Exploring experiences with sensitivity to cultural practices among birth attendants in Kenya: A phenomenological study

Background: Sensitivity to women's cultural needs and expectations by care providers is essential. Skilled birth services for women are as essential as traditional birth services. Therefore, collaborative skilled and cultural care optimises childbearing experiences. Aim: This study explored the experiences of birth attendants (BAs) with sensitivity to cultural practices (CPs) during pregnancy and birth among the Keiyo community in Kenya. Setting: The study was conducted in the purposively selected public health centres and dispensaries offering maternity services and the villages in Keiyo South Sub County in Kenya. Methods: A qualitative interpretive phenomenological study of BAs was conducted. Iterative and inductive interviews using a semistructured guide were conducted with 11 skilled BAs (SBAs) and eight traditional BAs (TBAs). Audio-recorded interviews were transcribed and analysed using ATLAS.ti software version 8.4.4 (1135), following Van Manen's five thematic analysis steps. Results: Three themes emerged: birth attendants' cultural encounters, response to cultural encounters and collaboration. Birth attendants' responses to different cultural encounters revealed their awareness of CPs. The response was experienced as a sensitivity to the need for a triad (woman, TBAs and SBAs) collaborative care, enabling collaborative, woman-centred and culturally safe care. Conclusion: Birth attendants are exposed to cultural encounters, and their responses determine their awareness of enabling sensitive care for optimal childbearing experiences. The study illuminated the need for further collaborative engagements between the BAs and the community to facilitate positive experiences by women through woman-centred, culturally safe care.

Cost and consequence analysis of the Healthy Choices at Work programme to prevent non-communicable diseases in a commercial power plant, South Africa

Background: The workplace is an ideal setting for the implementation of a health promotion programmes to prevent non-communicable diseases (NCD). There are limited resources assigned to workplace health promotion programmes in low-and middle-income countries (LMIC). Aim: This study aimed to conduct a cost and consequence analysis of the Healthy Choices at Work programme. Setting: This study was conducted at a commercial power plant in South Africa. Methods: Incremental costs were obtained for the activities of the Healthy Choices at Work programme over a two-year period. A total of 156 employees were evaluated in the intervention, although the effect was experienced by all employees. An annual health risk factor assessment at baseline and follow up evaluated the consequences of the programme. Results: The total incremental costs over the two-year period accumulated to $4015 for 1743 employees. The cost per employee on an annual basis was $1.15 and was associated with a −10.2mmHg decrease in systolic blood pressure, −3.87mmHg in diastolic blood pressure, −0.45mmol/l in total cholesterol and significant improvement in harmful alcohol use, fruit and vegetable intake and physical inactivity (p < 0.001). There was no correlation between sickness absenteeism and risk factors for NCDs. Conclusion: The cost to implement the multicomponent HCW programme was low with significant beneficial consequences in transforming the workplace environment and reducing risks factors for NCDs. Findings of this study will be useful for small, medium and large organisations, the national department of health, and similar settings in LMICs

Figuring it out by yourself: Perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa

Background: In less resourced settings, formal rehabilitation services for stroke survivors were often absent. Stroke survivors were referred to community health workers (CHWs) who were untrained in rehabilitation. Aim: To describe the experience and perceived needs of stroke survivors, their caregivers and CHWs in a context with limited access to and support from formal rehabilitation services. Setting: The Breede Valley subdistrict, Western Cape, South Africa, a rural, less resourced setting. Methods: A descriptive exploratory qualitative study. Four focus group interviews were held with purposively selected stroke survivors and caregivers and four with CHWs. A thematic approach and the framework method were used to analyse the transcripts. Findings: A total of 41 CHWs, 21 caregivers and 26 stroke survivors participated. Four main themes and 11 sub-themes were identified. Because of the lack of knowledge, training and rehabilitation services, the main theme for all groups was having to 'figure things out' independently, with incontinence management being particularly challenging. Secondly was the need for emotional support for stroke survivors and caregivers. Thirdly, contextual factors such as architectural barriers and lack of assistive products negatively impacted care and function. Lastly, the organisation of health and rehabilitation services negatively impacted home-based services and professional support. Conclusions: With appropriate training, the CHWs can be pivotal in the training and support of family caregivers and stroke survivors. Care pathways and the role and scope of both CHWs and therapists in home-based stroke rehabilitation should be defined and restructured, including the links with formal services

Family physicians' experience and understanding of evidence-based practice and guideline implementation in primary care practice, Cape Town, South Africa

Background: In primary care, patients present with multimorbidity and a wide spectrum of undifferentiated illnesses, which makes the application of evidence-based practice (EBP) principles more challenging than in other practice contexts. Aim: The goal of this study was to explore the experiences and understanding of family physicians (FP) in primary care with regard to EBP and the implementation of evidence-based guidelines.Setting: The study was conducted in Cape Town primary care facilities and South African university departments of Family Medicine. Methods: For this phenomenological, qualitative study, 27 purposefully selected FPs from three groups were interviewed: senior academic FPs; local FPs in public-sector practice; and local FPs in private-sector practice. Data were analysed using the framework method with the assistance of ATLAS.ti, version 6.1. Results: Guideline development should be a more inclusive process that incorporates more evidence from primary care. Contextualisation should happen at an organisational level and may include adaptation as well as the development of practical or integrated tools. Organisations should ensure synergy between corporate and clinical governance activities. Dissemination should ensure that all practitioners are aware of and know how to access guidelines. Implementation should include training that is interactive and recognises individual practitioners' readiness to change, as well as local barriers. Quality improvement cycles may reinforce implementation and provide feedback on the process. Conclusion: Evidence-based practice is currently limited in its capacity to inform primary care. The conceptual framework provided illustrates the key steps in guideline development, contextualisation, dissemination, implementation and evaluation, as well as the interconnections between steps and barriers or enablers to progress. The framework may be useful for policymakers, health care managers and practitioners in similar settings

The perceptions of general practitioners on National Health Insurance in Chris Hani district, Eastern Cape, South Africa

Background: National Health Insurance (NHI) intends to provide universal health coverage to all South Africans, with equity and quality as its tenets. The participation of private general practitioners (GPs) in NHI is essential. The aim was to explore perceptions of GPs on NHI in Chris Hani district, Eastern Cape, South Africa.Methods: A descriptive phenomenological qualitative study using semi-structured individual interviews of 12 GPs from six municipalities was undertaken. Data analysis used the framework method assisted by Atlas.ti software.Results: GPs in Chris Hani district felt that NHI would improve health and benefit society and be of particular benefit to poor andrural people as it will improve access to healthcare. Lack of governmental administrative capacity and a human resource plan were seen as barriers to implementation. They believed that NHI would benefit them through a single purchaser system and support more comprehensive care. GPs were concerned about a lack of information on primary care packages, accreditation,remuneration and patient allocation. They thought that NHI might disadvantage solo GPs. NHI implementation could be improved by actively engaging with GP organisations. Improvement of existing government health facilities and continued medical education were seen as possible ways to better implement NHI.Conclusion GPs in this study were generally positive about NHI and thought it would benefit both patients and providers.However, they had concerns regarding the capacity of government to implement NHI and the implications for solo GPs, and needed more information. Government needs to actively engage GPs

Conference report: undergraduate family medicine and primary care training in Sub-Saharan Africa: reflections of the PRIMAFAMED network

Internationally, there is a move towards strengthening primary healthcare systems and encouraging community-based and socially responsible education. The development of doctors with an interest in primary healthcare and family medicine in the African region should begin during undergraduate training. Over the last few years, attention has been given to the development of postgraduate training in family medicine in the African region, but little attention has been given to undergraduate training. This article reports on the 8th PRIMAFAMED (Primary Care and Family Medicine Education) network meeting held in Nairobi from 21 to 24 May 2016. At this meeting the delegates spent time presenting and discussing the current state of undergraduate training at 18 universities in the region and shared lessons on how to successfully implement undergraduate training. This article reports on the rationale for, information presented, process followed and conclusions reached at the conference

Quality of care for patients with non-communicable diseases in the Dedza District, Malawi

Introduction: In Malawi, non-communicable diseases (NCDs) are thought to cause 28% of deaths in adults. The aim of this study was to establish the extent of primary care morbidity related to NCDs, as well as to audit the quality of care, in the primary care setting of Dedza District, central Malawi. Methods: This study was a baseline audit using clinic registers and a questionnaire survey of senior health workers at 5 clinics, focusing on care for hypertension, diabetes, asthma and epilepsy. Results: A total of 82 581 consultations were recorded, of which 2489 (3.0%) were for the selected NCDs. Only 5 out of 32 structural criteria were met at all 5 clinics and 9 out of 29 process criteria were never performed at any clinic. The only process criteria performed at all five clinics was measurement of blood pressure. The staff's knowledge on NCDs was basic and the main barriers to providing quality care were lack of medication and essential equipment, inadequate knowledge and guidelines, fee-for-service at two clinics, geographic inaccessibility and lack of confidence in the primary health care system by patients. Conclusion: Primary care morbidity from NCDs is currently low, although other studies suggest a significant burden of disease. This most likely represents a lack of utilisation, recognition, diagnosis and ability to manage patients with NCDs. Quality of care is poor due to a lack of essential resources, guidelines, and training

Causes of mortality and associated modifiable health care factors for children (< 5-years) admitted at Onandjokwe Hospital, Namibia

Introduction: Many countries, especially those from sub-Saharan Africa; are unlikely to reach the Millennium Development Goal for under-5 mortality reduction by 2015. This study aimed to identify the causes of mortality and associated modifiable health care factors for under-5year-old children admitted to Onandjokwe Hospital, Namibia. Method: A descriptive retrospective review of the medical records of all children under fiveyears who died in the hospital for the period of 12 months during 2013, using two different structured questionnaires targeting perinatal deaths and post-perinatal deaths respectively. Results: The top five causes of 125 perinatal deaths were prematurity 22 (17.6%), birth asphyxia 19 (15.2%), congenital anomalies 16 (12.8%); unknown 13 (10.4%) and abruptio placenta 11 (8.8%). The top five causes of 60 post-perinatal deaths were bacterial pneumonia 21 (35%), gastroenteritis 12 (20%), severe malnutrition 6 (10%), septicaemia 6 (10%); and tuberculosis 4 (6.7%). Sixty-nine (55%) perinatal deaths and 42 (70%) post-perinatal deaths were potentially avoidable. The modifiable factors were: late presentation to a health care facility, antenatal clinics not screening for danger signs, long distance referral, district hospitals not providing emergency obstetric care, poor monitoring of labour and admitted children in the wards, lack of screening for malnutrition, failure to repeat an HIV test in pregnant women in the third trimesteror during breastfeeding; and a lack of review of the urgent results of critically ill children. Conclusion: A significant number of deaths in children under 5-years of age could be avoided by paying attention to the modifiable factors identified in this study

HIV and/or AIDS-related deaths and modifiable risk factors: a descriptive study of medical admissions at Oshakati Intermediate Hospital in Northern Namibia

Background: High rates of HIV infection have decreased life expectancy in many African countries. Regardless of worldwide efforts to escalate treatment; care and prevention strategies; the number of deaths due to AIDS-related disorders is still high. Local healthcare workers suspect that there are modifiable factors in the care of HIV and/or AIDS patients which can be identified and improved. Aim: To describe the HIV and/or AIDS-related causes of adult mortality and identify modifiable factors amongst patients admitted to Oshakati Intermediate Hospital; northern Namibia. Methods: Data was extracted retrospectively and coded using the modified CoDe protocol for AIDS. Modifiable factors relating to the patient; health system or clinical care were identified using a standardised data collection tool.Results: A total of 177 HIV and/or AIDS patients were identified; 94 (53.1%) were male and 120 (68%) had a CD4 count of less than 200 cells/mL. The common HIV-related causes of death were tuberculosis (25.9%); renal failure (15.8%); Pneumocystis jirovecii pneumonia (11.3%); cryptococcal meningitis (9%); HIV wasting syndrome (7.9%) and AIDS-defining malignancy (7.9%). The analysis revealed 281 modifiable factors; patient-related factors were the most common (153 [54.4%]); followed by health system factors (97 [34.5%]) and healthcare personnel factors (31 [11%]).Conclusion: Our findings have highlighted the challenges in overall HIV and/or AIDS inpatient care and surrounding primary care facilities. The identification of specific modifiable factors can be used to reduce mortality by providing training as well as rational monitoring; planning and resource allocation