Ga Ogunbanjo

Adherence to HIV antiretroviral therapy - Part I: A review of factors that influence adherence

Abstract Near perfect adherence to ART is required to prevent treatment failure in the individual and to prevent the spread of drug-resistant viruses. Factors that influence adherence to ART can be divided into factors related to the treatment regimen; social and psychological factors; institutional resources; and personal attributes. The treatment regimen should be kept as simple as possible and be tailored to the patients lifestyle. Untreated side effects are one of the strongest predictors of non-adherence. Mental disorders and drug/alcohol abuse should be addressed before initiating treatment. The patients attitude towards medication and health beliefs could adversely influence adherence. The development of healthcare infrastructure should be a high priority and services should be patient orientated. Few personal attributes are consistently associated with adherence. Healthcare workers are poor at predicting adherence. The South African guidelines therefore focus on providing comprehensive adherence support to all patients.

Neonatal tetanus elimination in Mpumalanga Province, South Africa

Neonatal tetanus (NNT) is a serious but preventable disease, and the World Health Organization (WHO) wants to eliminate NNT globally by reducing its incidence to <1 case per 1000 live births. South Africa adopted this goal in 1995, but Mpumalanga, a rural province, has consistently reported cases of NNT despite an appropriate vaccination strategy to eliminate the disease. The aim of the study was to investigate the completeness of the passive notification system and to explore reasons for ongoing NNT cases despite implementation of the provincial vaccination strategy. We reviewed all hospital admissions in the province between 1996 and 2000 meeting the case definition for NNT and interviewed mothers of the NNT cases reported in 2000. We identified 26 NNT cases, of which only 14 (54%) were reported through the routine notification system. Most cases occurred as a result of the cultural practice of applying cow dung or rat faeces to the umbilical stump in the neonatal period. Although all districts met the WHO elimination target during the review period, there is scope to prevent unnecessary NNT deaths through culturally acceptable public awareness campaigns aimed at changing harmful practices, and encouraging hygienic births and postnatal cord care.

Communitarianism and Communitarian Bioethics

Communitarian means pertaining to or characteristic of a community. It is the perspective that recognises both individual human dignity and the social dimension of being human. 1 According to the Concise Oxford Dictionary, communitarianism and communalism are synonymous. 2 Communal means relating to or benefiting a community. Communalism is a political theory advocating a society in which all property is publicly owned and each person is paid and works according to his needs and her ability. According to the Oxford Dictionary of Philosophy, communitarianism is a model of political organisation that stresses ties of affection, kinship, and a sense of common purpose and tradition. 3 The meaning of community varies from exclusively the political state to smaller communities and institutions and to the family. 4 For full text, click here: SA Fam Pract 2005;47(10):51-53

Perceptions of hospital managers regarding the impact of doctors' community service

Abstract Background: In South Africa, the distribution of doctors is skewed in favour of the urban areas, but it is not uncommon to find many peri-urban facilities in short supply of doctors. In 1997, the South African government introduced compulsory community service (CS) to address this uneven distribution of doctors in the country. The CS doctors posted to the Letaba-Sekororo hospital complex in Limpopo Province refused to take up their appointments for various reasons, ranging from lack of supervision to poor basic infrastructure. This study is one of the earliest conducted to understand the perceptions of hospital managers on the impact of the national community service on the health service. Methods: After ethical approval was obtained from the Research, Ethics and Publications Committee (REPC) of the Medical University of Southern Africa (now University of Limpopo—Medunsa Campus), three focus group interviews were conducted with hospital managers from three purposefully selected hospitals. The interviews were audio-visually taped and supplemented with field notes, transcribed verbatim, with themes identified using the ‘cut and paste’ and ‘colour coding’ methods. Combined themes were categorised and interpreted within the context of the study and the available literature. Results: CS has improved health services delivery, alleviated work pressure, and improved the image of hospital managers. In addition, it has provided a constant supply of manpower, and increased the utilisation of health services by the community. The negative perceptions identified included a lack of experience and skills, poor relationships with the rural health team, lack of support structures for CS doctors, poor continuity of care and budgetary constraints. Conclusions: Hospital managers perceive CS to have had a positive impact on the supply of needed manpower, health service delivery and patient care. As this was a qualitative study, further quantitative and community-oriented studies are required to validate the results.

Predictors of topical steroid misuse among patrons of pharmacies in Pretoria

Abstract Background: The misuse of topical steroids, i.e. the usage of these products for skin lightening, is a widespread phenomenon among African men and women. Studies have reported prevalence rates of 18.5% to 70% among participants. Though women constitute the majority of users, people of various age groups, socioeconomic status, employment and marital status practise skin lightening. Besides topical steroid products, other commonly used products include preparations containing hydroquinone or mercury derivatives. The misuse of these products is associated with skin problems such as cellulitis, contact eczema, bacterial and fungal infections, Cushings syndrome, acne, skin atrophy and pigmentation disorders. Although these effects are well documented, it seems that there is little awareness of them among the general public. Other less commonly reported problems include delaying the diagnosis of leprosy, and erythrodermic psoriasis. Data on the misuse and side effects of topical steroids have been gathered primarily from prescriptions, despite the fact that these products could be obtained over the counter, shared between relatives or friends, or come from other informal sources. Moreover, we found no community-based study that investigated the prevalence of the misuse of topical steroid products in South Africa. This survey was therefore conducted to examine the misuse of topical steroid products for skin lightening, among patrons of pharmacies in Pretoria and to determine the potential predictors of misuse. Methods: The aim of this study was to examine the misuse of topical steroid products for skin lightening by patrons of pharmacies in Pretoria and to determine the potential predictors of misuse. Exit interviews were conducted at 21 randomly selected pharmacies by trained interviewers using a structured questionnaire. A total of 1 228 patrons were approached, of which 225 gave verbal consent to be interviewed. Results: Of the 225 participants, 83% were female, 50.7% were 20–40 years old, 56% were employed, and 53.3% were married. The majority of participants (75.1%) were black Africans. About half of them (50.2%) had high school education. The prevalence of topical steroid misuse for skin lightening was 35.5%. A logistic regression analysis revealed that being a black female African and initially being advised to use the products by a friend were the only parameters that significantly correlated with topical steroid misuse. Conclusion: In conclusion, the prevalence of the misuse of topical steroid products among the respondents was 35.5%. The following predictors were associated with topical steroid misuse: being a black female African, not being aware of the side effects of these products, and initially being advised to use the products by a friend. In a logistic regression model, the last two predictors were the only parameters that significantly correlated with topical steroid misuse.

Paraffin poisoning in children: what can we do differently?

Abstract Background: The purpose of this study was to describe the occurrence, health cost and management of paraffin poisoning in a rural South African hospital. Methods: A retrospective study was undertaken of 145 children admitted with a diagnosis of paraffin poisoning at Philadelphia Hospital, Mpumalanga from January 2000 to June 2001. A pre-tested form was used to collect data from the admission files. Where applicable, the Chi-square test or t-test was used to determine statistical significance. Results: Children younger than five years of age were affected significantly more than those older than five years of age (91% vs. 9%, p<0.001), and boys were affected more than girls (58% vs. 42%, p=0.034). The average length of stay and cost of treatment were 2.5±2 days and R617.24 respectively. Prophylactic antibiotics were prescribed in 86% of cases (125/145) and the average number of medications prescribed per child was 3.5±1.8. Conclusions: Although no mortality was reported, paraffin poisoning contributed substantially to the morbidity of, health expenditure for and antibiotic overuse in these children. Provision of child-resistant paraffin container caps, retraining of doctors on appropriate antibiotic use and community education are necessary and crucial in reducing the occurrence of paraffin poisoning in children.

Rabies: an evidence-based approach to management

Abstract Human rabies in South Africa is largely due to infection with the classical rabies virus (genotype 1), with the yellow mongoose the commonest vector except in KwaZulu-Natal, Eastern Cape, Mpumalanga and now Limpopo provinces where the dog is predominantly responsible for most bites. Rabies is always fatal in humans but can be prevented by timeous administration of post exposure prophylaxis (PEP). This article discusses an evidence-based approach to rabies management in South Africa.

The Hippocratic Oath: Revisited

Abstract Traditionally, the model of the physician-patient relationship was rooted in the Hippocratic Oath that condoned paternalism. The current emphasis on autonomy and distributive justice has changed the relationship to such extent that one might argue that the Oath has become irrelevant. This article will discuss whether the obligations dictated by the Oath are specifically Western or not, what has changed in the current medical environment and what should replace this traditional Oath?

Confidentiality and Privacy: What is the difference?

Abstract In the practice of medicine, the idea of confidentiality is articulated in almost all its oaths, guidelines and codes. Dating at least as far back to the Hippocratics, swearing that “… What I may see or hear in the course of the treatment, or even outside of the treatment, which of no account one must spread abroad, I will keep to myself…” Confidentiality is not only of practical importance (who would continue to consult with a doctor who divulged personal information), but it is an ethical mandate as well. Privacy is similar in that it concerns ones person and is value-laden. The distinctions between confidentiality and privacy however are often unclear. In this article, we will articulate some of the conceptual differences, similarities and end with an example from current news which illuminates both concepts.

Post-birth Rituals: Ethics and the Law

Abstract Placental rituals and other birth-by rituals are common in various societies. These rituals often include culturally determined behavioural sequences which operate as anxiety-releasing mechanisms and they serve to offer a spiritual means of ‘control’ over the future health and welfare of mother, child, and even the community. As long as such rituals do not cause harm, they should be respected for the role that they play and be left alone. This article discusses ethical and legal considerations regarding post-birth rituals and its relevance to South Africa with special reference to the South African Human Tissue Act.