D.Cur. / Not only do communities and individuals have the right to participate in their own health care, but a key means to reducing the risk of potential social and psychological harm of people participating in clinical health research, especially efficacy trials, is to ensure that the community in which the research is being carried out, as well as health service providers, are meaningfully involved in the research process. One of the requirements of the South African White Paper for the Transformation of the Health System (South Africa, 1997: 74-78) which refers to Essential National Health Research (ENHR), is that the research agenda should initiate a process whereby stakeholders are equal inclusive partners in the research. Therefore researchers are no longer perceived as having the right to exercise a monopoly on conducting and explaining their research but now have a duty to empower their research participants and the research community to understand their own situation and become a collaborative partner in the research process. In this participatory approach to research, a collegiate partnership needs to be facilitated, but the power differentials that exist between stakeholders in community research make this a difficult partnership. The researcher, having had prolonged interaction with a community which has been targeted for large efficacy trials, initiated this research to gain insight into some of these difficulties and to describe the understanding and expectations of key stakeholders into community participation in clinical health research and develop a model to manage this participation. The critical elements in the study took cognisance of the research context, the dynamics within that context, the relevant stakeholders in a participatory approach to clinical health research and the processes within which they engage. Literature was reviewed throughout the study that was conducted in two phases. Phase one of the research design is ideographic, contextual and descriptive in nature. A perception survey, within a targeted community, was conducted to describe the understanding and expectations of community representatives, health service providers and researchers of community participation in clinical health research. The analysis of the perception survey endorsed the notion that community participation needs to be an v integral part of all clinical health research. The findings from the perception survey and a further literature search enabled the researcher to develop a theoretical framework for the construction of a model to manage community participation in clinical health research. The model is overarching with multiple processes namely: the participatory management process central to the model; the preparatory process; research process and quality improvement process. The model facilitates a collegiate partnership between stakeholders where there is mutual influence and collaborative interaction. Its implementation requires a radical paradigm shift in research and a commitment on the part of those "in power" to share power. It is recommended that standards that monitor, measure and evaluate community participation in clinical health research be developed to operationalise the model. Funders increasingly mandate community participation in clinical health research and the challenge is to ensure that this process goes beyond tokenism. A model to manage community participation in clinical health research will facilitate the conscious integration of key stakeholders into the research process to provide a platform for the voiceless and powerless within the research community, so that they become active participants and partners, not merely 'objects' in the process of research and knowledge creation. This will not only meet the requirements of funders and the ENHR, but this collaboration and partnership will foster trust between researcher, health service providers, community representatives and trial participants. There will be mutual understanding of the research issues and this will ensure that the study or clinical trial respects cultural and ethnic differences among participants. The primary outcome of the operationalisation of the model will be to facilitate quality management of community participation in clinical health research.

M.Cur. / The aim of this study is to describe a quality improvement programme for nursing education in the private health care services. In the present economic climate of South Africa everybody strives towards quality service and as a result it has also became a customer demand. The learning accompanist is thus faced with the challenge to create a service which accommodates the expectations of the student as the customer. In the dynamic interactive relationship between the learning accompanist and the student, the student has the right to receive quality education which would enable him/her to function as an independent practitioner with critical and analytical thinking skills and able to provide quality nursing. The paradigmatic perspective that guides this research is based on metatheoretical, theoretical and methodological assumptions. The metatheoretical assumption utilised the Nursing Theory for the whole person, whereas the theoretical assumption utilised three sources:- the Nursing Theory for the Whole Person, the Quality Improvement Model of Muller (1986) and the Adult-Learner proposed by Knowles (1980). The methodological assumptions of this study are based on Botes' research model (1992), which imply a functional approach to practice of nursing science. The expectations of students regarding quality nursing education in the private health care services were initially explored by means of focus group interviews and these ideas are supported by literature searches. The sample population was N = 76 and the sample realization was N =12 for the focus group interview. Trustworthiness was ensured using the strategies proposed by Lincoln and Guba (1985: 290). A questionnaire based on this data was constructed to confirm these expectations as well as to explore-the theological dimension ("how") of the identified expectations. Analysis of the resultant data enabled the generation of specific statements which embodied the expectations with respect to the learning accompanist, nursing education and the system (N=9). In chapter four the conceptual framework is described based on the identified concepts.. relevant national and international literature. Trustworthiness was ensured by means of sound literature scrutiny and literature analysis (N=64). From the analysis of the description of the conceptual framework, six main and related concepts which resulted in concise and clear statements on nursing care could be generated (N =30). The contents of a desirable quality improvement programme were drawn up by means of deductive and inductive reasoning from these statements. The resultant programme focuses on the actions which should be carried out in order to improve quality in nursing education in the private health care services.

M.A. (Public Management and Governance) / The study deals with the nature and problems of the proposed National Health Insurance system in South Africa in order to develop a management and governance model to promote universal healthcare in South Africa. The general aim of the study is, therefore, to analyse the concepts and policy initiatives related to the resolution on the National Health Insurance (NHI) scheme being passed at the ANC’s 52nd National Conference in Polokwane in 2009. Calls for a NHI together with relevant legislation and programmes, have consistently formed an integral part of Government’s national effort to build a united national health system in which the public health sector plays a dominant role as provider of first choice. The proposed NHI is a state-mandated and state-administered health insurance scheme that provides universal and comprehensive cover to all South Africans in spite of their financial status. In essence therefore, the vision of the NHI system is to be inclusive of the unemployed and the indigent who will also be afforded the opportunity to receive healthcare which is on par with everyone else’s and not based on what they can or cannot afford. This enquiry is premised on the variables that have influenced the development of South Africa’s healthcare system, the implementation challenges of the proposed NHI, according to the National Health Insurance Policy Paper of 2011, and the lessons that South Africa can derive from the implementation of the national health insurance schemes of Brazil and Ghana. The dissertation concludes that there are certain challenges in the current NHI debate in terms of the lack of technical details on the proposed NHI system, a lack of transparency in terms of the process, as well as problems related to the exclusion of the main stakeholders in the public and private health sector.

M. Tech. / It is well known internationally that the high prevalence of back pain costs the economies of the world many billions of dollars annually. This has prompted a great deal of research abroad into means of reducing the deleterious economic effects of back pain. One of the results of this research is the realisation that Chiropractic treatment of back pain offers an efficacious and cost effective alternative to the conventional medical treatments currently employed in most countries. To this end there has been a move, by health management organisations in the USA and Canada, toward the integration of Chiropractic into their health care systems in a gatekeeper role with notable success in terms of cost reduction. Similar research has not been conducted in the Republic of South Africa and, notwithstanding the evidence emerging from abroad, Chiropractic, although integrated into many health care systems, remains inaccessible to most back pain sufferers, particularly those employed in the lower ranks of industry. This is in large part due to the unavailability of Chiropractic services in the more remote areas of the country where many mines are situated, but also partly due to the lack of incentive for mining companies to make use of Chiropractic services. The data used in this study was obtained from the in-house medical aid of a reputable South African mining company. The data was used to summarise the cost of treatment of selected categories of back pain by the various service providers within the medical fraternity. The medical costs were then compared to the similarly summarised Chiropractic cost of treatment for the same categories of back pain. The results indicate that Chiropractic costs compare favourably with those of the General Practitioner (GP) and Physiotherapists on a stand alone basis. The data indicates however that the medical approach invariable leads to specialist referral that in turn often results in surgery with the associated imaging, theatre and hospitalisation costs. When these costs are considered it becomes obvious that Chiropractic involvement at an early stage has the potential to considerably reduce the cost of treatment of back pain.

Programs and facilities necessary for the proper care and treatment of the senile are many and varied. This study is concerned with one of the institutional resources: the policies and procedures governing admission to Valleyview Hospital, an institution designed specifically for the aged with other disabilities of senility. To apply "operational" tests to policy and procedure, a sample of (30) applicants from the waiting list were selected for study, the purposes being (a) to determine what factors were operative in securing admission, (b) how the stated criteria for assessing priority of admission were utilized. A number of special personal circumstances affected the appropriateness of the group. Apart from this, it was found that the formal criteria for acceptance of applications to the hospital are employed with reasonable consistency, when measured against the time an individual applicant spends on the waiting list. It was also found that when a community agency initiated the application, admission was granted after relatively short periods on the waiting list, if there was no other resource readily available. Prom this study, the roles of the social worker in pre-admission services can be delineated as (a) helping the applicant to find other forms of care over the waiting period, (b) helping the Medical Superintendent to assess priorities for admission, and (c) helping applicants and families to accept the need for hospitalization when this is justifiable. Recommendations for needed changes in procedures and in legislation are made, particularly in the present cumbersome application arrangements, which require certification of the applicant as mentally ill before an application can he placed on the waiting list. Development in the community of specialized types of boarding and nursing homes for the care of the less severely handicapped by emotional and behavioural disturbances is also recommended. / Arts, Faculty of / Social Work, School of / Graduate

This thesis examines the historical development and the present state of health services in the Greater Vancouver area. With particular reference to its advocacy of universal and comprehensive medical care coverage, the Hall Report is used as a framework from which these services are evaluated. Recommendations of the Report and implications of these for the future development of health services are considered. Basic concern about health needs has historically been an integral part of social work and social welfare. Although health and welfare have developed into separate areas of concern their common focus continues to be the provision of services adequate to meet existing need. This focus is the rationale upon which the thesis is based. Included in this study are public health services, hospitals, and non-profit medical care coverage plans. These are the major public institutions through which community health services are provided. Information was obtained through interviews with relevant personnel, and from a review of pertinent literature and legislation. On the basis of this information, the nature, extent, and organization of these services are described. The institutions are examined, both as to their individual programmes, and their part in the total network of health care. The findings and recommendations of the Hall Report are taken into consideration in assessing the present organization and provision of health services. It is concluded that although the organization and provision of health services, on an individual basis, appears adequate, optimum functioning could be achieved by a policy of over-all planning and coordination. / Arts, Faculty of / Social Work, School of / Graduate

The purpose of the study was to design a reliable and valid assessment instrument that would provide a multidimensional profile of the elderly resident of a long term care facility. Use of this instrument would be a method of collecting and corrmunicating information concerning the full range of problems experienced by this group, in a form that is suitable for use at different levels of decisionmaking. The instrument consists of 31 unweighted items measuring functioning in 5 essential areas - cognitive, physical, emotional, social, and instrumental. Ratings were based on the observations of long term care staff who were in close contact with the individual over extended periods. Reliability and validity were tested using a non random sample of 76 elderly residents of one extended care unit. Both test-retest and interjudge reliability proved to be high and item analysis indicated that, with the exception of 2 items, the instrument provides levels of functioning appropriate to the sample population. The instrument also showed a high degree of internal consistency with the 3 major components identified as - cognitive behaviour, independence in daily living, and physical functioning. The validity of the instrument and its subsections was demonstrated through significant relationships with external criteria, namely - the number of problems listed on the multidisciplinary problem-oriented record, a health index measure, and a mental status rating. Further evidence of the instrument's validity was its ability to predict, retrospectively, 72 percent of the sample deaths in the first year following admission. Although only a preliminary form of analysis, this showed that a high level of mental functioning, combined with a low level of independence in daily living, was predictive of death within 3 to 9 months in the sample population. The implications of these results are discussed along with suggestions for further research in the area. Finally, potential uses for the assessment instrument in the field of long term care are provided. / Applied Science, Faculty of / Nursing, School of / Graduate

M.Comm. / The present study was undertaken in a bid to meet an urgent need uncovered in medical-information systems (MIS) for a formal process whereby risks posing a threat to patients in medical institutions could be identified and controlled by means of the appropriate security measures. At the time of the study, however, no such formal risk-analysis model had yet been developed specifically for application in MIS. This gave rise to the development of RAMMO, a riskanalysis model specifically aimed at the identification of risks threatening the patient in his or her capacity as an asset in a medical institution. The author, therefore, managed to achieve her object with the study, namely to initiate a riskanalysis model that could be applied to medical environments. Following, an overview of the research method used in order to achieve the objectives of the study: Firstly, background information regarding the issues and problems to be addressed was obtained, and they provided the well-founded motivation for the study. Secondly, the development and importance of MIS in medical environments came under consideration, as well as the applicability of information security in an MIS. In the third instance, general terms and concepts used in the risk-management process were defined, by means of which definitions existing risk-analysis models were investigated and critically evaluated in a bid to identify a model that could be applied to a medical environment. Fourthly, a conceptual or draft design was suggested for a risk-analysis model developed specifically for medical environments. In doing so, the first two stages of the model, namely risk identification and risk assessment, were given special emphasis. The said model was then illustrated by means of a practical application in a general hospital in South Africa. The study culminated in a summation of the results of and the conclusions reached on the strength of the research. Further problem areas were also touched upon, which could become the focus of future research projects.

This study is a part of a three stage pursuit to examine and to comprehend the relationship between the resources available, the apparent utilization patterns of those resources by the population being served, and the selected characteristics of the populations utilizing and not utilizing the prevailing medical care system. The first stage of the research involves the examination of the existing patterns of medical care utilization by socioeconomic status groups. Cross-national Comparison of Physician Utilization by the Socioeconomic Status Groups is the pilot research for the first stage and both modifies and develops the methodology for this type of research and also examines the physician utilization patterns of a population in well defined basic measurements — in this case the socioeconomic status index, the diagnosed disease, and the number of physician contacts. The comparison of the physician utilization patterns of socioeconomic status groups in respect to the prevailing medical care delivery system necessarily involves cross-area studies at least at regional level, but most likely cross-national comparisons as well. This study used already collected data, nevertheless, primary data, which had been collected and partly analysed in the World Health Organization/International Collaborative Study of Medical Care Utilization. The data came from twelve geographical areas, altogether from seven countries, and provided documented research material on the surveyed respondents' social characteristics, standard diagnostic procedures, and standard definitions of the interactions between the users and the prevailing medical care delivery systems. The social characteristics were used separately, but in a standardized way, in order to derive socioeconomic status groups in each area; the diseases distributions were examined in relationship to the socioeconomic status groups, and the physician utilization patterns were related to the socioeconomic status groups while controlling for the distributions of selected diseases, after which the study areas were compared to each other in terms of the exhibited relationships between the physician utilization and the socioeconomic status groups. The physician utilization patterns were found to vary only little from one area to another, however, consistently, to warrant the use of derived information for the second stage of the research. Physician utilizations were very weakly correlated to the socioeconomic status and these correlations were not substantially effected by the selection of the controlling disease, i.e., they were consistent. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

The provision of health care and preventive services that has evolved in Canada was based on the concept of equality. Within any one province all but a few selected groups pay equal prepaid insurance premiums or tax and are given the same benefit; payment of the provider for services rendered. The concept of Distributive Justice suggests that those with special needs should receive special services but selective provision of care or services may give rise to feelings of Relative Deprivation in non-recipients. For a health service to be equitable and perceived as "fair" there must be maximal distributive justice and minimal relative deprivation. During a research project in the Kitimat-Stikine Regional District during the summer of 19 75, it was found that northern British Columbians viewed their health services as unfair. They believed they subsidized the care and services used by southern British Columbia residents. This study investigates the factors in the health service system which affect the utilization and provision of health services and compares the utilization of hospital services of the Kitimat-Stikine Regional District with three other regional districts; Cowichan Valley, North Okanagan and East Kootenay and with British Columbia as a whole province. The comparative regional districts were chosen on the basis of demography, lifestyle, industrial, ethnic and geographic similarities and differences. Statistical tools used were Frequency Distribution, Simple and Multiple Regression. Determinants of access to care are discussed; the perception of illness, convenience costs, financial costs, availability of manpower, programmes and facilities, social and geographic isolation. An examination is made of the distribution of power in the health system and the use that is made of it by political decision makers, government administrators and planners, professional organizations, educators and pressure groups. The health services in the Kitimat-Stikine Regional District are described with emphasis given to missing programmes. The regional district has a high facilities-population ratio and a low manpower-population ratio. The expectations of the residents of northern British Columbia for provision of health care are presented, noting a concentration of expectation on access to acute health care. The planner's expectations, arising from elements in the health system are delineated. Manpower, facility and hospital utilization data were obtained for the four regional districts and the province. The hospital utilization data, separations by disease of residents from hospitals within and without their domiciliary regional district are subjected to statistical testing to determine whether access to care is reduced in the remote regional districts. The data are adjusted for the age and sex composition of the populations of each region-.and the province. There is no indication from the examination of hospital utilization data that the barriers to access to care that exist are effective in reducing the access gained. In each of the four regional districts, the numbers of separations are higher than expected based on the age and sex composition of the populations. A breakdown of the data on the 186 diseases into disease grouping indicates that hospital utilization is significantly high in some regions for particular groups of diseases. The results indicate a need to examine lifestyle and environmental factors in the four regional districts that may be influencing hospital use for these diseases. There are implications for policy formulation and for health planning activities. There is a need for regional districts to broaden their area of concern to include health services other than hospitals, to control environmental health hazards of industries, agencies and homes within their boundaries and to educate the residents about their personal responsibility for their health status, the special needs of some groups of people, the services required to meet those needs and why some services cannot be offered locally but require referral outside the regional district. The health system which has developed, based on the concept of equality does not provide northerners with a perception of equity or fairness. There is a need to obtain innovative services to meet special needs and to ensure the people excluded from the extra benefit are aware of the special needs of those for whom it is provided. Services which provide a high degree of distributive justice and minimize relative deprivation would result in an equitable and unequal service that could be perceived as fair by all. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate