TB, a major public health problem in India since the 1900s, has a current prevalence of 14 million and an estimated annual mortality of 500,000 persons. Nation-wide government sponsored anti-TB public health measures introduced in 1948, developed into the National TB Programme in 1962. Despite gains, implementation gaps between programme goals and performance, over 35 years, have been of a magnitude sufficient to cause concern. This study aimed to understand explanatory factors underlying the implementation gap. A policy analysis approach was adopted, focusing on the policy process and specifically on implementation, at national, state, district and local levels. It undertook a historical review with a two-tiered framework covering the period 1947-97. In the first tier the historical narrative is woven around a framework of context, content, process and actors. The nature of the problem and policy relevant technical dimensions of intervention measures are discussed, as are effects of pharmaceutical policies and financial resource flows on TB policy. The second tier applies a framework of implementation factors to national policy development and implementation at state and district level. Interviews were conducted with TB patients, elected representatives, front-line health workers, doctors, district and state staff, national programme managers, researchers and representatives from international agencies. Documents were reviewed. Thus the study incorporated an integrative bottom-up cum top-down approach. Findings highlight that interests of patients, medical and allied professionals, pharmaceutical and diagnostic industries and the state are interdependent, but often conflictual. Unequal societal relations affect not only the development and transmission of TB, but also the implementation of control programmes, particularly for the impoverished, among whom high levels of indebtedness due to the disease and difficulties accessing private services were noted. Techno-managerial approaches to TB control often mask societal and policy process factors accounting for the implementation gap. The importance of leadership, institutional development, capacity at the patient provider interface and accountability and need for sustained policies were noted, within an affirmative framework embodying social justice and safeguarding the interests of the majority of patients.

Background: The demand for healthcare services has been steadily increasing over the years whilst the health system is subjected to increasing resource limitations. The private sector has therefore, in various ways, including Public Private Partnerships, been viewed as a means to address these resource limitations. The Western Cape Department of Health has undertaken to expand the Expanded Programme for Immunisation as a Public Private Partnership. The programme aims to improve population health outcomes through increased vaccination coverage and service access. Benefits and challenges of such partnerships have been identified in various contexts. However, there is a significant research gap pertaining to public partnerships with for-profit entities, particularly in Sub-Saharan Africa. Objectives: The study sought firstly to describe the socio-demographic characteristics of clients who utilised the Expanded Programme for Immunisation public private partnership services in the 2016/17 financial year. Secondly, to compare the socio-demographic characteristics of those using the Expanded Programme for Immunisation public private partnership services to those using the Expanded Programme for Immunisation services in Western Cape public sector facilities. Thirdly to describe the proportion of Expanded Programme for Immunisation public private partnership clients who have utilised public sector facilities for healthcare in the Western Cape. Finally, to describe the provincial health staff experiences of the service. Methods: A descriptive quantitative cross sectional study and 12 semi- structured interviews were undertaken to fulfill the objectives of the study. The study population was clients who utilised the Western Cape Department of Health Expanded Programme for Immunisation services from April 2016 to March 2017 in the Western Cape Province. Convenience sampling of public private partnership clients was conducted which enabled the descriptive analysis whilst a random sample of public sector immunisation clients enabled the socio-economic status comparison to the public private partnership clients. Socio-economic status was analysed by reviewing the annual head of household income of clients estimated by client postal code. Western Cape Government staff were selected for interviews to gain insights into provinical staff experiences of the partnership. This was conducted by snowball sampling methods. Univariate analysis was conducted on data submitted by 80 private partners and thematic coding was used to analyse the staff interviews. Results: The proportion of provincial Expanded Programme for Immunisation client visits attributable to the public private partnerships was approximately 12% in 2016/17. The 80 participating private partners provided almost 60, 000 vaccinations to 23,695 clients in the period of a year. The public private partnership appears to be accessed by users who are of similar socioeconomic status to the Expanded Programme for Immunisation clients accessing public sector facilities. Additionally, the small proportion (12.2%) of public private partnership clients having access to medical insurance further supports the findings of the similar socioeconomic profile of the two groups. 42.7% of public private partnership clients were found to have visited public sector facilities therefore suggesting that in the absence of the public private partnership they might otherwise have utilised the public sector to attain the service. Notwithstanding concerns around management and governance, the initiative is generally appreciated and supported by government stakeholders. Conclusions and recommendations: The Western Cape Department of Health Expanded Programme for Immunisation public private partnerships operate at a scale that accounts for a meaningful proportion of the immunisation coverage and is utilised by clients of similar socioeconomic status when compared to Expanded Programme for Immunisation clients accessing public sector facilities. The small proportion of public private partnership clients having access to medical insurance suggests public private partnership clients might otherwise have utilised the public sector in the absence of the partnership. Overall, the public private partnership has been appreciated by the Western Cape Department of Health staff and affords clients a degree of financial risk protection. Future research areas include an economic evaluation, a benefits incidence analysis and the describing barriers to uptake of the service from the perspective of stakeholders external to the Western Cape Department of Health.

This study aimed to evaluate the long-term trend in quality improvement and determine whether there had been an increase in the performance of diabetic clinical processes.

Background: Childhood immunisations are a cost effective public health intervention for prevention of infectious diseases. Immunisation coverage, however, is still sub-optimal which may result in disease outbreaks. Immunisation at every contact with a health facility is a strategy developed by the World Health Organization (WHO) in order to improve immunisation coverage. Objectives: The aim of this study was to estimate the prevalence of missed opportunities for immunisation at different levels of healthcare in the Western Cape and assess factors associated with missed opportunities. Methods: The study included a health-facility based cross-sectional exit survey of caregivers with children up to 5 years of age, followed by a qualitative exploration of staff attitudes towards immunisation. Results: The prevalence of missed opportunities for immunisation was 4.6%; 81.3% of caregivers brought Road-To-Health- Booklets (RTHB's) to consultations. Overall, 56.0% of health workers requested to see the RTHB's during consultations. Children attending primary level facilities were significantly more likely to have their RTHB's requested than children attending a tertiary level facility. Lack of training, resources and heavy workloads were the main challenges reported at secondary/tertiary level facilities.

<p><em>Syfte</em></p><p>Huvudsyftet med denna studie var att undersöka om det finns ett samband mellan graden av fysisk aktivitet och nedstämdhet/depression bland elever i årskurs 3 på gymnasiet. Vidare syften var att undersöka om nedstämda/deprimerade elever upplever känsla av meningsfullhet, glädje och lycka, lugn och harmoni samt kontroll över sin vardag i samma utsträckning som icke nedstämda eller deprimerade elever. Dessutom är ambitionen att undersöka om den upplevda stressnivån samvarierar med graden av fysisk aktivitet. Slutligen skulle alla dessa aspekter undersökas ur ett genusperspektiv.</p><p><em>Metod</em></p><p>Till denna studie har en kvantitativ enkätmetod använts. Deltagarna i undersökningen bestod av 252 gymnasieelever i årskurs tre från olika gymnasieprogram på två gymnasieskolor. Enkätsvaren behandlades statistiskt med hjälp av SPSS där signifikansnivån var satt till (p<0,05)</p><p><em>Resultat</em></p><p>Resultaten visar att mer än var tredje elev på de aktuella skolorna var nedstämda eller deprimerade, flickorna i högre grad än pojkarna. Den fysiska aktivitetsnivån var låg, 37 % av flickorna och 28 % av pojkarna var fysisk inaktiva. De fysiskt aktiva eleverna hade signifikant lägre CES-D värde dvs. var i betydande lägre grad nedstämda och deprimerade. Resultaten visade att elever med hög fysisk aktivitetsgrad upplever sig ha en betydligt lägre stressnivå än eleverna med lägre eller obefintlig fysisk aktivitetsgrad. De nedstämda och deprimerade eleverna visade i denna studie med god signifikans att såväl flickor som pojkar till mellan 70 % och 90 % sällan eller aldrig upplever följande känslor: Lugn och harmoni, Glädje och/eller lycka, Kontroll över sin vardag samt Meningsfullhet </p><p><em>Slutsats</em></p><p>Resultaten i denna studie tyder på att den fysiska aktiviteten samvarierar med nedstämdhet och depression, men för att undersöka vad som är orsak och verkan måste interventionsstudier och vidare longitudinella studier i frågan utföras. Den fysiska aktiviteten verkar således samvariera med graden av nedstämdhet och depression.</p> / <p><em>The aim</em></p><p>The main aim of this study was to investigate if there is a correlation between the extent of physical activity and low-spiritedness/depression among students in the third year of upper secondary school. Further aims were to investigate if low-spirited or depressed students experienced the feelings of sense of meaning, joy and happiness, calm and harmony, and control of the weekday to the same extent as non low-spirited/depressed students. Moreover to investigate if the experienced level of stress relates to the amount of physical activity. Finally all these aspects where investigated with a gender perspective.</p><p><em>Method</em></p><p>In this study a quantitative questionnaire method was used. The participants were 252 students in the third year of upper secondary school from different study programmes. The questionnaire answers were statistically analyzed with SPSS, and the level of significance was set at p<0, 05.</p><p><em>Results</em></p><p>The results showed that more than a third of the students at the current schools where low-spirited or depressed, the girls to a higher degree than boys. The extent of physical activity was low, 37 % of the girls and 28 % of the boys where physically inactive.  The students who were very physically active had lower CES-D value i.e. they where less low-spirited and depressed. The results also showed that the students who had a higher extent of physical activity experienced a lower level of stress then students with lower extent or non physical activity. Seventy to ninety percent of those in this study who were low-spirited or depressed exhibited, girls as well as boys, that they seldom or never experienced the following feelings: sense of meaning, joy and happiness, calm and harmony, and control of the weekday.</p><p><em>Conclusion</em></p><p>The results from this study indicate that the extent of physical activity has a covariance with low-spiritedness and depression. To investigate what the cause and effect is intervention studies and longitudinal studies of this effect must be done. However, it appears that physical activity covariates with the extent of low spiritedness and depression.</p>

The overall aim of this thesis was to explore the impact of workplace social relations on the implementation of return-to-work interventions. The thesis consists of four separate papers with specific aims. In Paper I, the overall purpose of the study was to analyse how a multi-stakeholder return-to-work programme was implemented and experienced from the perspective of the stakeholders involved, i.e. supervisors, occupational health consultants and a project coordinator. The objective was to identify and analyse how these stakeholders perceived that the programme had been implemented in relation to its intentions. In Paper II, the objective was to explore how workplace actors experience social relations, and how organisational dynamics in workplace-based return-to-work start before and extend beyond the initial return of the sick-listed worker to the workplace. In Paper III, the objective was to explore the meaning of early contact in return-to-work, and how social relational actions and conditions can facilitate or impede early contact among workplace actors. In Paper IV, the objective was to explore the role of co-workers in the return-to-work process, and their contribution to the process, starting from when a colleague falls ill, continuing when he/she subsequently becomes sick-listed and finally when he/she re-enters the workgroup. The general methodological approach to the papers in this thesis has been explorative and interpretive; qualitative methods have been used, involving interviews, group interviews and collection of employer policies on return-to-work. The data material has been analysed through back-and-forth abductive (Paper I), and inductive (Papers II-IV) content analysis. The main findings from Paper I show that discrepancies in the interpretations of policy intentions between key stakeholders (project coordinator, occupational health consultants and supervisors) created barriers for implementing the employer-based return-to-work programme, due to lack of communication, support, coaching and training activities of key stakeholders dedicated to the biopsychosocial intentions of the programme. In Papers II-IV, the workplace actors (re-entering workers, co-workers, supervisors and/or human resources manager) experienced the return-to-work process as phases (time before the sick leave, when on sick leave, when re-entering the workplace, and future sustainability). The findings highlight the importance and relevance of the varied roles of the different workplace actors during the identified phases of the return-to-work process. In particular, the positive contribution of co-workers, and their experience of shifting demands and expectations during each phase, is acknowledged. During the period of time before sick leave the main findings show how workplace actors experience the meaning of early contact within a social relational context, and how early contact is more than an activity that is merely carried out (or not carried out). The findings show how workplace actors experience uncertainties about how and when contact should take place, and the need to balance possible infringement that early contact might cause for the re-entering worker between pressure to return to work and their private health management. The findings in this thesis show how the workplace is a socially complex dynamic setting, which challenges some static models of return-to-work. The biopsychosocial and ecological/case management models and policies for return-to-work have been criticised for neglecting social relations in a return-to-work process at the workplace. This thesis provides increased knowledge and explanations regarding important factors in workplace social relations that facilitate an understanding of what might “make or break” the return-to-work process.

No description available.

Syfte Huvudsyftet med denna studie var att undersöka om det finns ett samband mellan graden av fysisk aktivitet och nedstämdhet/depression bland elever i årskurs 3 på gymnasiet. Vidare syften var att undersöka om nedstämda/deprimerade elever upplever känsla av meningsfullhet, glädje och lycka, lugn och harmoni samt kontroll över sin vardag i samma utsträckning som icke nedstämda eller deprimerade elever. Dessutom är ambitionen att undersöka om den upplevda stressnivån samvarierar med graden av fysisk aktivitet. Slutligen skulle alla dessa aspekter undersökas ur ett genusperspektiv. Metod Till denna studie har en kvantitativ enkätmetod använts. Deltagarna i undersökningen bestod av 252 gymnasieelever i årskurs tre från olika gymnasieprogram på två gymnasieskolor. Enkätsvaren behandlades statistiskt med hjälp av SPSS där signifikansnivån var satt till (p&lt;0,05) Resultat Resultaten visar att mer än var tredje elev på de aktuella skolorna var nedstämda eller deprimerade, flickorna i högre grad än pojkarna. Den fysiska aktivitetsnivån var låg, 37 % av flickorna och 28 % av pojkarna var fysisk inaktiva. De fysiskt aktiva eleverna hade signifikant lägre CES-D värde dvs. var i betydande lägre grad nedstämda och deprimerade. Resultaten visade att elever med hög fysisk aktivitetsgrad upplever sig ha en betydligt lägre stressnivå än eleverna med lägre eller obefintlig fysisk aktivitetsgrad. De nedstämda och deprimerade eleverna visade i denna studie med god signifikans att såväl flickor som pojkar till mellan 70 % och 90 % sällan eller aldrig upplever följande känslor: Lugn och harmoni, Glädje och/eller lycka, Kontroll över sin vardag samt Meningsfullhet  Slutsats Resultaten i denna studie tyder på att den fysiska aktiviteten samvarierar med nedstämdhet och depression, men för att undersöka vad som är orsak och verkan måste interventionsstudier och vidare longitudinella studier i frågan utföras. Den fysiska aktiviteten verkar således samvariera med graden av nedstämdhet och depression. / The aim The main aim of this study was to investigate if there is a correlation between the extent of physical activity and low-spiritedness/depression among students in the third year of upper secondary school. Further aims were to investigate if low-spirited or depressed students experienced the feelings of sense of meaning, joy and happiness, calm and harmony, and control of the weekday to the same extent as non low-spirited/depressed students. Moreover to investigate if the experienced level of stress relates to the amount of physical activity. Finally all these aspects where investigated with a gender perspective. Method In this study a quantitative questionnaire method was used. The participants were 252 students in the third year of upper secondary school from different study programmes. The questionnaire answers were statistically analyzed with SPSS, and the level of significance was set at p&lt;0, 05. Results The results showed that more than a third of the students at the current schools where low-spirited or depressed, the girls to a higher degree than boys. The extent of physical activity was low, 37 % of the girls and 28 % of the boys where physically inactive.  The students who were very physically active had lower CES-D value i.e. they where less low-spirited and depressed. The results also showed that the students who had a higher extent of physical activity experienced a lower level of stress then students with lower extent or non physical activity. Seventy to ninety percent of those in this study who were low-spirited or depressed exhibited, girls as well as boys, that they seldom or never experienced the following feelings: sense of meaning, joy and happiness, calm and harmony, and control of the weekday. Conclusion The results from this study indicate that the extent of physical activity has a covariance with low-spiritedness and depression. To investigate what the cause and effect is intervention studies and longitudinal studies of this effect must be done. However, it appears that physical activity covariates with the extent of low spiritedness and depression.

Nutrition education is recognised as being of value in the prevention of malnutrition. However, in order for it to be effective, an in-depth study of the community prior to the implementation of any nutrition education programme is essential. A study of the nutritional status of pre-school children in Malukazi (an informal, unplanned Black township in the greater Durban area) together with background information on the household and the childminder was therefore undertaken, so that recommendations for a nutrition education programme in the area could be made. The relationship between nutritional status and certain ecological variables was also studied in order to determine which of these, if any, was a significant factor in the development of malnutrition. Nutritional status was assessed by using anthropometric measures (height and weight) and dietary intake (24-hour recall and food frequency). Background information obtained included socio-economic status; food purchasing, preparation and storage patterns; intrafamilial pattern of eating; food taboos; clinic attendance; and the childminder's sage, educational level, body size, nutritional knowledge and attitude towards nutrition education. Information was obtained by means of face-to-face interviews using a single, trained interviewer. The incidence of low weight-for-age was relatively low and that of low height-for-age ("stunting") considerably higher (14,2% and 47,3% below the 3rd percentile respectively), indicating that chronic malnutrition is a serious problem in this community. Information on dietary intake showed that intakes of several nutrients notably energy, calcium, vitamin A, ascorbic acid and vitamin D were low for the study population. The percentage of total energy provided by the various macronutrients was however in line with recommendations, which tends to indicate that the greatest need is for an overall increase in food intake. Of the ecological variables studied, only two were found to be significantly associated with the incidence of malnutrition. These were the number of children cared for by the childminder (p=0,04) and whether or not the household grew their own vegetables (p=0,02). The degree of malnutrition found to exist in this community, together with the unsatisfactory level of nutritional knowledge of the childminders and their apparent willingness to learn more, revealed the desirability for further nutrition education in this area. Recommendations regarding future nutrition education programmes for this community based on the findings of the study are submitted. / Thesis (M.Med.)-University of Natal, Durban, 1991.

Introduction Tuberculosis (TB) causes approximately 2 million deaths every year. The problem is escalating explosively in sub-Saharan Africa and is directly related to the increase in the prevalence ofHuman Immunodeficiency Virus infection. South Africa was ranked as having the fourth highest global incidence of TB in 2006. In 1993, the World Health Organization introduced the Directly Observed Treatment Short-Course strategy to increase efficiency of national TB programmes. The Direct Observation of TB therapy element of the strategy has been contentious. An ideal method of direct observation remains elusive and its role in improving adherence is questionable. Aim The purpose ofthis research is to detennine the most effective directly observed method for pulmonary TB offered in an urban area of South Africa. Methods A retrospective cohort analysis was conducted at the Prince Cyril Zulu Communicable Diseases Centre in Durban, KwaZulu-Natal. The study population consisted of adult patients who commenced a course of TB therapy between July 2005 and June 2006. The effect of clinic based, family member, community health worker, lay community health volunteer and workplace based direct observation on TB treatment outcomes, and frequency of recurrence was detennined. A sub analysis was perfonned of the effect of the different methods ofdirect observation in employed patients. Results Workplace based direct observation resulted in a higher frequency of successful treatment outcomes than the other methods of Direct Observation. Being a re treatment patient was the only significant factor associated with recurrence, both for the entire study population and for those who were employed. Discussion The findings of this study are generalizable to other developing countries where challenges in implementation ofan effective TB programme such as poverty, high burden of HIV infection, a migrant population with strong rural ties and reliance on traditional practices to cure illness play a major role. Recommendations There is often no best treatment observer. Every case has to be individually evaluated and the most acceptable and accessible treatment observer chosen. The findings ofthis study strongly suggest that workplace Direct Obse ation can have a significant impact in improving TB treatment outcomes. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2008.