Masters Degrees (Public Health)

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A prospective study of the value of the oesophageal electrocardiogram in the differentiation of wide complex tachycardias.
(1990) Moodley, Rajendran.; Sewdarsen, Mohan.
The accurate differentiation of a ventricular from a supraventricular origin of a wide QRS tachycardia (QRS > 120 milliseconds) is an important clinical problem. Misdiagnosis of this arrhythmia can lead to institution of inappropriate drug therapy acutely with potentially catastrophic consequences. Various diagnostic aids have been used to obtain electrocardiographic potentials to aid in the differentiation. This report assesses the clinical usefulness of oesophageal electrocardiography in the differentiation of wide complex tachycardias and describes a simple, safe technique to obtain oesophageal electrocardiograms. Eighteen consecutive patients between the ages of 27 and 71 years who were haemodynamically stable were selected for this study. The technique was performed in the following manner: A temporary pacing catheter was lubricated and passed nasally and advanced with the patient being instructed to swallow. Adjustments in catheter depth were made as necessary to obtain an optimal recording on a standard electrocardiograph recorder. Satisfactory placement with minimal patient discomfort was achieved within 6.5 minutes (average 4.5 minutes) in all cases. High quality tracings were obtained in every instance. In the 18 patients with tachyarrhythmia, AV dissociation consistent with ventricular tachycardia was demonstrated in 11 instances; in the remainder the diagnosis was supraventricular tachycardia. Of the 11 patients diagnosed as ventricular tachycardia, 9 were initially misdiagnosed as supraventricular tachycardia, whilst only 1 of 7 patients with supraventricular tachycardia was misdiagnosed. This study has demonstrated that oesophageal electrocardiography is useful in the differentiation of wide complex tachycardias. The technique outlined in this report is simple and offers the following advantages: the temporary pacing catheter is associated with minimal discomfort; the catheter allows easy manoeuverability within the oesophagus which allows proper depth to be easily obtained; the equipment used is routinely available. Therefore the technique offers a rapid, safe and simple method of obtaining an oesophageal electrocardiogram which is invaluable in the electrocardiographic differentiation of a wide complex tachycardia.
Adapting the WHO Health Promoting Hospitals strategy for South African hospitals : an evaluation.
(2008) Geddes, Rosemary Veronica.; Jinabhai, Champaklal Chhaganlal.; Knight, Stephen Eric.
Objective To conduct an evaluation of the pilot implementation of the World Health Organization Health Promoting Hospitals initiative and its self-assessment tool in public hospitals in KwaZulu-Natal in 2004/2005 Study design This evaluation utilised a cross-sectional design that incorporated both qualitative and quantitative research methods. Main measures Throughout the Health Promoting Hospital pilot project the opinions and responses of those with a legitimate interest in the initiative were monitored. Data collection methods utilised in this evaluation included participant observation, the World Health Organisation metaevaluation questionnaire, records of workshops and feedback meetings and secondary analysis of all data collected by the six pilot hospitals during the implementation of the project in KwaZulu-Natal. Results Major constraints were found to be time, human and financial resources, lack of training and expertise and insufficient support for the project. The self-assessment tool was found to be insufficiently adapted and not all outcomes were found to be reliable and useful. Despite this, institutional staff found the Health Promoting Hospital project to be capacity building and morale boosting. Relationships between health service levels improved. All hospitals who participated recommended that other hospitals become Health Promoting Hospitals. Conclusion If the World Health Organisation Health Promoting Hospital initiative with its selfassessment tool is to be rolled out to the rest of KwaZulu-Natal province, then substantial changes have to be made to the process. Amongst these are: further adaptation of the selfassessment tool, improved methods of data collection, provision of sufficient resources and increased and sustained provincial support for the project. In addition it is imperative that outcome and impact evaluations be done.
Adherence to antiretroviral therapy by HIV infected patients in rural UMkhanyakude District, South Africa.
(2008) Mthiyane, Italia Nokulunga.; Taylor, Myra.
The background. HIV and AIDS is a huge problem in sub-Saharan Africa where an estimated 22.5 million people were living with HIV in 2007.1 South Africa has the worst epidemic in the world.1 There were about 5.5 million people living with HIV and 1000 AIDS deaths daily in South Africa by the end of 2005.17 In 2007 the number of people living with HIV in South Africa increased to 5.7 million.1 The HIV prevalence in Umkhanyakude district, KwaZulu Natal, where Hlabisa subdistrict is situated, amongst public antenatal clinic attenders was 39.8% in 2007.19 AIDS is the cause of 50.0% of deaths in the Hlabisa sub-District.15 In 2003 the South African government decided to provide antiretroviral therapy (ART) in the public health sector, giving hope to thousands of people who are in need of this intervention to improve their quality of life and reduce premature deaths.7,13 However adherence to antiretroviral drugs is essential for successful treatment. Adherence to antiretroviral therapy in South Africa as in other African countries was expected to be low31 (<95.0%), however, in a study that was done in Cape Town during 1996 – 2001, the authors concluded that adherence was high.28 The aim of that study was to identify predictors of low adherence (<95.0%) and failure of viral suppression (>400 HIV copies/mm3). Pill counts and records of treatment refills from pharmacy were used to measure adherence.28 The results revealed no significant difference in adherence between patients on protease inhibitor based regimens and/or those on nonnucleoside based regimens nor with socioeconomic status, sex and HIV stage. Independent predictors of low adherence were English language speaking, age, and three times per day dosing. The following were found to be independent predictors of failure of viral suppression: baseline viral load, <95.0% adherence, age and dual nucleoside therapy.28This study however was done in an urban area before the antiretroviral therapy (ART) roll out in South Africa when the cost of treatment limited the accessibility of ART. These patients may have been different to patients who access free treatment in public health facilities today. Other South African studies have also reported good adherence rates.39,40 In another study in Soweto, South Africa, adherence was high, 88.0% of patients achieved > 95.0% goal, 9.0% achieved 90.0-95.0% adherence and only 3.0% achieved <90.0%.39In a study done at Khayelitsha, adherence was also high, viral load level was < 400 in 88.1%, 89.2%, 84.2%, 75% and 69.7% of patients at 3, 6, 12, 18 and 24 months.40 However, Soweto and Khayelitsha are urban and different from Hlabisa, and it is difficult to generalize these results to the sub-district. This study intended to assess how adherent patients are to antiretroviral therapy in a typical rural district in order to inform policy to enhance adherence to ART.
An analysis and evaluation of the child survival project in the uThukela district of KwaZulu-Natal.
(2005) Pillay, J. D.; Knight, Stephen Eric.
The uThukela District in the province of Kwazulu-Natal, Republic of South Africa, has been involved in improving Primary Health Care (PHC) in the district through evaluation surveys carried out at regular intervals during the past six years. World Vision's uThukela District Child Survival Project (TDCSP) began in November 16, 1999. This has been made possible by a Child Survival Grants Program from the Unites States Agency for International Development (USAID). In all previous surveys a 30-cluster sampling methodology was used to select individuals from the survey population. This time however, the Lot Quality Assurance Sampling (LQAS) methodology was used. The recent re-organization of the District into municipalities enabled each municipality to function as one Supervision Area (SA) or Lot. Even with a small sample size (in this case 24 per SA), poor health service performance could be identified so that resources are appropriately distributed. Furthermore, people from the community such as Community Health Workers (CHW) were involved in all phases of the study, including the manual analysis of the results, upon being trained appropriate. However, it is questionable as to how accurate and reliable such a manual analysis was. In this dissertation, the manual results of the study were evaluated by doing an electronic analysis. In addition, a more refined analysis of the data has been produced (e.g. population-weighted coverage, graphs and stratified analyses in some cases). From the comparisons made, it was concluded that the manual analysis was very similar to the electronic analysis and that differences obtained were not statistically significant. In addition, due to each municipality varying in population size, it was queried as to whether population-weighted results would produce a marked difference from the un-weighted, manual results. Again, the differences produced were in most cases not statistically significant. This concluded that the manual analysis carried out by the TDCSP team was accurate and that it is appropriate to use such results in determining individual municipality performance and overall District performance so that responsive action can then be taken immediately, without necessarily having to wait for electronic results.
An analysis of health inspection as a component of school health service, in Kwazulu-Natal.
(2000) Memela, Daphne Thembile.; Jinabhai, Champaklal Chhaganlal.
Introduction In 1996 there were 1,847,440 pupils in 4007 primary schools in KwaZulu-Natal (KZN) who were targeted for school Health Inspection (HI). In the same year there were only 95 school health teams who were visiting schools for HI. The School Health Service (SHS) had been running on a racial basis since the Apartheid era of government, and needed to be reviewed in order to measure its effectiveness and to make it relevant to the new government and its new health policies. Purpose To review HI as a key component of School Health Services (SHS) and make recommendations to improve it's impact on the health of the school child and on health promotion in schools. Objectives To describe the structure, process, output and outcome of HI in KZN; to measure the impact of HI on the health of school children; and to calculate the SHS consultation cost and compare it with other primary health care services. Methodology A cross sectional study involving 21 schools covered by the SHS and 5 schools not covered by SHS was undertaken. The study area was KZN and the sample area was Indlovu region. All health authorities and racial groups participated in the study. Results A total of 212 children and 129 parents were interviewed. Of the children interviewed, 156 pupils (73.5%) had been involved in HI and 56 (26%) had not. The average nurse/pupil ratio was 1:49301. HI coverage was 62%. Of the 156 pupils examined, 108 were referred and 53% of them went for treatment. 93 % of parents interviewed gave a positive comment on HI and 24.8 % of them did not know their children's problems before they were informed by the SHN. Std. 5 pupils interviewed before and after HI were compared and it was found that 57% from the after-HI group went for treatment for their health problems compared to 53% before HI. Subjective feelings improved from 15% pain before HI to 0% after HI. Conclusion HI had a positive influence on encouraging pupils to seek recommended treatment and this is likely to improve their health.
Antiretroviral therapy initiation of pregnant women before and during the implementation of Nurse Initiated and Management of Antiretroviral Therapy in eThekwini District Community Health Centres.
(2016) Nozulu, Nomonde.; Gaede, Bernhard Martin.
When the Prevention of Mother to Child Transmission of HIV programme was introduced in South Africa in 2002, doctors were the health professionals tasked with Antiretroviral Therapy (ART) initiation and management of patients. In a country with a known shortage of doctors and in which about 80% of the healthcare workers are nurses, the dependency on doctors negatively affected management of patients needing ART. The introduction of the Nurse Initiated Management of ART (NIMART) programme expanded the healthcare skill set necessary for ART initiation. With the implementation of NIMART, pregnant women who are regarded as a priority group in the country‟s ART programme would have ART initiation services offered as part of the antenatal care package. Aim The aim of this study was to evaluate ART initiation of pregnant women attending antenatal care in eThekwini district Community Health Centres (CHCs) between the Financial Years (FY) 10/11 (when NIMART was newly introduced) and FY13/14 (when NIMART was in full implementation). Methods An observational descriptive retrospective chart review study was conducted in 2015 at four eThekwini district CHCs. From these CHCs, records of pregnant women living with HIV that initiated ART in FY10/11 and FY13/14 were evaluated and compared. Results Approximately, 2749 pregnant women who attended antenatal care at the study sites during the two years were eligible for ART. Of the eligible women, 49% (N = 1334) attended antenatal care in FY10/11 while, 51% (N = 1414) attended in FY13/14. In FY10/11, 46% (n = 610) of the eligible women were initiated while 60 % (n = 855) of the1414 eligible in FY13/14 started ART during pregnancy. All women seen in FY10/11 were initiated at ART clinics. In FY13/14, 97% (n=826) of women initiated ART within the antenatal care clinics. ART in FY10/11 was started within 38 days after antenatal care booking while in FY13/14 initiations were within 4.12 days. Antenatal care booking before 20 weeks was found to have improved between the two years from 39 % to 58%.
The application and use of the partogram in evaluating the Saving Mothers programme in South Africa in 2002.
(2004) Mehari, Tesfai T.; Knight, Stephen Eric.
The SA National Department of Health made maternal deaths notifiable in 1997. It also commissioned a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) to confidentially investigate all maternal deaths, to write the "Saving Mothers Report" and to make recommendations based on the findings of the study. The Department of Health in 2003 commissioned an evaluation of the extent to which the 10 recommendations contained in the first "Saving Mother's Report" had been implemented. This rapid appraisal was carried out by Centre for Health and Social Studies (CHESS), University of Natal. A report 'The Progress with the Implementation of the Key Recommendations of the 1998 "Saving Mothers Report" on the Confidential Enquiry into Maternal Deaths in South Africa - A Rapid Appraisal," was published in 2003. The data collected on Recommendation 5 on the use of the obstetric partogram in 46 selected provincial hospitals in all the 9 provinces was only partially analysed in this report. This study reports on a secondary analysis of the 942 questionnaires that were completed on the use and application of the partogram in hospitals in South Africa. In the rapid appraisal experienced field workers evaluated the use of the partogram using a 36-point checklist. Provincial and national averages for each of these variables were calculated and hospitals were evaluated into how they performed according to these averages using Lot Quality Assurance Sampling methodologies. Using national and provincial averages, the hospitals in each province are compared with one another provincially and nationally. In addition, the application and use of partograms in areas and levels of hospitals are described. An attempt is made to show if there is relation between the number of deliveries and the recording of the partogram. The main findings were that, of all the provinces KwaZulu-Natal had the lowest number variables below the national average from the 36 variables used as a checklist. Eastern Cape and Limpopo had the highest number of variables below the national average. The hospital with the highest number below the national average is in the Eastern Cape. In the recording of the chart rural and level one hospitals are low in comparison with urban and level three hospitals. There was no relation in the recording of the chart and the number of deliveries.
Aspects of primary health care in a rural KwaZulu community : a descriptive study and literature survey.
(1990) Emerson, C. P. D.
No abstract available.
Assessing nursing students' readiness for e-learning.
(2014) Coopasami, Marilynne.; Knight, Stephen Eric.
Introduction e-Learning has been integrated and implemented in education and training to the level that it is now a well-established global practice. If used judiciously, e-Learning is a tool that enables active, individual and flexible learning. When integrated into medical education, it offers features that allow lecturers to be not merely content distributors, but also facilitators of learning. Aim The aim of this study was to assess the readiness of students to make the shift from traditional learning, to the technological culture of e-Learning. Methods An observational, cross-sectional, analytical study design was used and data was collected using a validated questionnaire. The sample comprised of all students enrolled in the first year nursing programme at the Durban University of Technology registered for anatomy and physiology in 2013. Informed consent was obtained from each participant prior to conducting the study. Results Three quarters (77/101 76%) of the participants were females. The psychological readiness score was noted to be high in the “could be worse” category (pre-72%, post- 64%). The technological readiness score was noted to be in the “dig deeper” category (pre- 58%, post- 65%) whilst the equipment readiness score fell in the e-Learning “not ready category” (pre- and post- 68%). Discussion The Chapnick Readiness Score Guide was used to analyse psychological, technological and equipment readiness. e-Learning has been identified as a multi-disciplinary field, which is dominated by information technology. Technological and equipment readiness factors of e-Learning are easier to resolve than the psychological readiness factor. Recommendations Although e-Learning could be a key tool in nursing education, a few factors require attention before it can be effectively implemented in this tertiary level education facility.
The assessment of knowledge and attitudes of health legislation (HL) among private family practitioners (FP) working in a defined geographical area.
(2011) Mahomed, Mahomed Faruk.; Gray, Andrew Lofts.
Introduction Since the 1994 change in power in South Africa, there have been many necessary changes in health legislation (HL), in accordance with the principles enshrined in the Constitution, Such changes have been recognized as being both complex and fraught with stakeholder interests. There is a perception that private family practitioners (FP) generally harbour negative attitudes towards HL that has been brought into effect in recent years. It is also possible that FP, in general, lack knowledge regarding HL. The aim of the study was to assess the knowledge and attitudes of private family practitioners (FP) to health legislation (HL) within a localized geographical area of the eThekweni Metro, KwaZulu-Natal Province. The specific objectives were: To determine family practitioners’ knowledge of health legislation. To determine family practitioners’ attitudes towards health legislation. To assess the correlation between family practitioners’ knowledge and attitudes. To compare the self-reported knowledge of health legislation with the objective assessment of knowledge and attitudes. To establish practitioners’ perceptions of the future of the profession, and of family practice in particular. Methods A cross-sectional descriptive and analytical study was performed, using a pre-tested, validated, structured questionnaire. This instrument was personally hand-delivered to each of a group of private family practitioners practising within a confined geographical area. The sample comprised of 101 family practitioners. Data were analysed using SPSS version 15.0 (SPSS Inc., Chicago, Illinois). Results The study revealed that private FP possess limited knowledge about HL and have a negative attitude in general towards HL. The mean knowledge score was 55% (standard deviation 12.2%). The mean score for attitudes towards health legislation was 46,3% (standard deviation 4.2%). The correlation coefficient between knowledge and attitudes was 0.244 (p=0.022). Therefore, there was a weak positive, but statistically significant, correlation between knowledge and attitudes. Thus, in general, as knowledge increased, so did attitudes improve and become more positive. The self reported knowledge and attitudes of FPs seemed to show some unexpected though non-statistically significant anomaly, in that FPs who considered themselves “well aware” of certain parts of HL, together with those who were “not aware”, reporting a more negative attitude towards HL than those who considered themselves to be “aware”. FPs’ perceptions of the future of the profession, and of family practice in particular, were generally reported as being reasonable to poor. Financial viability and sustainability of FP, in particular, were reported as being reasonable to poor. The attractiveness of the profession to the youth of today was reported as being poorer than in the past. However, the majority of FP held the perception that medicine as a profession was distinct as it responds to a calling to serve society at large, giving this aspect of the question a ranking of “reasonable to good”. Conclusion and Recommendations The study revealed that this group of FPs attained an overall mean knowledge score of 55% with respect to HL. FPs’ knowledge of HL requires improvement, which can be achieved through effective education and training programmes. Private FPs need to embrace the change process, but also need to be more pro-active in vocalizing their opinions. The Health Ministry and relevant authorities and policymakers need to play a greater role in creating an atmosphere that embraces and facilitates change by involving iii relevant stakeholders. Lastly, it is recommended that this study serve as a template for a broader research project involving larger numbers of participants and a wider geographical area. In addition, an intervention tool should be devised. Such a tool could take the form of a structured education programme on HL, with an associated monitoring and evaluation aspect, which would enable an assessment of the intervention programme in terms of its value and the influence it has on improving knowledge and attitudes.
Assessment of the therapeutic efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in northern KwaZulu-Natal.
(2013) Vaughan-Williams, Charles Hervey.; Knight, Stephen Eric.
Background Recent malaria epidemics in KwaZulu-Natal indicate that effective anti-malarial therapy is essential for malaria control. Although artemether-lumefantrine has been used as firstline treatment for uncomplicated Plasmodium falciparum malaria in northern KwaZulu- Natal since 2001, its efficacy has not been assessed since 2002. The objectives of this study were to quantify the proportion of patients treated for uncomplicated P. falciparum malaria with artemether-lumefantrine who failed treatment after 28 days, and to determine the prevalence of molecular markers associated with artemether-lumefantrine and chloroquine resistance. Methods An observational cohort of 49 symptomatic patients, diagnosed with uncomplicated P. falciparum malaria by rapid diagnostic test, had blood taken for malaria blood films and P. falciparum DNA polymerase chain reaction (PCR). Following diagnosis, patients were treated with artemether-lumefantrine (Coartem®) and invited to return to the health facility after 28 days for repeat blood film and PCR. All PCR P. falciparum positive samples were analysed for molecular markers of lumefantrine and chloroquine resistance. Results Of 49 patients recruited on the basis of a positive rapid diagnostic test, only 16 were confirmed to have P. falciparum by PCR. At follow-up, 14 were PCR-negative for malaria, one was lost to follow-up and one blood specimen had insufficient blood for a PCR analysis. All 16 with PCR-confirmed malaria carried a single copy of the multi-drug resistant (mdr1) gene, and the wild type asparagine allele mdr1 codon 86 (mdr1 86N). Ten of the 16 samples carried the wild type haplotype (CVMNK) at codons 72-76 of the chloroquine resistance transporter gene (pfcrt); three samples carried the resistant CVIET allele; one carried both the resistant and wild type, and in two samples the allele could not be analysed. ii Conclusions The absence of mdr1 gene copy number variation detected in this study suggests lumefantrine resistance has yet to emerge in KwaZulu-Natal. In addition, data from this investigation implies the possible re-emergence of chloroquine-sensitive parasites. Results from this study must be viewed with caution, given the extremely small sample size. Recommendations A larger study is needed to accurately determine therapeutic efficacy of artemetherlumefantrine and resistance marker prevalence. The high proportion of rapid diagnostic test false-positive results requires further investigation.
Attitudes of African males to contraception.
(1986) Luthuli, H. V.; Arbuckle, Derek Dennis.; Naidoo, K.
The attitude of the African male to contraception and the role he plays in the acceptance of contraceptives by his racial group is presented. Over a period of one month the researcher interviewed 220 African males at a primary care private practice. In this study 186 (85%) were aware of contraceptives and 34 (15%) had no knowledge of contraception; 111 (60%) were married and 75 (40%) were unmarried. The 26 - 35 year age group were the most familiar with contraception (57%). The unemployed were the least users of contraceptives (8%), whereas 69% of the professional group were using contraceptives. The average ideal family size of the group was 4 children. No significant cultural barriers to contraception were found. Religion was found to have little effect on contraceptive practice by the African male. Fifty-three percent of the Urban dwellers were using contraceptives compared with only 30% of the Rural inhabitants. Modern methods of contraception are not yet sufficiently known by the African male to be useful to him. Health workers should educate the African male in matters of contraception to achieve the desired objectives of family planning campaigns among this racial group.
The birth prevalence of congenital CMV infection in HIV-exposed newborns in Cape Town, South Africa : a pilot study. The "CYPREHEN" (Cytomegalovirus prevalence in HIV-exposed newborns) study.
(2014) Manicklal, Sheetal.; Knight, Stephen Eric.; Boppana, Suresh B.
Background Congenital cytomegalovirus infection (CMV) is a leading non-genetic cause of sensorineural hearing loss worldwide. The birth prevalence of congenital CMV infection correlates positively with the level of CMV seroimmunity in the adult population. In addition, women infected with Human Immunodeficiency Virus (HIV) constitute a special at risk subpopulation for the intrauterine transmission of CMV. Despite a high prevalence of both HIV and CMV, the birth prevalence of congenital CMV infection has not been assessed in sub-Saharan Africa. Purpose The purpose of the study was to determine the birth prevalence of congenital CMV infection among HIV-exposed newborns born in a public sector hospital in the Western Cape in 2012, during the era of prenatal antiretroviral therapy. Objectives The objectives of this study were: To determine the prevalence of congenital CMV infection among HIV-exposed newborns; To assess the predictors of congenital CMV infection transmission among HIV-infected women; and To inform the design of an analytic study to determine if newborn CMV screening should be implemented in this population. Study design An observational descriptive cross-sectional study design was used. Settings The study was conducted at Mowbray Maternity Hospital (MMH), which serves the Cape Town Metropole area. Study population The study population comprised infants born to HIV-infected mothers delivering at MMH. Study sample Non-probability convenience sampling was used to enroll 750 newborns. Methods HIV-infected mothers were recruited in the immediate postnatal period at a referral maternity hospital between April and October 2012. Maternal and infant clinical data and newborn oral swabs (saliva) were collected. Saliva was assayed by real-time PCR for CMV. Data were analysed using univariate and multivariate logistic regression analyses to determine specific demographic, maternal and newborn characteristics associated with congenital CMV infection. Results CMV was detected in 22/748 newborn oral swabs (2.9%; 95% Confidence Interval (CI), 1. 9%-4.4%). Maternal CD4 count less than 200 cells/μL during pregnancy was independently associated with congenital CMV infection (adjusted Odds Ratio (aOR) 2.9; 95% CI, 1.2-7.3). A negative correlation between CMV viral load in saliva and maternal CD4 count was observed (r = -0.495, n = 22, p = 0.019). Conclusions The birth prevalence of congenital CMV infection was high despite prenatal ARV prophylaxis, and was associated with advanced maternal immunosuppression.
Caesarean section rates at the Standerton Hospital, 2004-2007.
(2011) Dlamini, Sibongile Margaret.; Jinabhai, Champaklal Chhaganlal.
Introduction Increased use of caesarean section (CS) as a mode of delivery is of concern for maternal and child health in many countries. The World Health Organization (WHO) has set guideline of population caesarean section rate between 5% - 15% for CS deliveries. Accordingly the South African National Department of Health (NDOH) has set a national target for district hospitals, that no more than 10% of all deliveries should be by CS. Standerton District Hospital experienced a sudden increase in the caesarean section rate (CSR), from 17.5% in 2004 to 30.8% in 2007. The reasons for this increase are not known. Purpose of the study This study aims to investigate factors which contributed to the sudden increase of CSR from 17.5% in 2004 to 30.8% in 2007 at Standerton District Hospital, Gert Sibande District Mpumalanga. Method A retrospective record review of 790 women who delivered at Standerton District Hospital by caesarean section from January 2004 to December 2007 was done. Fifty percent of the total number of records for each year was retrieved and to achieve this every second record was selected from the maternity and theatre registers for patients who have undergone CS. Systematic sampling selection of records of all women who have undergone CS was conducted during the identified period. Data on patient demographics, the reasons for the CS, the maternal and neonatal outcomes achieved, antenatal care profile, the employment status and the responsible medical practitioner were extracted from existing records maintained by the hospital. Analysis ascertained factors associated with increased CSR. Results The Caesarean section rate at Standerton District Hospital has increased annually since 2004. The factors contributed to the increase include medical indications, clients who are primigravida and the less experienced community service doctors who performed the CS. There was no evidence that education, high income clients, or maternal request contributed to the increase of Caesarean Section rate (CSR). The outcome of mother and baby were positive except for 1% of babies who were not alive. Robson’s group classification (classification system which defines 10 groups of women according to obstetric record, category of pregnancy, the presence of previous uterine scar, the course of labour, delivery and gestational age), revealed that groups two and four played a major role. Conclusion CSR has increased over the years and strategies needs to be developed to reduce this by having experienced doctors supervising community service doctors, training of professionals working in maternity and monitoring of labour by midwives. Recommendation Standerton District Hospital management should intensify recruitment and retention of experienced medical officers, train additional midwives on advanced courses, intensify ante natal care, establish a high risk clinic at the hospital, review hospital policies on maternal care and monitoring of compliance to mother and baby’s national and provincial policies.
Case management and clinical outcomes of people living with HIV and admitted to a state-aided district hospital in Durban, South Africa in 2007.
(2011) Sunpath, Henry.; Knight, Stephen Eric.
Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to a State-aided District Hospital in Durban, South Africa in 2007. Introduction: A proportion of the many patients who have advanced AIDS in South Africa present for the first time requiring admission to hospital, the number of which are limited by the availability of beds. Novel ways were developed to offer subacute inpatient care at Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate antiretroviral therapy (ART) (exposed) for patients with advanced disease before their discharge (ART group) . Different components of palliative care were offered for those who did not enter the inpatient ART programme or who were terminally ill (non-ART group) (non-exposed) . Aim: The aim of the study is to describe the clinical condition, inpatient case management and outcomes before discharge of people living with HIV admitted to Siyaphila in order to assist in developing appropriate protocols for inpatient care. Methods: This was an observational, analytic, cohort study using a convenience sample of all patients consecutively admitted to Siyaphila during nine months in 2006/2007. Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one stage of care to another and outcomes for the two groups before discharge were determined. Univariate and multivariate logistic regression analysis was performed on the ART group to identify risk factors for mortality before discharge. A comparison between the ART and non-ART group was also undertaken. Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251; 62%) was the most common opportunistic infection followed by cryptococcal meningitis (68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The median time from initial admission until discharge was 13 days in the non-ART group and 18 days in the ART group. The mortality before discharge among the non-ART group was 24% compared to 6% among the ART group. (p =0.001). The median number of days before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome was diagnosed in seven patients (4%) among the admissions but caused no deaths. In the multivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1 (95% Confidence Interval: 0.01 - 0.9). Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART uptake after discharge. The findings of this study should be adopted as the best clinical practice for PLHIV and AIDS admitted in the late stages of the disease. 0Nords 423) Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to a State-aided District Hospital in Durban, South Africa in 2007. Introduction: A proportion of the many patients who have advanced AIDS in South Africa present for the first time requiring admission to hospital, the number of which are limited by the availability of beds. Novel ways were developed to offer subacute inpatient care at Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate antiretroviral therapy (ART) (exposed) for patients with advanced disease before their discharge (ART group) . Different components of palliative care were offered for those who did not enter the inpatient ART programme or who were terminally ill (non-ART group) (non-exposed). Aim: The aim of the study is to describe the clinical condition, inpatient case management and outcomes before discharge of people living with HIV admitted to Siyaphila in order to assist in developing appropriate protocols for inpatient care. Methods: This was an observational, analytic, cohort study using a convenience sample of all patients consecutively admitted to Siyaphila during nine months in 2006/2007. Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one stage of care to another and outcomes for the two groups before discharge were determined. Univariate and mUltivariate logistic regression analysis was performed on the ART group to identify risk factors for mortality before discharge. A comparison between the ART and non-ART group was also undertaken. Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251; 62%) was the most common opportunistic infection followed by cryptococcal meningitis (68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The median time from initial admission until discharge was 13 days in the non-ART group and 18 days in the ART group. The mortality before discharge among the non-ART group was 24% compared to 6% among the ART group. (p =0.001). The median number of days before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome was diagnosed in seven patients (4%) among the admissions but caused no deaths. In the mUltivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1 (95% Confidence Interval: 0.01 - 0.9). Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART uptake after discharge. The findings of this study should be adopted as the best clinical practice for PLHIV and AIDS admitted in the late stages of the disease. (Words 423)
Challenges faced by professional nurses in accessing information technology in health care facilities for healthcare delivery in northern KwaZulu-Natal.
(2010) Asah, Flora Nah.; Reid, Stephen John Young.
Information Technology (IT) is revolutionizing every sphere of human interaction. IT has changed the way individuals communicate. In the healthcare system, information technologies are considered the key to addressing challenges to healthcare delivery such as shortages of healthcare professionals, and networking. Therefore, healthcare providers need to possess information technology skills, knowledge, and resources to communicate and manage information effectively and efficiently and also to be able to perform their duties adequately in such an information technology age. Nurses, the largest group of healthcare providers who spend the most time with patients, are also frontline healthcare managers and need to have access to IT and should be computer literate in order to perform their duties quickly and adequately. In South Africa, the health system has been slow in integrating IT into healthcare delivery, particularly in rural and remote areas where such services are most needed. A "digital divide" exists, by which access to computers and the internet remain a privilege, and many nurses are unable to use a computer even after completing the computer literacy courses. This study aims to investigate the challenges faced by professional nurses to access and use information technology in healthcare facilities after being trained. Data was collected through focus group discussions conducted with professional nurses from two regional and four district hospitals. Participants who had received computer training offered by the Department of Health were selected to ensure that issues beyond a lack of training could be explored. Focus group discussions were recorded and transcribed verbatim. Content analysis was used to identify themes from the transcriptions. Results show that professional nurses had little access to information technology. Reasons given were a lack of hardware and appropriate software, insufficient training and lack of support, irrelevance of the computer courses, and negative attitudes towards computers. Despite previous computer training, the professional nurses interviewed felt they lacked the skills to use computers confidently in their daily activities. The quality of the training was perceived as inadequate and irrelevant with a lack of ongoing support to cement new skills and build confidence. The provision of training workshops for nurses is not sufficient to ensure that IT will be used for healthcare delivery. On-going support an motivation, among others, are needed to encourage nurses to use IT efficiently.
Challenges facing a community health physician in Bophuthatswana.
(1981) Matjila, Maila John.
No abstract available.
Challenges in the integration of municipal health services in the uMgungundlovu District Municipality, KwaZulu-Natal.
(2011) Chapi, Nompumelelo.; Gray, Andrew Lofts.; Blanchard, Catherine.
The National Health Act (Act 61 of 2003) defined Municipal Health Services and gave full responsibility for this function to district municipalities and metropolitan municipalities. District municipalities were required, by law, to provide municipal health services which were previously rendered by local municipalities and the Provincial Department of Health. This, therefore, required the transfer of staff, assets and liabilities from local municipalities and the Provincial Department of Health to district municipalities. The purpose of the study was to identify barriers to and facilitating factors for the transfer of municipal health services from the seven local municipalities and the Provincial Department of Health to the uMgungundlovu district municipality. A cross-sectional, descriptive study design was employed. A structured questionnaire was used to collect quantitative data from local municipalities and the Provincial Department of Health on the package of environmental health services offered and the available human resources. Qualitative data was collected through in-depth interviews and focus group discussions with key role players in the provision of environmental health within the district. The key findings of the study were: There were no changes to the package of environmental health services offered by local municipalities and the Provincial Health following the definition of Municipal Health Services. The Provincial Department of Health continues to play an important role in the provision of Municipal Health Services in the district There was a lot of awareness-raising on the integration process; however planning for the integration was very poor. The lack of progress in integration has had a negative impact on service delivery and on the environmental health personnel involved. The relationship between district and local municipalities, a lack of understanding of environmental health, budget allocation, communication, lack of commitment, capacity, and lack of a champion were seen as the main barriers to the integration process. The study was able to identify possible gaps in the planning process that, if revisited could assist the district municipality in better handling the process.
Challenges in the integration of TB and HIV care : evidence for improving patient management and health care policy.
(2016) Naidoo, Kogieleum.; Abdool Karim, Salim Safurdeen.
TB infection remains a leading cause of morbidity and mortality among patients with HIV infection, while HIV is the strongest risk factor for development of active TB. Integration of HIV and TB treatment is key to reducing mortality in co-infected patients; but many obstacles stand in the way of effective scale-up of this approach to HIV-TB treatment. The challenges associated with HIV-TB integration extend from clinical complexities in individual patient management, to impediments in health service organization and prioritization to address this urgent public health priority, especially in sub-Saharan Africa where TB-HIV co-infection rates reach 80%. The purpose of this study was to assess and identify strategies to overcome the challenges in immune reconstitution and drug safety/tolerability when integrating HIV and TB care in a cost-effective manner to reduce co-infection mortality. Clinical and operational service data from the Starting Antiretroviral therapy at three Points in Tuberculosis Treatment (SAPiT – CAPRISA 003) study, a 3-arm, randomized control trial in 642 newly diagnosed sputum smear-positive TB-HIV co-infected adult patients with screening CD4+ cell count < 500 cells/mm3, were analysed. In addition, the incidence rate of unmasked clinical TB following ART initiation was assessed through a retrospective chart review conducted in HIV infected patients enrolled at the rural CAPRISA AIDS Treatment Programme. Overall, mortality was 56% lower (RR=0.44; 95% CI: 0.25 to 0.79; P = 0.003) in patients initiated on ART during TB treatment compared to ART deferral to after TB treatment completion. However, the risk of immune reconstitution inflammatory syndrome (IRIS) was higher (incidence rate ratio (IRR), 2.6 (95% CI, 1.5 to 4.8); P < 0.001, in patients initiating ART within the first 2 months compared to later ART initiation during TB treatment. In the most severely immuno-compromised patients (CD4 counts <50 cells/mm3) early ART integration was associated with an almost five-fold increased risk of IRIS (IRR 4.7 (95% CI, 1.5 to 19.6); P = 0.004. Patients initiating ART in the first 2 months of TB therapy had higher hospitalization rates (42% vs. 14%; P = 0.007) and longer time to resolution (70.5 vs. 29.0 days; P = 0.001) than patients in the other two groups. When assessing available evidence, these results indicate that ART initiation in patients with CD4 cell counts >50 cells/mm3 would be most appropriate after completion of intensive phase of TB therapy, a strategy that was found to cost $1840 per patient treated. Among HIV infected patients initially screening negative for TB there was a fourfold higher incidence rate of unmasking TB in the first 3 months after ART initiation, compared to the subsequent 21 months post-ART initiation. The new information generated by this study provides important evidence for policy and clinical management of patients with HIV and TB co-infection. Firstly, careful clinical vigilance for ‘unmasked’ TB is required in patients initiating ART. Secondly, the survival benefit of AIDS therapy in TB patients can be maximized by initiating ART as soon as possible after TB therapy has been started in patients with advanced immunosuppression, i.e., those with CD4+ counts <50 cells/mm3. However, patients with higher CD4+ cell counts should delay ART initiation to at least 8 weeks after the start of TB therapy to minimize the incidence and duration of immune reconstitution disease and consequent hospitalization. Thirdly, this approach, which is at variance with current World Health Organization policy and guidelines, is cost-effective and readily implementable within the clinical setting. Finally, addressing the operational challenges to HIV-TB treatment integration can improve patient outcomes with substantial public health by reducing mortality by the most important causes of death in South Africa.
Community awareness of GOBI-FFF and its implementation in two urban communities
(1985) Dada, Ebrahim.
The health picture in the developing world is still very bleak. The varlOUS Black populations of South Africa (be they Africans, Indians or Coloureds) are part of this developing world. In a total world population of 4,607 million (of which 75 % are in the developing world); there are 10.3 million annual infant deaths (0-11 months) (of which 97 % are ln the developing countries); and 4.3 million annual child deaths (1-4 years) (of which 98 % are in the developing countries).*l The infant mortality rate (IMR) (infant deaths per 1,000 live births) in 1980 for the developing countries as a whole, and for Southern Africa specifically is 100; as compared to the IMR of 20 for developed countries. South Africa has an IMR of 90 (1982). However, a few relatively simple and inexpensive methods could enable parents themselves to bring about a revolution ln child survival and development. The idea that could make this revolution possible is primary health care. The vehicles that could make this revolution achievable are the spread of education, communications and social organization. The techniques which could make this revolution affordable even with very limited resources, are growth monitoring, oral rehydration therapy, breast-feeding and immunization (GOBI). These four principle life line techniques are low-cost, available now, achieve rapid results and a l most universally relevant. They involve people in taking more responsibility for their own health, and thus promote primary health care. In combination they offer an even greater degree of protection against the synergistic alliance of malnutrition and infection which is the central problem of child health and child development today. *3 In addition, three other changes-female education, family spacing and food supplementation (FFF) are also among the most powerful levers for raising the level of child survival and child health. Although more costly and more difficult to achieve, these changes in the lives of women are of such potential significance that they must also now be count ed among the breakthrough in knowledge which could change the ratio between the health and wealth of nations. *3 However, against this information is the stark reality that only up to 15 % of the world's families are using oral rehydration therapy (ORT), the revolutionary low-cost technique for preventing and treating diarrhoeal dehydration, the biggest single killer of children in the world. *4 This then rai ses the vital question that although the potential for child survival and a healthy and normal child development is there, to what extent is the average mother aware of and implementing these cost-effective methods of GOBI-FFF in her own situation? These questions are thus addressed in this study in an African and an Indian urban communities ln Natal/Kwa Zulu.

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