3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item An analysis of impaired fasting glucose and diabetes risk factors in Yaounde, Cameroon in 2007 for adults aged 25 years and above(2011-10-11) Kufe, Nyuyki ClementItem An evaluation of a chronic disease outreach program (CDOP) - a primary care and tertiary care kidney and cardiovascular prevention, detection and management program(2011-02-01) Katz, Ivor JonathanBackground: Chronic diseases have increased worldwide. Despite the significant advances in medical science, the management of chronic diseases continues to be poor. To meet this challenge, we need to try to implement existing chronic illness models of prevention, early detection, and risk factor management. This is achievable in part by linking primary health care clinicians, such as primary health care nurses (PHCNs) and hospital-based medical specialists. This study evaluated a ‘real life’ chronic disease outreach program (CDOP), which assisted PHCNs with the early detection and management of chronic illnesses known to cause chronic kidney disease (CKD) and cardiovascular disease (CVD). PHCNs are critical in the management of chronic illnesses but they require ongoing support of and links with specialists. This will ensure that current guidelines reach the people receiving primary health care (PHC) and detection of those needing referrals. Aims: The study aimed to determine if CDOP was an effective method for the early detection and management of diabetic and hypertensive patients at high risk for complications like stroke, ischaemic heart disease and CKD. It also aimed to evaluate the PHCNs’ knowledge and motivation, and to elucidate the challenges facing the current health system in the management of patients with chronic conditions. Methods: Patients at risk for complications were enrolled for increased monitoring and clinical support and management, at 20 clinics in Soweto, South Africa (SA). CDOP used a paper-based support and patient care system, modelled on the Wagner Chronic Illness Care Model (CICM). The components for evaluation included: (i) Focus on monitoring functional and clinical outcomes (ii) Health system interventions, such as increased ‘decision support’ and the development of a ‘prepared motivated health care team’ and (iii) Enhancing PHCNs’ knowledge and motivation. The evaluation followed the various elements of the Wagner CICM, as well as drawing on the WHO Innovative Care for Chronic Conditions (ICCC) Framework. A cohort analysis of functional and clinical outcomes in enrolled patients was conducted. PHCN knowledge and motivation was assessed through self administered questionnaires. Health worker knowledge was evaluated through the use of case scenarios and multiple choice questions. On the theme of health worker motivation, Franco’s model, with Penn-Kekana’s adaptation, was used to develop the questions and analyse diary recordings. Diary recordings of PHCNs and meetings with regional and provincial health managers’ discussions were collected by CDOP staff during follow-up focus groups and feedback meetings. Diaries were analysed thematically. The CDOP evaluation is thus a triangulated analysis of clinical and functional outcomes, diary recordings, and the self-administered questionnaire. Results: The CDOP ran from 2003-2006, during which time 618 patients (61% females, 39% males) deemed at risk of CKD or CVD were enrolled; 55% had uncontrolled hypertension (HTN), 45% DM with HT and/or proteinuria. Patients were followed for 2 years. In total, 108 patients completed 2 years of follow up, most of whom were referred for specialist support (n=69, 11%), more intensive medication regimes or because were not available in the PHC system. Most did not require referral (515, 82%), 35 (6%) were referred but never arrived at the hospital and 6 (1%) died. Twelve percent had advanced CKD, 2% required dialysis, 6.9% required medications not available to primary care clinics, and 1% died. As a tool to detect those needing referral, the program was successful. The sensitivity and specificity for detecting those needing referral was 95% and 100%, respectively.. However, although PHCNs were able to detect high risk patients, not all those referred arrived at the hospital. Hypertension, blood glucose, cholesterol and proteinuria control significantly improved in those followed (p<0.01) over 2 years, but no improvement was noted with weight control. Importantly, proteinuria and kidney function, in patients with static stable renal function, measured by estimated GFR equations and urine dipstick or albumin creatinine ratio (ACR), did not worsen significantly. Of the remaining 510 patient enrolled but not followed up, 213 (35%) were reabsorbed into the routine clinics, and a further, 123 (20%) of patients enrolled were lost to follow up completely. The diary recording thematic analysis revealed the problem of poor patient follow up, attributed to the poor existing health system in the clinics, competing demands on PHCNs, staff shortages, high staff turnover, and the low motivation and morale of clinicians. The analysis of the health worker questionnaire showed improved motivation and statistically better knowledge in those PHCNs involved with CDOP compared to those who were not exposed to the program (p<0.0034). Conclusions: CDOP was successful in supporting PHCNs, detecting patients with advanced disease and ensuring their early referral. Such programs are able to correctly detect people with disease, but this is dependent on the health and program systems being intact. It also improved patient risk factor control in the sub-set of referred patients and impacted on PHCNs’ existing knowledge and motivation for caring for patients. Its weaknesses were related to the poor existing health systems and infrastructure, and the poor integration of chronic illness care in the region. The PHC clinics had poor follow up compared with that in the hospital setting. The study also revealed an overworked, poorly supported, and frustrated primary health care team. This was despite the fact that the PHCNs were willing and motivated to deliver a good service.Item Cui bono?: a capabilities approach to understanding HIV prevention and treatment for pregnant women and children in South Africa(2010-06-29T06:52:34Z) Sprague, CourtenayThe global health revolution of the last 50 years has generated significant health gains in terms of increased life expectancy and reduced maternal mortality. South Africa, an upper middle income country, has performed poorly along the same development indicators. Development gains for women and children won over two decades are now being reversed, largely due to HIV/AIDS. This is in spite of the evidence that lifesaving antiretroviral medication can prolong life and enhance quality of life. Using a joint capabilities and health equity lens, this thesis seeks to understand a critical development problem in South Africa – premature mortality in pregnant women and children attributed to HIV – an infectious disease that is both preventable and treatable. The research identifies key barriers faced by pregnant and postnatal women with HIV who seek (freely available) access to PMTCT (prevention of mother to child HIV transmission) and ART (antiretroviral therapy) programmes in the public health sector. The study considers whether disparities in, and missed opportunities for, preventing and treating HIV in these population groups comprise avoidable, systematic and unfair health inequities. The implications for the capabilities of women and children with HIV in this country are also explored. Qualitative research methods are employed to investigate the research concern. Semi-structured interviews with 83 women comprise the mainstay of the field research. Interviews with 37 caregivers of children with HIV, together with patient files and interviews with key informants, supplement the data collection. Research was undertaken in two sites in two provinces: Eastern Cape and Gauteng. Each site constitutes a bounded case study. A rural-urban perspective is put forward – with attention to equity considerations in access to maternal-child HIV services. The study evinces a host of avoidable factors in the operational delivery of ART/PMTCT, along a range of intervention points in the continuum of care: including the antenatal, labour, postnatal and pediatric wards. While some of these factors are influenced by individual behaviour, the vast majority are directly linked to the health system – illuminating the ways in which the health system serves as a social determinant of health (SDH), and often restricting, constraining, and ironically, preventing people from obtaining the interventions and information they need to improve their health. iii By connecting the empirical findings related to ART/PMTCT within the health system to the capabilities and health equity literatures, an understanding of disparities in access to, and delivery of, such services – and their importance in shaping health, development and health outcomes of these population groups – becomes clearer. As a consequence, strengthening the public health system is a necessary first step to ensuring at least some of the minimum conditions that allow people to be healthy. As an entry point, there is great scope for systems’ interventions that would address the shortfall in health for black South Africans and deprivations in their health capability. At the same time, the research reveals that – owing to the contribution of social determinants of health (e.g., factors that impact on health such as living and working conditions, but lie outside the realm of healthcare) to health status: good health is not achieved solely by access to and provision of good healthcare. This reality underscores the importance of health as a central capability; and good health as a normative social goal. In the capability view, the moral concern for state and society is the reduced capability of individuals due to health inequities that are socially-constructed, and in turn, changeable. Recommendations to address modifiable factors related to effective ART/PMTCT provision in these facilities are put forward, with a set of suggestions for future research in maternal, child and women’s health in South Africa.Item Can a routine peri-partum HIV counselling and testing service for women improve access to HIV prevention, early testing and treatment of children?(2010-04-19T13:04:09Z) Technau, Karl-GunterContext Prevention of mother to child transmission (PMTCT) of HIV relies on identification of HIV-positive pregnant women at the first antenatal visit and at time points thereafter. As not all women who attend antenatal care initially agree to test or maintain an HIV-negative status the lack of re-establishing HIV prevalence at delivery may result in missed prevention opportunities and a false impression of PMTCT coverage. Objectives To assess whether a routine peri-partum HIV counseling and testing service improves access to HIV prevention, testing and care of infants by identifying additional HIV-positive women at the time of delivery. To assess the effect on the PMTCT coverage indicator when HIV prevalence is reestablished in the delivery population. Design and Patients All women 18 years or older with live births in the labour and postnatal wards of the Rahima Moosa Mother and Child Hospital (RMMCH) were interviewed and invited to enrol irrespective of their need to retest/test for HIV or their potential refusal of an HIV test. Rapid HIV antibody tests were offered to women who had no HIV result, reported an HIV-negative result performed more than six weeks prior to delivery or reported an HIV result discrepant with her documented result. vi Test acceptance and HIV prevalence were calculated for the enrolled population. The rate of return and results for early infant diagnosis in HIV-exposed infants and the follow-up of infected infants were documented. HIV polymerase chain reaction (PCR) results for infants not returning to the facility were retrieved from the National Health Laboratory Services database. Results Between 9th April 2008 and the 23rd of September 2008 there were 5169 women with live births. A total of 3684 (71.3%) of the 5169 women delivering were interviewed and 2419 (46.8%) were enrolled. Of the women enrolled, 2140 (88.5%) reported a known HIV status and 490 (22.9%) of these were HIV-positive. After counseling and testing, an additional 101 HIV-positive women were identified increasing the number of HIV-positive women by 20.6%. An additional 177 women were identified as being HIV-negative. The true infant PMTCT coverage increased by 17% as a result of newly identified HIV-positive women. Of 591 HIV-exposed infants identified, 284 (48.0%) underwent PCR testing at RMMCH or surrounding facilities and 16 (5.6%) tested PCR-positive. Of the infants expected to return to RMMCH for PCR testing 155/203 (76.4%) antenataly diagnosed versus 12/83 (14.5%) newly diagnosed women returned with their infants (p<0.001). Ten HIVinfected infants were diagnosed at RMMCH of which nine were in care with six initiated on antiretrovirals.Item Assessing the determinants of sexual risk-behaviour amongst young men in rural South Africa to inform male-oriented HIV prevention programming(2009-05-04T11:20:33Z) Anifowoshe-Kehinde, Adebimpe WasilatNo abstract or preliminary pages submitted on diskItem Knowledge levels of voluntary counselling and testing for human immunodeficiency virus amoungst taxi drivers in Kampala, Uganda(2007-02-28T12:12:53Z) Kizito, Assisi-FranklinIntroduction: Human Immunodeficiency Virus (HIV) was first isolated from human blood in 1983 at the Pasteur Institute, Paris. Currently there is no cure for HIV and control efforts emphasize prevention. One of the components of the Global Strategy put forward to preventing HIV transmission is HIV Voluntary Counselling and Testing (VCT) (Ginwalla, Grant & Day:2002). Taxi drivers are part of the Ugandan population at special risk of acquiring this virus. It was therefore necessary to carry out a study in this group of people to assess how much they knew about HIV/VCT services. Study Objectives To establish the level of knowledge amongst the taxi drivers about the availability and accessibility of HIV VCT services in Kampala. To identify factors that influence the taxi drivers in Kampala, Uganda to access the VCT services. Methods and materials A cross-sectional descriptive study design was used to carry out the study amongst 400 taxi drivers who consented to participate and operated within and around the city of Kampala during 2004. A structured questionnaire to record variables that included, age, sex, marital status, level of education, level of knowledge of VCT, factors that enhance VCT uptake, factors that inhibit VCT uptake, history of having ever had VCT, and knowledge of spouse or sexual partner’s HIV serostatus, was used. Data was entered into EPI-INFO 6 computer program and descriptive and analytic investigation using proportion or percentages to compare the level of knowledge generated was used. Findings/Results A total of 399 taxi drivers with 52.8% of them aged between 26 – 35 years participated in the study. 68.8% lived within 6 km of the city centre. All were married and 78.8% had one spouse. 0.75% were lady drivers. 55% of the participants had attained secondary school level of education. 69% of the taxi drivers knew that HIV/AIDS was the commonest health problem in the country and 57.4% of the participants mentioned HIV testing as the only way one would ascertain their serostatus. 94.2% had heard about HIV/VCT mainly from the media and as much as 98.7% of the taxi drivers knew a place where such services could be got. 82.2% confirmed that these places were accessible and 85.9% said that the services were not expensive. However, 57.3% of the participants preferred getting these services where they were known in order to get genuine results and subsequent support. The 26% who opposed this idea sighted confidentiality as the main obstacle. Despite the knowledge level about HIV/VCT amongst the participants, 68.3% of the communal taxi drivers were willing to go for the service and only 16.1% had actually taken the test. Out of the 399 participants 59.6% felt that they could share their serostatus with their spouses. Conclusion The taxi drivers are knowledgeable about HIV/VCT services and these findings lie within the overall range of knowledge of the population in urban Uganda. The HIV/VCT services are accessible and affordable to the taxi drivers but the fear to receive the unexpected results and the consequences of having positive results hinder the taxi drivers from seeking the VCT services. The majority of taxi drivers preferred to go to HIV/VCT service points where they were known. This factor could have contributed to the small number of taxi drivers that had taken the test. Probably few suitable service points to go to had been identified by these taxi drivers. Recommendations The government and other organizations that provide care in the field of HIV should organize sensitization seminars for taxi drivers to address issues aimed at allaying their anxiety or fear to receive positive results. Also, there is a need to intensify counselling services for the taxi drivers by establishing counselling centres close to the two taxi parks in the City. HIV/VCT service centres should be integrated with other health services so that people who seek either of the services can gain from both. This will encourage more taxi drivers to come to these centres.Item Role of men in programme to prevent mother-to-child transmission of HIV in Jwaneng,Botswana(2006-10-26T11:43:18Z) Kayembe, Kazadi NshindanyiBackground - The programme of prevention of mother- to-child transmission of HIV (PMTCT) was rolled out to the entire country in November 2001 after its launch in April 2000. The role of men had not been clearly defined. According to the progress report of February 2002 from PMTCT national coordination unit at family health division ministry of health, countrywide, out of 85% of pregnant women who came for antenatal care (ANC), less than 1% of these women were accompanied by their partners. However, in Jwaneng, 81% (526) of women agreed PMTCT counselling for HIV in 2003. Less than 5% (6/526) of women who agreed to be counseled, were accompanied by their men since the programme was launched in October 2001 in Jwaneng. In addition, less than 1% (2/160) of women who tested for HIV came with their partners for HIV test. Out of them, 30.5% (160/526) women agreed and tested for HIV. This testing rate was far less than the national targets of 70%. Then, 33% (52 women) tested HIV positive and 108 tested HIV negative. Of the 52 HIV positive women, 70% (36 women) joined the PMTCT programme and 4 women did not adhere. Furthermore, of 52 HIV positive women, 60% (32) of women agreed to receive AZT, adhered and chose one of the recommended methods of infant feeding. No study in Botswana had been done in a mining town to establish whether, there was a need for men to play a role in PMTCT in Jwaneng. 2 The researcher did not know whether Jwaneng pregnant women want their men or family members to come with them for PMTCT services as a motive for easy acceptance and increase of the programme uptake.