ETD Collection
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Item HIV and TB care and treatment: patient utilization and provider perspectives in rural KwaZulu-Natal(2017) Chimbindi, Natsayi ZanileThe epidemics of tuberculosis (TB) and Human Immunodeficiency Virus (HIV) in sub-Saharan Africa are closely related and particularly persistent, proving a considerable burden for healthcare provision, and complicating utilization of care. Concern has been expressed about patients’ experience at healthcare facilities as this may impact on drug adherence, treatment success and willingness to return for regular monitoring and drug pick-up. This is particularly relevant for HIV programmes, with HIV now a chronic disease, with daily treatment necessary for life; TB treatment is limited in duration, to six months although can be as long as two years in case of multiple drug resistant TB. Utilization of healthcare services is an important determinant of health outcomes generally, with public health relevance, particularly for HIV and TB services in areas of high prevalence. The main aim of universal health coverage is to make healthcare accessible without barriers based on affordability, availability or acceptability of services. Various factors have been shown to hinder or enable patient utilization of healthcare services, such as organization of services, costs of transport to and from clinics, time loss at clinics receiving care, staff attitudes, waiting times and cleanliness of facilities. Objectives This study aimed to determine and quantify factors associated with healthcare utilization in patients utilizing HIV care (including those not yet initiated on antiretroviral treatment (ART) - pre-ART) or TB treatments in a rural sub-district of Hlabisa in KwaZulu-Natal and to understand healthcare providers’ perspectives regarding patient care and provision of quality care. The study used data from patient exit interviews, and additionally findings from interviews with healthcare providers in the local HIV treatment and care programme, structured around the responses from the patient-exit interviews. The study had three specific objectives: 1) to establish and quantify factors associated with healthcare utilization, with utilization decomposed to availability, affordability and acceptability of healthcare services, for patients in HIV or TB treatment and care; 2) to quantify ability-to-pay for healthcare and identify associated factors for patients in pre-ART care, or on ART or TB treatment; 3) to understand the healthcare providers’ perspectives regarding patient care and provision of quality HIV care. Methods In 2009 patient-exit interviews were conducted in six primary healthcare (phc) clinics in rural South Africa with 300 patients receiving ART and 300 patients receiving TB treatment; patients were randomly selected using a two-stage cluster random sampling approach with primary sampling units (phc) selected with probability-proportional-to-size. In 2010 an additional 200 HIV-infected patients in pre-ART care from the same clinics were interviewed. Patient-exit interviews were conducted in a private room outside the facility and all data were analysed using STATA 11. In 2012, a qualitative study was carried out with healthcare providers in eight (of 17) randomly selected phc clinics; 25 ART healthcare providers were engaged in discussion structured around patient-exit interviews feedback to assess possible challenges/facilitators ART healthcare providers face when providing care. Discussions took place in the consultation rooms when no clinical sessions were ongoing and these were recorded and transcribed; and data were managed using Nvivo 10. Thematic content analysis was conducted using both inductive and deductive approaches and clinic or healthcare provider identifiers were removed and replaced with pseudonyms. Summary statistics describe patient characteristics by patient group and key availability, acceptability and affordability factors associated with utilization of healthcare services; separate univariate and multivariable regression models were run to assess associations between patient characteristics and these key availability, acceptability and affordability factors. Patient socio-demographic characteristics (sex, age, education, employment and marital status) were controlled for and adjusted for clustering at facility-level. Factor analysis was performed to investigate underlying patient satisfaction factors. Results Socio-demographic characteristics of the patients More women than men were seen in the primary care clinic, especially among pre-ART patients (79%), followed by 62% HIV and 53% utilized TB care, with an age-sex profile comparable to previous studies in the area. Pre-ART patients were significantly younger than ART and TB patients, with a median age of 32 years for pre-ART patients, 39 years for ART patients and 37 years for TB patients. Unemployment at household level was high, up to 86% of ART patients’ head of households were unemployed and only 9% of TB patients were employed.Item Determinants of condom use among young adults aged 15-24 years in the Africa Centre Demographic Surveillance Area in Kwazulu Natal, South Africa, 2005(2009-02-11T10:56:44Z) Chimbindi, Natsayi ZanileAbstract Objectives This study investigates the patterns and levels of condom use; the determinants of condom use and of consistency of use among young adults aged 15-24 years in the Africa Centre Demographic Surveillance Area (ACDSA) in 2005. Methodology Secondary data analysis of data from three sources of surveys conducted in ACDSA in 2005 was done. A sample of 4 157 respondents was analyzed. Univariate and multivariate analysis was employed to compare determinants of condom use and of consistency of use. Results Condom use with the most recent partner in the last year was (51.7%). The main determinants of condom use were partner age difference, residence of partner and assets. Having an older partner than a same age partner was associated with less likely to use condoms (AOR=0.71 p=0.03 females, AOR=0.51 p=0.01 males). Those who were not residing with their partners were more likely to use condoms than those residing with their partners (AOR=1.62 p=0.01 females, AOR=1.61 p=0.03 males). Having more than seven assets was associated with increased chances of using condoms than those with less than seven assets (AOR=1.51 p<0.01 females, AOR=1.67 p<0.01 males). The key determinants of consistent condom use were: age, sex and type of relationship. Females were less likely to use condoms consistently (AOR=0.63 p=0.02) and growing older was associated with lower consistent condom use (AOR=0.88 p<0.01 females, AOR=0.90 p<0.01 males). Being in a marital/cohabiting relationship was associated with lower consistent condom use (AOR=0.68 p<0.01 both sexes and AOR=0.64 p=0.01 males) than those in non-marital/non-cohabiting relationship. v Conclusion Condom use differs between sexes and decreases with age probably because condoms are a male determined method, high contraception use, poor negotiation skills for condom use, need for children and formation of more stable relationships. A better socio-economic status increases condom use. Consistent condom use is lower in marital relationships and when the partner is older. This could be because of gender power inequalities in sexual relationships.