published_or_final_version / abstract / Community Medicine / Doctoral / Doctor of Philosophy

The purpose of this study was to explore HIV/AIDS client experiences with supportive services. The consumption of social services for individuals living with HIV/AIDS has assumed increasing importance. This is a crucial population that requires a multifaceted approach to treatment in order to remain active and productive for longer periods of time.

This study used a qualitative research design to explore and identify, from participant's perspective, the aspects of a breast cancer support group that facilitate a quality experience of support.

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: This thesis focused on the provision of economic support to improve the outcomes of patients on TB treatment. Although the association between poverty and tuberculosis is generally acknowledged, there is little evidence to guide the use of economic interventions to improve tuberculosis control. In South Africa, a high burden country with extensive poverty, such evidence is particularly important. The first part of this thesis is a Cochrane systematic review of evidence from randomized controlled trials regarding the effectiveness of economic support among patients with tuberculosis. Eleven trials were included: ten conducted among marginalised groups in the United States on economic support for people on prophylactic treatment for latent TB; and one from Timor-Leste on economic support for patients with active TB. The review found that the use of economic interventions in patients with latent TB may increase the return rate for reading tuberculin skin test results, probably improves clinic re-attendance for initiation or continuation of prophylaxis and may improve completion of prophylaxis, compared to normal care. However, it is uncertain if economic support improves treatment completion in patients with active TB (low quality evidence). The second part of the thesis reports the findings of a pragmatic, cluster randomized controlled trial to evaluate the feasibility and effectiveness of delivering economic support to patients on treatment for active TB in South Africa. Patients with drug sensitive pulmonary TB were offered a monthly voucher valued at ZAR120 until completion of treatment or a maximum of eight months. Patients in control clinics received usual TB care. A parallel process evaluation provided contextual information to explain the trial findings. The qualitative component of this evaluation consisted of in-depth interviews with a sample of trial participants, including patients, nurses and health managers, to assess responses to the voucher and its administration. The quantitative component included a survey of patients’ household expenditure to assess patients’ levels of poverty and the effects of the voucher on these, and an analysis of the goods on which patients spent their vouchers. 4091 patients were included in the trial: 1984 in the control arm (10 clinics) and 2107 in the intervention arm (10 clinics). Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (-1.2; 12.3%), p = 0.107). Fidelity to the intervention was low, partly because nurses preferred to issue vouchers based on perceived financial need, rather than on eligibility. Logistical difficulties in delivering vouchers to clinics also undermined fidelity. The vouchers did not significantly increase patients’ household expenditure, but were experienced by patients as helpful, especially in providing more food with which to take their tablets. Factors related to the administration of economic support may undermine its effectiveness in improving TB treatment outcomes. Further research is needed to explore how best to deliver such economic support to those eligible to receive it, particularly in low and middle income countries where the burden of tuberculosis is highest. / AFRIKAANSE OPSOMMING: Hierdie tesis was toegespits op die verlening van ekonomiese steun om die uitkomste van pasiënte op tuberkulose- (TB-) behandeling te verbeter. Hoewel die verband tussen armoede en TB in die algemeen erken word, is daar nie veel bewyse om die gebruik van ekonomiese intervensies ter verbetering van TB-beheer te staaf nie. In Suid-Afrika – ’n land met ’n hoë TB-las en wydverspreide armoede – is sulke bewyse veral belangrik. Die eerste deel van hierdie tesis behels ’n sistematiese Cochrane-oorweging van bewysmateriaal afkomstig van verewekansigde, gekontroleerde proewe oor die doeltreffendheid van ekonomiese steun aan pasiënte met tuberkulose. Altesame 11 proewe is ingesluit: Tien is gedoen onder gemarginaliseerde groepe in die Verenigde State met die fokus op ekonomiese ondersteuning aan mense wat profilaktiese behandeling vir latente TB ontvang het. Een, van Timor-Leste, was gefokus op ekonomiese ondersteuning aan pasiënte met aktiewe tuberkulose. Die ondersoek het aan die lig gebring dat, vergeleke met normale sorg, die gebruik van ekonomiese intervensies by pasiënte met latente tuberkulose tog die omdraaikoers vir die lees van tuberkulien-veltoetsresultate kan verhoog, waarskynlik hertoelating tot klinieke vir die inisiëring of voortsetting van profilakse verbeter, en die voltooiing van profilakse kan verbeter. Die tweede gedeelte van die tesis behels ’n verslag oor die bevindings van ’n pragmatiese, trosverewekansigde gekontroleerde proef, om te bepaal hoe doenlik en doeltreffend dit sou wees om ekonomiese steun te verleen aan pasiënte wat in Suid-Afrika vir aktiewe tuberkulose behandel word. Pasiënte met middelsensitiewe pulmonêre tuberkulose het tot en met die voltooiing van hul behandeling, of tot ’n maksimum van agt maande, ’n maandelikse koopbewys ter waarde van ZAR120 ontvang. Pasiënte in kontroleklinieke het die gewone TB-sorg ontvang. ’n Parallelle prosesevaluering het kontekstuele inligting voorsien ter verklaring van die bevindinge van die proef. Die kwalitatiewe komponent van hierdie evaluering het bestaan uit diepte-onderhoude met ’n steekproef van alle deelnemers aan die proefneming, insluitend pasiënte, verpleegpersoneel en gesondheidsbestuurders, om hul reaksies te bepaal op die koopbewys self sowel as op die administrasie daarvan. Die kwantitatiewe komponent het ’n opname oor pasiënte se huishoudelike besteding ingesluit, ter vasstelling van hul armoedevlak en die moontlike uitwerking van die koopbewys daarop, asook ’n ontleding van die goedere waarop pasiënte hul koopbewyse bestee het. Altesame 4 091 pasiënte is by die proef ingesluit – 1 984 in die kontrole-afdeling (10 klinieke) en 2 107 in die intervensie-afdeling (10 klinieke). ’n Voorneme-om-te-behandel- (ITT-) ontleding toon ’n klein dog nie-betekenisvolle verbetering in behandelingsuksessyfers in intervensieklinieke (intervensie 76,2%; kontrole 70,7%; risikoverskil 5,6% (-1,2; 12,3%), p = 0.107). Getrouheid aan die intervensie was laag – deels omdat verpleegkundiges verkies het om die koopbewyse op grond van veronderstelde finansiële behoeftigheid eerder as volgens die studiekriteria uit te deel. Die koopbewyse het nie pasiënte se huishoudelike besteding beduidend verhoog nie, maar pasiënte het dit wél as nuttig ervaar, veral omdat hulle daarmee meer kos kon koop om saam met hul pille in te neem. Faktore wat verband hou met die administrasie van ekonomiese ondersteuning kan die doeltreffendheid van sodanige steun in die verbetering van TB-behandelingsuitkomste ondermyn. Verdere navorsing word vereis om te verken wat die beste manier sou wees om sodanige ekonomiese steun te bied aan diegene wat daarvoor in aanmerking kom, veral in lae- en middel-inkomstelande, waar die TB-las die hoogste is.

published_or_final_version / Community Medicine / Doctoral / Doctor of Philosophy

published_or_final_version / Public Administration / Master / Master of Public Administration

The HIV/AIDS orphan crisis is one of the humanitarian and developmental challenges facing the global community. Providing a home, medical care, education, psychosocial support and basic needs for these children is part of the challenge that faces our generation. The purpose of this study was to explore whether an AIDS CARE pilot project implemented at DCS was able to successfully place ten HIV/AIDS infected orphans in fostercare. The ecological perspective provided the theoretical framework within which the study was conducted. This perspective guided the selection of the study samples and the analysis of data. Sample one comprised ten foster parents who resided in various townships and suburbs in Durban. Sample two comprised of semi professional and professional staff that were involved in the daily care of the HIV infected orphans and well as ensuring their placement in fostercare. The study found that recruitment, training and support were vital aspects in preparing foster parents to care for the HIV/AIDS infected child. The study also found that while residential child care institutions will continue to play a role in the care of children affected by HIV/AIDS, the magnitude and social impact of the disease renders it necessary that alternate models of care (this study proposes one model), within a community development paradigm be developed. / Thesis (M.A.)-University of Natal, Durban, 2003.

This thesis explores and explains the development of day care for people with dementia in Kerala, India. The development process is framed within the context of social globalisation. The central aim of the thesis is to further build theory on how and why social policy from one context is transferred and utilised in the development of social policy in another. The theoretical constructs of policy transfer and policy translation are used to explore the development process. Policy transfer is an existing concept within policy and politics literature. Theory on the concept of policy translation is built up within the thesis using theories of literary translation. Exploration of these processes provides an explanation of the development of day care. Policy transfer and policy translation are found to take place between the UK and Kerala. Policy ideas and information from the UK are transferred and then used within the implementation of day care in Kerala. A two-part research design explores firstly policy transfer and then policy translation. Policy transfer is examined within an analytical framework developed from existing models of policy transfer. Policy translation is investigated through a comparative analysis of day care for people with dementia between the UK and Kerala. The differences between day care in the two contexts represent the changes caused by the processes of policy transfer and policy translation. The main findings of the thesis are that policy transfer and policy translation have taken place within the development of day care in Kerala. The two concepts are found to complement each other. The theoretical construct of policy translation provides additional detail and clarity on the process of policy development to that provided by policy transfer. Policy transfer and policy translation can be described as mechanisms by which social globalisation is taking place and in turn globalisation promotes these processes. The thesis concludes that the theoretical constructs of policy transfer and policy translation as developed here could be used within other research to explore the processes of globalisation.

The Home and Community Based Care (HCBC) and Support programme has been established as a cost effective response for communities to tackle HIV and AIDS and many other chronic conditions and vulnerabilities which are faced by individuals, families and communities. In terms of the Framework for Home and Community Based Care and Support Programme (2012: 4) HCBCs create an enabling platform for “individuals, families and communities to have access to holistic and comprehensive services nearest to home, which encourages participations by people, responds to the needs of the people, encourages traditional community life and strengthens mutual support opportunity and social responsibility”. Victor Khanye Local Municipality, IDP (2010-2011: 116) states that VKLM is faced with: a high incidence of HIV and AIDS due to poverty, ignorance and a lack of proper entertainment facilities; shortage of clinics and professional staff members, which makes it difficult for patients to access treatment and maximum care and support; and an increase in the number of OVCs which results in a lack of parental care and guidance, poverty, illiteracy, lack of access to medical care, school drop-outs and ultimately an increase in criminal activity and the further spread of HIV and AIDS. The research will assess the effectiveness of Home Community Based Care programmes (HCBCs) on orphaned and vulnerable children with specific reference to the Victor Khanye sub-district in Nkangala District, Mpumalanga Province. The research was conducted in Delmas and its surrounding farming areas. Victor Khanye sub-District has nine wards, most of which are predominantly farming rural areas. The field research took place during June and August 2013 and represents observations recorded at the field interviews, the local AIDS committee and one-on-one interviews with beneficiaries The study is concluded with conclusions drawn from the field study and recommendations.

Existing research on health disparities in breast cancer is heavily focused on outcomes for poor or low-income women. Little is known about the experience of privately insured Black breast cancer patients that have moderate to high SES. As a result, the present study was conducted to learn more about their experiences. It examines differences in physician prescribing of two breast cancer pain treatments, peripheral nerve block (PNB) and opioids, for Black and White women with like levels of health insurance coverage and socioeconomic status (SES). Three specific questions are addressed: 1. What, if any, race-based disparities exist in usage of PNBs at time of total mastectomy? 2. What, if any, race based disparities exist in the prescription of opioids for postoperative pain following total mastectomy? 3. What, if any, changes have occurred in the frequency of orders placed for PNBs and prescription opioids over time, to treat postoperative pain resulting from mastectomy? A cross-sectional designed was used relying on an existing national dataset, Optum Clinformatics Data Mart. The study period was January 1, 2012, through December 31, 2019. Study results revealed that while moderate to higher SES Black women have equitable access to PNB and opioids - a kind of shield from long established physician bias against Black women – this protection is quite porous. They still do not have open and ready access to PNB as a more advanced pain treatment. Nor do they have assurance that they are protected from the overprescribing of opioids, a class of drugs with serious and well-known safety risks. Therefore, on the surface, it appears that equity and racial inclusion are hallmarks of physician prescribing of postoperative breast cancer pain treatment. However, further interrogation reveals that ‘separate and somewhat equal’ is a more accurate characterization of their prescribing practices, based both on race and SES.