Time-to-Treatment Initiation in a Decentralised Community-Care Model of Drug-Resistant Tuberculosis Management in the OR Tambo District Municipality of South Africa.

BACKGROUND: Drug-resistant tuberculosis (DR-TB) continues to challenge global efforts toward eradicating and having a tuberculosis-free world. Considering the high early mortality, especially among HIV-infected individuals, early diagnosis and prompt initiation of effective treatment are needed to significantly reduce mortality and halt transmission of DR-TB in the community. AIM: This study aims to assess the effectiveness of a community DR-TB care model with the specific objective of determining the Time-to-treatment initiation of DR-TB among patients in the OR Tambo district municipality. METHODS: A prospective cohort study of patients with DR-TB was conducted in the OR Tambo district municipality of Eastern Cape Province, South Africa. Patients were enrolled as they presented for treatment initiation at the decentralised facilities following a diagnosis of DR-TB and compared with a centralised site. RESULTS: A total of 454 DR-TB patients from six facilities between 2018 and 2020 were included in the analysis. The mean age was 37.54 (SD = 14.94) years. There were slightly more males (56.2%) than females (43.8%). Most of the patients were aged 18-44 years (67.5%), without income (82.3%). Results showed that slightly over thirteen percent (13.4%) of patients initiated treatment the same day they were diagnosed with DR-TB, while 36.3% were on the time-to-treatment target of being initiated within 5 days. However, about a quarter (25.8%) of patients failed to initiate treatment two weeks after diagnosis. Time-to-treatment initiation (TTTI) varied according to the decentralised sites, with progressive improvement with each successive year between 2018 and 2021. No demographic factor was significantly associated with TTTI. CONCLUSION: Despite rapid diagnosis, only 36% of patients were initiated on treatment promptly. Operational challenges remained, and services needed to be reorganised to maximise the exceptional potentials that a decentralised community DR-TB care model brings.

Point-of-care ultrasound: The new district focus.

BACKGROUND: Point-of-care ultrasound (POCUS) improves patient outcomes. The current POCUS curriculum of the Emergency Medicine Society of South Africa is based on guidelines from the United Kingdom with a different burden of disease (BoD) and available resources than encountered locally. AIM: To determine which modules of the POCUS curriculum should be implemented to better equip doctors working at a district hospital in the West Coast District (WCD), South Africa. SETTING: Six district hospitals within the WCD. METHODS: A descriptive cross-sectional survey with questionnaires for medical managers (MMs) and medical practitioners (MPs). RESULTS: A response rate of 78.9% for MPs and 100% for MMs was obtained. MPs rated the following modules of POCUS most relevant to their daily practice: (1) first trimester pregnancy; (2) deep vein thrombosis; (3) extended focused assessment with sonography in trauma; (4) central vascular access; and (5) focused assessment with sonography for human immunodeficiency virus (HIV) and tuberculosis (TB) (FASH). CONCLUSION: There is a need for a POCUS curriculum informed by the local pattern of disease. Priority modules were identified based on the local BoD and reported relevance to practice. Despite the availability of ultrasound machines within the WCD, few MPs were accredited and able to perform POCUS independently. There is a need to implement training programmes for medical interns, MPs, family medicine registrars and family physicians working in district hospitals. A relevant curriculum for POCUS training based on the local needs within communities has to be developed.Contribution: This study emphasises the need for a locally informed POCUS curriculum and training programmes.

Knowledge, beliefs and practices of nurses with long-acting reversible contraception, Cape Town.

BACKGROUND: Implanon and copper intrauterine contraceptive device (IUCD) are long-acting reversible contraceptives (LARC) available in public primary health care (PHC) South Africa. These methods are the most effective forms of contraception. AIM: To evaluate the knowledge, beliefs and practices on provision of LARC. SETTING: Primary health care facilities within the Khayelitsha Eastern Substructure, Cape Town. METHODS: A descriptive survey of all permanent nurses who provided contraception. Data were collected from 72/90 (80% response rate) via a validated questionnaire and evaluated using Statistical Package for Social Sciences (SPSS). RESULTS: Knowledge of eligibility for LARC was tested. The mean knowledge scores for Implanon were 8.56/11 (s.d. 1.42) for the trained and 7.16/11 (s.d. 2.83) for the untrained (p = 0.007). The mean knowledge scores for IUCD were 10.42/12 (s.d. 1.80) for the trained and 8.03/12 (s.d. 3.70) for the untrained (p = 0.019). Participants believed that inaccessibility to training courses (29%), no skilled person available (24%) and staff shortages (35%) were barriers. Less than 50% of women were routinely counselled for LARC. Forty-one percent of nurses were trained and performed IUCD insertion, and 64% were trained and performed Implanon insertion, while 61% and 45% required further training. Confidence was low, with 32% trained and confident in IUCD and 56% trained and confident in Implanon insertion. CONCLUSION: Lack of training, poor confidence and deficient counselling skills were barriers to effective LARC provision. The identified system-specific barriers must be addressed to improve uptake.Contribution: The first study to evaluate knowledge, beliefs and practices on LARC in providers in the Western Cape.

Lived experiences of patients and families with decentralised drug-resistant tuberculosis care in the Eastern Cape, South Africa.

BACKGROUND: South Africa adopted the decentralised Drug Resistant Tuberculosis (DR-TB) care model in 2011 with a view of improving clinical outcomes. AIM: This study explores the experiences and perceptions of patients and family members on the effectiveness of a decentralised community DR-TB care model in the Oliver Reginald Kaizana (OR) Tambo district municipality of the Eastern Cape, South Africa. METHOD: In this phenomenological qualitative research design, a semi-structured interview with prompts was conducted on 30 participants (15 patients and 15 family members). Framework approach to thematic content analysis was adopted for qualitative data analysis. RESULTS: Four themes emerged from the patients' interviews: adequate knowledge of DR-TB and its transmission, fear of death and isolation, long travel distances, and exorbitant transportation cost. A 'ready' health system influenced the effectiveness of community DR-TB management, while interviews with family members yielded five themes: misconceptions about DR-TB, rapid diagnosis and adherence counselling, long travel distances, activated healthcare workers, and little role of traditional healer. CONCLUSION: A perceived effectiveness of a community DR-TB care model in the OR Tambo district was demonstrated through the quality and comprehensiveness of care rendered by a 'ready' health system with activated health care workers (HCWs) who provided robust support and adequate knowledge of DR-TB and its treatment/side effects. However, misconceptions about DR-TB, long travel distances to treatment facilities, high cost of transportation and stigma remained challenging for most patients and family members.Contribution: This study provides insight into the lived experiences of a decentralised community DR-TB care model in the OR Tambo district in 2020.

Exploring resilience in family physicians working in primary health care in the Cape Metropole.

BACKGROUND: Despite the high prevalence of burnout among doctors, studies have shown that some doctors who choose to remain in primary healthcare (PHC) survive, even thrive, despite stressful working conditions. The ability to be resilient may assist family physicians (FPs) to adapt successfully to the relatively new challenges they are faced with. This research seeks to explore resilience through reflection on the lived experiences of FPs who have been working in PHC. AIM: To explore the resilience of FPs working in PHC in the Cape Metropole. SETTING: The study was conducted among FPs in PHC in the Cape Town metropole, Western Cape province, South Africa. METHODS: A phenomenological qualitative study involved interviewing 13 purposefully selected FPs working in the public sector PHC in the Cape Metropole. Data were analysed using the framework method. RESULTS: The mean resilience scale was moderate. Six key aspects of resilience were identified: having a sense of purpose, 'silver lining' thinking, having several roles with autonomy, skilful leadership, having a support network and self-care. CONCLUSION: The aspects that contribute to FP resilience are multi-faceted. It entails having a sense of purpose, 'silver lining' thinking, having several roles with autonomy, skilful leadership, having a support network and valuing self-care. Our exploration of resilience in FPs in the Cape Metropole corroborates the findings of previous studies. To ensure physician wellness and improved patient outcomes, we recommend that individual and organisational strategies should be implemented in the absence of long-term policy changes.

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.

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