South African Family Practice - Volume 50, Issue 5, 2008
Volume 50, Issue 5, 2008
Improving the annual review of diabetic patients in primary care : an appreciative inquiry in the Cape Town District Health Services : original researchSource: South African Family Practice 50 (2008)More Less
Background: Diabetes is a common chronic disease in the Cape Town District Health Services and yet an audit of diabetic care demonstrated serious deficiencies in the quality of care. The Metro District Health Services (MDHS) decided to focus on improving the annual review of the diabetic patient. The MDHS provides primary care to the uninsured population of Cape Town through a network of 45 Community Health Centres (CHC).
Methods: An appreciative inquiry was established amongst the staff responsible for diabetic care at the 15 CHCs that had newly appointed facility managers. The inquiry completed three cycles of action-reflection over a period of one year and included training in clinical skills as requested by the participants. At the end of the inquiry a consensus was reached on the learning of the group.
Results: This consensus was expressed in the form of 11 key themes. CHCs that reported success with improving the annual review formed chronic care teams that met regularly to discuss their goals, roles and to plan improvements. These teams developed more structured and systematic approaches to care, which included the creation of special clubs, attention to the steps in patient flow and methods of summarising and accessing key information. These teams also appointed specific champions who would notrotate to other duties and who would provide continuity of leadership and organisation. These teams also supported continuity of relationships, clinical management and organisation of care. Teams involved the community and local non-profit organisations,particularly in the establishment of support groups that could disseminate medications and build health literacy and self-efficacy. Some teams emphasised the need to also care for the carers and to not just focus on workload and output indicators. More successful CHCs also grappled with balancing of the workload, quality of care and waiting times in a way that improved all three in an upward spiral. Patient satisfaction, staff satisfaction and clinical outcomes were seen as interlinked. There was a need to plan methods for empowering patients and build self-efficacy through a variety of facility- and community-based as well as individual-and group-orientated initiatives. Training in clinical skills was requested for foot and eye screening. Feedback was given to the MDHS on the need to improve referral pathways and access to preventative services such as dieticians, podiatrists and vascular surgery. Finally, the inquiry process itself together with the annual audit supported organisational learning and change at the facility level.
Conclusion: Improving the annual review has more to do with the organisation of care than gaps in knowledge or skills that can be addressed through training. While such gaps do exist, as shown by the training around foot screening, the main focus was on issues of leadership, teamwork, systematic organisation, continuity, staff satisfaction, motivation and the balancing of quality care provided, quantity of care demanded and queuing required. The appreciative inquiry (AI) process supported decentralised organisational learning and, while key themes were shared, the specific solutions were localised.
Self-reported adverse effects as barriers to adherence to antiretroviral therapy in HIV-infected patients in Pretoria : original researchAuthor N.G. MalanguSource: South African Family Practice 50 (2008)More Less
Background: Adherence is the key to the effectiveness of antiretroviral therapy. However, many factors have been identified as facilitating or hampering adherence. The aim of this study was to determine barriers and facilitators of adherence with particular emphasis on adverse effects.
Methods: A survey of patients, who started antiretroviral treatment between July 2004 and August 2005, was conducted by means of a semi-structured questionnaire. Those who consented to participate were interviewed for the collection of information on sociodemographic characteristics and clinical and other data.
Results: The 180 patients who participated had a mean age of 36.7 (±8.1); 68.8% were female, 86.7% unemployed, 73.9% had a high school level of education, and 77.8% were single. Some 8.9% of the respondents used at least one non-prescribed medicine, while 34.4% received disability grants. Overall, 94% of the respondents reported at least one side effect; the mean number of self-reported side effects was 2.6 (± 1.4). With regard to adherence, the mean number of doses missed during the last seven days prior to the interview was 2.7 (±3.9), ranging from 0 to 18. The mean adherence level was 92.3%, ranging from 48.6% to 100.0%; overall, only 57.2% reported taking at least or over 95% of their prescribed doses. The two most common reasons for missing doses were forgetting (26.6%) followed by being away from home (15.6%). In the bivariate analysis, the only facilitator or factor that was significantly associated with at least or over 95% self-reported adherence was eating well (80.6% vs 64.5%; p = 0.025), whereas barriers or factors more likely and significantly associated with with self-reported adherence of at least or over 95% included having used non-prescribed medicines (15.6% vs 3.9%; p = 0.008), having suffered from headaches (28.6 vs 14.6%; p = 0.026) and reported symptoms such as insomnia (27.3% vs 12.6%; p = 0.013) and abdominal pain (20.8% vs 9.7%; p = 0.037). In the multivariate analysis, the facilitators or factors that were significantly associated with self-reported adherence of at least or over 95% were having an initial bodyweight of less than 50 kg (p = 0.026) and viral load of >33 000 copies /ml (p = 0.047).
Conclusions: In conclusion, self-reported barriers to optimal adherence included the use of non-prescribed drugs, and the presence of side effects such as insomnia, headaches and abdominal pain; while eating well was a facilitator. These findings emphasise the need for better communication between patients and clinicians, and the need for integrating pharmacovigilance concepts in clinical practice.
Knowledge and experiences of needle prick injuries (NPI) among nursing students at a university in Gauteng, South Africa : original researchSource: South African Family Practice 50 (2008)More Less
Background: Healthcare workers and students on training who are directly involved in treating and nursing patients face a great risk of acquiring blood-borne infections from the workplace. Needle prick injuries (NPI) are the commonest route by which such infections are transmitted from patients to healthcare providers. Nursing students on training are no exception, as they get exposed to accidental needle pricks and contamination during their hospital activities. Lack of appropriate resources, knowledge and skills, coupled with the unavailability of the universal standard precautionary procedures and compliance thereof, constitute high risks for needle prick injuries. Adequate knowledge and adherence to safety practices could prevent the occurrence of NPI and the related consequences. A survey was conducted among nursing students at a specific university in Gauteng to assess their knowledge of NPI, to identify and describe factors that contribute to the occurrence of NPI, and to discover the circumstances of needle prick accidents among the targeted group of students.
Methods: A cross-sectional quantitative survey was conducted among nursing students from the second to the fourth year of study registered at the specific university for the 2007 academic year. Questionnaires were hand delivered to a convenient sample of nursing students attending mandatory nursing classes. Those who consented signed a consent form. Participants completed and handed back the questionnaires to the researchers on the same day that they were delivered. Data collected included factors contributing to NPI and high-risk procedures leading to NPI, as perceived by these students. A knowledge assessment of NPI guidelines, policies and protocols and prevalence of NPI among these students was also done.
Results: A response rate of 96 (74%) was achieved. The average age of the respondents was 23 years, with a minimum age of 18 and a maximum age of 35. The sample consisted of more females than males. The majority of respondents were in the second year of study. The majority (56%) rated needle recapping, disposing used needles (28.1%) and cleaning sharp instruments (56.3%) as extremely high-risk procedures. Furthermore, 30.2% of the respondents thought suturing and blood taking (33.3%) were high-risk procedures for NPI, while 25% rated administering injections, 35.5% rated blood transfusion and 74.8% rated the lack of adequate containers for sharps disposal to be highly associated with the risk of NPI. A significant proportion of the respondents rated the lack of knowledge about NPI (policies and protocols) at institutions of clinical training as an extremely high risk, followed by the lack of accompaniment and in-service training. Only 16.0% of the respondents had suffered NPI and only 8.3% had reported the incident.
Conclusion: Procedures rated as high risk were considered to be most likely associated with the occurrence of NPI. Appropriate guidelines, adequate knowledge and the enforcement of compliance with standard precautionary measures could reduce the incidence of NPI among nursing students.
Relationships as determinants of substance use amongst street children in a local government area in south-western Nigeria : original researchSource: South African Family Practice 50 (2008)More Less
Background: Unrestrained exposure to street life often makes the street child vulnerable to psychoactive substances. In other settings, the social relationships of the substance user with those around him or her and family norms of parenting have been documented to modulate use. However, there is a dearth of literature on the role of relationships in substance use in Nigeria.
Methods: A cross-sectional analytical study of street children was conducted in a local government area of south-western Nigeria between November 2004 and March 2005, with data analysis being undertaken in April 2005 and November 2006. A cluster sampling method was used to recruit 360 consenting street children into the study. Information was collected on socio-demographic characteristics, parental and friend connectedness, familial stress and current psychoactive substance use.
Results: The mean age was 16.2 ± 1.3 years, and there were more males (58.3%) than females. Most of the respondents (65%) were still living with their parents. Fifty-three per cent of the respondents were current psychoactive substance users and the five commonest substances used were kola nut (58.6%), alcohol (43.6%), tobacco (41.4%), marijuana (25.4%) and "sokudaye" (24.9%). Of the respondents who live alone and of those whose fathers work outside of the town, 84% and 57.9% respectively were more likely to be current users at P < 0.05. Similarly, low connectedness with mother and friends and low parental presence were significantly associated with current substance use (75.7%, 77.5% and 58.3% respectively at P < 0.05). On logistic regression, only low connectedness with mother (OR 2.4, 95% CI 1.194.98) and friend (OR 3.1, 95% CI 1.705.72) predicted current substance use.
Conclusion: The study documented the important role of positive relationships between street children and their friends / mothers in preventing psychoactive substance use.
Author Douw GreeffSource: South African Family Practice 50 (2008)More Less
It is my privilege to write the CPD editorial for this issue and I hope that you will enjoy this issue as much as I did. Being the publisher of eight other South African peer reviewed journals, comprising 50 journal editions per annum, doesn't always allow me time to read every article every time.
Healthy lifestyle interventions in general practice : part 2 : lifestyle and cardiovascular disease : CPDSource: South African Family Practice 50, pp 6 –10 (2008)More Less
This article forms the second part of the series on the role of lifestyle modification in general practice with specific reference to chronic cardiovascular disease. Whilst the major risk factors which constitute an unhealthy lifestyle were discussed in part 1 of this series, the focus of part 2 will give specific practical guidelines which the general practitioner may incorporate into their practice when counselling patients with chronic cardiovascular disease.
Source: South African Family Practice 50, pp 12 –16 (2008)More Less
Mycobacterium tuberculosis has been identified as the aetiological agent of tuberculosis for many centuries. Genital tuberculosis is a chronic disease and often has low-grade symptomatology, with very few specific complaints. A study from South Africa found an incidence of 6% of culture-positive tuberculosis in an infertile population. The fallopian tubes are involved in most cases of genital tuberculosis and, together with endometrial involvement, cause infertility in patients. Many patients present with a symptom complex similar to that of ovarian carcinoma, i.e. abdominal distension, pelvic tumour and ascites, which may easily be confused with ovarian carcinoma. Biopsies should be obtained by either laparoscopy or laparotomy if examination of the ascitic fluid could not confirm the diagnosis. Genital tuberculosis is an elusive diagnosis and requires a high index of suspicion as a first step in the diagnostic process. Excellent cure rates are reported on all of the standard treatment regimens.
Author P.C. PotterSource: South African Family Practice 50, pp 18 –26 (2008)More Less
Atopy is defined as an inherited predisposition to produce immunoglobulin E (IgE) antibodies in response to natural exposure to minute quantities of environmental allergens, manifesting clinically with atopic diseases. These include food allergy, eczema, asthma, seasonal and persistent rhinitis and urticaria. Not all allergic diseases are atopic in nature.
Examples of non-atopic allergic diseases include allergy to drugs (e.g. penicillin), venoms (e.g. bee sting allergy) and some occupational allergies.
The cornerstone of the clinical diagnosis of any atopic disease is a detailed history, followed by specific IgE sensitivity testing. This requires knowledge of the patient's presenting symptoms, his family history and a careful knowledge of the environment in which the patient lives or works.
History taking is time consuming, but always rewarding and the most cost effective part of the clinical evaluation. The history guides the clinician as to the most appropriate clinical or laboratory test and can save the patient and health funder unnecessary expenses since there are hundreds of allergen sensitivities which can be tested.
In clinical practice, it is important to distinguish those patients with eczema, rhinitis, asthma and adverse food reactions who are truly allergic or "atopic" from those who are not. This distinction has a direct bearing on the treatment options for the patient (Figure 1). There are a number of unscientific and unvalidated tests which attempt to identify allergic factors playing a role in the patient's disease, but many of these are expensive and those which do not specifically determine IgE levels or evidence of mast cell or eosinophil activation are not recommended by allergologists.
Source: South African Family Practice 50, pp 27 –34 (2008)More Less
The biggest problems in prostate cancer management are how to identify patients with potentially life-threatening cancer, and how to choose the best form of management from among the large array of treatment options. Although prostate cancer is the second or third most common cause of cancer death in males, most men with this diagnosis will die of other causes.
The most important prognostic factors are the patient's life expectancy, the grade and stage of the tumour and the serum prostate specific antigen (PSA) at diagnosis. The most important management options are (1) active surveillance (watchful waiting), (2) androgen deprivation therapy (ADT), (3) radical prostatectomy and (4) radiotherapy.
Patients with a limited life expectancy or non-aggressive cancer can be managed with active surveillance and be treated only if and when it becomes necessary. ADT (hormone therapy) provides excellent palliation in men with locally advanced or metastatic cancer, but the side-effects decrease quality of life.
Radical prostatectomy and radiotherapy are potentially curative if the cancer is localised to the prostate. The use of laparoscopic radical prostatectomy is increasing in affluent countries, although (apart from reduced blood loss) there are no significant advantages compared to retropubic or perineal radical prostatectomy. The main complications are erectile dysfunction and urinary incontinence. The use of brachytherapy is increasing, although there is no convincing evidence that it is more effective or has fewer complications than external beam radiotherapy.
Although a vast amount of information on prostate cancer is available on the internet, some of the websites are driven by financial incentives to promote their products or procedures, and patients may emerge with unrealistic expectations based on misinformation. There are certain websites, based on the Partin tables or the Kattan nomogram, which can be used by the doctor to calculate the patient's statistical probability of being cured with radical prostatectomy or radiotherapy.
The probability of cure has to be weighed up against the risk of complications or side-effects that impair quality of life. There are very few randomised clinical trials comparing treatment options, so there is no real answer to the question which form of management is "best".
Patients and their families should be given comprehensive and unbiased information and sufficient time to make decisions. Because there are no absolutely right or wrong choices, and because patients all have different expectations, it is best for the patient himself to decide what form of management would be best for him.
Source: South African Family Practice 50, pp 36 –40 (2008)More Less
Medical practitioners in the past mainly relied on ethical guidelines of the Health Professions Council of South Africa, international codes, declarations and common ethical principles as guidance to practice. In the past twelve years several pieces of legislation have been promulgated which totally changed this situation. Important issues in medicine such as the way in which medical treatment and or services are rendered, the privacy of a patient, the confidentiality of patients' information, the patient's right to self-determination and the informed consent of a patient are now all influenced and regulated by statutes. It is thus very important that the training programmes of medical schools and the further training of medical practitioners makes provision for the inclusion of the study of human rights issues, medical law and bio-ethics.
Author Pierre J.T. De VilliersSource: South African Family Practice 50 (2008)More Less
The task of family medicine as the primary health care discipline differs markedly from that of other disciplines. Comprehensive care including ambulatory care in the context of the district health service is important. Family medicine as a discipline is mainly tasked with chronic illness care, preventative care and ambulatory care. Rural health and care in the district hospital are included in the scope of family medicine. Private general practice is an important specific context.
Source: South African Family Practice 50 (2008)More Less
Author J.L. CarapinhaSource: South African Family Practice 50, pp 43 –46 (2008)More Less
Background: Biological medicines are clinically effective but very expensive in South Africa. The business decisions of biological manufacturers and payers (medical schemes) impact the access patient's have to biological medicines. The paper is the second paper of a two part series that explore risk-sharing agreements for biologic medicines. In this paper, the events related to trastuzumab and Discovery Health are presented as a vehicle to explore the application of risk-sharing agreements in South Africa.
Methods: The paper critically reviews the current policy framework and assesses the implications for the manufacturer and the payer. The structural necessities for the outcomes-based reimbursement of biologic medicine are revisited and the paper extracts key lessons and presents these as policy guidelines covering the following four phases: pre-planning phase, planning, implementation and monitoring.
Results: There are numerous policy implications for the manufacturer of biological medicines and the payers (medical schemes). Each implication directly impacts the establishment of risk sharing agreements and inevitably determines the success or failure of such agreements. Two organisations comparable to the NCQA and NICE are required for the successful implementation of out-comes-based reimbursement. The precursors for the development of the such organisations already exist in South African legislation. Risk-sharing agreements have been narrowly conceptualized as a financial risk management tool devoid of clinical and QoL outcomes measurement.
Conclusions: A risk-sharing agreement is a useful tool to manage the risk of introducing clinically effective and very expensive medicines into the healthcare market. Clinical, QoL and financial outcome measures should be integrated into a risk-sharing agreement. A risk-sharing agreement is a tool that bridges the conflicting priorities of the manufacturer of biological medicine and the payer. Moreover, it is a mechanism that mitigates the ethical, social, and political consequences of denying care to patients often confronted with an all-or-nothing situation.
A description of the psychosocial factors associated with depression and anxiety in South African adolescents attending urban private practices in Johannesburg : scientific letterSource: South African Family Practice 50 (2008)More Less
Source: South African Family Practice 50 (2008)More Less
The purpose of this study therefore is to define the information needs and information-seeking behaviour of family physicians in Nigeria. This will enable an evaluation of whether these information needs are being met or not. A structured, self-administered questionnaire that had been pre-tested and validated was distributed to all the 125 family physicians at the 25th anniversary of the Faculty of Family Medicine in Nigeria.
Author Bernard BromSource: South African Family Practice 50, pp 53 –54 (2008)More Less
Everything in Chinese Medicine has a Yin and Yang pole to it. Poles are not parts but belong together, and Yin and Yang are in a dynamic relationship to each other. This may not make much sense to Westerners until one explains that the Yin pole can also be interpreted as order and the Yang pole as change. So in all seemingly-isolated systems there is both a Yin (order) and a Yang (change) functioning pole.
Author Ronald IngleSource: South African Family Practice 50 (2008)More Less
The authors aim to open up a debate that has stagnated in South Africa. I recently resorted to the SAMJ to discover what had happened to the South African Law Commission's Report 86 and the Draft Bill with the short title of End of Life Decisions Act 1999 . I wrote that an outstanding feature of the Report was its survey of worldwide debate and legislation that had made so much progress in many countries and its excellent overview and discussion of end-of-life decision making. I remain none the wiser.
Three-letter plague : A young man's journey through a great epidemic, Jonny Steinberg : book review : correspondenceAuthor R. MashSource: South African Family Practice 50 (2008)More Less