Access to health care for people with stroke in South Africa: a qualitative study of community perspectives.

BACKGROUND: Incidence of stroke is increasing in sub-Saharan Africa. People who survive stroke experience disability and require long-term care. Health systems in South Africa (SA) are experiencing important challenges, and services in the public health system for people with stroke (PWS) are fragmented. We aimed to explore the perspectives and experiences of PWS related to stroke care services to inform health system strengthening measures. METHODS: In-depth interviews with 16 PWS in urban and rural areas in the Western and Eastern Cape Provinces of SA were conducted between August and October 2020. PWS were recruited through existing research networks, non-government organisations and organisations of persons with disabilities by snowball sampling. Interviews were transcribed, coded, and thematically analysed. We used the conceptual framework of access to health care as proposed by Levesque et al. to map and inform barriers to accessing health care from the user perspective. RESULTS: PWS recognised the need for health care when they experienced signs of acute stroke. Health literacy on determinants of stroke was low. Challenges to accessing stroke care include complex pathways to care, physical mobility related to stroke, long travel distances and limited transport options, waiting times and out of pocket expenses. The perceived quality of services was influenced by cultural beliefs, attitudinal barriers, and information challenges. Some PWS experienced excellent care and others particularly poor care. Positive staff attitude, perceived competence and trustworthiness went in hand with many technical and interpersonal deficits, such as long waiting times and poor staff attitude that resulted in poor satisfaction and reportedly poor outcomes for PWS. CONCLUSIONS: Strategic leadership, governance and better resources at multiple levels are required to address the unmet demands and needs for health care of PWS. Stroke care could be strengthened by service providers routinely providing information about prevention and symptoms of stroke, treatment, and services to patients and their social support network. The role of family members in continuity of care could be strengthened by raising awareness of existing resources and referral pathways, and facilitating connections within services.

Standardising evidence strength grading for recommendations from multiple clinical practice guidelines: a South African case study.

BACKGROUND: Significant resources are required to write de novo clinical practice guidelines (CPGs). There are many freely-available CPGs internationally, for many health conditions. Developing countries rarely have the resources for de novo CPGs, and there could be efficiencies in using CPGs developed elsewhere. This paper outlines a novel process developed and tested in a resource-constrained country (South Africa) to synthesise findings from multiple international CPGs on allied health (AH) stroke rehabilitation. METHODS: Methodologists, policy-makers, content experts and consumers collaborated to describe the pathway of an 'average' stroke patient through the South African public healthcare system and pose questions about best-practice stroke rehabilitation along this pathway. A comprehensive search identified international guidance documents published since January 2010. These were scanned for relevance to the South African AH stroke rehabilitation questions and critically appraised for methodological quality. Recommendations were extracted from guidance documents for each question. Strength of the body of evidence (SoBE) gradings underpinning recommendations were standardised, and composite recommendations were developed using qualitative synthesis. An algorithm was developed to guide assignment of overall SoBE gradings to composite recommendations. RESULTS: Sixteen CPGs were identified, and all were included, as they answered different project questions differently. Methodological quality varied and was unrelated to currency. Seven clusters, outlining 20 composite recommendations were proposed (organise for best practice rehabilitation, operationalise strategies for best practice communication throughout the patient journey, admit to an acute hospital, refer to inpatient rehabilitation, action inpatient rehabilitation, discharge from inpatient rehabilitation and longer-term community-based rehabilitation). CONCLUSION: The methodological development process, tested by writing a South African AH stroke rehabilitation guideline from existing evidence sources, took 9 months. The process was efficient, collaborative, effective, rewarding and positive. Using the proposed methods, similar synthesis of existing evidence could be conducted in shorter time periods, in other resource-constrained countries, avoiding the need for expensive and time-consuming de novo CPG development.

Measuring distress in South African children during burns dressing changes: A pilot study.

OBJECTIVES: To establish and trial a practical, evidence-based, sensitive, language-fair, and culture-fair test battery to measure South African children's distress during burns dressing change. METHODS: We previously identified a broad test battery for pediatric procedural distress from the literature. This comprised child and parent heart rate; three instruments for observed distress behaviors-(1) Face, Legs, Activity, Cry, Consolability (FLACC); (2) Pain Behavior Check List (PBCL); and (3) Children's Hospital Eastern Ontario Pain Scale (CHEOPS); and dressing change time, number of nurses required, and nurses' perspectives of child's distress. A consecutive cohort of South African inpatient children with burns was recruited. In the first study, three observers independently piloted the broad set of measures on four children. This set was subsequently modified to increase practicality of application and measurement sensitivity. In the second study, the modified battery was tested on 16 children for sensitivity to different children's distress levels during burns dressing change phases. RESULTS: The modified test battery was comprised of the CHEOPS, dressing change time, number of nurses required, and nurses' qualitative perspectives of child's distress. In combination, these tests were practical and sensitive to children's distress. DISCUSSION: South African children's distress during burn dressing changes manifests in different ways. Adequate capture of it requires a comprehensive set of objective, observational, and qualitative measures, which are independent of language and culture.

Postural dynamism during computer mouse and keyboard use: A pilot study.

Prolonged sedentary computer use is a risk factor for musculoskeletal pain. The aim of this study was to explore postural dynamism during two common computer tasks, namely mouse use and keyboard typing. Postural dynamism was described as the total number of postural changes that occurred during the data capture period. Twelve participants were recruited to perform a mouse and a typing task. The data of only eight participants could be analysed. A 3D motion analysis system measured the number of cervical and thoracic postural changes as well as, the range in which the postural changes occurred. The study findings illustrate that there is less postural dynamism of the cervical and thoracic spinal regions during computer mouse use, when compared to keyboard typing.

Brain activity in predictive sensorimotor control for landings: an EEG pilot study.

Landing from a jump is related to predictive sensorimotor control. Frontal, central and parietal brain areas are known to play a role in this process based on online sensory feedback. This can be measured by EEG. However, there is only limited knowledge about brain activity during predictive preparation for drop landings (DL). The purpose is to demonstrate changes in brain activity in preparation for DL in different conditions. After resting, 10 athletes performed a series of DLs and were asked to concentrate on the landing preparation for 10 s before an auditory signal required them to drop land from a 30 cm platform. This task was executed before and after a standardized fatigue protocol. EEG spectral power was calculated during DL preparation. Frontal Theta power was increased during preparation compared to rest. Parietal Alpha-2 power demonstrated higher values in preparation after fatigue condition while lower limb kinematics remained unchanged. Cortical activity in frontal and parietal brain areas is sensitive for predictive sensorimotor control of drop landings. Frontal Theta power demonstrates an increase and is related to higher attentional control. In a fatigued condition the parietal Alpha-2 power increase might be related to a deactivation in the somatosensory brain areas.