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.

Opportunities for primary health care in South Africa - Reflections from the USA.

No abstract available.

From the President's Desk: Part 3, 2023.

No abstract available.

Comprehensive patient education and counselling for non-communicable diseases in primary care, Western Cape.

BACKGROUND: Treatment of non-communicable diseases (NCD) requires patient education and counselling (PEC). Initiatives have focused on Group Empowerment and Training (GREAT) for diabetes and Brief behaviour change counselling (BBCC). However, the implementation of comprehensive PEC in primary care remains a challenge. The aim of this study was to explore how such PEC could be implemented. METHODS: This was a descriptive, exploratory, qualitative study at the end of the first year of a participatory action research project to implement comprehensive PEC for NCDs at two primary care facilities in the Western Cape. Focus group interviews were held with healthcare workers and reports from co-operative inquiry group meetings were used as qualitative data. RESULTS: Staff were trained in GREAT for diabetes and BBCC. There were problems with training appropriate staff and sufficient numbers and a need for ongoing support. Implementation was limited by poor internal sharing of information, staff turnover and leave, rotation of staff, lack of space and fears of disrupting the efficiency of service delivery. Facilities had to embed the initiatives into appointment systems and fast track patients who attended GREAT. For those patients that were exposed to PEC, there were reported benefits. CONCLUSION: Group empowerment was feasible to introduce, while BBCC was more challenging as it required extra time in the consultation.Contribution: Implementation of PEC requires alternative approaches that do not extend consultations (such as GREAT and maybe digital solutions) as well as commitment to facility organisation for PEC from managers.

Piloting of virtual group education for diabetes in Cape Town: An exploratory qualitative study.

BACKGROUND: Diabetes is a major public health problem. During the coronavirus disease 2019 (COVID-19) pandemic, patient education and counselling (PEC) for diabetes were curtailed. This project explored the possibility of offering group empowerment and training (GREAT) for diabetes via computer or tablets and Zoom video conferencing. The aim was to explore whether this was feasible in the low-income community context of primary health care in Cape Town, South Africa. METHODS: Three dieticians facilitated four sessions of GREAT for diabetes with a group of five patients with type-2 diabetes. Once the programme was completed, focus group interviews were held with the facilitators and the patients to explore their experience. Interviews were recorded and analysed using a simplified framework method. RESULTS: Usual primary care was not offering PEC and service delivery was brief and mechanistic. The content, resources and group processes were successfully translated into the virtual environment. The guiding style of communication was more difficult. Patients reported changes in their self-management and appreciated being able to save time and money while participating from home. Patients required considerable support and training to use the technology. All participants were concerned about safety and crime with the hardware. CONCLUSION: It was feasible to conduct GREAT for diabetes via tablets and Zoom video conferencing in this low-income community. To implement at scale, a number of concerns need to be addressed. The feasibility of conducting the sessions via smartphone technology should be evaluated.Contribution: Demonstrates how digital technology could be used to develop new ways of empowering people with type 2 diabetes.

Evaluation of factors associated with medical male circumcision in South Africa: A case-control study.

BACKGROUND: The World Health Organization recommends medical male circumcision (MMC) to prevent human immunodeficiency virus (HIV). More research is needed in South Africa on factors influencing the uptake of MMC. AIM: To evaluate factors associated with uptake of MMC. SETTING: Diepsloot, Johannesburg, South Africa. METHODS: An observational case-control study. Cases (men attending a private general practice (GP) offering free MMC) were compared to controls (uncircumcised men attending a local shopping mall) for a variety of demographic, sociocultural and financial factors. Factors were analysed using bivariate and multiple-variable binary forward logistic regression with the Statistical Package for Social Sciences. RESULTS: There were 350 cases and 350 controls. Four factors were associated with the uptake of MMC: being a student (adjusted odds ratio [AOR]: 6.29, 95% confidence interval [CI]: 2.29-17.26), attending a mainline Christian denomination (AOR 2.85, 95% CI: 1.39-5.78), speaking an African language other than Zulu (range of AORs: 2.5-6.8, p 0.05) and being South African (AOR: 2.50, 95% CI: 1.58-3.96). MMC was associated with feeling susceptible to HIV, seeing it as a serious health problem and being encouraged by partners. Men who were sterilised, not sexually active and without symptoms of a sexually transmitted infection felt less susceptible. Other barriers included the pain of the procedure, indirect costs, anticipated impact on sexual activity, lack of information, cultural beliefs, embarrassment and access to health services.

Implementing active surveillance for tuberculosis: The experiences of healthcare workers at four sites in two provinces in South Africa.

BACKGROUND: The high burden of tuberculosis (TB) in South Africa (SA) is associated with uncontrolled transmission in communities and delayed diagnosis of active cases. Active surveillance for TB is provided by community-based services (CBS). Research is required to understand key factors influencing TB screening services in the CBS. This study explored the implementation of active surveillance for TB where community-oriented primary care (COPC) had been successfully implemented to identify these factors. METHODS: This was a qualitative study of four established COPC sites across two provinces in SA where active surveillance for TB is implemented. Semi-structured interviews were conducted with purposively selected healthcare workers in the CBS and citizens in these communities. The recorded interviews were transcribed for data analysis using ATLAS.ti software. RESULTS: The factors influencing active surveillance for TB were directly related to the major players in the delivery of CBS. These factors interacted in a complex network influencing implementation of active surveillance for TB. Building effective relationships across stakeholder platforms by community health workers (CHWs) was directly influenced by the training, capacity building afforded these CHWs by the district health services; and acceptability of CBS. Each factor interplayed with others to influence active surveillance for TB. CONCLUSION: Community health workers were central to the success of active surveillance for TB. The complex interactions of the social determinants of health and TB transmission in communities required CHWs to develop trusting relationships that responded to these issues that have impact on TB disease and linked clients to healthcare.

Retention of medical officers in the district health services of the Western Cape, South Africa: An exploratory descriptive qualitative study.

BACKGROUND: An adequate health workforce is an essential building block of effective health systems. In South Africa, medical officers (MOs) are a key component of service delivery in district health services. The Stellenbosch University Family Physician Research Network in the Western Cape identified that retention of MOs was a key issue. The aim of this study was to explore the factors that influence the retention of MOs in public sector district health services in the Western Cape, South Africa. METHODS: This is a descriptive exploratory qualitative study. Medical officers were purposefully selected in terms of districts, facility types, gender, seniority and perceived likelihood of leaving in the next four years. Semi-structured interviews were performed by family physicians, and the qualitative data were analysed using the framework method. RESULTS: Fourteen MOs were interviewed, and four major themes were identified: career intentions; experience of clinical work; experience of the organisation; and personal, family and community issues. Key issues that influenced retention were: ensure that the foundational elements are in place (e.g. adequate salary and good infrastructure), nurture cohesive team dynamics and relationships, have a family physician, continue the shift towards more collaborative and appreciative management styles, create stronger career pathways and opportunities for professional development in the district health services, be open to flexible working hours and overtime, and ensure workload is manageable. CONCLUSION: A number of important factors influencing retention were identified. Leaders and managers of the healthcare services could intervene across these multiple factors to enhance the conditions needed to retain MOs.

Use of the Vula App to refer patients in the West Coast District: A descriptive exploratory qualitative study.

BACKGROUND: Referral systems play a pivotal role in coordination and quality of care and should be evaluated for their utility. The Vula App is used by various disciplines and hospitals in South Africa to refer patients. The aim was to explore the perceptions of medical practitioners regarding the use of the Vula App in the West Coast District. METHODS: A descriptive, exploratory qualitative study used semi-structured interviews with 11 medical practitioners. The highest and lowest users of the Vula App were selected from seven district hospitals. Qualitative data analysis used the framework method and Atlas-ti. RESULTS: There were five themes: impact on the referral process, quality of care, coordination of care, continuous professional development, and how to improve the Vula App. Its use was well established in the outpatient and semi-urgent setting, but participants were hesitant to rely on it for immediate advice. Specialist advice via the Vula App enabled practitioners to manage patients remotely. The referral hand-over function had a positive impact on the coordination of care. Advice and feedback via the Vula App assisted with continuous professional development. CONCLUSION: The Vula App is a useful tool to refer patients to the emergency centre and outpatient departments. It can improve the immediate quality of care and sequential coordination of care. It has the potential to enable continuous professional development. There is a need to standardise its use, to ensure electronic information flows back to the district and to integrate the data into the district's health information system.

The contribution of family physicians to surgical capacity at district hospitals in South Africa.

The World Health Organization states that essential, cost-effective surgical care should be delivered at district hospitals. In South Africa significant skills gap exist at district hospitals, particularly in the area of surgery and anaesthesia. These small to moderate sized hospitals are too small to support a range of full time specialists even if they could be recruited and were cost-effective. Family physicians (FPs) are trained in the clinical skills required for district hospitals and primary health care. Clinical associates have also been introduced to perform procedures at district hospitals. This report illustrates the contribution of a FP to surgical care at Zithulele Hospital in the Eastern Cape. Family physicians not only bring the necessary clinical skills set but also increase the confidence and capacity of the whole team. Outreach and support by surgeons, as well as continuing professional development, are important. Surgical and anaesthetic skills must be developed together. Family physicians also bring leadership and clinical governance skills that ensure the inputs to support surgery, such as equipment and information systems are available. The contribution of FPs to surgery and district hospitals is overlooked in both policy and practice. Human resources for health policy should recognise their contribution and increase the numbers available and FP posts at district hospitals. There is also a need to update the package of emergency and essential surgical procedures in policy.

Implementing active surveillance for TB-The views of managers in a resource limited setting, South Africa.

BACKGROUND: The achievement of the World Health Organization's END TB goals will depend on the successful implementation of strategies for early diagnosis and retention of patients on effective therapy until cure. An estimated 150,000 cases are missed annually in South Africa. It is necessary to look at means for identifying these missed cases. This requires the implementation of active surveillance for TB, a policy adopted by the National Department of Health. AIM: To explore the views of managers of the TB program on the implementation of active surveillance for TB in the resource constrained setting of the Eastern Cape, South Africa. METHODS: A descriptive, explorative, thematically analysed qualitative study based on 10 semi-structured interviews of managers of the TB program. Interviews were transcribed verbatim and analysed using the framework method and Atlas-ti. RESULTS: Active case finding of people attending health facilities was the dominant approach, although screening by community health workers (CHWs) was available. Both government and non-government organisations employed CHWs to screen door to door and sometimes as part of campaigns or community events. Some CHWs focused only on contact tracing or people that were non-adherent to TB treatment. Challenges for CHWs included poor coordination and duplication of services, failure to investigate those identified in the community, lack of transport and supportive supervision as well as security issues. Successes included expanding coverage by government CHW teams, innovations to improve screening, strategies to improve CHW capability and attention to social determinants. CONCLUSION: A multifaceted facility- and community-based approach was seen as ideal for active surveillance. More resources should be targeted at strengthening teams of CHWs, for whom this would be part of a comprehensive and integrated service in a community-orientated primary care framework, and community engagement to strengthen community level interventions.

Evaluating the validity and reliability of the Medical Interview Satisfaction Scale in South African primary care consultations.

BACKGROUND: Effective primary care is vital for improving health outcomes. Patient-centred consultations are important and one way of assessing this is to evaluate patient satisfaction. The Medical Interview Satisfaction Scale (MISS) has not been used in South Africa. AIM: To test validity and reliability of the MISS and evaluate patient satisfaction with consultations. SETTING: Primary care facilities in the Helderberg sub-district, South Africa. METHODS: The MISS tool was adapted and validated by a panel of experts. The internal consistency was evaluated on 150 consultations. The level of patient satisfaction on 23 items, in consultations by nurses and doctors, was measured. Respondents indicated agreement with each item on a scale (1 = very strongly disagree, 7 = very strongly agree). RESULTS: The wording of the items were adapted and translated into Afrikaans and Xhosa. There was good overall internal consistency (Cronbach alpha 0.889), but not in all subscales. Patients were most satisfied with rapport (Median score 6.2 (IQR 5.3-5.9)) and understanding of their concerns, fears and beliefs (5.7 (IQR 5.1-6.3)). They were less satisfied with the ability to foster an acceptable management plan (5.5 (IQR 4.5-6.5)) and with accuracy of information (5.0 (IQR 4.2-5.8)). Scores for nurses and doctors were not significantly different. CONCLUSION: Further work is needed to improve the reliability of MISS subscales in the South African context and the best internal consistency was found with 21 items. Patients showed high levels of satisfaction with primary care consultations, although other studies suggest this may reflect low expectations rather than high quality consultations.

The perceived impact of family physicians on the district health system in South Africa: a cross-sectional survey.

BACKGROUND: Evidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province. METHODS: A cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool. RESULTS: A total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SD = 3.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP's impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥ 2011). CONCLUSIONS: The findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper.

The Influence of Family Physicians Within the South African District Health System: A Cross-Sectional Study.

PURPOSE: Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system. METHODS: We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size. RESULTS: Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02). CONCLUSIONS: In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level.

Guiding the development of family medicine training in Africa through collaboration with the Medical Education Partnership Initiative.

Africa's health care challenges include a high burden of disease, low life expectancy, health workforce shortages, and varying degrees of commitment to primary health care on the part of policy makers and government officials. One overarching goal of the Medical Education Partnership Initiative (MEPI) is to develop models of medical education in Sub-Saharan Africa. To do this, MEPI has created a network of universities and other institutions that, among other things, recognizes the importance of supporting training programs in family medicine. This article provides a framework for assessing the stage of the development of family medicine training in Africa, including the challenges that were encountered and how educational organizations can help to address them. A modified "stages of change" model (precontemplation, contemplation, action, maintenance, and relapse) was used as a conceptual framework to understand the various phases that countries go through in developing family medicine in the public sector and to determine the type of assistance that is useful at each phase.

Developing generalism in the South African context.

The largest impact on the South African burden of disease will be made in community-based and primary healthcare (PHC) settings and not in referral hospitals. Medical generalism is an approach to the delivery of healthcare that routinely applies a broad and holistic perspective to the patient's problems and is a feature of PHC. A multi-professional team of generalists, who share similar values and principles, is needed to make this a reality. Ward-based outreach teams include community health workers and nurses with essential support from doctors. Expert generalists - family physicians - are required to support PHC as well as provide care at the district hospital. All require sufficient training, at scale, with greater collaboration and integration between training programmes. District clinical specialist teams are both an opportunity and a threat. The value of medical generalism needs to be explained, advocated and communicated more actively.