South African Family Practice - Volume 50, Issue 6, 2008
Volume 50, Issue 6, 2008
The prevalence of and reasons for interruption of anti-tuberculosis treatment by patients at Mbekweni Health Centre in the King Sabata Dalindyebo (KSD) District in the Eastern Cape province : original researchSource: South African Family Practice 50 (2008)More Less
Background : In spite of effective therapy, tuberculosis (TB) is still a major health problem in developing countries. In 1993, therefore, the World Health Organization declared TB a global emergency. In South Africa, TB is one of the most prevalent diseases, with an incidence of 556 per 100 000 population. In spite of free TB drugs in the public service and the directly observed treatment short course (DOTS) strategies, there is still a high prevalence of TB and a high treatment interruption rate in rural South Africa.
Methods : The objectives of this study were to establish the prevalence of TB and reasons for the interruption of TB treatment by patients attending Mbekweni Health Centre in King Sabata Dalidyebo (KSD) district in the Eastern Cape province. This was a cross-sectional study in which data were collected from 15 July 2004 to 15 January 2005 from patients who were on TB treatment and interrupted their treatment between 6 August 2001 and 30 December 2003.
Results : Of the 255 TB patients who attended for treatment, 121 (47.5%) had interrupted their treatment. Reasons given for interruption included change of living place (18.96%), no money to go to the clinic (15.52%), feeling better (13.78%), side effects of the drug (6.90%), did not know the treatment course (5.17%), physical disability either old or too sick to collect treatment and nobody to help (5.17%), clinic too far (1.73%), drug not available in the clinic (13.83%) and no reasons (8.62%).
Conclusion : The prevalence of treatment interruption was high in this study. Change of living place, lack of money for visiting the clinic to collect treatment, feeling better, and no drugs at the clinic were the major reasons given for interruption of treatment. Ensuring the availability of TB drugs at the health centre / clinic, patient education about TB and strengthening the DOTS programme, including a stipend for the DOTS supervisors, would help to reduce the prevalence of treatment interruption.
Profile of rape victims attending the Karl Bremer Hospital Rape Centre, Tygerberg, Cape Town : original researchSource: South African Family Practice 50 (2008)More Less
Background : Given the high prevalence of HIV infection in this country today it is not difficult to observe the risk faced by victims of sexual assault. In addition, there is a lack of available data on the per-episode risk of HIV infection with specific sexual encounters, and in combination with poor follow-up of sexual assault victims, this has resulted in few studies assessing the risk of HIV infection after sexual assault. There is a paucity of research conducted in this field particularly at rape centres in the Cape Metropolitan area of the Western Cape.
Methods : Aim : To obtain a profile of sexual assault victims and the treatment received at the Karl Bremer Hospital Rape Centre over a period of one year.
Study design : Descriptive cross-sectional survey.
Setting : The study was conducted at the rape centre at the Karl Bremer Hospital, Cape Town, South Africa. To describe the frequency of sexually transmitted infections (STIs) in rape victims, all consecutive patients who presented to the rape centre over the one-year period from 1 April 2006 to 31 March 2007 were included in the sample. A total of 820 patient records were evaluated. The researcher and research assistant examined the victims' folders at the rape centre for information covered in the objectives. A checklist was used as an instrument to obtain relevant information on pregnancy, STIs, pre- and post-test counselling, HIV status, tolerance to anti-retroviral (ARV) treatment post sexual assault and other information covered in the objectives. Informed consent was obtained from all participants.
Results : The age of the victims ranged from six to 70 years (average age 23.3). Most of the victims (76.5%) were aged 10-29, 14.3% were aged 30-39, 2.1% were 50 or older and 0.2% were less than 10 years of age. About 5.5% had completed primary school, 26.8% had completed secondary school and only 1.8% had tertiary education. Most of the victims were not married (91.8%) and had experienced their first episode of sexual assault (88.4%). In addition, about 24.6% presented with STI and 12.1% were HIV positive at presentation. About two-thirds (67.2%) of the victims were offered post-coital contraception. It is, however, disturbing to note that only 6.2% had pre-test counselling and only 6.1% had post-test counselling.
About two-thirds (66.83%) of the victims were offered ARV therapy. Of the 548 patients who received ARV therapy, 64.2% were placed on Combivir® and only 1.5% took zidovudine. There seems to be a positive association between STI and HIV infection at presentation (OR 2.96; 95% CI 1.96-4.56). There was no statistically significant difference between level of education, employment status or marital status and HIV status at presentation. In addition, there was no statistically significant difference between number of episodes of sexual assault and HIV status.
Conclusion : The prevalence of STI in victims of sexual assault attending the Karl Bremer Hospital Rape Centre during the period 1 April 2006 to 31 March 2007 is 24.6% and that of documented HIV infection, 12.1%. The results also seem to confirm a positive association between STI and HIV infection in this study population. Pre-test and post-test counselling occurred very infrequently and this needs to be addressed. Further, attention needs to be focused on proper training of professional staff members with regard to counselling skills to further enhance the quality of care of sexual assault victims at the Karl Bremer Hospital Rape Centre.
The management of sexual assault victims at Odi District Hospital in the North-West Province : how can the quality of hospital care be improved? : original researchSource: South African Family Practice 50 (2008)More Less
Background : This six-month study at Odi Hospital in the district of Mabopane in the North-West Province was undertaken to gain insight into the way in which alleged sexual assault victims experienced the treatment they received from doctors, nurses and others and how the quality of the care they received can be improved.
Methods : Design : A descriptive cross-sectional survey was conducted using a questionnaire as well as interviews and focus group discussions.
Setting : Odi District Hospital in the North-West Province, South Africa.
Subjects : The subjects of the study were the patients who presented at Odi Hospital for alleged sexual assault between 1 March and 31 August 2001. A nurse or medical doctor completed a questionnaire for each patient. In addition, individual and focus group interviews were conducted with 20 rape victims, three rape crisis counsellors, nursing staff and doctors working in the casualty department.
Results : A total of 213 patients presenting at Odi Hospital during the research period formed the sample group of this study. This group consisted of one male (a four-year-old child) and 212 female patients. The majority were black (211) as only two were coloured people. The ages of the victims ranged from two to 70 years. The highest percentage of victims was in the age group 16 to 20 years (25.4%), followed by the age group 11 to 15 years (16.4%) and 21 to 25 years (14.1%). A total of 68.2% of the assailants were known to their victims. The assailants' estimated age ranged from 15 to 50 years, and in almost 80% of the cases they operated on their own. Most rapes took place in the victims' homes (36.2%) and visible lesions were found only in 32.4% of cases.
The following themes were identified and reported on : In terms of the "quality of service" offered by rape crisis counsellors, rape victims were "satisfied" with the service offered by rape crisis counsellors on the day of the assault and afterwards. The "waiting time" at the police station and at the hospital was apparently "too long". All parties involved agreed that the "waiting area" was not appropriate and that rape victims should be "separated" from other patients. As for the "consulting room", except for the younger group of victims, all other parties agreed that it "wasn't suitable" for the interview and examination of rape victims. There were mixed feelings about the attitude of nurses and doctors attending to rape victims. Some patients said that they were treated "nicely by both doctors and nurses". Others said they had the impression that "doctors and nurses did not believe they were really raped". Nurses and doctors complained about the "impatience of police officers and rape crisis counsellors".
Conclusion : The quality of care of sexual assault victims presenting at Odi Hospital can be improved. The waiting time of sexual assaulted victims is too long and attempts should be made to provide dedicated rooms and staff to assist in the care of sexual assault victims. Further, attention needs to be focused on ongoing educational activities as part of a holistic approach to management. Such education may assist in informing potential victims of the general modus operandi of perpetrators and encouraging victims of sexual assault to come forward without fear of victimisation.
Source: South African Family Practice 50 (2008)More Less
Background : It has become increasingly difficult to assist an individual to maintain long-term recovery from substance abuse. Irrespective of which treatment centre the individual has been to, none guarantees a successful recovery. This is frustrating to individuals, their families and service providers. The reason for this trend is not absolutely clear. Many treatment centres are rigid in the use of their programmes and depend on aftercare to improve recovery rates. Service providers are increasingly acknowledging that there is no one "best treatment" option, as there are too many variations and complexities in reaching the goal of freedom from dependence and social reintegration. Hence the focus of this article is on research that has been undertaken to identify the strengths and weaknesses of the different models / programmes used in different residential treatment centres in South Africa with a view to recommending changes to accommodate such complexities and sustain recovery.
Methods : Qualitative methodology was used to assess the strengths and weaknesses of programmes at three key residential rehabilitation centres in South Africa. The sample comprised both patients and service providers at each centre and the research instrument was focus group discussions with the former and individual, semi-structured interviews with the latter. Non-probability criterion sampling was employed to secure the participation of the required categories of treatment centres, and probability sampling was used thereafter, based on availability of respondents (both patients and staff) and easy access to them.
Results : Despite tradition dictating a fairly rigid programme, most of the centres' staff and patients requested attention to the full biopsychosocial self of the patient, instead of being unidimensional such as paying more attention to one aspect at the expense of another such as to the physical as in the case of the disease model. A key finding was the need for a paradigm shift away from the disease model, with its accompanying helplessness, to that of a holistic approach that emphasises empowerment, embraces alternative strategies such as massage, sauna for detoxification, dietary improvements and physical activity, and uses language that is consistent with power and control. The centres also employed a multidisciplinary team, consistent with a focus on the "mind, body and spirit", albeit requesting additional staff to comprehensively and effectively address all aspects of the holistic approach. Thus, they accorded importance to the spiritual dimension of the patient, although this did not always translate to action or programme content.
Conclusion : The weakness of existing programmes was clearly found to lie in a unidimensional philosophy and a programme that was repetitive and unchanging. Staff and students identified the need for more holistic, comprehensive and creative approaches. These had to complement traditional strategies, rather than replace them, in accordance with the multi-faceted and multi-layered complexities of substance abuse. In keeping with this finding was the call for in-depth interventions to make the transition from being an addict and substance dependent to a person who is empowered and free from dependence. Users must not be viewed as victims of their circumstances, but be encouraged to reclaim an inner locus of control.
Quality improvement cycles that reduced waiting times at Tshwane District Hospital Emergency Department : original researchSource: South African Family Practice 50 (2008)More Less
Background : Tshwane District Hospital (TDH) is a level-one hospital, delivering services in the centre of Pretoria since February 2006. It is unique in location, being only 100 meters away from the tertiary hospital, Pretoria Academic Hospital (PAH). In South Africa, public sector emergency units are under enormous pressure with large patient numbers, understaffing and poor resources. TDH Emergency Department (ED) is a typical example. An average of 3 900 patients per month visited this ED in 2006. Recurrent complaints and dissatisfaction shown by the patients about prolonged waiting times before consulting the medical practitioners (MPs) in the ED were one of the initial challenges faced by the newly established hospital. It was decided to undertake quality improvement (QI) cycles to analyse and improve the situation, using waiting time as a measure of improvement.
Methods : A QI team was chosen to conduct two QI cycles. The allocated time for QI cycle 1 was from May to August 2006 and for QI cycle 2 from September to December 2006. A total of 150 waiting times of stable and unstable patients were evaluated. Fifty waiting times were recorded over a span of 24 hours for each data collection in May, September and December 2006. Waiting time was defined as the time from arrival of the patient in the unit until the start of the consultation by the MP. Surveys were done in May and September to analyse the problems causing prolonged waiting times. The implemented change included instituting a functional triage system, improvement of the process of up- and down-referrals to and from the tertiary hospital, easy access to stock, reorganisation of doctors' duty roster, reorganisation of the academic programme, announcement on waiting time to patients, nurses carrying out minor procedures and availability of reference books.
Results : The median waiting times for stable patients were as follows : May 2006: 545 minutes (range 200 to 1 260), September 2006: 230 minutes (range 15 to 480) and December 2006: 89 minutes (range 15 to 230). There was a significant difference among these waiting times for May, September and December 2006 (p < 0.001; Kruskal-Wallis H test). The median waiting times for unstable patients were as follows: May 2006: zero minutes (range 0 to 30), September 2006: zero minutes (range 0 to 3) and December 2006: 0.5 minutes (range 0 to 2). There was no difference among the waiting times for unstable patients for May, September and December 2006 (p = 0.90; Kruskal-Wallis H test).
Conclusion : This QI exercise identified problems causing prolonged waiting time for stable patients at TDH ED. It rectified most of the identified problems. However, goals regarding registration and laboratory delays could not be successfully achieved. This study showed the significance of QI cycles in improving waiting times for stable patients at TDH ED without any additional financial or human resources. This was done without compromising the time taken to see unstable patients.
Impact of recent evidence on the use of hormone therapy in the South African private sector (2001-2005) : original researchSource: South African Family Practice 50 (2008)More Less
Background : The release of the results of the oestrogen plus progesterone therapy (EPT) arm of the Women's Health Initiative (WHI) in July 2002 started a worldwide process of reconsideration of the rationale behind hormone therapy (HT). This process was accelerated after the release of the results from the oestrogen-only (ET) arm of the same study. The results of the WHI reinforced the indications of HT to alleviate vasomotor symptoms and to prevent bone loss associated with early menopause, but refuted the possibility of cardioprotective effects and raised uncertainty around the risk of breast cancer for long-term users. In response, new guidelines and position statements were developed to aid healthcare practitioners and patients in various countries, including South Africa. The dissemination and penetration of all this information has been assessed in a number of countries, but the extent of its effect on the South African market is as yet unknown. Accordingly, the aim of this study was to assess the use of HT in the South African private sector from 2001 to 2005.
Methods : Monthly HT sales data for January 2001 to October 2005 were obtained from IMS Health (SA). Three successive periods were compared : (1) January 2001 to June 2002 (discontinuation of the WHI oestrogen plus progestogen arm), (2) July 2002 to February 2004 (termination of the WHI oestrogen only arm) and (3) March 2004 to October 2005.
Results : Overall, sales of HT fell 6.9% between periods 1 and 2 and 14.6% between periods 2 and 3. The total sales of ET predominated; they were more than double those of EPT. For ET, the sale of conjugated equine oestrogen (CEE) preparations exceeded those of non-CEE ET preparations, while for EPT preparations the reverse was true. The decline in ET sales was mostly accounted for by the fall in sales of CEE, by 9.8% and 20.6% for the two periods respectively. There was an increase in sales of both low-dose CEE and non-CEE, although the magnitude of increase in the case of the latter was much greater. Throughout the entire study period, CEE 0.625 mg tablets were found to account for the greatest sales volumes. Private sector sales represented 74.4% of total national HT sales over this period.
Conclusion : The release of the WHI findings resulted in a modest decrease in HT sales in South Africa, although it was less dramatic than sales reported elsewhere. The change in prescribing cannot be attributed to any single factor. Factors such as publicity, adherence to new guidelines, and pharmaceutical marketing may all have contributed. Guidelines need to be updated as the results of new research continue to be published. There is also a need to periodically review prescribing trends, and to assess compliance with evidence-based guidelines, in order to improve the quality of medicines use. The majority of prescriptions for HT in South Africa are written by general practitioners, rather than by specialists. It is thus imperative that guidelines be appropriately framed for this market, as well as interpreted and applied.
Author Gboyega A. OgunbanjoSource: South African Family Practice 50 (2008)More Less
This is the last issue of the South African Family Practice journal for 2008. Our objective of providing relevant, up-to-date continuing professional development (CPD) articles was realized and we hope to continue with more vigour into the future. In this issue the article on healthy lifestyle interventions in general practice (part 3) by Schwellnus MP et al focuses on chronic respiratory disease. It mentions the main indication for referral to a lifestyle intervention program in any symptomatic patient with either chronic obstructive airway (COPD) or any other chronic respiratory disease and who also has limited functional capacity. COPD is a disease that is on the increase in women and there are about 280 million suffers globally. In predicting the outcome, the BODE index is used which is based on four functional measures namely Body Mass Index, Obstruction (FEV1), Dyspnoea and Exercise tolerance (6-minute walk distance). The main elements of the intervention program are smoking cessation, exercise training, education, psychosocial and nutritional support. It concludes that regular monitoring should be conducted during the training sessions and follow-up assessment done every 2-3 months to assess progress and to re-set goals.
Healthy lifestyle interventions in general practice : part 3 : lifestyle and chronic respiratory disease : CPDSource: South African Family Practice 50, pp 6 –14 (2008)More Less
Chronic respiratory diseases, in particular chronic obstructive pulmonary disease (COPD), can be classified as a part of the chronic diseases of lifestyle. A lifestyle intervention programme is therefore an essential component of the non-pharmacological management of COPD and other chronic respiratory diseases. The main indication for referral to a lifestyle intervention programme is any symptomatic patient with either COPD or any other chronic respiratory disease, and who also has limited functional capacity. Following a comprehensive initial assessment, patients are recommended to attend either a group-based programme (medically supervised or medically directed, depending on the severity of the disease and the presence of any co-morbidities) or a home-based intervention programme. The main elements of the intervention programme are smoking cessation, exercise training (minimum of three times per week), education, psychosocial support and nutritional support. Regular monitoring should be conducted during training sessions, and a follow-up assessment is indicated after 2-3 months to assess progress and to re-set goals. Longer-term (56 months) intervention programmes are associated with better long-term outcomes.
Author H.F. JordaanSource: South African Family Practice 50, pp 14 –23 (2008)More Less
The human immunodeficiency virus (HIV) epidemic continues to spread and evolve on a worldwide basis. Currently more than five million patients in South Africa are living with HIV / AIDS. Cutaneous and mucosal complications eventually occur in nearly all individuals with HIV infection, and can be debilitating, disfiguring, and life-threatening. Their incidence increases with deteriorating immune function. Familiarity with cutaneous disease patterns in this population enables early diagnosis and institution of correct treatment, detection of unrecognised HIV infection or progression to the acquired immunodeficiency syndrome (AIDS), and, counselling and prevention of further transmission. Knowledge of the skin and mucosal signs of HIV / AIDS is important.
Source: South African Family Practice 50, pp 25 –29 (2008)More Less
Suicide can be defined as intentional self-inflicted death. It is a serious cause of mortality worldwide. Suicide is considered as a psychiatric emergency and the awareness of the seriousness of suicide in our society should not be overlooked. It is a significant cause of death worldwide. It accounts for about 30,000 deaths annually in the USA and more than 5,000 deaths annually in South Africa, and the prevalence of suicide in our society is on the increase. Etiological factors for suicide include social, psychological and physical factors. But suicide is multi-factorial in nature. This review focuses mainly on the associated risk factors for suicide : demographic factors, psychiatric disorders, terminal or chronic medical conditions, and recurrent unresolved psychological stressors.
Concepts concerning 'disease' causation, control, and the current cholera outbreak in Zimbabwe : CPDSource: South African Family Practice 50, pp 30 –32 (2008)More Less
There is an ethical necessity that doctors understand the complex social, political, environmental and economic dynamics involved in infectious disease outbreaks. This article discusses some important concepts concerning 'disease' causation and control with specific reference to the current cholera outbreak in Zimbabwe and its effects on the Limpopo Province in South Africa.
Tetracyclines equally effective for acne vulgaris
Oral prednisolone is equal to naproxen in acute gout : infoPOEMsSource: South African Family Practice 50 (2008)More Less
Source: South African Family Practice 50, pp 36 –38 (2008)More Less
Masters Degree in Clinical Pharmacology (MPharmMed), presented by the Department of Pharmacology at University of Pretoria
The Aga Khan University invites applications
Specialist Clinical Associate Educator / Family Physician / Medical Officer - x 1 Position (Mankweng Hospital in Polokwane)
Specialist Clinical Associate Teacher - 1x Position (Mankweng Hospital in Polokwane)
Specialist Clinical Associate Educator / Family Physician / Medical Officer x 4 Positions (Wits University and South Rand Hospital)
Author David P. Van VeldenSource: South African Family Practice 50 (2008)More Less
The discipline of family medicine is now recognised as an essential component in the health care system with a unique body of knowledge, skills and attitudes embodied in defined post graduate curricula in various academic institutions worldwide. Integrative medicine should be incorporated into the paradigm of family medicine to combine the best insights of both conventional and alternative / complementary medicine, while providing a unifying perspective to guide physicians in intelligently combining these heterogeneous systems of thought.
Author B. BromSource: South African Family Practice 50 (2008)More Less
Integrative medicine is not alternative medicine or complementary medicine. It has developed within the ranks of conventional doctors and has been hailed as a paradigm shift in medicine. I will explore this paradigm shift and why it is important, especially in the family practice setting.
Breast cancer profiles of women presenting with newly diagnosed breast cancer at Universitas Hospital (Bloemfontein, South Africa) : scientific letterSource: South African Family Practice 50, pp 48 –49 (2008)More Less
Breast cancer is arguably the most-researched cancer in the world. Environmental factors, including diet and lifestyle, have been widely investigated, but these variables have not been able to explain international or ethnic variability in breast cancer. In South Africa breast cancer is most prevalent amongst white and Asian women and is the second most common cancer among black and coloured women. In South Africa an alarming increase in the incidence of breast cancer among young black women, a group that was previously considered to have the lowest breast cancer risk, is reported. There are several possible reasons why increasingly more young women appear to be contracting breast cancer.
Author R. MashSource: South African Family Practice 50, pp 50 –51 (2008)More Less
Recently I had the privilege of visiting Botswana and Malawi and discussing the development of family medicine training programmes in these two countries. The outcome is encouraging for the discipline of family medicine, but more importantly for the development of district health services in these countries.
SAAFP / Schering Plough Award : JM Mugambe wins award for best original article by a registrar : correspondenceSource: South African Family Practice 50 (2008)More Less
A research article on pain relief for women during labour has earned Dr JM Mugambe, at the time a postgraduate student of the Free State University, special honours at the 12th National Family Practitioner Congress that was held in Rustenburg in August 2008. As principal author of the article "Knowledge of and Attitude Towards Pain Relief During Labour of Women Attending Cecilia Makiwane Hospital's Antenatal Clinic, South Africa", Mugambe received the award for the best original research article by a South African registrar / MMed student in family medicine, published in South African Family Practice in 2007. His co-authors were M Nel, LA Hiemstra, and WJ Steinberg. The award comprises R5,000 donated by Schering Plough, South Africa. Mugambe is the first recipient of this award.
Author Sybelle AlbrechtSource: South African Family Practice 50 (2008)More Less
A research article on the provision of emergency care for, and psychological distress in, survivors of domestic violence has earned Ms Kate Joyner of the Nursing Division in the Stellenbosch University Faculty of Health Sciences special honours at the 12th National Family Practitioner Congress that was held in Rustenburg in August.