Thesis (PhD (Education)--Stellenbosch University, 2008. / ENGLISH ABSTRACT: Before the implementation of abortion legislation in South Africa in February 1997, illegal abortions were the only way out for women with unwanted pregnancies. Because of the high morbidity and mortality rate of the women concerned, abortion legislation was implemented with the aim of ending illegal abortions in South Africa by having abortions carried out legally on request in designated health care facilities. The abortion legislation stipulates that registered nurses who have undergone the proposed abortion care training may terminate a pregnancy upon request of a woman during the first twelve weeks of the gestation period of her pregnancy. Although legislation authorises registered nurses to carry out first trimester abortions, an inadequate number of nurses are being trained in the Western Cape to provide pregnant women with guidance and counselling services, carry out the abortions and/or refer problem cases. Since the implementation of the abortion legislation no real attempts have been made by higher education institutions in the Western Cape to offer abortion care training for nurses. A need has therefore been identified to develop a comprehensive training framework for higher education institutions in the Western Cape for the training of nurses in abortion care. The case study was used as research design and the specific unit of analysis on which the researcher focused were the registered nurses who had received training in abortion care and the context in which they provide abortion care at the various levels of service provision in the different regions of the Western Cape. A random, stratified sample (non-proportional) was taken of the designated state health care facilities in the Western Cape, as well as a non-probability purposive sampling of registered nurses who provide abortion care, a non-probability convenience sample of women who have received abortion care and a non-probability purposive sampling of final-year pre-registration nursing students. Data was generated by means of questionnaires to the women who received abortions and/or counselling, the registered nurses who carried out abortions as well as final-year preregistration nursing students. A checklist was used to observe the abortions that were carried out by registered nurses in an objective and non-participatory manner and semi-structured interviews were conducted with various role-players in abortion care and training. The main findings of this study indicate that the necessary infrastructure within which the services could be provided according to the abortion legislation was adequate, but that the ongoing shortage of trained health care practitioners hampers the abortion care services. Only 10 (n=10) of the 15 certified nurses employed in state health care facilities actively offered abortion care services in the various designated facilities in the Western Cape. Deficiencies were identified in the existing provincial protocol and it was clear that some of the guidelines are either not in use or have become obsolete in the light of new research findings. It was found that midwives with appropriate and effective training are the ideal category of health practitioner for the provision of abortion care. The certified nurses who have been trained by the various regional offices of the Department of Health: Western Cape are skilled in carrying out the abortion procedure, but the other aspects of abortion care, that are mainly carried out by other categories of nurses, will probably require greater attention. The recommendations, which are based on a thorough literature study as well as on the findings and conclusions that arose from the empirical part of this study, have been included in a training framework. The researcher recommends that the training framework provide the basis for the development of a formal programme or programmes for the training of nurses in abortion care at higher education institutions. The purpose of the proposed framework is therefore to determine the context within which curriculation ought to take place, and to provide a focus or format for those who develop the curriculum for prospective students. / AFRIKAANSE OPSOMMING: Voor die implementering van aborsiewetgewing in Februarie 1997 was onwettige aborsies die enigste uitweg vir vroue met ongewenste swangerskappe in Suid-Afrika. Weens die hoë morbiditeit- en mortaliteitsyfer van die betrokke vroue is aborsiewetgewing geïmplementeer met die doel om onwettige aborsies in Suid-Afrika te beëindig en aborsies op versoek wettiglik in aangewysde gesondheidsorgfasiliteite uit te voer. Die aborsiewetgewing stipuleer dat verpleegkundiges wat die voorgestelde aborsiesorgopleiding ondergaan het, ‘n swangerskap kan beëindig op versoek van ‘n vrou gedurende die eerste 12 weke van die draagtyd van haar swangerskap. Ten spyte van wetgewing wat verpleegkundiges magtig om eerste trimester aborsies uit te voer, word daar om verskeie redes onvoldoende aantal verpleegkundiges in die Wes-Kaap opgelei wat voorligting en berading aan swanger vroue gee, die aborsies uitvoer en/of probleemgevalle moet verwys. Geen daadwerklike pogings is sedert die inwerkingstelling van die aborsiewetgewing deur hoëronderwysinstellings in die Wes-Kaap aangewend om aborsiesorgopleiding vir verpleegkundiges aan te bied nie. Derhalwe is ’n behoefte geïdentifiseer om ’n omvattende opleidingsraamwerk vir hoëronderwysinstellings in die Wes- Kaap te ontwikkel vir die opleiding van verpleegkundiges in aborsiesorg. Die gevallestudie is as navorsingsontwerp gebruik en die spesifieke eenheid van analise waarop gefokus is was die verpleegkundiges wat opleiding in aborsiesorg ontvang het en die konteks waarbinne hulle aborsiesorg lewer by die onderskeie vlakke van dienslewering in die onderskeie streke van die Wes-Kaap. ’n Ewekansige, gestratifiseerde steekproef (nie-proporsioneel) is geneem van die aangewysde staatsgesondheidsorgfasiliteite in die Wes-Kaap, sowel as ’n nie-waarskynlike, doelbewuste steekproefneming van verpleegkundiges wat aborsiesorg verskaf, ’n nie-waarskynlike gerieflikheidsteekproefneming van vroue wat aborsiesorg ontvang het en ’n nie-waarskynlike, doelbewuste steekproefneming van finalejaar voorregistrasie verpleegstudente. Data is gegenereer met behulp van vraelyste aan onderskeidelik die vroue wat aborsies en/of berading ontvang het, die verpleegkundiges wat aborsies uitgevoer het, asook finalejaar voorregistrasie verpleegstudente. ’n Kontrolelys is gebruik om die aborsies wat deur verpleegkundiges uitgevoer is objektief en nie-deelnemend te observeer en semigestruktureerde onderhoude is met verskeie rolspelers in aborsiesorgdienste en -opleiding gevoer. Die hoofbevindings van hierdie studie dui daarop dat die nodige infrastruktuur waarbinne die dienste ingevolge die aborsiewetgewing gelewer kon word voldoende was, maar dat die voortslepende tekort aan opgeleide gesondheidsorgpraktisyns die aborsiesorgdienste kortwiek. Slegs 10 (n=10) van die 15 gesertifiseerde verpleegkundiges in diens van staatsgesondheidsorgfasiliteite het aktief aborsiesorgdienste aangebied in die onderskeie aangewysde fasiliteite in die Wes-Kaap. Leemtes is in die bestaande provinsiale protokol geïdentifiseer en dit het in die lig van nuwe navorsingsbevindings geblyk dat sommige van die riglyne óf nie in gebruik was nie, óf dat hulle intussen verouderd geraak het. Daar is bevind dat vroedvroue met toepaslike en doeltreffende opleiding die ideale kategorie gesondheidsorgpraktisyn is vir die verskaffing van aborsiesorg. Die gesertifiseerde verpleegkundiges wat deur die Departement van Gesondheid: Wes-Kaap se onderskeie streekskantore opgelei is, is vaardig in die uitvoer van die aborsieprosedure as sulks, maar die ander aspekte van aborsiesorg, wat meestal ook deur ander kategorieë verpleegkundiges uitgevoer word, sal waarskynlik groter aandag moet kry. Die aanbevelings is gegrond op ’n deeglike literatuurstudie sowel as op die bevindings en gevolgtrekkings wat uit die empiriese gedeelte van hierdie studie spruit en is vervat in ’n opleidingsraamwerk. Die navorser beveel aan dat die opleidingsraamwerk die grondslag sal bied vir die ontwikkeling van ’n formele program of programme vir die opleiding van verpleegkundiges in aborsiesorg aan hoëronderwysinstellings. Die doel van die voorgestelde raamwerk is dus om die konteks te bepaal waarbinne kurrikulering moet plaasvind, asook om ’n fokus of formaat te verskaf vir diegene wat die kurrikulum vir voornemende studente ontwikkel.

A partir de données en population, nous avons: 1) évalué le risque de cardiopathies congénitales (CC) chez les fœtus conçus par assistance médicale à la procréation (AMP); et 2) déterminé les effets de l’AMP sur la prise en charge prénatale et le devenir périnatal des fœtus porteurs de CC. Nous avons observé que l'AMP était associée à une augmentation de 40% du risque de CC sans anomalies chromosomiques associées (OR ajusté = 1,4 IC95% 1,1-1,7). Nous avons également retrouvé qu'il existait des associations variables selon la catégorie de CC et la méthode d'AMP considérées. Nous avons observé que l'AMP était associée à une multiplication par 2,4 du risque de tétralogie de Fallot (OR ajusté = 2,4 IC95% 1,5-3,7), alors que nous n’avons pas retrouvé d’association statistiquement significative pour les trois autres CC spécifiques étudiées. Dans notre population, l'exposition à l'AMP ne semblait pas modifier le recours au diagnostic prénatal et à l'interruption médicale de grossesse chez les fœtus porteurs de CC comparés aux fœtus porteurs de CC conçus spontanément. Nous avons par ailleurs observé que le risque de prématurité des fœtus porteurs de CC conçus par AMP était environ 5 fois plus élevé que celui des fœtus porteurs de CC conçus spontanément (OR ajusté = 5,0 IC95% 2,9-8,6). En nous basant sur une méthodologie d'analyses de cheminement, nous avons retrouvé que les grossesses multiples contribuaient pour environ 20% au risque plus élevé de tétralogie de Fallot associé à l'AMP que nous avons observé. Enfin, les grossesses multiples contribuaient pour environ 2/3 du risque de prématurité associé à l'AMP chez les fœtus porteurs de CC. / Using population-Based data, we: 1) assessed the risk of congenital heart defects (CHD) in assisted reproductive techniques (ART) conceived fetuses; and 2) evaluated the effects of ART on prenatal management and perinatal outcomes of fetuses with CHD. We observed that ART were associated with a 40% increased risk of CHD without associated chromosomal anomalies (adjusted OR = 1.4 95%CI 1.1-1.7). We also found varying associations between the different methods of ART and categories of CHD. We observed that ART were associated with 2.4-Higher odds of tetralogy of Fallot (adjusted OR = 2.4 95%CI 1.5-3.7), whereas no statistically significant association was found for the three other specific CHD included. In our population, ART exposure did not seem to modify prenatal diagnosis and termination of pregnancy for fetal anomaly in fetuses with CHD compared to fetuses with CHD conceived spontaneously. The risk for premature birth in fetuses with CHD conceived following ART was 5-Fold higher as compared to fetuses with CHD conceived spontaneously (adjusted OR = 5.0 95%CI 2.9-8.6). Using a path-Analysis method, we found that multiple pregnancies contributed for about 20% to the higher risk of tetralogy of Fallot associated with ART that we had found. Finally, multiple pregnancies contributed for the 2/3 of the risk of premature birth associated with ART in fetuses with CHD.

This thesis explores the entire cycle of education, from initial access to schooling, over degree completion, to returns to education. Despite recent gains in increasing access, an tens of millions of children worldwide are still out of school. Abolishing school fees has increased enrollment rates in several countries where enrollments were low and fees were high. However, such policies may be less effective, or even have negative consequences, when supply-side responses are weak. The first part of the thesis evaluates the impacts of a tuition waiver program in Haiti, which provided public financing to nonpublic schools conditional on not charging tuition. The chapter concludes that school's participation in the program results in more students enrolled, more staff, and slightly higher student-teacher ratios. The program also reduces grade repetition and the share of overage students. While the increase in students does not directly equate to a reduction in the number of children out of school, it does demonstrate strong demand from families for the program and a correspondingly strong supply response from the nonpublic sector.Pertaining degree completion, it is well established that natural disasters can have a negative effect on human capital accumulation. However, a comparison of the differential impacts of distinct disaster classes is missing. Using census data and information from DesInventar and EMDAT, two large disaster databases, the second part of the thesis assesses how geological disasters and climatic shocks affect the upper secondary degree attainment of adolescents. The chapter focuses on Mexico, given its diverse disaster landscape and lack of obligatory upper secondary education over the observed time period. While all disaster types are found to impede attainment, climatic disasters that are not infrastructure-destructive (e.g. droughts) have the strongest negative effect, decreasing educational expansion by over 40%. The effects seem largely driven by demand-side changes such as increases in school dropouts and fertility, especially for young women. The results may also be influenced by deteriorated parental labor market outcomes. Supply-side effects appear to be solely driven by infrastructure-destructive climatic shocks (e.g. floods). These findings thus call for differential public measures according to specific disaster types and an enhanced attention to climatic events given their potentially stronger impact on younger generations.It is also widely appreciated that natural disasters can have negative impacts on local labor market outcomes. However, the study of differential types of negative capital shocks, the underlying labor market mechanisms, and the context of the poorest countries have been neglected. Following testable predictions of economic theory, the third part of the thesis exploits the exogenous variation of destruction of human and physical capital caused by the 2010 Haiti earthquake to disentangle the differential impact on local individual monetary returns to education. Employing individual-level survey data from before and after the earthquake the chapter finds that the returns decreased on average by 37%, especially in equipment-capital intensive industry. Higher educated individuals adjust into low-paying self-employment or agriculture. The returns are particularly shock-sensitive for urban residents, migrants, males, and people over age 25. / Doctorat en Sciences économiques et de gestion / info:eu-repo/semantics/nonPublished

Contraceptives are available free of charge throughout South Africa. Nevertheless the number of requests for termination of pregnancy (TOP) services continues to increase. This research investigated challenges preventing women from using contraceptives effectively. Structured interviews were conducted with 47 women who requested TOP services. Gender and financial issues posed challenges for some women to access contraceptives as well as their reported inability to access contraceptives. Most (85,5%) of the respondents used contraceptives. They discontinued using contraceptives because they experienced side-effects, necessitating them to request TOPs. Knowledge about, access to, nor the actual use of contraceptive enabled these women to prevent unwanted pregnancies. More effective counselling about the side-effects of contraceptives and enhanced accessibility of contraceptives during weekends and lunch breaks could enable more women to prevent unwanted pregnancies and reduce the number of requests for TOPs in the Gert Sibande District (Mpumalanga). / Health Studies / M.A. (Health Studies)

Teenage pregnancies are currently a social problem in South Africa and in the rest of the world. Social workers are involved with teenage girls by providing guidance during their pregnancies and face many challenges by accepting this role. The objective of this qualitative study was to identify and describe the needs of social workers when guiding pregnant teenage girls. A conceptual framework with the Gestalt approach as the theoretical framework for the study was stated after which an empirical study took place. In-depth interviews took place with nine social workers. Results were then verified in a focus group discussion. From the empirical data themes and sub themes were identified and verified with relevant literature. These themes and sub themes were then interpreted through the Gestalt approach. Conclusions and recommendations were made to social workers and interdisciplinary teams, which form part of the network that are involved with pregnant teenage girls. / Thesis (M.Diac. (Spelterapie)

Contraceptives are available free of charge throughout South Africa. Nevertheless the number of requests for termination of pregnancy (TOP) services continues to increase. This research investigated challenges preventing women from using contraceptives effectively. Structured interviews were conducted with 47 women who requested TOP services. Gender and financial issues posed challenges for some women to access contraceptives as well as their reported inability to access contraceptives. Most (85,5%) of the respondents used contraceptives. They discontinued using contraceptives because they experienced side-effects, necessitating them to request TOPs. Knowledge about, access to, nor the actual use of contraceptive enabled these women to prevent unwanted pregnancies. More effective counselling about the side-effects of contraceptives and enhanced accessibility of contraceptives during weekends and lunch breaks could enable more women to prevent unwanted pregnancies and reduce the number of requests for TOPs in the Gert Sibande District (Mpumalanga). / Health Studies / M.A. (Health Studies)

Teenage pregnancies are currently a social problem in South Africa and in the rest of the world. Social workers are involved with teenage girls by providing guidance during their pregnancies and face many challenges by accepting this role. The objective of this qualitative study was to identify and describe the needs of social workers when guiding pregnant teenage girls. A conceptual framework with the Gestalt approach as the theoretical framework for the study was stated after which an empirical study took place. In-depth interviews took place with nine social workers. Results were then verified in a focus group discussion. From the empirical data themes and sub themes were identified and verified with relevant literature. These themes and sub themes were then interpreted through the Gestalt approach. Conclusions and recommendations were made to social workers and interdisciplinary teams, which form part of the network that are involved with pregnant teenage girls. / Thesis (M.Diac. (Spelterapie)

Adolescent pregnancies are high risks obstetric occurrences. Antenatal care (ANC) provides opportunities to recognise and treat obstetric complications, enhancing the pregnancy outcomes for mothers and babies. This study investigated factors influencing pregnant adolescents' utilisation of ANC services in Bulawayo, using the Health Belief Model's major tenets. A quantitative descriptive design was used in four phases: 80 adolescents' ANC records were audited; structured interviews were conducted with 200 adolescents attending ANC and with 80 adolescents who had delivered their babies without attending ANC; and 52 midwives completed questionnaires portraying their perceptions on adolescents' utilisation of ANC services in Bulawayo. Documentation of ANC services provided to adolescents did not meet the expected standards. Poor or non utilisation of ANC services was influenced by socio demographic factors, individual perceptions of adolescents about antenatal care, perceived benefits of and perceived barriers to the utilisation of ANC. Most pregnant adolescents could not access these services because they could not pay the ANC and/or delivery fees charged at government clinics/hospitals. Midwives required more training in providing and recording adequate ANC services. Free ANC and delivery services could enhance adolescents' pregnancy outcomes in Zimbabawe. An information brochure on the importance of ANC attendance for adolescents has been compiled, based on the research results (see Annexure J). / Health Studies / D.Litt. et Phil. (Health Studies)

Adolescent pregnancies are high risks obstetric occurrences. Antenatal care (ANC) provides opportunities to recognise and treat obstetric complications, enhancing the pregnancy outcomes for mothers and babies. This study investigated factors influencing pregnant adolescents' utilisation of ANC services in Bulawayo, using the Health Belief Model's major tenets. A quantitative descriptive design was used in four phases: 80 adolescents' ANC records were audited; structured interviews were conducted with 200 adolescents attending ANC and with 80 adolescents who had delivered their babies without attending ANC; and 52 midwives completed questionnaires portraying their perceptions on adolescents' utilisation of ANC services in Bulawayo. Documentation of ANC services provided to adolescents did not meet the expected standards. Poor or non utilisation of ANC services was influenced by socio demographic factors, individual perceptions of adolescents about antenatal care, perceived benefits of and perceived barriers to the utilisation of ANC. Most pregnant adolescents could not access these services because they could not pay the ANC and/or delivery fees charged at government clinics/hospitals. Midwives required more training in providing and recording adequate ANC services. Free ANC and delivery services could enhance adolescents' pregnancy outcomes in Zimbabawe. An information brochure on the importance of ANC attendance for adolescents has been compiled, based on the research results (see Annexure J). / Health Studies / D.Litt. et Phil. (Health Studies)

Resumé<p><p>Dans le présent travail de recherche, nous présentons un cadre d’analyse, de planification et de mise en œuvre d’une recherche-action portant sur l’apport de l’éducation sexuelle participative comme démarche de la communication stratégique, et ses effets sur le public d’adolescents en milieu scolaire. Le but ultime étant de proposer une meilleure alternative à l’amélioration de la double prévention des IST/VIH/SIDA et des grossesses non désirées chez les adolescents scolarisés de 15-19 ans à Kinshasa, RDC.<p>Les principaux objectifs fixés à la présente recherche étaient :i) d’évaluer l’ampleur de la situation épidémiologique et sociale liée à la santé de reproduction y compris la prévention du VIH/SIDA chez les jeunes adolescents (15-19 ans) ;ii) d’identifier les besoins ainsi que les préoccupations spécifiques des adolescents et jeunes notamment en terme de vie sexuelle et affective ;iii) de projeter les axes de communication stratégiques susceptibles d’influencer positivement les comportements en vue d’améliorer la prévention des IST/VIH/SIDA et des grossesses précoces des adolescents et jeunes en milieu urbain ;iv) de construire sur base des observations et analyses précédentes, une approche de communication stratégique fondée sur l’éducation sexuelle participative; iv) et mesurer au point de vue cognitif et comportemental, l’écart attribuable à l’éducation sexuelle sur l’amélioration des connaissances, des attitudes et des pratiques favorables à la double prévention des IST/VIH/SIDA et des grossesses précoces chez les adolescents de 15-19 ans en milieu urbain de la RDC.<p>Réalisée dans une perspective de la promotion de la santé, son cadre théorique chemine avec celui de l’évidence des liens entre les IST/VIH/SIDA et la santé sexuelle et de reproduction. La combinaison du modèle d’analyse PRECEDE avec l’outil de planification PROCESSUS-P, a servi de fil conducteur de ce travail.<p>Cette étude confronte également la théorie de la communication avec les modèles de changement de comportement. En effet, les messages sur la sexualité émis par un émetteur, permettent à l’individu qui les reçoit, de se persuader à amorcer le changement de comportement qui passe par différents étapes. Mais au delà de la volonté individuelle, les relations de sexualité se vivent dans une interaction sociale dont il faudra tenir compte. <p>La construction de cette recherche a fait appel aux disciplines des sciences sociales, comportementales, de l’éducation, et de l’épidémiologie.<p>Nous avons combiné quatre approches différentes pour cerner nos hypothèses de recherche :i) la revue documentaire, ii) l’approche socio-anthropologique (qualitative) par des focus groups, entretiens semi dirigés, observations directes, iii) l’approche socio-épidémiologique (quantitative) par des enquêtes transversales et iv) l’approche opérationnelle par l’introduction d’une approche innovante utilisant le téléphone et la radio comme moyen pour identifier et orienter des messages à diffuser en milieu scolaire sur la prévention des IST/VIH/SIDA et les grossesses précoces.<p>Ce travail propose deux formats de résultats :les articles publiés ou en cours de l’être et les résultats complémentaires synthétisés dans différents tableaux. <p>Les articles abordent successivement :i) le profil de risque et de vulnérabilité lié au VIH/SIDA et à la santé des adolescents ;ii) la perception des adolescents en matière de santé sexuelle et reproductive ;iii) l’ analyse de l’intégration de l’éducation sexuelle dans les médias ;iv) l’utilisation du téléphone portable et de la radio pour identifier les préoccupations sexuelles des adolescents, v) les déterminants associés à la pratique de la double prévention des IST/VIH/SIDA et des grossesses précoces et vi) les effets cognitifs et comportementaux de l’éducation sexuelle participative sur la double prévention des IST/VIH/SIDA et des grossesses précoces en milieu scolaire de Kinshasa.<p>Les données synthétisées dans différents tableaux rendent compte de l’analyse de la réponse nationale sur la santé de la reproduction des adolescents et des différents aspects du cadre théorique d’analyse et de planification d’une communication stratégique pour la prévention des IST/VIH/SIDA et des grossesses précoces.<p>L’ensemble des résultats de cette recherche peut se résumer en dix points importants ci-après :<p>1.\ / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished