Family medicine in Tanzania: Seize the moment

In the context of addressing the pressing health needs for the global population, the World Health Organization has repeatedly called for universal health coverage (UHC) to be prioritised by its member countries. This is to be achieved through a high-quality primary health care (PHC) approach that provides comprehensive and integrated generalist care as close to where people live as well as links the clinical care to health promotion and disease prevention. In this paper, we argue for the introduction of family medicines as a critical player in the healthcare system of Tanzania to strengthen the strategies towards UHC. The paper reviews how PHC is understood, the context of family medicine in sub-Saharan Africa and makes a case for how family medicine can assist in addressing the current burden of disease in Tanzania

Support for family members who are caregivers to relatives with acquired brain injury

Objectives. Family members caring for a patient with acquired brain injury (ABI) are coping with inordinate levels of stress partially due to their lack of understanding of the neuropsychological effects of acquired brain injury in the patient. The objective of this research is to show that as the caregivers’ stress levels increase, there is an increase in suicidal ideation. This highlights the causal relationship between unhealthy stress and reduced psychological well-being in these caregivers. In addition, qualitative research evidence regarding the caregivers’ views of their main sources of stress are presented. Methods. The participants were a random sample of 80 family caregivers of patients with acquired brain injury, out of whom 72.5% (58) are primary caregivers and 27.5% (22) are secondary caregivers. A mixed methodology was utilized. It comprised cross-sectional descriptive and phenomenological approaches. Quantitative data were obtained from two standardized measures: The Stress Symptom Checklist (SSCL) and item 9 of the Beck Depression Inventory. The qualitative data were derived from self-report procedures that were part of a structured questionnaire administered individually during the interviews. Results. The Kruskal-Wallis test with a significance level of p = .05 was used to compare the stress and suicidal ideation scores, which revealed that increasing levels of stress led to increased suicidality. The analysis of the qualitative data revealed five themes which were identified as the triggers of the caregivers’ profound stress. Most caregivers felt that it was predominantly the patient’s neuropsychological deficits, such as emotions and/or moods, cognitive ability, behavior and personality, executive function, and social factors that caused them profound stress. Conclusions. Support and education are needed to help family caregivers understand the neuropsychological impact of acquired brain injury on the patient. Once caregivers have an improved understanding and receive better support from healthcare providers, they should experience less stress and be better prepared to provide the appropriate support to patients with acquired brain injury

Description of an internal medicine outreach consultant appointment in western KwaZulu-Natal, South Africa, 2007 to mid-2014

This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented ‘multifaceted’ as opposed to ‘simple’ outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes. Document type: Articl

Description of an internal medicine outreach consultant appointment in western KwaZulu-Natal, South Africa, 2007 to mid-2014

This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented ‘multifaceted’ as opposed to ‘simple’ outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes.

The value of internal medicine outreach in rural KwaZulu-Natal, South Africa

Background. Sustainable multifaceted outreach is crucial when equity between specialist services available to different sections of South Africa (SA)’s population is addressed. The healthcare disadvantage for rural compared with urban populations is exemplified in KwaZulu-Natal Province (KZN). Outreach to rural hospitals has reduced the need for patients to undergo journeys to regional or tertiary hospitals for specialist care.Objectives. Multifaceted outreach visits to seven district hospitals in western KZN by a specialist in the Pietermaritzburg Department of Internal Medicine were analysed for the period 2013 - 2014.Methods. Church of Scotland, Vryheid, Dundee, Charles Johnson Memorial, Rietvlei, Estcourt and Greytown hospitals were visited. During each visit, data were collected on data collection forms, including patient numbers, gender and age, whether out- or inpatient, whether referred, and diagnostic categories.Results. During 113 visits, of 1 377 contacts made, 631 were outpatients and 746 were inpatients. Females formed the majority overall, but for inpatients males outnumbered females. The majority of patients were aged >40 years, but over half of inpatients seen were aged <40 years. A modest 15% of patients seen were referred to hospitals with specialist services. Overall, cardiovascular disease, predominantly among outpatients, was the biggest diagnostic category. Infectious diseases followed, primarily among inpatients, and then general medicine. No other category reached 10%.Conclusion. The analysis showed differences between diagnostic categories, especially when outpatients and inpatients were separated out. Referral patterns, age-distribution and gender distinctions were made. The value of a good database was confirmed. The multifaceted outreach may have suggested useful outcomes as well as output. The vulnerability v. sustainability of outreach programmes was emphasised

Social support and health behaviour in women living with HIV in KwaZulu-Natal

The article explores the relationship between social support and health behaviour of rural and urban women who are living with HIV in South Africa. Our study was a descriptive survey of a group of pregnant and non-pregnant women living with HIV.The sample size was 262 women, 165 from urban area and 97 from rural area. Data were collected using 3 instruments, namely a demographic questionnaire, the health behaviour schedule and the Medical Outcomes Study (MOS) Social Support Survey. Significant findings indicate that in the urban area 71% of women had disclosed their HIV status to someone, while in the rural area 49% had done so.A total of 77% of the women indicated that they were sexually active – 21% had 2 partners and 20% indicated that they had at least one episode of a sexually transmitted disease since finding out their HIV status. A total of 16% said that they currently received counselling, which was significantly more frequent in the rural sample (27%) than the urban (11%).The membership of support groups is at 12% among the participating women, and social support as well as membership of a support group was higher in the rural group than the urban group. Good social support showed an association with condom use, support group attendance and taking vitamins. However, receiving counselling as well as membership of a support group showed stronger association with positive health behaviour than social support on its own.The higher social support was not associated with increased disclosure. Keywords: HIV, health behaviour, social support, rural/urban, women. Résumé Cet article va à la découverte de la relation entre le soutien social et le comportement sanitaire des femmes rurales et urbaines qui vivent avec le VIH en Afrique du Sud. Notre étude était une enquête descriptive d'un groupe de femmes enceintes et non enceintes vivant avec le VIH. L'échantillon était de 262 femmes, 165 originaires d'un milieu urbain et 97 d'un milieu rural. Les données ont été recueillies par le biais de trois utiles, notamment un questionnaire démographique, un barème du comportement sanitaire et l'Enquête du Soutien Social de l'Étude Médicale de Résultats. Les résultats significatifs de recherche démontrent que dans le milieu urbain 71% de femmes avaient révélé leur statut séropositif à quelqu'un alors que seulement 49% du milieu rural l'ont fait. 77% de femmes ont signalé qu'elles avaient des rapports sexuels – 21% avaient deux partenaires et 20% ont signalé qu'elles ont eu au moins une épisode de maladies sexuellement transmises depuis qu'elles ont découvert leur statut séropositif. 16% de ces femmes ont dit qu'elles sont actuellement en consultation psychologique. Les consultations se sont passées plus fréquemment auprès de l'échantillon rural (27%) par rapport à l'échantillon urbain (11%). 12% de femmes participantes fait partie des groupes de soutien. Le soutien social ainsi qu'appartenir à un groupe de soutien étaient plus importants dans le groupe rural que dans le groupe urbain. Un bon soutien social a démontré un lien avec l'utilisation de préservatifs, l'assister au groupe de soutien et la prise des vitamines. Cependant, être en consultation psychologique et appartenir à un groupe de soutien ont démontré une association forte à un comportement sanitaire positif beaucoup plus que le soutien social en tant que tel. Le soutien social plus élevé n'a pas été associé aux révélations augmentées. Mots clés:VIH, comportement sanitaire, soutien social, rural/urbain, femmes

Improving access to antiretrovirals in rural South Africa – a call to action

South Africa already has the world’s biggest antiretroviral (ARV) programme. With the introduction of extended criteria for initiating ARVs, the National Department of Health wishes to increase the number of people on ARVs by around two million over the next 2 years. Adoption of a chronic disease management model, with extended task shifting, decentralisation and new approaches to distribution of ARVs, must be embraced if this is to be successfully achieved without huge increases in resources. In this editorial we discuss the need for change, and the current substantial blocks to progress (principally in prescribing and dispensing legislation) that contradict national treatment guidance and should be addressed as a matter of urgency. In addition, we draw attention to threatened regulatory changes that may further worsen the situation.

Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries

Purpose: African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities. Method: Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences. Results: The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students. Conclusions: Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments

Revisiting the doctor’s role at the primary healthcare clinic

With the growing evidence regarding the benefit of a primary healthcare (PHC) approach to both individual patients and for a healthier community, a number of policy initiatives in South Africa are aimed at strengthening services at subdistrict level. Historically, the role of the doctor in many PHC clinics in South Africa had been limited to a clinical role. However, in the context of wanting to have a greater impact on social determinants of health, the role of the doctor at the PHC clinic needs to be revisited. A wider role of the doctor, in the context of an expanded multidisciplinary team is being explored