Research Articles (Family Medicine and Primary Care)

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The ability of health promoters to deliver group diabetes education in South African primary care
(AOSIS Publishing, 2013-04) Botes, Anna S.; Majikela-Dlangamandla, Buyelwa; Mash, Robert
ENGLISH SUMMARY : Background: Diabetes makes a significant contribution to the burden of disease in South Africa. This study assesses a group diabetes education programme using motivational interviewing in public sector health centres serving low socio-economic communities in Cape Town. The programme was delivered by mid-level health promotion officers (HPOs). Objectives: The aim of the study was to explore the experience of the HPOs and to observe their fidelity to the educational programme. Methods: Three focus group interviews were held with the 14 HPOs who delivered the educational programme in 17 health centres. Thirty-three sessions were observed directly and the audio tapes were analysed using the motivational interviewing (MI) integrity code. Results: The HPOs felt confident in their ability to deliver group education after receiving the training. They reported a significant shift in their communication style and skills. They felt the new approach was feasible and better than before. The resource material was found to be relevant, understandable and useful. The HPOs struggled with poor patient attendance and a lack of suitable space at the facilities. They delivered the majority of the content and achieved beginning-level proficiency in the MI guiding style of communication and the use of open questions. The HPOs did not demonstrate proficiency in active listening and continued to offer some unsolicited advice. Conclusion: The HPOs demonstrated their potential to deliver group diabetes education despite issues that should be addressed in future training and the district health services. The findings will help with the interpretation of results from a randomised controlled trial evaluating the effectiveness of the education.
Academy calls on South Africans to vaccinate
(AOSIS, 2021-10) Mash, Bob
Coronavirus disease 2019 (COVID-19) vaccine hesitancy in South Africa has been fuelled by conspiracy theories and misinformation. Unfortunately, some of this misinformation has come from health professionals, the most notable recent example being Dr Susan Vosloo, a cardiothoracic surgeon in Cape Town. However, family physicians have also been seen to promote unproven treatments such as ivermectin and even nebulised colloidal silver.
Advance directives or living wills : reflections of general practitioners and frail care coordinators in a small town in KwaZulu-Natal
(Medpharm Publications, 2012) Bull, A. P. A.; Mash, B.
Background: Living wills have long been associated with end-of-life care. This study explored the promotion of living wills by general practitioners (GPs) and frail care nursing coordinators who were directly involved in the care of the elderly in Howick, KwaZulu-Natal. The study also explored their views regarding the pro forma living will disseminated by the Living Will Society. Subjects: Seven GPs and three frail care nursing coordinators; 10 in total. Design: The design was qualitative in-depth interviews and analysis, using the Framework method. Results: Both doctors and nursing staff understood the concept of living wills and acknowledged that they were beneficial to patients, their families and staff. They were concerned about the lack of legal status of the living will. They felt that the pro forma document from the Living Will Society was simple and clear. Despite identifying the low level of living will usage among patients, doctors and nursing staff felt that third-party organisations and individuals should promote living wills to patients, rather than promoting them to patients themselves. Conclusion: GPs and frail care nurse coordinators were knowledgeable about living wills in general, and the Living Will Society pro forma document in particular. They valued the contribution that living wills make to the care of the elderly, as they benefit patients, their families, healthcare workers and the health system. They also valued the pro forma living will document from the Living Will Society for its clarity and simplicity. However, the GPs and frail care nursing coordinators viewed the living will process as patient driven. They viewed their main role to be that of custodians, and not advocates, of the living wills.
African leaders views on critical human resource issues for the implementation of family medicine in Africa
(BioMed Central, 2014-01) Moosa, Shabir; Downing, Raymond; Essuman, Akye; Pentz, Stephen; Reid, Stephen; Mash, Robert
ENGLISH ABSTRACT: Background: The World Health Organisation has advocated for comprehensive primary care teams, which include family physicians. However, despite (or because of) severe doctor shortages in Africa, there is insufficient clarity on the role of the family physician in the primary health care team. Instead there is a trend towards task shifting without thought for teamwork, which runs the risk of dangerous oversimplification. It is not clear how African leaders understand the challenges of implementing family medicine, especially in human resource terms. This study, therefore, sought to explore the views of academic and government leaders on critical human resource issues for implementation of family medicine in Africa. Method: In this qualitative study, key academic and government leaders were purposively selected from sixteen African countries. In-depth interviews were conducted using an interview guide. All interviews were audio-recorded, transcribed and thematically analysed. Results: There were 27 interviews conducted with 16 government and 11 academic leaders in nine Sub-Saharan African countries: Botswana, Democratic Republic of Congo, Ghana, Kenya, Malawi, Nigeria, Rwanda, South Africa and Uganda. Respondents spoke about: educating doctors in family medicine suited to Africa, including procedural skills and holistic care, to address the difficulty of recruiting and retaining doctors in rural and underserved areas; planning for primary health care teams, including family physicians; new supervisory models in primary health care; and general human resource management issues. Conclusions: Important milestones in African health care fail to specifically address the human resource issues of integrated primary health care teamwork that includes family physicians. Leaders interviewed in this study, however, proposed organising the district health system with a strong embrace of family medicine in Africa, especially with regard to providing clinical leadership in team-based primary health care. Whilst these leaders focussed positively on entry and workforce issues, in terms of the 2006 World Health Report on human resources for health, they did not substantially address retention of family physicians. Family physicians need to respond to the challenge by respondents to articulate human resource policies appropriate to Africa, including the organisational development of the primary health care team with more sophisticated skills and teamwork.
African primary care research : choosing a topic and developing a proposal
(AOSIS Publishing, 2014-02) Mash, Bob
This is the first in a series of articles on primary care research in the African context. The aim of the series is to help build capacity for primary care research amongst the emerging departments of family medicine and primary care on the continent. Many of the departments are developing Masters of Medicine programmes in Family Medicine and their students will all be required to complete research studies as part of their degree. This series is being written with this audience in particular in mind – both the students who must conceptualise and implement a research project as well as their supervisors who must assist them. This article gives an overview of the African primary care context, followed by a typology of primary care research. The article then goes on to assist the reader with choosing a topic and defining their research question. Finally the article addresses the structure and contents of a research proposal and the ethical issues that should be considered.
African primary care research : current situation, priorities and capacity building
(AOSIS Publishing, 2014-12) Mash, Robert; Essuman, Akye; Ratansi, Riaz; Goodyear-Smith, Felicity; Von Pressentin, Klaus; Malan, Zelra; Van Lancker, Marianne; De Maeseneer, Jan
Introduction: The Sixth PRIMAFAMED (Primary Health Care/Family Medicine Education Network) workshop on ‘Capacity Building and Priorities in Primary Care Research’ was held in Pretoria, South Africa (SA), from 22 to 24 June 2014. Delegates from the following countries attended the workshop: Ghana, Nigeria, Uganda, Kenya, Tanzania, Sudan, Malawi, Zimbabwe, Botswana, Namibia, SA, Zambia, Ethiopia, Rwanda, Mozambique, Swaziland, Belgium, and Denmark (Figure 1). Delegates were from established or emerging departments of family medicine and primary care in these countries. The central theme of the workshop was primary care research – the current situation, the priorities for research and the need for capacity building. This report gives a summary of the consensus on these matters that emerged from the workshop. The motivation for the conference was derived in part from the involvement of Professor Bob Mash (SA) and Professor Olayinka Ayankogbe (Nigeria) in the World Organization of Family Doctors (WONCA) Global Working Party on Primary Care Research, which has a goal of promoting primary care research.
African primary care research : participatory action research
(AOSIS Publishing, 2014-03) Mash, Bob
This article is part of the series on African primary care research and focuses on participatory action research. The article gives an overview of the emancipatory-critical research paradigm, the key characteristics and different types of participatory action research. Following this it describes in detail the methodological issues involved in professional participatory action research and running a cooperative inquiry group. The article is intended to help students with writing their research proposal.
African primary care research : performing a programme evaluation
(AOSIS Publishing, 2014-06) Dudley, Lilian
This article is part of a series on Primary Care Research in the African context and focuses on programme evaluation. Different types of programme evaluation are outlined: developmental, process, outcome and impact. Eight steps to follow in designing your programme evaluation are then described in some detail: engage stakeholders; establish what is known; describe the programme; define the evaluation and select a study design; define the indicators; plan and manage data collection and analysis; make judgements and recommendations; and disseminate the findings. Other articles in the series cover related topics such as writing your research proposal, performing a literature review, conducting surveys with questionnaires, qualitative interviewing and approaches to quantitative and qualitative data analysis.
African primary care research : performing surveys using questionnaires
(AOSIS Publishing, 2014-05) Govender, Indiran; Mabuza, Langalibalele, H.; Ogunbanjo, Gboyega, A.; Mash, Bob
The aim of this article is to provide practical guidance on conducting surveys and the use of questionnaires for postgraduate students at a Masters level who are undertaking primary care research. The article is intended to assist with writing the methods section of the research proposal and thinking through the relevant issues that apply to sample size calculation, sampling strategy, design of a questionnaire and administration of a questionnaire. The article is part of a larger series on primary care research, with other articles in the series focusing on the structure of the research proposal and the literature review, as well as quantitative data analysis.
African primary care research : qualitative data analysis and writing results
(AOSIS Publishing, 2014-06) Mabuza, Langalibalele H.; Govender, Indiran; Ogunbanjo, Gboyega, A.; Mash, Bob
This article is part of a series on African primary care research and gives practical guidance on qualitative data analysis and the presentation of qualitative findings. After an overview of qualitative methods and analytical approaches, the article focuses particularly on content analysis, using the framework method as an example. The steps of familiarisation, creating a thematic index, indexing, charting, interpretation and confirmation are described. Key concepts with regard to establishing the quality and trustworthiness of data analysis are described. Finally, an approach to the presentation of qualitative findings is given.
African primary care research : qualitative interviewing in primary care
(AOSIS Publishing, 2014-06) Reid, Steve; Mash, Robert
This article is part of a series on African Primary Care Research and focuses on the topic of qualitative interviewing in primary care. In particular it looks at issues of study design, sample size, sampling and interviewing in relation to individual and focus group interviews. There is a particular focus on helping postgraduate students at a Masters level to write their research proposals.
African primary care research : quality improvement cycles
(AOSIS Publishing, 2014-04) Van Deventer, Claire; Mash, Bob
Improving the quality of clinical care and translating evidence into clinical practice is commonly a focus of primary care research. This article is part of a series on primary care research and outlines an approach to performing a quality improvement cycle as part of a research assignment at a Masters level. The article aims to help researchers design their quality improvement cycle and write their research project proposal.
African primary care research : quantitative analysis and presentation of results
(AOSIS Publishing, 2014-06) Mash, Bob; Ogunbanjo, Gboyega, A.
This article is part of a series on Primary Care Research Methods. The article describes types of continuous and categorical data, how to capture data in a spreadsheet, how to use descriptive and inferential statistics and, finally, gives advice on how to present the results in text, figures and tables. The article intends to help Master’s level students with writing the data analysis section of their research proposal and presenting their results in their final research report.
African primary care research : reviewing the literature
(AOSIS Publishing, 2014-02) Ross, Andrew; Mash, Bob
This is the second article in the series on African primary care research. The article focuses on how to search for relevant evidence in the published literature that can be used in the development of a research proposal. The article addresses the style of writing required and the nature of the arguments for the social and scientific value of the proposed study, as well as the use of literature in conceptual frameworks and in the methods. Finally, the article looks at how to keep track of the literature used and to reference it appropriately.
African primary care research : writing a research report
(AOSIS Publishing, 2014-06) Couper, Ian; Mash, Bob
Presenting a research report is an important way of demonstrating one’s ability to conduct research and is a requirement of most research-based degrees. Although known by various names across academic institutions, the structure required is mostly very similar, being based on the Introduction, Methods, Results, Discussion format of scientific articles. This article offers some guidance on the process of writing, aimed at helping readers to start and to continue their writing; and to assist them in presenting a report that is received positively by their readers, including examiners. It also details the typical components of the research report, providing some guidelines for each, as well as the pitfalls to avoid. This article is part of a series on African Primary Care Research that aims to build capacity for research particularly at a Master’s level.
The after-hours case mix of patients attending the George Provincial Hospital Emergency Centre
(Medpharm Publications, 2014-12-13) Van Wyk, Patricia S.; Jenkins, Louis
Background: The emergency care of patients in South Africa has improved with the establishment of Emergency and Family Medicine as specialities, the introduction of the Cape Triage Scoring (CTS), and the upgrading of emergency care services. The Western Cape Comprehensive Service Plan stipulates that 90% of care should be delivered through primary and district (level1) services, 8% through general specialist (level 2) services and 2% through super-specialist (level 3) services. Many patients needing level 1 care present after hours at level 2 facilities. This study was undertaken to determine the after-hours emergency centre case mix and workload at George Provincial Hospital Emergency Centre. Method: This was a descriptive retrospective study. Using the CTS, emergency centre staff triaged 2 560 patients who presented for care after hours in May 2010. The data were entered and analysed in MS Excel®. The case mix and workload were then determined. Results: Adults comprised 75% of the case mix. Sixty-five per cent of patients had routine (CTS “green”) complaints, 27% had urgent (CTS “yellow”) complaints, 5% had very urgent complaints (CTS “orange”) and 2% needed immediate care (CTS “red”). Trauma, respiratory and gastrointestinal problems were the most common presentations. The workload during the study period from 1–31 May 2010 included 54 patients after hours on weekdays, 138 patients per 24-hour (08h00-08h00) weekend days and 147 on public holidays. Conclusion: This study showed that 47% of patients who presented after hours at the George Provincial Hospital Emergency Centre required primary or level 1 care. These patients could be more appropriately managed at a level 1 facility.
Alcohol misuse in patients attending a defence force general medical clinic
(Medpharm Publications, 2003) Bekker, D.; Van Velden, D. P.
Alcohol misuse may come to be recognized as one of the most significant public health concerns facing South Africa over the next few years. This is a direct result of alcohol's impact on the health services, the economy, and the South African society as a whole. Alcohol misuse is common world-wide and in South Africa there is an estimated prevalence of 10% of alcohol dependence in the adult population. However, relatively few studies have been published on drinking patterns in South Africa. With regards to adults, epidemiological studies in recent years have also focussed almost entirely on the black and coloured population while they are not the only groups who have high levels of risky drinking.
Allergies and integrative medicine – making sense as a primary care practitioner
(Allergy Society of South Africa, 2010-11) Christodoulou, Maria
Integrative medicine (IM) is defined as a healing-oriented medicine that takes account of the whole person (body, mind and spirit) including all aspects of lifestyle. It emphasises the therapeutic relationship and makes use of all appropriate therapies, healthcare professionals and disciplines, in an evidence-based approach. The IM approach presented here considers a different perspective on disease manifestations, explores the pathophysiology of allergy in the context of biochemical individuality and emphasises a systems-oriented approach. Evidence-based dietary guidelines, supplements, botanicals and mind-body modalities that may be of benefit to the allergic patient are presented.
Alternative mechanisms for delivery of medication in South Africa : a scoping review
(AOSIS, 2021-08) Mash, Robert; Christian, Carmen; Chigwanda, Ruvimbo V.
Background: The number of people in South Africa with chronic conditions is a challenge to the health system. In response to the coronavirus infection, health services in Cape Town introduced home delivery of medication by community health workers. In planning for the future, they requested a scoping review of alternative mechanisms for delivery of medication to patients in primary health care in South Africa. Methods: Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Data was analysed both quantitatively and qualitatively. Results: A total of 4253 publications were identified and 26 included. Most publications were from the last 5 years (n = 21), research (n = 24), Western Cape (n = 15) and focused on adherence clubs (n = 17), alternative pick-up-points (n = 14), home delivery (n = 5) and HIV (n = 17). The majority of alternative mechanisms were supported by a centralised dispensing and packaging system. New technology such as smart lockers and automated pharmacy dispensing units have been piloted. Patients benefited from these alternatives and had improved adherence. Available evidence suggests alternative mechanisms were cheaper and more beneficial than attending the facility to collect medication. Conclusion: A mix of options tailored to the local context and patient choice that can be adequately managed by the system would be ideal. More economic evaluations are required of the alternatives, particularly before going to scale and for newer technology.
An analysis of blood pressure measurement in a primary care hospital in Swaziland
(AOSIS Publishing, 2014-12) Mlawanda, Ganizani; Pather, Michael; Govender, Srini
Background: Measurement of blood pressure (BP) is done poorly because of both human and machine errors. Aim: To assess the difference between BP recorded in a pragmatic way and that recorded using standard guidelines; to assess differences between wrist- and mercury sphygmomanometerbased readings; and to assess the impact on clinical decision-making. Setting: Royal Swaziland Sugar Corporation Mhlume hospital, Swaziland. Method: After obtaining consent, BP was measured in a pragmatic way by a nurse practitioner who made treatment decisions. Thereafter, patients had their BP re-assessed using standard guidelines by mercury (gold standard) and wrist sphygmomanometer. Results: The prevalence of hypertension was 25%. The mean systolic BP was 143 mmHg (pragmatic) and 133 mmHg (standard) using a mercury sphygmomanometer; and 140 mmHg for standard BP assessed using wrist device. The mean diastolic BP was 90 mmHg, 87 mmHg and 91 mmHg for pragmatic, standard mercury and wrist, respectively. Bland Altman analyses showed that pragmatic and standard BP measurements were different and could not be interchanged clinically. Treatment decisions between those based on pragmatic BP and standard BP agreed in 83.3% of cases, whilst 16.7% of participants had their treatment outcomes misclassified. A total of 19.5% of patients were started erroneously on anti-hypertensive therapy based on pragmatic BP. Conclusion: Clinicians need to revert to basic good clinical practice and measure BP more accurately in order to avoid unnecessary additional costs and morbidity associated with incorrect treatment resulting from disease misclassification. Contrary to existing research, wrist devices need to be used with caution.

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