12th month (during the first 12 months of treatment); and survival or death at by the 12th and 18th month on treatment. RESULTS: In total, 114 children were included in the sample. Among them, 54.4% of children were initiated late. Based on age, children 6 years old and younger were more likely and significantly initiated late as compared to those over 6 years old as about 70% of them were actually initiated late. Based on sex, female children older than 6 years were significantly initiated late as compared to boys. The characteristics of care providers that were associated with children being initiated late were being male, less than 40 years old, with a primary school level of education, and not knowing their own HIV status. With regard to outcomes of the treatment, adherence, hospitalisation, and survival were assessed. Overall, 59.4% of children achieved an adherence level of 90% or more; 17.3% of children had been hospitalised at least once; and the mortality was 17.5% during the 2 year period covered by the study. Adherence was influenced slightly by the timing of the start of the treatment since less than half (46.34%) of those initiated late achieved an adherence level of 90% or more as compared to over 53% among those initiated timely. Though there was not statistically significant difference, adherence was slightly better in children whose care providers were biological parents, whose HIV status was known as positive, and female. With regard to hospitalisation, children less than 6 years were significantly more hospitalised than the older ones; their care providers were relatives, not educated, and of unknown HIV status. Those initiated late were significantly more hospitalised than those initiated timely (63.15% versus 36.84%, p=0.03). With regard to survival, the majority of children who died were over 6 years old, and female. The majority of their care providers were female, under 40 years old, and known HIV-positive. In children initiated late, the mortality was 50% (n=14) and 83.3% (n=6) respectively by the 12th and 18th month of treatment as compared to those initiated timely. In conclusion, 54.4% of children were initiated late. Late initiation was associated with negative outcomes such as low adherence to treatment as less than half of them achieved a adherence level of 90% or more; hospitalisation as those initiated late were significantly more hospitalised than those initiated timely; and high mortality since among those who died, 50% and 83.3% of deaths occurred respectively by the 12th and 18th month of treatment among those initiated late. In order to minimize the probability that the majority of children are initiated late, a general awareness campaign should be directed at the general public so that they can be sensitized to the need to bring children to medical attention as soon as possible

A travers des systèmes d’assistance à la conduite, l’automatisation de la conduite est introduite graduellement, avec le but de créer un transport plus sûr, confortable et moins polluant. Cette thèse discute le développement d’un système d’assistance à la conduite qui permet une conduite automatisée sur autoroute. La thèse présente le concept « Legal Safety », qui base le développement d’un système d’assistance à la conduite sur le code de la route international. Ceci permet de partager la route avec des conducteurs humains, sans nécessairement changer l’équipement sur l’infrastructure ou sur les autres véhicules. Le « Legal Safety » permet aussi un partage intuitif avec le conducteur du véhicule égo. Chapitre 1 situe le concept « Legal Safety » dans les concepts des systèmes d’assistance à la conduite existants, et discute la méthodologie de recherche de la thèse. Chapitre 2 présente les spécifications sur les composants de perception, contrôle et IHM et compare ces spécifications avec l’état de l’art de ces composants. Chapitre 3 propose le développement d’un composant de calculation de trajectories pour une conduite sur autoroute et discute la contribution de la thèse par rapport l’état de l’art. Chapitre 4 présente le développement du système sur les véhicules et simulateurs du laboratoire LIVIC et des projets HAVEit et ABV. Les différentes implémentations sur PC et sur ECU sont discutées. Chapitre 5 discute les contributions de la thèse. Ce chapitre conclue que le « Legal Safety » pour les composants décision, contrôle et IHM serait possible avec la technologie état de l’art. Une perception selon le « Legal Safety » pourrait être développée en moyen terme. / Vehicle automation is proposed as one of the solutions to make transport safer, more comfortable and more environmentally friendly. It is gradually being introduced through Advanced Driver Assistance Systems (ADAS). This work aims to contribute to this evolution, by discussing how driving systems can share the road with human drivers. It presents the legal safety concept for the design of a highly automated driving system for highways. The legal safety concept proposes to base driving system design on traffic rules. This allows fully automated driving in traffic with human drivers, without necessarily changing equipment on other vehicles or infrastructure. The driving system can interact with the human driver, via human rules. If needed, the driving system takes over control in order to avoid accidents. With the third set of rules of the legal safety concept, system rules, system components respect the limitations of other system components. The requirements on PERCEPTION, control and Human-Machine Interface (HMI) components of the legal safety system are discussed. The decision component, which is the central component of the legal safety system, is completely worked out from requirements to design. The legal safety system has been implemented on PC and automotive Electronic Control Units (ECUs). The integration and validation of legal safety components on LIVIC, HAVEit and ABV demonstrators are presented. The work concludes that, for highway environments, legal safety decision, control and HMI can be achieved with state-of-the-art technology, and legal safety perception could be available in medium term.

Batu velakero iri kenaga, loboro mana vakatikili gira vano muzi (Highly effective leaders are at the front, walk in the middle, and encourage those from behind to catch up) My uncle Zorapa said, while I was on a 'pig-hunting' trip with him some twenty odd years ago, that school principals, like all leaders, can only be called leaders if they make a difference. In modern parlance, one frequently encounters this homespun wisdom in the statement that highly effective schools are led by highly effective principals. This study investigates the perceptions of six practicing principals of the elements of highly effective principalship in Solomon Islands' Community High schools. The study investigates and explores these perceptions and tries to describe the elements of highly effective principalship and the impediments that may prevent principals from becoming effective. The study hopes to contribute towards the possible development of highly effective principalship in the Solomon Islands schools. The finding of this research reveals that although the participating principals were very experienced, their responses indicate that there appeared to be no theory-driven basis for their practice. Similarly, the perceptions expressed reveal the urgent need for the Solomon Islands to pay more attention to leadership development strategies that will see the creation of national, and personal, leadership philosophies and set the process of ongoing leadership development, enhancement and improvement in the country. The proposed strategies must incorporate current international research and literature on educational leadership theories as well as building on current practice in the Solomon Islands that is nationally and culturally appropriate. In addition, the study suggests that current practitioners should be encouraged to engage in educational leadership research and begin to build a national literature base. This study suggests that the process of establishing the notion of highly effective educational leadership in the country's school system should start as soon as possible. Those in policy and decision-making positions must have the courage to implement strategies that will contribute to improved levels of educational leadership in order to raise the quality of education for all learners in the country. The children are the future prosperity of the country.

This correlation design study investigated the relationship between urban first and second grade classroom teachers’ sense of efficacy for literacy instruction and the reading achievement of their highly mobile students. Teachers’ sense of efficacy for literacy instruction was shown in previous studies to be correlated to student achievement. To obtain data for this study, a modified version of the Teachers’ Sense of Efficacy for Literacy Instruction Scale (TSELS) questionnaire was administered to 48 urban first and second grade classroom teachers within a single school district located in the southwestern region of the United States. Students’ pre and posttest scores in fluency and comprehension obtained from beginning- and end-of-the-year Texas Primary Reading Inventory (TPRI) provided additional data on student achievement. Analyses using a multivariate analysis of variance (MANOVA) determined that there was not a statistically significant difference between urban first grade classroom teachers’ sense of efficacy and urban second grade classroom teachers’ overall sense of efficacy for literacy instruction for their highly mobile students: F(2, 45a0 = .94, p = .40; Wilks Lambda = .96 at p, .05; partial eta squared = .04. There was not a statistically significant difference between first and second grade classroom teachers’ sense of efficacy on the subscales of efficacy for integrating the language arts and differentiating instruction. Paired sample t-tests determined there was significant growth in the reading achievement of highly mobile first grade students and highly mobile second grade students. Independent samples t-tests found no significant difference in the growth of reading achievement between highly mobile first grade students and highly mobile second grade students. Finally, multiple regression analyses concluded that there was not a statistical relationship between teachers’ sense of efficacy for literacy instruction and the reading achievement of their highly mobile first and second grade students.

Background Adherence to HAART is key to any successful HAART programme. In Madzikane KaZulu Memorial Hospital ARV Clinic, there is an increasing number of patients on HAART and an increasing number of patients still awaiting HAART initiation. With the paucity of healthcare personnel in this rural district hospital, suboptimal patient’s preparation for HAART often occurs, and the HAART defaulter rate is on the increase. This is may be attributed to an interplay of factors affecting HAART adherence. Aim and Objectives The aim of this research was to determine the prevalence of established factors associated with adherence to Highly Active Antiretroviral Therapy (HAART) in non-adhering patients at the Madzikane KaZulu Memorial Hospital (MKMH) ARV clinic. The objectives were: • To conduct an audit on all case files of patients on HAART over the study period. • To explore the behavioural aspects of poor HAART adherence in a focused group discussion. • To describe the factors associated with good HAART adherence Methods Study design: A cross-sectional descriptive study which focused on determining the prevalence of established factors( patient-related, therapy-related and facility-related factors) affecting HAART adherence at the ARV clinic was carried out among identified HAART non-adhering patients. Patients that were not adhering with HAART between the period of January 2009 and December 2010 were selected for the study. These patients were 19 years or more and had been on HAART for at least two months. The study was carried out between November and December 2010. The result of the focused group discussion was utilized to refine the development of the questionnaire. Setting: The study was conducted at the Madzikane KaZulu Memorial Hospital ARV clinic. This is a modern 269 bed district hospital in the Mount Frere, Alfred Nzo district, Eastern Cape Province of South Africa. This is a predominantly rural region. Results: Data for analysis was provided by 215 patients that fulfilled the inclusion criteria. The prevalence rate of the factors affecting HAART adherence at the hospitals ARV clinic was 24%. A total of 60% of the patients were females. Majority of the patients (86.1%) had treatment supporters, and more than half of the patients (57.2%) were unemployed and not on disability grant. A total of 62.8% of the patients prefer to take their ARV at a clinic near them, and the majority of these patients (96.3%) want to start taking their ARV in a nearby clinic within 6months. The female gender, unemployment not on disability grant, longer period on HAART, Regimen 1A ARV( stavudine or tenofovir plus lamivudine and efavirenz according to the National ART guideline 2004 and its modified version of April 2010) single marital status and probably poorly selected unprepared treatment supporters, are associated with poor HAART adherence at this ARV clinic. Conclusion The study revealed that the prevalence rate of the factors affecting HAART adherence at the Madzikane KaZulu Hospital ARV clinic was 24% amongst HAART non-adhering patients. These patients had the prevalence rate of patient-related factors (12.4%) more than double of the prevalence rates of therapy related factors (5.8%), and facility related factors (5.7%). Topmost amongst the associated factors for not adhering to HAART were: not belonging to a support group, the pills making the patient feel unwell, and the ARV clinic being too far from where the patients live. Efforts should be targeted at enrolling the patients in support groups, encouraging the use of HAART regimens that have good tolerability profiles, and establishing the down referral.

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the Degree of Master of Science in Epidemiology and Biostatistics. Johannesburg, November 2017. / Introduction Viral load is the most reliable indicator of poor adherence to anti-retroviral therapy (ART). However, this assay is difficult to implement in resource-limited settings due to financial and technical constraints. Laboratory markers, combined with the patient’s demographic and clinical details, have been described as better proxies of adherence than the current self-reported adherence measures. However, the real diagnostic value of these biomarkers remains unknown. Therefore, the aim of this study was to assess the usefulness of a composite marker to identify poor adherence to ART defined as a detectable plasma viral load in HIV-positive patients on first-line regimen at Themba Lethu Clinic (TLC) in Johannesburg, South Africa Materials and Methods: This study was retrospective cohort analysis of data collected on HIV-positive ART naïve adults initiating first line antiretroviral regimen at TLC following the 2010 South African antiretroviral treatment guidelines. The data collection was carried out as part of the low-cost monitoring (LCM) study at Themba Lethu Clinic in Johannesburg from February 2012 to 2014. The LCM cohort which aims to look at low cost monitoring of HIV treatment in resource limited settings was initiated in 2009 in Johannesburg, South Africa. The study or treatment outcome was failure to suppress viral load (VL ≥ 400 copies/ml) at 6 and at 12 months. Adherence to antiretroviral treatment was assessed using four (4) self-reported adherence (SRA) measures namely: a self-reporting questionnaire, a Visual Analogue Scale (VAS), a pill identification test (PIT) and the Simplified Medication Adherence Questionnaire (SMAQ). The result of each self-reported measure was classified as either positive or negative given a conventional threshold. In our study three (3) self-reported adherence (SRA) measures were combined into a multi-method approach tool which included self-reports combined with VAS and the pill identification test (PIT). Continuous variables were summarized by median with interquartile range. Categorical variables were summarized by giving their frequencies. To compare continuous variables, we used an unpaired t-test if the variable was normally distributed. When continuous variables were compared from baseline to the previous 6 months, a paired t-test was done. In the case of skewed distribution, we used a non-parametric variant of the t-test such as the Mann-Whitney U-test. To compare categorical variables, we used cross-tables with corresponding chi-square test or Fisher exact test. A Modified Poisson Generalized Linear Model (GLM) with robust variance was used to estimate adjusted relative risks (aRR) of failing to suppress viral load at 6 and at 12 months adjusting for age age, gender, self-reported adherence measures, changes in laboratory markers and missed appointments at 6 and 12 months after ART initiation. As there was missing values in the covariatess and the outcome, we performed a multiple imputation technique under missing at random (MAR) assumption in order to compare the robustness of the estimations between the complete case analysis and the imputation model under MAR after imputing missing values. with the imputed dataset. Additionally, we calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each self-reported adherence measure using viral load as the reference standard. Thus, we derived two diagnostic risk scores from rounding and adding together the adjusted regression coefficients used to estimate adjusted relative risk and following the Spiegelhalter and Knill-Jones approach, at 6 and at 12 months. The Receiver Operating characteristic (ROC) curves were computed to see the overall discriminative value of each continuous risk score. To assess the clinical usefulness of the continuous riskscores we dichotomized them from 2 ≥ vs < 1 to 5 ≥ vs < 5 and calculated the sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) at each cut-off, taking detectable viral load as a gold standard. Results: There were 353 HIV-positive patients initiated on first line ART at TLC for the LCM cohort study. Of these, 80.7% did not suppress viral load after 6 months while 30.1% did not suppress viral load at 12 months. The proportion of patients classified as being highly adherent was 86.7% but this proportion decreased to 60% at 12 months. By 6 months, after adjusting for gender and age, the variables that were significantly associated with detectable viral load included: having missed at least two ARV visits by ≥ 7 days (aRR: 2.35 95% CI: 1.08 -5.11); platelet count < 150 cells/mm3 (aRR: 2.73 95% CI: 1.04 -7.18) and VAS ≤ 95% (aRR: 1.65. 95% CI: 1.01-2.71). At 12 months, the estimates showed a positive relationship only with age group and unemployment. There were no similarities in the results found using complete case analysis and analysis with imputed datasets. However, the largest standard errors were obtained from the complete case analysis. At 6 months, the AUC ROC curve was calculated as 0.63 (95% CI, 0.53 - 0.72) while, for the visual analogue scale, the AUC decreased to 0.55 (95% CI, 0.49 - 0.62); for the Simplified Medication Adherence Questionnaire (SMAQ), the AUC decreased to 0.52 (95%CI, 0.45 - 0.60), while for the multi-method approach, it decreased to 0.53 (95% CI, 0.46 - 0.58). The optimal diagnostic accuracy was obtained with the score 5 (≥5 vs <5 Se: 64% and a Sp: 50.0%) followed by a risk score of 4 (Se of 76.0%, Sp of 34.7%). At 12 months, the AUC of the diagnostic risk score was calculated as 0.44 (95%CI, 0.40 - 0.60) while for the three self-reported adherence methods, it decreased to 0.48 (95% CI, 0.40 - 0.60), 0.51 (95%CI, 0.40 - 0.60) and 0.50 (95%CI, 0.41 - 0.59) respectively for the visual analogue scale, the SMAQ and the multi-method approach method respectively. Conclusion. This study shows that after ART initiation, the 6-month’s adherence can be better diagnosed using laboratory markers combined with patient’s information and traditional self-reported adherence measures at Themba Lethu Clinic. The advantage of this proposed method is that it is based on routine and accessible informations collected during HIV-positive patient visits, thus incurring no additional cost for its implementation. An external validation of this diagnostic risk score is needed for its translation into clinical practice in resource-limited settings. / LG2018

Research report submitted in fulfilment of the degree of Master of Public Health (MPH) at the University of Witwatersrand July 2015 / Introduction: Swaziland is facing a very high HIV prevalence and critical human resources for health (HRH) crisis. The Nurse Initiated and Managed Anti-Retroviral Treatment (NIMART), a task shifting program to capacitate nurses to offer ART services, was introduced in 2009 by the government of Swaziland to address the human resources for health (HRH) challenges in the country. Although the country has attained 80% coverage in ART provision amongst adults, the ART coverage in children below 15 years of age is 9% which falls way below the WHO stipulated proportion of 15% in that age group. In addition, ever since the NIMART was introduced there have been limited studies done in Swaziland to explore the perceptions of health workers with regards to its implementation. This study explored providers’ perceptions on the facilitators and barriers to the NIMART implementation in Manzini Region. Materials and Methods: An exploratory qualitative study was used to explore providers’ perceptions of the facilitators and barriers to the implementation of NIMART services in Manzini Region, Swaziland. A semi-structured interview guide was used to interviews with nurses, clinic managers and medical doctors who were purposively selected from five urban and three rural clinics offering NIMART services in Manzini Region, Swaziland. Thematic content analysis was used to analyse data guided by the Donabedian conceptual framework. Results: The findings showed that two weeks training was offered to the professional nurses before they were certified as NIMART nurses. The first week of training was mainly theory classes while the second week was on-site practical training. The NIMART program was perceived as vital by the providers interviewed as it improved access to ART, reduced patient waiting times, empowered nurses and was a cost effective program to address the shortages of doctors in the country. Structural factors like availability of health facilities, professional nurses, antiretroviral drugs and antiretroviral treatment guidelines at the facilities visited were reported by most respondents as facilitators of the implementation of the program. Process factors like the training of NIMART nurses in some facilities, the partnership between the Ministry of Health and various nongovernmental organisations, the health workers commitment and team work greatly facilitated NIMART implementation. Structural barriers like limited paediatric antiretroviral regimen choices and limitations in paediatric ART policy and legislation were mentioned to negatively affect ART uptake in children. Other barriers like children’s dependency on adult caregivers for their health issues and poor socioeconomic circumstances in communities were mentioned to be hampering ART uptake in children. Process factors like inadequate training of the NIMART nurses in some clinics, parents’ and caregivers’ myths and misconceptions around HIV, AIDS and ART, high HIV and AIDS stigma and poor access to health services were also raised. Conclusion and Recommendations: Even though there were facilitating factors of the NIMART program like availability of ART drugs and ART treatment guidelines which have been seen to have played a major role in ART uptake in adults, there are still many barriers to the implementation of NIMART as evidenced by the poor ART uptake in children. The inadequate training of NIMART nurses on paediatric ART, children’s total dependency on adults for their health needs and parents’ and caregivers’ misconceptions around HIV and AIDS negatively impacted the paediatric ART program. Other barriers included poor socioeconomic status and paediatric ART policy and legislation limitations. As a result, the recommendations are that the NIMART training program for nurses be improved with particular emphasis on paediatric ART. There is need to incorporate NIMART training into the nursing curriculum to ensure that more nurses are trained in ART provision. Community awareness needs be raised to address the issues around stigma, myths and misconceptions of HIV and AIDS through educational programs. There is also a need to increase the recruitment of nurses and improve motivation of nurses through provision of incentives.

No description available.

There is a dearth of research on migrant entrepreneurship in the context of contemporary UK policy. At the same time, there is evidence of burgeoning transnational socio cultural connectivity. This thesis evaluates the impact of these conditions on migrant entrepreneurship in a rapidly changing policy environment. Migrant entrepreneurship is viewed differently in academia, policy and public perception. This causes significant policy tensions and disjunctions that are manifest a migration policy system which fails to take into account the agency of migrant entrepreneurs. In a break from previous studies, the migrant entrepreneur s negotiations of power and agency that stem from transnational connections in a contemporary UK context will be addressed. It is important to acknowledge structures of migration policy and economic landscape at national, regional and local scales. Three areas of the UK are addressed; London, focusing on Inner London East, Birmingham and the West Midlands and Cambridgeshire.

No description available.