South African Family Practice - Volume 50, Issue 2, 2008
Volume 50, Issue 2, 2008
Factors that influence doctors in the assessment of applicants for disability grant : original researchAuthor J.M. TumboSource: South African Family Practice 50 (2008)More Less
Background: A disability grant is the financial assistance given by the government to South African citizens and bona fide refugees who have debility that results in inability to work. Doctors in state hospitals and clinics are tasked with the duty of assessing applicants for this grant. Ideally, the assessment is done by an institutional committee consisting of a doctor, physiotherapist, social worker, occupational therapist and specialised nurses. However, this is not always the case because of a shortage of personnel, particularly in rural areas. A lack of clear guidelines for the assessment process has led to confusion and differences in the outcomes. This poses major problems for the doctors, as well as the applicants, who often are dependent on the grant for survival. The aim of this study was to explore the factors that influence doctors in the assessment of applicants for a disability grant.
Methods: A qualitative study using free attitude interviews was conducted amongst doctors involved in the assessment process in Limpopo province. Content analysis was used to identify themes from the interviews.
Results: The assessment process was not entirely objective and was influenced by subjective factors. These included the mood of the doctors, emotions such as anger and sympathy, and feelings of desperation. Perceptions by the doctors regarding abuse of the system, abuse of the grant, the inappropriateness of the task, lack of clear guidelines and the usefulness of the committees were important in decision making. The doctors' personal life experiences were a major determinant of the outcome of the application.
Conclusion: The assessment of applicants for a disability grant is a subjective and emotional task. There is need for policy makers to appreciate the difficulties inherent in the current medicalised process. Demedicalisation of certain aspects of disability assessment and other social needs that doctors do not view as a purely clinical functions is necessary. In addition, there is a need for clear, uniform policy on and guidelines for the management of the grant, the role of the doctor has to be defined, healthcare practitioners must be trained in disability assessment, institutional committees should be established and intersectoral initiatives should be encouraged to address issues of poverty and dependence.
Source: South African Family Practice 50 (2008)More Less
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.
Source: South African Family Practice 50 (2008)More Less
Background: This study determines the pattern of depression among patients attending the Family Practice Clinic at Wesley Guild Hospital, Ilesa, Nigeria. Socio-demographic and clinical correlates associated with depression were identified.
Methods: Two hundred and fifty (250) newly registered patients who attended the clinic between June and September 2005 were selected by the systematic random sampling method and studied. Relevant data were collected using a pre-tested interviewer-administered questionnaire that incorporated Zung's Depression Scale.
Results: The age of the study subjects ranged from 16 to 84 years, with a mean age of 49.66 + 14.95 years. One hundred and forty-nine of the 250 subjects (59.6%) were found to have one form of depression or the other. Of these, one hundred and seven (42.8%) had mild depression, forty (16.0%) had moderate depression and only two (0.8%) had severe depression. Depression was found to be commoner in the age groups from 45 years and above, and there was a significant association between age and depression. There were 74 males and 176 females in the sample population, showing a male to female ratio of 1:2.4. Out of 149 depressed subjects, one hundred and four females (69.8%) had depression, while depression was present in 45 males (30.2%). Forty-seven (87.0%) of 54 subjects with no formal education had depression, while depression was found in 102 (52.0%) of the 196 educated subjects. Low educational status was significantly associated with depression in this study. Only two (0.8%) of the 250 subjects gave a positive family history of psychiatric illness, and these two subjects had mild to moderate depression. The proportion of depressed subjects who lived below the poverty level was significantly greater than that of non-depressed subjects. Substance use was also significantly more common among depressed subjects than the non-depressed group.
Conclusion: The proportion of patients with depressive symptoms in family practice clinics is high, and it is highly correlated with socio-demographic factors and low socioeconomic status. Family physicians are hereby enjoined to pay greater attention to patients with these factors, as they are at increased risk of depression. In order to reduce the high proportion of depressive symptoms and its adverse impacts on patients seen in family practice clinics and in the community as a whole, there is a need for effective implementation of poverty-alleviation programmes and universal basic education.
The impact of diarrhoea in infants on the quality of life of low-income households : original researchSource: South African Family Practice 50 (2008)More Less
Background: This article reports on a study that explored the impact of diarrhoea in babies on the quality of life of low-income households. Diarrhoeal diseases continue to be an important cause of illness and death worldwide. One major cause of infantile diarrhoea is the rotavirus, an airborne virus to which almost all children in both the developing and developed world will be exposed to at least once. The study, as well as the clinical trials and cost studies, was commissioned by GlaxoSmithKline to assist in the decision-making processes regarding whether and how to implement a newly developed vaccine against rotavirus through national immunisation programmes. The objective of the study was to obtain a comprehensive understanding of the impact of severe diarrhoea in babies on the quality of life of a selected group of low-income households.
Methods: The study was qualitative, explorative and descriptive in nature. A recently developed quality of life (QoL) assessment instrument, based on a comprehensive list of fundamental needs developed by development expert Manfred Max-Neef, was used to assess the impact of diarrhoea in babies on households. The QoL instrument includes 125 open questions related to basic necessities and activities, localisation, relationships and consciousness of household members. In addition, group and individual interviews were held. Twenty-nine households with children younger than two years of age who had experienced diarrhoea in the previous two months were selected. By means of a number of medical questions related to the duration of the diarrhoea and related symptoms, babies with severe diarrhoea were purposively sampled. After analysis of the data, these babies were classified as follows: 20 had severe diarrhoea, six had moderate diarrhoea and three were diagnosed as having had mild diarrhoea. Two babies were previously admitted to the hospital. Of the 29 households surveyed, 22 households were interviewed using the QoL assessment instrument, and seven households were interviewed by means of group and individual interviews. Ethical approval for the research was obtained from the ethics committee of the Faculty of Theology at the University of Pretoria.
Results: Poor housing conditions exacerbated the effect of diarrhoea in infants on the primary caregiver as well as the other household members. Household members complained about the sound of the babies crying and almost half of the mothers reported that they felt stressed or ashamed about the quality of air in their dwellings. One mother said that the smell was so bad that she could not eat her food because it caused her to vomit. The lack of basic necessities, for example the shortage of water in a number of households, intensified the struggle to cope with the diarrhoea. It was found that the burden of care fell mainly on the mothers of the babies with diarrhoea. The pressure experienced by some mothers seems to be related to the way they experience their identity. Mothers indicated that they felt responsible for tasks in and around the household, including the duty of caring for their children. This places a physical and emotional burden on the primary caregiver. Diarrhoea was the cause of tension and conflict in a number of households, not only because of inflated financial costs related to efforts to cope with the illness, but also because of differing views among household members regarding the most suitable treatment Western or traditional medicine. Mothers identified different causes of the diarrhoea, including teething, heat, wrong food and 'the problem of the fontanelle'. It became evident that some mothers believed that a sunken fontanelle was the cause of diarrhoea, and this was believed to be best treated by traditional healing methods.
Conclusion: A vaccine against rotavirus diarrhoea could benefit the households in this research by:
- Reducing the emotional burden of care on the mother;
- Reducing the physical burden of care on the mother, and
- Reducing the financial burden that childhood diarrhoea imposes on households.
Note of caution: The findings show how rotavirus vaccines could be an adjunct to the primary prevention approach for diarrhoea diseases in children. A vaccine will not substitute for all the other important requirements for a respectable quality of life, such as love, care, education, healthy nutrition, a regular safe water supply, and good sanitation. It is also important to interpret the findings in conjunction with other rotavirus vaccine clinical trials and cost-benefit studies.
Immunisation-related knowledge, attitudes and practices of mothers in Kinshasa, Democratic Republic of the Congo : original researchSource: South African Family Practice 50 (2008)More Less
Background: In the Democratic Republic of Congo, it was reported in 1995 that the routine coverage for BCG was as low as 47%, and that it was 27% for DPT3, 28% for OPV3 and 39% for measles vaccine. The trend also was declining unevenly. This study aimed to determine the reasons for such low coverage, examining the socio-demographic characteristics of mothers and health system factors such as health services barriers. It further sought to assess the knowledge, attitudes and practices of mothers associated with routine immunisation.
Methods: In 1999, a cross-sectional household survey applied a systematic sampling technique in a sample of eight out of the 22 health zones that then served the population of Kinshasa. These were dichotomised into low- and high-coverage health zones, based on BCG immunisation coverage. Mothers of children aged from zero to four years were the respondents to a standardised questionnaire.
Results: A total of 1 613 children aged zero to four years participated in the study. Awareness of immunisation and its importance in protecting a child against diseases was universal, although most mothers could not tell exactly against which diseases. Mothers had positive attitudes towards immunisation (98%). Coverage based on the immunisation card, however, was as low as 37%, indicating a discrepancy between the high level of knowledge and positive attitudes, with the observed low immunisation coverage. The father's education and the mother's experience of an EPI-targeted disease in the family emerged as significant predictors of complete immunisation of the child. The father's involvement and the mother's ability to cite signs of severity of EPI diseases were associated with the child's vaccination status in the high-coverage health zone. The mother's vaccine-related knowledge was a predictor of immunisation status only in the low-coverage zone.
Conclusion: Different factors determine the complete vaccination status, depending on whether the child lives in a zone with low or high routine EPI coverage. For example, the father's involvement is associated with the child's vaccination status in the high-coverage zone, but not in the low-coverage zone. Programmes and policy makers should take these factors into account when designing strategies to increase immunisation coverage.
Source: South African Family Practice 50 (2008)More Less
Background: Telemedicine is viewed as a new way of offering medical services. It is seen as a means of overcoming the growing shortage of health practitioners in developing countries. The aim of this paper is to highlight the need for the formulation of guidelines for the ethical practice of telemedicine in South Africa.
Methods: Full-length, peer-reviewed journal papers were obtained for review by searching the electronic databases Pubmed, CINAHL and CAB International, using the Boolean-linked keywords ethics AND telemedicine, ethics AND telecare, ethics AND telehealth, and ethics AND ehealth. Additional searches were made of Google Scholar using the same search strategies, and of the web pages of national telemedicine associations.
Results: A total of 152 relevant papers were identified. Twenty-one telemedicine guidelines were obtained. Only four countries and one international association have developed ethical guidelines. Several medical disciplines have established national guidelines for their speciality. Common ethical issues identified include the doctor-patient relationship, informed consent, confidentiality, data security, adequacy of records, data standards and quality, clinical competence, licensure and medical responsibility. These are discussed with reference to the developing world where appropriate.
Conclusion: Resource constraints and other issues relevant to developing countries may require the formulation of guidelines that do not necessarily conform with those of the developed world. It is in the interests of patients and practitioners that ethical guidelines for the practice of telemedicine are developed for South Africa. If telemedicine is to be used to overcome shortages of health practitioners, it is important that contentious issues are resolved in a pragmatic way that is appropriate to our circumstances and in the best interests of the majority of our population.
Author Gboyega A. OgunbanjoSource: South African Family Practice 50, pp 3 –4 (2008)More Less
This is the second issue (March / April 2008) of the new look CPD section of the South African Family Practice journal. In each issue, 6 - 8 CPD articles are published in very reader-friendly formats with practical tips. The focus of this section is to present relevant articles in family practice with evidence-based information to assist clinicians with management decisions.
Source: South African Family Practice 50, pp 6 –12 (2008)More Less
Upper respiratory tract infection (URTI) occurs commonly in both children and adults and is a major cause of mild morbidity. It has a high cost to society, being responsible for absenteeism from school and work and unnecessary medical care, and is occasionally associated with serious sequelae. URTIs are usually caused by several families of virus; these are the rhinovirus, coronavirus, parainfluenza, respiratory syncytial virus (RSV), adenovirus, human metapneumovirus, influenza, enterovirus and the recently discovered bocavirus. This review will mainly focus on the rhinovirus, where significant advances have been made in understanding the epidemiology, natural history and relationship with other pathogens.
Author B.G. LindequeSource: South African Family Practice 50, pp 13 –18 (2008)More Less
First-time users of contraception are mostly young sexually active patients who may or may not be in a stable relationship who would want to prevent an unwanted pregnancy. Seeing these patients presents a golden opportunity to counsel patients about sexually transmitted diseases, sexual health and also legal aspects regarding sexual offences. Contraceptives may also be prescribed for their additional benefits like cycle control and acne and are also used to assist couples to space and plan their families. This article presents value information on the various methods of contraception for product selection and counselling.
Source: South African Family Practice 50, pp 19 –24 (2008)More Less
Prostate specific antigen (PSA) testing of asymptomatic men enables the diagnosis of localised prostate cancer which is potentially curable, but it also poses certain risks. Doctors run the risk of litigation for failure to diagnose cancer at a curable stage, while patients run the risk of being diagnosed with non-significant cancer, incurring costs and possible complications without any survival benefit.
PSA reflects a 'range of risk' for prostate cancer: the higher the PSA, the greater the risk. There is no 'normal' PSA, because even with a PSA below 4 ng/ml cancer can be detected on biopsy in up to 20% of men. However, the prevalence of high-grade (life-threatening) cancer is relatively low at low PSA values.
The following recommendations appear reasonable:
- PSA testing should be offered to all men aged 50 years or more (45 years in those with a family history of prostate cancer and - possibly - African men);
- Alternatively, PSA testing should be done at 40, 45 and 50 years and then every two to four years (the lower the baseline value, the lower the risk of ever developing prostate cancer);
- PSA testing should be repeated annually if it is more than 2 ng/ml and every two years if less than 2 ng/ml;
- Stop PSA testing in asymptomatic men over 75 years or with less than 10 years' life expectancy, and in those aged over 65 years with PSA less than 0.5 to 1 ng/ml.
The free-to-total PSA ratio and PSA density (PSA divided by prostate volume) can be used to decide which patients need prostatic biopsy. PSA velocity (increase of PSA per year) can predict which men are likely to develop prostate cancer or to die of it (the higher the PSA velocity, the greater the risk). PSA doubling time (the period it takes for the PSA to double) correlates with the prognosis both before and after treatment (the shorter the doubling time, the worse the prognosis).
An internet Prostate Cancer Risk Calculator is available which calculates a man's risk by taking into account his age, race, family history, PSA level, findings on rectal examination and prior negative biopsy. Although this is a very convenient tool, it should be used with caution, especially at low PSA values, because there is a real risk of overdiagnosis.
Source: South African Family Practice 50, pp 26 –32 (2008)More Less
Many surveys of asthma care suggest that only 5% of asthmatics are meeting the 'Goals of asthma management' as set out in the Global Initiative for Asthma (GINA) guidelines. Despite the availability of useful asthma therapies and treatment strategies, the morbidity from asthma has remained significant. This review includes practical suggestions on optimal asthma control for the family practitioner.
Source: South African Family Practice 50, pp 33 –35 (2008)More Less
Tick bite fever has been a constant feature of the South African medical landscape. While it was recognised many years ago that there was a wide spectrum of clinical severity of infection, only recently has it been established that there are two aetiological agents, with different epidemiologies and clinical presentations. Rickettsia conorii infections resemble the classical Mediterranean spotted fever (fièvre boutonneuse), and patients are sometimes at risk of severe or even fatal complications. On the other hand, African tick bite fever is a separate entity caused by Rickettsia africae and tends to be a milder illness, with less prominent rash and little tendency to progress to complicated disease. Irrespective of the agent, the treatment of choice for tick bite fever in South Africa remains doxycycline or tetracycline, and the role of macrolide and quinolone antibiotics is still unclear, or at least restricted.
Excerpt from a tribute to Dr James MacDonald Troup (11 November 1867 - 31 July 1945) : special featureAuthor Adrianus PijperSource: South African Family Practice 50, pp 36 –37 (2008)More Less
This excerpt is published in reference to the article on tick bite fever that is published in this edition of SA Family Practice. Troup and Pijper first described tick bite fever in South Africa and this piece eloquently describes the relationship between these two colleagues from 1920 to 1945. Dr Troup was a formidable family doctor in Pretoria; Dr Adrianus Pijper, a pathologist who settled in Pretoria in 1920 and brought with him the first pathology laboratory Pretoria had ever known. Up till then all laboratory specimens had to be sent to a Johannesburg laboratory with the unavoidable delay and other disadvantages attached to a postal laboratory service.
Source: South African Family Practice 50, pp 38 –41 (2008)More Less
Influenza spreads rapidly to affect 515% of the global population on an annual basis. It is estimated that influenza causes between three and five million cases of severe illness and between a quarter and half a million deaths every year. In South Africa during the period from 1997 to 2001, influenza and pneumonia combined was one of the top five causes of death for both males and females. Influenza illness causes substantial morbidity and mortality, with healthcare costs and lost productivity due to absenteeism resulting in both direct and indirect costs and, ultimately, a formidable economic burden.
Source: South African Family Practice 50, pp 42 –44 (2008)More Less
Diffuse infiltrative lymphocytosis syndrome (DILS) is characterised by a persistent CD8+ lymphocytosis and lymphocytic infiltration of various organs. The reported prevalence varies between 0.85 - 3%, and appears to be more common in Africans. Patients with DILS tend to have higher CD4+ cell counts and survive longer than those patients without DILS. Most patients present with bilateral parotid gland enlargement and features of the Sicca syndrome. Extraglandular involvement is common with the lungs being the most common site, followed by peripheral neuropathy and liver involvement. DILS is a benign presentation in most patients with few complications. Therapeutic trials are lacking although there are isolated reports of good response to antiretroviral and steroid therapy. With the high incidence of HIV in our population it is likely that DILS is under diagnosed probably due to our ignorance of this disease. Awareness of its various presentations may bring to light undiscovered patients with DILS.
Source: South African Family Practice 50, pp 45 –46 (2008)More Less
Placental rituals and other birth-by rituals are common in various societies. These rituals often include culturally determined behavioural sequences which operate as anxiety-releasing mechanisms and they serve to offer a spiritual means of 'control' over the future health and welfare of mother, child, and even the community. As long as such rituals do not cause harm, they should be respected for the role that they play and be left alone. This article discusses ethical and legal considerations regarding post-birth rituals and its relevance to South Africa with special reference to the South African Human Tissue Act.
Author M.H. MotswalediSource: South African Family Practice 50 (2008)More Less
A 36-year- old male presented with a history of nodules on the face for 3 months. He is HIV positive with a CD4 count of 92 cells/mm3. The patient has not yet been receiving anti-retroviral therapy. On clinical examination he was emaciated, had generalised lymphadenopathy and oral thrush. He had several nodular lesions on the face. These lesions bled easily on contact (Figure 1). Biopsy from one of the nodules showed an atrophic epidermis, proliferation of capillaries in the dermis and an inflammatory infiltrate of lymphocytes, histiocytes and neutrophils (Figure 2)
Author Pierre J.T. De VilliersSource: South African Family Practice 50 (2008)More Less
Author Stephen RollnickSource: South African Family Practice 50 (2008)More Less
Motivating others to change their behaviour is often not straightforward. People tend to react against well-intentioned efforts to persuade them to change. This common approach to the challenge of patient behaviour change is pragmatic, for sure, but probably not good enough.
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 : open forumSource: South African Family Practice 50, pp 53 –59 (2008)More Less
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.