Pierre de Villiers

The Delphi technique in health sciences education research.

The Delphi technique is a method of collecting opinion on a particular research question. It is based on the premise that pooled intelligence enhances individual judgement and captures the collective opinion of a group of experts without being physically assembled. The conventional Delphi uses a series of questionnaires to generate expert opinion in an anonymous fashion and takes place over a series of rounds. The technique is becoming a popular strategy that straddles both quantitative and qualitative realms. Issues that are critical to its validity are the development of the questionnaire; definition of consensus and how to interpret non-consensus; criteria for and selection of the expert panel; sample size; and data analysis. The authors used the Delphi technique to assist with making recommendations regarding education and training for medical practitioners working in district hospitals in South Africa. The objective of this Delphi was to obtain consensus opinion on content and methods relating to the maintenance of competence of these doctors. They believe the experience gained from their work may be useful for other health science education researchers wishing to use the Delphi method.

Efficacy and safety of a live attenuated influenza vaccine in adults 60 years of age and older.

This randomized, double-blind, placebo-controlled study investigated the efficacy, safety, and immunogenicity of LAIV in community-dwelling ambulatory adults > or =60 years of age in South Africa in 2001. Nose and throat swabs were obtained for influenza virus culture based on the symptoms of influenza-like illness. A total of 3242 subjects were enrolled, with a mean age of 69.5 years. The efficacy of LAIV against influenza viruses antigenically similar to the vaccine was 42.3% (95% CI, 21.6-57.8%). Efficacy against A/H3N2 viruses was 52.5% (95% CI, 32.1-67.2%); vaccine efficacy was not observed against antigenically similar B strains. In post hoc analyses, efficacy in subjects 60 to <70 years of age was 41.8% and -22.7% against A/H3N2 and B, respectively and 65.7% and 9.9%, respectively, for subjects > or =70 years. Reactogenicity events were higher among LAIV than placebo recipients during 11 days postvaccination (P=0.042), including runny nose/nasal congestion, cough, sore throat, headache, muscle aches, tiredness, and decreased appetite. Rates of serious adverse events were similar for LAIV and placebo recipients. This was the first demonstration of statistically significant protection by LAIV against culture-confirmed influenza in adults > or =60 years of age. These results suggest that LAIV may provide an additional public health tool in the prevention of influenza in the elderly. (ClinicalTrials.gov identifier, NCT00217230.).

The current status and future needs of education and training in family medicine and primary care in South Africa.

South Africa is undergoing tremendous political and social change affecting every sphere of society, including medical education and the delivery of health services. The legacy of its history created a health system that in some respects can be compared to the best in the world, but one also characterized by inequity, discrimination and lack of access to even basic services for the rural and the poor. Its medical education system trails behind modern trends such as problem‐based learning, community‐based education and the utilizing of general/family practitioners as trainers. Vocational training in family practice is not compulsory for independent practice. The discipline of family practice has nevertheless developed the programmes and core infrastructure for such a future undertaking in the form of masters programmes in family medicine at all medical schools. The recently introduced system of compulsory recertification through continuous professional development provides a window of opportunity to develop locally relevant curricula and appropriate education and training methods for family practitioners. Challenges for family practice include the establishment of the role and value of the discipline in a developing country with a health system based on a nurse‐driven primary care service and the re‐orientation of family medicine teachers, trained in a biomedical paradigm, to the patient‐centred approach. The aspirations of family practice are to define the core content of the discipline, establish and nurture a culture of research in primary care, and to develop and introduce appropriate under and postgraduate training programmes for the new generation of family doctors.

Morbidity profile of admissions to GF Jooste Hospital, Manenberg, Cape Town

Abstract Background Secondary hospitals play an important, yet overlooked, role in reflecting public health status, both locally and nationally. Relatively few reports analysing the causes of secondary hospital admissions exist, which is especially unfortunate in the case of developing countries, considering the huge numbers of admissions and people at risk. In developing countries like South Africa, the quality of records varies among institutions. Some hospitals have computerised data, while others may keep no records whatsoever. A major problem facing the quality of hospital records is the constant shortage of staff in rural and urban hospitals. Thorough documentation is essential in providing an invaluable database for researchers, but morbidity statistics are unfortunately scarce. GF Jooste Hospital in Manenberg is the busiest hospital in Cape Town—serving 1.1 million people, with 224 beds and over 12 000 admissions annually. Budgetary constraints in the South African public health sector means that providing healthcare services at higher levels than necessary is too costly. Because hospitals consume the largest share of the public healthcare budget, they have been the focus in cost cutting. In particular, the budgets of referral (tertiary or teaching) hospitals have been trimmed in order to promote primary and secondary care. It is imperative to identify those services that are required most at secondary hospitals in order to improve budgeting and, more appropriately, train doctors and medical students for the job at hand. Identifying the morbidity profile of the population for which the hospital caters can aid the optimal utilisation of the available resources, as well as focusing the continuing medical education of hospital physicians. We determined disease patterns of admissions over a three-year period (2001–2003), primarily as insight towards optimal hospital resource management. Methods A retrospective study examined ward records, totalling 36 657 admissions, from which a random sample (N=608) was selected. A stratified sample (N=462) was constructed, considering the relative proportions admitted to the wards. The International Statistical Classification of Diseases (ICD) directed diagnosis sorting. Disease prevalence was expressed as the percentage of patients allocated to each ICD category among those admitted to the hospital and respective wards and, additionally, the percentage of diagnoses for each ICD subcategory among patients assigned to each major category. Results Trauma (represented by ICD categories S/T 23% and V/X/Y 16%), specifically assault-related, was most prevalent. This was followed by circulatory diseases (22%) and infectious diseases (19%), dominated by HIV (61%) and associated diseases like TB (57%). The age of the patients ranged from 13 to 87 (mean: 40 years), with the 20 to 30-year-olds predominating. Surgical patients were younger (mean: 35 years) than medical (mean: 45 years). In the medical wards, infectious (39% in men; 38% in women) and circulatory aetiologies (39% and 41% in men and women respectively) dominated. In the surgical wards, the trend varied according to sex: assault (43%) and other injuries (61%) for males; pregnancy-related (42%) for females. Conclusion The morbidity distribution reflects the ills affecting South African urban society, with young trauma admissions predominating. The hospitals budget is insufficient, considering its populations demands.

Safety and immunogenicity of 13-valent pneumococcal conjugate vaccine formulations with and without aluminum phosphate and comparison of the formulation of choice with 23-valent pneumococcal polysaccharide vaccine in elderly adults: a randomized open-label trial.

This randomized open-label trial was designed to provide preliminary immunogenicity and safety data to support development of the pediatric 13-valent pneumococcal conjugate vaccine (PCV13) for adults. The aims were to: identify an age-appropriate PCV13 formulation, i.e., with (n = 309) or without (n = 304) aluminum phosphate (AlPO4); compare the selected PCV13 formulation (n = 309) with 23-valent pneumococcal polysaccharide vaccine (PPSV23; n = 301); and, together with an extension study, assess sequential use of pneumococcal vaccines at 1-year intervals in adults aged ≥65 years (n = 105) not pre-vaccinated with PPSV23. Immune responses were measured by ELISA and opsonophagocytic activity assays 1 month postvaccination. Immunoglobulin G responses elicited by PCV13 with AlPO4 and PCV13 without AlPO4 were similar for the majority, and noninferior for all PCV13 serotypes. PCV13 with AlPO4 was generally more reactogenic, with reactions mainly mild or moderate. Thus, PCV13 with AlPO4 (hereafter PCV13) became the selected formulation. Immune responses to PCV13 were noninferior for all but one serotype and for most PCV13 serotypes superior to PPSV23. Vaccine sequence assessments showed that for PCV13/PPSV23, the initial PCV13 dose generally enhanced responses to a subsequent PPSV23 dose, compared with PPSV23 alone. For PCV13/PCV13, a second dose did not enhance the first dose response when given after 1 year. For PCV13/PPSV23/PCV13, priming with PCV13 (vaccination 1) did not protect against lower responses induced by PPSV23 to subsequent PCV13 (vaccination 3). In conclusion, the pediatric PCV13 formulation with AlPO4 is well tolerated and immunogenic in adults, is generally more immunogenic than PPSV23, and subsequent vaccination with PPSV23 is possible if required.

Transforming the Academy

Readers of this journal and members of the South African Academy of Family Practice/Primary Care (SAAFP) will know that the SAAFP is currently going through a process of profound change, which started during January 2006.1 The main driver behind this was the ideal to form a single organisation that could serve the needs of academic family medicine in South Africa, both in the private and public sectors, in close collaboration with the universities. This process gained more momentum when family medicine finally became a specialty with the HPCSA at the beginning of 2007.

“The times are a-changin”

It is often said that the only constant thing in the universe is change. That indeed also applies to our discipline, family medicine. On 17 August 2007 regulations were promulgated making family medicine a medical specialty in South Africa, following the example of many other countries.1 This has far reaching implications for the discipline, such as education and training, and for the delivery of health services in the private and public sectors. Since the publication of these regulations registrar training programmes had to be developed and accredited by the Health Professions Council of South Africa (HPCSA), to be in time for the new academic year in 2008. Fortunately, we could lean on the excellent groundwork done in the development of vocational training and masters programmes in family medicine over the previous two decades.

Becoming a Family Medicine Specialist

South Africa embarked on the road to establish family medicine as a medical specialty during the early 1990’s. A special registration category of “family physician” was created to give recognition to practitioners who have completed postgraduate education in family medicine, such as the MFamMed or MCFP(SA). In 2000, a compulsory period of vocational training for registration in this category was introduced, which meant a period of supervised clinical training in an approved clinical training position. Applicants for registration in this category were screened and accredited by the Committee for Family Medicine (CFM) of the Medical and Dental Professions Board (MDPB).

The journal: a change at the helm

This is my last editorial in South African Family Practice, since my term finally expired on 31 December 2011, after 13 years. I can remember how Sam Fehrsen, a former editor, always used to talk about “the journal”, and so we all followed. To me, this is a term of endearment, respect, and recognition of the important role it played in the development of the discipline of family medicine.

The Academy in 2011: a time of difficulty and opportunity

These are difficult times in our country. The effects of the worldwide economic recession are evident in job losses and financial hardship. Socially and morally, our country seems to be leaderless, crime ridden, and filled with corruption and mismanagement. Globally, we are facing the possible devastating effects of overpopulation: climate change, disease and wars.