M.Cur. / The role players participating within the support groups for patients with chronic diseases in Primary Health care services are facing a difficult task of managing support groups effectively. They are confronted by managerial challenges involved in the managing of support groups for patients with chronic diseases, such as careful planning, organising, leading and controlling the support groups. This is evidently confirmed by the disintegration of support groups and patients openly and deliberately rebelling and ignoring participation in support groups. The resistance and opposition is also displayed by other staff members within the clinic. The general dissatisfaction and frustration among the primary health care facilitators serves as proof of the poor management of support groups. The need to investigate and address this dilemma is important. It is therefore the reason why the researcher embarked on this studying order to explore the I experiences of the role players with regard to the management of the support groups for patients with chronic diseases within the clinic context, and then utilise the results ad basis for formulating guidelines for quality management of support groups within Primary Health Care clinics in Soweto. The following research questions are therefore relevant: ~ What are the experiences of the primary health care facilitators with regard to the management of support groups for the patients with chronic diseases with primary health care clinics in Soweto? ~ What are the experiences of the facility managers with regard to the management of support groups for patients with chronic diseases within primary health care clinics in Soweto? ~ What are the experiences of patients with chronic diseases with regard to the management of support groups? ~ What guidelines should be formulated to ensure quality management and sustainability of support groups for patients with chronic diseases within the primary health care clinics in Soweto? The following research objectives were formulated: ~ To explore and describe the experiences offacility managers with regard to the management of support groups for patients with chronic diseases within primary health care clinics in Soweto. ~ To explore and describe the experiences of the primary health care facilitators with regard to the management of support groups for patients with chronic diseases within primary health care clinics in Soweto. ~ To explore and describe the experiences of the patients with chronic diseases with regard to the management of support groups within primary health care clinics in Soweto. ~ To formulate guidelines for quality management and sustainability of support groups for patients with chronic diseases within the primary health care clinics in Soweto.

A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg 2016 / Introduction: The African continent, particularly sub-Saharan Africa, is facing a high burden of disease from the human immunodeficiency virus (HIV) pandemic and nutritional deficiencies, while at the same time, facing ever increasing rates of cardiovascular diseases (CVDs). The mortality rates from CVD are almost equal to the death rates from communicable diseases. In Sub-Saharan countries CVD prevention and management faces many barriers. One such difficulty is the shortage of data for the descriptive epidemiology of CVD risk factors. In an attempt to address this shortage of data, we established the Heart of Soweto (HOS) study in one of the largest African urban communities in South Africa. The purpose of this study was to identify and describe some of the factors contributing to the emergence of chronic diseases of lifestyle, such as heart disease, high blood pressure, diabetes and obesity in a black urban African population, within the framework of the HOS study. We also investigated the impact of a dietary intervention on cardiac function in subjects with chronic heart failure (CHF) in this black urban cohort. Methods: Data was collected as part of the “Heart of Soweto” (HOS) study, which was a prospectively designed registry that recorded data relating to the presentation, investigation and treatment of patients with newly diagnosed cardiovascular disease presenting to Chris Hani Baragwanath Hospital (CHBH), Soweto in 2006. Data collected included socio-demographic profile and all major cardiovascular diagnoses. Heart disease was defined as non-communicable (ND) e.g. coronary artery disease or communicable (CD) e.g. rheumatic heart disease. A survey was also conducted on consecutive patients attending two pre-selected primary care clinics in Soweto (644 and 667 patients from the Mandela Sisulu and Michael Maponya clinics, respectively). Data collected included, ethnicity, duration of residence in Soweto, highest level of education and employment status. Clinical data collected included prior or current diagnoses of diabetes and hypertension and pharmacological therapy related to the treatment of hypertension, as well as smoking status and exposure to second-hand smoking. Weight, height, and waist and hip circumference were measured. Questions were asked regarding the duration of night-time sleep and napping during the day. Descriptive studies were undertaken at the Heart Failure Clinic at CHBH, Soweto to firstly describe the food choices and macro-and micronutrients intake of 50 consecutive patients presenting with heart failure using an interviewer-administered quantitative food frequency questionnaire (QFFQ). Food data were translated into nutrient data using the Medical Research Council (MRC) Food Finder 3, 2007, which is based on South African food composition tables. Secondly we performed a randomized controlled study of a multidisciplinary, community-based, chronic HF management program in Soweto, compared with usual care, at CHBH Heart Failure Clinic located at the Soweto Cardiovascular Research Unit (SOCRU), or at the General Cardiac ix Clinic (standard care) in Soweto. In this study 49 consenting, eligible patients were individually randomized on a 1:1 basis to either usual care or to the study intervention and cardiac function was measured before and after the intervention. Results: Data collected at Chris Hani Baragwanath hospital (CHBH) cardiology clinic from 5328 suspected cases of heart disease, demonstrated that the most prevalent form of heart disease was hypertensive heart failure (22.0%). It was found that those participants who presented with ND (35.0%) were older and had higher BMI and mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) than those with CD (39.0%; all comparisons p<0.001). Within this cohort of 5328 de novo cases of heart disease, 2505 (47%) were diagnosed with HF, of which 697 (28%) were diagnosed with r i g h t h e a r t f a i l u r e ( RHF). There were more women than men diagnosed with RHF (379 vs. 318 cases), and on an adjusted basis, compared with the remainder of the Heart of Soweto cohort (n = 4631), RHF cases were more likely to be African (adjusted OR 2.33, 95% CI 1.59 – 3.41), with a history of smoking (OR 1.72, 95% CI 1.42 – 2.10), a lower body mass index (OR 0.96, 95% CI 0.94 – 0.97 per kg/m2) and were less likely to have a family history of heart disease (OR 0.79, 95% CI 0.64 – 0.96). Data collected at 2 primary health care clinics in Soweto from 862 women (mean age 41 ± 16 years and mean BMI 29.9 ± 9.2 kg/m2) and 449 men (38 ± 14 years and 24.8 ± 8.3 kg/m2) indicated that in females, former smokers had a higher BMI (p<0.001) than current smokers, while exposure to second hand smoking was associated with a lower BMI (p<0.001) in both genders. Longer sleep duration in females was associated with a lower BMI (p=0.01). Napping during the day for > 30 minutes in males was related to a lower BMI and waist circumference (β=-0.03, p<0.05 for both) and lower systolic (β=-0.02, p<0.05) and diastolic BP (β=-0.02, p<0.05). Longer night time sleep duration was associated with lower diastolic (β=0.004, p<0.01) and systolic BP (β=0.003, p<0.05) in females. Within this same cohort, o b e s i t y w a s m o r e p r e v a l e n t i n f e m a l e s ( 4 1 . 8 % ) t h a n m a l e s ( 1 4 . 1 % ; p < 0 . 0 0 1 ) , 16% (n = 205) had an abnormal 12- lead ECG with more men than women showing a major abnormality (24% vs. 11%; OR 2.63, 95% CI 1.89–3.46). Of 99 cases (7.6%) subject to advanced cardiologic assessment, 29 (2.2%) had newly diagnosed heart disease which included hypertensive heart failure (13 women vs. 2 men, OR 4.51 95% CI 1.00–21.2), coronary artery disease (n = 3), valve disease (n = 3), dilated cardiomyopathy (n = 3) and 2 cases of acute myocarditis. Nutritional deficiencies were observed in a cohort presenting with HF at the cardiology outpatient clinic, CHBH. In women, food choices likely to negatively impact on heart health included added sugar [consumed by 75%: median daily intake (interquartile range) 16 g (10–20)], sweet drinks [54%: 310 ml (85–400)] and salted snacks [61%: 15 g (2–17)]. Corresponding figures for men were added sugar [74%: 15 g (10–15)], sweet drinks [65%: 439 ml (71–670)] and salted snacks [74%: 15 g (4–22)]. The women’s intake of calcium, vitamin C and vitamin E was only 66%, 37% and 40% of the age-specific requirement, respectively. For men, equivalent figures were 66%, 87% and 67%, respectively. Mean sodium intake was 2 372 g/day for men and 1 972 g/day for women, 470 and 294% respectively, of daily recommended intakes (DRI). In men, vitamin C intake was 71 ± 90 (79% of DRI). Similarly, in women vitamin C intake was 66 ± 80 (88% of DRI). Data collected from our HF management programme study supported the deficient intake of vitamin C in African subjects presenting with heart failure. Thus, plasma vitamin C concentrations (normal range 23 – 85 μmol/L) were markedly deficient in both standard care [6.53 (3.80, 9.22) μmol/L] and managed care [3.65 (1.75, 8.23) μmol/L] groups. In terms of clinical presentation, males were significantly older (49.9 ± 10.9 years; p<0.005) than females (37.2 ± 12.8) and at follow-up females had a significantly higher ejection fraction (34.8 ± 9.56 %) than males (29.5 ± 8.27; p<0.05) and when the groups were combined, the ejection fraction was significantly higher (32.2 ± 9.27; p<0.05) at follow-up compared to baseline (29.9 ± 8.80). We found that heart rate was significantly lower at follow-up (89.9 ± 14.6 beats/min) compared to baseline (93.4 ± 17.2; p<0.05) only in the managed care group. Furthermore, if diastolic blood pressure increased over the follow-up period, ejection fraction fell by 5.98% (p=0.009) in comparison to cases where diastolic blood pressure remained the same or fell. In addition, thiamine levels at baseline correlated negatively with systolic blood pressure (r=-0.68, p=0.04) at follow-up. Conclusion: Non-communicable heart disease and other diseases of lifestyle, such as high blood pressure, obesity and diabetes, are drastically increasing in Sub-Saharan Africa in general and in a black urban African community, such as Soweto, specifically. Soweto can clearly be described as a community in epidemiological and nutrition transition and is facing a double or even triple burden of disease. This is a community that is still being burdened by historically prevalent forms of communicable or infectious diseases juxtaposed against people who have lived their whole lives in Soweto and are increasingly suffering from newer or non-communicable diseases of lifestyle. Women seem to be especially burdened by this increase in non-communicable diseases, with a predominance of women suffering from heart disease and obesity. Certain exacerbating risk factors have been identified from the HOS in this community, namely the gender specific effects of sleep, smoking and other environmental factors on BMI and blood pressure, and the adverse effects of changing dietary patterns particularly the increased consumption of refined and processed foods, high in sugar, salt and fats and insufficient intakes of fruits and vegetables. Although there are some limitations to our HF management study, it serves as an indication that targeted, culturally sensitive care, adapted to an urban African population, might contribute to improved patient outcomes. However, prevention should always be our first priority through community-based and gender specific screening and the development and implementation of targeted prevention programs. / MT2017

Thesis advisor: Sara Moorman / Improved survival for medical conditions that were previously fatal in infancy has led to more individuals living longer with chronic illnesses. These individuals, some of whom have largely unapparent, unpredictable, and yet severe symptoms from birth, may experience a unique set of physical, social, and emotional impacts associated with their condition as compared to youth with less severe, treatable pediatric conditions or individuals with adult-onset conditions. This dissertation explores these challenges using the case of youth with Barth Syndrome (BTHS), a rare, severe, genetic condition in males associated with life-limiting and life-threatening symptoms. Research questions explored: (1) how symptom severity, visibility, and controllability informed individuals’ social management and legitimization of BTHS; (2) how awareness regarding their limited, uncertain prognosis impacted life planning for youth with BTHS; and (3) which coping strategies individuals with BTHS used to manage the physical, social, and emotional impacts associated with their incurable, life-limiting condition. Thirty-three sixty-minute interviews were conducted in two groups: individuals with BTHS ≤15 years of age (n=18) and/or their caregivers, and individuals with BTHS ≥16 years of age (n=15). Interview transcripts were analyzed using Atlas.ti. Results demonstrated that (1) the severity, visibility, and lack of control over BTHS symptoms was associated with individuals needing to seek social support for their condition, rather than attempting to pass as healthy as other males with chronic conditions have been found to do; (2) individuals opted to forgo socially “on-time” goals (i.e., long-term, knowledge-based goals) based on their perceptions of their limited, uncertain time horizons and struggled to identify alternative goals; and (3) individuals used secondary coping strategies (i.e., regulating their emotional responses to their external stressor rather than controlling the stressor itself) to cope with the impacts associated with having an incurable, severe, and chronic health condition. These results can be used to inform practices for providing increased social and institutional support to chronically ill youth, including promoting positive coping strategies and facilitating meaningful, attainable, goal selection. These interventions may alleviate some of the challenges faced by the growing number of youth living with chronic illnesses seeking to safely and meaningfully engage in the realms of work, family, education, and social life. / Thesis (PhD) — Boston College, 2019. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Sociology.

ABSTRACT The aim of this study was to review the clinical presentation and contribution of various independent variables to the clinical outcome of surgically treated chronic subdural haematoma at the time of discharge. The records of one hundred fifty patients harbouring chronic subdural haematomas who were treated at Chris Hani Baragwanath Hospital between November 2001 and March 2004 were studied, for the following data • Demographic details such as age, gender and race. • Pre-operative clinical data including clinical presentation, predisposing factors, neurological grade, duration of symptoms to treatment, pupillary size and reaction, CT brain appearance. • Type of operation. • Post-operative data including presence of symptomatic recurrence and outcome data as expressed by Glasgow outcome score.It was found that the clinical presentation varies between the age group below sixty years and above sixty years. The following factors were found to be statistically significant in determining likelihood of poor outcome. • Neurological grade on admission. • Abnormal pupils. • Associated co morbid conditions.

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016 / Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (<140/90 mmHg) and CD4 counts (>350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs. / MT2017

Chronic renal failure patients develop a coagulopathy primarily due to reversible platelet dysfunction. This coagulopathy makes certain anaesthetic techniques and procedures such as neuraxial anaesthesia and invasive line placement possibly contra-indicated or risky. There is no evidence to suggest that the degree of platelet dysfunction is proportional to the degree of renal dysfunction. In this research project the platelet function of 39 end stage renal failure patients, who received regular dialysis and who presented to theatre for vascular access, was assessed using the thromboelastogram. A bleeding time was also performed pre-operatively. A linear regression model was used to determine if the bleeding time, plasma urea, plasma creatinine or creatinine clearance could predict maximum amplitude (and therefore clot strength) on the thromboelastogram. No such regression could be found. The clinical implication of this result is that there exists no "safe" plasma urea or creatinine, below which it is safe to perform procedures which are contra-indicated in coagulopathies. The degree of renal dysfunction did not predict the degree of platelet dysfunction. Since dialysis reverses the platelet dysfunction, the question that should be asked before performing such a procedure is not "how severe is the renal dysfunction?" but rather "has the patient been receiving regular dialysis?"

Perceived benefits and burdens encountered by relatives caring for person on long-term haemodialysis in Johannesburg. This study examines the perceived benefits and burdens of family members caring for persons on long term Haemodialysis. The caregiver burden scale by Elmastahl, Malmeberg and Annerstedtl (1996) was used for the purposes of the study. The participants were selected by Census (total) sampling. The sample consisted of family caregivers who were 18 years and above who were selected from three haemodialysis units in Johannesburg. Permission to conduct the study was requested and granted from all relevant authorities. One hundred and fifty questionnaires were distributed amongst the three haemodialysis units of which seventy nine participants responded to the study. Data were analysed using the statistical package STATA version 12. Demographic data and the caregiver burden scale were analysed through frequency counts, percentages and graphs were constructed from the collected data and analysed. Cross tabulations, using Fisher’s exact test were performed to determine the relationship between the demographic information and factors of the caregiver burden scale. The results are presented in the form of tables and graphs. Semi structured questionnaire with an option for elaboration were analysed using content analysis to enumerate a deeper understanding of the perceived burdens and benefits of caring for a person on Haemodialysis. Findings from the study concluded that family caregivers have encountered both benefits and burdens when caring for a person on Haemodialysis. The following factors have emerged namely demographics which include age, gender, relation to patient, highest education level, employment, ethnicity and duration of care and the factors surrounding general strain, isolation, disappointment, emotional involvement and environment. The factors, whether good or poor, are not always a predictor of perceived benefits and burdens of caring for persons on long term haemodialysis. The overall caregiver burden score, inclusive of all factors, showed a median score of 46.59% of all family caregivers’ experienced burden in caring for their relative on haemodialysis. Health education and support for the family caregivers proved to be a need in improving and reducing the caregiver burden. Caregiver health is quickly becoming a public health care issue that requires a more focused attention from health professionals, policy makers and caregivers themselves to ensure the health and safety of those dedicating their lives to the care of their relatives on haemodialysis.

Purpose: To study this locally unexplored scenario and provide a platform of knowledge base and information on physical restraint use, securing relevant information of essence to the older person, care provider and policy makers within care homes. Aims and objectives: This dissertation focuses on care providers’ observations and perceptions concerning (a) the types of restraint devices used in government and privately managed long term care homes for older persons in Malta, (b) their mode and extent of application, (c) older person characteristics which may be conducive to physical restraint use, (d) older persons’ reactions to restraint use (e) care providers’ perceptions to physical restraint use within the context of work, environmental and safety concerns, and (f) how the effects of physical restraint use could influence the older person’s rights, autonomy and integrity. Relevance: The demand for long term care for older persons increases as the population ages. This, coupled with an increasing demand for human resources, aggravates the risk for less humane care for frail and vulnerable older persons. Person centred care is the fulcrum for the quality of service delivery in the care of older persons. It recognises the distinctiveness of each and every person irrespective of mental and functional capabilities, and moves away from the routine-driven, task-oriented and depersonalised services to focus on specific personal needs. Although there is an increasing international body of literature, exploring the concept of physical restraint use in care homes, there is a lack of research-based evidence exploring care providers’ holistic approach to physical restraint use in long term care settings in Malta. More importantly, published papers fail to captivate the human and humane elements of the physically restrained older person. The relevance of physical restraint use is central within care home environments. The knowledge of the framework within which this use operates is necessary for the establishment of a paradigm that places the older person within the hubs of her/his care. Study design: A questionnaire booklet incorporating quantitative and qualitative components was developed, designed and adopted. The questionnaire was anonymous and self-administered by care providers within all Maltese care homes (n=13), managed by the government and private sectors. All care providers within these care homes were eligible for study participation, (medical, allied health, nursing, and nursing support staff). Care providers have direct contact with the older persons, and are therefore in a position to provide first-hand information about the use of physical restraints. Participants were requested to complete and return ‘Physical Restraint Use’ (PRU) questionnaire booklet developed for this study. Four hundred and thirty four questionnaire booklets were distributed and 180 booklets were returned over a 3 month time frame, providing a response rate of 41.5%. Findings: A high observed incidence of physical restraint devices particularly for bed rails and harnesses was registered within both the government and privately managed care homes. Moreover, respondents acknowledged the use of 16 different types of devices, which raised questions as to multiple use of restraining. Privately managed care homes reported a slightly higher incidence of observed devices in use. The observed total duration of restraints in excess of 2 hours by far exceeded durations less than 2 hours in both government and privately managed care homes. Data pertaining to the private care homes points to the existence of potential continual application of restraint. With respect to observations of modalities of physical restraint use (person recommending, explaining, monitoring and deciding, and documentation), within government and privately managed care homes, a consistent statistically higher involvement of management staff in all of the procedures related to the use of restraining was reported. This was however not evident with respect to documenting restraint use within the private sector. Additionally family members/substitute decision makers had a greater influence on recommending restraint use and its removal within privately managed care homes. Nursing support staff offered a greater contribution to monitoring, documenting restraint use in private than in government managed care homes, whilst nurses in government homes contributed more to monitoring restraint use than their professional counterparts within private homes. Care providers’ attitudes on the use of restraining were reported to be the strongest advocators for using physical restraints within care homes, rather than issues related to older persons themselves such as mobility and physical limitations, cognitive problems, continence issues, problems with communication/hearing/vision and activity participation and pharmacological treatment. Respondents also acknowledged observing adverse reactions to restraint use. Care providers reported restlessness to be the most observed reaction from older persons to physical restraint use (87.9%), followed by physical and cognitive consequences (66.7%) and apathy (30.3%). Participants were uncertain that there would be no serious concerns related to work, environment, safety, and caring, should restraints be reduced, scoring between 3.0 and 4.0 on a 5-point Likert scale, with high scores expressing high concerns. Further analysis revealed that both care home sectors tended to favour least restraint use but were reluctant to remove restraint completely. Similarly, private care home respondents disagreed more than government care home respondents with the statement that the majority of physical restraints in use are necessary while nursing and nursing support staff showed a higher agreement with physical restraining being an invasion of a human right than did managers. Training did not impact on the use of restraining within the care homes. . Conclusion: This study highlighted the sensitivity surrounding physical restraint use. It substantiated published data and also offered novel contributions to the body of knowledge pertaining to the physical restraints and their use. Primarily, the study indicated that training had no impact to effecting restraint minimisation approaches within the care homes. Secondly, respondents acknowledged the use of 16 different types of restraining devices. Also, arguments that bed rail use was not considered a restraining device, having become unconditionally and unquestionably the accepted norm within care homes was corroborated through the high reported observed incidence of use. The study also offered a fresh insight into the modalities of physical restraint use, (recommendation to, explaining on, and monitoring/removing restraint device). Few insights into the impact of physical restraining on the human and humane aspects of older person care were captivated in this study, more so as the sensitivity surrounding physical restraining required that the investigation be carried out through care providers’ observations. This situation, within this project, was perhaps the biggest contribution yet, moreover when the study was indicative that care providers’ attitudes towards restraint use were reported to be the strongest advocator for their use. At its most basic level, physical restraining is tantamount to blocking or limiting a person’s free ability to move as she/he pleases, thus infringing on the older person’s human rights. Indeed, physical restraining is the inability of care providers’ to identify and address the needs of the older persons and provide innovative paradigms of care. Restraining implies a failure in people relationships and consequently in the system of care delivery. The message in the bottle must address the urgent provision for personalised services that enable the older person to make full decisions about her/his care through the support of care providers when called for and at later stages through advocates. It is only through these approaches that policies and guidelines could be put in place and managed effectively and efficiently.

There is much observational evidence to suggest that patients with chronic kidney disease are biologically 'older' than their unaffected peers. This is most obviously seen with cardiovascular disease: young patients on haemodialysis have a relative risk of cardiovascular mortality similar to that of people over 50 years their senior in the general population. Moreover, there are striking analogies between the effects of physiological ageing and uraemia on the structure and function of the heart and vasculature. Despite this, little work has been published looking at whether these similarities are reflected at a molecular and cellular level. Two processes implicated in ageing are autophagy and senescence. There is much inferred evidence that these processes are affected by chronic kidney disease. The aim of this work was to investigate whether autophagy and senescence are indeed altered in the uraemic heart, whether these processes might be linked, and whether the findings of these enquiries might suggest their involvement in the pathogenesis of the prematurely aged cardiac phenotype. An in vitro model of the uraemic myocardium was created using rat cardiac myoblast cells exposed to the uraemic toxin indoxyl sulphate, and in vivo models using adenine-diet and subtotal (5/6) nephrectomy rodents. Autophagy was assayed using immunoblotting, PCR array, immunohistochemistry and fluorescence microscopy, and senescence by immunoblotting and as part of an ageing-dedicated PCR array. Though not achieving statistical significance, markers of autophagy activity appeared to be increased in rat cardiac myoblast cells exposed to indoxyl sulfate, and in cardiac tissue from adenine-diet rats. Interestingly markers of autophagy activity were significantly increased in hepatic tissue from subtotal nephrectomy rats. PCR of RNA purified from cardiac tissue from adenine-diet rats demonstrated an expression of ageing-related genes analogous to that in physiological ageing. Though limited by numbers, these findings present evidence to suggest that autophagy may be upregulated as a protective mechanism in the progeroid uraemic heart, a situation possibly comparable to that in physiological ageing. Changes in cardiac autophagy and ageing in uraemia present new avenues for translational research into pathological ageing in chronic kidney disease.

Objective: Chronic pain is a common condition worldwide that poses significant impact to society in terms of its health and economic costs. It has been found to be related to a number of emotional and cognitive factors that are amenable to psychological treatments. Traditional cognitive-behavioral therapy (CBT) for chronic pain has become the gold standard of psychological treatment with reported efficacy. However, recent meta-analyses have found its effect size to be only modest at most. Moreover, its specific mechanisms of action are not well elucidated. With recent advances in neuroscience on possible neurocognitive processes underlying chronic pain, alternative treatment models targeting these specific neurocognitive processes are worth exploring. The present study tested the effectiveness of the Four-step Mindfulness-based Therapy (FSMT) for chronic pain in a randomized-controlled trial. The FSMT was chosen because of its explicit emphasis on altering neurocognitive processes that appear to be highly relevant in treating chronic pain. Method: Ninety-nine chronic pain patients in a hospital cluster-based outpatient pain clinic were randomly allocated to either the FSMT treatment or wait-list control group. The FSMT was modified for use with chronic pain and incorporated mindfulness exercises, such as mindful breathing and mindful meditation. Treatment consisted of eight weekly two-hour group sessions conducted by a clinical psychologist experienced in the implementation of the FSMT protocol. Assessment took place at baseline and post-treatment for both the FSMT and wait-list control. For the FSMT, assessment also took place at mid-group and 3-month follow-up. Results: Findings showed that the FSMT produced superior outcomes in terms of activity interference (primary endpoint), pain unpleasantness, and depression when compared to the wait-list control group or over time. Improvements were also found in the process measures of pain catastrophizing and pain acceptance. All treatment effects were maintained at follow-up. Further, the effects have been shown to be clinically significant and reliable above and beyond measurement errors. Mediational analyses revealed that pain catastrophizing and pain acceptance mediated the effects of FSMT on the outcomes of activity interference and depression; pain catastrophizing also mediated the effect of FSMT on the outcome of pain unpleasantness. Conclusions: The present study was the first to establish statistical and clinical evidence of the FSMT for chronic pain. It also revealed possible processes and mechanisms that might have brought about the changes in outcome, namely reduction in pain catastrophizing and improvement in pain acceptance. How the FSMT led to the outcome changes via these two processes was discussed and enriched by neurocognitive perspectives. Future studies should seek to further compare the FSMT with other active psychological treatments for chronic pain and collect neuroimaging data to further illustrate the neurocognitive processes involved. / Wong, Chi Ming. / "October 2009." / Adviser: Freedom Leung. / Source: Dissertation Abstracts International, Volume: 72-01, Section: B, page: . / Thesis (Ph.D.)--Chinese University of Hong Kong, 2010. / Includes bibliographical references (leaves 139-175). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. Ann Arbor, MI : ProQuest Information and Learning Company, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese.