Olufemi B. Omole

Drug therapy, lifestyle modification and blood pressure control in a primary care facility, south of Johannesburg, South Africa: an audit of hypertension management

Abstract Background: Hypertension management is suboptimal in many settings. We assessed blood pressure (BP) control according to target, the appropriateness of antihypertensive therapy and the extent of implementing lifestyle modification among hypertensive patients. Method: This study was an audit involving a retrospective review of medical records of hypertensive patients who were 18 years of age and older (n = 300), attended to by doctors or primary health care nurses at a large community health centre, south of Johannesburg, South Africa. Demographic, anthropometric, clinical and management data were extracted from the files of hypertensive patients who met the inclusion criteria. Data analysis included the use of descriptive statistics, the chi-square test and Fishers exact test. The main outcome measures were the proportions of patients with controlled BP, who used appropriate antihypertensive drugs and who had documented lifestyle modifications. Results: Most patients were black (75.7%) and female (68.3%). The mean age was 60 years. The majority of the patients (55.7%) were either overweight or obese. Fifty-seven per cent of the patients (n = 171) had BP control meeting the target. Appropriate choice of antihypertensive drugs was documented in 81.3% of patients (n = 244), while 56.3% had lifestyle modification documented in their records. Significantly more women had their BP controlled to target compared to men (P = 0.0028). Factors significantly associated with good BP control were white race (P = 0.0001) and documentation of adherence to therapy (P = 0.000). Conclusion: BP control was achieved in the majority of patients and the vast majority was on appropriate drug therapy. White race, female sex and adherence to treatment documented in the medical record were significantly associated with BP controlled to target.

Snuff use and the risk for hypertension among black South African women

Abstract Background: Snuff or smokeless tobacco, used orally or by nasal application, is the predominant form of tobacco used by black South African women. Little is known about the risk of cardiovascular disease associated with the use of snuff in developing countries. This study therefore sought to determine the association between snuff use and hypertension among black South African women. Methods: This study involved secondary data analysis of a cross-sectional representative sample of black women aged 25 to 70 years (n = 4092) who participated in the 1998 South African Demographic and Health Survey, the largest to date. Data analysis included chi-square statistics, t-tests, ANOVA and multiple logistic regression analysis. The outcome measure was hypertension, defined as presenting with an average blood pressure (BP) of ≥ 160/95 mmHg, and/or reporting the use of antihypertensive medication. Results: The prevalence of snuff use and hypertension was 14.6% and 18.0% respectively. Compared to non-users of snuff, those who used snuff more than eight times a day had significantly higher mean systolic (131 mmHg vs. 121 mmHg) and diastolic (84 mmHg vs. 77 mmHg) BP. Hypertension was more prevalent among snuff users than among non-users of snuff (23.9% vs. 17%; p<0.001). However, after adjusting for potential confounders, although current snuff use as compared to non-current use produced a dose response, it was not associated with a statistically significant increased risk for hypertension (OR = 1.12; 95% CI: 0.84–1.50). Conclusion: This study failed to show a significant association between snuff use and hypertension. However, heavy snuff use significantly increased BP to levels that have been shown to increase the risk for cardiovascular diseases at a population level. While there is need for follow-up studies, this finding of the study highlights the need for primary care physicians to offer tobacco use cessation services to their patients, especially those who may already be exposed to other risk factors for hypertension.

Smokeless Tobacco: Is It Really Safe?

Abstract Antismoking campaigns and government legislation have resulted in a decline in smoking. However, the use of smokeless tobacco (SLT) is on the increase. Smokeless tobacco is non-smoked tobacco used either intranasally or intraorally. The increase in its use is possibly due to the perception that SLT is a safe alternative to smoking. SLT includes tobacco products such as snuff (sniffed or placed in the oral cavity) and tobacco leaves (which are chewed). In South Africa, traditional and social practices influence SLT use. While the adverse health outcomes associated with smoking are well established, some health risks attributable to SLT use have not been studied conclusively, especially those that affect the cardiovascular system. Although some studies have found some relationships between SLT use and adverse health outcomes, others have found SLT use to be associated with risks not higher than those in non-users. This article reviews the available literature on the use of SLT, the associated health risks and adverse health outcomes with the aim of providing a scientific basis on which primary care physicians can make rational decisions when confronted with current SLT users or those who contemplate using SLT as a nicotine harm-reduction substance.

Factors associated with blood pressure control among patients attending the outpatient clinic of a South African district hospital

Objective To determine the prevalence and factors associated with blood pressure (BP) control. Methods In a cross-sectional study involving 251 consecutively-sampled patients, a semi-structured questionnaire collected information on socio-demography, co-morbidities, hypertension treatments and BP control. Data analysis included descriptive statistics and logistic regression. Results Most participants were: on treatment for >5 years (60.6%); on three or more drugs (93.6%); treated according to guidelines (77%); and reported not missing medications in the last week (86.5%). BP control was achieved in only 31.5% and 16.7% of participants at the current and last visits, respectively. In multivariate regression analysis, a history of myocardial infarction (odd ratio [OR] = 0.41; P = 0.04) and being divorced/widowed (OR = 3.1; P = 0.01) predicted poor BP control. Conclusion This study confirms the prevalent sub-optimal control of BP and suggests the need for further studies to examine the relationship between marital support, critical medical events and BP control.

Postdural puncture headache: evidence-based review for primary care

The promotion of epidural and spinal blocks as preferred and safe techniques for Caesarean section and the use of lumbar puncture for diagnostic and therapeutic purposes place patients at risk of developing postdural puncture headache (PDPH). This article reviews the literature for evidence that provides an approach to diagnosis and management of this condition for the primary care physician. A dull and throbbing, bilateral headache associated with changes in posture (worsened by sitting and standing, and better lying down), that develops within seven days of a lumbar puncture or an inadvertent dural puncture must raise the suspicion of PDPH. The exact causative mechanism is unclear but symptoms of PDPH are generally attributed to excessive loss of cerebrospinal fluid (CSF). The risk of PDPH is increased with the use of cutting and large-bore needles, and with horizontal orientation of the needle bevel. Given that symptoms overlap, other organic causes of headache such as intracerebral/subdural haemorrhage, pneumocephalus, central nervous system infections, adverse effects of anticoagulants and functional headaches such as migraine must be excluded. Although the initial management of PDPH comprises several conservative interventions, evidence is only available for the effectiveness of the usage of caffeine, analgesics, gabapectin, hydrocortisone, dexamethasone and cosyntropin. Epidural blood patch (EDBP) offers the most favourable outcomes for patients who fail to respond to conservative management. However, given the lack of skills for performing EDBP in primary care, such patients should be referred to secondary or tertiary level of care.

Reasons for inpatients not to seek clarity at Dr George Mukhari Academic Hospital, Pretoria

Background Healthcare practitioners should provide patients with information regarding their clinical conditions. Patients should also feel free to seek clarity on information provided. However, not all patients seek this clarity. Objectives To explore the reasons inpatients gave for not seeking clarity on information that was received but not understood. Methods This was a qualitative arm of a larger study, titled ‘Are inpatients aware of the admission reasons and management plans of their clinical conditions? A survey at a tertiary hospital in South Africa’, conducted in 2010. Of the 264 inpatients who participated in the larger study, we extracted the unstructured responses from those participants (n = 152) who had indicated in the questionnaire that there was information they had not understood during their encounter with healthcare practitioners, but that they had nonetheless not sought clarity. Data were analysed thematically. Results Themes that emerged were that inpatients did not ask for clarity as they perceived healthcare practitioners to be ‘too busy’, aloof, non-communicators and sometimes uncertain about patients’ conditions. Some inpatients had unquestioning trust in healthcare practitioners, whilst others had experiences of bad treatment. Inpatients had poor self-esteem, incapacitating clinical conditions, fear of bad news and prior knowledge of their clinical conditions. Some inpatients stated that they had no reason for not seeking clarity. Conclusion The reasons for not seeking clarity were based on patients’ experiences with the healthcare practitioners and their perceptions of the latter and of themselves. A programme should be developed in order to educate inpatients on effective communication with their healthcare practitioners.

Management of gout: Primary care approach

Abstract Great strides have been made in understanding gout as a disease over the centuries. Despite these advances, reports suggest that the management of gout is relatively suboptimal at the primary care level. This article reviews important considerations in the management of gout and provides an evidence-based approach for the management of acute and chronic gouty arthritis at the primary care level. Recurrent monoarticular pain and swelling should raise the suspicion of gout and the demonstration of urate crystals in synovial fluid during a clinical episode confirms the diagnosis. Acute gouty attacks should be managed with appropriate doses of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicines or steroids. Recurrent attacks of gout, presence of tophi and urate stones necessitate urate-lowering drugs. Prophylactic anti-inflammatory agents for up to six months should be added at initiation of urate-lowering therapy to reduce flares of acute attacks. Gout management requires lifelong commitment and adherence to lifestyle modification and treatment improves clinical outcomes.

Implementing tobacco dependence treatment during clinical consultations: a qualitative study of clinicians’ experiences, perceptions and behaviours in a South African primary health care setting

BackgroundEvidence suggests that healthcare providers (HCPs) in South Africa do not consistently offer tobacco dependence treatment (TDT) during clinical consultations. In order to understand and explain this behaviour in a South African context, we conducted a qualitative exploration of HCPs’ experiences, perceptions and behaviours regarding TDT.MethodsIndividual qualitative interviews were conducted with physicians and nurses who were purposively selected. Themes were identified from interview transcripts using content analysis. Findings were triangulated and peer-reviewed, and were also verified by the participants.ResultsFifteen physicians and four nurses were interviewed, none of whom used tobacco. These participants perceived TDT as an important task, but could not consistently implement it during clinical consultations due to health systems constraints (time-constraints because of patient-overload, the unavailability of cessation medications and a lack of support for referrals), misperceptions and misconceptions (negative outcome expectations about the effectiveness and feasibility of TDT), socio-cultural barriers (counselling older persons was perceived as challenging) and personal limitations (perceived low self-efficacy, poor knowledge and skills on implementing any evidence-based TDT framework). Patients are therefore selectively screened based on clinical relevance and offered only prescriptive brief advice. Participants recommended several systems changes, including academic detailing of tobacco status, training HCPs and incorporating tobacco cessation medications in the Essential Drug List.ConclusionThe reported selective screening and limited TDT interventions offered by HCPs are related to interactions between health systems constraints, personal limitations, and misperceptions and misconceptions about the effectiveness and feasibility of TDT during clinical consultation. Implementing the recommended systems changes has the potential to improve the implementation of TDT in South African primary health care (PHC).

Review of alternative practices to cigarette smoking and nicotine replacement therapy: how safe are they?

Abstract Most adverse health effects of cigarette smoking are attributed to the products of combustion. Efforts to avoid the adverse health effects of cigarette smoking have led to the promotion of alternative products that are perceived to be less harmful. In this paper, we review the available literature for evidence of the effectiveness of the products commonly presented as alternatives to cigarette smoking, and discuss evidence-based information on whether they should be promoted as safe alternatives for long-term use or are effective as cessation aid. Water pipe smoking is becoming prevalent among young people and the electronic cigarette has been recently introduced as smoking alternative in smoke-free areas. Available limited data suggest that while smokers may perceive these alternatives as safer than cigarette smoking, they contain toxic substances and therefore are not harmless alternatives. Data on herbal products are not easily available and where they are, evidence shows that these products are also not effective alternatives. Smokeless tobacco products vary in composition and health effects worldwide. The available literature suggests that these products may be associated with adverse health outcomes and that they cannot be promoted as ‘safe’ alternative tobacco products. Nicotine replacement therapy (NRT) formulations, such as chewing gums and skin patches, have been well studied and evidence suggests that all forms are effective smoking cessation aids, either used alone and in combination with other NRT or cessation medication and behavioural therapy. Primary care physicians should therefore only offer NRT to smokers who are willing to quit in combination with behavioural therapy or other cessation medications approved by the South African Medicines Control Council.

Factors influencing regular physical exercise among the elderly in residential care facilities in a South African health district

Background Physical exercise plays an important role in healthy ageing, but the elderly do not engage in it regularly. Methods In this cross-sectional study, we sampled 139 residents of residential care facility. A questionnaire was used to obtain information on participants’ demography, health problems, nature, motivators and barriers to exercise. Chi-square test examined the relationship between participants’ characteristics and their engagement in regular exercise. Results Of the 139 participants, the majority were females (71.9%), white people (82.7%), aged 70 years or more (70.5%), had at least one health problem (85.6%) and were overweight or obese (60.4%). Approximately 89.2% engaged in some form of physical activities but only 50.3% reported engaging regularly. Participant’s knowledge of the benefits of regular physical activities, opportunities to socialise, encouragement by health care workers and availability of exercise facilities and trainers promote regular physical exercise. Barriers to regular exercise included poor health status, lack of knowledge of the benefits of regular physical activities, lack of opportunities to socialise, lack of encouragement by health care workers and unavailability of exercise facilities and trainers. Factors that predicted exercise were age 60–69 years (p = 0.02), being Afrikaans speaking (p = 0.04) and completing high school (p = 0.03). Conclusion A significant proportion of the elderly do not engage in regular physical exercise, and this behaviour is influenced by personal health status and systems-related motivators and barriers.