Facility Managers’ Perceptions of Support and Supervision of Ward Based Primary Health Care Outreach Teams in National Health Insurance Pilot Districts in KwaZulu-Natal, South Africa. A Qualitative Study

Introduction: Evidence from many countries suggests that provision of home and community-based health services, linked to care at fixed primary health care facilities, is critical to good health outcomes. In South Africa, the Ward-Based Primary Health Care Outreach Teams are well placed to provide these services. The teams report to a primary health care facility through their outreach team leader. The facility manager/operational manager provides guidance and support to the outreach team leader. Aim: The aim of the study was to explore and describe the perceptions of facility managers regarding support and supervision of ward-based outreach teams in the National Health Insurance pilot sites in Kwa Zulu-Natal. Setting: The study was carried out in three National Health Insurance pilot districts in KwaZulu- Natal. Methods: An exploratory qualitative design was used to interview 12 primary health care facility managers at a sub-district (municipal) level. The researchers conducted thematic analysis of data. Findings: Some gaps in the supervisory and managerial relationships between ward based primary health care outreach teams and primary health care facility managers were identified. High workload at clinics may undermine the capacity of PHC facility managers to support and supervise the teams. Field supervision seems to take place only rarely and for those teams living far away from the clinic, communication with the clinic manager may be difficult. The study further highlights issues around the training and preparation of the teams. Conclusions: Ward based primary health care outreach teams have a positive impact in preventive and promotive health in rural communities. Furthermore, these teams have also made impact in improving facility indicators. However, their work does not happen without challenges.

Prevalence of Otolaryngology Diseases in an Urban Homeless Population

Objective Otolaryngology diseases are common among people experiencing homelessness; however, they are seldom evaluated in a specialist setting, and investigations on their prevalence have rarely been conducted. The aim of this retrospective study was to evaluate the prevalence of otolaryngology conditions in an urban homeless population. Study Design Retrospective study. Setting Primary health care facility. Methods The clinical records of patients referred to the medical facilities of the Primary Care Services of the Eleemosynaria Apostolica, Vatican City, between October 1, 2019, and July 31, 2021, were retrospectively reviewed; those reporting at least 1 otolaryngology disease were included in the study. Results A total of 2516 records were retrospectively reviewed, and 484 (19.24%) were included in the study. The most common otolaryngology disease was pharyngotonsillitis (n = 118, 24.13%), followed by rhinitis with nasal obstruction (n = 107, 21.88%), hearing loss (n = 93, 19.01%), otitis (n = 81, 16.56%), abscess (n = 46, 9.40%), and sinusitis (n = 33, 6.74%). Head and neck cancer or precancerous lesions were reported in 34 subjects (7.02%). More than 1 simultaneous otolaryngology disorder was found in nearly 50% of our sample. A wide range of comorbidities was also reported. Conclusions Our results confirm an elevated otolaryngology demand in the homeless population and encourage the development of more efficient and effective strategies for a population-tailored diagnosis and treatment of these conditions.

Linkage to TB care: A qualitative study to understand linkage from the patients’ perspective in the Western Cape Province, South Africa

Background Delayed linkage to tuberculosis (TB) treatment leads to poor patient outcomes and increased onward transmission. Between 12% and 25% of people diagnosed with TB are never linked to a primary health care facility for continued care. The TB health program is for creating processes that promote and facilitates easy access to care. We explored how TB patients experience TB services and how this influenced their choices around linkage to TB care and treatment. Methods We enrolled 20 participants routinely diagnosed with TB in hospital or at primary health care facilities (PHC) in a high TB/HIV burdened peri-urban community in South Africa. Using the Western Cape Provincial Health Data centre (PHDC) which consolidates person-level clinical data, we used dates of diagnosis and treatment initiation to select participants who had been linked (immediately, after a delay, or never). Between June 2019 and January 2020, we facilitated in-depth discussions to explore both the participants’ experience of their TB diagnosis and their journey around linking to TB care at a primary health care facility. We analysed the data using case descriptions. Results Twelve of twenty (12/20) participants interviewed who experienced a delay linking were diagnosed at the hospital. Participants who experienced delays in linking or never linked explained this as a result of lack of information and support from health care providers. Unpleasant previous TB treatment episodes made it difficult to ‘face’ TB again and being uncertain of their TB diagnosis. In contrast, participants said the main motivator for linking was a personal will to get better. Conclusion The health care system, especially in hospitals, should focus on strengthening patient-centred care. Communication and clear messaging on TB processes is key, to prepare patients in transitioning from a hospital setting to PHC facilities for continuation of care. This should not just include a thorough explanation of their TB diagnosis but ensure that patients understand treatment processes. Former TB patients may require additional counselling and support to re-engage in care.

EMS non-conveyance: A safe practice to decrease ED crowding or a threat to patient safety?

Background The safety of the Emergency Medical Service’s (EMS’s) non-conveyance decision was evaluated by EMS re-contacts, primary health care or emergency department (ED) visits, and hospitalization within 48 h. The secondary outcome was 28-day mortality. Methods This cohort study used prospectively collected data on non-conveyed EMS patients from three different regions in Finland between June 1 and November 30, 2018. The Adjusted International Classification of Primary Care (ICPC2) as the reason for care was compared to hospital discharge diagnoses (ICD10). Multivariable logistic regressions were used to determine factors that were independently associated with adverse outcomes. Results are presented with adjusted odds ratios (aORs) together with 95% confidence intervals (CIs). Data regarding deceased patients were reviewed by the study group. Results Of the non-conveyed EMS patients (n = 11,861), 6.3% re-contacted the EMS, 8.3% attended a primary health care facility, 4.2% went to the ED, 1.6% were hospitalized, and 0.1% died 0–24 h after the EMS mission. The 0–24 h adverse event rate was higher than 24–48 h. After non-conveyance, 32 (0.3%) patients were admitted to an intensive care unit within 24 h. Primary non-urgent EMS mission (aOR 1.49; 95% CI 1.25 to 1.77), EMS arrival at night (aOR 1.82; 95% CI 1.58 to 2.09), ALS unit type vs BLS (aOR 1.43; 95% CI 1.16 to 1.77), rural area (aOR 1.74; 95% CI 1.51 to 1.99), and older patient age (aOR 1.41; 95% CI 1.20 to 1.66) were associated with subsequent primary health care visits (0–24 h). Conclusions Four in five non-conveyed patients did not have any re-contact in follow-up period. EMS non-conveyance seems to be a relatively safe method of focusing ED resources and avoiding ED crowding.

A fatal combination of disseminated strongyloidiasis with two bacterial infections in an immunocompromised host

Introduction. Strongyloides stercoralis is an intestinal nematode that is endemic in tropical countries. It can have a variable presentation ranging from asymptomatic eosinophilia in immunocompetent hosts to disseminated disease with sepsis in immunocompromised hosts. Case report. We report a case of chronic diarrhoea and decreased appetite in a 53-year-old man. He was a chronic alcoholic with diabetes, hypertension and dyslipidaemia and had earlier been treated for pulmonary tuberculosis. He was treated symptomatically for loose stools at a primary health care facility without relief. Following referral to our tertiary care centre, microscopic examination of the stool showed numerous larvae and a few eggs of Strongyloides stercoralis. Additionally, Aeromonas sobria was isolated from stool culture. The patient was discharged following improvement with a combination therapy of ivermectin, albendazole and ciprofloxacin. However, within 3 days, he was readmitted and succumbed to Escherichia coli sepsis. Conclusion. Strongyloidiasis can be diagnosed easily using a very simple but often neglected investigation, namely stool microscopy. This provides an early diagnosis, based on which prompt treatment with the appropriate antihelminthics can be started, thereby reducing the probability of disseminated infection. Disseminated strongyloidiasis is a medical emergency with a poor prognosis, especially in an immunocompromised state. Such patients should be treated aggressively with antihelminthics. They must be monitored for sufficient duration in the hospital for early signs of complication. Their discharge from hospital should be planned based on a negative stool microscopy report in addition to clinical improvement, so as to decrease the mortality reported for both untreated and treated individuals.

Prevalence of Celiac Disease in Omani Adults with Iron Deficiency Anemia of Unknown Cause

Objectives: This study aimed to estimate the serological prevalence of celiac disease in patients with IDA of unknown cause at primary health care facility. Methods: This is a prospective case finding study that was conducted at the primary care clinics in the Sultan Qaboos University Hospital (SQUH) from September 2018 to June 2020. A total of 104 patients aged 18 to 55 years old, with a hemoglobin (Hb) level less than 11.5 g/dl for males and less than 11.0 g/dl for females and a ferritin level less than 30 ng/mL for males and less than 13 ng/mL for females participated in the study. Blood samples were obtained for an initial serological screen using serum IgA level and then those with normal level of IgA, had IgA- Anti-tissue transglutaminase antibody (tTG) and IgA- anti-deamidated gliadin peptide (DGP). Positive IgA-tTG test was confirmed using IgA-endomysial antibodies. Patients with low IgA level were tested using IgG-tTG and IgG-DGP. Results: Eight patients out of the 104 (7.7%) found to have positive serological screening for celiac disease. Three patients out of the eight (37.5%) had a positive IgA tTG. Two of those three (66.7%) had a positive IgA-endomysial antibody as well. The IgA-DGP was positive in seven patients out of the 104 (6.7 %). Out of those seven patients, two also had a positive IgA tTG. Conclusion: Celiac disease is not a rare disorder. There is a need to increase awareness among healthcare professionals about celiac disease and its non-classical manifestations such as IDA.Keywords: cervical smears, conventional slides, ThinPrep slides, cervical organisms.

Can public sector community health workers deliver a nurturing care intervention in South Africa? The Amagugu Asakhula feasibility study

Background Nurturing care interventions have the potential to promote health and development in early childhood. Amagugu Asakhula was designed to promote developmentally important dietary and movement behaviours among children of preschool age (3–5 years) in South Africa. An initial formative study in Cape Town found the intervention to be feasible and acceptable when delivered by community health workers (CHWs) linked to a community-based organisation. This study evaluated the delivery of the Amagugu Asakhula intervention by CHWs linked to a public sector primary health care facility in Soweto, as this mode of delivery could have more potential for sustainability and scalability. Methods A qualitative design was utilised to assess feasibility, acceptability, adoption, appropriateness, implementation, fidelity and context. CHWs (n = 14) delivered the intervention to caregivers (n = 23) of preschool-age children in Soweto over 6 weeks. Following the completion of the intervention, focus group discussions were held with CHWs and caregivers. Further data were obtained through observations, study records and key informant interviews (n = 5). Data were analysed using deductive thematic analysis guided by a process evaluation framework. Results The delivery of the Amagugu Asakhula intervention through CHWs linked to a primary health care facility in Soweto was not found to be feasible due to contextual challenges such as late payment of salaries influencing CHW performance and willingness to deliver the intervention. CHWs expressed dissatisfaction with their general working conditions and were thus reluctant to take on new tasks. Despite barriers to successful delivery, the intervention was well received by both CHWs and caregivers and was considered a good fit with the CHWs’ scope of work. Conclusions Based on these findings, delivery of the Amagugu Asakhula intervention is not recommended through public sector CHWs in South Africa. This feasibility study informs the optimisation of implementation and supports further testing of the intervention’s effectiveness when delivered by CHWs linked to community-based organisations. The present study further demonstrates how implementation challenges can be identified through qualitative feasibility studies and subsequently addressed prior to large-scale trials, avoiding the wasting of research and resources.

Knowledge and perception about the ongoing COVID-19 pandemic among patients attending a rural primary health care facility in Delhi

Another decade is suffering from the wrath of another coronavirus. Currently, this pandemic has spread to almost all countries of the world taking lives of millions of people globally. This study has uncovered the perceived facts about COVID-19 by general population as well as the effect of IEC in modulating their perception and presenting right amount of information in a scientific manner. A cross-sectional, descriptive study was carried out at rural health training center, Barwala on patients attending out-patient department at RHTC, for a duration of 2 months. Pre-tested questionnaire for assessing public perception and awareness were used to collect data. Appropriate statistical tests were applied to find out association between different variables. Majority of study subjects (98.5%) were aware about the ongoing pandemic of COVID-19. Out of the total study subjects, 90% of them had correct knowledge about various preventive strategies undertaken to break the chain of transmission. However, only about half of the study subjects (53.1%) had correct knowledge regarding various modes of transmission of novel coronavirus. Motivating the people to report any possible infection and to follow the preventive strategies being recommended by experts on timely basis is an important aspect to curb the ongoing menace of COVID-19.

Estimates and Determinants of Psychological Problems of Pregnant Women during COVID-19 Epidemic in South Africa

The COVID-19 epidemic has impacted significantly on the general population including pregnant women. The psychological impact of COVID-19 among vulnerable population like pregnant women is yet to be estimated. Therefore, the objective of this study was to estimate the prevalence and factors associated with anxiety, depression, and overall psychological problems. A questionnaire-based cross-sectional study was conducted among black pregnant women attending a Primary Health Care facility in South Africa. Logistic regression analysis was performed to determine the significant factors for psychological problems. A total of 346 pregnant women participated in this study. The rates of anxiety, depression and overall psychological problems were 35.7%, 38.2% and 34.3% respectively. Gestational age between 14-26 weeks were 60% (OR=.397, p<0.05), part-time employment 53% (OR=0.47, p<0.05) and pregnant women having adequate funding for monthly expenses were 62% less likely (OR=0.381, p<0.05) to have anxiety problems. Married women were 2.5 times more likely (OR=2.54, p<0.05) and women living together or widowed were 2.9 times more likely (OR=2.91, p<0.05) to have anxiety. Pregnant women aged between 20-29 years were nine times (OR=9.03, p=0.016), women aged 30 to 39 years were 6.3 times (OR=6.3, p=0.032) more likely to have depression. Parity one 91% (OR=0.094, p=0.007), parity two 86% (OR=.143, p=0.027) and part-time employment 65% (OR=0.354, p=0.002) were less likely to have depression. Comparing with women aged >39 years, women who were between 20-29 years were 28 times (OR=27.8, p<0.01) and women aged between 30-39 years were nine times more likely to have overall psychological problems. Respondents with parity one was 83% (OR=0.17, p<0.05) less likely to have psychological problems when compared with other parity groups and women having adequate funding were 65% less likely (OR=0.35, p<0.05) to have overall psychological problems than those did not have adequate funding. Higher rates of anxiety, depression and overall psychological problems are found among black pregnant women. It is therefore imperative that appropriate and timely mental health care supports are provided to reduce adverse health outcomes.