Thesis (D. Min.)--Logos Evangelical Seminary, 2004. / Vita. Includes bibliographical references (leaves 305-315).

Introduction: Diabetes in Africa has been described as a pandemic, with the prevalence in South Africa estimated at 4.5% of the population. Despite clear national guidelines from the Society of Endocrinology, Metabolism and Diabetes of South Africa, an unpublished quality improvement cycle in 2007 has shown poor patient knowledge with associated uncontrolled glycaemic and hypertensive control in diabetic patients in a district health system. The purpose of the study was to identify possible reasons for this and to find solutions for improving diabetic care within the Wesbank/ Ilingu Lethu suburb of Malmesbury, Western Cape. Methods: A cooperative inquiry group was established, consisting of primary health care providers at a district hospital and a primary health care clinic. The inquiry completed several cycles of action-reflection over a period of eight months, and included training in diabetic related topics and critical reflection techniques. At the end of the inquiry consensus was reached on key findings by group and learning within the group. Findings: Consensus was expressed in two key findings. The group identified and prioritized continuity of care and diabetic education key areas where diabetic care could be improved in the research population. The first was addressed by initiating diabetic registries, establishment of a regular diabetic clinic, implementation of a diabetic schedule within the medical records and the forming of a diabetic team that could support continuity of relationships, clinical management and organisation of care between both facilities. The diabetic team involved non-governmental organizations, private health providers and the community to increase awareness and develop capacity to improve diabetic care. The other finding confirmed diabetic education as a critical area in diabetic self management. The diabetic team initiated a diabetic community forum for educational and informative group activities. There was also continued professional development with education sessions within the cooperative inquiry group themselves. Conclusions: Improving diabetic care through continuity of care and education is well supported in known evidence based literature. The challenge is to translate/ transfer the available knowledge and render it operational and clinical in any health setting. The co-operative inquiry process was a valuable tool to identify, prioritized and addresses unique challenges for improving diabetic care in our specific context.

Thesis (M.S.)--Boston University

Rational planning for the delivery of health care services is the primary concern of this thesis. Various aspects of the demand for, and the supply and characteristics of these services are discussed, since an understanding of these topics is essential to rational planning. Chapter I examines the relative importance of the influences of health care services, socio-economic structures and life styles on individual and societal health status. Various criteria for the evaluation of health care services and for the allocation of societal resources between health care services and other social services influencing health and well-being are discussed. Chapter II deals with consumer behaviour and the demand for medical services. This discussion entails Individual perception of medical needs, factors influencing health knowledge, sources and effectiveness of health information dissemination, and various factors which inhibit utilization. Chapter III is concerned with the supply of health care services, their financing and interrelationships. In particular, the role, characteristics, and costs of physician and hospital services are examined. Chapter IV discusses the resolution of supply and demand with an emphasis on financial considerations and the organizational arrangements between the various components of supply. Chapter V reviews and discusses some of the major problems of various techniques which have been employed to forecast future health care service requirements. Various aspects of future modes of health care delivery are discussed. Chapter VI presents a simulation model which may be used as an aid in regional planning of health care services. Chapter VII illustrates several results for various simulated conditions and strategies. Chapter VIII suggests future improvements to the simulation model and describes several possible experiments which are being planned. / Business, Sauder School of / Graduate

This thesis is concerned with a cognitive-behavioural approach toward location theory. Specifically it deals with the 'site characteristics' of medical practice sites and their relationships to the 'Degree of Specialism' and 'Need Constructs' of the physicians operant from the sites. The 'Need Construct' of physicians is seen to vary between actors as a result of the different temporal and functional practice characteristics found within the Medical Community. The practice site location decisions of specialist physicians are seen to be dependent on the actor's 'internal needs' for complex functional linkages with other specialist physicians and with medical facilities such as hospitals and diagnostic radiology and laboratory sites. Primary care physicians in contrast are seen as making practice site location decisions in response to the 'external needs' of their patients and hence, adopt sites minimizing inconvenience to this group. Physicians are thus seen, through function and functioning as adopting sites possessing those characteristics that will satisfy their dominant set of needs. Hence, physicians with a high 'Degree of Specialism' adopt sites with a high degree of linkage with other physicians and ancilliary medical facilities, whereas physicians with a low 'Degree of Specialism' adopt sites to minimize inconvenience to their patients. In order to test the hypotheses derived from the above conceptual structure, an interview survey was conducted in Vancouver, British Columbia, Canada. Instruments were developed and pre-tested using standard psychometric techniques to measure the 'Degree of Specialism' and the 'Need Construct' of a physician actor. The 'site characteristics' of a medical practice site were measured on nine variables falling into two groups. Group one comprised those variables measuring the relative-locational aspects of a practice site to other physician practice sites, diagnostic facilities, hospitals, etc., whereas group two comprised variables measuring intrinsic qualities of the site such as the number of physicians practicing from the site. A random sample of twenty primary care physicians and twenty specialist physicians were interviewed to provide the data for the study. A hypothesis testing and correlation analysis was performed on the data to test the study hypotheses. These analyses confirmed that statistically significant relationships existed between the 'Degree of Specialism' and the 'Need Construct' of an actor, between the 'Need Construct' and the 'Practice Site Characteristics' of an actor and between the 'Degree of Specialism' and the 'practice Site Characteristics' of an actor. It was also shown that there existed statistically significant differences between the 'site characteristics' of Specialist and Primary Care physicians. This was also the case for the "Need Constructs' of the two groups. On the basis of the analyses conducted it was concluded that the conceptual structure of the study provided useful insights into the processes of physician site adoption. Recommendations for further research suggest that two fruitful areas of study would be to investigate, over time, changes in the spatial pattern of the medical community relating this to changes in the functional structure of the profession and to investigate explicitly the relationships between the 'Degree of Specialism', 'Need Constructs', and, 'Time Budgets' of physician actors. / Arts, Faculty of / Geography, Department of / Graduate

Abstract not available

Includes bibliographical references. / Palliative care, for those dying from a life-threatening disease, has developed to become a definite discipline in mostly developed countries. Through this palliative care has become accepted as a human right to all in need of end-of-life care. The stark reality in developing countries is that palliative care is in the early stages of development, with the result that if it is available at all, it usually is very basic. These countries which have restricted resources available are faced with an increased and overwhelming demand for palliative care because of the AIDS pandemic and also an expected massive increase in the incidence of cancer and non-communicable diseases. This raises the question how this demand will be met? The WHO is again looking at primary care as the way of meeting increased health care demands, including palliative care. The importance of the role of the general practitioner in delivering palliative care is widely accepted. The greatest majority of general practitioners in South Africa have never received official palliative care training. The question to be answered then is how well are they equipped to meet this increasing demand for end-of-life care. The study was designed as a descriptive cross-sectional KABP study. The study population was defined as all practising GPs working in a particular area in the northern suburbs of Cape Town and a number of Boland towns. The data collection tool used was a self-administered questionnaire that was developed through a process of review and through a pilot process. The questionnaire was then posted to all identified GPs with a return envelope with follow-up of non-respondents to ensure a better response rate. The response rate was 34,7%. Overall 69,45% of the questions were answered correctly and 30,55% incorrectly. The respondents showed good knowledge on morphine use and respiratory depression, the dangers of addiction to morphine, emergencies in palliative care and spinal cord compression. The greatest majority of respondents do not understand the holistic approach to pain management and also do not have knowledge about the use of syringe drivers. A high percentage of participants have a positive attitude towards palliative care in general, feel comfortable with their own emotions in end-of-life care and acknowledge their need for further training. On the questions on belief, respondents believe that the family must be involved in decision-making and that the GP must be doing bereavement care. Unfortunately most participants believe the management of physical symptoms ensures quality of life and seem not to grasp the holistic approach followed in palliative care. In practice only a few respondents understand the routine use of anti-emetics with initial opioid prescriptions. There is a significant number of GPs uncertain about the use of combinations of analgesics, the use of intravenous fluids in end-of-life care and the use of the subcutaneous route to administer drugs and fluids. The importance of the role of the GP in palliative care has to be recognized and acknowledged by all involved in such care. Programmes have to be initiated to train and educate practising GPs in palliative care to empower them and also to spread the end-of-life care message.

Includes bibliographical details. / In Tanzania, palliative care is relatively new, and faces the common challenges of access to services, crucial medications, and education. Since 2004, an initiative within the health system of the Evangelical Lutheran Church in Tanzania (ELCT) began to promote and develop palliative care, using as a model the Selian Hospice and Palliative Care Programme. The hospitals which are the sites for team development and service delivery are widely scattered throughout rural Tanzania. Access to oral morphine was only a dream, as it is for much of the rural population of the world. In 2007, a program called CHAT (Continuum of care for people living with HIV/AIDS in Tanzania), funded by the U.S. government, allowed the up-scaling of these palliative care programs, resulting in 13 strong and mature teams by 2011, though still lacking oral morphine. Part of the monitoring and quality assurance of the program has been use of a tool developed by APCA: the APCA African Palliative Outcome Scale (POS). Hundreds of people living with cancer and HIV were subjected to the questions of the tool, which was always sent on to the core supervising team for assessment and feedback. Tramadol was the strongest analgesic available to the teams throughout the study time. 145 APCA African POS results on cancer patients were assessed, looking at differences in pain scores (0 to 5 scale) over time as well as assessing the other domains of care (psychological, spiritual, social, and family). 11 Palliative care nurses were also interviewed, asked to reflect on specific cases from their experience with both good and bad pain control. 5 of the nurses came from Selian, with access to oral morphine, while 6 of them came from the CHAT hospitals. Significant improvement in pain scores over 4 weeks was noted (3.83 to 2.31, p < 0.0001). All other domains assessed in the POS also improved significantly. Nurse interviews revealed an emphasis on the holistic approach and a strong preference for having access to oral morphine. In this rural Tanzanian environment, effective palliative care services – including pain control - were delivered even in the absence of oral morphine. Such services can become a strong advocacy at the government level for achieving breakthroughs in palliative care, including access to oral morphine.

Includes abstract. / Includes bibliographical references (leaves 138-149). / A survey was done in the City of Cape Town Health District to identify possible barriers and other factors that influence the referral of patients to hospice by oncologists. Factors that influenced referral of patients to hospice included lack of training of oncologists in palliative care, the view of the oncologist's individual role in the care of his patients as well as the ability to communicate comfortably with patients regarding end-of-life care. Reasons for non-referral included hospice not being available in the area or not accessible to patients, the perception of the doctor that he/she is giving up on the patient, previous dissatisfaction with service by hospice and not wanting to lose control of the treatment of the patient.

Background: Palliative care (PC) is considered a necessary component of care that needs to be integrated into the South African health care system, including hospitals. In South Africa there has been a growth in legislation and policy frameworks stating the need for and promoting the development of hospital based PC programmes, however, how hospitals implement these policies is still unknown. Aim: The aim of this study was to identify factors that influence integration of PC in state hospitals and develop implementation recommendations. Objectives: The objectives of this study were (1) To describe existing PC services in three state hospitals in the Western Cape as perceived by the PC team; (2) To identify prohibiting and promoting factors in the integration of PC services in the three hospitals; and (3) To elicit views of health care professionals on how challenges to integrating PC in a hospital setting could be addressed. Method: This was a qualitative study whereby individual semi-structured interviews were conducted with 17 key informants (five-seven at each hospital). To obtain perspectives from relevant professionals on an operational and management level, key informants included chief executive officers, nursing managers, PC programme managers, physicians, nursing sisters, pharmacists, and social workers. The data was recorded, transcribed and analysed through steps of thematic analysis. Results: A description of each hospital’s PC programme was provided. Prohibiting factors identified most frequently related to resource challenges (insufficient human resources, time for PC, infrastructure and funding), followed by the hospital culture (limiting attitudes and beliefs about PC), education and training (limited opportunity, time and funding), health care providers (lack of PC knowledge, communication and hierarchy), as well as patient, family, community, and policy factors. Enabling factors identified were mainly related to having adequate resources (PC champions, effective teamwork, infrastructure and financial support). Raising awareness of PC needs and benefits (using practical methods), education and training in PC (formal and informal training opportunities), support structures (self-care, management and government support), partnerships (networking), and community-based support were also identified as promoting factors. Conclusion: Recommendations generated from this study were as follows: (1) Conduct a needs assessment to determine the organisations’ readiness and needs for PC integration; (2) Identify PC champions who have an interest in PC and influence in the organisation; (3) Raise PC awareness by providing education and training opportunities, and making PC part of the hospital culture; (4) Ensure adequate amount and use of human and material resources for PC; and (5) Network and build partnerships with other organisations who already have PC services.