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Item Open Access Community participation in the upgrading of informal settlements: theoretical and practical guidelines(University of the Free State, 1999-05) Botes, Lucius Johannes Snyman; Van Rensburg, H. C. J.; Beukes, E. P.English: The emergence of participation as an alternative paradigm of development has been phenomenal. All over the world, and in South Africa in particular, enthusiasm for community participation in development exists. Moreover, many development initiatives in South Africa aspire to be participatory and people-driven processes. However, the difficulties of achieving participation at grassroots level is not always fully recognised or analysed. Therefore, participatory development, specifically in urban upgrading in South Africa, was the focus of this research. This study attempted to move beyond both the development rhetoric and the lofty sentiments associated with participatory development, and to search for a deeper understanding of community participation in development. In this search for a more in-depth understanding of the dynamics of participatory development, the study firstly traced the roots of community participation back to some of the social and development theories and paradigms from which community participation originated. The acceptance of participatory approaches to development reflects an awareness of the inadequacy of previous development efforts that failed to communicate effectively with local persons and considers their felt needs and potential contributions. Participatory development was developed primarily in a Third World context, albeit with Western influences, and it grew out of a wide range of alternative and divergent ideas, theories and paradigms, from all over, and from a multitude and rich legacy of development forces and approaches that influenced and co-shaped it. Secondly, this thesis attempted to achieve conceptual clarity on community participation in relation to development projects. Community participation is for the purposes of this study, defined as a collective process that has its focus on the active collaborative involvement of keystakeholders in joint decision-making that will influence the outcome of development decisions and of actions impacting on the broader development context of an end-beneficiary community. Thirdly, this research paid some attention to community participation in low-income urban housing projects. Important impediments or obstacles to community participation were exposed, with some reference to their application in urban upqradinq contexts. This study highlighted the emergence and evolution of participatory housing processes in urban low-income communities, both internationally and in South Africa. The global nature of shelter poverty, specifically in urban environments, was explored and the extent of shelter poverty in South Africa's urban areas and related low-income housing initiatives was discussed. r,e emergence of participatory urban development in South Africa was also analysed. Fourthly, the research described and analysed the community participation dynamics of a selected case study of informal settlement upgrading. For this purpose Freedom Square (an informal settlement on the outskirts of Bloemfontein, the capital of the Free State Province in South Africa) was selected as a case study. The findings demonstrated that informal settlers do have the inherent ability to participate meaningfully in their own development, albeit not without conflict among the different stakeholders involved. Lastly, the study proposed some emergent guidelines for promoting or facilitating community participation in urban upgrading projects. These guidelines could serve as a developmental strategy of conduct for the practice of participatory development and also as a development ethical code. Participatory development, and for that matter human development, is about processes whereby people empower themselves to participate continuously in improving their own destiny. A constant reorientation of the thinking of development professionals is therefore necessary, during which process they should rather adopt the motto of planning with and not for the people. In this reorientation they should change from being implementers to being facilitators and enablers who foster the principle of minimum intervention and who respect the indigenous knowledge of ordinary community members. The participatory development paradigm is here to stay, but the challenge remains to make community participation more than an empty catchword. Although there are major issues and problems associated with community participation in development, the benefits of participation by far outweigh these problems. Despite its ambiguities and limitations, the participatory approach enables ordinary people to assume responsibility for policies and decisions, and also for actions which concern them.Item Open Access The role of practitioners of traditional medicine in the treatment, care and support of people living with HIV/AIDS(University of the Free State, 2005-05) Summerton, Joy Violet; Van Rensburg, H. C. J.; Pretorius, E.; Ngwena, C.The ravaging impact of the HIV/AIDS epidemic on societies, especially in developing countries, has evoked a renewed urgency to consolidate all available resources to address the health needs of individuals living with HIV and AIDS. One such resource to the avail of many resource-ridden countries is the traditional healing system. Despite global proclamations and national policies that propagate the inclusion of traditional health practitioners into national health systems and priority programmes in order to address the health care needs of communities, in practice, traditional healing remains shadowed by its western health care counterpart. The South African government has declared traditional health practitioners partners in the national emasculation of the HIV/AIDS epidemic. However, significant results to this effect have not as yet been produced. The lack of effective integration of traditional health practitioners into national health programmes, such as for HIV/AIDS in South Africa, points towards a discrepancy between policies and proclamations propagating the inclusion of traditional health practitioners into the mainstream of health care, and actual integration. It is in the light of this discrepancy that this study proposes the exploration of factors that hinder collaboration between practitioners of the traditional and western health care systems. Key factors to successful collaboration between traditional and western health practitioners are identified from various initiatives in Africa and Asia, and against the backdrop of the WHO suggested integrated health care systems. These success factors are used as a bench mark to analyse collaboration in the study area and propose recommendations towards successful and meaningful collaboration. The study explores the perceived value and weaknesses of the traditional healing system in the treatment and care of people living with HIV/AIDS. This entailed ascertaining impediments to effective collaboration between traditional and western health practitioners for the purpose of informing the two categories of practitioners as well as policy developments aimed at integrating traditional and western health care. A literature study of the traditional healing system, international and national policies relating to HIV/AIDS and traditional healing, and lessons learnt from developed and developing countries on collaboration between the two health care systems informed the development of the research instruments and served as a conceptual framework for interpretation of the findings. The study was conducted in five urban settlements in the Buffalo City Municipality, in the Eastern Cape Province. The Eastern Cape was selected due to the researcher’s affiliation to the culture and vernacular of the research respondents, and due to the venerable nature of traditional health practitioners in many communities in the Eastern Cape. Preliminary investigations in preparation for the research revealed that the organisation and regulation of traditional health practitioners is more problematic in urban than in rural areas, thus the selection of an urban area to conduct the research. Due to the exploratory nature of the research, a qualitative research design was applied whereby indepth semi-structured individual interviews were conducted with 23 western health practitioners, 20 traditional health practitioners and three managers from the Department of Health. The focus of the interviews was to explore the perceived strengths and weaknesses of traditional health practitioners; impediments to collaboration between traditional and western practitioners; the structure and organisation of the traditional healing system; and views about the legalisation and professionalisation of traditional health practitioners. Purposive, snowball and sequential sampling was applied to select respondents. The main findings of the research points towards a dire need for closer collaboration between traditional and western health practitioners. The need for collaboration is based on both the perceived weaknesses and strengths of the traditional healing system. However, the nature of collaboration envisaged differs significantly between the two groups of practitioners. On the one hand, traditional practitioners envisage collaboration as entailing a bilateral (two-way) referral system between traditional and western practitioners, and joint decision making about certain patients and conditions between the two practitioners. On the other, western health practitioners envisage a far more unilateral collaboration which entails a one-way referral system from traditional to western practitioner, traditional practitioners receiving training in western medicine and traditional practitioners sharing information about the contents of proclaimed curative medicines/remedies. Furthermore, the absence of unequivocally delineated guidelines for collaboration is one other major hindrance to effective collaboration between the two traditions of practitioners. In general, the legalisation and professionalisation of traditional health practitioner is welcomed by both genres of practitioners. However, the lack of knowledge about the content and implications of the Traditional Health Practitioners Bill posses major threats to the successful implementation of the proposed Act. Overall, the research indicates that traditional healing has a role to play in the provision of health care to people living with HIV/AIDS. However, the weaknesses of this system of health care, which undermine its value, need to be addressed. Furthermore, clearly delineated policies need to be developed in close collaboration with the major stakeholders, namely traditional and western practitioners, to guide effective collaboration as envisaged by both groups of practitioners. Local government should adopt a more active role in initiating collaboration as well as monitoring its effective and culture-sensitive implementation.Item Open Access Living with TB: the ‘career’ of the tuberculosis patient in the Free State, South Africa(University of the Free State, 2004-05) Matebesi, Sethulego. Zacheus; Van Rensburg, H. C. J.; Meulemans, HermanThis thesis has three main aims. The first aim is to profile the ‘career’ of tuberculosis patients. In this regard, the focus is broadly on the socio-economic and socio-cultural variables impinging on the health-seeking behaviour and adherence to treatment of pulmonary TB patients. Secondary to this aim, the intention is to provide all stakeholders with insight into the living circumstances and experiences of pulmonary TB patients. The third main aim is to propose criteria for innovative behavioural prevention strategies and health-seeking behaviour for TB patients. The study was conducted at nine primary health care clinics in three geographic areas or health districts in the Free State province (South Africa). The areas were purposively selected to represent different regions in the Free State, including rural and urban areas. Together, the selected areas represent the broad spectrum of socio-economic and socio-cultural variables impinging on the illness ‘career’ of TB patients. The study was conducted using a combination of quantitative and qualitative research methods. Face-to-face interviews was conducted with 220 randomly selected pulmonary TB patients. In addition, nine focus group discussions (FGDs) were conducted with 85 PTB patients. Fifty-five percent of interviewed patients were male and 45% female. The majority of patients were new patients (68%), while almost a third was re-treatment patients (32%). Of the re-treatment patients, just more than half were on re-treatment following previous cure (53%), while just more than a fifth (21%) was on re-treatment following treatment completion. A third (35%) of the patients was married. On average, the patients lived in families of 4.4 persons per household with an average of 2.1 persons per room.The majority of the patients indicated that they had access to electricity (80%), piped water (85%) and to refuse removal services at least once a week (77%). However, a third (35%) reported having no proper sanitation. While the average monthly per capita income of patients increased from R985.36 immediately prior to illness with TB to R1 113.16 afterwards, the mean cumulative monthly household income decreased from R1 214.50 before being diagnosed with TB to R946.85 afterwards. It was shown that the illness ‘career’ of individuals with TB is characterised as a long-term experience in which the individuals had to rely families and friends to overcome daily challenges. In an attempt to provide a meaningful separation of events constituting the illness experience, the illness ‘career’ of the TB patient was divided into five different phases from experiencing symptoms, to assuming the sick role, to contacting a health care provider, to being a patient and, finally, relinquishing the sick role. The findings indicate that the patients in this study not only had to cope with physical disabilities and the side effects of treatment, but also with the psychological traumas of fear of recurrence of the disease and social stigma, and the disappointment of a considerably reduced range of future possibilities for career and marriage. It was also indicated that few of the patients in this study were treated negatively by their spouses/partners, family members or their communities. Living with TB in “modern” society where stress, AIDS and an array other social and psychological factors are seen to threaten the individuals, is an enormous burden In respect of determinants of treatment adherence, the quantitative evidence shows that stigma, the socio-economic circumstances of the patient, and migrancy play an important role in explaining non-adherence. In addition, patients whose tablet taking was supervised were more likely to adhere to treatment. Based on the qualitative evidence, some of the perceived factors affecting adherence included lack of knowledge about TB, non-sustainability of educational campaigns, side effects of drugs, hunger and lack of family support, stigma attached to TB, and the attitude of health care workers and the long delay in obtaining a diagnosis. Based on this evidence, recommendations are made regarding a number of provider-, patient- and communitycentred interventions that can improve adherence.Item Open Access The socio-economic impact of the Lesotho Highlands Water Project resettlement programme at Makhoakhoeng(University of the Free State, 2007) Kotelo-Molaoa, Mampho N.; Pelser, A. J.; Botes, L. J. S.Large dams are constructed for irrigation, generation of hydroelectricity, consumption and so forth. In the case of Lesotho, the LHWP was constructed with the sole purpose of selling water to South Africa in order to earn royalties and to generate hydroelectricity. Although a number of factors are used to justify the construction of large dams, worldwide experience has shown that the consequences emanating from their construction are sometimes irreversible and painful like having to be resettled. This study therefore sought to establish the extent of the impacts emanating from the LHWP Resettlement Programme at Makhoakhoeng, whether the standard of living of resettlees as measured in terms of access to services has improved or not, the extent of their participation in the resettlement programme, and their perception on their standard of living. The specific study objectives were to: i) determine the socio-economic impacts of the resettlement on the resettled communities; ii) elicit the perceptions of the displaced people about their participation in resettlement programme decision making; iii) evaluate the adequacy of the compensation and resettlement packages; and iv) ascertain the level of satisfaction of the resettlees with the resettlement programme. A combination of research techniques was used to collect both the qualitative and the quantitative data. Data collection instruments employed were: i) A literature review was undertaken to provide background information to the problem statement, the design of the methodology, and also on the theories and other factors used to justify the construction of large dams. Perusal of the existing literature also led to a deeper understanding of the impacts of large dams, international experiences and reaction towards construction of large dams and Lesotho’s experience regarding the construction of large dams. ii) Key informants interviews were conducted with selected individuals who in one way or another were key in terms of implementing the resettlement programme at Makhoakhoeng. iii) A questionnaire survey was conducted with the households who came from Molika-Liko and were resettled at Makhoakhoeng. iv) A focus group discussion was held with some of the resettlees. Information collected through filling in the questionnaire was keyed into the microcomputer network system using Microsoft Excel to produce graphs and tables. The data collected through key informants, special cases and focus group discussions were collated and written into descriptive reports, i.e., summarised field discussion records. The LHWP Resettlement Programme at Makhoakhoeng has resulted in both positive and the negative impacts. Furthermore, the study has concluded that there is a need to: i) engage with all the stakeholders affected by involuntary resettlement through an open and transparent public participation process ii) pay attention to the identification of more sustainable means of livelihoods iii) conduct SIAs that can point to those intangible aspects of resettlement iv) put in place an appeal system that is affordable and accessible to people who are dissatisfied with the resettlement package v) present resettlees with information on each of the options so as to enable them to make informed decisions vi) honour promises in order to build trust with the resettlees. The following recommendations are being made for future resettlement programmes: i) Change the mindset of those charged with the management of resettlement programmes so that they are more empathetic towards resettlees ii) Reform institutions within the water sector iii) Adopt a multidisciplinary approach in resettlement programmes iv) Differentiate resettlees into subgroups v) Engage in an open and transparent public participation process vi) Conduct SIAs with a monitoring and evaluation component vii) Identify sustainable means of livelihoods for the resettlees viii) Compensate affected people for loss of access to common property.Item Open Access International conflict over fresh water resources: the formulation of preventive and interventive guidelines(University of the Free State, 2008) Redelinghuys, Nola; Pelser, A. J.The pressures of human society on available water resources lead to the grave and everworsening scarcity of this resource, which locally and internationally, strains policy and institutional capacity to deal with the issue cooperatively. While conflict over fresh water, to the extent even of war, is not generally characteristic of relations over water, tension is nevertheless felt between countries over various issues surrounding access to water. It is thus imperative to determine the nature and extent of issues that may give rise to future tension and conflict over freshwater resources. Given the above situation, this study aimed to meet the following objectives: - To gain in-depth understanding of the social, economic and political dynamics that underlie current relations over water, globally and more specifically in the Southern African region. - To assess current ways in which water issues are being addressed at the international and the regional level, by focusing on the existing global and regional policy frameworks for dealing with water scarcity. - To assess the institutional frameworks within which water issues are currently being dealt with at the international and the regional levels. - To develop a set of policy guidelines that can be used to facilitate cooperation over water issues in Southern Africa. The research design of this study was qualitative and interpretative, and four sources of information were utilised in data collection, namely primary and secondary literature sources; secondary demographic and environmental data; policy and legislative documents; and, information obtained from personal key-informant interviews. The following conclusions were drawn from the study - The dominant social paradigm underlying decision making with regard to natural resources does not support closer cooperation over fresh water. - The emphasis on political sovereignty in policy is inconsistent with the international commitment to cooperation over freshwater resources. - The policy obligation of equitable distribution of water between sectors and states is hampered by unresolved tensions in policy and institutional frameworks. - As a result of the vagueness with which contentious issues are addressed in international policy, current policy options may neither be adequately able to intervene in nor to prevent conflicts over fresh water. - A lack of both ratification and enforcement of the existing international policy framework renders these instruments powerless to prevent or intervene in future conflicts over fresh water. - Effective cooperation between water-resource institutions is hampered by significant shortcomings in vertical and horizontal communication linkages between such institutions. Recommendations made based on the study are: - A transition needs to be made from a technocentric approach focused on managing the issues arising from water scarcity, to an ecocentric approach focused on radical changes in policy formulation. - Current vague statements and terms in the international policy framework need to be conceptualised more clearly. - Policy makers at the regional and national levels should specifically work toward diffusing subtle tensions in current policy and institutional arrangements through closer integration of sectoral policies. - A regional perspective on the issues of water scarcity, conflict and cooperation over fresh water needs to be strengthened. - In line with the IWRM strategy’s emphasis on decentralisation, appropriate mechanisms need to be found to link institutions horizontally. - The capacity and functioning of multistakeholder platforms in the water sector need to be strengthened.Item Open Access A community-based conservation programme for the management and conservation of land resources in Lesotho(University of the Free State, 2004-11) Esenjor, Akinagum Fidelis; Pelser, A. J.; Botes, L.English: Literature abounds with discussions regarding land degradation and the sustainability of land resources conservation programmes in sub-Saharan Africa. A thorough understanding of past and present intervention mechanisms and the consequences both to humans and to the entire ecosystem is necessary to advise stakeholders in conservation initiatives. This study employs comprehensive multiple participatory methodologies in analysing both the causes of land degradation and the importance of local communities’ real involvement in land resources conservation initiatives. The participatory methodologies include focus group discussions. The consequences of the paternalist classical model of land resources conservation programmes practised in the developing countries include endless conflicts between conservation officers and local communities, a lack of unequivocal acknowledgement of indigenous knowledge, denial to local communities of access to rights and adequate benefits, and a lack of local support and community participation which results in the sudden collapse and abandonment of conservation programmes. This indicates a wasting of government agencies’ heavy investment in conservation initiatives. Yet, worldwide advocation of a shift from official to community-based conservation approaches does not mean the total withdrawal of government agencies. It only means a trimming down of government agencies’ “do it all” recurrent roles to one of facilitation of the conservation initiatives of local communities. Government agencies may also give unconditional support in community-based initiatives. It has been established that the continuous occupation of the centre stage in land resources conservation programmes by government agencies has accelerated land degradation, has intensified conflicts between government officers and local communities, has wasted local available resources input, has denied local communities access, rights and benefits of land resources, and has increased the number of abandoned conservation projects. The hope of effectively practising real community-based land resources is an uphill task. This is so because government agencies operating in Lesotho have raised unsustainable expectations of food-for-work and/or cash payment incentives to local community members for participating in conservation work. This poor practice has established a false impression that land resources conservation is the sole responsibility of government agencies. This study has established that to practise community-based conservation would require drastic new training of government agencies; it would necessitate providing more sustainable incentives to local communities, and also re-orientating, empowering and capacitating the people for the challenging tasks ahead. Real involvement of local communities in the processes of identification of conservation needs, planning, implementation, monitoring and evaluation are sure ways of ensuring sustainable land resources conservation programmes.Item Open Access Hospitalisation for tuberculosis in the Free State, South Africa(University of the Free State, 2004-05) Heunis, James Christoffel; Van Rensburg, H. C. J.; Meulemans, H.Abstract not availableItem Open Access Adherence and sustained access to antiretroviral treatment in the Free State public health sector: a gender perspective(University of the Free State, 2008-11) De Reuck, Chantell Jacqualine; Pretorius, E.; Van Rensburg, H. C. J.English: Sustained access to ART and adherence to ARV medications remain crucial for reducing AIDS-related mortality and morbidity, minimising the development of drug resistance, and for appropriate treatment decision-making by health care providers. Thus, the factors associated with non-adherence to ARV medication and poor sustained access need to be identified and addressed. Although there is a preponderance of treatment adherence research, in which social aspects that affect the way patients manage HIV/AIDS and related treatment have been identified, far less attention has been paid to the relevant gender dimensions of treatment, care and support. The aim of this study was to examine how gender influences adherence to ARV medications and sustained access to treatment among patients on ART in the Free State public health sector. To achieve this aim, several methods were deemed necessary. First, current literature was reviewed to identify factors that predict nonadherence to ARV medications and impede sustained access to ART. Second, a framework was adapted to focus on inequalities in treatment from a gender perspective, and to take cognisance of both biological sex and socially constructed gender influences on the health of patients on ARV treatment, with specific reference to access and adherence to treatment. Masculinity and femininity is discussed in respect of the varied resources that an individual has access to and control over, an individual’s decision-making power, the gender norms held by society, and gender roles that men and women are expected to adhere to. Third, an empirical investigation of data from a prospective cohort study was conducted to identify similarities and differences in factors associated with nonadherence to ARV medications and to poor sustained access among men and women on ART in the Free State’s public health sector. A total of 1609 patients were interviewed in face-to-face interviews using semi-structured questionnaires. Patients were interviewed six times during the course of this study with an average six-month interval between interviews. The outcome variables assessed included self-reported seven-day adherence to ARV medication regimens and self-reported adherence to scheduled appointments over a six-month period as a measure of sustained assess to treatment. Sex was used as the dependent variable in all analyses. Demographic, psychosocial/behavioural, clinical, and service delivery variables were all tested for a statistically significant association with non-adherence to medications and appointments in separate sex-disaggregated multivariate regression analyses (P≤0.05). Logistic regression models showed that the strongest predictors of medication nonadherence among men included financial difficulties in visiting hospital facilities and poor treatment knowledge. Among women, tobacco use and perceived stigma were identified as the strongest predictors of medication non-adherence. Self-reported depression or anxiety and experiencing difficulties in visiting clinic and hospital facilities were similarly associated with non-adherence to appointments for men and women. Service satisfaction at clinics and having few self-reported service needs were also independently associated with appointment non-adherence among women, but not among men. Findings for men do however need to be interpreted with caution, as both outcomes, despite being valid measures for the combined sample and among women, were not valid for men. Marked differences and similarities in the factors influencing medication adherence and sustained access to treatment between men and women were identified, reflecting the different lived experiences of men and women on ART in the Free State. Gender-sensitive interventions - as opposed to standardised ones - are thus required to improve adherence and sustained access in this population. Further research and possible interventions are required in respect of gender-sensitive outcome measures for adherence, improving treatment knowledge among men, coping responses to gender role stressors among women, less stigmatising means for taking medications, improving mental health and improving the quality of services rendered at health care facilities.