Scielo RSS <![CDATA[African Journal of Primary Health Care & Family Medicine ]]> vol. 11 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>A description of community-based participatory research of hypertension awareness, prevention and treatment in a district of Matabeleland South Province, Zimbabwe</b>]]> BACKGROUND: Hypertension is an important worldwide public health challenge because of its high prevalence and concomitant risks of cardiovascular and kidney diseases. The risk factors for hypertension are well known, and screening, diagnosis and treatment of hypertension have been well researched. However, this knowledge has not been translated into community practice as there remains a huge knowledge gap between the academics, health workers and the communities. There is need for community participation in developing and implementation of health interventions among marginalised communities. AIM: The aim of this project was to improve the community's knowledge about hypertension by positively influencing beliefs and behaviours, leading to improved community hypertension outcomes. SETTING: The study was undertaken in Ward 14, a rural area situated south-west of Gwanda District, Matebeleland South Province in Zimbabwe METHODS: We conducted a health services research utilising qualitative methods by using a community-based participatory approach using a cooperative inquiry group. RESULTS: There was improvement in knowledge about awareness and primary prevention of hypertension. Community hypertension care was established through competence training of village health workers (VHWs) and more persons living with hypertension were enrolled into care. Pill pickup rate and treatment compliance improved and the community's confidence in VHWs was restored. Community hypertension screening, treatment registers and health facility referrals were established. CONCLUSION: The community was empowered; the VHW was established as a key link between the community and the formal health delivery. This was a sustainable form of improving community hypertension health outcomes. <![CDATA[<b>Accessible continued professional development for maternal mental health</b>]]> BACKGROUND: Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD. AIM: The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors. SETTING: One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study. METHODS: Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians' Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively RESULTS: Participants' knowledge showed a statistically significant (p < 0.001) improvement between the pre- and post-test results, for all six chapters of the book. However, participants' attitudes towards mental illness did not show a statistically significant change between the pre- and post-test results. CONCLUSION: We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings. <![CDATA[<b>Does the public antiretroviral treatment programme meet patients' needs? A study at four hospitals in eThekwini, KwaZulu-Natal, South Africa</b>]]> BACKGROUND: Patients play a major role in the success of any antiretroviral treatment (ART) programme. Hence, their needs should be articulated on a regular basis for interventional processes to promote adherence, retention and quality care. AIM: This study investigated whether patients' needs were being met, described which needs were met, which were not and how such needs could be met. SETTING: The study took place at four ART clinics in eThekwini district public hospitals. METHODS: This study formed part of a larger study that utilised a sequential mixed-methods design. However, only the qualitative component is documented herein. Twelve HIV-infected patients engaged in in-depth interviews (three patients from each of the four hospitals). A socio-ecological framework divided responses into four categories, namely, the individual, interpersonal, institutional and policy. Each category presented (1) patients' needs that are being met, (2) needs that are not being met, (3) recommendations on how they can be met and (4) researchers' observations. RESULTS: All 12 patients reported that all their needs were not being met. They further shared their met needs, unmet needs and made recommendations for meeting their unmet needs. These needs varied per antiretroviral clinic because of unique processes at each institution CONCLUSION: To adequately address the needs of HIV-infected patients, it is imperative for all stakeholders involved in the public ART programme to gain an understanding of what constitutes 'patients' needs'. The results reflect patients' willingness to be involved in their care, treatment and interventional strategies to adequately meet their needs. <![CDATA[<b>A preliminary analysis of the association between perceived stigma and HIV-related pain in South Africans living with HIV</b>]]> BACKGROUND: Stigma related to the human immunodeficiency virus (HIV) remains common and has been associated with severity of HIV-related symptoms. Associations between HIV stigma and HIV-related pain, one of the most common symptoms in HIV, have however not been investigated. Data from low back pain populations suggest that stigma is associated with worse pain intensity and so we hypothesised that the same would be the case in HIV. AIM: The goal of this study was to assess the association between HIV stigma and pain intensity in people living with HIV (PLWH) with chronic pain whilst controlling for depression, a well-established correlate of pain. SETTING: The study took place at an HIV clinic in Johannesburg, South Africa. METHODS: Mediation analysis was used to assess the effect of depression on the relationship between stigma and pain intensity in a cross-sectional cohort of 50 PLWH and chronic pain (pain most days of the week for > 3 months). All participants were assessed using the HIV/AIDS Stigma Instrument - PLWA, an 11-point numerical pain rating scale and the Beck Depression Inventory II. RESULTS: In all, 88% (44/50) of participants reported experiencing some form of HIV stigma (HIV stigma scale score ≥ 1). Worst pain intensity and depressive symptoms individually correlated with total stigma score (Spearman's r = 0.33, p = 0.02 for both). The mediation analysis highlighted that mediation of the relationship by depression was equivocal (b = -0.002, bootstrapped confidence interval -0.02 to 0.00. CONCLUSION: Whilst these preliminary data are marginal, they do suggest that associations between HIV stigma and HIV-related pain warrant further investigation. Future study should also include potential mechanisms, which may include mediation through depression. <![CDATA[<b>Lifestyle, cardiovascular risk knowledge and patient counselling among selected sub-Saharan African family physicians and trainees</b>]]> BACKGROUND: Cardiovascular disease (CVD)-related deaths in sub-Saharan Africa (SSA) are on the rise, and primary care physicians could facilitate the reversal of this trend through treatment and prevention strategies. AIM: The aim of this study was to determine the relationship between physician lifestyle practices, CVD prevention knowledge and patient CVD counselling practices among family physicians (FPs) and family medicine (FM) trainees affiliated to FM colleges and organisations in SSA. SETTING: FPs and FM trainees affiliated to FM colleges and organisations in Anglophone SSA. METHODS: A web-based cross-sectional analytical study was conducted using validated, self-administered questionnaires. Following collation of responses, the relationship between the participants' CVD prevention knowledge, lifestyle practices and CVD counselling rates was assessed. RESULTS: Of the 174 participants (53% response rate), 83% were married, 51% were females and the mean age was 39.2 (standard deviation [SD] 7.6) years. Most of the participants responded accurately to the CVD prevention knowledge items, but few had accurate responses on prioritising care by 10-year risk. Most participants had less than optimal lifestyle practices except for smoking, vegetable or fruit ingestion and sleep habits. Most participants (65%) usually counselled patients on nutrition, but less frequently on weight management, exercise, smoking and alcohol. The region of practice and physicians with poor lifestyle were predictive of patient counselling rates. CONCLUSION: Training on patient counselling and self-awareness for CVD prevention may influence patient counselling practice. Promoting quality training on patient counselling among FPs as well as a healthy self-awareness for CVD prevention is thus needed. The complex relationship between physician lifestyle and patient counselling warrants further study. <![CDATA[<b>Reasons why insured consumers co-pay for medicines at retail pharmacies in Pretoria, South Africa</b>]]> BACKGROUND: Costly prescription medicines with existing cheaper alternatives tend to be purchased by medically insured consumers of healthcare. In South Africa medical scheme members pay higher out-of-pocket payments for medicines than those without insurance. AIM: This study explored reasons for co-payments among insured Pretoria medical scheme members purchasing prescription medicines at private retail pharmacies, despite being insured and protected against such payments. SETTING: The study took place in retail pharmacies in Pretoria, Gauteng Province, South Africa. METHODS: An exploratory qualitative study was performed. Semi-structured interviews were conducted among purposefully sampled medical scheme members (12) and nine key informants (six pharmacists and three regulators - one for the pharmaceutical industry, one for medical schemes and one for pharmacists). Three pharmacies (two corporate and one independent) each were identified from high and low socio-economic areas. Scheme members were interviewed immediately after having made a co-payment (eight) or no co-payment (four) from the selected pharmacies. Interviews were recorded, coded and organised into themes. RESULTS: Co-payments were deemed confusing, unpredictable and inconsistent between and within pharmacies. Members blamed schemes for causing co-payments. Six sampled pharmacies rarely stocked the lowest-priced medicines; instead, they dispensed medicines from manufacturers with whom they had a relationship. Corporate pharmacies were favoured compared to independents and brand loyalty superseded cost considerations. Medical scheme members did not understand how medical schemes' function. CONCLUSION: Unavailability of lowest-priced medicines at pharmacies contributes to co-payments. Consumer education about generics and expedited implementation of National Health Insurance could significantly reduce co-payments. <![CDATA[<b>Descriptive epidemiology of anaemia among pregnant women initiating antenatal care in rural Northern Ghana</b>]]> BACKGROUND: Anaemia in pregnancy is associated with adverse obstetric outcomes. When detected early in pregnancy, it can be treated; however, information on its prevalence and associated factors is limited in rural Ghana. AIM: The aim of this study was to determine the prevalence and maternal factors associated with anaemia in pregnancy at first antenatal care (ANC) visits. SETTING: The study was conducted in the Navrongo War Memorial Hospital, a secondary referral facility in the Kassena-Nankana district in rural northern Ghana. METHODS: A retrospective analysis of antenatal clinic records of pregnant women collected from January to December 2014. All pregnant women initiating antenatal clinic, who had initial haemoglobin (Hb) levels measured, were included in the study. Logistic regression analyses were carried out to determine factors associated with anaemia at the initiation of ANC. RESULTS: We analysed data from 506 women with median Hb of 11.1 g/dL (IQR 7.31-13.8). The median gestational age at booking was 14 weeks (5-36 weeks). The prevalence of anaemia was 42.7%, with 95% confidence interval (CI) [38.4-47.1], and was high among teenage mothers (52% [34.9-67.8]), mothers who booked in the third trimester (55% [33.6-74.7]) and grand multiparous women (58% [30.7-81.6]). Factors associated with anaemia included grand multiparity (odds ratio [OR] = 1.94 with 95% CI [1.58-2.46]), booking during the third trimester (OR = 2.06 [1.78-2.21]) and mother who were underweight compared to those with normal weight (OR = 3.17 [1.19-8.32. CONCLUSION: Burden of anaemia in pregnancy is still high in rural northern Ghana. We advocate further strengthening of the primary health care system to improve early access to ANC delivery <![CDATA[<b>A practice framework to enhance the implementation of the Policy on Integration of Mental Health Care into primary health care in KwaZulu-Natal province</b>]]> BACKGROUND: Mental health care at primary health care (PHC) still remains a challenge despite the Policy on Integration of Mental Health Care into PHC which was developed in 1997 at the time when the White Paper for the Transformation of the Health System in South Africa was published. The White Paper made provision for a new health care system based on the principles of the PHC approach to care. This was followed by the promulgation of the Mental Health Care Act No. 17 of 2002 which is based on the principle that mental health care should be integrated into PHC; however, there have been challenges with regard to the implementation of this policy, AIM: This study aimed to analyse the implementation of Policy on Integration of Mental Health Care into PHC with the ultimate aim of developing a practice framework for PHC nurses to enhance such implementation in KwaZulu-Natal (KZN). SETTING: The study took place in selected health districts in KZN, namely, Ugu, eThekwini, iLembe and uMgungundlovu. METHODS: A qualitative approach using grounded theory design was used to develop a practice framework to enhance the implementation of Policy on Integration of Mental Health Care into PHC. A theoretical sampling method was used to select the sample from PHC managers, operational managers and professional nurses for the collection of data. The sample consisted of 42 participants. Data were collected by means of one-on-one interviews and focus group interviews. Strauss and Corbin's approach of data analysis was used for analysing data. The paradigm model was used as a guide to develop a practice framework to enhance the implementation of the Policy on Integration of Mental Health Care into PHC in KZN. RESULTS: This study found that integration of mental health care into PHC is understood as a provision of comprehensive care to mental health care users using either a supermarket approach or a one-stop-shop approach at PHC clinics. Strategies that are used at PHC clinics in KZN ensure that the integration of mental health care into PHC is implemented, includes the screening of all patients that come to the PHC clinic for mental illness, fast tracking of mental health care users once they have been assessed, and found to be mentally ill and management of all mental health care users as patients with chronic diseases. CONCLUSION: The practice framework developed identifies comprehensive mental health care being offered to mental health care users using either a supermarket approach or a one-stop-shop approach, depending on the availability of staff with a qualification in psychiatric nursing science. <![CDATA[<b>Social and economic barriers to adherence among patients at Livingstone General Hospital in Zambia</b>]]> BACKGROUND: Zambia is one of the countries hardest hit by the human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) pandemic with a national HIV prevalence estimated at 14% among those aged 15-49 years in 2012. Antiretroviral therapy (ART) has been available in public health facilities in Zambia since 2003. By early 2016, 65% of the 1.2 million Zambians living with HIV were accessing ART. While access to ART has improved the lives of people living with HIV globally, the lack of adherence to ART is a major challenge to treatment success globally. AIM: This article reports on social and economic barriers to ART adherence among HIV patients being attended to at Livingstone General Hospital in Zambia. SETTING: Livingstone General Hospital is located in the Southern province of Zambia, and had over 7000 patients enrolled for HIV care of whom 3880 patients were on ART. METHODS: An explorative, qualitative study was conducted with 42 patients on ART where data were collected through six focus group discussions (3 male and 3 female groups) and seven in-depth interviews. Data were audio-recorded and transcribed verbatim and subjected to thematic content analysis. RESULTS: Economic factors such as poverty and unemployment and the lack of food were reported as major barriers to adherence. Furthermore, social factors such as traditional medicine, religion, lack of family and partner support, and disclosure were also reported as critical barriers to adherence to ART. CONCLUSION: Interventions to improve adherence among ART patients should aim to redress the socio-economic challenges at community and individual levels. <![CDATA[<b>Knowledge and home treatment of measles infection by caregivers of children under five in a low-income urban community, Nigeria</b>]]> BACKGROUND: Despite the availability of a safe and effective vaccine for over 50 years, measles remains a leading cause of death among young children in developing countries. AIM: This study assessed the knowledge and home treatment of measles by caregivers of children under 5 years. SETTING: Abebi community, Ibadan, Oyo State, Nigeria. METHODS: A descriptive cross-sectional study of 509 caregivers of children aged 6 months to 5 years in a semi-urban community in Ibadan was conducted using a multi-stage sampling method. An interviewer administered structured questionnaire was used to collect information on socio-demographic characteristics, knowledge of aetiology, main symptoms and signs, and home treatment of measles. Chi-square test and logistic regression were used to explore associations at 5% level of significance. RESULTS: Most of the caregivers were females (96.3%), married (86.1%) and were the biological parents of the children (90.9%). More than half had good knowledge of the cause (59.7%) and main symptoms and signs (52.8%) of measles. However, the composite knowledge was good in 57.6% of caregivers. Over half (54.4%) of the caregivers reported that their children ever had measles. Majority (91.3%) of caregivers whose children had measles gave home treatment, while 24 (8.7%) sought treatment from health facilities alone. There was a significant association between caregivers' educational status, age, tribe and marital status and their knowledge of measles; however, tribe was the only significant predictor of knowledge after regression analysis. Caregivers from other tribes were 3.3 times more likely to have good knowledge of measles than Yoruba caregivers. Caregivers who were 35 years and older compared to those younger than 35 years (OR: 0.625; 95% CI: 0.425-0.921) and those who were not currently married compared to those married (OR: 0.455; 95% CI: 0.273-0.758) had lower odds of having good knowledge of measles, respectively. CONCLUSION: Home treatment by caregivers of children with measles is high. Health education on the cause, prevention and treatment of measles should be provided for caregivers. <![CDATA[<b>Low back pain among primary school teachers in Rural Kenya: Prevalence and contributing factors</b>]]> BACKGROUND: Low back pain (LBP) has been recognised as a common occupational problem with a high prevalence among work-related musculoskeletal disorders. Although there appears to be a high prevalence of LBP among school teachers, there is inadequate information on the prevalence and predisposing factors of LBP among primary school teachers in rural Western Kenya. AIM: To determine the prevalence, factors associated with LBP and physical disability caused by LBP. SETTING: The setting was public schools in rural Western Kenya selected by simple random sampling method. METHODS: A cross-sectional study was conducted among primary teachers from public schools using a self-administered questionnaire. The questionnaire included information on LBP, demographic data, occupational and psychosocial factors and disability score. The 12-month prevalence, associated factors and LBP disability were analysed. RESULTS: The 12-month self-reported prevalence of LBP among primary teachers was 64.98%, with close to 70% of them reporting minimal disability. The logistic regression analysis showed that female gender (odds ratio [OR]: 1.692, p < 0.02) was associated with LBP and high supervisor support (OR: 0.46, p < 0.003) was negatively associated with LBP. CONCLUSION: The prevalence of LBP among primary school teachers in rural Western Kenya is 64.98%, with the majority of them reporting minimal disability. The identified risk factors were female gender and low supervisor support. The presence of work-related psychosocial risk factors in this study suggests a comprehensive approach in evaluation and management of LBP. Preventive measures should be in place to prevent and reduce the progression of LBP disability. <![CDATA[<b>Nurses' perception of the multidisciplinary team approach of care for adolescent mothers and their children in Ugu, KwaZulu-Natal</b>]]> BACKGROUND: Adolescent childbearing has numerous consequences on maternal health, child health and the well-being of society. Because of the high-risk nature of adolescent pregnancy, a multidisciplinary team (MDT) approach is recommended to achieve satisfactory pregnancy outcomes. AIM: The aim of this study was to explore nurses' perceptions of the MDT approach in the continuum of care for adolescent mothers and their children. SETTING: The study was conducted in a local district hospital in Ugu, KwaZulu-Natal. METHODS: An explorative and descriptive qualitative study design was used. The first author and hospital staff (clinical midwives and the clinical manager of obstetrics and gynaecology) collaborated on the development of the focus group discussion (FGD) guide to explore nurses' perception of the MDT approach of care for adolescent mothers and their children. A total of three FGDs were conducted. Data were analysed using thematic analysis. RESULTS: Six overarching themes emerged from the data analysis which included professional benefits of adopting the MDT approach of care for adolescent mothers and their children, barriers to the multidisciplinary collaboration, clinical benefits of adopting the MDT approach of care for parenting adolescent mothers, problems and needs of adolescent mothers, and nurses' reasons regarding their willingness to participate in a multidisciplinary collaboration in the care of parenting adolescent mothers. CONCLUSION: In the opinion of nurses, the MDT approach of care for adolescent mothers and their children is an important strategy to improve maternal and child health outcomes. This study has important implications for the design of an intervention. <![CDATA[<b>Contribution of the Nelson R. Mandela School of Medicine to a socially accountable health workforce</b>]]> BACKGROUND: A socially accountable health professional education curriculum aims to produce fit-for-purpose graduates to work in areas of need. 'Fit-for-purpose' can be assessed by monitoring graduate practice attributes. AIM: The aim of this article was to identify whether graduates of 'fit-for-purpose' programmes are socially accountable. SETTING: The setting for this project was all 37 district hospitals in the KwaZulu-Natal province in Durban, South Africa. METHODS: We surveyed healthcare professionals working at district hospitals in the KwaZulu-Natal province. We compared four social accountability indicators identified by the Training for Health Network Framework, comparing medical doctors educated at the Nelson R. Mandela School of Medicine (NRMSM) with medical doctors educated at other South African and non-South African medical schools. In addition, we explored medical doctors' characteristics and reasons for leaving or staying at district hospitals. RESULTS: The pursuit of specialisation or skills development were identified as reasons for leaving in the next 5 years. Although one-third of all medical doctors reported an intention to stay, graduates from non-South African schools remained working at a district hospital longer than graduates of NRMSM or other South African schools and they held a majority of leadership positions. Across all schools, graduates who worked at the district hospital longer than 5 years cited remaining close to family and enjoyment of the work and lifestyle as motivating factors. CONCLUSION: Using a social accountability approach, this research assists in identifying areas of improvement in workforce development. Tracking what medical doctors do and where they work after graduation is important to ensure that medical schools are meeting their social accountability mandate to meet community needs. <![CDATA[<b>'No one prepared me to go home': Cerebrovascular accident survivors' experiences of community reintegration in a peri-urban context</b>]]> BACKGROUND: The South African health system has policies and strategies to ensure effective rehabilitation and reintegration of individuals who have survived a cerebrovascular accident into their respective communities. However, implementation of such guidelines remains an issue AIM: This study sought to explore cerebrovascular accident (CVA) survivors' experiences of community integration SETTING: The study was located in a peri-urban community within the KwaZulu-Natal Province, South Africa METHODS: An explorative qualitative study with eight purposively selected CVA survivors was conducted via semi-structured individual interviews. Data were audio-recorded and manually transcribed prior to thematic analysis. Trustworthiness of the study was maintained by strategies such as analyst triangulation, an audit trail and use of thick descriptions. Ethical principles of autonomy, informed consent, confidentiality and privacy were also maintained in the study RESULTS: Six themes emerged that highlighted (1) loss of autonomy and roles, (2) barriers to community reintegration, (3) social isolation of participants, (4) finding internal strength, (5) enablers of community reintegration including the positive influence of support and the benefits derived from rehabilitation and (6) recommendations for rehabilitation CONCLUSION: The study revealed both positive and negative influences that impact CVA survivors' ability to effectively reintegrate into their respective communities following a CVA. Recommendations include the need for education and awareness around access to rehabilitation services for CVA survivors, advice on how to improve CVA survivors' ability to mobilise in the community and make environmental adaption to facilitate universal access, provision of home programmes and caregiver training for continuity of care and for inclusion of home-based rehabilitation into current models of care <![CDATA[<b>Development of a Sesotho health literacy test in a South African context</b>]]> BACKGROUND: Research shows that poor health literacy (HL) can be a threat to health and health care. Health literacy is under-researched and poorly understood in developing countries, including South Africa, because of the absence of language and context-specific HL tests AIM: The researchers aimed to develop an appropriate HL test for use among South African public health service users with Sesotho as their first language. SETTING: The test was developed in the Free State Province of South Africa, for use among Sesotho speakers. METHODS: Mixed methods were employed to develop the Sesotho Health Literacy Test (SHLT). The process of developing the test was carried out in distinctive methodological steps. RESULTS: The stepwise process set out by identifying abstracts (n = 206) referring to HL tests. Sourcing of HL tests followed a tapered process resulting in the use of 17 HL tests. Elements within a conceptual framework guided HL test item selection (n = 47). Two Delphi sessions assisted in reaching consensus regarding final HL test items (n = 40). The readability testing of the SHLT tested 4.19 on the Coleman-Liau Index score. A context-suitable and comprehensive SHLT ensued from this work. CONCLUSION: The SHLT assessment instrument development creates a platform for HL testing among Sesotho first language speakers in South Africa. The context-sensitive methodology is entrenched in a theoretical framework, distributing HL test items between identified competencies and related skill dimensions and domains. The methodology can be applied to the development of HL tests for other languages and population groups in developing countries. <![CDATA[<b>Implementation of postnatal care for HIV-positive mothers in the Free State: Nurses' perspectives</b>]]> BACKGROUND: Postnatal care (PNC) provides the opportunity for protecting the lives of women infected with human immune deficiency virus (HIV) and their babies. The prevention of mother-to-child transmission of HIV (PMTCT) guidelines provide a framework for implementation of PNC. There has been no empirical evidence on how the nurses at the clinic level implement these guidelines. In addition, there are reports that PNC has been neglected in South Africa. AIM: The study aimed to explore the implementation of PNC for HIV-positive women, by explicating nurses' views regarding their practices SETTING: The study was conducted in 2015 at three clinics at Mangaung Metro Municipality in the Free State. METHODS: A qualitative, evaluative case study was conducted to provide a detailed account of the implementation of PNC, using 2015 PMTCT guidelines as a framework for evaluation. Eighteen key informants participated in three focus groups. Data were reviewed through direct thematic analysis. RESULTS: Four themes emerged from data analysis, namely, guidelines as an empowering tool, implementation of HIV guidelines, perceived successes and challenges of postnatal HIV care, and measures to strengthen postnatal HIV care services. The study found that nurses interpreted and used guidelines to direct their practice. However, there were challenges and some successes. CONCLUSION: It was concluded that nurses had a good understanding of the guidelines provided for their practices and implemented them with various levels of success. Effective management of HIV-infected women during the postnatal period requires well-designed multidisciplinary collaborations, adequate resources, continuous professional development programmes, a high level of competence and confidence. <![CDATA[<b>Nutrition knowledge, attitudes and practices of primary school children in Tshwane Metropole, South Africa</b>]]> BACKGROUND: The increasing prevalence of being overweight and obesity in South African school children requires interventions that are evidence based. Nutrition knowledge, attitudes and practices (KAP) studies are thus needed to provide evidence for the planning of interventions that address and prevent nutrition problems in school children. AIM: The aim of the study on which this article is based was to assess nutrition knowledge, attitudes and practices of grade 4-6 learners from three primary schools in a South African township. The article seeks to highlight the key results of this quantitative study SETTING: The study took place in three primary schools in Mamelodi township, Pretoria, South Africa. METHODS: Data were collected from grade 4-6 learners using self-administered questionnaires. After coding and collating data using Epi infoTM, STATA was then used for analysis. A description of KAP results was carried out using simple descriptive statistics, while the associations were tested using a chi-square test. RESULTS: Learners displayed inadequate knowledge of a balanced diet (23%) as well as low knowledge of food groups. With regard to attitudes, the most liked food group was the drinks and snacks (72.9%), while the least liked food group was the fruits and vegetables (8.11%). With regard to practices, the most frequently consumed food group was the drinks and snacks (72.6%), while fruits and vegetables were the least consumed. However, 78.91% of the learners displayed very good nutrition-related practices, such as making their own breakfast and eating breakfast. CONCLUSION: The inadequate knowledge displayed by learners indicates a gap with nutrition education in the curriculum. There is a need to explore innovative and novel approaches to improve nutrition knowledge of school children. Parents also need to be targeted to ensure better outcomes. <![CDATA[<b>Factors that impact the timely treatment of obstetric fistulas in Malawi: The perspective of health care providers</b>]]> BACKGROUND: In sub-Saharan African countries, women face a high risk of obstetric fistulas. In Malawi, the prevalence rate is 1 per 1000 women. Studies suggest that several obstacles exist that prevent obstetric fistula patients from getting timely treatment for their condition. AIM: The aim of this article was to find out the factors that delay the timely treatment of obstetric fistula patients at Malawian hospitals SETTING: The study was conducted at the Queen Elizabeth Central Hospital, a referral hospital, situated in Blantyre, Malawi, and the findings have been generalised to all the hospitals in Malawi. METHODS: An exploratory case study, employing key interview questions, was used to provide insights into why there are delays in providing treatment and care for fistula patients. Purposive sampling technique was used to identify study respondents. Key informant interviews were conducted with 16 health care personnel at a hospital in Malawi. RESULTS: The presence of numerous cases of complicated obstetric fistula cases overwhelms the health care system in Malawi. In addition, the severe shortage of staff, lack of obstetric fistula surgery training, low staff morale, inadequate infrastructure or equipment and water scarcity in the city of Blantyre contribute towards delayed treatment of fistulas at the hospitals. CONCLUSION: The presence of numerous cases of obstetric fistulas is overwhelming health services, and hence there is a need for devising and implementing health policies that will motivate Malawian health personnel to undertake obstetric fistula surgery and care. <![CDATA[<b>Community healthcare worker response to childhood disorders: Inadequacies and needs</b>]]> BACKGROUND: Community healthcare workers (CHWs) play a vital role in linking health facilities and communities where there is a high prevalence of childhood disorders. However, there is limited literature on whether this cadre of workers is adequately prepared for this task. AIM: This study explored the training needs of CHWs working in the field of childhood disorders and disabilities to improve the future training of CHWs and service delivery. SETTING: This study was conducted in an urban district in KwaZulu-Natal, South Africa. METHODS: This qualitative study used purposive sampling to recruit 28 CHWs and 4 key informants working in health facilities in one district of the KwaZulu-Natal Province in South Africa. Data were collected via semi-structured interviews and focus groups. Interviews were conducted in the first language (isiZulu) of the CHWs. Data were analysed thematically. Ethical clearance was obtained from a Biomedical Science Research Ethics Committee. RESULTS: There was an evident lack of knowledge and skill in managing childhood disorders and disabilities by CHWs. Enablers and restrictors affecting service delivery were highlighted. Moreover, the training needs of CHWs have raised critical concerns because of the variable nature of training and perceived inadequate preparation for service delivery. The challenges raised were also generic to the holistic role of CHWs and not particularly specific to the CHW role in childhood disorders and disabilities. CONCLUSION: Training of CHWs in childhood disorders may assist in improving CHWs' competence and confidence in the field, which may enhance service delivery and thus may assist in contributing towards improving healthcare for children at this level of care. <![CDATA[<b>Health system challenges affecting HIV and tuberculosis integration at primary healthcare clinics in Durban, South Africa</b>]]> BACKGROUND: Tuberculosis (TB) is the most common presenting illness among people living with human immunodeficiency virus (HIV), with co-infection occurring in up to 60% of cases in South Africa. In line with international guidelines, South Africa has adopted an integrated model at primary healthcare level to provide HIV and TB services by the same healthcare provider at the same visit. AIM: The aim of the study was to conduct a rapid appraisal of integration of HIV and TB services at primary healthcare level in eThekwini District in 2015. SETTING: The study was conducted in 10 provincial primary healthcare clinics in the eThekwini Metropolitan Health District in KwaZulu-Natal Province. METHODS: An observational, cross-sectional study was conducted. Key informant interviews with operational managers and community health workers were conducted, as well as a review of registers and electronic databases for the period of January to March 2015. RESULTS: Two clinics complied with the mandated integrated model. Three clinics were partially integrated; while five clinics maintained the stand-alone model. Possible constraints included reorganisation of on-site location of services, drug provision, TB infection control and inadequate capacity building, while potential enablers comprised structural infrastructure, staffing ratios and stakeholder engagement CONCLUSION: HIV and TB integration is suboptimal and will need to be improved by addressing the systemic challenges affecting health service delivery, including strengthening supervision, training and the implementation of a change management programme. <![CDATA[<b>Knowledge, attitudes and practices regarding HIV/AIDS among senior high school students in Sekondi-Takoradi metropolis, Ghana</b>]]> BACKGROUND: In Ghana, youths aged 15-24 years constitute the group most vulnerable to HIV infection. Inadequate knowledge, negative attitudes and risky practices are major hindrances to preventing the spread of HIV. AIM: This study sought to investigate the knowledge, attitudes and practices regarding HIV/AIDS among senior high school (SHS) students SETTING: Sekondi-Takoradi metropolis, Ghana. METHODS: A descriptive, cross-sectional design was adopted, using a validated self-administered questionnaire, to collect data from a stratified sample of 294 senior students selected from three participating high schools in August 2017. The data collected were analysed using Stata version 12. Descriptive and inferential statistics were at a significance level of 0.05. RESULTS: Among the participants, 61.6% had good knowledge about HIV/AIDS, 172 (58.5%) showed positive attitudes towards people living with HIV (PLHIV) and 79.1% reported HIV-related risky practices. We found a significant association between age and attitudes (p < 0.05). Poor knowledge was associated with being Muslim (aOR = 1.51 and 1.93; CI 1.19-1.91; p = 0.00) and being a student from school 'F' senior high school (F SHS) (aOR = 1.93; CI 1.71-2.18; p = 0.00). Bad attitude towards PLHIV and HIV was associated with ages 15-19 years (aOR = 3.20[2.58-3.96]; p = 0.03) p confirmed; and single marital status (aOR = 1.79[1.44-2.23]; p = 0.00). Bad practices were associated with ages 15-19 years (aOR = 1.72[1.41-2.11]; p = 0.08), belonging to the Akans ethnic group (aOR = 1.57[1.26-1.97]; p = 0.00) or being single (aOR = 1.79[1.44-2.23]; p = 0.00). Associations between misconceptions and HIV transmission were found: HIV can be transmitted by a handshake (aOR = 3.45[2.34-5.68]; p = 0.000), HIV can be cured (aOR = 2.01[2.12-5.04]; p = 0.004) and HIV/AIDS can be transmitted by witchcraft (aOR = 3.12[3.21-7.26]; p = 0.001. CONCLUSION: Participants generally had inadequate knowledge regarding HIV/AIDS, manifested negative attitudes towards PLHIV and also engaged in risky practices that might predispose them to HIV transmission. Our findings underscore the need for culturally adapted and age-oriented basic HIV information for youths in the metropolis on misconceptions about HIV transmission, negative attitudes of students towards PLHIV as well as the risky practices of students regarding HIV. <![CDATA[<b>Ingestion of mammalian meat and alpha-gal allergy: Clinical relevance in primary care</b>]]> BACKGROUND: An allergic reaction to mammalian meat has recently been reported in rural parts of South Africa and throughout other parts of the world. The cause of this allergic reaction is because of an oligosaccharide antigen known as galactose-alpha-1, 3-galactose (alpha-gal) found in mammalian meat. Hard ticks in various parts of the world have been identified as a cause of sensitisation to the alpha-gal antigen. However, mechanisms of sensitisation in Africa are poorly understood. AIM: The aim of this article is to review current literature on the alpha-gal allergy and mammalian meat ingestion and the family physician's role in diagnosing and managing this condition. METHOD: Indexes were searched using the keywords in the following electronic databases: Elsevier Science Direct, Google Scholar, Medline and PubMed. RESULTS: Clinical presentation of the alpha-gal allergy occurs typically as a delayed anaphylaxis occurring within 3-6 hours after the ingestion of mammalian meat. A subset of patients described in South Africa presented with a rapid onset of symptoms occurring within 45 minutes. Furthermore, some of these patients present with abdominal symptoms only, which may be mistaken as food poisoning. Diagnosis is based on a history of reaction to mammalian meats (especially to fatty portions or organs) and serum specific alpha-gal antibodies. The main management of the alpha-gal allergy is avoidance of red meat and in mild reactions treatment with oral H1 receptor antihistamines CONCLUSION: Sensitisation to the alpha-gal allergy results in adverse reactions to red meat, with tolerance to turkey, chicken and fish. A family physician can safely manage this condition. <![CDATA[<b>Calling non-governmental organisations to strengthen primary health care: Lessons following Alma-Ata</b>]]> BACKGROUND: The Alma-Ata Declaration's commitment to primary health care (PHC) reaches its 40th anniversary in 2018. Over the last 40 years, the number of non-governmental organisations (NGOs) working in low-income countries (LICs) has rapidly multiplied, and over time, NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems in LICs AIM: The authors aim to demonstrate that at the 40th anniversary of the Alma-Ata Declaration's commitment to PHC, NGOs are particularly poised to strengthen PHC in LICs METHODS: In this letter, the authors reflect on how NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems based on their experience working with NGOs in LICs RESULTS: NGOs are poised to strengthen PHC in LICs in four distinct ways: assisting with local human resources development, strengthening local information systems, enabling community-based health services and testing innovative service delivery projects CONCLUSIONS: The authors call for NGOs to commit their expertise and resources to long-term strengthening of PHC in LICs and to critically examine the factors that prevent or assist them in this goal. As the principles of Alma-Ata are renewed, NGOs should be responsibly engaged in strengthening the declaration's goal of 'health for all' <![CDATA[<b>World Family Doctors Day 2019: Reflections from an African perspective</b>]]> BACKGROUND: The Alma-Ata Declaration's commitment to primary health care (PHC) reaches its 40th anniversary in 2018. Over the last 40 years, the number of non-governmental organisations (NGOs) working in low-income countries (LICs) has rapidly multiplied, and over time, NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems in LICs AIM: The authors aim to demonstrate that at the 40th anniversary of the Alma-Ata Declaration's commitment to PHC, NGOs are particularly poised to strengthen PHC in LICs METHODS: In this letter, the authors reflect on how NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems based on their experience working with NGOs in LICs RESULTS: NGOs are poised to strengthen PHC in LICs in four distinct ways: assisting with local human resources development, strengthening local information systems, enabling community-based health services and testing innovative service delivery projects CONCLUSIONS: The authors call for NGOs to commit their expertise and resources to long-term strengthening of PHC in LICs and to critically examine the factors that prevent or assist them in this goal. As the principles of Alma-Ata are renewed, NGOs should be responsibly engaged in strengthening the declaration's goal of 'health for all' <![CDATA[<b>A declaration for all?</b>]]> BACKGROUND: The Alma-Ata Declaration's commitment to primary health care (PHC) reaches its 40th anniversary in 2018. Over the last 40 years, the number of non-governmental organisations (NGOs) working in low-income countries (LICs) has rapidly multiplied, and over time, NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems in LICs AIM: The authors aim to demonstrate that at the 40th anniversary of the Alma-Ata Declaration's commitment to PHC, NGOs are particularly poised to strengthen PHC in LICs METHODS: In this letter, the authors reflect on how NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems based on their experience working with NGOs in LICs RESULTS: NGOs are poised to strengthen PHC in LICs in four distinct ways: assisting with local human resources development, strengthening local information systems, enabling community-based health services and testing innovative service delivery projects CONCLUSIONS: The authors call for NGOs to commit their expertise and resources to long-term strengthening of PHC in LICs and to critically examine the factors that prevent or assist them in this goal. As the principles of Alma-Ata are renewed, NGOs should be responsibly engaged in strengthening the declaration's goal of 'health for all' <![CDATA[<b>Family physicians' experience and understanding of evidence-based practice and guideline implementation in primary care practice, Cape Town, South Africa</b>]]> 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 <![CDATA[<b>The differential effect of the free maternity services policy in Kenya</b>]]> BACKGROUND: The Government of Kenya introduced the free maternity services (FMS) policy to enable mothers deliver at a health facility and thus improve maternal health indicators.AIM: The aim of this study was to determine if there was a differential effec.t of the policy by region (sub-county) and by facility type (hospitals vs. primary healthcare facilities [PHCFsSETTING: The study was conducted in Nyamira County in western KenyaMETHODS: This was an interrupted time series study where 42 data sets (24 pre- and 18 post-intervention) were collected for each observation. Monthly data were abstracted from the District Health Information System-2, verified, keyed into and analysed by using IBM-Statistical Package for the Social Sciences (SPSS-17).RESULTS: The relative effect of the policy on facility deliveries in the county was an increase of 22.5%, significant up to the 12th month (p < 0.05). The effect of the policy on deliveries by region was highest in Nyamira North and Masaba North (p < 0.001 up to the 18th month). The effect was larger (46.5% vs. 18.3%) and lasted longer (18 months vs. 6 months) in the hospitals than in the PHCFs. The increase in hospital deliveries was most significant in Nyamira North (61%; p < 0.001). There was a medium-term effect on hospital deliveries in Borabu (up to 9 months) and an effect that started in the sixth month in Manga. The relative effect of the policy on facility deliveries in PHCFs was only significant in Nyamira North and Masaba North (p < 0.001).CONCLUSION: The effect of the FMS policy was varied by region (sub-county) and by facility type. <![CDATA[<b>Measuring empathy in a group of South African undergraduate medical students using the student version of the Jefferson Scale of Empathy</b>]]> BACKGROUND: Patient-centred care is a model of care that demands healthcare providers change their focus from the disease to the patient and his or her perceived physical and psycho-social needs. This model requires healthcare workers to listen actively and to have effective communication skills and well-developed levels of empathy. AIM: The aim of this study was to determine the suitability of the Jefferson Scale for Empathy (JSE-S) as a valid test for empathy in third-year medical students at a South African university and also to determine the baseline level of empathy in this same group of students. SETTING: The study took place at a medical school in the Western Cape, South Africa. This medical degree (MB ChB) is a 6-year programme. Students are first exposed to patients within their second year of training, but it is during their third-year that they start their clinical rotations. We wanted to test whether our empathy training would give students the necessary skills and enable them to establish good empathic communication habits in order to prevent a fall in empathy during this vulnerable period. METHODS: This article explores the suitability of the student version of the JSE-S as a valid test for empathy, within the South African medical school context. We briefly discuss the psychometrics and the scores against what is already known in countries like ours, specifically, developing nations where cultural and language differences exist in the student populations. Furthermore, we explore whether the JSE-S is a valid scale for pre- and post-intervention measurement of medical student empathy within our context and discuss the limitations of self-assessment. We also report on baseline levels of empathy in third-year medical students. RESULTS: Two hundred and six third-year medical students (69% females) completed the JSE-S prior to the intervention. Females and students aged 25 years and older had significantly higher scores than males and those 22 years old or less. The mean JSE was 109.98 (SD = 12.54), which is lower than most internationally reported scores. The Cronbach's alpha coefficient was 0.81, indicating scale reliability and consistency, but graded item response testing highlighted variance in three reverse-scored questions. CONCLUSION: The JSE-S is an appropriate and valid scale for measuring levels of empathy in undergraduate medical students in South Africa. However, language may need to be clarified in the negatively phrased items. <![CDATA[<b>A self-assessment study of procedural skills of doctors in peri-urban district hospitals of Gauteng, South Africa</b>]]> BACKGROUND: Several studies have been carried out on procedural skills of doctors in district hospitals in rural South Africa. However, there is insufficient information about skills of doctors in peri-urban district hospitals. This paper attempts to supplement this vital information.AIM: The aim of the study was to determine self-reported levels of competence in procedural skills of doctors in peri-urban district hospitals and to assess factors influencing this.SETTING: The study was undertaken in three district hospitals in two health districts of Gauteng Province.METHODS: A cross-sectional descriptive study using a self-administered questionnaire was undertaken in three district hospitals in two health districts of Gauteng Province. The questionnaire assessed procedural skills based on district health service delivery requirements for doctors in district hospitals using a modified skill set developed for family medicine training in South AfricaRESULTS: There was a wide range of self-reported competence and experience among doctors for various skill sets. Doctors were generally more competent for procedures in general surgery, medicine, orthopaedics, obstetrics and gynaecology and paediatrics than anaesthesia, ear, nose and throat and ophthalmology. There were statistically significant associations between age and overall anaesthetic competence (p = 0.03); gender and overall competence in surgery (p = 0.03), orthopaedics (p = 0.02) and urology (p = 0.005); years of experience and overall competence in dermatology skills; current hospital and overall competence in anaesthesia (p = 0.01), obstetrics and gynaecology (p = 0.015) and dermatology skills (p = 0.01).CONCLUSION: This was one of the first studies to look at self-reported procedural competence of doctors in a peri-urban setting in South Africa. The results highlight the need for regular skills audits, standardised training and updating of skills of doctors in district hospitals. <![CDATA[<b>The physical, psychological and social impact of long bone fractures on adults: A review</b>]]> BACKGROUND: Long bone fractures are common injuries caused by trauma and are a common cause for referral to hospitals. Little consideration has been given to the impact of long bone fractures in adults despite the World Health Organization's statement that such injuries cause substantial morbidity in low- and middle-income countries. AIM: This review targeted published studies conducted from 1990 to 2017 that examined the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults METHOD: This scoping review involved a systematic literature search using key terms in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight and Ebscohost Research databases and Google Scholar. RESULTS: From a total of 297 publications, 19 met the inclusion criteria: four publications focused on the impact of fractures of the humerus, one publication looked at ulna fractures, six publications focused on distal radius fractures, five looked at femur fractures and three focused on tibial fractures. CONCLUSION: Long bone fractures have a considerable impact on many facets of a patient's life. In some cases, the fracture prevents patients from working and meeting financial obligations. The injury limited previously normal social interactions and pre-injury functioning. Future research should examine the impact of long bone fractures in Africa, as there were very limited studies, which were identified. <![CDATA[<b>Professional nurses' experiences of caring for patients in public health clinics in Ekurhuleni, South Africa</b>]]> BACKGROUND: Caring for patients is the core aspect of nursing and a cornerstone of all nursing duties. Although caring is seen as a critical component of nursing delivery and an essential characteristic of nursing, there seems to be a gap between theory and practice AIM: The aim of this article was to explore and describe the experiences of caring for patients by professional nurses in public health clinics in Ekurhuleni SETTING: The study was conducted in Ekurhuleni, an area east of the Gauteng Province in two public health clinics METHODS: A qualitative, exploratory, descriptive phenomenological and contextual research design was used. In-depth, individual phenomenological interviews were conducted with eight purposefully sampled professional nurses to explore their experiences of caring for patients in public health clinics in Ekurhuleni. Data were analysed using Giorgi's coding method RESULTS: Two themes were revealed in the study findings. The first theme was the experienced empowering aspects of caring while the second theme was the experienced disempowering aspects of caring. The experienced empowering aspects of caring had two categories: empowering interpersonal experiences and the empowering experiences through client affirmation. These were identified by the participants as enabling effective caring for patients. The experienced disempowering aspects of caring also had two categories: disempowering interpersonal experiences and the disempowering experiences resulting from public health clinic system challenges. The disempowering aspects were identified by participants as disenabling effective caring for patients CONCLUSION: The study findings reveal that the professional nurses had empowering and disempowering experiences while caring for patients in the public health clinics <![CDATA[<b>Evidence of interventions for improving healthcare access for lesbian, gay, bisexual and transgender people in South Africa: A scoping review</b>]]> BACKGROUND: The lesbian, gay, bisexual and transgender (LGBT) populations have unique health risks including an increased risk of mental health problems, high usage of recreational drugs and alcohol, and high rates of infection with human immunodeficiency virus (HIV). Healthcare workers' heteronormative attitudes compromise the quality of care to the LGBT population AIM: The objective of this study was to provide an overview of documented evidence on South Africa interventions aimed at improving healthcare access for LGBT individuals using a systematic scoping review SETTING: This is a secondary literature review METHODS: An electronic search was conducted using the following databases: EBSCOhost, PubMed, Cumulative Index to Nursing and Allied Health Literature, and Google Scholar. Abstract and full article data were screened using inclusion and exclusion criteria by two researchers. Data extracted from the eligible studies were analysed using thematic analysis. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool, version 2011 RESULTS: Seventeen articles of the initial 151 hits were selected for review and an additional five files were identified through bibliographical search. Most studies had small sample sizes and focused on sexual health, targeting gay men and men who have sex with men in urban areas. Lesbians and bisexual women were not prioritised DISCUSSION: It emerged from the review that LGBT issues were not covered in the healthcare worker curriculum. Further it was noted that there is a paucity of data on the South African LGBT population, as sexual orientation does not form part of the routine data set. The findings of this review indicate gaps in the literature, practice guidelines and policies in LGBT healthcare in South Africa <![CDATA[<b>Rural-urban health disparities among older adults in South Africa</b>]]> BACKGROUND: There are limited studies assessing rural-urban disparities among older adults in Africa including South Africa AIM: This study explores rural-urban health disparities among older adults in a population-based survey in South Africa SETTING: Data for this study emanated from the 2008 study on 'Global Ageing and Adult Health (SAGE) wave 1' (N = 3280) aged 50 years or older in South Africa METHODS: Associations between exposure variables and outcome variables (health status variables and chronic conditions) were examined through bivariate analyses and multivariable logistic regression RESULTS: Rural dwellers were more likely to be older, black African and had lower education and wealth than urban dwellers. Rural and urban dwellers reported a similar prevalence of self-rated health status, quality of life, severe functional disability, arthritis, asthma, lung disease, hypertension, obesity, underweight, stroke and/or angina, low vision, depression, anxiety and nocturnal sleep problems. Adjusting for socio-demographic and health risk behaviour variables, urban dwellers had a higher prevalence of diabetes (OR: 2.36, 95% CI: 1.37, 4.04), edentulism (OR: 2.79, 95% CI: 1.27, 6.09) and cognitive functioning (OR: 1.91, 95% CI: 1.27, 2.85) than rural dwellers CONCLUSION: There are some rural-urban health disparities in South Africa, that is, urban dwellers had a higher prevalence of diabetes, edentulism and cognitive functioning than rural ones. Understanding these rural-urban health variations may help in developing better strategies to improve health across geolocality in South Africa <![CDATA[<b>Evolution of attitudes, trends and perceptions of smoking among middle and secondary school students in the Gharb Region, Morocco, 2010-2015</b>]]> BACKGROUND: Tobacco use is an important public health issue. Morocco implemented a tobacco control programme, which has been ongoing among students at middle and secondary schools since 2010 AIM: This study aims to compare the trend in smoking among the programme beneficiaries with the results of the initial study conducted prior to the implementation of the programme SETTING: This study was conducted in middle and secondary schools of the Gharb Region in Morocco between 2010 and 2015 METHODS: Two cross-sectional studies were conducted in 2010 and 2015 in the middle and secondary schools of the Gharb Region. Multistage cluster sampling was used. The information was collected using a self-administered questionnaire RESULTS: In the first study in 2010, 5312 students participated, and in the second one in 2015, 4208 students participated. The level of information on smoking and its effects was higher in 2015 (94.0%) than in 2010 (92.5%). In 2010, parents, primary schools and television and radio were more involved in student information on smoking compared to 2015. The proportion of students claiming that tobacco was not a pleasure (86.3%) and that it does not calm nerves (76.5%) was significantly higher in 2015 than in 2010. The prevalence of smoking increased significantly in 2015 (2.9%) against 2010 (1.8% CONCLUSION: This study reports the general positive evolution in knowledge about smoking and its effects. Despite that the prevalence of smokers increased in 2015. The results suggest the need to address family influences on adolescent smoking and to investigate participation of schools in education and training students in tobacco dependence prevention <![CDATA[<b>Institutional tuberculosis infection control in a rural sub-district in South Africa: A quality improvement study</b>]]> BACKGROUND: Tuberculosis (TB) is a major global health challenge, and South Africa is one of the high-burden countries. A national TB infection control (TBIC) guideline has stipulated three areas of infection control at health facilities: work practice and administrative control, environmental control, and personal protection for health workers AIM: The aim of this study was to identify the gaps and address the challenges in institutional TBIC SETTING: The district hospital and a primary health care clinic within the Mossel Bay sub-district in the Western Cape METHODS: According to the national TBIC draft guideline, a quality improvement cycle was used to evaluate and improve TBIC. Each facility had an existing infection and prevention control and occupational health and safety team, which were used as the audit teams RESULTS: A baseline assessment was followed by a set of interventions, which did not show a significant improvement in TBIC. The difference between the pre- and post-intervention TB screening rate was not statistically significant. An assessment of time interval between 101 patients presenting with TB symptoms and diagnosed with TB was 4 days at baseline and post-intervention. Most of the anticipated improvements were dependent on the health workers' adherence to the local TBIC policies, which emerged as an unexpected finding CONCLUSION: We found good managerial commitment reflected by the presence of various policies, guidelines, specific personnel and committees to deal with infection control in general. This study has created awareness about TBIC among staff and pointed out the complexity of health workers' behaviour towards adhering to policies <![CDATA[<b>Building consensus on identifying research mentoring gaps and finding ways of addressing the gap in a Kenyan college of health sciences</b>]]> BACKGROUND: The concept of mentoring in clinical practice has traditionally focused on moving graduates from novice to more respectable positions within the clinical practice hierarchy. With the growing emphasis on evidence-based practice, the role of research in generating evidence for practice cannot be overemphasised. Mentoring in clinical operational research for both students and junior members of academic staff in health professionals' training colleges is as important as mentoring for clinical skills AIM: This study aimed at building consensus on possible ways of enhancing research mentoring for graduate students and members of academic staff in a college of health sciences SETTING: The study was conducted within Moi University College of Health Sciences (MUCHS) in Eldoret, Kenya METHODS: The study population was composed of academic staff members and registered graduate students by the end of 2015. All academic staff and graduate students were eligible to participate. The Delphi technique was used to not only collect individual opinions but also build consensus. During the first iteration, questions were sent for which open-ended responses were needed. Responses from the first round were grouped into patterns and themes that guided the writing of questions for the subsequent rounds RESULTS: The response rate was 78%. There was consensus in appreciating that mentoring was fundamental for career growth in clinical practice and research and needed for improving and developing formal structure for effective mentoring. It was crucial to establish training programmes for mentors and for accrediting them CONCLUSION: Enhancing of current research mentoring in MUCHS was needed and expected by graduate students and academic staff <![CDATA[<b>Transgender population's experiences with regard to accessing reproductive health care in Kwazulu-Natal, South Africa: A qualitative study</b>]]> BACKGROUND: The transgender population has unique health risks, including increased risk of mental illness, substance abuse, suicide and a high prevalence of human immunodeficiency virus (HIV). Worldwide studies indicate that this population is marginalised and faces barriers in accessing health care. In South Africa, there is limited information and research on the transgender population's interaction with health services AIM: The purpose of this study was to examine the experiences of the transgender population in accessing health care facilities for sexual and reproductive needs SETTING: The study took place in KwaZulu-Natal province of South Africa METHODS: A qualitative study combining phenomenological and critical ethnographic approaches was conducted to explore the experiences of the transgender population in the health care setting. Critical ethnography was chosen because it is an emancipatory method that highlights the plight of disenfranchised groups, and phenomenology was used to illuminate experiences of the transgender population. Purposive snowball sampling was applied to select nine transgender participants who had experiences of contact with a health care setting. Data collection was performed through semi-structured interviews and a focus group discussion RESULTS: Participants provided details about the paucity of facilities, resources and targeted programmes to cater for the transgender populations' sexual and reproductive health needs. The participants engage in high-risk behaviour, comprising unprotected sex and use of cross-gender hormones without medical supervision. Furthermore, the participants reported experiences of hostile and discriminatory behaviour by healthcare workers CONCLUSION: It emerged that there is a paucity of resources and knowledge to provide appropriate health care services to the transgender population, resulting in adverse experiences. Policies on transgender care and training of health workers will contribute towards improvement of health care access for the transgender population <![CDATA[<b>Barriers to men's involvement in antenatal and postnatal care in Butula, western Kenya</b>]]> BACKGROUND: Men have a lot of influence on their partners' and children's health. However, studies have shown their involvement in antenatal care (ANC) and postnatal care (PNC) is relatively low owing to several factors AIM: To explore the barriers to men's involvement in ANC and PNC in Butula sub-county, western Kenya SETTING: Butula sub-county, Busia county, western Kenya METHODS: A mixed methods study design, descriptive in nature, was used to collect both quantitative and qualitative data. A total of 96 men were selected to participate in the surveys. Also, four focus group discussions and four key informant interviews were conducted RESULTS: We found out that some men still participate in ANC and PNC despite the barriers. The perception that maternal health is a women's domain and existence of alternative traditional maternal services were key cultural barriers. The men's nature of work, low income and expenses incurred at ANC/PNC clinics were significant economic barriers. The lack of services targeting men, provider attitude, non-invitation to the clinic, time spent at the clinic and lack of privacy at the clinics were key facility-based barriers CONCLUSION: A myriad of cultural, economic and health-facility barriers hinder men from active involvement in ANC and PNC. Awareness creation among men on ANC and PNC services and creating a client-friendly environment at the clinics is key in enhancing their involvement. This should be a concerted effort of all stake holders in maternal health services, as male involvement is a strong influencer to their partners' and children's health outcomes <![CDATA[<b>Prevalence and determinants of psychological insulin resistance among type 2 diabetic patients in Kinshasa, Democratic Republic of Congo</b>]]> BACKGROUND: Psychological insulin resistance (PIR) is a common but unappreciated phenomenon by health care providers with a negative impact on the control of type 2 diabetes mellitus AIM: To determine the frequency of PIR and its determinants in patients with type 2 diabetes SETTING: This study was conducted in Kinshasa in three health centres providing management of diabetic patients METHODS: This study was a multicentric, cross-sectional study conducted from 01 November 2017 to 31 March 2018 in Kinshasa among 213 type 2 diabetic patients who were taking oral anti-diabetic drugs. A standardised questionnaire, the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ), was used for data collection RESULTS: The average age of participants was 59.8 ± 11.1 years with a male to female ratio of 1.5. The prevalence of PIR was 42.7%; and its main determinants were 50 years of age (odds ratios [OR] adjusted 2.05; 95% confidence interval [CI] 1.98-4.27; p = 0.045), the presence of complications (OR adjusted 3.33; 95% CI 1.68-6.60; p = 0.001), lack of knowledge about insulin therapy (OR adjusted 1.96; 95% CI 1.03-3.71; p = 0.040) and the high cost of insulin (OR adjusted 2.32; 95% CI 1.08-4.95; p = 0.030 CONCLUSION: The study showed that almost half of type 2 diabetic patients had PIR with the main determinant factors related to the patient and the health system. The establishment of a therapeutic education programme, improved 'provider-patient' communication and the development of approaches to increase access to drugs are crucial to reduce the prevalence of PIR <![CDATA[<b>Assessment of tuberculosis knowledge among Lesotho village health workers and utilisation of their tuberculosis services by the communities they serve</b>]]> BACKGROUND: The role of village health workers (VHWs), among other roles is to educate communities about tuberculosis (TB), TB screening and its treatment. The knowledge of TB among VHWs is crucial because they will carry out their role at the community well and this will impact the overall outcome of TB treatment AIM: The study is aimed at assessing the knowledge of TB among VHWs and households at the village level and the utilisation of VHWs' TB services SETTING: The study took place in 19 health centres from 10 districts of Lesotho METHODS: The study used a cross-sectional descriptive design. Three study populations were interviewed, two at the household level (2040 households, 8295 individuals) and one at the clinic level (723 VHW RESULTS: Overall, TB knowledge among VHWs for the majority of clinics except two was inadequate (below mean of 31.5). The utilisation of VHWs' TB services among community members was also low CONCLUSION: Low utilisation of VHWs' TB services by community members emanated from inadequate TB knowledge of VHWs. Regular refresher training among VHWs is recommended as the way forward in order to keep VHWs abreast with new TB developments <![CDATA[<b>Exploring factors influencing integration of traditional and medical male circumcision methods at Ingquza Hill Local Municipality, Eastern Cape: A socio-ecological perspective</b>]]> BACKGROUND: Medical male circumcision (MMC) and traditional male circumcision (TMC) are reportedly having negative and positive outcomes in the Eastern Cape province. Researchers show contradictory remedies; some advocate for abolishment of TMC and others call for the integration of both methods AIM: This study aimed to explore factors influencing the integration of TMC and MMC at different socio-ecological levels SETTING: The study was conducted at Ingquza Hill Local Municipality in the Eastern Cape province METHODS: An explorative qualitative study design, using in-depth interviews (IDIs) and focus group discussions (FGDs), was employed in this study. Purposive sampling was used to select the participants. A framework analysis approach was used to analyse the data, and the themes were developed in line with the socio-ecological model RESULTS: Four main themes emerged from the data as important in influencing the integration of TMC and MMC methods. These incluided: (1) individual factors, related to circumcision age eligibility and post-circumcision behaviour; (2) microsystem factors, related to alcohol and drug abuse, peer pressure, abuse of initiates, and family influence; (3) exosystem factors, related to financial gains associated with circumcision and the role of community forums; and (4) macrosystem factors, related to stigma and discrimination, and male youth dominance in circumcision practices CONCLUSION: Male circumcision in this area is influenced by complex factors at multiple social levels. Interventions directed at all of these levels are urgently needed to facilitate integration of the TMC and MMC methods <![CDATA[<b>Child sexual abuse: The significance of the history and testifying on non-confirmatory findings</b>]]> BACKGROUND: Despite numerous studies and publications, there is still a common expectation that a medical assessment can confirm or rule out child sexual abuse (CSA). The truth is that CSA can never be ruled out and can seldom be confirmed on clinical grounds AIM: The objective of this article was to suggest which aspects to consider when the expert medical witness in a CSA case needs to explain why CSA can seldom be confirmed and can never be ruled out. The importance of a sound medical and medico-legal history was discussed because the history was generally the only positive 'finding' of the assessment of children who have possibly been abused METHOD: Authoritative sources were used to support the explanation of reasons for an absence of corroborative clinical findings in CSA, as defined by the World Health Organization. The authors structured the individual sections by providing a background on which to base the testimony. They then summarised the clinical forensic significance of the information which should be offered in the courts and which should reflect on the court records, to be taken into account in the eventual decision, which will be made by the court RESULTS: A guideline was provided for answering questions frequently posed to the expert witness in child abuse cases where there were no positive findings CONCLUSION: A structure for the explanation of reasons for a normal clinical examination when evaluating children who may have been sexually abused may reduce the discomfort of medical witnesses and improve the quality of expert medical testimony <![CDATA[<b>Towards national health insurance: Alignment of strategic human resources in South Africa</b>]]> BACKGROUND: South Africa is implementing national health insurance (NHI) and primary health care (PHC) re-engineering, and has concomitantly introduced the Human Resources for Health (HRH) Strategy. These policies are underpinned by the National Development Plan (NDP), which aims to address widespread inequality and inequity AIM: The aim of this study was to analyse the alignment of national HRH-related policies to implement NHI and PHC re-engineering and determine knowledge gaps and research needs METHOD: A narrative review of the NDP, PHC re-engineering, HRH and NHI strategies was carried out, supplemented by key HRH reports, data and articles RESULTS: Current policies stress NHI and PHC re-engineering without effectively addressing shortages and maldistribution of HRH across the provincial and public-private divides. In line with PHC re-engineering, the HRH Strategy emphasised strengthening of community health workers (CHWs), professional nurses (PNs), mid-level workers (MLWs), medical practitioners (MPs) and clinical specialists (CSs). Four of these, CHWs, MLWs, MPs and CSs, are varyingly still in absolute shortfall, as well as being inequitably distributed across the provincial and public-private divides. The seeming adequacy in the absolute number of PNs may disguise provincial and public-private sector disparities. Although expedited HRH development and equitable deployment are crucial, it is also vital to resolve extant education and accreditation challenges delaying HRH policy implementation CONCLUSION: The current lack of alignment of HRH policies does not portend well for the successful implementation of NHI and PHC re-engineering. Knowledge gaps include the need for further clarification of ideal multi-disciplinary team compositions and responsibilities <![CDATA[<b>Indigenous and faith healing for mental health in Ghana: An examination of the literature on reported beliefs, practices and use of alternative mental health care in Ghana</b>]]> BACKGROUND: For many people in African countries, various forms of health care are utilised for the treatment of illness. This pluralistic nature of health seeking includes the use of indigenous, faith and allopathic medicines for care AIM: In this article, our aim was to gain insight into the existing knowledge on indigenous and faith healing in Ghana, with a particular focus on mental health care. We first examine the reported mental health beliefs and practices of Ghanaian alternative healers. Following this, we look at the use and purported preference for non-biomedical mental health care by patients METHODS: Relevant literature was examined to explore the beliefs, practices and use of non-biomedical mental health care systems in Ghana RESULTS: Evidence for the use and preference for non-biomedical mental health care is largely anecdotal. Similarly, the mental health beliefs of alternative healers have been documented in various small-scale studies. However, such information is important if mental health services in Ghana are to be improved CONCLUSION: Integration of the different healthcare systems must be built on knowledge of beliefs and methods. A clearer understanding of the work of non-biomedical healers is important if appropriate recommendations are to be made for collaboration between biomedical and non-biomedical systems in Ghana <![CDATA[<b>Indigenous and faith healing in Ghana: A brief examination of the formalising process and collaborative efforts with the biomedical health system</b>]]> BACKGROUND: Health seeking in many African countries typically involves making use of multiple healing systems, including indigenous and faith systems, as well as biomedical healthcare systems. These different systems have co-existed for many years in Africa, including in Ghana AIM: In this article, we examine the formalising processes that non-biomedical healthcare in Ghana has undergone in postcolonial times. We first present a brief historical analysis of the process of organising indigenous medical systems into formal bodies. We then conclude by exploring collaborative efforts that have been undertaken between biomedical and non-biomedical health systems in Ghana METHOD: A historical analysis of formalised indigenous healing systems in Ghana was done through an examination of relevant literature RESULTS: Formal groups of indigenous healers in Ghana who are organised into specific categories have undergone various transformations over the years. Evidence also exists of collaborative programmes developed with traditional healers in Ghana, although these have been largely for primary health partnerships. With regard to mental health collaborations, attempts at integration have been generally unsuccessful, with various factors identified as hindering successful partnerships CONCLUSION: Indigenous healing is an important component of healthcare in Ghana. Collaboration between the different healthcare systems can be strengthened through accurate understandings of how key stakeholders are situated (and indeed situate themselves) in the conversation <![CDATA[<b>Systematic review of factors influencing oral health-related quality of life in children in Africa</b>]]> BACKGROUND: Oral health-related quality of life (OHRQoL) is influenced by cultural and societal context. Existing OHRQoL children measurement tools have been conceptualised in high-income countries. Probing whether the factors influencing OHRQoL are context-reliant in the African setting is necessary and is the purpose of the current review AIM: To investigate if the factors influencing OHRQoL are context-reliant METHODS: Seven databases were searched using search terms ('oral health'; and 'quality of life', 'health-related quality of life', 'patient-reported outcomes', 'well-being'; and 'child*', 'adolescents', 'teen*', 'youth'; and 'determinants', 'factors', 'predictors'; and 'oral health quality of life tools/instruments/scales'; and 'Africa*'). Abstracts identified were exported to a reference software manager. Three of the authors used specific selection criteria to review, firstly, 307 abstracts and, secondly, 30 full papers. Data were extracted from these papers using a pre-designed data extraction form, after which quantitative synthesis of data was performed RESULTS: Key factors influencing OHRQoL followed an existing conceptual framework where environmental and individual factors in the form of socio-economic status (SES), area of residence and children psyche status, and the presence of any oral condition other than dental caries were reported among child populations in Africa CONCLUSION: There is preliminary evidence to suggest an association between individual factors such as children's psyche and oral problems, excluding dental caries, and environmental determinants such as area of residence and SES in children's OHRQoL in African children. The finding that dental caries was not a key factor in child-oral health is unexpected. There seemed to be a contextual viewpoint underpinning the current OHRQoL frameworks and OHRQoL was context-reliant <![CDATA[<b>Primary health care and family medicine in Sierra Leone</b>]]> This article is a country profile of Sierra Leone describing the state of primary health care and family medicine in early 2019. Family medicine in Sierra Leone faces many challenges but recent changes in the location of the training programme encourage optimism that it may become better established within the next few years.