High pest burdens in low-income urban areas pose a significant public health threat to residents due to pest-induced diseases and other negative health consequences. Furthermore, pests can also be a source of nuisance and social stigma. To ward off pests and the problems they are associated with, many residents of socioeconomically disadvantaged urban areas frequently use pesticides, including highly toxic illegal pesticides. Inappropriate and indiscriminate use of pesticide is a concern since pesticide exposures can put residents, especially children, at risk for negative health effects. While pesticide use and exposures are common in many low socioeconomic urban areas globally, pesticide-induced adverse health effects are of particular concern in developing countries, such as South Africa, where pesticide regulations and enforcement thereof is often lacking. Following the alarming rise in number of children hospitalized with pesticide poisoning in the Cape Town surrounds, researchers at the University of Cape Town conducted a study whose aim was to identify common in-home pests, pesticide use and exposure patterns, and pesticide risk perceptions in Khayelitsha and Philippi, two low socioeconomic communities of Cape Town. This study was part of the larger project and was focused on investigating factors that contribute to pest infestation in low socioeconomic urban areas. An analysis of qualitative data that examined factors in housing, environment and practices and pest control behaviours of poor urban residents that facilitate pest infestation is presented in this mini-dissertation. The protocol (Part A) describes the study population and the methods used to collect and analyse the data. The structured literature review (Part B) describes the double health burden from pests and pesticide exposure faced by low-income urban residents. It also discusses the poverty-related factors that contribute to pest infestations in impoverished urban areas. Lastly, it critically evaluates research on alternative non-toxic pest control methods relevant for low socioeconomic urban communities.

Strokes and ischaemic heart disease are among the top ten causes of death in South Africa. Given that burden of disease, it is important to establish whether interventions aimed at preventing cardiovascular disease are not only effective, but cost effective too. Cost-effectiveness analyses compare interventions in terms of both their costs and consequences and are a useful tool for policymakers. Statins reduce the risk of cardiovascular events such as myocardial infarctions and strokes, by lowering low density lipoprotein cholesterol (LDL-C) concentrations. Several studies, mostly conducted in Europe or North America, have demonstrated that statins are cost effective, particularly when used to reduce the risk of further cardiovascular events in patients who already have cardiovascular disease (secondary prevention). Despite their widespread use, there are no published cost-effectiveness analyses of statins for the secondary prevention of cardiovascular disease in South Africa. There are also only limited local efficacy data from clinical trials and no costing data of cardiovascular events from a public healthcare sector perspective. There is some debate regarding the optimal statin dose. Some guidelines recommend increasing statin doses until target LDL-C concentrations are achieved, while others recommend prescribing statins at a fixed high dose without monitoring LDL-C. Monitoring LDL-C is relatively expensive compared to the cost of statins, but there is limited evidence that it might improve adherence. I compared the costs (from a provider perspective) and outcomes (life years), of increasing statin doses based on regular measurement of LDL-C concentrations, to achieve a target LDL-C concentration of <1.8 mmol/L; prescribing atorvastatin 80 mg without LDL-C monitoring; and the status quo, simvastatin 20 mg without LDL-C monitoring. I constructed a Markov model with annual cycles; a five-year timeline; starting age of 60 years; and the following health states: ≤1 year after first cardiovascular event, ≤1 year after subsequent cardiovascular event, >1 year after any cardiovascular event, and dead. I estimated transition probabilities using published literature. I estimated the costs of hospitalisation for myocardial infarctions, strokes, unstable angina pectoris and coronary revascularisation procedures using health services utilisation and expenditure data from a sample of patients at a public sector hospital. I discounted costs and outcomes at 3% per year; and explored alternative scenarios and timelines in sensitivity analyses. Atorvastatin 80 mg without LDL-C monitoring, was both the cheapest and most effective option over a five-year period. It remained the most effective option over a lifetime period, but with an incremental cost-effectiveness ratio (ICER) of $146.94 per life year gained relative to the status quo. Treat to target was as effective as atorvastatin 80 mg if I assumed adherence rates of 80% and 60% respectively, but with an ICER of $54 930.96. Treat to target would dominate atorvastin 80 mg only if the frequency of LDL-C monitoring was reduced from 3-monthly to 6-monthly until targets were reached, and the cost of LDL-C monitoring decreased by $9.25 (84%). Fixed-dose statin treatment without cholesterol monitoring is the most cost-effective option for providing statins for the secondary prevention of cardiovascular disease. The costs of regular LDL-C monitoring currently make a treat to target strategy unaffordable in our setting. These results might be used to help guide policy regarding secondary prevention of cardiovascular disease in South Africa.

Includes bibliographical references (leaves 59-63). / We conducted a systematic review and meta-analysis of randomised and quasi-randomised trials to determine the effectiveness of community-based rehabilitation versus hospital/institution based rehabilitation in providing rehabilitative services to people with stroke with functional limitations and participation restriction. Data sources: Using a highly sensitive search strategy, duplicate searches were conducted for the following databases from January 1976 to May 2010: MEDLINE via PubMed, African Wide Information via EBSCO, Academic Search Premier via EBSCO, Cochrane CENTRAL, CINAHL, PsycInfo, PEDro. Review methods: Abstracts were scanned in duplicate for all randomised and quasi-randomised trials comparing the effectiveness of community-based rehabilitation with hospital/institution based rehabilitation in providing rehabiliative service to people with stroke with functional limitations and participation restriction. For this review, the primary outcome was functional independence while secondary outcomes included quality of life, physical, psychological and social functioning and, community participation of people with stroke and their caregivers. Results: Twelve randomised controlled trials with 2707 people with stroke were included. Percentage of males included in studies ranged from 42% to 75% and the participants ranged in age from a mean or median of 52 years to 78 years for those receiving the intervention and 55 years to 80 years for control participants. The treatment duration of community-based rehabilitation programmes ranged from three weeks to six months. Overall the meta-analysis found no evidence for the effectiveness of community-based rehabilitation as compared with hospital/institution based rehabilitation with respect to functional outcome (Standardised Mean Difference (SMD) 0.09; 95% Confidence Interval (CI) -0.08 to 0.26) or quality of life (Mean Difference (MD) 1.32; 95% CI -4.30 to 6.93) or carer strain (MD 0.76; 95% CI -0.19 to 1.77). Subgroup analyses at three months showed a significant effect for community-based rehabilitation over hospital/institution based rehabilitation on quality of life (MD 5.00; 95% CI 0.82 to 9.18); however, this effect was not maintained at six months. Cost-effectiveness tended towards a cost reduction associated with community-based rehabilitation.Conclusion: Use of community-based rehabilitation may be associated with positive and negative effects. However, there is currently insufficient supporting evidence to justify the implementation of community-based rehabilitation for stroke rehabilitation. A stronger evidence base is required to adequately inform health policy decisions and guide methods of service delivery to effectively improve stroke patient outcomes.

Late antenatal care (ANC) booking remains the trend in most countries in sub- Saharan Africa despite the known benefits of early booking. Infrequent, poor and no antenatal care are among the most frequent patient-related avoidable factors and missed opportunities identified for many cases of maternal death in South Africa. Whilst most country guidelines recommend that a woman initiates antenatal care (ANC) within the first 16 weeks of pregnancy and the Basic Antenatal Care (BANC) approach recommends at least 4 visits during pregnancy, this has not translated into practice amongst women in South Africa. Disparities in timing of initiation of antenatal care and frequency of attendance exist between countries and between rural and urban settings within a country. Previous studies have identified demographic factors, physical access to health facilities, parity, lack of health education, relationships with health care providers and misconceptions of antenatal care (ANC) as factors influencing timing of ANC booking. Psychosocial factors have been found to also play an important role in timing and frequency of attendance to antenatal care. Strong social capital and social support were identified as protective factors against late ANC initiation and inadequate attendance whilst substance use, experiencing negative feelings about the pregnancy, misconceptions about antenatal care, poor mental health were mostly associated with poor ANC attendance. In the literature, partner characteristics and cultural and religious beliefs were associated with both early and late ANC initiation depending on the specific factors investigated. Research on the associations between psychosocial factors and antenatal care attendance is currently quite limited and fairly new and in addition, some psychosocial factors may not be associated with timing of initiation but may have an effect on the frequency of attendance of follow-up visits. The aim of the study was to examine the association between psychosocial factors and ANC booking to determine whether psychosocial factors (particularly substance use, feelings about pregnancy, social capital, social support, cultural beliefs, mental health perceptions, self-esteem and partner characteristics) were associated with not only timing of initiation of antenatal care but also frequency of attendance of antenatal care visits during a previous pregnancy among women in an urban and rural location in South Africa.

The concept of health committees has been promoted as an effective mechanism for assisting communities to realize their health rights. These committees tend to be formal structures made up of representatives from local government, health facilities and communities. Much of the attention has focused on identifying strategies and interventions to strengthen health committees as vehicles for achieving the right to health and the focus has been on educating, raising awareness, training and policy advocacy. However, it is important to understand what participation looks like on the ground and to take in to account the day-to-day challenges and obstacles that health committees as a vehicle for community participation; interacting with stakeholders; and getting support from health facility managers and staff. These factors impact on the health committees 'ability to facilitate and support community participation, yet they are driven by power dynamics and human interactions and relationships. Little attention has been paid to these dynamics, which play an important role in meaningful community participation at grassroots. The Power Cube framework was used to explore the multiple dimensions of power that hinder or enable the health committees' ability to support the community to realize their right to health. The Power Cube framework allowed for an investigation of how power dynamics are perceived by a particular group, as well as providing for the comparison of different social, economic and political context. It enabled a comparison with different contexts where there are policies for supporting the community participation in health but implementation has been difficult it in practice.

This research project, undertaken for a MPH dissertation investigated and analysed the situation of diabetes and diabetic retinopathy services and management systems in four (4) government hospitals in Akwa Ibom State Nigeria using the World Health Organisation (WHO) Tool for the Assessment of Diabetic Retinopathy and Diabetes Management Systems (TADDS). Part A is the research protocol, which explains the background and the key components of this research study. This is a cross sectional descriptive case study involving primary data collection. We conducted the case study using the WHO TADDS to survey health personnel involved in the management of diabetes mellitus (DM) and diabetic retinopathy (DR) in four (4) government hospitals in Akwa Ibom State. Concurrently, semi-structured interviews were conducted with key informants to investigate and analyse the situation of DM and DR services in Akwa Ibom State in Nigeria. Part B is a structured literature review of published articles, online reports, and summaries related to DR. It covers the review of scientific evidence (clinical overview) about the aetiology and prevention of DR and the known risk factors; the review of epidemiological evidence on DM and DR globally and in sub-Saharan Africa (SSA); and the review of the evidence on effectiveness and cost-effectiveness of public health and health system interventions for the prevention and management of DR. Part C is the journal-ready manuscript. In this part, the format of the journal Ophthalmic Epidemiology was used to present the research project and its main findings. Part D contains all the relevant appendices used during the research project.

Bibliography: leaves 37-38. / Malaria is a major public health problem in Namibia and this problem warrants special attention in terms of monitoring the trends and formulating controls and prevention strategies at all levels of the health care system and the community. Malaria accounts for more than 40 % of the diagnosed outpatients cases in the health facilities. Malaria is the leading cause of ill health and deaths among both children and adults, particularly in the northern regions of Namibia where about 60% of the population lives. This disease is seasonal with the potential for epidemic proportions, which are related to exceptionally heavy rainfall. There is increasing evidence that malaria cases are poorly managed and the staffs is poorly supervised, especially at clinic levels where all malaria cases are clinically diagnosed A number of health workers have been trained in various aspects of malaria control including case management; there is a need to evaluate their performance in order to sustain high quality care. Their performance must be evaluated regularly and feedback given so that practices could be adjusted and improved. What is required is a validated, acceptable, applicable and useful instrument that can be used routinely for assessment clinic based quality care performance. The Ministry of Health and Social Services developed a national guideline for malaria case management used at different facilities and levels in the country. There is no affordable and applicable continuous assessment instrument of the quality of health care that can be used by primary health care supervisors to assess the quality of malaria case management at health care clinics. The aim of this study is to develop and pilot a performance based quality assessment instrument for routine quality assessment of malaria case management to be used by district supervisors in public health care clinics in Namibia. The instrument developed was found to be useful by the district supervisors and the clinic staff interviewed during the assessment period. Poor referral systems, lack of training on malaria case management and poor supervision were the major problems identified in this pilot study. These problems have been discussed with the clinic staffs and the district supervisors concerned for appropriate action. The developed instrument has enabled me to obtain a rapid and general overview of the clinic performances related to quality services provided to malaria patients. The information obtained evidenced the usefulness of this instrument. This pilot study has established the baseline information for quality assessment of malaria case management for the primary health care clinics assessed. However, it has been noted that continuous assessment of health services performances is very important if the quality of malaria case management is to be achieved.

Includes bibliographical references. / This study sought to determine: i) the extent of continuity in Cape Town public sector clinics; ii) patients' views of continuity; iii) senior managers ideas of how continuity can be improved; iv) clinical managers' views of a proposed practice team model to improve continuity. Continuity, defined as present if patients saw the same doctor for at least 80% of visits in a 2 year period, was present for less than 9% of patients.

Includes bibliographical references (leaves 75-81). / Many researchers consider breastfeeding as the best way to feed an infant, as it provides numerous benefits both physical and psychological for mother and child (Baumslag & Michels, 1995; Preble & Piwoz, 1998; Smith & Kuhn, 2000; World Health Organization (WHO), 2000; WHO, 2003). However, breast milk is a body fluid, like blood or semen, which can transmit the Human Immunodeficiency Virus (HIV) from mother to baby (White, 1999). A woman infected with HIV may pass the virus on to her child via pregnancy, labour or delivery or through breastfeeding (WHO, 2003). In developing countries where the prevalence of HIV/AIDS is high, particularly among women of reproductive age, protecting children from HIV infection is a critical public health concern.

Background: Hospital database research has the potential to provide useful insights into health systems functioning, population health, clinical conditions and epidemiological trends thereof. This type of research is routinely done in countries that have large national hospital databases where results are usually extrapolated to the national population. South Africa does not have a national hospital database, but individual healthcare institutions, such as the Red Cross War Memorial Children's Hospital (RCCH) in Cape Town, collects routine patient data in a computerised database that if tapped should yield valuable information about child health of the catchment population as well as of the functioning of that health institution. Methods: Selected data from the RCCH database were converted into spreadsheet format and then exported into a statistical programme, Stata. Variables included patient demographic details, ICD-10 diagnostic codes, length of hospital stay and outcomes at discharge. Stata was used to clean and code the data and perform basic descriptive analyses of contained variables. Medians and interquartile ranges described numerical variables. Frequencies, proportions and percentages described categorical variables. Appropriate tests of statistical significance were performed where applicable. Admission and mortality trends were analysed across a decade and common conditions were explored. Findings and Conclusions: Overall admissions to RCCH increased by 9.3% across a decade while the number of new patients decreased by 8.6%, indicating an increase in readmissions. In-patient mortality decreased consistently across a decade despite an increase in admissions, which suggests an improvement in quality of care. The median ages of admissions and deaths increased across the decade, which correlates with less HIV and improved management thereof. Infections remain the commonest causes of in-hospital mortality. Admissions and mortality for diarrhoea and pneumonia displayed a consistent decline across 6 years corresponding with the introduction of new vaccines; however, diarrhoea and lower respiratory tract illness remained the commonest causes of medical admission. Injuries were the commonest reason for surgical admissions. Computerised hospital databases contain useful information for healthcare research.