South African Family Practice - Volume 49, Issue 9, 2007
Volume 49, Issue 9, 2007
Variables influencing delay in antenatal clinic attendance among teenagers in Lesotho : original researchSource: South African Family Practice 49 (2007)More Less
Background: A delay in deciding to seek antenatal care is predominant among pregnant teenagers in Lesotho. This subsequently leads to delay in reaching treatment and in receiving adequate treatment. Early antenatal care attendance plays a major role in detecting and treating complications of pregnancy and forms a good basis for appropriate management during delivery and after childbirth.
Although antenatal care is provided at different levels, Lesotho still has a high maternal mortality rate, estimated at 762 per 100 000 live births, and an infant mortality rate of 72 per 1 000 live births.1 Lesotho has a chronic shortage of doctors and nurses. According to the Lesotho Population Data Sheet of 2000, the doctor-patient ratio for this country for the year 1999 was 1:13 041 and the nurse ratio was 1:2 035. About 31% of the adult population between the ages of 15 to 49 years is infected with HIV / Aids.
This shortage of health care personnel and the impact of HIV / Aids result in insufficient focus on health promotion in reproductive health, especially birth preparedness, and lack of community participation and male involvement in reproductive health care issues. Early sexual activities with consequent early pregnancy lead to high maternal and neonatal morbidity and mortality. As a result, the National Adolescent and Development Programme was started in 1998 by the Ministry of Health and Social Welfare to address the needs of teenagers. This led to the establishment of adolescent health clinics (referred to as teenage corners) that focus on teenagers in three districts of Lesotho, namely Mafeteng, Maseru and Leribe.
Despite the establishment of these teenage corners, delay in antenatal attendance is still prevalent in Lesotho. Out of 632 pregnant teenagers in 2003 who attended the clinic at Queen II Teenage Corner, the majority (43%) visited the antenatal clinic for the first time during the third trimester and only 14.9% attended in the first trimester. This late antenatal clinic attendance provides little or no time for appropriate screening, management of risk factors, if detected, and timely referral.
The aim of this study was to identify variables that contribute to delay in antenatal clinic attendance among pregnant teenagers and to make recommendations based on the research findings for the development of policies that will ensure early attendance.
Methods: An exploratory, descriptive research design was used to acquire understanding of the variables that contribute to the delay in antenatal clinic attendance among teenagers in Lesotho. The population composed of all pregnant teenagers who have started their antenatal clinic attendance at the three teenage corners after the thirteenth week of gestation. Purposive sampling was used and the sample was considered adequate when saturation of data was reached. A total of 21 pregnant teenagers and 21 parents / guardians participated. Data was gathered through observation of records and activities undertaken at the teenage corners and through in-depth interviews with the teenagers and their parents / guardians. A semi-structured interview schedule was used.
Results and conclusions: Twenty-one pregnant adolescents were interviewed, of which 71.3% started antenatal clinic attendance during the second trimester, while 28 (57%) started during the third trimester. Variables that contributed to the delay in early antenatal attendance included lack of knowledge regarding the importance of early attendance, denial of the pregnancy by the boyfriend, the fact that sex outside of marriage in Lesotho is still taboo and structural variables related to service provision.
The interviews with the pregnant teenagers and their parents / guardians highlighted the need to empower teenagers through education and counselling and the need for the Minister of Education and Training to review policy regarding the expulsion of pregnant teenagers from school. Community awareness campaigns should be held annually to sensitise the public about the increasing rates of teenage pregnancies in Lesotho and the consequences thereof. Life skills education and teenage pregnancy issues should be included in the health courses for primary school learners as early as grade 6 and 7.
Management of erectile dysfunction : perceptions and practices of Nigerian primary care clinicians : original researchSource: South African Family Practice 49 (2007)More Less
Background: Erectile dysfunction (ED) is a prevalent health problem in many societies, but the diagnosis is seldom documented in primary care. The objective of this study was to investigate the perception and practices of clinicians regarding the management of ED in primary care settings in Nigeria.
Methods: A self-administered semi-structured questionnaire was applied to a purposive sample of clinicians attending conferences / workshops organised by the Society of Family Physicians of Nigeria and Update Courses of the Faculties of Family Medicine of the National Postgraduate Medical College of Nigeria and the West African College of Physicians. Information was obtained on their professional characteristics, experiences with the management of ED and possible barriers to the effective management of ED.
Results: A total of 187 completed questionnaires were analysed. Most (87.2%) of the respondents were general practitioners, while the rest were specialists in various fields (excluding sexual health) who worked at the primary care level. One hundred and forty-seven respondents (76%) reported that ED was common in their clinical practice. Over half (56.2%) of the respondents ascribed a high priority to ED management in their day-to-day clinical practice, while 33.2% and 10.6% of them ascribed medium and low priority to ED management respectively. Although 80.8% of the respondents agreed that ED patients could benefit from orthodox treatments, only 18% of them had ever prescribed any medication for affected patients; most (82%) of them either counselled or referred ED patients to secondary or tertiary care level for further management. Most of the clinicians (62%) would not take a sexual history unless the patient brought it up. The reported barriers to the management of ED include lack of a standardised protocol (64.2%), inadequate experience in ED management (85.6%), preference of patients for native medication (42.3%), and the high cost of modern medication (48.1%).
Conclusion: The clinicians acknowledged the high prevalence of ED in the primary care setting and recognised that they had a role to play in managing affected patients. The identified barriers to the management of the condition point to the need for education of both clinicians and patients, as well as the provision of guidelines for the management of ED in primary care settings.
Noodlottige kindermishandeling : 'n literatuuroorsig en die profiel in die Suid-Vrystaat (1995-2003)
Fatal child abuse : a literature review and the profile in the Southern Free State (1995-2003) : original researchSource: South African Family Practice 49 (2007)More Less
Agtergrond: Kindermishandeling is 'n sosiale probleem met verreikende gevolge. Ernstige onderrapportering van gevalle vind plaas, en geen studies kon opgespoor word wat die Suid-Afrikaanse konteks van die probleem ondersoek nie. In hierdie studie is gepoog om die profiel van die slagoffers van noodlottige kindermishandeling in die Suid-Vrystaat te ondersoek.
Metodes: Alle kindersterftes van kinders van tien jaar en jonger is uit die register van sterftes by die SAPD- (Suid-Afrikaanse Polisiediens-) lykshuis, Bloemfontein, geïdentifiseer. Hierdie sterftes se verslae is vir gevalle van noodlottige kindermishandeling geëvalueer. Irrelevante verslae is geëlimineer totdat 'n groep moontlike gevalle van noodlottige kindermishandeling verkry is. In gevalle waar daar twyfel oor die oorsaak van dood was, is 'n kliniese assistent in Geregtelike Geneeskunde geraadpleeg. In sommige gevalle het die assistent aanbeveel dat 'n geskiedenis uit polisieverslae verkry moes word. Indien gevalle nie op so 'n wyse bevestig kon word nie, is dit in die sogenaamde 'grys area' ingesluit. Negentien gevalle is geïdentifiseer en vier is in die grys area geplaas.
Resultate: Uit die 19 gevalle was die meerderheid vroulik (14). Die mediaanouderdom van slagoffers was twee jaar. Die slag-offers toon 'n eweredige verspreiding t.o.v. ras. Geen patroon kon geïdentifiseer word in die jaarlikse en maandelikse verspreiding van sterftes nie. Die meeste van die slagoffers, 73.7% (14 van 19 gevalle), was van normale massa, en geen slagoffers het aan 'n wanvoedingsiekte gely nie. Hoofbese-rings was die algemeenste oorsaak van sterftes (63.2%), gevolg deur veelvuldige beserings (21.2%).
Gevolgtrekking: Indien dokters bedag is op die tekens van kindermishandeling, kan gevalle vroeg geïdentifiseer word. Sodoende kan 'n beduidende verlaging in mortaliteit en morbiditeit bewerkstellig word.
Introduction: Child abuse is a social problem with far-reaching consequences. Serious underreporting of cases occurs, and no studies could be found which investigates the South African context of the problem. In this study we aimed to determine the profile of victims of fatal child abuse in the Southern Free State.
Methods: All child deaths of children 10 years and younger in the period 1 January 1995 to 31 December 2003 were identified in the register of deaths at the SA Police Mortuary, Bloemfontein. The reports of these deaths were evaluated to identify possible cases of fatal child abuse. Irrelevant reports were eliminated until a group of possible cases of fatal child abuse were identified. In cases where there was uncertainty about the cause of death, a registrar in Forensic Medicine was consulted. In some cases she advised that a history be obtained from police reports. Cases which could not be confirmed in this way were included in a so-called grey area. Nineteen cases were identified, and a further 4 placed in the grey area.
Results: Of the 19 cases, the majority were female (14). The median age of cases was 2 years. Cases showed an even distribution regarding race. No patterns regarding annual or monthly distribution were found. Most victims, 73.7% (14 of 19 cases), were of normal weight and no victims suffered from malnutrition. Head injuries were the most common cause of death (63.2%) followed by multiple injuries (21.2%).
Conclusion: If doctors are aware of the signs of child abuse cases can be identified early. In this way a significant decrease in mortality and morbidity can occur.
Non-compliance with treatment by epileptic patients at George Provincial Hospital : original researchSource: South African Family Practice 49 (2007)More Less
Background: Non-compliance with anti-epileptic drug treatment in the George area, resulting in recurrent seizures and visits to the emergency department of the George Provincial Hospital, has been identified as a social and economic problem. The aim of this study was to determine the socio-economic and medical factors, the information given to patients by healthcare workers, and the understanding of patients living with epilepsy who presented to the emergency department with seizures.
Methods: A descriptive study design was employed and the data-collection tools were a questionnaire and structured interview.
Results: The median age of the study population was 32 years. The patients had suffered from epilepsy for a median of two years and visited a clinic for a median of seven times a year. The median education level was primary school and three quarters had no employment or government grant. The majority did not understand the disease, the side effects of the medication and why they should be on medication. In addition, it became apparent from patient reports that healthcare workers showed a lack of counselling skills, time and appropriate knowledge.
Conclusions: There is a general lack of understanding of epilepsy by the patient. Not only were the patients uninformed, but they also showed apathy towards the management of their condition.
Author Steve ReidSource: South African Family Practice 49 (2007)More Less
A group of 8 South African academics in Family Medicine met recently at a workshop in Kampala, Uganda, with some 20 colleagues from a number of sub-Saharan African countries in order to promote the development of Family Medicine throughout the continent. While this seems a lofty goal, the practitioner on the ground may ask: "What for?" Well, this is one response.
Assessing and serving families and communities responsibly : challenges posed in an urban, marginalised setting : open forumSource: South African Family Practice 49, pp 4 –8 (2007)More Less
Service provision to families and communities has long been recognised as a complex undertaking involving a multiplicity of role players and systems of care. Systems theory and ecological theory provide useful frameworks for understanding and servicing families and communities, yet there is a clear absence of literature and research on how to converge microsystemic with macrosystemic interventions.
Using Rojano's community family therapy model, which is applicable to South American communities, and Kasiram and Oliphant's strategies for changing traditional family therapy to suit broader contexts in South Africa, the authors used developmental research within a qualitative framework to develop an indigenous community family therapy model in an urban setting in KwaZulu-Natal, South Africa. The authors utilised nursing students as fieldworkers and service providers in this study. The research process involved several steps: a state-of-the-art review of the family and community, achieved through an assessment of the family and community through community profiling and an epidemiological study of the community; family assessment of families with one child under the age of five years; best practice and model development to intervene at the family and community levels, achieved with the help of community and school meetings and workshops to identify and prioritise needs and problems, followed by bio-psychosocial interventions; refining the model achieved by an evaluation of the interventions through report assessment and on-site assessment and recommending model adjustments based on the evaluation.
In designing a community family therapy model, the state-of-the-art review of community needs established several core issues requiring services / interventions. These were problems relating to HIV / AIDS; a lack of knowledge of the immunisation programme in South Africa and of the Road to Health chart; teenage pregnancy and its relationship to risky behaviours, HIV / AIDS, poverty and crime; and a lack of communication within the family.
The development of the model involved determining interventions with families and the community, using macrosystemic approaches, such as community meetings and workshops, where priorities were established and joint strategies were planned to address the identified problems. Individual and small-group discussions enriched the understanding of problems / needs, which, combined with macrosystemic approaches such as media coverage and community meetings and workshop / events, worked in synchrony to effectively assess and then service the families and communities. The goal of developing a community family therapy model was achieved.
Combining microsystemic and macrosystemic approaches to assess and serve families and communities is particularly helpful in the face of apathy. However, once momentum is achieved in securing a community spirit, it needs to be sustained or else it is lost and may require more effort to reclaim in the future. Thus, if services are provided by educational institutions, it would be in the best interests of both future students and the community if there is funding to support service outside of the academic year.
Young breast cancer patients in the developing world : incidence, choice of surgical treatment and genetic factors : CPDSource: South African Family Practice 49, pp 18 –24 (2007)More Less
Carcinoma of the breast is the most common cause of cancer in women in Western society. Although breast cancer occurs predominantly in older premenopausal and postmenopausal women, it also occurs in young women. Literature defines breast cancer in a young woman (or early onset breast cancer) as occurring in a woman less than 35 years of age. A diagnosis of breast cancer in a young woman impacts severely on all aspects of her life, as well as on those around her.
In Africa and other developing countries, the breast cancer burden is increasing and poor reporting and data availability may underestimate the exact numbers. The average age of diagnosis may be younger for women in developing countries than for women in developed countries. African patients are more likely to be premenopausal at diagnosis and the breast cancers tend to be more advanced at presentation than in other population groups in a country such as South Africa.
The choice of surgical treatment in early onset cancer depends on various factors. Young age is an independent risk factor for worse outcome regardless of whether a patient had a mastectomy or breast conserving therapy. Breast conserving treatment is an option for treatment of breast cancer in a young patient given the correct indications and that the patient is fully informed about the high risk of local recurrence.
The extent of genetic factors such as mutations on BRCA 1 and 2 (BReast CAncer 1 and 2) genes is still largely unknown on the continent of Africa, and much research still needs to be done. In the USA, only 5-10% of early onset breast cancers are attributable to mutations on BRCA 1 and 2 genes, and another 15-20% of early onset breast cancers are due to gene polimorphisms and environmental factors.
General breast awareness among women of all age groups in Africa should be promoted. This includes how to perform self breast examinations and to seek urgent medical attention when a breast lump is discovered. In time, given the resources, good screening programmes on this continent to detect breast cancer at its earliest presentation would be the ideal.
Author Arina SchlemmerSource: South African Family Practice 49 (2007)More Less
This book offers information on all the common disorders that a general practitioner will see from day to day. You will not find the very rare syndromes in this text but it does cover a wide variety of subjects, from the bread and butter diabetes mellitus to chapters on evidence based medicine and complementary and alternative medicine.
Author S. HoughSource: South African Family Practice 49, pp 26 –34 (2007)More Less
Osteoporosis is a common, costly and serious disease. The life-time risk of an osteoporotic fracture in Caucasian women approximates 50%. Epidemiologic fracture data in South Africa are limited, but the incidence of osteoporosis appears to be similar in white, Indian and mixed ancestry (Coloured) females.
Author Helmuth ReuterSource: South African Family Practice 49 (2007)More Less
Source: South African Family Practice 49, pp 42 –43 (2007)More Less
While schistosomiasis is endemic in South Africa, cutaneous manifestations are relatively uncommon. This case report describes the clinical findings in a patient with vulval schistosomiasis. Schistosomiasis should be considered in the differential diagnosis of genital lesions in residents in endemic areas or visitors to these areas.
Author G.L. MuntinghSource: South African Family Practice 49, pp 44 –49 (2007)More Less
The Aviation Medicine Department of the South African Civil Aviation Authority (SACAA), Aviation Medical Examiners (AME), and Institute for Aviation Medicine (IAM) receive numerous inquiries regarding the use of medication in the aviation environment. Flying an aircraft or controlling aircraft on the ground are highly demanding cognitive and psychomotor tasks, performed in an often inhospitable environment, with exposure to various sources of stress. It is therefore important for aviation personnel (i.e. aviation medical examiners, pilots, cabin crew and air traffic services personnel) to consider the effects that medicine or drugs may have on performance. Studies confirm that some pilots, and other crew members while on duty, used prohibited medications or illegal substances or performed duties while suffering significant unreported medical conditions. When considering aircraft mishaps and their causes, we tend to focus on the pilot. After all, he's in the driver's seat, there to troubleshoot any problems that may arise, and he's expected to bring the "on-loan" aircraft back to base, in one piece, after a mission. If a mishap occurs, investigators look for causes related to pilot error along with evidence of mechanical failure, weather factors, and runway condition and air traffic control (ATC) issues. Reviews of data from general aviation, commercial and military aircraft mishaps show that the two most often cited causal issues are pilot error and mechanical / logistical factors. If pilot error was identified, the question now arises: Are some instances of incorrect controlling of an aircraft due to human factors, such as poor diet or insufficient rest (self-imposed), fatigue, poor concentration, shift-work problems, inadequate training or lack of motivation?
More specifically, the following in terms of pilot error have been identified in the USA:
- Flying under the influence of alcohol - 15%
- Conducting unwarranted manoeuvers - 30%
- Penetrating known adverse weather conditions beyond pilot and aircraft capabilities - 40%
- Drug impairment of the pilot (includes prescribed medication) - 6%
- Miscellaneous - 9%
Although these statistics relate to the pilot, they can no doubt be extended to other aviation personnel e.g. ATC, cabin crew (CC) and aircraft maintenance officers (AMO). Of note is that up to 6% of aircrew are 'under the influence of medication' while operating an aircraft. Aircrew, like all of us, are prone to illness, but those who take medicine on an inadequately informed basis or undertake self-medication, not only endanger their lives but also jeopardise the safety of passengers and costly aircraft.
The Aviation Medicine Department of the South African Civil Aviation Authority, Aviation Medical Examiners, and the Institute for Aviation Medicine receive numerous inquiries regarding the use of medication in the aviation environment. In addition, reports have been received relating to aviation personnel using unapproved medication or illegal drugs. Furthermore, a physician may prescribe medication for a patient while being unaware that the patient is performing duties within the aviation environment. Or, a pilot self-medicates because consulting an AME may result in flying privileges being withdrawn.
Flying an aircraft or controlling aircraft on the ground are highly demanding cognitive and psychomotor tasks, performed in an inhospitable environment, with exposure to various sources of stress. It is therefore important for aviation personnel (i.e. aviation medical examiners, pilots, cabin crew and air traffic controllers) and non-aviation medical examiners to consider the effect that medicine or drugs may have on aviation performance. A study performed in 1994 by the FAA revealed that an estimated 14 000 US pilots flew while using prohibited medications or illegal substances or flew with significant unreported medical conditions.
Greater understanding of the effects of medication in humans, and advances in drug development have now made possible the use of various medications by aircrew. In this context assessment of side effects which a drug may have on performance, has become an important part of its clinical profile and provides increased and more informed availability of potential therapy for aircrew.
The aim of this review is to make the non-aviation medical examiner aware of, and to provide an understanding of the issues involved rather than to provide recommendations for drug use in aviation and to outline the various approaches that can be adopted to assess whether a drug can be used safely.
Improving long-term graft survival in kidney transplant recipients reduces the need for dialysis or re-transplantation : press releaseSource: South African Family Practice 49 (2007)More Less
Management strategies which provide optimal long-term protection to already transplanted kidneys are highly cost effective and can help patients avoid the need for dialysis or re-transplantation, according to an innovative, new transplant healthcare model presented for the first time today at the 13th Congress of the European Society for Organ Transplantation (ESOT), Prague, Czech Republic.
Source: South African Family Practice 49 (2007)More Less
Despite this being the sixth production of the Moments in Time project, the reveal of the 2008 product range does not disappoint and delivers what South Africans around the country were expecting and hoping for: another uniquely charged offering more magical than the years that have come before it.
Pharma dynamics launches Zartan 50 mg - the first generic Angiotensin Receptor Blocker (ARB) : press releaseSource: South African Family Practice 49 (2007)More Less
Author G.B. TheronSource: South African Family Practice 49, pp 50 –54 (2007)More Less
An effective perinatal mother to child transmission (PMTCT) programme will reduce perinatal acquired HIV infections. This goal is within reach of the South African public health sector. Early antenatal attendance and knowledge of HIV status allows sufficient time to implement highly active antiretroviral therapy (HAART) or ART intervention. Both measures have been proved to be efficient to reduce MTCT of HIV. A transmission rate of 2% can be achieved with a dual therapy regimen in non-breastfeeding women. Mono therapy with single dose nevirapine (sd NVP) often fails due to the once off nature of the intervention as opposed to ample opportunity to administer zudovudine (AZT) antenatally with dual therapy. A higher CD4 threshold to initiate HAART increases the window of opportunity while women are reasonably healthy. Irrespective of the maternal disease the newborn babies receive the same ART regimen. Women requiring HAART following pregnancy with an interval of 6 months or longer since NVP exposure had the same virological response as compared to NVP naïve women. Dual or mono therapy for a second time will be as effective as with NVP naïve women. The present day routine use of ART will reduce the risk of obstetric interventions.