The contribution of Specialist Family Physicians to South Africa's private sector: A position statement.

No abstract available.

Strengthening clinical trials in African primary care.

Not applicable.

Migration and primary healthcare in sub-Saharan Africa: A scoping review.

BACKGROUND:  Migration in Africa is increasing and driven by a variety of inter-related socio-economic, conflict and climate-related causes. Primary healthcare (PHC) migration on PHC service will be in the forefront of responding to the associated health issues. AIM:  This study aimed to review the literature on the effect of migration on PHC service delivery in Africa and the challenges facing migrants in accessing PHC. METHOD:  A systematic approach (Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews) was applied across six databases and grey literature from African universities (2010 to 2021). Data were extracted and analysed quantitatively and qualitatively. RESULTS:  A total of 3628 studies were identified and 50 were included. Most studies were descriptive or used mixed methods. Publications came from 25 countries, with 52% of studies from South Africa, Uganda and Kenya. Most migrants originated from Zimbabwe, the Democratic Republic of Congo and Somalia. Population health management for migrant communities was challenging. Migration impacted PHC services through an increase in infectious diseases, mental health disorders, reproductive health issues and malnutrition. Primary healthcare services were poorly prepared for handling displaced populations in disaster situations. Access to PHC services was compromised by factors related to migrants, health services and healthcare workers. CONCLUSION:  Several countries in Africa need to better prepare their PHC services and providers to handle the increasing number of migrants in the African context.Contribution: The review points to the need for a focus on policy, reducing barriers to access and upskilling primary care providers to handle diversity and complexity.

Characteristics of women on opioid substitution therapy in primary healthcare in Tshwane (South Africa): a retrospective observational study.

BACKGROUND: Women who use drugs face specific challenges compared to men, such as higher rates of HIV infection, unsafe injecting practices and intimate partner violence. However, this population's access to drug dependence treatment and gender-sensitive interventions remains limited, leading to unmet needs and increased vulnerability. AIM: To investigate the characteristics of and associations with retention in care among women on opioid substitution therapy (OST) in a community based primary care setting. DESIGN & SETTING: A descriptive observational study within the Community Orientated Substance Use Programme in Tshwane, South Africa. METHOD: Data from 199 women (>18 years) on OST was extracted from an electronic database and paper-based files. Data was analysed descriptively, and inferential analysis looked for association of variables with retention on OST for≥6 months. RESULTS: Majority of participants were unemployed, with 44.3% falling within the 20-29 years age range. During the initiation and course of OST, 39.2% of women experienced intimate partner violence, and 19.0% were pregnant. Retention on OST was significantly associated with increasing age at initiation (p=0.047), knowledge of HIV status (p=0.029), an increase in the ASSIST score (p=0.023), and methadone dose (p<0.001). Factors such as race, employment status, health system level, pregnancy, intimate partner using substances, intimate partner violence, route of administering opioids, and having tuberculosis and/or hepatitis C exposure did not show a significant relationship with retention on OST (p>0.05). CONCLUSION: This study reveals specific vulnerabilities in women receiving OST, emphasising the need for the integration of interventions to address reproductive health, violence mitigation, infectious disease and polydrug use into care.

Adapting the primary care assessment tool for sub-saharan Africa.

BACKGROUND: The World Health Organization's (WHO) measurement framework for primary health care includes the core functions of primary care: first contact access, comprehensiveness, coordination, continuity, and person-centredness. The Primary Care Assessment Tool (PCAT), originally developed in the United States, was adapted for use by four African countries, and can measure the core functions of primary care. AIM: To face and content validate a sub-Saharan PCAT that measures the core functions of primary care. DESIGN & SETTING: Twenty countries within the Primary Care and Family Medicine (PRIMAFAMED) network for sub-Saharan Africa participated in a validation study. METHOD: Two stages included a PRIMAFAMED workshop to assess face validity and a Delphi study to reach consensus on content validity amongst an expert panel as well as key stakeholders. RESULTS: Thirteen countries participated in the workshop and suggested re-phrasing 39 items, deleting 6 and adding 4. Twenty countries participated in the Delphi and all panel members reached consensus (>70%) on including the items as written. Seven experts and stakeholders reviewed the PCAT and suggested re-phrasing 23 items, deleting 1 and adding 1. The final Sub-Saharan PCAT (PCAT-SSA) consists of 85 items that measure affiliation with the primary care facility, first contact access and utilisation, comprehensiveness, continuity, coordination, and person-centredness, as well as health, demographic and socio-economic status. CONCLUSIONS: The PCAT-SSA will now be piloted in Benin, Uganda, and South Africa. Further psychometric evaluation will be possible followed by more widespread use by researchers, district managers and policymakers in the region.

Global lessons on delivery of primary healthcare services for people with non-communicable diseases: convergent mixed methods.

OBJECTIVE: To extract key lessons on primary healthcare (PHC) service delivery strategies for non-communicable diseases (NCD) from the work of researchers funded by the Global Alliance for Chronic Diseases (GACD). DESIGN: A convergent mixed methods study that extracted data using a standardised template from research projects funded by the GACD that focused on PHC. The strategies implemented in these studies were mapped onto the PHC Performance Initiative framework. Semistructured qualitative interviews were conducted with researchers from purposefully selected projects to understand the strategies and contextual factors in more depth. SETTING: PHC contexts from low or middle-income countries (LMIC) as well as vulnerable groups within high-income countries. Projects came from all regions of the world, particularly East Asia and Pacific, sub-Saharan Africa, South Asia, Latin America and Caribbean. PARTICIPANTS: The study extracted data on 84 research projects and interviewed researchers from 16 research projects. RESULTS: Research projects came from all regions of the world, and mainly focused on diabetes (35.3%), hypertension (28.3%) and mental health (27.6%). Mapped onto the PHC Performance Initiative framework: 49.4% focused on high-quality PHC (particularly the comprehensiveness of NCD care, 41.2%); 41.2% on the availability of PHC services (particularly the competence of healthcare workers, 36.5%); 35.3% on population health management (particularly community-based services, 35.3%); 34.1% on facility organisation and management (particularly team-based care, 20.0%) and 31.8% on access (particularly digital technology, 23.5%). Most common strategies were task shifting and training to improve the comprehensiveness of NCD care through community-based services. Contextual factors related to inputs: infrastructure, equipment and medication, workforce (particularly community health workers), finances, health information systems and digital technology. CONCLUSION: Key strategies and contextual factors to improve PHC service delivery for NCDs in LMICs were identified. These strategies should combine with other strategies to strengthen the PHC system as a whole, while improving care for NCDs.

Developing an electronic portfolio of learning for family medicine training in South Africa.

Workplace-based assessment has become increasingly crucial in the postgraduate training of specialists in South Africa, particularly for family physicians. The development of a Portfolio of Learning (PoL) has been a central focus within the discipline of family medicine for over a decade. Initially, a paper-based portfolio was adopted to collect evidence of learning for 50 out of 85 agreed exit-level outcomes. Stellenbosch University led the conversion of this portfolio into an electronic format, known as e-PoL, utilising Scorion software. The e-PoL was successfully implemented in the Western and Eastern Cape regions and was subsequently adopted nationally under the coordination of the South African Academy of Family Physicians. In 2023, the e-PoL underwent a redesign to gather evidence of learning for 22 entrustable professional activities (EPAs). Key insights from this development process underscore the importance of the PoL in supporting assessment-for-learning rather than merely assessment-of-learning. This necessitates features for feedback and interaction, ensuring that the PoL functions beyond a mere repository of forms. Additionally, the e-PoL should facilitate triangulation, aggregation, and saturation of data points to effectively measure EPAs. Furthermore, the PoL has not only documented learning but has also played a pivotal role in guiding the development of clinical training by explicitly outlining expectations for both registrars and supervisors. While the initial design and development costs are significant, operational costs become affordable when shared across all training programmes.

Identifying research gaps and priorities for African family medicine and primary health care.

No abstract available.

Evaluating the new family medicine internship programmes in the Western Cape, South Africa.

BACKGROUND:  In 2021, South Africa introduced a new 6-month internship in family medicine and primary care. This study aimed to assess the new rotation at district health facilities in the Western Cape. METHODS:  A descriptive survey of interns and supervisors, as phase-two of an exploratory sequential mixed methods study. Questionnaires were developed from a descriptive exploratory qualitative study. Data were analysed with the Statistical Package for Social Sciences. RESULTS:  Questionnaires were completed by 72 interns (response rate 21%) and 36 supervisors (response rate 90%), across 10 training programmes. Interns felt more independent (97.2%), confident (90.3%) and resilient (91.6%). They learnt to manage undifferentiated and chronic conditions (91.6%), to refer patients (94.3%) and conduct procedures (77.8%). Most interns were not exposed to community-based services (68.0%) and continuity of care (54.1%). Supervision was mostly adequate during the day (79.1%) and afterhours (80.6%). Many interns reported no structured teaching programme (41.7% - 55.6%). Most supervision was from medical officers and registrars. Supervisors saw interns as valuable members of the clinical team (100.0%), who required extra support and administration (42.5%). The majority of interns (75.0%) and supervisors (72.7%) thought the rotation was the right length and the best preparation for community service (67.6%). CONCLUSION:  The rotation met most expectations of the Health Professions Council of South Africa. Programmes need to improve exposure to community-orientated primary care, public health medicine, palliative and ongoing care. Supervision and orientation of interns needs improvement.Contribution: This is the first evaluation of the new family medicine internship programme in South Africa.

The career pathways of new family physicians in South Africa from 2008 to 2022.

BACKGROUND:  Family medicine has trained specialist family physicians in South Africa since 2008, but not investigated their career pathways. The study aimed to determine the career pathways of newly qualified family physicians between 2008 and 2022. METHODS:  A cross-sectional descriptive survey of all 186 family physicians via an electronic questionnaire. RESULTS:  Response rate was 44.6% (83/186). Overall, 9.6% emigrated, 10.8% were no longer practising, and 79.5% were still practising in South Africa. Of the latter, 14.5% were in the private sector, 55.4% in the public sector and 9.6% in both. Of those in the public sector, 33.7% were in specialist family physician posts, 12% in medical officer posts, 4.8% in managerial positions and 4.8% in academic positions. Issues relating to safety and security were important to those working in both sectors and relationships with colleagues in the clinical team, to those in the public sector. Overall, participants practised near or within their province of training and were not equitably distributed. CONCLUSION:  Only a third of graduates were in specialist family physician posts in the public sector. Attention needs to be given to retaining more graduates in such posts to achieve the goals of the national position paper. The proportion in the private sector was lower than expected. The reasons for no longer practising medicine should be further explored.Contribution: This is the first study on the career pathways of family physicians in South Africa since the new speciality was created. Understanding these pathways will assist with human resources for health planning.

Registrars' experience with research in family medicine training programmes in South Africa.

BACKGROUND:  Completion of a research assignment is a requirement for specialist training in South Africa. Difficulty with completion delays graduation and the supply of family physicians. The aim of this study was to explore the experience of registrars with their research in postgraduate family medicine training programmes. METHODS:  An explorative descriptive qualitative study. Extreme case purposive sampling selected registrars who had and had not completed their research on time, from all nine training programmes. Saturation was achieved after 12 semi-structured interviews. The framework method was used for data analysis, assisted by ATLAS.ti software. RESULTS:  The assumption of prior learning by teachers and supervisors contributed to a sense of being overwhelmed and stressed. Teaching modules should be more standardised and focussed on the practical tasks and skills, rather than didactic theory. Lengthy provincial and ethics processes, and lack of institutional support, such as scholarly services and financial support, caused delays. The expertise of the supervisor was important, and the registrar-supervisor relationship should be constructive, collaborative and responsive. The individual research experience was dependent on choosing a feasible project and having dedicated time. The balancing of personal, professional and academic responsibilities was challenging. CONCLUSION:  Training programmes should revise the teaching of research and improve institutional processes. Supervisors need to become more responsive, with adequate expertise. Provincial support is needed for streamlined approval and dedicated research time.Contribution: The study highlights ways in which teaching, and completion of research can be improved, to increase the supply of family physicians to the country.

Lived experiences of women with spontaneous abortion at a district hospital, South Africa.

BACKGROUND:  Spontaneous abortions occur in 12.5% of pregnancies and have a significant impact on the well-being of women. Dissatisfaction with health services is well-documented, but no studies have been conducted in district health services of the Western Cape. The aim was to explore the lived experiences of women presenting with spontaneous abortions to the emergency department at Helderberg Hospital. METHODS:  A descriptive phenomenological qualitative study used criterion-based purposive sampling to identify suitable participants. Data were collected through semi-structured individual interviews. Atlas-ti (version 22) software assisted with data analysis using the framework method. RESULTS:  A total of nine participants were interviewed. There were four main themes: a supportive environment, staff attitudes and behaviour, the impact of time, and sharing of information. The comfort, cleanliness and privacy of the environment were important. COVID-19 had also impacted on this. Showing interest, demonstrating empathy and being nonjudgemental were important, as well as the waiting time for definitive treatment and the time needed to assimilate and accept the diagnosis. In addition, the ability to give relevant information, explain the diagnosis and help patients share in decision-making were key issues. CONCLUSION:  This study highlighted the need for a more person-centred approach and managers should focus on changes to organisational culture through training and clinical governance activities. Attention should be paid to the physical environment, availability of patient information materials and sequential coordination of care with primary care services.Contribution: This study identifies issues that can improve person-centredness and women's satisfaction with care for spontaneous abortion.

The role of community health workers in non-communicable diseases in Cape Town, South Africa: descriptive exploratory qualitative study.

BACKGROUND: Community health workers (CHW) are an integral part of primary health care re-engineering in South Africa. Cape Town is developing community-orientated primary care, with a central role for CHWs. Their role in human immunodeficiency virus, tuberculosis, maternal and child health has been articulated, but is less clear for non-communicable diseases (NCDs). Non-communicable diseases are now a major contributor to the burden of disease. The aim was to explore the current role of CHWs regarding NCDs in the Eastern sub-district of Cape Town, South Africa. METHODS: An exploratory descriptive qualitative study made use of non-participant observation and qualitative interviews with CHWs, their managers, and nurse coordinators. Data from nine semi-structured interviews and ten observations were analysed with the framework method and Atlas-ti. RESULTS: The CHWs were embedded in their communities and provided services via support groups, household visits and delivery of medication. They linked people to care with assistance of nurse coordinators. They could also provide physical care in the home. They lacked the ability to counsel people on the risk factors for NCDs and their role in rehabilitation and palliative care was unclear. More nurse coordinators were needed to provide supportive supervision. Inter-sectoral collaboration was weak and hindered CHWs from addressing social issues. More standardised and comprehensive training should equip CHWs for health promotion and disease prevention during household visits. Data collected in the community needed to be analysed, reported on and integrated with data from the primary care facility. This should also contribute to a community diagnosis. Their relationship with facility-based members of the primary health care team needed to be improved. Attention needed to be given to the requirements for and conditions of employment, as well as working hours and remuneration. Some equipment was absent and hindered their services for NCDs. CONCLUSIONS: CHWs have the potential to provide a comprehensive approach to NCDs, but community-orientated primary care needs to be strengthened in many of the key areas to support their activities. In relation to NCDs, they need training in basic and brief behaviour change counselling and risk factors as well as in the areas of rehabilitation and palliative care.

Evaluating the implementation of group empowerment and training (GREAT) for diabetes in South Africa: convergent mixed methods.

OBJECTIVE: Type 2 diabetes is a leading contributor to the burden of disease in South Africa. Primary care is struggling to support self-management and lifestyle change. Group empowerment and training (GREAT) for diabetes is a feasible and cost-effective intervention in our setting. This study aimed to evaluate the implementation of GREAT for diabetes. DESIGN: A convergent mixed-methods study evaluated a range of implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, reach and cost. SETTING: Ten primary care facilities from a district in all nine provinces of South Africa. PARTICIPANTS: Descriptive exploratory individual semistructured interviews were conducted with 34 key stakeholders from national policy-makers to primary care providers. Three focus group interviews were held with 35 patients. RESULTS: The National Department of Health saw GREAT as an acceptable and appropriate intervention, but only five of the nine provinces adopted GREAT. District-level and facility-level managers also saw GREAT as an acceptable and appropriate intervention. Factors related to feasibility included physical space, sufficient staff numbers, availability of resource materials, the health information system, adaptation to the model of care (selection of facilities, patients, adjustment of patient flow and appointment systems, leadership from local managers and the whole clinical team) and inclusion in systems for quality improvement. No major changes were made to the design of GREAT and fidelity to the session content ranged from 66% to 94%. Incremental costs were US$494 per facility. Due to disruption from the COVID-19 pandemic, only 14 facilities implemented and reached 588 patients at the time of evaluation. CONCLUSION: Key lessons were learnt on how to implement GREAT for diabetes in a middle-income country setting. The findings informed the design of a programme theory using a health system framework. The programme theory will guide further scale-up in each province and scale-out to provinces that have not yet implemented. QUESTION: This study focused on evaluating how to implement GREAT for type 2 diabetes in primary care and to take it to scale in South Africa. FINDING: The findings led to a programme theory on how to successfully implement GREAT for diabetes in the South African context. MEANING: The study demonstrates relevant contextual factors that need to be considered in the implementation of group diabetes education programme in a middle-income country.

The sustainability of group empowerment and training for people with diabetes in South Africa.

BACKGROUND:  Group empowerment and training (GREAT) for people with type 2 diabetes enables self-management and lifestyle modification. GREAT for diabetes was implemented in primary care facilities in five South African provinces in the beginning of 2022. The aim was to evaluate implementation and to particularly explore factors that influenced the sustainability of implementation. METHODS:  An exploratory, descriptive qualitative study conducted semi-structured individual interviews with 17 key stakeholders at the end of 2023. Interviews explored factors within a theory of change framework derived from an initial evaluation in 2022. Data were analysed using the framework method and ATLAS.ti. RESULTS:  Implementation and scale-up was sustained in the Western Cape. Governance and financing at a provincial and district level were key to health system structures. Space, staffing, resource materials and monitoring of implementation were key to the inputs. Facility managers, training and performance of facilitators, including the whole team, selecting patients, patient flow and appointments, stakeholder support and clinical governance were key to service delivery. Facilities that had implemented, reported reaching 300 patients per year. A range of motivational, behavioural and clinical outcomes were reported. Future implementation could include community health workers and group empowerment for insulin initiation. CONCLUSION:  Implementation and scale-up was only sustained in one province and a range of factors related to sustained implementation were identified.Contribution: The factors identified can guide the successful implementation and scale-up of GREAT for diabetes in South Africa.

Development of entrustable professional activities for family medicine in South Africa.

South Africa is undergoing a significant shift towards implementing enhanced workplace-based assessment methodologies across various specialist training programmes, including family medicine. This paradigm involves the evaluation of Entrustable Professional Activities (EPAs) through comprehensive portfolios of evidence, which a local and national clinical competency committee then assesses. The initial phase of this transformative journey entails the meticulous development of EPAs rooted in discrete units of work. Each EPA delineates the registrar's level of entrustment for autonomous practice, along with the specific supervision requirements. This concise report details the collaborative effort within the discipline of family medicine in South Africa, culminating in the consensus formation of 22 meticulously crafted EPAs for postgraduate family medicine training. The article intricately outlines the systematic structuring and rationale behind the EPAs, elucidating the iterative process employed in their development. Notably, this marks a groundbreaking milestone as the first comprehensive documentation of EPAs nationally for family medicine training in Africa.

Implementing active surveillance for TB: A descriptive survey of healthcare workers in the Eastern Cape, South Africa.

BACKGROUND:  South Africa is a tuberculosis (TB) high-burden country. In the Eastern Cape (EC), community health worker (CHW) teams implement active surveillance for TB to curb spread in disadvantaged communities. However, achieving the goals of the End-TB strategy require coordinated efforts that implement policy and strengthen health systems. AIM:  This survey described views of healthcare workers (HCWs) in primary care facilities on factors that influence implementation of active surveillance for TB. SETTING:  This survey was conducted across two districts, among healthcare workers working in TB rooms at primary health facilities. METHOD:  A cross-sectional survey of HCW in the EC. RESULTS:  The survey included 37 clinics in the OR Tambo Health District (ORTHD) and 44 clinics in the Nelson Mandela Bay Health District (NMBHD). Routine screening at primary care facilities (88.2%) and contact tracing initiatives (80.8%) were the common modes of TB screening. Tuberculosis screening services in the community were only provided by CHWs in 67.3% of instances. Although CHWs were adequately trained and motivated; the lack of transport, limited availability of outreach team leaders (OTLs) and poor security limited implementation of TB screening services in the community. Comparison between both districts revealed TB screening was limited by lack of transport in the rural district and poor security in the urban context. Community engagement provided a platform for improving acceptability. CONCLUSION:  Community-based TB screening was limited. Inadequate coordination of services between stakeholders in the community has limited reach. Further research should describe that coordinating resource allocation and community empowerment could improve the implementation of active surveillance for TB.Contribution: This study highlights the views of TB room HCWs who believe the opportunity for community-level TB screening is improved with effective leadership and community engagement for acceptability of these services.

Family practice research in the African region 2020-2022.

BACKGROUND:  The African region produces a small proportion of all health research, including primary health care research. The SCOPUS database only lists the African Journal of Primary Health Care Family Medicine (PHCFM) and the South African Family Practice Journal (SAFP) in the field of family practice. AIM:  To review the nature of all original research (2020-2022) published in PHCFM and SAFP. SETTING:  African region. METHOD:  All 327 articles were included. Data were extracted into REDCap, using a standardised tool and exported to the Statistical Package for Social Sciences. RESULTS:  The median number of authors was 3 (interquartile range [IQR]: 2-4) and institutions and disciplines 1 (IQR: 1-2). Most authors were from South Africa (79.8%) and family medicine (45.3%) or public health (34.2%). Research focused on integrated health services (76.1%) and was mostly clinical (66.1%) or service delivery (37.9%). Clinical research addressed infectious diseases (23.4%), non-communicable diseases (24.6%) and maternal and women's health (19.4%). Service delivery research addressed the core functions of primary care (35.8%), particularly person-centredness and comprehensiveness. Research targeted adults and older adults (77.0%) as well as health promotion or disease prevention (38.5%) and treatment (30.9%). Almost all research was descriptive (73.7%), mostly surveys. CONCLUSION:  Future research should include community empowerment and multisectoral action. Within integrated health services, some areas need more attention, for example, children, palliative and rehabilitative care, continuity and coordination. Capacity building and support should enable larger, less-descriptive and more collaborative interdisciplinary studies with authors outside of South Africa.Contribution: The results highlight the strengths and weaknesses of family practice research in Africa.

Undergraduate teaching in family medicine within the PRIMAFAMED network.

No abstract available.