Includes bibliographical references. / The study aimed to provide an understanding of health-related quality of life and psychological well-being amongst low-income women living with the Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) in South Africa. The research examined the relationships among biomedical and psychosocial factors and health-related quality of life (HRQOL) and the levels of suicidality (psychological distress) of women with HIV and AIDS in the province of KwaZulu-Natal. One hundred and thirty three (133) women over the age of 18 years (average age 32.96 yrs) participated in the study. In order to assess psychological distress, participants completed a Suicidality Measure (SM). Psychosocial factors were accessed through participants’ perceived social support as measured by the Multidimensional Scale of Perceived Social Support (MPSS). Information on social/contextual variables including income, marital status, employment status, number of children and number of family members in the household was obtained. Participants completed the Health Related Quality of Life Survey (HRQOL) – SF-36. The two biomedical measures were CD-4 count and time since diagnosis information. The findings revealed that perceived social support was inversely related to suicidality, and there was a significant correlation between perceived social support and two SF-36 domains: vitality (VT) and mental health (MH). Overall, the findings indicated that the women did not have adequate social support in their lives. Certain social/contextual factors, for example low income; being employed; number of family members in the household and having a greater number of children negatively impacted on aspects of health-related quality of life of the women. CD-4 count was not a significant predictor of health-related quality of life and suicidality (psychological distress). The findings further indicated a compromised level of HRQOL (i.e. physical, social and emotional functioning) in the HIV-infected women in the study. After controlling for biomedical factors, all the psychosocial factors did not explain the majority of the variance in quality of life. This suggests that these may not have been the most suitable variables used to explain health-related quality of life. Similarly, the psychosocial variables did not account for the variance in suicide scale once the effect of the biomedical variables had been taken into account. Although the women seldom thought of suicide, there was a significant negative relationship between time since diagnosis and suicidality. Newly diagnosed patients were less likely to think of suicide as an option than women who had been diagnosed some time before.

Includes abstract. / Includes bibliographical references (leaves 61-67). / The study was conducted at Tshwane District Hospital (TDH) in Pretoria, Gauteng Province, South Africa. TDH is a district hospital that provides comprehensive primary level health care services to patients from a large part of the greater Tshwane Municipality (estimated population of 2,2 million people). The aim of this retrospective cohort study was to identify factors that may predict the outcome of individuals started on HAART and to formulate a guideline to assist health care workers to identify and better support patients more at risk of mortality or poor outcome.

Includes bibliographical references. / The objective of this study is to identify the common medical problems seen in late stage HIV/AIDS patients in rural Mpumalanga, South Africa and the resources used for their care.

Background: Patients often present to the Emergency Department (ED) at the end of life. Caring for these patients present a unique set of challenges, and often the patients' and families' needs are at odds with the pervasive rescue-oriented ED culture. A potential solution to this problem is an Acute Palliative Care Unit. Groote Schuur Hospital opened such a unit in April 2011, managed by the ED staff. This kind of service was not available in this tertiary, academic state hospital prior to that. Objectives: This study aimed to evaluate aspects of care at the Groote Schuur Hospital Palliative Care unit by designing a questionnaire based on the Liverpool Care Pathway assessing elements of care, describing the population admitted demographically, recording outcomes and making recommendations based on the findings. Methods: A retrospective folder review was completed on all patients who were admitted to the unit between April 2011 and May 2013. Data was collected onto an Excel spreadsheet, and was analysed using the SmallStata 13 software package. Demographic data collected included sex, age, area from which the referral came, diagnosis, length of stay and outcomes. Data on care were grouped into physical care, psychological care, spiritual care, communication skills and bereavement care. Results: 176 folders were identified. 167 were reviewed (nine were missing). Nine folders did not meet inclusion criteria. 158 folders were included in the study. The vast majority of patients were admitted from home via the ED. Mean age was 59.49 years (95% CI 56.76 – 61.53). Median length of stay was 25 hours (IQR 7-47). 97 patients had palliative care needs in the absence of malignancy, 60 had cancer. 111 (70.7%) patients died in the unit, 5 (3.18%) died en route to the unit, 16 (10.19%) went home, 8 (5. 1%) were referred back to other specialities and 17 (10.83%) were referred to step down facilities. 96% of patients had their medication adjusted, and 128 (81.53%) were commenced on syringe drivers. Morphine, haloperidol and hyoscine butyl bromide were the commonest prescribed medicine in the syringe driver. None of the patients had an official "Do Not Resuscitate" (DNR) form completed, but more than 75% of patients had a note or clear proxy measures indicating that resuscitation is not indicated. Difficulty with communication was present in 8 (5.26%) patients and 10 (6.58%) families. Less than 15% of patients had documented psychological support and less than 30% had documented spiritual care. Bereavement care was also poorly documented. Conclusion: This study described the demographics of, and evaluated the care offered in the Groote Schuur End-of-Life unit. Much of the care is comparable to current recommendations, but there is concern that symptoms may be underestimated in the absence of formal tools. Recommendations include using different terminology w.r.t. the unit, establishing a consulting and outpatient service based at the hospital, implementing formal symptom assessment tools, implementing the formal policy w.r.t. DNR orders, and improved overall documentation. There is scope for further research on interventions such as this one, especially on its impact on staff and its cost-effectiveness. This model of care achieves care comparable to current global recommendations in end-of-life care and can be implemented in similarly resource-restricted contexts.

Bibliography leaves 66-68. / The Tumelong Hospice in Winterveldt, North West Province, South Africa, is a residential care backup for a home based care program. It is unique in that it is run by a staff of lay caregivers trained in basic palliative care with the support of one professional nurse and a visiting doctor. The hospice experienced criticism from some professionals who feel that lay caregivers are not able to run a residential hospice service. Past experience in Winterveldt has shown that lay caregivers can deliver good care with appropriate training and backup support. A literature review revealed that little research has been done in palliative care in Africa. The aim of this study was to determine patients' experience of care in Tumelong Hospice, and whether the standard of care is acceptable to the people who utilise the serivce.

INTRODUCTION: Heart failure is a chronic cardiac condition that would benefit from palliative care and yet palliative care is still mainly provided for people with cancer or HIV. Patients with end-stage heart failure experience similar clinical symptoms as patients with advanced cancer with significant physical and emotional suffering. This research study investigated and assessed the benefits of palliative care in this vulnerable population at a district hospital in Cape Town and emphasized the importance of a hospital-based palliative care facility. METHODOLOGY: A cross-sectional descriptive qualitative study was conducted with in-depth interviews of people living with heart failure using thematic analysis of patient interviews. The study was conducted at a palliative care facility at a government district hospital. Purposive sampling was used for patient selection. A total of 12 participants were interviewed until data saturation. RESULTS: The mean age of the 7 men and 5 women interviewed was 52 years, the youngest participant was aged 27 years old and the eldest was 78. Analysis of these 12 semi- structured interviews produced five main themes. The first theme that emerged focused on issues of high service usage due to recurrent hospitalizations in the group, the second on communication factors in palliative care. The third theme was on information and education, the fourth on the importance of resources in palliative care and the last theme was on the Abundant Life Palliative Care Programme. DISCUSSION: Findings from this study supports the importance of palliative care for people with heart failure. Palliative care early in the disease aims to improve the quality of life for such patients and their families. The data supports the fact that early referral for palliative care resulted in greater symptom control and benefit to the patient long before hospice care is needed. Previous studies have also proven to reduce re-hospitalization rates of this population while reducing costs to the healthcare system.

Includes bibliographical references. / Background: Quality of life is an important concept because it is the essence of health as defined by the WHO. Pain and other distressing symptoms affect children's quality of life. There is very little published information on pain in children with HIV infection, its prevalence or its affect on their quality of life. This study will add to a growing body of literature on health-related quality of life (HRQOL), but more specifically address these issues in a South African context of HlV/AIDS in children. Such data is currently not available. Methods: A cross sectional descriptive study with an analytic component was performed on a convenience sample of 30 caregivers who attended the Paediatric HIV Clinic at Chris Hani Baragwanath Hospital, Johannesburg. All data was collected by a single investigator over a 4 month period. An established, multidimensional health related quality of life assessment tool (The PedsQL(TM) 4.0) designed for children, was used to measure HRQOL. Results: Mean HRQOL scores were evaluated as well as those for physical and psychosocial health. Scores resembled those of children with other chronic diseases. Disease progression affected the scores with lower values for those children with advanced disease. Where no disclosure of HIV status occurred scores were lower for all dimensions. The prevalence of pain in HIV-affected children was 83%. Caregivers reported 55 individual pains in 12 different regions of the body. On average each patient had 2.3 pain sites. Parents often had difficulty describing the nature of the children's pain. Moderate to severe pain was associated with decreased HRQL scores. Discussion: This study is the first to examine pain and HRQOL in HIV-infected children in South Africa. As the nature of HIV changes to a chronic disease with the availability of antiretroviral treatment, HRQOL will become more important as a medical outcome measure. The PedsQL inventory is brief, easy to understand and takes only about 10 minutes to complete. This makes it an ideal tool for a busy clinic setting. Comprehensive, multidisciplinary health services will be required to minimize long-term illness and disability and to maximize children's potential as they move into adolescence and adulthood. The small study number leant itself to a descriptive study of exploratory nature. A follow up study which includes children's self report in their first language would be valuable.

Background: The prevalence of use of traditional medicines by patients receiving palliative care is poorly documented. In 2002, the World Health Organisation estimated about 4 billion people (80% of the world’s population) used traditional medicines for some aspect of primary healthcare, with 90% of users living in low and middle income countries. Studies in Africa have shown that patients on palliative care are more likely to use traditional medicines especially after the diagnosis of cancer. This study describes the prevalence of and reasons for TM use amongst PC patients and also explores the common herbs used by this population. Methodology: A mixed method descriptive cross sectional study design was used including the following: questionnaire administered to patients attending palliative care clinic and focus group discussions with palliative care patients. Results: 60.4% of palliative care patients (n = 96; males = 53%) reported use of traditional herbal medicines. The majority of survey participants had the diagnosis of cancer (94%; n = 90) and HIV (89%; n = 85). Traditional herbal medicine use was common in participants who had the following symptoms: diarrhoea 83%, anorexia 63%, pain 61% etc. Traditional medicine use was not associated with age, gender, education, occupation, distance from hospital, diagnosis or symptom. 62% of the participants who used herbal medicines did not know the herbs they were taking. Kigelia Africana, Moringa oleifera, Cyphostema sp, and Strychnos innocua were the common herbs used. Cultural practices, limitations of conventional health system and credibility of traditional healers were the main reasons for using traditional herbal medicines. Conclusion: Use of traditional herbal medicines is high among patients receiving palliative care at Mulanje Mission hospital mainly for symptom management and cancer. Further research is needed to investigate effectiveness of identified herbs and also assess their potential herb-drug interactions. Ongoing work including liaison with traditional healers would assist to formulate effective local palliative care management programs that are sensitive to traditional medicine practices.

Introduction-The WHA resolution in 2014 to strengthen PC as a continuum of health care service delivery mandated member states to incorporate PC into their NHS using the PHS. An assessment of a health system will only be complete when the four elements of the PHS that (entrenches palliative care) are assessed alongside preventative, curative and rehabilitative care. Aim-To assess the current status of integration of PC into the PHC centers in Alexandra community in Johannesburg, South Africa. Objectives - 1) to identify the existing policies including budgets available in the clinics relating to PC, 2) to identify the availability of PC essential medicines in the PHC and 3) to survey the HCPs training in PC. Methodology- Each objective has different targets. Objective number 1) has clinic managers as its targets. Objective 2), HCPs and people involved in procuring and prescribing essential medications and objective 3), all the HCPS. Data was collected using structured questionnaires administered by the researcher and analyzed using statistical tables. Results-The clinic mangers are not aware of NPFSPC, there is no provincial policy, budget or any existing policy on PC in any of the clinics. The essential medicines are available in the clinics, only recent graduates has undergraduate trainings in PC, no HCP has any post graduate training in PC at any level (Certificate, Diploma or Masters) as recommended by the WHA resolution to member countries. Skills in PC is close to zero in the PHCs. Conclusion-The study confirm the findings in previous literature and highlights the needs for PC policies and continuous training in PC for HCPs, essential medicines for PC are in the clinics contrary to findings in other LMIC.

Includes abstract.~Includes bibliographical references. / Managing patients whose disease has become unresponsive to anticancer treatment confronts oncologists with major stressors which may range from the management of distressing physical symptoms to complex psychosocial issues. These sets of circumstances prompted the undertaking of this study: An evaluation of the current practices followed by oncologists in private practice in Cape Town, South Africa, in the management of patients with advanced cancer which no longer responds to anticancer treatment and the identification of the needs associated with such management. A descriptive qualitative study was selected for data collection. Cross-sectional, in-depth semi structured face to face interviews were conducted with fifteen radio-oncologists working in five satellite units of a private oncology company in Cape Town. The interviews were conducted with the aid of a topic guide. The process of coding was employed to organise and manage the collected data. The following six themes which had a bearing on the main topic were distilled from the data: Oncologists' experiences pertaining to the management of patients with advanced disease; the difficult discussion necessary when a patient's disease became incurable and when it had to be decided whether anticancer treatment should be stopped; the decision to stop anticancer treatment; advance directives; oncologists’ burnout and the palliative care team approach. A description of challenging aspects associated with the management of terminally ill cancer patients is given. Identified needs include training of staff in palliative care; guidance for oncologists regarding the discussion of and the decision to stop anticancer treatment; implementation of advance directives; the development and employment of a multidisciplinary approach to provide palliative care; and support for oncologists facing burnout. Recommendations were made pertaining to appropriate training in the field of palliative care; the development of guidelines to aid oncologists in the discussion of and decision to stop anticancer treatment and the implementation of advance directives; the provision of palliative care through employment of a multidisciplinary approach led by a palliative care physician; and external support which should be provided by the oncologists' company to prevent and treat burnout.