Improving the annual review of diabetic patients in primary care: an appreciative inquiry in the Cape Town District Health Services

Assessing the impact of a motivational intervention to improve the working lives of maternity healthcare workers: a quantitative and qualitative evaluation of a feasibility study in Malawi

BACKGROUND

Globally too many mothers and babies die during childbirth; 98% of maternal deaths are avoidable. Skilled clinicians can reduce these deaths; however, there is a world-wide shortage of maternity healthcare workers. Malawi has enough to deliver 20% of its maternity care. A motivating work environment is important for healthcare worker retention. To inform a future trial, we aimed to assess the feasibility of implementing a motivational intervention (Appreciative Inquiry) to improve the working lives of maternity healthcare workers and patient satisfaction in Malawi.

METHODS

Three government hospitals participated over 1 year. Its effectiveness was assessed through: a monthly longitudinal survey of working life using psychometrically validated instruments (basic psychological needs, job satisfaction and work-related quality of life); a before and after questionnaire of patient satisfaction using a patient satisfaction tool validated in low-income settings with a maximum score of 80; and a qualitative template analysis encompassing ethnographic data, semi-structured interviews and focus groups with staff.

RESULTS

The intervention was attended by all 145 eligible staff, who also participated in the longitudinal study. The general trend was an increase in the scores for each scale except for the basic psychological needs score in one site. Only one site demonstrated strong evidence for the intervention working in the work-related quality of life scales. Pre-intervention, 162 postnatal women completed the questionnaire; post-intervention, 191 postnatal women participated. Patient satisfaction rose in all three sites; referral hospital 4.41 rise (95% CI 1.89 to 6.95), district hospital 10.22 (95% CI 7.38 to 13.07) and community hospital 13.02 (95% CI 10.48 to 15.57). The qualitative data revealed that staff felt happier, that their skills (especially communication) had improved, behaviour had changed and systems had developed.

CONCLUSIONS

We have shown that it is possible to implement Appreciative Inquiry in government facilities in Malawi, which has the potential to change the way staff work and improve patient satisfaction. The mixed methods approach revealed important findings including the importance of staff relationships. We have identified clear implementation elements that will be important to measure in a future trial such as implementation fidelity and inter-personal relationship factors.

"By working together and caring for one another we can win this fight": A qualitative exploration of a traditional healer's perspectives of care of people with epilepsy in a South African urban township in Cape Town

There is a gap in knowledge about the construction of care in the Global South where biomedical care remains largely inaccessible to many people, resulting in people seeking health care from the indigenous sector of health care. As part of a larger study, in this, article we present findings from a single individual interview with an indigenous healer using a semi-structured interview guide that was based on Kleinman's Explanatory Model Framework. Key themes that emerged from the thematic analysis of our indigenous healer's audio-recorded transcribed transcript were about "care". The four overarching subthemes were the following: (i) care in the family, (ii) care in the community, (iii) care in the health system, and (iv) respondents' construction of care. A key feature of care, for this healer, is its explicit location in lineages of community - care is seen not as an individual or organizational issue, but part of the shared social fabric. We argue that it is crucial to attend to the lay understandings and practices of care which reflect diverse ways of understanding care and relationality in context. Future research is needed to close this gap.

"The others look at you as if you are a grave": a qualitative study of subjective experiences of patients with epilepsy regarding their treatment and care in Cape Town, South Africa

BACKGROUND

Existing evidence shows that the majority of people with epilepsy in lower and middle income countries are not receiving appropriate treatment and care. Although this problem has been reported as one of the factors affecting the quality of lives of people with epilepsy, very few studies have investigated patients' perspectives and their experiences about the problem. This qualitative study explored perspectives and subjective experiences of people with epilepsy about their illness in an urban township in South Africa.

METHODS

Individual face-to-face interviews included twelve people who had epilepsy. A semi-structured interview guide which was based on Kleinman (1980) Explanatory Models Framework was used to elicit participants' perspectives and subjective experiences about their illness and its treatment. Thematic analysis method was used to analyse the data.

RESULTS

The main theme reflecting participants' verbatim accounts was about their perceived difficulties affecting their access to treatment and care during their routine clinical follow up visits. These concerned rushed consultations which focussed on seizure frequency and adherence to medication with no attention to personal concerns. They perceived that part of the problem could be that some health care practitioners were not adequately trained and lacked empathy, interest, respect and listening skills. We argue that in a health system where patients feel that they are not respected and their concerns are not listened to or are ignored, they may lack trust in the system and this may violate their right to access treatment and care.

CONCLUSIONS

The findings provide a glimpse of the extent to which the power and nature of the routine task-centred system can lead to violation of patients' health rights - especially with epilepsy which is poorly understood and stigmatized. Appropriate interventions are needed to address health system factors affecting the treatment and care of this marginalized and vulnerable group of patients.

'A thing full of stories': Traditional healers' explanations of epilepsy and perspectives on collaboration with biomedical health care in Cape Town

The experience of epilepsy is profoundly culturally mediated and the meanings attributed to the condition can have a great impact on its social course. This qualitative study used Kleinman's Explanatory Model framework to explore traditional healers' perspectives on epilepsy in an urban township in Cape Town, South Africa. The healers who participated in the study were Xhosa-speaking, had experience caring for patients with epilepsy, and had not received any training on epilepsy. Six individual in-depth interviews and one focus group with nine traditional healers were conducted using a semi-structured interview guide. Traditional healers identified several different names referring to epilepsy. They explained epilepsy as a thing inside the body which is recognized by the way it presents itself during an epileptic seizure. According to these healers, epilepsy is difficult to understand because it is not easily detectable. Their biomedical explanations of the cause of epilepsy included, among others, lack of immunizations, child asphyxia, heredity, traumatic birth injuries and dehydration. These healers believed that epilepsy could be caused by amafufunyana (evil spirits) and that biomedical doctors could not treat the supernatural causes of epilepsy. However, the healers believed that western medicines, as well as traditional medicines, could be effective in treating the epileptic seizures. Traditional healers were supportive of collaboration with western-trained practitioners and highlighted that the strategy must have formal agreements in view of protection of intellectual property, accountability and respect of their indigenous knowledge. The findings suggest a need for interventions that promote cultural literacy among mental health practitioners. Research is urgently needed to assess the impact of such collaborations between biomedical services and traditional healers on epilepsy treatment and care.

Auditing chronic disease care: Does it make a difference?

Background

An integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa's Western Cape Province participated in the audit process.

Aim

To determine whether clinical audits improve chronic disease care in health districts over time.

Setting

Western Cape Province, South Africa.

Methods

Internal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 (‘2012 old’) to districts that started auditing recently (‘2012 new’).

Results

The number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the ‘2012 old’ districts compared to the ‘2012 new’ districts for both the facility audit and the folder review, including for eight clinical indicators, with ‘2012 new’ districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21–0.31).

Conclusion

These findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes.

Cost-effectiveness of a diabetes group education program delivered by health promoters with a guiding style in underserved communities in Cape Town, South Africa

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of a group diabetes education program delivered by health promoters in community health centers in the Western Cape, South Africa.

METHODS

The effectiveness of the education program was derived from the outcomes of a pragmatic cluster randomized controlled trial (RCT). Incremental operational costs of the intervention, as implemented in the trial, were calculated. All these data were entered into a Markov micro-simulation model to simulate clinical outcomes and health costs that were expressed as an Incremental Cost Effectiveness Ratio (ICER).

RESULTS

The only significant effect from the RCT at one year was a reduction in blood pressure (systolic blood pressure -4.65 mmHg (95%CI:-9.18 to -0.12) and diastolic blood pressure -3.30 mmHg (95%CI:-5.35 to -1.26)). The ICER for the intervention, based on the assumption that the costs would recur every year and the effect could be maintained, was 1862 $/QALY gained.

CONCLUSION

A structured group education program performed by mid-level trained healthcare workers at community health centers, for the management of Type II diabetes in the Western Cape, South Africa is therefore cost-effective.

PRACTICE IMPLICATIONS

This cost-effectiveness analysis supports the more widespread implementation of this intervention in primary care within South Africa.

Effectiveness of a group diabetes education programme in under-served communities in South Africa: a pragmatic cluster randomized controlled trial

AIM

To evaluate the effectiveness of group education, led by health promoters using a guiding style, for people with type 2 diabetes in public sector community health centres in Cape Town.

METHODS

This was a pragmatic clustered randomized controlled trial with 17 randomly selected intervention and 17 control sites. A total of 860 patients with type 2 diabetes, regardless of therapy used, were recruited from the control sites and 710 were recruited from the intervention sites. The control sites offered usual care, while the intervention sites offered a total of four monthly sessions of group diabetes education led by a health promoter. Participants were measured at baseline and 12 months later. Primary outcomes were diabetes self-care activities, 5% weight loss and a 1% reduction in HbA(1c) levels. Secondary outcomes were self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c and mean total cholesterol levels and quality of life.

RESULTS

A total of 422 (59.4%) participants in the intervention group did not attend any education sessions. No significant improvement was found in any of the primary or secondary outcomes, apart from a significant reduction in mean systolic (-4.65 mmHg, 95% CI 9.18 to -0.12; P = 0.04) and diastolic blood pressure (-3.30 mmHg, 95% CI -5.35 to -1.26; P = 0.002). Process evaluation suggested that there were problems with finding suitable space for group education in these under-resourced settings, with patient attendance and with full adoption of a guiding style by the health promoters.

CONCLUSION

The reported effectiveness of group diabetes education offered by more highly trained professionals, in well-resourced settings, was not replicated in the present study, although the reduction in participants' mean blood pressure is likely to be of clinical significance.

Evaluation of the "Take Five School": an education programme for people with Type 2 Diabetes in the Western Cape, South Africa

AIM

To evaluate the Take Five School (TFS) group education programme for patients with Type 2 Diabetes in South Africa.

METHODS

Questionnaires, administered before and after 4 sessions of an hour each of group education, measured the effect on self-care activities in 84 patients from 6 different clinics. Individual interviews with health care workers (HCWs) and focus group interviews (FGI's) with patients explored attitudes.

RESULTS

A significant improvement in adherence to a diabetic diet, physical activity, foot care and the perceived ability to teach others was seen. There was no significant change in smoking or adherence to medication. Qualitative data revealed that comprehensive education was appreciated, that the group process was deemed supportive, that HCWs doubt the effect of education in general and that a combination of group and individual sessions was seen as an option worth exploring. Strengths, weaknesses, opportunities and threats to the TFS are identified. Recommendations are made to improve the programme and its environment.

CONCLUSION

Significant self-reported improvements in self-care activities after a group-education programme support the view that introducing structured group education for Type 2 Diabetics in a South African public sector primary care context holds promise. Group education for diabetics, especially in resource limited settings, should be sustained and further research should focus on clinical outcomes.

Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial

BACKGROUND

Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life.

METHODS

TRIAL DESIGN

Pragmatic cluster randomized controlled trialParticipants: Type 2 diabetic patients attending 45 public sector community health centres in Cape TownInterventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.

OBJECTIVE

To evaluate the effectiveness of the group diabetes education programmeOutcomes:

PRIMARY OUTCOMES

diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c.

SECONDARY OUTCOMES

self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of lifeRandomisation: Computer generated random numbersBlinding: Patients, health promoters and research assistants could not be blinded to the health centre's allocationNumbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.

DISCUSSION

The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.

TRIAL REGISTER

Pan African Clinical Trial Registry PACTR201205000380384.