Dissertations / Theses on the topic 'Medical care – Africa, Sub-Saharan'

The entire thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file; a non-technical public abstract appears in the public.pdf file. Title from PDF of title page (University of Missouri--Columbia, viewed on March 23, 2010). Thesis advisor: Dr. Stephen Quackenbush. Includes bibliographical references.

Health economists, national decision-makers and global health specialists have been interested in calculating the cost of a disease for many years. Only more recently they started to generate more comprehensive frameworks and tools to estimate the full range of healthcare related costs of illness in a user’s perspective in resource-poor settings. There is now an ongoing trend to guide health policy, and identify the most effective ways to achieve universal health coverage. The user fee exemptions health financing schemes, which grounded the tuberculosis control strategy, have been designed to improve access to essential care for ill individuals with a low capacity to pay. After decades of functioning and substantial progress in tuberculosis detection rate and treatment success, this thesis analyses the extent of the coverage (financial and social protection) of two disease control programs in West Africa. Learning from the concept of the medical poverty trap (Whitehead, Dahlgren, et Evans 2001) and available framework related to the economic consequences of illness (McIntyre et al. 2006), a conceptual framework and a data collection tool have been developed to incorporate the direct, indirect and intangible costs and consequences of illness incurred by chronic patients. In several ways, we have sought to provide baseline for comprehensive analysis and standardized methodology to allow comparison across settings, and to contribute to the development of evidence-based knowledge.

To begin, filling a knowledge gap (Russell 2004), we have performed microeconomic research on the households’ costs-and-consequences-of-tuberculosis in Burkina Faso and Benin. The two case studies have been conducted both in rural and urban resource-poor settings between 2007 and 2009. This thesis provides new empirical findings on the remaining financial, social and ‘healthcare delivery related organizational’ barriers to access diagnosis and treatment services that are delivered free-of-charge to the population. The direct costs associated with illness incurred by the tuberculosis pulmonary smear-positive patients have constituted a severe economic burden for these households living in permanent budget constraints. Most of these people have spent catastrophic health expenditure to cure tuberculosis and, at the same time, have faced income loss caused by the care-seeking. To cope with the substantial direct and indirect costs of tuberculosis, the patients have shipped their families in impoverishing strategies to mobilize funds for health such as depleting savings, being indebted and even selling livestock and property. Damaging asset portfolios of the disease-affected households on the long run, the coping strategies result in a public health threat. In resource-poor settings, the lack of financial protection for health may impose inability to meet basic needs such as the rights to education, housing, food, social capital and access to primary healthcare. Special feature of our work lies in the breakdown of the information gathered. We have been able to demonstrate significant differences in the volume and nature of the amounts spent across the successive stages of the care-seeking pathway. Notably, pre-diagnosis spending has been proved critical both in the rural and urban contexts. Moreover, disaggregated cost data across income quintiles have highlighted inequities in relation to the direct costs and to the risk of incurring catastrophic health expenditure because of tuberculosis. As part of the case studies, the tuberculosis control strategies have failed to protect the most vulnerable care users from delayed diagnosis and treatment, from important spending even during treatment – including significant medical costs, and from hidden costs that might have been exacerbated by poor health systems. To such devastating situations, the tuberculosis patients have had to endure other difficulties; we mean intangible costs such as pain and suffering including stigmatization and social exclusion as a result of being ill or attending tuberculosis care facilities. The analysis of all the social and economic consequences for tuberculosis-affected households over the entire care-seeking pathway has been identified as an essential element of future cost-of-illness evaluations, as well as the need to conduct benefit incidence assessment to measure equity.

This work has allowed identifying a series of policy weaknesses related to the three dimensions of the universal health coverage for tuberculosis (healthcare services, population and financial protection coverage). The findings have highlighted a gap between the standard costs foreseen by the national programs and the costs in real life. This has suggested that the current strategies lack of patient-centered care, context-oriented approaches and systemic vision resulting in a quality issue in healthcare delivery system (e.g. hidden healthcare related costs). Besides, various adverse effects on households have been raised as potential consequences of illness; such as illness poverty trap, social stigma, possible exclusion from services and participation, and overburdened individuals. These effects have disclosed the lack of social protection at the country level and call for the inclusion of tuberculosis patients in national social schemes. A last policy gap refers to the lack of financial protection and remaining inequities with regards to catastrophic health expenditure still occurring under use fee exemptions strategies. Thereby, one year before 2015 – the deadline set for the Millennium Development Goals – it is a matter of priority for Benin and Burkina Faso and many other countries to tackle adverse effects of the remaining social, economic and health policy and system related barriers to tuberculosis control. These factors have led us to emphasize the need for countries to develop sustainable knowledge.

National decision-makers urgently need to document the failures and bottlenecks. Drawing on the findings, we have considered different ways to strengthen local capacity and generate bottom-up decision-making. To get there, we have shaped a decision framework intended to produce local evidence on the root causes of the lack of policy responsiveness, synthesize available evidence, develop data-driven policies, and translate them into actions.

Beyond this, we have demonstrated that controlling tuberculosis was much more complex than providing free services. The socio-economic context in which people affected by this disease live cannot be dissociated from health policy. The implications of microeconomic research on the households’ costs and responses to tuberculosis may have a larger scope than informing implementation and adaptation of national disease-specific strategies. They can be of great interest to support the definition of guiding principles for further research on social protection schemes, and to produce evidence-based targets and indicators for the reduction and the monitoring of economic burden of illness. In this thesis, we have build on prevailing debates in the field and formulated different assumptions and proposals to inform the WHO Global Strategy and Targets for Tuberculosis Prevention, Care and Control After 2015. For us, to reflect poor populations’ needs and experiences, global stakeholders should endorse bottom-up and systemic policy-making approaches towards sustainable people-centered health systems.

The findings of the thesis and the various global and national challenges that have emerged from case studies are crucial as the problems we have seen for tuberculosis in West Africa are not limited to this illness, and far outweigh the geographical context of developing countries.

Keywords: Catastrophic health expenditure, Coping strategies, Cost-of-illness studies, Direct, indirect and intangible costs, Evidence-based Public health, Financial and Social protection for health, Health Economics, Health Policy and Systems, Informed Decision-making, Knowledge translation, People-centered policy-making, Systemic approach, Universal Health Coverage

Doctorat en Sciences de la santé publique
info:eu-repo/semantics/nonPublished

Severe acute malnutrition (SAM) affects approximately 13 million children under-five and is associated with over 1.5 million preventable child deaths each year. Case fatality rates in hospitals treating SAM remain at 20-30%, and coverage of those affected remains low. Training and support to improve centre-based management can reduce case fatality rates. However, an exclusive inpatient approach does not consider the many barriers to accessing treatment that exist for poor people in the developing world. Community-based therapeutic care (CTC) is a new approach for the management of SAM that uses Ready-to-Use Therapeutic Foods (RUTF) and triage to refer cases without complications to outpatient care and those with complications to inpatient treatment. This thesis aims to test the hypotheses that a CTC strategy can treat children with SAM effectively and can achieve better population treatment coverage than a centre-based approach. Five studies, using primary data, are presented. The first 3 studies evaluate the clinical effectiveness of CTC through examination of individual outcome data from research programmes in Ethiopia and Malawi. The fourth study examines the coverage of a CTC programme for SAM in Malawi and compares this with coverage of a centre- based programme. The final study is a multi-country evaluation of 17 CTC programmes implemented across Africa. Results from all studies that use the CTC treatment model show that outcomes can meet the international Sphere standard indicators of < 10% mortality and > 50% coverage. Coverage of a CTC programme in Malawi was three times that of a centre-based programme in the same region (73.64% (95% C.I. 66.0%, 81.3%) vs. 24.5% (95% C.I. 17.8%, 31.4%)). A number of factors were vital to achieving low mortality and high coverage in these programmes. These included decentralisation of outpatient treatment services and community mobilisation techniques to encourage early presentation, and the use of appropriate triage criteria, to identify children suffering from SAM with no complications that could be treated safely as outpatients. The use of triage did not appear to increase mortality (OR 0.51 95% CI 0.28, 0.94). This thesis suggests that CTC does not increase case fatality rates associated with SAM and could reduce them, and that it could increase the number of children receiving treatment.

Background: Sub-Saharan Africa is home to 85% of the world's HIV-positive adolescents: an estimated 1.3-2.2 million 10-19 year olds. Adolescents living with HIV face multiple sexual and reproductive health risks: unwanted pregnancies and the risk of mother-to-child-transmission, risk of infecting partners, co-infection with other STIs, and the rising but undocumented risk of re-infection by potentially resistant HI-virus strains. Using contraception, especially condoms, is particularly challenging for all adolescents. It is even more difficult for HIV-positive adolescents due to HIV-related factors such as learning their HIV-positive status, withholding or disclosing their HIV-status to sexual partners, and accessing services in the home, clinics, and schools. This thesis aims to understand which factors shape sexual risk-taking among HIV-positive adolescents to inform the development of interventions that promote safe sexual practices in this population. Methodology: This thesis applies a socio-ecological model to investigate factors associated with sexual risk-taking among HIV-positive adolescents. It consists of three stand-alone papers: a systematic review and two quantitative papers based on a cross-sectional epidemiological and aetiological study of unprotected sex among HIV-positive adolescents and community controls in South Africa. Paper 1 is a systematic review of rates, correlates, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Paper 2 looks at associations between HIV-status knowledge and disclosure and protective sexual practices in the cross-sectional study sample. Paper 3 explores the relationship between various social protection provisions and unprotected sex among HIV-positive adolescents. The candidate co-developed and conducted a community-traced study of adolescents in the Eastern Cape, in South Africa: 1,060 HIV-positive adolescents and 467 community controls. HIV-positive 10-19 year old adolescents were recruited from 53 government facilities in a health sub-district with antenatal HIV prevalence of over 30%. 90.1% of the eligible sample was traced, with only 4.1% refusing to take part. Community controls were neighbouring or co-habiting 10-19 year old adolescents, 92% of whom agreed to take part. Voluntary informed consent was obtained from adolescents and caregivers in the language of their choice: English or Xhosa. Questionnaires were administered by trained research assistants using mobile devices (tablets) with adolescent-friendly graphic content to ensure participant interest and reduce participant burden through skip-patterns. The systematic review (Paper 1) included studies located through electronic databases and grey literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies reporting on HIV-positive participants (10-24 year old) included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older sexual partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy). Only studies conducted in sub-Saharan Africa were included. The candidate and a second author independently piloted all processes, screened studies, extracted data independently, and resolved any discrepancies. Due to variance in reported rates and correlates, no meta-analyses was conducted. The systematic review informed the analyses conducted for the two quantitative papers. Analyses for Papers 2 and 3 used condom use at last sexual encounter (dichotomised either as safe sex/abstinence or unprotected sex) as the outcome, controlling for a series of covariates. Analyses used SPSS 22 and STATA 11. For each paper, the hypothesised factors were entered as independent variables in multivariate logistic regressions controlling for potential confounders. Based on the findings of the systematic review, gender moderation analyses was run entering a 2-way interaction term of gender*correlate in multivariate logistic regressions, controlling for covariates. Marginal effect models explored the effect of combinations of risk/ protective factors. Predicted probabilities for safe sex/ unprotected sex were computed for different two- and three-way combinations of the independent variables, controlling for covariates significantly associated with the outcome. Paper 2 tested the effect of three types of disclosure on protective sexual practices: (i) knowledge of one's own HIV-positive status, (ii) disclosing one's HIV-status to a partner, and (iii) knowing a partner's HIV-status. It compared HIV-positive status aware adolescents (n=794) with the rest of the sample (n=733). Paper 3 investigated associations between nine types of social protection provisions and unprotected sex. In line with UNICEF's definition, social protection was defined as any provision aimed at preventing, reducing and eliminating economic and social vulnerabilities to poverty and deprivation among HIV-positive adolescents. The nine social protection provisions tested by the analyses included ‘cash' and ‘care' factors accessed in the home, school, and community. Results: Paper 1 – ‘Sexual Risk-Taking among HIV-Positive Adolescents and Youth in Sub-Saharan Africa: A systematic review of prevalence rates, risk factors, and interventions.' The systematic review (Chapter 4) found that, despite their heightened vulnerabilities and high rates of sexual risk-taking, there is a dearth of evidence on interventions which may help HIV-positive adolescents engage in safe sexual practices. The review included 35 studies, four of which were interventions aiming to reduce sexual risk-taking. The quality of the included studies was low with most studies (k=31) reporting findings from cross-sectional data. HIV-positive adolescents and youth reported high rates of sexual risk-taking, however findings were inconsistent about potential factors associated with sexual risk-taking. Factors consistently associated with sexual risk-taking in multivariate analyses included: food insecurity, living alone, living with a partner, and gender-based violence. No significant associations were reported for: rural residence, informal housing, anxiety, religious guidance, STI prevention knowledge, poor birth outcomes, orphanhood, parental monitoring, having a supportive family, social support, maternal education level, poverty, disclosing one's HIV-status to a partner, time on ART, ART adherence, receiving care at a hospital, opportunistic infections. However, most of the above associations were reported by only one study, therefore further analyses is needed to build the evidence base on potential determinants of sexual risk-taking among HIV-positive adolescents and youth. The included interventions consist of three individual- and group-based psychosocial interventions evaluated in three small-scale trials (n<150) and one large trial of combination interventions for HIV-positive orphaned adolescent girls (n=710). Three of these interventions had positive effects in reducing sexual risk-taking: an individual based 18-session counselling intervention in Uganda, a support group intervention in South Africa, and a combination intervention in Zimbabwe. Quantitative data analyses of cross-sectional study data: Overall, adolescents in the full sample (n=1,527) reported high rates of sexual activity (34.9%) and high rates of unprotected sex (22%), with adolescent girls reporting higher rates of unprotected sex than boys (33% vs. 7%).

Philosophiae Doctor - PhD
This thesis purposes to examine the impact of financial development on health outcomes, health care expenditure and financial protection in health in 46 selected sub-Saharan African (SSA) countries from 1995 to 2014. It also estimates the impact of health care expenditure on health outcomes. The thesis is premised on the hypothesis that health care expenditure is a critical transmission mechanism through which financial development leads to better health outcomes. The health care expenditure channel is conspicuously absent in the literature on financial development and health outcomes; hence the need for this study to fill the gap in the literature. The thesis explores the effects of both depth and access dimensions of financial development on health outcomes, expenditure and financial protection. Throughout the study, financial access is measured by the number of automated teller machines (ATMs) and commercial bank branches per 100 000 people, while financial depth is measured by the proportion of broad money and bank credit to the private sector, to Gross Domestic Product (GDP). The study uses fixed and random effects and the Two-Stage Least Squares estimation approaches. The Generalised Method of Moments (GMM) is also used to estimate the impact of health care expenditure and health outcomes given the absence of valid instrumental variables. The results of the regression analyses show that financial development leads to increased health care expenditure and health outcomes. The analysis also shows that health care expenditure leads to better health outcomes. Additionally, the study indicates that financial development leads to financial protection in health care by reducing out-of-pocket health care expenditure. Well-developed financial systems provide financial protection from the risk of catastrophic health care expenditure and impoverishment resulting from illness. The study shows that health care systems financed through prepaid mechanisms reduce neonatal, infant and under-five mortality rates and increase life expectancy, while those relying on out-of-pocket expenditure have adverse effects on health outcomes.

Thesis advisor: James F. Keenan
Thesis advisor: Andrea Vicini
Sub-Saharan Africa has one of the worst health care systems in the world. Besides, underdeveloped economies paired with political instability do not offer much hope for improvement. In fact, despite many efforts by local, international organizations and governments to help in this field, the majority of the populations in this region do not have access to basic health care. With this in mind, the aim of this research project is to develop a personal and social anthropology of the human rights language read through the lens of the common good in order to contribute to creating and developing sustainable healthcare systems. While agreeing that many efforts have been made using different frameworks in the sphere of public health ethics in the past two decades and aware of the possibility that other underlying causes may have contributed to the failure of health systems in Sub-Saharan Africa, we will choose to address the human rights language as the main interlocutor for future contribution. This choice is motivated by the influence of human rights on public health policies that affect the lives of people in general
Thesis (STL) — Boston College, 2016
Submitted to: Boston College. School of Theology and Ministry
Discipline: Sacred Theology

Some scholars argue that the principle of voluntary informed consent is rooted in the Western ethos of liberal individualism; that it would be difficult to implement this requirement in societies where the norms of decision-making emphasize collective rather than individual decision-making (for example, Sub-Saharan Africa); that it would amount to “cultural imperialism” to seek to implement the principle of voluntary informed consent in non-Western societies. This thesis rejects this skepticism about the possibility of implementing the informed consent requirement in non-Western environments and argues that applying the principle of voluntary informed consent in human subjects’ research in Sub-Saharan African communal culture could serve as an effective measure to protect vulnerable subjects from possible abuses or exploitations. The thesis proposes the “multi-step” approach to informed consent as the best approach to the implementation of the principle in the African communal setting. The thesis argues that the importance of the “multi-step” approach lies in the fact that it is one that is sensitive to local culture and customs. On the question of whether the principle of voluntary informed consent should be made compulsory in research, the thesis answers that we have no choice in the matter.

Thesis advisor: Donald Cox
I investigate the effect of the medical brain drain on health in sub-Saharan Africa. Such information would be invaluable to policymakers; if doctors are likely to emigrate, there is little benefit in investing in their training. Previous work has mostly been limited to measuring correlations, which fail to illuminate causal pathways; countries with weakly structured healthcare systems may have both poor health and high physician emigration. I address the problem with an instrumental variable. For African countries with historic colonial ties to the United Kingdom or France, I used immigration policy changes in these European nations to instrument for the medical brain drain. Higher rates of medical brain drain cause decreased physician density, decreased rates of measles immunizations among children, and increased rates of HIV prevalence in sub-Saharan Africa. Therefore, I conclude that targeting physician emigration would help improve health in the region
Thesis (BA) — Boston College, 2013
Submitted to: Boston College. College of Arts and Sciences
Discipline: College Honors Program
Discipline: Economics Honors Program
Discipline: Economics

Background Pneumonia, diarrhoea and perinatal factors are the foremost killers of South African children as in other low- and middle-income countries. Poverty, poor access to care and pre-hospital care are reported major pre-hospital factors and lack of triage, poor skills, delays, poor adherence to treatment protocols and inadequate emergency care determining mortality have been reported to increase in-hospital mortality. Objectives To describe the clinical presentation and management of children admitted via the medical emergency unit (MEU) of the Red Cross War Memorial Children's Hospital (RCWMCH) who subsequently died. Methods We did a retrospective study undertaking a cross-sectional review of children who died following admission via RCWMCH MEU in 2008. Demographic information, clinical data, time factors and mortality data were reviewed and summarised by descriptive and inferential statistics. The unit utilised the WHO Emergency Triage Assessment and Treatment (ETAT) triage tool, categorising children into Red (emergency), orange (priority) and Green (non-urgent). Patient management was assessed by means of ETAT and the Integrated Management of Childhood Illness (IMCI) tools, which is used to identify severity of illness and strategize treatment plans accordingly. Results A total of 135 children met the inclusion criteria. The crude mortality rate was of 6.25 per 1000 admissions. Of the 135 children who died, 119 (88%) were under five years of age, 33(24%) were HIV-infected, of whom (88%) were under 5 years old. In 67 (50%), a chronic medical condition could be identified while 67 (50 %) were moderately or severely malnourished. There were 29 (22%) deaths within 24 hours of arrival at the MEU. Fifty-five (41%) presented after hours. Community health centres referred 65 (48%) patients, general practitioners referred 20 (15%) and 38 (28%) were self-referred. Ambulance services provided pre-hospital transport to 69 (51%). The two top presenting illnesses in 88 (65%) of the children were acute respiratory illness and acute gastroenteritis. Prior to referral, oxygen was not provided in 57 (59%) children, 35 (71%) with suspected sepsis did not receive antibiotics and glucose was not checked in 39 (80%) with depressed level of consciousness. The median time to ward transfer was 3.23 (IQR: 2.12-4.92) hours. Twelve deaths (9%) occurred in the MEU, 57 (42%) in PICU, 56 (42%) in medical wards and 10 (7%) in specialist wards. The five most common causes of death were acute respiratory infections in 45 (33%), acute gastroenteritis in 27 (20%), septicaemia 22 (16%), meningitis in 13 (10%) and cardiac conditions in 12 (9%) children. Conclusion The top causes of mortality in this hospital cohort in 2008 were pneumonia, acute gastroenteritis, and septicaemia. Using the IMCI and ETAT standard of care, suboptimal management was identified in pre-hospital management, as well as MEU management. Appropriate training and protocol implementation to improve morbidity and mortality should be undertaken.

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 2002.
Includes bibliographical references (leaves 67-69).
This thesis is about expanding the "first line of defense" for children and families affected by AIDS in sub-Saharan Africa. The overwhelming consensus among actors leading the fight against AIDS, ranging from USAID and UNICEF to local NGOs, is that extended families and communities are the "first line of defense" and will absorb the millions of children orphaned by AIDS. With this basic premise, the thinking follows that 1) families are almost always the best place for the child; 2) primary interventions should be centered on building the capacities of families to care for orphans and; 3) residential orphan care is the least desirable option for children because "orphan care institutions" are inherently "anti-community". I challenge this prevailing wisdom. I argue that this donor-driven approach, loosely termed "community based orphan care", is limited by, among other things, AIDS induced pressures on families and growing numbers of children disconnected from families (e.g. street children). Additionally, the approach imposes a false dichotomy between "the community" and "orphan care institutions". Drawing from case studies of three residential institutions caring for orphans and street children in Zambia, I deconstruct the common perceptions of orphan-care institutions. In particular, I challenge the characterization that they are isolated and disconnected from communities. My findings reveal a more complicated picture in which a subset of orphan care institutions share objectives and practices with the prevailing donor model of community-based orphan care - such as mobilizing local volunteers to care for orphans. I describe this neglected subset as "community-centered orphan care institutions" and explore the various ways in which they are embedded in and support communities. I assert that as the AIDS epidemic expands and the orphan crisis worsens, community-centered orphan care institutions must serve as key actors in expanding the first line of defense.
by Diana Aubourg.
M.C.P.

Background: Prior work examining the association of maternal obesity and neonatal mortality indicate the presence of a positive relationship. However, regional evidence to provide insight on country-level heterogeneities within sub-Saharan Africa (SSA) with nationally representative datasets are non-existent. Objective: We aimed to determine the relationship between maternal obesity and neonatal mortality at the country level in SSA countries. Moreover, we also estimate regional measures of association to complement previous findings. Methods: Demographic and Health Survey (DHS) data from 34 SSA countries conducted from 2006–2016 were used for this study. After missing data (36.9% of cases) were addressed with multiple imputations, we identified a total of 175,860 women for the analysis. Complete case and multiply imputed datasets were analyzed individually with multilevel logistic regression models. Potential confounders adjusted for in the regression model included maternal age, level of educational attainment, area of residence, access to prenatal care, birth order and multiple birth (singleton vs twin birth). Regional and country-specific associations were computed, and unadjusted and adjusted odds ratios (ORs), along with the confidence intervals (CIs) were reported. Findings: Of the total study population, 8,451 (7.6%) were obese. In the regional level analyses, maternal obesity was associated with 40% increased odds of neonatal deaths. This finding was consistent in subgroup analyses by urban and rural residence, and geographic region of residence in SSA. Additionally, obese women were more likely to report neonatal death in the first week of life (OR, days 0–1: 1.39, 95% CI 1.15–1.69; OR, days 2–6: 1.35, 95% CI 1.02–1.79). In the individual country analyses, majority of the countries studied had central estimates supporting elevated odds of neonatal mortality, but the confidence intervals were imprecise. Conclusion: This study highlights the potential burden of neonatal mortality borne by obese women in SSA. There is, however, a need for longitudinal studies to confirm the results.

The purpose of this qualitative, grounded theory study was to explore and describe the perceptions and experiences of African-born and educated nurses (ABEN) in order to understand how the nurses influenced systems of professional practice in healthcare systems of Maricopa County of Arizona. The overarching research question for the study directly reflected the purpose statement. Four sub-questions were also used in the study. These centered on was how care experiences shaped ABEN perceptions of the healthcare delivery system, how ABEN informed and shaped their social interactions when caring for patients and residents, the barriers to providing care and to fulfilling work practices and processes that ABEN described and the components of a model to adjust or remove experienced barriers. The sample consisted of 17 registered nurses, 16 females and one male, from five African countries, who participated in individual interviews. Lee's push-pull theory formed the theoretical framework of the study. Responses from interviews and researcher field notes were coded and thematically analyzed to determine answers to research questions. Six categories emerged from conceptual data analysis: optimism, self-development, confronting barriers, discovering, assimilation drive, and adaptability. A four-stage model of acclimation was developed from these six components. Results have implications for healthcare policy changes such that ABEN become fully assimilated and accepted as contributors to healthcare delivery in Maricopa County.

Includes bibliographical references.
Do any validated dementia screening tools exist for use in palliative care populations in sub-Saharan Africa? Around the world populations have increased life expectancies. The tendency to develop dementia increases with age. By 2040, it is projected that more than 80 million people worldwide will suffer from dementia. Effective and validated dementia screening tools are used for screening and identifying people with dementia at an early stage, allowing for the possibility of earlier intervention. Validated tools are used internationally, but there is a need to determine if such tools have been validated for use in a sub-Saharan African palliative care population, which presents with the distinct challenges of literacy, language and culture. There is also a high incidence of HIV in sub-Saharan Africa, with a concomitant high prevalence of HIV-associated dementia. Sub-Saharan Africa therefore needs a unique, validated dementia screening tool for use in a palliative care population. Dementia causes a high burden of suffering for patients, their families, and communities. There is a similarity between many of the symptoms of cancer and dementia, although patients with dementia have a longer life expectancy. Palliative care is the cornerstone in the management of cancer patients and is therefore clearly ideal for people suffering from dementia. The World Health Organization, in their publication: "Palliative Care for Older People: Better Practices", state that people who suffer from dementia are in urgent need of improved palliative care services 2.2. Aim The aim of this systematic review was to identify validated dementia screening tools, and of those tools, to determine, specifically, whether they had been validated in a palliative care population in sub-Saharan Africa. This was done by following 3 objectives: Page 14 1. To identify which validated dementia screening tools are available. 2. To identify and isolate those tools which have been validated in sub-Saharan Africa. 3. To determine from those tools validated in sub-Saharan Africa, which have been validated in a palliative care population. To clarify, the aim of the study was to identify the validated tools, for dementia screening in sub-Saharan Africa, in a palliative care population. This study did not endeavor to conduct an in-depth analysis of the psychometric properties of the identified tools. 2.3. Methods The EBSCO, PUBMED, SCOPUS, Medline, Psych INFO, CINAHL and Africa-Wide Information databases were searched to identify dementia screening tools. The comprehensive search strategy focused on search terms in the categories of dementia, screening tools and subSaharan Africa. Included were all tools used to screen dementia in an adult population, provided the tools met one of the following validity criteria: face validity, or content validity, or concurrent validity as well as internal consistency. An abstract had to be available. The tool had to be peer reviewed, for use with human subjects, and in English. Exclusion criteria for the validated tools were: grey literature and the screening of children. 2.4. Results Stage 1 was to identify validated dementia screening tools internationally using the electronic databases listed above under methods. This search identified 116 articles written on global dementia screening tools. Stage 2 was performed on the same electronic databases to determine if any tools had been validated in sub-Saharan Africa. This search identified 8 articles on dementia screening tools validated in sub-Saharan Africa. The 3rd stage was to determine if any of the dementia screening tools from stage 2 had been validated in a palliative care population. In stage 3, 3 articles were identified all pertaining to the same dementia screening tool. The International HIV Dementia Scale (IHDS) was the only validated dementia r a g " I s screening tool found that had been validated in sub-Saharan Africa in an HIV population but not in a palliative care population. HIV can be seen as being included in a palliative care population. 2.5. Conclusion No validated tool was identified for the broad-based screening of dementia in sub-Saharan Africa in a palliative care population. The IHDS has been validated for use in screening for HIV-associated dementia in this region. This tool can still be used in the HIV population, but the author is of the opinion that the IHDS, as a screening tool for dementia, is not adequate in the general palliative care population. In the current clinical setting, the international gold standard tool for dementia screening, the Mini Mental State Examination (MMSE), is regularly used, and despite certain limitations associated with its use in the sub-Saharan Africa setting, the author recommends its continued use. The author recommends that the MMSE be revalidated for use in the sub-Saharan Africa palliative care population.

付記する学位プログラム名: グローバル生存学大学院連携プログラム
Kyoto University (京都大学)
0048
新制・課程博士
博士(医学)
甲第20266号
医博第4225号
新制||医||1021(附属図書館)
京都大学大学院医学研究科医学専攻
(主査)教授 小泉 昭夫, 教授 中山 健夫, 教授 髙折 晃史
学位規則第4条第1項該当

Magister Chirurgiae Dentium (MChD)
CONTEXT Limited data on the prevalence of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) in Sub-Saharan Africa exist. The aim of the current study was to determine the prevalence of HPV-positive OPSCC at one of the largest tertiary care centers in the region (Tygerberg Hospital, Cape Town, South Africa). METHODS Sequential surgical samples of 266 cases of OPSCC diagnosed over a 10-year period (2007-2017) were selected for evaluation and relevant patient characteristics were documented. p16 immunohistochemistry (IHC) was performed as a screening test. All p16 positive cases were further evaluated for HR-HPV using BD onclarity™ HPV assay (BD Diagnostics, Sparks, USA), a real-time PCR assay that detects type-specific E6 and E7 genomic DNA. RESULTS Of 266 OPSCC cases, 14% (n=36) were positive for p16. Of those p16-positive cases, 23 were negative and 13 (13/266=5%) were positive for HR-HPV when evaluated by PCR. P16 was found to have a positive predictive value (PPV) of only 36.1%. HPV subtypes were HPV-16 (n=10), HPV-18 (n=1), HPV-52 (n=1) and HPV-31 (n=1). One case was positive for HPV-16 and HPV-31. HPV-positive OPSCC occurred in 10 men and 3 women (male: female ratio 3.3:1) with a mean age of 51 years (range: 33 to 72 years). All HPV-positive OPSCC arose from the tonsil (n=10) and base of tongue (n=3). Most HPV-positive OPSCC were non-keratinizing (n=10) or partially keratinizing (n=1). In contrast, HPV-negative OPSCC were predominantly keratinizing (n=218). A positive history of smoking was significantly correlated with a negative HPV status (p=0.08) CONCLUSIONS The presence of HR-HPV in 5% of OPSCC cases, in one of the largest tertiary care centers in Sub-Saharan Africa (Tygerberg Hospital), suggests HR-HPV as a minor etiologic agent in OPSCC in this region. Due to its sub-optimal positive predictive value (36.1%), p16 IHC is a less reliable marker for HR-HPV infection due to high incidence of tobacco and alcohol related diseases in this region. When positive, HPV-specific testing should be performed by one of the available platforms. The identification of the less common HR-HPV types; HPV-52 and HPV-31, in our cohort of HPV-positive OPSCC cases, may have implications for in-situ hybridization (ISH) HPV cocktails and current local vaccination strategies.

Maternal mortality is a huge concern globally leading to more than a quarter of a million deaths every year. Similarly, an estimated 4 million neonates die every year worldwide, contributing to the majority of deaths of under-5 children. The majority of these deaths take place in under-developed countries, and specifically, in the sub-Saharan Africa region. It is evidenced that maternal ill-health and death contribute to the majority of child deaths. Reducing the death of children under 5 years by two thirds and also improving maternal health/reducing maternal death by three quarters between the years 1990 and 2015 are two of the eight aims of the Millennium Development Goals (MDGs), MDG-4 and MDG-5 respectively. The report on maternal health services in Eritrea, a nation in the sub-Saharan Africa, shows a low utilization of antenatal care, family planning services, and postnatal care. Furthermore, there is insufficient use of skilled assistance at delivery. The purpose of this study was to explore the reproductive health knowledge and practice of women aged 18-49 and the impact of these on infant birth outcomes. Participants were all living in the Central Zone of Eritrea. This study proposed that knowledge of reproductive health is one of the key factors contributing to the health of women in the reproductive age group, and thereby reduction of maternal and child deaths and morbidities. An exploratory cross-sectional study design was implemented in this study using an investigator-designed questionnaire. Data were collected from participants intending to assess awareness on the domains of reproductive health including knowledge of family planning, sexually transmitted diseases (STDs), antenatal and postnatal care, importance of vaccinations, and identification of pregnancy/labor danger signs. Data on the most recent birth outcome that took place in the past five years were collected to investigate any existing associations. Findings showed that a majority of participants recognized danger signs and where to seek help in case of complications related to pregnancy and childbirth. Participants also stated the importance of child vaccination, identified STDs and family planning methods as well. Further, the majority also acknowledged the importance of antenatal care (ANC) and postnatal care by skilled personnel. However, a large percentage did not start ANC visits until after the first trimester. Also, a large number of participants did not know when fetal anomalies were most likely to occur or when conception can happen in relation to the menstrual cycle. Looking at birth outcomes, marital status and educational status showed a significant relationship with birth weight, while educational status was further a significant predictor of maturity of fetus at birth. Overall, these findings indicate the need for increased efforts in providing adequate reproductive health education, especially in certain target areas, so that women are better equipped with the necessary basic reproductive health information. This will hopefully contribute to the betterment of maternal health, further leading to a desired birth outcome.

Without exception, healthcare systems in the Sub-Saharan Africa, including Ghana, face many challenges. Difficulties in Ghana’s healthcare system stem from many factors, but the most notable one is professional migration, which has crippled the former British colony since 1980. Statistical data demonstrate the yearly migration of healthcare workers from Ghana and its impact on healthcare services (the doctor/nurse population ratio). This study used a quantitative multiple regression research method to examine and empirically analyze the relationship between healthcare workers, technological innovations, and changes in healthcare services in Ghana from 1990 to 2010. The main result was that technological innovations had a significant impact on healthcare services in Ghana during the observed period. Also, regional disparities in the number of medical doctors and nurses were largely explained by the degree of urbanization and economic development. Therefore, the pooled regression analysis from the panel data consistently showed that technological innovations significantly impacted the healthcare system in Ghana during the observed period. However, the numerical impact of the technological innovation coefficients was relatively lower in Ghana during the observed period.

In 2013, 2 million people were newly infected with HIV, and 11% of those new infections were infants that obtained the disease from their mother. In resource poor settings, like Sub-Saharan Africa, infection rates from mother to child can range from 15-45%. With proper prevention of mother to child transmission (MTCT), these rates can drop to 5%. Proper prevention includes the use of antiretroviral treatment (ART) during pregnancy, delivery, and post-partum and breastfeeding. In 2010, WHO proposed a model that required all HIV positive mothers to receive ART. The model successfully increased the amount of women on treatment, and many countries also saw a decrease in the rate of MTCT, however barriers still exist. In my thesis, I explain how HIV attacks an individual’s immune system, and why it has been such a difficult epidemic to control in regards to mother to child transmission. I also examine how different models of prevention are successful, and why Option B+, proposed by WHO in 2010, has been the most successful. Lastly, I propose new additions to the model in an attempt to circumvent the barriers.

Background: As the world becomes more urban and slums continue to grow in developing countries, research is needed to measure utilization of health services, health outcomes, and access to health care providers among urban slum residents. Estimating trends in urban health among slum residents relative to other urban inhabitants provides evidence of health disparities for priority-setting by program implementers and policy-makers. Research on the negative effects of slum environments on human health has started to emerge, yet there remains a paucity of evidence on morbidity trends over time and inequalities between slum residents and other urban residents. The goal of this study is to quantify maternal and child health care access, utilization and outcomes among urban slum dwellers in selected countries in sub-Saharan Africa and South Asia over time. These three areas are addressed in three separate dissertation manuscripts.

Methods: This dissertation offers an in-depth analysis of household and health facility data to measure trends in maternal and child health care utilization and health outcomes among slum residents over time, as well as inequalities in access, utilization and outcomes between other urban and rural populations. Manuscripts 1 and 2 apply a unique spatial inequality approach to existing population-based household data from the Demographic and Health Surveys (DHS) to identify a sample of slum residents. Manuscript 1 assesses trends in maternal and child health care (MCH) utilization and health outcomes using DHS data in Bangladesh, Ethiopia, Kenya, Malawi, Nepal, Nigeria and Tanzania between 2003 and 2011. In Manuscript 2, a trend analysis is performed in Kenya to examine diarrheal disease and acute respiratory infection (ARI) in children under-five in both slums and other urban and rural areas during the roll-out of a national slum upgrading program. Manuscript 3 further explores local-level dimensions of health care access from two slums in Kenya, generating evidence on service availability and readiness in slums. In this section, we analyze health facility data collected using a modified version of the World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA).

Results: Manuscript 1 reports significant disparities between slum dwellers and other urban residents’ utilization of key maternal health interventions—appropriate antenatal care (ANC), tetanus toxoid vaccination, and skilled delivery—in Bangladesh, Ethiopia, Kenya and Nigeria. In addition, child health outcomes examined in Manuscript 1 suggest that the prevalence of diarrheal disease in children under-five is declining among other urban and rural residents, but not significantly among slum residents. Nigeria was the only exception, with significant declines in diarrheal disease prevalence in slums over the study period. Because ARI improvements are found across populations, the data suggests this condition is not unique to slum settings. The trend analysis in Manuscript 2 supports these findings—ARI is declining steadily over time not only among slum residents, but also among other urban and rural residents as well. Diarrheal disease prevalence, on the other hand, has not changed significantly over time, with stable levels among slum dwellers between 1993 and 2014. In Manuscript 3, analysis of general service availability and readiness in two locations—the Nyalenda slum of Kisumu and the Langas slum of Eldoret—reveals that slums perform far below recommended benchmarks set by WHO. When we compare service availability and readiness indicators with regional, urban, and national averages, in general slums in Kisumu and Eldoret perform poorly. However, there were some instances—typically involving standard precautions for infection control—where Kenyan slums actually performed better than comparison sites.

Conclusions: This research provides a comprehensive view of health systems dimensions in urban slums in sub-Saharan Africa and South Asia. Manuscript 1 confirms evidence of an urban penalty and emphasizes a need to focus on maternal health care utilization in slums. Manuscript 2 detects little improvement in child health outcomes among slum dwellers in Kenya during the roll-out of the country’s national slum upgrading program. An integrated approach to health and urban policy development is recommended based on these results. Manuscript 3 identifies areas of service availability and readiness in two Kenyan slums that fall below global targets and are in need of improvement in order to achieve desired health outcomes. Taken together, this study makes a significant contribution to the crucial demand for research on growing marginalized urban populations in developing countries.

Men in sub-Saharan Africa are less likely than women to use HIV services and, thus, are more likely to die from AIDS. While much of the literature argues that men’s views of masculinity keep them from services, I use the theory of gendered organizations to provide another perspective. In this dissertation, I use a mixed methods approach to examine the gendered organization of facility-based HIV testing services in southern Malawi and how the organization of services creates additional barriers to men’s use of care.

I combine four types of data: (1) survey data with facility clients to assess if quality of care differs by sex of client; (2) in-depth interviews with healthcare providers and policy makers to examine perceptions of men as clients; (3) participant observation in health facilities to understand how institutional protocols are enacted at the local level; and (4) international and national policy documents to situate local health institutions within broader global constructs of gender and HIV priorities.

I find that heterosexual men have become an invisible category within both international and national HIV policy. When they are included, they are described as the problem, not part of the solution to HIV epidemics. On the ground, the organization of HIV testing services has followed suit.

Health institutions, like other organizations, are not gender-neutral. Men in southern Malawi were not recruited for health services, were less likely than women to receive health education when they did attend a facility, and were less likely to have access to HIV testing because services were, at times, only offered during hours for antenatal services. Furthermore, HIV testing was often located near antenatal services, again contributing to the perception that testing was designed for women – because it was. Based on these findings, I argue that HIV testing is gendered across three levels of the health institution: (1) the organizational HIV policies; (2) the physical environment in which testing occurs; and (3) interactions within facilities that require clients to enact qualities typically viewed as feminine in order to successfully receive care (e.g., waiting long hours, being compliant, and being a caregiver).

The World Bank and the International Monetary Fund have been active in Africa for several decades. In the early 1980s both institutions expanded the role that they play in the restructuring of African economies through the introduction of structural adjustment loans. These programme loans sought to provide the basis for sustainable economic expansion following a period of near economic collapse in the region. In the case of the Fund, public expenditure reducing and expenditure switching policies were encouraged. The Bank, also, was active in these areas and focused on long-term measures to restore efficiency to the ailing economies. These policies, although not novel, were implemented on a large scale were perceived to have a pervasive influence on the economic and social performance of African countries. It was theorised by some that such programme lending would have a long-run beneficial impact on social development. However, other authors, observers and researchers have criticised the activities of the Bretton Woods institutions. First, the loans have been heavily criticised in the past for the supposedly heavy handed nature that Bank and Fund staff use in implementing their programmes. The main idea is that the institutions have too much leverage when bargaining with African governments to undertake reforms. Second, it has been said that the use of programme loans will have adverse consequences for national welfare. UNICEF, the main critic, has pointed out, and provided evidence, to indicate that vulnerable groups in society may suffer under adjustment schemes. This thesis looks at the areas of macroeconomic reforms and the impact that they may have on one part of the social area: the health sector. The thesis examines the pre-adjustment situation in Sub Saharan Africa and reviews the role and the tools that the Bank and the Fund have at their disposal to tackle economic problems. The thesis then moves on to explore the linkages between these policy weapons and changes in health care development. In order to fully understand the implications for Africa considerable attention is devoted to exploring the health problems that the region faces and the health care delivery systems and health conditions that are prevalent in many of the countries. The last part of the thesis provides an aggregate study and a case study analysis of the impact of adjustment in Africa. Although, it is determined that the impact, overall, has not been unfavourable, recommendations for the future design of adjustment programmes is offered in the conclusion.

The purpose of this study is to examine how the health care system in Babati meets the increasing need for control, treatment and prevention of diabetes and hypertension. By defining what kind of specific problems and obstacles that exists in this area, the result of the research can contribute to creation and adoption of improved policies and interventions. Field studies were conducted in Babati, Tanzania for three weeks in February and March 2014. This is a qualitative study with data collected through semi-structured interviews with informants from different levels of the health system, based on the pyramidal structure of Tanzania's health care system. The theoretical framework for the study is based on aspects that corresponding to critical functions of health systems. The type of problem being treated affects the adoption and diffusion of new health interventions and the extent to which they are integrated into critical health systems functions. The study shows that diabetes and hypertension is an increasing problem in Babati. In relation to the burden, resources are lacking at all investigated levels. Therefore it is difficult to meet the increasing needs for diabetes and hypertension. To meet the future challenges, a number of cost effective strategies with focus to improve the prevention, control and reduce modifiable risk factors is suggested.
Syftet med studien är att undersöka hur hälso-och sjukvården i Babati möter det ökande behovet för kontroll, behandling och förebyggande åtgärder för diabetes och högt blodtryck. Genom att definiera vilka typer av specifika problem och hinder som finns, kan resultat från studien bidra till att skapandet och antagandet av förbättrade strategier och åtgärder. Fältstudier genomföres i Babati, Tanzania under tre veckor i februari och mars 2014. Detta är en kvalitativ studie med data insamlat genom semistrukturerade intervjuer med informanter från olika nivåer inom sjukvårdsystemet baserat på den pyramidala struktur Tanzanias sjukvårdssystem bygger på. Det teoretiska ramverket för studien baseras på aspekter som motsvarar kritiska funktioner för sjukvårdssystem. Antagandet och spridning av nya hälsointerventioner och i vilken mån de är integrerade i kritiska hälso- systemfunktioner påverkas av den typ av problem som behandlas. Studien visar att diabetes och högt blodtryck är ett ökande problem i Babati. I relation till hur sjukdomsbördan ser ut, saknas det resurser på samtliga undersökta nivåer. Därför är det svårt att möta de ökande behov som finns för att hantera diabetes och högt blodtryck. För att möta de framtida utmaningarna i Babati har ett antal kostnadseffektiva strategier med fokus att förbättra förebyggande, kontroll och minska påverkbara riskfaktorer föreslagits.

Les immigrés originaires d’Afrique subsaharienne (ASS) sont souvent exposés à des périodes de précarité et sont également une des populations les plus touchées par les infections par le VIH et le VHB. L’objectif de cette thèse était d’étudier leur accès aux soins en fonction de leur statut vis-à-vis du VIH ou le VHB. L’enquête ANRS-Parcours a été réalisée auprès de 2468 immigrés d’ASS vivant en Ile-de-France. Elle a utilisé une grille biographique analysée à l’aide de modèles de régression logistique à temps discret. L’enquête Baromètre santé 2010 a interrogé 27 653 personnes vivant en France dont 9% d’immigrés. Les immigrés subsahariens accèdent à une couverture maladie l’année de leur arrivée en France, mais un sur dix n’en disposait toujours pas trois ans après l’arrivée (plus souvent en l'absence de droit au séjour). Ils renoncent plus souvent aux soins pour raisons financières que la population majoritaire. Ce constat est aggravé par des refus de prise en charge des bénéficiaires de la CMU-C ou l’AME et des participants vivant avec le VIH. L’entrée en soins a lieu la même année que celle du diagnostic. La probabilité d’avoir fait une demande de titre de séjour pour raison de santé était plus élevée parmi les participants vivant avec le VIH. Les difficultés que peuvent rencontrer les immigrés dans la prise en charge de leurs maladies dépendent de leur situation sociale qui peut varier selon les étapes de la vie. Dans des vies marquées par une migration, ces situations sociales diffèrent selon les raisons et les conditions d’arrivée en France, selon le statut du séjour en France (avoir ou pas un titre de séjour, le droit de travailler…) et la façon dont celui-ci évolue
Immigrants from sub-Saharan Africa (SSA) are often exposed to periods of precariousness after arriving in France and are also one of the most affected populations by HIV and HBV infections. The aim of this thesis was to study the access to care of SSA immigrants according to their HIV or HBV status. The ANRS-Parcours survey was conducted among 2,468 SSA immigrants living in Paris area and the Baromètre santé 2010 among 27,653 people living in France. The Parcours survey used a biographical grid to collect indicators year after year analysed with a discrete-time logistic regression method. Sub-Saharan immigrants have access to health insurance coverage the year they arrived in France, but one in ten still did not have one three years after their arrival (more often in the absence of a permit of residence). They are more exposed to unmet health care needs than the rest of the population in France. This finding is aggravated by refusals to provide healthcare for participants covered by the specific health insurance for precarious or undocumented migrants and people living with HIV. The linkage to care takes place the year of the diagnosis. The likelihood of applying for a medical residence permit was higher among participants living with HIV. Social situations, which can change over time, affect the ability of immigrants to access health care. In the context of immigration, these social situations differ according to the reasons and conditions of arrival in France, depending on the status of the stay in France (having or not a residence permit, the right to work ...) and the way in which it evolves

Aims The purpose of this study is to explore the possibilities for video-based learning of computer systems in the field of medical education in rural sub-Saharan Africa. Background Low-income countries are forced to perform healthcare services with resources already spread too thin. The use of electronic medical records can increase the cost-effectiveness of delivering healthcare services, but the low computer literacy in sub-Saharan Africa is an obstacle necessary to overcome. E-learning and video-based learning has the potential to partially solve this problem. Methods User observations were conducted on five healthcare workers in rural Uganda. The users watched an instruction video, after which they performed an assessment test of an electronic medical record system. Results Some effectiveness was perceived – but it was slight, and varied greatly between the test subjects. Computer experience is an important prerequisite for the success of e-learning initiatives. Effectiveness was higher for more simple tasks. Conclusion This paper does not propose video-based learning as the only source of training for the target group. However, there is a possibility to envision video-based learning as a building block in a blended-learning strategy – utilising video-based learning for easier tasks and knowledge retention for users who are already familiar with the system.

In the first part of the work discribes the poverty as the main development problem of the region sub-saharan Africa and other problems connected with poverty. The second part of the work summarizes the state and diferences of social systems in individual countries of the region. The last part is focusing on the possibilities of improvement social systems to achieve the reduction of development problems.

Le paysage associatif français de lutte contre le VIH/sida voit émerger dès la fin des années 1990 un ensemble d'associations d'immigrant-e-s, en particulier porté par des personnes nées en Afrique Subsaharienne. Lourdement affectées par l'épidémie et longtemps oubliées des programmes de lutte contre le VIH/sida, les femmes immigrantes devenues une cible prioritaire des autorités sanitaires y occupent une position particulière. L'objectif de cette thèse est d'éclairer le rôle spécifique joué par les femmes nées en Afrique Subsaharienne dans la lutte contre le VIH/sida en France et d'analyser les conséquences d'un tel engagement associatif sur les différentes sphères de leur vie. Une enquête socio-ethnographique a été réalisée en Île-de-France, entre 2011 et 2013, à partir de l'observation du quotidien de six associations, d'actions et d'événements associatifs divers. Quatre-vingt-six entretiens ont été conduits auprès de femmes rencontrées dans douze associations, afin de reconstituer leur trajectoire biographique, et auprès de médecins et assistantes sociales hospitalières pour saisir leurs représentations de ces actrices associatives. Le care et l'agency forment le cadre analytique émergeant des matériaux empiriques. L'enquête montre que les projets associatifs menés par les femmes nées en Afrique Subsaharienne répondent de manière sensible aux besoins des immigrant-e-s les plus vulnérables mais également aux besoins de soutien des professionnel-le-s de l'action sociale et de santé. Majoritairement féminins, ces collectifs s'inscrivent dans une grammaire associative du care reposant sur l'auto-support et la rencontre entre deux profils : les usagères en situation de liminalité et les aidantes aux ressources diverses. Les usagères puisent dans ces espaces les supports nécessaires à la sortie du statut liminal, tandis que les aidantes développent une expertise du terrain qui leur permet de s'insérer dans les sphères professionnelles et politiques du VIH/sida. Les analyses pointent le processus d'agence des femmes engagées au sein de ces associations. Les usagères négocient les modalités de leur insertion sociale en France en recourant de manière tactique aux associations qu'elles fréquentent. Les aidantes s'appuient sur la lutte contre le VIH/sida pour dépasser la place traditionnellement réservée aux immigrant-e-s en France et accéder à l'espace public. De plus, le positionnement spécifique des femmes aux sein des associations d'immigrant-e-s leur offre une opportunité particulière de s'approprier stratégiquement les normes de genre intégrées au fil de leur socialisation. Cependant, les enjeux sociaux de la lutte contre le VIH/sida articulés à la position sociale de ces femmes dans le contexte migratoire freinent la voix/e différente qui semble leur être ouverte par la lutte contre l'épidémie en France
The French associative landscape against HIV/AIDS sees at the end of the 1990s the emergence of a set of immigrant organizations, especially led by persons born in sub-Saharan Africa. Heavily affected by the epidemic and long forgotten by the programs to combat the epidemic, immigrant women became a priority target of the health authorities and now occupy a particular position within immigrant organizations. The objective of this thesis is to shed light on the specific role played by women born in sub-Saharan Africa in the fight against HIV/AIDS in France and to analyze the consequences of such an associative commitment on various spheres of their lives. A socio-ethnographic survey was conducted in the Ile-de-France region, between 2011 and 2013, from the observation of the daily lives, actions and events of six organizations. Eighty-six interviews were conducted among women met in twelve organizations, in order to reconstruct their biographical trajectory, and among doctors and hospital social workers in order to seize their representations of these associative players. Theories of care and agency form the analytical framework emerging from the empirical materials. The survey shows that the associative projects led by women born in sub-Saharan Africa respond sensitively to the needs of the most vulnerable immigrants but also to the needs of the social and health professionals. Predominantly female, these groups fit into an associative grammar of care based on self-support and the meeting between two profiles: the female users in a liminal position and the caregivers with diverse resources. The female users draw on these spaces the necessary supports to get out of the liminal status, while the caregivers develop a field expertise which allows them to fit into HIV/AIDS policies and professional spheres. The analyses point out the agency process of the women engaged within these organizations. The female users negotiate the mode of their social integration in France tactically resorting to the associations they frequent. The caregivers rely on the fight against HIV/AIDS to exceed the position traditionally assigned to immigrants in France and to have access to the public space. Furthermore, the specific positioning of women within immigrant organizations offers them a special opportunity to strategically appropriate the gender norms integrated over their socialization. However, HIV/AIDS social issues linked to the social position of women in the migration context hamper the different voice/way which seems to be open to them in the fight against the epidemic in France

Background South Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided. Methods The Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded. Results A comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART. Conclusions Understanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.

South Africa's HIV prevalence rate is estimated to be 5.7 million and at the end of2007 a total of 45845 HIV/AIDS adult patients were taking antiretroviral therapy (ART). The global incidence of HIV/AIDS has been slowly decreasing over the years but is still widespread. This disease is still more prevalent in sub-Saharan Africa than in other parts of the world, with more than 60% people living with HIV/AIDS. Highly active antiretroviral therapy (HAART), the treatment of choice, slows the progression of the human immunovirus but demands a high adherence rate in excess of 95%. Patients who are poorly informed about antiretrovirals (ARVs) and misunderstand medicine-taking instructions or experience unexpected side effects may interrupt therapy, predisposing them to the development of resistance. Such patients need information but, given the poor literacy skills prevalent in South Africa, written information is often not fully comprehended and is often written at too high a reading level. The objectives of this research project were to design, modify and evaluate HIV / AIDS patient education materials for low-literate isiXhosa speaking adults residing in Grahamstown and to examine their impact on the understanding of various aspects of the disease and its treatment. Pictograms illustrating common side effects of ARVs (e.g. stavudine, efavirenz, lamivudine), as well as various sources 'for purchasing nonprescription medicines, storage and medicine-taking instructions were designed and evaluated both qualitatively, using group discussions, and quantitatively through individual interviews where interpretation of the pictograms was assessed. These pictograms were incorporated in a patient information leaflet (PIL) which had been specifically designed for people with limited reading skills and was a simple document containing the minimum of essential text. A previously developed PIL was modified in collaboration with the target population and two versions were produced, one incorporating pictograms illustrating side effects, the other with none. Pictograms were used in both to illustrate other medicine-taking instructions. The PILs were tested objectively to assess the readability, format, content, and general design. They were translated into isiXhosa prior to being qualitatively and quantitatively evaluated in a low-literate isiXhosa speaking population. Understanding of the PILs was assessed by asking a series of questions about the PIL content. Participant opinion of the readability and appearance of the PIL was recorded. The relationship between PIL understanding and selected demographic variables was investigated. Findings from this study illustrated that well designed pictograms assist in the location of information in written leaflets and they may enhance understanding of the information. It was further demonstrated that education influences total understanding of PIL content thus emphasizing the need for tailor-written information in accordance with the education level of the target population. A desire to receive PILs incorporating pictograms was expressed by the majority of participants. Collaboration with the intended target population is essential to design culturally acceptable, easily interpreted pictograms and to produce user-friendly, easy-to-read, comprehensible patient education materials. The rigorous, iterative design, modification and testing process described in this study is one that should be adopted in producing all health-related education materials.

Cette thèse étudie l'effet des prix sur les décisions des professionnels de santé et l'utilisation des services de santé maternelle dans le contexte de l'Afrique sub-saharienne. Les deux premiers chapitres s'intéressent à l'effet de la rémunération du travail sur les choix d'effort et la pluriactivité des professionnels de santé. En se basant sur des données collectées au niveau périphérique du système de santé Camerounais (Yaoundé et Douala), il apparaît que la rémunération du travail dans l'emploi principal n'a aucun effet significatif sur les choix d'effort et la pluriactivité des professionnels de santé. Une politique de hauts salaires apparaît ainsi insuffisante pour contrôler l'effort au travail et le phénomène d'emploi multiple des professionnels de santé. Le troisième chapitre analyse l'impact à court terme de la gratuité des soins d'accouchement et de césarienne sur l'utilisation des services de santé maternelle au Sénégal. Cette évaluation ne permet pas à court terme de mettre en évidence à un quelconque impact positif de la mesure de gratuité sur l'utilisation des services de santé maternelle. La mise à l'échelle précipitée des politiques de gratuité peut dès lors être interrogée dans ce contexte
This thesis studies the effect of prices on the decisions of health professionals and the use of maternal health services in sub-Saharan Africa. The first two chapters are concerned with the effect of wages on the effort choices and the multiple job holding of health professionals. Based on data collected at the peripheral level of the Cameroonian health system (Yaoundé and Douala), it appears that wages in the main job have no significant effect on the effort choice and the multiple job holding of the health professionals. Thus, a policy of high wages appears insufficient to control the shirking behaviour and the multiple job holding phenomenon of health professionals in the sub-Saharan context. The third chapter analyzes the short-term impact of the free delivery and caesarean program on the use of maternal health services in Senegal. This evaluation does not show in a short-term any positive impact of the free-of-charge measure on the use of maternal health services. The hasty scaling-up of free-of-charge policies can be then questioned in this context

RESUME

La Trypanosomiase Humain Africaine (THA) demeure un problème de santé publique pour plusieurs pays en Afrique subsaharienne. Le contrôle de la THA est basé essentiellement sur la stratégie de dépistage actif suivi du traitement des personnes infectées. Le dépistage actif est réalisé par des unités mobiles spécialisées, bien que les services de santé fixes jouent un rôle important en détectant « passivement » des cas. Le dépistage reposait jadis sur la palpation ganglionnaire mais, depuis le développement du test d’agglutination sur carte (CATT), trois possibilités se sont offertes aux programmes de contrôle à savoir: i) continuer avec la palpation ganglionnaire ii) combiner la palpation ganglionnaire avec le CATT iii) recourir au CATT seul. Certains programmes comme celui de la République Démocratique du Congo (RDC) ont opté pour la combinaison en parallèle de la palpation ganglionnaire avec le CATT. Toute personne ayant une hypertrophie ganglionnaire cervicale et/ou un CATT positif est considéré comme suspecte de la THA. Elle sera soumise aux tests parasitologiques de confirmation à cause de la toxicité des médicaments anti-THA. Les tests parasitologiques classiques sont l’examen du suc ganglionnaire (PG), l’examen du sang à l’état frais (SF), la goutte épaisse colorée (GE). La sensibilité de cette séquence a été estimée insuffisante par plusieurs auteurs et serait à la base d’une grande perte de l’efficacité de la stratégie dépistage-traitement. D’autres techniques de concentration ont été développées comme la mini-Anion Exchange Concentration Technique (mAECT), la Centrifugation en Tube Capillaire (CTC) et le Quantitative Buffy Coat (QBC), mais ces techniques de concentration ne sont pas utilisées en routine.

En RDC, une interruption des activités de contrôle en 1990 a eu comme conséquence une réémergence importante de la maladie du sommeil. Depuis 1998 les activités de contrôle ont été refinancées de manière structurée.

Ce travail vise deux buts à savoir le plaidoyer pour la continuité des activités de contrôle et la rationalisation des stratégies de contrôle. Nous avons évalué l’évolution de la maladie du sommeil en rapport avec le financement, son impact sur les ménages ainsi que la communauté. L’exercice de rationalisation a porté sur les outils de dépistage et de confirmation. Nous avons d’abord évalué la validité des tests, leur faisabilité ainsi que les coûts et ensuite nous avons effectué une analyse décisionnelle formelle pour comparer les algorithmes de dépistage et pour les tests de confirmation.

Pendant la période de refinancement structurel de la lutte contre la THA en RDC (1998-2003), le budget alloué aux activités a été doublé lorsqu’on le compare à la période précédente (1993-1997). Le nombre des personnes examinées a aussi doublé mais par contre le nombre des nouveaux cas de THA est passé d’un pic de 26 000 cas en 1998 à 11 000 en 2003. Le coût par personne examinée a été de 1,5 US$ et celui d’un cas détecté et sauvé à 300 US$. Pendant cette période, les activités ont été financées par l’aide extérieure à plus de 95%. Cette subvention pourrait laisser supposer que l’impact de la THA au niveau des ménages et des communautés est réduit mais lorsque nous avons abordé cet aspect, il s’est avéré que le coût de la THA au niveau des ménages équivaut à un mois de leur revenu et que la THA fait perdre 2145 DALYs dans la communauté. L’intervention par la stratégie de dépistage-traitement a permis de sauver 1408 DALYs à un coût de 17 US$ par DALYs sauvé. Ce coût classe l’intervention comme « good value for money ».

Le recours au CATT seul s’est avéré comme la stratégie la plus efficiente pour le dépistage actif. Le gain marginal lorsque l’on ajoute la palpation ganglionnaire en parallèle est minime et n’est pas compensé par le coût élevé lié à un nombre important des suspects soumis aux tests parasitologiques. Les techniques de concentration ont une bonne sensibilité et leur faisabilité est acceptable. Leur ajout à l’arbre classique améliore la sensibilité de 29 % pour la CTC et de 42% pour la mAECT. Le coût de la CTC a été de 0,76 € et celui de la mAECT de 2,82 €. Le SF a été estimé très peu sensible. L’algorithme PG- GE-CTC-mAECT a été le plus efficient avec 277 € par vie sauvée et un ratio de coût-efficacité marginal de 125 € par unité de vie supplémentaire sauvée. L’algorithme PG-GE-CATT titration avec traitement des personnes avec une parasitologie négative mais un CATT positif à un seuil de 1/8 devient compétitif lorsque la prévalence de la THA est élevée.

Il est donc possible dans le contexte actuel de réduire la prévalence de la THA mais à condition que les activités ne soient pas interrompues. Le recours à un algorithme recourant au CATT dans le dépistage actif et à la séquence PG-GE-CTC-mAECT est le plus efficient et une efficacité de 80%. La faisabilité et l’efficacité peut être différent d’un endroit à l’autre à cause de la focalisation de la THA. Il est donc nécessaire de réévaluer cet algorithme dans un autre foyer de THA en étude pilote avant de décider d’un changement de politique. Le recours à cet algorithme implique un financement supplémentaire et une volonté politique.

SUMMARY

Human African Trypanosomiasis (HAT) remains a major public health problem affecting several countries in sub-Saharan Africa. HAT control is essentially based on active case finding conducted by specialized mobile teams. In the past the population screening was based on neck gland palpation, but since the development of the Card Agglutination Test for Trypanosomiasis (CATT) three control options are available to the control program: i) neck gland palpation ii) CATT iii) neck gland palpation and CATT done in parallel .Certain programs such as the one in DRC opted for the latter, combining CATT and neck gland palpation. All persons having hypertrophy of the neck gland and/or a positive CATT test are considered to be a HAT suspect. Confirmation tests are necessary because the screening algorithms are not 100 % specific and HAT drugs are very toxic. The classic parasitological confirmation tests are lymph node puncture (LNP), fresh blood examination (FBE) and thick blood film (TBF). The sensitivity of this combination is considered insufficient by several authors and causes important losses of efficacy of the screening-treatment strategy. More sensitive concentration methods were developed such as the mini Anion Exchange Concentration Techniques (mAECT), Capillary Tube Centrifugation (CTC) and the Quantitative Buffy Coat (QBC), but they are not used on a routine basis. Main reasons put forward are low feasibility, high cost and long time of execution.

In the Democratic Republic of Congo, HAT control activities were suddenly interrupted in 1990 and this led to an important re-emergence or the epidemic. Since 1998 onwards, control activities were financed again in a structured way.

This works aims to be both a plea for the continuation of HAT control as well as a contribution to the rationalization of the control strategies. We analyzed the evolution of sleeping sickness in the light of its financing, and we studied its impact on the household and the community. We aimed at a rationalization of the use of the screening and confirmation tools. We first evaluated the validity of the tests, their feasibility and the cost and we did a formal decision analysis to compare screening and confirmation algorithms.

The budget allocated to control activities was doubled during the period when structural aid funding was again granted (1998-2003) compared with the period before (1993-1997). The number of persons examined per year doubled as well but the number of cases found peaked at 26 000 in 1998 and dropped to 11 000 in the period afterwards. The cost per person examined was 1.5 US$ and per case detected and saved was 300 US$. The activities were financed for 95 % by external donors during this period. This subvention could give the impression that the impact of HAT on the household and the household was limited but when we took a closer look at this aspect we found that the cost at household level amounted to one month of income and that HAT caused the loss of 2145 DALYs in the community. The intervention consisting of active case finding and treatment allowed to save 1408 DALY’s at a cost of 17 US$ per DALY, putting the intervention in the class of “good value for money”.

The use of CATT alone as screening test emerged as the most efficient strategy for active case finding. The marginal gain when neck gland palpation is added is minor and is not compensated by the high cost of doing the parasitological confirmation test on a high number of suspected cases. The concentration methods have a good sensitivity and acceptable feasibility. Adding them to the classical tree improves its sensitivity with 29 % for CTC and with 42 % for mAECT. The cost of CTC was 0.76 US$ and of mAECT was 2.82 US$. Sensitivity of fresh blood examination was poor. The algorithm LNP-TBF-CTC-mAECT was the most efficient costing 277 Euro per life saved and a marginal cost effectiveness ratio of 125 Euro per supplementary life saved. The algorithm LNP-TBF-CATT titration with treatment of persons with a negative parasitology but a CATT positive at a dilution of 1/8 and more becomes competitive when HAT prevalence is high.

We conclude that it is possible in the current RDC context to reduce HAT prevalence on condition that control activities are not interrupted. Using an algorithm that includes CATT in active case finding and the combination LNP-TBF-CTC-mAECT is the most efficient with an efficacy of 80 %. Feasibility and efficacy may differ from one place to another because HAT is very focalized, so it is necessary to test this novel algorithm in another HAT focus on a pilot basis, before deciding on a policy change. Implementation of this algorithm will require additional financial resources and political commitment.

Doctorat en Sciences de la santé publique
info:eu-repo/semantics/nonPublished

Introduction

Depuis une quinzaine d'années en Afrique, cercles de qualité, audits cliniques, cycles de résolution de problèmes et autres 'projets qualité' ont été mis en oeuvre dans les services publics de santé pour améliorer la qualité des soins. Ces projets ont souvent mis l'accent sur des approches participatives, la résolution locale de problèmes et le changement, bousculant les pratiques managériales traditionnelles. A court terme, les évaluations montrent l'amélioration des résultats de programmes ou d'activités. Mais la pérennité de la dynamique reste largement à prouver. Le véritable aboutissement d'un programme d'assurance qualité devrait être apprécié à l'aune de sa capacité à mettre la préoccupation pour la qualité au cœur du management et du fonctionnement du système, et ce de façon continue. C'est en effet la vision moderne de l'assurance qualité déclinée dans les approches du management de la qualité totale, de l'amélioration continue de la qualité ou de l'organisation apprenante.

Méthode

La définition, la mesure et le management de la qualité en santé se révèlent être beaucoup plus qu'une simple procédure technique: c'est un processus social dans un système complexe dont l'étude requiert une approche méthodologique appropriée (Chapitre 1). Notre objectif est d'explorer dans quelle mesure les projets qualité ont permis aux systèmes de santé d'adopter les principes du management de la qualité.

Nous proposons de conduire une 'évaluation réaliste' de projets qualité en Afrique (Chapitre 2). Conceptualisée par Pawson et Tilley (1997) dans le domaine des sciences sociales, l'évaluation réaliste ('realistic evaluation') est une approche méthodologique de la famille des theory based evaluations. Au-delà du constat d'un effet produit par une intervention, l'évaluation réaliste cherche à comprendre ce qui marche, pour qui, dans quelles circonstances et comment. Alors que les résultats issus de la 'grounded theory', de la recherche action et d'autres méthodes de recherche sur les systèmes de santé restent très liés à un contexte, l'évaluation réaliste génère des théories intermédiaires ('middle range theories') qui permettent d'étendre la validité des interprétations au-delà d'un contexte particulier. Construite autour d'études de cas menées dans des contextes multiples et variés, l'évaluation réaliste met en effet l'accent sur l'interaction entre le contexte et la logique d'une intervention.

Résultats

Afin de construire une théorie initiale, nous comparons les systèmes de santé Européens et Africains à l'aide des configurations organisationnelles de Mintzberg (chapitre 3). Nous mettons ainsi en évidence le rôle joué par la nature bureaucratique ou professionnelle de la configuration des organisations de santé dans les résistances à l'introduction des principes du management de la qualité.

Nous menons ensuite une série d'études de cas au Niger, en Guinée, au Maroc et au Zimbabwe pour étudier cette interaction. Dans une première série comparative de trois études de cas (Chapitre 4), nous mettons en évidence la tension qui existe entre la logique de commande et de contrôle des organisations bureaucratiques et la logique de l'assurance qualité valorisant la prise d'initiative de changement par des équipes non hiérarchisées. Nous explorons ensuite cette tension dans trois études de cas distinctes au Zimbabwe et au Maroc. Laissées à la merci des contraintes bureaucratiques, les initiatives locales pour améliorer la qualité apparaissent dépendantes de la capacité des acteurs à développer des stratégies de contournement (Chapitre 6). Faute de quoi elles doivent réduire fortement leurs ambitions à moins qu'elles ne bénéficient d'un soutien émanant d'une institution située hors de la ligne hiérarchique mais reconnue légitime (Chapitre 5). Les systèmes publics de santé de ces pays, conçus comme des organisations bureaucratiques structurées autour de relations hiérarchiques de commande et de contrôle tolèrent une démarche qualité, valorisant l'innovation, la créativité, la prise d'initiative locale et le travail en équipes non hiérarchisées, à la condition qu'elle se déroule à l'abri d'un projet. Force est de constater que ces dimensions clé de la culture qualité n'ont pas fondamentalement ni durablement imprégné des pratiques de management restées bureaucratiques. L'émergence d'une véritable 'culture qualité', un produit attendu de l'introduction de projets qualité, ne semble pas s'être produite au niveau organisationnel (Chapitre 7).

Nous procédons ensuite à la synthèse 'réaliste' de l'ensemble de nos études de cas (Chapitre 8). Nous en tirons les leçons sous la forme d'un enrichissement progressif de notre théorie initiale. Nous pouvons alors formuler une théorie améliorée, toujours intermédiaire et provisoire, dérivée de nos théories intermédiaires successives.

Discussion

Notre discussion s'organise autour de deux thèmes (chapitre 9).

Dans une première partie, nous discutons le potentiel et les limites de nos résultats et de l'approche réaliste de l'évaluation. Nous montrons que nos résultats sont des théories provisoires et incomplètes, deux caractéristiques d'une middle range theory. En dépit de ces limites, l'approche réaliste est potentiellement très riche pour interpréter les effets d'interventions dans des systèmes complexes. Elle se situe dans une perspective d'aide à la décision pour orienter l'action sur le terrain plutôt que dans une perspective de genèse de lois universelles. Elle représente une avancée méthodologique particulièrement pertinente pour la recherche sur les systèmes de santé dans un monde turbulent où de multiples initiatives se télescopent.

Dans une deuxième partie, nous discutons les conséquences de nos résultats pour le futur de l'assurance qualité dans les systèmes de santé. Les projets qualité étudiés ne parviennent pas à changer une culture organisationnelle bureaucratique qui compromet pourtant leur pérennisation. Nous envisageons alors les stratégies susceptibles de permettre à la culture qualité de s'épanouir et au contexte organisationnel d'évoluer en conséquence. Décentralisation et nouveau management public, en vogue hier et aujourd'hui, montrent leurs limites. Il faut probablement trouver un équilibre entre trois idéaux-types décrits par Freidson: l'idéal-type bureaucratique, malmené par les stratégies de débrouille locale, l'idéal-type du marché, valorisant l'initiative, et l'idéal-type professionnel, émergent mais encore embryonnaire en Afrique. Finalement, à côté des mécanismes du contrôle et de la compétition, un troisième mécanisme régulateur devrait prendre toute sa place: la confiance.

Introduction

For nearly two decades in Africa, quality circles, clinical audits, problem solving cycles and other quality projects have been implemented in public health services to improve quality of care. Challenging traditional managerial practices, these projects usually emphasized participatory approaches, local problem solving and change. At short term, evaluation shows improvement in programs and activities output. However the capacity to put quality at the heart of system's management should be considered as the genuine achievement of a quality assurance program. Did quality projects contribute to the adoption of quality management principles by health systems ?This is the question addressed in the present thesis.

Method

Our methodology belongs to the realistic evaluation paradigm conceptualized by Pawson and Tilley and focuses on the interaction between an intervention mechanism and its context in order to understand what works, for whom, in what circumstances and how ?Based on case studies in various contexts in Niger, Guinea, Morocco and Zimbabwe, we build a middle range theory, that explains organizational behavior towards quality management.

Results

Based on Mintzberg's models, we show the role of health care organizational configuration in resisting to quality management principles. We then explore the tension between the bureaucratic organization's command and control approach and the quality assurance approach promoting initiative and change through team work. Local initiative had to develop coping strategies to overcome bureaucratic constraints. Failing to do so, ambitions had to be reduced unless there was support from an external, yet legitimate institution. Public health systems of these countries, structured as command and control hierarchical organizations, allowed innovation, creativity, local initiative and non hierarchical relationships as long as they developed within the boundaries of a project. However, these key characteristics of a quality culture did not permeate routine management. The quality culture shift expected from quality projects does not seem to have happened at organizational level.

Discussion

We first discuss the potential and limitation of realistic evaluation which appear particularly relevant for complex health systems research. We then discuss consequences of our results on the future of quality assurance in health systems. Since quality projects fail to transform a bureaucratic organizational culture, which in turn undermines their sustainability, alternative strategies must be sought to promote quality culture and relevant organizational change. Decentralization and new public management show their limitations. We suggest a balance between three ideal-types described by Freidson: The bureaucratic ideal-type, challenged by local coping strategies, the market ideal-type, which is fashionable today and promote initiative, and the professional ideal-type, emerging and promising, yet still embryonic in Africa.
Doctorat en Sciences de la santé publique
info:eu-repo/semantics/nonPublished

HIV/AIDS-related stigma and discrimination (S&D), lack of social support, poverty, and gender inequalities have been identified as factors in the increased prevalence rate of HIV transmission in Enugu, Nigeria, especially among women ages 15 to 49 years. Despite the funding of reduction programs, HIV/AIDS-related S&D remain a major driving force in the increased rate of new HIV cases in Enugu. This study addressed a perceived need for behavioral change intervention approaches that span all societal factors to reduce the HIV infection rate in Enugu Nigeria. The study was guided by Goffman’s (1963) social S&D theory. The sample was composed of 132 women living with HIV/AIDS WLWHA ages 21 to 54 years, purposefully sampled from the 4 HIV and AIDS comprehensive initiatives care centers in Enugu, Nigeria. Fifteen WLWHA were interviewed and 114 participated in an online survey. The descriptive statistics and a multiple linear regression analysis and comparison revealed a convergent significant relationship between the S&D determinants (social, political, psychological, environmental, and cultural) and HIV/AIDS-related S&D towards WLWHA in Enugu F (4,109) = 45.09, p <.001). It also revealed that the cultural determinant of S&D was a significant predictor of HIV/AIDS-related S&D towards WLWHA in Enugu (? = 0.81, p < 0.001). The implications for positive social change include providing public health professionals evidence-based data to inform policy change, plan and to implement programs that will change societal attitudes and mobilize broad-based community actions to eradicate HIV/AIDS–related S&D toward WLWHA in Enugu, Nigeria, and in Sub-Saharan African Countries.

Immunisations are one of the most important interventions to decrease mortality and provide a foundation for a successful health system. Eliminating disparities in immunisation access is needed to meet immunisation coverage goals. Although migrants have been identified as influencing recent measles outbreaks in South Africa, research on access to immunisations is lacking for migrants in the country. Numerous barriers to accessing health care have been reported for international migrants in South Africa despite official policies of equal access. Children of Mozambican refugees may be a vulnerable group and not being immunised because of their migration status or other socio-economic and demographic factors. This study aims to determine immunisation rates in rural South Africa and identify socioeconomic and demographic factors influencing immunisation access including being a child of a refugee. All children under 5 years during 2003 and 2006 censuses in the Agincourt subdistrict, Mpumalanga, South Africa (N=17,532) are included in this retrospective, nested cross-sectional multivariate analysis of immunisation access community level data. Immunisation rates are approximately 85% for the first immunisation but rates for subsequent dosing decreased and only 5% of children of appropriate age obtained all immunisations on the South African immunisation schedule. Children of former Mozambican refugees were significantly more likely to be immunised than South African children (OR=1.59, p=0.018) controlling for other socio-economic and demographic characteristics. Children who lived in a village with a clinic (OR=1.43, p=0.015), children with older mothers (OR=1.02, p=0.028), and children in households with higher wealth (OR=1.13, p=0.033) were also more likely to be immunised. Strategies for increasing immunisation access should focus on delivery of services to villages without health care facilities, providing support and outreach to poorer and younger mothers, and ensuring continuing engagement with the immunisation programme. This study adds to the sparse existing research on predictors of immunisation access in South Africa as well as health care access for refugees in South Africa. This research shows that health care access can be higher for international migrants than the host population. Policymakers can use this research to target vulnerable groups to decrease disparities.
Thesis (M.Dev.Studies)-University of KwaZulu-Natal, Durban, 2011.

Text in English
Cervical cancer remains the leading cause of cancer mortality among women worldwide, a burden in the developing countries and commonly detected through symptoms at later invasive stages. The study aimed at establishing knowledge and awareness of the importance of cervical cancer screening in the Makhuduthamaga Sub-district by exploring the perceptions of women and professional nurses and through the review of the National Cervical Cancer Screening Policy (2013). Recommendations to address the gap in knowledge and to inform the National Cervical Cancer Screening Policy were developed based on the study findings. A mixed-method approach was used in this study through a sequential explanatory design, which is quantitatively driven was used. Quantitative data were obtained by using a researcher developed checklist. The checklist was developed from variables stated in the National Cervical Cancer Screening Policy and was used to review its implementation. Qualitative data was obtained through in-depth interviews with individual women and focus group discussions with professional nurses. The study was conducted in ten randomly selected clinics of Makhuduthamaga Sub-district. Purposive sampling was done to obtain qualitative data. An average score of 9.7 was obtained for all ten clinics that participated in the study with regard to the evaluation of the implementation of the National Cervical Cancer Screening Policy. Only 6 (60%) clinics implemented the policy whereas 4 (40%) clinics did not implement the policy. Women and professional nurses perceived cervical cancer screening as important. Lack of knowledge among women regarding cervical cancer screening contributed to the majority of women not screening for cervical cancer. Lack of resources, the 10 year interval of normal cervical cancer screening, the use of disposable vaginal speculums and brushes, lack of standardized cervical cancer screening training, centralization of cytology laboratories came out as factors that negatively influence the uptake of cervical cancer screening. Cervical cancer screening awareness campaigns, availability of resources and standardized in-service trainings on cervical cancer screening were recommended to enhance the cervical cancer screening uptake. Key concepts:
Health Studies
D. Litt. et Phil. (Health Studies)

The system of care for persons suffering from mental retardation is in a state of upheaval. Considering the mentally handicapped as holistic beings, this study explored and assessed the needs of those residing in the community of District 22 (sub-district 222), KwaZulu-Natal, thus facilitating the planning of care and care facilities for these individuals to enable them to function optimally in the community. To accomplish this purpose, specific objectives were formulated. A quantitative, exploratory and descriptive study based on Maslow's hierarchy of needs theory was carried out, using 167 respondents. The study revealed that despite being mentally retarded, they were still regarded as valuable members of the community, their needs did not differ from the needs of others in the rest of the world and that mental retardation is still rated low in the prioritization of health problems, hence the lack of resources and support needed for the rehabilitation of such persons.
Health Studies
M.A. (Health Studies)

abstract: This study aims to unearth monological and monocultural discourses buried under the power of the dominant biomedical model governing the HIV/AIDS debate. The study responds to an apparent consensus, rooted in Western biomedicine and its "standardizations of knowledge," in the production of the current HIV/AIDS discourse, especially in Sub-Saharan Africa. As a result, biomedicine has become the dominant actor (in) writing and rewriting discourse for the masses while marginalizing other forms of medical knowledge. Specifically, in its development, the Western biomedical model has arguably isolated the disease from its human host and the social experiences that facilitate the disease's transmission, placing it in the realm of laboratories and scientific experts and giving full ownership to Western medical discourse. Coupled with Western assumptions about African culture that reproduce a one-sided discourse informing the social construction of HIV/AIDS in Africa, this Western monopoly thus constrained the extent and efficacy of international prevention efforts. In this context, the goal for this study is not to demonize the West and biomedicine in general. Rather, this study seeks an alternative and less monolithic understanding currently absent in scientific discourses of HIV/AIDS that frequently elevates Western biomedicine over indigenous medicine; the Western expert over the local. The study takes into account the local voices of Sub-Saharan Africa and how the system has affected them, this study utilizes a Foucauldian approach to analyze discourse as a way to explore how certain ways of knowledge are formed in relation to power. This study also examines how certain knowlege is maintaned and reinforced within specific discourses.
Dissertation/Thesis
M.S. Biology 2014

Introduction Air ambulances transport patients to their home country or to centres of medical excellence when they are critically ill or injured. From stranded hikers to cancer patients, individuals worldwide use air ambulance transport when they need care that cannot be provided in the country or area where they are situated. Aim The overall aim of this study was to explore the challenges experienced by health care professionals during air ambulance transport of patients in sub-Saharan Africa. Research method A quantitative, non-experimental, descriptive, exploratory design was used. The study was conducted in three phases. Phase 1 was the planning of the questionnaire, Phase 2 was the pre-testing of the questionnaire and Phase 3 was the execution phase in which the questionnaires were distributed, and data were captured and analysed. Results The researcher used the data generated from the questionnaires to indicate short falls within air ambulance transport services in sub-Saharan Africa. Conclusion The researcher made recommendations in order to increase the level of air ambulance services in sub-Saharan Africa.
Dissertation (MCur)--University of Pretoria, 2011.
Nursing Science
unrestricted

This study sought to examine health care decisions and choices that women make during pregnancy and childbirth in selected low-income and poor urban communities in Ghana. Specifically, it examined women's and community members' knowledge and perceptions about pregnancy and childbirth; existing forms of health care available to women during pregnancy and childbirth; and factors that influence preference for the type of health care that women use during pregnancy and childbirth. The study employed a two-phased data collection strategy involving in-depth interviews and focus group discussions to examine maternal health care seeking behavior of the target population. The findings revealed that the poor urban women have a wide range of perceptions and knowledge about pregnancy including knowledge about what constitutes a successful pregnancy and risk factors of pregnancy and childbirth complications. The study found that three major forms of health care exist for pregnant women: biomedical care; herbal-traditional birth attendant care; and spiritual care. While some women use or prefer to use either solely medical care or herbal-traditional birth attendant care for their pregnancy and delivery, others combine two or all the three forms of health care. Pregnant women seek traditional birth attendants (TBAs) and spiritual care for spiritual protection against death, due to affection and cultural attachment to TBAs, fears about medical care and health facilities, and due to cost of seeking medical care. Long waiting time and early reporting time at antenatal clinic were identified as partly limiting the use of medical care during pregnancy. Intimate partners of pregnant women were identified as negative normative influence since most of them do not support their wives during pregnancy. Quality and safety of care were the major reasons why pregnant mothers seek biomedical care other than other forms of care. However, majority of women who seek biomedical care do not seek timely antenatal care. Only 42 percent made their first antenatal visit in the first trimester. These findings have implications for policies and programs that are likely to help increase the use of skilled attendance and improve maternal health outcomes in the study population and other similar low-income urban communities in Ghana.