Background: The Choice on Termination of Pregnancy Act of 1996 makes provision for access to safe abortion, free of charge in government facilities in South Africa. Despite liberal abortion legislation, unsafe abortion persists in South Africa. Increasing access to information about safe and legal abortion providers through methods such as online databases, community health workers, and telephone hotlines will most likely decrease the number of women using illegal/unsafe abortion providers. This study aims to: determine how women prefer to access information on safe abortion providers and services in Cape Town, South Africa; determine which avenues of obtaining information are most accessible for women; and determine if there is a preferential difference in accessing information based on age, education and socioeconomic status. The purpose of this research is to provide knowledge on how to increase the accessibility of safe abortion providers and services through preferential information dissemination. Methods: Participants were recruited from Marie Stopes International South Africa, a non-profit organization (NGO) that provides sexual and reproductive health services in Cape Town, South Africa. Recruitment of participants took place between September and November 2017. Eligibility criteria included that participants be between 18 to 49 years of age and presenting for an abortion. Data was collected through a self-administered paper-based questionnaire. There were four sections of the questionnaire: Socio-Demographics, Reproductive History, Interactions with Sources of Health Information, and Preferred Method to Access Information. Results: Ninety-eight women completed the self-administered questionnaire. Over 59 % of women preferred to use the internet to access information about safe abortion providers. Participants had access to the internet via their mobile phones, computers, laptops, and tablets. Internet access was more accessible for women who had completed secondary school and/or acquired a post-secondary degree, was employed, and/or earned more than USD 258 a month. Participants also preferred to use health care providers (29%), and community health workers (20%) for accessing information about safe and legal abortion services. Conclusions: This study identified the most preferred and acceptable methods to access information about safe abortion providers by women at an NGO clinic in Cape Town. Community health workers, the internet and health care providers and hotlines should be used to formulate dissemination methods that are tailored to women in South Africa. Information about government facilities, their current abortion provision status, and the type of abortion services they provide should be compiled, continually updated, and made available to women in dissemination methods that are most preferred, accessible and acceptable to women. Options for socioeconomically disadvantaged women should be developed in conjunction with Internet-based options for accessing information about safe abortion providers and services.

Background: Diabetes Mellitus is an emerging public health problem in Africa. Evidence suggests that globalization, rapid urbanization and a nutritional transition have led to the rise in the prevalence of diabetes mellitus in Africa. Diabetic retinopathy is a common complication of diabetes mellitus that causes visual impairment and subsequent blindness. Early detection and prompt treatment can prevent blindness in up to 90% of patients. The common risk factors for diabetic retinopathy include hypertension, hyperglycemia and long duration of diabetes. Other risk factors include obesity, hyperlipidemia, smoking, puberty and pregnancy. There is limited data on diabetic retinopathy and its associated risk factors in Zambia. An understanding of these factors would help in the effective management of diabetic retinopathy. Methods: A secondary data analysis of data obtained from a hospital-based cross-sectional study of diabetic patients attending diabetic clinics in the Copperbelt Province in Zambia was carried out. All diabetic patients that attended the retinopathy-screening program between April 2012 and September 2012 were eligible for the primary study. The secondary data analysis was restricted to patients 18 years and older. Data analysis was carried out by R version 3.3.1. The characteristics of the study population were summarized using descriptive statistics. Univariate logistic regression analysis was used to select potential candidates for the multivariate regression model at p-value cutoff point ≤ 0.25 and variables of known clinical relevance were also included in the multivariable analysis. The final model fitness was checked using Hosmer and Lemeshow chi-square test. Finally, statistical significance was tested at P-value <0.05. Results: The prevalence of diabetic retinopathy was 19.4%. Multivariate analysis showed that the odds of diabetic retinopathy were significantly associated with age (OR =1.05: 95%Cl; 1.03-1.06), duration (OR=1.39: 95%Cl; 1.27-1.52), weight (OR =0.98: 95%Cl; 0.97-0.98), blood glucose (OR =1.04: 95Cl; 1.02-1.07) and systolic blood pressure (OR = 1.01: 95Cl; 1.00-1.02). Conclusion: Duration of diabetes, age, systolic blood pressure, weight and blood glucose levels were significantly associated with diabetic retinopathy in this study. More comprehensive population screening strategies and treatment programs addressing these risk factors should be put in place.

[Background] Tuberculosis (TB) is a significant global health problem and the development of new TB vaccines is one strategy proposed to address this scourge. Adolescents are a potential target group for new TB vaccines. Limited data are available in the scientific literature on the epidemiology of TB in adolescents. This thesis aimed to add substantial data on adolescent TB epidemiology through a cohort study of TB infection and disease in adolescents in a high burden setting. Such data will support clinical trials of new TB vaccines in adolescents but the knowledge gained will also be of value for TB Control Programmes. [Methods] Adolescents aged 12-18 years were recruited from 11 high schools in the rural town of Worcester and surrounding areas of the Western Cape Province of South Africa. They were screened at baseline for latent TB infection using both the tuberculin skin test (TST) and an interferon gamma release assay, the QuantiFERON® TB Gold (in-tube) assay (QFT). They were also screened for TB disease using an algorithm composed of a set of screening tests. They were followed up for at least two years for incident TB and the predictive value of the baseline TST and QFT for incident TB disease was compared. Demographic, socio-economic and clinical predictive factors for latent TB infection prevalence at enrolment and for incident TB disease during follow up were determined. A survey of attitudes to participation in TB vaccine clinical trials in a subset of adolescents from these schools was also conducted. Both studies had ethics approval. Standard scientific statistical techniques were used to analyse the data. [Results] Fifty eight percent (6363) of the target population of 10,492 adolescents were recruited into the main cohort study. A prevalence of latent TB infection amongst the study participants at enrolment of 55% (TST) and 51% (QFT) was found. Predictive factors for latent infection were: being of black or mixed race origin compared to being of white or indian origin, older age (>15 years), previous household TB contact, low parental income and low education status of the parents. The TST and QFT were found to have good agreement (% agreement 84.8%, kappa [κ] = 0.70, 95%CI 0.68–0.71) in contrast to certain studies in other settings. A baseline prevalence of TB disease of 3/1000 was found in adolescents. While the TST and QFT were sensitive predictors of the presence of TB disease, none of the screening tests evaluated (TB related symptoms, recent household contact, TST or QFT) had high positive predictive values (all less than 2%) making these tests impractical for routine use. Given the imperative for screening in TB vaccine trials, these data are important for deciding on choice of screening tests in a clinical trial setting. Both the TST and QFT were found to be predictive of the onset of TB and were equally predictive. An incidence of bacteriologically confirmed active TB of 0.45/100 (95% confidence interval 0.29-0.72) person years (pyrs) was found in this cohort. Using different definitions of active TB, the rate varied from 0.31-0.59/ 100 pyrs. Risk factors gleaned at baseline that were predictive of the onset of TB disease were: being of black or mixed race origin, maternal education of primary school or less or unknown, evidence of latent infection (positive TST or QFT) and absence of a BCG scar. Knowledge of TB was fair amongst adolescents but willingness to participate in TB vaccine trials varied depending on the procedures involved. [Limitations] Important limitations were as follows. The data presented are likely to underestimate the true prevalence and incidence of TB amongst adolescents in general since adolescents not at school are likely to have higher rates of TB than those attending school. On the other hand TB rates amongst those recruited are likely to have been higher than those not agreeing to participate since participation rates were higher in poorer schools than in more affluent schools. Chest radiographs as a screening tool for TB could not be evaluated because this method of screening was excluded for logistical reasons. The number of TB cases is likely to have been underestimated since smear screening was the main method of case detection and smear negative culture positive TB cases would have been missed. [Application of results] A range of data was obtained through these analyses which will be very useful for planning TB vaccine trials in adolescents and also for TB Control Programmes. Since data were collected in a high TB burden setting, the findings are mainly generalisable to such settings rather than low burden settings. Nevertheless, efficacy trials of new TB vaccines are likely to be carried out in high TB burden settings making these results highly relevant to TB vaccine efficacy trial planning. Policy with respect to the use of interferon gamma release assays will be informed by this data given that it is a relatively new diagnostic modality. Knowledge of the baseline prevalence of TB disease and the utility of different screening tools amongst healthy adolescents would help the design and costing of screening approaches to be used in TB vaccine clinical trials which include adolescents. The data on the prevalence of latent TB infection will assist with the selection of TB vaccine candidates for this target group will be of value given that certain vaccines are designed to target those with latent infection. These data will also support planning where latent TB infection is an exclusion criterion such as in safety trials. TB incidence rates can be used to plan samples sizes for efficacy trials. The comparison of the TST and QFT with respect to prevalence of latent TB infection and predictive value for TB disease provide evidence for policies on the use of these tools in clinical trials and for TB Control Programmes in high burden settings. The fact that these measures showed good agreement and were equally predictive of the onset of TB disease, suggest that the QFT need not replace the TST in current routine practice. However, the two tests may be used interchangeably to equal effect. The knowledge and attitudes of adolescents towards participation in TB vaccine trials provides some guidance with respect to what to expect when approaching this group for recruitment purposes. In summary, the prevalence of latent TB infection, the prevalence and incidence of TB disease and predictive factors for latent infection and disease as well as the knowledge and attitudes of adolescents towards participating in TB vaccine trials are described in this thesis. The application of these results to TB vaccines trials and potential value in TB Control Programmes is discussed.

Includes bibliographical references (leaves 59-67). / This study aims to use factor analysis to increase our understanding of how these threats covary and comibe to increase the vulnerability of groups of children. Data was drawn from a survey of children aged 6-14 in Kanana in the North West Province, which was part of a larger study to develop best practice interventions for working with orphaned and vulnerable children.

Includes bibliographical references (leaves 53-60). / Pneumocystis pneumonia (PCP) is an important cause of morbidity and mortality amongst HIV-infected children in Africa. Definitive diagnostic resources for PCP in Africa are limited due to their expense and technical difficulty, however recognising and treating children at risk is essential. As management decisions for children with pneumonia are made primarily on a clinical basis in many African regions, it is important to attempt to define a valid clinical diagnostic technique for PCP that could be used by clinicians to determine the use of correct empirical antibiotic therapy. The objectives of this study were to identify clinical features (associated with PCP in HIV-infected children hospitalised with pneumonia, to determine the combination of features that best predicts PCP in these children, and to calculate the diagnostic accuracy of these features. This study was a re-analysis of a database of a prospective study. Consecutive children below ten years of age, with a primary diagnosis of pneumonia or severe pneumonia, and who were known to be HIV-infected or were suspected of having HIV infection, were included prospectively over a 12 month period. Clinical data and diagnostic testing for PCP were obtained on admission. Bi­ and multivariate analysis of associations of the clinical variables with PCP were performed using logistic regression, to identify the combination of variables that best predicted PCP. The diagnostic accuracy of the best predicted features were calculated.

Includes bibliographical references. / The prevalence of late attendance for antenatal care in South Africa remains high despite the reported benefits of early initiation of antenatal care. The study aimedat identifying factors associated with late initiation of antenatal care. Methods: Cross sectional survey data collected for a FAS prevention programme in rural and urban South Africa were used. The primary study made use of face-to-face interviews with female participants the age range of 18 to 44 years. The dependent variable, gestational age, was categorized into a binary variable across 4 months gestational age. Independent variables consisted of scales and categorical variables (mostly binary) within the following domains: (a) socio-demographic factors; (b) characteristics of index pregnancy including substance use information; (c) psychosocial factors; (d) community factors; and (e) partner characteristics.

Background: A leading research priority worldwide is the need to improve the lives of those with disabilities through the effective development of interventions that can be carried out by non-specialists. Recent research has indicated that parent training interventions have shown to benefit both children with, and parents of children with disabilities. Aims: This systematic review sought to assess the effectiveness of interventions aimed at increasing parental self-efficacy levels in parents of young children with developmental disabilities. Methods and Procedures: We conducted a broad literature search across a number of databases to identify all relevant prospective studies meeting our study objective. Articles were selected using predefined criteria and data were extracted onto a purposely-designed data extracted form.

Background: Globally, food allergies (FAs) have become a public health concern with research suggesting a rising prevalence. FAs affect both the individual and their family advocating for a need to understand the extent of the problem. Allergies have increasingly been recognised as diseases of life-style resulting from interaction between genes and the environment in both the pre and post-natal periods. Various factors including socio-economic status (SES) have been identified from studies as risk factors that are associated with FAs in children. Generally higher SES has been correlated with improved health outcomes, however, in respiratory allergies higher SES may be associated with higher prevalence. With regards to SES as a risk factor for food allergy development, literature has indicated evidence of a relationship between SES and allergies but with conflicting results of both high and low SES postulated as risk factors. Methodology: This study is a sub-study of the South African Food sensitisation and Food Allergy (SAFFA) study, an on-going cross-sectional, observational study of IgE-mediated food allergy in an unselected population of children aged 12-36 months. The aim is to explore the influence of SES on food sensitisation and food allergy prevalence in children. We used a variety of measures of SES including household size, parental education, employment status and household income to investigate the association between SES and food allergy prevalence using sensitisation, self-reported respiratory and skin allergy and challenge proven food allergy data from children across the urban Cape Town Metropole. Associations between the SES variables and sensitisation/allergy were assessed using the Z-test for proportions and Chi-square/Fisher's exact. Part A comprises the protocol which describes the methodology of the research. Part B is the review of literature on food allergy prevalence and risk factors associated with food allergy development. Section C presents the "journal ready" manuscript according to the requirements of the Annals of Allergy, Asthma & Immunology Journal (Appendix 3). Results: The prevalence of low level sensitisation (at Skin Prick Test (SPT) ≥1mm) to any food was 12.3%, medium level (at SPT≥3mm) was 9.6%, high level (at SPT≥7mm) was 4.5% and challenge proven IgE mediated FA was 2.4%. Of the total 739 participants in the sample, 91 were sensitised to 1 or more foods. A trend of increased sensitisation at SPT≥1mm, ≥3mm, ≥7mm and proven food allergy in children of parents with tertiary education was observed (14.8%, 11.9%, 5.8% and 2.9%) compared to parents who attained primary/secondary education (10.5%, 7.9%, 3.5%, and 2.1%) respectively though these results did not reach statistical significance. Highest risk for food sensitisation (FS) and FA were in children with parents who are employed (p=0.03) and in children who are from homes with higher household income (p=0.02). Household size showed no association with FS and FA. No significant differences in sensitisation patterns were noted between ethnic groups. Conclusion: The analysis showed an existing burden of IgE mediated FAs in South African children advocating for diagnosis and management. SES is associated with food allergy in young children with a positive relationship to parental employment status and income.

Includes bibliographical references. / [Background] Research in adults and older children has shown an association between Mycobacterium tuberculosis and helminth infection, with those infected with helminths at greater risk of tuberculosis. This association is believed to be on the basis that chronic helminth infection can result in a functional impairment of the immune response that is necessary to clear or control infection by Mycobacterium tuberculosis (Elias et al. 2001; Rook et al. 2006; Fincham 2001). It is thus possible that the introduction of regular deworming programmes in a vulnerable population of children under the age of five years could assist their immune systems to ward off tuberculosis infection and reduce the risk of tuberculosis disease in such a population. A randomised controlled trial to compare two methods of administering bacille Camlette-Guerin (BCG) vaccination to newborns from a high tuberculosis risk population provided an opportunity to test this hypothesis in a sub-study. [Objective] The objective of this study is to determine if young children in a high-risk tuberculosis population who have been vaccinated with BCG at birth and have been treated for helminth infection are at lower risk of tuberculosis disease than children who have been vaccinated with BCG at birth but not treated for helminth infection. [Method] A case control study nested within a cohort recruited for a separate randomised control trial to compare two methods of administering BCG vaccination was carried out. Children who presented to their local clinic or hospital with symptoms of tuberculosis or a history of exposure to tuberculosis were admitted to a case verification (CV) ward for investigation of tuberculosis. Investigation of tuberculosis included a detailed history, including past helminth treatment, physical examination, tuberculin skin test, chest radiograph, gastric washing and induced sputum for culture of tuberculosis and clinical examination. A diagnostic algorithm was developed by specialist physicians and biostatisticians to classify the children into one of five tuberculosis categories. A total of 510 children (median age 18.13 months) were included in the primary analysis of this case control study. Those defined as cases were the 328 classified as "definite or probable TB" and 182, classified as "not TB", comprised the control group. Those classified as "possible TB" or "unlikely TB" were excluded. A secondary analysis was performed that included the 337 children who had been classified as "unlikely TB" with the controls resulting in a total of 847 children (median age 18.37 months). The 328 children classified as "definite or probable TB" were defined as cases and the 519 classified as "unlikely or not TB" comprised the control group. Univariate analysis was used to explore a possible relationship between tuberculosis and helminth treatment using all the variables in the sub-study (n=510 primary analysis; n=847 secondary analysis). For both the primary and secondary analysis a multivariate logistic regression model was built using a reduced sample that had a complete set of data for all the variables: primary analysis (n=435); secondary analysis (n=724). This final model was then fitted on a more complete sample as the final variables selected had fewer missing data for the observations: primary analysis (n=493); secondary analysis (n=822). [Result] A total of 35.69% of the study sample in the primary analysis had been treated for helminth infection. The proportion of children who had been treated for helminth infection was similar in the cases and controls (35.98% and 35.16% respectively). Univariate logistic regression showed no association between tuberculosis and treatment for helminth infection: [odds ratio (OR) 1.04; 95% confidence interval (CI) 0.71 - 1.51]. Multivariate analysis adjusted for the effect of nutritional status, recorded as height for age z score (haz), number of occupants sharing the same dwelling as the child, gender and birth site showed a similar result: (OR 1.03; 95% CI 0.69 " 1.53). The OR is very close to 1 with a 95% CI that includes 1, which indicates that there is not a statistically significant association between tuberculosis and helminth treatment. In the secondary analysis, a total of 38.61% of the study sample had been treated for helminth infection. In this analysis the proportion of children who had been treated for helminth infection showed a difference between the cases and controls (35.98% and 40.27% respectively). Univariate logistic regression showed a 17% relative reduction in tuberculosis odds but this was not a statistically significant result: (OR 0.83; 95% CI 0.63 " 1.11). Multivariate analysis adjusted for the effect of haz, number of children sharing the same dwelling as the child and gender, showed a similar result: (OR 0.85; 95% CI 0.63 " 1.15). [Conclusion] The primary analysis of this observational study does not support the hypothesis that helminth treatment reduces the risk of tuberculosis disease in young children in a high-risk tuberculosis population. Although the secondary analysis showed a 15% relative reduction in tuberculosis odds after adjusting for the effect of haz, number of occupants sharing the same dwelling as the child and gender, this was not a statistically significant result. [Final Conclusion] This study does not support the hypothesis that helminth treatment reduces the risk of tuberculosis disease in young children in a high-risk tuberculosis population.

Includes bibliographical references (leaves 95-104). / Chronic pain is considered a significant burden at both a personal and social level. Not only does it lead to individual suffering and loss of work or social roles, but it also places a great demand on health care systems. Chronic pain has been shown to be associated with both depression and anxiety disorders, adding to the drain on society. Most of the existing research on chronic pain and its association with mental disorders has focused on Europe and North America, with little research firom developing countries. There are few data on the prevalence of chronic pain at a population level in South Africa, and no research into the association between chronic pain and mental health. This study assessed the population prevaicnce and demographic characteristics of people with chronic pain conditions in South Africa, focusing on arthritisirhenrnatisrn and chronic back/neck pain, the two most common forms of chronic pain. The thesis examined the associations between these chronic pain conditions and common mental disorders in South Africa, with particular attention to possible gender differences in this association.