Bob Mash

A Morbidity Survey of South African Primary Care

Background Recent studies have described the burden of disease in South Africa. However these studies do not tell us which of these conditions commonly present to primary care providers, how these conditions may present and how providers make sense of them in terms of their diagnoses. Clinical nurse practitioners are the main primary care providers and need to be better prepared for this role. This study aimed to determine the range and prevalence of reasons for encounter and diagnoses found among ambulatory patients attending public sector primary care facilities in South Africa. Methodology/Principal Findings The study was a multi-centre prospective cross-sectional survey of consultations in primary care in four provinces of South Africa: Western Cape, Limpopo, Northern Cape and North West. Consultations were coded prior to analysis by using the International Classification of Primary Care-Version 2 in terms of reasons for encounter (REF) and diagnoses. Altogether 18856 consultations were included in the survey and generated 31451 reasons for encounter (RFE) and 24561 diagnoses. Women accounted for 12526 (66.6%) and men 6288 (33.4%). Nurses saw 16238 (86.1%) and doctors 2612 (13.9%) of patients. The top 80 RFE and top 25 diagnoses are reported and ongoing care for hypertension was the commonest RFE and diagnosis. The 20 commonest RFE and diagnoses by age group are also reported. Conclusions/Significance Ambulatory primary care is dominated by non-communicable chronic diseases. HIV/AIDS and TB are common, but not to the extent predicted by the burden of disease. Pneumonia and gastroenteritis are commonly seen especially in children. Womens health issues such as family planning and pregnancy related visits are also common. Injuries are not as common as expected from the burden of disease. Primary care providers did not recognise mental health problems. The results should guide the future training and assessment of primary care providers.

The effects of a language barrier in a South African district hospital

BACKGROUND Communication between health workers and patients at Hottentots Holland Hospital (HHH) is hindered by staff and patients not speaking the same language. HHH is a district hospital in the Cape Town Metropolitan District of the Western Cape where staff mainly speak Afrikaans or English and a large number of patients mainly Xhosa. OBJECTIVES The study aimed to explore the effects of this language barrier on health workers and patients at HHH. DESIGN Three focus group interviews were held with 21 members of staff and 5 in-depth patient interviews were conducted. RESULTS The language barrier was found to interfere with working efficiently, create uncertainty about the accuracy of interpretation, be enhanced by a lack of education or training, cause significant ethical dilemmas, negatively influence the attitudes of patients and staff towards each other, decrease the quality of and satisfaction with care, and cause cross-cultural misunderstandings. CONCLUSION The effects of the language barrier were considerable and persistent despite an official language policy in the province. The training and employment of professional interpreters as well as teaching of basic Xhosa to staff are recommended.

Screening for diabetic retinopathy in primary care with a mobile fundal camera - evaluation of a South African pilot project

BACKGROUND AND AIMS In South Africa diabetes makes a significant contribution to the burden of disease. Diabetic retinopathy is a leading cause of adult blindness, and screening can reduce the incidence. This project aimed to implement and evaluate a new service for retinal screening that uses a non-mydriatic mobile fundal camera in primary care. This is the first time such a service has been evaluated in an African primary care context. METHODS The service was implemented as an operational research study at three community health centres and data were collected to evaluate the operational issues, screening, reporting and referral of patients. RESULTS Out of 400 patients screened 84% had a significantly reduced visual acuity, 63% had retinopathy (22% severe nonproliferative, 6% proliferative and 15% maculopathy), 2% of eyes could not be screened and 14% of patients required dilatation. Referral was necessary in 27% of cases for cataracts, in 7% for laser treatment and in 4% for other specialist services. Repeat photography was needed in 8% and urgent follow-up in 12%. A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. CONCLUSION Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician should be able to photograph almost 10,000 patients a year.

Preventing diabetes blindness : Cost effectiveness of a screening programme using digital non-mydriatic fundus photography for diabetic retinopathy in a primary health care setting in South Africa.

BACKGROUND South Africa like many other developing countries is experiencing an epidemiologic transition with a marked increase in the non-communicable disease (NCD) burden. Diabetic retinopathy is the most common cause of incidental blindness in adults. A screening programme using a mobile fundal camera in a primary care setting has been shown to be effective in the country. Information on affordability and cost is essential for policymakers to consider its adoption. METHODS Economic evaluation is the comparative analysis of competing alternative interventions in terms of costs and consequences. A cost effectiveness analysis was done using actual costs from the primary care screening programme. RESULTS A total of 14,541 patients were screened in three primary healthcare facilities in the Western Cape. Photographs were taken by a trained technician with supervision by an ophthalmic nurse. The photographs were then read by a medical officer with ophthalmic experience. A cost effective ratio of

A comprehensive model for intimate partner violence in South African primary care: action research

1206 per blindness case averted was obtained. This included costs for screening and treating an individual. The cost just to screen a patient for retinopathy was

Peripheral arterial disease – high prevalence in rural black South Africans

22. The costs of screening and treating all incident cases of blindness due to diabetes in South Africa would be 168,000,000 ZAR (

The value of small group learning : an evaluation of an innovative CPD programme for primary care medical practitioners.

19,310,344) per annum. CONCLUSION Non mydriatic digital fundoscopy is a cost effective measure in the screening and diagnosis of diabetic retinopathy in a primary care setting in South Africa. The major savings in the long term are a result of avoiding government disability grant for people who suffer loss of vision.

‘Holding it lightly’: the co-operative inquiry group: a method for developing educational materials

BackgroundDespite extensive evidence on the magnitude of intimate partner violence (IPV) as a public health problem worldwide, insubstantial progress has been made in the development and implementation of sufficiently comprehensive health services. This study aimed to implement, evaluate and adapt a published protocol for the screening and management of IPV and to recommend a model of care that could be taken to scale in our underdeveloped South African primary health care system.MethodsProfessional action research utilised a co-operative inquiry group that consisted of four nurses, one doctor and a qualitative researcher. The inquiry group implemented the protocol in two urban and three rural primary care facilities. Over a period of 14 months the group reflected on their experience, modified the protocol and developed recommendations on a practical but comprehensive model of care.ResultsThe original protocol had to be adapted in terms of its expectations of the primary care providers, overly forensic orientation, lack of depth in terms of mental health, validity of the danger assessment and safety planning process, and need for ongoing empowerment and support. A three-tier model resulted: case finding and clinical care provision by primary care providers; psychological, social and legal assistance by ‘IPV champions’ followed by a group empowerment process; and then ongoing community-based support groups.ConclusionThe inquiry process led to a model of comprehensive and intersectoral care that is integrated at the facility level and which is now being piloted in the Western Cape, South Africa.

Assessment of the quality of interaction in distance learning programmes utilizing the Internet or interactive television: perceptions of students and lecturers

BACKGROUND The prevalence of peripheral arterial disease (PAD) worldwide has been estimated at between 4.5% and 29%. PAD has been associated with male gender, advanced age, diabetes, hypertension, hypercholesterolaemia and smoking. Clinical experience with amputations at Mthatha General Hospital, a district hospital in the Eastern Cape, suggests that PAD is common, but the actual prevalence has not been determined. The Eastern Cape is a rural area and patients attending the hospital are mostly Xhosa-speakers. OBJECTIVES To assess the prevalence of PAD and associated risk factors among patients attending the hospital. METHODS Five hundred and forty-two patients over 50 years of age attending the outpatient department were systematically selected. Gender, body mass index (BMI), blood pressure, capillary blood glucose and smoking status were determined. The ankle-brachial pressure index (ABPI) was measured by Doppler ultrasound, and PAD was defined as a ratio less than 0.9. RESULTS Of 542 patients (315 females, 227 males), 159 (29.3%) had an ABPI of less than 0.9. The mean age was 62.4 years and the range 50 - 95 years. In a stepwise logistical regression analysis smoking had a significant adjusted odds ratio for PAD of 4.29 (2.68 - 6.95), diabetes 1.72 (1.11 - 2.69) and male sex 1.69 (1.06 - 2.68). Obesity as measured by BMI and hypertension were not associated with PAD. CONCLUSION AND RECOMMENDATIONS Prevalence of PAD was relatively high in this sample of rural black patients when compared with findings from other countries. Preventive interventions should focus on control of diabetes and smoking cessation. Surprisingly, the prevalence was higher in those with a normal BMI and without hypertension, and risk factors in this community should be studied further. Physicians in this setting should be more aware of the possibility of undetected PAD.

Reflections on the development of family medicine in the Western Cape: a 15-year review

Introduction  A ‘competence’ model of CPD using facilitated small groups covering a range of clinical topics is an alternative model to lecture‐based CPD. The aim of this study was to evaluate a new small group CPD programme and to determine whether the anticipated improvements in the quality of learning were realised.