The work described in this thesis concerns the use and quality of primary care service use by people living beyond a diagnosis of breast, colorectal and prostate cancer and long-term risks associated with cancer. Firstly, the thesis provides a background for this work, with a definition of long-term survivors as those living at least five years past cancer, and the role of primary care in the care of this population. The second section describes use of the General Practice Research Database amongst a cohort of cancer survivors compared to a control population. Breast and colorectal cancer survivors consult more frequently than controls up to 10 years post-diagnosis, while prostate survivors continue to see their GP up to 3 times more for at least 15 years. Most survivors receive adequate preventative care and chronic disease monitoring, excepting mammography for long-term breast cancer survivors. Cancer survivors receive more prescriptions for pain relief, anti-depressants and erectile dysfunction, suggesting higher rates of pain, depression and sexual dysfunction. Breast cancer survivors have an elevated risk of incident heart failure, coronary artery disease and hypothyroidism, while colorectal survivors experience increased risk of dementia and diabetes. All three groups of cancer survivors had higher risks of osteoporosis and second cancers, all-cause, non-cancer and cancer mortality compared to controls. The third section describes a qualitative study of the primary care usage and unmet needs of 40 long-term survivors of breast, colorectal and prostate cancer. Most respondents did not need active GP involvement. Others had ongoing information and psychological service needs. Some felt that their GPs did not have the right expertise for cancer related issues or were too busy, while others had concerns about continuity of GP care. Overall, this thesis provides a background on how the increasing numbers of cancer survivors use and experience primary care in the UK, areas of good practice, and areas where care can be improved in the future.

M.Cur. / The overall aim of the study is to explore and describe the factors that influence the accessibility of PHC services in Alexandra Township. Most of the time the public clinics in Alexandra rely on part-time nursing personnel to render health services. Sometimes there are so few nurses on duty that they cannot manage to perform all the services required in the clinic and the community. There are long queues of patients and they are often turned away because they cannot be attended to. Statistics (Clinic Statistics, Jan 2000-Dec 2000) show that about 100 000 people out of the total population of 350 000 people (Community Statistics, 1999) attend these clinics in a year. This number includes people who come to the clinics three or more times per year for services such as family planning, Tuberculosis and well baby. To achieve the objectives of the study a quantitative, non-experimental, exploratory, descriptive and contextual design as described by Polit and Hungler (1997:166,456 & 466) and Burns and Grove (1997:52) was chosen. A pilot study (Burns and Grove 1997:52) was done in three phases with 12 patients, 10 community members and two professional nurses from the clinics. After that 300 interview schedules were administered to 160 randomly selected patients attending the four public clinics in the area and 140 members of the community. Ten questionnaires were distributed among the remaining 10 professional nurses. The researcher as a participant observer, made observations with the aid of an observation list, which was developed after the three phases of data collection to verify the data, collected. A quantitative descriptive data analysis (Burns & Groove 1997:779) was done with the use of SPSS computer program. Content analysis was done on the open-ended questions and the results of the observations. The demographics of the residents reveal that the community is a vulnerable area (White paper, 1997:14) which should be the focus of the health service providers. Although the iii services are geographically accessible, they are provided in an unacceptable, inefficient, ineffective and inequitable manner. Moreover services are functionally, socially, physica.lly and financially inaccessible. Health education factors add to the inaccessibility of the services to the people. Guidelines to improve these factors were formulated to make public PHC services in the area more accessible. These findings have implications on nursing practice, education and research. A replica of the study in similar and different contexts in SA is recommended.

M.Com. (Economics) / Access to health care is a basic human right in South Africa. Primary health care is viewed by the South African government as the means to improving access to health care in the country. The concept of primary health care is based on the importance of first contact with a primary health worker. The Department of Health introduced free primary health care because it believes that the most significant barrier to access to health care is poverty. When a service is provided for free there is no income generated from user fees and the issue of funding becomes very important. This study performs an analysis of the free primary health care programme in South Africa and how it is financed. An important feature that characterizes South Africa is high inequality which is reflected in the high level ofpreventable diseases as well as high incidents of chronic diseases. The implementation of free primary health care has led to improved access to health care and somewhat improved the health status of the South African population. In order to address the inequalities in the health sector there must be funding targeted towards the needs of the poor. Government's fiscal policy places limits on the expansion of public expenditure, which poses a strain on resources flowing to the health sector. In addition to that there has not been a significant shift of funds from higher levels of care to primary health care. The funding issue will need to be urgently resolved for primary health care to be sustainable...

Philosophiae Doctor - PhD / Introduction: The overall aim of this study was to develop a programme to facilitate quality client-centred care in Primary Health Care clinics of the rural West Coast District. Research design and -method: Both quantitative and qualitative methods were applied for this study . Phase 1, a situational analysis collected and analysed quantitative data from the perspective of clients and clinical nurse practitioners via structured questionnaires. The population included all clients 18 years and older (N=137 991) of the fixed clinics (N=25) in the five subdistricts of the West Coast District. According to the Cochran formula a sample of (n=383) should be adequate to represent the population. Non-proportional sampling was applied to estimate the number of participants per clinic. An all-inclusive sample of (n=64) clinical nurse practitioners participated in the study. Phase 2, the qualitative part of the situational analysis, applied five focus group discussions to explore and describe the managers and allied health professionals’ perceptions about quality client-centred care. A semi-structured interview schedule was compiled to guide the focus group discussions. An all-inclusive sample was utilised to include all the managers and allied health professionals of the five subdistricts (N=43). Phase 3 included the development of the programme based on the study findings and literature. Quantitative results: The analysis revealed the following quality client-centred care challenges, namely: Patient Rights (Domain 1) were not always respected and adhered to as these were characterised by: language (statistical p<0.001 and practical significant with a large effect size d=0.74); Satisfaction and Safety (statistical p<0.001 and practical significant with a medium effect size d=0.55); Referral Procedures (statistical significant p<0.001); Waiting Times (statistical p<0.001 and practical significant with a medium effect size d=0.47) and Confidentiality difficulties (statistical p<0.001 and practical significant with a medium effect size d=0.68). The Domain 2, Clinical Governance, Care and Safety showed shortcomings as highlighted by the Client and his/her Family (statistical p<0.001 and practical significant with a large effect size d=0.77). Clinical Support Services, Domain 3, revealed inadequacies regarding the continuous availability of medication (statistical significant p<0.008) and the reporting of side-effects (statistical significant p<0.001). Furthermore, Public Health Domain 4, showed that clients identified community health promotion and disease prevention events (statistical p<0.01 and practical significant with a large effect size d=0.79), and home visits by the community healthcare workers (statistical p<0.001 and practical significant with a large effect size d=1.09) as both a “problem” and a “gap”. Leadership and Corporate Governance, Domain 5 was characterised by the lack of: visible organograms (clients mean 2.40), community communication (clients mean 2.12 & clinical nurse practitioners mean 2.36), visibility of goals, values and future plans of the Western Cape Department of Health (statistical p<0.001 and practical significant with a medium effect size d=0.59) and role and function of the clinic committees (statistical significant p<0.008). Moreover, Domain 6, Operational Management was challenged by inadequate staffing levels (statistical significant p<0.003). Lastly, Domain 7: Infrastructure was characterised by the lack of drinking water in the waiting areas (clients mean 2.08 & clinical nurse practitioners mean 2.02), inadequate clinic space (clients mean 2.10 & clinical nurse practitioners 2.23); maintenance not up-to-date (statistical significant p<0.002); physical appearance of the clinic (statistically significant p<0.001) did not have a positive effect on staff morale and evacuation plans (statistical p<0.001 and practical significant with a medium effect size d=0.54) were not visible. In addition, correlations between the domains showed that the domains are not in silos, but are interdependent on another. Qualitative results The qualitative, thematic data analysis revealed various inadequacies regarding quality client-centred care. Theme One about the Patient Rights revealed that patients were not always treated with the necessary respect and dignity. Theme Two concerning Patient Care, revealed that focus group participants were well-informed on what the concept client-centred care entailed. However, patients and or clients did not always experience their care as client-centred. Theme Three about the Clinical Support Services, indicated shortages of medication and medical equipment; long waiting time for specialists and rehabilitation referral appointments. Theme Four, referring to the Public Health confirmed that health promotion and prevention activities are limited, due to various organizational factors and community healthcare workers’ activities which are limited to home-based care activities. Theme Five, Corporate Governance and Leadership matters were characterised by too many processes or “red tape” resulting in inefficient procurement processes, inadequate staffing and inactive health committees. Theme Six, Operational Management highlighted the severe pressure under which the operational managers have to work, resulting from their twofold role of being the clinic manager and at the same time operate as a clinical nurse practitioner. Theme Seven refers to Infrastructure and Facilities and is characterised by inadequate maintenance and lack of space according to the number of clients and package of care. To summarise: The situational analysis revealed 81 problems. These problems form the evidence base for the development of the programme to facilitate quality client-centred care in primary helth care clinics of the rural West Coast District.

Magister Curationis - MCur / Globally, there has been significant progress in reducing preventable maternal deaths and disability, and growing attention on improving the quality of care in maternal health care facilities. The World Health Organization (WHO) describes quality care as delivering healthcare that is effective, efficient, accessible, acceptable, patient–centred, equitable and safe (WHO, 2014). Midwives are the backbone of midwifery and therefore the primary care giver for pregnant women accessing maternal care and women’s ability to access quality midwifery care during the antenatal, labour and postnatal period is the key component in midwifery care. The Primary Level Protocol of South Africa is under the umbrella of the Primary Health Care System, and according to this system low risk women are expected to seek antenatal, intrapartum and postnatal care from the nearest Midwife Obstetric Unit (MOU). The choice a woman makes regarding access to maternity care depends on the social norms in her society and what services are offered. However, the services that are available may not meet the needs of pregnant women. Women may need detailed information about the availability of the maternity care system in order to make an informed decision on where to access the health system. The gap between the perceived needs of pregnant women and the care provided by midwives can be bridged by listening to women to create a reciprocal understanding of quality care. In South Africa, limited research has been conducted on midwives and women’s perceptions of maternity care. In the absence of such information, this study was conducted at an MOU in the Western Cape, with the aim of exploring women and midwives’ perceptions of quality care during childbirth.

Master of Public Health - MPH / Introduction: Tuberculosis (TB) is one of the most infectious diseases globally and is a huge public health concern. In 2016, the Western Cape Province had the fourth highest incidence of TB in South Africa, with 728 new cases per 100 000 population. Effective management of TB includes screening, diagnosis, treatment, control and elimination. The local health authority (municipality) has historically managed tuberculosis in the Cape Metropole but due to the increased TB burden, primary health care (PHC) facilities managed by Metro Health Services (MHS) (provincial government) have recently commenced providing TB services. The challenge that the Cape Metropole is facing, is whether the clinicians in MHS facilities are equipped to manage these patients effectively. Aim: To determine the knowledge, attitude and practices of clinicians in the screening, diagnosis and treatment of tuberculosis in the MHS PHC facilities in the Northern Tygerberg Sub-structure, Cape Town between mid-March 2018 and mid- June 2018.

Thesis presented in partial fulfilment for the degree of Master of Management (in the field of Public Sector Monitoring and Evaluation) to the Faculty of Commerce, Law, and Management, University of the Witwatersrand March 2016 / The South African public health care system is and continues to experience shortage of professional health care workers like other developing countries. These professional health care workers leave the country for better salaries and working environment for private sector and developed countries. The aim of the study is to gather and analyse information on how to integrate traditional health practitioners into the South African primary health care system to address the shortage of the health care workers. This qualitative study used a cross-sectional design to explore the perception, knowledge and recommendation of the national and district Department of Health officials, the western practitioners, the traditional practitioners and the SA citizens in Pretoria, South Africa on how to address this problem. Thirteen individual in-depth interviews and one focus group with the four categories of the research participants were conducted using a semi-structured interview guide. The results indicated that the SA government in partnership with the Interim Traditional Health Practitioners Council have opted for a parallel system to integrate the traditional practitioners into the primary health care level. For the parallel system to be fully implemented there are still issues that need to be achieved by the key stakeholders, one is for the government to build the traditional health care facilities for traditional practitioners, whilst the ITHPC finalise the registration of the traditional practitioners and approval of the Traditional Health Practitioners Regulations of 2015. Lastly, the District Health System has to prepare themselves for a new entrant, which is the traditional health care, into the primary health care to complement the existing system. / MT2017

A dissertation submitted to the Faculty of Architecture, University of the Witwatersrand, Johannesburg in fulfilment of the requirements for the Degree of Master of Architecture. / The theoretical case that architecture should he functionally responsive to user needs is examined with particular reference to tne design of Primary Health Care (PHC) facilities in rural South Africa, In particular, the study investigates the effectiveness of architectural practice in meeting the spatial demands of health care facilities in a changing social and cultural environment. The functlonal requirernents of modern and traditional health care facilities are examined, the aim being to examine to what extent important traditlonal requirements are taken into account in the modern sector. The research relies on: 1. A comparative literature review on the interaction between the social requirements, architectural practices, traditional and modern healing systems. 2. Data collection on the study case (Mhala). 3. In-depth interview with 'users' (patients, relatives and health professionals) from both formal and informal health sectors. 4. A physical survey of traditional healers stations and Primary Health Care (PHC)facilities. 5. Analysis. 6. Conclusions and recommendations / AC2017

Objetivo: identificar as necessidades de aprendizagem sobre o acolhimento com classificação de risco da demanda espontânea na Atenção Primária à Saúde. Método: estudo descritivo com abordagem qualitativa; coleta de dados realizada entre junho a agosto de 2017, com 15 enfermeiros da Atenção Primária à Saúde e que participam de Núcleo de Educação Permanente e Humanização no interior do Estado de São Paulo. Resultados: os resultados foram organizados em categorias resultantes da análise de conteúdo, que são as seguintes: Entre a demanda de implantação do protocolo e a ausência de conhecimento teórico e prático; As incompreensões sobre a inserção do ACCR na Atenção Primaria à Saúde nas Redes de Atenção à Saúde; Entre a agenda do ACCR e os encaminhamentos: o que fazer?; Da obstinação ao modelo curativista às possibilidades do ACCR da demanda espontânea no SUS; A (in)compreensão das necessidades de saúde dos usuários e os possíveis preconceitos da equipe; e A necessidade da Educação Permanente em Saúde para o fortalecimento do ACCR. Assim, 80% nunca utilizaram o protocolo de Manchester; entre as necessidades de aprendizagem estão o conhecimento teórico-prático da clínica, em como articular as ações programáticas e as vulnerabilidades sociais com o atendimento da demanda espontânea, e como superar o modelo médico-centrado. Conclusão: o reconhecimento das limitações para implementação do protocolo, requer a sistematização de processo de educação permanente em saúde para problematizar a realidade da unidade de saúde e proporcionar a capacitação aos enfermeiros que são os responsáveis legais pelo protocolo de Manchester / Objective: to identify learning needs about the host with spontaneous demand risk classification in Primary Health Care. Method: descriptive study with a qualitative approach; data collection between June and August of 2017, with 15 primary health care nurses participating in the Permanent Education and Humanization Center in the interior of the State of São Paulo. Results: the results were organized into categories resulting from content analysis, which are as follows: Between the demand for implementation of the protocol and the lack of theoretical and practical knowledge; The misunderstandings about the insertion of the ACCR in the Primary Attention to Health in the Networks of Attention to Health; Between the ACCR agenda and referrals: what to do ?; From the obstinacy of the curative model to the possibilities of the CCR of spontaneous demand in the SUS; The (in) understanding of the health needs of users and the possible prejudices of the team; and The need for continuing education in health to strengthen the CRA. Thus, 80% never used the Manchester protocol; among the learning needs are the theoretical-practical knowledge of the clinic, how to articulate programmatic actions and social vulnerabilities with the attendance of spontaneous demand, and how to overcome the medicocentered model. Conclusion: the recognition of the limitations for the implementation of the protocol requires the systematization of a permanent health education process to problematize the reality of the health unit and provide training to nurses who are legally responsible for the Manchester protocol

Estudo realizado com o principal objetivo de verificar a existência de atividades de assistência primária ou cuidados básicos de saúde nos serviços ambulatoriais do Instituto Nacional de Assistência Mêdica da Previdência Social (INAMPS), nos Estados do São Paulo e do Rio de Janeiro. Todos os 394 enfermeiros lotados nesses serviços, no período de novembro de 1981 a agosto de 1982, foram incluídos no estudo. Houve retorno de 84,0 por cento dos questionários enviados. Foram identificados diversos fatores institucionais e organizacionais que influenciavam favoravelmente o desempenho profissional do enfermeiro, tais como: a presença de enfermeiros nas coordenadorias regionais das superintendências, a existência de campo adequado para o enfermeiro desenvolver-se profissionalmente, o apoio da chefia, a existência de supervisão do trabalho de enfermagem e a realização de reuniões de serviço. Os resultados obtidos demonstraram que muitas atividades que podem ser enquadradas como sendo de assistência primária ou serviços básicos de saúde já vinham sendo executadas por enfermeiros e equipe de enfermagem, porem de forma esparsa e assistemática. Essas atividades foram classificadas em assistenciais subsidiárias, assistenciais independentes, educativas e tenico-administrativas. Os obstáculos na execução de mais atividades de assistência primária de saúde por esses profissionais eram, principalmente, falta de pessoal de enfermagem e falta de área física. Havia também existência de médicos em tal quantidade que algumas atividades simples tais como: controle de gestantes ou crianças sadias, controle de portadores de moléstias crônicas comuns de evolução previsível ocupavam espaço como consulta medica. A contribuição do enfermeiro na assistência primária, ou nos serviços básicos de saúde, pode ser agrupada em três níveis, de acordo com o grau de necessidade de preparaçao adicional do profissional, bem como com providências administrativas em termos de recursos humanos e materiais. Nessas condições, esses três níveis de contribuição do enfermeiro podem ser implantados, gradualmente, a curto, médio ou longo prazo. Os clientes portadores de patologias seriam encaminhados aos médicos para atendimento especializado. A esses clientes poderia ser dada assistência completa com a utilização total de recursos tecnológicos disponíveis para diagnóstico e tratamento. Dessa forma, a assistência médica curativa ficaria concentrada no paciente realmente necessitado; aos demais seria prestada a assistência primária, ou cuidados básicos de saÚde, podendo assim melhorar sensivelmente a qualidade dos serviços assistenciais prestado a população que busca a Previdência Social. / The study was carried out with the purpose of discovering what kind of primary health care was available at outpatients\' departments of the INAMPS (National Health Service) in the states of São Paulo and Rio de Janeiro. All 394 nurses engaged in this service, from November 1981 to August 1982, were included in the study. 84 per cent of the questionnaires distributed were completed. Various organizational and institutional factors were identified which favourably influenced nursing performance such as the presence of nurses on regional boards, the chances of professional development, support lent by superiors, the supervision of nursing duties as well as periodic discussion of work related topics. Results show that much of the health care at community level is already being carried out by individual nurses and by teams, but in an unsystematic way and on an irregular basis. These activities have been grouped under the following headings: subsidiary and independent care, educational and technical/administrative activities. These professionals were prevented from further developing health care at community level mainly due to a lack of trained nursing staff and of space. There were also so many doctors avaiable that certain areas of health care such as pre-natal checks, routine pediatric visits and control of patients with controllable chronic ailments were all carried out by doctors. The nurse\'s role in providing basic health care may be examined at three levels and depends on the need for further professional training, as well as human and material resources. Bearing these conditions in mind, it is possible to put into practice these recommendations either in the short or medium term or even on a long term basis. Patients suffering from pathological conditions would be sent to doctors for specialized care. For these patients complete diagnostic and technological resources would be made available as well as complete medical assistance. In this way, the role of the doctor could concentrate on cases which required actual medical attention, whereas basic health care would be provided in all other cases, thus improving the quality of National Health Assistance.