Executive Summary Non-communicable disease currently accounts for 59% of global deaths and 46% of the global burden of disease. In 2000, 38% of all male deaths and 43% of all female deaths, in South Africa, were due to non-communicable disease. Like all health systems, the South African health system is not adequately equipped to deal with these types of diseases. The burden of chronic disease will grow over time due to factors such as urbanisation and associated behaviours regarding food consumption and physical activity. The World Health Organisation has developed the Innovative Care for Chronic Conditions (ICCC) framework for resource-constrained settings. The ICCC framework is structured into three levels: macro (positive policy environment), meso (community and health care organisation) and micro (health care interactions) levels. Using diabetes and hypertension as examples of chronic disease, this research drew upon portions of this framework to examine service provision for chronic diseases in the Gauteng Province. The overall aim of the study was to document the resources available to manage chronic disease in the Gauteng Province by investigating primary health care clinics, community organisations, and provincial and district support. The objectives were to describe the following: health services offered by primary health care clinics in the city of iv Johannesburg for the management of patients with diabetes and hypertension; the role of district and provincial management in chronic disease care; and the role of community based organisations within the city of Johannesburg in promoting good health, preventing chronic illness, and providing curative and rehabilitative services. The micro level is represented by primary health care (PHC) clinics, the meso level is represented by community-based organisations (CBOs), and the macro level is represented by provincial and regional managers. This is a qualitative, cross-sectional descriptive study. The study population is PHC clinics, associated CBOs, and managers operating in Metropolitan Johannesburg, which is managed by the provincial government. One Gauteng province sub-district was selected by simple random sampling from a list of sub-districts containing at least five provincial PHC clinics. The selected sub-district was located in Soweto and the four PHC clinics and two community health centres were included in the study. Snowball sampling was used to select the CBOs after contacting the PHC clinics. Chronic disease managers at the regional and provincial level were also selected for the study. Data was collected entirely through interviews. One key respondent was selected at each site after contacting the site via telephone. The interview was in-depth and guided by a pre-determined list of questions. The issues probed included topics common to all three levels such as: challenges in chronic disease management, goals for chronic disease management, financial and human resource issues and patient information. Interviews were tape recorded, transcribed and analysed thematically. Ethics approval for the study was obtained from the University of the Witwatersrand’s Human Research Ethics Committee and authorisation to conduct the research was acquired from the Gauteng Provincial Department of Health. A total of 13 people were interviewed. At the micro level (PHC clinics), health care workers believed there was an adequate skill mix for chronic disease care but felt unsupported and understaffed. They did not feel motivated by the incentives currently offered. No health information was maintained at the clinic and all patient information was kept on cards. These cards were used to track patients’ progress, clinic attendance and compliance. The only information collected, and sent for analysis, was a patient headcount. Clinics primarily focused on curative treatment. Patients were deemed to be ‘controlled’ or ‘uncontrolled’ based on their ability to return to the clinic for monthly check-ups and consistently achieve acceptable clinical indicators such as blood pressure and/or blood glucose level. Medical doctors, the only health care workers permitted to initiate insulin therapy, are present only at the community health centres. Patients at PHC clinics must therefore receive referrals and travel to CHC to receive such treatment. PHC sisters did not express an interest in being able to begin insulin therapy, suggesting it is too dangerous and should only be performed by a medical doctor. Five CBO representatives were interviewed. Only two community-based organisations could be identified as having dealt specifically with chronic disease. Both of which focused on diabetes but were inclusive of hypertension due to the number of patients with both conditions. These organisations operated with no budget, paid staff or dedicated office space. They maintained close relationships with clinic staff and ran support groups at the clinic, many times with the help of sisters at the clinic. The other CBOs included in the study were home-based care in nature and dealt primarily with HIV/AIDS. They began treating these chronic disease patients when they realised the stigma of HIV/AIDS was ultimately affecting their outreach. In contrast to the two chronic disease CBOs, the AIDS related organisations all received government training and funding, which included stipends. It was felt that the government training did not provide enough information regarding noncommunicable chronic disease such as hypertension, and instead focused almost exclusively on HIV/AIDS. A monthly meeting was held for all Soweto-based CBOs to discuss issues and receive information from government representatives. There exist dedicated chronic disease programme managers at both regional (covering two districts) and provincial levels. Both levels support one another as they work with the PHC clinics in managing chronic disease. Managers felt free to communicate ‘upwards’ from region to province and province to the national level on an as-needed basis. With respect to PHC services, they saw their role largely as conduits. They provided guidelines to the clinics that were created at the national level and then subsequently monitored their guideline implementation by conducting random site visits. Managers felt that health care worker support was to be accomplished at the clinic level, rather than being their personal responsibility. Chronic disease services, in the study area, held the primarily focus on curative care rather than on health promotion, prevention and early diagnosis through screening. Nearly all patient education was delivered to individuals who had already developed one or more chronic conditions. Community-based organisations motivated those with chronic disease to adhere to treatment protocols, make positive lifestyle choices, and provide patients with a forum to discuss their conditions and learn from one another. They also worked with the government to implement awareness campaigns each month. These campaigns included the community and provided education to those whom had not yet developed a chronic disease. All three levels of the ICCC are functional and communicate with each other, though to varying degrees. While communication between levels is present, there exists a top-down management style where workers feel unsupported. The government is heavily involved in all three levels of chronic disease management. They train and pay PHC clinic staff and CBO workers. The government produces and disseminates all guidelines and protocols and monitor their implementation. The government accomplishes all these tasks while collecting only monthly patient headcounts from each clinic. Patients retain all clinical data and managers see no need to collect any data other than a monthly headcount from each clinic. Nurses are unable to initiate insulin therapy and are unhappy with the current incentive program. There are only two CBOs dedicated to chronic disease, all the rest focus primarily on HIV/AIDS. CBO workers do not feel there is enough training regarding chronic diseases. Each level cite various challenges to successfully managing chronic disease. These include, but are not limited to, low patient compliance, finances, lack of family support, and human resource issues. The research applied only a portion of the ICCC framework to one group of government clinics - provincial PHC clinics and CHCs. Examining a larger number of clinics and managers and applying a greater portion of the ICCC framework would be valuable further research. The following recommendations are a partial list of those generated by this research: • Increase the amount of chronic disease information presented in the mandatory government training of all CBO health care workers. • Construct a comprehensive list of all CBOs that includes: contact information, where they operate, services provided, current client addresses, etc. This will strengthen their ability to partner with one another and reduce overlap in patient care. • Educate patients better regarding how insulin works. This will decrease the usage of herbal medicines that mask health problems and lessen patients’ fear of insulin. • PHC nurses could be trained and permitted to administer and/or initiate insulin therapy. • Enable managers to realise they can affect change in clinic staff, rather than feeling this responsibility belongs solely to the clinic manager.

Purpose: The overall objective of the present study was to conduct a series of investigations to examine the need for, and use of speech pathology services by school-aged children in Tasmania. Specifically, investigations aimed to: a) report the prevalence of speech and/or language impairment amongst the preparatory student population enrolled in 2005 in the Northern Branch of the Department of Education Tasmania; b) determine the extent to which speech pathology services were used by this preparatory student population during their prior kindergarten year (2004); c) quantify the presence and degree of any unmet speech pathology service need within this specific student population; d) examine the nature and accuracy of teacher identification of speech and language impairment amongst the student population during their prior kindergarten year using current mandatory educational assessment (Kindergarten Development Check [KDC]); and e) explore teacher referral patternsfor students identified as having speech and/or language impairment on mandatory educational assessment, to speech pathology services. Methods: To address the aims of the present study, three individual data sets were used. The first data set was obtained through direct assessment of the speech and language skills of a cohort (N = 308) of preparatory students by a speech-language pathologist in 2005. This data was used to determine the prevalence of speech and/or language impairment. The second data set was information pertaining to the number of enrolled preparatory students who had accessed speech pathology services in their prior kindergarten year (2004), sourced from the speech pathology database of the Northern Branch of the Department of Education Tasmania. Comparison of data from the direct assessment of students by the speech-language pathologist and information from the speech pathology database enabled a determination of the presence and degree of any unmet speech pathology service need within this specific student population. The third and final data set was the results of the KDC, conducted by teachers on all students in their kindergarten year (2004). This data was obtained following a search within the electronic KDC database. Subsequent comparison between the student results from this KDC database and the direct assessment by the speech-language pathologist determined the accuracy of teacher identification of speech and/or language impairment using this specific tool. Further comparison of the student results from the KDC database, direct assessment and the speech pathology database also yielded information on teacher referral patterns for students identified as either speech or language-impaired on the KDC, together with the overall percentage of confirmed speech or language-impaired students referred to speech pathology services.Results: The overall prevalence of speech and/or language impairment was found to be 41.2% within the population studied. Specifically, 8.7% of students were found to have isolated speech impairment, 18.2% had isolated language impairment, and 14.3% were diagnosed with comorbid speech and language impairment. Despite the high overall prevalence of speech and/or language impairment, only 18.4% of the total enrolled preparatory student population was found to have accessed speech pathology services during their kindergarten year. It was therefore estimated that 36.1% of speech-impaired and 75.8% of language-impaired preparatory students respectively did not access speech pathology services during their first year at school. Comparison of student data from educational and speech pathology testing observed that the current teacher-administered kindergarten assessment (KDC) was ineffective in facilitating student access to speech pathology services where needed. The sensitivity of teacher identification of speech and language impairment on the KDC was only 50% and 15% respectively, indicating that 50% of all students confirmed as having speech impairment and 85% of students confirmed as having language impairment on speech pathology testing failed to be identified by teaching professionals on this specific tool. Further consideration of teacher referral patterns found that only 57.1% of students identified by teachers as having some type of communication impairment on the KDC were subsequently referred to speech pathology services. Of those students referred, only just over half (51.4%) were confirmed by speech pathology assessment as being either speech or languageimpaired, with the remainder found to have typical speech and language skills. When the total speech and language-impaired population was examined, the percentage of children appropriately referred by teachers was therefore only 25.3%.Conclusions: The present study illustrated that speech and language impairment are prevalent conditions within the preparatory student population of northern Tasmania. Unfortunately, a substantial number of these speech and/or language-impaired students failed to access available speech pathology services during their kindergarten year. Teacher administration of mandatory educational assessment, designed to identify ‘at risk’ kindergarten students, has been identified as one reason for poor student access to speech pathology services during the first year of formal schooling. Not only were teachers found to be inaccurate in identifying students with speech, and to a greater extent language impairment using the KDC, but students identified as having speech and/or language impairment on this specific tool were not routinely referred to speech pathology services. Given the key role of teachers in administering the KDC to identify students in need of speech pathology services, local speechlanguage pathologists must seek to improve: a) the sensitivity of the KDC; and b) the knowledge of teaching professionals regarding the presentation of speech and/or language impairment and the importance of early referral.

This research study proposed to view a remote service delivery system from three distinct perspectives: connected home environments (user perspective), remote service delivery platform (service enabler), and remote service providers (service provider perspective); to establish a holistic view on the requirements of remote service provision to connected home environments. A reference architecture for remote service provision based on the proposed views has been devised, which provides built-in support for an “On-Demand” operating model and facilitate “Freedom of Choice” via different levels of interoperability.

In adopting a tabula rasa approach, this study sought to determine those elements of care that should be prioritised in the service provision for families with children who have cancer. An innovative approach was adopted, as opposed to a conventional thesis structure, in which the literature in this study was used both as a means of informing the research rationale and design as well as being a data source in its own right and precluded providing a conventional literature review. Conventionally a thesis contains an introduction, chapters that review the literature, describe the methods, present results and ends with a discussion and conclusions. However, because there are many different elements to this thesis it is intended to structure it differently. Given that each form of data requires a different form of analysis, each data source has its own chapter. The reader will therefore find chapters headed The Professional Literature, The Charity Leaflets, and The Delphi Study. Furthermore, within each chapter methodological considerations, and the reasons for the methodological decisions taken are discussed. These are made in the appropriate places. Three sources of data were investigated including the professional and relevant charity leaflets literature and a Delphi study was undertaken to obtain the views of both professionals («=31) and families («=15). A content analysis was conducted for the first two sources of data and the first round of the Delphi study. All sources were essential in compiling a comprehensive list of desirable elements of care. The salient elements of care from the three sources of data were synthesised in order to identify elements that were common to all data sources. The elements of care were grouped under six headings as categories with relevant subcategories. The main categories were 'Communication and Cooperation', 'Maintaining Normality', 'Professional Issues', 'Research', 'Resources and 'Treatment Issues' for the professional literature and charity leaflets. Inter-rater reliability was established indicating a high level of agreement between both raters (Kappa = 0.677 and 0.958 respectively, p < 0.001 in both cases). 'Partnership in Care' was the analytical framework devised from the government directives of involving patients and their carers more in the healthcare process. The framework adopted was based on the families' participation as informed, decision making and empowered families. The framework was then used as a means by which the data for all three sources could be summarised, compared and contrasted. This then enabled a comparison between the service provision advocated for children with cancer and what the Delphi study of the families' opinions had highlighted. Given the rhetoric of policy directives in involving the family more in participation of care, the findings have shown that there is a disparity between the perspectives of the families and professionals. In line with policy directives, the professionals had prioritised the involvement of families as partners. However, their commitment to the partnership is questionable, as they did not regard more training in understanding the impact of the disease on the family as important. The main emphasis was on clinical service provision in terms of dedicated adolescent units in regional centres and emergency contact provision. The families placed an emphasis on communication in terms of their contact with the GP in avoiding late diagnosis, having a key worker, providing continuity between hospital and home, and training courses for the professionals to better understand the impact of the disease in the family. By contrast the professionals placed an emphasis on clinical provision namely age appropriate environment for care and 24 hour emergency contact and input from regional units. The findings suggest that in reality, families cannot always be equal partners with the professionals, nor do they necessarily wish to be. From the families' perspective a partnership in care has been defined as mutual respect, advocacy, encouragement, and having continuity of care between hospital and home, given by practitioners who have the expertise and who understand the impact of the disease on the family.

Higher education institutions (HEIs) around the world and in the developing countries in particular e.g. Libyan HEIs are facing challenges that increase the pressure on them. Some of these challenges are related to the remarkable changes in population growth and fast changes in the development of knowledge and technology. Also, providing adequate resources, maintaining quality, raising funding and strengthening the curriculum are other challenges that need to be faced by those institutions. This research is aimed to investigate issues enabling and affecting the quality of services provided by Libyan public universities using principles of Total Quality Management (TQM) philosophy as a framework: Al-Fateh University (AFU) as a case study. The research is qualitative in nature, employing a case study approach and using indepth semi-structured interviews (from different levels including senior leaders, faculty members, support staff, students, and main employers) as the main data collection tool within the two selected embedded case studies. Those embedded cases are Electric and Electronic Department (EED)-Faculty of Engineering-AFU and Social Service Department (SSD)-Literature Faculty-AFU. Documents are used in addition to interviews in order to fully understand issues enabling and affecting the quality of services provided by the two embedded case studies. Contribution to knowledge is evident by the study, which represents the first attempt to empirically investigate issues enabling and affecting the quality of services provided by Libyan public universities: AFU as a case study through two selected embedded cases EED and SSD. This research provides specific original findings which include the use of Arabic and English language in the same lecture, the concept of students' administration and its consequences, the speciality of leaders biases the understanding of the needs of subordinate staff, suspension of the students' performance regulations affected the quality of education programmes, and a unique situation was found to be the senior and junior staff programme that attempted to improve teaching through knowledge transfer. This research has reduced the gap in knowledge in Libyan HE context in specific and in Arabic HE context in general. Other implications for HEIs are also provided by this research.

Yes / This deliberately dual perspective paper seeks to deepen our understanding of the engagement of SMEs in hosted enterprise applications in the UK. The emergence and development of the ASP sector has attracted much interest and highly optimistic forecasts for revenues. The paper starts by considering ICT adoption by SMEs in general before reviewing the provision of hosted enterprise applications in the US and UK (market perspective). The study is extended by qualitative empirical data collected by semi-structured interviews with SME users of hosted enterprise applications (user perspective) and subsequent analysis in order to develop the key findings and conclusions. From an SME user perspective the key findings to emerge from the study include: i) confirmation that ICT infrastructure was no longer a barrier to adoption, ii) the pragmatic approach taken to security issues, iii) the use of both multiple information systems and multiple service providers, iv) the financial attractiveness of the rental model and v) the intention to continue or extend the use of hosted applications. It also highlights the opportunity for gaining competitive advantage by using hosted enterprise applications to reduce costs. There are very few empirical studies of hosted applications which take deliberately market and SME user perspectives - this paper makes an important contribution in this emerging field.

Due to restricted budgets of relief organizations, costs of hiring transportation service providers steer distribution decisions and limit the impact of disaster relief. To improve the success of future humanitarian operations, it is of paramount importance to understand this relationship in detail and to identify mitigation actions, always considering the interdependencies between multiple independent actors in humanitarian logistics. In this paper, we develop a game-theoretic model in order to investigate the influence of transportation costs on distribution decisions in long-term relief operations and to evaluate measures for improving the fulfillment of beneficiary needs. The equilibrium of the model is a Generalized Nash Equilibrium, which has had few applications in the supply chain context to date. We formulate it, utilizing the construct of a Variational Equilibrium, as a Variational Inequality and perform numerical simulations in order to study the effects of three interventions: an increase in carrier competition, a reduction of transportation costs and an extension of framework agreements. The results yield important implications for policy makers and humanitarian organizations (HOs). Increasing the number of preselected carriers strengthens the bargaining power of HOs and improves impact up to a certain limit. The limit is reached when carriers set framework rates equal to transportation unit costs. Reductions of transportation costs have a consistently positive, but decreasing marginal benefit without any upper bound. They provide the highest benefit when the bargaining power of HOs is weak. On the contrary, extending framework agreements enables most improvements when the bargaining power of HOs is strong.

Student Number : 9410914W - MA research report - School of Social Work - Faculty of Humanities / The study aimed at exploring the perceptions of occupational social workers on how their service provision has been affected by the HIV/AIDS pandemic. The focus was on whether they thought that the increasing prevalence of HIV/AIDS in the workplace had led to a shift in their service provision. That was done through: - An investigation of ways in which social worker’s service provision has had to be adjusted in the context of HIV/AIDS in the workplace. - An assessment of the extent to which occupational social workers perceive their HIV/AIDS services at macro level to be acknowledged as valuable by management and the workforce. - An exploration of perceptions of occupational social workers on how HIV/AIDS has affected their relationship with management The research was quantitative and qualitative in approach and the design used was descriptive. Various sectors like manufacturing, government departments, para-statal, military and finance that employ social workers were identified. A list of occupational social workers was obtained from the School of Social Work, University of the Witwatersrand and from the Gauteng EAP Association. A non-probability sample of twenty seven social workers participated in the study. Semi structured interviews lasting for approximately forty five minutes were used as a form of data collection. Data collected was analysed through simple descriptive statistics and development of core themes and common concerns. The findings indicated that most occupational social workers perceived their services not to have been affected by HIV/AIDS, management and employees to have regarded their HIV/AIDS macro practice as valuable and their relationship with management have not been affected negatively by HIV/AIDS.

MSc Occupational Therapy, Faculty of Health Sciences, University of the Witwatersrand, 2009 / An increase in the prevalence of ASD has led to increased demands on service provision. This questionnaire-based, descriptive study aimed to explore service use and experiences of health and education service delivery by caregivers and their children with ASD in Johannesburg. The sample size was 39. Comparisons were drawn between the experiences of the participants accessing the private and public service sectors. Children were diagnosed at an average age of 4 years; 2 years after the first symptoms were noted by their caregivers. Families accessed a mean of 3 institutions and 6 professionals in seeking diagnosis and treatment. No specific referral patterns could be established. Challenges to service access identified by caregivers included: logistical problems, lack of professional knowledge and experience, poor parental coping and insight, and lack of community support. Solutions identified by the caregivers included: marketing, training, better referral procedures, and establishment of educational facilities.

Objective. As a result of newborn hearing screenings, an increasing number of infants are being identified with a hearing loss at birth or within a few months of life. The literature supports that early identification in conjunction with early intervention services have led to drastic improvements in speech and language outcomes for children who have a received a cochlear implant (CI). The purpose of this study was to investigate the amount, type, and quality of services that young children with CI(s) are receiving. Methods. Participants in this study included 22 teachers of the deaf/hard of hearing (TD/HH), 7 speech-language pathologists (SLP), and 4 early childhood interventionists (ECI). All of the service providers were serving at least one child with a CI(s) at the time of the study. Three on-line service provider surveys were modified from the National Early Intervention Longitudinal Study (NEILS) in order to specifically address the concerns and interests of service provision for children with CIs. The three surveys addressed the birth-3, preschool, and school-age populations. Results. Results from the birth-3 and preschool populations with CIs were analyzed. The school-age population was not analyzed due to the low response rate from that age group. Findings from this study revealed that the TD/HH is the primary service provider for the birth-5 population with CIs. In addition, other service providers (i.e. SLP, ECI) reported that they do not feel completely comfortable working with the CI device (i.e. troubleshooting, utilizing the Ling Six Sound test). Another area of concern was the child's compliance in wearing the CI on a full-time, daily basis. Collaboration and education among professionals and the families of children with CIs must be stressed in order for early intervention services to effectively facilitate the child's speech, language, and educational development. Conclusion. The results revealed characteristics specific to both the child (i.e. services the child has received in the past 6 months as part of his/her intervention program) and the service provider (i.e. amount of professional education concerning children with CIs). More research is needed to assess the relationship between the amount and quality of service provision and the child's speech and language performance to ensure that this population is receiving appropriate early intervention services.