This thesis seeks to fill the gap in the literature by exploring CHW IEC roles through: a protocol for the Health Information in the Home (HIH) study of the quality of IEC services by Community Care Workers; a structured literature review of the current state of the evidence and a journal manuscript based on the HIH study findings.

This study sought to explore the role of men in the prevention of mother-to-child transmission services in Khayelitsha, South Africa. Two focus group discussions were held with 25 men of unknown status and one focus group discussion held with 12 HIV-positive women in the community. In-depth interviews were also conducted with four HIV-positive couples and five service providers purposely sampled from the community and a health facility, respectively.

Background: While South Africa's Constitution, health legislation and policies value public health (PH) approaches, Public Health Medicine (PHM) specialists are largely invisible in the health services. Despite this, many undertake specialist training. The reasons for this mismatch, for doctors' motivations for this training, and the career paths of PHM specialists are not known – nor is it known if their practice is aligned with the intentions of trainers, policy makers and employers. Postulates for their invisibility are that they are not required, are unknown, are interchangeable, not 'service-ready' or unavailable. Aims: This thesis investigates the match between 'desired', 'actual' and 'intended' use of doctors with PH expertise in contemporary South Africa. It explores the motivations of doctors undertaking PH studies, the actual careers of PHM specialists and the intended roles of this cadre of staff. Methods: Firstly, through an electronic survey, motivations for studying and career paths of doctors completing Master of Public Health (MPH) at the University of Cape Town – the foundational PH training for selected specialist training – were examined. Secondly, through focus groups and in-depth interviews, motivations for specialist training, anticipated career paths and perspectives of the future of PHM and of specialists-intraining (registrars), were probed. An on-line survey of PHM specialists' career paths, their reflections on the speciality's value and future was undertaken. Finally, through in-depth interviews, a qualitative study explored the perspectives of key stakeholders in South Africa's health service about PHM's value in the context of current health system reform. Findings: A number of factors underlie PHM's absence in the services. In post-apartheid South Africa, PH functions have been overshadowed by an inordinate focus on 'personal' curative services. Under current legislation, PHM is largely not a requirement for service positions, resulting in many participants (20%) not registering as specialists. PH practice is context-specific and its core functions are practised by others, resulting in overlapping boundaries between PHM and other trained professionals. Together with poor advocacy for the speciality, these resulted in PHM largely being eclipsed in health system design. In 2010, PHM comprised less than 200 specialists, mainly mature doctors who are increasingly female. There was a close match between 'desired', 'actual' and 'intended' roles of PHM specialists. Unlike doctors who undertook MPH studies to obtain research and technical skills, together with population approaches for career progression, PHM registrars and specialists trained to impact on health systems, underpinned by a commitment to social justice. Specialists' broad theoretical and experiential training produced versatile professionals able to work in complex service settings, with competencies spanning strategic and technical functions, which fast-tracked them for leadership. In 2010, a third of PHM specialists worked for the state health sector and a third for universities, mostly as managers or academics; the rest in NGOs, research institutions or independently. Besides those in 'joint appointment' health service and academic posts, less than a handful worked in designated service specialist posts. Specialists were highly satisfied with their careers. The majority had worked in the state sector at one time, but many had left to pursue academic and other careers. Although salaried specialists' remuneration had improved following the Occupational Specific Dispensation (OSD), this had not affected those in management and would not attract prospective specialists to management positions unless the work environment favouring autonomy and innovation improved. Despite an uneven presence, study participants agreed that the PHM's contribution centred on a 'public health intelligence' function – finding and interpreting information; supporting services through management and leadership; providing policy making and planning capacity and research at various levels. Some argued for PHM to be a requirement for senior line management posts in the future. Conclusions and recommendations: South Africa's current health reform is an opportunity for PHM to refine its professional identity, competencies and location. Being cognisant of its multi-disciplinary nature, it must locate itself in a common identity of a profession and workforce, in "a fabric of many professions dedicated to a common endeavour".10 A 'public health identity' needs to be constructed, reflecting the diverse PH professional functions.11 The desired size, shape and roles of the PH workforce, including PHM specialists, needs to be addressed through fora of PH stakeholders – the governmental health sector, civil society employers, universities, existing and prospective specialists - focussing on positions for specialists and PH professionals, the creation of posts, the design of training curricula, and registrar placements. Research that evaluates and explores the development of the PH workforce in South Africa, comparing it with other country settings, will inform the development and competency of the profession, and the health sector that aims to "improve quality of life for all".

Background The incidence of TB in children under 15 years, accounts for 8% of the global TB burden. In 2018, the World Health Organisation (WHO) estimated that there were approximately 11 000 multi-drug resistant (MDR) TB cases in South Africa. Despite having very clear guidelines on TB treatment programs and management, availability of inexpensive diagnostic tests, curative and preventive therapies, and the widespread use of the BCG vaccines, South Africa continues to have the highest the number of MDR-TB cases per capita. Levofloxacin is used as part of the group of fluoroquinolones in the drug regimen recommended in the treatment of MDR-TB patients. In addition to investigating the clinical impact of levofloxacin as preventative antibiotic therapy, the expected costs of the intervention will be a critical input to determining feasibility and costs effectiveness, which will inform policy and implementation considerations. Methods We performed a cost analysis on using existing data from the Tuberculosis Child Multi-drug-resistant Preventative Therapy (TB-CHAMP) trial, conducted from a TB control program perspective. We used data from 510 childhood household contacts of MDR-TB patients in South Africa that were treated with levofloxacin for 6 months as a preventative therapy for MDR-TB. In our analysis we evaluated the estimated health system cost associated with provision of levofloxacin to childhood contacts of MDRTB patients in South Africa. Results The mean total cost of treating a child household contact, irrespective of their weight band is ZAR 5,289.79. When the cost were analysed by weight categories we found that the cost increased by weight category; ZAR 2,146.78 (under 5 kg), ZAR 4,714.58 (between 5-15.9 kg) and ZAR 6,606.67 (over 16 kg). We performed a comprehensive sensitivity analysis and found that the scheduled clinic visits were the major cost driver. Aside from the scheduled visits we observed that there was an increase in additional health service utilization for children with a weight more than 5kg. Conclusion We envisage that based on our analysis we will be able to inform policy decisions about the management and prevention of childhood household contacts of MDR-TB patients in developing TB themselves.

Includes bibliographical references (leaves 73-80). / Drugs are an important factor of production in health care. They constitute a significant proportion of health care expenditure in both developed and developing countries rendering financing of drugs an important health care concern. Previous studies have focused on health care financing in general and less on drug financing specifically and more so in least developed countries. This study therefore aims to provide an overview of the drug-financing situation in Uganda demonstrating the flow of funds for drugs in the health sector. The study further investigates whether the available financial resources could be sustained over time and assesses financial sustainability of resources for drugs in the public sector required to meet the drug component in the National Minimum Health Care Package. Data collection methods involved in-depth interviews with key informants in the relevant institutions and document reviews of financial records and other major relevant publications. The data obtained was analyzed using well-established methodologies. Financing mechanisms were analyzed using a framework consisting of aspects regarding viability, reliability and level of funding. The fund flows for drugs in the health sector were analyzed using the modified National Health Accounts methodology and finally financial sustainability was assessed using projections from the available financial resources. The study findings reveal a mix of financing mechanisms from both the public and the private sector employed to make drugs available to the population. The largest source of drug funding is out-of-pocket expenditure by households followed by central government tax revenue including donor support. There has been a noted increase in drug funding in the public sector though this is not adequate to cover the quantified drug need in the country. The size of the market for drugs increased over the review period (2001-2004) with an estimated total drug expenditure of 210 billion Uganda shillings. The projections show that the available financial resources for drugs will not be able to cover the predicted drug requirement within the National Minimum Health Care Package more so with the introduction of drugs required to treat new diseases like HIV/AIDS and the change to more expensive treatments for endemic diseases like malaria. The study concludes with policy recommendations urging government's commitment to allocate more resources to health and consequently to drugs so that there is less reliance on donor funding. It recommends that more effective means of utilizing available resources by mobilization of domestic resources including out-of-pocket payments through better-designed and well-managed health insurance schemes.

No description available.

Introduction. Non-Hispanic blacks (blacks) are more insulin resistant compared to non-Hispanic whites (whites), increasing their risk for Type 2 diabetes. The role played by ethnic/racial disparities in the response to physical activity in mediating those higher rates of insulin resistance in blacks is unknown. Because the beneficial effects of exercise are transient and require subsequent doses of exercise to maintain the effect; the metabolic and psychosocial responses to single exercise bouts have strong implications for both opposing insulin resistance and raising the probability that an individual will continue to exercise. Purpose. To compare the metabolic and psychosocial responses to individual bouts of exercise, at the intensity and duration corresponding to the current Institute of Medicine guidelines, in blacks and age/gender/BMI-matched whites. Methods. Insulin sensitivity (hyperinsulinemic-euglycemic clamp) and metabolic flexibility (suppression of resting fat oxidation) along with exercise task self-efficacy, mood, and state-anxiety were assessed before and after a bout of exercise in black and white men and women (metabolic n = 21; psychosocial n = 31). Participants walked on a treadmill at 75% of maximum heart rate for 75 minutes. Exercise sessions were repeated on three separate occasions to assess the cumulative change in psychosocial responses to exercise. Results. There were no ethnic/racial differences in baseline measures of whole-body insulin sensitivity (p = 0.95). Black participants demonstrated larger improvements in the insulin sensitivity response to individual bouts of exercise compared to their white counterparts (+18% vs. -1.8%), which was primarily the result of enhanced non-oxidative glucose disposal during the clamp. Additionally, blacks demonstrated a greater capacity to switch from primarily fat oxidation at rest to primarily carbohydrate oxidation during the clamp (p <0.003). There were no ethnic/racial differences in the psychosocial response to individual bouts of exercise; individual bouts of exercise improved exercise task self-efficacy and reduced psychological distress in both black and white participants (p = 0.006). Black participants reported higher positive in-task mood during all three bouts of exercise (p = 0.003) and lower RPE scores (p = 0.04) during the third exercise bout compared to white participants, despite similar heart rates in both groups. Conclusions. These data demonstrate that metabolic and psychosocial responses to individual bouts of exercise do not help to explain the increased insulin resistance and lower adherence rates to exercise programs reported in blacks compared to whites. If these results are confirmed in a larger, more diverse, free-living population, future research should focus on social determinants of insulin resistance and physical inactivity to obtain a better understanding of the root causes of increased risk of Type 2 diabetes in black populations.

BACKGROUND: Suicide is a preventable public health problem affecting 800 000 people every year and 79% occurs in low to middle incomes countries. Males are mostly affected, and at-risk age groups are adolescents and young adults. Hanging, firearms and ingestion of pesticides are amongst the most common methods of suicide. Prevention strategies have been applied by various countries to target the use of common methods of suicide however there is little evidence that supports detection of suicide risk in healthcare facilities. This study profiles all suicides that occurred in the Western Cape during the year 2011-2015 and their interface with the healthcare facilities up to one year prior to death. OBJECTIVES: This study assesses the incidence of suicides in the Western Cape. It tests for associations between methods of suicide and demographic characteristics for suicide. Ascertains the characteristics of those suicide cases who made previous contact with a healthcare facility in the past 12 months and proposes context specific interventions for the prevention of suicides. METHODS: A retrospective descriptive study was conducted. All suicides recorded by the forensic pathology service during the years 2011-2015 were linked to patient data held by the provincial health data centre. A total of 3 561 suicides were recorded during the study period. Crude suicide rates were calculated using population denominator from the Statistics South Africa's national census projections. Multiple logistic regression was used to determine associations between the group utilising various methods of suicide and demographic characteristics. FINDINGS: Males were found to be four times more likely to die from suicide compared to females. The age groups most at risk were 20-39 years. Hanging was the method of choice by males and overdose on medication, in females. Two thirds of the 2 367 suicides were positively linked to healthcare facilities. Most cases who sought healthcare up to one year prior to suicide were males that presented with ‘other medical conditions' rather than mental health conditions. CONCLUSION: This study highlights missed opportunities for the detection of suicide risk for those who seek healthcare for all healthcare conditions. Although suicide rates have remained constant over the assessment period, a key focus for prevention should be interventions applied at healthcare facilities as well as other ‘upstream' preventions that reduce the availability of various methods for suicide.

OBJECTIVES: Depression is the leading cause of disability in the world and its association with oral health is not fully established. The purpose of this study was to examine the association between depression and the patient’s willingness to go to the dentist on their own. A secondary data analysis was performed to study the association between depression and the patient’s last dental visit. METHODS: This is a cross-sectional analysis of NHANES deidentified data from 2011 to 2018 (N =17,330). Logistic regression models were tested for reason and the time of last dental visit and covariates. Multiple logistic regression models were analyzed for associations between dental visit variables and the outcomes. RESULTS: After adjusting for potential confounders: age, gender, ethnicity, marital status; levels of income and education we found statistically significant results in both bivariate and adjusted multivariate regression models that people with moderate to severe depression were 0.7 times less likely to visit the dentist on the own (OR 0.7, CI 0.6 -0.8) as compared to patients with none to mild depression. For the secondary outcome variable of interest, people with moderate to severe depression has 1.2 times the odds of having visited the dentist more than 2 years ago as compared to people with none to mild depression (OR 1.23, CI 1.08 -1.4). CONCLUSIONS: Our results suggest that people with moderate to severe depression tend to avoid visiting dentist for regular checkups and cleanings and are more likely to delay their visit to more than two years.

It is important to examine the forces that influence urban hospital financial sustainability and survival because nearly 250 million Americans rely on these hospitals. The COVID-19 pandemic magnified financial pressures on urban hospitals, especially those in low-income areas and communities of color, raising their risk of closing, and jeopardizing access for their patients. Most studies of the financial sustainability and survival of urban U.S. hospitals were conducted during the 1970s through the 1990s. They focused on various economic forces influencing a hospital’s financial sustainability and survival over time and across space (cities and states). Few studies have examined these forces in the last twenty years. Even fewer have considered political influences on hospital sustainability . Using a modified Resource Dependence Theory (an organizational survival theory), one that adds sociodemographic and political constructs, this study updates the literature by pursuing three aims. Aim 1 is a cross-sectional study that examines predictors of common measures of financial sustainability, using 2019 American Hospital Directory financial data that abstract hospitals’ Medicare Cost Reports. This is the most recent year available. Aim 2 uses these data to evaluate inter-state differences in hospital financial performance. It separately examines hospitals in states with high and low financially performing hospitals. Aim 3 uses longitudinal comparative case studies to examine pairs of financially distressed urban hospitals in three metropolitan areas with high hospital closure rates. Each city pair consists of one closed hospital and one surviving hospital. Findings suggest that political forces and public interventions are as important as financial pressures in shaping the sustainability and survival of urban hospitals. This study is useful in three ways. First, it updates the evidence on hospital financial sustainability and survival. Second, it guides the development of new policies to protect needed hospitals in several states. Third, it points toward ways to support equitable access to health care.