An assessment of asthmatic patients at four Western Cape community pharmacies

Objectives. To identify the profile of asthmatic patients visiting community pharmacies and to assess the appropriateness of their current asthma therapy.Design. Patients were identified as either chronic, newly diagnosed or undiagnosed. Asthma status was assessed from their current symptom and medication profiles and from performance in an airways responsiveness test. Reversibility of > 15% was suggestive of probable airflow obstruction and such patients were referred to a medical practitioner.Setting. Four community pharmacies located in different socio-economic areas, viz. Khayelitsha, Wynberg, Mitchell's Plain and Vrijzee, were selected.Subjects. Participants over the age of 6 years, who suffered from recurrent cough, wheeze, chest tightness and/or breathlessness and used over-the-counter (OTC) and/or asthma medications, completed a questionnaire and participated in the airways responsiveness test. Outcome measures. Effective control of asthma based on minimal symptoms, appropriate use of bronchodilator and anti-inflammatory therapies and absence of airflow obstruction.Results. Of the 220 participants, 120 were identified as chronic, 7 as newly diagnosed and 93 as undiagnosed. Chronic asthmatics suffered daily symptoms and used inadequate prophylactic anti-inflammatory therapy. Many undiagnosed asthmatics were unaware of their symptoms and took OTC medication indiscriminately. Based on peak expiratory flow rate measurements, > 50% of the screened patients displayed a reversibility of > 15%.Conclusions. Chronic and many undiagnosed asthmatic patients frequent community pharmacies for their medication. Such patients suffer recurrent asthma symptoms and use medication inappropriately, which results in suboptimal lung function. Pharmacists should play a more participatory role in the detection andmanagement of asthma in the community

The dissemination and implementation of national asthma guidelines in south africa: the use of outcome mapping

Asthma is an important chronic inflammatory disorder with significant morbidity and mortality in South Africa. The development of national asthma guidelines by the South African Thoracic Society and National Asthma Education Programme has been one approach to try and improve the quality of care. The impact of previous guidelines has been limited and therefore it is hoped that the newly revised 2007 guidelines will have a more effective approach to dissemination, implementation and evaluation. Outcome mapping (OM) is one approach to integrated planning, monitoring and evaluation of projects that intend to contribute to change in complex systems. It has a structured, systematic and logical approach that focuses on changes in behaviour, actions or relationships in the people or organizations that the project is working with. OM has three stages - intentional design, outcome/performance monitoring and evaluation - which are described in this article and illustrated with reference to the Asthma Guideline Implementation Project (AGIP). In the intentional design stage the AGIP created a vision and mission statement to guide the project and then identified seven boundary partners. For each boundary partner the AGIP defined the project's outcome challenge and a series of progress markers to monitor achievement of the outcome. Following this the AGIP conceptualized the strategies and organizational practices that will be engaged with to realize the outcomes. In the monitoring stage the AGIP will regularly document and reflect on the progress markers, strategies and organizational practices using pre-determined structured journals. In the evaluation stage there is the opportunity to plan the evaluation of key aspects of the project in more depth. In the AGIP project the team engaged with the development of a doctoral research project to evaluate the process of implementation in private and public primary care settings in the Cape Town metropole. This article describes the methodology of Outcome Mapping and illustrates this in relation to the Asthma Guidelines Implementation Project. The methodology has the potential to be applied in many other development projects and is also congruent with action research. It is hoped that the readers will find this approach useful in their own settings

Building capacity for antiretroviral delivery in South Africa: A qualitative evaluation of the PALSA PLUS nurse training programme

BACKGROUND: South Africa recently launched a national antiretroviral treatment programme. This has created an urgent need for nurse-training in antiretroviral treatment (ART) delivery. The PALSA PLUS programme provides guidelines and training for primary health care (PHC) nurses in the management of adult lung diseases and HIV/AIDS, including ART. A process evaluation was undertaken to document the training, explore perceptions regarding the value of the training, and compare the PALSA PLUS training approach (used at intervention sites) with the provincial training model. The evaluation was conducted alongside a randomized controlled trial measuring the effects of the PALSA PLUS nurse-training (Trial reference number ISRCTN24820584). METHODS: Qualitative methods were utilized, including participant observation of training sessions, focus group discussions and interviews. Data were analyzed thematically. RESULTS: Nurse uptake of PALSA PLUS training, with regard not only to ART specific components but also lung health, was high. The ongoing on-site training of all PHC nurses, as opposed to the once-off centralized training provided for ART nurses only at non-intervention clinics, enhanced nurses' experience of support for their work by allowing, not only for ongoing experiential learning, supervision and emotional support, but also for the ongoing managerial review of all those infrastructural and system-level changes required to facilitate health provider behaviour change and guideline implementation. The training of all PHC nurses in PALSA PLUS guideline use, as opposed to ART nurses only, was also perceived to better facilitate the integration of AIDS care within the clinic context. CONCLUSION: PALSA PLUS training successfully engaged all PHC nurses in a comprehensive approach to a range of illnesses affecting both HIV positive and negative patients. PHC nurse-training for integrated systems-based interventions should be prioritized on the ART funding agenda. Training for individual provider behaviour change is nonetheless only one aspect of the ongoing system-wide interventions required to effect lasting improvements in patient care in the context of an over-burdened and under-resourced PHC system

Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Childhood asthma is common in Cape Town, a province of South Africa, but is underdiagnosed by general practitioners. Medications are often prescribed inappropriately, and care is episodic. The objective of this study is to assess the impact of educational outreach to general practitioners on asthma symptoms of children in their practice.</p> <p>Methods</p> <p>This is a cluster randomised trial with general practices as the unit of intervention, randomisation, and analysis. The setting is Mitchells Plain (population 300,000), a dormitory town near Cape Town. Solo general practitioners, without nurse support, operate from storefront practices. Caregiver-reported symptom data were collected for 318 eligible children (2 to 17 years) with moderate to severe asthma, who were attending general practitioners in Mitchells Plain. One year post-intervention follow-up data were collected for 271 (85%) of these children in all 43 practices.</p> <p>Practices randomised to intervention (21) received two 30-minute educational outreach visits by a trained pharmacist who left materials describing key interventions to improve asthma care. Intervention and control practices received the national childhood asthma guideline. Asthma severity was measured in a parent-completed survey administered through schools using a symptom frequency and severity scale. We compared intervention and control group children on the change in score from pre-to one-year post-intervention.</p> <p>Results</p> <p>Symptom scores declined an additional 0.84 points in the intervention vs. control group (on a nine-point scale. p = 0.03). For every 12 children with asthma exposed to a doctor allocated to the intervention, one extra child will have substantially reduced symptoms.</p> <p>Conclusion</p> <p>Educational outreach was accepted by general practitioners and was effective. It could be applied to other health care quality problems in this setting.</p

Effectiveness of a training-of-trainers model in a HIV counseling and testing program in the Caribbean Region

<p>Abstract</p> <p>Objectives</p> <p>To evaluate the effectiveness and sustainability of a voluntary counseling and testing (VCT) training program based on a training-of-trainers (TOT) model in the Caribbean Region, we gathered data on the percentage of participants trained as VCT providers who were providing VCT services, and those trained as VCT trainers who were conducting VCT training.</p> <p>Methods</p> <p>The VCT training program trained 3,489 providers in VCT clinical skills and 167 in VCT training skills within a defined timeframe. An information-monitoring system tracked HIV trainings conducted, along with information about course participants and trainers. Drawing from this database, a telephone survey followed up on program-trained VCT providers; an external evaluation analyzed data on VCT trainers.</p> <p>Results</p> <p>Almost 65% of trained VCT providers could be confirmed as currently providing VCT services. This percentage did not decrease significantly with time. Of the VCT trainers, 80% became certified as trainers by teaching at least one course; of these, 66% taught more than one course.</p> <p>Conclusion</p> <p>A TOT-based training program is an effective and sustainable method for rapid scale-up of VCT services and training capacity in a large-scale VCT program.</p

Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Background: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. Methods: Developing the intervention: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. Results: Components of the intervention: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. Discussion: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout

Re-engineering of South Africa’s primary health care system: where is the pharmacist?

South Africa’s transition towards a district-based health system (DHS) aims to offer health promotion and prevention services at community level, through re-engineered primary health care (PHC) services. Along with pharmacy workforce shortages and service delivery challenges, health reform is a clarion call to strategically re-position the pharmacist’s role in DHS strengthening. The pharmacist’s involvement in the three DHS streams, namely the clinical specialist support teams, school health services and municipal ward-based PHC outreach teams, is pertinent. This paper contextualises pharmacists’ current peripheral role in the health system, discusses a team-based approach and identifies opportunities to integrate pharmacy students into the re-vitalised PHC framework. Re-positioning of pharmacists within district clinical specialist support and school health teams could create opportunities for community-based and population-based services whereby a range of clinical and pharmaceutical services could materialise. Pharmacy training institutions could strengthen the DHS through established partnerships with the community and health services. Academic service learning programmes could integrate pharmacy students as part of the PHC outreach teams to promote community health. Interdependence between the health services, pharmacy schools and the community would create a platform to contextualise learning and dismantle existing silos between them. Multi-sectoral engagement could enable pharmacy schools to design strategies to optimise pharmaceutical service delivery and align their activities towards social accountability.DHE

The dissemination and implementation of national asthma guidelines in South Africa: The use of outcome mapping

Asthma is an important chronic inflammatory disorder with significant morbidity and mortality in South Africa. The development of national asthma guidelines by the South African Thoracic Society and National Asthma Education Programme has been one approach to try and improve the quality of care. The impact of previous guidelines has been limited and therefore it is hoped that the newly revised 2007 guidelines will have a more effective approach to dissemination, implementation and evaluation. Outcome mapping (OM) is one approach to integrated planning, monitoring and evaluation of projects that intend to contribute to change in complex systems. It has a structured, systematic and logical approach that focuses on changes in behaviour, actions or relationships in the people or organizations that the project is working with. OM has three stages - intentional design, outcome/performance monitoring and evaluation - which are described in this article and illustrated with reference to the Asthma Guideline Implementation Project (AGIP). In the intentional design stage the AGIP created a vision and mission statement to guide the project and then identified seven boundary partners. For each boundary partner the AGIP defined the project's outcome challenge and a series of progress markers to monitor achievement of the outcome. Following this the AGIP conceptualized the strategies and organizational practices that will be engaged with to realize the outcomes. In the monitoring stage the AGIP will regularly document and reflect on the progress markers, strategies and organizational practices using pre-determined structured journals. In the evaluation stage there is the opportunity to plan the evaluation of key aspects of the project in more depth. In the AGIP project the team engaged with the development of a doctoral research project to evaluate the process of implementation in private and public primary care settings in the Cape Town metropole. This article describes the methodology of Outcome Mapping and illustrates this in relation to the Asthma Guidelines Implementation Project. The methodology has the potential to be applied in many other development projects and is also congruent with action research. It is hoped that the readers will find this approach useful in their own settings. South African Family Practice Vol. 49 (5) 2007: pp. 5-