Magister Artium (Social Work) - MA(SW) / Primary Health Care (PHC) is the cornerstone of health care globally, nationally and locally and, therefore, should be regarded as the foundation of health care provision. In South Africa, Community Day Clinics (CDCs) are part of the bouquet of services that is being offered at a PHC level. There are various factors that generate inconsistency in the provision of care to people accessing these CDCs. The purpose of this study was to identify and explore how these factors impact on the care practices that health care professional’s provide. Research suggests that the majority of health care workers are women, who play a double role as carers in their professional and private lives. Therefore, the political ethics of care, a feminist theoretical approach, was utilized to understand care practices in these health settings. The aim of the study was to develop an in-depth understanding of the care practices of health care workers at two CDC facilities on the Cape Flats. A qualitative research methodology was used to explore and identify the phenomenon under study. The research project followed an explorative and descriptive research design, as the researcher sought to understand the care practices of health care workers and how their values and ethics further influenced care practices at these two CDC settings. The data was gathered using semi-structured one-on-one interviews, and later analysed using qualitative thematic analysis. The research findings were grouped in terms of the values entrenched in the political ethics ofcare, which are attentiveness, responsibility, competence, responsiveness and trust. The research findings identified various aspects that, either negatively or positively, impact on these values. Finally, recommendations were made to management, as well as care workers. These recommendations were in terms of implementing care services that are attentive to service-users and care-workers; providing a service that takes into consideration the value of responsibility; the provision of competent services; and finally creating trusting relationships within the CDC.

Philosophiae Doctor - PhD / Background: Syphilis transmission remains a global problem with an estimated 12 million people infected each year. Ninety percent of syphilis cases occur in low income countries. Syphilis is a serious source of adverse pregnancy outcomes for both mother and infant. Ideally, syphilis screening should be provided as part of a package of maternal and newborn health-care services. This thesis reports on a pilot intervention study to develop, implement and evaluate a point of care test for syphilis in antenatal care services in rural Burkina Faso. Methods: This study used a pre post intervention mixed methods quasi-experimental design with a group of health facilities offering ANC services (primary health centers in rural area) as the sampling units. This study was conducted in three phases, which consisted of a situational analysis using qualitative methods (Phase 1), selecting an appropriate test through evaluating 4 candidate tests and the participatory design and implementation of an intervention that included onsite training, provision of supplies and medicines, quality control and supervision (Phase 2), and an evaluation combining review of record tools, interviews, time motion study and estimating incremental costs (Phase 3). The conceptual framework draws on multilevel assessment (MLA), policy triangle framework, MRC framework for designing complex interventions and the Normalization Process Model (NPM). Methods included document review, seventy five interviews were conducted with health providers, district managers, facility managers, traditional healers, pregnant women, community health workers, and Non-Governmental Organizations (NGO) managers in phase I and fourteen in phase III, non-participant observation, time-motion study, incremental cost analysis, and sensitivity, specificity and ease of use analysis of four candidate point-of care tests. Data were collected between 2012 and 2014. Qualitative data were analyzed through thematic analysis supported by Nvivo software. Quantitative data were analyzed through descriptive statistics such as frequency, mean and median supported by SPSS. Findings: Phase I identified barriers to implementation and uptake of syphilis testing at health provider and community levels. The most important barriers at provider level included fragmentation of services, poor communication between health workers and clients, failure to prescribe syphilis test, and low awareness of syphilis burden. Cost of testing, distance to laboratory and lack of knowledge about syphilis were identified as barriers at community level. Phase II: Alere DetermineTM Syphilis was the most sensitive of the four point-of-care tests evaluated. The components of the intervention were successfully implemented in the selected health facilities. Overall, phase III showed that it is feasible and acceptable to introduce a point of care test for syphilis in antenatal care services at primary health care level using the available staff. The intervention was reported as acceptable, but of 812 pregnant women who came for their first visit 39% were screened during the study period. Rural facilities had higher coverage (66.8%) than the urban ones (25.6%). Quality control found no discordance between the rapid test and TPHA results. The average cost of ANC per unscreened pregnant woman was 3.11 USD (±0.14) vs 5.06 USD (±0.16) per screened woman. The main cost driver was the material costs notably the test itself. The test’s cost is comparable to HIV test costs, but funder support for integrating this additional test is less readily available than for HIV tests. Conclusions: The findings suggested that an intervention that introduces point of care test for syphilis at antenatal care services is feasible, acceptable, and of comparable costs to HIV screening in pregnancy. Nonetheless, instructions and supervision need to be clearer to achieve optimal levels of screening and quality control, and barriers identified by health workers need to be overcome. The point-of care test for syphilis is likely to be acceptable by health workers as a routine service and incorporated as a normal practice in Burkina Faso context. / This research was made financially possible by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR); and the African Doctoral Dissertation Research Fellowship (ADDRF 2012) award offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC).

Magister Public Health - MPH / BACKGROUND AND RATIONALE: The Cape Town Metro District Health Service (MDHS) has introduced a Diabetic RetinopathyScreening (DRS) programme incorporating retinal fundal photography in diabetic services at primary health care (PHC) facilities. Hitherto, coverage of the DRS programme has been less than optimal in part due to volumes of diabetic patients attending PHC facilities. The aim of this study was to identify possible sub-groups of patients, attending the Cape Town DRS Programme, who are at most risk of diabetic retinopathy and might be prioritised for early diabetic retinopathy detection and subsequent sight-saving treatment. METHODOLOGY: A case-control study of risk factors for treatment-requiring diabetic retinopathy was conducted. This research sampled participants from the DRS programme provided by the MDHS eye care team to Type II diabetics attending public PHC facilities within the Klipfontein and Mitchells Plain Sub-Districts. Based on fundal images, cases were selected as those requiring ophthalmological treatment; and controls (three matched per case by area of residence) as those judged as not requiring ophthalmological treatment for diabetic retinopathy. Data on possible risk factors (clinical, laboratory) were extracted from the patients' folders. RESULT: The study included 453 participants, of whom 113 (24.9%) were cases and 340 (75.1%) were controls. Three factors were significantly associated with treatment-requiring diabetic retinopathy on multivariate analysis: Insulin dependency (OR of 2.96, 95% CI: 1.75 – 5.00); duration of diabetes of more than 10 years (OR of 3.44, 95% CI: 2.06 – 5.74) and sustained hyperglycaemia over the past six months (OR of 3.73, 95% CI: 1.69 – 8.22). A screening algorithm combining these criteria had a sensitivity of 61.2% (95% CI: 51.9 – 70.5). CONCLUSION: The findings indicate that a sub-set of patients attending the DRS programme in the Klipfontein and Mitchells Plain Sub-Districts have a greater likelihood of presenting with treatment-requiring diabetic retinopathy. Further research is required to develop a tool that is sufficiently sensitive to safely prioritise patients for fundal screening. / National Research Foundation (NRF)

Magister Curationis - MCur / The introduction of primary health care in South Africa in 1994 marks a new beginning for the majority of the marginalised population in South Africa during the apartheid era. This introduction has improved access to health care in most communities. Health services are now more decentralised with community health centres that are primarily run by nurses. Violence continues to take its toll in post-apartheid South Africa and the youth remain the most affected group of most communities. It often leaves the youth shattered and traumatised with alarming psychological effects, including poor self-esteem. There is a steady increase of youths who are visiting community health centres to seek health care from nurses with a subsequent increased workload for the nurses at these centres. Previous research has dwelt more on either violence on its own, or the youth affected by violence but very little is known about the nurses caring for these youth victims of violence. It is unclear how nurses who are working at a community health centre experience caring for youth victims of violence. The purpose of this study was to explore and describe the experiences of nurses caring for youth victims of violence at a community health centre in Khayelitsha and to develop guidelines for supporting nurses caring for youth victims. A qualitative, exploratory, descriptive, and contextual design was used. The accessible population (N = 40) included all nurses who are registered under Section 31(1) of the Nursing Act No 33 of 2005 in order to practice nursing or midwifery, and who were working at a community health centre in Khayelisha. Purposive and snowball sampling were used. The data collection method comprised an individual unstructured interview while using an audio recorder and documenting field notes. Tesch's descriptive method of open coding was used for data analysis. Trustworthiness was ensured by means of applicability, dependability, transferability and confirmability. The findings from this study indicated that the experience of nurses who were caring for youth victims of violence was particularly related to a number of factors. These factors included challenges faced by the youth in the community, their socio-economic situation, violence and abuse, gangs, substance abuse, illiteracy, teenage pregnancy; as well as challenges face by nurses, under-preparedness, staff shortage, increase workload, rudeness, and verbal and physical abuse of the nurses. They also emphasised some rewarding experiences. There were some psychological effects on nurses and their emotional responses reported by these nurses. The study also revealed the different coping mechanism these nurses were using and their need for support. Guidelines were developed to support nurses. Recommendations for future implementation are presented in the last chapter. / National Research Fund (NRF)

Magister Public Health - MPH / Introduction: Health Sector Reform was initiated as a component of the Structural Adjustment Policies that were imposed on the developing countries by the international monetary organizations such as the International Monetary Fund and the World Bank during the 1980s and the 1990s. It included three main components, that is, financing reforms, decentralization and introducing competition to the health sector. Changes to the Egyptian health system were introduced in the 1980s through the cost recovery projects, while the Health Sector Reform Program was announced in 1997. This culminated in a change from a Primary Health Care model to a Family Health Model as regards the Primary Health Care sector of the Egyptian health system. Changes in the health systems have profound effects on people, so that it is essential to study the ongoing transformation of the Egyptian health system and its implications. Aim: The aim of the current study was to determine the acceptability of the Family Health Model, which replaces Primary Health Care, as currently implemented in Wardan Village, Giza, Egypt. Methodology: The study was a cross sectional survey utilizing a structured questionnaire that was used to determine the awareness and perception/satisfaction of the community members in an Egyptian rural area (Wardan village, Giza Governorate) towards the transformation from primary health care to family health model. 357 subjects participated in this study. Results: Awareness of the study participants towards the transformation process was 15.6%. The overall satisfaction with the family health unit by the participants was 80.5% compared with 35.7% for the old PHC one. Higher satisfaction was associated with older age (p=0.02), less education (p<0.001), being married in the past or present (p=0.02), working status (p=0.007), and more years of using the unit (p<0.001). Acceptability of the family health model among the participants of the current study was high at 88.3%. Higher score of acceptability were associated with less education (p<0.001), being or have been married (p=0.048), and with working status (p=0.005). 93.8% of the participants think that family health unit services are accessible and 79.9% of the participants think that the family health unit provides quality services. Conclusion: The Family Health Model has achieved successes when implemented but encountered some difficulties that have limited the gains and interfered with some of its aspects. The current study has shown that the Family Health Unit has gained a high score of satisfaction and acceptability by the study participants, although the awareness of the study participants about the transformation of the Primary Health Care Model to a Family Health Model was low.

Purpose of this treatise- This Paper aims to investigate the Sustainability of Health Facility Committees in the Nelson Mandela Bay Health District. Design/methodology/approach – This study consists of a literature review and a pilot study. Qualitative research approach was used in order to obtain descriptive data from the targeted group. The primary sources of data collection the researcher used were from the members of the committee, health facility manager, chairperson and the health promoter who are members of the health committees. Focus group discussions with health committees were conducted to provide rich in-depth data. Literature and journal articles were also used to provide secondary data to corroborate findings. Research limitations- A major limitation to this study is that due to the nature of the nature of the research report it was not possible to assess the sustainability of health Facility Committees from other areas in the Nelson Mandela Bay Health District. Findings-The study has revealed that Community Health committees are sustained by the commitment and passion members have for the work done in the facilities and health committees. The study also revealed that social cohesion plays a major part in the sustainability of Community Health Committees (CHC). Lack of involvement by ward councilors, support from the Health Department, uncertainty of responsibilities by the health committees and limited skills were indicated as major setbacks threatening the sustainability of Community Health Committees. It can thus be concluded that these limitations must be properly addressed in order to enable and uphold the sustainability of Community Health Committees. Original/value -So far, there has been limited research which has been undertaken with regards to the subject of Sustainability of Health Facility Committees in Nelson Mandela Bay Health District. This study will aid in enabling a better understanding of what sustains Community Health Committees and the Challenges facing such communities in order to enable individuals and the parties involved to better formulate solutions to overcome these challenges in Nelson Mandela Bay.

Research in Canada and abroad has shown that newcomers face multiple obstacles in their search for health care during their resettlement and integration to the host society. In Ontario, primary care services are organized in three main models based on the remuneration scheme to physicians: fee for service, capitation, and salaried. During the Primary Care reforms in early 2000s, the province introduced new models of primary care practices to enhance the quality of care through the expansion of comprehensive multidisciplinary care, applying more preventive measures and enhanced chronic disease management strategies. Along with these innovative reforms, the province promoted an enrollment system with a family doctor in the primary care practices. This research examined the access of immigrants to the enrollment system in Ontario. A review of the literature contrasting a PMC and PHC approaches showed that the latter has more potential to address social determinants of health of immigrant populations. Taking into account the organization of health services in the province, immigrants can receive primary care services mainly through PMC practices (FFS and capitation-based), but also through PHC-type of models, such as Community Health Centers. The analysis of enrollment in primary care was conducted using a secondary analysis of administrative data. The main findings have shown that immigrants’ enrollment in primary care services has increased over time, but the levels of enrollment remain lower compared to long-term residents. Moreover, compared to long-term residents, immigrants have less access to the most comprehensive models of care, which represents an important inequity. In exploring the perceptions of immigrants in two major cities of the province, most of the participants perceived that important factors, such as information, knowledge, language barriers, cultural issues; are affecting their capacity to understand and navigate the system. Hence, it takes a long time for them to make sense and learn how to connect and use the system.

Bakgrund Kardiovaskulära sjukdomar är en av de stora folksjukdomarna i Sverige som bidrar till lidande och dödsfall. Sjukdomstillståndet är delvis kopplat till levnadsvanor såsom ohälsosamma matvanor och fysisk inaktivitet. Motiverande samtal är en av många åtgärdsmetoder i primärvården som erbjuds patienter med kardiovaskulära sjukdomar för att förhindra ohälsa och motivera till livsstilsförändring. Syfte Syftet var att beskriva motiverande samtal som intervention i vård av patienter med kardiovaskulära sjukdomar inom primärvården. Metod En litteraturöversikt där 15 artiklar valdes ut och granskades. Sökningarna gjordes via databaserna PubMed/Medline, CINAHL Complete, SveMed +, PsychINFO samt Cochrane Library. Sökorden som användes i databaserna var: Nursing, Cardiovascular diseases, Motivational interviewing, Health promotion, Lifestyle, Person-centered, Primary Care, Primary Health Care, Lifestyle Counselling och Experiences. Resultat Majoriteten av studierna påvisade en god effekt av motiverande samtal vid förändring av levnadsvanor hos patienter med kardiovaskulära sjukdomar, i jämförelse med traditionell rådgivning. Slutsats MI är en övervägande effektiv metod för livsstilsförändring av ohälsosamma matvanor och otillräcklig fysisk aktivitet hos patienter med kardiovaskulära sjukdomar i primärvården i jämförelse med traditionell rådgivning. Det råder även en övervägande positiv inställning till MI från patientens och sjuksköterskans perspektiv. Effekten av metoden och dess funktion är dock kopplade till flera faktorer som bör överensstämma för att MI ska fungera i praktiken. Dessa faktorer kan sammanfattas som: sjuksköterskans utbildning och attityd till MI, patientens motivation till förändring samt ledningens satsning på implementering och uppföljning.

It is argued that the holistic health care movement in the United States has emerged as a response to dissatisfactions with the existing health care delivery system—a system which has become too concerned with technological solutions and insufficiently concerned with social and psychosocial issues. The holistic health care movement is defined. The movement's emphasis on prevention through the use of teamwork and its concern with whole patient care is explained. Next consideration is given to the present process of planning, financing and delivering health services in the United States; and the other models which have been developed to try to take account of prevention, social and psychosocial issues are described and criticized. The way in which holistic health care needs to be organized is described—the need for involvement of allied health professionals such as nutritionists and psychologists is discussed and better record keeping is examined. The need to be open to new techniques such as acupuncture and other marginal activities is argued. The difficulties in financing are discussed. However, discussion of a model health center presently operating in Illinois gives hope that demonstrations may convince Americans that it is a service worth paying for. The method of introducing new models of health service delivery into the United States is examined. They are generally accepted by the upper-middle class and then work down through the system. It is argued that the model (holistic health care) is quite likely to become more widely accepted because it appeals to the American individualistic, selfhelp ideology. Whilst it may work itself down the class structure it is not likely to solve social problems because the orientation is psychosocial and individualistic. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

D.Litt. et Phil. / The mentally ill population is one of the most neglected subpopulations of the Western World and this is most certainly the case in Southern Africa. With the restructuring of the mental health system, the process of discharging properly rehabilitated individuals from long term hospital stays into a strong community mental health support structure has become a priority. In order to embark on a process driven by an ethos of primary health care, the present inpatients in custodial settings need to be discharged into the open community. This process is termed deinstitutionalisation, and involves the discharge of all able patients from chronic or long-term custodial care institutions, into the open community as functional members, with all of the rights and freedom which this may imply. Deinstitutionalisation as a concept embraces the essence of human rights, as the person takes control of his/ her life circumstances with all of the accompanying responsibilities. Present deinstitutionalisation practice in traditional South African long-term care facilities has no rehabilitation/ recovery focus with which to drive the discharge process of patients. Barriers to the success of the process are the lack of rehabilitation services, poor discharge planning and process, and lack of follow-up and integration of community services. These would seem to be the biggest stumbling blocks to the success of a deinstitutionalisation initiative. The initial process of design and implementation of a viable programme, and one that addresses uniquely South African issues was challenging. This was because of the lack of information, and reliable reporting systems with which to identify availability and need of service, client subpopulations, and service provision agencies. A preexisting NGO system was described and assessed for service provision and success rates, and the same system was used to measure the availability and applicability of psychosocial rehabilitation service in South Africa. The process comprised describing a the necessary components required by a recovery-driven, psychosocial rehabilitation system, using international literature as well as the early findings and results of the changed system. Suggestions have been made in terms of necessary facilities and services required, as well as staff competencies and methods of addressing historic issues of anti trust which have developed because of apartheid mental health practice.