Hanneke Dippenaar

Nutritional, immune, micronutrient and health status of HIV-infected children in care centres in Mangaung

Abstract Aim: To assess the nutritional, immune, micronutrient and health status of antiretroviral-naïve HIV-infected children. Method: A cross-sectional descriptive study was undertaken between September 2004 and March 2006 amongst HIV-infected children of which none received antiretroviral therapy, in care centres in Mangaung, Free State. Results: The study included 37 clinically stable and food-secure HIV-infected children. Their median age was 5.4 years (range 1.2–10.2 years). Fifteen children (41%) were underweight, 30 (81%) were stunted and one (3%) was wasted. The most commonly observed clinical features were lymphadenopathy (84%), skin rashes (51%), hepatomegaly (32%) and pallor (41%). Eight per cent of children had features of TB, while 19% had a lower respiratory tract infection. The median viral load of the group (n = 35) was 117 000 copies/ml, the median CD4+ cell count was 477 cells/mm3 and the median CD4 percentage was 22.5%. A significant negative correlation could be demonstrated between viral load and nutritional indicators. Children had deficient serum levels relative to normal reference values for glutathione (91% of children), albumin (78%), vitamin A (63%), vitamin D (44%), zinc (38%) and vitamin E (13%). Sixty per cent of the children were anaemic and 30% were iron deficient. Conclusion: A high prevalence of acute and chronic malnutrition and micronutrient deficiencies occurred among HIV-infected children residing in care centres. The study highlights the need to investigate early initiation of antiretroviral therapy and nutrition interventions, including aggressive supplementation, in order to improve the prognosis of these children.

Guidelines for kangaroo care in district hospitals and primary healthcare maternity sections in the Free State

Abstract Background Kangaroo care was introduced in Bogotá, Colombia in 1979 by Dr Edgar Ray and Dr Hector Martinez due to the shortage of resources and the large number of premature babies that needed special care. Kangaroo care implies direct skin-to-skin contact between the mother and her premature/newborn baby. The advantages of kangaroo care are well known and have been published widely. In the National District Hospital in Bloemfontein, South Africa, stable babies are admitted from 1.2 kg and above and the babies are discharged at around 1.8 kg, when they are able to drink adequately. Babies above 1.2 kg are given kangaroo care by their mothers in the day, but sleep in an incubator at night. Babies with a weight of between 1.5 kg and 1.6 kg are started with around-the-clock kangaroo care. The aim of this study was to determine predictors for good and poor outcomes in kangaroo mother care practiced at the primary healthcare level. This information was then used to compile a protocol for kangaroo care in hospitals and maternity sections at the primary care level. The aim of the protocol is to provide specific inclusion and exclusion criteria for kangaroo care, to indicate all the absolute and relative needs for such a unit, to provide guidelines for managing babies with insufficient weight gain, and to provide guidance for follow-up. Methods In this cohort study, the patient files of premature babies that received kangaroo care in the National District Hospital were evaluated in order to establish indicators for good and poor outcomes. Patient files were selected consecutively from the last entry in the admissions register from May 2005 backwards until June 2003. Data was collected on a standard data- collection form. Reasons for not gaining weight and the need for special investigations were investigated and noted. Poor weight gain was regarded as weight gain of less than 17 g/kg/day. Results A total of 200 files were audited. In 62% of the cases (95% CI 55.1%; 68.4%), the babies gained weight satisfactorily, while weight gain was unsatisfactory in 38% of the cases. The mean admission weight of the babies was 1 545 g (range 1 100 g to 2 100 g) and the mean discharge weight was 1 800 g (range 1 700 g to 2 100 g). The chance of weight gain was reduced if one of the following occurred: anaemia, low body temperature, inappropriate amount and route of milk administered, sepsis, transport, procedures and other medical conditions. The reinsertion of nasogastric tubes (53%), improved temperature control with improved kangaroo care technique (79%), the correction of anaemia with blood transfusion (12%) and the correction of the volume of milk (5%) were the major corrective steps taken to address the problem. In 29% of the cases, extra energy in the form of FM 85 was added to the breast milk. The type of milk that the babies received, namely breast milk (n=113), premature milk formula (n=40) and a combination of breast milk and formula milk (n=46), did not significantly influence weight gain. Gender, birth weight and gestational age at birth also did not have a significant influence on weight gain. If the problem was properly addressed, the babies started gaining weight within an average of four days. Conclusion It is possible to render safe kangaroo care to all stable premature babies in a primary healthcare setting, provided that the set guidelines are adhered to.

Evaluation of Clinical Medicine in the Final Postgraduate Examinations in Family Medicine

Abstract Background: The Family Medicine Department, University of the Free State (UFS) recently supervised the MFGP assessments of the College of Medicine in South Africa (first sitting), as well as the final assessment of the M Med Fam programme of the UFS (second sitting). The examinations, which took place in October and November 2006, were subjected to an internal quality assurance evaluation with the view to improve the standard and reliability of the examinations. Methods: All the candidates, as well as the examiners who participated in the MFGP and M Fam Med examinations, were included in the evaluation. Opinions were obtained from the students and examiners for each assessment on a structured data form directly after the examinations. A Smits blueprint was established for the written paper. Results: The majority of the students assessed the OSCE as being fair, understood the questions and agreed with the time allocated per question. A broad variety of competencies were assessed in a structured manner, which enhances the reliability of the examinations. The examiners evaluated the OSCE as being well structured and fair, as well as testing for the competencies of a family physician. Good agreement was achieved between the two different sets of candidates and examiners, and similar marks were achieved despite the separate settings, thus enhancing the validity of the examinations. The structured oral was evaluated as being fair regarding the variety and relevance of the questions by all the candidates and examiners. The written paper was on a relatively high cognitive level and tested a broad spectrum of knowledge. Although it did not cover the entire module, skills and approaches necessary for problem solving were tested. If a student could master these problems, he/she should be able to manage other areas not covered in the paper. Conclusion: The authors are of the opinion that the quality evaluation of clinical medicine in the final postgraduate examinations in Family Medicine held at UFS in 2006 showed it to be authentic, fair, reliable and objective, and that it assessed competencies for real-life situations, as well as the theoretical knowledge, attitudes and values required for a family practitioner.

How cheap is primary health care? Cost per script at the Heidedal Community Health Centre and National District Hospital in Bloemfontein

Abstract Background: It is essential to manage and budget for primary health care in order to deliver a sustainable, accessible and quality health service to the majority of the population. The aim of the study was to establish the cost per script at the Heidedal Community Health Centre (HCHC) and at the National District Hospital (NDH) in Bloemfontein and to evaluate prescribing patterns, the protocols and use of the Essential Drug List (EDL) and Standard Treatment Guidelines (STGs) and to budget more accurately for medicine. Methods: During a two-month period, every fifth script dispensed at HCHC and NDH was included in the study and analysed until we had included 1 000 scripts from each facility. Results: The mean number of items per script at the CHC was 3.3 and at the DH was 4.1, and the mean cost was R14.66 versus R64.69 respectively. At HCHC, 62 025 prescriptions were dispensed and at NDH 56 312 were dispensed at an estimated total value of R 4.5 million during 2002. Conclusion: Many problem areas and incorrect prescribing patterns were identified and need to be addressed. Although the cost per script at primary care level is not high, the number of patients that need treatment is enormous. Primary health care is actually very expensive and good quality control is necessary.

Multidisciplinary training of undergraduate students in the Faculty of Health Sciences: Hypertension as a case study

Abstract Background: Healthcare students should be aware of the specific skills, knowledge and management options of other disciplines in order to achieve an effective and cohesive working relationship. Aim: The aim of this study was to expose healthcare students at the University of the Free State to one anothers domains, as related to hypertension management, during a formal didactic lecture attended by medical, physiotherapy and dietetic students, and to determine whether they could apply in practice the theoretical knowledge regarding blood pressure measurement and exercise, obtained during a multidisciplinary session. The perceptions of students regarding multidisciplinary sessions were also to be obtained. Method: Students received a formal lecture on hypertension from a medical doctor, a dietitian, a physiotherapist and an occupational therapist and they then worked in multidisciplinary groups to demonstrate the physiological effect of exercise on blood pressure and pulse rate. Students had to report their findings and perceptions of the session by completing data forms. Results: A total of 125 medical, physiotherapy and human nutrition students participated in the session. The students were able to demonstrate the influence of exercise on blood pressure and pulse measurements. They reported that they enjoyed the multidisciplinary session and gained information on the scope of practice of the domains of the other disciplines. Negative feedback was received on the size of the groups and lack of equipment. Conclusion: The students could apply theoretical knowledge in practice and all gave positive feedback. The sessions will continue in the current format but attention will be given to smaller groups and the availability of more equipment.

Is quality control useful? An audit of the saving measures regarding prescriptions at National District Hospital in Bloemfontein

Abstract Background: This is a follow-up study to evaluate and improve quality health care for the majority of the population in Bloemfontein. The aim of this study was to evaluate the changes implemented to address the cost of prescribing drugs at National District Hospital, Bloemfontein as described in a previous study Methods: The 20 most expensive or inappropriate prescribed drugs were identified from the results of the first study. These drugs were grouped together in order to address the problems systematically, e.g. revising and updating the current treatment protocols for chronic conditions and using cheaper alternatives. Three months after the implementation of the new measures, the affected drugs were re-evaluated over an eight-week period. Results: A total of 28 drugs (the 20 drugs + eight drugs on which they may have a direct influence) was evaluated over an eight-week period. The introduction of the treatment protocols not only saved a large amount of money, but also made prescribers aware of the correct dosages of the drugs. A saving of R215 395 in the dispensing of medicine in eight weeks was demonstrated. A massive calculated saving of R1.4 million could be achieved over a one-year period at NDH with adherence to the saving measures. Conclusion: Drug costs can be substantially reduced through review of drug use and introduction of protocols and guidelines.