Community perceptions of community health worker effectiveness: Contributions to health behaviour change in an urban health district in South Africa

BACKGROUND

Community health worker (CHW) programmes contribute towards strengthening adherence support, improving maternal and child health outcomes and providing support for social services. They play a valuable role in health behaviour change in vulnerable communities. Large-scale, comprehensive CHW programmes at health district level are part of a South African (SA) strategy to re-engineer primary healthcare and take health directly into communities and households, contributing to universal health coverage.

OBJECTIVE

These CHW programmes across health districts were introduced in SA in 2010 - 11. Their overall purpose is to improve access to healthcare and encourage healthy behaviour in vulnerable communities, through community and family engagements, leading to less disease and better population health. Communities therefore need to accept and support these initiatives. There is, however, inadequate local evidence on community perceptions of the effectiveness of such programmes.

METHODS

A cross-sectional descriptive study to determine community perceptions of the role and contributions of the CHW programme was conducted in the Ekurhuleni health district, an urban metropolis in SA. Members from 417 households supported by CHWs were interviewed in May 2019 by retired nurses used as fieldworkers. Frequencies and descriptive analyses were used to report on the main study outcomes of community acceptance and satisfaction.

RESULTS

Nearly all the study households were poor and had at least one vulnerable member, either a child under 5, an elderly person, a pregnant woman or someone with a chronic condition. CHWs had supported these households for 2 years or longer. More than 90% of households were extremely satisfied with their CHW; they found it easy to talk to them within the privacy of their homes and to follow the health education and advice given by the CHWs. The community members highly rated care for chronic conditions (82%), indicated that children were healthier (41%) and had safer pregnancies (6%).

CONCLUSION

As important stakeholders in CHW programmes, exploring community acceptance, appreciation and support is critical in understanding the drivers of programme performance. Community acceptance of the CHWs in the Ekurhuleni health district was high. The perspective of the community was that the CHWs were quite effective. This was demonstrated when they reported changes in household behaviour with regard to improved access to care through early screening, referrals and improved management of chronic and other conditions.

Improving health outcomes and quality at the subdistrict level: Evaluation of the '3 feet model' in Waterberg District, Limpopo Province, South Africa

BACKGROUND

There is a gap in understanding of potential roles and actions at the subdistrict level to improve quality of care and health outcomes in South Africa (SA).

OBJECTIVES

To report on the evaluation of a subdistrict health system-strengthening initiative that aimed to reduce maternal, newborn and child mortality, referred to as the '3 feet model' in Waterberg District, Limpopo Province, SA. The model is centred on systems of real-time morbidity/mortality surveillance and co-ordinated responses. It was implemented in three of five Waterberg subdistricts over an 18-month period in 2021 and 2022.

METHODS

A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined ~100 hours of researcher participant observation, interviews with 14 health system actors, structured reflections by three subdistrict managers and information from the routine District Health Information System. Sources were triangulated and analysed based on a priori hypotheses on mechanisms of action.

RESULTS

Following uptake of the model, the perinatal mortality rate (PMR) improved by 28.8%, 11.5% and 28% in the three subdistricts, respectively, while the PMR worsened in two of four neighbouring subdistricts. Plausible factors in implementation successes were the presence of stable and committed hybrid (clinical-managerial) subdistrict leaders and their ability to overcome entrenched silos between a variety of system actors; new collaborative relationships between primary healthcare facilities, hospitals and emergency medical services; the generation and packaging of information in ways that directed responses ('actionable intelligence'); and support from senior district managers.

CONCLUSION

While not advocating for a cut-and-paste approach to improving quality and outcomes, positive experiences in Waterberg District suggest that the principles and mechanisms of action of the 3 feet model have wider relevance for policy and practice, especially as emphasis shifts towards the subdistrict as a core unit of population health and wellbeing in SA.

Urgent appeal to allow all professional nurses and midwives to prescribe pre-exposure prophylaxis (PrEP) in South Africa

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Evaluation of the national clinical sentinel surveillance system for sexually transmitted infections in South Africa: Analysis of provincial and district-level data

BACKGROUND

Globally, >1 million new cases of curable sexually transmitted infections (STIs) are estimated to occur daily, an alarming rate that has prevailed for over a decade. Modelled STI prevalence estimates for South Africa (SA) are among the highest globally. Robust STI surveillance systems have implications for policy and planning, antimicrobial stewardship and prevention strategies, and are critical in stemming the tide of STIs.

OBJECTIVES

To evaluate the STI clinical sentinel surveillance system (STI CSSS) in SA, to describe the population incidence of four designated STI syndromes in males and females ≥15 years, and to provide recommendations for strengthening the STI CSSS.

METHODS

This was a retrospective analysis of the STI CSSS in SA. Distribution of the primary healthcare facilities designated as STI CSSS sites was described, taking into account provincial population distribution and headcount coverage of STI CSSS facilities. Reporting compliance was evaluated to determine completion of data reporting. Further analysis was undertaken for those provinces that had good reporting compliance over a 12-month period. Population-level and demographic STI syndrome incidence were estimated from CSSS data using case reports of male urethritis syndrome (MUS) as a proxy for data extrapolation.

RESULTS

Reporting compliance exceeded 70% for seven of the nine provinces. STI syndromes with the highest incidence were MUS and vaginal discharge syndrome (VDS). The 20 - 24 years age group had the highest STI incidence, at least double the incidence estimated in the other two age groups. Overall STI incidence in females was higher than among males in all provinces, except Limpopo and Western Cape. The 15 - 19 years age group had the most prominent gender disparity, with the national STI incidence in females 70% higher than in males. District-level analysis revealed high regional STI incidence even in provinces with lower overall incidence.

CONCLUSION

The STI CSSS is pivotal to epidemiological monitoring and proactive management of STIs, especially in view of the high HIV prevalence in SA. CSSS processes and facility selection should be reviewed and revised to be representative and responsive to the current STI needs of the country, with biennial analysis and reporting to support evidence-based policy development and targeted implementation.

Paramedics' knowledge, attitudes, and practices regarding the use of personal protective equipment against COVID-19

The risk of novel coronavirus disease (COVID-19) transmission in the confined mobile ambulance compartment is increased during aerosol-generating procedures and close proximity. Paramedics are encouraged to increase body-surface-isolation by donning additional personal protective equipment (PPE) during patient encounters. This study aimed to better understand paramedics’ knowledge, attitudes, and practices related to PPE use during the COVID-19 pandemic in the prehospital setting with a focus on mitigating risks associated with infection control.

This prospective quantitative study collected descriptive data using a specifically designed data collection tool. The survey data was then cleaned and analyzed with Microsoft Excel® and the latest version of the Statistical Package for Social Sciences.

One thousand frontline paramedics employed by the Hamad Medical Corporation Ambulance Service (HMCAS) were invited via email to participate in the study. A total of 282 (28.2% of frontline paramedics) paramedics completed the online survey, of which 80.1% completed the mandatory HMCAS online infection control training program within the last year, and 17.0% between one to two years ago. Approximately 83% of the participants had completed an N95 mask fit test at HMCAS within the past five years, and 91.5% completed the hand hygiene training.

The study found that 98.2% of the paramedics were knowledgeable about COVID-19 and its transmission, while 96.1% agreed that aerosol-generating procedures increased airborne transmission. The paramedics’ attitudes were mainly positive toward the use of PPE to prevent the spread of the virus, which was synchronous with their practice. The sample population demonstrated a strong knowledge of COVID-19 and its transmission. Their overall positive attitudes and good infection control practices were demonstrative of efforts to mitigate risks associated with the spread of the virus.

Teenage births and pregnancies in South Africa, 2017 - 2021 - a reflection of a troubled country: Analysis of public sector data

Articles on teenage pregnancies have been proliferating in both the popular press and the medical media. We analysed data available in the public sector database, the District Health Information System, from 2017 to 2021. During this time, the number of births to young teenagers aged 10 - 14 years increased by 48.7% (from a baseline of 2 726, which is very high by developed-country standards) and the birth rate per 1 000 girls in this age category increased from 1.1 to 1.5. These increases occurred year on year in most provinces. In adolescent girls aged 15 - 19, the number of births increased by 17.9% (from a baseline of 114 329) and the birth rate per 1 000 girls in this age category increased from 49.6 to 55.6. These increases also occurred year on year in a continuous upward trend as well as in all provinces, but at different rates. Generally, rates were higher in the more rural provinces such as Limpopo, Mpumalanga and Eastern Cape than in more urban provinces such as Gauteng and Western Cape. The increases during the past 2 years were particularly large and may be due to disruption of health and school services with decreased access to these as a result of COVID-19. These metrics pose serious questions to society in general and especially to the health, education and social sectors, as they reflect socioeconomic circumstances (e.g. sexual and gender-based violence, economic security of families, school attendance) as well as inadequate health education, life skills and access to health services.

Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: the experience of an urban health district in South Africa

INTRODUCTION

South Africa is an upper middle-income country with wide wealth inequality. It faces a quadruple burden of disease and poor health outcomes, with access to appropriate and adequate health care a challenge for millions of South Africans. The introduction of large-scale, comprehensive community health worker (CHW) programs in the country, within the context of implementing universal health coverage, was anticipated to improve population health outcomes. However, there is inadequate local (or global) evidence on whether such programs are effective, especially in urban settings.

METHODS

This study is part of a multi-method, quasi-experimental intervention study measuring effectiveness of a large-scale CHW program in a health district in an urban province of South Africa, where CHWs now support approximately one million people in 280,000 households. Using interviewer administered questionnaires, a 2019 cross-sectional survey of 417 vulnerable households with long-term CHW support (intervention households) are compared to 417 households with no CHW support (control households). Households were selected from similar vulnerable areas from all sub-levels of the Ekurhuleni health district.

RESULTS

The 417 intervention and control households each had good health knowledge. Compared to controls, intervention households with long-term comprehensive CHW support were more likely to access early care, get diagnosed for a chronic condition, be put on treatment and be well controlled on chronic treatment. They were also more likely to receive a social grant, and have a birth certificate or identity document. The differences were statistically significant for social support, health seeking behavior, and health outcomes for maternal, child health and chronic care.

CONCLUSION

A large-scale and sustained comprehensive CHW program in an urban setting improved access to social support, chronic and minor acute health services at household and population level through better health-seeking behavior and adherence to treatment. Direct evidence from households illustrated that such community health worker programs are therefore effective and should be part of health systems in low- and middle-income countries.

An analysis of the services provided by community health workers within an urban district in South Africa: a key contribution towards universal access to care

INTRODUCTION

Community health worker teams are potential game-changers in ensuring access to care in vulnerable communities. Who are they? What do they actually do? Can they help South Africa realize universal health coverage? As the proactive arm of the health services, community health workers teams provide household and community education, early screening, tracing and referrals for a range of health and social services. There is little local or global evidence on the household services provided by such teams, beyond specific disease-oriented activities such as for HIV and TB. This paper seeks to address this gap.

METHODS

Descriptive secondary data analysis of community health worker team activities in the Ekurhuleni health district, South Africa covering approximately 280,000 households with 1 million people.

RESULTS

Study findings illustrated that community health workers in these teams provided early screening and referrals for pregnant women and children under five. They distributed condoms and chronic medication to homes. They screened and referred for hypertension, diabetes mellitus, HIV and TB. The teams also undertook defaulter and contact tracing, the majority of which was for HIV and TB clients. Psychosocial support provided was in the form of access to social grants, access to child and gender-based violence protection services, food parcels and other services.

CONCLUSION

Community health workers form the core of these teams and perform several health and psychosocial services in households and poor communities in South Africa, in addition to general health education. The teams studied provided a range of activities across many health conditions (mother and child related, HIV and TB, non-communicable diseases), as well as social services. These teams provided comprehensive care in a large-scale urban setting and can improve access to care.

Prehospital conversion of paroxysmal supraventricular tachycardia using the modified Valsalva maneuver: A case report

The modified Valsalva maneuver (MVM) has never before been performed in the prehospital setting by the Hamad Medical Corporation Ambulance Service (HMCAS) clinicians in the State of Qatar. Currently, their clinical practice guidelines (CPG) prescribe the vagal maneuver (VM) using a 10 cc syringe as first-line therapy for patients presenting with symptomatic paroxysmal supraventricular tachycardia (pSVT). The effectiveness of the MVM in terminating pSVT compared to the traditional VM is well documented, although prehospital studies in this area are lacking. In this case, a generally healthy, 47-year-old male migrant worker presented with new-onset symptomatic pSVT, which was successfully terminated by a MVM after initial failed attempts of the traditional VM. The MVM is a postural technique performed by initially placing the patient in a semirecumbent position. The patient is then encouraged to blow into a manometer to achieve a 40 mmHg intrathoracic pressure for 15 seconds. Once the 40 mmHg intrathoracic pressure is achieved, the patient is repositioned supine, and their legs are raised passively to 45 degrees for 15 seconds. The patient is then returned to the semirecumbent position for 45 seconds before cardiac rhythm reassessment. The MVM has shown to have an increased termination rate of pSVT with no documented serious adverse events. The MVM can be performed in a time-effective manner and is cost effective as intravenous (IV) cannulation is not required. The prevention of adenosine-associated transient asystole is prevented. It is recommended that ambulance services consider the inclusion of the MVM in their CPGs for the treatment of new-onset pSVT.

Are large scale, urban, comprehensive CHW programs effective? The South African experience

Background

South Africa is an upper middle-income country, but has one of the widest GINI co-efficients in the world. It faces a heavy burden of disease and poor health outcomes remain a challenge for millions of South Africans. Slow economic growth, rapid urbanization and high unemployment could de-rail the efforts to improve access to health care and health outcomes amongst the most vulnerable in the country. Within this context, the introduction of large scale, comprehensive community health worker (CHW) programs, in urban areas are seen to be game changers. However, there is inadequate global evidence on whether such programs work.

Methods

This is a multi-method, quasi-experimental intervention study measuring the effectiveness of a CHW program in the Ekurhuleni health district; set in an urban province of South Africa, where CHWs support approximately one million people. Health indicator performance was compared in clinics with good coverage of CHWs and those with low or no CHW support. Poor and vulnerable households with CHW support were compared to those with no CHW support.

Results

Over a nine-year period since implementation, clinics with CHW programs improved better than clinics without; on identified pregnancy, child health, infectious disease and non-communicable disease indicators. Odds ratios showed that households with good CHW coverage had better social support, health-seeking behavior, morbidity and mortality than households without. p-values were statistically significant (<0.05) for social support, chronic disease diagnosis and chronic disease control outputs.

Conclusions

This CHW program has shown its worth as it has been effective in improving early screening, referrals, diagnosis and disease control across a number of health conditions in an urban setting.

Key messages

Large-scale comprehensive CHW programs are a good investment towards achieving universal health coverage for all by improving access and care to the poor and vulnerable. Community Health Worker services in households are effective and should be a legitimate level of health care delivery in developing countries.

Examining the cost of community-based tuberculosis treatment in South Africa

SETTING: While South Africa has improved access to tuberculosis (TB) treatment and care, the 2015 treatment success rate for multidrug-resistant TB (MDR-TB) remains low, at 55%. Community-based TB treatment and care improves patient retention compared to the standard of care alone.OBJECTIVE: To assess the cost of a USAID-funded community-based TB model in Nelson Mandela Bay Health District (NMBHD), Eastern Cape Province, South Africa compared to the national standard of care alone.DESIGN: We estimated the cost of community-based DR-TB treatment and adherence support compared to the standard of care alone.RESULTS: Average overall costs were US$2827 lower per patient on the community-based model than the standard of care alone.CONCLUSION: The per-patient cost of the community-based model is lower than the standard of care alone. Assuming the costs and effects of a community-based model implemented in NMBHD were observed at a larger scale, implementing the model could reduce overall health system costs.

Prehospital analgesia for femur fractures: An improvement study

Background: Management of pain in the prehospital setting is an important priority for prehospital clinicians, yet is often underestimated, either due to poor pain assessment, under dosing and inadequate provision of analgesia^1,2. A femur fracture is considered a painful injury and as such, should be managed with effective analgesia. Pain is associated with multiple negative physiological effects which may potentially worsen a patient's clinical condition¹, further highlighting the importance of providing effective analgesia. Vassiliadis et al., highlighted that patients with a femur fracture receive only moderate analgesia in the prehospital setting and this requires a focused strategy to improve the care received by these patients³. A retrospective audit of the Hamad Medical Corporation Ambulance Service (HMCAS) electronic patient care records (ePCR) highlighted the low frequency of prehospital analgesia for the management of femur fractures (October 2016 – December 2016). The provision of three pharmacological agents (Methoxyflurane, Fentanyl and Ketamine) which are the primary analgesics used by the HMCAS for the management of pain associated with femur fractures was reviewed. These drugs are often used together in a multimodal strategy to manage pain effectively. A multimodal approach to managing trauma pain has the benefit of improving efficacy with multiple mechanisms of action, limiting the number of doses required of a single drug, as well as reducing the risk of side effects⁴. The aim of this study was to improve prehospital analgesia for femur fractures, by means of introducing a purpose-designed trauma CPD training course. Focused training through the means of high fidelity simulations and simple skills training leads to improved performance and an increase in knowledge gained by the practitioner⁵, resulting in improved and safer care delivered to patients. Methods: An intervention consisting of a theoretical, individual skills and simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a three-month period (January 2017 – March 2017). The eight-hour trauma CPD training session focused on managing major trauma with specific focus on femur fracture identification and optimization of analgesia (Figure 1). Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the frequency of prehospital analgesia for patients with femur fractures (April 2017 – June 2017). Results: The mean provision of prehospital analgesia for a femur fracture in the pre-intervention stage was found to be suboptimal (Methoxyflurane 61%; Fentanyl 21%; Ketamine 12%). Whereas, following the intervention period, the mean provision of prehospital analgesia for femur fractures increased significantly (Methoxyflurane 100%; Fentanyl 30%; Ketamine 52%). See Figure 2. Conclusion: This study found that focused trauma training is an effective means to improve prehospital analgesia for femur fractures as well as overall patient care. Introduction of the trauma CPD training session resulted in an improvement in the management of pain associated with a femur fracture. Significant room for improvement still exists and prehospital analgesia should continue to be developed. Further research is still required.

Pre-hospital use of capnography during emergency sedation analgesia

Background: Providing optimal patient care in the challenging, uncontrolled, and sometimes hostile pre-hospital environment may require the use of potent analgesics and sedatives. During pre-hospital emergencies, narcotics or sedatives administered for sedation, anxiolysis, or analgesia to allow the patient to tolerate unpleasant procedures, such as traction splint application, can result in cardiovascular and respiratory adverse events.¹ Early recognition of poor oxygenation may prevent unnecessary patient hypoxia. The European Society of Anaesthesiology and the American Society of Anaesthesiologist mandate continuous capnography, in addition to standard monitoring which include pulse oximetry, 4-lead ECG, blood pressure, and heart rate measurements.^1,2 Capnography refers to the non-invasive measurement of the partial pressure of carbon dioxide (CO₂) in exhaled breath. Monitoring respiratory status provides early warning, thereby allowing clinicians to intervene before the onset of respiratory depression, potentially leading to bradypnoea, apnoea, hypoxia, and death.³ In addition, late identification of respiratory failure may lead to unnecessary endotracheal intubation and mechanical ventilation, increasing risk of protracted hospital stay and associated hospital-acquired infections.

Oxygenation and ventilation must be measured in both intubated and spontaneously breathing patients. While clinical indicators like chest rise or the plethysmography-derived respiratory rate can be used, monitoring the capnographic waveform for hypopnoeic and bradypnoeic patterns provides the clinician with a quick, accurate indication of acute adverse respiratory events.⁴ In two randomized trials, patients monitored with capnography in addition to standard of care, experienced significantly fewer episodes of hypoxia than those monitored without capnography.^3,5 Hamad Medical Corporation Ambulance Service (HMCAS) in Qatar introduced a new clinical practice guideline (CPG) for safe sedation and monitoring in August 2017, mandating the routine use of capnography for all sedated patients. Safe sedation is achieved when the patient's oxygenation, ventilation, or haemodynamic status is not negatively impacted by the sedation procedure. Methods: The study aimed to describe trends in the use of capnography and other monitoring modalities for patients receiving Ketamine, Fentanyl, or Midazolam. Retrospective quantitative analysis of an existing HMCAS medical records database linked to a Business Intelligence (BI) tool enabled direct analysis on the tool and via a linked Microsoft Excel^® spreadsheet, reviewing all emergency cases from 1st January 2017 to 31st December 2018. Frequency analysis and measures of central tendency was applied to the relevant clinical variables. All patient and practitioner identifiable data fields were redacted and not reported on. Results: Oxygen saturation (SpO₂) and blood pressure monitoring was used on all patients (n = 5157, 100%), 4-lead ECG was placed on 3710 (72%) patients, while capnography was used on 4096 patients (79%, range = 39% to 99%). Capnography usage steadily improved over the 24-month period, especially for patients receiving Fentanyl (Figure 1). Conclusion: There was a significant improvement in the use of capnography during monitoring of patients that received Fentanyl, Ketamine, or Midazolam, with the most significant improvement for patients receiving Fentanyl alone. Further studies are required to determine the impact of this improvement on actual adverse event frequency.

The use of screening tools in the early recognition of sepsis in the prehospital adult patient: a review of the literature

Background: Sepsis has been identified as a time critical and life-threatening condition resulting from the body's own systemic response to infection leading to multi-organ dysfunction and failure, and remains a major frontrunner in the morbidity and mortality of critically ill patients^1–3. The 2016 Surviving Sepsis Campaign¹ identified that similar to patients with polytrauma, stroke and acute myocardial infarction, the early identification and timeous delivery of appropriate treatment for patients with sepsis could improve patient outcomes and decrease mortality rates^1,4. Prehospital sepsis screening tools could provide a systematic approach to critically ill patients in order to identify those patients with a high index of suspicion for sepsis and allow for early and aggressive management.

Methods: A literature review was conducted for the period January 2011 to September 2017. A database search was conducted via the electronic databases Ovid MEDLINE (without revisions), CINAHL and The Cochrane Library. The websites ScienceDirect, Wiley Online Library, British Medical Journal (BMJ) and Google Scholar were also used in the search for literature. Full search strategies are detailed in Table 1. The selection and rejection of all articles can be reviewed in Figure 1.

Results: All articles identified for full review (n = 13) were between the period January 2011 and September 2017. The three most common methodologies identified were systematic review (n = 3), prospective cohort study (n = 3) and prospective observational study (n = 3). Other methodologies included literature review (n = 1), retrospective cohort study (n = 1), retrospective analysis (n = 1), and retrospective cross-sectional study (n = 1). Through literature analysis, three main areas of interest were identified in which articles were reviewed: the early recognition of sepsis by Emergency Medical Services (EMS) staff (n = 2), the early recognition of sepsis using a prehospital sepsis screening tool by EMS (n = 6), and the impact of EMS sepsis recognition and management on patient outcomes (n = 4). A comparison summary of the various sepsis screening tools can be viewed in Table 2.

Conclusion: Previous literature has described EMS transport rates of approximately 3.3 sepsis patients per 100 and approximately 40% of septic patients admitted having been transported by EMS⁵. Despite this relatively high prevalence, the review identified that recognition of sepsis by EMS personnel was poor. The use of various sepsis screening tools showed improved recognition by EMS but validation studies on the accuracy of these tools is required. In patients in whom a screening tool was used and early pre-notification given to receiving facilities, a decrease time to definitive management of these patients was identified. These varied findings in outcomes of septic patients transported by EMS identifies the need for further studies on EMS recognition of sepsis and the impact it has on the outcomes of these patients. A specific prehospital sepsis screening tool could possibly assist in the early recognition of sepsis. Pre-notification to receiving facilities could allow the facility to prepare for EMS arrival and continue aggressive early goal directed therapy (EGDT) as required.

The author acknowledges the possibility of publication and selection bias within this review due to single author selection and only English studies being included.

Prehospital use of the traction splint for suspected mid-shaft femur fractures

Introduction:

A retrospective audit of electronic patient care records (ePCRs) highlighted the infrequent use of the traction splint for the management of femur fractures. The aim of this study was to improve the use of the traction splint for patients presenting with a mid-shaft femur fracture in the absence of contraindications, by means of introducing a purpose-designed trauma CPD training course.

Methods:

An intervention consisting of a simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a 3-month period, supported by a pre- and post-implementation staff survey regarding staff perceptions of using a traction splint. Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the use of the traction splint.

Results:

The use of the traction splint for a femur fracture in the pre-intervention stage was found to be underutilised (Median 16%). Following the intervention period, however, traction splint use increased significantly (Median 50%). An improvement was also noted in staff perception and understanding of the management of femur fractures.

Conclusion:

This study found that focused trauma training is an effective means to improve patient care. Training should be ongoing in order to maintain skills and knowledge needed for management of femur fractures.

Evidence-informed policy making at country level: lessons learned from the South African Tuberculosis Think Tank

BACKGROUND:

National Tuberculosis Programmes (NTPs) require specialist input to support the development of policy and practice informed by evidence, typically against tight deadlines.

OBJECTIVE:

To describe lessons learned from establishing a dedicated tuberculosis (TB) think tank to advise the South African NTP on TB policy.

INTERVENTION AND EVALUATION METHODS:

A national TB think tank was established to advise the NTP in support of evidence-informed policy. Support was provided for activities, including meetings, modelling and regular telephone calls, with a wider network of unpaid expert advisers under an executive committee and working groups. Intervention evaluation used desktop analysis of documentary evidence, interviews and direct observation.

RESULTS:

The TB Think Tank evolved over time to acquire three key roles: an ‘institution’, a ‘policy dialogue forum’ and an ‘interface’. Although enthusiasm was high, motivating participation among the NTP and external experts proved challenging. Motivation of working groups was most successful when aligned to a specific need for NTP decision making. Despite challenges, the TB Think Tank contributed to South Africa's first ever TB and human immunodeficiency virus (HIV) investment case, and the decision to create South Africa's first ever ring-fenced grant for TB. The TB Think Tank also assisted the NTP in formulating strategy to accelerate progress towards reaching World Health Organization targets.

DISCUSSION:

With partners, the TB Think Tank achieved major successes in supporting evidence-informed decision making, and garnered increased funding for TB in South Africa. Identifying ways to increase the involvement of NTP staff and other experts, and keeping the scope of the Think Tank well defined, could facilitate greater impact. Think tank initiatives could be replicated in other settings to support evidence-informed policy making.

Differences in Attitude towards Cadaveric Organ Donation: Observations in a Multiracial Malaysian Society

Background

Willingness to donate organs is affected by socio-cultural and religious values. The Malaysian society is made up of three ethnic groups: Malay, Chinese, and Indian, with Islam, Buddhism and Hinduism as their religions respectively. This study examined the knowledge and perception towards organ donation for each group.

Methods

This study was conducted at University Malaya Medical Centre, Kuala Lumpur, Malaysia. Relatives of patients awaiting treatment at the emergency department answered a questionnaire on knowledge and attitude on organ transplantation.

Results

A total of 904 questionnaires were completed; 90.6% would accept organs, 43.6% would donate, and 4.0% carried donor cards. The reasons for reluctance to donate included: fear of organs being used for research (18.8%), desire to be buried whole (18.0%), fear of less active treatment if patient is known to be a donor (12.8%). Malays were less willing to accept organs from a different race (63.5%) compared to Chinese (83.3%) and Indians (83.8%) (OR=0.35, 95%CI: 0.23-0.54 and OR=0.34, 95%CI: 0.22-0.51 respectively) and also less likely to donate organs (29.8%) as compared to Chinese (42.1%) and Indians (63.2%) (OR=0.57, 95%CI 0.40-0.83 and OR=0.24, 95%CI 0.17-0.35 respectively). Malays were less willing to donate organs to another race compared to Chinese or Indians (OR=0.48, 95%CI 0.33-0.70 and OR=0.22, 95%CI 0.15-0.31 respectively). Only 34.7% of Muslims are aware of fatwa supporting organ donation.

Conclusions

The awareness of organ donation was low. Clear differences exist among ethnic groups. Cultural-religious attitudes and lack of trust in the medical systems were reasons for reluctance to donation. Identifying socio-cultural barriers and reassuring donors regarding medical care are required.

Hospital Mortality Based on the Mode of Emergency Medical Services Transportation

OBJECTIVE

We assessed the presentations and outcomes of trauma patients transported by helicopter emergency medical services (HEMS) versus ground emergency medical services (GEMS).

METHODS

A retrospective analysis of trauma registry data at a level I trauma center was conducted for patients transported by GEMS and HEMS between 2011 and 2013. Data were analyzed and categorized based on the mode of transportation.

RESULTS

A total of 4,596 trauma patients were admitted to the hospital with a mean age of 31 ± 15 years. Injured patients were transported to the trauma center by GEMS (93.3%) and HEMS (6.7%). The common mechanisms of injury were motor vehicle crash (37%) and falls (25%). Compared with GEMS, patients transported by HEMS were characterized by having a greater injury severity, more proportion of traumatic brain injury, on-scene intubation, and a 2.5-fold higher mortality. However, the impact of mode of transportation on the hospital mortality among severely injured patients has disappeared after adjusting for potential confounders.

CONCLUSION

Patients transported by HEMS may have different characteristic features and outcomes when compared with GEMS. However, further work is needed to identify the subgroups of trauma patients who clearly benefit from the use of HEMS.

Evidence-based medicine (EBM) in pre-hospital care: Our 4-year experience in designing and implementing Clinical Practice Guidelines (CPG)

Background: In 2011, HMCAS designed new Evidence-Based CPG. The previous protocols were not fit for purpose and not best practice. The service had multiple tiers of clinical practice among staff without standardization of care. CPG development is a knowledge management process to ensure standardization of care and a safer patient experience. This research sets out learning from two rounds of CPG development over 4 years.

Methods: The guidelines development process was mapped prior to starting in January 2015. CPG development and implementation went through 5 steps: 1. Scoping the guidelines: defining the purpose, the scope of service, and the end users of the guidelines. We conducted a staff survey to understand their views on presentation and purpose. 2. Establishing a working group to identify specific guidelines, clinical outcomes desired, and develop a writing template. 3. Conducting evidence reviews to draft the guidelines and then consulting with all role players to ensure guidelines are best practice and practical, and aligned to clinical pathways. 4. Guidelines publication considering ease of use, clarity, and balance between details and practicality. Finally, guidelines approval. 5. Guidelines implementation: Identifying champions to action alignment to systems (logistics/governance/management) and to redesign the corresponding educational curriculum.

Results: The development and implementation of the guidelines has resulted in significant changes within the Ambulance Service over 4 years. Reducing multiple tiers of care down to two tiers, standardized education of 900 existing and new clinical staff around guidelines, implementation of standardized pre-packed equipment within the ambulances, and standardized care to the community. This project was recognized by the MD's Stars of Excellence award 2013.

Conclusions: To implement standardized care and EBM, CPG are required. Guidelines development and implementation needs expertise, collaborative development, and champions who will undertake deliberate alignment of service activities and education to the guidelines.

In-Hospital Outcome Based on the Mode of EMS Transportation in a High-Income Rapidly Developing Middle Eastern Country

<p><strong>BACKGROUND:</strong> Helicopter emergency medical services (HEMS) are considered as a standard component of advanced pre-hospital emergency care system. We assessed the clinical presentation and outcomes of trauma patients transported by HEMS versus ground emergency medical services (GEMS).</p><p><strong>METHODS:</strong> A retrospective analysis of prospectively collected trauma registry data at a level I trauma center was conducted for patients transported by GEMS and HEMS between 2011 and 2013. Patients’ data were categorized and analyzed based on the mode of transportation (MOT).</p><p><strong>RESULTS:</strong> A total of 4596 trauma patients were admitted to the hospital with a mean age of 31±15 years. Injured patients were transported to the trauma centre by GEMS (93.3%) and HEMS (6.7%). The common mechanisms of injury were motor vehicle crash (37%) and fall (25%). MVC victims were transported to the hospital by HEMS, whereas, patients with fall and pedestrian injuries (P=0.001 for all) were more likely to be transported by GEMS. Moreover, patients in the HEMS group had a higher frequency of head (p=0.001) and chest (p=0.001) injuries and required prolonged ICU and overall hospital stay (p=0.001). When compared with GEMS, HEMS group were more likely to sustain severe injuries (ISS&gt;15; p=0.001) and needed frequent on-scene intubation (P=0.001). Hospital mortality was grater in HEMS patients (10% vs 4%, p=0.001) in comparison to GEMS. Multivariate analysis, after adjusting for the confounding factors demonstrated that polytrauma and lower scene GCS were the independent predictors of mortality.</p><p><strong>CONCLUSIONS: </strong>Patients transported by HEMS are characterized by greater injury severity, traumatic brain injury and on-scene intubation. Moreover, the mortality is 2.5 fold greater in patients transported by GEMS, however, the impact of MOT on mortality disappear after adjusting for potential confounders. Institutional guidelines that focus on clinical triage criteria, key environmental factors and reducing transport time may be informed by this study. Further investigations are needed to better quantifyestimate the pre-hospital time intervals and to identify the sub-groups of trauma patients who will clearly benefit from the use of HEMS.</p>

TIME Impact - a new user-friendly tuberculosis (TB) model to inform TB policy decisions

Tuberculosis (TB) is the leading cause of death from infectious disease worldwide, predominantly affecting low- and middle-income countries (LMICs), where resources are limited. As such, countries need to be able to choose the most efficient interventions for their respective setting. Mathematical models can be valuable tools to inform rational policy decisions and improve resource allocation, but are often unavailable or inaccessible for LMICs, particularly in TB. We developed TIME Impact, a user-friendly TB model that enables local capacity building and strengthens country-specific policy discussions to inform support funding applications at the (sub-)national level (e.g. Ministry of Finance) or to international donors (e.g. the Global Fund to Fight AIDS, Tuberculosis and Malaria).TIME Impact is an epidemiological transmission model nested in TIME, a set of TB modelling tools available for free download within the widely-used Spectrum software. The TIME Impact model reflects key aspects of the natural history of TB, with additional structure for HIV/ART, drug resistance, treatment history and age. TIME Impact enables national TB programmes (NTPs) and other TB policymakers to better understand their own TB epidemic, plan their response, apply for funding and evaluate the implementation of the response.The explicit aim of TIME Impact's user-friendly interface is to enable training of local and international TB experts towards independent use. During application of TIME Impact, close involvement of the NTPs and other local partners also builds critical understanding of the modelling methods, assumptions and limitations inherent to modelling. This is essential to generate broad country-level ownership of the modelling data inputs and results. In turn, it stimulates discussions and a review of the current evidence and assumptions, strengthening the decision-making process in general.TIME Impact has been effectively applied in a variety of settings. In South Africa, it informed the first South African HIV and TB Investment Cases and successfully leveraged additional resources from the National Treasury at a time of austerity. In Ghana, a long-term TIME model-centred interaction with the NTP provided new insights into the local epidemiology and guided resource allocation decisions to improve impact.

Comparison of two training programmes on paramedic-delivered CPR performance

OBJECTIVE

To compare CPR performance in two groups of paramedics who received CPR training from two different CPR training programmes.

METHODS

Conducted in June 2014 at the Hamad Medical Corporation Ambulance Service, the national ambulance service of the State of Qatar, the CPR performances of 149 new paramedic recruits were evaluated after they had received training from either a traditional CPR programme or a tailored CPR programme. Both programmes taught the same content but differed in the way in which this content was delivered to learners. Exclusive to the tailored programme was mandatory precourse work, continuous assessments, a locally developed CPR instructional video and pedagogical activities tailored to the background education and learner style preferences of paramedics. At the end of each respective training programme, a single examiner who was blinded to the type of training paramedics had received, rated them as competent or non-competent on basic life support skills, condition specific skills, specific overall skills and non-technical skills during a simulated out-of-hospital cardiac arrest (OHCA) assessment.

RESULTS

Paramedics who received CPR training with the tailored programme were rated competent 70.9% of the time, compared with paramedics who attended the traditional programme and who achieved this rating 7.9% of the time (p<0.001). Specific improvements were seen in the time required to detect cardiac arrest, chest compression quality, and time to first monitored rhythm and delivered shock.

CONCLUSIONS

In an OHCA scenario, CPR performance rated as competent was significantly higher when training was received using a tailored CPR programme.

Accelerating progress towards tuberculosis elimination: the need for combination treatment and prevention

Although estimated tuberculosis (TB) incidence is now falling globally, we are unlikely to achieve the Millennium Development Goal (MDG) TB targets without changing the emphasis of the global TB response in high human immunodeficiency virus prevalence settings. Two independent modelling exercises using South African data with different structures and assumptions conclude that, until new drugs, diagnostics and vaccines are available, a fully funded and accessible combination approach to anti-tuberculosis treatment and prevention, based on knowledge of local TB epidemiology and evidence-informed policy, is essential to accelerate progress towards zero new tuberculous infections, zero TB deaths and zero suffering from TB.

The prevalence of strabismus in schizophrenic patients in Durban, KwaZulu Natal

Purpose:    The psychosocial implications of a strabismus have not received sufficient attention and yet may have a significantly negative effect on a person’s life.  Schizophrenia is the fourth leading cause of mental disability in the developed world.  Both schizophrenia and strabismus appear to share a genetic and neurological origin.  This study thus set out to assess the prevalence of strabismus in a sample of schizophrenic subjects. Setting:  The study was carried out in Durban, Kwazulu-Natal inSouth Africa specifically at the Durban and Coastal Mental Health Institution. Method:  Fifty schizophrenic subjects residing at the Durban and Coastal Mental Health (DMH) Institution were assessedfor the presence of strabismus using the cover test and modified Krimsky test.  The inclusion criteria were all subjects diagnosed with schizophrenia, of both genders and any race.  The subjects werebetween fifteen to seventy years of age.  The exclusion criteria included any other mental illness, systemic disease or medication other than that usedon schizophrenic patients.  Results:   The prevalence of strabismus in this sample was found tobe 74% which was considerably higher than thatreported by other studies1,2.  There was a greater incidence of exotropia as opposed to esotropia.  The mean distance exotropia as detected with the cover test was 33 prism dioptres.  Similarly, the near cover test indicated a mean of 11 prism dioptres exotropia, and with the modified Krimsky test a mean of 9 prism dioptres exotropia.   Most of the strabismic subjects (86.5%) presented with a strabismus when fixating a near target.  Generally the strabismus was found to be constant and unilateral and no gender bias was found.  Conclusion:There appears to be a strong relationship between strabismus and schizophrenia.  Health care professionals, especially those dealing with paediatric care, parents and the public should be made awareof this relationship so that psychological adviceand early intervention can be sought for strabismic children. (S Afr Optom 2011 70(3) 101-108)

Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear-personal protective equipment: a manikin study

Six different supraglottic airway devices: Combitube™, laryngeal mask airway, intubating laryngeal mask airway (Fastrach™), i-gel™, Laryngeal Tube™ and Pro-Seal™ laryngeal mask airway were assessed by 58 paramedic students for speed and ease of insertion in a manikin, whilst wearing either chemical, biological, radiation, nuclear-personal protective equipment (CBRN-PPE) or a standard uniform. All devices took significantly longer to insert when wearing CBRN-PPE compared with standard uniform (p < 0.001). In standard uniform, insertion time was shorter than 45 s in 90% of attempts for all devices except the Combitube, for which 90% of attempts were completed by 53 s. Whilst wearing CBRN-PPE the i-gel was the fastest device to insert with a mean (SD (95% CI)) insertion time of 19 (8 (17-21))s, p < 0.001, with the Combitube the slowest with mean (65 (23 (59-71))s. Wearing of CBRN-PPE has a negative impact on supraglottic airway insertion time.

The current standard of care in the periprocedural management of the patient with obstructive jaundice

This review provides a literature-based guide to the optimal management of the patient with obstructive jaundice with emphasis placed on prevention of complications.

The impact of South Africa's new constitution on the organization of health services in the post-apartheid era

This essay evaluates the transformation of the health care system in South Africa in the five years following the end of apartheid. This period has witnessed dramatic and wide-ranging changes in the roles of the central and provincial governments as well as many of the same problems related to decentralization as have been seen elsewhere in the world. The importance of effective intergovernmental relations to the creation of a national health system is highlighted. Negotiation. contracting, and coordination skills and mechanisms need to be strengthened to ensure a more effective national health system within a decentralized political system.

Reconstructing and developing the health system--the first 1,000 days

This paper attempts to document the successes and failures of the Department of Health during the first 1,000 days of the Government of National Unity. The achievements of the Department are reflected against the backdrop of the legacies inherited by the current Ministry and Department.

The effects of chronic violence on preschool children living in South African townships

Violence in South Africa has reached endemic proportions. To date, more than 11,000 people have died in politically related violence. The present study is specifically concerned with researching the psychological sequelae of civil conflict and violence on preschool children. Using a combination of participatory and empirical methods, five creche teachers (also trained as field workers) took a random sample of 148 children in their creches. The Post Traumatic Stress Disorder Questionnaire for Children was completed by the creche teachers for each of the children under their care. Second, the children were asked to draw pictures of things they had experienced in their life. A significant finding of this study was that preschool children exposed to violence suffered from PTSD. Further, children's drawings showed severe emotional indicators. However, an interesting finding was that these drawings were not good predictors of PTSD; the more a child was able to express emotional trauma through drawings, the less likely he/she would suffer from PTSD. This finding has interesting ramifications for trauma intervention programs for preschool children.