Thesis (M.Fam.Med.)--University of the Witwatersrand, Faculty of Health Sciences, 2014. / Background The combined influence of processes of care, lifestyle advice and drug treatment on glycaemic control in Type 2 diabetes in primary care settings is not well documented. Aim To describe the provision of lifestyle advice, selected processes of care and drug treatment to, and assess the influence of these factors on glycaemic control in, a sample of adults with type 2 diabetes mellitus attending the Johan Heyns Community Health Centre in Sedibeng District, Gauteng. Methods A cross-sectional design was used. Participants consisted of 200, consecutively chosen, adult volunteers with type 2 diabetes. Information on demographics, reported receipt of lifestyle advice and anthropomorphic measurements was collected through questionnaire-based interviews. This was followed by a record review of all participants’ clinic files for information on current drug management, co-morbid medical conditions and documentation of processes of care, in the preceding 12 months, in respect of HbA1c, blood pressure (BP), weight, waist circumference (WC) and body mass index (BMI) monitoring. HbA1c values were used to ascertain glycaemic control. Performance of processes of care was assessed in accordance with Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines. Parsimonious models for glycaemic control were constructed through multivariate logistic regression. Results Mean age of the sample was 58 years with 58% in the 50-64 year age group. Blacks (88%) and females (63%) were in the majority. Over two-thirds had diabetes for under 10 years and 98% had at least one co-morbid condition, mainly hypertension (92%). Obesity was noted in 65%, while 95% of females and 83% of males had a WC that conferred substantial cardio-metabolic risk. Receipt of advice on any of diet, exercise or weight control from a health professional in the preceding 12 months was reported by 79%, with 67% reporting receipt of advice on all three. Under 2% of patient records met the SEMDSA standard for processes of care for HbA1c, weight, WC and BMI monitoring, while 93% achieved the standard for BP monitoring. Exclusive oral treatment was prescribed in 62%, and the majority of these were on combined metformin and sulphonylurea; 5% were on insulin monotherapy. Optimal glycaemic control (HbA1c < 7%) was noted in only 25% of the sample. On multivariate analyses, the presence of CCF conferred higher odds of controlled glycaemia (OR = 3.17, P = 0.035). Compared with insulin monotherapy, treatment with either combined metformin and insulin (OR = 0.216, P = 0.02), or with the combination of all 3 drug classes ( metformin, sulphonylurea and insulin) (OR = 0.185, P = 0.027), conferred lower odds of glycaemic control. Conclusions This study highlights substantial shortcomings in the compliance with key processes of care and the achievement of optimal glycaemic control for type 2 diabetes mellitus in the current research setting. An inverse association was noted between glycaemic control and the use of combined oral and insulin drug therapy. Measured processes of care and reported receipt of lifestyle advice showed no association with glycaemic control. CCF co-morbidity conferred improved odds of controlled glycaemia.

Masters report: Faculty of Health Sciences / ABSTRACT This study was conducted to determine the opinion of physiotherapists and physiotherapy assistants with regards to physiotherapy services required at a Primary Health Care (PHC) level in two provinces of South Africa, one being urban (Gauteng) and the other one more rural (Limpopo). Using a descriptive study design, a sample size consisting of 728 physiotherapists and assistants was selected from HPCSA register list. Data collection was by a self-administered questionnaire. Sixty six percent of physiotherapists in Gauteng Province and 68% in Limpopo Province agreed that promotive services are required whereas the percentage for physiotherapy assistants in Gauteng province and Limpopo province were 78% and 89% respectively. Preventative services were required by 82% and 85% by Physiotherapists and 95% and 96% by Physiotherapy assistants in Gauteng and Limpopo. 89% and 88% of Physiotherapists, 80% and 85% of Physiotherapy assistants in Gauteng and Limpopo respectively agreed that curative services are required. The rehabilitative services were required 83% and 90% by Physiotherapists, 85% and 95% by Physiotherapy assistants in Gauteng and Limpopo respectively. The provision of promotive, preventative, curative and rehabilitative services were seen as required in the two provinces in terms of physiotherapy services at a PHC level by both professional categories.

Philosophiae Doctor - PhD / In the thesis, I analyse a facilitated pilot project of integration of health care services at the community-level. The importance of the thesis is justified by three reasons: firstly integration and the creation of a district health system, as envisaged under Primary Health Care, is promoted as the solution to the health inequalities inherited from Apartheid in South Africa. However, many pilot integration projects have failed and analysing a failed project from an anthropological perspective provides valuable insight. Secondly a renewed interest in Primary Health Care, as the World Health Report of 2008 sets out, also makes this a pertinent pursuit from an international viewpoint. Thirdly the human experience is often ignored in health reform literature. I argue that anthropology can provide valuable insight into integration processes in a health system. Because anthropology explores the human experience, it provides a detailed understanding of the changes in a community health system and their impact on all role players. The data presented in the thesis were collected in an ethnographic communitylevel study in one township urban South Africa between October 1999 and October 2002. This makes this it a historical piece of work to a degree. I describe and critically analyse the facilitated process from the start of the project in October 1999 till its disintegration in failure in June 2001. I also describe and analyse the findings from community research conducted in 2002. For the analysis, firstly I build upon Scott’s concepts of dominance and resistance from his book Dominance and the Arts of Resistance to construct a framework. I argue that to understand a change process fully requires considering the historical context, the international arena, the present context and the facilitator.

This study explores the constructions of primary health care held by remote area nurses working in indigenous communities without resident medical practitioners, in the Northern Territory. Primary health care is increasingly permeating health policy in Australia, and nurses in remote areas are responsible for its implementation. The study investigates past and present discussions of the meaning of the concept of primary health care to begin to identify the major forces which have problematically impacted on its evolution and interpretation. It traces the threads which emerge from these forces through the more recent developments of health promotion and new pubflc health to explore the discourses and strategies they have produced, and which overtly and covertly influence the implementation of primary health care. Remote area nurses are individually interviewed and their discussions analysed to explore the constructions of primary health care which they hold. The analysis also explores some of the ways in which these constructions may have come to exist, the evident impact of current discourses, and the absence of effective support in the further development of these constructions. The remote area nurses' discussions display a view of primary health care as the most basic of health services, focussed on personal hygiene and the individual's responsibility in prevention of illness, operated through encounters which offer opportunities for education and basic curative care. While several of the nurses indicate discomfort with the paternalistic nature of such a service, none are aware of ways in which they might resolve their concerns about it. The study briefly explores positive approaches towards the democratization of health care, and examines the support needed by remote area nurses if primary health care is to be effectively implemented by them.

Primary health care as a model for the provision of health services was introduced by the World Health Organization In the mid 1970s. Initially viewed as a means of health promotion and advancement of wellness in developing countries., it was soon to be adopted by industrialised countries to assist in relieving the demand on acute care services. This was to be achieved through education of the community towards good health practices and the preparation of nurses to practice in the community, outside of the acute care environment Australian nurses were slow to respond to this philosophy of health care and this study has sought to examine why this is so. It has been found that there are a multitude of reasons for the lack of action In the decade or more following the Declaration of Alma Ata and the major Issues have been identified and elaborated. Some of the major reports of the time that were associated with and had some Influence on health care and nurse education have been examined to identify recommendations and how much they support the ethos of primary health care. These include the Sax committee report of 1978 and a submission by the Department of Employment and Industrial Relations In 1987. As part of the investigation, nursing curricula from around Australia in the mid 1980s have been examined to determine the degree of the primary health care content according to guidelines recommended by the World Health Organization. It was found that generally at that time, there was a deficit In the preparation of undergraduate students of nursing for practice In the area of primary health care when the world, including industrialised nations, was making moves towards this model of health care delivery. Factors Influencing the slow response of nursing have been examined and finally recommendations for further studies have been put forward.

<p>The study aims to assess the readiness of professional nurses in Khayelitsha health sub district to render mental health care services as stipulated in the Healthcare 2010 Plans for the western Cape. The Main objectives are to assess the readiness of professional nurses in the Khayelitsha health sub district to render mental health care services after de institutionalisation of mentally ill persons in terms of skills and resources, as well as to explore feelings and perceptions of professional nurses regarding the Healthcare 2010 plans for the Western Cape with refernce to mental health.</p>

Objective: To explore the role of interprofessional collaboration in the delivery of team-based tobacco dependence treatments within primary care. Methods: A narrative review of the literature was completed to examine FHT team functioning in Ontario, followed by a single, multi-site qualitative exploratory case study. Results: Interprofessional collaboration contributed to changes in tobacco dependence treatment through the initiation of system-wide change, cultivation of collective action, and supporting enhanced quality of smoking cessation care. Conclusion: Interprofessional collaboration can enhance the comprehensive delivery of evidence-based treatments for individuals trying to quit smoking. Supportive public policy, education for patients and providers, and evaluation research is needed to advance FHT functioning.

Background: The translation of new knowledge, such as research findings, new tools or methods into health care practice has gained increased  interest in recent years. Important factors that determine implementation outcome have been identified, and models and checklists to be followed in planning as well as in carrying out an implementation process have been produced. However, there are still knowledge gaps regarding what approach should be used in which setting and for which problems. Primary health care (PHC) in Sweden is an area where there is a paucity of research regarding implementation of new methods into practice. The aim of the thesis was to apply theory in the study of the implementation of an innovation in Swedish PHC, and identify factors that influenced outcome. Methods: The study was performed using a quasi-experimental design, and included six PHC units, two from each one of three county councils in the southeast part of Sweden. A computer-based lifestyle intervention tool (CLT) developed to facilitate addressing lifestyle issues, was introduced at the units. Two different strategies were used for the introduction, both aiming to facilitate the process: a theory-based explicit strategy and an implicit strategy requiring a minimum of effort. Data collection was performed at baseline, and after six, nine and 24 months. Questionnaires were distributed to staff and managers, and data was also collected from the CLT database and county council registers. Implementation outcome was defined as the proportion of eligible patients being referred to the CLT, and was also measured in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance according to the RE-AIM framework. Interviews were performed in order to explore experiences of the implementation process as perceived by staff and managers. Results: A positive organizational climate seemed to promote implementation. Organizational changes or staff shortages coinciding with the implementation process had a negative influence on outcome. The explicit implementation strategy seemed to be more effective than the implicit strategy in the short term, but the differences levelled out over time. The adopters’ perceptions of the implementation seemed to be influenced by the existing professional sub-cultures. Successful implementation was associated with positive expectations, perceptions of the innovation being compatible with existing routines and perceptions of relative advantage. Conclusions: The general conclusion is that when theory was applied in the implementation of a lifestyle intervention tool in Swedish PHC, factors related to the adopters and to the innovation seemed to be more important over time than the strategy used. Staff expectations, perceptions of the innovation’s relative advantage and potential compatibility with existing routines were found to be positively associated with implementation outcome, and other major organizational changes concurrent with implementation seemed to affect the outcome in a negative way. Values, beliefs and behaviour associated with the existing sub-cultures in PHC appeared to influence how the implementation of an innovation was perceived by managers and the different professionals.

Globally tobacco use and exposure to tobacco smoke represent some of the greatest risk factors for mortality. Best practice guidelines and standards of practice support nurses' provision of smoking cessation interventions. Nurses employed in primary health care settings interact with large numbers of people who smoke, and have the potential to significantly reduce tobacco use in the population. Evidence shows that nurses do not consistently implement smoking cessation interventions. The purpose of this cross-sectional study was to describe nurses' perceptions of factors that influence their intentions related to providing smoking cessation interventions in primary health care settings. A conceptual framework derived from the Theory of Planned Behavior and relevant empirical literature guided the study. A questionnaire measuring the concepts of interest was mailed to a random sample of Registered Nurses and Nurse Practitioners in Ontario. Responses of 237 eligible participants were available for analysis. Multiple regression analyses were used to examine the hypothesized relationships between nurses' attitudes, subjective norms and perceived behavioural control, and their intention to implement smoking cessation interventions, and the association between intention and practice related to smoking cessation. The Theory of Planned Behavior concepts explained up to 48.5% of variance in behavioural intention. Perceived behavioural control was most strongly associated with intention to provide smoking cessation interventions. Behavioural intention was correlated with smoking cessation practice. Analysis of responses to open-ended questions identified factors that facilitated (wish to improve patients' health, organizational support, access to resources, a perception of patient readiness to quit, and training in smoking cessation) and hindered (lack of time, lack of patient readiness, lack of support and resources, and lack of knowledge) nurses' provision of smoking cessation interventions. Overall, the study results suggest that nursing intention to engage in smoking cessation practices in primary health care settings was associated with organizational factors. Further research is required to explore how primary health care organizations can support nurses so that they fully realize their role in reducing the impact of tobacco use on the health of the people in Ontario.

Globally tobacco use and exposure to tobacco smoke represent some of the greatest risk factors for mortality. Best practice guidelines and standards of practice support nurses' provision of smoking cessation interventions. Nurses employed in primary health care settings interact with large numbers of people who smoke, and have the potential to significantly reduce tobacco use in the population. Evidence shows that nurses do not consistently implement smoking cessation interventions. The purpose of this cross-sectional study was to describe nurses' perceptions of factors that influence their intentions related to providing smoking cessation interventions in primary health care settings. A conceptual framework derived from the Theory of Planned Behavior and relevant empirical literature guided the study. A questionnaire measuring the concepts of interest was mailed to a random sample of Registered Nurses and Nurse Practitioners in Ontario. Responses of 237 eligible participants were available for analysis. Multiple regression analyses were used to examine the hypothesized relationships between nurses' attitudes, subjective norms and perceived behavioural control, and their intention to implement smoking cessation interventions, and the association between intention and practice related to smoking cessation. The Theory of Planned Behavior concepts explained up to 48.5% of variance in behavioural intention. Perceived behavioural control was most strongly associated with intention to provide smoking cessation interventions. Behavioural intention was correlated with smoking cessation practice. Analysis of responses to open-ended questions identified factors that facilitated (wish to improve patients' health, organizational support, access to resources, a perception of patient readiness to quit, and training in smoking cessation) and hindered (lack of time, lack of patient readiness, lack of support and resources, and lack of knowledge) nurses' provision of smoking cessation interventions. Overall, the study results suggest that nursing intention to engage in smoking cessation practices in primary health care settings was associated with organizational factors. Further research is required to explore how primary health care organizations can support nurses so that they fully realize their role in reducing the impact of tobacco use on the health of the people in Ontario.