Evaluation of a project to reduce morbidity and mortality from traditional male circumcision in Umlamli, Eastern Cape, South Africa:Outcome mapping

Background: Traditional circumcision is common among the amaXhosa in Umlamli, Eastern Cape. Circumcision is associated with high morbidity and mortality. The need to reduce complications was identified as a priority by the local community. The aim was to design, implement and evaluate a project to improve the safety of traditional circumcision.Method: A safe circumcision team was established and comprised health workers, community leaders and traditional surgeons. Outcome mapping involved three stages: intentional design, outcome, and performance monitoring and evaluation. The eight boundary partners were the initiates, parents, community leaders, traditional surgeons, the District Health Services, the provincial Department of Health, the emergency services and the police. Outcomes, progress markers and strategies were designed for each boundary partner. The team kept an outcome and strategy journal and evaluated hospital admissions, genital amputations and mortality.Results: Ninety-two initiates were circumcised, with two admissions for minor complications, compared to 10 admissions, two amputations and two deaths previously. More than 70% of the outcome measures were achieved in all boundary partners, except emergency services and the Department of Health. The key aspects were: the use of outcome mapping, the participatory process, a lower age limit, closure of illegal schools,  consolidation of accredited schools, training workshops for traditional surgeons, private treatment room for initiates, assistance with medical materials, pre-circumcision examination, certificates of fitness.Conclusion: This study has shown the value of community-orientated primary care initiatives to address local health problems. Key lessons were identified and the project could easily be replicated in communities facing similar challenges

Attitudes, perceptions and understanding amongst teenagers regarding teenage pregnancy, sexuality and contraception in Taung

Background: South African teenage pregnancy rates remain high by international comparison and, in the rural town of Taung, the rate of 13% is twice the national average of 6.5%. Teenage pregnancy is a risk factor for disruption of education, future unemployment, sexually transmitted infections, HIV, preterm birth and poor mental health. The aim of this study was to understand the attitudes and perceptions of teenagers in Taung regarding teenage pregnancy and to explore their understanding of sexuality and contraception. This study intended to contribute to a deeper understanding by exploring teenagers’ own perceptions on the matter, to identify factors that, in their view, may influence the risk of pregnancy and suggest possible interventions. No previous studies from the Taung area have been identified.Methods: The qualitative study entailed 13 in-depth interviews with pregnant teenagers and three focus groups: one with 10 women aged 19 to 25 years who had a baby as a teenager, one with 14 teenage girls aged 16 to 19 years who had never been pregnant, and one with 11 males aged 18 to 23 years. Qualitative data was analysed through the framework method. Results: Factors influencing teenage pregnancy were found to be broad and complex: 1) Socioeconomic factors included poverty, the controversial influence of the child support grant, transgenerational sex and financial support from an older partner to secure income for the teenage girl or her family. 2) Substance abuse, particularly alcohol, in either the teenager or her parents was found to have a critical influence. A lack of alternative entertainment and social infrastructure made shebeens (local bars) a normal part of teenage social life. 3) Peer pressure from boyfriends and the broader social network. 4) Other factors included the right to motherhood before becoming HIV positive, poor sexual negotiation skills, the need to prove one’s fertility, sexual coercion and low self-esteem.Understanding of contraceptives and reproductive health was poor, condoms were the contraceptive method most known by teenagers and their understanding of the menstrual cycle was inaccurate. Most teenagers perceived falling pregnant as a negative event with consequences such as unemployment, loss of a boyfriend, blame from friends and family members, feeling guilty, difficulty at school, complications during pregnancy or delivery, risk of HIV, secondary infertility if an abortion is done and not being prepared for motherhood. A number of teenagers, however, perceived some benefits and saw that it could be a positive event depending on the circumstances.Conclusions: The study identified a number of factors that may influence the teenage pregnancy rate. These factors may influence teenagers’ behavioural intentions through altering their perceptions of the personal and social consequences of falling pregnant and their self-efficacy in relation to sexual behaviour. Environmental factors may also facilitate or prevent teenagers from fulfilling their intentions. Teenagers may also vary in their ability to carry out these intentions. Strategies to reduce teenage pregnancy should focus on building social capital for teenagers in communities, further exploring the influence of the child support grant, targeting transgenerational sexual norms, applying the law on underagedrinking, making information on contraception more accessible and offering programmes that empower girls in the area of sexuality. Multifaceted and intersectoral approaches are required and it is likely that strategies to reduce teenage pregnancy will also impact on HIV and other sexually transmitted infections.Keywords: teenage pregnancy; adolescence; sexuality; contraceptio

How children access antiretroviral treatment at Kgapane District Hospital, Limpopo, South Africa

Background: At Kgapane Hospital, Limpopo Province, only 20% of eligible children initiated antiretroviral treatment (ART) in 2007. The aim of this study was to improve the ART programme by assessing how children were accessing ART, and to explore the factors that facilitate or obstruct this access.Method: Mixed methods were used in a descriptive study of human immunodeficiency virus (HIV)-infected children admitted to the hospital over a seven-month period and their caregivers. Children’s subsequent attendance for ART was tracked and caregivers were interviewed about factors influencing access and attendance.Results: Of 132 children initially admitted, 14 (10.6%) subsequently died and 13 (9.8%) relocated. Sixty of the remaining 105 (57.1%) returned within one month to the antiretroviral clinic, three (2.9%) attended later and 42 (40.0%) did not return at all. Quantitative data associated with poor attendance were younger age, higher CD4 count, maternal caregiver, no income and participation in the prevention of mother-to-child transmission program. Qualitative factors included a lack of money for transport, poor social support, and mothers who struggled to accept their diagnosis, had poor understanding of HIV and strong traditional beliefs. Primary care providers delayed HIV testing and referral, displayed poor attitudes, and were insufficient in number. Quantitative factors significantly associated with good attendance were prior knowledge of the child/mother’s HIV status, mother’s ART treatment and referral to the dietician.Conclusion: There are serious deficiencies in the prevention, diagnosis and treatment of HIV in children. Factors were identified to improve health services and these highlight the need for broader strategies aimed at addressing poverty, stigma and education

Perceptions of the role of the clinical nurse practitioner in the Cape Metropolitan doctor-driven community health centres

Background: The purpose of this study was to evaluate the role of the clinical nurse practitioner (CNP) in a doctordriven primary health care setting. A descriptive study was undertaken, using both a quantitative and a qualitative methodology. The study was undertaken in community health centres (CHC) in the Cape Metropolitan area.Method: A situational analysis was conducted of all 41 CHCs in the Cape Metropolitan area. Three focus group interviews were then undertaken with CNPs, doctors and managers to determine the factors influencing the effective functioning of the CNP. Results: Five-seven percent of the 88 CNPs were totally inactive with regard to consulting patients and only 28% were utilised in a full-time capacity. The major themes to emerge were the factors that determine the effective functioning of the CNP, including self-confidence gained from regular practise, support for their role from doctors and managers, role clarity, and enrolment in the course for the appropriate reason. Conclusions: When enrolling nurses for the CNP course, preference should be given to nurses who will be able to immediately put their training into practise. The managers need to foster a strong CNP identity and ensure maximum opportunities to practise in order for nurses to attain the status of a secure CNP. The doctors need to appreciate the nurses' value in the multidisciplinary team and offer the necessary support. Furthermore, the nurses' role needs to be properly conceptualised by policy makers and contextualised at ground level for them to be effectively utilised in a doctor-driven CHC. SA Fam Pract 2004;46(10): 21-2

Medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape

Background: Cryptococcal meningitis (CM) has become the most common type of community-acquired meningitis. CM has a poor outcome if the initial in-hospital treatment does not adhere to standard guidelines. The aim of this audit was to improve the quality of the care of human immunodeficiency virus (HIV) positive patients with CM in the Cape Winelands District.Method: Following an initial audit in 2008, the researchers and a new audit team introduced interventions, and planned a second audit cycle. The folders of 25 HIV-positive adults (admitted to three district hospitals, one regional hospital, and one tuberculosis hospital) were audited.Results: Spinal manometry was performed more consistently in the regional hospital, than in the district hospitals. Reasons for failing to reach the 14-day amphotericin B target were in-patient deaths, drug stock problems, and renal impairment. The renal monitoring of amphotericin B treatment was suboptimal. The quality of care at district hospitals appeared to be comparable to that found at the regional hospital. The in-patient referral for antiretroviral treatment (ART) counselling wasbetter in the district hospital setting. However, both levels of care had difficulty in achieving the four-week target between the onset of amphotericin B and onset of ART.Conclusion: Deficiencies in the quality of care remained. Between the prior and current audit cycles, there was no consistent improvement in care at the regional hospital. An integrated care pathway document has been developed, and adopted as policy in the Cape Winelands district. Its impact on the quality of care will be evaluated by a dedicated audit team in the future

Improving the annual review of diabetic patients in primary care: an appreciative inquiry in the Cape Town District Health Services

Background: Diabetes in a common chronic disease in the Cape Town District Health Services and yet an audit of diabetic care demonstrated serious deficiencies in the quality of care. The Metro District Health Services (MDHS) decided to focus on improving the annual review of the diabetic patient. The MDHS provides primary care to the uninsured population of Cape Town through a network of 45 Community Health Centres (CHC). Methods: An appreciative inquiry was established amongst the staff responsible for diabetic care at the 15 CHCs that had newly appointed facility managers. The inquiry completed three cycles of action-reflection over a period of one year and included training in clinical skills as requested by the participants. At the end of the inquiry a consensus was reached on the learning of the group. Results: This consensus was expressed in the form of 11 key themes. CHCs that reported success with improving the annual review formed chronic care teams that met regularly to discuss their goals, roles and to plan improvements. These teams developed more structured and systematic approaches to care, which included the creation of special clubs, attention to the steps in patient flow and methods of summarising and accessing key information. These teams also appointed specific champions who would not rotate to other duties and who would provide continuity of leadership and organisation. These teams also supported continuity of relationships, clinical management and organisation of care. Teams involved the community and local non-profit organisations, particularly in the establishment of support groups that could disseminate medications and build health literacy and self-efficacy. Some teams emphasised the need to also care for the carers and to not just focus on workload and output indicators. More successful CHCs also grappled with balancing of the workload, quality of care and waiting times in a way that improved all three in an upward spiral. Patient satisfaction, staff satisfaction and clinical outcomes were seen as interlinked' There was a need to plan methods for empowering patients and build self-efficacy through a variety of facility- and community-based as well as individual- and group-orientated initiatives. Training in clinical skills was requested for foot and eye screening. Feedback was given to the MDHS on the need to improve referral pathways and access to preventative services such as dieticians, podiatrists and vascular surgery. Finally, the inquiry process itself together with the annual audit supported organisational learning and change at the facility level. Conclusion: Improving the annual review has more to do with the organisation of care than gaps in knowledge or skills that can be addressed through training. While such gaps do exist, as shown by the training around foot screening, the main focus was on issues of leadership, teamwork, systematic organisation, continuity, staff satisfaction, motivation and the balancing of quality care provided, quantity of care demanded and queuing required. The appreciative inquiry (Al) process supported decentralised organisational learning and, while key themes were shared, the specific solutions were localised

Evaluating point-of-care testing for glycosylated haemoglobin in public sector primary care facilities in the Western Cape, South Africa

Background. Diabetes mellitus contributes significantly to the burden of disease in South Africa (SA). Monitoring of glycaemic control with glycosylated haemoglobin (HbA1c) is recommended, even though current laboratory-based testing does not support immediate clinical decision-making.Objectives. To evaluate the costs and consequences for quality of care by introducing point-of-care (POC) testing for HbA1c for patients with type 2 diabetes at community health centres in Cape Town, SA.Methods. A quasi-experimental study was conducted at two control and two intervention sites in the same sub-district. The DCA Vantage Analyzer (Siemens, Germany) for POC testing was introduced at the intervention sites for 12 months. Patients were randomly selected from the diabetes register at the intervention (n=300) and control (n=300) sites, respectively, and data were collected from patient records at baseline and 12 months. Focus group interviews were performed at the intervention sites. Technical quality and cost implications were evaluated.Results. POC testing was feasible, easy to integrate into the organisation of care, resulted in more immediate feedback to patients (p<0.001) and patients appeared more satisfied. POC testing did not improve test coverage, treatment intensification, counselling or glycaemic control. There was an incremental cost of ZAR2 110 per 100 tests. Compliance with quality control was poor, although control tests showed good reliability.Conclusion. This study does not support the introduction of POC testing for HbA1c in public sector primary care practice in the current context. POC testing should be evaluated further in combination with interventions to overcome clinical inertia and strengthen primary healthcare

Improving the annual review of diabetic patients in primary care: an appreciative inquiry in the Cape Town District Health Services

Background: Diabetes in a common chronic disease in the Cape Town District Health Services and yet an audit of diabetic care demonstrated serious deficiencies in the quality of care. The Metro District Health Services (MDHS) decided to focus on improving the annual review of the diabetic patient. The MDHS provides primary care to the uninsured population of Cape Town through a network of 45 Community Health Centres (CHC). Methods: An appreciative inquiry was established amongst the staff responsible for diabetic care at the 15 CHCs that had newly appointed facility managers. The inquiry completed three cycles of action-reflection over a period of one year and included training in clinical skills as requested by the participants. At the end of the inquiry a consensus was reached on the learning of the group. Results: This consensus was expressed in the form of 11 key themes. CHCs that reported success with improving the annual review formed chronic care teams that met regularly to discuss their goals, roles and to plan improvements. These teams developed more structured and systematic approaches to care, which included the creation of special clubs, attention to the steps in patient flow and methods of summarising and accessing key information. These teams also appointed specific champions who would not rotate to other duties and who would provide continuity of leadership and organisation. These teams also supported continuity of relationships, clinical management and organisation of care. Teams involved the community and local non-profit organisations, particularly in the establishment of support groups that could disseminate medications and build health literacy and self-efficacy. Some teams emphasised the need to also care for the carers and to not just focus on workload and output indicators. More successful CHCs also grappled with balancing of the workload, quality of care and waiting times in a way that improved all three in an upward spiral. Patient satisfaction, staff satisfaction and clinical outcomes were seen as interlinked' There was a need to plan methods for empowering patients and build self-efficacy through a variety of facility- and community-based as well as individual- and group-orientated initiatives. Training in clinical skills was requested for foot and eye screening. Feedback was given to the MDHS on the need to improve referral pathways and access to preventative services such as dieticians, podiatrists and vascular surgery. Finally, the inquiry process itself together with the annual audit supported organisational learning and change at the facility level. Conclusion: Improving the annual review has more to do with the organisation of care than gaps in knowledge or skills that can be addressed through training. While such gaps do exist, as shown by the training around foot screening, the main focus was on issues of leadership, teamwork, systematic organisation, continuity, staff satisfaction, motivation and the balancing of quality care provided, quantity of care demanded and queuing required. The appreciative inquiry (Al) process supported decentralised organisational learning and, while key themes were shared, the specific solutions were localised

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