African Journal of Primary Health Care & Family Medicine最新文献

Background:  Oral pre-exposure prophylaxis (PrEP) uses antiretroviral medication to reduce HIV risk in HIV-negative individuals. Despite its effectiveness, global uptake faces policy and accessibility challenges. In Eswatini, PrEP introduction in 2017 showed promise despite stigma and COVID-19 disruptions.

Aim:  This study compared PrEP uptake and retention during and after COVID-19.

Setting and methods:  An analytical cross-sectional study was conducted among clients accessing HIV testing services in selected Eswatini facilities. Data from the HIV testing register, PrEP register, and Client Management Information System (CMIS) were analysed. Uptake, retention, and client outcomes were measured during COVID-19 (March 2020-March 2021) and post-COVID-19 (April 2021-April 2022).

Results:  Of 5286 clients, 45% (n = 2380) initiated PrEP during COVID-19, while 55% (n = 2906) initiated post-pandemic. Facility 3 had the highest initiations during COVID-19 (844), while Facility 5 had the lowest (7). Retention was lower among clients aged 15-29 years. Females initially showed higher retention odds (odds ratio [OR]: 1.50), but this was insignificant after adjusting for confounders. Clients initiated post-COVID-19 had higher retention odds (OR: 2.96).

Conclusion:  COVID-19 impacted PrEP uptake in Eswatini, emphasising the need for flexible healthcare delivery. Targeted campaigns and tailored interventions are crucial for sustaining HIV prevention efforts and addressing demographic shifts.Contribution: This study highlights the importance of responsive healthcare systems and tailored approaches to maintaining HIV prevention during public health crises.

In older adults with type 2 diabetes (T2DM), tight glycaemic control (HbA1c 7%) can result in more harm than benefit, especially when using insulin or sulfonylureas. Older adults are at higher risk for adverse drug events, especially hypoglycaemia, which may cause falls, confusion and hospitalisations. This Therapeutic Letter evaluates the risks of tight glycaemic control in older adults with T2DM, focusing on deprescribing diabetes medications in those over 65, especially those with multimorbidity and polypharmacy. It assesses the evidence from clinical trials and guidelines, with a focus on preventing hypoglycaemia and improving patient-centred care through relaxed HbA1c targets. Large randomised controlled trials show that intensive glycaemic control (HbA1c ≤ 7%) does not reduce cardiovascular risk, but increases hypoglycaemia and mortality, particularly in older adults. Instead, glycaemic targets should be adjusted based on the patient's overall health and life expectancy. Deprescribing may be considered, starting with drugs most likely to cause hypoglycaemia (sulfonylureas or insulin). Regular reassessment and patient involvement in creating individualised treatment plans are essential.

Background:  Village health workers (VHWs), popularly known as community health workers (CHWs) in some contexts and settings, should effectively complement health care providers in primary health care (PHC) delivery in Zimbabwe. However, they continue to offer services that do not address current and emerging health issues.

Aim:  This study aims to review the literature and develop a conceptual framework to improve the effectiveness and efficiency of VHWs in service delivery.

Method:  Rodgers' evolutionary framework was used to analyse the concept of 'strategies for effective and efficient delivery of PHC by VHWs'. Articles and reports published in English from 2010 to 2022 in peer-reviewed journals from the PUBMED, EBSCO, ScienceDirect and Google Scholar databases were reviewed.

Results:  After screening and removal of duplicates a total of 52 articles and two reports were reviewed to identify antecedents, attributes and consequences of strategies to improve PHC services by village health workers. The antecedents included an enabling work environment, community participation, motivation, incentives, integration of community health into national health systems, and information and communication technology. The attributes consisted of ongoing training and skills development, mutual respect and trust, enhanced contact between VHWs and communities and supportive supervision. The consequences were equitable access to and improved quality of PHC service delivery.

Conclusion:  The concept of PHC service delivery by VHWs has evolved from health promotion to curative care through task shifting and is now an integral part of the health system. A supportive and enabling work environment, anchored in community participation, empowers VHWs to deliver equitable services effectively and efficiently.Contribution: The development of strategies for improving VHW service delivery and a conceptual framework informed by findings from the reviewed literature.

Background:  Interprofessional education (IPE) during undergraduate training (UGT) is considered important for new graduates to collaborate inter-professionally. There are, however, well-documented workplace challenges that hinder their involvement in interprofessional collaborative practice (IPCP) such as professional hierarchy, poor role clarification and communication challenges.

Aim:  This article explores graduates' perceptions of the value rural undergraduate IPE had on their IPCP during their first year of work.

Setting:  Graduates were based in seven different provinces of South Africa ranging from tertiary-level institutions to community day clinics.

Methods:  A qualitative case study was conducted with 16 first-year graduate participants from 5 different health professions who participated in undergraduate IPE while placed on a rural platform. Individual semi-structured interviews were conducted in 2023.

Results:  Key factors related to UGT that facilitated IPCP during graduates' first year of work were interprofessional relationship development, practice-based IPE and the focus on holistic patient-centred care. Graduates were, however, challenged by self-doubt, communication barriers and hierarchy in the workplace. Their recommendations for undergraduate IPE included role modelled and contextually relevant interprofessional skills development, practical advocacy and communication training, longer placements or shared learning spaces.

Conclusion:  Findings indicate that IPE during undergraduate rural clinical placements promotes interprofessional relationship development that extends into the workplace after graduation. However, IPE must be role modelled in the clinical environment and aligned to the reality of the healthcare system for students to develop the skills required to navigate IPCP as graduates.Contribution: This article offers recommendations for responsive undergraduate IPE to promote IPCP after graduation.

This Therapeutic Letter considers the evidence for inhaled corticosteroids (ICS) as a treatment for Chronic Obstructive Pulmonary Disease (COPD). Drug therapy aims to alleviate symptoms, enhance functional capacity and prevent exacerbations, but has not consistently shown to reduce mortality or improve quality of life based on randomised trials.Inhaled corticosteroids have shown limited benefits for COPD symptoms and exacerbations but increased risks of serious harms. Guidelines recommend limiting ICS to severe COPD and only for repeated exacerbations. Studies show withdrawing ICS can be done safely for stable COPD patients with infrequent exacerbations, especially those with lower eosinophil counts. Provincial, national and international guidelines now recommend limiting ICS prescriptions to severe COPD stages. Long-term ICS use may lead to serious side effects, including pneumonia and fractures. Initial COPD therapy should focus on short-acting bronchodilators, not ICS. Adding long-acting bronchodilators is recommended before considering ICS because of limited benefits and risks of serious harms. For persistent symptoms, long-acting muscarinic antagonists (LAMA) or long-acting beta2 agonists (LABA) are recommended, with the addition of ICS reserved for those with repeated exacerbations and severe COPD. Deprescribing ICS can be considered in clinically stable patients, particularly for those with infrequent exacerbations and mild COPD. When applicable, tapering ICS over several months is advised for patients with elevated eosinophil counts. Overall, the risks of serious harms from ICS typically outweigh their limited benefits for mild COPD patients in primary care.

Background:  For continuity and quality of care, accurate record-keeping is crucial. Complete care is facilitated by completing a child's Road to Health Booklet (RTHB) as well as prompt interpretation and appropriate action. This could result in a decrease in child morbidity and mortality.

Aim:  The study was aimed at assessing the completeness of the RTHB of children younger than 5 years.

Setting:  Temba Community Health Centre (CHC), Tshwane District, South Africa.

Methods:  A cross-sectional study was conducted using a data collection sheet adopted from previous studies.

Results:  Children less than 1-year-old accounted for 70.2% of the 255 RTHBs. The mean ± s.d. age was 11.5 ±10.76 months. The study finding showed no section was 100% fully completed. Of the 255 records studied, 38 (14.9%) human immunodeficiency virus (HIV)-exposed babies were recorded at birth, 39.5% were negative at 6 weeks and 60.5% were not recorded. Ninety-one (35.7%) children were unexposed. The HIV status of 126 (49.4%) children was not recorded. Sixty-six per cent (66%) of recorded maternal syphilis was negative. Immunisations, weight-for-age, neonatal information, and details of the family and child were fully completed in 80% of the booklets. Developmental screening was 17.2% completed, and oral health was 1.6% partially completed. The overall completeness was 40.3%.

Conclusion:  The completeness of RTHBs was found to be suboptimal.Contribution: The present study's findings should serve as a reminder that healthcare practitioners must complete RTHBs in their totality in order to improve continuity and care quality, as the results indicated that RTHB completion was below ideal.

Background:  Maternal clinical guidelines (MCGs) provide evidence-based recommendations for skilled birth professionals (SBPs) at the point of care. The dissemination strategies and use of MCGs are inconsistent among skilled birth providers despite their potential to improve the maternal care outcomes.

Aim:  This study examined the effectiveness of dissemination strategies of MCGs by SBPs in a primary care setting.

Method:  We searched in Medline, PubMed, CINAHL and Google Scholar. Search terms were effectiveness, dissemination and use, MCGs, SBPs and primary health care facilities. Studies published in English, conducted between 2010 and 2023 and focussing on dissemination strategies and use of MCGs were included. The final articles were presented in narrative format.

Results:  The search yielded 212 studies. After removing duplicates, seven articles that met the inclusion criteria for the review were included. The narrative review summarised the findings as: Use of MCGs which showed the barriers and enablers for the use of maternal guidelines. The level of adherence to MCGs was summarised, and one study showed the use of support supervision and collaboration improved aspects of MCGs.

Conclusion:  The findings show how skilled attendants acknowledge that MCGs can contribute to improving maternal outcomes. They further describe how, in practice, they are rarely used at the facility level. There is a need for more research on dissemination strategies to ensure improved use of MCGs in primary health care facilities.Contribution: We highlight the key gap in the dissemination of MCGs at primary health care facilities which if improved can potentially improve the use of MCGs.

The training of Family Medicine residents in the West Africa College of Physicians (WACP) has steadily upscaled to a competency-based approach over the years. The latest review of the curriculum (2022) includes self-directed online modules on clinical postings, health management, patient safety, quality assurance research and medical education among others. The operationalisation of the revised curriculum involves the use of workplace-based tools for formative assessments. However, some shortcomings of the traditional work place based assessment (WPBA) have been observed, including a lack of standardisation, time consumption, variability in the assessors' judgements and systematic biases. These shortcomings can be mitigated through the adoption of entrustable professional activities (EPA) along with the use of WPBA.

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