Indiran Govender

Adherence of doctors to a clinical guideline for hypertension in Bojanala district, North-West Province, South Africa.

Background Clinical guidelines are systematically developed statements that assist practitioners and patients to make healthcare decisions for specific clinical circumstances. Non-adherence of doctors to guidelines is thought to contribute significantly to poor delivery of clinical care, resulting in poor clinical outcomes. Aim To investigate adherence of doctors in rural district hospitals to clinical guidelines using the South African Hypertension Guideline 2006 as an example. Setting Four district hospitals in Bojanala district of North-West Province, South Africa. Methods A cross-sectional study determined adherence practices of doctors from records of patients with established hypertension seen at the four district hospitals. Results Of the 490 total records documented by 29 doctors, screening for co-morbidity or associated factors was carried out as follows: diabetes mellitus 99.2%, obesity 6.1%, smoking 53.5%, dyslipidaemia 36.9%, abdominal circumference 3.3%; organ damage: eye 0, kidney 82%, heart 43.5%, chronic kidney disease 38.2%, stroke/transient ischaemic attack 15.9%, heart failure 23.5%, advanced retinopathy 0.2%, coronary heart disease 23.7%, peripheral arterial disease 13.9%. Critical tests/measurements were documented in the following proportions: blood pressure 99.8%, weight 85.3%, height 65.7%, body mass index 3.1%, urinalysis 74.5%, lipogram 76.1%, urea/creatinine 80.4%, electrocardiogram 42.9%, blood glucose 100%; risk determination and grading: diagnosis by hypertension severity 19%, low added risk 57.1%, moderate added risk 64.7%, high added risk 89.6%, very high added risk 89.2%. Adherence to therapies was as follows: first-line guideline drugs 69.4%, second line 84.7%, third line 87.8% and fourth-line 89.6%. Conclusion Overall adherence of doctors to treatment guidelines for hypertension was found to be low (51.9%). Low adherence rates were related to age (older doctors) and less clinical experience, and differed with regard to various aspects of the guidelines.

The characteristics of HIV and AIDS patients with deep vein thrombosis at Dr. George Mukhari Academic Hospital

Background Deep vein thrombosis (DVT) is 10 times more prevalent in HIV and AIDS patients than in the general population and is more common in patients with severe immune suppression (CD4 < 200 cells/mL). Opportunistic infections render HIV and AIDS patients susceptible to a hypercoaguable state, including lower protein S levels. Aim and setting To present the profile of HIV and AIDS patients who developed DVT in the primary care wards of Dr. George Mukhari Academic Hospital (DGMAH), Garankuwa. Methods Cross-sectional study of clinical records of admitted HIV and AIDS patients without DVT to the primary care wards, DGMAH, from 01 February 2010 to 31 January 2011. Results Two hundred and twenty-nine patients were admitted and 17 (7.4%) developed DVT. Of those that developed DVT, eight (47%) had infection with tuberculosis (TB), four (24%) had pneumonia and four (24%) had gastroenteritis. The risk of developing DVT was 8/94 (8.5%) in those with TB, 4/53 (7.5%) in those with gastroenteritis and 4/75 (5.3%) in those with pneumonia. The mean duration of stay was 14.1 days in those with DVT versus 4.0 days in those without. Conclusion HIV (and AIDS) is a hypercoaguable state and the risk of DVT is relatively high in patients with opportunistic infections. HIV and AIDS patients who are admitted to hospital with opportunistic infections may benefit from anti-thrombotic prophylaxis and further studies are needed to evaluate this.

The bird’s-eye perspective: how do district health managers experience the impact of family physicians within the South African district health system? A qualitative study

Abstract Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems. Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes. Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities. Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems’ performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine.

The perceived impact of family physicians on the district health system in South Africa : a cross-sectional survey

BackgroundEvidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province.MethodsA cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool.ResultsA total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SDu2009=u20093.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP’s impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥u20092011).ConclusionsThe findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper.

Glass injuries seen in the emergency department of a South African district hospital

BACKGROUNDnThe emergency department of Embhuleni Hospital frequently manages patients with glass-related injuries. This study assessed these injuries and the glass that caused them in more detail.nnnAIMnThe objectives of our study included determining the type of glass causing these injuries and describing the circumstances associated with different types of glass injuries.nnnSETTINGnThe emergency department of Embhuleni Hospital in Elukwatini, Mpumalanga province, South Africa.nnnMETHODSnThis was a cross-sectional study with a sample size of 104 patients. Descriptive statistics were used to assess the characteristics of the glass injuries.nnnRESULTSnFive different types of glass were reported to have caused the injuries, namely car glass (7.69%), glass ampoules (3.85%), glass bottles (82.69%), glass windows (3.85%) and street glass shards (1.92%). Glass bottle injuries were mainly caused by assaults (90.47%) and most victims were mostly young males (80.23%). The assaults occurred at alcohol-licensed premises in 65.11% of cases. These injuries occurred mostly over weekends (83.72%), between 18:00 and 04:00. The face (34.23%) and the scalp (26.84%) were the sites that were injured most often.nnnCONCLUSIONnAssault is the most common cause of glass injuries, usually involving young men at alcohol-licensed premises. Glass injuries generally resulted in minor lacerations, with few complications (2.68%).BACKGROUNDnThe emergency department of Embhuleni Hospital frequently manages patients with glass-related injuries. This study assessed these injuries and the glass that caused them in more detail.nnnAIMnThe objectives of our study included determining the type of glass causing these injuries and describing the circumstances associated with different types of glass injuries.nnnSETTINGnThe emergency department of Embhuleni Hospital in Elukwatini, Mpumalanga province, South Africa.nnnMETHODSnThis was a cross-sectional study with a sample size of 104 patients. Descriptive statistics were used to assess the characteristics of the glass injuries.nnnRESULTSnFive different types of glass were reported to have caused the injuries, namely car glass (7.69%), glass ampoules (3.85%), glass bottles (82.69%), glass windows (3.85%) and street glass shards (1.92%). Glass bottle injuries were mainly caused by assaults (90.47%) and most victims were mostly young males (80.23%). The assaults occurred at alcohol-licensed premises in 65.11% of cases. These injuries occurred mostly over weekends (83.72%), between 18:00 and 04:00. The face (34.23%) and the scalp (26.84%) were the sites that were injured most often.nnnCONCLUSIONnAssault is the most common cause of glass injuries, usually involving young men at alcohol-licensed premises. Glass injuries generally resulted in minor lacerations, with few complications (2.68%).

Mass hysteria with possible pseudoseizures at a primary school

Newspapers and magazines are full of sensational reports regarding child sexual abuse. Proper reporting on the real facts surrounding child sexual abuse, such as that the majority of child offenders are family, neighbours or close friends of the patient, might actually open the eyes of currently inactive witnesses. Anybody who has ever been confronted with a patient suffering from detrimental after-effects after being sexually abused as a child will agree that creating as much awareness as possible is justified.

The Influence of Family Physicians Within the South African District Health System: A Cross-Sectional Study

PURPOSE Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system. METHODS We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size. RESULTS Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02). CONCLUSIONS In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level.

Experiences of general practitioners in the Ga-Rankuwa and Mabopane areas in dealing with patients who have sexual problems

Abstract Background Sexual problems are common. Many patients with sexual health dysfunction use self-help literature or are often managed in general practice. However, many general practitioners (GPs) find it difficult to discuss sexual health issues because they feel uncomfortable with this and lack training in these matters. These GPs are now referring patients with sexual dysfunction to specialists. Aim We sought to explore how GPs working in the Mabopane and Ga-Rankuwa areas of handle sexual problems of their patients. Setting The setting was the Mabopane and Ga-Rankuwa areas of North-West Tshwane, in Gauteng Province. Methods A qualitative study comprising eight free attitude interviews with purposefully selected four male and four female GPs. All interviews were conducted in English and tape-recorded. Field notes in the form of a detailed diary was kept. The tapes were transcribed verbatim, and the transcriptions were checked against the tapes for omissions and inaccuracies. Results Six themes emerged from the interviews: causes of sexual problems; presentation of sexual problems to the doctor; management of sexual health problems; sex is a taboo topic; societys need for sexual health discussions, and these discussions have already begun; previous limited exposure and training, and a need for more sexual health training. Conclusion This study confirms earlier findings that patients could be either reluctant to discuss their problems or are open about them when presenting to doctors with sexual dysfunction. GPs were not exposed to sexual health training at medical school and, because of this shortcoming, felt that training in sexual medicine should be part of the curriculum.

Use of the partogram by doctors and midwives at Odi District Hospital, Gauteng, South Africa

Background: There is scientific evidence that using the partogram reduces maternal and foetal morbidity and mortality. The use of partograms by doctors and midwives at Odi District Hospital has been reported as inadequate by external audits. The level of knowledge of and use of partograms amongst doctors and midwives at Odi District Hospital was investigated. Methods: A cross-sectional survey of doctors and midwives was undertaken using a self-administered questionnaire. A mixed-methods research approach was used to elicit information on the knowledge and use of the partogram. Results: Despite 57 (83.8%) participants having had some form of training on the partogram, only 54 (79.4%) routinely used it. All but one participant had heard of the partogram. Reasons for not using the partogram included being unsure how to use it (13%), partogram charts not available (8.7%), partogram takes too long (21.7%), being too busy (26.1%), and a feeling that the partogram was not the doctor’s responsibility (26.1%). Overall knowledge of partograms was insufficient, resulting in inadequate use of partograms. In-service training is required to improve the skills of doctors and midwives in the correct knowledge and use of partograms. Conclusion: Partograms are not used as required by doctors and midwives, and further training is needed.

Reasons for and perceptions of patients with minor ailments bypassing local primary health care facilities

Introduction: Despite having access to several clinics and health centres in their local communities, numerous patients opt to go directly to hospitals for non-emergencies and minor ailments. Reasons for this include their perceptions of the quality of primary health care services, the attitudes and perceptions of health workers, opening hours of clinics, community involvement and participation, and drug and equipment availability as well as the quality of infrastructure. Perceptions of size, a lack of specialty care and limited services were most frequently mentioned as reasons why patients bypassed their local primary health care facilities. Aim: This study aimed to identify the reasons given by patients presenting with minor ailments, for bypassing their local primary health care facilities in the Greater Tzaneen municipal area to Letaba Hospital. Methods: A cross-sectional descriptive study was performed at Letaba Hospital over a three-month period, from 23 June 2008 to 15 August 2008, in which non-referred patients presenting with minor ailments were randomised and entered into the study on a voluntary basis. A preset questionnaire was utilised for data-collection purposes. A total of 293 participants were included in the study. The questionnaire aimed to determine the demographic profile of patients who present with minor ailments at hospital, to explore the reasons why these patients bypass their local clinics and to evaluate their knowledge, perceptions and attitudes regarding their local clinics. Results: Most patients indicated that they came to the hospital because they wanted to be seen by a doctor, followed by the request to see a dentist. The study identified that patients expressed both positive and negative opinions concerning their local clinics. Conclusion: Numerous factors influence the service-seeking behaviour of rural patients. Patients bypass their local clinics due to perceptions regarding the quality of health care services at the hospital. Improving the quality aspects of clinics and enhancing the services rendered will not only increase the utilisation of clinic services, but also reduce hospital overcrowding.