A thesis submitted for the degree of Doctor of Philosophy in the Faculty of Humanities, University of the Witwatersrand, 2017 / This study explores the role of the doctor-patient relationship in the management of diabetes in South Africa. The originality of this study lies in the unique manner in which the topic is approached from an explicit theoretical perspective as well as the context in which it is studied. It takes into account the biomedical aims of diabetes management as well as the socio-cultural context of the environment in which communication occurs. Diabetes Mellitus is a chronic disease of lifestyle (CDL) and one of the most prevalent chronic diseases, both globally and within South Africa. In South Africa, although statistics vary across provinces and within different demographic and socio-economic groups, it is estimated that about 5.5% of the population over the age of 30 years, has diabetes. The disease has a significant impact on morbidity and mortality in the country, as well as on socio-economic development. The need to improve diabetes education and awareness, in addition to the need to address patient adherence to management plans and the prevention of complications, are vital in order to effectively manage this rising epidemic. Current management of diabetes favours an individualised approach to risk reduction. This involves patient adherence to a negotiated (between doctor and patient) management plan, as well as modifications in the patient’s lifestyle behaviours. International literature on adherence to the management plans of all CDLs suggests that there are many challenges. Furthermore, most studies have shown that there are shared common barriers inherent to all chronic diseases, where the complexity and chronicity of treatment are major factors in adherence. Despite the large number of studies and the identification of many influencing factors, few direct and replicable causal links to adherence have been found. Models of adherence from other chronic diseases in South Africa have highlighted the importance of patient motivation to change behaviour as being linked to their perceptions and beliefs, formed by the attitudes of those with whom they interact. A review of the literature on health communication in various fields of medicine identifies the need for a firm perspective and justification of the methodology employed in the study. Various theoretical stances are examined but it is ultimately the interaction between doctor and patient within the sociocultural context of the consultation that is seen to be most relevant. A social constructionist perspective is justified as the basis from which a disease such as diabetes, which requires complex therapeutic manipulation and lifestyle adaptations, can be studied. A brief overview of medical education is also discussed as it pertains particularly to the teaching of communication skills and behaviours. This becomes relevant as it is medical training that ultimately informs clinical practice. In recent years, medical education has been called upon to be more socially relevant and incorporate a multitude of supporting competencies into training. These models are described and interrogated with relevance to the study aims. The research was conducted in the province of KwaZulu-Natal (KZN) in South Africa within the diabetes clinics of two district level public health care institutions; one was located in the eThekwini metropolitan area (Durban) and the second at a rural site in northern KZN. These hospitals were purposively selected because of their contrasting locations, reflecting diverse socio-economic, ethnic, racial and language groups, thus providing a rich set of data. In keeping with the social constructionist perspective of the study, natural consultations at both sites were the primary source of data aimed to focus on the communication between doctor and patient. A total of 24 routine diabetes follow-up consultations provided the data source. Consultations between patients and doctors were audio- and video-recorded and ethnographic observations were made by the researcher, who was an observer in all consultations. All consultations were transcribed, translated into English if necessary, and analysed using elements of conversational analysis transcription conventions. In order to understand the contextual environment of the study, ethnographic observations made by the researcher during the consultations and other site visits are also included in the data set. These observations are presented and contrasted with the experiences of doctors and patients as explored in interviews and focus group discussions at each site. Participants were asked to comment on their experience of their clinical care as well as the interaction with their doctor and their ability to manage their diabetes. By using multiple data sources and contrasting the findings, the study provides a robust framework from where communication in diabetes can be examined. By analysing the data from a socio-constructionist viewpoint it became evident that the relationship between doctor and patient was a strong influential factor on disease management. Furthermore, the manner in which various communication behaviours were interpreted was seen to be able to transcend the superficial socio-cultural environment should other interpersonal factors mitigate the relationship. Not only was the process by which communication content delivered important, but also the underlying attitudes, past experiences and broader context of the consultation. If patients and doctors found themselves in the position to internalise the behaviours experienced in the consultation, their feelings, ideas and beliefs towards one another and diabetes was seen to change. Over time, it was suggested that these new attitudes would feedback either positively or negatively on future interactions. This study also showed how cultural norms cannot be part of a checklist but that they are dynamic over time and are influenced by a multitude of factors, including past experiences and mutual respect, which need to be understood from an interactional and relational perspective. A new model that incorporates existing knowledge coupled with integration of clinical, scientific diabetes management and the art of communication is also described. The findings from this study should be used to guide and inform clinical practice in order to improve health outcomes for those living with diabetes. By extension, they should also be used to inform medical education models where communication is being incorporated into clinical skills training. As was found by observing and analysing clinical practice behaviours for the purpose of this study, the author believes that by internalising experiences, students may be able to forms new ideas and attitudes towards communication which will enhance their clinical practice. The methods utilised in this study have also highlighted the fact that previous methods have not been sensitive enough to the human dynamics that occur in health communication in diabetes and future research should be developed with a strong theoretical perspective that guides an appropriate methodological approach. This study depicts the pivotal role communication plays within each unique consultation and how the manner in which the interaction is perceived and interpreted will have a strong influence on behavioural decisions. However, it is not merely the words that are spoken or the language in which they are spoken but rather the internalisation and adaptation to the context that will ultimately will guide behavioural change. / XL2018

Medicine unavailability, also known as stock-outs is a global problem. South Africa is not exempt from this problem which impacts negatively on the way in which healthcare services are rendered, more especially in the public sector. Communities are complaining about the unavailability of medicines at public health facilities particularly in primary health care clinics. In an effort to address this problem, the Minister of Health has declared medicine availability as one of the six priorities of the Department of Health. The aim of this study was to explore and describe the experiences and perceptions of healthcare professionals practicing at primary healthcare clinics in a peri-urban area of the Eastern Cape regarding the unavailability of medicines. Understanding the experiences and perceptions was expected to assist in addressing the problem at hand and help management in developing ways to address the problem and support the employees. Semi-structured interviews were conducted with healthcare professionals working at primary health care clinics in and around Mdantsane Township in the Eastern Cape. The main findings of the study can be divided into the following topics: perceived causes of medicine stock-outs, the implications of stock shortages, actions taken in the case of stock-outs and the role to play by in mitigating the impact of stock shortages. The limitations of the study include the research sample which was not truly representative of all healthcare professionals working at Mdantsane sub-district primary healthcare clinics. The study recommends various strategies that management should follow to assist in addressing medicine shortages. The researcher recommends further research to describe the experiences of healthcare professional regarding medicine unavailability.

This study addresses the effectiveness of communication between the team (doctors, sisters and social workers) and patients at the Breast Cancer Clinic of the Johannesburg Hospital. Tue needs of patients were highlighted, as well as the role of care-giver, both as a group and in their separate disciplines, in attempting to meet these needs. Tue empirical survey was carried out through the use of questionnaires as well as interview schedules. Patients, doctors, nurses and social workers were used as respondents. Results indicated that the majority of patients' needs for information and support were met by the team in general; however, a need for further social work intervention seemed to be apparent. In addition, several barriers were found to inhibit both team-patient and inter-team communication. Tue researcher used the information gathered in this study to make recommendations that will facilitate improved communication in the clinic, with specific reference to the role of the social worker. / Social Work / M.A.(Social Science: Mental Health)

Mental health care in South Africa has long been governed by inequalities (Foster & Swartz, 1997). During apartheid, those who did not speak English and Afrikaans could not access mental health services in the same way as those who did (Foster & Swartz, 1997). One main reason for this is the majority of mental health practitioners could not, and were not required to speak languages other than English and Afrikaans (Swartz, 1991). The South African mental health literature suggests that language and communication must be prioritised if there is to be an improvement in mental health care services for those individuals who do not speak English and Afrikaans (Bantjes, 1999; Drennan & Swartz, 1999; Swartz & Drennan, 2000; Swartz & MacGregor, 2002). Drawing on Prasad's (2002) interpretation of Gadamer's critical hermeneutic theory and utilising thematic networks analysis (Attride-Stirling, 2001), this study investigated the process of translated clinical assessment interviews within a psychiatric hospital in the Eastern Cape Province within South Africa. Results of the study revealed that contextual factors, issues concerning linguistic and cultural heritage, clinicians' role expectations regarding translators' role performance, as well as relational dynamics regarding individual levels of control and influence within the translation triad, all impacted on the effectiveness of communication, translation and service provision. These fmdings are supported by literature on the theory and practice of translation that identifies these issues as prominent (Robinson, 2003). Specific recommendations regarding the formalisation of translation practices within the hospital setting, as well as the familiari~ation of clinical practitioners and psychiatric nurses with the intricacies of translation processes are offered.

This study addresses the effectiveness of communication between the team (doctors, sisters and social workers) and patients at the Breast Cancer Clinic of the Johannesburg Hospital. Tue needs of patients were highlighted, as well as the role of care-giver, both as a group and in their separate disciplines, in attempting to meet these needs. Tue empirical survey was carried out through the use of questionnaires as well as interview schedules. Patients, doctors, nurses and social workers were used as respondents. Results indicated that the majority of patients' needs for information and support were met by the team in general; however, a need for further social work intervention seemed to be apparent. In addition, several barriers were found to inhibit both team-patient and inter-team communication. Tue researcher used the information gathered in this study to make recommendations that will facilitate improved communication in the clinic, with specific reference to the role of the social worker. / Social Work / M.A.(Social Science: Mental Health)

There are many inequities that exist in health-care that stem from culture related communication misunderstandings. In most cases where doctors and patients from different cultural and linguistic background interact, doctors use medical language which is different from everyday language used by patients. Patients enter this communication context with anxiety because they depend on the physicians to give them accurate information concerning their health, but they do not always understand all the terms used by physicians to inform them about their conditions. In some cases interpreters are used but their expertise is often inadequate and the interpreting of the patient’s statements to the health staff is also prone to distortion by interpreter / doctor because of the lack of proper understanding of the messages / languages. This may result in a deterioration of the patient’s health condition and unavoidable complications.

PhD (Advanced Nursing Science) / Department of Advanced Nursing Science / iii Abstract The Mental Health Act is the law which sets out when you can be admitted, detained, and treated in hospital against your wishes. It is also known as being “sectioned”. For this to happen, certain people must agree that you have a mental disorder that requires a stay in hospital. In South Africa, the Mental Health Act of 1973 was noted to have many gaps. Due to all the shortcomings, in 2004 the Mental Health Care Act No. 17 of 2002 came into being in order to protect human rights of the mental health care users. This study sought to determine the knowledge and explore the experiences of medical doctors regarding the implementation of Mental Health Care Act No. 17 of 2002. Secondly, based on the findings, to develop a programme to facilitate the implementation of the Mental Health Care Act No. 17 of 2002 by medical doctors in Vhembe District. The population of this study consisted of all medical doctors working in Vhembe District Hospitals with mental health units and at a specialized mental health hospital as well as all documents completed by medical doctors during admission, care and discharge of mental health care users were purposively sampled. The study was conducted in two phases. In phase 1, where quantitative and qualitative designs were followed to do situational analysis. In phase 2, the programme was developed using results from phase 1, the theoretical framework and approaches outlined by Dickoff, James and Wiedenbach (1968); Chinn and Krammer (1999); Walker and Avant (1995). Individual in-depth interviews and questionnaires checklist were used to collect data which was analysed through opened coding method and SPSS. The findings of this study indicate that medical doctors have knowledge and skills deficit regarding implementation of the Mental Health Care Act No. 17 of 2002 during the admission, care, and discharge of mental health care users. Based on these, a programme to facilitate the implementation of the Mental Health Care Act No. 17 of 2002 by medical doctors during admission, care and discharge of mental health care users was developed. The study concludes that this is a significant contributor in supporting the vision of the National Department of Health to ensure improved mental health for all in South Africa. The study recommends a longitudinal study, tracking the impact of a developed programme, the knowledge of medical doctors regarding the implementation of Mental Health Care Act No. 17 of 2002, and its contribution to the improvement of mental health for all should be conducted over a period of 5 (five) to 10 (ten) years