Masters Degrees (Family Medicine and Primary Care)

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After hours case mix at George provincial hospital emergency centre: a descriptive study
(Stellenbosch : Stellenbosch University, 2011-12) Van Wyk, P. S.; Jenkins, Louis; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Introduction: Emergency care of patients in South Africa has become a priority, with the establishment of emergency medicine as a specialty, developing a triage scoring system, and upgrading facilities and services. The Western Cape Comprehensive Service Plan stipulates that ninety percent of health care should be offered at level 1 (primary and district) health care, eight percent at level 2 (general specialist) care, and two percent at level 3 (super specialist) care. It is suspected that a significant proportion of primary health care patients are presenting after hours to level 2 facilities, like George hospital. Little is known about the nature or acuity levels of patients presenting after hours to the George provincial hospital Emergency Centre. A retrospective descriptive study was performed at George hospital in May 2010 to determine the afterhours case mix and workload. Methods: A total of 2560 patients presented afterhours at the emergency centre for the month of May 2010 that was triaged according to the Cape Triage Score (CTS). The case mix was analyzed according to a pre designed Microsoft Excel data sheet. Results: Three quarters of the case mix were adults and 25% were paediatric cases. Sixty five percent of patients were triaged green, followed by twenty seven percent yellow, five percent orange and two percent red (one percent absconded before doctors evaluation). Besides trauma related cases, respiratory and gastrointestinal problems were the most common presentations. The workload included on average fifty four patients per afterhours weekday, one hundred and thirty eight patients per 24-hour weekend days and one hundred and forty seven for the public holiday. Discussion: This study demonstrated that a significant number of the afterhours case mix presenting at George provincial hospital emergency centre consists of green and yellow level 1 cases which could be more appropriately managed at a level 1 health care facility.
Does the provision of services for HIV positive patients, including the provision of antiretroviral therapy, meet the needs and expectations of employers in Knysna?
(Stellenbosch : Stellenbosch University, 2009-12) Giddy, Laurel Anne; Jenkins, Louis; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences
ENGLISH ABSTRACT: In South Africa, the highest HIV prevalence is amongst young people, who may have the greatest potential to contribute to the country’s economy. South Africa has one of the world’s largest antiretroviral (ARV) rollout programs. Like all medications, ARVs need to be taken as prescribed to be safe and effective. Excellent adherence is necessary to ensure that drug resistance does not develop. HIV cannot be cured, and at present ARVs must be taken for the rest of the patient’s life. In the ARV clinic in Knysna, an unanticipated category of patients has been identified: those who “bounce” in and out of long term therapy. Not only do these patients put their own health at risk, but the development and transmission of drug resistant HIV threatens the potential treatment options of the whole community. One of the problems identified in recurrently defaulting patients, is the difficulty in maintaining long term adherence to an ARV treatment program, while in full time employment. This is because as time goes on, patients need to balance the need for ARV care, which has rigorous clinic attendance parameters, with work attendance. Many employees have only twelve days of paid sick leave per annum, and patients require an average of eleven clinic visits in the first six months of treatment. This qualitative study gauges whether the services provided to HIV positive people living in Knysna meets the needs of their employers. The study interviewed both employees and employers to gauge the effects of HIV on local businesses, and explored the knowledge and attitudes of employers towards services provided by the Knysna ARV program. Employers were asked to suggest ways in which the services could be improved to better meet their needs, and ultimately, the needs of their employees.
Drug interactions in primary healthcare in the George area, South Africa : a cross-sectional study
(Stellenbosch : University of Stellenbosch, 2011-12) Kapp, Paul Alfred; Klop, Andre; Jenkins, Louis; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH ABSTRACT: Aim: To investigate the prevalence of potential drug-drug interactions in primary healthcare clinics in the George subdistrict. Objectives included: To investigate and quantify the following risk factors: patient age, poly-pharmacy, gender, multiple prescribers and recorded diagnoses, as well as to identify and quantify the drugs involved, including the level of any drug-drug interactions. Design: A descriptive cross-sectional study was performed at four primary healthcare clinics in George from 400 randomly selected patients’ files for patients who attended these clinics from 1 February to 30 April 2010. Demographics, recorded diagnoses and all concurrently prescribed drugs were recorded and analysed. The level of drug-drug interaction was classified using the OpeRational Classification of drug-drug interactions designed by Hansten and Horn. Results: The prevalence for moderate interactions was 42%, severe interactions 5.25% and contraindicated combinations was 0.5%. The most common drugs involved in potential drug interactions were: enalapril, aspirin, ibuprofen, furosemide and fluoxetine. The most common drugs involved in potentially severe interactions were: warfarin, aspirin, fluoxetine, tramadol and allopurinol. Two contraindicated combinations were found: verapamil plus simvastatin, and hyoscine butyl bromide with oral potassium chloride. Increasing age and poly-pharmacy were associated with an increased risk for potential drug-drug interactions. Input from the regional hospital specialist departments greatly increased the risk of being prescribed a potential drug-drug interaction. Eighty one per cent (17/21) of severe interactions were from this group. The majority of patients in the sample were female (65.5%) but there was no differences in the percentage of drug interactions between males (43.4%) and females (43.1%). Conclusion: Potential drug-drug interactions are commonly prescribed in primary healthcare clinics in the George subdistrict. Drug interactions are predictable and preventable. It would seem prudent to put into place a method of reducing the risk. Further research is needed to identify effective interventions suitable for resource constrained centres. The risk factors identified in this study may assist in designing such an intervention.
Evaluating the growth, associated co-morbidities and mortality in children under the age of five years, six months after treatment for Severe Acute Malnutrition (SAM) in the Oudtshoorn sub-district.
(Stellenbosch : Stellenbosch University, 2017-12) Groenewald, Milton; Jenkins, Louis; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Background: Malnutrition is an important cause of childhood mortality in South Africa. Severe acute malnutrition (SAM) is a major public health problem. The focus of treatment is awareness, early identification and nutritional intervention. With implementation of the revised World Health Organization’s (WHO) guideline to diagnose SAM in the Oudtshoorn sub-district in the Western Cape more children are being identified and admitted for treatment. Very little data exists about the outcome of children after being discharged back into the community following treatment for SAM. The aim of the study was to assess the success of the current rehabilitative and nutritional management programme for SAM by looking at weight gain, associated co-morbidities and mortality of children under five years of age six-months after discharge from Oudtshoorn District Hospital. Methods: A descriptive survey was conducted by extracting data from the medical records. All children aged 6-59 months who were admitted for SAM from 2014 to 2016 were included. Weight-for-height, mid-upper-arm circumference (MUAC) and the presence of peripheral oedema were recorded on hospital admission. Co-morbidities, specifically HIV and TB, were also recorded. Mortality and repeated anthropometric measurements were captured at the six-month follow-up at the respective primary care clinics from the medical record or the nutritional treatment programme register. Results: Sixty-three children were included with a median age 52 weeks (IQR 28-92). Six died (9.5%), ten failed to gain weight satisfactorily (15.8%) and overall children showed a median monthly weight increase of 325 grams per child (IQR 192-475). Co-morbidities were seen in 53 (84.1%) of children. The main associated co-morbidities were gastroenteritis, TB, anaemia, and respiratory tract infections. All participants were HIV negative. Only 73% of children had a MUAC measured at admission and 27% at follow up in primary care. Conclusion: Overall 25% of children had an adverse outcome, although weight gain and mortality was within the minimum acceptable standards for community based programmes. Primary care clinics did not perform MUAC measurements adequately and relied only on weight-for-height. The usual co-morbidities were seen, although none of the children were HIV positive.
Factors influencing the use of contraceptive methods amongst adolescents in George, South Africa
(Stellenbosch : Stellenbosch University, 2015-12) De Klerk, Elmari; Jenkins, Louis; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
ENGLISH SUMMARY: Introduction A broad understanding of adolescent sexual behaviour is crucial: sexual experience and risky sexual behaviour are prevalent among adolescents. Many studies have been done and opinions have been given about adolescent behaviour regarding contraception and safe sexual practices. There seems to be sufficient knowledge, but passing it on to adolescents is inadequate. The aim of this study was to identify the factors that influence the use of contraceptive methods amongst 16 year old adolescents attending high schools in George, South Africa. Method This was a descriptive, cross-sectional study. Consent from parents/guardians and assent from study participants were obtained. Three high schools in George were randomly selected. All 16 year old learners attending these 3 schools, which assented and consented, were invited to voluntarily complete a self-administered questionnaire, specifically developed for this study. Results One hundred and eighty four 16-year old adolescents voluntarily took part. The male: female ratio was fairly equal. The average age of sexual debut was 15 years, with 42% using contraception at the time of the study. 33% of the sexually active respondents were not using contraception. Knowledge about contraception was reasonably good, with school, home and friends playing pivotal roles. Condoms were perceived to be to easiest available by the sexually active and non-active respondents, whereas injectable contraception was perceived easily available by the sexually active participants, but not by the sexually inactive participants. Contraception is being used mostly by instruction from parents, but peer pressure plays a role here too, as indicated by 20% of the respondents. The most popular reasons for not using contraception whilst being sexually active include: Sensation loss with condoms and partner pressure. Conclusion 16 year old adolescents attending high schools in George do not differ much from their peers nationally and internationally. Their sexual debut is slightly earlier; therefore their contraception use debut is also earlier. Their knowledge regarding contraceptive methods is acceptable, showing that previous educational programmes are bearing fruit and still need to continue. Friend/peer factors play an important role in the decision making of the respondents. This has been shown in their knowledge gain, access to and reasoning behind the use or non-use of contraception. These should be considered in new strategies aiming to improve the educational programmes.
Health literacy and adherence to chronic medication : a descriptive study in a primary health care clinic in the Eden District
(Stellenbosch : Stellenbosch University, 2015-12) Kleinhans, Shaun; Jenkins, Louis; University of Stellenbosch. Faculty of Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Introduction: Non-communicable disease is a major cause of morbidity in South Africa. Poor adherence to long-term medication severely compromises the effectiveness of treatment. Multiple factors have been described that affect adherence, with health literacy suggested as an independent predictor of medication adherence. This study explored patients’ health literacy and adherence in a primary health care setting in the Eden district of the Western Cape Province. Methods: This was a cross-sectional observational study. Two validated questionnaires were used in a primary health clinic. The Morisky 8 item medication adherence questionnaire was used to assess participants’ adherence. To evaluate participants’ health literacy, the Adaptation of the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) to the South African context was used. Results: Of the total 265 patients interviewed the literacy scores were “poor” for 244 (92%) and “good” for 21 (8%). On the self-reported adherence, 204 (77%) reported “low” adherence, 61 (23%) reported “medium” adherence and none reported “good” adherence. Conclusion: Most participants had poor health literacy and poor to medium adherence to medication. Factors influencing adherence are multiple and diverse. Health literacy might improve adherence but all the factors influencing adherence need to be taken into account.
Implementing and evaluating an e-portfolio for postgraduate family medicine training in the Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2018-12) De Swardt, Magdaleen; Jenkins, Louis; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Background: In South Africa it is compulsory to submit a portfolio of learning to qualify for the national exit exam of the College of Family Physicians of South Africa to qualify as a family physician. A paper-based portfolio has been implemented thus far and the need for an electronic portfolio (e-portfolio) was identified. Aim: To describe and evaluate the implementation of an e-portfolio for the training of family medicine registrars in the Western Cape province of South Africa. Methods: Mixed methods were used. A quasi-experimental study compared paper- and e-portfolios and semi-structured in-depth interviews were conducted with 11 information rich respondents. Quantitative data was captured from the paper portfolios of registrars in 2015 and compared with the e-portfolios of registrars in 2016. Results: Most respondents found the e-portfolio easier to use and more accessible. It made progress easier to monitor and provided sufficient evidence of learning. Feedback was made easier and more explicit. There were concerns regarding face-to-face feedback being negatively affected. It was suggested to have a feedback template to further improve feedback. There was a statistically significant improvement in general feedback from the paper portfolio in 2015 to the e-portfolio in 2016. Although not statistically significant, there was an increase in the usage of the e-portfolio, compared to the paper portfolio. Conclusion: The e-portfolio is an improvement on the paper-based portfolio. It is easier to access, more user-friendly and less cumbersome. It makes feedback and monitoring of progress and development of registrars easier and more visible and provides sufficient evidence of learning. Its implementation throughout South Africa is recommended.
Induction of labour at district hospitals in the Cape Winelands District of South Africa : a quality of care audit
(Stellenbosch : Stellenbosch University, 2023-12) Hattingh, Daniel Wilhelmus; Jenkins, Louis; Williams, Andrew; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Introduction: Induction of labour (IOL) is when the process of labour is artificially initiated before the onset of spontaneous labour. Evidence suggests that IOL can improve obstetric outcomes, especially in the context of prolonged pregnancy, hypertensive disorders and prolonged rupture of membranes. Limited information is available on the quality of care received during IOL at district hospitals in South Africa. Aim: To audit the quality of care provided during IOL at district hospitals in the Cape Winelands District (CWD) of South Africa. Methods: An audit of the structure, process and outcomes of IOL performed at three district hospitals in the CWD. Retrospective data was collected from records of patients who underwent IOL at the district hospitals between 1 July 2021 and 31 December 2021. Results: This audit included 147 IOL cases. The IOL rate was 6.8 %. The most common indication for IOL was prolonged pregnancy (57.8%). Misoprostol was the induction agent of choice in 70,1 % of cases while mechanical IOL was performed in only 6.1% of cases. After IOL, 39.8 % of patients had a caesarean delivery. Vaginal delivery within 24-hours after starting IOL was achieved in 47.6% of cases. No cases of maternal or neonatal morbidity were recorded. Conclusion: Adequate structures were in place at the district hospitals to perform IOL, including the availability of medication, equipment and surgical capacity. The process of IOL did not fully align with the South African Maternity Care Guidelines regarding the correct use of the Bishop score and mechanical methods of IOL. Maternal and neonatal outcomes were satisfactory, however the high caesarean delivery rate after IOL and the low delivery rate within 24 hours after IOL were concerning.
Lifestyle modifications in hypertension : an assessment of reported adherence knowledge and attitudes at Mankayane Hospital, Swaziland
(Stellenbosch : Stellenbosch University, 2013-03) Murove, Casper Takura; Jenkins, Louis; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Background: Lifestyle modifications have been shown to lower blood pressure. Many guidelines recommend lifestyle modifications in the management of hypertension. Comprehensive adoption of the relevant lifestyle modifications has the greatest benefit. Methods: This was a cross-sectional descriptive study with a qualitative component. Information on adherence was collected from 227 participants, using a structured questionnaire utilising Likert scales. In-depth interviews to assess knowledge and attitudes were conducted. Interviews were recorded, transcribed verbatim and analysed. Results: Reported adherence to salt intake reduction and increased consumption of fruits and vegetables were 81.1% and 90.7% respectively. Reported adherence to exercise and weight reduction were 4.0% and 6.2% respectively. Reported adherence to alcohol intake reduction and smoking cessation were 50.6% and 56.5% respectively. The lifestyle modifications known by most participants were consumption of local vegetables, salt reduction, weight reduction and reduction of fats in the diet. The attitudes towards the recommended lifestyle modifications were mostly positive. Exercise in any form was reported as beneficial but time to exercise was a major limiting factor. Weight reduction was reported as difficult but possible. Salt reduction emerged as the most important lifestyle modification. Alcohol and smoking were reported to be addictive and difficult to stop. Increasing consumption of fruits and vegetables emerged as the easiest to adhere to. Conclusion: Reported adherences to exercise and weight reduction were very low whilst increased consumption of fruits and vegetables and salt reduction had fairly high reported adherences. Participants had more knowledge about increased intake of fruits and vegetables, salt reduction and weight reduction when compared to the other recommended lifestyle modifications. The attitude to the recommended lifestyle modifications was positive with the participants acknowledging that they are important in controlling blood pressure. Greater emphasis may be required on some lifestyle modifications where knowledge is lacking and different approaches may be required for each lifestyle modification so as to improve adherence.
Preventing venous thromboembolism at a district hospital : a quality improvement study
(Stellenbosch : Stellenbosch University, 2013-12) Beutel, Bernhard; Jenkins, Louis; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences
ENGLISH ABSTRACT: Background: Pulmonary embolism (PE) is the most common preventable cause of hospital deaths, and almost all hospitalised patients have at least one risk factor for venous thrombo-embolism (VTE). Despite the availability of highly effective thromboprophylaxis in prevent-ing VTE, numerous studies worldwide have demonstrated its under-utilization. The aim of this study was to review and improve the utilization of thromboprophylaxis in the prevention of VTE in hospitalized patients at Oudtshoorn district hospital. Method: A quality improvement cycle (QIC). Retrospective analysis of files of adult patients admitted to the male and female wards at Oudtshoorn district hospital was performed prior to and after a 5 month intervention phase. The target standards for the QIC were: 1) Availability of a written hospital policy on VTE prevention; 2) Every adult admission should have a for-mal VTE risk assessment documented; 3) Every adult admission who is at risk for VTE should receive thromboprophylaxis. Results: Thirty eight percent of adult patients admitted to Oudtshoorn hospital, excluding the maternity ward, were at risk of developing VTE. There was no written hospital policy on VTE prevention. This was developed and made available during the intervention. In the pre-intervention group there were no patients who had a documented VTE risk assessment. The post intervention group showed a considerable increase with 45.2% having had a completed VTE risk assessment on admission (p<0.00001). In the pre-intervention group only 4.6 per-cent of patients who were at risk of VTE received thromboprophylaxis. There was a statisti-cally significant difference in the number of patients at risk who received thromboprophylax-is in the post-intervention group where 36% of these patients received thromboprophylaxis (p<0.00001). Conclusions: The study identified a major shortcoming in the prevention of VTE in those patients at risk who were admitted to Oudtshoorn district hospital. An intervention as part of a quality improvement cycle has been able to demonstrate a significant improvement in the detection of patients who are at risk of VTE and a subsequent improvement in appropriate thromboprophylaxis. A number of barriers to their implementation have been identified and need to be addressed. This QIC may in time be of value to assist other district hospitals in addressing the issue of VTE prevention.
A review of the implementation of the prevention of mother-to-child transmission program in the George sub-district, Western Cape
(Stellenbosch : Stellenbosch University, 2012-03-15) Schaefer, Rachel; Jenkins, Louis; Stellenbosch University. Faculty of Health Sciences. Department of Interdisciplinary Health Sciences.
Introduction The most common cause for HIV infection in children in developing countries is the vertical transmission of HIV from mother to child. Without any intervention the vertical transmission rate from mother to child will be between 15-50%, depending on a number of factors. An effective prevention of mother-to-child transmission (PMTCT) program can dramatically reduce this transmission rate to as low as 2-5%. There appears to be a gap between PMTCT policy guidelines and actual implementation, and while the reasons for this are multi-factorial, one facet may be local shortfalls in the program. Aim: To review the implementation of the PMTCT program in the George sub-district for 2010. Objectives: To assess whether the PMTCT program is being conducted according to established provincial protocol; to describe possible local shortfalls in the PMTCT program; to make recommendations to improve the identified shortfalls. Methods A retrospective descriptive study, based on a record review of patient files, the PMTCT register, and birth registers in the labour ward of George provincial hospital. Every HIV positive pregnant woman from the George sub-district who delivered at the George provincial hospital obstetric unit during 2010 was included. Missing files and medical records were excluded. Data was collected from each record in the registers according to set criteria, and entered into a Microsoft Excel data sheet. Results 95% of women in the study had an HIV test at the clinic, and 93% had a CD4 count. This shows good initial uptake and acceptance of the program. However, 28% did not receive adequate antenatal PMTCT cover, 33% of patients who required highly active antiretroviral treatment (HAART) did not receive it, and 34% of women did not receive adequate PMTCT cover during labour. 86% of babies received their initial PMTCT medication within 72 hours of birth. The one month zidovudine treatment for babies (before October 2010) and six weeks nevirapine treatment (after October 2010) was not documented in 30% and 74% of cases respectively. Discussion While many aspects of the PMTCT program are being well applied in the George sub-district, there are significant shortfalls in the implementation of the program. These need to be addressed to ensure optimal prevention of HIV transmission from mother to child. Particular points which need to be focused on are improved record keeping, increasing the percentage of HIV positive women receiving adequate antenatal and intrapartum PMTCT, and increasing the percentage of HIV positive women receiving HAART.

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