Multilingual education: medical interns perceptions regarding the usefulness of non-mother tongue communications skills taught during the undergraduate curriculum.

BACKGROUND: This paper investigates the perceptions of medical interns regarding the usefulness of non-mother tongue communication skills taught during the undergraduate curriculum at the University of Cape Town in South Africa. In 2003, the university decided to incorporate Afrikaans and IsiXhosa communication skills into the new MBChB curriculum in order to meet the Faculty of Health Sciences goals to promote quality and equity in healthcare, and to prepare graduating health practitioners for multilingual communities where they would be serving. Despite annual internal evaluations and reviews of the languages courses, the usefulness, if any, of the additional languages in the working clinical environment had not been determined. METHODS: Data were collected during the second year of medical internship across a five-year period through survey questionnaires, as well as focus group interviews conducted in the Western Cape, South Africa. Surveys were conducted from 2009 to 2013. RESULTS: The study shows that the usefulness of each of the probed categories was not consistent across both languages. The interns expressed a need for an overall improvement of the isiXhosa course offering, while the outcomes for the Afrikaans language were more positive across all categories except for cultural understanding. CONCLUSION: The study indicates a positive trend amongst the interns towards developing usefulness in communication skills in Afrikaans and isiXhosa to communicate with their patients.

A framework for implementation of community-orientated primary care in the Metro Health Services, Cape Town, South Africa.

In South Africa, the national policy on re-engineering primary health care (PHC) supports the implementation of ward-based outreach teams with community health workers. In the Western Cape, a community-orientated primary care (COPC) approach has been adopted in provincial goals for 2030 and the key strategies for the improvement of district health services. This approach is expected to improve health and also save costs. A task team was established in the Metropolitan Health Services to develop an implementation framework for COPC. The framework was developed in an iterative process with four learning sites in the metropole over a period of 18 months. The framework consists of 10 inter-related elements: geographic delineation of PHC teams, composition of PHC teams, facility-based and community-based teamwork, partnership of government and non-government organisations, scope of practice, information system, community engagement, stakeholder engagement, training and development of PHC teams, system preparation and change management. This framework was implemented at the four learning sites and is now being taken to scale and further assessed in the metropole.

Training family physicians: A qualitative exploration of experiences of registrars in a family medicine training programme in Cape Town, South Africa.

BACKGROUND: The MMed in Family Medicine is a professional Master's qualification spanning 4 years of training. The outcomes were predetermined by national consensus. While these outcomes are measured in the form of a national exit examination, there has been no exploration of the experiences of registrars (residents) in this relatively new programme. To evaluate the experiences of registrars in one of the nine training programmes in South Africa and to identify areas for improvement. METHODS: This study used purposive sampling to recruit registrar (n = 9) and supervisor (n = 8) participants into respective groups. Data were collected via semi-structured interviews and analysed thematically, and consensus was built using the nominal group technique. RESULTS: Supervisors identified the strengths and weaknesses of the programme which will impact on further strategic planning. Data from registrar interviews yielded two themes: affirmation, referring to the positive social engagement and facilitation of professional identity formation; and frustrations, referring to structural aspects of the programme which hindered academic progress. CONCLUSION: Qualitative programme evaluation is a useful tool in understanding the learning environment. The student perspective helped to identify the unintended consequences of the programme. It was also shown that the nominal group consensus building technique worked well in a resource-constrained environment.

Development and validation of a tool to measure patient experience in chronic disease care.

BACKGROUND:  There is a global increase in the prevalence of non-communicable diseases and a growing understanding that patients need to be involved in their care. Patient experience should be assessed and the information used to improve on the planning and delivery of health services. AIM:  This study described the development and validation of a patient-reported experience measure (PREM) tool which is appropriate for the South African context, to assess self-reported patient experience of chronic care. SETTING:  The study was conducted at four primary health care facilities in the Cape Town Metropole. METHODS:  This was a validity and reliability study with multiple phases to develop and determine the psychometric properties of a novel tool. It consisted of three phases, namely: Phase 1 - Consensus Validity; Phase 2 - Face Validity; Phase 3 - Reliability. Phase 1 consisted of an expert panel reaching consensus on a draft tool. Phase 2a consisted of qualitative semi-structured interviews and cognitive interviews. Phase 3 tested the internal consistency of the tool, the time necessary to complete, as well as floor and ceiling effects with 200 questionnaires. RESULTS:  The process described resulted in a final questionnaire with n = 10 items in three languages that was easily understood by patients. Internal consistency was determined with the overall Cronbach's alpha 0.86. This PREM has been named Chronic Care Assessment of Patient Experience. CONCLUSION:  Using best practice guidance in tool construction and validation, we delivered a PREM with the potential to improve the quality of care from the perspective of patients. Implementation studies are now required to determine how best to use this tool in routine practice.

Strengths and limitations of a family physician.

Family physicians (FP) practising in different parts of the world may require different sets of knowledge and skills to satisfy the needs of the communities in which they work as well as the requirements of the professional bodies with which they are registered. This article gives an overview of the strengths and limitations of the FP globally and more specifically within India, South Africa, and the United States of America. The historical context and evolution of FM as a clinical and academic discipline is discussed in this article. The article recommends suggestions for a better future for Family Medicine as a specialty thereby providing quality primary healthcare to the community, based on the needs of the population of each country.

Building freeways: piloting communication skills in additional languages to health service personnel in Cape Town, South Africa.

BACKGROUND: This study reflects on the development and teaching of communication skills courses in additional national languages to health care staff within two primary health care facilities in Cape Town, South Africa. These courses were aimed at addressing the language disparities that recent research has identified globally between patients and health care staff. Communication skills courses were offered to staff at two Metropolitan District Health Services clinics to strengthen patient access to health care services. This study reflects on the communicative proficiency in the additional languages that were offered to health care staff. METHODS: A mixed-method approach was utilised during this case study with quantitative data-gathering through surveys and qualitative analysis of assessment results. The language profiles of the respective communities were assessed through data obtained from the South African National census, while staff language profiles were obtained at the health care centres. Quantitative measuring, by means of a patient survey at the centres, occurred on a randomly chosen day to ascertain the language profile of the patient population. Participating staff performed assessments at different phases of the training courses to determine their skill levels by the end of the course. RESULTS: The performances of the participating staff during the Xhosa and Afrikaans language courses were assessed, and the development of the staff communicative competencies was measured. Health care staff learning the additional languages could develop Basic or Intermediate Xhosa and Afrikaans that enables communication with patients. CONCLUSIONS: In multilingual countries such as South Africa, language has been recognised as a health care barrier preventing patients from receiving quality care. Equipping health care staff with communication skills in the additional languages, represents an attempt to bridge a vital barrier in the South African health care system. The study proves that offering communication skills courses in additional languages, begins to equip health care staff to be multilingual, that allows patients to communicate about their illnesses within their mother tongues.

Western Cape Primary Care Assessment Tool (PCAT) study: Measuring primary care organisation and performance in the Western Cape Province, South Africa (2013).

BACKGROUND: Major health sector reform and the need for baseline measures of performance to determine impact. AIM: Baseline audit of primary healthcare (PHC) performance. SETTING: Cape Town and Cape Winelands (rural) PHC facilities (PCFs) in Western Cape Province, South Africa. METHOD: The South African cross-culturally validated ZA PCAT to audit PHC performance on 11 subdomains associated with improved health and reduced costs. Adult PCF users systematically sampled. All full-time doctors and nurse practitioners in PCFs sampled and all PCF managers in sub-districts sampled invited into the study. RESULTS: Data from 1432 users, 100 clinicians and 64 managers from 13 PCFs in 10 sub-districts analysed (figures show stakeholder percentages scoring subdomain performance 'acceptable to good'). 11.5% users scored access 'acceptable to good'; community orientation and comprehensive services provided 20.8% and 39.9%, respectively. Total PHC score for users 50.2%; for managers and practitioners 82.8% and 88.0%, respectively. Among practitioners access was lowest (33.3%); PHC team (98.0%) and comprehensive services available (100.0%) highest. Among managers, access (13.5%) and family centredness (45.6%) are lowest; PHC team (85.9%) and comprehensive services available (90.6%) highest. Managers scored access, family centredness and cultural competence significantly lower than practitioners. Users scored comprehensive services available, comprehensive services provided and community orientation significantly lower than practitioners and managers. CONCLUSION: Gaps between users' experience and providers' assessments of PHC performance are identified. Features that need strengthening and alignment with best practice, provincial and national, and health policies are highlighted with implications for practitioner and manager training, health policy, and research.

Profile and anticoagulation outcomes of patients on warfarin therapy in an urban hospital in Cape Town, South Africa.

BACKGROUND: Warfarin is the most frequently used oral anticoagulant worldwide and it is the oral anticoagulant of choice in South Africa for reducing thrombosis-related morbidity and mortality. However, the safety and efficacy of warfarin therapy depends mainly on careful monitoring and maintenance of the international normalised ratio (INR) within an optimal therapeutic range. AIM: The aim of this study was to describe the profile and the anticoagulation outcomes of patients on warfarin therapy in a major warfarin clinic in the Western Cape Province of South Africa. SETTING: Victoria Hospital - a district hospital in Cape Town. METHODS: A cross sectional review of clinical records of patients on warfarin therapy who attended the INR clinic from 01 January 2014 to 30 June 2014 was done. Data analysis was done with STATA to generate appropriate descriptive data. RESULTS: Our study showed that atrial fibrillation (AF) was the commonest indication for warfarin use in this study and hypertension was the commonest comorbidity among these patients. Only 48.5% achieved target therapeutic range; 51.5% were out-of-range. There was a significant association between alcohol consumption and poor anticoagulation outcomes (p-value < 0.022). Anticoagulation outcomes were better among the older age groups, male patients and in those with AF. The prevalence of thrombotic events while on warfarin treatment was 2.2%, while prevalence of haemorrhagic events was 14%. Most of the patients with bleeding events were on concurrent use of warfarin and other medications with potential drug interactions. CONCLUSION: In our study, patients who achieved target therapeutic control were less than the acceptable 60%.

Diabetes mellitus and non-traumatic lower extremity amputations in four public sector hospitals in Cape Town, South Africa, during 2009 and 2010.

BACKGROUND: Diabetes mellitus (DM) is the most commonly reported cause of non-trauma-related lower extremity amputations (LEAs) worldwide, but there is a dearth of such information for South Africa (SA). OBJECTIVES: To examine the proportion of LEAs due to diabetes and to describe the associated characteristics of these patients. METHODS: A retrospective analysis of all LEAs was performed in four public sector hospitals in Cape Town, SA, for 2009 and 2010. Operating theatre records were reviewed to identify all patients who had an LEA. Patient records were perused and information extracted using a structured questionnaire. RESULTS: Records for 941 of 1,134 patients identified as having an LEA were found (recovery rate 82.9%). Of the 867 patients with 1,280 LEAs included in the study, 925 LEAs were in 593 patients with DM and 355 LEAs in 274 non-DM patients. Therefore 72.3% (95% confidence interval (CI) 69.8-74.7) of LEAs were in people with DM, while 68.4% (95% CI 65.2-71.4) of the total patients had DM. The DM group underwent more multiple LEAs (42.0% v. 23%; p<0.001) and had more multiple admissions (14.3% v. 7.7%; p<0.005) than the non-DM group. Infection (85.7% v. 63.5%,; p<0.001) and ulcer (25.3% v. 15.3%; p=0.001) were the leading causes for LEA in the DM group compared with the non-DM group. Ischaemia was the dominant cause in the non-DM patients (49.3% v. 23.3%; p<0.001), as was smoking (69.7% v. 43.5%, p<0.001), compared with the DM patients. CONCLUSIONS: These data demonstrate an alarming burden of LEAs due to DM in the public sector in Cape Town. Given that the majority of LEAs are preventable with adequate education, screening, treatment and follow-up, effective interventions are needed.

Health Sciences undergraduate education at UCT: a story of transformation.

Undergraduate education and training in the Faculty of Health Sciences at the University of Cape Town has become socially responsive. A story of transformation that is consonant with wider societal developments since the 1994 democratic elections, outlining the changes in undergraduate curricula across the faculty, is presented.

Developing family medicine in South africa: a new and important step for medical education.

The announcement by the National Ministry of Health on the 17th August 2007 (South African Government 2007), officially recognizing family medicine as a speciality in its own right is an indication of just how far 'general practice' has developed in South Africa. From January 2008 there is to be a compulsory, full-time four- year training programme for registrars in Family Medicine which should result in a well trained cohort of Family Physicians suitable to staff Community Health Centres and Primary Care Hospitals in the future. This article seeks to explore some of the milestones reached in the development of the community of family medicine professionals and teachers, the roles taken by the major protagonists in the development and the way that medical education can promote and sustain the discipline.

Family medicine in South Africa: where are we now and where do we want to be?

OBJECTIVES: This paper outlines the development of family medicine in South Africa with special reference to the process leading to the recognition of this discipline as a medical specialty. It also examines the constraints under which the discipline has had to function, considers where the discipline should be, seeks to identify the barriers to its further development and suggests ways in which to overcome these. METHODS: A short review was carried out of the available South African literature to record the advancement of the discipline and the international literature was searched for articles supporting this direction. RESULTS: The situation in South Africa is complicated by the existence of many doctor groupings claiming to represent the generalist and the perception that family medicine only addresses the needs of middle-class citizens. A flawed consultative process leading up to the present stage has contributed to this perception. CONCLUSIONS: The available literature supports the establishment of family medicine as a speciality. Developments in South Africa, such as raising the status of Family Medicine and creating a compulsory rotation through family medicine as an extended internship and the creation of registrar posts in family medicine will advance the discipline in a positive manner, whilst possibly attempting to resolve the medical migration issues that are presently destroying Sub-Saharan Africa's health services.