Doctoral Degrees (Health Systems and Public Health)

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Browsing Doctoral Degrees (Health Systems and Public Health) by Author "Dudley, Lilian Diana"

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    Continuity of care for tuberculosis patients between hospital and primary health care services in South Africa
    (Stellenbosch : Stellenbosch University, 2020-03) Dudley, Lilian Diana; Volmink, Jimmy; Zwarenstein, Merrick; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems & Public Health.
    ENGLISH ABSTRACT : Many tuberculosis (TB) patients in South Africa are admitted to acute care hospitals, but large numbers are lost to care after discharge, and few complete their TB treatment. This contributes to ongoing transmission of TB in communities, frequent hospital readmissions, a high mortality rate and avoidable costs to the health system and society. This thesis studied continuity of care for TB patients discharged from hospital in South Africa. It aimed to describe the problem, identify risk factors for poor continuity of care, synthesise evidence to inform, implement and evaluate an intervention, and produce a policy brief to translate the evidence into policy and practice. The research methods included an observational study, research synthesis, qualitative research, participatory action research, a quasi-experimental study as well as knowledge translation methods to address the various research questions. The study found that a third of TB patients discharged from hospital did not continue TB treatment, and that inadequate clinical management of TB patients in hospital showed a significant correlation with poorer continuity of care and an increased mortality rate. Evidence of strategies to improve continuity of care for chronically ill patients was identified in high-income countries, but no such evidence could be found for TB patients in low and middle-income countries. Using the available evidence and participatory action research, a multicomponent discharge planning and support intervention was designed and implemented in collaboration with a referral hospital in the Western Cape. A before-and-after evaluation found that continuity of care for TB patients improved significantly after implementing the intervention. A process assessment revealed that the characteristics of the intervention, the external context, the persons involved and the methods of implementation had a favourable impact on implementation. Yet the internal context of the hospital was unfavourable for implementation, and in-hospital intervention activities were not sustained. In contrast, information linkages and community-based follow-up and support of TB patients continued. More rigorous studies of interventions to improve continuity of care for TB patients discharged from hospital in similar settings are required. This should be complemented by implementation research to understand and address health systems challenges. Both types of research are needed to effectively translate evidence into practice in the health systems of low and middle-income countries.