PRIMARY CARE RESEARCH: 2012 - Stellenbosch University Medicine and... · PRIMARY CARE RESEARCH 2012...

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Division of Family Medicine and Primary Care, Faculty of Health Sciences, Stellenbosch University

PRIMARY CARE RESEARCH: 2012DIVISION OF FAMILY MEDICINE AND PRIMARY CARE, FACULTY OF MEDICINE AND HEALTH SCIENCES, STELLENBOSCH UNIVERSITY

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PRIMARY CARE RESEARCH 2012 PRIMARY CARE RESEARCH 2012

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INTRODUCTION

CLINICAL RESEARCH: HIV, AIDS AND TUBERCULOSIS

• Aquasi-experimentalevaluationofanHIVpreventionprogrammebypeereducationintheAnglicanChurchof

the Western Cape, South Africa

• Measuringadherencetoantiretroviraltreatmentandassessingfactorsaffectingadherenceinastateprimary

healthcare clinic, Mitchells Plain Community Health Centre

• HowchildrenaccessantiretroviraltreatmentatKgapaneDistrictHospital,Limpopo,SouthAfrica

• DrugInteractionsinPrimaryHealthcareintheGeorgearea,SouthAfrica:ACross-SectionalStudy

• AmedicalauditofthemanagementofcryptococcalmeningitisinHIV-positivepatientsintheCapeWinelands

district, Western Cape

• AstudyoffactorsinthetreatmentsupportsystemthatcontributetosuccessfulHAARTadherenceatTshepang

clinic

• AcomparisonoftreatmentresponseintwocohortsofpatientswithHIVtakingoncedailyversustwicedailyART

inGaborone,Botswana.

CLINICALRESEARCH:NON-COMMUNICABLEDISEASES

• EffectivenessofagroupdiabeteseducationprogrammeinunderservedcommunitiesinSouthAfrica:pragmatic

clusterrandomizedcontroltrial.

• Viewsofpatientsonagroupdiabeticeducationprogrammeusingmotivationalinterviewinginunderserved

communitiesinSouthAfrica:Qualitativestudy.

• TheabilityofhealthpromoterstodelivergroupdiabeteseducationinSouthAfricanprimarycare.

• Clinicalauditofdiabetesmanagementcanimprovethequalityofcareinaresource-limitedprimarycaresetting.

• Beliefsandattitudestoobesity,itsriskfactorsandconsequencesinaXhosacommunity:aqualitativestudy.

• Thevalidityofmonitoringthecontrolofdiabeteswithrandombloodglucosetesting.

• Acomparisonofthequalityofchroniccareofhypertensivepatientsattendingafastlaneclinicversusastandard

clinicinDitsobotlasubdistrict,NgakaModiriMolemadistrictinNorthWestprovinceinSouthAfrica.

• Cervicalcancerprevention:PerceptionsofwomenattendingKnysnaprimaryhealthcareclinics

CLINICAL RESEARCH: VIOLENCE AND TRAUMA

• RecognizingIntimatePartnerViolenceinPrimaryCare:WesternCape,SouthAfrica.

• AcomprehensivemodelforintimatepartnerviolenceinSouthAfricanprimarycare:actionresearch

• EvaluationofaprojecttoreducemorbidityandmortalityfromtraditionalmalecircumcisioninUmlamli,Eastern

Cape,SouthAfrica:Outcomemapping

CLINICAL RESEARCH: MATERNAL AND CHILD HEALTH

• UseofOxytocinduringCaesareanSectionatPrincessMarinaHospital,Botswana:Anauditofclinicalpractice.

HEALTH SERVICES AND SYSTEMS RESEARCH

• A Morbidity Survey of South African Primary Care

• ReasonsforencounteranddiagnosesofpatientsattendingprimarycareclinicsintheSaldanhaBayandSwartland

ruralsubdistricts,WesternCapeProvince:Aprospectivecross-sectionalsurvey.

• Reasonswhypatientswithprimaryhealthcareproblemsaccessasecondaryhospitalemergencycentre

• FactorsinfluencingspecialistoutreachandsupportservicestoruralpopulationsintheEdenandCentralKaroodis-

tricts of the Western Cape – a Delphi study

• Advancedirectivesorlivingwills:reflectionsofgeneralpractitionersandfrailcarecoordinatorsinasmalltownin

KwaZulu-Natal

EDUCATIONAL RESEARCH

• DevelopmentofaportfoliooflearningforpostgraduatefamilymedicinetraininginSouthAfrica:ADelphistudy

• OutcomesforfamilymedicinepostgraduatetraininginSouthAfrica

TABLE OF CONTENTS

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INTRODUCTION

This booklet presents the research output of the

Division of Family Medicine and Primary Care at

StellenboschUniversityin2012.Thebookletincludes

work thatwas published aswell aswork thatwas

examined and approved for the Master of Medicine

degree. Each study is presented in the form of a

structuredabstract.Whentheworkhasalreadybeen

publishedthereferencetothefullarticleisgivenat

theendoftheabstract.Theemailofatleastoneof

the researchers is givenwith each abstract should

thereaderwishtoobtainfurtherinformation.

The purpose of the booklet is to improve access

to this collection of primary care research by

policymakers, within the health services and

educational institutions, as well as by colleagues

within the discipline of family medicine and primary

care.

Thereisaseparatebriefoverviewofthekeypoints

arisingfromthisworkforpolicymakersandwehope

thatthiswillmakethefindingsevenmoreaccessible

anduser friendly. Ifnothingelsewehopethatyou

willreadthissection.

The structure of the rest of the booklet has been

derived from a paper by John Beasley and Barbara

Starfield that offers a typology of Primary Care

Research.1

Clinical research, which is the largest section, has

beensubdividedaccordingtotheburdenofdisease

intoworkon:

• HIV/AIDS,TBandSTIs

• Non-communicablechronicdiseases

• Women’sandmaternalhealth

• Violenceandinjury

After the material on clinical research there are

sectionsonhealthservicesandsystemsresearchas

wellaseducationalresearch.

1 Beasley JW, Starfield B, vanWeel C, RosserWW,

HaqCL.Globalhealthandprimarycareresearch.The

Journal of the American Board of Family Medicine

2007;20(6):518-526.

PRIMARY CARE RESEARCH: 2012

Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University

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WorkonHIV/AIDSandTB

A quasi-experimental study evaluated a peer

educationprogrammetopreventHIVinfectionina

faithbasedcontextandfoundthattheprogramme

waseffectiveatdelayingtheageofsexualdebutand

increasingcondomusage.Theprogrammehasbeen

implementedwithintheAnglicanChurchofSouthern

Africaandshouldbeevaluatedfurther.

An audit of the management of cryptococcal

meningitis in both district hospitals and regional

hospitals found that care was comparable and

implemented an integrated care pathway for the

management of cryptococcal meningitis in the

WinelandsDistrict.

A study at a district hospital found that 40% of HIV

positivechildrenthatweredischargedfailedtoreturn

foranti-retroviraltreatment.Healthservicefactors

inprimarycarewererelatedtopoorstaffattitudes,

staff shortages and delays in referring children.

A number of patient related socio-economic and

culturalissueswerealsoidentified.

Two studies explored the factors that affect

adherence and the one identified 13 factors that

influencethesuccessoftreatmentsupporters.

Workonnon-communicablechronic diseases

A number of abstracts relate to a randomised

controlledtrialongroupeducationforpeoplewith

diabetes by health promoters. The intervention

was a 4 session, comprehensive and systematic

educational programme. Health promoters are at

the level of community health workers and have

beenspecificallytrainedtoprovidehealtheducation

withinprimarycarefacilities.Arangeofeducational

materials were developed to support the group

education,suchasaflipchart.Healthpromoterswere

trained to deliver the education in a guiding style

that was characterised by collaboration, empathy

andevocationofideasandsolutions.Theresultsof

the trial will be published in 2013, but show that the

interventionwassuccessfulatsignificantlylowering

blood pressure at 12months. The effect on blood

pressure was analysed in a model using mortality

data from South Africa and on the assumption

that education would be repeated annually with

a persistent beneficial effect, thiswould prevent a

largenumberofdeaths fromstrokeand ischaemic

heartdisease.Thiswasfoundtobeacost-effective

intervention (Incremental cost effectiveness ratio

1862).

A study looking at the validity of using random

bloodglucosetodeterminecontrolofpatientswith

diabetes found that10mmol/lwas thebestcutoff

figure to use, but that clinicians would still assess

thepatientsincorrectly23%ofthetime.Thisstudy

therefore supports further work to make HbA1c

testingmoreavailable,particularlyintermsofpoint

ofcaretesting.

Quality improvement cycles continued to show

promise at improving the quality of care with

relativelysimpleinterventions.Anauditofdiabetes

careinCapeTownshowedencouragingimprovement

in the quality of care, while another audit showed

benefitofhavingamorededicatedfast-laneservice

forpatientswithhypertension.

AstudyontheperceptionsofpeopleinKhayelitsha

with regards to obesity again highlighted that

upstream factors are critical in terms of access to

affordable healthy food and support for physical

activity that provides safe opportunities in the

community.

A study on screening for cervical cancer found

good knowledgeand reasonableuptakeof testing,

but difficultywith recall and followupof patients.

Interestinglyallpatientsinthestudyweresupportive

of HPV vaccination as an intervention to prevent

cervicalcancer.

Workonviolenceandtrauma

Two published articles from a body of work on

intimate partner violence (IPV) demonstrate that

primarycareprovidersdonoteasilyidentifywomen

who attend with symptoms related to IPV. Only

10%ofsuchwomenwere identifiedinthemedical

recordandyettheirreasonsforencountersuggested

a number of symptoms that could be used to raise

thesuspicionofIPV.Followingonfromthisaservice

forwomensurvivorsofIPVinprimarycarefacilities

was developed through action-research. The study

presents a model of how primary care services

in South Africa can incorporate a comprehensive

approachtohelpingwomenwithIPV.Themodel is

currentlybeingfurtherpilotedintheWesternCape.

The other study in this section demonstrates the

value of community-orientated primary care, when

outcomemappingwasusedtoworkwithtraditional

surgeons, community elders, parents, initiates,

health workers, emergency services and police to

prevent mortality and morbidity amongst young

mengoingfortraditionalcircumcision.

Workonmaternalandchildhealth

Theonestudyhighlightstheneedforclearguidelines

andauditofclinicalpracticefortheuseofoxytocin

incaesareansections.

Workonhealthservicesand systems

Anationalsurveyofprimarycaremorbidityshowed

the common reasons for encounter and diagnoses

made in South African ambulatory primary care.

Thesurveyhighlightedthatmentalhealthdisorders

arenotbeingrecognisedortreatedbyprimarycare

providers.WithHIV/AIDSandTBlargelyinseparate

vertical services the primary care services are

dominated by non-communicable chronic diseases,

as well as maternal and child health problems.

The results can be used to develop guidelines

for primary care, such as the PC101 primary care

guideline.Theresultsshouldalsobeusedtoinform

the learning outcomes for the training of clinical

nurse practitioners and ensure that they have the

necessarycompetenciestoworkinprimarycare.

Educationalresearch

Theonepublishedarticledescribesthekeynational

learningoutcomesforthetrainingoffamilyphysicians.

Theseoutcomesshouldguidethedevelopmentofall

trainingprogrammesinthecountryandensurethat

familyphysiciansaretrainedtofulfiltheirroleinthe

district health services. The secondarticleoutlines

thedevelopmentofanationallearningportfoliothat

can be used to develop and assess the competency

of registrars in training in the work-based setting.

Subsequentworkontheportfoliohasestablishedits

acceptability,feasibilityandreliability.Theportfolio

hasbeenimplementednationally.

KEYPOINTSFORPOLICYMAKERS

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Introduction: Religion is important inmostAfrican

communities, but faith-based HIV prevention

programmes are infrequent and very rarely

evaluated.Theaimofthisstudywastoevaluatethe

effectivenessofachurch-basedpeereducationHIV

preventionprogrammethatfocusedonyouth.

Design:Aquasi-experimentalstudydesigncompared

non-randomly chosen intervention and control

groups.Setting:ThisstudywasconductedintheCape

Town Diocese of the Anglican Church of Southern

Africa.Theinterventiongroupof176teenagerswas

selectedfromyouthgroupsat14churchesandthe

controlgroupof92fromyouthgroupsat17churches.

Intervention and control churches were chosen to

be as similar as possible to decrease confounding.

The intervention was a 20-session peer education

programme (Fikelela: Agents of Change) aimed at

changingriskysexualbehaviouramongyouth(aged

12e19years).Threeworkshopswerealsoheldwith

parents.Themainoutcomemeasureswerechanges

in age of sexual debut, secondary abstinence,

condomuseandnumbersofpartners.

CLINICAL RESEARCH: HIV, AIDS AND TUBERCULOSIS

Results:Theprogrammewassuccessfulatincreasing

condomusage(condomusescore3.5vs2.1;p=0.02),

OR6.7(95%CI1.1to40.7),andpostponingsexual

debut(11.9%vs21.4%;p=0.04)absolutedifference

9.5%. There was no difference in secondary

abstinence (14.6% vs 12.5%; p=0.25) or with the

numberofpartners (mean1.7vs1.4;p¼0.67)and

OR2.2(95%CI0.7to7.4).

Conclusion: Aninitialexploratoryquasi-experimental

evaluationoftheAgentsofChangepeereducation

programme in a church-based context found that

the age of sexual debut and condom usage was

significantly increased. The study demonstrated

thepotentialof faith-basedpeereducationamong

youth tomake a contribution toHIVprevention in

Africa.Furtherevaluationoftheeffectivenessofthe

programmeis,however,requiredbeforewidespread

implementationcanberecommended.

Publication:MashR,MashRJ.Aquasi-experimental

evaluationofanHIVpreventionprogrammebypeer

education in the Anglican Church of the Western

Cape, South Africa.BMJ Open 2012;2:e000638.

doi:10.1136/bmjopen-2011-000638

Aquasi-experimentalevaluationofanHIVpreventionprogrammebypeereducationintheAnglicanChurchoftheWesternCape,SouthAfrica

Rachel Mash, Robert James Mash

[email protected]

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Measuringadherencetoantiretroviraltreatmentandassessingfactorsaffectingadherenceinastateprimaryhealthcareclinic,MitchellsPlain

Community Health Centre

TaniaEngel,ArinaSchlemmer

[email protected]

HowchildrenaccessantiretroviraltreatmentatKgapaneDistrictHospital, Limpopo, South Africa

Jean Railton, Bob Mash

[email protected]

Background: A need was identified to measure

adherence levels to antiretroviral treatment (ART)

inaresource-poorsettingandtoassesstheimpact

on adherence to ART of partner disclosure, partner

support,othersupport,andlengthoftimebetween

diagnosisandARTcommencement.

Method: A retrospective case-control study was

conducted and the information was obtained by

meansofafileaudit.Onehundredandninety-nine

participantswerechosenbasedontheinclusionand

exclusion criteria. Adherence for each patient was

measuredusingaformuladocumentedinaprevious

study. For the comparison group, 82 cases (non-

adherentpatients)werematchedforageandgender

with82adherentcontrols.

Results:Themeanadherenceforthetotalgroupof

199 participantswas 80%. Disclosure to a partner,

partnersupportandthetimebetweenHIVdiagnosis

and ART commencement was not found to make

a statistically significant difference to adherence.

Thereappearedtobeatrend,thoughnotstatistically

significant,betweensupportfromothersourcesand

betteradherence(P=0.058).

Conclusion: The mean adherence level of 80% is

an indication that more work is urgently needed

to improve adherence levels in state-run clinics in

SouthAfrica.

More qualitative studies or larger samples are

recommended for further assessment of the impact

on adherence of social support. Approaches to

partnerdisclosurepriortocommencingARTshould

bereviewed.

Published: Engel T, Schlemmer A. Measuring

adherencetoantiretroviraltreatmentandassessing

factors affecting adherence in a state primary

healthcare clinic, Mitchells Plain Community Health

Centre.SAfrFamPract2012;54(1):77-78

www.safpj.co.za

Background:AtKgapaneHospital,LimpopoProvince,

only20%ofeligible children initiatedantiretroviral

treatment(ART)in2007.Theaimofthisstudywas

to improve the ART programme by assessing how

children were accessing ART, and to explore the

factorsthatfacilitateorobstructthisaccess.

Method:Mixedmethodswereusedinadescriptive

study of HIV infected children admitted to the

hospital over a seven-month period and their

caregivers. Children’s subsequent attendance for

ART was tracked and caregivers were interviewed

aboutfactorsinfluencingaccessandattendance.

Results:Of132childreninitiallyadmitted,14(10.6%)

subsequentlydiedand13(9.8%)relocated.Sixtyof

theremaining105(57.1%)returnedwithinonemonth

totheantiretroviralclinic,three(2.9%)attendedlater

and42(40.0%)didnotreturnatall.Quantitativedata

associatedwithpoorattendancewereyoungerage,

higher CD4 count, maternal caregiver, no income

and participation in the prevention of mother-to-

child transmission program. Qualitative factors

includeda lackofmoney for transport,poorsocial

support,andmotherswhostruggledtoaccepttheir

diagnosis,hadpoorunderstandingofHIVandstrong

traditional beliefs. Primary care providers delayed

HIV testing and referral, displayed poor attitudes,

andwereinsufficientinnumber.Quantitativefactors

significantlyassociatedwithgoodattendancewere

prior knowledge of the child/mother’s HIV status,

mother’sARTtreatmentandreferraltothedietician.

Conclusion: There are serious deficiencies in the

prevention, diagnosis and treatment of HIV in

children. Factorswere identified to improvehealth

services and these highlight the need for broader

strategiesaimedat addressingpoverty, stigmaand

education.

Published: Railton J,Mash B. How children access

antiretroviral treatment at Kgapane District

Hospital, Limpopo, South Africa. S Afr Fam Pract

2012;54(3):229-236.

www.safpj.co.za

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AmedicalauditofthemanagementofcryptococcalmeningitisinHIV-positivepatientsintheCapeWinelandsdistrict,WesternCape

KlausBvonPressentin,HoffieHConradie,BobMash

[email protected]

A study of factors in the treatment support system that contribute to successfulHAARTadherenceatTshepangclinic

LT Mbala, J Blitz

[email protected]

Background: Cryptococcal meningitis (CM) has

become the most common type of community-

acquired meningitis. CM has a poor outcome if

the initial in-hospital treatment does not adhere

to standard guidelines. The aim of this audit

was to improve the quality of the care of human

immunodeficiencyvirus(HIV)positivepatientswith

CMintheCapeWinelandsDistrict.

Method: Following an initial audit in 2008, the

researchers and a new audit team introduced

interventions,andplannedasecondauditcycle.The

foldersof25HIV-positiveadults(admittedtothree

district hospitals, one regional hospital, and one

tuberculosishospital)wereaudited.

Results: Spinal manometry was performed more

consistently in the regional hospital, than in the

districthospitals.Reasonsforfailingtoreachthe14-

day amphotericin B target were in-patient deaths,

drug stock problems, and renal impairment. The

renal monitoring of amphotericin B treatment

was suboptimal. The quality of care at district

hospitals appeared to be comparable to that found

at the regional hospital. The in-patient referral for

antiretroviraltreatment(ART)counsellingwasbetter

inthedistricthospitalsetting.However,bothlevels

of care had difficulty in achieving the four-week

target between the onset of amphotericin B and

onsetofART.

Conclusion: Deficiencies in the quality of care

remained. Between the prior and current audit

cycles, there was no consistent improvement in care

attheregionalhospital.Anintegratedcarepathway

document has been developed, and adopted as

policy intheCapeWinelandsdistrict. Its impacton

the quality of care will be evaluated by a dedicated

auditteaminthefuture.

Published:VonPressentinK,ConradieH,MashB.A

medical audit of the management of cryptococcal

meningitis in HIV-positive patients in the Cape

Winelands district,Western Cape. S Afr Fam Pract

2012;54(4):339-346.

www.safpj.co.za

Background:HighlyActiveAntiretroviral Treatment

(HAART) is currently the beest available treatment

for HIV but adherence is crucial in managing our

patients. In South-Africa, Tshepang clinic is one

of the facilitieswhichofferHAART. The aimof the

studywas to understand the relationship between

patients’adherencetoHAARTanduseoftreatment

supporters (“buddies”). The objectives were to

explore the views of adherent patients on ARVs

about the role of their buddy and to describe the

views of buddies of patients who are adherent to

ARVsontheirroleastreatmentsupporters.

Methods: A qualitative study included 22

respondentswhowereinterviewedin2focusgroups

forpatients’adherenttoHAARTand2focusgroups

withtreatmentsupporters.

Results: The buddy’s underlying knowledge of HIV

wasimportantinimprovingadherence.Disclosureof

theHIVstatuswasakeyelementinthemanagement

of HIV/AIDS despite the barriers and the buddy

was expected to assist the patient in that regard.

The buddy should be trustworthy and capable of

complyingwiththeneedforconfidentiality.Mutual

respect and good communication between the

buddy and the patient were to be encouraged. A

buddy is expected to take the patient through the

process of acceptance of the HIV status even in cases

where thepatienthas startedHAART,but is still in

denial.Themindsetofthebuddyandthepatientis

the foundation onwhich every strategy should be

built.Buddiesofpatientswithotherco-morbidities

should be allowed to collect medications on their

behalf.Thebuddiesshouldtakeaninterestinthelife

styleandbehaviouroftheirpatients.

Conclusion: The 13 themes generated from the

respondentswerewellknowninourhealthfacility,

buttheyhavenotbeenfullyunderstood.Thefindings

of this study can be applied at Tshepang clinic in

order to improvesupportofpatientswithHIVand

adherencetoHAART.

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AcomparisonoftreatmentresponseintwocohortsofpatientswithHIVtakingoncedailyversustwicedailyARTinGaborone,Botswana.

RachelSeleke,MichaelPather

[email protected]

Background: With the reduction of mortality and

the indisputablepositive results seen fromtheuse

ofAnti-RetroviralTreatment(ART),thedemandboth

frompeoplelivingwithHIVandhealthcareproviders

tophaseinlesstoxicARTwhilemaintainingsimplified

fixed-dosecombinationshasincreasedconsiderably.

Botswana like most low-resource countries has

adaptedtheWHOrecommendationofdailyARTas

opposed to the previous twice daily ART. The aim

was to compare the treatment response at 3-months

betweentwocohortsofpatientstakingARToncevs.

twicedaily.

Method:Thestudywasaretrospectivecomparative

cohort study. Three ART sites were selected and

a total of 263 patient records were selected, data

extractedandanalysed.

Results: The overall sample was predominantly

male (75.2%). An overwhelming majority (95.9%)

of patients in both arms had undetectable viral

loads (VL<400).A significantassociationwas found

betweenthetypeofregimenandviralload(p=0.03).

ThedifferenceinCD4betweenthetwoarmswasnot

statisticallysignificant(p=0.66).

Conclusion:Virologicalandimmunologicalresponse

at3monthspostinitiationbetweenoncedailyand

twicedailyARTinGaboroneBotswanawasshownto

becomparable.

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Background: Diabetes is an important contributor to

the burden of disease in South Africa and prevalence

rates as high as 33% have been recorded in Cape

Town. Previous studies show that quality of care

andhealthoutcomesarepoor.Thedevelopmentof

an effective education programme should impact

on self-care, lifestyle change and adherence to

medication;and lead tobettercontrolofdiabetes,

fewercomplicationsandbetterqualityoflife.

Methods:

Trial design: Pragmaticclusterrandomizedcontrolled

trial

Participants: Type 2 diabetic patients attending 45

public sector community health centres in Cape

Town

Interventions:The interventiongroupwill receive4

sessions of group diabetes education delivered by

a health promotion officer in a guiding style. The

controlgroupwillreceiveusualcarewhichconsists

ofadhocadviceduringconsultationsandoccasional

educationaltalksinthewaitingroom.

Objective:Toevaluatetheeffectivenessofthegroup

diabeteseducationprogramme

Outcomes: Primary outcomes: diabetes self-care

activities,5%weightloss,1%reductioninHbA1c.

CLINICAL RESEARCH: NON-COMMUNICA-BLE DISEASES

Secondary outcomes: self-efficacy, locus of control,

meanbloodpressure,meanweightloss,meanwaist

circumference, mean HbA1c, mean total cholesterol,

quality of life

Randomisation: Computer generated random

numbers

Blinding: Patients, health promoters and research

assistantscouldnotbeblindedtothehealthcentre’s

allocation

Numbers randomized: Seventeen health centres

(34 in total) will be randomly assigned to either

control or intervention groups. A sample size of

1360patientsin34clustersof40patientswillgivea

power of 80% to detect the primary outcomes with

5%precision.Altogether720patientswererecruited

inthe interventionarmand850inthecontrolarm

givingatotalof1570.

Discussion: Thestudywillinformpolicymakersand

managersof thedistricthealthsystem,particularly

inlowtomiddleincomecountries,ifthisprogramme

canbeimplementedmorewidely.

Publication:Mashetal.BMCFamilyPractice2012,

13:126http://www.biomedcentral.com/1471-

2296/13/126

EffectivenessofagroupdiabeteseducationprogrammeinunderservedcommunitiesinSouthAfrica:pragmaticclusterrandomizedcontroltrial

BobMash,NaomiLevitt,KriselaSteyn,MerrickZwarenstein,StephenRollnick

[email protected]

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ViewsofpatientsonagroupdiabeticeducationprogrammeusingmotivationalinterviewinginunderservedcommunitiesinSouthAfrica:

Qualitativestudy

Fanie Serfontein, Bob Mash

[email protected]

TheabilityofhealthpromoterstodelivergroupdiabeteseducationinSouth African primary care

AnnieBotes,BuyelwaMajikela-Dlangamandla,BobMash

[email protected]

Background: Diabetes is a significant contributor

to the burden of disease in South Africa and to

the reasons for encounter in primary care. There

is little structured and systematic education of

patients that supports self-care. This study was a

qualitativeassessmentofadiabetesgroupeducation

programme in Community Health Centres of the

Cape Town Metropolitan District. The programme

offered four sessions of group education and

was delivered by trained health promoters using

motivationalinterviewingasacommunicationstyle.

Theaimofthestudywastoevaluatetheprogramme

by exploring the experiences of the patients who

attended.

Methods: Thirteen individual in depth interviews

were conducted. Each patient had attended the

educationalprogrammeandcame fromadifferent

health centre in the intervention arm of a larger

randomised controlled trial. The interviews were

audiotaped,transcribedandthenanalyzedusingthe

frameworkapproach.

Results: Patients expressed that they gained

usefulnewknowledgeaboutdiabetes. Theuseof

educationalmaterialwasexperiencedpositivelyand

enhanced recall andunderstandingof information.

Thegeneralexperiencewasthatthehealthpromoters

were competent, utilised useful communication

skills and the structure of sessions was suitable.

Patients reported a change in behaviour especially

with diet, physical activity, medication and foot

care. Therewereorganizationalandinfrastructural

problems experienced specifically with regards to

the suitability of the venue and communication of

informationregardingthetimingandlocationofthe

sessions.

Conclusion: This study supports the wider

implementation of this programme following

considerationofrecommendationsfromthepatient

feedback and results of the larger randomised

controlledtrial.

Background: Diabetes makes a significant

contribution to the burden of disease in South

Afri¬ca. This study assesses a group diabetes

education programme using motivational

interview¬inginpublicsectorhealthcentresserving

low socio-economic communities in Cape Town.

The programmewas delivered bymid-level health

promotion officers (HPOs). The aim of the study

was to explore the experience of the HPOs and to

observetheirfidelitytotheeducationalprogramme.

Methods: Three focus group interviews were held

with the 14 HPOs who delivered the educational

programme in 17 health centres. Thirty-three

sessions were observed directly and the audio tapes

were analysed using themotivational interviewing

(MI)integritycode.

Results: The HPOs felt confident in their ability

to deliver group education after receiving the

training. They reported a significant shift in their

communication style and skills. They felt the new

approach was feasible and better than before.

The resource material was found to be relevant,

understandableanduseful.TheHPOsstruggledwith

poorpatientattendanceandalackofsuitablespace

at the facilities. Theydelivered themajorityof the

contentandachievedbeginning-levelproficiencyin

theMIguidingstyleofcommunicationandtheuse

of open questions. TheHPOs did not demonstrate

proficiencyinactivelisteningandcontinuedtoof¬fer

someunsolicitedadvice.

Conclusion: TheHPOsdemonstratedtheirpotential

todelivergroupdiabeteseducationde¬spiteissues

thatshouldbeaddressedinfuturetrainingandthe

district health services. The findingswill helpwith

the interpretation of results from a randomised

controlledtrialevaluat¬ingtheeffectivenessof the

education.

Publication: Botes AS,Majikela- Dlangamandla B,

MashR. The ability of health promoters to deliver

groupdiabetes education in SouthAfricanprimary

care.AfrJPrmHealthCareFamMed.2013;5(1),Art.

#484, 8 pages. http://dx.doi.org/10.4102/ phcfm.

v5i1.484

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Clinicalauditofdiabetesmanagementcanimprovethequalityofcareinaresource-limitedprimarycaresetting.

GovenderI,EhrlichR,VanVuurenU,DeVriesE,NamaneM,DeSaA,MurieK,SchlemmerA,GovenderS,

IsaacsA,MartellR.

[email protected]

Beliefsandattitudestoobesity,itsriskfactorsandconsequencesinaXhosacommunity:aqualitativestudy.

AkinrinlolaO,BlitzJ

[email protected]

Objective: To determine whether clinical audit

improved the performance of diabetic clinical

processes in the health district in which it was

implemented.

Design:Patientfoldersweresystematicallysampled

annuallyforreview.

Setting: Primary health-care facilities in theMetro

health district of the Western Cape Province in South

Africa.

Participants: Health-care workers involved in

diabetesmanagement.

Intervention:Clinicalauditandfeedback.

Mainoutcomemeasure:TheSkillings-Macktestwas

applied to median values of pooled audit results for

ninediabeticclinicalprocessestomeasurewhether

there were statistically significant differences

between annual audits performed in 2005, 2007,

2008 and 2009.Descriptive statisticswere used to

illustratetheorderofvaluesperprocess.

Results: A total of 40 community health centres

participated in the baseline audit of 2005 that

decreased to 30 in 2009. Except for two routine

processes, baseline medians for six out of nine

processes were below 50%. Pooled audit results

showed statistically significant improvements in

sevenoutofnineclinicalprocesses.

Conclusions: The findings indicate an association

betweentheapplicationofclinicalauditandquality

improvement in resource-limited settings. Co-

interventionsintroducedafterthebaselineauditare

likely to have contributed to improved outcomes.

Inaddition, support from the relevantgovernment

health programmes and commitment ofmanagers

andfrontlinestaffcontributedtotheaudit’ssuccess.

Publication:GovenderI,EhrlichR,VanVuurenU,De

Vries E,NamaneM,De SaA,Murie K, Schlemmer

A,GovenderS, IsaacsA,MartellR.Clinicalauditof

diabetes management can improve the quality of

care in a resource-limited primary care setting. Int

JQual Health Care. Dec;24(6):612-8. doi: 10.1093/

intqhc/mzs063.Epub2012Oct31.

Background: The issue of obesity and overweight

isoftennot recognisedasaproblem in theXhosa-

speaking community of Khayelitsha despite high

levelsofobesityandassociateddiseases.Thisstudy

aimed to explore this phenomenon by trying to

understand how people think and feel about their

weight,withaviewtoimprovinginterventionsthat

could reduce the burden of disease related to the

riskfactorsofoverweightandobesity.

Methods: A qualitative study recorded interviews

of 8 purposively selected subjects who were long

term Xhosa-speaking residents, 18 years and

older,with abodymass index> 30 andno known

diabetes,hypertensionorosteoarthritisatNolungile

Community Health Centre. Khayelitsha is a peri-

urbanblackcommunityinCapeTown,SouthAfrica.

Results: Interviewed subjects identified various

dietary factors in their obesity. These included

overeating widely available fatty diets from street

vendors,withaperceptionthatcheapfood is fatty

food. They also attributed their obesity to other

factors likepoverty and clearly expressed that it is

expensive toeathealthily.Other reasonsgivenare

a sedentary lifestyle, fear of embarrassment, safety

issuesandapoorsupportsystemregardingexercise.

Respondents differed in their reactions towards

theirobesity,butgenerallyacceptedtheircondition.

Obesitywasassociatedwithbeingmoreaffluentand

havinggoodhealth, respondentswereawareof its

effects on performing their daily activities, risk of

chronicillnesses,difficultieswithdressing,problems

withgettingolderandothernegativeeffects.

Conclusions: Respondents expressed ambivalent

views,withbothprosandconsofobesityidentified

intheircontext.Environmentalfactorsthatimpacted

onthisambivalencewerealso identified.Basedon

these understandings, health intervention should

be directed at addressing such local beliefs and

behaviour at the community level, with a need for

attentiontotheenvironmentalfactors.

24 25


Thevalidityofmonitoringthecontrolofdiabeteswithrandombloodglucosetesting

KemiDaramola,BobMash

[email protected]

AcomparisonofthequalityofchroniccareofhypertensivepatientsattendingafastlaneclinicversusastandardclinicinDitsobotlasubdistrict,NgakaModiriMolemadistrictinNorthWestprovincein

SouthAfrica.

S Mampe-Tembo, J Blitz

[email protected]

Background:Itisimportanttodecideonwhethera

patientwithdiabeteshasgoodglycaemiccontrolin

ordertoguidetreatmentandofferbehaviourchange

counselling.Currently randombloodglucose (RBG)

isusuallyusedinpublicsectorprimarycaretomake

thisdecision. This study investigates the validityof

thesedecisions.

Methods:Retrospectivedata,fromadistricthospital

setting,wasusedtoanalysethecorrelationbetween

glycated haemoglobin (HbA1c) and RBG, the best

predictivevalueofRBGanditspredictiveproperties.

Results: The best value of RBG to predict control

(HbA1c<7%)was9.8mmol/l.Thisthresholdhowever

onlygaveasensitivityof77%andaspecificityof75%.

Conclusion:Clinicianswillbewrong23%ofthetime

when using RBG to determine glycaemic control

andattemptsshouldbemadetomakeHbA1cmore

availableforclinicaldecisionmaking. Pointofcare

testingforHbA1cshouldbeconsidered.

Background:DitsobotlasubdistrictisinNgakaModiri

MolemaDistrict,NorthWestprovince,SouthAfrica.

Patientswithchronicdiseasesinthesubdistrictare

mainly taken care of at the clinics. There are two

typesofclinicsthatcaterforchronicpatients–fast

laneandstandardclinics.Fast laneclinicscater for

patientswith chronic diseases and family planning

only whilst standard clinics cater for acute illnesses,

chronic patients and family planning. Fast lane

clinicswerestartedbecauseofthedissatisfactionof

chronicpatientswithlongwaitingtimes.Therewere

nostandardisedguidelinesfortheestablishmentof

fast lane clinics. This study attempted to compare

thequalityofcaregiventopatientsatfastlaneand

standardclinics.

Methods:Thiswasacrosssectionaldescriptivestudy

usingavalidatedaudittoolfromtheWesternCape,

DepartmentofHealthtoassessfacilitiesandpatients

folders. There were 145 and 55 medical record

systematicallyselectedfromfast laneandstandard

clinicsrespectively.Selectedpatientsneededtohave

been attending for hypertension treatment from

JanuarytoDecember2010.

Results:Thepatientsatthestandardclinichadbetter

adherence to their appointments than fast lane

clinic, more counselling on diet, exercise, smoking

andalcoholandbetterrecordingofbloodpressure

and body weight than fast lane clinic (p< 0.05).

However,fastlaneclinicshadmorepatientswithwell

controlledbloodpressure,normal creatinine levels

and normal random cholesterol than standard clinic

(p<0.05). There were no differences between the

clinics in terms of equipment and other processes of

care(p>0.05).

Conclusion:Fastlaneclinicshadbetteroutcomesand

thusqualityofcarethanstandardclinics.Therefore

maintenance and expansion of this type of clinic may

beofvalue.

26 27


Cervicalcancerprevention:PerceptionsofwomenattendingKnysnaprimary health care clinics

LiezelVisser,LouisJenkins

[email protected]

Background: Cervical cancer is the cancer with

thehighestprevalenceandmortality inAfrica.The

current screening method is by pap-smear, but

othermethodsofprimarypreventionagainsthuman

papillomavirus(HPV)byimmunizationarecurrently

being investigated. The aim of this study was to

explore the experience, knowledge, attitudes and

beliefs of women attending clinics in the Knysna

sub-districtregardingthecurrentcervicalscreening

programme and to obtain their opinion on the

possiblealternativesmethodsavailable.

Method: A prospective mixed methods study was

conducted in six primary health care clinics in the

Knysna sub-district. Data was collected from 206

sequentially selected women aged 20-65 years by

meansofaquestionnaire.Sixfocusgroupdiscussions

wereheld.

Results:179 (87%)womenknew thatapap-smear

wastoscreenforpre-malignantormalignantcells.17

(8%) did not believe that cervix cancer is preventable

byregularpap-smearsand204(99%)believedthat

abnormal cells are treatable before they become

cancer. 123 (60%) did not know that different

screening programmes exist for HIV positive and

negative women. 141 (68%) had had a pap-smear

and the result was collected by 115 (82%) of which

108(77%)reportedunderstandingthemeaning.14

(10%) were referred for further treatment, 47

(33%) were requested to return for another smear

the subsequent year. Of this collective group 31

(62%) complied. The Visual Inspection with Acetic

acid (VIA) method was acceptable to 153 (74%).

HPV DNA-testing was acceptable to 171 (83%).

HPVvaccinationwasacceptable to all participants.

The focus groups identified the following themes:

knowledge,application,personalesteem,community

influenceandprotectionofyouth.

Conclusion:Participantshadagoodbasicknowledge

of pap smears. Uptake of pap-smears was

acceptablebutthefollow-throughwasincomplete

and influential, external factors were identified.

The influence of the community’s opinion on

the women’s ideas should not be disregarded.

The participants were serious about protecting

the youth and felt unable to do so within the

current system. Alternative methods of cervix

cancerpreventionareacceptabletothecommunity

inKnysnasandshouldbeexploredfurther.

28 29


Introduction: Interpersonal violence in South Africa

is the secondhighest contributor to theburdenof

disease afterHIV/AIDS and62% is estimated tobe

from intimate partner violence (IPV). This study

aimed to evaluate how women experiencing IPV

presentinprimarycare,howoftenIPVisrecognized

byhealthcarepractitionersandwhatotherdiagnoses

aremade.

Methods: At two urban and three rural community

healthcentres,healthpractitionersweretrainedto

screen all women for IPV over a period of up to 8

weeks.Medicalrecordsof114thusidentifiedwomen

were then examined and their reasons for encounter

(RFE) and diagnoses over the previous 2-years

werecodedusingtheInternationalClassificationof

PrimaryCare.Threefocusgroupinterviewswereheld

withthepractitionersandinterviewswiththefacility

managerstoexploretheirexperienceofscreening.

Results:IPVwaspreviouslyrecognizedin11women

(9.6%). Women presented with a variety of RFE

CLINICAL RESEARCH: VIOLENCE AND TRAUMA

that should raise the index of suspicion for IPV–

headache,requestforpsychiatricmedication,sleep

disturbance, tiredness, assault, feeling anxious

and depressed. Depression was the commonest

diagnosis. Interviews identified key issues that

preventedhealthpractitionersfromscreening.

Conclusion:Thisstudydemonstratedthatrecognition

of women with IPV is very low in South African

primary care and adds useful new information on

howwomenpresenttoambulatoryhealthservices.

These findings offer key cues that can be used to

improve selective case finding for IPV in resource-

poorsettings.Universalscreeningwasnotsupported

bythisstudy.

Publication: Joyner K, Mash R (2012) Recognizing

IntimatePartnerViolenceinPrimaryCare:Western

Cape, South Africa. PLoS ONE 7(1): e29540.

doi:10.1371/journal.pone.0029540

RecognizingIntimatePartnerViolenceinPrimaryCare:WesternCape,South Africa

KateJoyner,RobertMash

[email protected]

30 31


AcomprehensivemodelforintimatepartnerviolenceinSouthAfricanprimarycare:actionresearch

KateJoyner,BobMash

[email protected]

EvaluationofaprojecttoreducemorbidityandmortalityfromtraditionalmalecircumcisioninUmlamli,EasternCape,SouthAfrica:

outcomemapping

Obi Nwanze, Bob Mash

[email protected]

Background: Despite extensive evidence on the

magnitude of intimate partner violence (IPV) as

a public health problem worldwide, insubstantial

progress has been made in the development and

implementationofsufficientlycomprehensivehealth

services. This study aimed to implement, evaluate

and adapt a published protocol for the screening

and management of IPV and to recommend a

model of care that could be taken to scale in our

underdeveloped South African primary health care

system.

Methods: Professional action research utilised a

co-operative inquiry group that consisted of four

nurses, one doctor and a qualitative researcher.

Theinquirygroupimplementedtheprotocolintwo

urban and three rural primary care facilities. Over

aperiodof14monthsthegroupreflectedontheir

experience, modified the protocol and developed

recommendationsonapracticalbutcomprehensive

modelofcare.

Results: The original protocol had to be adapted

in terms of its expectations of the primary care

providers,overlyforensicorientation, lackofdepth

in terms of mental health, validity of the danger

assessment and safety planning process, and need

for ongoing empowerment and support. A three-

tier model resulted: case finding and clinical care

provision by primary care providers; psychological,

social and legal assistance by ‘IPV champions’

followed by a group empowerment process; and

thenongoingcommunity-basedsupportgroups.

Conclusion: The inquiry process led to a model

of comprehensive and intersectoral care that is

integratedatthefacilitylevelandwhichisnowbeing

pilotedintheWesternCape,SouthAfrica.

Publication: JoynerandMashBMCHealthServices

Research 2012, 12:399 http://www.biomedcentral.

com/1472-6963/12/399

Background: Traditional circumcision is common

among the amaXhosa in Umlamli, Eastern Cape.

Circumcision is associatedwithhighmorbidity and

mortality. The need to reduce complications was

identifiedasaprioritybythelocalcommunity.The

aimwastodesign,implementandevaluateaproject

toimprovethesafetyoftraditionalcircumcision.

Method: A safe circumcision team was established

and comprised healthworkers, community leaders

and traditional surgeons. Outcome mapping

involved threestages: intentionaldesign,outcome,

and performance monitoring and evaluation. The

eightboundarypartnersweretheinitiates,parents,

communityleaders,traditionalsurgeons,theDistrict

Health Services, the provincial Department of Health,

the emergency services and the police.Outcomes,

progressmarkers and strategieswere designed for

eachboundarypartner.Theteamkeptanoutcome

and strategy journal and evaluated hospital

admissions,genitalamputationsandmortality.

Results:Ninety-twoinitiateswerecircumcised,with

twoadmissionsforminorcomplications,compared

to10admissions,twoamputationsandtwodeaths

previously.Morethan70%oftheoutcomemeasures

were achieved in all boundary partners, except

emergencyservicesandtheDepartmentofHealth.

Thekeyaspectswere:theuseofoutcomemapping,

theparticipatoryprocess,aloweragelimit,closure

ofillegalschools,consolidationofaccreditedschools,

trainingworkshopsfortraditionalsurgeons,private

treatmentroomforinitiates,assistancewithmedical

materials,pre-circumcisionexamination,certificates

offitness.

Conclusion: This study has shown the value of

community-orientated primary care initiatives to

address local health problems. Key lessons were

identifiedandtheprojectcouldeasilybereplicated

incommunitiesfacingsimilarchallenges.

Published: Nwanze O, Mash B. Evaluation of a

project to reduce morbidity and mortality from

traditional male circumcision in Umlamli, Eastern

Cape, South Africa: outcome mapping. S Afr Fam

Pract 2012;54(3):237-243

www.safpj.co.za

32 33


UseofOxytocinduringCaesareanSectionatPrincessMarinaHospital,Botswana:Anauditofclinicalpractice

B Tsima, F Madzimbamuto, B Mash

[email protected]

Background: Oxytocin is widely used for the

prevention of postpartum haemorrhage. In the

setting of Caesarean section (CS), the dosage and

mode of administrating oxytocin differs according

todifferentguidelines.Inappropriateoxytocindoses

havebeenidentifiedascontributorytosomecases

ofmaternaldeaths.Themainaimofthisstudywas

toauditthecurrentstandardofclinicalpracticewith

regardtotheuseofoxytocinduringCSatareferral

hospitalinBotswana.

Methods:Aclinicalauditofpregnantwomenhaving

CSandgivenoxytocinat thetimeof theoperation

was conducted over a period of three months.

Data included indications for CS, oxytocin dose

regimen,prescribingclinician’sdesignation, typeof

anaesthesiafortheCSandestimatedbloodloss.

Results:Atotalof139caserecordswere included.

Thecommonestdosewas20IUinfusion(31.7%).The

potentiallydangerousregimenof10IUintravenous

bolusofoxytocinwasused in12.9%ofCS.Further

doses were utilized in 57 patients (41%). The top

three indications for CS were fetal distress (36

patients, 24.5%), dystocia (32patients, 21.8%) and

apreviousCS(25patients,17.0%).Estimatedblood

lossrangedfrom50mL–2000mL.

Conclusion:TheuseofoxytocinduringCSinthelocal

settingdoesnotfollowrecommendedpractice.This

has potentially harmful consequences. Education

and guidance through evidence based national

guidelinescouldhelpalleviatetheproblem.

Publication:TsimaBM,MadzimbamutoFD,MashB.

UseofOxytocinduringCaesareanSectionatPrincess

Marina Hospital, Botswana: An audit of clinical

practice.AfrJPrmHealthCareFamMed.2013;5(1),

Art.#418,6pages.

http://dx.doi.org/10.4102/phcfm.v5i1.418

CLINICAL RESEARCH: MATERNAL AND CHILD HEALTH

34 35


A Morbidity Survey of South African Primary Care

BobMash,LaraFairall,OlubunmiAdejayan,OmozuanvboIkpefan,JyotiKumari,

ShaheedMathee,RonitOkun,WillyYogolelo

[email protected]

Background: Recent studies have described the

burden of disease in South Africa. However these

studies do not tell us which of these conditions

commonly present to primary care providers, how

these conditions may present and how providers

make sense of them in terms of their diagnoses.

Clinicalnursepractitionersarethemainprimarycare

providers and need to be better prepared for this

role. This studyaimed todetermine the rangeand

prevalenceofreasonsforencounteranddiagnoses

foundamongambulatorypatientsattendingpublic

sectorprimarycarefacilitiesinSouthAfrica.

Methodology/Principal Findings: The study was a

multi-centre prospective cross-sectional survey of

consultations in primary care in four provinces of

South Africa: Western Cape, Limpopo, Northern Cape

andNorthWest.Consultationswerecodedpriorto

analysis by using the International Classification

of Primary Care-Version 2 in terms of reasons for

encounter (REF) and diagnoses. Altogether 18856

consultations were included in the survey and

generated 31451 reasons for encounter (RFE) and

24561 diagnoses. Women accounted for 12526

(66.6%) andmen6288 (33.4%).Nurses saw16238

(86.1%) and doctors 2612 (13.9%) of patients. The

top80RFEandtop25diagnosesarereportedand

ongoingcare forhypertensionwas thecommonest

RFE and diagnosis. The 20 commonest RFE and

diagnosesbyagegrouparealsoreported.

Conclusions/Significance: Ambulatory primary

care is dominated by non-communicable chronic

diseases. HIV/AIDS and TB are common, but not

to the extent predicted by the burden of disease.

Pneumoniaandgastroenteritisarecommonly seen

especially in children.Women’s health issues such

as family planning and pregnancy related visits

are also common. Injuries are not as common as

expectedfromtheburdenofdisease.Primarycare

providersdidnotrecognisementalhealthproblems.

The results should guide the future training and

assessmentofprimarycareproviders.

Publication:MashB, Fairall L, AdejayanO, Ikpefan

O, Kumari J, et al. (2012) A Morbidity Survey of

SouthAfricanPrimaryCare.PLoSONE7(3):e32358.

doi:10.1371/journal.pone.0032358

HEALTH SERVICES AND SYSTEMS RESEARCH

36 37


38 39


Reasonsforencounteranddiagnosesofpatientsattendingprimarycareclinics in the Saldanha Bay and Swartland rural sub districts, Western

CapeProvince:Aprospectivecross-sectionalsurvey.

Shaheed Mathee, Bob Mash

[email protected]

Reasonswhypatientswithprimaryhealthcareproblemsaccessasecondaryhospitalemergencycentre

JuanitaBecker,AngelaDell,LouisJenkins,RaufSayed

[email protected]

Background:Theprimaryhealthcare (PHC) system

was designed to provide equitable and accessible

healthcaretoall,butthesystemremainsplaguedby

manychallenges.Keytoovercomingthesechallenges

istohaveabetterunderstandingofthereasonswhy

patientsaccesstheservice inthefirst instanceand

alsoofthecasemixofdiseasesseen.Theaimofthe

study was to assess the main reasons for encounter

(RFE) and the diagnoses made by the healthcare

providersofpatientsattendingprimaryhealthcare

clinics in the two rural sub districts of Saldanha Bay

andSwartlandintheWesternCape.

Methods: The prospective cross-sectional study

involved 13 healthcare providers (mainly clinical

nursepractitioners)workingat10randomlyselected

primaryhealthcarefacilitiesinthetwosubdistricts.

TheparticipantswereaskedtorecordtheRFE’sand

diagnoses of all the patients they consulted on a

datacollectionsheet.Datawascollectedonsixdays

overa12monthperiod fromAugust2009 to June

2010. The International Classification of Primary

Care(ICPC-2)systemwasusedtocodetheRFE’sand

problemsdefinedduringallpatientencounters.

Results: Out of 1277 consultations there were

2091 RFE’s and 1706 diagnoses. The majority of

complaints were respiratory (19.9%), digestive

(11.2%), musculoskeletal (9.6%), cardiovascular

(9.3%), skin (8.8%) andgeneral/unspecified (7.6%).

Themajorityofdiagnoseswererespiratory(21.4%),

cardiovascular (14.2%), skin (9.1%) and digestive

(8.6%). Hypertension (10.8%) was the commonest

condition. TB and HIV occurred at low frequency

(2.9% and 1.5% respectively). Gender did not

influence the number of RFE’s and diagnoses. The

majorityofpatientsseenduringallencounterswere

childrenundertheageof4years(17.3%).

Conclusion: We were able to ascertain the RFE and

diagnoses made by the health care providers of

patientsattendingpublicprimarycarefacilitiesinthe

ruralsubdistrictsofSaldanhaBayandSwartland.This

informationcanbeusedforguidelinedevelopment

andtrainingaswellastheplanningofservices.

Background:Manypatientspresenttoanemergency

centre (EC) with problems that could bemanaged

at primary healthcare (PHC) level. This has been

notedatGeorgeProvincialHospital intheWestern

CapeprovinceofSouthAfrica. Inorder to improve

servicedelivery,weaimedtodeterminethepatient-

specific reasons for accessing the hospital ECwith

PHCproblems.

Method: A descriptive study using a validated

questionnaire to determine reasons for accessing

the EC was conducted among 277 patients who

weretriagedasgreen(routinecare),usingtheSouth

AfricanTriageScore.Thedurationofthecomplaint,

referral source and appropriateness of referral were

recorded.

Results:Of the cases88.2%were self-referredand

30.2% had complaints persisting for more than a

month.Only4.7%ofself-referredgreencaseswere

appropriate for the EC. The three most common

reasons for attending the EC were that the clinic

medicinewasnothelping(27.5%),aperceptionthat

thetreatmentatthehospitalissuperior(23.7%),and

thattherewasnoPHCserviceafter-hours(22%).

Conclusions: Increased acceptability of the PHC

services isneeded.Thecurrent triagesystemmust

beadaptedtoallowchannellingofPHCpatientsto

theappropriatelevelofcare.Strictreferralguidelines

areneeded.

Publication: Becker J, Dell A, Jenkins L, Sayed R.

Reasons why patients with primary health care

problems access a secondary hospital emergency

centre. S Afr Med J 2012;102(10):800-801.

DOI:10.7196/SAMJ.6059

40 41


FactorsinfluencingspecialistoutreachandsupportservicestoruralpopulationsintheEdenandCentralKaroodistrictsoftheWesternCape

– a Delphi study

JohanSchoevers,LouisJenkins

[email protected]

Advancedirectivesorlivingwills:reflectionsofgeneralpractitionersandfrailcarecoordinatorsinasmalltowninKwaZulu-Natal

Alastair Bull, Bob Mash

[email protected]

Introduction: Access to health care often depends

on where one lives. Rural populations have

significantly poorer health outcomes than their

urban counterparts. Specialist outreach to rural

communitiesisonewayofimprovingaccesstocare.

Amultifacetedapproachtothepurposeofoutreach

may improve both access and health outcomes, while

anapproachthatjustrelocatestheoutpatientclinic

fromthereferralhospitalmayonlyimproveaccess.

In principle, stakeholders agree that specialist

outreachandsupport (O&S)toruralpopulations is

necessary.Inpracticehowever,therearefactorsthat

influencewhetherornotO&Sreachesitsgoalsand

issustainable.

Aim:Theaimwastobetterunderstandthefactors

associated with the success or failure of specialist

O&S to rural populations in the Eden and Central

KaroodistrictsintheWesternCape.

Method:AnanonymousthreestageDelphiprocess

was followed to obtain consensus in a specialist and

districthospitalpanel.

Results:Twentyeightspecialistand31districthospital

experts were invited, with response rates between

60.7-71.4%and58.1-74.2%respectivelyacrossthe

three rounds. Relationships, communication and

planningwerefoundtobethekeyfactorsinfluencing

the success of O&S and shaping tension between

O&S as service delivery vs. capacity building. The

success of theO&Sprogramme is dependenton a

site specific model that is acceptable to both the

outreaching specialists and the hosting district

hospital.

Conclusion: Attention to good communication,

constructive feedback and improved planningmay

enable the development of more effective and

sustainableO&S.

Background:Livingwillshave longbeenassociated

with end-of-life care. This study explored the

promotion of living wills by general practitioners

(GPs)and frail carenursingcoordinatorswhowere

directlyinvolvedinthecareoftheelderlyinHowick,

KwaZulu-Natal.Thestudyalsoexplored theirviews

regardingthepro forma livingwilldisseminatedby

theLivingWillSociety.

Subjects: Seven GPs and three frail care nursing

coordinators;10intotal.

Design: The design was qualitative in-depth

interviews and analysis, using the Framework

method.

Results:Bothdoctorsandnursingstaffunderstood

the concept of living wills and acknowledged that

theywerebeneficial topatients, their families and

staff. Theywere concerned about the lack of legal

statusofthelivingwill.Theyfeltthattheproforma

document from the LivingWill Society was simple

andclear.Despite identifyingthelowlevelof living

willusageamongpatients,doctorsandnursingstaff

felt that third-party organisations and individuals

shouldpromote livingwills topatients, ratherthan

promotingthemtopatientsthemselves.

Conclusion: GPs and frail care nurse coordinators

were knowledgeable about living wills in general,

and the LivingWill Societypro formadocument in

particular. They valued the contribution that living

willsmaketothecareoftheelderly,astheybenefit

patients, their families,healthcareworkersandthe

healthsystem.Theyalsovaluedtheproformaliving

will document from the Living Will Society for its

clarityandsimplicity.However,theGPsandfrailcare

nursing coordinators viewed the livingwill process

aspatientdriven.Theyviewedtheirmainroletobe

thatofcustodians,andnotadvocates,of the living

wills.

Publication: Bull A, Mash B. Advance directives

or living wills: reflections of general practitioners

and frail care coordinators in a small town in

KwaZulu-Natal.SAfrFamPract2012;54(6):507-512

www.safpj.co.za

42 43


EDUCATIONAL RESEARCH

DevelopmentofaportfoliooflearningforpostgraduatefamilymedicinetraininginSouthAfrica:aDelphistudy

LouisJenkins,BobMashandAnselmeDerese

[email protected]

Background: Within the 52 health districts in South

Africa, the family physician is seen as the clinical

leader within a multi-professional district health

team.Familyphysiciansmustbecompetenttomeet

90%ofthehealthneedsofthecommunitiesintheir

districts.TheeightuniversitydepartmentsofFamily

Medicinehaveidentifiedfiveunitstandards,broken

down into 85 training outcomes, for postgraduate

training. The family medicine registrar must prove

at theendof training thatall the required training

outcomes have been attained. District health

managersmustbeassuredthatthefamilyphysician

is competent to deliver the expected service. The

CollegesofMedicineofSouthAfrica(CMSA)require

a portfolio to be submitted as part of the uniform

assessment of all registrars applying to write the

nationalfellowshipexaminations.Thisstudyaimedto

achieve a consensus on the contents and principles of

thefirstnationalportfolioforuseinfamilymedicine

traininginSouthAfrica.

Methods: A workshop held at the WONCA Africa

RegionalConference in2009explored thepurpose

andbroadcontentsoftheportfolio.The85training

outcomes, ideas from the WONCA workshop, the

literature, and existing portfolios in the various

universities were used to develop a questionnaire

that was tested for content validity by a panel of 31

experts in family medicine in South Africa, via the

Delphitechniqueinfourrounds.Eightyfivecontent

itemsand27principlesweretested.Consensuswas

definedas70%agreement.

Results: Consensus was reached on 61 of the 85

nationallearningoutcomes.Thepanelrecommended

that50beassessedbytheportfolioand11shouldnot

be.Noconsensuscouldbereachedontheremaining

24outcomesandthesewerealsoomittedfromthe

portfolio. The panel recommended that various

typesofevidencebe included in theportfolio.The

panel supported 26 of the 27 principles, but could

notreachconsensusonwhethertheportfolioshould

reflect on the relationship between the supervisor

andregistrar.

Conclusion: A portfolio was developed and

distributed to the eight departments of Family

Medicine in South Africa, and the CMSA, to be

furthertestedinimplementation.

Publication: Jenkins et al. BMC Family Practice

2012, 13:11. http://www.biomedcentral.com/1471-

2296/13/11

44 45


OutcomesforfamilymedicinepostgraduatetraininginSouthAfrica

Couper I, Mash B, Selma S, Schweitzer B

[email protected]

This article described the final result of a national

process to agree on learning outcomes for the

trainingoffamilyphysicians.Thefiveunitstandards

were that the candidate will be able to:

• Effectivelymanagehimselforherself,hisorher

teamandhisorherpractice inanysectorwith

visionary leadership and self-awareness in order

toensuretheprovisionofhigh-quality,evidence-

basedcare.

• Evaluate and manage patients with both

undifferentiated and more specific problems

cost-effectivelyaccordingtothebiopsychosocial

approach.

• Facilitate the health and quality of life of the

community

• Facilitate the learning of others regarding the

discipline of family medicine, primary health

care,andotherhealth-relatedmatters.

• Conduct all aspects of health care in an ethical

andprofessionalmanner.

Foreachoftheseunitstandardsanumberofspecific

learningoutcomesweredescribed.

Publication: CouperI,MashB,SmithS,SchweitzerB.

Outcomesforfamilymedicinepostgraduatetraining

inSouthAfrica.SAfrFamPract2012;54(6):501-506.

www.safpj.co.za

46

PRIMARY CARE RESEARCH 2012

Family Medicine and Primary Care Stellenbosch University

Box 19063 Tygerberg

7505 SOUTH AFRICA

Tel +27 21 938 9061 Fax +27 21 938 9704

www.sun.ac.za/fammed

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