4. Electronic Theses and Dissertations (ETDs) - Faculties submissions
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Item Birth Freedom: Healing Architecture’s Impact on the Experience of Childbirth and Healthcare Through a Community Maternity Centre in Alberton(University of the Witwatersrand, Johannesburg, 2024) Grobler, Leonie; Szentesi, AnitaThis research explores the topic of childbirth and maternal health care in a community context where such facilities are lacking in focus and accessibility. The study explores the narratives of pregnancy, childbirth, and the postnatal period through the lenses of phenomenological experience, feminist theory, and healing. Its focus lies in how these concepts can shape the design of maternal healthcare architecture. The aim is to research and design a community health care centre that focusses primarily on aspects surrounding childbirth, and secondarily, aspects of female reproductive healthcare and family planning. The intervention aims to challenge the clinical nature of healthcare, improve accessibility to quality and affordable healthcare, and give women freedom over their reproductive healthcare choices. The site of the study is within the town of Alberton, located South of Johannesburg, in the Ekurhuleni Metropolitan Municipality. The goal of the research study is the development of a birthing centre model that serves as an alternative option to existing clinical birth settings which are part of larger hospitals. Research will be conducted through site analysis, contextual analysis, data analysis, theoretical and architectural research and precedent studies. This information will be used to guide the design process and develop a resolved building. This research project consists of two parts, a research report, and a set of design drawings, which will be combined into a single thesis document.Item Operational challenges and financial sustainability of delivering dialysis services in South Africa(University of the Witwatersrand, Johannesburg, 2023) Avanasigan, Thareshni; Appiah, ErasmusThe provision of dialysis services in South Africa presents a multifaceted landscape which is characterised by both operational challenges and financial sustainability concerns. This study explores the intricate dynamics and impediments faced within the healthcare system and focuses on the delivery of dialysis services. The reviewed literature examined the operational complexities which encompass limited access to resources, inadequate infrastructure, shortage of skilled personnel, and geographic disparities that impede the delivery of services. Moreover, the financial sustainability of dialysis services is a critical issue, and is compounded by the high costs for equipment, consumables, and maintenance, coupled with limited funding and reimbursement mechanisms. This study aims to shed light on the complexity surrounding the provision of dialysis services in South Africa. The challenges are synthesised and methods to enhance operational efficiency and acquire financial sustainability within the healthcare system is recommendedItem Epistemic (in)justice, social identity and the Black Box problem in patient care(University of the Witwatersrand, Johannesburg, 2024) Khan, Muneerah; Ewuoso, CorneliusThis research report draws on (for the first time) the moral norms arising from the nuanced accounts of epistemic (in)justice in the work of decolonial scholars, and social identity in the work of relational autonomists to defend the thesis that using AI in patient care in light of the Black Box problem is deeply problematic and is ethically impermissible. This does not necessarily doom AI since it may be used for other purposes within the healthcare system. The report highlights what needs to happen to align AI with the moral norms it draws on. Deeper thinking – from backgrounds other than decolonial scholarship and relational autonomy – about the impact of AI on the human experience needs to be done to appreciate any other barriers that may exist. Future studies can take up this task.Item Health Financing and its Effect on the Equity of Healthcare Systems and Universal Coverage in Sub-Saharan Africa(University of the Witwatersrand, Johannesburg, 2023) Okaka, Damianus Ochieng; Ojah, KaluThis work examines the contribution of different arrangements for financing healthcare to health systems’ equity in Sub-Saharan Africa (SSA); with equity of the health system measured as health outcomes. More specifically, the study explores: 1) How financing of healthcare using domestic resources affects health outcomes. The effect of increased budgetary allocation to healthcare on health outcomes. And the effect of financial pooling and financial risk mitigation on the health systems’ equity. The concept of health production, based on Grossman’s (1972 & 2017) health capital theory, serves as the framework for empirical analysis of this work, using balanced panel data from 47 SSA countries, over 19 years. The dataset is pulled from relevant governments’ and multi-lateral organizations’ databases. Broadly, descriptive statistics and multivariate regression analysis are deployed in assessing the hypothesized relationships between the study’s relevant variables – financing of countries’ healthcare systems and various forms of health outcomes (i.e., life expectancy at birth, 5-year mortality rate, crude death mortality rate, and rate of infant mortality). The results indicate that financing healthcare using domestic public resources does relate insignificantly or negatively to health outcomes, but financing healthcare using domestic private resources relates significantly well with health outcomes. An increase in budgetary allocation to healthcare per capita relates beneficially to health outcomes. However, an increase in budgetary allocation as a percentage of total government expenditure affects the region’s health outcomes adversely; however, further tests of this relationship reveal that a reduction in indirect investment in healthcare could be responsible for the adverse effects. Thus, pointing to the need to balance the effects of the increase in both direct and indirect healthcare investments (expenditures). Lastly, apart from financial pooling using the private health insurance method, which affects health outcomes negatively, all the other pooling methods of healthcare financing affect the region’s health outcomes favorably. However, the social health insurance (SHI) effect on the region’s health outcomes is largely insignificant. Which may call into question its appropriateness as a vehicle for universal health coverage (UHC). The main conclusion of the study is that governments’ participation in healthcare financing is necessary for the SSA region’s health systems. However, increased government allocation should not be done at the expense of allocation to health-related activities (like the provision of clean water, sanitary services, etc.). We also found that domestic private healthcare funding methods associate favorably with health outcomes while domestic public healthcare funds do not. We argue that the reason for these confounding results is because of allocation problems, and recommend redistributive policies with a focus on the indigent and rural areas. Further diagnostic tests show that domestic public financing methods increase access to healthcare but not health outcomes. This shows that a financing method can increase access to healthcare but fail to improve population health status. Our findings also show that SSA health systems still need external financial assistance to be equitable. We recommend a gradual weaning from external assistance. On risk pooling, we recommend an increase in pool sizes and more accurate actuarial data to improve the performance of SHI and, to make it appropriate for UHC. Finally, governments of the SSA region should increase funding of healthcare by using public resources, ensure healthcare financing risk mitigation by increasing pool sizes of public financial pooling methods, and enact requisite legal and regulatory frameworks to guide the administration of private non-profit healthcare finance pooling schemes. Importantly, these governments should consider policies that correct for imbalances in the distribution of healthcare between the rich and the poor, and between rural and urban areasItem Combining complexity leadership with operational systems and structures for adaptability in South African private hospitals(University of the Witwatersrand, Johannesburg, 2022) Nel, KarenThe global healthcare landscape is complex. The South African Government and various other researchers have highlighted the unequal nature of the healthcare system in South Africa. The system is unsustainable and urgently needs substantial transformation in its current form. As set out by the South African Government, introducing universal healthcare coverage for the whole population is a solution. This will, however, significantly impact and change all role- players relatively quickly, especially for private hospitals. The purpose of this study was to critically examine whether private hospitals in South Africa were positioned for adaptability, considering complexity leadership (with concepts: entrepreneurial leadership, operational leadership and enabling leadership) and operational systems and structures (with concepts: agile, lean and leagile), as an approach to deal with the potential changes. A mixed methods study with an explanatory sequential design was utilised where the quantitative results and sample informed the population and questions of the qualitative study. Additionally, the quantitative results' drivers were identified in the qualitative study, namely causal factors, leadership and operational consequences, and aggravating factors. This study confirmed that the leadership displayed in private hospitals and the operational systems and structures implemented in private hospitals were not aligned with complexity leadership and operational systems and structures as defined in the conceptual model of this study. A unique finding was that operational systems and structures in private hospitals had a significantly higher impact on the hospitals' daily management than the leadership displayed in these hospitals. This was especially evident between managers and non-managers and between clinical and non-clinical employees, with non-clinical employees viewing the impact of the operational systems and structures implemented in hospitals as significantly more impactful than the leadership displayed in these hospitals. Furthermore, it was identified that operational leadership and lean systems and structures were the preferred approaches in private hospitals and negatively impacted the display of entrepreneurial leadership and agile systems and structures in these hospitals. Moreover, it was found that exploitative leadership, which is the leadership approach when dealing with old certainties, labelled as operational leadership in the current complexity leadership framework, should be relabelled a administrative-operational leadership in South African private hospitals, as a result of the hierarchical, autocratic culture. Assessing the impact of the COVID-19 pandemic on the leadership displayed and the operational systems and structures that were implemented in these hospitals, it was identified that employees can either experience disruption in a positive light through an adaptive response supported flexibility, or be traumatised by it when management implemented an order response with increased controls. It was conclusively confirmed that private hospitals in South Africa do not regularly display complexity leadership nor implement operational systems and structures as defined in this study's conceptual model. Four recommendations were made that can assist the private hospital industry in becoming more adaptable. The first recommendation is for the industry to implement CL and OSS as defined by the study's conceptual model. This implementation will naturally develop into an adaptive space. The second recommendation is to overcome the disconnect between industry players, head offices and hospitals, and to increase collaboration. Although the adaptive space will impact this recommendation positively, it has to be driven and supported by senior leadership. The third recommendation is to develop a formal industry framework for adaptability in private hospitals. The fourth recommendation is for the implementation of integrated and applied development programmes for leaders and staff at all levels. The programmes will assist everyone to better understand the relationship between CL, OSS, business acumen, and business successItem The effect of smartwatches on patient-centered healthcare(University of the Witwatersrand, Johannesburg, 2022) Ndhlovu, Patson; Ndayizigamiye, PatrickPatient-centered healthcare lies at the core of health and social services, where individuals are recognized and encouraged to take an active role in their own care. The literature suggests that technological advancements are contributing to achieving patient-centred care. As technology is advancing, it is important to keep abreast of how emerging technologies are affecting patient-centred healthcare. Thus, the purpose of this study was to investigate the effects of smartwatches on patient-centred healthcare. To achieve this, this study assessed the effect of features of smartwatches on the Picker's 8 principles of patient-centred healthcare. The sample for this study was 141 participants who use smartwatches. These participants were all part of a running club based in Gauteng province of South Africa. The findings revealed that the activity tracking feature of a smartwatch has a moderate impact on emotional comfort and coordination and integration of care. Similarly, the vital signs monitoring feature has a moderate effect on the continuity and transition of care, while the data management feature demonstrated a moderate effect on the coordination and integration of care. Moreover, the activity tracking feature of a smartwatch has the strongest effect on the coordination and integration of care, while vital signs monitoring has the strongest effect on the continuity and transition of care. The data management feature, on the other hand, has the strongest effect on the coordination and integration of care. Findings from this study, albeit their limitations, can assist healthcare providers to make informed decisions on which features of smartwatches they should focus on when promoting the use of wearables to provide patient-centred carItem Examining the bidirectional relationship between comorbid depression and Type 2 diabetes: a managed healthcare perspective(2024) Naidoo, Lovina Asha CorrienIntroduction-Type 2 diabetes mellitus (T2DM) is common and has devastating outcomes for patients diagnosed with this disease. In Africa, the prevalence of T2DM is reaching epidemic proportions, especially in developing countries like Ghana, Nigeria and South Africa (SA). The financial burden of T2DM is seen in the public and private healthcare sectors in Africa. Major depressive disorder (MDD) frequently co-occurs as a discordant comorbidity with T2DM. MDD is an important component in the holistic management of T2DM care as the outcomes of both conditions are exacerbated by the presence of the other. T2DM patients are at high risk for cardiovascular (CV) morbidity and mortality. The comorbidity of MDD among these individuals is associated with poor diabetes-related cardiovascular disease (CVD) outcomes such as myocardial infarction, stroke and cardiac failure, because MDD is a highly prevalent risk factor for CVD and T2DM alike. Little is known of the prevalence of MDD as a comorbidity of T2DM in SA or if MDD is a risk factor for the onset of T2DM. It is also unclear whether the treatment of depressive disorders in T2DM would improve glycaemic control. While the association between depression and T2DM in America and Europe is established, understanding the relationship between these two non-communicable diseases (NCDs) is lacking in SA. The relationship between T2DM and associated co-morbidities, particularly MDD, is poorly acknowledged in chronic disease management practices in SA. The management of co-morbid conditions may influence managed healthcare costs and hospitalisation rates. Aim and objectives -This thesis investigated the bidirectional relationship between T2DM and comorbid MDD within a South African privately managed healthcare organisation. The objectives of the study were to estimate the comorbidity incidence, resource utilisation (medicine, services and hospital), assess the cost between two T2DM management funding models, the influence of MDD on glycaemia, blood pressure and lipid control (ABC guidelines) and finally identify the depressive symptom and CV risk profiles of patients with T2DM with or without MDD and those with MDD alone. Method -The thesis comprised four quantitative studies that analysed claims data from a privately funded healthcare insurer and electronic health records (EHR) from 2012 to 2019, and a cross-sectional survey from 2016 to 2019. The methodology in the first study was a retrospective descriptive analysis of 902 adult patients with T2DM in 2014. Patients were identified with T2DM and their comorbidities and categorised as those with concordant comorbidities (CC), and those with discordant comorbidities (DC). Hospital admissions of patients with T2DM, with MDD (T2DM+MDD) versus those without MDD (T2DM-MDD), were further analysed. The second study analysed the claims data of patients with T2DM and T2DM+MDD from 2012 to 2016. Annual healthcare costs were assessed between two funding models and categorised as in-hospital and out-of-hospital medicines and out-of-hospital services. Diabetes-related and other medicine-plus-services and hospitalisation costs between T2DM and T2DM+MDD were estimated In the third study, the cardiometabolic indices control of 1211 patients with T2DM+MDD, T2DMMDD and MDD only were measured using their EHR for the year 2019. Claims for lipid-lowering therapy, hypoglycaemic agents, antihypertensives and antidepressant selective-serotoninreuptake inhibitors (SSRI) were assessed between the study groups. Frequencies of patients achieving target glycated haemoglobin (HbA1c), systolic blood pressure (SBP) and low-densitylipoprotein (LDL-C) were compared between groups. A stepwise multivariate logistic regression analysis was performed to identify predictors of HbA1c and LDL-C control of the study groups. The fourth study conducted a cross-sectional survey of a random sample of members with T2DM+MDD, T2DM-MDD, MDD only, and a healthy control group between the years 2016 to 2019. The survey comprised a Patient Health Questionnaire-9 (PHQ-9) to assess possible depressive symptoms, and anthropometric measures (body mass index (BMI), family history of diabetes and/or heart disease, and smoking status as CV risk profiles). Findings- The first study revealed a high incidence of CV concordant comorbidities (hypertension )and hyperlipidaemia) in patients with T2DM+MDD, with MDD being the most prevalent discordant comorbidity of T2DM (17%). A higher percentage of patients with T2DM+MDD were admitted to 3 hospital (42%, p=0.004) compared with those with T2DM-MDD (30%). The number of overnight admissions was higher among the T2DM+MDD (76%, p=0.016) compared with T2DM-MDD (66%). The second study focused on health care costs and the funding models associated with managed care. The direct medical costs of patients with T2DM and T2DM+MDD registered with a medical scheme over a 5-year period between two funding models were estimated and compared: a capitation risk-sharing model (CM) versus a traditional fee-for-service (FFS) model. Of the identified T2DM patients, 64% were enrolled in CM in 2012 and this rose to 81% by 2016. The implementation of CM resulted in a significantly higher cost to the scheme ($1,095) compared to FFS ($296) in 2016 (p<0.0001). Forty-six T2DM patients in this study incurred hospitalisation costs of ≥ $24,243 for T2DM-related or other hospital admissions (non T2DM-related). The healthcare expenditure consumed by patients with T2DM and T2DM+MDD on a capitation model of care for diabetes was high compared to patients on FFS. While the diabetes-related treatment and management were similar between patients with T2DM+MDD and T2DM-MDD, other medicine and services, expenditure was significantly higher in the T2DM+MDD group, for example T2DM+MDD patients had a median expenditure of $1,414 in 2016 compared to a median of $614 in T2DM-MDD patients (p<0.0001). The third study assessed the HbA1c, SBP and LDL-C control target attainment (as per South African ABC guidelines) in patients with T2DM+MDD and T2DM-MDD and those with MDD alone. Only 13% of the patients in T2DM+MDD group and 7.1% in the T2DM-MDD group achieved ABC (HbA1c<7%, LDL-C<1.8mmol/l and SBP<140/90 mmHg) targets, despite hypoglycaemic, lipidlowering therapy and antihypertensive claims, indicating a possible risk for CVD in T2DM+MDD and T2DM-MDD patients. A higher proportion of patients with T2DM+MDD (56%) achieved an HbA1c target of <7% compared to the T2DM-MDD group (45%, p<0.05). Multiple regression analysis showed that HbA1c control was independently associated (p<0.001) with older age, claims for statins and having a history of MDD, after adjusting for claims for antihypertensive therapy, metformin, newer hypoglycaemic agents, sex, and interaction factor of newer hypoglycaemic agents and metformin. Only 24% of patients in both the T2DM+MDD and T2DMMDD groups reached the LDL-C target <1.8mmol/l. The predictors of LDL-C control between the T2DM+MDD and T2DM-MDD groups were older age (p<0.0001) and claiming statin therapy (p=0.001), after adjusting for antihypertensive therapy and metformin claims and sex The fourth study identified the depressive symptoms and CV risk factors (such as obesity, smoker status and family history of diabetes and heart disease) in individuals with T2DM+MDD, T2DMMDD or MDD alone compared to a healthy control. The PHQ-9 scores revealed that patients in all four groups were within a range of mild to moderate-severe depressive symptoms. The T2DM+MDD group had moderate-severe (PHQ-9≥10) depressive symptoms (58.8%) similar to the MDD group (54.2%, p=1.0) suggesting a poor response to antidepressants. Patients with T2DM-MDD had underlying unrecognized depressive symptoms: 20.5% had moderate-severe (PHQ-9≥10) depressive symptoms and 23.1% had mild (PHQ-9=5-9) depressive symptoms. Of concern was that 25% of the control (healthy) group recorded having moderate-severe (PHQ9≥10) depressive symptoms and 21.4% of having mild depressive (PHQ-9=5-9) symptoms. The majority of the T2DM+MDD group obese (76.5%) whereas 46.2% of the T2DM-MDD group were overweight. However, the control group, with no stated disease, were overweight (37.5%) or obese (30.4%). This study highlights the undetected MDD and high CV risk prevalent in this setting. Conclusion- Within this South African private managed healthcare setting, comorbidities associated in patients with T2DM, i.e. MDD and CVD, are managed discretely. High-risk individuals with T2DM increase costs and resource utilisation within the private managed healthcare setting. In summary, the relevance of the research was to increase awareness of the consequences of comorbidity of T2DM and MDD and encourage routine screening for depression in T2DM patients, and glycaemic screening among patients with MDD. Managed care programmes should consider a patient-centric approach to assist patients in engaging with their T2DM and comorbidities more effectively by listening to their difficulties in terms of medication compliance, offering regular glycaemic and lipid blood tests and encouraging healthier diet through visits to dieticians or nurse educators. Targeting primary healthcare as an intervention has the potential to reduce the hospitalisation burden by initially stabilizing patients with T2DM+MDD, providing cost-effective and appropriate medicine management (i.e. statins), improving attainment of ABC control targets and early screening for depression and non-invasive CV risk factors. Resource allocation for a coordinated care team that includes health professionals such as dieticians, endocrinologists, drug review utilisation (DUR) pharmacists, psychologists and nurse educators to treat patients with T2DM+MDD is indicated.