End-stage conditions such as chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) have shown some of the most dramatic increases in mortality in the developed world over the past 40 years. Both are therefore leading causes of morbidity and mortality worldwide and should be considered as a major economic and social burden that is both substantial and increasing. In these conditions, exercise therapy should play an integral part in maintaining the patient’s maximal level of independence and functioning, as well as slowing or possibly even stopping the progression of the condition. In this context the main objectives of these doctoral theses are: a. Proving the safety of different exercise modalities. b. Identifying the most effective exercise interventions in regards to clinical parameters. c. Proving the feasibility of outpatient rehabilitation programmes for these high risk populations. This work, therefore, combines three studies looking into the effects of non-pharmaceutical interventions – predominantly different exercise regimes in the two major conditions in the mortality statistics of CHF and COPD - both with a very poor prognosis. In conclusion it can be said that the results and experience of all three studies demonstrate the safe feasibility of different outpatient exercise interventions and suggest specific positive adaptations in patients with heart failure and COPD which also led to a lower hospitalisation rate. There are clear hints that the therapy spectrum could be supplemented significantly by specific training interventions. The financial implications for any health care system are also highly relevant.

Introduction: Guinea worm disease (GWD) is a painful, disabling disease caused by the parasite dracunculus medinensis. The implementation of the global GWD eradication campaign resulted in a decrease of global burden of disease and several countries have been proclaimed free of the disease. Though, Ethiopia has implemented the GWD eradication programme since 1992 the disease remains endemic in the Gambella region. Purpose of the study: The purpose of this study was to explore the perceptions and experiences of the community of Gambella region on Guinea worm disease (GWD) eradication interventions. Methodology: A qualitative study paradigm with a phenomenological research design was employed to collect data using focus group discussions, in-depth individual interviews, document reviews, and observations. The study participants were determined by purposive sampling. Qualitative data analysis involved transcription, data entry, and management of verbal information followed by coding, categorizing into themes. Interpretation of the data was done using triangulation methodology with appropriate mechanisms for validity and trustworthiness. Result: The study found that there are gaps in the perceptions and understanding of the community and programme implementers about the achievement and application of the various interventions on the eradication of Guinea worm disease. Health education programme was not fine-tuned to the eradication of GWD by community participation. Community perception was not at the required level for the eradication of GWD due to the low success of the educational intervention. Conclusion: continuous health education targeting the community with clear objectives of helping to eradicate GWD was found to be limited in its coverage. In addition, provision of water filters necessary for GWD eradication was inadequate. Moreover, the community did not have clear understanding of the causes of GWD and its eradication strategy. It is hoped that the findings of this study would contribute significantly to the GWEP in Gambella region, as well as elsewhere where GWD may be endemic / Health Studies / M.A. (Public Health)

Natural populations may be managed by humans for a number of reasons, with mathematical modelling playing an increasing role in the planning of such management and control strategies. In an increasingly heterogeneous, or `patchy' landscape, the interactions between distinct groups of individuals must be taken into account to predict meaningful management strategies. Invasive control strategies, involving reduction of populations, such as harvesting or culling have been shown to cause a level of disturbance, or spatial perturbation, to these groups, a factor which is largely ignored in the modelling literature. In this thesis, we present a series of deterministic, differential equation models which are used to investigate the impact of this disturbance in response to control. We address this impact in two scenarios. Firstly, in terms of a harvested population, where extinction must be prevented whilst maximising the yield obtained. Secondly, we address the impact of disturbance in an epidemic model, where the aim of the control strategy is to eradicate an endemic pathogen, or to prevent the invasion of a pathogen into a susceptible population. The movement of individuals between patches is modelled as both a constant rate, and a function which is increasing with population density. Finally, we discuss the 'optimal' control strategy in this context. We find that, whilst a population harvested from a coupled system is able to produce an inflated yield, this coupling can also cause the population to be more resistant to higher harvesting efforts, increasing the effort required to drive the population to extinction. Spatial perturbation raises this extinction threshold further still, providing a survival mechanism not only for the individuals that avoid being killed, but for the population as a whole. With regards to the eradication of disease, we show that disturbance may either raise or lower the pathogen exclusion threshold depending on the particular characteristics of the pathogen. In certain cases, we have shown that spatial perturbation may force a population to be susceptible to an infectious invasion where its natural carrying capacity would prevent this.

Thesis (MSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Aim: The aim of this qualitative study was to explore the experiences of individuals with Huntington’s disease (HD) in a South African context. The focus of the current study was not only on the challenges faced by individuals with HD, but also the resources/supports that help them cope with their neurological condition. Method: I conducted twelve semi-structured interviews with the participants and they transcribed verbatim. I then performed a thematic analysis. Results: Using Bronfenbrenner’s Ecological System’s Theory as the theoretical framework, several themes were identified that related to the participants’ experiences of living with HD. Challenges included: triad of symptoms, sleep problems, testing process, relationships, children, it’s a monster, employment, social support, partners and family members with HD, medical aid, life insurance, financial problems, lack of HD facilities, lack of understanding of HD, symptoms watching and the progression of HD. Several supports/resources were also identified and included: knowledge about HD, counselling, medication, coping, employment, social support, testing process, partners and family members with HD, medical aid, life insurance, cure, possible HD facilities, religion, grant and adaptation over time. Conclusion: This was the first study of this kind in a South African context, which set out to explore the experiences of individuals with HD in the Western Cape, South Africa. The findings from this study demonstrate that although these individuals with HD experience several challenges due to their debilitating condition, they also employ several resources to help them cope with HD. Lastly, the findings that emerged from this study contribute to raising awareness about the experiences of these individuals living with HD and could serve as a valuable foundation for tailor-made interventions for these unique individuals. / AFRIKAANSE OPSOMMING: Doel: Die doel van hierdie kwalitatiewe studie was om die ervaringe van individue met Huntington se siekte (HS) in 'n Suid-Afrikaanse konteks te verken. Die fokus van die huidige studie het verband gehou nie net met die uitdagings wat deur individue met HS ervaar word, maar ook die hulpbronne / ondersteuning wat hulp verleen met hulle neurologiese toestand om dit te beter te hanteer. Metode: Ek het twaalf semi- gestruktureerde onderhoude met die deelnemers gevoer en woordeliks getranskribeer , waarna tematiese analise uitgevoer is. Resultate: Met behulp van Bronfenbrenner se Ekologiese Sisteem Teorie as die teoretiese raamwerk , is verskeie temas wat verband hou met die deelnemers se ervarings van die lewe met HD geïdentifiseer. Uitdagings sluit in: drietal van die simptome, slaap probleme, toets-proses, verhoudings, kinders, dit is 'n monster, indiensneming, sosiale ondersteuning, metgeselle en familie-lede met HD, mediese fonds , lewensversekering, finansiële probleme, die gebrek aan HD fasiliteite, 'n gebrek aan begrip van HD, dophou van simptome en die vordering van HD. Verskeie ondersteuning / hulpbronne is ook geïdentifiseer en sluit in: kennis oor HD, berading, medisyne, hantering, werk, sosiale ondersteuning, toetsproses, vennote en familie -lede met HD, mediese fonds, lewensversekering, genesing, moontlike HD fasiliteite , godsdiens, staats-toelaag en aanpassing oor tyd. Gevolgtrekking: Dit was die eerste studie van hierdie aard in 'n Suid-Afrikaanse konteks wat die ervarings van individue met HD in die Wes-Kaap , Suid-Afrika uiteensit. Die bevindinge van hierdie studie toon dat, alhoewel hierdie individue met HD verskeie uitdagings as gevolg van hul aftakenlende toestand ondervind, is daar ook 'n paar hulpbronne in plek om hulle met die hantering van hierdie neurologiese toestand te help. Laastens , die bevindinge uit hierdie studie dra by tot die verhoging van bewustheid oor die ervarings van hierdie individue wat met HD lewe en kan as 'n waardevolle fondament vir pasgemaakte intervensies vir hierdie unieke individue dien.

Compared to the general population, diabetic patients experience a higher prevalence of depression, which can often exacerbate diabetic symptoms and complicate treatment. Studies show that religion is associated with both better physical health and better psychological functioning; however, studies incorporating religion and depression among diabetic individuals are scarce. The present study addressed this gap in the literature by examining archival data from the 2008 and 2010 data waves of the Health and Retirement Study (HRS). Cross-sectional findings confirmed that stronger religiosity was positively correlated with perceived diabetes control and positive diabetes change, and negatively correlated with total number of depressive symptoms and total number of weeks depressed. Longitudinal findings confirmed that stronger religiosity in 2008 was positively correlated with perceived diabetes change in 2010 and negatively correlated with total number of depressive symptoms in 2010. Logistic regression and multiple regression analyses were performed to test four moderation models. Results showed that religiosity significantly moderated the relationship between perceived diabetes control and total number of weeks depressed. More specifically, for diabetics with low levels of religiosity, whether they believed their diabetes was under control or not did not make a significant difference in the total number of weeks depressed. However, high levels of religiosity served as a buffer against the duration of depressive symptoms but only for diabetics who perceived to have their diabetes under control. Understanding how these constructs jointly influence diabetes management and psychological functioning is critical in that medical professionals may utilize such knowledge to enhance treatment outcomes.

Target spot is a foliar disease of soybean that can produce yield losses. The disease has recently become a concern due to increasing intensity of its epidemics in the main soybean growing countries (USA, Brazil and Argentina). The goals of this study were to i) estimate the target spot control efficiency and yield response of labeled fungicides for the main soybean growing region of Brazil and identify factors affecting their performance; ii) characterize the relationship between target spot severity and soybean yield using meta-analytic techniques, and to identify patterns which allow understanding the heterogeneity in the relationship; iii) to explore the variability of genetic resistance of cultivars and verify the less time-consuming methodology for doing it; iv) explore the pathogen-host interaction effects on the epidemic development; v) compare the sensitiveness of the canopy strata position injured by C. cassiicola to reduce grain yield. Fungicides containing fluxapyroxad + pyraclostrobin were the most efficient ones to control target spot, with control levels of 75% and their yield response depended on the disease pressure (DP, DPLow < 35% target spot severity at untreated checks <= DPHigh). At DPLow was unprofitable the use of fungicides and at DPHigh the latter fungicides had the best performances increasing yield relative to the untreated check in > 469 kg ha-1 (+19.1%). Potential yield of soybean in absence of target spot was estimated in 3507 kg ha-1 for 41 trials in Brazil and the percentual reduction for each target spot severity point was calculated in 0.48%, what would represent a reduction of 24% in a hypothetical target spot severity of 50% (ranging from 8% to 42%). The soybean cultivar had a significant effect to explain this wide range of responses: potential losses of 11%, 18.5% and 42% was calculated for cultivar BMX Potência RR, TMG803 and M9144RR respectively at target spot severity = 50%. We observed high variability on the genetic resistance in the tested germplasm: cultivars with very low target spot intensity (BRS360) to highly susceptible cultivars. A single-point disease severity assessment was not as reliably as an integrative three-point assessment, which had no difference with a less time-consuming two-point disease assessment. In trials where 3 C.cassicola isolates from different regions of Brazil were inoculated individually on 3 soybean cultivars contrasting in their resistance level we observed that the incubation period, disease severity, lesion density and lesion size at 14 days after inoculation, were influenced by the cultivar and not by isolate geographical origin. Using disease severity coupled with defoliation assessments throughout the reproductive growth stages, we performed correlations between grain yield and the leaf area injury at different plant positions - growth stages. The best correlation was observed with the assessments at R5.5 for injuries at middle canopy section. / A mancha alvo é uma doença foliar que pode ocasionar perdas de rendimento na cultura da soja. A doença tornou-se recentemente uma preocupação nos principais países produtores de soja (EUA, Brasil e Argentina), devido à crescente intensidade de suas epidemias. Os objetivos deste estudo foram: i) estimar a eficiência de controle da mancha alvo por fungicidas comerciais registrados no Brasil e a resposta em rendimento da soja, identificando fatores que afetam o desempenho dos fungicidas; ii) caracterizar a relação entre a severidade da mancha alvo e o rendimento da soja, utilizando técnicas meta-analíticas e identificar padrões que permitam compreender a heterogeneidade existente nessa relação; iii) explorar a variabilidade da resistência genética de cultivares de soja e verificar a metodologia mais eficiente para discriminar cultivares suscetíveis de resistentes; iv) explorar os efeitos da interação entre a origem do isolado de C. cassiicola e a cultivar de soja no desenvolvimento da epidemia; v) comparar a sensibilidade da posição do estrato do dossel afetado por C. cassiicola na redução do rendimento de grãos. Fungicidas compostos pelos ingredientes ativos fluxapyroxad + piraclostrobina foram os mais eficientes para controlar a mancha alvo, com níveis de controle de até 75%, e sua resposta ao rendimento dependeu da pressão da doença (PD, PDbaixa < 35% de severidade da mancha alvo na testemunha não tratada <= PDalta). Na PDbaixa, a aplicação de fungicidas não foi lucrativa, e em PDalta os fungicidas compostos por fluxapyroxad + piraclostrobina apresentaram os melhores desempenhos, superando o rendimento em relação à testemunha em 469 kg ha-1 (+ 19,1%). O rendimento potencial geral da soja, na ausência da mancha alvo, foi estimado em 3507 kg ha-1 para 41 ensaios distribuídos no Brasil. A redução no rendimento para cada ponto percentual de incremento na severidade da mancha alvo foi calculada em 0,48%. Com isso, níveis (hipotéticos) de severidade de mancha alvo de 50% ocasionariam uma redução de rendimento de 24% (variando entre 8% a 42%). A cultivar de soja teve um efeito significativo para explicar esta grande amplitude de respostas: reduções potenciais (com 50% de severidade) de 11%, 18,5% e 42% foram calculadas, respectivamente, para as cultivares BMX Potência RR, TMG803 e M9144RR. Foi constatada alta variabilidade na resistência genética no germoplasma testado, desde cultivares com intensidade de mancha alvo muito baixa (BRS360) até cultivares altamente suscetíveis. Avaliações da severidade da doença em uma única data não foi tão confiável quanto a avaliação integrada de duas ou três datas. Em experimentos onde 3 isolados de diferentes regiões do Brasil foram inoculados isoladamente em 3 cultivares contrastantes nos níveis de resistência, observou-se que o período de incubação, a severidade da doença, a densidade de lesões e o tamanho das lesões aos 14 dias após a inoculação foram influenciados pela cultivar. Porém, não foi observado efeito da origem geográfica do isolado de C. cassiicola nos componentes monocíclicos avaliados. A severidade da doença em diferentes posições da planta, juntamente com as avaliações de desfolha ao longo dos estádios de crescimento reprodutivo da soja, foi correlacionada ao rendimento de grãos. A melhor correlação entre o rendimento de grãos e a intensidade da doença (severidade + desfolha) foi observada nas avaliações em R5.5 na seção média do dossel.

The major part of care in type 2 diabetes is in the hands of the patient so the focus of educational interventions should be on the person behind the disease. An experience-based group education programme that actively promotes participants’ reflection and understanding has been designed and implemented in cooperation with the Swedish Pharmacy. The regression model presented in Paper I revealed the importance of self-perceived role in diabetes management. Blood glucose control two years after baseline was improved for participants who described themselves as having an active role in their treatment, compared to those taking on a passive or a compliant role. Paper II described the resulting categories from content analysis of three open-ended questions about participants’ role, goal and support needs in diabetes management. The people taking care of diabetes most effectively and needing least support were called Disease Managers; those following the health professionals’ orders and depending on regular controls were categorised as Compliant, whereas the Disheartened had difficulties in achieving good metabolic control and often described both medical and social obstacles. These three self-management profiles were strongly correlated to metabolic outcomes. In Paper III perceptions of diabetes management were reassessed: perceptions were only stable in approximately half of participants, thus providing evidence for a dynamic model of learning self-management in diabetes. The three self-management profiles still correlated with metabolic outcomes. In paper IV the long-term metabolic outcome (HbA1c) of the study population was investigated. Metabolic control was stable up to seven years following the intervention, in contrast to the metabolic deterioration often present in diabetes. The main message of this thesis is that participants’ self-perceived role had a major influence on metabolic outcomes. Assessing self-management profiles both in diabetes and possibly other chronic conditions can help health care providers to tailor their educational efforts accordingly. Furthermore, this experience-based patient education programme outside the framework of routine diabetes care has the potential to stabilise metabolic control on the long run effectively.

For the second study, a web-based survey was developed and distributed to all members of four major health education organizations. A total of 1,925 HEs’ completed the survey and 1,607 responses were utilized in the final analysis. This study indicated that participants had deficient knowledge and unfavorable attitudes toward the CDCproposed genomic competencies. In the third study, a theoretical model was developed to predict HEs’ likelihood to incorporate genomic competencies into their practice. Using techniques from Structural Equation Modeling (SEM), the model was tested with the same data of the second study. Findings supported the proposed theoretical model. While genomic knowledge, attitudes, and self-efficacy were significantly associated with HEs’ likelihood to incorporate genomic competencies into their practice, attitudes was the strongest predictor of likelihood. In summary, these studies indicated that participating HEs had deficient genomic knowledge, unfavorable attitudes toward a set of CDC-proposed genomic competencies, and low likelihood to adopt genomic competencies into health promotion. Relevant training should be developed and advocated. As the SEM analysis results indicated the survey findings supported the proposed theoretical model, which can be utilized to steer future training for HEs. statistics, 2) unadjusted inferential statistics, 3) stratified analysis, and 4) multivariable models. My investigation produced results in accord with generally accepted notions in addition to significant findings that interestingly counter current preconceptions. Intraspecies contact was more common than inter-species, with indirect contact occurring more frequently than direct. Direct contact between species occurred extremely rarely. The most important factors that influenced the rate of contact for both species were water, winter, and cultivated fields. Information regarding probability of infectious agent survival and transfer will be used in the future to advance current epidemiological models, including geographicautomata (Ward et al. 2007: In Press) and cellular automata models (Doran and Laffan 2005) to better understand and manage integrated domestic cattle and free-ranging wildlife populations. Such modeling provides essential and necessary knowledge for developing prevention, detection, response, and recovery strategies – employed in advance, during, and after a disease outbreak, respectively.

In South Africa, significant changes in health care have taken place since the first democratic elections in 1994. The change had lead to a position of integrated service delivery with specific reference to primary health care. Increasingly in developing countries, the private sector impacts significantly on the rights to education and the highest attainable standard of health. Inappropriate prescribing e.g. prescribing a drug without an acceptable indication, specifying an incorrect dosage, schedule or duration of treatment, duplicating therapeutic agents and prescribing drugs without adequate regard to potential interactions, can cause adverse outcomes, deplete health care resources, compromise the quality of care and possible increase in health costs. One approach monitoring prescribing practices is drug utilisation review. The general objective of this study was to review and interpret aspects of drug usage patterns in a private primary health care setting, with special reference to the top ten diagnoses made and the top twenty medicine items prescribed as well as the associated costs. A quantitative, retrospective drug utilisation review as well as certain aspects of managed and primary health care, pharmacoeconomics, pharmacoepidemiology, medicine formularies and standard treatment guidelines were reviewed in the literature as a base for the study. The results of the empirical study showed that 83648 patients consulted at the nine medicentres during the study period (1 January to 31 December 2001). A total number of 132591 patient visits (consultations) were made, 140723 medical conditions (diagnoses) performed and 516177 medicine items prescribed during the study period. Analysis of medicine usage patterns and associated costs of the top ten diagnoses made and top twenty medicine items prescribed in the study population, revealed the following: The top ten diagnoses determined accounted for 29.07% of the total number of diagnoses made, . a total medicine treatment cost accounting for 32.11% in the study population, . the top twenty medicine items determined accounted for 56.23% of the total medicine items prescribed and . a total medicine treatment cost accounting for 28.63% in the study population. The highest prevalence of diagnoses made and medicine items prescribed was found in age groups 4 and 5 (Le. patients between the ages of 19 to 40 years) and was also found to be more prevalent in the female than in the male population. In completion of the research, recommendations to review the medicentres medicine treatment protocols and on provision of primary health care education were made. Reference to the investigation of environmental factors is also made. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2004.

Health is a fundamental human right. Access to health care, which includes providing a population with safe, effective, good quality drugs at the least possible cost, is a prerequisite to realising that right. Drugs or medicines play a fundamental role in the effectiveness, efficiency and responsiveness of health care systems. Drugs also constitute a major recurrent expense in both state-run and private sector health care. To ensure that health care workers prescribe the most cost-effective drugs through the essential drugs list, training, as well as evaluation and monitoring systems must be regarded as important elements of containing costs. Pharmaceutical benefit management programmes such as pharmacoeconomics, drug utilisation review (DUR), evidence-based medicine and disease management have emerged as tools to ensure cost-effective selection and use of drugs, particularly for chronic diseases. These managed care tools are often investigated to determine whether new technologies or interventions are appropriate and have "value". Affordable prices of medicines, on their own, however, do not ensure access to medicines. Also important are reliable procurement, distribution and storage systems, and appropriately trained personnel to manage these components of drug management. Poorly regulated drug supply systems can have serious consequences such as antibiotic resistance, problems with safety or quality and most importantly wastage, as it is believed that a significant proportion of drugs purchased by the state in South Africa find their way into the private sector market through a "grey market". The general objective of this study was to review and analyse the cost and medicine usage of the "top twenty" pharmaceutical products according to the monthly pharmaceutical purchasing reports of the Department of Health in the North West Province. The research can be classified as retrospective and quantitative. The data used for the analysis were obtained over a two-year study period (1 Apr 2000 - 28 Feb 2002) from the private provider operating the medical stores in the North West Province. The results of the empirical investigation, showed the total number of "top twenty" products appearing during the study period amounted to 460 different products having a total purchasing cost of R 66,263,674.51 representing 37.2% (n = R 178,163,061.50) of all pharmaceutical products purchased during the two-year period. Through analysis it was found, when classified according the Anatomical Therapeutic Chemical (ATC) therapeutic main group, antihypertensives had the highest quantity purchased for year one (20.69%; n = 134,515,640) with cough and cold preparations revealing the highest purchasing quantity for year two (40.55%; n = 103,567,031) of all "top twenty" pharmaceuticals during the study period. Antibacterials for systemic use presented with the highest cost percentages for both years, representing 20.68% (n = R35, 568,221.31) and 16.72% (n = R 31,370,435.51) respectively. Hydrochlorothiazide presented with the highest purchasing quantity for both years when classified according to chemical substance with, Methyldopa having the highest purchasing cost for year one followed by vaccine Hib-DTP 10 dose vial (Haemophilus influenzae type B vaccine-diphtheria, pertusis and tetanus vaccine) for year two. Furthermore it was also found that the majority of the "top twenty" products were in the oral dosage form. Finally it was concluded that drugs used in the treatment of hypertension and cardiac failure were the most utilised in comparison to other "top twenty" products during the study period. Possible misappropriation based on the defined daily dose of the "top twenty" products might have occurred. In completion of this study, recommendations for future research were made. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2004.