Magister Public Health - MPH / BACKGROUND: Namibia has generalised Human Immunodeficiency Virus (HIV) and tuberculosis (TB) epidemics. In response to the TB/HIV co-epidemics in Namibia, the Ministry of Health and Social Services approved a policy of TB/HIV collaborative activities at national level and the integration of TB/HIV services at the point of service delivery. The present study explored barriers and facilitators of integration of TB and HIV service delivery in Tsandi District Hospital, which lies in rural northern Namibia. It focused on understanding the perspectives of healthcare workers and service users on integration of TB and HIV services at the health facility. AIMS & OBJECTIVES: The study aimed to describe the barriers, facilitators, and opportunities of integrated TB/HIV service delivery in Tsandi District Hospital. The specific objectives were: to describe the staffing and support systems in place for the integration of TB/HIV care; to describe the perceptions and experiences of integrated TB/HIV care by the health care workers, management and co-infected clients; and to describe the factors that facilitate or hinder the integration of TB/HIV services in the district from the point of view of district hospital managers, health care workers and co-infected clients. METHODS: The study used a descriptive qualitative study design with semistructured key-informant interviews conducted with five healthcare managers and senior clinicians and focus group discussions with 14 healthcare workers and five TB/HIV co-infected patients, supplemented by non-participant observation in Tsandi district hospital over two weeks between May – June 2011. Sessions were audiorecorded, transcribed, and thematically analysed. RESULTS: Several factors influenced whether and to what degree Tsandi district hospital was able to achieve integration of TB and HIV services. These are: (1) model of care and nature of referral links; (2) the availability and use of human resources and workspace; (3) the system of rotating staff among departments in the hospital; (4) the supply and mode of providing medicines to patients; (5) information systems, recording and reporting arrangements; (6) and the amount of follow-up and supervision of the integrated services. The main suggested barrier factors are: (1) poor communication and weak referrals links between services; (2) inadequate infrastructure to encourage and deliver TB and HIV care; (3) staff shortages and high workload; (4) lack of training and skills among healthcare workers; (5) financial constraints and other socioeconomic challenges; and (6) fragmented recording and reporting systems with limited data use to improve service delivery. The four main facilitating factors are: (1) positive staff attitudes towards TB/HIV integration; (2) common pool of staff managing different programmes; (3) joint planning and review of TB and HIV activities at the ARV Committee; and (4) informal task sharing to alleviate healthcare worker shortages. CONCLUSIONS: This study recommends that the district build on the current facilitators of integration, while the inhibitors should be worked on in order to improve the delivery of TB/HIV services in the district. Simple and practical recommendations have been made to address the some of the barriers at district level. It is hoped that these will inform future planning and review of the current model of care by the District nagement Team.

Background: Risk factors for acquired multidrug resistant tuberculosis (MDR TB) are well described but risk factors of primary MDR TB is understudied. We aimed to 1) assess risk factors for primary MDR TB, including diabetes, and 2) determine if diabetes reduced the rate of sputum culture conversion in patients with primary MDR TB. Methods: From 2011-2014 we conducted a prospective cohort study at the National Center for TB and Lung Disease in Tbilisi, Georgia. Adult (≥35 years) patients with primary TB were eligible. MDR TB was defined as resistance to at least rifampicin and isoniazid. Patients with HbA1c ≥6.5% were defined to have diabetes. Polytomous regression was used to estimate the association of patient characteristics with drug resistance. Cox regression was used to compare the hazard rate of sputum culture conversion in patients with and without diabetes. Results: Among 318 patients, 268 had drug susceptibility test results. Among patients with DST results, 19.4% was primary MDR TB and 13.4% had diabetes. In adjusted analyses, diabetes (aOR 2.51 95%CI 1.00 – 6.31) and lower socioeconomic status (aOR 3.51 95%CI 1.56 – 8.20) were associated with primary MDR TB. Among patients with primary MDR TB, 44 (84.6%) converted sputum cultures to negative. The hazard rate of sputum culture conversion was lower among patients with diabetes (aHR 0.34 95%CI 0.13 – 0.87) and among smokers (aHR 0.16 95%CI 0.04 – 0.61). Conclusions: We found diabetes to be associated with an increased risk of primary MDR TB; both diabetes and smoking were associated with a decreased rate of sputum culture conversion.

Thesis (MCurr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Non-compliance with (tuberculosis) TB treatment is a problem at the Nyanga Clinic in the Western Cape Province. Non-compliance is defined as when a patient interrupted TB treatment for more than two months consecutively, at any time during the treatment period. The aim of the study was to explore the patient experiences and perceptions of non-compliance regarding their TB treatment. The following research question was posed by the researcher as a guide for this study: “What are the patient experiences and perceptions of non-compliance with TB treatment?” The objectives of this study were to determine the: - patients’ experiences and perceptions of non-compliance with TB treatment - non-compliant patients’ knowledge regarding TB - reasons why patients are not compliant with TB treatment. A qualitative, explorative, descriptive and contextual design was applied. The target population included the 354 non-compliant with TB treatment patients from March 2010 until May 2011. A purposive, non-random sampling technique was used to select participants for the study. Every tenth participant who, according to the TB register, was colour-coded as non-compliant with TB treatment, was selected for interviewing until data saturation should occurred. A sample of fourteen (14) participants was realised. A semi-structured interview schedule was developed based on the objectives of the study, which was validated by experts in nursing and approved by the Human Resources Ethics Committee of the Faculty of Health Sciences of the University of Stellenbosch. Data was collected personally by the researcher. Informed written consent was obtained from the participants. One patient who was not included in the main study was selected at random to pre-test the semi-structured interview. The pilot study revealed no pitfalls. Trustworthiness of the research was enhanced by adhering to the principles of credibility, confirmability, transferability and dependability. Credibility was ensured by member checking, data saturation, triangulation and involvement of an experienced research supervisor. Confirmability was enhanced through member checking and the leaving of an audit trail. Transferability through keeping an intensive description of all the processes and dependability by using an interview schedule and by submitting the transcribed tape-recorded data and field notes to the research supervisor for verification. The quantitative data was summarised in a table format to enhance clarity and facilitate a rapid overview of the results. The qualitative data was analysed manually with the findings coded and divided into subthemes and themes. Four themes emerged, namely: health system, client-related, social-economic and therapy factors. These themes identified the impeding factors regarding the non-compliance with TB treatment. The main conclusion is that there is a need to educate the community regarding the lengthy duration of the TB treatment, its side-effects, its curability and the spread of the infection as well as the consequences of inadequate treatment to empower the community at large about the disease. The National Department of Health framework of contributing to non-compliance with TB treatment was used as the conceptual framework for this study. The researcher applied the problem-solving approach of Faye Glen Abdellah’s theory. According to this theory it is anticipated that by solving the problems or needs of patients, through appropriate and organised health strategies the client will be moved towards ultimate health. / AFRIKAANSE OPSOMMING: Onderbreking van tuberkulose (TB) behandeling is ’n probleem by die Nyanga-kliniek in die Wes-Kaap Provinsie. Onderbreking kan gedefinieer word wanneer’n pasiënt vir twee of drie opeenvolgende maande TB behandeling onderbreek het (Jaggarajamma, Sudha, Chandrasekaran, Nirupa, Thomas, Santha, Muniyandi & Narayanan, 2007:131). Die doel van die studie is om die pasiënte se ervaringe en persepsies betreffende die onderbreking in TB behandeling te ondersoek. Die navorser het die volgende navorsingsvraag as riglyn vir hierdie studie gestel: “Wat is die pasiënte se ervaringe en persepsies wat TB-behandeling onderbreek het?” Die doelwitte van die studie was om te bepaal wat die: - pasiëntervaringe en persepsies is wat TB-behandeling onderbreek - kennis van pasiënte is wat TB-behandeling onderbreek - redes is waarom pasiënte TB-behandeling onderbreek. ’n Kwalitatiewe navorsingsontwerp met’n ondersoekende, beskrywende en kontekstuele benadering is aangewend. ’n Doelbewuste, lukrake steekproef is gebruik om deelnemers te selekteer. ‘n Steekproef van veertien (14) deelnemers uit ’n totale populasie van 354 hetrealiseer en sluit pasiënte in wat behandeling onderbreek het vanaf Maart 2010 tot en met Mei 2011. ’n Semi-gestruktureerde onderhoudsgids is ontwerp, gebaseer op die doelwitte van die studie en gevalideer deur kundiges in verpleegkunde en die Etiese Komitee van die Fakulteit van Gesondheidswetenskappe aan die Universiteit van Stellenbosch. Die data is persoonlik deur die navorser ingesamel. Ingeligte skriftelike toestemming is van die deelnemers verkry. Een deelnemer wat nie ingesluit is by die hoofstudie nie, is lukraak gekies om die semi-gestruktureerde onderhoud te toets. Die loodsondersoek het geen tekortkominge aangedui nie. Betroubaarheid van die studie is verseker deur die beginsels van objektiwiteit, bevestiging, veralgemening en neutraliteit te verseker. Getranskribeerde data is gekontroleer met die deelnemers, volledige beskrywings van alle prosesse is bygehou, ’n onderhoudsgids is gebruik om te verseker dat vir al die deelnemers dieselfde vrae gevra word, en ’n ervare navorsing toesighouers was deurgaans teenwoordig wat alle data gevalideer het. Kwantitatiewe data is in ’n tabel opgesom ten einde goeie oorsig te bied. Kwalitatiewe data-analise is met die hand gedoen. Die data wat uit die analise na vore gekom het, is geënkodeer en in subtemas en temasgekategoriseer. Die vier temas wat hieruit voortspruit, is faktore betreffende die gesondheidsorgsisteem, kliënte, sosio-ekonomiese en terapie-verwante faktore. Die navorser het n geskrewe verslag saamgestel betreffende die weergawe van die data-analise ten einde te verseker dat belangrike data nie verlore gaan. Die belangrikste bevindinge van die studie dui daarop dat die gemeenskap ’n behoefte aan opleiding het betreffende die onderbreking in TB behandeling, die langdurige tydperk van behandeling, newe-effekte van die medikasie, geneesbaarheid daarvan, hoe die siekte versprei en die gevolge betreffende onvoldoende medikasie ten einde die gemeenskap te bemagtig betreffende die siekte. Die raamwerk van die Nasionale Departement van Gesondheid (2009:45) betreffende die faktore wat bydra tot onderbreking in TB-behandeling is gebruik as konseptuele raamwerk vir die studie. Faye Abdellah se teorie (George, 2002:173-1830)verduidelik verpleging as ’n omvattende diens wat insluit: identifisering van die pasiënt se verplegingsprobleme, die besluit van ’n toepaslike plan van aksie, sowel as die voortgesette sorg betreffende die individu se totale behoeftes.

This thesis aimed to investigate, first, the potentially traumatic effects of AIDS-related bereavement on HIV/AIDS aid workers in South Africa; second, the resources that aid workers utilise in order to cope with their work; and third, differences in the experiences of local versus international aid workers. HIV/AIDS work is associated with various stresses and burnout is commonly observed among HIV/AIDS caregivers. Care of HIV/AIDS aid workers, however, has been largely overlooked; research has typically focused on the experiences of professional health workers, and often outside of an African setting. This present study, therefore, addressed these limitations with the use of participant observation ethnography and ethnographic interviewing. A period of one year was spent with an organisation in South Africa that provides care for vulnerable children in need and affected by HIV/AIDS. Openended semi-structured interviews were conducted with 63 male and female local and international staff and volunteers. The interviews were analysed using discourse analysis (DA), a methodology novel within HIV/AIDS and trauma research and particularly suitable for investigating language, social context and interaction, and identities, which are factors found to be important in HIV/AIDS work. Participants’ discourses were analysed to identify how they construct their identities, concepts such as HIV/AIDS and tuberculosis, events they experienced, and how they made sense of these phenomena. The main finding of this study was that contemporary HIV/AIDS aid work involves new challenges that have surpassed AIDS-related bereavement as the most prominent concern. The main challenges reported by participants involved the inability to control HIV/AIDS treatment and consequently inability to prevent, or control, AIDS-related death as a result of patient non-compliance. Participants further constructed HIV contraction as controllable and, therefore, avoidable, and used this micro discourse on control to counter HIV-related stigma, particularly stigma they experienced as HIV/AIDS aid workers. This rhetorical technique, however, rather maintains the macro discourse on HIV-related stigma by maintaining the blame component of the disease. Two identity constructions emerged in participants’ discourses. First, the characteristics inherent in the child identity suggested that loss is not merely a matter of death but also sadness for and on behalf of children for their various losses. Second, the caregiver identity prescribed how ‘proper’ and ‘genuine’ HIV/AIDS caregivers are expected to behave. The prescriptive nature of this identity can explain burnout among HIV/AIDS caregivers. The rewards of caregiving, however, can act as a buffer against difficult or traumatic experiences inherent in HIV/AIDS work. Managerial support and global belief systems that allow finding meaning were further identified as important coping resources for HIV/AIDS aid workers. Finally, differences between local and international participants, in terms of how they conceptualise phenomena and consequently have different needs, emphasise the role of culture in the experiences of HIV/AIDS aid workers. In the thesis I further discuss these findings in light of theories of social psychology, such as the Just World hypothesis, Cognitive Dissonance, and Identity Control Theory and Self-Categorization Theory. I conclude that although AIDS-related death no longer is a prominent issue, care of HIV/AIDS aid workers should not be overlooked. Contemporary HIV/AIDS work simply involves new challenges and traumas, and it is important that such work is continuously researched to identify evolving needs.

Magister Public Health - MPH / Introduction: Despite ongoing training provided to healthcare workers (HCWs) on tuberculosis infection prevention and control (TB IPC), at the health institution and implementation of TB IPC precautions, nosocomial TB infection within the hospital persist. The facility’s 2017 Occupational Infection & Needle Prick Report showed the proportions of new nosocomial TB infection cases among HCWs rose steadily from (5.6%) n=2 in 2013/14, (7.8%) n= 4 2015/16 and (9%) n=7, to (11%) n=11 cases in 2017/18. Study findings confirmed high new nosocomial TB infections among HCWs and a likelihood that these cases were usually under- reported meaning the problem of nosocomial TB infection among HCWs was actually bigger than understood at the hospital. In fact during the period of the mini-thesis study (July 2018) alone, three (3) cases of nosocomial TB infections were reported among HCWs (a porter and 2 nurses). Aim: The aim of this study was to explore the factors which are perceived to be contributing to nosocomial TB infection amongst doctors and nurses in a Level 2 referral hospital in the Free State Province of South Africa.

Magister Public Health - MPH / Background: TB is one of the most common opportunistic infections in the HIV infected population. In 2014, of the 9.6 million people estimated to have TB globally, 1.2 million were also infected with HIV. In the same year WHO reported 400 000 TB deaths in HIV infected people worldwide. TB Prevention strategies include ensuring HIV infected people take ART, TB infection control, treatment of TB cases and pharmacological prevention of primary TB infection or progression of latent TB into active TB. Isoniazid preventive therapy for a minimum of six months has been recommended to reduce the risk of TB in people living with HIV. Aim: The study’s aim was to determine the programmatic outcomes of isoniazid preventive therapy (IPT) and factors associated with treatment completion among people living with HIV aged 15 years and above at the AIDS Healthcare Foundation LaMvelase clinic in Manzini Swaziland, who were enrolled for IPT during the period March to December 2014. Methodology: This was a quantitative retrospective analytical cohort study that reviewed 3642 patient care records. IBM SPSS 20 was used for descriptive and statistical analysis of the data. Descriptive statistics were calculated and reported as frequencies and percentages. Bivariate statistics were carried out to test independent associations between socio-demographic and clinical characteristics, and IPT completion. Further multiple logistic regression analysis was done to determine the nature of association between the dependent and independent variables which had p < 0.1.

Magister Public Health - MPH / Ototoxic induced hearing loss is a common adverse event related to aminoglycosides used in Multi Drug Resistant -Tuberculosis treatment. Exposure to ototoxic drugs damages the structures of the inner ear. Symptomatic hearing loss presents as tinnitus, decreased hearing, a blocked sensation, difficulty understanding speech, and perception of fluctuating hearing, dizziness and hyperacusis/recruitment. The World Health Organization (1995) indicated that most cases of ototoxic hearing loss globally could be attributed to treatment with aminoglycosides. The aim of the study was to determine the proportion of DR-TB patients initiated on treatment at three decentralized sites during a defined period (1st October to 31st December 2015) who developed ototoxic induced hearing loss and the corresponding risk factors, whilst receiving audiological monitoring with an extended high frequency audiometer (KUDUwave). A retrospective cross-sectional study was conducted. Cumulatively across the three decentralized sites, 69 patient records were reviewed that met the inclusion criteria of the study. The mean age of the patients was 36.1, with a standard deviation (SD) of 10.7 years; more than half (37) were female. Ototoxicity , a threshold shift, placing patients at risk of developing a hearing loss was detected in 56.5% (n=39)of patients and not detected in 30.4%(n=21).The remaining 13,1% (n=9)is missing data. As a result, the regimen was adjusted in 36.2% of patients. . From the 53 patients who were tested for hearing loss post completion of the injectable phase of treatment, 22.6% (n=12) had normal hearing, 17.0 % (n=9) had unilateral hearing loss, and 60.4% (n=32) had bilateral hearing loss. Therefore, a total of 41 patients had a degree of hearing loss: over 30% (n=22)had mild to moderate hearing loss, and only about 15% (n=11)had severe to profound hearing loss. Analysis of risk factors showed that having ototoxicity detected and not adjusting regimen significantly increases the risk of patients developing a hearing loss. The key findings of the study have shown that a significant proportion of DR-TB patients receiving an aminoglycoside based regimen are at risk of developing ototoxic induced hearing loss, despite receiving audiological monitoring with an extended high frequency audiometer that allows for early detection of ototoxicity (threshold shift).

Multidrug-resistant Mycobacterium tuberculosis (MDR-TB) is a leading cause of morbidity and mortality in the Philippines. The purpose of this study was to gain knowledge about the relationship between potential risk factors and MDR-TB. Risk factors (the independent variables) for MDR-TB (the dependent variable) include previous TB treatment, infection with HIV, exposure to patients with drug-susceptible TB/MDR-TB, delays in diagnosis and treatment, employment status, smoking, imprisonment, alcohol abuse, and poor compliance with TB treatment regimens. The study was based on the epidemiological approach to causal inference work. A case-control study design was used wherein a quantitative method was applied in data analysis to assess the strength of the pre-identified possible risk factor(s) association to MDR-TB infection. Data were collected using survey questionnaires that were administered to patients (N = 172) from health centers in Leyte, San Mateo Rizal, and San Lazaro. Hypotheses were tested using chi-square analysis, Fisher's exact test, and an odd ratio. Drug-susceptible TB respondents who smoked on a daily basis were three times more likely (95% CI 1.021-13.341, OR 3.69) to develop an MDR-TB infection than were other respondents. Respondents who did not comply with the anti-TB treatment regimen were nine times more likely (95% CI 2.104-43.059, OR 9.519) to develop an MDR-TB infection than other respondents. Health care providers may be able to use study findings to develop programs to help drug-susceptible TB patients stop smoking and better comply with treatment regimens designed to prevent MDR-TB infection, resulting, potentially, in improved public health outcomes for patients.

Drawing from medical anthropology's approach to global health, this dissertation examines well-being among HIV- and TB-infected labor migrants in South Africa. Based on forty-four months of fieldwork from 2005 to 2013, it narrates households' struggles to make ends meet materially and morally in a context of unemployment, scarcity, and epidemic. / Anthropology

Background: Globally tuberculosis (TB) is one of the leading causes of mortality. There is scientific evidence of sociodemographic, behavioral and health risk factors associated with TB infection and TB disease. In the United States (US), there is a low endemicity of TB and a goal of TB elimination. Objective: The primary objective of the study was to examine the correlation of TB risk factors at the state level in the US to obtain insights specific to the state of TB in the US. The risk factors examined were diabetes rates, smoking rates, alcohol abuse rates, AIDS rates, foreign-born vs. US-born, poverty as expressed by GINI and per capita income and race/ethnicity. Methods: Secondary data from the Centers for Disease Control and Prevention (CDC) and US Census Bureau on line databases were used. Simple linear regression, bivariate correlation and multiple linear regression were carried out. Results: Significant correlations were found at the state level between TB disease rates and being non-Hispanic White (r=-0.856, p<0.001), foreign-born (r=0.649, p<0.001), GINI (r=0.588, p<0.001) and AIDS diagnosis rates (r=0.579, p<0.001). No significant associations were found between TB disease rates and diabetes rates, smoking rates and alcohol abuse rates. Conclusion: The focus of the fight against TB in the US should be on minority communities, those populated by the foreign-born and those with high rates of AIDS particularly where a large degree of income inequality is present.