Robert Mash

The development and psychometric evaluation of a safety climate measure for primary care

Introduction Building a safety culture is an important part of improving patient care. Measuring perceptions of safety climate among healthcare teams and organisations is a key element of this process. Existing measurement instruments are largely developed for secondary care settings in North America and many lack adequate psychometric testing. Our aim was to develop and test an instrument to measure perceptions of safety climate among primary care teams in National Health Service for Scotland. Method Questionnaire development was facilitated through a steering group, literature review, semistructured interviews with primary care team members, a modified Delphi and completion of a content validity index by experts. A cross-sectional postal survey utilising the questionnaire was undertaken in a random sample of west of Scotland general practices to facilitate psychometric evaluation. Statistical methods, including exploratory and confirmatory factor analysis, and Cronbach and Raykov reliability coefficients were conducted. Results Of the 667 primary care team members based in 49 general practices surveyed, 563 returned completed questionnaires (84.4%). Psychometric evaluation resulted in the development of a 30-item questionnaire with five safety climate factors: leadership, teamwork, communication, workload and safety systems. Retained items have strong factor loadings to only one factor. Reliability coefficients was satisfactory (α=0.94 and ρ=0.93). Discussion This study is the first stage in the development of an appropriately valid and reliable safety climate measure for primary care. Measuring safety climate perceptions has the potential to help primary care organisations and teams focus attention on safety-related issues and target improvement through educational interventions. Further research is required to explore acceptability and feasibility issues for primary care teams and the potential for organisational benchmarking.

Exploring the Key Principles of Family Medicine in Sub-Saharan Africa: International Delphi Consensus Process

Abstract Background: The purpose of this study was to establish consensus on the key principles of Family Medicine for Sub-Saharan Africa. Methods: A three-stage Delphi technique process involving nine countries in sub-Saharan Africa and individuals from two stakeholder groups (teachers or students/graduates of family medicine programmes). Consensus in rounds one and two was defined as at least 70% agreement. Ranking in round three depended on individuals selecting and ranking the top 20 principles; following this, aggregate scores were calculated. Results: Of the participants, 40 gave consent and 28 participated in the first round (23 teachers and 17 students/graduates); 27/40 (67.5%) participated in the second round; 22/40 (60%) in the third round. The 50 principles seen as relevant were ranked in order of importance. Core values and characteristics such as holistic, longitudinal, comprehensive and family-orientated care and community orientation were recognised as relevant, with differences from more developed settings in terms of emphasis. Several key organisational principles, such as home visiting and definition of the practice population, were seen differently. Principles relating to the scope of practice showed the greatest difference, with the need for family physicians to perform major surgery in the district hospital, to act as consultant and teacher to the first-contact primary care team and to include clinical nurse practitioners in the definition of family medicine being raised. Conclusion: The study contributes towards a clearer definition of Family Medicine in the region, which would enable comparison between regions, influence local curriculum content and outcomes, as well as inform the policy makers and managers of the health system.

Recognizing intimate partner violence in primary care: Western cape, South Africa

Introduction Interpersonal violence in South Africa is the second highest contributor to the burden of disease after HIV/AIDS and 62% is estimated to be from intimate partner violence (IPV). This study aimed to evaluate how women experiencing IPV present in primary care, how often IPV is recognized by health care practitioners and what other diagnoses are made. Methods At two urban and three rural community health centres, health practitioners were trained to screen all women for IPV over a period of up to 8 weeks. Medical records of 114 thus identified women were then examined and their reasons for encounter (RFE) and diagnoses over the previous 2-years were coded using the International Classification of Primary Care. Three focus group interviews were held with the practitioners and interviews with the facility managers to explore their experience of screening. Results IPV was previously recognized in 11 women (9.6%). Women presented with a variety of RFE that should raise the index of suspicion for IPV– headache, request for psychiatric medication, sleep disturbance, tiredness, assault, feeling anxious and depressed. Depression was the commonest diagnosis. Interviews identified key issues that prevented health practitioners from screening. Conclusion This study demonstrated that recognition of women with IPV is very low in South African primary care and adds useful new information on how women present to ambulatory health services. These findings offer key cues that can be used to improve selective case finding for IPV in resource-poor settings. Universal screening was not supported by this study.

The value of intervening for intimate partner violence in South African primary care: project evaluation

Objectives Intimate partner violence (IPV) is an important contributor to the burden of disease in South Africa. Evidence-based approaches to IPV in primary care are lacking. This study evaluated a project that implemented a South African protocol for screening and managing IPV. This article reports primarily on the benefits of this intervention from the perspective of women IPV survivors. Design This was a project evaluation involving two urban and three rural primary care facilities. Over 4–8 weeks primary care providers screened adult women for a history of IPV within the previous 24 months and offered referral to the study nurse. The study nurse assessed and managed the women according to the protocol. Researchers interviewed the participants 1 month later to ascertain adherence to their care plan and their views on the intervention. Results In total, 168 women were assisted and 124 (73.8%) returned for follow-up. Emotional (139, 82.7%), physical (115, 68.5%), sexual (72, 42.9%) and financial abuse (72, 42.9%) was common and 114 (67.9%) were at high/severe risk of harm. Adherence to the management plan ranged from testing for syphilis 10/25 (40.0%) to consulting a psychiatric nurse 28/58 (48.3%) to obtaining a protection order 28/28 (100.0%). Over 75% perceived all aspects of their care as helpful, except for legal advice from a non-profit organisation. Women reported significant benefits to their mental health, reduced alcohol abuse, improved relationships, increased self-efficacy and reduced abusive behaviour. Two characteristics seemed particularly important: the style of interaction with the nurse and the comprehensive nature of the assessment. Conclusion Female IPV survivors in primary care experience benefit from an empathic, comprehensive approach to assessing and assisting with the clinical, mental, social and legal aspects. Primary care managers should find ways to integrate this into primary care services and evaluate it further.

Reflections on the training of counsellors in motivational interviewing for programmes for the prevention of mother to child transmission of HIV in sub-Saharan Africa

Abstract Introduction: Within the Southern African prevention of mother to child transmission (PMTCT) programmes, counsellors talk with pregnant mothers about a number of interrelated decisions and behaviour changes. Current counselling has been characterised as ineffective in eliciting behaviour change and as adopting a predominantly informational and directive approach. Motivational interviewing (MI) was chosen as a more appropriate approach to guide mothers in these difficult decisions, as it is designed for conversations about behaviour change. MI has not previously been attempted in this context. This paper reflects on how MI can be incorporated successfully into PMTCT counselling and what lessons can be learnt regarding how to conduct training with counsellors. Methods: Thirty-eight lay and nurse counsellors at four sites in Southern Africa were trained in MI. After the initial training, they participated in a five-month inquiry group at each site, where an action researcher (AR) facilitated ongoing learning of new counselling skills and reflection. Transcripts of recorded counselling sessions were then analysed using the motivational interviewing treatment integrity (MITI) code to assess their skills in MI. The MITI analysis was discussed with the action researchers and a consensus was reached on how to improve training. Results: Overall, the counsellors showed a global rating score of four out of seven, a reflection-to-question ratio of 0, a 43% open question score, an 18% complex reflection score and a 58% MI-adherent score. There were significant differences between the sites and between nurses and lay counsellors (p < 0.05). The action researchers suggested that the following factors were important in enabling learning and change: assessment of the baseline level of skills and readiness to change, reflection on real consultations, differences between the ARs and counsellors, a focus on the overall spirit of MI versus technical skills, the approach to information giving, managerial support and an appreciative versus a critical facilitation style. Conclusion: Nurse counsellors in Namibia and Swaziland demonstrated beginning proficiency in MI, while lay counsellors in South Africa did not. From the dialogue with the action researchers, nine recommendations were made to guide the development of future training programmes.

Cost-effectiveness of a diabetes group education program delivered by health promoters with a guiding style in underserved communities in Cape Town, South Africa

OBJECTIVE This study aimed to evaluate the cost-effectiveness of a group diabetes education program delivered by health promoters in community health centers in the Western Cape, South Africa. METHODS The effectiveness of the education program was derived from the outcomes of a pragmatic cluster randomized controlled trial (RCT). Incremental operational costs of the intervention, as implemented in the trial, were calculated. All these data were entered into a Markov micro-simulation model to simulate clinical outcomes and health costs that were expressed as an Incremental Cost Effectiveness Ratio (ICER). RESULTS The only significant effect from the RCT at one year was a reduction in blood pressure (systolic blood pressure -4.65 mmHg (95%CI:-9.18 to -0.12) and diastolic blood pressure -3.30 mmHg (95%CI:-5.35 to -1.26)). The ICER for the intervention, based on the assumption that the costs would recur every year and the effect could be maintained, was 1862

A quasi-experimental evaluation of an HIV prevention programme by peer education in the Anglican Church of the Western Cape, South Africa

/QALY gained. CONCLUSION A structured group education program performed by mid-level trained healthcare workers at community health centers, for the management of Type II diabetes in the Western Cape, South Africa is therefore cost-effective. PRACTICE IMPLICATIONS This cost-effectiveness analysis supports the more widespread implementation of this intervention in primary care within South Africa.

Evaluation of the "Take Five School": an education programme for people with Type 2 Diabetes in the Western Cape, South Africa.

Introduction Religion is important in most African communities, but faith-based HIV prevention programmes are infrequent and very rarely evaluated. Objective The aim of this study was to evaluate the effectiveness of a church-based peer education HIV prevention programme that focused on youth. Design A quasi-experimental study design compared non-randomly chosen intervention and control groups. Setting This study was conducted in the Cape Town Diocese of the Anglican Church of Southern Africa. Participants The intervention group of 176 teenagers was selected from youth groups at 14 churches and the control group of 92 from youth groups at 17 churches. Intervention and control churches were chosen to be as similar as possible to decrease confounding. Intervention The intervention was a 20-session peer education programme (Fikelela: Agents of Change) aimed at changing risky sexual behaviour among youth (aged 12–19 years). Three workshops were also held with parents. Primary and secondary outcome measures The main outcome measures were changes in age of sexual debut, secondary abstinence, condom use and numbers of partners. Results The programme was successful at increasing condom usage (condom use score 3.5 vs 2.1; p=0.02), OR 6.7 (95% CI 1.1 to 40.7), and postponing sexual debut (11.9% vs 21.4%; p=0.04) absolute difference 9.5%. There was no difference in secondary abstinence (14.6% vs 12.5%; p=0.25) or with the number of partners (mean 1.7 vs 1.4; p=0.67) and OR 2.2 (95% CI 0.7 to 7.4). Conclusion An initial exploratory quasi-experimental evaluation of the Agents of Change peer education programme in a church-based context found that the age of sexual debut and condom usage was significantly increased. The study demonstrated the potential of faith-based peer education among youth to make a contribution to HIV prevention in Africa. Further evaluation of the effectiveness of the programme is, however, required before widespread implementation can be recommended.

The prevalence of substance use and its associations amongst students attending high school in Mitchells Plain, Cape Town

AIM To evaluate the Take Five School (TFS) group education programme for patients with Type 2 Diabetes in South Africa. METHODS Questionnaires, administered before and after 4 sessions of an hour each of group education, measured the effect on self-care activities in 84 patients from 6 different clinics. Individual interviews with health care workers (HCWs) and focus group interviews (FGIs) with patients explored attitudes. RESULTS A significant improvement in adherence to a diabetic diet, physical activity, foot care and the perceived ability to teach others was seen. There was no significant change in smoking or adherence to medication. Qualitative data revealed that comprehensive education was appreciated, that the group process was deemed supportive, that HCWs doubt the effect of education in general and that a combination of group and individual sessions was seen as an option worth exploring. Strengths, weaknesses, opportunities and threats to the TFS are identified. Recommendations are made to improve the programme and its environment. CONCLUSION Significant self-reported improvements in self-care activities after a group-education programme support the view that introducing structured group education for Type 2 Diabetics in a South African public sector primary care context holds promise. Group education for diabetics, especially in resource limited settings, should be sustained and further research should focus on clinical outcomes.

African leaders’ views on critical human resource issues for the implementation of family medicine in Africa

Abstract Purpose: In South Africa, there has been an increase in illicit drug trafficking and consumption and associated problems since the 1990s. Mitchells Plain in Cape Town is seen as a community battling with crime, gangsterism, unemployment, overcrowding, substance abuse and poverty. This study evaluated the actual prevalence of substance abuse amongst high school students in this community and factors associated with substance use. In particular, the study evaluated the use of tik (crystal methamphetamine), a relatively new drug. Method: A cross-sectional study was performed amongst 12 secondary schools in Mitchells Plain; Grade 8 and Grade 11 classes were randomly selected to produce a sample of 438 learners. The students completed an anonymous questionnaire that contained enquiries on substance use, demographic and school performance details, and personal and sexual risks. Results: Lifetime and annual prevalence rates were: alcohol (50.6%/41.0%), tobacco smoking (49.7%/36.2%), cannabis (32.1%/21.1%), crystal methamphetamine (9.2%/4.6%), ecstasy (4.4%/2.7%), mandrax (2.1%/0.9%), solvents (3.0%/0.9%) and cocaine (0.9%/0.9%). Illicit substance use was significantly associated with age (OR 1.6; CI 1.2–2.2), substance use by other members of the household (OR 2.8; CI 1.2–6.3), carrying a knife (OR 10.9; CI 4.2–28.8), attempted suicide (OR 3.7; CI 1.4–9.5) and higher sexual risk (OR 1.6; CI 1.2–2.3). Conclusion: The prevalence of substance use amongst adolescent students attending high schools in Mitchells Plain, Cape Town, is high for all substances relative to national and international figures. Government officials, educators and health care workers are alerted to the need for more comprehensive interventions to prevent and treat substance abuse in this and similar communities.