3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Factors associated with the health and wellbeing of older people in a rural African setting(2015-03-27) Gomez-Olive, Francesc XavierBackground South Africa is experiencing a massive HIV epidemic that together with the new epidemic of non-communicable diseases is directly affecting the health and wellbeing of older people. For policy makers, there is a crucial need for information on how this dual epidemic is evolving and how this may affect older people's health, mortality and health care needs. 2. Aims To better understand factors that influence the health, wellbeing and survival of older people, and their need for care in rural South Africa at a time of a growing dual epidemic of chronic diseases (non-communicable and communicable). To provide information which may assist in the planning of health services for older people. 3. Methods Applying the WHO Study on Global Ageing and Adult Health (SAGE) and a study on HIV and non-communicable diseases (NCD), we investigated the health, wellbeing and mortality of the population 50 years and older in the Agincourt sub-district in north-east South Africa which is underpinned by health and demographic surveillance. A random sample of the population 50 years and older was selected for the SAGE survey. A random sample of the population 15 years and older was selected for the HIV and NCD study. All available adults 50 plus were invited to participate in the SAGE module in the 2006 census round. We assessed self-reported health, anthropometric measures, blood pressure and HIV status using dried blood spots. Statistical analysis included simple frequencies, univariate and multivariate analysis and Cox proportional hazard models. 4. Findings The usual pattern of mortality, of increasing death rates with age, is not observed in this population, where those in their 50s have higher mortality compared to older age groups. The high prevalence of HIV in this age group (50 to 59) appears to be the main explanation for the observed pattern. Hypertension affects two thirds of this older population and, although there are no differences by gender, women are more aware of their condition. This is reflected in more women attending primary health care services. Reporting lower quality of life and greater disability are associated with higher likelihood of death. We observed gender differences in the process of ageing with women reporting higher prevalence of mortality risk factors but living longer than men, a phenomenon known as the "survival paradox".Item The effect of a workplace intervention programme on return to work after stroke(2014-02-06) Ntsiea, Mokgobadibe VeronicaStroke impacts on a survivor’s ability to participate in community activities such as return to work (RTW) and affects people who are still within the working age. Return to work contributes to life satisfaction and social identity at least partly through independence gained from income-generation. The impact of RTW programmes for stroke survivors is limited and not generalisable to South Africa. This study aimed to bridge this gap in South Africa, and was conducted within the Gauteng province as it comprises the largest share of the South African population. Objectives and Methodology: The aim of the study was to determine the current practice in RTW intervention programmes for stroke survivors in the Gauteng Province of South Africa and to establish the effect of a workplace intervention programme on the rate of RTW of previously employed stroke survivors. This study had two stages: Stage one: A cross sectional survey was performed using a self administered questionnaire to establish current practice in RTW intervention programmes and the therapists’ perceived barriers and enablers of RTW after stroke. Stage two study included: a) a randomised controlled trial (RCT) to evaluate a six week RTW intervention, with follow-up at three and six months. The workplace intervention programme was tailored according to the functional ability and workplace challenges of each stroke survivor and was as follows: Week one: Assessment for work skill. The assessment included work modules which identified potential problems such as: visual discrimination; eye hand coordination; form and spatial perception; manual dexterity; colour discrimination; cognitive problems, and job specific physical demand factors. Week two: The therapist interviewed the stroke survivor and employer separately to establish perceived barriers and enablers of RTW. This was followed by a meeting between the therapist, stroke survivor and employer/supervisor to discuss and develop a plan to overcome identified barriers and to strengthen identified enablers based on consensus between stroke survivor and employer. Week three: A work visit for the stroke survivor to demonstrate what they did at work and identify what they could still do safely and what they could not do. This included vocational counselling and coaching; emotional support; adaptation of the working environment; advice on coping strategies to compensate for mobility and upper limb functional limitations; and fatigue management. Weeks four, five and six: continuation of the work visits, while monitoring progress, and making necessary adjustments as per stroke survivor and employer’s needs. This was done at the workplace while the participants continued with their usual therapy at the hospital. The control group received usual care. The primary outcome was RTW rate. The secondary outcomes included activities of daily living (measured with the Barthel Index); mobility (measured with the Modified Rivermead Mobility Index); basic cognitive function (measured with the Montreal Cognitive Assessment) and perceived quality of life (measured with the Stroke Specific Quality of life Scale). Another aim of stage two study was to: b) establish the stroke survivors’ and employers’ perceived barriers and enablers of RTW (this was done with the experimental group only); and to: c) identify predictors of RTW. Stage one study results: Thirty six (68%) of the 53 questionnaires sent to stroke rehabilitation facilities were returned. Seventeen (47%) of the 36 clinical settings referred stroke survivors to facilities offering RTW services; 12 (33%) facilities did not refer stroke survivors for RTW and did not offer RTW services; and seven (20%) facilities offered RTW services. Of the seven facilities that rendered RTW services for stroke survivors, five (71%) communicated with the employer to discuss reasonable accommodation and four (57%) did assessments for potential to RTW. The most common reason given by the 29 facilities for not offering RTW services was that they referred stroke survivors to other therapists who offered these services. The second most common reason was the unemployment status of the stroke survivor at the time of having stroke. The therapists’ most commonly perceived barriers of RTW were the severity of the stroke survivors’ physical impairments (n = 3) (36%) and their employment status (n = 11) (31%) at the time of having stroke. The most commonly perceived enablers were willingness of the employer to reasonably accommodate the stroke survivor at work (n = 12) (33%), family support (n = 8) (22%) and increased length of hospital stay to allow for intensive rehabilitation (n = 7) (19%). Stigma in the workplace was the only variable which had a statistically significant relationship with the type of clinical facility therapists worked at (p = 0.02). Stage two study results: The average age for the study group was 45 (SD: 8.7) years and the average stroke duration was 4.6 (SD: 1.8) weeks. There were 41 (51%) male stroke survivors and 39 (49%) female stroke survivors. Majority (55%) of the stroke survivors were breadwinners (63%), had a grade 11 to 12 educational level (64%), an income above R5000 (46%) and had a helper (74%) whom they did not have to pay (81%). Stroke survivors who returned to work had better quality of life at six months after stroke than those who did not RTW (p = 0.05). Results from the qualitative study indicated that the perceived enablers of RTW included: ability of the employer to provide reasonable accommodation and good interpersonal working relationships between stroke survivor, employer and co-workers. The perceived barriers of RTW included: unaffordable reasonable accommodation costs; inaccessible transport; having cognitive (memory and attention) and speech impairments and high unemployment rates. The overall RTW rate was 20% at three months follow-up and 40% at six months follow-up. Twenty seven percent of the stroke survivors in the intervention group returned to work at three months compared to 12% in the control group (p = 0.13). At six months, the majority of stroke survivors (60%) in the intervention group returned to work compared to 20% in the control group (p <0.001). The following factors were predictive of RTW: male gender (p = 0.03); fewer speech problems (p = 0.02); increased time off work post stroke (p = 0.001); ability to perform activities of daily living (p = 0.02); good mobility (p = 0.01) and good cognitive ability (p = 0.02). The stroke survivors in the intervention group were 5.2 times more likely to RTW than those in the control group at six months following stroke, and for every unit increase in the activities of the Barthel Index and Montreal Cognitive assessment score, the likelihood of RTW increased by 1.7 and 1.3 respectively. Conclusion: A RTW intervention consisting of workability assessments and workplace visits was effective in facilitating RTW for stroke survivors in Gauteng province, South Africa. Key predictors of RTW included male gender; increased time off work post stroke; ability to perform activities of daily living; good mobility and good cognitive ability and were identified as facilitating RTW; speech problems were identified as barriers to RTW. Overall, these results suggest the need to direct resources towards increasing work place intervention strategies after stroke.Item Impact of caregiver education on stroke survivors and their caregivers(2010-09-20) Mudzi, WitnessDespite the improvements that have been made in health care over the years, stroke remains a serious public health problem in low, middle and high-income countries. Post-stroke, there are many consequences that manifest and these include mortality, morbidity and socioeconomic, affecting not only the stroke survivor but also the caregiver. These consequences are felt hardest in low and middleincome countries because they are the least able to deal with health related setbacks to development. Pressure for beds and the need to reduce hospitalisation related costs have resulted in early discharge home of patients culminating in caregivers playing a more significant role post-stroke. The role played by caregivers has of late received much attention and is well documented in highincome regions. Informal caregivers are particularly important in low resourced settings. Caregivers play an important role in the rehabilitation process of the stroke survivor. The discharge home of patients with stroke to unprepared caregivers is associated with burden or strain, which negatively affects the quality of life of not only the caregiver but the stroke survivor as well. The effect of a structured, individualised caregiver training programme on patients with stroke and their carers has not been established in sub-Saharan Africa in general and South Africa in particular. With this in mind, the aim of the study was to establish the impact of caregiver education on the morbidity of the stroke survivors and on the quality of life of the stroke survivors and their carers. The specific objectives of the study were to establish the: physiotherapy caregiver education programmes and associated content in use for managing patients with stroke at Chris Hani Baragwanath hospital, effect of caregiver education on the mobility of the stroke survivors, effect of caregiver education on the health related quality of life of the stroke survivor and the caregivers, effect of caregiver education on the ability of the stroke survivor to socialise and participate in community issues and also the patient and caregiver characteristics associated with caregiver strain post-stroke. To achieve the first objective, a self designed questionnaire was used to establish the physiotherapy caregiver education programmes and associated content in use for managing patients with stroke at Chris Hani Baragwanath hospital from the physiotherapists at the hospital. For the rest of the objectives, a stratified randomised controlled trial using concealed allocation with a broad entry and blinded outcome assessment at baseline, three, six and 12 months was used for data collection. The participants for the study were first time ischaemic patients with stroke admitted to Chris Hani Baragwanath hospital, Soweto, Johannesburg, South Africa. A total of 200 patients and their caregivers participated in the study. These were randomly assigned to either the control group or the experimental group. The caregivers in the experimental group were subjected to an individualised training programme just prior to discharge of the patient with stroke and at the three month follow up. The assessor was blinded to the group allocation of the patients and caregivers until after completion of the study. From the study, the one-year case fatality was 38%. The mean hospital length of stay for patients with stroke was six days and the average number of physiotherapy contacts for the stroke survivors was one. The content of the rehabilitation programme of patients post-stroke was well structured and appropriate at Chris Hani Baragwanath. However, there was no caregiver involvement or training during in-patient rehabilitation. The barriers to caregiver involvement included perceived high workload by therapists, short hospital length of stay, poor referral systems between clinicians and therapists of patients post-stroke and caregivers being unavailable during working hours for training purposes. Using the Barthel Index (BI) scores, 78% of the patients were functionally dependent at 12 months post discharge. None of the patients were fully independent in mobility and stair climbing. The experimental group had better mean BI scores at the three and 12 month follow up periods (p = 0.01 and p = 0.05 respectively) when compared to the control group. Caregiver education had the effect of improving the BI scores by one and 0.7 at the three and 12 months follow ups respectively. However, the functional abilities of the patients from both groups were still low at 12 months with averages of 13.3 and 12.6 for the experimental and control groups respectively (out of a possible 20). The overall patient mobility scores as measured on the Rivermead Mobility Index were low over the study period with averages of 9.1 and 8.5 for the experimental and control group respectively (out of a possible 15). However, the experimental group had slightly better Rivermead Mobility Index (RMI) scores, which were not statistically significant. Caregiver education had the effect of reducing the risk of death by 27% relative to that occurring among the control group patients. The health related quality of life of the stroke survivors was generally poor over the study period. The baseline means from their EQ-5D scores (for health related quality of life) were 42.4 and 43.7 for the control and experimental groups respectively, which rose to 67 and 68.8 at 12 months respectively post discharge. Caregiver education had the effect of improving patients’ EQ-5D scores by a factor of three and this was only at 12 months. The caregivers’ quality of life generally declined over the 12 months of the study period (more in the control group than the experimental group) from averages of 92 and 93 at three months (for the control and experimental groups respectively) to 83 and 86 (respectively) at 12 months. However, the experimental group had better mean EQ-5D scores (health related quality of life) than the control group (p = 0.001). Caregiver education had the effect of improving EQ-5D scores by factors of 3.4 and 3.6 at the six and twelve month follow up period. The ability to socialise and participate in community issues was poor. None of the participants could carry out single and multiple tasks without assistance at 12 months post discharge. More than 87% of the patients had mild to moderate difficulty with walking at 12 months post discharge and they were all unable to lift and carry objects, have fine hand use and move around with equipment without assistance. None of the patients was able to carry out domestic activities without any difficulty and consequently they could not prepare meals and do housework without assistance from helpers. All of the participants had mild to moderate and severe to complete difficulty in basic interpersonal interactions, complex interpersonal interactions and formal relationships. They all had mild to moderate difficulty engaging in recreation and leisure activities while 27% of the control group and 25% of the experimental group had severe to complete difficulty with community life at 12 months post discharge. The design, construction and building products and technology for both public and private use were cited as barriers to community participation. More than 50% of the patients also cited friends as being barriers to community participation but acquaintances, colleagues, neighbours and community members were cited as being facilitators together with personal care providers (caregivers). Transport services, systems and policies were also cited as barriers by more than 80% of the participants. Caregiver education did not seem to influence patients’ ability to participate in community issues given the similarities in percentages between the control and experimental groups. At three months post discharge, 89% of the caregivers in the control group and 92% of those in the experimental group were strained from caregiving duties. However, these percentages declined to 78% and 43% respectively at 12 months, showing the effectiveness of caregiver education. Caregiver education had the effect of reducing strain by a factor of 2.6 at 12 months. The patient characteristics that were associated with caregiver strain were the dependency levels in transfers, mobility, dressing, bathing, poor activities of daily living scores, patient anxiety/depression, pain and poor perceived health state. The only caregiver characteristic that influenced caregiver strain was the level of education. The reduced hospital length of stay, pressure for beds and possibly inadequate rehabilitation personnel levels means that its possible that some caregivers are not adequately trained to meet patient needs, although this needs to be confirmed with further controlled research. The current pressure on in-patient services at Chris Hani Baragwanath hospital is resulting in suboptimal exposure to rehabilitation of patients post-stroke. There is insufficient organised caregiver education at present. Structured individualised caregiver training has the effect of positively influencing the health related quality of life of the patients especially at six and 12 months post discharge. Caregivers for patients with stroke suffer from physical, financial and psychological problems, which negatively affect their health related quality of life. Currently, high levels of caregiver strain persist poststroke. Caregiver education however has the effect of reducing the decline in caregiver health related quality of life over time. Caregiver training did not positively influence patient mobility and this is most probably because the patients had very low or poor functional ability levels at discharge from hospital. However, structured and individualised caregiver training has the effect of improving patients’ quality of life and can help reduce deaths among stroke survivors. The patient ability to socialise and participate in community issues post-stroke is currently poor. This mainly stems from the poor functional ability levels, which necessitate dependency on caregivers. Compounding the low functional ability levels are the transport systems, services and policies, attitudes of friends and the design, construction and building products and technology for both public and private use, which are barriers to community participation. The high patient dependency levels result in caregivers being highly strained. The patient characteristics that influence caregiver strain are dependence in transfers, grooming, mobility, dressing, poor activities of daily living, patient anxiety/depression, pain and poor perceived health state (health related quality of life). The only caregiver characteristic that was associated with caregiver strain is the level of education. The early discharge home with little caregiver training calls for provision of community rehabilitation services preferably through domiciliary visits. Caregivers of patients with stroke should be assessed and treated for depression given its high prevalence among this cohort. The referral system between the local community health centres and the discharging hospital need to be strengthened to ensure access to rehabilitation by all patients post discharge from hospital. The referral to social workers during in-patient and out-patient rehabilitation also need to be strengthened to ensure processing of social grants to alleviate financial strain as is appropriate. Caregiver strain is a complex and multifaceted problem with no single causation or solution. As a result, further research is needed to establish the reasons for poor rehabilitation service provision post-stroke for patients and caregivers and find solutions to these. It is important to explore different methods of caregiver education programmes so that the method that yields the best results for both patients and caregivers can be established in our setting and internationally.Item A pilot study to determine the effects of a manual compression foot-pump on dialysis efficacy and the quality of life of patients with end stage renal disease(ESRD)(2008-03-12T12:00:14Z) Kern, JeremyAbstract This pilot study aimed to establish if an exercise programme utilizing the world’s first manual compression foot-pump, commonly known as “Venous Anti-Stasis Slippers”, could be used as an intervention to improve dialysis efficacy (Kt/V) and the quality of life (QOL) of patients with end stage renal disease (ESRD). The entire population of 34 self-care renal patients at the Flora Clinic renal unit were screened and 19 patients who met the inclusion criteria for the study were invited to participate in this 16 week pilot study. Baseline dialysis efficacy values were obtained from the analysis of routine blood tests and quality of life values were established with the use of the South African English version of the EQ-5D health questionnaire. This was followed by an eight week non-intervention period. Pre-intervention values were then established prior to the implementation of an eight week exercise programme using the manual compression foot pumps. A single group time series design was used and 12 of the initial 19 subjects completed the study by performing seated calf raising exercises, with manual compression foot pumps on their feet, for 20 minutes per hour during the first three hours of their routine dialysis sessions (2 - 3 times per week) over a period of eight weeks. Exercise diaries were kept to record exercise times, heart rates and exercise intensities. At the end of the eight week exercise programme, dialysis efficacy and quality of life values were re-measured. An intention to treat analysis of routine blood test results revealed statistically significant changes in dialysis efficacy (Kt/V) values between baseline (1.70 ± 0.48), pre-intervention (1.39 ± 0.43) and post intervention (1.50 ± 0.47) with a resultant 7.91% improvement in Kt/V values as a result of the exercise programme. There were however no statistically significant changes observed in overall quality of life (QOL) values, but noticeable improvements in self-care ability and a reduction in depression/anxiety scores were observed during this pilot study. The frequency of exercise per week had no significant effect on the changes in Kt/V.