Family Medicine and Primary Care

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A Medical audit of the management of cryptococcal meningitis in HIV patients in the Cape Winelands (East) district, Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2010-12) Von Pressentin, Klaus Botho; Conradie, Hoffie H.
ENGLISH ABSTRACT: Introduction: This thesis summarises the findings of a medical audit on the management of Cryptococcal Meningitis (CM). The study population of HIV positive adults (N = twenty five) were admitted during November 2009 – June 2010 to five hospitals of the Cape Winelands (East) District, Western Cape, South Africa. In the context of the HIV pandemic, CM has become the most common cause of community-acquired meningitis, and has poor outcomes if left untreated. The South African HIV Clinician Society has published treatment guidelines in 2007. These guidelines have been used by the audit team to compile a list of measurable criteria (with set targets) to evaluate the structure, process and outcome of CM management. A pilot audit (2008) at the regional hospital has demonstrated that certain target standards were not met. Aims and Objectives: The aim was to improve the quality of the clinical care of HIV-patients diagnosed with CM in the Cape Winelands (East) district. The objectives included the review of the audit criteria and target standards, demonstrating improvement in quality of CM care at the Level 1 and 2 hospitals, identifying new interventions based on the findings and providing recommendations to the health facilities. Methods In 2009, the researcher formed a new audit team, reviewed the audit criteria and held teaching interventions based on the national treatment guidelines. An intervention, based on the findings of the pilot audit, aimed at improving the clinical team’s adherence to the treatment guidelines. Results The audit identified the following areas that did not meet the target standards: the availability of Amphotericin B (Ampho B) and spinal manometers; the use of manometry in all initial lumbar punctures (LPs); completing fourteen days of the required Ampho B treatment; renal monitoring in patients on Ampho B; commencement of antiretroviral treatment (ART) by week four; and, the two-month survival figures post-diagnosis. The re-audit at the Level 2 hospital highlighted the need for improved medical record keeping to aid the audit process. Arrangement of inpatient ART counselling happened more consistently at the Level 1 hospitals. Adherence to the ART target and measures to prevent Ampho B related morbidity is comparable to that of the Level 2 hospital. The audit has also provided insight to the researcher and audit team on the practical challenges of conducting a prospective data collection technique across different care settings. Recommendations Level 1 hospitals should continue to manage CM patients. The availability of spinal manometers and closer adherence to renal monitoring require attention. Formal feedback to the audit team and clinical teams is planned. A multimodal interdisciplinary Quality Improvement approach (such as an integrated care pathway) is recommended and a future re-audit is encouraged to assess improved adherence to the CM management guidelines. The buy-in of stakeholders (management, health care workers and patients), the ongoing support of an audit team and a committed Quality Improvement environment will allow the medical audit process to become ingrained in the South African public healthcare setting.
The ability of health promoters to deliver group diabetes education in South African primary care
(AOSIS Publishing, 2013-04) Botes, Anna S.; Majikela-Dlangamandla, Buyelwa; Mash, Robert
ENGLISH SUMMARY : Background: Diabetes makes a significant contribution to the burden of disease in South Africa. This study assesses a group diabetes education programme using motivational interviewing in public sector health centres serving low socio-economic communities in Cape Town. The programme was delivered by mid-level health promotion officers (HPOs). Objectives: The aim of the study was to explore the experience of the HPOs and to observe their fidelity to the educational programme. 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 the motivational interviewing (MI) integrity code. 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, understandable and useful. The HPOs struggled with poor patient attendance and a lack of suitable space at the facilities. They delivered the majority of the content and achieved beginning-level proficiency in the MI guiding style of communication and the use of open questions. The HPOs did not demonstrate proficiency in active listening and continued to offer some unsolicited advice. Conclusion: The HPOs demonstrated their potential to deliver group diabetes education despite issues that should be addressed in future training and the district health services. The findings will help with the interpretation of results from a randomised controlled trial evaluating the effectiveness of the education.
Academy calls on South Africans to vaccinate
(AOSIS, 2021-10) Mash, Bob
Coronavirus disease 2019 (COVID-19) vaccine hesitancy in South Africa has been fuelled by conspiracy theories and misinformation. Unfortunately, some of this misinformation has come from health professionals, the most notable recent example being Dr Susan Vosloo, a cardiothoracic surgeon in Cape Town. However, family physicians have also been seen to promote unproven treatments such as ivermectin and even nebulised colloidal silver.
Acceptance of and adherence to full anti-retroviral therapy for prevention of mother to child transmission in HIV infected pregnant women with CD4 count above 350 at Nhlangano Health Centre, Swaziland.
(Stellenbosch : Stellenbosch University, 2018-03) Ndakit, Manighuli Kambasu; Blitz, Julia; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Epidemic of HIV infection is hitting Swaziland where the prevalence is among the highest in the world. Nhlangano Health Centre (NHC) in collaboration with Medecins Sans Frontiers Switzerland (MSF Switzerland) opted to hit early by starting Highly Active Anti-retroviral Therapy (HAART) among HIV infected pregnant women with CD4 count cells above 350. This new intervention raised concerns on acceptability and adherence which needed to be assessed. Study design: This was a descriptive study which explored the acceptance of and adherence of pregnant women to full anti-retroviral therapy at Nhlangano Health Centre in the period from 24th June 2014 to 23rd June 2015. The level of adherence was assessed by announced pill counts on subsequent visits. Then, 6 months after initiation, the viral load and a second CD4 count were determined. Results: 98 participants were recruited and initiated; one later died. 80.6% resided in the rural area. 80.6% attended secondary school. Majority were single (79.6%). Mean age was 25.4 years. 64.3% booked at 2nd trimester. Most were multiparous (75.5%). Mean haemoglobin was 11.1g/dl. After 6 months, mean CD4 count was 709.4 up from 554.4 (initial) and 66 (95.6%) had undetectable viral load risen from 14 (20.2%) at initiation. 69 participants (70.4%) were adherent to treatment; 3 (3.1%) of them failed to suppress completely the viral loads. 13 pregnant women refused HAART; of these 12 were interviewed and one declined. The rate of acceptance was 88.3%. Conclusion: Most of the HIV infected pregnant women who visited the clinic accepted the treatment, their CD4 count increased and had undetectable viral loads after 6 months. Anti-retroviral therapy is effective and can be successfully initiated in pregnant women with CD4 count above 350 but should be monitored closely to avoid loss to follow-up.
Adherence of HIV/AIDS patients to antiretroviral therapy in a district hospital in Nankudu, Namibia
(Stellenbosch : Stellenbosch University, 2014-04) Okebie, C. O.; Pather, Michael; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Background: Non-adherence to highly active antiretroviral therapy (HAART) is a strong predictor of progression to AIDS and death. It remains the most important potentially alterable factor that determines treatment outcome. AIM: The main purpose of this study is to determine the current frequency of adherence to HAART in a major HIV/AIDS treatment center in Nankudu District and to identify the local factors contributing to non-adherence. OBJECTIVES: To assess and measure the adherence to antiretroviral therapy. To assess and describe the defaulter rate To assess and describe the interruption rate To describe the local barriers to sub-optimal adherence in the sample patients Methods: The study was a descriptive survey of the below mentioned three methods used to assess adherence to HAART and the determination of local barriers to adherence. The three methods used to measure HAART adherence were: pill counts, pharmacy refill data and self-report. The participants CD4 counts and viral loads were also evaluated. It included a randomly selected sample of 225 adult patients receiving HAART treatment in the Communication for Disease Control (CDC)-HIV clinic of Nankudu district hospital of Namibia. Results: A total of 90% of the patients had an adherence >95% comparable to those reported in most sub-Saharan Africa. The major local barriers to adherence included: distance from clinic (100%), lack of food (100%), lack of money (100%), poverty (100%), occupational factors-migration (100%), travel (81%), ran out of medicine (69%), too busy (69%), medication side effects (56%), felt better ( 56%) and too sick (50%). The major reasons given by the treatment defaulters were similar to those given by the treatment interrupters except for stigma (100%), compared to 19% for the treatment interrupter. Conclusion: The level of HAART adherence in the Communication Diseases Control (CDC)- HIV Clinic, of Nankudu District Hospital in Namibia is comparable to those reported in most sub-Saharan Africa, which is the recommended 95%. The pattern of non-adherence is characterized by treatment defaulters and interrupters. The study revealed that there were more treatment interrupters than defaulters. Financial constraints, travel, running out of ARV medicine, food insecurity, poverty, distance from the clinic, were the major reasons given by the treatment interrupters, while occupational factors, lack of transport, stigma, and long distance of the health facility were the major reasons given by the treatment defaulters.
Adherence to antiretroviral therapy at the Dora Nginza Hospital adult wellness clinic, Port Elizabeth, South Africa
(Stellenbosch : University of Stellenbosch, 2015-04) Ajudua, Febisola Ibilola; Pather, Michael; Ford, Pelisa; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY: Background: Sub Saharan Africa is home to approximately two thirds of the world’s population of HIV positive individuals. In view of the socioeconomic challenges of the region governments have provided antiretroviral therapy free to improve chances of survival among patients. However, adherence to antiretroviral therapy is recognised as more important in predicting patient survival. Aim: The study aimed to describe the prevailing factors that influence adherence to antiretroviral therapy. Methods: The study design was carried out using three methods of data collection. Focus group discussions, semi structured interviews and a questionnaire format. Setting: This study has been conducted among adult patients attending the Dora Nginza Hospital Adult wellness clinic. Results: The methods highlighted factors that influence antiretroviral therapy revealing psychosocial factors – lack of family support, not wanting to take medicines in front of people outside the home; patient factors – co morbidities that disturb patient adherence to therapy, a lack of trust in the patient-care giver relationship, fear of the drug side effects; socioeconomic factors – patients’ inability to afford food or transport costs to clinic appointments. In the semi structured interviews, 25% of patients self reported on poor adherence while in the questionnaire 5% of patients reported poor adherence. In assessing the effect of adherence to therapy on CD4 count and viral load there was a general increase in CD 4 count and a drop in viral load indicating clinical improvement in patients on therapy. Recommendation: There is a need for clinicians developing a health relationship with patients to facilitate adherence. The interventions designed to help patients in adherence to therapy should involve the patients in question in the designing of these interventions. Conclusion: Adherence monitoring is an important aspect of managing patients on antiretroviral therapy. The factors highlighted are similar to findings of other studies in similar contexts i.e. resource poor settings.
Advance directives or living wills : reflections of general practitioners and frail care coordinators in a small town in KwaZulu-Natal
(Medpharm Publications, 2012) Bull, A. P. A.; Mash, B.
Background: Living wills have long been associated with end-of-life care. This study explored the promotion of living wills by general practitioners (GPs) and frail care nursing coordinators who were directly involved in the care of the elderly in Howick, KwaZulu-Natal. The study also explored their views regarding the pro forma living will disseminated by the Living Will Society. Subjects: Seven GPs and three frail care nursing coordinators; 10 in total. Design: The design was qualitative in-depth interviews and analysis, using the Framework method. Results: Both doctors and nursing staff understood the concept of living wills and acknowledged that they were beneficial to patients, their families and staff. They were concerned about the lack of legal status of the living will. They felt that the pro forma document from the Living Will Society was simple and clear. Despite identifying the low level of living will usage among patients, doctors and nursing staff felt that third-party organisations and individuals should promote living wills to patients, rather than promoting them to patients themselves. Conclusion: GPs and frail care nurse coordinators were knowledgeable about living wills in general, and the Living Will Society pro forma document in particular. They valued the contribution that living wills make to the care of the elderly, as they benefit patients, their families, healthcare workers and the health system. They also valued the pro forma living will document from the Living Will Society for its clarity and simplicity. However, the GPs and frail care nursing coordinators viewed the living will process as patient driven. They viewed their main role to be that of custodians, and not advocates, of the living wills.
Advance directives or living wills- some reflections from general practitioners and frail care coordinators in a small town in KwaZulu Natal
(Stellenbosch : Stellenbosch University, 2012-12) Bull, A. P. A.; Mash, Bob; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
Background: - Living wills have long been associated with end-of- life care. This study explored the promotion and use of living wills amongst general practitioners and frail care nursing coordinators directly involved in the care of the elderly in Howick, Kwa-Zulu Natal. The study also explored their views regarding the proforma living will disseminated by the Living Will Society. Participants: - Seven general practitioners and three frail care nursing coordinators, making ten in total. Design: - Qualitative in-depth interviews and analysis, using the Framework method. Results:- Both doctors and nursing staff understood the concept of living wills and acknowledged their varied benefits to patient, family and staff. They were concerned about the lack of legal status. They felt that the proforma document from the Living Will Society was simple and clear. Despite identifying the low level of use of living wills, they felt that third party organisations and individuals should promote living wills Conclusion: - GPs and frail care nurse coordinators were knowledgeable of living wills in general and the Living Will Society proforma document in particular. They valued the contribution that living wills can make in the care of the elderly, benefitting patients, their families, health care workers and even the health system. They also valued the proforma living will document from the Living Will Society for its clarity and simplicity. However, both GPs and frail care nursing coordinators viewed the living will process as patient- driven and their main role was as custodians and not advocates of the living will.
African leaders views on critical human resource issues for the implementation of family medicine in Africa
(BioMed Central, 2014-01) Moosa, Shabir; Downing, Raymond; Essuman, Akye; Pentz, Stephen; Reid, Stephen; Mash, Robert
ENGLISH ABSTRACT: Background: The World Health Organisation has advocated for comprehensive primary care teams, which include family physicians. However, despite (or because of) severe doctor shortages in Africa, there is insufficient clarity on the role of the family physician in the primary health care team. Instead there is a trend towards task shifting without thought for teamwork, which runs the risk of dangerous oversimplification. It is not clear how African leaders understand the challenges of implementing family medicine, especially in human resource terms. This study, therefore, sought to explore the views of academic and government leaders on critical human resource issues for implementation of family medicine in Africa. Method: In this qualitative study, key academic and government leaders were purposively selected from sixteen African countries. In-depth interviews were conducted using an interview guide. All interviews were audio-recorded, transcribed and thematically analysed. Results: There were 27 interviews conducted with 16 government and 11 academic leaders in nine Sub-Saharan African countries: Botswana, Democratic Republic of Congo, Ghana, Kenya, Malawi, Nigeria, Rwanda, South Africa and Uganda. Respondents spoke about: educating doctors in family medicine suited to Africa, including procedural skills and holistic care, to address the difficulty of recruiting and retaining doctors in rural and underserved areas; planning for primary health care teams, including family physicians; new supervisory models in primary health care; and general human resource management issues. Conclusions: Important milestones in African health care fail to specifically address the human resource issues of integrated primary health care teamwork that includes family physicians. Leaders interviewed in this study, however, proposed organising the district health system with a strong embrace of family medicine in Africa, especially with regard to providing clinical leadership in team-based primary health care. Whilst these leaders focussed positively on entry and workforce issues, in terms of the 2006 World Health Report on human resources for health, they did not substantially address retention of family physicians. Family physicians need to respond to the challenge by respondents to articulate human resource policies appropriate to Africa, including the organisational development of the primary health care team with more sophisticated skills and teamwork.
African primary care research : choosing a topic and developing a proposal
(AOSIS Publishing, 2014-02) Mash, Bob
This is the first in a series of articles on primary care research in the African context. The aim of the series is to help build capacity for primary care research amongst the emerging departments of family medicine and primary care on the continent. Many of the departments are developing Masters of Medicine programmes in Family Medicine and their students will all be required to complete research studies as part of their degree. This series is being written with this audience in particular in mind – both the students who must conceptualise and implement a research project as well as their supervisors who must assist them. This article gives an overview of the African primary care context, followed by a typology of primary care research. The article then goes on to assist the reader with choosing a topic and defining their research question. Finally the article addresses the structure and contents of a research proposal and the ethical issues that should be considered.
African primary care research : current situation, priorities and capacity building
(AOSIS Publishing, 2014-12) Mash, Robert; Essuman, Akye; Ratansi, Riaz; Goodyear-Smith, Felicity; Von Pressentin, Klaus; Malan, Zelra; Van Lancker, Marianne; De Maeseneer, Jan
Introduction: The Sixth PRIMAFAMED (Primary Health Care/Family Medicine Education Network) workshop on ‘Capacity Building and Priorities in Primary Care Research’ was held in Pretoria, South Africa (SA), from 22 to 24 June 2014. Delegates from the following countries attended the workshop: Ghana, Nigeria, Uganda, Kenya, Tanzania, Sudan, Malawi, Zimbabwe, Botswana, Namibia, SA, Zambia, Ethiopia, Rwanda, Mozambique, Swaziland, Belgium, and Denmark (Figure 1). Delegates were from established or emerging departments of family medicine and primary care in these countries. The central theme of the workshop was primary care research – the current situation, the priorities for research and the need for capacity building. This report gives a summary of the consensus on these matters that emerged from the workshop. The motivation for the conference was derived in part from the involvement of Professor Bob Mash (SA) and Professor Olayinka Ayankogbe (Nigeria) in the World Organization of Family Doctors (WONCA) Global Working Party on Primary Care Research, which has a goal of promoting primary care research.
African primary care research : participatory action research
(AOSIS Publishing, 2014-03) Mash, Bob
This article is part of the series on African primary care research and focuses on participatory action research. The article gives an overview of the emancipatory-critical research paradigm, the key characteristics and different types of participatory action research. Following this it describes in detail the methodological issues involved in professional participatory action research and running a cooperative inquiry group. The article is intended to help students with writing their research proposal.
African primary care research : performing a programme evaluation
(AOSIS Publishing, 2014-06) Dudley, Lilian
This article is part of a series on Primary Care Research in the African context and focuses on programme evaluation. Different types of programme evaluation are outlined: developmental, process, outcome and impact. Eight steps to follow in designing your programme evaluation are then described in some detail: engage stakeholders; establish what is known; describe the programme; define the evaluation and select a study design; define the indicators; plan and manage data collection and analysis; make judgements and recommendations; and disseminate the findings. Other articles in the series cover related topics such as writing your research proposal, performing a literature review, conducting surveys with questionnaires, qualitative interviewing and approaches to quantitative and qualitative data analysis.
African primary care research : performing surveys using questionnaires
(AOSIS Publishing, 2014-05) Govender, Indiran; Mabuza, Langalibalele, H.; Ogunbanjo, Gboyega, A.; Mash, Bob
The aim of this article is to provide practical guidance on conducting surveys and the use of questionnaires for postgraduate students at a Masters level who are undertaking primary care research. The article is intended to assist with writing the methods section of the research proposal and thinking through the relevant issues that apply to sample size calculation, sampling strategy, design of a questionnaire and administration of a questionnaire. The article is part of a larger series on primary care research, with other articles in the series focusing on the structure of the research proposal and the literature review, as well as quantitative data analysis.
African primary care research : qualitative data analysis and writing results
(AOSIS Publishing, 2014-06) Mabuza, Langalibalele H.; Govender, Indiran; Ogunbanjo, Gboyega, A.; Mash, Bob
This article is part of a series on African primary care research and gives practical guidance on qualitative data analysis and the presentation of qualitative findings. After an overview of qualitative methods and analytical approaches, the article focuses particularly on content analysis, using the framework method as an example. The steps of familiarisation, creating a thematic index, indexing, charting, interpretation and confirmation are described. Key concepts with regard to establishing the quality and trustworthiness of data analysis are described. Finally, an approach to the presentation of qualitative findings is given.
African primary care research : qualitative interviewing in primary care
(AOSIS Publishing, 2014-06) Reid, Steve; Mash, Robert
This article is part of a series on African Primary Care Research and focuses on the topic of qualitative interviewing in primary care. In particular it looks at issues of study design, sample size, sampling and interviewing in relation to individual and focus group interviews. There is a particular focus on helping postgraduate students at a Masters level to write their research proposals.
African primary care research : quality improvement cycles
(AOSIS Publishing, 2014-04) Van Deventer, Claire; Mash, Bob
Improving the quality of clinical care and translating evidence into clinical practice is commonly a focus of primary care research. This article is part of a series on primary care research and outlines an approach to performing a quality improvement cycle as part of a research assignment at a Masters level. The article aims to help researchers design their quality improvement cycle and write their research project proposal.
African primary care research : quantitative analysis and presentation of results
(AOSIS Publishing, 2014-06) Mash, Bob; Ogunbanjo, Gboyega, A.
This article is part of a series on Primary Care Research Methods. The article describes types of continuous and categorical data, how to capture data in a spreadsheet, how to use descriptive and inferential statistics and, finally, gives advice on how to present the results in text, figures and tables. The article intends to help Master’s level students with writing the data analysis section of their research proposal and presenting their results in their final research report.
African primary care research : reviewing the literature
(AOSIS Publishing, 2014-02) Ross, Andrew; Mash, Bob
This is the second article in the series on African primary care research. The article focuses on how to search for relevant evidence in the published literature that can be used in the development of a research proposal. The article addresses the style of writing required and the nature of the arguments for the social and scientific value of the proposed study, as well as the use of literature in conceptual frameworks and in the methods. Finally, the article looks at how to keep track of the literature used and to reference it appropriately.
African primary care research : writing a research report
(AOSIS Publishing, 2014-06) Couper, Ian; Mash, Bob
Presenting a research report is an important way of demonstrating one’s ability to conduct research and is a requirement of most research-based degrees. Although known by various names across academic institutions, the structure required is mostly very similar, being based on the Introduction, Methods, Results, Discussion format of scientific articles. This article offers some guidance on the process of writing, aimed at helping readers to start and to continue their writing; and to assist them in presenting a report that is received positively by their readers, including examiners. It also details the typical components of the research report, providing some guidelines for each, as well as the pitfalls to avoid. This article is part of a series on African Primary Care Research that aims to build capacity for research particularly at a Master’s level.