Debate: Why should gender-affirming health care be included in health science curricula?

BACKGROUND: Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care. MAIN BODY: Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care. Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance. This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to gender-affirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that upholds autonomy by empowering patients to make their own health care decisions. CONCLUSION: There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.

An introduction to gender affirming healthcare: What the family physician needs to know.

Gender affirming healthcare (GAHC) is a relatively new field in primary health care that describes a range of gender affirming practices, including hormone therapy, for transgender and gender diverse (TGD) people. In 2019, gender affirming hormones were approved by South African National Essential Medicine List Committee (NEMLC) for tertiary-level care, and in October 2021 the Southern Africa HIV Clinicians Society published a GAHC guideline for South Africa. Unfortunately, TGD people still experience discrimination and stigmatisation in healthcare facilities in South Africa, leading to poor access to care and higher health risks with poorer outcomes. Gender affirming care in the primary health care clinic can improve access to health care, with improved provision of preventative services. This article defines key transgender concepts, describes the informed consent process and outlines the initiation and monitoring of both feminising and masculinising hormone treatment for TGD people. Staff at healthcare facilities need to receive training on gender affirming practices and how to ensure a safe environment for TGD clients.

Clinical audit of diabetes management can improve the quality of care in a resource-limited primary care setting.

OBJECTIVE: To determine whether clinical audit improved the performance of diabetic clinical processes in the health district in which it was implemented. DESIGN: Patient folders were systematically sampled annually for review. SETTING: Primary health-care facilities in the Metro health district of the Western Cape Province in South Africa. PARTICIPANTS: Health-care workers involved in diabetes management. INTERVENTION: Clinical audit and feedback. MAIN OUTCOME MEASURE: The Skillings-Mack test was applied to median values of pooled audit results for nine diabetic clinical processes to measure whether there were statistically significant differences between annual audits performed in 2005, 2007, 2008 and 2009. Descriptive statistics were used to illustrate the order of values per process. RESULTS: A total of 40 community health centres participated in the baseline audit of 2005 that decreased to 30 in 2009. Except for two routine processes, baseline medians for six out of nine processes were below 50%. Pooled audit results showed statistically significant improvements in seven out of nine clinical processes. CONCLUSIONS: The findings indicate an association between the application of clinical audit and quality improvement in resource-limited settings. Co-interventions introduced after the baseline audit are likely to have contributed to improved outcomes. In addition, support from the relevant government health programmes and commitment of managers and frontline staff contributed to the audit's success.

Predictors of low antiretroviral adherence at an urban South African clinic: A mixed-methods study.

Background: Low adherence to antiretroviral treatment (ART) in people living with HIV (PLHIV) remains a critical issue, especially in vulnerable populations. Although ART is responsible for greatly reducing the mortality and morbidity associated with HIV, low treatment adherence continues to impact the effectiveness of ART. Considering that a high level of adherence to ART is required for the excellent clinical outcomes with which ART is often associated, understanding the complex contextual and personal factors that limit high levels of treatment adherence remains paramount. Poor adherence remains an issue in many South African communities many years after the introduction of ART. Objectives: Our study sought to understand the specific factors and the interactions among them that contribute to non-adherence in this patient population in order to devise successful and contextually appropriate interventions to support ART adherence in PLHIV. Methods: This mixed-methods study employed a study-specific questionnaire (N = 103) and semi-structured interviews (N = 8) to investigate the factors linked to non-adherence at the Heideveld Community Day Centre in Cape Town, South Africa. Results: Over half (57.3%) of participants were ART non-adherent. Non-adherence was correlated with younger age, negative self-image and a low belief in the necessity of ART (P < 0.05). In patient interviews, alcohol use, treatment fatigue and stigmatisation emerged as contributors to suboptimal adherence. Conclusion: The results suggest that there remains a need for context-sensitive interventions to support PLHIV in South African communities. Future research needs to ensure that these targeted interventions take these factors into consideration.

Reference intervals for biochemical analytes in transgender individuals on hormone therapy.

BACKGROUND: Hormone therapy in transgender individuals may impact processes that lead to changes in biochemical analytes, and therefore reference intervals. Currently, few reference interval studies are available for the transgender population. We determined biochemical reference intervals for transgender individuals receiving hormone therapy. METHODS: Our retrospective, laboratory-based, observational study included healthy transgender males (N = 24) and transgender females (N = 84) on hormone therapy. Various biochemical reference intervals were established for each cohort and compared to their cisgender counterparts. RESULTS: We detected significant differences in reference intervals for sodium, 139-142 mmol/L vs. 136-145 mmol/L when comparing transgender males (TM) with cisgender males (CM). The following significant changes in upper reference limits (URL) for TM versus CM were detected, ALP (URL: 96 U/L vs. 128 U/L), GGT (URL: 27 U/L vs. 67 U/L) and testosterone (URL: 46.7 nmol/L vs. 29.0 nmol/L), respectively. Moreover, when comparing transgender female (TF) to cisgender female (CF), significant differences in creatinine (URL: 117 µmol/L vs. 90 µmol/L), albumin (lower reference limit: 41 g/L, vs. 35 g/L), AST (URL: 50 U/L vs. 35 U/L), ALP (URL: 118 U/L vs. 98 U/L) and oestradiol (URL: 934 pmol/L vs. 213 pmol/L) were noted, respectively. Significantly higher LDL-C was observed for TM on hormone treatment, compared to baseline (2.9 mmol/L vs. 2.2 mmol/L, p <0.01). CONCLUSIONS: Biochemical results for TM and TF receiving hormone therapy can be evaluated against our transgender-specific reference intervals for some analytes, while others can be compared to their identified gender reference intervals.

Assessment and management of shoulder pain at primary care level.

Most patients with shoulder pain will initially visit their community health centre, private general practitioner or family physician, with various levels of experience in the assessment and management of shoulder conditions. Shoulder conditions will range from early, simple ailments that can be treated in the primary care setting, to post-traumatic injuries and complex pathologies requiring the expertise of an orthopaedic surgeon or a fellowship-trained shoulder surgeon. Correct assessment of the patient's shoulder condition at the index consultation is a prerequisite for appropriate management. This article sets out straightforward guidelines to help general practitioners confidently identify the patient's source of shoulder pain and initiate an appropriate management plan at primary care level. Criteria for urgent and elective referral for specialist care are also outlined.

A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas.

INTRODUCTION: The shortage of healthcare professionals in rural communities is a global problem that poses a serious challenge to equitable healthcare delivery. Both developed and developing countries report geographically skewed distributions of healthcare professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems. This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. METHODS: A comprehensive search of the English literature was conducted using the National Library of Medicine's (PubMed) database and the keywords '(rural OR remote) AND (recruitment OR retention)' on 3 July 2008. In total, 1261 references were identified and screened; all primary studies that reported the outcome of an actual intervention and all relevant review articles were selected. Due to the paucity of prospective primary intervention studies, retrospective observational studies and questionnaire-driven surveys were included as well. The search was extended by scrutinizing the references of selected articles to identify additional studies that may have been missed. In total, 110 articles were included. RESULTS: In order to provide a comprehensive overview in a clear and user-friendly fashion, the available evidence was classified into five intervention categories: Selection, Education, Coercion, Incentives and Support - and the strength of the available evidence was rated as convincing, strong, moderate, weak or absent. The main definitions used to define 'rural and/or remote' in the articles reviewed are summarized, before the evidence in support of each of the five intervention categories is reflected in detail. CONCLUSION: We argue for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. There remains an urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to identify winning strategies for guiding future practice and policy.

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.

Routine cranial computed tomography before lumbar puncture in HIV-positive adults presenting with seizures at Mitchells Plain Hospital, Cape Town.

BACKGROUND: Current international guidelines recommend that a cranial computed tomography (CT) be performed on all HIV-positive patients presenting with new onset seizures, before a lumbar puncture (LP) is performed. In the South African setting, however, this delay could be life threatening. The present study sought to measure the number of cranial CTs that contraindicate an LP and to predict which clinical signs and symptoms are likely to pose an increased risk from LP. METHODS: The study was performed at a district level hospital in Western Cape Province. Data were collected retrospectively from October 2013 to October 2014. Associations between categorical variables were analysed using Pearson's chi-squared test. Generalised linear regression was used to estimate prevalence ratios. RESULTS: One hundred out of 132 patients were studied. Brain shift contraindicated an LP in 5% of patients. Patients with brain shift presented with decreased level of consciousness, focal signs, headache and neck stiffness. Twenty-five per cent of patients had a space-occupying lesion (SOL) (defined as a discrete lesion that has a measurable volume) or cerebral oedema. Multivariate analysis showed a CD4 count <50 (p = 0.033) to be a statistically significant predictor of patients with SOL and cerebral oedema. Univariate analysis showed focal signs (p = 0.0001), neck stiffness (p = 0.05), vomiting (p = 0.018) and a Glascow Coma Scale (GCS) < 15 (p = 0.002) to be predictors of SOL and cerebral oedema. CONCLUSION: HIV-positive patients with seizures have a high prevalence of SOL and cerebral oedema but the majority of them are safe for LP. Doctors can use clinical parameters to determine which patients can undergo immediate LP.

Auditing chronic disease care: Does it make a difference?

BACKGROUND: An integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa's Western Cape Province participated in the audit process. AIM: To determine whether clinical audits improve chronic disease care in health districts over time. SETTING: Western Cape Province, South Africa. METHODS: Internal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 ('2012 old') to districts that started auditing recently ('2012 new'). RESULTS: The number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the '2012 old' districts compared to the '2012 new' districts for both the facility audit and the folder review, including for eight clinical indicators, with '2012 new' districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21-0.31). CONCLUSION: These findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes.

Where there is no morphine: the challenge and hope of palliative care delivery in Tanzania.

BACKGROUND: In Tanzania, a country of 42 million, access to oral morphine is rare. AIM: To demonstrate the effectiveness of palliative care teams in reducing patients' pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain. SETTING: One hundred and forty-fie cancer patients were included from 13 rural hospitals spread across Tanzania. METHOD: A mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than fie years' palliative care experience and no access to strong opioids. RESULTS: Patients and their family caregivers identifid statistically signifiant (p < 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefis from palliative care but also their great distress when 'bad cases' arose who would likely benefi only from oral morphine. CONCLUSION: People living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefis even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services.

Do South African medical students of rural origin return to rural practice?

OBJECTIVES: To investigate the career choices of medical graduates of rural origin in the South African context, and to determine what proportion of rural-origin graduates are currently practising in a rural area. DESIGN: This is a retrospective descriptive study. Doctors' addresses at the time of graduation were compared with their current addresses in terms of rural/urban classification, and a questionnaire survey was done. SUBJECTS: Sample A consisted of a cohort of doctors who graduated in 1991 and 1992. Sample B consisted of the 1994-1996 graduates of two medical schools. OUTCOME MEASURES: Percentage of rural-origin graduates in rural practice. RESULTS: In sample A 14.4% were rural-origin students. When comparing addresses, it was found that 38.4% of rural-origin graduates are currently practising in rural areas, compared with 12.4% of urban-origin graduates (p < 0.001). The questionnaire data showed that 45.9% of the rural-origin respondents are in rural practice, compared with 13.3% of the urban-origin respondents (p = 0.001). In sample B, 41.61% of the rural-origin graduates are in rural practice compared with 5.08% of urban-origin graduates (p < 0.001). CONCLUSION AND RECOMMENDATIONS: The findings suggest that the South African situation is similar to that in other countries, with rural-origin medical students more likely to choose rural careers than urban-origin students. Rural-origin graduates are also more likely to choose general practice. It is recommended that the selection criteria of the medical faculties be reviewed with regard to rural origin, and that the career aspirations of applicants to medical school be taken into account in selection, particularly with regard to primary care or general practice.