Browsing by Author "Hoffman, M"

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    Challenges to cervical screening in the Western Cape province
    (2003) Smith, N; Moodley, J R; Hoffman, M
    Carcinoma of the cervix is the second most common cancer among South African women, with 1 in 41 women developing the disease in her lifetime.1 Although population-based screening programmes using Pap smears can substantially decrease the incidence of the disease, such programmes remain remarkably difficult to implement. Lack of resources and available treatment, low community awareness, poor quality of Pap smears, and inadequate rates of follow-up are foremost among the documented obstacles to successful cytological screening.2,3 In South Africa, work to develop a nationwide screening programme has been ongoing, culminating in 1999 in the release of a national cervical screening policy.4 The screening protocol is based on World Health Organisation (WHO) recommendations for regions with limited resources5 and models of the natural history of the disease.6 The incidence of invasive cancer in South Africa begins to rise for women between the ages of 35 and 39 years, with 87% of cases occurring in women over 35.1 A lifetime total of three Pap smears, taken at 10-year intervals, is to be made available free to all women aged over 30 years, with follow-up and treatment for abnormal tests also free. The goal is to screen 70% of women in the target age group within 10 years of initiating the programme. Screening and treatment based on this model should theoretically decrease cancer incidence by 64%.
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    Health systems appraisal of a primary health care services appointment system in Cape Town
    (1996) Mahomed, Hassan; Hoffman, M
    BACKGROUND: Community surveys have indicated that patients are dissatisfied with their waiting times at public health services in Cape Town (3-6). In order to reduce waiting times and improve service efficiency, some community health centres (CHCs) in Cape Town have implemented a booking/appointment system which hitherto has been lacking. As part of an evaluative study at one community health centre in Cape Town, waiting time measurements were performed and attitudes of patients and staff assessed before (September 1993) and after (March 1995) the implementation of the intervention. Participation in the appointment system was voluntary but open to all and patients were booked into one hour periods between eight a.m. and one p.m., at 40 patients per hour. The appointment system had a "fast track" for patients with appointments. On average, 60% of patients turned up for appointments. METHODS: Waiting times of all patients attending the CHC were measured over a one week period before, and for one week after, implementation of appointments. Comparisons were made between "before" and "after'' measurements and, in the followup survey, between those using the appointment system and a control group of those who did not. Focus group and individual interviews were conducted with staff and patients. RESULTS: The median waiting times were 3 hours and 35 min before and 3 hours and 55 minutes after implementation - a difference of 20 minutes. In the "after'' study, those with appointments waited only ten minutes shorter than those without appointments. However, further analysis which involved stratification by day of the week, time of arrival and reason for attendance, revealed confounding by these factors and thus a greater waiting time advantage for patients with appointments which was statistically significant in most instances. Staff interviews revealed that although most staff were sceptical at baseline, at followup, most staff believe the system to be working well and that it does not require much improvement. At baseline, patients were enthusiastic about the idea of an appointment system. At followup, some patients felt that the system was working well, whereas others felt that much improvement could be made to the system. All patients however, felt that it would be worthwhile keeping the system in place. Suggestions for improvements came from both staff and patients. CONCLUSIONS: Implementation of the booking/appointment system was justified by the baseline findings. The minimal effect on waiting times and the smallness of the advantage to patients with appointments appears to be due in part to the type of appointment system that was implemented. It is acknowledged that other factors such as resource constraints and staff and patient motivation influence waiting times and these factors impacted on the effectiveness of the implementation of the booking/appointment system. There was some divergence between staff and patients regarding waiting time and the appointment system. RECOMMENDATIONS: Suggested improvements to the system are: Inclusion of the pharmacy in the "fast track" process, preparation of folders of patients with appointments the day before, bringing about an improvement in patient compliance with appointments and the distribution of more patient load to the afternoon. Consideration should be given to why an effective appointment system was not achieved. Joint planning between staff and patients is suggested. Further research and investigation is recommended because of the complex nature of the factors influencing waiting times and it was also thought important to evaluate the impact on consultation times of whatever interventions are considered. Further interventions not necessarily related to an appointment system might be indicated.