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

Reduced LRRK2 in association with retromer dysfunction in post-mortem brain tissue from LRRK2 mutation carriers

Missense mutations in leucine-rich repeat kinase 2 (LRRK2) are pathogenic for familial Parkinson's disease. However, it is unknown whether levels of LRRK2 protein in the brain are altered in patients with LRRK2-associated Parkinson's disease. Because LRRK2 mutations are relatively rare, accounting for approximately 1% of all Parkinson's disease, we accessioned cases from five international brain banks to investigate levels of the LRRK2 protein, and other genetically associated Parkinson's disease proteins. Brain tissue was obtained from 17 LRRK2 mutation carriers (12 with the G2019S mutation and five with the I2020T mutation) and assayed by immunoblot. Compared to matched controls and idiopathic Parkinson's disease cases, we found levels of LRRK2 protein were reduced in the LRRK2 mutation cases. We also measured a decrease in two other proteins genetically implicated in Parkinson's disease, the core retromer component, vacuolar protein sorting associated protein 35 (VPS35), and the lysosomal hydrolase, glucocerebrosidase (GBA). Moreover, the classical retromer cargo protein, cation-independent mannose-6-phosphate receptor (MPR300, encoded by IGF2R), was also reduced in the LRRK2 mutation cohort and protein levels of the receptor were correlated to levels of LRRK2. These results provide new data on LRRK2 protein expression in brain tissue from LRRK2 mutation carriers and support a relationship between LRRK2 and retromer dysfunction in LRRK2-associated Parkinson's disease brain

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

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

Focus on vulnerable populations and promoting equity in health service utilization ––an analysis of visitor characteristics and service utilization of the Chinese community health service

Background Community health service in China is designed to provide a convenient and affordable primary health service for the city residents, and to promote health equity. Based on data from a large national study of 35 cities across China, we examined the characteristics of the patients and the utilization of community health institutions (CHIs), and assessed the role of community health service in promoting equity in health service utilization for community residents. Methods Multistage sampling method was applied to select 35 cities in China. Four CHIs were randomly chosen in every district of the 35 cities. A total of 88,482 visitors to the selected CHIs were investigated by using intercept survey method at the exit of the CHIs in 2008, 2009, 2010, and 2011. Descriptive analyses were used to analyze the main characteristics (gender, age, and income) of the CHI visitors, and the results were compared with that from the National Health Services Survey (NHSS, including CHIs and higher levels of hospitals). We also analyzed the service utilization and the satisfactions of the CHI visitors. Results The proportions of the children (2.4%) and the elderly (about 22.7%) were lower in our survey than those in NHSS (9.8% and 38.8% respectively). The proportion of the low-income group (26.4%) was apparently higher than that in NHSS (12.5%). The children group had the lowest satisfaction with the CHIs than other age groups. The satisfaction of the low-income visitors was slightly higher than that of the higher-income visitors. The utilization rate of public health services was low in CHIs. Conclusions The CHIs in China appears to fulfill the public health target of uptake by vulnerable populations, and may play an important role in promoting equity in health service utilization. However, services for children and the elderly should be strengthened

Internet-based medical education: a realist review of what works, for whom and in what circumstances

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The implementation of community-oriented primary care in the Cape Metro Health District: A programme evaluation

Background. An implementation framework for community-oriented primary care (COPC) was developed in the Cape Metro, Western Cape Province, South Africa. In 2018, four learning sites were identified to experiment with the framework. A study was undertaken to explore the implementation of this framework. Objectives. To explore the process and progress of implementation, as well as the perceptions of the barriers and enablers of implementation. Methods. A programmatic process evaluation with a descriptive exploratory qualitative study design was used. A logic model was developed, and defined inputs, outputs and the sources of evidence for the implementation process. Results. The understanding of COPC and its underlying philosophy contrasted with the traditional model of care, and the paradigm shift was challenging. Strong leadership was identified as a facilitator for change. Community and stakeholder engagement were the most challenging issues. COPC requires a wide range of skills and expertise supported by appropriate training and clear role definition. The use of electronic devices in the community was both an advantage and a barrier. Conclusion. Implementation of COPC needs to be understood as a reform of the model of care, and not as an additional project or service. The findings can guide policy, further scale-up and implementation of COPC

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