Includes abstract. / Includes bibliographical references. / Few epidemiological studies have investigated the effect of pesticides on growth of boys and results are conflicting. Pesticide environmental exposure indices have not previously been developed. To investigate the effect of pesticide exposure using environmental exposure indices on pubertal growth of boys...

Includes bibliographical references. / There is growing concern that health care provided in the private sector is not always of high technical quality. Given the need to work with the private sector to increase access to services, various strategies have been proposed that governments can employ to engage the private sector in service provision. These include regulation, contracting, financing and social marketing, training, and coordination. These interventions are generally applied in combination to reach two important goals: (1) improving the quality of care delivered by existing service pro- viders; and (2) expanding the coverage of private sector services and rationalising this coverage with that of public sector provi- ders. However, there is a paucity of systematic reviews on the effects of these interventions on the quality and accessibility of private for-profit health care in low and middle-income countries.

Background: The literature suggests that although the idea of using evidence to inform policy making has come into favour, actualising this idea in practice is complex. Within the framework of these debates this dissertation focuses on the uptake of findings from research into policy making for the use of magnesium sulphate in the treatment of eclampsia and pre-eclampsia within South Africa. Despite the publication over the past decade of evidence suggesting the effectiveness of magnesium sulphate as a treatment for eclampsia and pre-eclampsia, eclampsia remains a leading cause of maternal death in South Africa and in many other low and middle-income countries. This dissertation forms part of a larger study investigating the uptake of research into policy making in South Africa, Mozambique and Zimbabwe. Aim: To describe and analyse the actual and perceived utilisation of research information in policy making and guideline development for the use of magnesium sulphate in the treatment of eclampsia and pre-eclampsia. Methods: This qualitative study triangulated three techniques in order to understand research utilisation in contemporary policy making. The techniques employed were: policy document review, a historical overview and individual qualitative interviews with 15 key informants. Data generated through these methods are reflected upon in relation to each other and within the context of relevant scientific and intellectual debates. Findings: This study shows a positive example of research utilisation in policy making and guideline development. In the late 1990's in South Africa, prompted by factors such as the recent political change, policies and management guidelines were being developed for maternal health. Simultaneously evidence from randomized controlled trials and systematic reviews showed the effectiveness of magnesium sulphate for the treatment of eclampsia and pre-eclampsia. Policies developed during this period make explicit reference to the use of the most recent published evidence. The uptake of this evidence into national policy development is likely explained by the complex interaction of a range of factors: the existence of a previously established evidence-based culture among obstetricians; the movement of "networked" individuals immersed in that culture into key positions in the new government; the involvement of researchers in policy development; and the willingness of individuals and groups to lobby and advocate both for the development of policy and for the use of evidence in that policy. Discussion and Conclusions: The findings highlight the role played by researchers in developing evidence based policies and guidelines. It also points to the complexity of the relationship between knowledge production and the utilisation of research in policy. It suggests that while researchers may not be in control of factors such as political change, they are presented with windows of opportunity that may allow them to affect policy change. Their capacity to affect such change can be enhanced through collective action when researchers are organised through academic networks.

Rationale – There is limited evidence about the effect of climate on blood pressure management of people living with and cared for hypertension in Sub-Sahara Africa. We investigate the relationship between outdoor temperature and blood pressure in a primary care setting with limited control of indoor climate in Cape Town, South Africa. Method – The study uses blood pressure data from 2494 participants screened and enrolled for entry in the SMS-text Adherence (StAR) trial study. Participants’ data were matched with outdoor temperature and air quality data using the nearest hour of enrolment. Individuals were included in this study if they were recruited during the study’s screening period (June 2012 to November 2014) and the clinic’s operating hours (7h00 and 17h00). Result - 72% of participants enrolled for the trial were female and had a BMI of 31 kg/m2 . There was an inter-subject variation of blood pressure between participants enrolled in winter and spring. Those enrolled in winter (June – July) and in the morning (07h00-10h00) when temperatures were generally low, had a higher mean blood pressure compared to those enrolled during spring (September - November) and in the afternoons (≥13h00). Mean outdoor temperature during the trial period was 16.7°C (min: 3.7°C –max: 30.7°C) with lowest temperatures recorded in June. Both outdoor temperature and blood pressure were found to be associated with nitrogen dioxide (NO2) and sulphur dioxide and (SO2) and therefore may be confounded by them. In a multivariate analysis controlling for air pollution, humidity and several leading cardiovascular risk factors, it was observed that a 10°C increase in outdoor temperature was associated with 7.5mmHg (95% CI: 3, 82 - 11, 18) change in systolic blood pressure. This association is modified by age, BMI and the time of the day. Those 65 years and older, with a low BMI and those enrolled in the morning (7h00 – 10h00) had the greatest change in blood pressure due to outdoor temperature Conclusion –The study shows an inverse association between outdoor temperature and clinic-based blood pressure in a primary care setting in South Africa. Given the fact that clinic-based blood pressure measures are used to direct the management of hypertension, greater attention needs to be given to environmental factors which may affect it. This may become of greater clinical relevance with changes in the climate and extreme weather patterns, including extensive smog

Includes bibliographical references (leaves 97-106). / [Background]The IUD is a highly effective, reliable, and safe contraceptive method that is under-utilised in many countries due to persistent fears that it causes pelvic infection. Reliable evidence of the safety of this contraceptive method has not been enough to effect a change in use. The aim of this study was to assess the knowledge and acceptability of the IUD among clients and providers in the Family Planning services in Cape Town and to attempt to identity obstacles to use. [Methods] A descriptive cross-sectional survey was conducted at eight Family Planning clinics in Cape Town. Two hundred and sixteen clients aged between 18 and 50 years, and 30 providers from the same clinics, were interviewed using structured questionnaires. [Results] Awareness of the IUD among clients was low - 81 women (41%) had heard of this contraceptive method. Ever and current use were very low. Only 9 women (4%) had ever used an IUD and 3 women were still using this method. Both the women who were interested in using this method in the future (n=77; 36%) and the women who were ambivalent or not interested in future use (n=139; 64%) cited a lack of knowledge as an obstacle to use. Although most providers were aware of the availability of the IUD (n=26; 87%). their factual knowledge was limited. Infection (n=14; 47%) and increased menstrual bleeding (n=12; 40%) were frequently mentioned as disadvantages. Referrals for and insertions of the IUD were low, and this method was often not discussed with women considering tubal ligation. Providers identified lack of client knowledge, myths and rumours among clients, lack of skilled providers to insert the device, and lack of promotion of the IUD, as significant obstacles to greater use of this method. [Conclusion] Although the IUD is available in the public sector services, it is not being utilized. Better education of both clients and providers is essential in order to improve accessibility and acceptability of this highly effective and cost effective contraceptive method.

Bibliography: leaves 54-55. / Hospice-in-the-West is situated in Krugersdorp on the West Rand. There is no hospice dispensary and the patients must, of necessity, obtain their terminal care medications from the Yusuf Daddoo Provincial Hospital. The hospital has a policy protocol in place that must be followed by all patients attending the hospital in order for them to obtain their monthly supply of medications. This policy has been in place for the past eight years. An evaluation of the provincial hospital's policy protocol was undertaken in an attempt to identify areas for possible improvement.

Includes bibliographical references. / Contemporary agricultural pesticides have been shown to possess hormonally-active properties, and have been associated with declining male reproductive health. These chemicals act by disrupting the normal functioning of the male endocrine system, through their actions on the hypothalamic-pituitary-gonadal axis. Reported male reproductive abnormalities are reproductive organ defects, cancers and declining fertility. Cryptorchidism, hypospadias, testicular cancer and poor sperm quality (testicular dysgenesis syndrome) have also been reported to be associated with these endocrine-disrupting chemicals. This study therefore aims to investigate the adverse reproductive health effects of environmental pesticide exposure in male children and adolescents, based on their lifetime residential history (namely, having lived on a farm or not).

Epilepsy, a chronic neurological disorder has an estimated prevalence of between 0.4% and 1.0% globally, and 1% in South Africa. Epilepsy has multiple underlying causes including head injuries, vascular insults, hippocampal sclerosis, cortical dysgenesis, drug or alcohol abuse and infectious diseases, such as neurocysticercosis and HIV/AIDS. Causes in South Africa are likely to be infectious due to the high HIV and tuberculosis prevalence. The condition has substantial individual and societal economic impacts, with economic costs ranging from the direct and indirect costs of treatment and loss of productivity due to illness. Primary treatment of epilepsy in the South African public sector is through pharmacotherapy, with monotherapy being preferred to polytherapy. No cost-effectiveness studies on the first-line treatment of epilepsy have been conducted in the South African context or in similar contexts using the combination of drugs in this analysis which are levetiracetam, lamotrigine, carbamazepine, phenytoin and valproate. The current first-line epilepsy treatment in South Africa is lamotrigine, phenytoin or carbamazepine. Levetiracetam is under consideration for use as a first-line treatment due to the reported minimal serious side effects, its ease of use, linear pharmacokinetics and reduced interaction with other drugs. The study was model-based and conducted from the providers’ perspective, specifically in the South African public health sector. It compared levetiracetam, lamotrigine, carbamazepine, phenytoin and valproate as first-line treatment in focal seizures (International Classification of Diseases (ICD)-10 code: G40.2) and generalized tonic-clonic seizures (ICD-10 code: G40.3). The population considered for the analysis was patients with newly diagnosed epilepsy expected to utilize services in the public health sector. The analysis consisted of a costeffectiveness analysis and a budget impact analysis. The budget impact analysis was conducted for the first year of treatment for each of the treatment strategies, while the cost-effectiveness analysis was conducted for a five-year period. Both a decision-tree representing the first six months of treatment and a Markov model representing the rest of the treatment period were used for the cost-effectiveness analysis. The methodology for the cost-effectiveness analysis was based on the International Decision Support Initiative (IDSI) reference case. Costs were expressed as South African Rands, 2018 value and effects were expressed as Quality Adjusted Life Years (QALYs). Results were expressed as Incremental Cost-Effectiveness Ratios (ICERs) and sensitivity analyses were performed to cater for uncertainty. The use of levetiracetam along with the use of phenytoin, valproate and carbamazepine in the treatment of newly diagnosed epilepsy was found to be dominated by treatment using lamotrigine. Treatment with lamotrigine over a five-year period was found to be the least costly option and had the highest number of QALYs gained. The estimated cost of treating one case of epilepsy was R1 252 higher using levetiracetam compared to using lamotrigine. Levetiracetam had 0,02 QALYs lower than those of lamotrigine. Phenytoin, carbamazepine and valproate were found to have the same effect size of 3,97 QALYs. Sensitivity analyses were conducted using some levetiracetam-related costs and quality of life values. Both the levetiracetam-related costs used in the sensitivity analyses showed that lower cost values were associated with less negative ICER values (i.e. levetiracetam became comparatively more cost-effective as the levetiracetam-related costs became lower). There were no trends observed regarding the impact of the quality of life measures and the probability of remaining controlled on levetiracetam on the ICER values obtained. The pharmaceutical costs of treating newly diagnosed epilepsy with levetiracetam were found to be higher in comparison to those of comparators. For a 100% treatment coverage, the cost of treatment with lamotrigine, the other second-generation AED under analysis was about R19 million cheaper compared to treatment with levetiracetam over a one-year period. Treatment with carbamazepine was found to be the cheapest option, costing about R20 million less than treatment with levetiracetam. On inclusion of other health systems costs associated with seizure and side-effect treatment levetiracetam was still found to be the costliest treatment option while lamotrigine became the least costly option. The effect sizes of all the treatments under analysis were similar, with a difference of 0,04 QALYs being observed between the most effective and the least effective treatment option. This led to costs being the main driver of the resulting ICER values. Approximately a 93% price reduction is required for levetiracetam to be more cost-effective than lamotrigine. The model results for the cost-effectiveness analysis agree with the findings from the study conducted to inform the National Institute for Health and Clinical Excellence (NICE) treatment guidelines in the United Kingdom, which found that levetiracetam was not cost-effective. Lamotrigine is recommended for the treatment of both partial and generalized tonic-clonic seizures by the Health Technology Assessment Agencies in the United Kingdom and Scotland. It is the only drug recommended for the treatment of both indications, with carbamazepine being recommended for the treatment of partial seizures and valproate for the treatment of generalized tonic-clonic seizures. Levetiracetam was found to not be a cost-effective treatment option for both generalized tonicclonic seizures and partial seizures in the South African public health sector context, even when accounting for the titration period and the drug prevalence of Steven Johnson Syndrome associated with some of the comparators. Lamotrigine is therefore recommended for use as the first-line treatment of epilepsy in the South African public health sector.

Includes bibliographical references. / [Objective] To determine the routine immunisation coverage rates in children aged 12-23 months in the Western Cape and factors affecting immunisation coverage. [Design] Cross-sectional Household Survey using an adaptation of the '30x7' cluster survey technique (multi-stage sampling). [Setting] Households across the Western Cape. [Subjects] 3705 caregivers of children aged 12-23 months who had been living in the Western Cape for at least 6 months. [Outcome Measures] Vaccination Status (1=fully vaccinated, 0=partially vaccinated) as recorded on a Road to Health card or given by history. Factors affecting caregivers' vaccination behaviour established from a questionnaire. [Results] The immunisation coverage was 76.8% for vaccines due by 9 months and 53.2% for vaccines due by 18 months. The reasons given for not being imunised were clinic-related factors (47%), lack of information (27%), lack of information (27%), caregiver being unable to attend the clinic (23%) and lack of motivation (14%). Of clinic factors cited, the two commonest factors were missed opportunities (34%) and being told by clinic staff to come back another time (20%). Factors enhancing coverage included possession of a Road-to-Health card, caregiver knowledge about vaccines and perceived attitude of clinic staff. Certain racial inequities in coverage were also apparent, particularly in the Boland-Overberg Region. [Conclusion] While the coverage indicated that a lot of good work has been done, the coverage was insufficient to prevent outbreaks of measles and other common childhood conditions including polio. The coverage was too low to consider not running periodic mass campaigns for measles and polio. The reasons given by caregivers for their children not being immunized and factors associated with increased coverage are valuable pointers as to where interventions should be focused.

Includes bibliographical references (leaves 17-20). / [Background] HIV-infected individuals may be at nutritional risk at any point in the course of their illness. Nutrition counselling has been found to be an important intervention for maintaining and improving nutritional status in HIV infection. The evidence for the magnitude of benefit has not previously been systematically reviewed. [Objectives] To assess the effectiveness of nutritional counselling in improving dietary intake and nutritional status in HIV-infected adults. [Methods] Eligible studies were identified from comprehensive searches of electronic databases and conference proceedings for all randomised controlled trials (RCTs) of nutrition counselling compared with either no nutrition counselling, oral supplements, or with nutrition counselling plus oral supplements. Two reviewers independently assessed the eligibility of the studies and their methodological quality, and extracted data on participants, interventions and outcomes. A meta-analysis of data on nutritional status and dietary intake was performed. Results Three studies with a total of 238 participants were included in the review. All three studies compared nutrition counselling with nutrition counselling plus oral supplements. Data were available from all three studies for changes from baseline in weight, lean body mass and body fat. ln one study the changes in both groups were significant, but the differences between groups did not reach statistical significance. Energy intake data were available from 2 studies, and both showed a significant increase from baseline in both groups.