Primary care morbidity in Eastern Cape Province.

BACKGROUND: Primary health care in rural South Africa is predominantly provided by remote clinics and health centres. In 1994, health centres were upgraded and new health centres developed to serve as a health care filter between community clinics and district hospitals. AIM: To describe the spectrum of clinical problems encountered at a new health centre in an area of high economic deprivation and compare this with an adjacent community clinic and district hospital. DESIGN: Cross-sectional survey. SETTING: A rural clinic, health centre and district hospital in Eastern Cape Province, South Africa. METHODS: The International Classification of Primary Care-2 (ICPC-2) was used to code data collected over a 13-week period from patients presenting at a community clinic, health centre and district hospital. RESULTS: Altogether, 4 383 patient encounters were recorded across all three sites in 2001. Most contacts at the clinic (97%) and the health centre (80%) were with a nurse. Females over 15 years of age comprised over half of all contacts at health facilities (53%). The most common diagnosis category was respiratory (23%). Cough was the most common symptom. Thirty per cent of children up to 5 years of age were seen for immunisations. Most childhood immunisations (79%) were carried out at the health centre. CONCLUSION: Of all the health care facilities surveyed, the health centre had the highest throughput of patients, indicating that the health centre is an efficient filter between the community and hospital. The ICPC-2 can be successfully used to monitor encounters at similar African health care facilities.

'Over-the-counter' genetic testing: what does it really mean for primary care?

The publication of More Genes Direct by the Human Genetics Commission is a timely reminder of the potential impact that 'over-the-counter' genetic testing (that is, a direct genetic test without the need for a medical referral) may have on the NHS. This article considers the relevance of current genetic research on complex common diseases and how this might translate into risk estimates for developing conditions such as dementia, cancer, and cardiovascular disease. The implications for primary care include the need to understand the current limitations of genetic testing and its commercial application over the counter, and the importance of continuing to make risk assessments using family history. The authors recommend caution in the premature introduction of over-the-counter testing without a sound evidence base.

Socio-economic inequalities as a predictor of health in South Africa--the Yenza cross-sectional study.

OBJECTIVES: To describe the demographic, environmental and health characteristics of the rural Eastern Cape and to explore demographic and environmental predictors of health. DESIGN: Cross-sectional study. SETTING: Engcobo and Umtata in the Eastern Cape, South Africa. SUBJECTS: 12,049 people from 4608 households. OUTCOME MEASURES: (i) Children: immunisation history and being breastfed; (ii) women aged 15-45 years: use of contraception; (iii) women aged 20-25 years: total numbers of dead children; and (iv) all adults: smoking status, body mass index and blood pressure. RESULTS: 2741 houses (59.5%) were structurally adequate, 1795 (39.0%) had access to clean water, and 1174 (25.6%) had access to gas or electric energy. Of children up to 5 years of age 1436 (44.2%) were fully immunised and 2472 (76.1%) were breastfed in their first year of life. Among women aged 15-45 years, 903 (37.8%) used contraceptives, and among women aged 20-25 years, 56 (11.8%) had lost at least 1 child. Self-report of chronic illness and disability was low. Current smokers include 264 men (12.7%) and 325 women (6.0%), and 315 men (15.2%) and 1439 women (26.7%) had a body mass index > 30. Adequate housing (odds ratio (OR) 1.31, 95% confidence interval (CI): 1.12-1.53) and access to refuse disposal (OR 1.65, 95% CI: 1.36-2.00) were predictive of complete immunisation in children. Children living in houses with access to clean water (OR 0.8, 95% CI: 0.64-0.99) and a fitted toilet (OR 0.56, 95% CI: 0.38-0.83) were less likely to be breastfed in the first year of their life. Women aged 15-45 years were likely to use contraception if they were well educated (OR 2.75, 95% CI: 1.76-4.28) and lived in houses with access to refuse disposal (OR 1.46, 95% CI: 1.20-1.78). Better education was associated with a reduced likelihood of loss of a child (OR 0.11, 95% CI: 0.02-0.51) and being a smoker (OR 0.52, 95% CI: 0.38-0.73). Obesity was associated with being female (OR 1.88, 95% CI: 1.62-2.18) and living in a house with electricity (OR 1.46, 95% CI: 1.26-1.68). High blood pressure was associated with living in a house with electricity (OR 1.36, 95% CI: 1.10-1.70) and with monthly household income exceeding R2 000 (OR 1.38, 95% CI: 1.07-1.78). CONCLUSIONS: High socio-economic deprivation in the Eastern Cape is associated with health status comparable to that of poorer regions in sub-Saharan Africa. The educational level of the population, access to electricity, clean water and refuse disposal facilities are important predictors of child, maternal and adult health.

Collecting genetic information in primary care: evaluating a new family history tool.

BACKGROUND: The family history is a time-honoured method for identifying genetic predisposition. In specialist practice the standard approach is to draw up a family tree based on a genetic pedigree interview, but this is too time-consuming and focused on single gene disorders to be applicable in primary care. OBJECTIVES: To assess the ability of a brief self-administered Family History Questionnaire (FHQ), given to patients when they register with a GP, to identify genetic risk. METHODS: A comparative study. Informants completed an FHQ at registration, and later participated in a genetic pedigree interview. Two clinical geneticists independently scored results obtained with each instrument. Discrepancies were agreed by consensus. The genetic risks identified by the two instruments were compared. RESULTS: 326 new registrants completed the FHQ, and 121 also completed the genetic interview. 24% of FHQs and 36% of genetic interviews resulted in a score 'higher than population risk'. There was 77% agreement in the scores obtained with the two instruments, with a moderate kappa of 0.52. (95% CI 0.40-0.64). There was 90% agreement in the scores for a family history of premature coronary heart disease (Kappa 0.67; 95% CI 0.49 to 0.85). The instruments were equally effective in identifying ethnicity-related risk of common recessive disorders. CONCLUSIONS: The FHQ identified most informants with genetic risks that are appropriately addressed in primary care-those with a family history of premature coronary heart disease, those warranting specialist referral, and those who might appropriately be offered carrier testing. However, it was less effective in identifying those with a possible Mendelian disorder for whom more information was required.

Timeline: Raising the profile of genetics in primary care.

Primary care practitioners recognize that genetics is relevant to their daily practice, for example, for detecting and managing the risk of multifactorial disorders and genetic reproductive risks, and, in future, for targeted drug therapy. However, they lack confidence in their ability to apply genetic approaches. In fact, genetics is already ingrained in current practice, and the development of appropriate guidelines and web-based information resources will help practitioners to make personalized genetic risk assessment a part of holistic, patient-oriented primary health care.

Clinical exposure during clinical method attachments in general practice.

BACKGROUND: There has been a significant decline in medical students' clinical experience in hospitals. Hospital-based teaching is struggling to provide medical students with sufficient experience of the common health problems of our industrialized ageing society. Hence, general practice has become an important locus for medical education. Published evidence, however, that students can access appropriate clinical experience in general practice is sparse. OBJECTIVE: To determine students' clinical exposure during clinical and method attachments based in general practice at two medical schools. EDUCATIONAL INITIATIVE: Students were attached to general practice tutors to learn clinical method in internal medicine. METHOD: General practice tutors from two medical schools collected data on age, gender, diagnoses, symptoms and signs of the patients they invited to teaching sessions. RESULTS: The frequency of diagnoses, symptoms and signs seen by medical students are recorded. Students mostly saw patients with chronic illnesses; the commonest diagnoses were ischaemic heart disease and angina. DISCUSSION: Our study has recorded the largest published database of clinical diagnoses, symptoms and signs encountered by students learning clinical method in general practice. It shows that students obtained a wealth of experience with patients with common chronic diseases. Students must also learn in the hospital setting, to experience the presentation of acute illness. The combination of teaching in these two settings is likely to provide the most effective technique to ensure that students encounter the common, acute and chronic conditions that affect patients in the 21st century.