Sputum induction for microbiological diagnosis of childhood pulmonary tuberculosis in a community setting.

SETTING: Sputum induction has increasingly enabled microbiological confirmation of pulmonary tuberculosis (PTB) in hospitalised children, but it has not been evaluated in a community setting. OBJECTIVE: To investigate the yield, feasibility and safety of sputum induction for the diagnosis of TB in children in a primary health care facility. DESIGN: A prospective study in a primary health care clinic in South Africa from April 2007 to June 2009. Consecutive children with clinically suspected PTB, with a household adult PTB contact or human immunodeficiency virus infected with respiratory symptoms were enrolled. History, clinical examination, tuberculin skin test and chest X-ray results were recorded. Two sequential induced sputum specimens were obtained for smear and culture. RESULTS: A total of 270 children were enrolled (median age 38 months); sputum induction was successful in 269 (99%); 65 (24%) children were clinically diagnosed, of whom 11 (16.9%) were microbiologically confirmed. An additional 18 children not clinically diagnosed had microbiological confirmation of PTB and were placed on TB treatment thereafter, increasing the diagnostic yield by 21.6%, from 65 to 83 cases. Sputum induction procedures were well tolerated; no major adverse events occurred. CONCLUSION: Sputum induction is feasible and safe in a community setting. Sputum induction was useful for making a microbiological diagnosis, increasing the number of children diagnosed and treated for PTB.

The knowledge and skills gap of medical practitioners delivering district hospital services in the Western Cape; South Africa

Introduction District (community) hospitals play an important role in the delivery of health services at community level; especially in rural areas. These hospitals provide comprehensive level-one health services to their communities; and serve as a resource for the whole health district. Most district hospitals are situated in rural areas; with medical services in these hospitals being rendered by generalist medical practitioners. The education and training of generalist practitioners for rural practice needs specific attention. Firstly; the unique nature of rural practice makes it necessary for doctors to undergo relevant and focused instruction. Rural family practice requires that doctors have the knowledge and skills to practise in settings where high technology and specialist resources are not available; while at the same time requiring that they be able to perform a wide range of advanced functions and procedures. Secondly; it is argued that appropriate education and training for rural practice can positively influence the recruitment and retention of medical practitioners in rural areas.5 The teaching of the knowledge and skills required for rural practice should take place in an appropriate setting that promotes interest in rural practice and familiarises the student with its particular challenges. There is a paucity of data in South Africa on medical practitioners staffing district hospitals; especially in terms of their knowledge and skills levels. Such information is critical if rural hospitals are to deliver equitable and quality health services; and also for guiding appropriate undergraduate; postgraduate and continuing professional education for rural practice. With this as background; health service managers in the Western Cape requested a skills audit of medical officers in district hospitals to identify a possible gap in competencies that may impact on service delivery. The aim of this study was thus to identify the knowledge and skills of medical practitioners delivering these services in the Western Cape and to compare them with service needs in order to make recommendations for education and training. This article reports on the results of the knowledge and skills gap analysis; while the results of the district hospital performance data and in-depth interviews are reported elsewhere. Method The competencies of medical practitioners working in 27 district hospitals were explored by using a self-administered questionnaire containing a competency rating of proxy markers. The data were analysed using the SAS statistical package. Variables were examined for statistically significant differences. Results A response rate of 75

The Knowledge and Skills Gap of Medical Practitioners Delivering District Hospital Services in the Western Cape; South Africa

Introduction: District (community) hospitals play an important role in the delivery of health services at community level; especially in rural areas. These hospitals provide comprehensive level-one health services to their communities; and serve as a resource for the whole health district. Most district hospitals are situated in rural areas; with medical services in these hospitals being rendered by generalist medical practitioners. The education and training of generalist practitioners for rural practice needs specific attention. Firstly; the unique nature of rural practice makes it necessary for doctors to undergo relevant and focused instruction. Rural family practice requires that doctors have the knowledge and skills to practise in settings where high technology and specialist resources are not available; while at the same time requiring that they be able to perform a wide range of advanced functions and procedures. Secondly; it is argued that appropriate education and training for rural practice can positively influence the recruitment and retention of medical practitioners in rural areas.5 The teaching of the knowledge and skills required for rural practice should take place in an appropriate setting that promotes interest in rural practice and familiarises the student with its particular challenges. There is a paucity of data in South Africa on medical practitioners staffing district hospitals; especially in terms of their knowledge and skills levels. Such information is critical if rural hospitals are to deliver equitable and quality health services; and also for guiding appropriate undergraduate; postgraduate and continuing professional education for rural practice. With this as background; health service managers in the Western Cape requested a skills audit of medical officers in district hospitals to identify a possible gap in competencies that may impact on service delivery. The aim of this study was thus to identify the knowledge and skills of medical practitioners delivering these services in the Western Cape and to compare them with service needs in order to make recommendations for education and training. This article reports on the results of the knowledge and skills gap analysis; while the results of the district hospital performance data and in-depth interviews are reported elsewhere.Method: The competencies of medical practitioners working in 27 district hospitals were explored by using a self-administered questionnaire containing a competency rating of proxy markers. The data were analysed using the SAS statistical package. Variables were examined for statistically significant differences.Results: A response rate of 75 (110/147) was achieved. Part-time (older) medical officers regarded themselves as more experienced and more competent than full-time (younger) employees in most areas; except when managing problems relating to HIV/AIDS. Termination of pregnancy was the procedure most frequently not performed despite practitioners being competent to do so. A substantial need for supervision was identified for managing less common emergency conditions; as well as for some outpatient problems; including preventative; promotive and rehabilitation activities.Conclusions: The knowledge and skills gaps varied considerably according to the individuals' education; training and experience; as well as their circumstances and working conditions. The superior competencies of the older practitioners reinforce the importance of the recruitment and retention of more experienced practitioners. The uneven skill and knowledge base in aspects of HIV/AIDS management should be addressed urgently by initiatives such as the internet-based course on HIV/AIDS developed by the Family Medicine Education Consortium (FaMEC). Departments of Family Medicine should urgently re-orientate their curricula to meet the training needs for level-one hospital practice

The Maintenance of Competence of Rural District Hospital Practitioners

Introduction: It is important for rural district hospital practitioners to maintain their competence to provide equitable health service for rural communities. The scope of their practice dictates that they must stay up-to-date with a large variety of knowledge and skills despite limited educational opportunities. Rural practitioners use continuing professional development (CPD) activities that are most accessible to them; but it is not known whether these activities are educationally sound and effective.Aim: We designed a study to investigate the content and methods used for the maintenance of competence by rural district hospital practitioners in the Western Cape Province; South Africa.Methods: Expert opinion was sought to evaluate the topics requiring up-dating and the validity of the learning methods to maintain competence in practice. This was achieved by employing the Delphi technique to reach consensus on content and methodology. Categorical data analysis and a principal factor analysis were performed. The qualitative data were developed into themes and presented as a conceptual framework.Results: Consensus was reached on the principal content areas requiring updating. Methods that were found most useful were in-service learning under supervision; structured courses; small group discussions and practical workshops. Rotations in tertiary hospitals; lectures by specialists; journal reading and Internet learning were less supported.Conclusion: This study provides a practical model for continuing instruction plus self-directed learning in context. Three content domains were established namely; commonly encountered areas of practice; identified gaps and needs specific to the practitioner and the setting. The implementation of external updating programmes must be tailored to suit the practitioners while the self-directed aspects should include reflective practice. Priority areas are identified and classified as well as educational methods which can contribute towards the maintenance of competence of rural practitioners

Breast Cancer: Early Detection and Screening in South African Women from the Bonteheuwel Township in the Western Cape: Knowledge; Attitudes and Practices

Background: Breast cancer is one of the most common cancers; rating among the most frequent causes of mortality in women worldwide; including in South Africa. Although curative treatment is increasingly successful; early detection and intervention are critical in reducing mortality rates. Early diagnosis is facilitated via breast self-examination (BSE); clinical breast examination (CBE); and mammography. Breast cancer presentation shows an apparent racial variation; with black; coloured and Indian patients presenting at a younger age than whites. In addition; whites tend to present at earlier stages of disease severity; coloureds and Indians at more intermediate stages and blacks at later stages. Socio-economic variables impact on screening practices. One American/Canadian study showed women with higher education and incomes were more likely to receive screening. In South Africa; there is scant research on breast cancer screening. In 2001; Prof. Karl Peltzer of the University of the North did a small telephonic comparative study between black and white women that identified low frequencies of BSE in both groups. Further research is necessary. While several international studies exist; little research is available on the screening behaviour of South African women. The aim of this study; therefore; was to evaluate the knowledge; attitudes; and actual screening practices regarding breast cancer among women in the Bonteheuwel township in the Western Cape.Methods: A random sample of 100 women completed a questionnaire administered by a research assistant. A separate; selected group of nine women participated in a focus group discussion.Results: The results indicate that the majority of the participants were aware of the dangers of breast cancer; perceived as a common (87; 95 CI: 80) and serious (88; 95 CI: 82-94) disease; which; if treated early; could be cured in most cases (82; 95 CI: 74-90). Most had previously examined their breasts (65; 95 CI: 56-74) and/or had been examined by their doctors (62; 95CI: 52-72). Only a minority; however; practised regular BSE (24; 95 CI: 16) or had received a CBE in the last year (29-32 ; 95 CI: 20-38). Fear of diagnosis was identified as the main barrier to screening (87; 95 CI: 80-94). Despite their fears; the participants were keen to improve their knowledge and participate in the further education of their community. However; only 40 (95 CI: 30-50) had ever been taught BSE by a healthcare professional. Moreover; only 34 (95 CI: 25-43) of women who had consulted a GP in the preceding year had received a CBE during this period. A total of 38 (95 CI: 28-48) had never had a CBE in their lives.Conclusion: The participants were better informed and more engaged in screening than had been anticipated. Still; healthcare professionals need to play a more proactive role in breast cancer screening and education

Morbidity profile of admissions to GF Jooste Hospital; Manenberg; Cape Town

BackgroundSecondary hospitals play an important; yet overlooked; role in reflecting public health status; both locally and nationally. Relatively few reports analysing the causes of secondary hospital admissions exist; which is especially unfortunate in the case of developing countries; considering the huge numbers of admissions and people at risk. In developing countries like South Africa; the quality of records varies among institutions. Some hospitals have computerised data; while others may keep no records whatsoever. A major problem facing the quality of hospital records is the constant shortage of staff in rural and urban hospitals. Thorough documentation is essential in providing an invaluable database for researchers; but morbidity statistics are unfortunately scarce.GF Jooste Hospital in Manenberg is the busiest hospital in Cape Town - serving 1.1 million people; with 224 beds and over 12 000 admissions annually. Budgetary constraints in the South African public health sector means that providing healthcare services at higher levels than necessary is too costly. Because hospitals consume the largest share of the public healthcare budget; they have been the focus in cost cutting. In particular; the budgets of referral (tertiary or teaching) hospitals have been trimmed in order to promote primary and secondary care. It is imperative to identify those services that are required most at secondary hospitals in order to improve budgeting and; more appropriately; train doctors and medical students for the job at hand. Identifying the morbidity profile of the population for which the hospital caters can aid the optimal utilisation of the available resources; as well as focusing the continuing medical education of hospital physicians. We determined disease patterns of admissions over a three-year period (2001-2003); primarily as insight towards optimal hospital resource management.MethodsA retrospective study examined ward records; totalling 36 657 admissions; from which a random sample (N=608) was selected. A stratified sample (N=462) was constructed; considering the relative proportions admitted to the wards. The International Statistical Classification of Diseases (ICD) directed diagnosis sorting. Disease prevalence was expressed as the percentage of patients allocated to each ICD category among those admitted to the hospital and respective wards and; additionally; the percentage of diagnoses for each ICD subcategory among patients assigned to each major category.ResultsTrauma (represented by ICD categories S/T 23and V/X/Y 16); specifically assault-related; was most prevalent. This was followed by circulatory diseases (22) and infectious diseases (19); dominated by HIV (61) and associated diseases like TB (57). The age of the patients ranged from 13 to 87 (mean: 40 years); with the 20 to 30-year-olds predominating. Surgical patients were younger (mean: 35 years) than medical (mean: 45 years). In the medical wards; infectious (39in men; 38in women) and circulatory aetiologies (39and 41in men and women respectively) dominated. In the surgical wards; the trend varied according to sex: assault (43) and other injuries (61) for males; pregnancy-related (42) for females. ConclusionThe morbidity distribution reflects the ills affecting South African urban society; with young trauma admissions predominating. The hospital's budget is insufficient; considering its population's demands

The current status and future needs of education and training in family medicine and primary care in South Africa.

South Africa is undergoing tremendous political and social change affecting every sphere of society, including medical education and the delivery of health services. The legacy of its history created a health system that in some respects can be compared to the best in the world, but one also characterized by inequity, discrimination and lack of access to even basic services for the rural and the poor. Its medical education system trails behind modern trends such as problem-based learning, community-based education and the utilizing of general/family practitioners as trainers. Vocational training in family practice is not compulsory for independent practice. The discipline of family practice has nevertheless developed the programmes and core infrastructure for such a future undertaking in the form of masters programmes in family medicine at all medical schools. The recently introduced system of compulsory recertification through continuous professional development provides a window of opportunity to develop locally relevant curricula and appropriate education and training methods for family practitioners. Challenges for family practice include the establishment of the role and value of the discipline in a developing country with a health system based on a nurse-driven primary care service and the re-orientation of family medicine teachers, trained in a biomedical paradigm, to the patient-centred approach. The aspirations of family practice are to define the core content of the discipline, establish and nurture a culture of research in primary care, and to develop and introduce appropriate under and postgraduate training programmes for the new generation of family doctors.

Domestic violence in patients visiting general practitioners--prevalence, phenomenology, and association with psychopathology.

BACKGROUND: It has been suggested that domestic violence is not only highly prevalent and associated with significant morbidity, but that it is also overlooked by medical practitioners. Despite this, few studies have focused on domestic violence in the South African setting, so that there is a paucity of data here on its prevalence, phenomenology, and associated psychopathology. METHODS: Sixteen general practitioners from the South African Sentinel Practitioner Research Network (SASPREN) screened all their female patients aged 18 years or older for a 3-month period (N = 1,050). A sociodemographic questionnaire was completed, and symptoms of post-traumatic stress disorder (PTSD) and major depression were assessed, both in subjects with a history of domestic violence and in a control group without such a history. RESULTS: 21.5% of patients reported a history of domestic violence at screening. Patients and controls did not differ significantly in terms of age or race. However, patients with a history of domestic violence were significantly more likely to be married, not to have begun a high-school education, and to be working outside the home. Both PTSD and major depression were significantly more common in patients with a history of domestic violence (35.3% and 48.2%, respectively) than in controls (2.6% and 11.4%, respectively). Compared with other patients reporting domestic violence, those with either PTSD or major depression were subjected to more violence and were more likely to report a suicide attempt. CONCLUSION: In a large, diverse population of adult female patients presenting to a range of general practitioners in South Africa, there was a high prevalence of reported domestic violence. A significant association was found between domestic violence and both PTSD and major depression, with these diagnoses indicative of increased severity of abuse and increased morbidity. Routine screening by medical practitioners of all female patients for a history of domestic violence seems warranted, and patients with a history of domestic violence should be assessed for PTSD and depression.

Constraints facing the female medical practitioner in private family practice in the Western Cape.

OBJECTIVES: To assess the existence and extent of employment-related problems facing female family practitioners in the context of a rapidly growing number of female doctors in South Africa. SUBJECTS AND METHODS: A descriptive survey was conducted using bilingual questionnaires. These were posted to all 280 female family practitioners in private practice in the Western Cape. RESULTS: Of the 280 questionnaires posted 169 were returned, but 45 of these were missampled. A response rate of 53% was obtained. The largest age category was 30-39 years. Of those not in solo practice, 68 (75%) were able to negotiate the terms of their working hours, 13 (19%) negotiated sick leave on commencing work, and only half had paid leave. Vacation leave was negotiated by 34 (50%), while only 6 (9%) discussed maternity leave with employers or colleagues. Of the 124 practices included in the survey, 6 (5%) had formal arrangements to cope with maternity leave. One hundred and seven respondents (86%) felt there was a need for maternity leave guidelines in the private sector in South Africa. Regarding practice-related problems, 33 female family practitioners (27%) reported some incidents of sexual harassment by patients. Despite these constraints, 88 respondents (71%) planned to continue working in this field. CONCLUSION: Definite obstacles exist in private family practice with regard to working conditions, in particular the lack of national regulations regarding maternity leave and the absence of legislation on pregnancy discrimination. This has important implications for the inclusion of female doctors in group practices and managed health care organisations--private primary health care of the present and future!

The development of passive health surveillance by a sentinel network of family practitioners in South Africa.

OBJECTIVE: For the South African Sentinel Practitioner Research Network (SASPREN), a volunteer network of family practitioners in South Africa, to develop a health surveillance system through the surveillance of important health events. MOTIVATION: The incidence of important preventable diseases and the burden of disease are not reliably known in South Africa, both in the public and private sector. Incidence rates determined at primary care level could help with planning and delivery of appropriate health services and monitoring of the impact of intervention programmes. METHODS: Altogether 183 sentinel practitioners were recruited in nine provinces, from 2,478 doctors invited to participate. Of these 120 were active in reporting all their new cases of 13 selected health events to the study centre on mailed postcards. After data-capturing, incidence rates were calculated for defined periods. Feedback was given to the sentinels through a newsletter and personalised reports. RESULTS: A network of sentinel family practitioners has been established in South Africa, and can provide incidence rates for both diseases and interventions through a simple and cheap surveillance system. The calculated rates demonstrated periodic trends for certain events, as well as inter-provincial, -gender and -population group differences. CONCLUSIONS: As the validity of the dataset and its generalisation to the whole population is uncertain, its usefulness as point estimates of incidence rates is unknown. This information serves as an important pointer for further research. The trends of these rates may provide a valuable tool for monitoring the impact of public health policies.

An analysis of the appropriate use of the Caledon ambulance service in the Overberg. A short report.

The objective of this study was to determine the possible extent of the inappropriate use of the ambulances of the Caledon station of the Overberg Regional Services Council. The trip sheets of the ambulances for the period 1987-1990 were retrospectively analysed, and the appropriateness of calls prospectively determined over a 7-month period. The results showed that the vast majority of calls (68%) were of a non-emergency nature, and that only 34% of the trips warranted the use of a fully equipped emergency vehicle. Various cost-containment measures are suggested.