Shift work is a work schedule being the opposite of normal daytime work, often defined as working time outside normal daytime hours (06:00 to 18:00). In recent years, shift work has been associated with an increased risk of numerous chronic conditions including for example cardiovascular disease, some types of cancer, type II diabetes, and the metabolic syndrome. While some studies on the association between shift work and chronic disease have found results supporting it, others have not. Therefore, more research is needed to clarify potential associations.The aim of this thesis was to further study the proposed association between shift work and cardiovascular disease. This was addressed by performing two studies, one analysing if shift workers had an increased risk of ischemic stroke compared to day workers. The other study analysed whether shift workers had an increased risk of short-term mortality (case fatality) after a myocardial infarction compared to day workers. The studies were performed using logistic regression analysis in two different case-control databasesThe findings from the first study indicated that shift workers did not have an increased risk of ischemic stroke. The findings from the second study showed that male shift workers had an increased risk of death within 28 days after a myocardial infarction; the results did not indicate an increased risk for female shift workers. The results from both studies were adjusted for both behavioural and medical risk factors without affecting the results. The findings from this thesis provide new evidence showing that male shift workers have an increased risk of death 28 days after a myocardial infarction, however more research is needed to clarify and characterise any such potential associations.

Thesis (MPH.) --University of Limpopo, 2016 / Background: Malaria is one of the important communicable diseases transmitted by Anopheline mosquitos to humans and is endemic in 108 countries around the world. Most malaria epidemics in African highland countries are caused by Plasmodium Falciparum (P Falciparum) and people residing in highlands are said to be having low immunity to malaria and both children and adults are affected by the disease, whereas vivax malaria is common in lowlands African countries. The current study was undertaken with an aim to determine the spatial distribution of malarial cases during the period 2006 to 2015 in Mopani District of Limpopo Province, South Africa. Methods: Quantitative retrospective descriptive methodology was employed to review the malaria distribution in Mopani district. A total of 12 037 malaria cases were identified for the period of the study and the data was kept anonymously by not using the names of the patients. Ethical clearance was received from the Turfloop Research Committee of University of Limpopo in consideration of section 14, 15, 16, and 17 of National Health Act 61 of 2004. The data was exported to excel spreadsheet and cleaned before exported into SPSS 23.0 software which was used for data analysis. Results: The findings revealed that most malaria cases were found in 2006 and again in 2014 and 2015 respectively. Malaria cases were also seen to be seasonal and were very high during January, February, March and April. Malaria cases also hiked during the month of October. The results also show that most malaria cases were reported between the patients aged of 16 to 25 and 26 to 40 years. There were more males than females who were infected by malaria in Mopani district and the sub district which was found to be having high malaria cases is Greater Giyani with more than 50% of the population (51.1%); followed by Ba Phalaborwa (23.1%); then Greater Tzaneen 13.1%. Conclusion: Mopani district has halved its malaria transmission for the comparison years, however the slow reduction in numbers of deaths is still a cause for concern. Key words: Malaria prevalence, spatial distribution, case fatality rate, elimination.

Stroke is a major cause of death and disability worldwide. In Sweden, about 30 000 strokes occur each year. The aim of this thesis was to analyse survival, functional outcome and self-reported depression after stroke, and to explore possible differences between men and women in stroke care and outcome. These studies were based on Riks-Stroke, the Swedish national quality register for stroke care. Information on background variables and treatment were collected during the hospital stay. The patient’s situation and outcome after stroke were followed-up after 3 months. Long term survival was retrieved from the Swedish Population Register (Folkbokföringen). Possible sex-differences in stroke care and outcome 3 months after stroke were explored in 24 633 strokes, registered during 2006. In conscious patients, the proportions treated at stroke units were similar for men and women. Men and women had equal chance to receive thrombolytic therapy or secondary prevention with oral anticoagulants. Compared to men, women were less likely to develop pneumonia, but more likely to experience deep venous thromboses and fractures during hospital stay. Women had worse 3-month survival and functional outcome, differences that were explained by their higher age and impaired level of consciousness on admission. Women felt more depressed and perceived their health as worse than men did. Women were also less satisfied with the care they had received in the hospital. The agreement between self-reported functional outcome 3 months after stroke and the commonly used modified Rankin Scale (mRS) was explored in 555 stroke survivors from 4 hospitals during May-September 2005. Riks-Stroke’s self-reported questions classified 76% of the patients into correct mRS grade. The association between functional outcome 3 months after stroke and 3-year survival was assessed in 15 959 men and women who had had a stroke during 2001-2002. Patients with estimated mRS grades 3, 4 and 5 had hazard ratios for death of 1.7, 2.5 and 3.8, respectively, as compared with patients with lower grades, 0-2. Depressed mood, male sex, high age, diabetes, smoking, antihypertensive therapy at onset and atrial fibrillation were also identified as predictors of poor survival. Self-reported depression 3 months after stroke and use of antidepressants were analysed in 15 747 stroke survivors from 2002. Fourteen percent felt depressed 3 months after stroke. Female sex, age <65, previous stroke, living alone or in institution, or being dependent in activities of daily living (ADL) were factors associated with self-reported depression. At the follow-up, 22% of the men and 28% of the women were using antidepressant medication, which were approximately twice as many as in the general population. Still, 8% of all patients in Riks-Stroke reported depressive mood but no treatment with antidepressants. In conclusion, men and women with stroke in Sweden experience similar treatment and outcome in most aspects. Patient-reported functional outcome can be reliably transformed to a standard disability scale. Impaired functional outcome three months after stroke is an independent predictor of poor long-term survival. Depressive mood is common after stroke and is associated with poor survival and impaired functional outcome.

Stroke is one of the leading causes of death and disability in Sweden and in the Western world. Despite this, stroke with focus on elderly is a field where few studies have been conducted from a gender and socioeconomic perspective. The objectives in this thesis were to analyse from a gender, age and socioeconomic perspective how women were affected by stroke compared with men. The focus was on what it meant for elderly women and men to live with stroke and to explore various gender constructions among men and women. The study also included aspects such as incidence, medical treatment and case fatality after stroke. Both quantitative and qualitative methods were used. During a two-year period (15 October 2000–14 October 2002), uniform information was collected for all cases of first-ever and recurrent (>28 days) stroke occurring in people of all ages living the region of Umeå, admitted to the University Hospital. Five different registers were used to achieve maximum coverage; the Riks-Stroke (RS) register, the Hospital Discharge Register (HDR), the Cause of Death Register, the northern Sweden WHO MONICA study, and one case-finding study in nursing homes and homes for elderly performed for this thesis. For the qualitative study a maximum variation sampling procedure was used to retrieve participants for in-depth interviews in a follow-up study. Nine women and seven men were interviewed about their experiences of treatment and care after suffering a stroke, as well as about their perceptions and experiences of help from others (health care personnel, relatives and home help personnel). The first-ever incidence of stroke was higher among low-educated than high educated men and women. Our study showed that there was an education-related age-dependent difference in stroke incidence, where elderly women had the highest incidence of stroke. The 28-day case fatality was shown to be associated with low educational level in patients above 75 years, after controlling for sex, risk factors and acute care variables. The elderly stroke patients experienced subordination in their contacts with health care personnel and the medical context. The participants used different ways to negotiate in the subordinate position, and some of these negotiations were interpreted as being gendered. We have also shown how the elderly stroke patients minimized their own needs of help, strove for independence and accepted help. The men and the women differed in their perceptions and experiences of help from others. Also, the participants expressed multiple types of needs. The elderly stroke patients’ perceptions and experiences of help from others must be studied in relation to their life circumstances and expectations from society. Further analyses of the patients’ perceptions and experiences of help from others were interpreted as being different examples of constructions of masculinities and femininities. Stroke with a focus on the elderly is a field where few studies have been conducted from a gender and socioeconomic perspective. With further community-based stroke incidence studies including elderly men and women and with the development of appropriately targeted interventions, the burden of stroke in the population could be reduced. More research is needed where both qualitative and quantitative methods are used, as this can provide a richer and perhaps more authentic description of the issue under investigation.

Background Malaria remains a serious epidemic threat in the Lowveld region of Mpumalanga Province. In order to appropriately target interventions to achieve substantial reductions in malaria morbidity and mortality, there is a need to assess the impact of current control interventions such as indoor residual spraying (IRS) for vector control. This study aimed to assess long-term changes in the burden of malaria in Mpumalanga Province during the past eight years (2001-2009) and whether IRS and climate variability had an effect on these changes. Methods All malaria cases and deaths notified to the Malaria Control Programme, Department of Health was reviewed for the period 2001 to 2009. Data were retrieved from the provincial Integrated Malaria Information System (IMIS) database. Climate and population data were obtained from the South Africa Weather Service and Statistics South Africa, respectively. Descriptive statistics were computed to determine any temporal changes in malaria morbidity and mortality. Autoregressive integrated moving average (ARIMA) models were developed to assess the effect of climatic factors on malaria. Results Within the eight-year period of the study, a total of 35,191 cases and 164 deaths-attributed to malaria were notified in Mpumalanga Province. There was a significant decrease in the incidence of malaria in Mpumalanga Province from 385 in 2001/02 to 50 cases per 100,000 population in 2008/09 (P < 0.005). The overall incidence and case fatality rates were 134 cases per 100,000 and 0.54%, respectively. Malaria incidence and case fatality rate by gender showed significant differences, higher in males than in L.M. Ngomane University of Pretoria, 2012 iv females (166.9 versus 106.4; P < 0.001; CFR 0.41% versus 0.55%). The incidence of malaria increased from age 5-14 years (70), reaching a peak at age 25-34 years (190), declining thereafter (50 in those >65 years). Mortality due to malaria was higher in those >65 years, the mean CFR reaching a 2.1% peak. Almost half (47.8%) of the notified cases originated from Mozambique and Mpumalanga Province itself constituted 50.1%. The distribution of malaria varied across the districts, highest in Ehlanzeni district (96.5%), lowest in Nkangala (<1%) and Gert Sibande (<1%). A notable decline in malaria case notification was observed following the increased IRS coverage from 2006/07 to 2008/09 malaria seasons. A distinct seasonal transmission pattern was found to be significantly related to changes in rainfall patterns (P = 0.007). Conclusion Decades of continuous IRS with insecticides have proved to be successful in reducing the burden of malaria morbidity and mortality in Mpumalanga Province between 2001 and 2009. A decline of above 50% in malaria morbidity and mortality was observed following expanded IRS coverage. These results highlight the need to continue with IRS together with other control strategies until interruption in local malaria transmission is completely achieved and alternative vector control strategies implemented. Efforts need to be directed towards the control of imported cases, interruption of local transmission and focus on research into sustainable and cost-effective combination of control interventions. / Dissertation (MSc)--University of Pretoria, 2012. / School of Health Systems and Public Health (SHSPH) / Unrestricted

Objetivos: Descrever o comportamento da Doença Meningocócica (DM) focalizando aspectos clínicos e seus desfechos, analisar o possível impacto da descentralização da assistência hospitalar, investigando também fatores associados à sua gravidade no município de São Paulo (SP), de 1986 a 2004. Metodologia: Trata-se de um estudo de corte transversal com componente descritivo e analítico, abrangendo o período de 1986 a 2004. A população de estudo abrange pacientes de DM, residentes no município de SP, notificados à vigilância. Os dados foram obtidos junto à vigilância passiva da DM e ao Instituto Adolfo Lutz de São Paulo. A descrição da doença foi efetuada segundo aspectos relativos ao tempo, espaço e pessoa. Para a investigação dos fatores associados à gravidade da DM tomou-se como variável dependente o óbito por DM e como variável independente, as exposições de interesse. Elas foram investigadas por meio das estimativas das odds ratio não ajustadas e ajustadas pela regressão logística não condicional, com os respectivos intervalos de confiança de 95 por cento. Resultados: Foram confirmados 10.087 casos de DM no município de São Paulo, durante o período de interesse. No pico epidêmico de 1995, a taxa de incidência média da DM foi de 8,1 casos/100.000 habitantes (hab), a mortalidade de 1,8 casos/hab/ano e letalidade média de 22 por cento. Crianças menores de quatro anos foram as mais atingidas, constituindo 54 por cento dos casos, principalmente entre os menores de um ano, com taxa de incidência média de 60,1/100000 casos/hab. Em 1986, o Hospital Especializado atendia 83 por cento dos casos e os Assistenciais apenas 12 por cento. No final do período estudado (2004), com a descentralização do serviço, o Hospital Especializado passou a atendeu 22 por cento dos casos e 71 por cento dos casos os Assistenciais. O Hospital Especializado manteve a letalidade anual dos casos de DM constante durante todo período, em torno de 11 por cento. A letalidade 15 dos Hospitais Assistenciais foi diminuindo gradativamente ao longo do período, inicialmente com 60 por cento e terminando com 16 por cento. Conclusão: A identificação de fatores associados à gravidade da DM e a repercussão da assistência hospital podem contribuir na melhoria das condutas clínicas, e subsidiar políticas públicas e intervenções de saúde pública / Objectives: To describe the behavior of meningococcal disease (MD) focusing on clinical features and outcomes, analyze the potential impacts of decentralization of hospital care, also investigating factors associated with the severity of MD in São Paulo (SP) city, from 1986 to 2004. Methods: This is a cross-sectional study with descriptive and analytical component covering the period 1986 to 2004. The population of the study was inhabitants in SP city, registered in the surveillance system. The data were obtained from the surveillance system of the DM MD and the Adolfo Lutz Institute of São Paulo. The descriptive analysis was presented by aspects of the time, space and person. The investigation of factors associated with the severity of the MD, it was considered as dependent variable death, and as independent variable, the exposure of interest. They were investigated by unadjusted and adjusted odds ratios by unconditional logistic regression, with their confidence intervals of 95 per cent. Results: There were 10,087 confirmed cases of MD in SP city, from 1986 to 2004. In epidemic peak (1995), the average rate of incidence of MD was 8.1 cases/100000 inhabitants (inhabit), the mortality rate was 1.8 cases/inhab/year and average case fatality rate (CFR) was of 22 per cent. Children under four years were the highest risk, representing 54 per cent of cases, especially among children under one year with average incidence rate of 60.1/100000 cases/inhab. In 1986, the specialized hospital cared 83 per cent of cases and non-specialized hospital only 12 per cent. At the end of the period studied (2004), with the decentralization of service, the specialized hospital has attended 22 per cent and 71 per cent of cases by the non-specialized. The referential hospital represented an annual CFR of MD constant in over time, around 11 per cent. The CFR of non-specialized hospital has been decreasing gradually 17 over the period, initially with 60 per cent and ending with 16 per cent. Conclusion: The identification of factors associated with the severity of DM and the impact of decentralization of the hospitals care can help in improving the clinical procedures, and support public policies and public health interventions

Objetivos: Descrever o comportamento da Doença Meningocócica (DM) focalizando aspectos clínicos e seus desfechos, analisar o possível impacto da descentralização da assistência hospitalar, investigando também fatores associados à sua gravidade no município de São Paulo (SP), de 1986 a 2004. Metodologia: Trata-se de um estudo de corte transversal com componente descritivo e analítico, abrangendo o período de 1986 a 2004. A população de estudo abrange pacientes de DM, residentes no município de SP, notificados à vigilância. Os dados foram obtidos junto à vigilância passiva da DM e ao Instituto Adolfo Lutz de São Paulo. A descrição da doença foi efetuada segundo aspectos relativos ao tempo, espaço e pessoa. Para a investigação dos fatores associados à gravidade da DM tomou-se como variável dependente o óbito por DM e como variável independente, as exposições de interesse. Elas foram investigadas por meio das estimativas das odds ratio não ajustadas e ajustadas pela regressão logística não condicional, com os respectivos intervalos de confiança de 95 por cento. Resultados: Foram confirmados 10.087 casos de DM no município de São Paulo, durante o período de interesse. No pico epidêmico de 1995, a taxa de incidência média da DM foi de 8,1 casos/100.000 habitantes (hab), a mortalidade de 1,8 casos/hab/ano e letalidade média de 22 por cento. Crianças menores de quatro anos foram as mais atingidas, constituindo 54 por cento dos casos, principalmente entre os menores de um ano, com taxa de incidência média de 60,1/100000 casos/hab. Em 1986, o Hospital Especializado atendia 83 por cento dos casos e os Assistenciais apenas 12 por cento. No final do período estudado (2004), com a descentralização do serviço, o Hospital Especializado passou a atendeu 22 por cento dos casos e 71 por cento dos casos os Assistenciais. O Hospital Especializado manteve a letalidade anual dos casos de DM constante durante todo período, em torno de 11 por cento. A letalidade 15 dos Hospitais Assistenciais foi diminuindo gradativamente ao longo do período, inicialmente com 60 por cento e terminando com 16 por cento. Conclusão: A identificação de fatores associados à gravidade da DM e a repercussão da assistência hospital podem contribuir na melhoria das condutas clínicas, e subsidiar políticas públicas e intervenções de saúde pública / Objectives: To describe the behavior of meningococcal disease (MD) focusing on clinical features and outcomes, analyze the potential impacts of decentralization of hospital care, also investigating factors associated with the severity of MD in São Paulo (SP) city, from 1986 to 2004. Methods: This is a cross-sectional study with descriptive and analytical component covering the period 1986 to 2004. The population of the study was inhabitants in SP city, registered in the surveillance system. The data were obtained from the surveillance system of the DM MD and the Adolfo Lutz Institute of São Paulo. The descriptive analysis was presented by aspects of the time, space and person. The investigation of factors associated with the severity of the MD, it was considered as dependent variable death, and as independent variable, the exposure of interest. They were investigated by unadjusted and adjusted odds ratios by unconditional logistic regression, with their confidence intervals of 95 per cent. Results: There were 10,087 confirmed cases of MD in SP city, from 1986 to 2004. In epidemic peak (1995), the average rate of incidence of MD was 8.1 cases/100000 inhabitants (inhabit), the mortality rate was 1.8 cases/inhab/year and average case fatality rate (CFR) was of 22 per cent. Children under four years were the highest risk, representing 54 per cent of cases, especially among children under one year with average incidence rate of 60.1/100000 cases/inhab. In 1986, the specialized hospital cared 83 per cent of cases and non-specialized hospital only 12 per cent. At the end of the period studied (2004), with the decentralization of service, the specialized hospital has attended 22 per cent and 71 per cent of cases by the non-specialized. The referential hospital represented an annual CFR of MD constant in over time, around 11 per cent. The CFR of non-specialized hospital has been decreasing gradually 17 over the period, initially with 60 per cent and ending with 16 per cent. Conclusion: The identification of factors associated with the severity of DM and the impact of decentralization of the hospitals care can help in improving the clinical procedures, and support public policies and public health interventions

Background. Swaziland adopted the World Health Organization’s (WHO) guidelines for the inpatient treatment of severely malnourished children in 2007 to reduce case -fatality rates for childhood malnutrition. However, no follow-up studies have been conducted to determine the reduction in the case -fatality rate post-implementation of the guidelines. Objectives. To determine the case -fatality rate for childhood malnutrition post-implementation of the WHO treatment guidelines and determine the level of adherence to the guidelines at Mbabane Government Hospital. Methods. A retrospective observational study was undertaken. All children under 5 years admitted for inpatient treatment of malnutrition between January 2010 and December 2011 had their demographic-, anthropometric- and clinical characteristics recorded and analysed, as well as the outcome of admission. Results. Of the 227 children admitted during the study period, 179 (64.6%) were severely malnourished and 98 (35.4%) had moderate malnutrition. One-hundred-and-eleven children died during admission, an overall case -fatality rate of 40.1%. Mortality was significantly higher among severely malnourished children compared to those with moderate malnutrition, (46.9% vs 27.6%, OR 3.0 (95% CI 1.7 to 5.3)). Comorbid pneumonia and gastroenteritis were significant predictors of mortality – , OR 2.0 (95% CI 1.2 to 3.4) and 1.9 (95% CI 1.1 to 3.2) respectively. Conclusion. Case -fatality rates for childhood malnutrition remain high, despite adoption of the WHO treatment guidelines. A need exists for improved adherence to the WHO guidelines and periodic clinical audits to reduce deaths from childhood malnutrition to meet the WHO mortality target of less than 5% and improve child survival. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Clinical Epidemiology / unrestricted

Abortion and severe pre-eclampsia/eclampsia remain the major causes of maternal mortality in Zimbabwe. Based on this problem, factors associated with maternal mortality due to abortion and severe pre-eclampsia/eclampsia were investigated to improve pregnancy outcomes. Cases and controls were selected from 4895 abortion and 318 severe preeclampsia/ eclampsia obstetric records to conduct a retrospective case-control study. Significant risk factors identified for reducing maternal mortality due to postabortion complications included the administration of oxytocic drugs and evacuations of the uterus whilst anaemia and sepsis apparently reduced these women's chances of survival. No significant factors could be identified which influenced maternal deaths among women suffering from severe pre-eclampsia/eclampsia. Magnesium sulphate was not routinely administered, as recommended internationally. In both groups, cases apparently received better reported quantitative care than controls. Recommendations based on this research report include improved midwifery education and in-service training, regular audits of patients' records and changed policies for managing these conditions more effectively in Zimbabwe. / Health Studies / D. Litt. et Phil. (Advanced Nursing Sciences)

Abortion and severe pre-eclampsia/eclampsia remain the major causes of maternal mortality in Zimbabwe. Based on this problem, factors associated with maternal mortality due to abortion and severe pre-eclampsia/eclampsia were investigated to improve pregnancy outcomes. Cases and controls were selected from 4895 abortion and 318 severe preeclampsia/ eclampsia obstetric records to conduct a retrospective case-control study. Significant risk factors identified for reducing maternal mortality due to postabortion complications included the administration of oxytocic drugs and evacuations of the uterus whilst anaemia and sepsis apparently reduced these women's chances of survival. No significant factors could be identified which influenced maternal deaths among women suffering from severe pre-eclampsia/eclampsia. Magnesium sulphate was not routinely administered, as recommended internationally. In both groups, cases apparently received better reported quantitative care than controls. Recommendations based on this research report include improved midwifery education and in-service training, regular audits of patients' records and changed policies for managing these conditions more effectively in Zimbabwe. / Health Studies / D. Litt. et Phil. (Advanced Nursing Sciences)