OBJECTIVE: To assess the knowledge of Doctors and Clinical Nurse Practitioners (CNPs) with regard to the case management of ARI in children under the age of 5 years in the Khayelitsha District of Western Cape Province. METHODS: The study was a descriptive survey of all the doctors and CNPs in Khayelitsha district. A questionnaire with closed and open-ended questions was self-administered. The international WHO case management guidelines were used as the gold standard except where the Paediatric Handbook was used as the reference with respect to questions on tuberculosis, bronchiolitis and croup. A comparative analysis was carried out on the knowledge scores of the doctors in the public sector, the private General Practitioners (GPs) and the CNPs. Correlation between years of experience and scores were measured. A further comparison was performed between doctors with and those without a post-graduate qualification in Paediatrics. The association of the use of WHO/ARI/90.5 manual and the Red books (University of Cape Town Paediatric handbooks) with the knowledge scores was also evaluated. RESULTS: 34 Doctors and 34 CNPs participated in the study. All the questionnaires administered were returned - 100% response rate. The median percentage scores of the doctors and the CNPs were 68.5 % and 63.0% respectively, p = 0.007. Twenty six percent of CNPs scored less than 50%. The median scores of the doctors with and of those without a post-graduate qualification in Paediatrics were 78.5% and 67.0% respectively, p = 0.005. The median scores of the doctors in the public sector and the private GPs were 71.0% and 65.0% respectively, p = 0.03. The median scores of participants who had seen and made use of the WHO/ARI/90.5 manual and of those who had not were 68.5% and 66.5% respectively, p = 0.13. The median scores of participants who had seen and made use of the University of Cape Town Paediatric handbooks and of those who had not were 67.0% and 64.0%, respectively, p = 0.37. The rank correlation co-efficients of doctors' and CNPs' scores with years of experience were 0.26 (p = 0.13) and -0.01 (p = 0.94) respectively. CONCLUSIONS AND RECOMMENDATIONS: (i) There was a wide range in knowledge scores, with approximately one quater of CNPs scoring less than 50%. Training in management of ARI is therefore necessary. (ii) The poor correlation between years of experience and knowledge indicates that experience is not by itself associated with improvement in knowledge, and supports the need for a service - oriented training programme. (iii) The impact of the recommended training programmes should be evaluated using this study as a baseline for comparison. (iv) There is a need for similar Knowledge, Attitude and Practice (KAP) studies on ARI in other areas to inform local trainers and to enable prioritisation of training.

Includes abstract. / Includes bibliographical references. / The purpose of this quantitative, descriptive, cross sectional survey was to determine whether maternal socio-economic status has an influence on infant feeding practices, nutrition and growth status of HIV-exposed infants at Delft Community Health Centre. The aim of this study was to describe the influence of maternal socioeconomic status on infant feeding practices and infant anthropometric measurements. Information was collected from 125 mother-infant pairs who presented at the health clinic with infants aged between six weeks to six months. The WHO anthropometry calculator was used to determine the z scores of the anthropometric measurements. One hundred and twenty five Case Report Forms of mother-infant pairs were analyzed. Few infants were underweight if their mothers’ personal income or total household income were more than R800.00 per month, 12.7% and 1% respectively. Nearly twice as many infants (49.6%) of the single mothers were underweight as compared to infants (19.8%) whose parents were married. Similarly, twice as many infants (50%) were underweight if their mothers walked to the health facility compared to 23.8% of infants’ whose mothers’ used taxis. Education and employment status of mothers appear to prevent infants from becoming underweight as twice as many infants (55.8%) were underweight when their mothers did not complete secondary school compared to 23.3% of infants whose mothers did complete secondary school. Nearly four-fold more infants (59.5%) were underweight if their mothers were unemployed compared to those infants (14.9%) whose mother were employed. Housing, the presence of a flush toilet or running tap water in the house did not improve the body mass index of infants. A total of 57.4% of infants whose mothers resided in brick houses, 71.9% of infants whose mothers had access to flush toilets and 57.5% who had running tap water in the house were still underweight. Infants whose mothers lived in houses with less than two rooms or where 3-4 people occupy the house had higher risk of being underweight (54.6% and 40.5% respectively). Underweight children were still prevalent even if the room were occupied by only one person (50%) of 1-2 children (67.2%). All women chose to formula feed their infants after receiving infant feeding counselling. Despite the availability of free replacement feeds there were evidence that infants were not properly fed.

Introduction: A continuous and concerning increase in the number of deliveries at Mowbray Maternity Hospital (MMH) has been noted over the years and now comprises a greater proportion of deliveries compared to deliveries conducted by midwives at midwife obstetric units (MOUs). To date there have been no studies assessing the changes in the pattern of deliveries at MMH. This study describes the antenatal and intrapartum referrals at MMH in 2005 and 2013, to identify any changes and whether or not referrals are appropriate. Method: This is a descriptive study with an analytic component involving review of a sample of hospital folders (138 for 2005 and 246 for 2013) of women who delivered at MMH from January to December 2005 and 2013. Results: The mean age of referred women was 27.259 (SD ± 6.277) years and 27.326 (SD ± 6.025) years in 2005 and 2013, respectively, with no significant statistical difference (p = 0.918). There was also no significant statistical difference (p=0.056) in the proportion of coloured, black or white women who delivered at MMH during 2005 and 2013. In 2005, a total of 27 (52.2 %) delivered women were single, 54 (39.1%) were married and two (1.4%) were divorced. In 2013, a total of 178 (72.4%) women were single, 65 (26.4%) were married and three (1.2%) were divorced, with a significant statistical difference (p < 0.001). In 2005, 75 (54.3%) women were unemployed and 46 (33.3%) were employed, whereas in 2013, 172 (69.9%) women were unemployed and 69 (28%) were employed, which shows a significant statistical difference (p < 0.001). In 2005, women mostly resided in Mitchell's Plain (32.6%), Gugulethu (28.3%) or in Khayelitsha (27.5%). In 2013, most women resided in Mitchell's plain (33.7%), Gugulethu (24.4%), Retreat 48 (19.5%) and Southern Peninsula 31 (12.6%), which represents a significant statistical difference (p= 0.001). 2 The median parity for 2005 sample was 1 (IQR: from 0 to 2), while in 2013 it was 1 (IQR: from 0 to 1). Although most women (94.2% versus 95.1%) booked at antenatal clinics in 2005 and 2013 respectively, with no significant statistical difference (p=0.697), the gestational age at first ANC differed significantly (p < 0.001) (median 24 versus 19 weeks). In 2005, the median number of ANC visits was five (IQR: from 4 to 7) visits, whereas the median was six (IQR: from 5 to 8) visits in 2013, with a significant statistical difference (p= 0.013). Over half of referred women (55.8% and 50.8%) in 2005 and 2013 respectively were delivered by normal vaginal delivery. The remainder had either a caesarean section or assisted delivery, with no significant statistical difference (p=0.139). Most women were referred from MOUs in both 2005 and 2013, at 90.6% and 85.45% respectively, with a significant statistical difference (p < 0.001). During both years virtually all pregnancies were considered high risk and the most common reason for referral was previous caesarean section (18.8% versus 19.9% respectively). For both years most pregnancy referrals experienced one, or more, antenatal risk factors, mainly previous caesarean section at 31 (12.5%), obesity at 27 (11%), prelabour rupture of membranes at 26 (10.6%) and HIV at 24 (9.8%) in 2005 and previous caesarean section accounted for 56 (11.1%), prolonged pregnancy for 51 (10.1), obesity for 50 (9.9%), HIV for 50 (9.9%) and tobacco use for 42 (8.3%) in 2013. The difference was statistically significant (p < 0.001). In 2005, the main intrapartum risk factors were fetal distress (23.6%), failure to progress and preterm labour (18% each). In 2013, fetal distress was most common (36.2%), followed by failure to progress (16.7%). The difference is statistically significant (p=0.034). Conclusion: The Cape Town Metro West health system features a functional maternity referral system. Midwives perform well in referring pregnant women who meet the criteria for high risk. There has been an increase in the number of women referred to the MMH over the study period but in this study group all referrals were found to be appropriate and were compliant with relevant obstetric management protocols. It appears there have not been large shifts in the demographics of referred women over the period reviewed. In addition, the change in the referral pathway has seen Southern Peninsula and Retreat referring to MMH but Khayelitsha no longer referring there. Furthermore, there are emerging risk factors that reflect the epidemiological changes currently being observed in the Cape Town Metro West region.

Includes bibliographical references (leaves 67-82). / This study deals with sexual behaviour of adolescents in a rural area of South Africa. The primary objective is to explore the sexual behaviour of rural adolescents, specifically with regard to the first time they engage in sexual intercourse, the number of sexual partners, their use of contraceptives and their knowledge of HIV/AIDS and how this influences their sexual activity. This study also examines how alcohol drinking, cigarette smoking, drug and substance use affect adolescent sexuality. Lastly, it explores the influence of religion and family connectedness on adolescent sexuality.

Aims: 1. To establish the extent of Syphilis in Pregnancy and the association of syphilis with unbooked status and perinatal deaths. 2. To determine why the diagnosis was not made in forty cases of Early Congenital Syphilis. Objectives: 1. To establish the percentage of patients with syphilis at delivery and possible association between unbooked status and positive syphilis serology. 2. To determine the Perinatal Mortality Rate and establish what percentage of perinatal death s occurred in unbooked patients and in those with positive syphilis serology. 3. To establish booking status, place of delivery, whether treated or not, serological findings, signs and symptoms of infants with Early Congenital Syphilis. Study Design: 1. A descriptive, retrospective study of deliveries in the month of March 1994. 2. A descriptive, prospective study of perinatal deaths over six-month period January to Jun e 1995. 3. A descriptive, retrospective study of Early Congenital Syphilis patients over five-year period 1990 - 1994. Setting: Maternity and paediatric wards at Provincial Hospital Uitenhage, East Cape. Patients and Methods: 1. Records were studied of 154 maternity patients delivering in March 1994 in order to ascertain booking status and serology results. 2. Data on sixty-one perinatal deaths weighing over 500 grams was examined to establish maternal booking and serological status. 3. Folders of forty patients with Early Congenital Syphilis admitted to the paediatric ward were examined. Results: 1. Syphilis in Pregnancy: i) Prevalence of syphilis at delivery was 9% for patients with titres =/> 1 :8. ii) Unbooked patients totalled 47% of deliveries (73/154). iii) Fifteen percent of deliveries had no syphilis serology tests performed and were discharged without screening (23/154). iv) No significant association was found between unbooked status and positive serology (p=0.35). 2. Perinatal Deaths: i) In instances of a perinatal death, a significant association was found between unbooked status and positive RPR serology (p=0.017). ii) Perinatal death rate due to syphilis totalled 10.8/1000 deliveries. 3. Early Congenital Syphilis: i) Eighty-five percent of cases (34/40) delivered at PHU and were mismanaged by personnel. ii) Eighteen of the thirty-four mothers had attended antenatal clinic and were untreated or inadequately treated by the time of delivery (53%). vii iii) Sixteen of the mothers had been unbooked and were discharged without screening or treatment (47%). iv) Four booked patients had negative sousveillance during the antenatal period. Conclusion: Provincial Hospital Uitenhage serves a poor community. This is reflected in the high prevalence of syphilis at delivery and the high proportion of unbooked patients. Time-consuming and inefficient methods of sero-surveillance plus separate clinics and staff for antenatal and Sexually Transmitted Diseases compounded existing problems. The standard of care anticipated at a Level 2 Referral Hospital was not delivered by Health Workers, largely due to lack of in-service training and guidelines for the management of Syphilis in Pregnancy. Recommendations: 1. In-service staff training by the Perinatal Education Programme (PEP) and adoption of protocols of management. 2. Rapid ("same-day") availability of serology results and initiation of treatment at Antenatal Clinic. 3. RPR at booking visit and repeated at delivery in all patients. 4. Monthly evaluation by Perinatal Problem Identification Programme (PPIP) and Obstetric/Paediatric meeting to monitor implementation.

Includes bibliographical references / Background: Global morbidity and mortality trends have changed over time and are expected to continue changing. Preventable diseases, such as those caused by infectious agents, still account for a large proportion of morbidity cases in Africa. With increased survival of children under five years old, there is likely to be a change in morbidity and mortality pattern s for children aged 6 - 18 years. However, there are few studies in Africa that explore the burden of disease (morbidity and mortality) and injuries in children above the age of five. This study aims to determine the morbidity and mortality patterns among children aged 5 - 17 years in six Kenyan hospitals in 2013. Methods: This study is designed as a retrospective review of patients' medical records. Data was collected from all patient records at Kisii Level 5 Hospital (KL5H), Naivasha County Referral Hospital, Karatina Hospital, Garissa Provincial General Hospital, Mbagathi District Hospital , and Gertrude ' s Children ' s Hospital in Kenya , of patients who presented from the 1st day of January to 31st December 2013. Data was analysed to provide descriptive statistics and Pearson's chi - square test and odds ratios were calculated to explore differences in morbidity and mortality rates between age categories, gender and hospitals. Results: 4 520 patient records were retrieved for patients who met the inclusion criteria. Among these admissions, 70% suffered from communicable diseases, maternal causes or nutritional diseases (32.3% were common infectious diseases , such as malaria and diarrhoea ; 14.9% were respiratory infections ; 24% were pregnancy related ), 33.1% suffered from non - communicable diseases , while 13% of the admissions had injuries (mainly from falls/trips and road traffic accidents), with motorcycles causing the majority (58%) of road traffic accidents . Injuries increased with age for males. The in-hospital mortality rate was 3.5%. Among deaths, 60% suffered from communicable diseases, maternal and nutritional causes; 41.3% suffered from non - communicable diseases and 11.9% had injuries. There were variations in admissions and deaths between the ages, gender s and hospitals. There were more female (57%) patients admitted but more male (57%) deaths. Conclusion: Infectious and maternal cause s are the biggest contributor to morbidity while infectious causes have the highest proportion of causes of death. There is a need to understand why the high proportion of females under 18 years of age is admitted for maternal al causes and to develop reproductive health services to better address the health care needs of adolescents on Kenya.

Introduction In sub-Saharan Africa the unmet need for contraception for married couples is estimated to be 24%, with rural, uneducated, poor women generally experiencing a greater risk for unplanned, unwanted pregnancies compared to their urban, educated, well informed counterparts. Recommendations for addressing unmet contraceptive need are inclined to emphasise family planning programmatic efforts. The role of men in contraceptive decisions tends to receive less attention, the perception being that men are often uninvolved and unsupportive of the contraceptive needs of their female partners. This study reviewed the attitudes and perceptions of men about contraceptive services in Engela District of the Ohangwena Region, Namibia. Methods A qualitative study was conducted using Focus Group Discussions (FGD) and Key Informant Interviews (KII) with men and women aged between 18-60 years residing in the Engela district of the Ohangwena Region. Men and women were purposively selected and participated in four and two focus group discussions respectively to explore the subject. Interviews with six influential and respected key informants, including government officials and community leaders were conducted. Data generated from the interviews were transcribed, coded, and content analysis conducted. Based on the research domain, themes and subthemes were generated. Purposive sampling was done. Many people were contacted to participate as participants in the research, some declined from participating due to lack of interest, and it was only those that were keen on participating that were enlisted by the research assistants. Influential leaders, respected in the community were also selected as KII. Results The findings revealed that specific reproductive health issues are common in the community, with a high level of awareness of family planning and contraceptives among men and women, many women having access to contraceptives Yet men held negative views about women’s decision to use contraceptives without their consideration and approval by them. The results indicated that community-level information was not ideal, and should be improved. Conclusion The study showed that most of the men who participated in the study are well informed about family planning and available contraceptive options for both men and women. It also revealed the attitudes and perceptions of men to FP and contraception use of women. However, there is little male involvement in contraceptive decisions.

Introduction: Malawi has one of the highest maternal mortality ratio (MMR) in sub-Saharan Africa (SSA). Despite investments in family planning and emergency obstetric care (EmOC), Malawi’s Millennium Development Goal (MDG) target of reducing maternal deaths to 155 deaths per 100,000 live births was not met by the end of 2015. Between 2010 and 2015, Malawi was only able to reduce the MMR from 675 to 439 per 100,000 live births. Inadequate utilisation of perinatal services is the contributing factor to the MMR target not being achieved. One approach for improving the utilisation of perinatal services is to invest in community health workers (CHWs). CHWs can be trained to: identify women of child bearing age (WCBA) who need perinatal services; provide community education; encourage timely referral of clients to the nearest health facility; and undertake community follow up for WCBA who are pregnant and/or have recently given birth. We evaluated changes in utilisation of antenatal care (ANC), facility based births, and postnatal care (PNC) after CHW deployment to conduct monthly home visits to WCBA for pregnancy identification and escorting women to ANC, labour and facility birth and PNC clinics in Neno district, Malawi. The CHW programme was implemented in two catchment areas from March 2015 to June 2016. Methodology: We employed a retrospective quasi-experimental study design to evaluate the impact of CHWs on changes in the utilisation of ANC, facility based births, and PNC in Neno district, Malawi between March 2014 and June 2016 (pre-intervention period: March 2014 to February 2015, and post- intervention period: March 2015 to June 2016). Monthly outcomes were compared between a combined CHW intervention area and its synthetic control area using the synthetic control method. The synthetic control area (or synthetic counterfactual of the CHW) was the control area that was created from multiple available control sites where the CHW programme was not implemented to allow the comparison of outcomes between the sites where CHWs were implemented and the sites where CHWs was not implemented. Two hundred and eleven CHWs (128 existing CHWs plus 83 new CHWs from the community) were trained in maternal health and deployed to cover an estimated 5,132 WCBA living in a catchment area of about 20,530 people. The primary focus of the CHWs was to conduct monthly household visits to identify pregnant women, and then escort pregnant women to their initial and subsequent ANC appointments, facility births, and to PNC check-ups. As part of package of care, community mobilisation and improvements in services to achieve a minimum package of services at the local health centres were also added. Using the synthetic control method, as developed by Abadie and Gardeazabal (2003) and Abadie, Diamond and Hainmueller (2010) and a Bayesian approach of synthetic control developed by Brodersen (2015), a synthetic counterfactual of the CHW intervention was created based on six available public control facilities. The synthetic counterfactual trend was created to have similar preintervention characteristics as the CHW intervention trend. The impact of the CHW intervention was the difference between the CHW intervention site and its synthetic counterfactual Results: CHWs in the intervention areas visited an average of 3,147 (range 3,036 – 3,218) of WCBA monthly, covering 61.0% of WCBA. During these visit 3.6% (97 women per month) of WCBA were suspected to be pregnant every month. Of those women suspected to be pregnant, 67.8% (66 women per month) were escorted to health facilities immediately every month. CHWs visited an average of 254 pregnant women enrolled in ANC and 64 women in postpartum period monthly. ANC and facility births utilisation in the CHW intervention site increased in comparison to the control site. Firstly, the number of new pregnant women enrolled in ANC per month increased by 18.0 % (95% Credible Interval (CrI) 8.0%, 28.0%), from 83 to 98 per pregnant women. Secondly, the proportion of women starting ANC in first trimester increased by 200.0% (95% CrI 162.0%, 234.0%), from 9.5% to 29.0% per month. Thirdly, the number of women attending four or more ANC visits increased by 37.0% (95% CrI 31.0%, 43.0%), from to 28.0% to 39.0%. Lastly, the number of facility births increases by 20% (CrI 13.0%, 28.0%), from 85 women to 102 per month. However, there was no net difference on PNC visits between the CHW intervention site and its counterfactual unit (-37.0%, 95% CrI -224.0%, 170.0%). Conclusions: CHW intervention significantly increased the utilisation of ANC and facility based births in Neno, Malawi. However, CHWs had no net difference on PNC utilisation.

Introduction: Tuberculosis is the second leading cause of death from an infectious cause worldwide having claimed approximately 1.5 million lives in 2013. Estimates suggest that children account for about six percent of the total number of TB cases globally, however in South Africa this figure is much higher (15%). Young children are at particularly high risk of mortality and significant morbidity from TB. Despite clear evidence that Isoniazid preventative therapy (IPT) can reduce the risk of progression from TB infection to disease, IPT has been a poorly implemented component of national TB control programmes, especially in high TB-burden areas, including South Africa. This study aims to determine current practices regarding the identification and management of child contacts < 5 years in an area with an extremely high TB incidence rate where little background data exists on the topic. It will also assess the operational aspects of the TB control programme relating to the spread of TB to children. Methodology: A cross-sectional descriptive study was conducted using a retrospective review of clinic records from infectious index patients aged ≥15 years at West End clinic in the Nelson Mandela Bay health district in the Eastern Cape Province. A sample size of 246 child contacts (<5 years) was required to obtain a 95% confidence index with a 5% precision. This is based on 20% of eligible child contacts < 5years receiving IPT, as described by van Wyk, et al. (2010). 491 Index patient records were assessed in order to identify 261 child contacts < 5 years of age. Results: Contacts were generally well recorded with only 12.5% of index patient folders having no contacts documented although only 0.53 child contacts <5years were identified per index patient. A total of 261 child contacts < 5 years were identified and of these 184 (70.5%) were screened for TB. Two contacts were started on TB treatment and 108/184 (58.7%) were initiated on TB prevention therapy. For the remaining 74 (40.2%) children who were screened there was no documentation of further management. Adherence to IPT was extremely poor with only 4 (3.7%) children who started TB prevention completing the 24 week course. Female index patients were more likely to have contacts documented and to bring their contacts for screening. Contacts of index 16 patients who had previous TB were less likely to be screened and initiated on TB prevention therapy. The results of the assessment of programmatic factors relating to childhood TB control showed that patients were diagnosed and were rapidly initiated on treatment (median time of 5 days from sputum collection to commencement of treatment). It took a median of 4 days for children to be screened once the index patient had started treatment and a further 2 days (median) for child contacts < 5 years to be initiated on preventative therapy. Conclusion and recommendations: The results of this study are in keeping with those obtained in other settings with a high burden of TB. Although the documentation of contacts in this setting was relatively good, child contacts < 5 years were poorly identified and the fall-out of children at each step from identification to preventative treatment completion was still unacceptably high. Contacts of men and retreatment index patients are at particularly high risk of poor management. Recommendations are made for interventions at national and local level to improve contact management and the documentation thereof.

Includes bibliographical references (leaves 71-76). / The aim of this study is to implement Perinatal Problem Identification Programme (PPIP) at public health facilities in the Emfuleni Sub-district, this will document the medical conditions that led to perinatal deaths and describe the avoidable factors, missed opportunities and sub-standard care.