Primary care management of the coronavirus (COVID-19)

South Africa is in the grip of a novel coronavirus pandemic (COVID-19). Primary care providers are in the frontline. COVID-19 is spread primarily by respiratory droplets contaminating surfaces and hands that then transmit the virus to another person's respiratory system. The incubation period is 2­9 days and the majority of cases are mild. The most common symptoms are fever, cough and shortness of breath. Older people and those with cardiopulmonary co-morbidities or immunological deficiency will be more at risk of severe disease. If people meet the case definition, the primary care provider should immediately adopt infection prevention and control measures. Diagnosis is made by a RT-PCR test using respiratory secretions, usually nasopharyngeal and oropharyngeal swabs. Mild cases can be managed at home with self-isolation, symptomatic treatment and follow-up if the disease worsens. Contact tracing is very important. Observed case fatality is between 0.5% and 4%, but may be overestimated as mild cases are not always counted. Primary care providers must give clear, accurate and consistent messages on infection prevention and control in communities and homes

African primary care research: participatory action research

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: reviewing the literature

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 develop -ment 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

Is Screening for Microalbuminuria in Patients with Type 2 Diabetes Feasible in the Cape Town Public Sector Primary Care Context? A Cost and Consequence Study

Background: Type 2 diabetes contributes significantly to the burden of disease in South Africa. Proteinuria is a marker for chronic kidney and cardiovascular disease. All guidelines recommend testing for microalbuminuria because intervention at this stage can prevent or delay the onset of disease. Currently; none of the community health centres (CHCs) in Cape Town test for microalbuminuria; and there are concerns about its costs and feasibility. Objectives: The aim of this study was to assess the practicality; costs and consequences of introducing a screening test for microalbuminuria into primary care. Design: Chronic care teams were trained to screen and treat all patients with diabetes (n = 1 675) over a one-year period. The fidelity of screening; costs and consequences was evaluated. Setting and subjects: Patients with type 2 diabetes and chronic care teams at two community health centres in the Cape Town Metro district. Outcome measures: Data to evaluate screening were extracted from the records of 342 randomly selected patients. Data to evaluate treatment were taken from the records of all 140 patients diagnosed with microalbuminuria. Results: Of the patients with diabetes; 14.6 already had macroalbuminuria. Of the eligible patients; 69.9 completed the screening process which led to a diagnosis of microalbuminuria in another 11.7. Of those who were positively diagnosed; the opportunity to initiate angiotensin-converting enzyme (ACE) inhibitors was missed in 20; while 49.2 had ACE inhibitors initiated; or the dosage thereof increased. It would cost the health system an additional R1 463 to screen 100 patients and provide additional ACE inhibitor treatment for a year to the 12 that were diagnosed. Conclusion: The study demonstrated the feasibility of incorporating microalbuminuria testing into routine care. The costs involved were minimal; compared to the likely benefits of preventing end-stage renal failure and the costs of dialysis (estimated at R120 000 per year per patient)

Evaluation of a School-based Nutrition and Physical Activity Programme for Grade 4 Learners in the Western Cape Province

Objective: This study aimed to evaluate the effectiveness of the Making the Difference programme (MTDP); an educationand activity-based intervention for Grade 4 learners at primary schools in the Western Cape. Design: This was a cross-sectional; post-intervention survey of an existing programme; using control schools as a comparator. Setting and subjects: The study involved Western Cape primary schools in the 2009 school year. Schools were randomly sampled from two regions. Four intervention (active in the MTDP) and five control (non-participating) schools (n = 325 learners) were selected. Outcome measures: The following outcome measures were assessed using an administered questionnaire to learners: learners' knowledge of; attitudes towards; and behaviour in relation to nutrition and physical activity. Results: A small but significant improvement (eating vegetables and taking lunch boxes to school) was demonstrated with regard to self-reported behaviour in relation to nutrition in the intervention group. However; this behaviour was not explained by differences in barriers to healthy eating; self-efficacy or knowledge; which were not different between the groups; or by perceived social support; which was actually significantly increased in the control group. Groups displayed no differences in physical activity or sedentary behaviour. However; the results showed a significant difference between the groups in terms of a reduction in perceived barriers to physical activity and increased physical activity self-efficacy in the active group. Conclusion: While the MTDP only had a modest effect on the self-reported nutrition and physical activity behaviour of the learners; results regarding lower perceived barriers to physical activity and increased physical activity self-efficacy were promising

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

A 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 was better 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

Advance Directives or Living Wills: Reflections of General Practitioners and Frail Care Coordinators in a Small Town in Kwazulu-Natal

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

The Prevalence of Substance Use and its Associations amongst Students Attending High School in Mitchells Plain; Cape Town

Purpose: In South Africa; there has been an increase in illicit drug trafficking and consumption and associated problems since the 1990s. Mitchells Plain in Cape Town is seen as a community battling with crime; gangsterism; unemployment; overcrowding; substance abuse and poverty. This study evaluated the actual prevalence of substance abuse amongst high school students in this community and factors associated with substance use. In particular; the study evaluated the use of tik (crystal methamphetamine); a relatively new drug. Method: A cross-sectional study was performed amongst 12 secondary schools in Mitchells Plain; Grade 8 and Grade 11 classes were randomly selected to produce a sample of 438 learners. The students completed an anonymous questionnaire that contained enquiries on substance use; demographic and school performance details; and personal and sexual risks. Results: Lifetime and annual prevalenc ne (9.2/4.6); ecstasy (4.4/2.7); mandrax (2.1/0.9); solvents (3.0/0.9) and cocaine (0.9/0.9). Illicit substance use was significantly associated with age (OR 1.6; CI 1.2-2.2); substance use by other members of the household (OR 2.8; CI 1.2-6.3); carrying a knife (OR 10.9; CI 4.2-28.8); attempted suicide (OR 3.7; CI 1.4-9.5) and higher sexual risk (OR 1.6; CI 1.2-2.3) Conclusion: The prevalence of substance use amongst adolescent students attending high schools in Mitchells Plain; Cape Town; is high for all substances relative to national and international figures. Government officials; educators and health care workers are alerted to the need for more comprehensive interventions to prevent and treat substance abuse in this and similar communities

The Prevalence of Substance Use and its Associations amongst Students Attending High School in Mitchells Plain; Cape Town

Purpose: In South Africa; there has been an increase in illicit drug trafficking and consumption and associated problems since the 1990s. Mitchells Plain in Cape Town is seen as a community battling with crime; gangsterism; unemployment; overcrowding; substance abuse and poverty. This study evaluated the actual prevalence of substance abuse amongst high school students in this community and factors associated with substance use. In particular; the study evaluated the use of tik (crystal methamphetamine); a relatively new drug. Method: A cross-sectional study was performed amongst 12 secondary schools in Mitchells Plain; Grade 8 and Grade 11 classes were randomly selected to produce a sample of 438 learners. The students completed an anonymous questionnaire that contained enquiries on substance use; demographic and school performance details; and personal and sexual risks. Results: Lifetime and annual prevalence rates were: alcohol (50.6/41.0); tobacco smoking (49.7/36.2); cannabis (32.1/21.1); crystal methamphetamine (9.2/4.6); ecstasy (4.4/2.7); mandrax (2.1/0.9); solvents (3.0/0.9) and cocaine (0.9/0.9). Illicit substance use was significantly associated with age (OR 1.6; CI 1.2-2.2); substance use by other members of the household (OR 2.8; CI 1.2-6.3); carrying a knife (OR 10.9; CI 4.2-28.8); attempted suicide (OR 3.7; CI 1.4-9.5) and higher sexual risk (OR 1.6; CI 1.2-2.3). Conclusion: The prevalence of substance use amongst adolescent students attending high schools in Mitchells Plain; Cape Town; is high for all substances relative to national and international figures. Government officials; educators and health care workers are alerted to the need for more comprehensive interventions to prevent and treat substance abuse in this and similar communities

Effectiveness of home-based directly observed treatment for tuberculosis in Kweneng West subdistrict, Botswana

Background: Tuberculosis (TB) and HIV are major public health problems in Botswana. In the face of growing TB notification rates, a low cure rate, human resource constraints and poor accessibility to health facilities, Botswana Ministry of Health decided to offer home-based directly observed treatment (DOT) using community volunteers. Objectives: The aim of this study was to assess the outcomes of home-based directly observed treatment (HB-DOT) versus facility-based, directly observed treatment (FB-DOT) in the Kweneng West subdistrict in Botswana and to explore the acceptability of HB-DOT among TB patients, community volunteers and health workers. Method: A quantitative, observational study using routinely collected TB data from 405 TB patients was conducted and combined with 20 qualitative in-depth interviews. Results: The overall cure rate for smear-positive pulmonary TB patients was 78.5. Treatment outcomes were not statistically different between FB-DOT and HB-DOT. Contact tracing was significantly better in FB-DOT patients. Interviews revealed advantages and disadvantages for both FB and HB options and that flexibility in the choice or mix of options was important. A number of suggestions were made by the interviewees to improve the HB-DOT programme. Conclusion: HB-DOT is at least as good as FB-DOT in terms of the treatment outcomes, but attention must be given to contact tracing. HB-DOT offers some patients the flexibility they need to adhere to TB treatment and community volunteers may be strengthened by ongoing training and support from health workers, financial incentives and provision of basic equipment