Magister Public Health - MPH / Background: Healthcare providers are critical to collecting information on drug safety and successful adverse drug reaction (ADR) reporting. The roles of doctors and pharmacists have been recognized as important to voluntary ADR reporting and their roles are consistently being investigated. However, despite the strategic role of nurses in medicine administration, their role in ADR reporting has not been widely explored, particularly in sub-Saharan African countries. Aim: To assess the knowledge, attitudes and practice of ADR reporting amongst nurses in Lagos University Teaching Hospital (LUTH), a tertiary hospital located in Lagos; the economic centre of Nigeria, as well as the most populous city in the country. Methodology: A cross-sectional descriptive survey with analytical components was conducted among nurses in a tertiary institution. All nurses working in major specialties - out-patients’ clinics, theatre and clinical wards in the facility, were eligible to participate in the study. Student nurses undergoing training or postings in the facility were excluded from the study. A sample size of 124 nurses was calculated using OpenEpi sample size calculator based on an estimated study population of 400 with a 95% confidence interval and an assumed 5% of nurses reporting an ADR based on National Pharmacovigilance Centre database. A sample of 140 nurses was selected in an attempt to realize sample. Cluster sampling was used to randomly select clinics and wards and all nurses in the selected clusters were included in the study. A structured questionnaire consisting of close-ended questions was used. It comprised sections on nurses’ characteristics, knowledge of pharmacovigilance concepts, attitudes towards ADR reporting, and barriers to and practice of ADR reporting. Data collected were entered into an Excel spreadsheet and imported to the SPSS version 20 software for analysis. Descriptive analyses were conducted on all the variables and cross-tabulation between selected variables was explored to test for statistical significance using chi-squared test.

Magister Pharmaceuticae - MPharm / Diabetes mellitus places a substantial financial burden on the funder for treatment of this disease. This burden is compounded by the development of diabetes mellitus related complications. The cost of management of diabetes mellitus and its complications in South Africa in a tertiary level hospital is unknown. The objectives of this study were to: (1) develop a method to determine the cost of management of diabetes mellitus and its complications at Groote Schuur hospital, (2) quantify the direct medical costs associated with diabetes mellitus and its complications, and (3) develop models which could predict the cost of management of diabetes mellitus and its complications at Groote Schuur hospital. Patients were conveniently selected from Groote Schuur Hospital. Retrospective data were collected for 20 months from the two data sources available at Groote Schuur hospital, i.e., (1) electronic patient records and (2) patient folders. Two methods of costing were developed, i.e., the combined method (using data from electronic database and patient folders) and the electronic method (using data from the electronic database only). The patient folders were used to complete any missing information from the electronic patient records. The combined method allowed better categorisation of costs compared to the electronic method. With the combined method the costs associated with diabetes mellitus (type I or type II) and diabetes mellitus complications could be categorized as the type of diabetes mellitus complications and the reasons for emergency room visits and hospitalisations were known. However, with the electronic method this categorisation could not be done. Both methods provided a total cost and cost per patient associated with diabetes mellitus and its complications. Data from the combined method were arranged in the following main sub-groups for analysis: (1) type I diabetes mellitus, (2) type II diabetes mellitus, (3) diabetes mellitus, (4) diabetes mellitus with complications (5) diabetes mellitus complications only. The electronic method estimated a total cost which was 6.4% more than the combined method .The electronic method did not require the perusal of patient folders for additional information and hence it is a simplified method that could be used. When comparing the total costs and the average cost per patient for diabetes mellitus and diabetes mellitus with complications, there was no statistically significant difference between the combined method and the electronic method (p= 0.41). The average cost per patient per year for diabetes mellitus and diabetes mellitus with complications was R 1 231.54 and R 3 208.71, respectively. These results show that a patient with diabetes mellitus and its complications cost 2.6 times more to treat than a patient with diabetes mellitus only. The complications of diabetes mellitus contributed 60.7% to the total cost of diabetes mellitus and its complications. The cost of treating diabetes mellitus only and the cost of treating diabetes mellitus complications only were separated into 2 distinct categories. In this case, the cost of treating the complications of diabetes mellitus only was 2 times more than treating diabetes mellitus only. Type I diabetes mellitus cost R 3 011.32 and type II diabetes mellitus cost R 2 649.40 per patient per year. The treatment costs for type I diabetic patients was 13.7% more than that for type II diabetic patients. The decision tree model determined a cost which was 0.23% more than the actual cost obtained by the combined method. Hence, the decision tree method could be used to predict the total cost of diabetes mellitus and its complications. Patients who attended Groote Schuur Hospital also received treatment for their diabetes at community health centres. A method was developed which could predict the cost of management of diabetes mellitus at community health centres. This will allow the calculation of the total cost of diabetes mellitus and its complications from the perspective of the government. Four methods (i.e. combined, electronic, decision tree and prediction of costs at cost at community health centres) were developed in this study.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Stroke is a leading cause of death and disability worldwide. Individuals with stroke often face functional limitations. There are several factors that are associated with functional outcome post stroke. Treatment in a stroke unit with a multidisciplinary approach reduces the likelihood of dependency after stroke. The aim of the present study is to identify factors influencing functional outcome of stroke patients admitted to a South African tertiary hospital. A descriptive, observational, longitudinal quantitative study design was used to obtain the data. Convenience non-probability sampling method was used. The research instruments used to collect the data were National Institute of Health Stroke Scale (NIHSS), Hospital Anxiety and Depression Scale (HADS), Barthel Index and a socio-demographic and medical profile data form. All the instruments were used at admission and discharge while at two months only Barthel Index was used for data collection. The data analysis was done using SPSS v 18 and SAS v 9. Mean, standard deviation, range and percentages were used for descriptive purposes and Tobit analysis was used to determine the association between independent and dependent variables. The descriptive results showed that the mean age was 59.83 years with number of females slightly more than males and hypertension being the most common risk factor. The results of the quantitative analysis revealed four factors that influence functional outcome at either discharge or at two months: age, severity of stroke, functional level at admission. Age and severity of stroke influenced the functional outcome at both the stages. The necessary ethical clearance was obtained in prior to commencement of the study. The outcomes of the study could contribute to enhance rehabilitation of stroke patients at an inpatient settings and awareness among population.

INTRODUCTION AND BACKGROUND: Traditionally, patient referral occurs from a primary healthcare facility to a secondary or tertiary healthcare facility. Despite these formalised procedures in place, it has been reported within the global context that patients often circumvent these procedures and apply various forms of selfreferral to tertiary hospitals. Through self –referral to the high level of care, patients’ diagnoses and care are interrupted and get lost along the way. AIM/ OBJECTIVES: The overall aim of this study was to develop strategies for patients’ self-referral in tertiary hospitals in Gauteng. In order to achieve this aim, the specific objectives of the study were: Phase 1 Objective 1: To explore and describe current patients’ self-referral patterns from patients and healthcare professionals’ perspectives in tertiary hospitals in Gauteng Province. Phase 2 Objective 2: To develop strategies for managing patients’ self-referral in tertiary hospitals in Gauteng Province. METHODOLOGY: A qualitative research approach using critical ethnography was used. Purposive or judgment sampling was used as the researcher considers the participants to have a profound knowledge and in-depth information on the phenomenon. Data was generated through three phases: in-depth interviews with patients and healthcare professionals (registered nurses and doctors) rendering services to self-referred patients in Gauteng Chronic clinics based in tertiary hospitals; reviewing of relevant site documents; and imbizo as policy discussion forum between the service providers and users of the services were held for the development of patient self-referral strategies. Data was analysed through the analytic five steps framework as advocated by the nurse ethnographers Roper and Shapira (2000: 98). FINDINGS: From the analysis of data five themes emerged as the pathways.. These pathways are emergency admissions, word of mouth, admissions in disguise, enabling patients to pay for admission, human rights, and sense of belonging. CONCLUSION: This study provided a baseline data on self –referral of chronic disease patients in tertiary hospitals in Gauteng Province. Given the epidemiology of chronic disease in South Africa, there is a need for innovative ways of bending the costs for treatment of such. The implementation of National Health Insurance (NHI) will address this problem as NHI has to have a self –referral scheme. The use of the hybrid (new technology and traditional) strategies will facilitate access to care and empowerment of patients to initiate self –referral. / Thesis (PhD)--University of Pretoria, 2019. / Nursing Science / PhD / Unrestricted

This phenomenological study has been conducted to reveal midwives’ experiences working as coordinator/charge midwives in tertiary hospital delivery suite settings. The methodology is informed by Heidegger’s interpretive phenomenological, hermeneutic philosophy (1927/1962). Data analysis is based on van Manen’s (1990) research methodology. Five coordinator/charge midwives who work at three tertiary hospitals were interviewed. These interviews were tape recorded, transcribed and analyzed to uncover commonality of themes which revealed what it felt like ‘being’ a coordinator/charge midwife. The three themes which emerged and are discussed in the data analysis chapters are: “The performing art of leadership”, “Time as lived” and “In the face of the ‘known’ and the ‘unknown’”. The findings of this study reveal coordinators are the ‘hub’ or the ‘pivot’ at their workplace with their art and soul of midwifery at the very core of their ‘being’. They ‘know’ the unpredictability of childbirth and are regularly challenged by ‘lived time’ as they ‘leap in’ to situations and ‘leap ahead’. Their ability to facilitate teamwork and their resilience in the face, at times, of seemingly insurmountable obstacles shines through.

This phenomenological study has been conducted to reveal midwives’ experiences working as coordinator/charge midwives in tertiary hospital delivery suite settings. The methodology is informed by Heidegger’s interpretive phenomenological, hermeneutic philosophy (1927/1962). Data analysis is based on van Manen’s (1990) research methodology. Five coordinator/charge midwives who work at three tertiary hospitals were interviewed. These interviews were tape recorded, transcribed and analyzed to uncover commonality of themes which revealed what it felt like ‘being’ a coordinator/charge midwife. The three themes which emerged and are discussed in the data analysis chapters are: “The performing art of leadership”, “Time as lived” and “In the face of the ‘known’ and the ‘unknown’”. The findings of this study reveal coordinators are the ‘hub’ or the ‘pivot’ at their workplace with their art and soul of midwifery at the very core of their ‘being’. They ‘know’ the unpredictability of childbirth and are regularly challenged by ‘lived time’ as they ‘leap in’ to situations and ‘leap ahead’. Their ability to facilitate teamwork and their resilience in the face, at times, of seemingly insurmountable obstacles shines through.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Este trabalho teve como objetivo geral caracterizar o tratamento de feridas complexas num hospital geral nos meses de fevereiro e março de 2013.

Master of Public Health - MPH / Introduction: Despite the progress that Zambia has made in reducing its maternal mortality ratio from 649 to 398 per 100,000 live births between 1996 and 2013/14, the country did not meet the Millennium Development Goal 5a target, of reducing the maternal mortality ratio by 75% (i.e. to a ratio of 162 per 100,000 live births) by the end of 2015. Thus, as is the case with many other countries, considerable challenges still remain in relation to reducing maternal mortality in Zambia. According to Zambia's Roadmap for Accelerating Reduction of Maternal, Newborn and Child Mortality (2013-2016), the continuum of care for reproductive and maternal, newborn, and child health includes integrated service delivery for mothers and children across these various time periods, and also across place: within the home, the community, and in health facilities. In this regard, a referral system plays a key role in linking the various levels at which care is provided, and the different types of services offered at these levels. In the urban district of Lusaka, Zambia, all complicated pregnancy-related cases received by health centres or clinics are referred to either Levy Mwanawasa General Hospital, or the University Teaching Hospital. However, it appears that at present those working at the primary level of care, who make such referrals up to these higher levels of care, receive no feedback on the outcome of their referrals; there are also few counter-referrals to the respective clinics in the district. With limited communication to the primary level of care, and with no formal handover of patients back to the clinics by the tertiary level institutions, it is difficult to ensure that the required continuum of care for the referred mothers and their children, post-delivery, has been established within the district. This explorative study aimed therefore to identify the strengths and weaknesses of the maternity-related referral system currently operating between primary and tertiary levels of health care in the district, and to consider how the system might be strengthened so as to support a stronger continuum of care with respect to maternal and neonatal health. Methods: Using a descriptive qualitative research approach, stakeholders involved in the planning, delivery and/or oversight of maternal and neonatal health services in the district were purposively sampled and asked to voluntarily participate in the study. Prior to all the interviews, after being informed about the study, and receiving information sheets to read through, participants were required to give informed consent. Their experiences and opinions regarding referrals and counter-referrals were collected through a series of 23 individual, semi-structured interviews. A Thematic Analysis approach was used to analyse data in this study. Ethics approval was first obtained from the Senate Research Committee, University of the Western Cape and thereafter from the Excellence in Research Ethics and Science Converge Ethical Review Board in Zambia, before proceeding with the study. Clearance was also obtained from the Ministry of Health, the Lusaka District Health Management Team and the University Teaching Hospital to facilitate entry into the health facilities. Findings: The study found that, in practice, the referral system for maternity and neonatal health does exist and is generally – but not optimally - functional in the Lusaka District. However, challenges were noted that included the fact that the district’s maternity referral system has not been revised since it was first developed in the 1980s and is not available in a comprehensive set of guidelines or standard operational procedures which explicitly outline the reasons for referral and the related referral steps and mechanisms. In addition, the referral forms currently in use in the district have not been standardised and appear to be inconsistently used by the different facilities. Interviewees reported that there were limitations in terms of the number of, and availability of ambulances, and that there was also an inadequate number of trained midwives. Limitations on the health service's infrastructure, namely, the physical space that is available, the number of delivery beds, and the limited supply of equipment place an additional burden on the staff working at both the primary and tertiary level. Conclusion: Overall, the study recommends that further research – possibly in the form of a baseline audit – be conducted so as to develop a more detailed and/or operational assessment of the actual rather than the reported level of functionality of the district's maternity referral system. Specific recommendations are also proposed for the various stakeholders who are critical role players in the referral system, namely, the clinics, the University Teaching Hospital, the Lusaka District Health Management Team, the Provincial Health Office, the Ministry of Health and Cooperating Partners.

Magister Public Health - MPH / Health systems require effective leadership and management in order to provide quality services especially in resource constrained low- and middle-income countries (LMICs). As in higher income countries (HICs), clinicians in LMICs often transition from a purely clinical to a hybrid role, which includes managerial responsibilities, without any management training. There are both challenges and opportunities in the hybrid manager role. This study explores clinicians’ experiences of the opportunities and challenges of being a hybrid manager in a tertiary academic hospital setting in the Western Cape, South Africa.

Introduction and background: The professional dignity of midwives is determined by their own perspectives of the contribution that they make to the optimal care of patients, the respect that they get from other members of the health team and the support that hospital management gives them. When midwives are not treated with respect and their professional competencies are not recognised, their professional dignity is violated. Aim of the study: The study aims to explore and describe how the professional dignity of midwives in the selected hospital can be enhanced. Methodology: A descriptive phenomenological research design was used. In-depth interviews were conducted once informed consent was obtained with purposively selected participants until data saturation occurred. At least 15 midwives from the antenatal, postnatal and delivery rooms of the selected hospital were interviewed. The interviews were audio-recorded with the permission of the participants and analysed through the method of Giorgi (1997:247). The essence of the phenomenon and the supporting constituents (themes) were identified. The essence and constituents will be described and thereafter the constituents will be discussed. Applicable literature was used to integrate the findings in the knowledge base of the phenomenon. Findings: The purpose of the research study was to explore how the professional dignity of midwives in the selected hospital can be enhanced. The essence (meaning) of the participants’ experiences was disclosed as: To dignify midwives in an academic tertiary hospital. The essence is supported by the following constituents (meaning units): ‘to acknowledge the capabilities of midwives’, ‘to appreciate interventions of midwives’, ‘to perceive midwives as equal health team members’, ‘to invest in midwives’, ‘to enhance collegiality’, ‘to be cared for by management’ and ‘to create conducive environments’. / Dissertation (MCur)--University of Pretoria, 2017. / Nursing Science / MCur / Unrestricted