Studies of smoking during pregnancy in South Africa have found exceptionally high smoking rates among disadvantaged women of mixed ethnic descent (46%) (Steyn et al., 1997; Petersen et al., 2009a). As a consequence, these women are at high risk of smoking-related pregnancy complications and poor birth outcomes. It has long been recommended that a smoking cessation intervention be developed specifically for this high risk group. There is strong evidence that best practice smoking cessation interventions for pregnant women can be effective in increasing quit rates, as well as in reducing the incidence of premature birth and low birth weight (Lumley et al., 2009). However, these interventions have only been studied in developed countries and it was unknown whether such programmes could be successfully applied to a South African setting. From 2002, the Medical Research Council of SA undertook a programme of research for the purposes of developing and evaluating a smoking cessation intervention, specifically for disadvantaged pregnant women attending public-sector, antenatal clinics in Cape Town. This thesis reports on several aspects of this research.

Includes bibliographical references (leaves 134-170). / [Introduction] Meta-analysis of the treatment of latent tuberculosis infection (LTBI) in HIV-infected adults has shown significant reduction in the incidence of tuberculosis in participants with a positive tuberculin skin test (TST), but not in those with a negative TST. However, there are insufficient data on patients with advanced HIV disease from high tuberculosis incidence areas. It is important to exclude tuberculosis prior to such preventive therapy, but this can be difficult in patients with symptomatic HIV disease. A tuberculosis screening instrument is thus needed to ensure that patients placed on preventive therapy do not have tuberculosis. Furthermore, to ensure adherence and avoid drug resistance optimal supervision of the treatment administrations is required. [ Methods ] Patients with clinically advanced HIV disease were screened for active tuberculosis using a symptom questionnaire, measured weight loss, chest radiography, sputum microscopy and culture prior to receiving tuberculosis preventive therapy. Once tuberculosis was excluded, a randomized doubleblind trial was conducted comparing INH with placebo among TST negative status participants with WHO Stage 3 or 4 HIV disease. INH/placebo was administered for 12 months by patient-nominated supervisors. TST-positive participants were given open-label INH. Participants who did not have access to ART were followed up for 24 months with 6-monthly sputum culture and chest radiography. All those enrolled for the trial were required to visit a clinic on a monthly basis for 12 months during the period of weekly intermittent supervised administration of INH/placebo to assess for tuberculosis and adherence. [ Results ] A total of 118 participants were enrolled: TST was negative in 98. Tuberculosis was diagnosed in 11 of 129 patients screened. A simple screening instrument of two or more of the symptoms cough, night sweats or fever, (plus measured weight loss) had a sensitivity of 100% and specificity of 88.1% (against the gold standard of sputum culture) and positive and negative predictive values of 44% and 100%, respectively. In the randomized trial arms, the incidence of tuberculosis was 18/100 person-years (py) in the INH arm and 11.6/100 py in the placebo arm [hazard ratio 1.59, 95% confidence interval (CI) 0.57-49)]. There was no significant difference in mortality, hospitalization rate or CD4+ lymphocyte decline. Patient adherence for INH/placebo was 8 5% and was significantly higher among participants with work-based treatment supervisors than among those who were supervised by home-based or community-based treatment supervisors. The daily self-administered treatment (SAT) of cotrimoxazole (CTX) showed a good adherence especially among the TST positive participants, where a greater benefit in terms of survival among participants with good cotrimoxazole adherence was observed.

Includes bibliographical references. / Using the theory of "street-level bureaucrats" , this thesis examines the implementation of the South African Choice on Termination of Pregnancy Act by exploring nurses' decision-making in termination of pregnancy services. As front-line providers, nurses play a critical role in the implementation of termination of pregnancy services. Nurses may be required to assist in informing, preparing or counselling women who request a termination of pregnancy and, if appropriately trained, nurses can perform terminations of pregnancy. Research suggests, however, that 15 years after the promulgation of the law, nurses continue to be reluctant to participate in termination of pregnancy services thereby undermining the successful implementation of the Choice on Termination of Pregnancy Act.

The Postgraduate Diploma in Community Eye Health (PgDCEH) has been offered at the University of Cape Town, South Africa since 2009 to develop management capacity in support of the delivery of effective and efficient eye care services in sub-Saharan Africa. We investigated how graduates applied the PgDCEH-acquired management competencies and the factors that enabled or constrained them to apply these competencies. A multiple case study design was used, employing mixed methods of data collection and analysis. Data collection comprised of a questionnaire survey, in-depth interviews and review of various supporting documents, including assignments submitted by students. Twenty-six of the 34 students who graduated from 2009 to 2014 submitted completed questionnaires. Of these, 15 purposively selected graduates and their secondary key informants participated in in-depth interviews. We found that the PgDCEH elicited some positive effects on the graduates, especially in their ability to perform management tasks and the level of confidence they have in their abilities. There were some personal achievements, but no significant programme improvements were observed. This study provided evidence that the PgDCEH as a health system strengthening intervention struggled to generate the anticipated response of improved eye care programme performance. Personal motivation, suitability of the training and opportunity to apply were the main factors determining how graduates apply management competencies. The utilization of the project management approach, a greater focus on health system maintenance and attention to the dynamic of change in people's lives are critical determinants of success in eye health programmes. The research also highlighted the importance of health care workers' personal motives and motivations as drivers of success and achievement on programme level, and that line management support, supervision and proper performance management are required to attain this. This research broadened understanding of how PgDCEH graduates interact with their work environment and uncovered ways to improve the design and delivery of management training for eye health workers in the future. Revision of the criteria for selection, strengthening focus on leadership, project and relationship management topics, and integrating the training into health professions' education programmes may substantially improve the impact of health management education. The study concluded that the constituent elements of the health system are not inanimate objects, as commonly portrayed, but people, who are connected in intimate, complex and multi-dimensional ways through communication, relationships and team dynamics to deliver health outcomes.

Access to health care is a very important concept which has equally important implications to the health status of individuals. However, there have been a lot of debates among researchers and policy makers on what constitutes access, and how it can be made less conceptual and more operational. The concept of access has continued to receive increased attention because of a growing realisation of its importance in health policy. Furthermore, provision of services alone without understanding barriers individuals face in accessing services could result in less optimal outcomes. It is therefore necessary to have an understanding of what "access" entails and factors that influence it if we are to have a real chance of improving access to health services and therefore enhance health. In this thesis access is viewed as consisting of three (3) interrelated and measurable dimensions (availability, affordability and acceptability). These access dimensions are related to both the system and user characteristics. Access is therefore said to have been achieved when all the three dimensions have been satisfied. Using the above definition of access, the main focus of this thesis is on access barriers (in relation to the three access dimensions) to both Tuberculosis (TB) and Antiretroviral Treatment (ART) services in Mitchell's Plain, Cape Town South Africa. Secondary cross-sectional data was used for this purpose. Access to TB and HIV treatment has been given priority because the two diseases have had a massive and negative impact on public health in the country. In addition, patients using these services may face similar barriers to care. Findings of this thesis are expected to provide insights into the barriers TB and HIV patients face in seeking care vis-a-vis availability, affordability and acceptability of services. Findings will therefore prove valuable in as far as improving access is concerned.

Includes bibliographical references (leaves 83-88). / [Background and rationale] Malaria accounts for a large public health burden in Mozambique and a treatment policy with effective anti-malarials is a key component of their malaria control programme. Artemisinin-based combination therapies (ACTs) are now generally considered as the best treatment for uncomplicated falciparum malaria; the use of artesunate (AS) in combination with sulfadoxine-pyrimethamine (SP) is recommended by the World Health Organisation (WHO). Mozambique policy-makers recommended that an ACT be implemented and studied in 2003. Therefore this RCT was conducted to compare SP monotherapy with AS, plus SP in order to provide further evidence of available treatment options in the region. [Trial design and methods] A prospective multi-centre, open-label, parallel-group randomised clinical trial (RCT) was conducted at 4 public health facilities in Maputo Province, Mozambique during the malaria seasons of 2003 - 2004 and 2004 - 2005. Eligible patients were aged over 1 year with body weight over 10kg and uncomplicated Plasmodium falciparum malaria (parasitaemia less than 500 000 asexual parasites/ml blood with axillary temperature less than or equal to 37.5oC or a history of fever). Patients were excluded if they took other anti- malarials or folate within 7 days, had moderately severe/severe malaria, history of G6PD deficiency or allergy to study drugs, or serious underlying disease. Patients were randomly assigned to sulfadoxine-pyrimethamine (SP): a single oral 25/1.25mg per kg dose on Day 0, with a maximum of 3 tablets), or artesunate (AS) plus SP: SP as above, plus single oral doses of 4mg/kg AS on Days 0, 1 and 2 with a maximum daily dose of 4 tablets). The study aimed to compare the efficacy of SP monotherapy to SP in combination with AS as first line treatment of uncomplicated falciparum malaria. The primary objective was the comparison of the time to treatment failure (the relative hazard of treatment failure) between groups using standard WHO response to treatment definitions for low to moderate malaria transmission areas, modified to a 42 day follow up. Randomisation was computer-generated with sequential allocation concealed in opaque sealed envelopes. Treatments were open-label, however laboratory staff responsible for parasite density measurements (in order to determine the primary efficacy end point) were blinded to treatment allocation.

Includes bibliographical references (leaves 95-105). / Tuberculosis has long been considered a disease of poverty but there has been little research into the pathways through which low socio-economic status leads to increased risk of disease. This study reviews the existing literature on risk factors for tuberculosis disease with a particular focus on those variables that reflect the social setting in which an individual lives. It then conducts a multilevel analysis of South African data from the 1998 South African Demographic and Health Survey and the 1996 national census to evaluate individual-, household -and community-level risk factors for tuberculosis disease using a hierarchical regression model.

Includes bibliographical references (leaves 86-91). / This study occurred in the context of three problems that have arisen within the South African HIV/AIDS crisis: the prevalent HIV and tubertulosis (TB) co-epidemic, the concern that antiretroviral (ARV) provision might compromise the existing TB control programme, and that the Western Cape's current limited vertical model of ARV roll-out will soon reach capacity. This study evaluated whether and how TB control changed following ARV introduction in a Cape Town primary care TB clinic and explored the process of integration of the TB and ARV services in the clinic.

Most analyses of International Study of Asthma and Allergies in Childhood (ISAAC) data in developing countries have suggested an increase over time in 12-month prevalence of rhinitis and eczema symptoms amongst adolescents. The objective of this study is to measure the sociodemographic, dietary and environmental risk factors of allergic rhinitis and atopic eczema symptoms amongst adolescents of the Cape Town centre of the ISAAC Phase Three study.

Includes bibliographical references. / [Background] Two injectable progestogen-only contraceptives (IPCs) depot medroxyprogesterone acetate (DMPA) and norethisterone oenanthate (NET-EN) continue to be extensively used in some countries, forming a large proportion of the health system's expenditure on contraception. Both these highly effective contraceptives receive wide acceptance amongst women in their fertile years. They differ in cost and frequently of administration. A systematic comparison was undertaken to investiage their rational use. [Objectives] To determine if there are differences between depot medroxyprogesterone acetate given at a dose of 150mg IM every three months and norethisterone oenathate given at a dose of 200mg IM every two months, in terms of contraceptive effectiveness, reversibility and discontinuation patterns, and adverse clinical effects. [Study Design] A Cochrane systematic review was used to answer the question posed in the research objective. This included a systematic search for all available literature comapring DMPA and NET-EN, followed by appraisal of all studies for inclusion in the review. Meta-analysis was then applied to the included study.