Browsing by Department "Division of Family Medicine"

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    A study to determine the palliative care needs of patients with drug resistant tuberculosis in the Southern sub-district of Cape Town
    (2018) Odell, Shannon; Krause, René; Gwyther, Liz
    Introduction: The Palliative Care needs of patients with Drug-Resistant Tuberculosis (DR-TB) are under-researched, yet pertinent in the management and control of DR-TB. Most literature reviewed focused on treatment schedules, outcomes, transmission, drug adherence, drug side effects and further drug-resistance. Aim: The aim was to determine the palliative care needs of patients infected with DR-TB living in the Southern sub-district of Cape Town. The Objectives The objectives were to determine the quality of life and symptom burden of DR-TB patients and to assess for correlation between these variables and palliative care needs. Methodology: In this cross-sectional study, twenty-eight participants were posed a culturally sensitive questionnaire designed by the researcher, that comprised: demographic questions, Likert-type questions for the African Palliative Care Association – Palliative Outcome Score (APCA-POS) tool, Eastern Co-operative Oncology Group (ECOG) score, a symptom checklist and open patient dignity questions. Quantitative and qualitative data of the respondents’ quality of life, functional status and burden of symptoms in the preceding week were ascertained. Pre-determined numerical scores in the Likert-type questions were deemed indicative of palliative care need. Results: Quantitative and qualitative analysis of the data showed that each participant had a palliative care need: be it either (or a combination of) unmet clinical, psychological, social and/or spiritual needs - despite being at differing stages of the DR-TB disease trajectory. These needs required contextualizing within the respondents’ communities where socio-economic issues were prevalent. Predominant physical complaints were tiredness (79%), joint pain (64%), confusion (61%) and shortness of breath (51%). Respondents’ also experienced a loss of autonomy, poor self-value and financial insecurity. Fifty percent of patients interviewed required urgent further management and referral to the local clinic. Conclusion: Despite the small cohort of patients and possible recruitment bias, this research concurred that a palliative care approach be adopted from the point of DR-TB diagnosis and throughout the treatment period – regardless of treatment outcome; and that DR-TB patients had significant unmet palliative care needs that affected their quality of life, functional status and dignity, regardless of whether pain was present.
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    A Study to Identify the Burden of Chronic Disease on a Private Emergency Medical Service in the Southern Sub-District of Cape Town, and if there is a Need for Palliative Care Provision in the Pre-Hospital Healthcare Sector
    (2023) Holmes, Linley; Odell, Shannon; Gwyther Elizabeth
    Introduction Paramedics are often the first healthcare personnel to provide contact and care to patients with exacerbation of their chronic, non-communicable disease. Many of these patients will call for assistance multiple times during the trajectory of disease, and may benefit from a palliative care program. Currently, paramedics are not trained to manage patients requiring palliative care, nor provided with specialist palliative care consultation resulting in many patients being transported to hospital unnecessarily. Aim This study aims to describe the burden placed on Emergency Medical Services due to the number of patients with chronic Non-Communicable Diseases experiencing acute symptoms, and to assess whether palliative care in the pre-hospital sector should be considered. The objectives of the study include understanding whether patients with non-communicable disease symptoms were transported to a medical facility or remained at home, what clinical management they received, and whether there is a need for education, inter-disciplinary consultation, and provision of palliative care, in the pre-hospital environment. Methods This was a retrospective descriptive analysis of de-identified patient PRFs of adult patients, attended to by a private Emergency Medical Service (EMS) between January 1st, 2019, up until 30th April 2019. Results Of the 283 patients included in the study, many had more than one NCD, often experiencing more than one of the primary symptoms of pain, SOB, cognitive changes, and N&V simultaneously. The majority of these patients were likely to go to hospital with ambulance transport and frequently there was no appropriate clinical intervention by paramedics. Clinical advice was seldom sought by paramedics for patients with NCDs (cancer, chronic heart disease, chronic lung disease, dementia, and chronic kidney disease) experiencing symptoms of pain, SOB, cognitive changes and N&V, and it was evident that palliative care access, and availability, for patients was minimal. Conclusion Palliative care is a necessary approach to patient-centred care, with specifically trained EMS and paramedics being an available resource to assist with this approach. Access to available palliative/ home care networks, in conjunction with education and EMS support, will facilitate care for patients that have a need for palliative care support in the out of hospital context, and will limit the inappropriate transport of patients to already over-burdened Emergency Departments.
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    An assessment of organisational values culture and performance in Cape Town's primary healthcare services
    (South African Academy of Family Physicians, 2013) Mash, R J; Govender, S; Isaacs A A; De Sa, A; Schlemmer, A
    Objectives: Improving the quality of primary health care in South Africa is a national priority and the Western Cape Department of Health has identified staff and patient experience as a key component. Its strategic plan, Vision 2020, espouses caring, competence, accountability, integrity, responsiveness and respect as the most important organisational values. This study aimed to measure the personal values of staff, as well as current and desired organisational values. Design: A cross-sectional survey used the cultural values assessment tool. Data were analysed by the Barrett Value Centre. Setting and subjects: Staff and managers at five community health centres in the Cape Town Metropole. Outcome measures: Personal values, current and desired organisational values, organisational entropy and organisational scorecard. Results: In total, 154 staff members completed the survey. Participants reported personal values that are congruent with a move towards more patient-centred care. The top 10 current organisational values were not sharing information, cost reduction, community involvement, confusion, control, manipulation, blame, power, results orientation, hierarchy, long hours and teamwork. Desired organisational values were open communication, shared decision-making, accountability, staff recognition, leadership development and professionalism. Organisational entropy was high at 36% of all values. Only teamwork and community involvement were found in both the current and desired culture. The organisational scorecard showed a lack of current focus on finances, evolution and patient experience. Conclusion: The organisational culture of the Metro District Health Services is currently not well aligned with the values expressed in Vision 2020, and the goal of delivering patient-centred care.
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    Breastfeeding knowledge, attitudes and practices among adolescent teenage mothers at Crossroads, Western Cape, South Africa
    (2023) Ashwehdi, Ahmad; Isaacs, Abdul-Aziez
    Background: Breastfeeding is important in supporting the normal growth and development of infants and young children. Evidence shows that breastfeeding is protective against infectious diseases such as upper and lower respiratory tract infections, gastrointestinal illnesses, and otitis media, during the infant period. South Africa has a low exclusive breastfeeding rate. Exclusive breastfeeding for the first six months is the best start for health and development. Adolescent pregnancy is detrimental to the health of mother and child and is a common public health problem worldwide. The identification of factors that promote or inhibit breastfeeding behavior is vitally important for the design of evidence-based policies and interventions. Despite the available knowledge of benefits of breastfeeding, this has not translated into practice in South Africa. Objective: This study aimed to investigate breastfeeding knowledge, attitudes, and practices among adolescent mothers at Crossroads, Western Cape, South Africa. Study- Design and Methods: An analytical cross-sectional study was conducted with 77 mothers aged between 16 and 19 years old, attending Crossroads Community Day Centre located in Mitchell's Plain sub-district, Western Cape. A skilled research assistant performed an in-person meeting with each mother in either English or isiXhosa. Closed-ended questions were used to gather information on socio-demographic characteristics, breastfeeding knowledge, attitudes, and practices. Results: The study analyzed the breastfeeding practices and knowledge of 77 mothers, all of whom reported initiating breastfeeding. However, 31.5% reported discontinuation at the time of the interview. Almost sixty percent of the mothers in this study were unemployed. Most of mothers reported that healthcare workers emphasized the importance of breastfeeding and educated them on appropriate breastfeeding practices. However, only 52.8% of mothers practiced exclusive breastfeeding. Most mothers recognized the benefits of breastfeeding for their babies, including reduced respiratory infections (72.6%), increased intelligence (86.7%), and protection from allergies (94.8%). They also acknowledged benefits for themselves, such as preventing breast Breastfeeding knowledge, attitudes and practices among adolescent mothers at Crossroads, Western Cape, South Africa engorgement (79.5%) and lowering the risk of breast cancer (50.0%). However, many mothers were unaware of the benefits of breastfeeding for child spacing (65.5%), and 56.8% of mothers lacked knowledge on breastfeeding and pre-pregnancy weight. The study found a statistically significant difference in mean knowledge scores for breastfeeding benefits to the baby and the mother. Conclusion: The importance of breastfeeding in babies' lives has been established. However, in low-income communities such as Crossroads, knowledge of the benefits of breastfeeding was variable, and the majority did not practice exclusive breastfeeding. it is important to implement promotional and educational programs in these communities to increase awareness of the vital role of breastfeeding in ensuring optimal development of children.
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    Does decentralising the care of patients with chronic disorders result in altered patient satisfaction
    (1997) Harley, Beth; Schweitzer, Beverley
    Introduction: In 1994 the Bonteheuwel and Valhalla Park clinics in Cape Town started a pilot project for the care of patients with chronic disorders. Patients in Bonteheuwel and Valhalla Park with chronic disorders who were previously under the care of Day Hospital or Hospitals in other suburbs, can now receive treatment and follow-up at the local authority clinic. There are currently nearly two thousand patients under Bonteheuwel clinic and nearly two hundred patients under Valhalla Park Clinic. Aim: To see if decentralising the care of patients with chronic medical conditions to local clinic level results in altered patient satisfaction. Objective: To look at patient satisfaction with clinic care compared to satisfaction with care at the previous place of service through administration of a comparative questionnaire. Methods: Data was collected by administering a questionnaire to a systematic sample of patients. The questionnaire was administered to 271 clients at Bonteheuwel and 43 clients at Valhalla Park clinics whilst they were waiting to see the doctor or to collect medication. The questionnaire asked patients to assess the clinic service in comparison to their previous place of service by asking whether various aspects of the service are better at the clinic, were better at their previous place or service or are much the same. Patients were also asked what they like best and least about the clinic's service and that of their previous place of service. Results: Results showed a high level of satisfaction with the clinic service compared to the previous place of service, especially in terms of access, cost, surroundings and waiting times. 95% of patients at Bonteheuwel and 98% of patients at Valhalla Park preferred being under the care of the clinic rather than under the care of their previous place of service. Patients felt there was not much difference in the doctor's technical or communication skills at the clinic compared to their previous place of service. Some patients at Bonteheuwel Clinic voiced concerns about the lack of facilities available at the clinic and felt that the clinic needed to be expanded to become a day hospital. Conclusions: Decentralising the care of patients with chronic medical conditions to local clinic level has resulted in increased satisfaction of patients. With the restructuring of health services in the Western Cape at present, decentralising the care of patients with chronic medical conditions to local clinic level may be an option for some communities.
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    Effective teaching through active learning
    (MedPharm Publications, 2005) Gibbs, T.J.; Brigden, D.; Hellenberg, D.A.
    There can be very few practitioners whose daily working life is not involved someway in teaching or learning. Used in its broadest sense, we engage teaching everyday in our advice to patients, and conversely we learn from each of our patients. As we move inexorably towards compulsory reaccredidation for all practitioners, purposeful and effective continuing professional development takes over from the previously passive continuing medical education model. As Universities and Medical Schools recognise where most healthcare occurs and see the benefits of community-based education, increasing numbers of undergraduate and postgraduate students pass daily through our surgery doors. No doubt, the majority of busy practitioners see these activities as an increased workload rather than an opportunity, a stress factor rather than a possibility to develop in their personal lives.
    In this article, we wish to suggest how some of our daily practice activities can be seen as opportunities to teach and learn; how by using the principles of being an effective teacher, we can create learning situations for all.
    "Learning and teaching should not stand on opposite banks and just watch the river flow by; instead, they should embark together on a journey down the water. Through an active, reciprocal exchange, teaching can strengthen learning how to learn". Loris Malaguzzi
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    Evaluation of a school-based nutrition and physical activity programme for Grade 4 learners in the Western Cape province
    (South African Academy of Family Practice, 2013) Jacobs, K L; Mash, B; Draper, C E; Forbes, J; Lambert, E V
    Objective: This study aimed to evaluate the effectiveness of the Making the Difference programme (MTDP), an education-and activity-based intervention for Grade 4 learners at primary schools in the Western Cape. Design: This was a cross-sectional, post-intervention survey of an existing programme, using control schools as a comparator. Setting and subjects: The study involved Western Cape primary schools in the 2009 school year. Schools were randomly sampled from two regions. Four intervention (active in the MTDP) and five control (non-participating) schools (n = 325 learners) were selected. Outcome measures: The following outcome measures were assessed using an administered questionnaire to learners: learners' knowledge of, attitudes towards, and behaviour in relation to nutrition and physical activity. Results: A small but significant improvement (eating vegetables and taking lunch boxes to school) was demonstrated with regard to self-reported behaviour in relation to nutrition in the intervention group. However, this behaviour was not explained by differences in barriers to healthy eating, self-efficacy or knowledge, which were not different between the groups, or by perceived social support, which was actually significantly increased in the control group. Groups displayed no differences in physical activity or sedentary behaviour. However, the results showed a significant difference between the groups in terms of a reduction in perceived barriers to physical activity and increased physical activity self-efficacy in the active group. Conclusion: While the MTDP only had a modest effect on the self-reported nutrition and physical activity behaviour of the learners, results regarding lower perceived barriers to physical activity and increased physical activity self-efficacy were promising.
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    Forty-five year apart: Confronting the legacy of racial discrimination at the University of Cape Town
    (2004) Perez, G; London, L
    One of the many consequences of South Africa's history of racial discrimination is the impact it had on the training of black medical students. Blacks, and particularly those classified as African under apartheid’s racial classification, were restricted from entry to medical schools by a permit system introduced in 1959 and only rescinded in 1986.1 In 1967, the ratio of white doctors trained per million of the white population in South Africa was almost 100 times higher than the equivalent ratio for Africans,2 and although whites constituted less than 20% of the population, 83% of all doctors and 94% of all specialists in South Africa in 1985 were white.3 Not only were blacks largely excluded from training opportunities but, for those gaining access to medical schools, the conditions under which they trained were extremely onerous, and lacked the educational, recreational, accommodation and social opportunities afforded their white colleagues.1,2,4,5 A comment by a leading academic in 1988 on the state of medical training could have been applied to almost all of South Africa’s medical schools during apartheid: ‘. . . in spite of our much vaunted Academic Freedom, our policy and practice is heavily influenced, if not determined, by . . . an oppressive apartheid ideology. Why else have we produced so few African doctors; why else does the University . . . not have a satisfactory teaching hospital or residence for its [African] students?’
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    Full-term, peri-urban South African infants under 6 months of age are at risk for early-onset anaemia
    (2004) Sibeko, L N; Dhansay, M A; Charlton, K E; Johns, T; Van Stuijvenberg, M E; Gray-Donald, K
    OBJECTIVE: There is a paucity of data on the micronutrient status of low-income, lactating South African women and their infants under 6 months of age. The aim of this study was to elucidate the level of anaemia and vitamin A deficiency (VAD) in peri-urban breast-feeding women and their young infants. DESIGN: Cross-sectional study including anthropometric, biochemical and infant feeding data. SETTING: Peri-urban settlement in Cape Town, South Africa. SUBJECTS: Breast-feeding women (n=113) and their infants (aged 1-6 months) attending a peri-urban clinic. RESULTS: Mean (standard deviation (SD)) haemoglobin (Hb) of the lactating mothers was 12.4 (1.3) g dl(-1), with 32% found to be anaemic (Hb<12 g dl(-1)). Maternal serum retinol was 49.8 (SD 13.3) microg dl(-1), with 4.5% VAD. Using breast milk, mean (SD) retinol concentration was found to be 70.6 (24.6) microg dl(-1) and 15.7 (8.3) microg/g milk fat, with 13% below the cut-off level of <8 microg/g fat. There was no correlation found between breast milk retinol and infant serum retinol. Z-scores (SD) of height-for-age, weight-for-age and weight-for-height were -0.69 (0.81), 0.89 (1.01) and 1.78 (0.83), respectively. Mean (SD) infant Hb was 10.9 (1.1) g dl(-1), with the prevalence of anaemia being 50%, 33% and 12% using Hb cut-offs below 11 g dl(-1), 10.5 g dl(-1) and 9.5 g dl(-1), respectively. Mean (SD) infant serum retinol was 26.9 (7.2) microg dl(-1), with 10% being VAD. None of the infants was exclusively breast-fed, 22% were predominantly breast-fed and 78% received complementary (mixed) breast-feeding. Thirty-two per cent of infants received weaning foods at an exceptionally young age (< or =1 month old). CONCLUSION: A high rate of anaemia is present in lactating women residing in resource-poor settings. Moreover, their seemingly healthy infants under 6 months of age are at an elevated risk of developing early-onset anaemia and at lower risk of VAD.
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    Imminent eclampsia: the clinical state and the treatment with Avertin of 100 cases
    (1962) Craig, Cecil
    The term eclampsia is derived from the Greek eklampien meaning a flesh, and its etymology suggests the acute onset of the convulsions. On the surface, therefore, it would appear paradoxical to define any state as being one of "imminent eclampsia". However, although the aetiology is unknown, sufficient knowledge of the preceding history and manifestations of eclampsia has accumulated to justify such a specific term. In a subsequent chapter, these symptoms and signs will be assessed and discussed in detail. Where the net of antenatal care is widespread and where such services are accepted and utilized by all who are pregnant in a community, the incidence of severe toxania and eclampsia is minimal. Few obstetricians in highly developed, civilized areas are afforded the opportunities for studing and treating any large numbers of cases of imminent eclampaia
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    Implementing a structured triage system at a community health centre using Kaizen
    (2009) Isaacs, A A; Hellenberg, D A
    Background: More than 100 unbooked patients present daily to the Mitchell’s Plain Community Health Centre (MPCHC), and are triaged by a doctor, with the assistance of a staff nurse. The quality of the triage assessments has been found to be variable, with patients often being deferred without their vital signs being recorded. This leads to frustration, and a resultant increased workload for doctors; management is concerned with the medicolegal risk of deferring patients who have not been triaged in accordance with the guidelines; and patients are unhappy with the quality of service they receive. Aim: We set out to standardise the triage process and to manage unbooked patients presenting to the community health centre (CHC) in a manner that is medico-legally safe, cost efficient and patient friendly, using the Kaizen method. Methods: The principles of Kaizen were used to observe and identify inefficiencies in the existing triage process at the MPCHC. Findings were analysed and interventions introduced to improve outcomes. The new processes were, in turn, validated and standardised. Results: The majority of patients presenting to Triage were those needing reissuing of prescriptions for their chronic medication, and this prevented practitioners from timeously attending to other patients waiting to be seen. Reorganising of the process was needed; it was necessary to separate the patients needing triage from those requiring only prescriptions to be reissued. After the intervention, triage was performed by a staff nurse only, using the Cape Triage Score (CTS) method. Subsequent to the implementation of interventions, no patients have been deferred, and all patients are now assessed according to a standardised protocol. The reasons for patients requiring reissuing of prescriptions were numerous, and implementing countermeasures to the main causes thereof decreased the number of reissues by 50%. Conclusion: The Kaizen method can be used to improve the triage process for unbooked patients at the MPCHC, thereby improving the quality of services delivered to these patients. As the needs of the various CHCs differ quite widely across the service platform, the model needs to be adapted to suit local conditions.
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    Mentoring in medical practice
    (MedPharm Publications, 2005) Gibbs, T.J.; Hellenberg, D.A.; Brigden, D.
    Previous articles in this series have defined words and concepts that guide our thinking in the areas of teaching and learning, set in the greater world of education; but what happens in the quiet and often lonely world of individual practice?
    As we reflect upon our pasts, many of us recognise that we have at some point in time engaged with a significant figure who has had a long term and positive influence on our personal development; someone who has the unusual and valuable qualities that mean that whatever else is happening to them personally, they maintain a genuine interest in at least one other person's development. All too frequently, this becomes an isolated event; a lost activity from which there is limited gain. This article explores how, as busy practitioners, we may think of using the principles implied in this experience and build upon them to facilitate a powerful and cost effective method that encourages personal development.
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    Outcomes for family medicine postgraduate training in South Africa
    (South African Academy of Family Physicians, 2012) Couper, I; Mash, B; Smith, S; Schweitzer, B
    After 1994, the post-apartheid government decided that primary health care and the district health system would be the cornerstone of their new health policy. As a consequence of this, the academic departments of Family Medicine and primary care recognised the need for a nationally agreed set of training outcomes that were more aligned with these new priorities within the public sector. Thus in 2001, the Family Medicine Education Consortium (FaMEC), representing the eight academic departments of family medicine in South Africa, agreed to a set of outcomes for postgraduate family medicine training. At that time, all departments were running Family Medicine Master’s programmes as part-time training courses for doctors in primary health care. Recognition of the need to move towards full-time registrar training already existed, and because of this steps were taken to register Family Medicine as a speciality with the Health Professions Council of South Africa (HPCSA).
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    The perceptions of rural women doctors about their work
    (MedPharm Publications, 2004) De Vries, E M; Marincowitz, G M
    Background: Recruitment and retention of medical staff are important issues in rural health. The aim of this study was to describe and understand the perceptions of women doctors working in rural hospitals in South Africa about their work. Methods: This was a descriptive study, using a qualitative methodology. Free attitude interviews were conducted with 14 women doctors. Themes were identified and tested against the data and comments from the research diary. Results: The main theme was balance. A rural woman doctor has to juggle different issues, including running the household and responsibilities at work. Other themes that were identified included the reason for working at a rural hospital, attitudes to rural life, opportunities for personal and professional growth, the feeling of being needed in a rural hospital, advantages and disadvantages for children and family, the impact of relationships on the rural woman doctor, issues regarding the environment and security, and that the proximity of home and work gives a rural woman doctor far more connection with her family. Conclusions: Some of the themes identified in this study agreed with international research, e.g. the importance of a job for the spouse, family considerations influencing the choice to specialise, and balancing responsibilities at home and work. The advantage of accommodation close to the hospital is a theme that has not been documented before. Based on the findings, recommendations are made to attract women doctors to rural areas. (SA Fam Pract 2004;46(3): 27-32)
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    Primary care practitioners' knowledge, attitudes and current practice in managing oral health conditions
    (2018) McCrindle, Lorna; Bresick, Graham F; Motsohi, Tsepo
    Background: Primary care practitioners are at the forefront of the health service and therefore have an opportunity to promote oral health, manage certain oral conditions, or refer appropriately to the closest dental service. In under-resourced areas, patients are more likely to present initially to a primary health care nurse or doctor, with oral or dental needs. Studies abroad have revealed that general practitioners do not always examine the oral cavity, enquire about oral health, or manage oral disease particularly well and have expressed an interest to learn more about oral health. A literature search for similar South African studies did not yield results. This study aims to describe current oral health care practice provided by primary care practitioners in Cape Town and to assess whether this level of service might benefit from interventions to improve the quality of care. Methods: The Nominal Group technique (NGT) was used to identify and achieve consensus among 8 community health centre primary care practitioners regarding the main challenges to providing oral health care and offer suggestions for strengthening oral health care. This assisted the development of a questionnaire, which was then distributed to practitioners at five Community Health Centres in the Cape Town Metropole. The questionnaire aimed to assess the knowledge, attitudes and current practices of practitioners in the area of oral health. Results: The NGT yielded valuable information to inform the questionnaire; two main topics were discussed which helped inform two sections of the 9-part questionnaire. A total of 53 doctors and clinical nurse practitioners completed the questionnaire. Only 17% of participants reported routinely examining the oral cavity, others examined it on request of the patient or suspicion of an abnormality. A minority (13.2%) stated that they routinely promote oral health in the consultation and reported limiting factors to include: insufficient time during consultations, forgetting to include oral health promotion, a limited knowledge of oral disease, and limited access to Oral Health Services. Suggestions for strengthening the oral health care included training clinicians in oral health, motivating clinicians to provide better oral health care, improving patient education on the importance of oral health care, and improving the integration of Primary Care services with Oral Health services. Limitations of this study include a small sample size, studying only urban community health centres in Cape Town, the absence of input from oral health experts, the absence of input from patients and missing data. Conclusion: It is apparent from this study that oral health is inadequately managed, for a number of reasons; including time constraints, limited knowledge of treating clinicians, and limited available oral health services. Possible interventions to improve this clinical area can be posed to relevant authorities and may include examining undergraduate curricula (medicine and nursing) to assess the content and quality of oral health education, provide in-house training to CHC staff by local dentists and oral hygienists, provide information sessions for staff at CHC about the local Oral Health Service available in their areas, and offering education to patients in the waiting room on the topic of good oral health.
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    A snapshot of noncommunicable disease profiles and their prescription costs at ten primary healthcare facilities in the in the western half of the Cape Town metropole
    (South African Academy of Family Physicians, 2014) Isaacs, A A; Manga, N; Le Grange, C; Hellenberg, D A; Titus, V; Sayed, R
    Objectives: There has been a rapid increase in the prevalence of noncommunicable diseases globally. It is thought that this increase will have the greatest impact on developing countries, such as South Africa, where it will adversely affect quality of life and increase healthcare costs. This research was conducted to determine the disease profile and cost of treating patients at 10 facilities in the western half of the Cape Town Metropole. Design: An analytical, cross-sectional study was carried out in order to interpret the cost of the medication in relation to the patient disease profile. Setting and subjects: Data were collected from 10 facilities in the western half of the Cape Town Metropole over a three-month period. Outcome measure: The outcome measure was the disease profile of patients attending the facilities and the cost of prescriptions for these patients. Results: Most patient visits to the community health centres were to treat chronic diseases (82%). The disease profile of patients was as follows: 58.96% had hypertension, 19.67% diabetes, 12.14% asthma and chronic obstructive pulmonary disease, and 21.80% arthritis. It was found that 65% of patients with a chronic condition had co-morbidities. The cost of prescriptions was significantly higher (p-value < 0.001) for chronic conditions than for acute conditions. The number of comorbidities per patient also influenced the cost of the prescriptions. Conclusion: The results indicated that most of the adults attending public sector facilities in the western half of the Cape Town Metropole have chronic diseases and that the cost of treating these conditions is significantly greater than that of treating acute conditions. An integrated approach to the management of chronic diseases is important in low-resource settings for the efficient utilisation of limited resources.
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    The development of a retrospective neonatal clinical audit tool for transfers: a modified delphi study
    (2024) Venter, Maryna; Stassen, Willem
    Background: Due to limited availability of neonatal and paediatric specialist centres in South Africa, interfacility transfer of high-risk neonates is frequently required in order to access appropriate care, often across vast distances. Due to limited Emergency Medical Services (EMS) capacity, the majority of inter-facility transfers are undertaken by general EMS, as opposed to dedicated neonatal transfer teams. Many high-risk neonates are therefore transported by EMS personnel with very limited neonatal care experience and knowledge, as well as limited equipment capabilities. Interfacility transport of at-risk neonates is directly associated with increased mortality and morbidity, and numerous studies have described higher rates of adverse events and mortality particularly when neonates are transported by non-specialist transfer teams. There is currently no standardised clinical audit tool to assess the risks and clinical quality of care provided during neonatal retrieval. An established clinical audit tool that could be used in further research to establish the safety of neonatal transfers in the South African context would provide clinical value. Aim: The aim of this study is to develop a retrospective neonatal clinical quality audit tool according to which the safety of neonatal transfers in South Africa can be assessed. Methods: This study was conducted in two phases using multiple methods. First, a scoping review was conducted to identify normal clinical parameters, aspects of neonatal patient safety, adverse events, and quality of care during transport. Multiple databases were searched using an a priori developed search strategy. Titles and abstracts were screened for relevance, before selecting full text articles for review and data extraction. Data from articles were collated into an extraction matrix, summarise and reported narratively. The results of the scoping review informed the first round survey tool of a modified Delphi study – the second phase of this study. A modified Delphi study was undertaken to obtain a list of consensus-based items that could be collated into a clinical quality audit tool for neonatal transfers in South Africa. Experts in neonatal retrieval, neonatology, paediatrics and intensive care were approached and asked to indicate whether they agreed with each item. They were also requested to provide free-text feedback on items. Consensus was set at 75%. Two rounds of the modified Delphi study were undertaken. Results: For the scoping review, a total of 866 articles were identified initially. Following application of eligibility criteria, ten articles were finally included in the scoping review. Most articles originated from high-income countries and were observational in nature. However, six categories of adverse events were identified (clinical events, equipment events, medical errors, patient safety risks, quality of care, and other). Specific adverse events and clinical parameters were also extracted and combined to form the first-round survey tool of a modified Delphi study. In round one 28 respondents consented to form part of the expert panel, and completed the Delphi questionnaire, yielding a response rate of 70%. In round one the expert panel consisted of neonatologists (n=4), paediatric intensivists (n=2), paediatricians (n=2), other medical doctor working in the field of retrieval (n=1) registered nurses (n=3), and advanced life support (ALS) paramedics or emergency care practitioners (ECPs) (n=16). In round two, 19 experts consented and completed the Delphi questionnaire, yielding an attrition rate of 33%. In round two the expert panel consisted of neonatologists (n=1), paediatric intensivists (n=2), other medical doctor working in the field of retrieval (n=1), registered nurses (n=3), and advanced life support (ALS) paramedic or emergency care practitioners (ECPs) (n=12). Following two rounds of consensus, a 41-item 6 retrospective audit tool was developed and organised into five sections: Airway, respiratory and ventilation, haemodynamic events, medication events, or general and logistic events. Additionally, each item was allocated a severity rating or range requiring additional information gathering to ascertain the severity of the event. Conclusion: This study enabled the development of a consensus-based retrospective clinical audit tool that can be utilised to assess the quality of care of neonatal transfers performed in South Africa. The clinical audit tool was developed through literature-based evidence, and validated for content through the contributions of a national multidisciplinary panel of experts in the field of neonatal retrieval. The utilisation of the audit tool in the framework of a robust clinical governance system, would enable reporting of adverse events according to standardised parameters. This would contribute to the identification of risk factors and knowledge gaps in neonatal transfer teams, which could assist in the development of improvement projects. In addition, it can be used in before-and after interventional studies, to assess for the effectiveness of the intervention in the setting of improved patient safety. Through utilisation in future research projects it can assist in the development of standardised guidelines for clinical care standards during neonatal transfer.
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    The education versus training and the skills versus competency debate
    (2004) Gibbs, T; Brigden, D; Hellenberg, D
    The essence of modern medical education lies in the ability of defining and developing its terminology, which all too often is used in a less than thoughtful and inappropriate manner. Educationalists place emphasis upon the concept of learning rather than teaching; learning which is specifically student centred and student directed learning rather than teacher centred didactic teaching. However within this change environment we still prefer to use the word training, as in vocational training, to describe a specific programme and aspire to levels of competency that hopefully match the learning outcomes of the programme. This article opens the debate on whether the satisfactory completion of a learning programme is sufficient (cf completion of vocational training) or whether we should be assessing the learner through levels of defined competency relevant to their professional career.