Defining and Measuring Spirituality in South African Specialist Psychiatry.

To define the meaning of "spirituality" in a South African phenomenological, theory-generating qualitative inquiry, theory construction methodology was used. This refers to the tradition of nursing theory development, where a central core concept identified from the integrated data-in this case, interviews and the literature content-had to be defined. A major focus of the study was to distinguish spirituality from religion. The denotative and connotative meanings of "spirituality" were explored to establish the components for a definition. The attributes of this definition included that spirituality constitutes a "quality", a "journey", a "relationship" as well as a "capacity". While these items derived from this local definition of spirituality can be proposed for inclusion in a questionnaire for measuring spirituality in a South African context, the limits of the scope of the explorative qualitative inquiry from which it was derived must be considered.

The role of spirituality in specialist psychiatry: a review of the medical literature.

A review of the international medical literature was undertaken on the role of spirituality in the discipline of psychiatry, within the context that a perceived change is taking place in the health care environment in South Africa. Revitalized interest in spirituality was evident from the literature partly because Western societies have, through the migration of people, become more heterogeneous in recent years. The literature concurred that spirituality must be incorporated into the current approach to the practice and training of psychiatry, but within the professional scope of the discipline, while all faith traditions and belief systems should be regarded equally. Beyond South Africa, it is envisaged that the review has implications for the practice of psychiatry in Africa.

Clinical and psycho-social profile of child and adolescent mental health care users and services at an urban child mental health clinic in South Africa.

OBJECTIVE: National and international child and adolescent mental healthcare policy and action advocate that the health and well being of children should be increasingly given greater attention. The purpose of this study was to describe the demographic, socio economic and clinical profile of the users at the child and adolescent mental health clinic of the Rahima Moosa Mother and Child Hospital (RMMCH). METHOD: A descriptive, retrospective clinical audit from users' clinical files was performed over a one-year period from January to December 2007. Descriptive statistical analyses of demographic and socio-economic variables were made and these variables were compared with the presenting clinical problems. Odds ratios were calculated for variables that showed a statistically significant association (p-value less than 0.05). RESULTS: A total of 303 users attended this clinic. Statistical comparisons between demographic data and disorders revealed that being male increased the likelihood of presenting with AHDH and disruptive behaviour disorders; being female increased the likelihood of being sexually abused. Race showed a significant association with parent-child relationship difficulties. Regarding socio-economic variables, the identity of the caregiver of the child influenced the risk of disruptive behaviour disorders, sexual abuse, neglect and academic problems. Where the child was placed was a risk factor for disruptive behaviour disorders, sexual abuse, neglect and academic problems. Whether the mother of a user was alive or deceased, was found to be related to ADHD and disruptive behaviour and whether the father of a user was alive or deceased, was found to be related to sexual abuse and academic problems. The education level of the caregiver showed a significant association with sexual abuse, neglect and academic problems; the marital status of the parent (widowed mother) showed a significant association with bereavement. Household income was associated with sexual abuse, neglect and academic problems. CONCLUSION: This study demonstrated the impact that socio-economic circumstances have on the prevalence of childhood disorders; hence the urgent need for government and social welfare departments to improve the socio-economic status of communities. There is a need to improve psychiatric services for the population served by this hospital, including more clinics in its catchment area, as well as child psychiatry training posts and extended social work services.

Acute mental health care according to recent mental health legislation. Part III. Structuring space for acute mental health care.

OBJECTIVE: This is the third of three reports on the follow-up review of mental health care at Helen Joseph Hospital (HJH). The study reviewed existing South African standards for mental health care facilities. Architectural principles and implications for the use of space were deducted from recent legislation. Objectives were to evaluate the use of space in the existing physical facilities, to identify appropriate architectural solutions considering identified human rights requirements and to provide provisional cost estimates to align the unit towards its designated functions. METHOD: Personal interviews were conducted. An on-site assessment and survey was made of existing and potential new spaces. RESULTS: Spatial requirements for implementing the Mental Health Act, No. 17 of 2002 (MHCA) were explored. Principles for spatial design of acute facilities include that: - spaces should communicate clear individual identity; - space should be segregated into zones according to user functionality and privacy; - communal leisure spaces should open into safe contained outdoor spaces; - circulation routes should preferably be circular; - sufficient visual connection should exist between circulation space and group activities; and - open lines of sight should be provided to all access points. The potential options for extension included: - an extensive unused single storey structural shell for a potential office wing on the same floor; - a huge vacant double volume space which could be accessed across the existing flat roof for potential occupational therapy activities; and - the existing roof area could be altered and secured to become an adequate outside leisure and garden area. A proposed concept design in two phases - based on these principles - was submitted to hospital and provincial management. CONCLUSION: To implement the MHCA without violating the human rights of mental health care users at HJH will require specific adjustment and extension of the current use of space at HJH.

Acute mental health care according to recent mental health legislation Part II. Activity-based costing.

OBJECTIVE: This is the second of three reports on the follow-up review of mental health care at Helen Joseph Hospital (HJH). Objectives for the review were to provide realistic estimates of cost for unit activities and to establish a quality assurance cycle that may facilitate cost centre management. METHOD: The study described and used activity-based costing (ABC) as an approach to analyse the recurrent cost of acute in-patient care for the financial year 2007-08. Fixed (e.g. goods and services, staff salaries) and variable recurrent costs (including laboratory' 'pharmacy') were calculated. Cost per day, per user and per diagnostic group was calculated. RESULTS: While the unit accounted for 4.6% of the hospital's total clinical activity (patient days), the cost of R8.12 million incurred represented only 2.4% of the total hospital expenditure (R341.36 million). Fixed costs constituted 90% of the total cost. For the total number of 520 users that stayed on average 15.4 days, the average cost was R1,023.00 per day and R15748.00 per user. Users with schizophrenia accounted for the most (35%) of the cost, while the care of users with dementia was the most expensive (R23,360.68 per user). Costing of the application of World Health Organization norms for acute care staffing for the unit, projected an average increase of 103% in recurrent costs (R5.1 million), with the bulk (a 267% increase) for nursing. CONCLUSION: In the absence of other guidelines, aligning clinical activity with the proportion of the hospital's total budget may be an approach to determine what amount should be afforded to acute mental health in-patient care activities in a general regional hospital such as HJH. Despite the potential benefits of ABC, its continued application will require time, infrastructure and staff investment to establish the capacity to maintain routine annual cost analyses for different cost centres.

A literature review and investigation of staphylococcal necrotic dermatitis in sheep.

An outbreak of necrotic dermatitis in sheep was intensively investigated. Initially 19 of 147 Letelle (Merino-type) ewes were identified but closer inspection revealed 57 sheep that had skin lesions, some very slight, and that the majority (46 or 80%) had lesions only above the lips. A small number of them had multiple lesions on the legs or vulvae apart from lip lesions. Seven had only vulvar lesions and 2 only leg lesions. Among the sheep with lip lesions, twice as many had lesions on the right as on the left. Electron micrographs did not reveal any virus particles from the lesions, but all bacterial swabs yielded pure cultures of beta-haemolytic, Gram-positive cocci that were catalase, coagulase and DNase positive. The organism was identified as Staphylococcus aureus. Histopathology was consistent with a dermotoxic insult. A review of available literature indicated that this outbreak was consistent with a diagnosis of ovine necrotic (staphylococcal) dermatitis, supported by data on signalment, lesions, distribution, size, number, epidemiology as well as specific tests. The range of differential diagnoses and possible confusers are discussed.

Acute mental health care and South African mental health legislation: part 1- morbidity, treatment and outcome.

OBJECTIVE: This is the first of three reports on a follow-up review of mental health care at Helen Joseph Hospital (HJH). In this first part, qualitative and quantitative descriptions were made of the services and of demographic and clinical data on acute mental health care users managed at HJH, in a retrospective review of clinical records over a four year period. Objectives for this review were to provide information on mental health care outcome, to do a cost analysis and to establish a quality assurance cycle that may facilitate a cost centre management approach. The operational areas identified were service delivery, teaching, and research. Activities within each area were in-patient care, out-patients and consultation/liaison, under- and postgraduate teaching and self initiated or contract research. METHOD: The study reviewed the existing mental health care program and activities in context of relevant policy and legislation. RESULTS: Norms from a World Health Organization model for acute mental health care showed that significant staff shortages existed, especially for nursing. A total of 520 users were admitted for in-patient mental health care during the financial year 2007/08. The average length of stay was 15.4 days and ranged from 1 to 85 days. Ninety users (17%) had an extended period of stay of 25 days and more, while 39 users had multiple admissions during the 12 month period. The most common Axis I diagnoses made were schizophrenia n=138 (29%), substance-related conditions n=99 (21%) and bipolar mood disorder n=69 (14%). After discharge, 139 users (27%) were referred back to the HJH out-patient department for follow-up. CONCLUSION: The information from these reports may be used in the allocation of adequate resources to align this acute unit with its responsibilities according to recent legislation.

A changed climate for mental health care delivery in South Africa.

OBJECTIVE: Traditional health practice was recently mainstreamed in South Africa by the promulgation of the Traditional Health Practitioners Act, No. 35 of 2004. Due to the extent of integration of mental health in the legal definition of traditional health practice, promulgation of this Act also has significant implications for mental health care delivery. This paper explored the documented interface of traditional health practice with mental health care in South Africa over the past almost 50 years. METHOD: A preliminary overview of health literature was done on formal mental health care and traditional alternatives in South Africa since the 1950's. Important themes were identified as first step in a qualitative approach to identify concepts. RESULTS: The search yielded 143 references, between 1958 and 2004, from articles, case reports, scientific letter, theses and chapters in books. A cross section of 56 references was selected for inclusion in this review of the material. CONCLUSION: The documentation on the interface between the two parallel systems contribute to establish a context against which the promulgation of the legislation to formally integrate and regulate African traditional health practice in South Africa can be considered. South African policy makers may now have ensured that a multi-faceted, multi-cultural and multi-cosmological context for health and mental health care delivery has come to pass. To health administrators, though, the inclusion of traditional healers into the formal public health system and mental health may still prove to be too costly to implement.

A framework for current public mental health care practice in South Africa.

One of the main aims of the new Mental Health Care Act, Act No. 17 of 2002 (MHCA) is to promote the human rights of people with mental disabilities in South Africa. However, the upholding of these rights seems to be subject to the availability of resources. Chapter 2 of the MHCA clarifies the responsibility of the State to provide infrastructure and systems. Chapters 5, 6 and 7 of the Act define and regulate the different categories of mental health care users, clarify the procedures around these categories and spell out mental health practitioners' roles and responsibilities in this regard. Also according to the National Health Act No. 61 of 2003, the State remains the key role player in mental health care provision, being responsible for adequate mental health infrastructure and resource allocation. Due to "limited resources" practitioners however often work in environments where staff ratios may be fractional of what should be expected and in units of which the physical structure and security is totally inadequate. The interface between professional responsibility of clinical workers versus the inadequacy of clinical interventions resulting from infrastructure and staffing constraints needs to be defined. This paper considered recent legislation currently relevant to mental health care practice in order to delineate the legal, ethical and labour framework in which public sector mental health practitioners operate as state employees. These included the Mental Health Care Act, No.17 of 2002; the National Health Act, No. 61 of 2003 and the proposed Traditional Health Practitioners Act, No. 35 of 2004. Formal legal review of and advice on this legislation as it pertains to public sector mental health practitioners as state employees, is necessary and should form the basis of the principles and standards for care endorsed by organized mental health care practitioner groups such as the South African Society of Psychiatrists (SASOP).

Clinical profile of acutely ill psychiatric patients admitted to a general hospital psychiatric unit.

OBJECTIVES: Helen Joseph Hospital in southern Gauteng Province is one of five specialist hospitals on the academic circuit of the University of theWitwatersrand. Against a background of new mental health legislation, implemented in South Africa during December 2004 with no formal mechanisms in place to monitor mental health services on different levels of care or in regions, a study with three objectives was undertaken, namely: (I) to provide a baseline on psychiatric morbidity and treatment outcome; (II) to establish the state of affairs analysis for mental health care and (III) to establish a framework for cost centre management. The current study focuses on objective one. METHOD: A retrospective clinical audit was undertaken of mental health service delivery, teaching and research at Helen Joseph Hospital over a one-year period from September 2003 to August 2004. This article reports on the two service delivery datasets identified: the "Inpatient Discharge Summary Report" and the "Consultation/Liaison Report". RESULTS: A total number of 438 service users were admitted and a monthly average of 80 consultation/liaison assessments was conducted during the study period. Persistent unfavourable nursing staff ratios continued, while the number of service users from other African countries was generally underrated. Non-compliance and substance abuse contributed significantly to the admission of service users. Schizophrenia was indicated as the most likely diagnosis in almost a quarter of cases. CONCLUSION: Morbidity and treatment outcome at Helen Joseph Hospital will only be contextualized after the implementation of a regular clinical audit process in all the facilities of its referral network.

Otorrhoea is a marker for symptomatic disease in HIV-infected children.

BACKGROUND: Chronic otorrhoea occurs commonly in HIV-infected children. However, there are few data on incidence and severity. OBJECTIVE: To document the prevalence of otorrhoea in the clinic attendees. METHODS: A retrospective chart review was done of all HIVI infected children seen at the Family Clinic for HIV from 1 February 1997 to 31 December 2001, a period preceding widespread availability of antiretrovirals. Otorrhoea was classified into two groups, viz. group 1 (mild): an episode lasting less than 1 month, and group 2 (severe): an episode lasting more than 1 month or more than 1 episode of otorrhoea. The clinical and immune stages of the children were noted. RESULTS: Of 326 children seen during the study period, 104 (32%) had otorrhoea. Forty-five (13.8%) had mild and 59 (18.1%) severe otorrhoea. Two hundred and eighty-eight (88.6%) had either Centers for Disease Control stage B or C disease. The median CD4 percentage in children with otorrhoea was 17.5% (8.3-23%) versus 21% (14-28%) in those without otorrhoea (p=0.004). The odds ratio (OR) of children in stage B or C not having severe otorrhoea was 0.1 (0.01 - 0.72, p = 0.013). The OR for immune class 2 or 3 without severe otorrhoea was 0.39 (0.18 - 0.85, p = 0.021). CONCLUSIONS: Otorrhoea contributes to the morbidity of HIV infection in children. It is a marker for symptomatic disease and CD4 depletion and should be included in clinical classifications.

Unexplained HIV-1 infection in children--documenting cases and assessing for possible risk factors.

BACKGROUND: In the year 2000 we reported possible horizontal transmission of HIV-1 infection between two siblings. An investigation of three families, each with an HIV-infected child but seronegative parents, permitted this finding. Sexual abuse and surrogate breast-feeding were thought unlikely. The children had overlapping hospitalisation in a regional hospital. Since then several cases of unexplained HIV infection in children have been reported. A registry was established at Tygerberg Children's Hospital for collection of data on the extent of horizontal or unexplained transmission of HIV in children. STUDY DESIGN: Retrospective chart review. RESULTS: Fourteen children were identified, 12 from the Western Cape and 1 each from the Eastern Cape and KwaZulu-Natal. Thirteen (92%) had been hospitalised previously. In the Western Cape, children had been hospitalised in 8 hospitals. Ten of 13 (77%) were admitted as neonates and 9 of 13 (69%) had 2 or more admissions. Intravascular cannulation and intravenous drug administration occurred in all but 2 children before HIV diagnosis. CONCLUSION: We have confirmed HIV infection in a number of cases where the source of infection has been inadequately explained. Circumstantial evidence supports but does not prove nosocomial transmission. Further studies and identification of medical procedures conducive to the spread of HIV are urgently needed.

The effect of adjuvant steroid treatment on serial cerebrospinal fluid changes in tuberculous meningitis.

Three recent studies found that corticosteroids improve clinical outcome and mortality in tuberculous meningitis (TBM), although the exact mechanism of action of the drug remains speculative. A number of reports on the effect of corticosteroids on cerebrospinal fluid (CSF) findings in TBM have been published, often with conflicting results regarding serial cell counts and protein levels. As part of a controlled, randomized trial on the effect of oral prednisone on outcome in childhood TBM at our institution, CSF was collected and analysed weekly during the 1st month of treatment. We found no significant difference in serial CSF cell counts between the steroid and non-steroid groups in the study. However, the steroid group had significantly lower CSF protein and globulin levels after the 1st month of treatment, and a more steady rise in CSF glucose levels than the non-steroid group. Knowledge of the different CSF responses during the course of anti-tuberculosis therapy is important in clinical decision-making.