Masters Degrees (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.
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- 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.
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.
Antibiotics stewardship in diarrheal cases amongst children under 5 years in primary care settings in Maseru District, Lesotho
(Stellenbosch : Stellenbosch University, 2019-12) Wa Kone, Olga Kone; Malan, Zelra; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : No abstract available.
Are we ready for an emergency
(Stellenbosch : Stellenbosch University, 2012-12) Adamson, Kaashiefah; Hill, Paul; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
Introduction Trauma and emergencies contribute to the quadruple burden of disease in South Africa and being prepared for an emergency requires rapid access to emergency equipment, drugs and emergency trolleys to optimally manage an emergency. This is the first descriptive study looking specifically at essential emergency equipment, drugs and the emergency trolley required for the provision of optimal emergency care at Community Health Centres (CHCs) in the Western Cape Metropole. Aims and Objectives The aim of the study was to evaluate whether eight 24 hour emergency units at CHCs in the Western Cape Metropole had the appropriate and essential emergency equipment, drugs and emergency trolleys necessary for the delivery of optimal emergency care, using the Emergency Medicine Society of South Africa (EMSSA) guidelines as the audit tool. Objectives included: 1. To assess availability of essential emergency equipment 2. To assess availability of essential emergency drugs 3. To assess the functionality of existing emergency trolleys Methodology EMSSA guidelines were used as the evaluation audit tool to perform a survey of emergency equipment, drugs and emergency trolleys at eight 24 hour CHCs in the Western Cape Metro pole. Data collection for the study was conducted at the eight 24 hour CHCs over a 3 month period during the months of June 2012 to August 2012. The data was analyzed using the Statistical Package for Health Sciences (Statistica, version 10 of 2012) and Microsoft Excel. Results A total of 81 emergency equipment items, 43 emergency drug items (37 emergency drugs, 6 intravenous fluids) and 78 emergency trolley items were required to be in each emergency unit. An average of 62% of all recommended emergency equipment items, 80% of all emergency drugs and 52.4% of all emergency trolley items were found to be present in this survey. Essential emergency paediatric equipment including bag ventilation devices, Magill’s forceps, masks, intraosseous needles and appropriate blood pressure cuffs were found to be absent at 2 CHCs. All CHCs had access to a defibrillator and ECG machine but these were found to be dysfunctional at 2 CHCs due to expired batteries and no tracing paper being available. Expired first line emergency drugs (adrenaline and atropine) were found at certain CHCs. The recording of emergency trolley checklists and stocking of essential emergency items were found to be incongruent, inconsistent and not up to the recommended standard. Conclusion Essential emergency equipment and drugs and the functionality of emergency trolleys were found to be generally inadequate. Considerable deficiencies of essential emergency items were found, particularly paediatric equipment and drugs and this may negatively impact on resuscitative efforts and outcome in both paediatric and adult emergency care at CHCs in the Western Cape Metropole.
Assessing the validity of random blood glucose testing for monitoring glycemic control and predicting HbA1c values in type 2 diabetics at Karl Bremer Hospital
(Stellenbosch : University of Stellenbosch, 2015-07-23) Oyekemi Funke, Daramola; Bob, Mash; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences
ENGLISH ABSTRACT : The number of adults affected by diabetes mellitus in developing countries, such as South Africa, is projected to grow by 170%, from 84 to 228 million people between 1995 and 2025 .This high and increasing prevalence of diabetes worldwide, and the economic burden of diabetes on developing countries like South Africa emphasizes the importance of ensuring good glycemic control so as to slow down the rate of disease progression and prevent complications. The district health care facilities are the foundation of the health care system of South Africa. The current practice is that diabetics have a point of care random blood glucose (RBG) done on the morning of their clinic appointment and this is used as a form of assessment of glycemic control during the consultation. For further clinical decision making a HbA1c is done once a year as a benchmark of glycemic control. The practical clinical question that arises is whether the assumptions underlying local clinical decision making using the RBG are valid and to what extent RBG can be used to guide clinical management. Aim and Objectives: The aim of this study was to assess the strength of the correlation between RBG and HbA1c and to make recommendations for the interpretation of RBG results in adult patients with Type 2 Diabetes taken at Karl Bremer District Hospital out-patient department. The objectives were: To determine glycaemic control in the study population and compare differences between age, sex and racial groups , and determine the RBG cut-off with the best sensitivity and specificity for predicting poor glycaemic control (HbA1c>7.0% ) as well as the predictive value, likelihood ratio and pre/post-test odds and probability at this cut off. Methods: A retrospective analysis of existing hospital data and the HbA1c tests requested from the NHLS by Karl Bremer Hospital over the 2011 year period. The data was analysed by means of a receiver operating characteristic (ROC) curve analysis to determine the value of RBG with the best combination of sensitivity and specificity to predict poor control of diabetes. A p-value of < 0.05 was assumed to represent statistical significance and 95% confidence intervals were used to describe the estimation of unknown parameters. HbA1c level of < = 7% was taken as representing good control and > 7% poor control. Results: Data was obtained on 349 diabetic patients of whom 203 (58.2%) were female and 146 (41.8%) male. This study population had a mean age of 54.7 years, mean RBG of 13.0mmol/l and mean HBA1c of 9.4%. The total number of black patients was 79 (23%), coloured patients 147 (42%) and white patients 122 (35) % and their mean RBG were 15.4 mmol/l, 12.8 mmol/l and 11.9 mol/l respectively. There was a statistically significant correlation between increasing RBG and increasing HbA1c (p< 0.01). The best value obtained on the ROC curve was an RBG of 9.8 mmol/l, which had a sensitivity of 77% and a specificity of 75%, positive predictive value of 0.88, positive likelihood ratio 3.08 and post-test probability of 88.2% for predicting an HbA1c above 7%. Conclusion: It was concluded that a moderate correlation exists between RBG and HbA1c in this population of diabetic patients. .The best RBG for determining poor control, defined as a HbA1c>7.0%, was found to be 9.8mmol/l and this RBG had a sensitivity of 77% , specificity of 75% and positive predictive value of 88%. Significant differences were found in pre- and post -test probability for different racial groups. Point of care testing using this level of RBG for clinical decision making will inappropriately categorise 23% of patients in this population and therefore introducing point of care testing for HbA1c is recommended.
Assessing the validity of random blood glucose testing for monitoring glycemic control and predicting HbA1c values in type 2 diabetics at Karl Bremer hospital
(Stellenbosch : Stellenbosch University, 2012-12) Daramola, Oyekemi Funke; Mash, R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH ABSTRACT: Background: The number of adults affected by diabetes mellitus in developing countries, such as South Africa, is projected to grow by 170%, from 84 to 228 million people between 1995 and 2025 .This high and increasing prevalence of diabetes worldwide, and the economic burden of diabetes on developing countries like South Africa emphasizes the importance of ensuring good glycemic control so as to slow down the rate of disease progression and prevent complications. The district health care facilities are the foundation of the health care system of South Africa. The current practice is that diabetics have a point of care random blood glucose (RBG) done on the morning of their clinic appointment and this is used as a form of assessment of glycemic control during the consultation. For further clinical decision making a HbA1c is done once a year as a benchmark of glycemic control. The practical clinical question that arises is whether the assumptions underlying local clinical decision making using the RBG are valid and to what extent RBG can be used to guide clinical management. Aim and Objectives: The aim of this study was to assess the strength of the correlation between RBG and HbA1c and to make recommendations for the interpretation of RBG results in adult patients with Type 2 Diabetes taken at Karl Bremer District Hospital out-patient department. The objectives were: To determine glycaemic control in the study population and compare differences between age, sex and racial groups , and determine the RBG cut-off with the best sensitivity and specificity for predicting poor glycaemic control (HbA1c>7.0% ) as well as the predictive value, likelihood ratio and pre/post-test odds and probability at this cut off. Methods: A retrospective analysis of existing hospital data and the HbA1c tests requested from the NHLS by Karl Bremer Hospital over the 2011 year period. The data was analysed by means of a receiver operating characteristic (ROC) curve analysis to determine the value of RBG with the best combination of sensitivity and specificity to predict poor control of diabetes. A p-value of < 0.05 was assumed to represent statistical significance and 95% confidence intervals were used to describe the estimation of unknown parameters. HbA1c level of < = 7% was taken as representing good control and > 7% poor control. Results: Data was obtained on 349 diabetic patients of whom 203 (58.2%) were female and 146 (41.8%) male. This study population had a mean age of 54.7 years, mean RBG of 13.0mmol/l and mean HBA1c of 9.4%. The total number of black patients was 79 (23%), coloured patients 147 (42%) and white patients 122 (35) % and their mean RBG were 15.4 mmol/l, 12.8 mmol/l and 11.9 mol/l respectively. There was a statistically significant correlation between increasing RBG and increasing HbA1c (p< 0.01). The best value obtained on the ROC curve was an RBG of 9.8 mmol/l, which had a sensitivity of 77% and a specificity of 75%, positive predictive value of 0.88, positive likelihood ratio 3.08 and post-test probability of 88.2% for predicting an HbA1c above 7%. Conclusion: It was concluded that a moderate correlation exists between RBG and HbA1c in this population of diabetic patients. .The best RBG for determining poor control, defined as a HbA1c>7.0%, was found to be 9.8mmol/l and this RBG had a sensitivity of 77% , specificity of 75% and positive predictive value of 88%. Significant differences were found in pre- and post -test probability for different racial groups. Point of care testing using this level of RBG for clinical decision making will inappropriately categorise 23% of patients in this population and therefore introducing point of care testing for HbA1c is recommended.
The assessment of acceptance and identification of barriers to use of electronic medical records by doctors in emergency centres in Cape Town, South Africa
(Stellenbosch : Stellenbosch University, 2017-12) Chagani, Mohamedsuhel; Allgaier, Rachel; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Introduction: Millions of people in developing countries face serious health risks. It is believed that incorporating technology into healthcare is one way to overcome some of these challenges faced by developing countries. However, acceptance of electronic medical records (EMRs) into daily practice has been poor despite these potential advantages. In order to realise the potential benefits from EMR technologies, they must be adopted broadly and assimilated deeply across healthcare settings. The study aimed to assess acceptance and barriers to use prior to implementation of EMRs. Methods: The Unified Theory of Acceptance and Use of Technology model was used to assess technology acceptance. A self-administered questionnaire-based survey was sent to emergency centre (EC) doctors working in district hospitals in the Cape Town metropolis. Results: With a 73% (n=105) response rate, participants believed that EMRs would be both useful in their practice and improve their productivity. Almost 50% (n=51) of participants felt that they would find EMRs easy to use and approximately 60% (n=61) felt they would receive management support. However, the participants felt that the necessary resources would not be available for success, specifically a lack of financial investment, training and support as well as poor infrastructure and project management skills. Conclusion: The study overall indicates that the majority of doctors are willing to use EMRs in their daily practice. Barriers to successful implementation were similar to those found in similar studies conducted in other environments, and include financial, technical and change process barriers. There is a need to conduct further studies involving other cadres of staff including ECs where EMRs are already in use.
Assessment of the impact of family physicians in the district health system of the Western Cape, South Africa
(Stellenbosch : University of Stellenbosch, 2015-12) Ferreira, Germarie; Mash, Bob; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
The main aim was to explore the perceptions of rural district and metropolitan sub-structure managers on the impact of family physicians on the district health services. There were three main objectives: •To explore the perceived effect of Family Physicians on the health system performance (e.g. access to care, continuity of care, comprehensiveness of care, co-ordination of care)(27) •To explore the perceived effect of the Family Physicians on clinical processes (e.g. quality of care for HIV/AIDS, TB, maternal and child healthcare, non-communicable diseases, trauma) •To explore the perceived effect of Family Physicians on health outcomes (e.g. facility level mortality) Conclusion It was perceived that family physicians were fulfilling the role of competent clinician, consultant and leader of clinical governance well. Their role as a champion of community orientated primary care and as a clinical teacher was much less developed. They seemed to have a positive impact on the clinical processes for non-communicable chronic diseases, HIV and TB, mental health, eye care, child health and obstetrics. A few concerns were expressed about their skills in anaesthetics and surgery at rural hospitals. Access, co-ordination, comprehensiveness and efficiency of the health system were positively impacted. It was anticipated that in the long run health outcomes will be positively impacted.
Assessment, diagnosis and management of pulmonary tuberculosis in children under five years of age in the Langeberg sub-district, Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2020-12) Williams, Andrew; Pather, Michael Karl; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Background: TB remains one of the top 10 leading causes of death worldwide as millions of people still contract the disease annually. It is estimated that TB caused between 1.2 and 1.4 million deaths globally in 2017. The incidence of TB in children is a reflection of the underlying factors that fuel the TB epidemic, as these infections reflect ongoing TB-transmission. Aim: To describe how the diagnosis of Pulmonary Tuberculosis (PTB) in children under 5 years is made in the Langeberg sub-district. Setting: The Langeberg sub-district includes Robertson and Montagu District Hospitals as well as their surrounding clinics. A total of nine primary healthcare (PHC) clinics as well as two mobile clinics serving the farm areas in the sub-district were included. Methods: A retrospective descriptive study was conducted. The researcher obtained statistics from the information management department of the Langeberg sub-district and utilised information of all known and notified cases of tuberculosis in the district. All cases of PTB diagnosed from 1st January 2018 to 31st December 2018, in children under 5 years of age were included. Results: A total sample of 166 folders were reviewed. A proven positive adult contact was identified in 39% of cases. A suggestive chest x-ray was found in 93,4% of cases although specific CXR findings were not documented. Gastric washings were done in 52 of the children and had a positive yield of 13%. A total of 4,7% had HIV/TB co-infection and 12% had comorbid malnutrition. 85,5% of children had a positive treatment outcome (treatment completed or cured). Conclusion: The diagnosis of PTB in children primarily remains a radiological diagnosis, but clinical factors like symptoms and their duration, weight trends and the presence of an adult contact have also been considered. Microbiological confirmation was absent in the majority of cases started on TB treatment. Comorbid HIV infection, malnutrition or asthma did not contribute to increased risk for adverse outcomes. Contact tracing needs to be improved within the sub-district.
At what cost? A descriptive study evaluating cost awareness of laboratory investigations in doctors working in district hospitals in the West Coast and Cape Winelands districts
(Stellenbosch : Stellenbosch University, 2019-12) Brownbridge, Joshua; Pather, Michael; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Background: Globally the cost of health care is steadily increasing, and in South Africa it is no different. The budget for health care in the 2018 / 2019 financial year is R205 billion and is expected to increase by 7.8%. International research has found cost awareness amongst doctors to be poor and there is limited research in the South Africa. Improving cost awareness amongst clinicians has shown to have a cost saving effect. Aim: To evaluate cost awareness of laboratory investigations among doctors working in district hospitals in the West Coast and Cape Winelands Districts. Setting: Nine district hospitals within the West Coast and Cape Winelands Districts. Methods: A descriptive cross-sectional study in the form of a questionnaire was used. This questionnaire was adapted from previous international research. Results: A response rate of ninety percent was obtained. Doctors accurately estimated cost in 23.53% (95% CI 21.09 – 25.97) of thirty commonly requested investigations. Age, gender, years of experience, position held, and district of practice had no significant impact on cost awareness. On a scale of ten, doctors rated their cost awareness as 5.48, previous training 3.00, access to information on cost as 4.88, cost influencing their decision making as 6.73 and increasing cost awareness would change their ordering as 7.58. Conclusion: Cost awareness was found to be poor amongst doctors working in the West Coast and Cape Winelands and was uninfluenced by their demographic factors. Doctors acknowledged this, however, and reported that they had received minimal cost awareness training and that they had limited access to information about cost.
Attitudes and perceptions of doctors and clinical nurse practitioners regarding the HIV patient
(Stellenbosch : Stellenbosch University, 2010-12) Wenteler, Anri; Conradie, Hoffie; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Seven point seven percent of the population in the Boland Overberg Region is HIV positive.23 Attitudes of Health Care Workers (HCWs) impact on the quality of care given to HIV positive patients. This study explores the attitudes and perceptions of doctors and clinical nurse practitioners towards the healthy HIV patient. Thirteen in-depth interviews, including doctors and Clinical Nurse Practitioners (CNPs), from a variety of departments and levels of experience were done over six months using the Q-sort instrument6 as the basis for these interviews. Interviews were transcribed and themes identified using the cut and paste method. Twelve themes were identified namely; Anti retro viral drugs (ARVs), complexity, perceived ability, prognosis, prejudice, perceived risk of infection, anger, children, distancing, patient relationships, making a difference and obligation. ARVs, while improving the health and prognosis of patients, also cause complications in patients. HIV patients were perceived to be more complex than others due to an increased incidence of infections, complications and uncommon presentations. Several respondents felt capable of managing HIV patients and knew where to refer while others perceived themselves to have a lack of knowledge. Most respondents viewed HIV as a chronic (manageable but not curable) disease. A shortening of life expectancy of ten years were expected. Prejudice regarding patients was due to heterosexual behaviour. Men were viewed much more negatively while women and children were seen as innocent. A fear of being stigmatised if the HCW became positive was shown. All respondents showed a change in behaviour due to perceived risk of infection, either by being more cautious or taking precautions. Anger was expressed regarding defaulters and failure to prevent infection. Children were viewed with sadness and anger towards the mother. Some respondents felt a need to emotionally distance themselves from patients while others built a relationship with patients. Several respondents felt they were making a difference in the lives of HIV patients. Two thirds of the respondents’ attitudes were generally positive.
Attitudes to sexual coercion and rape within the Anglican Church, Cape Town: a cross sectional survey
(Stellenbosch : Stellenbosch University, 2012-03) Okwuosa, Odili Sabastine; Mash, Bob; Mash, Rachel; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Introduction: In South Africa 5.6-5.9 million people are currently living with HIV/AIDS, making South Africa the country in the world with the largest number of people living with HIV/AIDS. Despite numerous government measures to curb the pandemic, the prevalence and deaths due to HIV/AIDS have continued to rise to unacceptable levels. South Africa is reported to have one of the highest rates of sexual violence in the world and has the worst known figures for gender–based violence for a country not at war. Violence and coercive practices have been found to dominate sexual relationships in South Africa. Male dominance in sexual relationships as well as the role of traditional masculinity has made women vulnerable and encouraged the spread of HIV/AIDS. Church attendance has been found to have an inverse relationship with domestic violence. This implies that the church through its community engagement could assist with reducing gender based violence and sexual coercion. Aims & Objectives: To determine to what extent the Anglican Church in the Cape Town Diocese is contributing to or challenging rape-supportive attitudes, sexual coercion and gender inequality. Specific objectives were: 1) To determine the beliefs, values and attitudes relevant to rape, sexual coercion and gender inequalities amongst people attending the Anglican Church in the Diocese of Cape Town: clergy, leaders and members of the church. 2) To make recommendations to the church regarding any specific issues that the church should address through its gender desk or other structures. Method: A cross sectional survey, which collected quantitative data. Study population was members of the Anglican Church from the 48 churches within the Diocese of Cape Town. 21churches were selected by simple random sampling that was stratified in terms of the membership numbers and predominant racial composition of the congregation. All people who attended the church on the study day were asked to complete a questionnaire. The data was analysed using Statistica version 8 with the help of the Centre for Statistical Consultation at Stellenbosch University. Results: There were 581 respondents from 21 churches of which 380 were females (65.4%), 184 were males (31.1%) and 17 (2.9%) did not indicate their gender. In general, the Anglican Church in the Diocese of Cape Town espoused progressive attitudes that did not create an environment conducive to sexual coercion, gender violence and rape. For instance, 98.8% of respondents disagreed that a man has good reason to hit his partner if she does not complete her housework to his satisfaction. 94.9% of respondents agreed that the church leadership considers rape and domestic violence to be important, while 98.3% of respondents disagreed that it is okay for a man to have multiple partners. However, the survey did show some potentially discriminatory attitudes amongst the church members towards those living with HIV and that different archdeaconries have different degree of openness in dealing with issues of rape, divorce, marriage and domestic violence. More than half of the respondents agreed that it is okay for a man to ask for a divorce or separation when he is afraid that the partner may infect him with HIV while two-third of respondents agreed that a woman could also do so for the same reason. Conclusion: In general the Anglican Church in the Diocese of Cape Town espoused progressive attitudes towards sexual coercion, rape and domestic violence that stand in contrast to more conservative and discriminatory attitudes reported in other denominations and African countries. Churches were willing to talk openly about the issues and to offer practical support and counselling. This implies that this faith based organization may be a useful ally in addressing these issues in South African society.
Attitudes, perceptions and understanding amongst teenagers regarding teenage pregnancy, sexuality and contraception in Taung
(Stellenbosch : University of Stellenbosch, 2009-12) Kanku, T.; Mash, Bob; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH ABSTRACT: Background Teenage pregnancy is a socio-economic challenge and an important public health problem for communities in South Africa. Teenage pregnancy is a risk factor for disruption of education, unemployment, sexually transmitted infections, HIV, preterm birth and poor mental health. In the rural town of Taung, North-West Province, the teenage pregnancy rate is approximately 13% and this study aimed to explore the attitudes and perceptions of teenagers regarding teenage pregnancy and to explore their understanding of sexuality and contraception. Methods A qualitative study involving 13 in-depth interviews with pregnant teenagers and 3 focus groups with women aged 19 -25 years who had a baby as a teenager, teenage girls aged 14-19 years who had never been pregnant and males aged 14-25 years. Results Factors influencing teenage pregnancy were found to be broad and complex: 1) Socio economic factors included poverty, the controversial influence of the child support grant, trans-generational sex and financial support from older partner to secure income for the teenage girl or her family. 2) Substance abuse, particularly alcohol, in either the teenager or her parents was found to have a critical influence. A lack of alternative entertainments and social infrastructure made taverns a normal part of teenage social life. 3) Peer pressure from boyfriends and the broader social network. 4) Other factors included the right to motherhood before catching HIV, poor sexual negotiation skills, the need to prove one’s fertility, sexual coercion and low self-esteem and hope. Understanding of contraceptives and reproductive health was poor, condoms were the contraceptive method most known by teenagers and their understanding of the menstrual cycle was inaccurate. Most teenagers perceived falling pregnant as a negative event with consequences such as unemployment, loss of boyfriend, blame from friends and family members, feeling guilty, difficulty at school, complications during pregnancy or delivery, risk of HIV, secondary infertility if abortion is done and not being prepared for motherhood. A number of teenagers however perceived benefits and saw that it could be a positive event depending on the circumstances. Conclusion Social cognitive theory provides a useful framework to make sense of the various factors uncovered in this study that influence behaviour leading to teenage pregnancy. A model utilizing this theory is presented. Strategies to reduce teenage pregnancy should focus on building social capital for teenagers in communities, exploring further the influence of the child support grant, targeting trans-generational sexual norms, applying the law on underage drinking, making information on contraception more accessible and offering programmes that empower girls in the area of sexuality. Multifaceted and inter-sectoral approaches are required and it is likely that strategies to reduce teenage pregnancy will also impact on HIV and other sexually transmitted infections.
Barriers and enablers to implementation of Botswana’s national maternal mortality reduction guidelines : a qualitative study
(Stellenbosch : Stellenbosch University, 2017-12) Mogatle, Mothusi; Blitz, Julia; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Introduction: Like in many low-and-middle income countries, maternal mortality remains a challenge to Botswana. A number of initiatives such as maternal mortality audit with generation of recommendations, development of guidelines and occasional issuing of clinical directives have not resulted in the desired change. Factors such as staff attitude, lack of administrative or management commitment are often postulated as possible reasons, but these have not been well researched locally. The aim of this study was to explore the context specific attitudes and experiences of managers and health professionals towards the implementation of maternal mortality reduction guidelines in Botswana. Methods: Face to face interviews (Exploratory Qualitative Study) using pre-developed semi-structured questions was undertaken in 4 district hospitals in Botswana. A non-probability sampling technique was used to select both the study sites and the informants. Two facilities with no significant decrease in maternal mortality cases and two which have been recording fewer cases in the recent past were selected. Content data analysis was done with the help of Atlas.ti. Results: Effective change in the health system can broadly be divided into four areas; policy, administration, clinical practice and training. Some of the policy related issues noted were; shortage of staff and equipment, staff distribution and movement. Both study groups were equally affected by these issues, but facilities with lower maternal mortality seemed to have developed better coping mechanism. Administratively, long standing unresolved issues such as erratic stocking levels, weaker disciplinary procedures, limited services at some facilities etc. were reported. Generally, the staff morale was reported to below, mainly due to these unresolved administrative issues. Fewer administrative issues were reported at facilities with lower mortality. Regarding clinical practise, both clinicians and managers were well aware of the guidelines. Variable patient monitoring before, during and after delivery, poor team work, too much or repetitive documentation, were commonly reported. Under training; lack of concrete, consistent on-going learning among healthcare workers was more pronounced at facilities with higher maternal mortalities. Conclusion: Findings from this study revealed that unresolved administrative issues compounded by policy related issues were noted as the main barriers to implementation of the various guidelines. Furthermore, addressing staff welfare/concerns, negatives attitudes and investing on on-going learning were noted as areas which could enable effective guidelines’ implementation.
Beliefs and attitudes to obesity, its risk factors and consequences in a Xhosa community : a qualitative study
(Stellenbosch : Stellenbosch University, 2012-12) Akinrinlola, Olatunbosun A.; Blitz, Julia; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences
Background: The issue of obesity is an important one because in some communities obesity is perceived in many ways such that it is not recognised as a problem as typified by the black community of Khayelitsha with high levels of obesity and associated diseases but low levels of concern and recognition of the problem. This study aimed to explore this by trying to understand how people think and feel about their obesity in a peri-urban Xhosa community, with a view to improving interventions that will reduce the burden of disease related to overweight and obesity as well as with prevention programmes targeted at obesity as a risk factor. Methods: A qualitative study was carried out using recorded interviews of 8 purposively selected subjects who are long term Xhosa-speaking residents, 18 years and older, with BMI more than 30 and no Diabetes, Hypertension or Osteoarthritis at Nolungile CHC, Khayelitsha, a peri-urban black community in Cape Town, South Africa. Results: Interviewed subjects identified various dietary factors for their obesity. These include overeating widely available fatty diets from street vendors, with a perception that cheap food is fatty food. They also attributed their obesity to other factors like poverty and clearly expressed that it is expensive to eat healthily. Other reasons given are a sedentary habit, fear of embarrassment, safety issues and a poor support system regarding exercise. Respondents also differ in their behaviours towards their obesity but generally accept their obesity. Furthermore, they experienced various effects of their obesity. Other than being viewed as affluent and in good health by the community, respondents are aware of effects like compromised daily activities, associated chronic illnesses, dressing difficulties, aging and other negative effects. Conclusions: A few concepts, in agreement with previous linked studies were identified in relation to the Burden of disease, diet, exercise, socio-economic and perception issues. However, the effects of environmental influence on perceptions and behaviour regarding exercise and diet were found. This seemed to indicate an evolving culture in transition. Based on these understandings, health intervention should be directed at addressing such local beliefs and behaviour at the community level, with a need for control of environmental factors. Further studies regarding weight loss was suggested.
Burnout in district hospital doctors in a rural area in the Western Cape
(Stellenbosch : Stellenbosch University, 2014-03) Liebenberg, Andrew; Conradie, Hoffie; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Aim: Burnout amongst doctors negatively effects recruitment and retention, effectiveness and efficiency of health systems, and ultimately, patient-care. The aim of this study is to fill the gap in published data concerning burnout among primary care district hospital doctors practicing in one rural area in South Africa. Methods: A validated questionnaire (Maslach Burnout Inventory) was sent to 42 doctors in 7 district hospitals in early 2013. Results: Response rate was 85.7%. Clinically significant burnout was found in 81% of respondents. Family physicians had significantly lower burnout levels than non-specialist colleagues (p=0.01). Conclusion: This study demonstrates high burnout rates, most importantly threatening the quality of patient care. Recommendations are made.

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