Infrastructural inequality and household COVID-19 vulnerability in a South African urban settlement

COVID-19 has highlighted the importance of household infrastructure in containing the spread of SARS-CoV-2, with Global South urban settlements particularly vulnerable. Targeted interventions have used area or dwelling type as proxies for infrastructural vulnerability, potentially missing vulnerable households. We use infrastructural determinants of COVID-19 (crowding, water source, toilet facilities, and indoor pollution) to create an Infrastructural Vulnerability Index using cross-sectional household data (2018–2019) from Mamelodi, a low-income urban settlement in South Africa. Households were stratified into vulnerability groups by index results; sociodemographic variables were assessed as predictors of index scores; and inequality analysis and decomposition were conducted. Thirty-three percent of households fell in the lowest risk group, 32% in the second, 21% in the third, and 14% in the highest. Dwelling type and geographical ward were associated with changes in index scores, with a shack (adjusted β (aβ) = 3.45, CI = 3.39–3.51) associated with highest increase compared to a house. Wards in more developed areas were not consistently associated with lower index scores in the final regression model. The infrastructural vulnerability of the top 10% of households was greater than the bottom 40%, and inequality was predominantly within (80%) rather than between (20%) wards, and more between (60%) than within (40%) dwelling types. Our results show a minority of households account for the majority of infrastructural vulnerability, with its distribution only partially explained by area and dwelling type. Efforts to contain COVID-19 can be improved by using local-level data, and a vulnerability index, to target infrastructural support to households in greatest need.https://link.springer.com/journal/11524hj2023Family Medicin

Circumcision weeks : making circumcision part of routine training and service delivery at district-level hospitals in South Africa

BACKGROUND : Medically safe, elective male circumcision supports traditional and cultural rites of passage by reducing the risk of adverse events and death among men undergoing initiation. It is a way of preventing penile conditions that arise from being uncircumcised. It also protects against various sexually transmitted infections, playing a particularly important role in human immunodeficiency virus (HIV) prevention, as it protects against HIV infection in men by up to 60%. It also helps reduce herpes simplex virus type 2, a key biological co-factor thought to account for some human susceptibility to HIV infection and human papillomavirus. To address these needs and to meet the World Health Organization’s call to upscale male circumcision to 80% in HIV/AIDS epidemic-gripped sub-Saharan Africa, there is a need to provide male circumcision as standard care in district health. METHOD : A retrospective review of three years of circumcision services, using the sleeve method, and not the high-volume, forceps-guided method, and training at a Level 1 district hospital in South Africa. RESULTS : Two hundred and twenty-one medical circumcisions were performed, increasing significantly in each successive year. Mostly, they were carried out under local anaesthetic, and there were only four complications, all of which were successfully resolved. The average age of the patients was 20, and generally, they elected to have medical circumcision carried out for cultural reasons. Some 60 students and clinicians were trained in safe medical male circumcision. CONCLUSION : To meet the growing demand for male medical circumcision, especially among teenagers and young adult men at district-level hospitals, there is a need to significantly expand the surgical competency of clinicians in this field. “Circumcision weeks” are one way of routinely upscaling surgical skill levels, while simultaneously responding to increased patient demand for safe medical circumcision.http://www.safpj.co.z

Peer-learning reviews to improve Gauteng community-oriented primary care : findings from AitaHealth™-enabled ward-based outreach teams

BACKGROUND : In 2016 the Gauteng Department of Health engaged University of Pretoria Family Medicine to provide` education, training and information and communication technology support for the phased scale-up of ward-based outreach teams (WBOTs) through community-oriented primary care (ICT-enabled COPC). As in all service delivery, quality assurance is essential. In contemporary best practice, it brings together peer-to-peer learning and quality improvement (QI) in what is termed here as peer-learning reviews (PLRs). AIM : To assess implementation fidelity and assure the quality of community-based healthcare services. SETTING : This study was conducted in two districts of Gauteng province, South Africa. METHODS : A 3-day PLR of paired WBOTs was conducted by multi-disciplinary teams of academics, partners and site-selected healthcare practitioners. Guided by a benchmark survey distilled from the seven COPC practice elements, they conducted individual interviews, accompanied WBOT members in field and facilitated solution-focused peer exchange workshops with all participants. RESULTS : At all sites there was clear evidence of achievements and practical challenges with respect to mapping; support, networks and partnerships; infrastructure and functional equipment; work integrated learning; data and service activities; and performance status and management. Methodologically, PLRs supported inclusive, context-specific learning for all along the healthcare service pathway. They generated action plans derived from shared understanding and joint decision-making. CONCLUSION : The PLRs and the implementation results demonstrate the importance of structuring learning into service and research. Both helped develop participants’ abilities to understand what they do, do their work, grow their sense of self-worth and improve their relationship with others.http://www.phcfm.orgam2020Family Medicin

Retard de détection du cancer du sein : les données des hôpitaux devraient informer une prise en charge primaire proactive

BACKGROUND: Breast (and cervical) cancer affects a growing proportion of women in South Africa. Although treatable, where health literacy is low, women typically seek medical attention only when their condition is at an advanced stage and difficult to contain. OBJECTIVES: To understand the sociodemographic characteristics of women who present with advanced breast cancer in order to intervene proactively in primary care. METHOD: A retrospective analysis of women with advanced breast cancer (Stage IIb and higher) at a Level 2 regional hospital in South Africa (2007–2010). RESULTS: The average age amongst the 103 women enrolled in this study was 59. One-third of the women had secondary education, 35% were unemployed and two-thirds were not married. Nearly 11% (n = 11) of the women had previously had cancer. Lumps (n = 87) were the most common reason for seeking healthcare and were, together with axillary lymph node abnormalities (84.5% and 19.4% respectively), the most common clinical symptoms. Symptoms were noticed by 52% (n = 54) of the women more than six months prior to their first consultation. A personal history of cancer increased threefold the odds of presenting within three months. Middle-aged women were twice as likely as those 65 to report within three to six months. Secondary education increased the odds of presenting within three to six months by 56%. Employment and marital status were not significant. CONCLUSION: The women most at risk for delayed detection and treatment were those without a history of breast cancer, aged 65, with low education. They can best be reached through low-cost community-orientated primary care that proactively provides health education and promotes self- and clinical examination at the individual, family, clinic and general practitioner level.CONTEXTE: Le cancer du sein (et du col de l’utérus) affecte une proportion croissante de femmes en Afrique du Sud. Bien que soignable, lorsque les informations sanitaires sont insuffisantes, les femmes ne consultent généralement que lorque leur état est à un stade avancé et difficile à contenir. OBJECTIFS: Comprendre les caractéristiques sociodémographiques des femmes qui présentent un cancer du sein avancé afin d’intervenir de manière proactive dans la prise en charge primaire. METHODES: Analyse rétrospective des femmes souffrant d’un cancer du sein avancé (Stade IIb et plus) dans un hôpital régional de niveau 2 en Afrique du Sud (2007–2010). RESULTATS: L’âge moyen des 103 femmes inscrites à cette étude était de 59 ans. Un tiers des femmes avaient suivi l’enseignement secondaire, 35% étaient sans emploi et les deux tiers n’étaient pas mariées. Près de 11% (n = 11) des femmes avaient déjà eu un cancer. Des grosseurs (n = 87) constituaient la raison les plus courante de recherche de soins de santé et étaient, avec les anomalies de ganglions lymphatiques axillaires (84,5% et 19,4% respectivement), les symptômes cliniques les plus courants. Les symptômes ont été remarqués par 52% (n = 54) des femmes, plus de six mois avant leur première consultation. Des antécédents personnels de cancer mutlipliaient par trois les chances de se présenter dans les trois mois. Les femmes d’âge moyen avaient deux fois plus de chances que celles de 65 ans de se présenter dans les trois à six mois. L’éducation secondaire augmentait de 56% les chances de se présenter dans les trois à six mois. Les situations professionnelle et conjugale n’étaient pas significatives. CONCLUSION: Les femmes courant le plus de risque d’une détection et d’un traitement retardés étaient celles sans antécédents de cancer du sein, dont l’âge était 65 ans, et ayant peu d’éducation. Elles peuvent être atteintes par le biais d’une prise en charge primaire à faible coût et orientée sur la communauté, qui fournit de manière proactive une éducation en santé et encourage l’auto-examen et l’examen clinique au niveau individuel, familial, clinique et du généraliste.http://www.phcfm.orgam2013ay201

The impact of substance use disorders on families and carers : a scoping review

Substance Use Disorder (SUD) is a persistent and global public health and social problem. This scoping review explores and describes the impact that Substance Use Disorders (SUDs) have on families and carers. It draws on 36 research articles published between January 2007 and August 2021. The review findings are presented according to three themes, namely (1) the impact of SUDs on families/ carers, (2) the burden on carers, and (3) coping responses to living with a person with SUD. The evidence indicates that SUDs in a family affects almost all domains of family members' and carers' lives, suggesting the need to develop targeted harm reduction interventions that could reduce vulnerability and help restore the bio-psychosocial well-being of family members and carers.http://www.crisaafrica.org/ajdashj2023Family MedicineSocial Work and Criminolog

Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa

Globally, models of extending universal health coverage through primary care are influenced by country-specific systems of health care and disease management. In 2015 a rapid assessment of the ward-based outreach component of primary care reengineering was commissioned to understand implementation and rollout challenges. AIM : This article aims to describe middle- and lower-level managers’ understanding of ward-based outreach teams (WBOTs) and the problems of authority, jurisdiction and practical functioning that arise from the way the model is constructed and has been operationalised. SETTING : Data are drawn from a rapid assessment of National Health Insurance (NHI) pilot sites in seven provinces. METHODS : The study used a modified version of CASCADE. Peer-review teams of public health researchers and district/sub-district managers collected data in two sites per province between March and July 2015. RESULTS : Respondents unequivocally support the strategy to extend primary health care services to people in their homes and communities both because it is responsive to the family context of individual health and because it reaches marginal people. They, however, identify critical issues that arise from basing WBOTs in facilities, including unspecific team leadership, inadequate supervision, poorly constituted teams, limited community reach and serious infrastructural and material under-provision. CONCLUSION : Many of the shortcomings of a facility-based extension model can be addressed by an independently resourced, geographic, community-based model of fully constituted teams that are clinically and organisationally supported in an integrated district health system. However, a community-oriented primary care approach will still have to grapple with overarching framework problems.http://www.phcfm.orgam2017Family Medicin

How to measure person-centred practice – an analysis of reviews of the literature

BACKGROUND: Facilitation and collaboration differentiates person-centred practice (PcP) from biomedical practice. In PcP, a person-centred consultation requires clinicians to juggle three processes: facilitation, clinical reasoning and collaboration. How best to measure PcP in these processes remains a challenge. AIM: To assess the measurement of facilitation and collaboration in selected reviews of PcP instruments. METHODS: Ovid Medline and Google Scholar were searched for review articles evaluating measurement instruments of patient-centredness or person-centredness in the medical consultation. RESULTS: Six of the nine review articles were selected for analysis. Those articles considered the psychometric properties and rigour of evaluation of reviewed instruments. Mostly, the articles did not find instruments with good evidence of reliability and validity. Evaluations in South Africa rendered poor psychometric properties. Tools were often not transferable to other sociocultural-linguistic contexts, both with and without adaptation. CONCLUSION: The multiplicity of measurement tools is a product of many dimensions of personcentredness, which can be approached from many perspectives and in many service scenarios inside and outside the medical consultation. Extensive research into the myriad instruments found no single valid and reliable measurement tool that can be recommended for general use. The best hope for developing one is to focus on a specific scenario, conduct a systematic literature review, combine the best items from existing tools, involve multiple disciplines and test the tool in real-life situations.http://www.phcfm.orgpm2020Family Medicin

A capability approach analysis of student perspectives of a medical consultation quality-improvement process

BACKGROUND. Research shows that person-centredness declines during medical education. This study examines the underlying assumptions and effects of clinical associate training interventions on person-centred practice. OBJECTIVES. To understand student experiences of a medical consultation quality-improvement (QI) process in terms of a capability approach to learning and the effects of this process on their person-centredness. METHODS. In a randomised controlled trial students from 8 clinical learning centres (CLCs) participated in a qualitative, medical consultation QI process. Qualitative data (focus group discussions and reflective reports) were analysed using a capability approach to the learning framework. RESULTS. Learning was triggered by disruptions to students’ abilities, knowledge, identity and relationships. Through facilitated review-read-reflectre/ action scaffolded by feedback and practical assessment tools they learnt new person-centred consultation skills. The QI process functioned as a learning cycle in which students reviewed disruptions, identified areas for improvement and developed improvement plans. Through it, awareness of themselves developed more deeply, their relationships with peers and patients grew and they improved their knowledge and consultation skills. CONCLUSIONS. Students demonstrated learning through their understanding of the skills and competencies required for person-centred practice. The study found students to be at different points along the directed/self-directed learning continuum, with most of them developing abilities to learn independently, work in groups, give and receive feedback and apply learning across different contexts. Facilitation is particularly important, given the uneven development of the ‘dimensions of a person’ at an individual level. Lastly, the capability approach is useful as an analytical framework and as a way of ‘doing learning’.The research for this study was done in partial fulfilment of the requirements for JML’s PhD (Family medicine) degree at the University of Pretoria. (http://hdl.handle.net/2263/72533)http://www.ajhpe.org.zaFamily Medicin

Diagnostic performance of stress myocardial perfusion imaging for coronary artery disease: a systematic review and meta-analysis

Objectives: To determine and compare the diagnostic performance of stress myocardial perfusion imaging (MPI) for the diagnosis of obstructive coronary artery disease (CAD), using conventional coronary angiography (CCA) as the reference standard. Methods: We searched Medline and Embase for literature that evaluated stress MPI for the diagnosis of obstructive CAD using magnetic resonance imaging (MRI), contrast-enhanced echocardiography (ECHO), single-photon emission computed tomography (SPECT) and positron emission tomography (PET). Results: All pooled analyses were based on random effects models. Articles on MRI yielded a total of 2,970 patients from 28 studies, articles on ECHO yielded a sample size of 795 from 10 studies, articles on SPECT yielded 1,323 from 13 studies. For CAD defined as either at least 50 %, at least 70 % or at least 75 % lumen diameter reduction on CCA, the natural logarithms of the diagnostic odds ratio (lnDOR) for MRI (3.63; 95 % CI 3.26–4.00) was significantly higher compared to that of SPECT (2.76; 95 % CI 2.28–3.25; P = 0.006) and that of ECHO (2.83; 95 % CI 2.29–3.37; P = 0.02). There was no significant difference between the lnDOR of SPECT and ECHO (P = 0.52). Conclusion: Our results suggest that MRI is superior for the diagnosis of obstructive CAD compared with ECHO and SPECT. ECHO and SPECT demonstrated similar diagnostic performance

Scaling community-based services in Gauteng, South Africa : a comparison of three workforce-planning scenarios

BACKGROUND : The introduction of community-based services through community health workers is an opportunity to redefine the approach and practice of primary health care. Based on bestpractice community oriented primary care (COPC), a COPC planning toolkit has been developed to model the creation of a community-based tier in an integrated district health system. AIM : The article describes the methodologies and assumptions used to determine workforce numbers and service costs for three scenarios and applies them to the poorest 60% of the population in Gauteng, South Africa. SETTING : The study derives from a Gauteng Department of Health, Family Medicine (University of Pretoria) partnership to support information and communication technology (ICT)-enabled COPC through community-based health teams (termed as ward-based outreach teams). METHODS : The modelling uses national census age, gender and income data at small area level, provincial facility and national burden of disease data. Service calculations take into account multidimensional poverty, demand-adjusted burden of disease and available work time adjusted for conditions of employment and geography. RESULTS : Assuming the use of ICT for each, a health workforce of 14 819, 17 925 and 7303 is required per scenario (current practice, national norms and full-time employed COPC), respectively. Total service costs for the respective scenarios range from R1.1 billion, through R947 million to R783 million. CONCLUSION : Modelling shows that delivering ICT-enabled COPC with full-time employees is the optimal scenario. It requires the smallest workforce, is the most economical, even when individual community health worker costs of employment are twice those of current practice, and is systemically the most effective.Rod Bennett and Geoff Abbott received payments for their work from the World Health Organization and the University of Pretoria (UP).http://www.phcfm.orgam2019Family Medicin