This epidemiological study is a longitudinal descriptive review of the mortuary register at Benedictine Hospital, with an analysis of the trends which emerge. The descriptive component describes mortality at Benedictine Hospital during the years 1995- 2001. It describes both the actual numbers of deaths which occurred according to each sex and age group, and the causes of death as recorded in the mortuary register. The purpose of this study was twofold. First it was desired to raise AIDS awareness in the district by examining the effects of the AIDS epidemic on mortality. Second as the new district health system was being established, it was desired to develop a baseline of mortality information to be utilized for management in the Nongoma Local Municipality. In the trend analysis component of the study, first, it is assumed that most of the deaths occurred at Benedictine Hospital as it is the only health facility which handles severe illness in the Nongoma Local Municipality; therefore the number of deaths within the hospital and the population of Nongoma were used to calculate Age Specific (ASMRs) and Cause Specific Mortality Rates (CSMRs). Secondly an analysis of the age and sex distribution of deaths, ASMRs, the distribution of causes of death, and CSMRs was done. Two research questions were posed. The first research question was, has there been any change in the age distribution of death? It was demonstrated that while there was an 80% increase in the number of deaths, and although deaths increased in every age group except for the neonatal group, 80% of the increase was in the young adult ages particularly in the 20 through 39 years old age groups. By 2001 these groups were recording the largest number of deaths, 179 male deaths and 133 female deaths in the 30 through 39 years old group. Also the ASMRs of young adults had increased three to four times. The second research question was, has there been any change in the distribution of causes of death? It was demonstrated that the infectious diseases which caused the largest numbers of deaths, pulmonary tuberculosis caused 353 deaths, pneumonia 250, gastroenteritis acute and chronic 203, retro-viral disease 66, and meningitis 59, were six of the top seven causes of death in 2001. Chronic gastroenteritis, retro-viral disease, and meningitis had strengthened their position moving from the second ten into the top seven. Only trauma which was in the top five was not an infectious disease. Infectious diseases increased their share of the burden of disease from 36% in 1995 to 57% in 2001. While CSMRs for trauma and the type II non-communicable diseases were basically stable or falling, those of the infectious diseases increased three to four times. It is estimated that because the mortality pattern is similar to that of AIDS deaths in South Africa and Zimbabwe, that because it is young adult mortality that has increased and that it is infectious diseases which have increased that about 50% of mortality in Nongoma is due to AIDS. Recommendations are put forward as to how to disseminate this information and also how to institute a system to carry on monitoring mortality in Nongoma. / Thesis (M.Med.)-University of Natal, Durban, 2003.

Introduction Nearly half of all new HIV infections worldwide occur in young people aged 15-24 years. Risky sexual behaviours may lead to the development of lifelong negative habits like having multiple partners, thereby placing young people at risk of a broad range of health problems, including HIV/AIDS. Prevention is therefore critical and includes changing behaviours that are risky, such as the early age of sexual initiation, having many sexual partners and non-use of condoms. The study aimed to evaluate whether a theory based HIV/AIDS intervention, 'Be A Responsible Teenager' (B.A.R.T.), could produce behaviour change among high school learners in South Africa. Methods A pre-test /multiple post-test intervention study was undertaken. All Grade 10 learners (n = 805) from all three public high schools in Wentworth were included in the study. Eleven teachers were interviewed from these schools. Learners completed a questionnaire at baseline (Tl), immediately post intervention 1 (T2), post intervention 2 (T3) and after a period of seven months (T4). The B.A.R.T.intervention was implemented in the intervention schools while the control group did not receive any intervention. Qualitative data was analyzed according to themes, while quantitative data was analyzed cross sectionally and longitudinally. Results Teachers reported many obstacles in implementing the HIV/AIDS Life Skills' curriculum, including the poor quality of training and inadequate resources in schools. Further, learners practised high-risk sexual behaviours. Gender differences in sexual behaviour were reported with males predominately practising higher risk behaviours than females.The B.A.R.T. intervention did show changes in behaviour for alcohol use at last sex and for the determinants knowledge, attitudes, beliefs, self-efficacy and intentions to practise safer sex respectively, over time. However, the intervention didnot positively impact abstinence behaviours, condom use and the reduction in partners. Further, subjective norms did not change. Conclusion The major obstacles to AIDS prevention include the current practices of risky sexual behaviours including age mixing, early sexual initiation, multiple partners, forced sex and receiving money or gifts for sex among others. Social norms as potrayed by parents, peers and religious groups play a pivotal role in promoting protective sexual behaviours. The role of gender and the gaps in LHAP (Life Skills' HIV/AIDS programme) also require urgent attention. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2008.

Routinely collected data on vaccines supplied and administered, measles notifications and hospital admissions for measles were used to evaluate the 1990 measles immunisation campaign in Natal/KwaZulu. comparisons of the monthly averages during the 12 month period before the campaign, 4 months of the campaign and 12 months after the campaign indicated that the 1990 measles campaign in Natal/KwaZulu demonstrated that the campaign was limited, not by design, to blacks only. The campaign galvanised a high degree of participation from almost all health services in this region and resulted in a rapid and marked plunge in the incidence of measles as reflected by declines in both measles notifications and measles hospital admissions. There was no deleterious shortterm residual effect of the measles campaign on routine measles immunisation services. The spillover effects of the measles campaign on routine immunisation services against polio, tuberculosis and tetanus was generally beneficial. While the campaign was a success in generating involvement of health services in Natal/KwaZulu and reducing the burden of measles in this region, this disease has not been eliminated. Vigilance and continued routine vaccination efforts are required to prevent further epidemics of measles in Natal/KwaZulu. / Thesis (M.Med.)-University of Natal, 1990.

HIV/AIDS is a significant social problem impacting on families, communities, the public health sector and greater society. This qualitative study looked at the experiences of social support among volunteer caregivers of people living with AIDS and relationships of trust and solidarity between caregivers and members of the community. KwaZulu-Natal has the highest HIV infection rate in South Africa. This further compounds the burden of care and stigma surrounding caring for people living with HIV/AIDS .This study draws on aspects of social support theory, social capital framework and the theoretical resources of socio-ecological theory more broadly. Methodologically, in-depth interviews were conducted with 10 female volunteer caregivers with a minimum of three months care work experience and Ulin’s thematic analysis was utilized to highlight the salient themes around their experiences of social support. The findings of this study revealed that the burden of care, stigma experienced by the volunteer caregivers and the relationships between the volunteers and community members as well as social networks all played a significant role in the need for the provision of social support to the volunteers. Furthermore, the findings of the study highlighted the social consequences of care work and the need for support in this ambit. The study concluded that social support for the volunteers is severely lacking for the following reasons; there was a complete breakdown of social cohesion between the volunteers and their community; the relationships between the volunteer and surrounding social networks were under strain and as a result had a negative impact on the accessing of social support. Factors such as social trust, social bonding, social bridging and social linking were lacking between the volunteers and the community therefore accessing social support becomes problematic. Poverty is a factor that had a ripple effect on the volunteer and resulted in the urgent need for support in the form of tangible and emotional resources. Volunteerism is an undeniable necessity in the treatment or care of HIV/AIDS patients. The issues around social trust and social networks played a key role in the accessing of social support which ultimately impacted on the efficacy of care provided by the volunteer. The findings highlighted that there was a dire need to mobilize social capital within the KwaNgcolosi community in order to create relationships that would facilitate the social support needed by the volunteer. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2009.

Introduction: While the antiretroviral (ARV) coverage has been scaled- up in the last 3 years in South Africa, there is limited data on the operating costs and financial sustainabihty of an anti- retroviral programme. Study Aim: To conduct a cost analysis of the stepdown ARV programme at the Kwadukuza Municipality Clinic (KMC) in the Ilembe district from a healthcare providers' perspective for the period 1st April 2005 to 31st March2006. Study Objectives: To determine the total costs and cost per patient per visit for outpatients attending the ARV, Wellness and VCT clinics respectively at KMC. Study Methods: Study location: This study was conducted at the Kwadukuza Municipality Clinic located in the Ilembe district in Kwazulu- Natal, South Africa. Study population: The population that is included in this study for the purposes of costing comprised: all the patients who received ARVs for the period under study; all the patients who attended the Wellness and VCT clinics and all the staff attached to the ARV programme at the KMC clinic Study design: This is a retrospective and cross- sectional study with both a descriptive and analytical component. Results: Seventy- one percent of the patients on ARVs were female with 50% of the patients being between 31 and 40 years of age. The total operating costs of running the ARV programme was R2 439 940- 90. The total cost accrued to the ARV clinic was R 1 698 003- 60. The Wellness clinic had a total cost of R 460 279- 68 and the VCT clinic accounted for the least total operating cost of R 281 657-77. The cost per patient visit was R440- 13 for the ARV clinic; R133- 05 for the VCT clinic and an amount of R61- 71 for the Wellness clinic. Conclusion This study provides the basis for determining the three cardinal cost components of the ARV programme, namely human resources, the cost of ARVs and the costs of viral load testing for the purposes of future planning and sustainability. The cost- effectiveness of ARV drugs can be improved if the healthcare providers negotiate a lower price for these drugs. The high cost due to monitoring tests can be lowered by decreasing the frequency of these tests but this may allow ARV drug resistance to be undetected. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2008.

Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to a State-aided District Hospital in Durban, South Africa in 2007. Introduction: A proportion of the many patients who have advanced AIDS in South Africa present for the first time requiring admission to hospital, the number of which are limited by the availability of beds. Novel ways were developed to offer subacute inpatient care at Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate antiretroviral therapy (ART) (exposed) for patients with advanced disease before their discharge (ART group) . Different components of palliative care were offered for those who did not enter the inpatient ART programme or who were terminally ill (non-ART group) (non-exposed) . Aim: The aim of the study is to describe the clinical condition, inpatient case management and outcomes before discharge of people living with HIV admitted to Siyaphila in order to assist in developing appropriate protocols for inpatient care. Methods: This was an observational, analytic, cohort study using a convenience sample of all patients consecutively admitted to Siyaphila during nine months in 2006/2007. Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one stage of care to another and outcomes for the two groups before discharge were determined. Univariate and multivariate logistic regression analysis was performed on the ART group to identify risk factors for mortality before discharge. A comparison between the ART and non-ART group was also undertaken. Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251; 62%) was the most common opportunistic infection followed by cryptococcal meningitis (68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The median time from initial admission until discharge was 13 days in the non-ART group and 18 days in the ART group. The mortality before discharge among the non-ART group was 24% compared to 6% among the ART group. (p =0.001). The median number of days before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome was diagnosed in seven patients (4%) among the admissions but caused no deaths. In the multivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1 (95% Confidence Interval: 0.01 - 0.9). Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART uptake after discharge. The findings of this study should be adopted as the best clinical practice for PLHIV and AIDS admitted in the late stages of the disease. 0Nords 423) Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to a State-aided District Hospital in Durban, South Africa in 2007. Introduction: A proportion of the many patients who have advanced AIDS in South Africa present for the first time requiring admission to hospital, the number of which are limited by the availability of beds. Novel ways were developed to offer subacute inpatient care at Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate antiretroviral therapy (ART) (exposed) for patients with advanced disease before their discharge (ART group) . Different components of palliative care were offered for those who did not enter the inpatient ART programme or who were terminally ill (non-ART group) (non-exposed). Aim: The aim of the study is to describe the clinical condition, inpatient case management and outcomes before discharge of people living with HIV admitted to Siyaphila in order to assist in developing appropriate protocols for inpatient care. Methods: This was an observational, analytic, cohort study using a convenience sample of all patients consecutively admitted to Siyaphila during nine months in 2006/2007. Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one stage of care to another and outcomes for the two groups before discharge were determined. Univariate and mUltivariate logistic regression analysis was performed on the ART group to identify risk factors for mortality before discharge. A comparison between the ART and non-ART group was also undertaken. Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251; 62%) was the most common opportunistic infection followed by cryptococcal meningitis (68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The median time from initial admission until discharge was 13 days in the non-ART group and 18 days in the ART group. The mortality before discharge among the non-ART group was 24% compared to 6% among the ART group. (p =0.001). The median number of days before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome was diagnosed in seven patients (4%) among the admissions but caused no deaths. In the mUltivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1 (95% Confidence Interval: 0.01 - 0.9). Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART uptake after discharge. The findings of this study should be adopted as the best clinical practice for PLHIV and AIDS admitted in the late stages of the disease. (Words 423) / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

One hundred take-away food outlets within the Central Operational Entity of eThekwini Municipality were investigated in order to assess the microbiological quality and safety of perishable food sold as well as the level of hygiene conditions under which these food shops operate. This cross sectional observational and descriptive study was conducted between August and September 2005 with the overall aim to improve the delivery of safe food, promote good hygiene practices from take-away food outlets and target interventions that will assist improvements of service delivery in the food control section of eThekwini Municipality Health Department. Ready-to-eat foods which were collected included salads, beef, chicken and chips to determine actual microbiological quality of these products. Food temperatures were recorded at the time of sampling. Premises were inspected by the teamof trained Environmental Health Practitioners who used pre-structured checklist forms to determine the status food preparation areas and associated food handling practices. Standard methods were used to determine total bacteria count, coliform count, Escherichia coli, Staphylococcus aureus and Salmonella. The overall microbiological quality of the food served by the take-away food outlets were found within acceptable safety limits. Escherichia coli, Staphylococcus aureus and Salmonella were evaluated and no incidence of these organisms was detected in all the food products sampled. 76% of samples showed high total bacteria count and coliforms were detected in 50% of food products. The results of the study indicate that there are some handling practices in the preparation process of ready- to-eat food that require more attention. In particular, control in food handling needs to be observed by food handlers as a result of significant incident of a high total bacteria count. There was a lack of correlation between bacterial count and the observed cleanliness of preparation areas and food handling practices. It is recommended that eThekwiniMunicipality Health Department embarks on a health education campaign on food safety. Food handlers should receive training and education in two aspects of food safety; namely, principles of good hygiene practice and the application of the Hazard Analysis and CriticalControl Point concept to food preparation. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2009.

Introduction A well-functioning primary health care system depends on all three levels of healthcare, that is, the primary, secondary and tertiary levels of care. District hospitals have a major role to play in the development of a strong referral system. This study was undertaken to evaluate whether the primary health care clinics in Area 3 possess all the key essential components for a strong referral system. Area 3 comprises 3 districts in northern KwaZulu-Natal, i.e. the Umkhanyakude, Uthungulu and Zululand districts. Aim The aim of the study was to evaluate referral support systems between fixed clinics and district hospitals in the three districts of Area 3 in KwaZulu-Natal province. Methods A descriptive study was undertaken in 58 randomly selected clinics in Area 3. Data was collected between July and August 2007, on availability of: communication technology, transport for patients being referred to the district hospital, and guidelines. Referral letters were reviewed to determine if they contained adequate information. Professional nurses were interviewed to determine the training they had attended. Results A third (34%) of clinic nurses on duty had been trained in Primary Health Care; 57% of clinics had at least one professional nurse on duty with a PHC diploma. The proportion of nurses trained in short courses ranged between 4% and 47%. Fifty-six out of fifty-eight (97%) of clinics had telephones; 57% reported problems with telephones. Eighty-eight out of one hundred and seven (88%) of selected referral letters did not have adequate information. Only 32% of urgently referred patients were collected by an ambulance within 1 hour. All 58 clinics had the Essential Drug List (EDL) available; availability of the other guidelines ranged between 29% and 79%. Discussion The percentage of clinic nurses with a PHC diploma or trained on short courses indicates that most clinic nurses render health services without or with inadequate knowledge and skills. Poor quality of referral letters and inefficient transportation of referred patients, especially emergencies, confirm a weak referral support system. User perceptions of the referral system have not been explored. Recommendations Training and support of clinic nurses needs to be prioritised to improve patient assessment and management, as well as the quality of referral letters. District management should advocate for improvement of patient transportation. Future studies should explore the use of referral letters by and training of, clinic nurses; as well as determine user perceptions. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2010.

Introduction Lake Mzingazi is the only suitable source of domestic water supply for the Richards Bay community. Rapid industrialisation in the city of uMhlathuze, accompanied by an influx of people, has resulted in informal settlement occurring around the lake. The uncontrolled activities of this development threaten to pollute the water source. Previous studies in1979 conducted by Council of Scientific & Industrial Research indicated that Lake Mzingazi water was still within acceptable limits in terms of the Department of Water Affairs & Forestry guidelines. The lake water quality was that of a Class I water resource, which is excellent for domestic use. Pollution of the lake can result from diffuse sources of pollution due to settlement of communities around it. Water purification costs could escalate thus forcing an increase in water tariffs. If pollution resulted in the lake being unable to be utilized, the Richards Bay community will be seriously affected, as it would necessitate the importing of water from distant regions. Either way, the expense of acquiring water would increase. All living organisms rely on adequate water for their survival. Worse still are human beings for their water should not only be adequate but should be of good quality to prevent health risks and even death. It is in view of these possibilities that the study was undertaken. Aim The aim of the study is to assess the extent of physical, chemical and biological pollution in Lake Mzingazi due to non-point sources and to recommend necessary protection measures that need to be implemented to prevent any negative health impact on surrounding communities. At present there are no restrictions and no protection of the lake from pollution except that no recreation is allowed into the lake at present. Methods Several objectives were set in order to focus on specific issues. One of the objectives was to inform the communities around the lake about the study. Sampling of the lake water was conducted monthly from June to November 2006 (using a boat). Pictures of areas around the lake were also taken for further analysis. At each sampling run, 36 samples were taken and delivered to a laboratory accredited by the South African National Accreditation Standards for analyses. Six sampling runs were completed. Secondary data for the period of 1998 to 2005 were obtained from uMhlathuze Municipality in order to establish pollution trends and for comparison purposes with the Department of Water Affairs and Forestry guidelines. Results The findings of the study revealed that the quality of the lake water is still within acceptable limits when compared with the Department of Water Affairs & Forestry guidelines; however, informal settlement threatens the future of the lake by encroaching into the lake banks. Discussion There is definitely a risk of pollution to Lake Mzingazi as long as there are no pollution prevention plans in place. Recommendations All data should be stored in a centralized information system to avoid losing valuable information. The Water Services Authority must develop and maintain a water quality-monitoring programme that will capture all changes occurring in the lake. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2009.

Introduction A plethora of health indicators have been added into the District Health Information System (DHIS) since its adoption and implementation as the routine health information for South Africa in 1999. The growing demand for the production and dissemination of routine health information has not been equally matched by improvements in the quality of data. In the health sector the value of monitoring and evaluation is not simply the product of conducting monitoring and evaluation but, rather from discussing and using performance indicators to improve health service delivery. Aim The aim of this study was to classify health care indicators in the national health data sets used for planning, monitoring and evaluation and to review the data management practices of personnel at provincial and district level. Methods An observational, cross sectional study with a descriptive component was conducted, in 2009, using a finite sample population from district and provincial level across eight provinces. The study participants completed a self-administered questionnaire which was e-mailed to them. Results A total of 32 (52%) participants responded to the questionnaire and of this total 21 (65.5%) responses were from district level and 11 (34.4%) from provincial level. The National Indicator Data Set, the key source for primary health care and hospital data, was implemented in 1999 with approximately 60 indicators. In less than 10 years it has grown in size and presently contains 219 performance indicators that are used for monitoring and evaluating service delivery in the public health sector. Whilst both district and provincial level personnel have a high awareness (83%) of the DHIS data sets there is variability in the implementation of these data sets across provinces. The number of indicators collected in the DHIS data sets for management decisions are “enough”, however a need was expressed for the collection of community health services data and district level mortality data. Similarities were noted with other studies that were conducted nationally with respect to data sharing, utilisation and feedback practices. Data utilisation for decision making was perceived by district level personnel to be adequate, whereas provincial level personnel indicated there is inadequate use of data for decision making. Whilst 87.1% of personnel indicated that they produce data analysis reports, 71.9% indicated that they never get feedback on the reports submitted. The top 4 data management constraints include: lack of human resources, lack of trained and competent staff, lack of understanding of data and information collected and the lack of financial and material resources. There was agreement by district and provincial level personnel for the need for additional capacity for data collection at health facility level. Discussion The increasing need for accurate, reliable and relevant health information for planning, monitoring and evaluation has highlighted critical areas where systems need to be developed in order to meet the information and reporting requirements of stakeholders at all levels in the health system Recommendations An overarching national policy for routine health information systems management needs to be developed which considers the following: emerging national and international reporting requirements, human resources requirements for health information and integration of systems for data collection. In the short-term a review of the National Indicator Data Set needs to be conducted. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2010.