Determinants of Blood Pressure Control among Hypertensive Patients Attending a Rural Teaching Hospital in Southern Nigeria

Hypertension (HTN) is the commonest cardiovascular risk factor in sub-Saharan Africa. It is a global public health threat, often associated with significant morbidities and mortality with rising prevalence both in rural and semi-urban areas of economically disadvantaged countries. Aim: This study aimed to assess the determinants of blood pressure control among patients with hypertension receiving care at the Irrua Specialist Teaching Hospital in Southern Nigeria. Patients and Methods: A cross-sectional study of 502 consenting hypertensive adults receiving care at the Irrua Specialist Teaching Hospital, Irrua in Edo State, South-south Nigeria. A pre-tested semi-structured interviewer-administered questionnaire was used to collect data which was analyzed using SPSS version 21 and the level of significance was set at P < 0.05. Results: Five hundred and two participants (226 males, 276 females) completed the study with a mean age of 52.98 ± 12.82 years. Optimal blood pressure control was found in 15.5% of the study participants. Blood pressure control was significantly associated with being married (OR 1.549, CI: 1.040­2.309), having a monthly household income of over N50,000 (OR 1.691, CI: 0.999-2.863), engaging in physical activity (OR = 1.537, CI: 0.989-2.388), and not being obese evidenced by a normal Waist Hip Ratio (OR = 2.276, CI: 1.555-3.332). Conclusion: Blood pressure control to target goal was low in the study population and achieved only in less than one­fifth of respondents on antihypertensive therapy. Numerous socio-demographic and lifestyle variables were shown to be associated with blood pressure control. Physicians should emphasize medication adherence and lifestyle modification approaches in hypertensive adults.

What presents to a rural district emergency department: a case mix

Background: There is little information available on the range of conditions presenting to generalist run rural district hospital emergency departments (EDs) which are the first point of acute care for many South Africans. Aim: This study aims to assess the range of acute presentations as well as the types of procedures required by patients in a rural district hospital context. Setting: Zithulele is a 147-bed district hospital in rural Eastern Cape. Methods: This is a cross-sectional study assessing all patients presenting to the Zithulele hospital emergency department from 01 October 2015 to 31 December 2015. Data collected included the triage acuity using the South African Triage Scale system, patient demographics, diagnosis, outcome and procedures performed. Diagnoses were coded retrospectively according to the international statistical classification of diseases and related health problems version 10 (ICD 10). Results: Of the 4 002 patients presenting to the ED during the study period, 2% were triaged as emergencies and 45% as non-urgent. The most common diagnostic categories were injuries, infections and respiratory illnesses respectively. Diagnoses from all broad categories of the ICD-10 were represented. 67% of patients required no procedure. Diagnostic procedures (n = 877) were more prevalent than therapeutic procedures (n = 377). Only 2.4% of patients were transferred to a referral centre acutely. Conclusion: Patients with conditions from all categories of the ICD-10 present for management at rural district hospitals. Healthcare professionals working in this setting need to independently diagnose and manage a wide range of ED presentations and execute an assortment of procedures

Predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in south Africa

Background. There is a dire need for medical schools in South Africa to train medical doctors who have the capacity and willingness to work in primary healthcare facilities; particularly in rural areas. Objectives. To assess the effect of students' gender; race; place of birth and place of high school completion on their choice of training site location and to assess the extent to which the training programme enhanced students' learning experiences relevant to primary care across training sites. Methods. A survey design involving six cohorts of 4th-year undergraduate medical students (N=187) who were part of the 2013 Family Medicine rotation at the Nelson R Mandela School of Medicine. Self-administered questionnaires were completed by students at the end of each rotation. Data analyses involved descriptive computations and inferential statistical tests; including non-parametric tests for group comparison and generalised polynomial logistic regression. Results. Students believed that their knowledge and skills relevant to primary care increased after the rotation (p0.0001). There were statistically significant differences between rural and urban sites on certain measures of perceived programme effectiveness. Male students were less likely to choose urban sites. Black students were less likely to choose rural sites compared with their white and Indian counterparts; as were students who attended rural high schools (odds ratio (OR) 9.3; p0.001). Students from a rural upbringing were also less likely to choose rural sites (OR 14; p0.001). Conclusion. Based on the findings; an objective approach for student allocation that considers students' background and individual-level characteristics is recommended to maximise learning experiences

Strengthening Rural Health Placements for Medical Students: Lessons for South Africa from International Experience

BACKGROUND:This article derives lessons from international experience of innovative rural health placements for medical students. It provides pointers for strengthening South African undergraduate rural health programmes in support of the government's rural health; primary healthcare and National Health Insurance strategies.METHODS:The article draws on a review of the literature on 39 training programmes around the world; and the experiential knowledge of 28 local and international experts consulted through a structured workshop.RESULTS:There is a range of models for rural health placements: some offer only limited exposure to rural settings; while others offer immersion experiences to students. Factors facilitating successful rural health placements include faculty champions who drive rural programmes and persuade faculties to embrace a rural mission; preferential selection of students with a rural background; positioning rural placements within a broader rural curriculum; creating rural training centres; the active nurturing of rural service staff; assigning students to mentors; the involvement of communities; and adapting rural programmes to the local context. Common obstacles include difficulties with student selection; negative social attitudes towards rural health; shortages of teaching staff; a sense of isolation experienced by rural students and staff; and difficulties with programme evaluation.CONCLUSIONS:Faculties seeking to expand rural placements should locate their vision within new health system developments; start off small and create voluntary rural tracks; apply preferential admission for rural students; set up a rural training centre; find practical ways of working with communities; and evaluate the educational and clinical achievements of rural health placements

Evaluation of a reproductive health program to support married adolescent girls in rural Ethiopia

Few reproductive health programs are targeted to married adolescent girls. This study measures changes associated with a program for married adolescent girls and a parallel husbands' program, in rural Ethiopia. The married girls' program provided information on communication, self-esteem, reproductive health and gender through girls' groups. The husbands' program focused on non-violence, support to families, and reproductive health. Population-based surveys were undertaken among married girls, at midterm and end line. Outcomes of interest were husbands' assistance with domestic work, accompaniment to the clinic, family planning use, voluntary counseling and testing (VCT), and domestic violence. Overall, 1,010 married girls were interviewed. Participation in the girls' groups was associated with improvements in help with domestic work, accompaniment to the clinic, family planning and VCT. Further improvements were recorded when both partners participated. For example, participating girls were nearly 8 times more likely to receive VCT (OR 7.7) than nonparticipants, and more than 18 times more likely if both partners participated (OR 18.3). While these results are promising, there were indications of selectivity bias that could have contributed to the positive results. Programs engaging both wives and husbands can result in incremental improvements to the health and well-being of girls married early. Afr J Reprod Health 2014; 18[2]: 68-76)

Enhancing Policy Maker Decisions: a Framework to Assess Determinants and Space-Time Risk of Infant; Child and Adult Mortality in Rural South Africa and Elsewhere

"Reliable mortality data are essential for planning health interventions; yet such data are often not available or reliable in developing countries; especially in sub-Saharan Africa. Health and socio-demographic surveillance sites; such as Agincourt in South Africa; are often the only way to assess and prospectively understand health trends at a population level; and thus have the potential to address this gap. This article summarises the main findings from my PhD in which advanced methods were applied to better understand the dynamics of age-specific mortality both in space and time; to identify age-specific mortality risk factors which have a high ""impact"" at a population level; and to relate inequalities in risk factor distributions to observed spatial mortality risk patterns."

A Qualitative Exploratory Study: Using Medical Students' Experiences to Review the Role of a Rural Clinical Attachment in KwaZulu-Natal

Objectives: There are challenges when it is considered that a main role of a rural clinical attachment for medical students is to encourage students to return after graduation to practise in rural areas. This view may lead to the relative neglect of other potential valuable roles with regard to rural exposure. This paper draws on the Force Field Model of teacher development to describe medical students' experiences; illustrate the complexity of interacting factors during rural exposure; caution that experiences cannot be predicted and highlight the positive incentives of a rural clinical attachment. Design: The design was explorative; descriptive and qualitative. Setting: The study setting was a district hospital in rural KwaZulu-Natal. Subjects: The participants were four final-year medical students who had completed a compulsory attachment during their Family Medicine rotation. Results: The participants felt that overall the experience was positive. The effect of biography and contextual forces were not as strong as expected. Institutional forces were important and programmatic forces tended to have a negative effect on experiences. The participants particularly enjoyed being acknowledged and felt empathy for the difficult tasks of doctors

Laboratory testing improves diagnosis and treatment outcomes in primary health care facilities

Objective: To determine if use of basic laboratory tests improves diagnosis and treatment outcomes in outpatients attending rural primary health care facilities. Setting: Six rural health centres in Kenya.Design: Cross-sectional study to observe change in diagnosis and treatment made by clinical officers after laboratory testing in outpatients attending six rural health centres in Kenya.Subject: The diagnosis and treatment of 1134 patients attending outpatient services in six rural health centres were compared before and after basic laboratory testing. Essential clinical diagnostic equipment and laboratory tests were established at each health centre. Clinical officers and laboratory technicians received on-site refresher training in good diagnostic practices and laboratory procedures before the study began. Results: Laboratory tests were ordered on 704 (62.1) patients. Diagnosis and treatment were changed in 45of tested patients who returned with laboratory results (21 of all patients attending the clinics). 166 (23.5 of all patients attending the clinics). 166 (23.5) patients did not return to the clinician for a final diagnosis and management decision after laboratory testing. Blood slide examination for malaria parasites; wet preparations; urine microscopy and stool microscopy resulted in most changes to diagnosis. There was no significant change in drug costs after laboratory testing. The greatest changes in numbers of recorded diseases following laboratory testing was for intestinal worms (53) and malaria (21). Conclusion: Effective use of basic laboratory tests at primary health care level significantly improves diagnosis and patient treatment. Use of laboratory testing can be readily incorporated into routine clinical practice. On-site refresher training is an effective means of improving the quality of patient care and communication between clinical and laboratory staff

Rural women's understanding of the concept of menopause in Limpopo Province, South Africa

The word 'menopause' is derived from men and pausis and is a direct description of the psychological and physical events in women where menstruation ceases to occur. It is the time in a woman's life when she has experienced the last menstrual bleed. Menopause is not a disease per se but a condition associated with hormonal changes where estrogen diminishes to a low level causing health related symptoms. The purpose of this study was to explore and describe the knowledge of rural women concerning menopause in Mutale Municipality; South Africa. A qualitative; explorative; descriptive and contextual design was used. Purposive sampling was used to select the four villages and the focus groups. Sample size was determined by data saturation. The findings of the study indicated that the rural women in Mutale community had the common traditional understanding of the concept menopause; that blood is gone; old age; it was God' nature of doing things and that cessation of menstruation was a normal and natural transition. They could not attach cessation of menstruation to menopausal conditions but to old age and physical as well as psychological health related problems. There is need for health care providers to conduct workshops in order to enlighten rural women in this community regarding phenomenal issues of menopause

Knowledge, attitude and practice study of HIV in female adolescents presenting for contraceptive services in a rural health district in the north-east of Namibia

Background: Namibia bears a large burden of Human Immunodeficiency Virus (HIV); and the youth are disproportionately affected. Objectives: To explore the current knowledge; attitudes and behaviour of female adolescents attending family planning to HIV prevention. Methods: A cross-sectional study design was used on a sample 251 unmarried female adolescents aged from 13 years to 19 years accessing primary care services for contraception using an interviewer-administered questionnaire. Data were analysed using Epi Info 2002. Crude associations were assessed using cross-tabulations of knowledge; attitude and behaviour scores against demographic variables. Chi-square tests and odds ratios were used to assess associations from the cross-tabulations. All p-values 0.05 were considered statistically significant. Results: A quarter of sexually active teenagers attending the family-planning services did not have adequate knowledge of HIV prevention strategies. Less than a quarter (23.9) always used a condom. Most respondents (83.3) started sexual intercourse when older than 16 years; but only 38.6used a condom at their sexual debut. The older the girls were at sexual debut; the more likely they were to use a condom for the event (8did so at age 13 years and 100at age 19 years). Conclusions: Knowledge of condom use as an HIV prevention strategy did not translate into consistent condom use. One alternate approach in family-planning facilities may be to encourage condom use as a dual protection method. Delayed onset of sexual activity and consistent use of condoms should be encouraged amongst schoolchildren; in the school setting

Evaluating the Rural Health Placements of the Rural Support Network at the Faculty of Health Sciences; University of Cape Town

Objectives: The Rural Support Network (RSN) is an undergraduate student society that aims to raise awareness among the student body of the plight of rural health in South Africa; and organises individual and group placements in rural hospitals during vacations. This research aimed to evaluate these placements from the students' perspectives.Design: In-depth; face-to-face interviews were conducted with 10 students and nine placement-reflective reports were reviewed. The data were analysed and coded for key themes using a constant; comparative grounded theory approach.Setting: Faculty of Health Sciences (FHS) at the University of Cape Town.Subjects: Students who had been on RSN placements in 2010.Results: Students reported that the experience exceeded their expectations of learning new skills and observing and performing procedures. They gained significant insights into rural health care and were inspired to contribute to rural health in future. Their experiences helped them to gain confidence and an appreciation of the psycho-social aspects of patient care. The importance of community empowerment and of connecting and building relationships with communities was also emphasised. Challenges pertained to conflict within groups; incidents of unprofessional health care and being unable to help as much as they would have liked.Conclusion: The study highlights the impact that positive experiences of rural health may have on health science students' interest in; passion for; and commitment to practising in underserved rural areas. Students' key recommendations for the FHS included the development of a rural programme within the undergraduate curriculum. Better group composition and improved planning and co-ordination of placements by the RSN were also recommended

Community Knowledge Variation; Bed-Net Coverage and the Role of a District Healthcare System; and their Implications for Malaria Control in Southern Malawi

This paper presents data on the pattern of knowledge of caregivers; bed-net coverage and the role of a rural district healthcare system; and their implications for malaria transmission; treatment; prevention and control in Chikhwawa; southern Malawi; using multi-level logistic regression modelling with Bayesian estimation. The majority of caregivers could identify the main symptoms of malaria; that the mosquito was the vector; and that insecticide-treated nets (ITN) could be used to cover beds as an effective preventative measure; although cost was a prohibitive factor. Use of bed nets displayed significant variation between communities. Groups that were more knowledgeable on malaria prevention and symptoms included young mothers; people who had attended school; wealthy individuals; those residing closest to government hospitals and health posts; and communities that had access to a health surveillance assistant (HSA). HSAs should be trained on malaria intervention programmes; and tasked with the responsibility of working with village health committees to develop community-based malaria intervention programmes. These programmes should include appropriate and affordable household improvement methods; identification of high-risk groups; distribution of ITNs and the incorporation of larval control measures; to reduce exposure to the vector and parasite. This would reduce the transmission and prevalence of malaria at community level

Access to Subsidized Artemether-Lumefantrine from the Private Sector among Febrile Children in Rural Setting in Kilosa; Tanzania

Abstract:The World Health Organization aims at universal access to effective antimalarial treatment by the year 2015. Consequently; an enormous financial resource has been invested on Artemisinin Combination Therapy (ACT))) subsidy. In Tanzania; strategies to increase access of artemether-lumufantrine (ALu) rural areas; where the burden is highest; includes subsidy to the Faith-based Organisations (FBO) facilities and accredited drug dispensing outlets (ADDOs). This study was done to assess the extent to which children suffering from malaria access ALu from the private sector in rural areas. A total of 1;235 under fives randomly selected from 12 rural villages were followed up at home on weekly basis for six months in Kilosa district in 2008. Using a structured questionnaire; caretakers were interviewed about the child's history of fever in the past 7 days; type of treatment given and the source. Baseline data were obtained on demographic characteristics; caretakers' knowledge about malaria and social economic indicators of the household. Of the 1;235 children followed-up; 740 care-seeking visits were recorded; of which; 264 (35.7) were made at government health facilities and nearly a quarter (24.1; 178/740) at ordinary shops that sell general merchandize including rice and sugar. Only 22 of the caretakers sought care from FBO and ADDOs. While 686 (86.6) of the episodes were treated with antimalarials; only 319 (43) received ALu; the recommended antimalarial. Majority (83) of the visits made at government facilities were prescribed with ALu compared to less than half who went to FBO facilities (40.0) and ADDOs (25.0). In conclusion; this study has shown that less than a quarter of fever episodes suspected to be malaria in rural areas were made at FBO facilities and ADDOs; of which; less than half were treated with ALu. This shows that ALu subsidy to formal private sector does not adequately reach children in rural areas; where the malaria burden is highest. This cast some doubts if the target of universal access to effective antimalarial; by 2015; will be reached. There is need to consider enlisting the services of community health workers in the efforts to improve access to ALu in rural areas. Further research is needed to explore providers' / dispensers' preference for non-recommended antimalarials in the private sector and caretakers' preference for ordinary

Determinants de la frequentation tardive des services de soins prenatals dans les zones de sante de l'Equateur et du Katanga en Republique Democratique du Congo

Objectifs. Estimer la frequence de la frequentation tardive des soins prenatals; et en identifier les principaux determinants dans certaines zones de sante de la Republique Democratique du Congo. Methodologie. Etude transversale analytique; dans 6 zones de sante de 2 provinces de la RD Congo; portant sur 465 gestantes ou femmes allaitantes; selectionnees selon un echantillonnage a plusieurs degres. Les caracteristiques sociodemographiques; l'histoire genesique; et les facteurs d'utilisation des soins de sante ontete collectes. La frequentation prenatale tardive etait definie comme une premiere visite accomplie par une femme enceinte apres le 4eme mois de gestation; ou apres la 16eme semaine d'amenorrhee. Le test de chi-carre; le test t de Student; et la regression logistique ont ete utilises pour etudier les associations; comparer les moyennes; et identifier les determinants. Resultats. La frequentation des soins prenatals interessait 85.7des repondantes; et etait tardive pour 59.8des grossesses (IC95: 54.0-65.6). Sa frequence etait plus elevee dans le milieu rural et parmi les multipares. Elle est motivee par les contraintes financieres ou l'absence de problemes lors de la grossesse. Elle est determinee par le milieu de vie; le niveau d'etude; la religion; la parite; la gestite; l'age; la taille du menage; l'occupation; et la perception du tarif applique. Elle est reduite par l'instruction et l'emploi remunere. Conclusion. Le delai dans l'initiation de la CPN demeure encore un probleme dans les zones de sante de notre pays. Cette situation handicape l'atteinte des objectifs de sante de la mere et de l'enfant. L'identification de principaux determinants de ce retard incite a promouvoir des strategies ciblees; en vue d'influencer les comportements et les attitudes des personnes les plus vulnerables. L'education sanitaire; l'implication de la communaute; et la mise en oeuvre desstrategies qui reduisent le payement direct au point de prestation; peuvent contribuer a minimiser ce phenomene dans notre contexte

Teenagers' Experiences of Sexual Health Dialogue in the Rural Villages of the Vhembe District; Limpopo Province

Dialogue with teenagers about sexual health is of global concern; as it is found mostly to be minimal; if not absent. This limitation is influenced by the cultural values; beliefs and norms of teenagers. To a great extent; culture influences which and how sexual health issues can be discussed between teenagers and adults. The purpose of this study was to explore and describe teenagers' experiences of sexual health dialogue in the rural areas of the Vhembe district in Limpopo province; South Africa. A qualitative; explorative; descriptive and contextual research approach was used. Data were collected by means of in-depth; individual interviews and focus-group discussions. A purposive sampling method was used to select the 57 participating teenagers; based on criteria that were set. The findings of the study indicated that there was minimal dialogue between adults and teenagers about sexual health. Most teenagers reported that they learned about issues related to sexual health from friends; the media; initiation schools and relatives who; most often; were aunts. It was also noted with concern that the teenagers always equated sexual health to the act of intercourse and that no attention was paid to other aspects of sexual health. Recommendations to improve the current situation were made

Evaluation of the parallel rural community curriculum at flinders university of south Australia: lessons learnt for Africa

Objectives. To review data collected during an evaluation of the Flinders University Parallel Rural Community Curriculum (PRCC) in order to reflect on its relevance for medical education in Africa.Setting. The PRCC offers a community-based longitudinal curriculum as an alternative for students in their pre-final year of medical training. Design. Individual and focus group interviews were conducted with students; staff; health service managers; preceptors and community members. Results. Students are exposed to comprehensive; holistic; relationship-based care of patients; with a graded increase in responsibility. Students have varying experience at different sites; yet achieve the same outcomes. There is a strong partnership with the health service.Conclusions. The principle of balancing sound education and exposure to a variety of contexts; including longitudinal community-based attachments; deserves consideration by medical educators in Africa

Continuing education in geriatrics for rural health care providers in Uganda: A needs assessment

Population trends in developing countries show an increasing population of older adults (OAs), especially in rural areas. The purpose of this study was to explore the geriatrics continuing education needs of health care providers (HCPs) working in rural Uganda. The study employed a descriptive design to collect data from HCPs working in Apac district, a rural district in northern Uganda. The 240 HCPs (mean age 33.8±10.5 years) from whom data were collected were nurses (52%), physician assistants (17%), social workers (12%), laboratory technologists (10%) and physicians (10%). Self-administered questionnaires composed of the Palmore's Facts on Aging Quiz (FAQ1) and Kogan's attitude towards old people (KAOP) scale were used for data collection. Results. Most HCPs (63%) regularly cared for OAs but their professional education did not include geriatric-specific courses (69%). The majority of HCPs had a poor or fair geriatric knowledge (88%) (FAQ1 mean score 11.6±2.3), but had a positive attitude towards OAs (80%) (KOAP mean score 115.9±11.5). Positive attitude was associated with personal experiences with OAs and a desire for a future career in geriatrics (p≤0.05). Conclusion. In Uganda training curricula for health professionals have not evolved to address the changing demographic trends showing increasing numbers of OAs. Consequently, there is a significant knowledge gap in certain aspects of health care, such as geriatrics, among currently practising HCPs. There is need for tailored geriatrics continuing education programmes to bridge the knowledge and skill gaps to ensure quality health care for OAs

Assessment of the Health System to Support Tuberculosis and AIDS Care. A Study of Three Rural Health Districts of Burkina Faso

There is increasing evidence demonstrating the importance of healthcare systems for improvement of chronic illness care. The aims of this study were to develop a comprehensive assessment of the health services capacity to provide tuberculosis (TB) and human immunodeficiency virus (HIV) care but also to enhance patient empowerment; social network and community support. A cross-sectional study was conducted from 1 to 31 of August 2007 in 3 districts of Burkina Faso. We used a step-by-step model and the assessment of chronic illness care (ACIC) scale to assess capacities of 24 first line health centres (FLHC) and 3 district hospitals (DH) for providing TB and HIV/AIDS care. Data for the step-by-step model were extracted from medical records of 75 TB and 66 HIV patients. The ACIC scale was completed by health professionals; 6 medical doctors and 18 nurses; working at the DH level and at the FLHC level; respectively. The biological test for confirmation was free of charge for all the TB patients but only for 10.6(7/66) HIV cases. Up to the time of the survey; 5 TB (6.6) and 18 HIV+ patients (27.3) have been hospitalised for care at least once; 64 TB (85.3) had been declared cured and 38 HIV (54.5) were under antiretroviral treatment. Health care process organisation for TB and HIV care had distinct areas of weaknesses. From a maximum ACIC score of 11; the overall score for TB care ranged between 1.9 and 4.9 with a median of 3.7 and for HIV care between 2.1 and 6.7 with a median of 4.1. This study provides an illustration of assessing the HIV and TB care combining data from the routine information system and from the chronic illness care assessment tool; to encompass both disease control and patient health perspective. It provides to health managers arguments for clear conclusions and sufficient data for action