Browsing by Author "Dudley, Lilian Diana"

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    Continuity of care for TB patients at a South African hospital : a qualitative participatory study of the experiences of hospital staff
    (Public Library of Science, 2019-09-18) Marais, Frederick; Kallon, Idriss Ibrahim; Dudley, Lilian Diana
    Background: Ensuring effective clinical management and continuity of TB care across hospital and primary health-care services remains challenging in South Africa. The high burden of TB, coupled with numerous health system problems, influence the TB care delivered by hospital staff. Objective: To understand factors from the perspectives of hospital staff that influence the clinical management and discharge of TB patients, and to elicit recommendations to improve continuity of care for TB patients. Design: Participatory action research was used to engage hospital staff working with TB patients admitted to a central public hospital in the Western Cape province, South Africa. Data were collected through eight focus group discussions with nurses, junior doctors and ward administrators. Data analysis was done using Miles and Huberman’s framework to identify emerging patterns and to develop categories with themes and sub-themes. The participants influenced all phases of the research process to inform better practices in TB clinical management and discharge planning at the hospital. Results: The emerging themes and sub-themes were categorized into two overall sections: The clinical care management process and the discharge and referral process. Nurses expressed a fear of exposure to TB and MDR-TB due to challenges in clinical and infection-prevention control. Clinical hierarchies, poor interdisciplinary teamwork, limited task shifting and poor communication interfered with effective clinical and discharge processes. A high workload, staff shortages and inadequate skills resulted in insufficient information and health education for TB patients and their caregivers. Despite awareness of the patients’ socio-economic challenges, some aspects of care were not patient-centered, and caregivers were not included in discharge planning. Communication between the hospital and referral points was inefficient and poorly supported by information systems. Hospital staff recommended improved infection prevention and control practices and interdisciplinary teamwork in the hospital, that TB education for patients be integrated with hospital staff functions, with more patient-centered discharge planning, and improved communication across hospitals and primary health care levels. Conclusions: Interdisciplinary teamwork, more patient-centered care, and better communication within the hospital and with primary health-care services are needed for improved continuity of care for TB patients. Further studies on factors contributing to, and interventions to improve, continuity of TB care in similar hospital settings are needed.
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    Continuity of care for tuberculosis patients between hospital and primary health care services in South Africa
    (Stellenbosch : Stellenbosch University, 2020-03) Dudley, Lilian Diana; Volmink, Jimmy; Zwarenstein, Merrick; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems & Public Health.
    ENGLISH ABSTRACT : Many tuberculosis (TB) patients in South Africa are admitted to acute care hospitals, but large numbers are lost to care after discharge, and few complete their TB treatment. This contributes to ongoing transmission of TB in communities, frequent hospital readmissions, a high mortality rate and avoidable costs to the health system and society. This thesis studied continuity of care for TB patients discharged from hospital in South Africa. It aimed to describe the problem, identify risk factors for poor continuity of care, synthesise evidence to inform, implement and evaluate an intervention, and produce a policy brief to translate the evidence into policy and practice. The research methods included an observational study, research synthesis, qualitative research, participatory action research, a quasi-experimental study as well as knowledge translation methods to address the various research questions. The study found that a third of TB patients discharged from hospital did not continue TB treatment, and that inadequate clinical management of TB patients in hospital showed a significant correlation with poorer continuity of care and an increased mortality rate. Evidence of strategies to improve continuity of care for chronically ill patients was identified in high-income countries, but no such evidence could be found for TB patients in low and middle-income countries. Using the available evidence and participatory action research, a multicomponent discharge planning and support intervention was designed and implemented in collaboration with a referral hospital in the Western Cape. A before-and-after evaluation found that continuity of care for TB patients improved significantly after implementing the intervention. A process assessment revealed that the characteristics of the intervention, the external context, the persons involved and the methods of implementation had a favourable impact on implementation. Yet the internal context of the hospital was unfavourable for implementation, and in-hospital intervention activities were not sustained. In contrast, information linkages and community-based follow-up and support of TB patients continued. More rigorous studies of interventions to improve continuity of care for TB patients discharged from hospital in similar settings are required. This should be complemented by implementation research to understand and address health systems challenges. Both types of research are needed to effectively translate evidence into practice in the health systems of low and middle-income countries.