Browsing by Department "Primary Health Care Directorate"

Now showing 1 - 13 of 13
  • Thumbnail Image
    Item
    Open Access
    A cost-effective strategy for primary prevention of acute rheumatic fever and rheumatic heart disease in children with pharyngitis
    (2013) Irlam, James H; Mayosi, Bongani M; Engel, Mark E; Gaziano, Thomas A
    Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in children depends on prompt and effective diagnosis and treatment of pharyngitis at the primary level of care. Cost-effectiveness modeling shows that the most cost-effective strategy for primary prevention in South Africa (SA) is to use a simple symptomatic clinical decision rule (CDR) to diagnose pharyngitis in children presenting at the primary level of care and then to treat them with a single dose of intramuscular penicillin. Treat All and CDR2+ strategies are affordable and simple and miss few cases of streptococcal pharyngitis at the primary level of care. The CDR2+ strategy is the most cost-effective for primary prevention of ARF and RHD in urban SA and should complement primordial and secondary prevention efforts.
  • Thumbnail Image
    Item
    Open Access
    African leaders’ views on critical human resource issues for the implementation of family medicine in Africa
    (2014-01-17) Moosa, Shabir; Downing, Raymond; Essuman, Akye; Pentz, Stephen; Reid, Stephen; Mash, Robert
    Abstract Background The World Health Organisation has advocated for comprehensive primary care teams, which include family physicians. However, despite (or because of) severe doctor shortages in Africa, there is insufficient clarity on the role of the family physician in the primary health care team. Instead there is a trend towards task shifting without thought for teamwork, which runs the risk of dangerous oversimplification. It is not clear how African leaders understand the challenges of implementing family medicine, especially in human resource terms. This study, therefore, sought to explore the views of academic and government leaders on critical human resource issues for implementation of family medicine in Africa. Method In this qualitative study, key academic and government leaders were purposively selected from sixteen African countries. In-depth interviews were conducted using an interview guide. All interviews were audio-recorded, transcribed and thematically analysed. Results There were 27 interviews conducted with 16 government and 11 academic leaders in nine Sub-Saharan African countries: Botswana, Democratic Republic of Congo, Ghana, Kenya, Malawi, Nigeria, Rwanda, South Africa and Uganda. Respondents spoke about: educating doctors in family medicine suited to Africa, including procedural skills and holistic care, to address the difficulty of recruiting and retaining doctors in rural and underserved areas; planning for primary health care teams, including family physicians; new supervisory models in primary health care; and general human resource management issues. Conclusions Important milestones in African health care fail to specifically address the human resource issues of integrated primary health care teamwork that includes family physicians. Leaders interviewed in this study, however, proposed organising the district health system with a strong embrace of family medicine in Africa, especially with regard to providing clinical leadership in team-based primary health care. Whilst these leaders focussed positively on entry and workforce issues, in terms of the 2006 World Health Report on human resources for health, they did not substantially address retention of family physicians. Family physicians need to respond to the challenge by respondents to articulate human resource policies appropriate to Africa, including the organisational development of the primary health care team with more sophisticated skills and teamwork.
  • Thumbnail Image
    Item
    Open Access
    Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis
    (BioMed Central Ltd, 2005) Robertson, Katharine; Volmink, Jimmy; Mayosi, Bongani
    BACKGROUND:Rheumatic fever continues to put a significant burden on the health of low socio-economic populations in low and middle-income countries despite the near disappearance of the disease in the developed world over the past century. Antibiotics have long been thought of as an effective method for preventing the onset of acute rheumatic fever following a Group-A streptococcal (GAS) throat infection; however, their use has not been widely adopted in developing countries for the treatment of sore throats. We have used the tools of systematic review and meta-analysis to quantify the effectiveness of antibiotic treatment for sore throat, with symptoms suggestive of group A streptococcal (GAS) infection, for the primary prevention of acute rheumatic fever. METHODS: Trials were identified through a systematic search of titles and abstracts found in the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 4, 2003), MEDLINE (1966-2003), EMBASE (1966-2003), and the reference lists of identified studies. The selection criteria included randomised or quasi-randomised controlled trials comparing the effectiveness of antibiotics versus no antibiotics for the prevention of rheumatic fever in patients presenting with a sore throat, with or without confirmation of GAS infection, and no history of rheumatic fever. RESULTS: Ten trials (n = 7665) were eligible for inclusion in this review. The methodological quality of the studies, in general, was poor. All of the included trials were conducted during the period of 1950 and 1961 and in 8 of the 10 trials the study population consisted of young adult males living on United States military bases. Fixed effects, meta-analysis revealed an overall protective effect for the use of antibiotics against acute rheumatic fever of 70% (RR = 0.32; 95% CI = 0.21-0.48). The absolute risk reduction was 1.67% with an NNT of 53. When meta-analysis was restricted to include only trials evaluating penicillin, a protective effect of 80% was found (Fixed effect RR = 0.20, 95% CI = 0.11-0.36) with an NNT of 60. The marginal cost of preventing one case of rheumatic fever by a single intramuscular injection of penicillin is approximately US$46 in South Africa. CONCLUSION: Antibiotics appear to be effective in reducing the incidence of acute rheumatic fever following an episode of suspected GAS pharyngitis. This effect may be achieved at relatively low cost if a single intramuscular penicillin injection is administered.
  • Thumbnail Image
    Item
    Open Access
    Evaluating the rural health placements of the Rural Support Network at the Faculty of Health Sciences University of Cape
    (South African Academy of Family Physicians, 2012) Naidu, C S; Irlam, J
    Objectives: The Rural Support Network (RSN) is an undergraduate student society that aims to raise awareness among the student body of the plight of rural health in South Africa, and organises individual and group placements in rural hospitals during vacations. This research aimed to evaluate these placements from the students' perspectives. Design: In-depth, face-to-face interviews were conducted with 10 students and nine placement-reflective reports were reviewed. The data were analysed and coded for key themes using a constant, comparative grounded theory approach. Setting: Faculty of Health Sciences (FHS) at the University of Cape Town. Subjects: Students who had been on RSN placements in 2010. Results: Students reported that the experience exceeded their expectations of learning new skills and observing and performing procedures. They gained significant insights into rural health care and were inspired to contribute to rural health in future. Their experiences helped them to gain confidence and an appreciation of the psycho-social aspects of patient care. The importance of community empowerment and of connecting and building relationships with communities was also emphasised. Challenges pertained to conflict within groups, incidents of unprofessional health care and being unable to help as much as they would have liked. Conclusion: The study highlights the impact that positive experiences of rural health may have on health science students' interest in, passion for, and commitment to practising in underserved rural areas. Students' key recommendations for the FHS included the development of a rural programme within the undergraduate curriculum. Better group composition and improved planning and co-ordination of placements by the RSN were also recommended.
  • Thumbnail Image
    Item
    Open Access
    Implementing a Substance-Use Screening and Intervention Program for People Living with Rifampicin-Resistant Tuberculosis: Pragmatic Experience from Khayelitsha, South Africa
    (2022-01-31) Reuter, Anja; Beko, Buci; Memani, Boniwe; Furin, Jennifer; Daniels, Johnny; Rodriguez, Erickmar; Reuter, Hermann; Weich, Lize; Isaakidis, Petros; von der Heyden, Erin; Kock, Yulene; Mohr-Holland, Erika
    Substance use (SU) is associated with poor rifampicin-resistant tuberculosis (RR-TB) treatment outcomes. In 2017, a SBIRT (SU screening-brief intervention-referral to treatment) was integrated into routine RR-TB care in Khayelitsha, South Africa. This was a retrospective study of persons with RR-TB who were screened for SU between 1 July 2018 and 30 September 2020 using the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test). Here we describe outcomes from this program. Persons scoring moderate/high risk received a brief intervention and referral to treatment. Overall, 333 persons were initiated on RR-TB treatment; 38% (n = 128) were screened for SU. Of those, 88% (n = 113/128) reported SU; 65% (n = 83/128) had moderate/high risk SU. Eighty percent (n = 103/128) reported alcohol use, of whom 52% (n = 54/103) reported moderate/high risk alcohol use. Seventy-seven persons were screened for SU within ≤2 months of RR-TB treatment initiation, of whom 69%, 12%, and 12% had outcomes of treatment success, loss to follow-up and death, respectively. Outcomes did not differ between persons with no/low risk and moderate/high risk SU or based on the receipt of naltrexone (p > 0.05). SU was common among persons with RR-TB; there is a need for interventions to address this co-morbidity as part of “person-centered care”. Integrated, holistic care is needed at the community level to address unique challenges of persons with RR-TB and SU.
  • Thumbnail Image
    Item
    Open Access
    Increased vulnerability of rural children on antiretroviral therapy attending public health facilities in South Africa: a retrospective cohort study
    (BioMed Central Ltd., 2010) Fatti, Geoffrey; Bock, Peter; Grimwood, Ashraf; Eley, Brian
    BACKGROUND: A large proportion of the 340,000 HIV-positive children in South Africa live in rural areas, yet there is little sub-Saharan data comparing rural paediatric antiretroviral therapy (ART) programme outcomes with urban facilities. We compared clinical, immunological and virological outcomes between children at seven rural and 37 urban facilities across four provinces in South Africa. METHODS: We conducted a retrospective cohort study of routine data of children enrolled on ART between November 2003 and March 2008 in three settings, namely: urban residence and facility attendance (urban group); rural residence and facility attendance (rural group); and rural residents attending urban facilities (rural/urban group). Outcome measures were: death, loss to follow up (LTFU), virological suppression, and changes in CD4 percentage and weight-for-age-z (WAZ) scores. Kaplan-Meier estimates, logrank tests, multivariable Cox regression and generalized estimating equation models were used to compare outcomes between groups. RESULTS: In total, 2332 ART-naive children were included, (1727, 228 and 377 children in the urban, rural and rural/urban groups, respectively). At presentation, rural group children were older (6.7 vs. 5.6 and 5.8 years), had lower CD4 cell percentages (10.0% vs. 12.8% and 12.7%), lower WAZ scores (-2.06 vs. -1.46 and -1.41) and higher proportions with severe underweight (26% vs.15% and 15%) compared with the urban and rural/urban groups, respectively. Mortality was significantly higher in the rural group and LTFU significantly increased in the rural/urban group. After 24 months of ART, mortality probabilities were 3.4% (CI: 2.4-4.8%), 7.7% (CI: 4.5-13.0%) and 3.1% (CI: 1.7-5.6%) p = 0.0137; LTFU probabilities were 11.5% (CI: 9.3-14.0%), 8.8% (CI: 4.5-16.9%) and 16.6% (CI: 12.4-22.6%), p = 0.0028 in the urban, rural and rural/urban groups, respectively. The rural group had an increased adjusted mortality probability, adjusted hazards ratio 2.41 (CI: 1.25-4.67) and the rural/urban group had an increased adjusted LTFU probability, aHR 2.85 (CI: 1.41-5.79). The rural/urban group had a decreased adjusted probability of virological suppression compared with the urban group at any timepoint on treatment, adjusted odds ratio 0.67 (CI: 0.48-0.93). CONCLUSIONS: Rural HIV-positive children are a vulnerable group, exhibiting delayed access to ART and an increased risk of poor outcomes while on ART. Expansion of rural paediatric ART programmes, with future research exploring improvements to rural health system effectiveness, is required.
  • Thumbnail Image
    Item
    Open Access
    Internship training adequately prepares South African medical graduates for community service – with exceptions
    (2013) Nkabinde, T C; Ross, A; Reid, S; Nkwanyana, N M
    BACKGROUND: The 2-year internship period for medical graduates began in South Africa in 2005 and has never been formally evaluated. OBJECTIVE: This study assessed the perceptions of community service medical officers (COSMOs) working at district hospitals (DHs) in KwaZulu-Natal (KZN) to determine whether the 2-year internship programme had adequately prepared them for community service (CS). METHOD: A cross-sectional descriptive study was conducted regarding the perceptions of COSMOs working at 22 district hospitals in KZN. Data were collected in July 2012, using a questionnaire based on the core skills and knowledge detailed in the Health Professions Council of South Africa intern log book. All eight domains were self-assessed and a score of 4 out of 5 indicated an ability to work independently. RESULTS: Of the COSMOs, 78% (60 out of 89) completed the questionnaire. Most felt well-prepared for CS in all disciplines, but critical gaps in knowledge and skills were identified in paediatrics, orthopaedics, anaesthetics and obstetrics. In addition, 75% of respondents (45 out of 60) expressed a need for additional training in the disciplines of ear, nose and throat (ENT), urology, ophthalmology and dermatology. CONCLUSION: The 2-year internship has provided the basis for independent medical practice in DHs. However, certain critical skill gaps need urgent attention, particularly in obstetrics and anaesthesia. Areas of weakness in ENT, urology, ophthalmology and dermatology could be addressed by including these specialities as a compulsory rotation in surgery, medicine or family medicine during internship training.
  • Thumbnail Image
    Item
    Open Access
    Lack of adherence to the national guidelines on the prevention of rheumatic fever
    (2005) Robertson, Katharine A; Volmink, Jimmy A; Mayosi, Bongani M
    Objectives. To explore the extent to which current practices for the secondary prevention of rheumatic fever (RF) in Cape Town adhere to those outlined in the national guidelines on the primary prevention and prophylaxis of RF and rheumatic heart disease (RHD) for health professionals at primary level. Methods. A combination of qualitative tools was used to evaluate the four priority issues identified in the guidelines as fundamental elements of a comprehensive programme for the secondary prophylaxis of RF/RHD: (i) health education and promotion; (ii) case detection of RF and RHD; (iii) secondary prophylaxis every 3 - 4 weeks at primary level; and (iv) notification of acute rheumatic fever (ARF). The qualitative tools included parent/child interviews of cases diagnosed with ARF in the Cape metropole area during the period 1999 - 2003; a physician questionnaire focused on awareness and adherence to the national guidelines; and a review of the records on acute rheumatic fever notification in the Cape metropole area from 1999 to 2003. Results. The evaluation revealed four key findings. First, patient knowledge on the disease was almost non-existent. Despite this lack of knowledge, adherence to secondary prophylactic treatment was good. Second, the physicians most likely to encounter a case of rheumatic fever were least likely to be aware of and to comply with the national guideline. Third, the guidelines do not clearly state how increased detection of ARF will be achieved. Finally, the RF notification system is dysfunctional, with discrepancies in the reporting of cases at hospital, city and provincial levels. Conclusions. Since the publication of the national guidelines in 1997, little progress has been made towards achieving the implementation of a comprehensive programme for the secondary prevention of RF/RHD.
  • Thumbnail Image
    Item
    Open Access
    “The others look at you as if you are a grave”: a qualitative study of subjective experiences of patients with epilepsy regarding their treatment and care in Cape Town, South Africa
    (BioMed Central, 2016) Keikelame, Mpoe J; Swartz, Leslie
    Background: Existing evidence shows that the majority of people with epilepsy in lower and middle income countries are not receiving appropriate treatment and care. Although this problem has been reported as one of the factors affecting the quality of lives of people with epilepsy, very few studies have investigated patients’ perspectives and their experiences about the problem. This qualitative study explored perspectives and subjective experiences of people with epilepsy about their illness in an urban township in South Africa. Methods: Individual face-to-face interviews included twelve people who had epilepsy. A semi-structured interview guide which was based on Kleinman (1980) Explanatory Models Framework was used to elicit participants’ perspectives and subjective experiences about their illness and its treatment. Thematic analysis method was used to analyse the data. Results: The main theme reflecting participants’ verbatim accounts was about their perceived difficulties affecting their access to treatment and care during their routine clinical follow up visits. These concerned rushed consultations which focussed on seizure frequency and adherence to medication with no attention to personal concerns. They perceived that part of the problem could be that some health care practitioners were not adequately trained and lacked empathy, interest, respect and listening skills. We argue that in a health system where patients feel that they are not respected and their concerns are not listened to or are ignored, they may lack trust in the system and this may violate their right to access treatment and care. Conclusions: The findings provide a glimpse of the extent to which the power and nature of the routine task-centred system can lead to violation of patients’ health rights – especially with epilepsy which is poorly understood and stigmatized. Appropriate interventions are needed to address health system factors affecting the treatment and care of this marginalized and vulnerable group of patients.
  • Thumbnail Image
    Item
    Open Access
    Patient Adherence to Tuberculosis Treatment: A Systematic Review of Qualitative Research
    (Public Library of Science, 2007) Munro, Salla A; Lewin, Simon A; Smith, Helen J; Engel, Mark E; Fretheim, Atle; Volmink, Jimmy
    From a systematic review of qualitative research, Munro and coauthors found that a range of interacting factors can lead to patients deciding not to complete their course of tuberculosis treatment.
  • Thumbnail Image
    Item
    Open Access
    Perspectives on key principles of generalist medical practice in public service in sub-saharan africa: a qualitative study
    (BioMed Central Ltd, 2011) Reid, Stephen J; Mash, Robert; Downing, Raymond V; Moosa, Shabir
    BACKGROUND: The principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context. METHODS: A descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed. RESULTS: The respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being life-long learners themselves. However, their role in the community, was found to be more aspirational than real. CONCLUSIONS: The study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.
  • Thumbnail Image
    Item
    Open Access
    Placement, support, and retention of health professionals: national, cross-sectional findings from medical and dental community service officers in South Africa
    (BioMed Central, 2014-02-26) Hatcher, Abigail M; Onah, Michael; Kornik, Saul; Peacocke, Julia; Reid, Stephen
    Background: In South Africa, community service following medical training serves as a mechanism for equitable distribution of health professionals and their professional development. Community service officers are required to contribute a year towards serving in a public health facility while receiving supervision and remuneration. Although the South African community service programme has been in effect since 1998, little is known about how placement and practical support occur, or how community service may impact future retention of health professionals. Methods: National, cross-sectional data were collected from community service officers who served during 2009 using a structured self-report questionnaire. A Supervision Satisfaction Scale (SSS) was created by summing scores of five questions rated on a three-point Likert scale (orientation, clinical advising, ongoing mentorship, accessibility of clinic leadership, and handling of community service officers’ concerns). Research endpoints were guided by community service programmatic goals and analysed as dichotomous outcomes. Bivariate and multivariate logistical regressions were conducted using Stata 12. Results: The sample population comprised 685 doctors and dentists (response rate 44%). Rural placement was more likely among unmarried, male, and black practitioners. Rates of self-reported professional development were high (470 out of 539 responses; 87%). Participants with higher scores on the SSS were more likely to report professional development. Although few participants planned to continue work in rural, underserved communities (n = 171 out of 657 responses, 25%), those serving in a rural facility during the community service year had higher intentions of continuing rural work. Those reporting professional development during the community service year were twice as likely to report intentions to remain in rural, underserved communities. Conclusions: Despite challenges in equitable distribution of practitioners, participant satisfaction with the compulsory community service programme appears to be high among those who responded to a 2009 questionnaire. These data offer a starting point for designing programmes and policies that better meet the health needs of the South African population through more appropriate human resource management. An emphasis on professional development and supervision is crucial if South Africa is to build practitioner skills, equitably distribute health professionals, and retain the medical workforce in rural, underserved areas.
  • Thumbnail Image
    Item
    Open Access
    Qualitative evaluation of primary care providers experiences of a training programme to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa
    (2015-08-19) Malan, Zelra; Mash, Robert; Everett-Murphy, Katherine
    Abstract Background The global epidemic of non-communicable disease (NCDs) has been linked with four modifiable risky lifestyle behaviours, namely smoking, unhealthy diet, physical inactivity and alcohol abuse. Primary care providers (PCPs) can play an important role in changing patient’s risky behaviours. It is recommended that PCPs provide individual brief behaviour change counselling (BBCC) as part of everyday primary care. This study is part of a larger project that re-designed the current training for PCPs in South Africa, to offer a standardized approach to BBCC based on the 5 As and a guiding style. This article reports on a qualitative sub-study, which explored whether the training intervention changed PCPs perception of their confidence in their ability to offer BBCC, whether they believed that the new approach could overcome the barriers to implementation in clinical practice and be sustained, and their recommendations on future training and integration of BBCC into curricula and clinical practice. Methods This was a qualitative study that used verbal feedback from participants at the beginning and end of the training course, and twelve individual in-depth interviews with participants once they had returned to their clinical practice. Results Although PCP’s confidence in their ability to counselling improved, and some thought that time constraints could be overcome, they still reported that understaffing, lack of support from within the facility and poor continuity of care were barriers to counselling. However, the current organisational culture was not congruent with the patient-centred guiding style of BBCC. Training should be incorporated into undergraduate curricula of PCPs for both nurses and doctors, to ensure that counselling skills are embedded from the start. Existing PCPs should be offered training as part of continued professional development programmes. Conclusions This study showed that although training changed PCPs perception of their ability to offer BBCC, and increased their confidence to overcome certain barriers to implementation, significant barriers remained. It is clear that to incorporate BBCC into everyday care, not only training, but also a whole systems approach is needed, that involves the patient, provider, and service organisation at different levels.