Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings.

BACKGROUND: In South Africa, initiating insulin for people with type 2 diabetes and subsequent titration is a major challenge for the resource-constrained healthcare system. Inadequate support systems in primary care, including not being able to access blood glucose monitors and test strips for self-monitoring of blood glucose, results in patients with type 2 diabetes being referred to higher levels of care. In primary care, initiation of insulin may be delayed due to a shortage of healthcare workers. The delayed initiation of insulin is also exacerbated by the reported resistance of both healthcare providers and people with type 2 diabetes to start insulin. In South Africa, telehealth provides an opportunity to overcome these challenges and manage insulin therapy in primary care. METHODS: We describe the development of a digital health intervention including the framework used, the theoretical approach and subsequent implementation strategies. RESULTS: This intervention is an innovative, nurse-driven and app-enabled intervention called 'the Tshwane Insulin Project intervention'. The Tshwane Insulin Project intervention was designed and evaluated using the framework recommended by the Medical Research Council for complex interventions. The Tshwane Insulin Project intervention was developed in four sequential phases: planning, design, implementation and evaluation. The Tshwane Insulin Project intervention followed the Integrated Chronic Disease Management framework to facilitate implementation and acceptability. The Tshwane Insulin Project comprises a facility-level intervention, where nurses evaluate patients and initiate insulin, an individual-level intervention where community healthcare workers visit patients at their homes to follow-up and provide educational information, while using telehealth to enable physician-directed insulin titration if needed, and a community-level intervention aimed at empowering community healthcare workers to support people living with diabetes and raise awareness of diabetes. CONCLUSION: The technological advancements in digital health and telemedicine present an opportunity to improve diabetes care in resource-limited countries. This work can inform those intending to develop and implement complex interventions in primary healthcare in developing countries.

The role played by family physicians in providing health services for the sheltered homeless populations during COVID-19 lockdown in the Tshwane district.

This short report describes the role that family physicians (FPs) (and family medicine registrars) played to provide care for the homeless people in shelters (both temporary and permanent) during the coronavirus disease 2019 (COVID-19) lockdown in the City of Tshwane, South Africa. The lockdown resulted in the establishment of a large number of temporary shelters. The FPs took on the task to provide comprehensive and coordinated primary care, whilst extending their activities in terms of data management, quality improvement, capacity building and research. The FPs worked in teams with other healthcare providers and contributed a unique set of skills to the process. This report demonstrates the value of responding quickly and appropriately through communication, cooperation and innovation. It also demonstrates the large number of areas in which FPs can make a difference when engaged appropriately, with the necessary support and collaboration, thus making a positive impact in the already overburdened health services.

COVID-19 disruption: Family physicians at the forefront.

No abstract available.

The contribution of family physicians and primary care doctors to community-orientated primary care.

South Africa envisages a community-orientated approach to primary health care (PHC). Family physicians and primary care doctors have important roles to play in leading, implementing, supporting and maintaining community-orientated primary care (COPC). In this article, we define COPC, its key principles and approaches to implementing it in health services. Following this we describe the key competencies expected of family physicians and primary care doctors in leading and supporting its implementation; providing clinical support to the PHC teams and linking these teams to other parts of the health system, other sectors and the community. The required knowledge and skills underlying these competencies are also discussed and some specific tools included.

Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future.

BACKGROUND: The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa. OBJECTIVE: Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups. OUR APPROACH: Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel. ONGOING ACTIVITIES: Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality. CONCLUSION: There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other.

Calorie Restriction Increases the Number of Competing Stem Cells and Decreases Mutation Retention in the Intestine.

Calorie restriction (CR) extends lifespan through several intracellular mechanisms, including increased DNA repair, leading to fewer DNA mutations that cause age-related pathologies. However, it remains unknown how CR acts on mutation retention at the tissue level. Here, we use Cre-mediated DNA recombination of the confetti reporter as proxy for neutral mutations and follow these mutations by intravital microscopy to identify how CR affects retention of mutations in the intestine. We find that CR leads to increased numbers of functional Lgr5+ stem cells that compete for niche occupancy, resulting in slower but stronger stem cell competition. Consequently, stem cells carrying neutral or Apc mutations encounter more wild-type competitors, thus increasing the chance that they get displaced from the niche to get lost over time. Thus, our data show that CR not only affects the acquisition of mutations but also leads to lower retention of mutations in the intestine.

Learning person-centred consultation skills in clinical medicine: A randomised controlled case study.

BACKGROUND: Training institutions need to ensure that healthcare students learn the skills to conduct person-centred consultations. We studied changes in person-centred practice over time following a quality improvement (QI) intervention among Bachelor of Clinical Medical Practice undergraduate students. METHODS: Students were randomised to intervention and control groups. The intervention group received training and did a QI cycle on their own consultation skills. Consultations with simulated patients were recorded during structured clinical examinations in June (baseline) and November (post-intervention) 2015. RESULTS: Matched consultations for 64 students were analysed. The total SEGUE (Set the stage, Elicit information, Give information, Understand the patient's perspective and End the encounter scores) were significantly higher in the final assessment compared to baseline for both the whole group and the intervention group (p = 0.005 and 0.015, respectively). The improvement did not differ significantly between intervention and control groups (p = 0.778). Third-year students improved significantly more than second years (p = 0.007). CONCLUSION: The person-centred practice (including collaboration) of clinical associate students did improve over the period studied. The results show that students' learning of person-centred practice also happened in ways other than through the QI intervention. There is a need to develop students' collaborative skills during the medical consultation.

Patient-Derived Ovarian Cancer Organoids Mimic Clinical Response and Exhibit Heterogeneous Inter- and Intrapatient Drug Responses.

There remains an unmet need for preclinical models to enable personalized therapy for ovarian cancer (OC) patients. Here we evaluate the capacity of patient-derived organoids (PDOs) to predict clinical drug response and functional consequences of tumor heterogeneity. We included 36 whole-genome-characterized PDOs from 23 OC patients with known clinical histories. OC PDOs maintain the genomic features of the original tumor lesion and recapitulate patient response to neoadjuvant carboplatin/paclitaxel combination treatment. PDOs display inter- and intrapatient drug response heterogeneity to chemotherapy and targeted drugs, which can be partially explained by genetic aberrations. PDO drug screening identifies high responsiveness to at least one drug for 88% of patients. PDOs are valuable preclinical models that can provide insights into drug response for individual patients with OC, complementary to genetic testing. Generating PDOs of multiple tumor locations can improve clinical decision making and increase our knowledge of genetic and drug response heterogeneity.

Harm reduction in practice - The Community Oriented Substance Use Programme in Tshwane.

BACKGROUND: The Community Oriented Substance Use Programme (COSUP) is the first publicly funded, community-based programmatic response to the use of illegal substances in South Africa. It is founded on a systems thinking, public health and clinical care harm reduction approach. AIM: To describe the critical components, key issues and accomplishments in the initiation and delivery of evidence-based, community-oriented, substance-use health and care services. SETTING: The Community Oriented Substance Use Programme is implemented by the University of Pretoria in four of seven Tshwane Metropolitan Municipality regions. METHODS: Quantitative and qualitative data were extracted and triangulated from plans, reports, minutes and other documents. RESULTS: Between 2016 and 2019, COSUP engaged in national and local policy and guidelines development. In Tshwane, it created practical working relations with 169 organisations and institutions and set up 17 service sites. These provide counselling, linkage to care and opioid substitution therapy services to 1513 adults (median age of 30 years), most of whom are male (90%), with similar proportions of clients who smoke (51%) or inject (49%) heroin. It also offers needle and syringe services (approximately 17 000 needles distributed/month) and has built human resource capacity in harm reduction among staff, clients and personnel in partner organisations. CONCLUSION: The Community Oriented Substance Use Programme offers an evidence-based, public-health informed, feasible alternative to an abstinence-based approach to substance use. However, to translate the programme's achievements into sustainable outcomes at scale requires health system integration; generalist, patient-centred care; affordable medication in a comprehensive package of harm reduction services; multisectoral partnerships; systematic, continuous capacity development; financial investment; and sustained political commitment.

Why high tech needs high touch: Supporting continuity of community primary health care.

BACKGROUND:  Integrated care through community-oriented primary care (COPC) deployed through municipal teams of community health workers (CHWs) has been part of health reform in South Africa since 2011. The role of COPC and integration of information and communication technology (ICT) information to improve patient health and access to care, require a better understanding of patient social behaviour. Aim: The study sought to understand how COPC with CHWs visiting households offering health education can support antenatal follow-up and what the barriers for access to care would be. Method: A mixed methodological approach was followed. Quantitative patient data were recorded on an electronic health record-keeping system. Qualitative data collection was performed through interviews of the COPC teams at seven health posts in Mamelodi and telephonic patient interviews. Interviews were analysed according to themes and summarised as barriers to access care from a social and community perspective. Results: An integrated COPC approach increased the number of traceable pregnant women followed up at home from 2016 - 2017. Wrong addresses or personal identification were given at the clinic because of fear of being denied care. Allocating patients correctly to a ward-based outreach team (WBOT) proved to be a challenge as many patients did not know their street address. Conclusion: Patient health data available to a health worker on a smartphone as part of COPC improve patient traceability and follow-up at home making timely referral possible. Health system developments that support patient care on community level could strengthen patient health access and overall health.

Anova Health Institute's harm reduction initiatives for people who use drugs.

Chemsex is the colloquial term used for a specific pattern of drug use that is increasingly common among men who have sex with men (MSM) globally. The recreational substances employed are used specifically in a sexualized context. The reasons for chemsex among MSM are complex. The Anova Health Institute (Anova) provided harm-reduction services in Cape Town, South Africa in 2013 and 2014. This project, known as Tikking the Boxes had two objectives: first to provide direct harm-reduction services to drug-using MSM in Cape Town, South Africa, and second, to reduce HIV and hepatitis B and C transmission among this population. This was done by identifying drug-using behaviour among MSM and linking them to harm-reduction services. Employing people who were currently using drugs was a novel aspect of this program, and successfully facilitated access to MSM drug-using networks. At the launch of the project, the concept of harm reduction was easily misunderstood by MSM. Another challenge was that the harm-reduction service, encompassing needle exchange, excluded opioid substitution therapy. People who use drugs were employed as outreach workers, requiring the project to be very flexible and adaptable to sometimes complex lives and difficult-to-reach peers. JAB SMART is Anova's new harm-reduction initiative and started in May 2017, with support from the City of Johannesburg Health Department, and is the first project of its kind in the city to provide harm-reduction services to people who inject drugs (PWID) and their sexual partners.

Patient- or person-centred practice in medicine? - A review of concepts.

BACKGROUND: Person-centred practice in medicine may provide solutions to several pressing problems in health care, including the cost of services, poor outcomes in chronic care and the rise in litigation. It is also an ethical imperative in itself. However, patient- or person-centred care is not well researched partly because of a lack of conceptual and definitional clarity. AIM: The aim of this review was to analyse essential elements, ethical principles, logic and the practical application of person-centred practice described in clinician- and researcher-defined conceptual frameworks, terms and practices. METHODS: A search of review articles on patient- and person-centred care or medicine was conducted using Medline and Google Scholar. Secondary searches were conducted using references and citations from selected articles. RESULTS: Five conceptual frameworks were identified in terms of their practical application of the ethical principles of beneficence, autonomy and justice. They converge around a few central ideas such as having a holistic perspective of patients and their illness experience, a therapeutic alliance between the patient and clinician as well as respectful, enabling collaboration with the patient. CONCLUSIONS: Terminological differences appear to owe more to disciplinary origins than to substantive meaning. Beneficence needs to be balanced by and practised through respect for patient autonomy. Core ideas in existing conceptual frameworks of patient or person centredness can guide teaching and research. Considering the value and ethical imperative of person-centred practice, training institutions should train health care students and practitioners in its precepts.