Background The burden of non-communicable diseases (NCDs) is rapidly increasing globally, and particularly in Africa, where the health focus, until recently, has been on infectious diseases. The response to this growing burden of NCDs in Africa has been affected owing to a poor understanding of the burden of NCDs, and the relative lack of data and low level of research on NCDs in the continent. Recent estimates on the burden of NCDs in Africa have been mostly derived from modelling based on data from other countries imputed into African countries, and not usually based on data originating from Africa itself. In instances where few data were available, estimates have been characterized by extrapolation and over-modelling of the scarce data. It is therefore believed that underestimation of NCDs burden in many parts of Africa cannot be unexpected. With a gradual increase in average life expectancy across Africa, the region now experiencing the fastest rate of urbanization globally, and an increase adoption of unhealthy lifestyles, the burden of NCDs is expected to rise. This thesis will, therefore, be focussing on understanding the prevalence, and/or where there are available data, the incidence, of four major NCDs in Africa, which have contributed highly to the burden of NCDs, not only in Africa, but also globally. Methods I conducted a systematic search of the literature on three main databases (Medline, EMBASE and Global Health) for epidemiological studies on NCDs conducted in Africa. I retained and extracted data from original population-based (cohort or cross sectional), and/or health service records (hospital or registry-based studies) on prevalence and/or incidence rates of four major NCDs in Africa. These include: cardiovascular diseases (hypertension and stroke), diabetes, major cancer types (cervical, breast, prostate, ovary, oesophagus, bladder, Kaposi, liver, stomach, colorectal, lung and non-Hodgkin lymphoma), and chronic respiratory diseases (chronic obstructive pulmonary disease (COPD) and asthma). From extracted crude prevalence and incidence rates, a random effect meta-analysis was conducted and reported for each NCD. An epidemiological model was applied on all extracted data points. The fitted curve explaining the largest proportion of variance (best fit) from the model was further applied. The equation generated from the fitted curve was used to determine the prevalence and cases of the specific NCD in Africa at midpoints of the United Nations (UN) population 5-year age-group population estimates for Africa. Results From the literature search, studies on hypertension had the highest publication output at 7680, 92 of which were selected, spreading across 31 African countries. Cancer had 9762 publications and 39 were selected across 20 countries; diabetes had 3701 publications and 48 were selected across 28 countries; stroke had 1227 publications and 19 were selected across 10 countries; asthma had 790 publications and 45 were selected across 24 countries; and COPD had the lowest output with 243 publications and 13 were selected across 8 countries. From studies reporting prevalence rates, hypertension, with a total sample size of 197734, accounted for 130.2 million cases and a prevalence of 25.9% (23.5, 34.0) in Africa in 2010. This is followed by asthma, with a sample size of 187904, accounting for 58.2 million cases and a prevalence of 6.6% (2.4, 7.9); COPD, with a sample size of 24747, accounting for 26.3 million cases and a prevalence of 13.4% (9.4, 22.1); diabetes, with a sample size of 102517, accounting for 24.5 million cases and a prevalence of 4.0% (2.7, 6.4); and stroke, with a sample size of about 6.3 million, accounting for 1.94 million cases and a prevalence of 317.3 per 100000 population (314.0, 748.2). From studies reporting incidence rates, stroke accounted for 496 thousand new cases in Africa in 2010, with a prevalence of 81.3 per 100000 person years (13.2, 94.9). For the 12 cancer types reviewed, a total of 775 thousand new cases were estimated in Africa in 2010 from registry-based data covering a total population of about 33 million. Among women, cervical cancer and breast cancer had 129 thousand and 81 thousand new cases, with incidence rates of 28.2 (22.1, 34.3) and 17.7 (13.0, 22.4) per 100000 person years, respectively. Among men, prostate cancer and Kaposi sarcoma closely follows with 75 thousand and 74 thousand new cases, with incidence rates of 14.5 (10.9, 18.0) and 14.3 (11.9, 16.7) per 100000 person years, respectively. Conclusion This study suggests the prevalence rates of the four major NCDs reviewed (cardiovascular diseases (hypertension and stroke), diabetes, major cancer types, and chronic respiratory diseases (COPD and asthma) in Africa are high relative to global estimates. Due to the lack of data on many NCDs across the continent, there are still doubts on the true prevalence of these diseases relative to the current African population. There is need for improvement in health information system and overall data management, especially at country level in Africa. Governments of African nations, international organizations, experts and other stakeholders need to invest more on NCDs research, particularly mortality, risk factors, and health determinants to have evidenced-based facts on the drivers of this epidemic in the continent, and prompt better, effective and overall public health response to NCDs in Africa.

Master of Public Health - MPH / Background: Namibia is one of the sub-Saharan African countries where diabetes mellitus ranks among the top ten health conditions contributing to the disease burden and among the top 15 in-patient causes of death. An understanding of the population's knowledge, attitudes and perceptions is required to inform health education and interventions targeting diabetes mellitus. Aim: The aim was to assess the level of knowledge, attitudes and perceptions about diabetes mellitus among an adult population living in Windhoek, Namibia. Methodology: A quantitative cross-sectional descriptive survey design was used. Data was collected from 300 adult respondents using a structured questionnaire administered by research assistants. Data was analysed using Epi-Info version 7. Descriptive statistics were used primarily to summarise and describe levels of knowledge, perceptions and attitudes. A scoring framework was developed to categorize responses. Analytical statistics was used to describe association between knowledge, attitudes and perceptions scores and demographic and socio-economic variables. A P-value < 0.05 was regarded as statistically significant. Results: Of the 300 respondents interviewed, 50.3% were males, 49.3% were females and 0.4 were missing. The majority of the respondents were between 26 – 30 years. With regards to employment, majority (62%) were employed full time. About 10.7% of the respondents had post-graduate degree, while 3.3% had no schooling. Knowledge about diabetes mellitus was higher amongst females (51.2%) compared to males (48.2%) and was associated with age. Only 34.7% of respondents had poor perceptions about diabetes (i.e. diet, curability and distribution). About 49.7% respondents had good knowledge about risk factors for diabetes mellitus while 50.3% had poor knowledge thereof. Conclusion: This study reveals that the general knowledge of respondents regarding diabetes mellitus was poor in Windhoek. Despite the respondents having good knowledge there were still misconceptions about diabetes related complications, risk factors and its treatment. In addition, attitudes and perceptions of respondents about diabetes were favourable and thus suggesting some level of understanding about diabetes in the different communities in Windhoek. This study shows that there is knowledge about diabetes, however lack of diabetes knowledge among some respondents suggests a need for a systematic education programme for diabetes. This study highlighted the areas that diabetes education programmes should focus on aspects or issues such as life style and healthy food intake.

>Magister Scientiae - MSc / Being overweight or obese are major factors contributing to the increased morbidity and mortality due to non-communicable diseases such as type 2 diabetes, cardiovascular disease and cancer. The treatment of obesity with pharmaceutical drugs is plagued by side effects. Plants and their phytochemicals possess a number of beneficial health effects including anti-oxidant,anti-mutagenic, anti-inflammatory, anti-obesity and anti-cancer effects, mediated by activation of the adenosine monophosphate protein kinase (AMPK).AMPK controls many metabolic processes including glucose uptake and utilisation, and adipogenesis, and is often referred to as the master regulator establishing cellular homeostasis.Cyclopia maculata, commonly known as honeybush, is an indigenous South Africa plant possessing anti-oxidant, anti-inflammatory and anti-cancer properties. Recently, others in our laboratory have shown that a hot water extract of fermented C. maculata inhibits adipocyte differentiation in 3T3-L1 pre-adipocytes, with some evidence of weight regulatory properties in a Wistar rat model of diet-induced obesity. In the rat study, 21 day old weanlings were fed a high fat, high sugar cafeteria diet for 3 months with (n=10) or without (n=10) C. maculata supplementation. This group of rats was referred to as the lean group (n=20). Another group of rats were fed a cafeteria diet for 4 months to induce obesity (obese group, n=20) and thereafter treated as described for the lean rats. The aim of this MSc study was to determine whether C. maculata induces AMPK activation.Proteins were extracted from the liver and muscle tissue of lean and obese Wistar rats using an optimized extraction method with a commercial lysis buffer and the TissueLyser.Treatment with the C. maculata extract had no effect on the protein yield in lean and obese rats. Interestingly, the protein yield in the liver of obese rats was significantly higher than that observed in lean rats. Although C. maculata treatment slightly increased AMPK activation (calculated as the ratio of phosphorylated AMPK to total AMPK) in the liver of lean and obese rats, the difference was not statistical significant. Conversely, C.maculata treatment decreased AMPK activity in muscle of lean and obese rats, with statistical significance observed in the lean group only (2.3-fold, p<0.05). Differences in AMPK activation between the groups were also noted, a 1.3-fold decreased activity observed in obese groups compared to their lean counterparts, although this was not statistically significant. Expression of PPARα, a downstream protein target affected by AMPK activation was reduced in the liver of lean and obese rats after C. maculata treatment. Moreover, PPARα expression was significantly higher in obese compared to lean rats (2.7-fold, p<0.001). PPARα is a transcription factor mediating fat metabolism (β-oxidation) and its expression is induced by circulating free fatty acids, which are increased in obese compared to lean rats. The expression of PPARα in muscle was too low for Western blot analysis and quantification.Cyclopia maculata treatment did not affect hepatic expression of UCP2, another protein important in establishing energy homeostasis. The expression of UCP2 was 2.9-fold higher in the liver of obese rats compared to their lean counterparts, although the difference was not statistically significant. The opposite results were observed in the muscle where C. maculata treatment decreased UCP2 expression in lean rats (2.8-fold,p<0.0001), and UCP2 expression was decreased 1.4-fold in obese rats compared to lean rats, although the difference was not statistically significant.ELISA results for AMPK activation revealed that C. maculata treatment increased AMPK activity, although not statistically significant. Histological analysis of retroperitoneal fat showed that C. maculata did not affect adipocyte size and number, although a slight decrease in adipocyte size was observed after treatment .This study has demonstrated that treatment of the cafeteria diet fed Wistar rats with 300 mg/kg of a hot water extract of fermented C. maculata does activate AMPK. This study revealed important differences between lean and obese rats. In particular, increased hepatic protein content, PPARα and UCP2 expression was observed in obese rats compared to the lean group. This suggests an adaptive response to the increased circulating free fatty acids during obesity and an increase in β-oxidation in these animals.

Magister Public Health - MPH / Background: The recognition of HIV/AIDS as a chronic life-long condition globally in recent years has demanded a different perception and an alignment to its association with other chronic diseases. Both HIV and other chronic non-communicable diseases are significant causes of morbidity and mortality. Their combined DALY contributions for Botswana would be significant if research and strategies in controlling these conditions are not put in place. Natural aging and specific HIV-related accelerated aging of patients who are on antiretroviral treatment means that age-related diseases will adversely affect this population. Princess Marina Hospital Infectious Diseases Care Clinic has been in operation since 2002. The clinic has initiated over 16 000 patients on anti-retroviral treatment (ART) since 2002. The current study estimated the prevalence of non-AIDS defining conditions (NADCs) in the attendees of the clinic in 2013. The majority of patients that attended the clinic had been on treatment for over three years with some patients more than ten years. These ART experienced patients were more likely to be susceptible to chronic non-communicable diseases, including non-AIDS defining conditions. The nomenclature used in classification of NADCs in the current study was appropriate for resource-limited settings; because the study setting offered HIV treatment under resources constraints. Aim: The current study characterised non-AIDS defining conditions, and determined their associations with virologic treatment failure in a cohort of patients that were enrolled at Princess Marina Hospital antiretroviral clinic in Gaborone, Botswana. Methods: A retrospective cross sectional study of records of patients who attended the Princess Marina Infectious Diseases Care Clinic in 2013. Stratified random sampling of a total of 228 patients’ records was achieved from a total population of 5,781 records. Data was transcribed into a Microsoft Excel Spreadsheet and then exported to Epi-Info statistical software for analysis. Results: Eighty (35%) cases of NADCs were reported/diagnosed in the study sample; with 27% (n=62) of the patients having at least one condition, 6.7% (n=17) two conditions, and 0.4% (n=1) three conditions. The top prevalent conditions were hypertension (n= 40), hyperlipidaemia (n=7) and lipodystrophy (n=7). The prevalence of NADCs on the various categories of patients compared with the total sample population was as follows: active patients (prevalence ratio= 0.70), transferred out patients (prevalence ratio = 1.24), patients who died (prevalence ratio=2.04) and patients who were lost to follow-up (prevalence ratio =2.86). The prevalence of NADCs was significantly associated with increasing age (p<0.001); having social problems (p=0.028); having been on treatment for over three years (p=0.007); an outcome of death (p = 0.03) and being lost to follow-up (p=0.007). The study showed that being controlled on second line or salvage regimen (p=0.014) and the presence of adherence problems in the past was associated with virologic failure (p=0.008). There was no association of presence of NADCs to virologic failure. Conclusions: There was significant morbidity of non-AIDS defining conditions in the Princess Marina Infectious Diseases Care Clinic shown by a prevalence of NADCs in the clinic of 35% in 2013.The significant associations of the presence of NADCs and virologic failure with outcomes of death and loss to follow-up illustrate the adverse effects that NADCs are having, and calls for strategies to address multi-morbidities in HIV patients on antiretroviral treatment.

The development and implementation of policy guidelines remains a contentious issue. Over the past few years, difficulty still exists in implementing the Department of Education (DoE) 1999, National Education Policy Act, 1996 (No. 27 of 1996): National Policy on HIV/AIDS for learners and educators in public schools, and students and educators in further education and training institutions [here after referred to as DoE HIV/AIDS policy (1999)], while at the same time trying to transform the entire education system. This research explored the perceptions of educators in the Port Elizabeth District regarding the implementation of DoE HIV/AIDS (1999) policy guidelines. A secondary objective was to provide a reflection of how the implementation of guidelines on HIV/AIDS interventions within the schools of the Port Elizabeth District either conformed to or deviated from the guidelines outlined in the DoE HIV/AIDS policy (1999). The study was executed within the paradigm of qualitative research and employed an exploratory, descriptive and contextual design. The researcher conducted a pilot study to enhance the trustworthiness of the study. Purposive sampling was employed to recruit research participants, consisting of 12 educators from 10 schools in the Port Elizabeth District where HIV/AIDS interventions were being implemented. Data was gathered through semi-structured interviewing and analysed using Tesch’s (1990) in De Vos, Strydom, Fouché & Delport (2005:340-341) framework for analysis of qualitative data. Guba’s model (in Krefting, 1991) was used to ensure the trustworthiness of the study. Three themes emerged from the results of the in-depth semi-structured interviews: (1) Educators’ views on the DoE HIV/AIDS policy (1999) guidelines and its implementation (2) Gaps or shortcomings in implementation of the DoE HIV/AIDS policy (1999) and (3) Educator suggestions’ to inform implementation of the DoE HIV/AIDS policy (1999) in schools. The results from the study indicate that there is inconsistency in the policy implementation approach employed by DoE district level representatives and there is a need for knowledge and capacity development at district and school level. The value of the study is outlined as well as recommendations.

Isolation of those ill with contagious disease has been a fundamental infection control concept for hundreds of years. However, recent studies suggest that fewer than 50% of health—care workers comply with their hospitals' isolation precaution policies and that efficacy of some of those policies is questionable. In response, two new systems, based upon fundamentally different goals, were promoted. The Centers for Disease Control, prompted by health—care worker& concerns about occupational risk of human immunodeficiency virus (HIV) from a growing number of patients with acquired immunodeficiency disease syndrome (AIDS), issued formal guidelines in 1987. This formed the basis for Universal Precautions (UP), a unifying strategy for precautions with all patients regardless of diagnosis intended to reduce risk to hospital staff members. Also in 1987, one hospital issued guidelines for Body Substance Isolation (BSI), hygienic precautions to be used with all patients based on recognition that colonized body substances are important reservoirs for cross—infection to both patients and staff members. These new strategies have been promoted widely, but there have been no formal assessments to reconcile controversies they raised nor to confirm their effectiveness. Further, necessary assessment tools have not been validated. This thesis provides new tools and new information to address three vital questions: Have hospitals adopted Universal Precautions or Body Substance Isolation? Do their staff members use the new system of precautions in daily practice? Has reliable use of a new system led to decreased risk of infection? A confidential mailed survey of all acute—care Canadian hospitals was conducted to measure rates of guideline receipt and adoption. It also obtained information on motivations for and perceived effectiveness of strategies adopted. A self—selected group of responding hospitals subsequently participated in standardized covert observation of their nurses infection control practices, then had the observed nurses complete a test examining their knowledge and beliefs. Employee health records were also examined to determine whether needlestick injury rates had changed since adoption of a new infection control strategy. Most Canadian hospitals adopted and modified new strategies based upon reasonable but unproven extensions of logic to protect health—care workers from HIV. 74% claimed UP (65%) or BSI (9%) but only 5% of 359 claiming UP and 0 of 50 claiming BSI adopted all policies expected. Many hospitals had not received key guideline publications. Guideline source, hospital size, and other variables were significantly associated with receipt. Nurses in 35 hospitals were observed to wear gloves during only z60% of procedures in which gloving was expected; rates varied widely among hospitals. Direct examination of sharps disposal containers confirmed compliance with a policy to not recap used needles (taken as recapping rate of 25%) in only 47% of 32 hospitals. Paired analysis of needlestick injury rates in 11 hospitals during comparable 90—day periods before versus after implementing UP/BSI showed no significant difference. 489 nurses completing a written test achieved their highest scores and least discordance among questions regarding procedural issues established long before UP/BSI, and lower scores or greater discordance on UP/BSJ concepts of philosophy, risk recognition and newer procedures. Positive correlation between knowledge and practice was not evident. UP and BSI now mean different things in different hospitals and have not been effective in harmonizing health—care workers’ infection control practices. Carefully standardized assessment methods are needed to guide their evolution to cost—effectiveness. / Graduate and Postdoctoral Studies / Graduate

Thesis(Ph.D.(Medical Science)) -- University of Limpopo, 2016 / Background: Chronic disease management (CDM) is an approach to health care that keeps people as healthy as possible through the prevention, early detection and management of chronic diseases. This approach offers holistic and comprehensive care, with a focus on rehabilitation, to achieve the highest level of independence possible for individuals.The aim of this study was to develop an integrated, evidence-based model for the management of chronic non-communicable diseases in a rural community of the Limpopo Province, South Africa. Methods: The study was conducted at Dikgale Health and Demographic Surveillance System (HDSS) site is situated in Capricorn District of Limpopo Province in South Africa. This study followed mixed methods methodology with an aim on integrating quantitative and qualitative data collection and analysis in a single study to develop an intervention program in a form of model to improve management of chronic diseases in a rural area. Therefore, this included literature review and WHO STEPwise approach to surveillance of NCD risk factors for quantitative techniques and focus group discussions, semi-structures interviews and quality circles for qualitative techniques. In the surveillance of NCD risk factors standardised international protocols were used to assess behavioural risk factors (smoking, alcohol consumption, fruit and vegetable consumption, physical activity) and physical characteristics (weight, height, waist and hip circumferences, and blood pressure). A purposive sampling method was used for qualitative research to determine knowledge, experience and barriers to chronic disease management in respect of patients, nurses, community health workers (CHWs), traditional health practitioners (THPs) and managers of chronic disease programmes. Data were analysed using STATA 12 for Windows, INVIVO and Excel Spreadsheets. Results: The study revealed that epidemiological transition is occurring in Dikgale HDSS. This rural area already demonstrates a high burden of risk factors for non-communicable diseases, especially smoking, alcohol consumption, low fruit and vegetable intake, physical inactivity, overweight and obesity, hypertension and dyslipidaemia, which can lead to cardiovascular diseases. The barriers mostly mentioned by the nurses, patients with chronic disease, CHWs and THPs include lack of knowledge of NCDs, shortages of medication and shortages of nurses in the clinics which cause patients to stay for long periods of time in a clinic. Lack of training on the management of chronic diseases, supervision by the district and provincial health managers, together with poor dissemination of guidelines, were contributing factors to lack of knowledge of NCDs management among nurses and CHWs. THPs revealed that cultural insensitivity on the part of nurses (disrespect) makes them unwilling to collaborate with the nurses in health service delivery. x The model developed in this study which was the main aim of the study describes four interacting system components which are health care providers, health care system, community partners and patients with their families. The main feature of this model is the integration of services from nurses, CHWs and THPs including a well-established clinical information system for health care providers to have better informed patient care. The developed model also has an intervention such as establishment of community ambassadors. Conclusion: Substantially high levels of the various risk factors for NCDs among adults in the Dikgale HDSS suggest an urgent need for adopting healthy life style modifications and the development of an integrated chronic care model. This highlights the need for health interventions that are aimed at controling risk factors at the population level in order to slow the progress of the coming non-communicable disease epidemic. Our study highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers and integrate their services in order to facilitate early detection and management of chronic diseases in the community. The developed model will serve as a contribution to the improvement of NCD management in rural areas. Lastly, concerted action is needed to strengthen the delivery of essential health services in a health care system based on this model which will be tasked to organize health care in the rural area to improve management and prevention of chronic illnesses. Support systems in a form of supervisory visits to clinics, provision of medical equipments and training of health care providers should be provided. Contribution from community partners in a form of better leadership to mobilise and coordinate resources for chronic care is emphasized in the model. This productive interaction will be supported by the district and provincial Health Departments through re-organization of health services to give traditional leaders a role to take part in leadership to improve community participation. / Medical Science Department, University of Limpopo in South Africa,International Health Unit, and Antwerp University

Master of Public Health - MPH / Non-communicable diseases (NCDs) are the leading causes of deaths worldwide and are shown to be responsible for approximately 71% of deaths globally. NCDs mainly affect individuals of working age, resulting in high sick leave absences and loss of productivity in the working environment. This presents a major barrier to economic growth, particularly in low- and middle-income countries where the impact is greatest. Among the interventions identified in the South African Strategic Plan for the control of NCDs, is the implementation of wellness initiatives (i.e. diet and exercise interventions) in the workplace. This has been to improve overall productivity and decrease absenteeism. This study was therefore aimed at investigating the effect that participating in workplace wellness initiatives targeted at employees, particularly those that are overweight, hypertensive and diabetic at Nestlé, had on the number of working days lost due to sick leave from NCDs.

Master of Public Health - MPH / Introduction: People with mental illness (PMI) are likely to die of chronic diseases, primarily cardiovascular, cerebrovascular and respiratory diseases at a younger age compared with the general population. The side-effects of psychotropic medications particularly weight gain and impaired glucose intolerance increase the risk of premature mortality in PMI. Behavioural risk factors for non-communicable diseases such as physical inactivity and unhealthy diet (diets high in fat and low in fruit and vegetables) are also thought to be consequences of negative symptoms of mental illness and emotional dysregulation.

Master of Public Health - MPH / Obesity is one of the critical problems that threatens not only health, but the economy at a global level. Among the factors associated with obesity is less than optimum level of nutrition literacy. Nutrition literacy is more than just the food knowledge, it is a combination of other essential factors that help individuals to maintain healthy a body size. These factors include the selection and consumption of nutritious food; acquiring knowledge and skills in the areas of meal planning and preparation; as well as using and knowing how to read food labels correctly.