Development of a measure of family-centred care for resource-poor South African settings: the experience of using a modified version of the MPOC-20.

BACKGROUND: The Measure of Processes of Care (MPOC) is a widely used tool to assess parents' self-reported experiences of family-centred behaviours of paediatric rehabilitation services. It has never been used in resource-constrained settings or in a cross-cultural environment where cultural and language differences may complicate effective implementation of family-centred services. In this study, the MPOC-20 was used as the starting point for the development of a measure of family-centred care in disadvantaged South African settings. The objective was to establish to what extent the MPOC-20 needed to be adapted for these settings. METHODS: After modifying MPOC-20 through focus groups, the adapted scale was translated into six local languages. Trained interviewers administered the scale to a convenience sample of 267 caregivers of children aged between 1 and 18 years with a diagnosis of cerebral palsy living in poorly resourced areas in two provinces in South Africa. RESULTS: The modified MPOC-20 was neither reliable nor valid in the new setting. Cronbach's alpha for each of the sub-scales varied between 0.30 and 0.66 while for the test-retest reliability, the Intraclass Correlation Coefficients were between 0.51 and 0.61. The first two criteria for item convergent validity were not met. Repeated multi-trait scaling identified eight items that when combined into a scale [named the MPOC-8(SA)] had acceptable reliability and validity. Factor analysis of the MPOC-8(SA) yielded two factors: an interpersonal factor and an informational factor. CONCLUSIONS: Although extreme caution has to be used when using measures created in one socio-cultural setting in a different context, the MPOC-20 provides a useful starting point for the development of a measure of family-centred care in a poor resourced setting. Caregivers in different settings have more in common than they have differences. However, the process of asking the questions and the words used to capture caregivers' experiences needs to be different.

Development and testing of a 25-item patient satisfaction scale for black South African diabetic outpatients.

Although there is general agreement that patient satisfaction is an integral component of service quality, there is a paucity of South African research on reliable and valid satisfaction measures and the effects of health status on satisfaction. A 25-item patient satisfaction scale was developed and tested for evaluating the quality of health care for black diabetic outpatients. It was hypothesised that: (1) the underlying dimensions of patient satisfaction were interpersonal and organisational; and (2) patients in poor health would be less satisfied with the quality of their care than patients in good health. The questionnaire was administered to 263 black outpatients from Pretoria Academic Hospital and Kalafong Hospital. Factor analysis was conducted on the patient satisfaction scale and three factors, accounting for 71% of the variance, were extracted. The major items on Factor I were helpfulness, communication, support and consideration, representing the interpersonal dimension. Factors II and III were mainly concerned with service logistics and technical expertise, with the emphasis on waiting time, follow-up and thoroughness of examination. The three factors had excellent reliability coefficients, ranging between 0.82 (technical), 0.85 (logistics) and 0.98 (interpersonal). Multiple analyses of co-variance showed that patients in poor general health were significantly less satisfied with the logistical (p = 0.004) and technical (p = 0.007) quality of their care than patients in good health; patients in poor mental health were significantly less satisfied with the interpersonal quality of their care (p = 0.05) than patients in good mental health. These findings provided support for both hypotheses and suggested that patients in poor health attend to different aspects of their care than patients in good health. Of more importance to clinical practice, the results endorsed the need for a multidisciplinary health team comprising nurse/social worker (Factor I: support, communication), health service managers (Factor II: service logistics) and physician (Factor III: technical expertise) to enhance treatment outcome for diabetic patients. It is recommended that: (1) further research is conducted on this patient satisfaction scale with diverse populations in different settings to complement and validate the scale for generalised use in South Africa; (2) the scale is used to collect information on patient satisfaction before and after implementing an intervention to improve the quality of health care, and (3) measurement of health status is an essential adjunct to assessment of patient satisfaction.

The effect of type 2 diabetes mellitus on health-related quality of life (HRQOL).

Improving the quality of life of all South Africans has become a major concern to health care practitioners, organisations and politicians. However, the paucity of local information on health-related quality of life (HRQOL) does not allow us to address this public health challenge. In order to rectify this deficiency and complement international research, we undertook a study with 281 Type 2 Black diabetic patients and 437 controls, with no self-reported chronic conditions, to ascertain HRQOL. We used the SF-20 to measure functioning, general health, well-being and bodily pain (HRQOL). It was hypothesised that diabetes mellitus significantly affects functioning, general health and well-being. Multiple analyses of covariance controlled for age, schooling, marital status, employment status and commodity ownership (a socio-economic measure). Patients were significantly more likely to report poorer role functioning, poorer general health and more pain than controls, providing partial support for the hypothesis. Reliability (internal consistency) coefficients on the four multi-item SF-20 sub-scales ranged between 0.79 (well-being), 0.81 (general health), 0.83 (physical functioning) and 0.94 (role functioning) for patients: for controls these coefficients ranged between 0.70 (well-being), 0.78 (general health), 0.80 (physical functioning) and 0.90 (role functioning). Inter-correlations among the sub-scales were significant for patients and controls (p = 0.01). It was concluded that the SF-20 is a reliable instrument for measuring HRQOL in both patient and control samples, and diabetes mellitus has more impact on general health and level of pain than on well-being.

Satisfaction with personal and environmental quality of life: a black South African informal settlement perspective.

A study was conducted with 487 black adult residents of a South African informal settlement (151 men and 336 women) to ascertain satisfaction with personal and environmental quality of life. It was hypothesised that: (1) health status and life satisfaction were the underlying dimensions of personal quality of life (PQOL); (2) health status and life satisfaction were more strongly associated with PQOL than environmental quality of life (EQOL); and (3) life satisfaction and satisfaction with EQOL were positively related. Seventy per cent of respondents rated their health as good or better. Age, schooling and employment status were significantly related to health, life satisfaction and PQOL. Reliability (internal consistency) coefficients were 0.77 for the 5-item life satisfaction scale and 0.82 for the 12-item EQOL measure. Factor analysis showed that safety and security was the major unmet service need. Health status and life satisfaction explained 38% of the variance in PQOL; health status explained only 4% of the variance in EQOL. Life satisfaction was significantly related to EQOL (r = 0.16, p = 0.01). The results provided support for all three hypotheses. It was concluded that the life satisfaction and EQOL measures had good reliability; there was a definite need for a safety and security programme; and good health was a more important predictor of PQOL than EQOL.

Health and hygiene knowledge, attitudes and behaviour.

The aim of this study was to develop and test measures of health and hygiene knowledge, attitudes and behaviour. A questionnaire was administered to 240 women: 80 from a squatter camp, 80 from an informal settlement and 80 from a formal township. Reliability of the knowledge scale was 0.73. Coefficient alpha was 0.87 for the attitude and behaviour scales. The knowledge, attitude and behaviour scales were significantly related (P<0.001). Factor analysis confirmed that domestic and personal hygiene were core components of the attitude scale, whereas the emphasis for behaviour was on personal hygiene. Stepwise regression showed that age explained 23% of the variance in knowledge and 18% in behaviour. Waste management significantly affected knowledge, attitudes and behaviour, suggesting that dustbin ownership was an important public health measure. It was concluded that these scales were useful measures of health and hygiene knowledge, attitudes and behaviour; provided baseline information for planning health promotion programmes; and could be used to evaluate the effectiveness of such programmes.

Utilisation of oral health services, oral health needs and oral health status in a peri-urban informal settlement.

Interviews were conducted with 294 black residents (155 females and 138 males) of a peri-urban informal settlement in Gauteng to ascertain utilisation of oral health services, oral health needs and oral health status. Only 37 per cent of the sample had consulted a dentist or medical practitioner, usually for extractions. Teenagers and employed persons were significantly less likely to utilise dentists than the older age groups and unemployed persons. Forty per cent were currently experiencing oral health problems such as a sore mouth, tooth decay and bleeding/painful gums. Two hundred and twelve (73 per cent) interviewees wanted dental treatment or advice. Residents who rated their oral health status as fair or poor appeared to have the greatest need for oral health services. The use of interviews appears to be a cost-effective method of determining oral morbidity.

Satisfaction with family planning services. Interpersonal and organisational dimensions.

In South Africa, client satisfaction with the quality of health care has received minimal attention; probably due to the lack of locally developed and tested measures. Therefore, we developed and tested a 20-item attitude scale to determine satisfaction with Family Planning (FP) services. The objectives of this study were to: ascertain reliability of the scale and confirm, through factor analysis, that satisfaction with the FP service was based on interpersonal and organisational dimensions. The sample comprised 199 black adult interviewees (158 women and 41 men), who had previously used or were currently using contraception, from an informal settlement in Gauteng, South Africa. Three items were removed from the scale due to unacceptable communality estimates. The reliability coefficient of 0.76 for the 17-item scale was satisfactory. The principal components analysis, with orthogonal and oblique rotations, extracted two factors; accounting for 51.8% of the variance. The highest loadings on Factor I involved an interpersonal dimension (friendly, encouraging, competent, informative and communicative). Factor II tended to focus on the organisational elements of the system, such as different methods, choice of methods, service availability and length of waiting time. It was concluded that this scale was a reliable, easily administered and scored measure of satisfaction, with underlying interpersonal and organisational dimensions.

Monitoring utilisation, quality & effectiveness of free antenatal care in an informal settlement in Gauteng.

The aim of this study was to monitor utilisation, quality and effectiveness of free antenatal care from a review of clinic records. Starting randomly, 197 clinic records from four clinics were reviewed. Antenatal care was initiated at the end of the second trimester or in the third trimester, in an inadequate quantity (64% had made less than three visits). Teenagers were significantly more likely to attend only once than the older age groups (Chi-square = 12.5, df = 6, p = 0.05). Standard tasks such as age, weight, blood pressure, foetal heart monitoring, estimated gestational age and urine test results were recorded correctly. However, the effectiveness of care was difficult to assess due to incomplete records and the lack of blood test results. It was concluded that the provision of a free antenatal care service does not automatically increase utilisation; timing and quantity of care obtained were inadequate; and improvements in record keeping are essential for assessing the quality and effectiveness of care.

Job satisfaction and self-esteem of South African nurses.

The overall aim of this study was to investigate job satisfaction and self-esteem among South African nurses. The objectives of the study were to: (1) ascertain South African nurses' satisfaction with their work, pay, promotion, supervision and co-workers; (2) compare job satisfaction of South African nurses with that of North American nurses; (3) determine levels of self-esteem; and (4) test the direct and indirect effects of self-esteem on job satisfaction. A postal survey was conducted on a random sample of 2,000 nurses registered with the South African Nursing Council; 396 persons returned the questionnaires (Group 1). A subsample of 93 nonrespondents was traced and agreed to complete the questionnaire (Group 2). Minimal differences justified combining the groups and conducting subsequent analyses on total sample scores. Nurses were most satisfied with supervision and co-workers and least satisfied with promotion and pay. Reliability coefficients for the five job satisfaction subscales and overall scale ranged between 0.79 (work) and 0.93 (overall scale). South African nurses were significantly less satisfied with all aspects of their jobs than their American counterparts. Coefficient alpha for the self-esteem scale was 0.72, 0.87 for the work-related needs scale and 0.80 for the social approval scale. High self-esteem nurses were more likely to attend to work-related needs in judging their job satisfaction than low self-esteem nurses. The best model for predicting job satisfaction was the linear incorporation of self-esteem and work-related needs. It was concluded that: (1) the Job Descriptive Index (JDI) was a useful measure of job satisfaction; (2) the quality of life in the South African nursing profession was lower than their American counterparts; (3) nurses had high levels of self-esteem; and (4) self-esteem directly and indirectly affected job satisfaction.

Expressed health education needs of black adults living in Ivory Park (Gauteng).

The overall aim of this study was to ascertain African male and female expressed needs for health education programmes. A random sample of 599 adults (229 males and 370 females over 15 years of age) from an informal settlement area (Ivory Park, Gauteng) was interviewed. Out of the 599 respondents, 467 (78%) said that they had received health education, usually through the radio or at a clinic/hospital. Ninety three per cent stated that they would like to receive health education; 52 topics were mentioned. Responses were grouped into six categories: AIDS (32%); Specific Diseases (31%); Child Health (13%); Family Planning (12%); General Health (10%); and Other (2%). Gender and age group were not related to health education category. Doctors and nurses were the preferred presenters of health education at a hospital, clinic or community health centre, through a talk or TV/Video. It was concluded that: (1) there was a definite need for health education, with a focus on AIDS, tuberculosis, child health and family planning; (2) men wanted to be involved in health education programmes; and (3) innovative delivery options need to be developed.

XVth World Conference of the International Union for Health Promotion and Education, Makuhari, Japan, 20-25 August 1995. Conference report.

PIP: This article briefly highlights information provided by speakers at the World Conference of the International Union for Health Promotion and Education. The conference took place during August 1995, in Makuhari, Japan. One paper focused on health education in Japan, which would not be suitable for health promotion efforts in South Africa. Another paper focused on intersectoral efforts for health, policy, and networking. This paper addressed an issue important for all countries; the need for better communication among people working in health fields and improved outreach. A paper focusing on strengthening community action was presented. South Africa, as well as Japan, must work to involve communities in health service management. The author found that the paper on policy, practice, and research for health promotion and education was relevant to South Africa. Policymakers and practitioners tend to rely on precedence, intuition, personal experience, and political experience. Academic research funding does not support research that is relevant to policymakers and practitioners. The papers on healthy cities research were stimulating and had practical input. The proposed model involved a 3-phase and 14-step process of choosing a topic for an intervention, analyzing the intervention's political environment, and planning the political aspects of intervention. Another model of intersectoral action was spiral shaped and centered problem definition, direction setting, and structuring between networking and interorganizational relations. Four papers from Botswana focused on reproductive health. Other papers focused on teenage pregnancy.^ieng

Cognitive and affective reactions of black urban South Africans towards tuberculosis.

SETTING: The core concepts of tuberculosis (TB) control programmes are case-finding (voluntary presentation) and case-holding (compliance for both patient and system). Voluntary presentation and compliance are complex behaviours that depend upon symptom recognition and evaluation, cultural and social influences and enabling factors such as time, money, skills and appropriate/accessible health services. It was hypothesised that cognitive and affective reactions towards TB were based on perceived prevalence, perceived seriousness and perceived social stigma. OBJECTIVES: To ascertain the underlying dimensions that are used when people react cognitively and emotionally to TB, and to determine possible restricting social influence factors on voluntary presentation and case-holding. DESIGN: A questionnaire was designed to obtain information on background details, perceptions of TB (transmission, prevention, diagnosis and treatment), and a 19-item cognitive/affective scale. 19 trained interviewers administered the questionnaire. Interviews were conducted with 487 black adults (67 TB patients on ambulatory therapy and 420 non-TB community members), from two urban townships in the Transvaal, South Africa. RESULTS: The majority of respondents were aware of the infectious nature of TB, that it could be cured and the length of treatment. The most problematic issues were isolation for TB sufferers and the harm TB sufferers do to others. Cognitive/affective reactions were similar for TB patients and community members. 10 items out of the 19-item cognitive/affective scale had communality estimates > or = 0.30. 3 factors were extracted. The first factor seemed to combine personal threat (high personal and family risk) with social rejection by the immediate family and community for TB sufferers. Factor 2 had strong overtones of social stigma, with its emphasis on dirt, poverty and poor nutrition. Factor 3 rejected alcohol and tobacco consumption as causal agents of TB. CONCLUSIONS: The predominant cognitive/affective reactions towards TB were personal threat, social rejection and social stigma, providing partial support for the hypothesis. The powerful force of social rejection and social stigma cannot be underestimated. These inhibiting factors require urgent attention to improve voluntary presentation and compliance behaviour.

Tuberculosis diagnosis and treatment of young South African children: experiences and perceptions of care-givers.

SETTING: Tuberculosis (TB) in infants and young children is a major public health concern in South Africa. As care-givers of young children often supervise TB treatment, we explored their experiences and perceptions of TB. OBJECTIVES: To ascertain TB awareness, feelings about and problems with the treatment and perceptions of TB health education among care-givers of young children being treated for TB. DESIGN: An interview schedule with closed and open-ended items was designed to obtain care-giver information on background details, TB awareness, feelings and problems with the treatment, and perceptions of TB health education. Two trained interviewers administered the schedule. Responses were analysed descriptively. Responses to open-ended items were grouped into common themes and given conceptual labels. RESULTS: 51 care-givers (36 black, 11 coloured and 4 white) were interviewed. Only 8 suspected that their children had TB, but 23 sought medical attention for the classic signs/symptoms of TB. The majority had positive feelings about the treatment and felt relief/happiness due to improvement in the child's physical health. The major problems with TB therapy were the child's refusal to take the medication and distance to the clinic. Out of the 41 care-givers who acted as supervisors of TB treatment, 9 had received TB health education at a clinic, usually once, through a talk. The most important parts were giving the child treatment as prescribed and signs/symptoms of TB. CONCLUSIONS: Care-givers had a low level of TB awareness, but were very concerned about their children's health. There is a vast discrepancy between system and care-giver perspectives on TB health education, requiring immediate and radical action.

Acceptability of the tuberculosis service: scale development.

Health workers require reliable, easily administered and scored measures to evaluate acceptability of a health service. A 13-item attitude scale was developed to determine acceptability of the tuberculosis (TB) service. The objectives of this study were to: ascertain reliability (internal consistency) of the scale and confirm, through factor analysis, that acceptability of the TB service was based on cognitive and affective reactions. The sample comprised 487 black adult interviewees (67 TB patients on ambulatory therapy and 420 non-TB community members) from two urban townships in the Transvaal, South Africa. The reliability coefficient revealed a high level of internal consistency for the scale (r = 0.84). A principal components analysis, with orthogonal and oblique rotations, was conducted. Two factors accounted for 45.4% of the variance. The highest loadings on Factor I involved an empathic dimension (friendly, helpful, encouraging and communicative). Factor II tended to focus on the organizational elements of the system, such as availability, consistency of information, length of waiting time and maintenance of contact. It was concluded that this scale was a reliable, easily administered and scored measure of acceptability, with underlying affective and cognitive components.

Depression and self-esteem: rapid screening for depression in black, low literacy, hospitalized tuberculosis patients.

One hundred black hospitalized tuberculosis (TB) patients (75 males and 25 females) were interviewed to ascertain levels of depression and self-esteem. The standard of literacy for 65% of the sample was such that they were unable to complete a self-report inventory. Reliability (internal consistency) was good for the 21-item Beck Depression Inventory (BDI: r = 0.79), the 13-item shortened BDI (ABDI: r = 0.76) and the Rosenberg Self-Esteem scale (RSE: r = 0.78). There was a significant positive relationship between the BDI and the ABDI (r = 0.92, P = 0.0001). The recommended ABDI cut-off scores established no depression for 32 patients, mild depression for 22 patients, moderate depression for 38 patients and severe depression for 8 patients. There were significant negative relationships between the BDI and the RSE (r = -0.54, P = 0.0001), and between the ABDI and the RSE (r = -0.56, P = 0.0001). Self-esteem scores dropped in accordance with category of depression, revealing that low self-esteem is a characteristic feature of depression. It was concluded that the ABDI was a reliable, rapid, initial screening device for depression in black persons with low literacy levels.