3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Chronic disease care in primary health care facilities in rural South African settings(2016) Ameh, Soter SundayBackground: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (<140/90 mmHg) and CD4 counts (>350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs.Item Chronic non-communicable diseases in black South African population living in a low-resource community(2016) Pretorius, Susan SIntroduction: The African continent, particularly sub-Saharan Africa, is facing a high burden of disease from the human immunodeficiency virus (HIV) pandemic and nutritional deficiencies, while at the same time, facing ever increasing rates of cardiovascular diseases (CVDs). The mortality rates from CVD are almost equal to the death rates from communicable diseases. In Sub-Saharan countries CVD prevention and management faces many barriers. One such difficulty is the shortage of data for the descriptive epidemiology of CVD risk factors. In an attempt to address this shortage of data, we established the Heart of Soweto (HOS) study in one of the largest African urban communities in South Africa. The purpose of this study was to identify and describe some of the factors contributing to the emergence of chronic diseases of lifestyle, such as heart disease, high blood pressure, diabetes and obesity in a black urban African population, within the framework of the HOS study. We also investigated the impact of a dietary intervention on cardiac function in subjects with chronic heart failure (CHF) in this black urban cohort. Methods: Data was collected as part of the “Heart of Soweto” (HOS) study, which was a prospectively designed registry that recorded data relating to the presentation, investigation and treatment of patients with newly diagnosed cardiovascular disease presenting to Chris Hani Baragwanath Hospital (CHBH), Soweto in 2006. Data collected included socio-demographic profile and all major cardiovascular diagnoses. Heart disease was defined as non-communicable (ND) e.g. coronary artery disease or communicable (CD) e.g. rheumatic heart disease. A survey was also conducted on consecutive patients attending two pre-selected primary care clinics in Soweto (644 and 667 patients from the Mandela Sisulu and Michael Maponya clinics, respectively). Data collected included, ethnicity, duration of residence in Soweto, highest level of education and employment status. Clinical data collected included prior or current diagnoses of diabetes and hypertension and pharmacological therapy related to the treatment of hypertension, as well as smoking status and exposure to second-hand smoking. Weight, height, and waist and hip circumference were measured. Questions were asked regarding the duration of night-time sleep and napping during the day. Descriptive studies were undertaken at the Heart Failure Clinic at CHBH, Soweto to firstly describe the food choices and macro-and micronutrients intake of 50 consecutive patients presenting with heart failure using an interviewer-administered quantitative food frequency questionnaire (QFFQ). Food data were translated into nutrient data using the Medical Research Council (MRC) Food Finder 3, 2007, which is based on South African food composition tables. Secondly we performed a randomized controlled study of a multidisciplinary, community-based, chronic HF management program in Soweto, compared with usual care, at CHBH Heart Failure Clinic located at the Soweto Cardiovascular Research Unit (SOCRU), or at the General Cardiac ix Clinic (standard care) in Soweto. In this study 49 consenting, eligible patients were individually randomized on a 1:1 basis to either usual care or to the study intervention and cardiac function was measured before and after the intervention. Results: Data collected at Chris Hani Baragwanath hospital (CHBH) cardiology clinic from 5328 suspected cases of heart disease, demonstrated that the most prevalent form of heart disease was hypertensive heart failure (22.0%). It was found that those participants who presented with ND (35.0%) were older and had higher BMI and mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) than those with CD (39.0%; all comparisons p<0.001). Within this cohort of 5328 de novo cases of heart disease, 2505 (47%) were diagnosed with HF, of which 697 (28%) were diagnosed with r i g h t h e a r t f a i l u r e ( RHF). There were more women than men diagnosed with RHF (379 vs. 318 cases), and on an adjusted basis, compared with the remainder of the Heart of Soweto cohort (n = 4631), RHF cases were more likely to be African (adjusted OR 2.33, 95% CI 1.59 – 3.41), with a history of smoking (OR 1.72, 95% CI 1.42 – 2.10), a lower body mass index (OR 0.96, 95% CI 0.94 – 0.97 per kg/m2) and were less likely to have a family history of heart disease (OR 0.79, 95% CI 0.64 – 0.96). Data collected at 2 primary health care clinics in Soweto from 862 women (mean age 41 ± 16 years and mean BMI 29.9 ± 9.2 kg/m2) and 449 men (38 ± 14 years and 24.8 ± 8.3 kg/m2) indicated that in females, former smokers had a higher BMI (p<0.001) than current smokers, while exposure to second hand smoking was associated with a lower BMI (p<0.001) in both genders. Longer sleep duration in females was associated with a lower BMI (p=0.01). Napping during the day for > 30 minutes in males was related to a lower BMI and waist circumference (β=-0.03, p<0.05 for both) and lower systolic (β=-0.02, p<0.05) and diastolic BP (β=-0.02, p<0.05). Longer night time sleep duration was associated with lower diastolic (β=0.004, p<0.01) and systolic BP (β=0.003, p<0.05) in females. Within this same cohort, o b e s i t y w a s m o r e p r e v a l e n t i n f e m a l e s ( 4 1 . 8 % ) t h a n m a l e s ( 1 4 . 1 % ; p < 0 . 0 0 1 ) , 16% (n = 205) had an abnormal 12- lead ECG with more men than women showing a major abnormality (24% vs. 11%; OR 2.63, 95% CI 1.89–3.46). Of 99 cases (7.6%) subject to advanced cardiologic assessment, 29 (2.2%) had newly diagnosed heart disease which included hypertensive heart failure (13 women vs. 2 men, OR 4.51 95% CI 1.00–21.2), coronary artery disease (n = 3), valve disease (n = 3), dilated cardiomyopathy (n = 3) and 2 cases of acute myocarditis. Nutritional deficiencies were observed in a cohort presenting with HF at the cardiology outpatient clinic, CHBH. In women, food choices likely to negatively impact on heart health included added sugar [consumed by 75%: median daily intake (interquartile range) 16 g (10–20)], sweet drinks [54%: 310 ml (85–400)] and salted snacks [61%: 15 g (2–17)]. Corresponding figures for men were added sugar [74%: 15 g (10–15)], sweet drinks [65%: 439 ml (71–670)] and salted snacks [74%: 15 g (4–22)]. The women’s intake of calcium, vitamin C and vitamin E was only 66%, 37% and 40% of the age-specific requirement, respectively. For men, equivalent figures were 66%, 87% and 67%, respectively. Mean sodium intake was 2 372 g/day for men and 1 972 g/day for women, 470 and 294% respectively, of daily recommended intakes (DRI). In men, vitamin C intake was 71 ± 90 (79% of DRI). Similarly, in women vitamin C intake was 66 ± 80 (88% of DRI). Data collected from our HF management programme study supported the deficient intake of vitamin C in African subjects presenting with heart failure. Thus, plasma vitamin C concentrations (normal range 23 – 85 μmol/L) were markedly deficient in both standard care [6.53 (3.80, 9.22) μmol/L] and managed care [3.65 (1.75, 8.23) μmol/L] groups. In terms of clinical presentation, males were significantly older (49.9 ± 10.9 years; p<0.005) than females (37.2 ± 12.8) and at follow-up females had a significantly higher ejection fraction (34.8 ± 9.56 %) than males (29.5 ± 8.27; p<0.05) and when the groups were combined, the ejection fraction was significantly higher (32.2 ± 9.27; p<0.05) at follow-up compared to baseline (29.9 ± 8.80). We found that heart rate was significantly lower at follow-up (89.9 ± 14.6 beats/min) compared to baseline (93.4 ± 17.2; p<0.05) only in the managed care group. Furthermore, if diastolic blood pressure increased over the follow-up period, ejection fraction fell by 5.98% (p=0.009) in comparison to cases where diastolic blood pressure remained the same or fell. In addition, thiamine levels at baseline correlated negatively with systolic blood pressure (r=-0.68, p=0.04) at follow-up. Conclusion: Non-communicable heart disease and other diseases of lifestyle, such as high blood pressure, obesity and diabetes, are drastically increasing in Sub-Saharan Africa in general and in a black urban African community, such as Soweto, specifically. Soweto can clearly be described as a community in epidemiological and nutrition transition and is facing a double or even triple burden of disease. This is a community that is still being burdened by historically prevalent forms of communicable or infectious diseases juxtaposed against people who have lived their whole lives in Soweto and are increasingly suffering from newer or non-communicable diseases of lifestyle. Women seem to be especially burdened by this increase in non-communicable diseases, with a predominance of women suffering from heart disease and obesity. Certain exacerbating risk factors have been identified from the HOS in this community, namely the gender specific effects of sleep, smoking and other environmental factors on BMI and blood pressure, and the adverse effects of changing dietary patterns particularly the increased consumption of refined and processed foods, high in sugar, salt and fats and insufficient intakes of fruits and vegetables. Although there are some limitations to our HF management study, it serves as an indication that targeted, culturally sensitive care, adapted to an urban African population, might contribute to improved patient outcomes. However, prevention should always be our first priority through community-based and gender specific screening and the development and implementation of targeted prevention programs.Item A retrospective review of lifetime prevalence of traditional healer consultation by an outpatient of Xhosa schizophrenia sufferers(2015) Sutherland, TAIM: To describe the demographic and clinical characteristics of a group of patients of Xhosa ethnicity diagnosed with schizophrenia. To also determine the prevalence of their consultations with a traditional healer as well as the factors associated with an increased likelihood of such consultations. METHOD: The study was a review of a database originally compiled as part of an ongoing genetic study. Patients on the database were all of Xhosa ethnicity, with a diagnosis of schizophrenia and had all been recruited from community clinics and psychiatric hospitals in the Cape Town Metropole region. RESULTS: Data was extracted and analysed for 92 patients, who met the criteria for inclusion in this study. The majority of the patients were male (77.2%), single (88%) and unemployed (96%). The mean duration of illness was 20.5 years and the mean number of hospital admissions for their mental illness was 2.4. Close to half (43.5%) of the patients reported being non-compliant on their medication. Ten percent admitted to making one or more suicide attempts in their lifetime. Nicotine was the most commonly used substance (69.6%) followed by alcohol (55.4%), cannabis (37%) and methamphetamines (9.8%). Thirty eight percent of the patients reported having a traditional healer in their family. Twenty two percent had consulted with a traditional healer. In the bivariate analysis the following factors were significantly associated with consulting a traditional healer: having two or less psychiatric admissions (p=0.014); compliance on medication (p=0,012); and having a traditional healer in the family iii (p=0.005). When controlling for age, sex and marital status only having a traditional healer in the family was significantly associated with consulting traditional healer (p=0.011). CONCLUSIONS: This study found that a high proportion of the participants had consulted a traditional healer. This was significantly associated with having a traditional healer as a family member. It is recommended that programmes, to improve the mutual understanding and co-operation between Western practitioners and traditional healers and consequently mental health outcomes, need to be developed and implemented.Item Factors affecting sustained employment of people with chronic illness(2015) Reynolds, Anne PatriciaNumerous factors influence the employment of people with chronic illness. At some point, these people withdraw from the labour market. This has both a direct and indirect cost to the person, their family and society as a whole. Aim: To explore the factors affecting sustained employment of people with chronic illness. A second component explored participants’ opinions regarding return to work in the future. Research Methods: The study was done in two phases: 1) The identification and validation of the research instrument; and 2) The administration of the research instrument. Descriptive statistics were utilised to analyse data obtained from the research instrument. Two sets of correlations were run to identify significant differences between the participants expecting to return to work and those who did not expect to return to work. Results: Descriptive statistics revealed no meaningful trend on self-reported factors. The Mann-Whitney U identified a number of significant differences between participants expecting to return to work and those who did not expect to return to work, in both personal and contextual factors. Conclusion: A broad range of factors were elicited regarding the barriers and accommodations required for sustained employment within both the personal and environmental constructs. Self-report questionnaires provided some useful information, but a broader understanding of the factors influencing work was obtained from a comprehensive interview. Significant differences were present between people expecting to return to work and those who did not expect to return to work regarding environmental and personal factors as well as factors supporting work.Item Independent relationship between 24-hour blood pressure and carotid intima-media thickness(2013) Metsing, Lebogang StanleyIntroduction: The changing socio-economic landscape in Africa has brought with it unique health challenges previously uncommon in people of African ancestry. Noncommunicable diseases such as coronary artery disease and stroke have emerged as pressing public health concern highlighting the need to find more on-target diagnostic tools as well as therapeutic interventions. Although ambulatory blood pressure (AMBP) has in many studies conducted in the western world proved to be an independent predictor of carotid intima-media thickness (C-IMT), such results cannot outright be imputed to people of African ancestry living in Africa. That is because people of African ancestry living in Africa are not only of a different ethnicity but are still in the early phases of an epidemiological transition while people in the western countries who are mostly Caucasians, are believed to be in the middle to late phases of an epidemiological transition. Methods: The relationship between the intima-media thickness of the common carotid artery (SonoCalcTM IMT version 3.4) and AMBP (Space labs model 90207) was determined in 320 randomly selected participants of African descent living in an urban developing community in South Africa. Relationships were determined after adjustment for (clinic blood pressure) BPc, age, gender, alcohol and tobacco use, the presence or absence of diabetes mellitus or inappropriate blood glucose control measured by glycated hemoglobin (ghb), antihypertensive therapy and menopausal status. III Results: Mean age for the study population was 43.7± 16.0 years. Both BPc and AMBP parameters were strongly associated with C-IMT (p<0.001) in univariate analysis. In multivariate analysis with BPc. and AMBP entered into separate models and after adjusting for cofounders, BPc. and AMBP maintained significant associations with CIMT. [BPc (partial r=0.0648, p< 0.1612), systolic blood pressure 24 (SBP24) (partial r= 0.236, p< 0.001), systolic blood pressure day (SBPd) (partial r= 0.302, p<0.05), systolic blood pressure night (SBPn) (partial r= 0.0983, p<0.05)]. When adjustments were made with BPc. and SBP24 entered into the same model, BPc lost its association with C-IMT, [SBP24 (partial r=0.236, p<0.001) SBPd (partial r=0.149, p<0.05), SBPn (partial r=0.172, p<0.05)]. Importantly the relationship between SBP24 and C-IMT persisted independent of body mass index (BMI), BPc and age. SBP24 had the highest significant association with C-IMT. Conclusion: SBP24 independently predicts C-IMT even in a model that includes conventional systolic blood pressure (SBPc) leading to the conclusion that AMBP is a more effective tool at diagnosing C-IMT alterations while BPcdoes not have an independent relationship C-IMT.