Evaluating the performance of South African primary care: a cross-sectional descriptive survey

Knowledge, attitudes and practices on diabetic foot care among nurses in Kimberley, South Africa

BACKGROUND

 Diabetic foot is a dangerous complication of diabetes and can lead to high morbidity and mortality. As essential team members of the healthcare system, nurses play an important role in diabetic foot management and are indispensable in patients' education to prevent diabetic foot. The study assessed nurses' knowledge, attitudes and practices regarding diabetic foot care in Sol Plaatje primary health care centres in the Northern Cape: Sol Plaatje's 14 district municipality clinics, Kimberley, Northern Cape.

METHODS

 This was a descriptive cross-sectional analytical study. A questionnaire assessed nurses' knowledge, practices and attitudes towards diabetic foot care in the above setting.

RESULTS

 A total of 128 professionals, enrolled and auxiliary nurses who are providing primary care to patients within the 14 clinics in the Sol-Plaatje sub-district were recruited for the study. Hundred and five participants completed the self-administered questionnaires. The majority (95%) were females and 58.1% knew that South African Diabetic Foot Guidelines existed, while 57.7% had read them. About 57% did not know about the 60-s diabetic foot screening tool, and 67% did not know the 10 g monofilament test. Approximately 29.8% had never attended a class on diabetic foot care and 85.6% required training on diabetic foot care.

CONCLUSION

 This study revealed that the majority of nurses working in the Sol-Plaatje sub-district primary health care centres are knowledgeable of the diabetic foot guidelines for primary care. However, there is a need for ongoing education on diabetic foot care.Contribution: The study results will help improve nurses' awareness of the importance of diabetic foot care.

High Prevalence and Burden of Physical and Psychological Symptoms in a Chronic Obstructive Pulmonary Disease Population in Primary Care Settings in South Africa

Background

Many deaths globally are attributable to non-communicable disease, and four-fifths of these deaths are in low- and middle-income countries. Globally, COPD is currently the third leading cause of mortality.

Research Question

1) To determine the prevalence and burden of symptoms and concerns, and 2) determine predicting factors of symptom burden among patients with COPD.

Methods

A cross-sectional survey was conducted at eight primary care sites in Western Cape. We collected socio-demographic data (age, gender, smoking status, number of missed doses of prescribed medication in the last seven days) and clinical data (PEF and KPS). The Memorial Symptom Assessment Scale (MSAS), the Medical Outcomes Study, Social Support Survey (MOS-SSS), the London Chest Activity of Daily Living Scale (LCADLS) and the COPD Assessment Test (CAT) (impairment on person's life) were administered to patients. We conducted ordered logistic regression analysis to assess factors associated with the burden of symptoms. MSAS subscales: 1) Global symptom distress index, 2) physical symptom distress and 3) psychological symptom distress were dependent outcomes. We constructed three ordinal logistic regression models for each of the three subscales. Covariates were MOS-SSS, LCADLS, CAT, demographic and clinical variables.

Results

We recruited n=387 patients, mean age 59.5 years, 53.0% female. In multivariate analysis, each of the three models (ie, global, psychological and physical symptom distress) was positively associated with impairment on person's life p<0.001, difficulty to perform activities of daily living p<0.001, and low social support p<0.001. Old age was associated with lower global symptom distress (p=0.004), psychological and (0.014) physical distress (0.005). Missing 1 or more doses of medication was associated with higher levels of global (0.004) and physical (0.005) symptom distress.

Interpretation

The high prevalence and burden of physical and psychological symptoms provides strong evidence of the need for integrating person-centred assessment and management of symptoms in primary care settings.

Adaptation and validation of the Ugandan Primary Care Assessment Tool

BACKGROUND

Health systems based on primary health care (PHC) have better outcomes at lower cost. Such health systems need regular performance assessment for quality improvement and maintenance. In many low- and middle-income countries (LMICs), there are no electronic databases for routine monitoring. There is an urgent need for valid and reliable tools to measure PHC performance.

AIM

This study aimed to adapt and validate the Primary Care Assessment Tool (PCAT) in the Ugandan context.

SETTING

The experts that participated in the Delphi process were recruited from almost all over the country.

METHODS

The study utilised a Delphi process with a panel of 20 experts (14 district health officers, 4 academics in primary care and 2 ministry of health [MOH] technical staff) who responded to iterative rounds of questionnaires in order to reach consensus (defined as 70% agreement).

RESULTS

Consensus was reached after two rounds of the Delphi. In round one, four items in the comprehensiveness domain (services available) were removed and five items needed rephrasing. A new domain on person-centredness with 13 items was suggested. In round two, the new domain with each and every single one of its items and the items for rephrasing all achieved consensus. The final Ugandan version of the PCAT (UG-PCAT) has 12 domains and 91 items.

CONCLUSION

The South African Primary Care Assessment Tool (ZA PCAT) was adapted and validated with an additional domain on person-centredness to measure primary care performance in the Ugandan context, and can now be used to measure the quality of core functions of primary care in Uganda.Contribution: The PCAT could fulfil the need for such a tool in a wider LMIC context. The UG-PCAT will be used to measure the quality of these core functions in Uganda and to assist with the improvement of PHC.

The quality of primary care performance in private sector facilities in Nairobi, Kenya: a cross-sectional descriptive survey

Background

Integrated health services with an emphasis on primary care are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality primary care are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is paucity of information on the performance of these key elements and such information is needed to improve service delivery. Therefore, the study aimed to evaluate the quality of primary care performance in private sector facilities in Nairobi, Kenya.

Methods

A cross-sectional descriptive study using an adapted Primary Care Assessment Tool for the Kenyan context and surveyed 412 systematically sampled primary care users, from 13 PC clinics. Data were analysed to measure 11 domains of primary care performance and two aggregated primary care scores using the Statistical Package for Social Sciences.

Results

Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying an overall low performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact-access, coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate primary care as acceptable to good.

Conclusion

These primary care clinics in Nairobi showed gaps in performance. Performance was rated as acceptable-to-good for first-contact utilisation, the information systems, family-centredness and cultural competence. However, patients rated low performance related to first-contact access, ongoing care, coordination of care, comprehensiveness of services, community orientation and availability of a complete primary health care team. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, incentivising use of these PC clinics rather than the tertiary hospital, improving access after-hours and marketing the use of the clinics to the practice population.

Newborn and infant hearing screening at primary healthcare clinics in South Africa designated as National Health Insurance pilot sites: An exploratory study

Background

Primary healthcare (PHC) is the first point of entry, providing basic services to individuals. South Africa is in the process of re-engineering its PHC as part of National Health Insurance (NHI) plans to ensure universal healthcare coverage.

Aim

This study aimed to establish whether newborn and infant hearing screening (NIHS) could be integrated into the re-engineering process of the PHC as part of the NHI framework.

Setting

The NHI pilot clinics in five provinces in South Africa.

Methods

A non-experimental, descriptive, cross-sectional survey research design was adopted. Questionnaires were sent to nursing managers, unit managers or acting managers at PHC facilities. Nineteen of these self-administered questionnaires were completed. Data were analysed using descriptive statistics.

Results

Immunisation services were the most common type of service offered at the clinics. Over a quarter of the respondents indicated that NIHS services were offered at their facility in the form of universal NIHS. Equipment was limited with a lack of valid and reliable screening measures. Only 2 (11%) respondents indicated budgetary resources. Follow-up and referral pathways were reported by 10 (53%) respondents, which did not include an audiologist.

Conclusions

There is a need for careful and systematic planning in terms of early hearing detection programmes at PHC level. Planning needs to commence with considerations of who will perform NIHS, training of these personnel by audiologists and the role of the audiologist within the teams outlined in the NHI Bill.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa

In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President’s Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.

Implementing the Ideal Clinic Program at Selected Primary Healthcare Facilities in South Africa

Background: Primary healthcare (PHC) in South Africa often experiences crucial challenges that lead to patients’ negative experiences regarding their care, compromising the significant role that PHC services could play in health promotion and disease prevention. The primary purpose of implementing the Ideal Clinic (IC) in South Africa was to improve patients’ care quality at the clinics. There seems to be a paucity of studies determining professional nurses’ experiences when implementing the IC. Purpose: This study aimed to explore and describe professional nurses’ experiences regarding implementing the IC at three selected clinics in the Makhado local area. Study method: A qualitative phenomenological research design was used to explore professional nurses’ experiences regarding IC implementation. Purposive sampling was used to select 15 professional nurses working at the three selected clinics. Data were collected using semi-structured one-on-one interviews. Interviews were conducted until saturation was reached. Trustworthiness was ensured by applying Lincoln and Guba’s four criteria, i.e., credibility, transferability, dependability, and confirmability. Ethical clearance was obtained from the University of Limpopo Turfloop Research and Ethics Committee, and permission to conduct the study was obtained from Limpopo Province Department of Health Research and Ethics Committee. Thematic analysis was used to analyze data. Results: The following themes emerged from the study findings: perceived benefits of the IC on the primary healthcare services provided to the community, challenges experienced by professional nurses when implementing the IC program, and challenges related to the supply of resources for implementing the IC. The study results revealed that, although the IC aimed to improve the overburdened PHC facilities in SA, the professional nurses still experienced some challenges when implementing the IC program. Some of the challenges faced were a lack of knowledge and training in the IC program, poor infrastructure and the shortage of equipment, and inadequate provision of support by line managers, all of which resulted in poor-quality patient care. Conclusion: This study revealed that the introduction and implementation of the IC can have potential benefits to the community and the primary healthcare system. However, it was not introduced and appropriately implemented, which resulted in professional nurses experiencing several challenges. The national department of health needs to strengthen the program’s implementation through proper training, consultation, and continuous support of the nurses. Provision of quality equipment and supplies is also recommended.

Self-referral and associated factors among patients attending adult outpatient departments in Debre tabor general hospital, North West Ethiopia

BACKGROUND

Self-referral leads to diminished quality of health care service; increase resource depletion and poorer patient outcomes. However, a significant number of patients referred themselves to the higher health care facilities without having referral sheets globally including Ethiopia. Even though the problem is much exacerbated in Ethiopia, there is limited evidence regarding self-referral patients in Ethiopia in particular in the study area.

OBJECTIVE

To assess the magnitude and associated factors of self-referral among patients at the adult outpatient department in Debre Tabor general hospital, North West Ethiopia.

METHOD

Institution-based cross-sectional study was conducted from March 11-April 9, 2020 among 693 patients who attended adult outpatient departments. A systematic sampling technique was employed. Structured and pretested interviewer-administered questionnaire was used for data collection. Data were coded, cleaned and entered into Epi Info version 7.1 and exported to SPSS version 23 for further analysis. Binary logistic regression analysis was employed. In bivariable analysis p-value, less than 0.25 was used to select candidate variables for multivariable analysis. P-values less than 0.05 and 95% confidence intervals were used to select significant variables on the outcome of interest.

RESULT

The proportion of self-referral was 443(63.9%) with 95% CI (60.5; 67.5). Formally educated, (AOR = 1.83; (95% CI: 1.12, 3.01)), enrolled to Community Based Health Insurance (AOR = 1.57; (95% CI: 1.03, 2.39)), poor knowledge about referral system (AOR = 2.07; 95% CI: (1.28, 3.39)), not and partially available medication in the nearby Primary Health Care facilities (AOR = 2.12; (95% CI: 1.82, 6.15)) & (AOR = 3.24; (95% CI: 1.75, 5.97)) respectively and history of visiting general hospital (AOR = 1.52; (95%CI: 1.03, 2.25)) were factors statistically associated with self-referral.

CONCLUSION AND RECOMMENDATION

The proportion of self-referral was low compared to the Ethiopian health sector transformation plan 2015/16-20. Socio-demographic and institutional factors were associated with self-referral. Therefore, regional health bureau better to work to fulfill the availability of medications in the primary health care facilities. In addition, Community Based Health Insurance (CBHI) agency should work to implement the law of out-of-pocket expenditure which states to pay 50% for self-referred patients who claim utilization of healthcare.

Trauma patients at the Helderberg District Hospital emergency centre, South Africa: A descriptive study

INTRODUCTION

Trauma is a substantial component of South Africa's burden of disease. District hospitals provide primary trauma care for a large proportion of this trauma burden, although most studies are in specialised or tertiary settings. The aim was to evaluate the profile of physical trauma patients attending the emergency centre at Helderberg District Hospital, Cape Town.

METHODS

An observational descriptive study was conducted between 1 January and 30 April 2019. Patients with trauma were identified from a register and systematically sampled to achieve a sample size of 377. Retrospective data from medical records was collected and analysed in the Statistical Package for Social Sciences.

RESULTS

Of the 14,873 patients attending the emergency centre 24.6% were trauma related and 381 folders were analysed. Of these patients 30.4% were female and 69.6% male with an average age of 27.8 years. Over 60% of patients used an ambulance to get to the hospital. Sundays were the busiest days with 23.9% of all cases. Intentional trauma accounted for 45.4% of cases and accidental injuries 49.1%. The commonest mechanisms were sharp injuries (27.6%), falls (22.0%) and blunt trauma (19.4%). Intentional trauma made up more than half of all trauma in males, was more prevalent than accidental trauma between 20 and 60 years and resulted in a higher proportion of admissions.

CONCLUSION

There were high levels of intentional trauma, especially involving young males over the weekend, mostly with sharp objects. This trauma burden resulted in high numbers of admissions and transfer to tertiary hospitals. Family physicians and other generalists need to be well trained in trauma resuscitation and stabilisation. District hospital need to be appropriately equipped and supplied to manage trauma. Further research is needed to identify underlying modifiable factors that can be addressed through community-orientated interventions.

Evaluation of patient characteristics, management and outcomes for COVID-19 at district hospitals in the Western Cape, South Africa: descriptive observational study

OBJECTIVES

To describe the characteristics, clinical management and outcomes of patients with COVID-19 at district hospitals.

DESIGN

A descriptive observational cross-sectional study.

SETTING

District hospitals (4 in metro and 4 in rural health services) in the Western Cape, South Africa. District hospitals were small (<150 beds) and led by family physicians.

PARTICIPANTS

All patients who presented to the hospitals' emergency centre and who tested positive for COVID-19 between March and June 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Source of referral, presenting symptoms, demographics, comorbidities, clinical assessment and management, laboratory turnaround time, clinical outcomes, factors related to mortality, length of stay and location.

RESULTS

1376 patients (73.9% metro, 26.1% rural). Mean age 46.3 years (SD 16.3), 58.5% females. The majority were self-referred (71%) and had comorbidities (67%): hypertension (41%), type 2 diabetes (25%), HIV (14%) and overweight/obesity (19%). Assessment of COVID-19 was mild (49%), moderate (18%) and severe (24%). Test turnaround time (median 3.0 days (IQR 2.0-5.0 days)) was longer than length of stay (median 2.0 day (IQR 2.0-3.0)). The most common treatment was oxygen (41%) and only 0.8% were intubated and ventilated. Overall mortality was 11%. Most were discharged home (60%) and only 9% transferred to higher levels of care. Increasing age (OR 1.06 (95% CI 1.04 to 1.07)), male (OR 2.02 (95% CI 1.37 to 2.98)), overweight/obesity (OR 1.58 (95% CI 1.02 to 2.46)), type 2 diabetes (OR 1.84 (95% CI 1.24 to 2.73)), HIV (OR 3.41 (95% CI 2.06 to 5.65)), chronic kidney disease (OR 5.16 (95% CI 2.82 to 9.43)) were significantly linked with mortality (p<0.05). Pulmonary diseases (tuberculosis (TB), asthma, chronic obstructive pulmonary disease, post-TB structural lung disease) were not associated with increased mortality.

CONCLUSION

District hospitals supported primary care and shielded tertiary hospitals. Patients had high levels of comorbidities and similar clinical pictures to that reported elsewhere. Most patients were treated as people under investigation. Mortality was comparable to similar settings and risk factors identified.

The effects of coronavirus disease 2019 pandemic on the South African health system: A call to maintain essential health services

South Africa had its first coronavirus disease 2019 (COVID-19) case on 06 March 2020 in an individual who travelled overseas. Since then, cases have constantly increased and the pandemic has taken a toll on the health system. This requires extra mobilisation of resources to curb the disease and overcome financial loses whilst providing social protection to the poor. Assessing the effects of COVID-19 on South African health system is critical to identify challenges and act timely to strike a balance between managing the emergency and maintaining essential health services. We applied the World Health Organization (WHO) health systems framework to assess the effects of COVID-19 on South African health system, and proposed solutions to address the gaps, with a focus on human immunodeficiency virus (HIV) and expanded programme on immunisation (EPI) programmes. The emergence of COVID-19 pandemic has direct impact on the health system, negatively affecting its functionality, as depletion of resources to curb the emergency is eminent. Diversion of health workforce, suspension of services, reduced health-seeking behaviour, unavailability of supplies, deterioration in data monitoring and funding crunches are some of the noted challenges. In such emergencies, the ability to deliver essential services is dependent on baseline capacity of health system. Our approach advocates for close collaboration between essential services and COVID-19 teams to identify priorities, restructure essential services to accommodate physical distancing, promote task shifting at primary level, optimise the use of mobile/web-based technologies for service delivery/training/monitoring and involve private sector and non-health departments to increase management capacity. Strategic responses thus planned can assist in mitigating the adverse effects of the pandemic whilst preventing morbidity and mortality from preventable diseases in the population.

Primary health care performance: a scoping review of the current state of measurement in Africa

INTRODUCTION

Countries with strong primary healthcare (PHC) report better health outcomes, fewer hospital admissions and lower expenditure. People-centred care that delivers essential elements of primary care (PC) leads to improved health outcomes and reduced costs and disparities. Such outcomes underscore the need for validated instruments that measure the extent to which essential, evidence-based features of PC are available and applied to users; and to ensure quality care and provider accountability.

METHODS

A systematic scoping review method was used to identify peer-reviewed African studies and grey literature on PC performance measurement. The service delivery dimension in the Primary Healthcare Performance Initiative conceptual framework was used to identify key measurable components of PC.

RESULTS

The review identified 19 African studies and reports that address measuring elements of PC performance. 13 studies included eight nationally validated performance measuring instruments. Of the eight, the South African and Malawian versions of Primary Care Assessment Tool measured service delivery comprehensively and involved PC user, provider and manager stakeholders.

CONCLUSION

40 years after Alma Ata and despite strong evidence for people-centred care, significant gaps remain regarding use of validated instruments to measure PC performance in Africa; few validated instruments have been used. Agreement on indicators, fit-for-purpose validated instruments and harmonising existing instruments is needed. Rigorous performance-based research is necessary to inform policy, resource allocation, practice and health worker training; and to ensure access to high quality care in a universal health coverage (UHC) system-research with potential to promote socially responsive, accountable PHC in the true spirit of the Alma Ata and Astana Declarations.