Rural Hospitals In South Africa Research Articles

Extent of caregiver burden among informal caregivers of persons with severe mental disorders in rural South Africa.

Informal caregivers are the backbone of recovery for people with severe mental disorders in South Africa, particularly in rural areas where access to mental health services is limited. While their unique contribution and the subsequent burden arising from occupying the role of informal caregiver are acknowledged, there is limited evidence on the extent of the subjective and objective burdens among informal caregivers of people with severe mental disorders in rural areas. This article reports on a study that aimed to establish the extent of subjective and objective burdens among informal caregivers of people with severe mental disorders in rural South Africa. A descriptive quantitative cross-sectional design was used. Data were gathered through structured interviews with 170 informal caregivers of people with severe mental disorders attending an outpatient clinic at a rural hospital in South Africa. A structured questionnaire guided the interviews and included demographics and caregiving characteristic information. Montgomery, Gonyea and Hooyman's scale was used to assess objective and subjective burdens. Data was analysed descriptively using Stata v15. The majority of the participants were female informal caregivers (83.5%) between the ages of 45 and 64 years (45.3%), and parents represented the largest proportion (45.3%) of caregivers. The global burden scores revealed that most informal caregivers reported moderate-to-severe objective burden and mild-to-moderate subjective burden. Significant associations with objective burden were established for age, gender and residence (p=0.025, p=0.034 and p=0.038, respectively), and subjective burden yielded significant associations with daily caregiving (p=0.012). Caring for people with severe mental disorders is associated with high levels of objective and subjective burdens. The present study highlights the need to integrate the assessment of burdens among informal caregivers of people with severe mental disorders in routine clinical practice. Additionally, the study urgently calls for the development of strategies to support informal caregivers to ensure successful community reintegration among people with severe mental disorders.

Health, hospital(ity) and hegemony: Artistic agencies of two women weavers at Ceza, 1962

Art history has yet to accord recognition to two women for their pivotal roles at a small tapestry-weaving project at Ceza Mission Hospital in rural South Africa in 1962. As I argue below, it was largely the agencies of Allina Ndebele from rural KwaZulu-Natal and Ulla Gowenius from Sweden that laid the groundwork for what would later evolve into a renowned tapestry centre at Rorke's Drift. Although representations depicted Ceza as idyllic, the women pursued this venture in what was a coercive environment, in which a rural black community was marginalised not merely by disease, but forms of power that included racial oppression, doctrine, patriarchy, social convention and biomedicine. This account recovers details of Ndebele and Gowenius's inventive interactions and accords subjectivity to convalescent weavers disenfranchised by modalities of social control, in turn disrupting homogenising notions of this pedagogic milieu as a duality of empowered trainers and those directed by them. Exposing the conditions in which the project was fostered, I situate the venture in a context of mid-century Swedish philanthropy, interrogating previous representations of Ceza as an outcome of benign modernity and the project as the fruits of foreign expertise.

Comparison of formulae for calculating the corrected QT (QTc) interval in an adult population attending a diabetes clinic at a rural hospital in South Africa.

Comparison of formulae for calculating the corrected QT (QTc) interval in an adult population attending a diabetes clinic at a rural hospital in South Africa.

Psychological PPE – Reflections on How to Implement Mindful Interventions to Protect the Healthcare Workforce

Interest in Mindfulness-based interventions (MBIs) with healthcare professionals has become increasingly popular. However, healthcare professionals’ busy schedules and low help-seeking behaviour requires the intervention to be easily accessible, convenient, and practical. This paper explores the reflections of multidisciplinary healthcare professionals regarding implementing a brief online MBI to draw on lessons learned that could guide future implementation and interventions in similar multicultural, resource-constrained settings. An online MBI was implemented with healthcare professionals (HCPs) working in urban and rural hospitals in South Africa during the first wave of Covid-19. Fifty-five healthcare professionals from various disciplines participated in a four-week online training programme via the Zoom platform. Participant reflections and feedback were collected via WhatsApp and Zoom room chats. The data collected were thematically analysed. Reflections from the implementation of the MBI were classified into questions of where, when, who, what, why, and how. The results reflect that a four-hour online mindfulness-based intervention could work more effectively if departments offered and supported the programme during work hours. The findings also reveal the greater potential for a brief online MBI to enhance resiliency in HCPs, especially during a pandemic emergency, as demonstrated in the study. The study proposes that mindfulness training could be offered to HCPs at many levels to help with psychological first aid and task shifting to reduce stress and prevent burnout.

Audit of surgical procedures in regional and central hospitals in Limpopo Province, South Africa.

There is a paucity of data on the functioning and surgical procedures performed in rural hospitals in South Africa. To determine the category of procedures performed at regional and tertiary hospitals in Limpopo Province, South Africa. We conducted a retrospective analysis of surgical procedures performed in the regional and tertiary hospitals in Limpopo Province during a 1-year period from 1 March 2019 to 29 February 2020. A total of 24 263 surgical procedures were performed during the study period. More than half of all cases (50.4%; n=12252) were operated on at the tertiary hospitals while regional hospitals performed the remaining 12 011 operations. There is a great necessity to alleviate the central hospitals from the bulk of surgical procedures.

An Unusual Case Report on Co-Morbidity with Sexual Assault in the Mthatha Hospital, South Africa

Background: Comorbidity or the co-occurrence of mental disorders and substance abuse disorders is common among victims of sexual assault. Occasionally life-threatening conditions have been observed in these patients which need immediate medical attention. Objective: To highlight the unusual case report of co-morbidity with sexual assault in a rural hospital in South Africa. Case History: A seven-year-old girl was referred from a health center to a rural hospital with a history of sexual assault over four days by an unknown man. She was threatened to be killed in the case of disclosure. Her aunt suspected that she had a problem as she was not walking normally. Then she opened and described the whole incident. She was having a history of vaginal discharge with vomiting and diarrhea along with mild fever. She was also depressed. On physical examination, genital injuries including a ruptured hymen were confirmed. She was having muscle guarding of abdominal muscles. The victim was refused admittance as she was labeled a case of rape, but after persistent persuasion of the staff, she was admitted and later operated on for acute appendicitis. This case history, her physical examination, and the difficulty in getting admission to a surgical ward are discussed in this report. Conclusion: Sexual assault may be associated with co-morbidity like acute appendicitis. Doctors must be vigilant in identifying such life-threatening co-morbidity to save the life of a patient.

Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa.

We explored the extent to which perceived HIV-related stigma influences the disclosure and concealment of HIV status to family among adult patients hospitalised for AIDS-related illness, and described reports of negative responses and enacted stigma following disclosure. We conducted interviews with a purposeful sample of 28 adult patients in a rural South African hospital. Data analysis was deductive and inductive and followed the thematic approach. We found evidence of delayed HIV diagnosis and initiation of treatment. There was delayed and selective disclosure as well as concealment of the HIV-positive status. The disclosure was delayed for months or even years. During that time, there was active concealment of the HIV status to avoid stigma from family, friends, and community. When disclosure occurred, there was selective disclosure to close family members who would keep the secret and respond favorably. Although the participants disclosed mostly to close family, some of their post-disclosure experiences included incidents of enacted stigma and discrimination. The fear of perceived stigma and self-stigma influenced the active concealment of their HIV status from others. Continuous concealment of one’s HIV status and delayed disclosure limit the opportunities for support and care. There is a need to take into consideration the interaction between HIV-related stigma and disclosure to develop disclosure-counselling strategies in primary health care settings.

Strategies to Enhance Knowledge and Practical Skills of Triage amongst Nurses Working in the Emergency Departments of Rural Hospitals in South Africa.

Purpose: Lack of knowledge and practical skills on triage remains a global problem, especially within rural hospitals, and very little is known about enhancing the knowledge and skills of emergency nursing staff in rural hospitals of South Africa. The objective was to describe the perceived strategies for enhancing knowledge and practices of triage among nurses working in the emergency departments (EDs) of rural hospitals in South Africa. Research methods: A descriptive qualitative research design was applied to achieve the research objective. A non-probability sampling method was applied to select 17 professional nurses from rural hospitals. An unstructured face-to-face interview method was used to collect data. Data collected were analyzed using Tesch’s method of data analysis. Results: The study findings highlighted the academic needs of nurses working in the ED of rural hospitals. Two themes emerged from this study; (1) The consistent description of the importance of triage training for emergency unit staff, and (2) The description of measures to enhance triage practices amongst emergency unit staff. Findings indicated that triage knowledge and practice remains a challenge, but with formulated strategies like continuous training by workshops, refresher courses, and offering a training module on triage, evaluation of developed guidelines and benchmarks is often enhanced. Conclusions: The study describes the strategies to enhance the conversion of knowledge and practice of triage amongst nurses working in the ED of rural hospitals. The paper argues that the knowledge and practical skills of nurses working in ED are enhanced through the provision of continuous training as workshops, triage module, evaluating the developed guidelines to implement triage, and benchmarking with other hospitals.

Hypoalbuminaemia in orthopaedic trauma patients in a rural hospital in South Africa.

The deleterious effects of hypoalbuminaemia in the peri-operative period are well documented. We aimed to review serum albumin levels in a cohort of orthopaedic trauma patients to determine the prevalence of hypoalbuminaemia. Secondarily, we aimed to identify factors associated with an increased risk of hypoalbuminaemia. A retrospective cross-sectional study was performed of data collected prospectively at a regional hospital serving primarily a rural population in South Africa. Two hundred ninety-five patients were included in the study. Twenty-nine per cent of the cohort was found to have hypoalbuminaemia. Femur neck fractures (p < 0.001), intertrochanteric fractures (p = 0.004), tibial plateau fractures (p = 0.034) and polytrauma (p = 0.013) were associated with hypoalbuminaemia. The mean albumin level was lower in HIV-positive patients when compared to HIV-negative patients (35.7 g/L vs 37.5 g/L, p = 0.007). The presence of comorbidities other than HIV, like diabetes mellitus (p = 0.001), previous pulmonary tuberculosis (p = 0.034) and chronic renal failure (p = 0.007) was associated with hypoalbuminaemia. In this cohort of orthopaedic trauma patients from rural South Africa, we found a 29% prevalence of hypoalbuminaemia at the time of presentation. High-risk subgroups include patients with pre-existing comorbidities and increased age, as well as patients presenting with polytrauma, femoral neck, intertrochanteric femur or tibial plateau fractures.

The impact of HIV infection and disease stage on the rate of weight gain and duration of refeeding and treatment in severely malnourished children in rural South African hospitals

Background. Evidence of the effects of HIV infection and clinical stage on the duration of refeeding and treatment (DRT) and the rate of weight gain (RWG) in severely malnourished children remains inconclusive. Objectives. To determine whether the RWG and DRT differ by baseline clinical characteristics, and to assess the effect of HIV status and disease stage on the relationship between these two clinical outcomes. Methods. This was a retrospective record review of 346 patiens discharged between 2009 and 2013 following treatment for severe acute malnutrition (SAM) at two rural hospitals in South Africa. Results. A third of the sample was HIV-positive, the RWG (measured as g/kg/day) was significantly slower in HIV-positive patients compared with HIV-negative cases (mean 5.2, 95% confidence interval (CI) 4.47 - 5.93 v. mean 8.51; CI 7.98 - 9.05; p <0.0001) and cases at stage IV of HIV infection had a significantly slower RWG (mean 3.97; CI 2.33 - 5.61) compared with those at stages I (mean 7.64; CI 6.21 - 9.07) ( p <0.0001) and II (mean 5.87; CI 4.74 - 6.99). The mean DRT was longer in HIV-positive cases and those at advanced stages of HIV infection. HIV-positive cases were renourished and treated for almost 3.5 times longer than their HIV-negative counterparts to achieve a moderate RWG (5 - 10 g/kg/day). Conclusion . This study highlights the need to reconsider energy requirements for HIV-positive cases at different clinical stages, for more rapid nutritional recovery in under-resourced settings where prolonged hospitalisation may be a challenge.

Short-term and sustained effects of a health system strengthening intervention to improve mortality trends for paediatric severe malnutrition in rural South African hospitals: An interrupted time series design

Background. Case fatality rates for childhood severe acute malnutrition (SAM) remain high in some resource-limited facilities in South Africa (SA), despite the widespread availability of the World Health Organization treatment guidelines. There is a need to develop reproducible interventions that reinforce the implementation of these guidelines and assess their effect and sustainability. Objectives. To assess the short-term and sustained effects of a health system strengthening intervention on mortality attributable to SAM in two hospitals located in the Eastern Cape Province of SA. Methods. This was a theory-driven evaluation conducted in two rural hospitals in SA over a 69-month period (2009 - 2014). In both facilities, a health system strengthening intervention was implemented within the first 32 months, and thereafter discontinued. Sixty-nine monthly data series were collected on: ( i ) monthly total SAM case fatality rate (CFR); ( ii ) monthly SAM CFR within 24 hours of admission; and ( iii ) monthly SAM CFR among HIV-positive cases, to determine the intervention’s effect within the first 32 months and sustainability over the remaining 37 months. The data were analysed using Linden’s method for analysing interrupted time series data. Results. The study revealed that the intervention was associated with a statistically significant decrease of up to 0.4% in monthly total SAM CFR, a non-statistically significant decrease of up to 0.09% in monthly SAM CFR within 24 hours of admission and a non-statistically significant decrease of up to 0.11% in monthly SAM CFR among HIV-positive cases. The decrease in mortality trends for both outcomes was only slightly reversed upon the discontinuation of the intervention. No autocorrelation was detected in the regression models generated during data analyses. Conclusion. The study findings suggest that although the intervention was designed to be self-sustaining, this may not have been the case. A qualitative enquiry into the moderating factors responsible for failure to sustain such an intervention, as well as the process of care, would add value to the findings presented in this study.

Doctors as street-level bureaucrats in a rural hospital in South Africa

In the perspectives of implementation of policy, the top-down and bottom-up perspectives of policy-making dominate the discourse. However, service delivery and therefore the experience of the policy by the citizen ultimately depend on the civil servant at the front line to implement the policy. Lipsky named this street-level bureaucracy, which has been used to understand professionals working in the public sector throughout the world. The public sector in South Africa has undergone a number of changes in the transition to a democratic state, post 1994. This needs to be understood in public administration developments throughout the world. At the time of the study, the public sector was characterized by considerable inefficiencies and system failures as well as inequitable distribution of resources. The context of the study was a rural hospital serving a population of approximately 150 000. An insider-ethnography over a period of 13 months explored the challenges of being a professional within the public sector in a rural hospital in South Africa. Data collection included participant observation, field notes of events and meetings, and documentation review supplemented with in-depth interviews of doctors working at a rural hospital. Street-level bureaucracy was used as a framework to understand the challenges of being a professional and civil servant in the public sector. The context of a resource-constrained setting was seen as a major limitation to delivering a quality service. Yet considerable evidence pointed to doctors (both individually and collectively) being active in managing the services in the context and aiming to achieve optimal health service coverage for the population. In the daily routine of the work, doctors often advocated for patients and went beyond the narrow definitions of the guidelines. They compensated for failing systems, beyond a local interpretation of policy. However, doctors also at times used their discretion negatively, to avoid work or to contribute to the inefficiencies of healthcare delivery. While appearing to be in conflict, the merging of the roles of the health professional and the bureaucrat is required to be able to function effectively within the healthcare system. Being a doctor and being a civil servant are synergistic in daily work, and as a result it is difficult to neatly differentiate professional and civil servant roles in decision-making. It is in the discretion of both roles that considerable flexibility within the roles is possible. Such freedom to act is critical for being able to find local solutions and thereby improve healthcare services. The findings resonate strongly with studies from other parts of the world and offer a window into making sense of the local decision making of doctors. Street-level bureaucracy remains an important lens to view the work of healthcare professionals in the public sector. In the tension between the top-down policy-making and the bottom-up pressure, street-level bureaucracy acts as an important terrain for improving the implementation of services and therefore advocacy and health system improvement.

Diarrhea etiological study in children under five in the Bengo General Hospital, Angola

Background: Delay in pulmonary tuberculosis (PTB) diagnosis is one of the major factors that affect outcome and threatens continued spread of tuberculosis. This study aimed at determining predictors of delayed PTB diagnosis among human immunodeficiency virus (HIV) infected individuals. Methods & Materials: A retrospective observational study was done using clinic records of HIV-infected PTB suspects attending an HIV/AIDS clinic at Tintswalo rural hospital in South Africa (SA) between January 2006 and December 2007. Using routine clinic registers, 480 records were identified Results: PTB diagnosis delay was found among 77/176 (43.8%) of the patients diagnosed with PTB. The mean delay of PTB diagnosis was 170.6 days; diagnosis delay ranged 1-30 days in 27 (35.1%) patients, 31-180 days in 24 (33.8%) patients; 24 (31.2%) patients remained undiagnosed for ≥180 days. Independent factors associated with delayed diagnosis were: older age>40 years (Odds Ratio (OR) 3.43, 95% CI 1.45 – 8.08) and virological failure (OR 2.72, 95% CI 1.09 – 6.74). Conclusion: There is a considerable delayed PTB diagnosis among HIV-infected patients in rural SA. Older patients as well as patients with high viral load are at a higher risk of PTB diagnosis delay. Therefore efforts to reduce PTB diagnosis delay need to be emphasised.

Predictors of diagnostic delays among pulmonary tuberculosis suspects attending health care services at Tintswalo rural hospital, Mpumalanga Province

Background: Delay in pulmonary tuberculosis (PTB) diagnosis is one of the major factors that affect outcome and threatens continued spread of tuberculosis. This study aimed at determining predictors of delayed PTB diagnosis among human immunodeficiency virus (HIV) infected individuals. Methods & Materials: A retrospective observational study was done using clinic records of HIV-infected PTB suspects attending an HIV/AIDS clinic at Tintswalo rural hospital in South Africa (SA) between January 2006 and December 2007. Using routine clinic registers, 480 records were identified Results: PTB diagnosis delay was found among 77/176 (43.8%) of the patients diagnosed with PTB. The mean delay of PTB diagnosis was 170.6 days; diagnosis delay ranged 1-30 days in 27 (35.1%) patients, 31-180 days in 24 (33.8%) patients; 24 (31.2%) patients remained undiagnosed for ≥180 days. Independent factors associated with delayed diagnosis were: older age>40 years (Odds Ratio (OR) 3.43, 95% CI 1.45 – 8.08) and virological failure (OR 2.72, 95% CI 1.09 – 6.74). Conclusion: There is a considerable delayed PTB diagnosis among HIV-infected patients in rural SA. Older patients as well as patients with high viral load are at a higher risk of PTB diagnosis delay. Therefore efforts to reduce PTB diagnosis delay need to be emphasised.

Early infant diagnosis of HIV and fast initiation of anti-retroviral therapy in a rural African setting: how well are we doing?

Background:In South Africa, current estimates indicate that 1% of infants will be HIV PCR-positive by 2 months of age. WHO recommends early infant diagnosis (EID) and immediate initiation of antiretroviral therapy (ART) in infants who are diagnosed with HIV infection within the first year of life.Aims:To investigate rates of EID and subsequent ART initiation in infants attending the Primary Health Care (PHC) clinics which fed Mseleni Hospital during 2012.Objectives:To measure the number of infants (<1 year of age) testing HIV PCR-positive who are currently collecting ART and those lost to follow-up.Methods:HIV PCR test results from Mseleni Hospital in 2012 were cross-referenced with the national database (TIER.net) for ART initiation and follow-up from the National Health Laboratory Service (NHLS) database.Results:455 of 843 (54%) HIV-exposed infants (<2 months) were tested by HIV PCR, 11 of whom (2·4%) tested positive, reflecting the national prevalence. Of 897 HIV PCR tests undertaken in infants <1 year, 51 (5·7%) were positive, and 36 were included for analysis. Only 13 (36·1%) of these infants are currently collecting ART; seven (19·4%) commenced ART but were lost to follow-up, and 16 (44·5%) never started ART.Conclusion:16 (44·5%) HIV PCR-positive infants in Mseleni Hospital and its feeder PHCs were not commenced on ART. This may reflect a similar problem in other rural hospitals in South Africa. Specific interventions are required to rapidly up-scale early initiation of ART in this vulnerable group of infants.

A Generic Quality Assurance Model (GQAM) for successful e-health implementation in rural hospitals in South Africa.

Although e-health can potentially facilitate the management of scarce resources and improve the quality of healthcare services, implementation of e-health programs continues to fail or not fulfil expectations. A key contributor to the failure of e-health implementation in rural hospitals is poor quality management of projects. Based on a survey 35 participants from five rural hospitals in the Eastern Cape Province of South Africa, and using a qualitative case study research methodology, this article attempted to answer the question: does the adoption of quality assurance (QA) models add value and help to ensure success of information technology projects, especially in rural health settings? The study identified several weaknesses in the application of QA in these hospitals; however, findings also showed that the QA methods used, in spite of not being formally applied in a standardised manner, did nonetheless contribute to the success of some projects. The authors outline a generic quality assurance model (GQAM), developed to enhance the potential for successful acquisition of e-health solutions in rural hospitals, in order to improve the quality of care and service delivery in these hospitals.

Using a Virtual ICT Training Framework to Support Doctors in Rural Hospitals in South Africa

This paper investigated how ICT skill levels of doctors deployed to rural hospitals contribute to effective usage of computer-mediated tools in hospitals in South Africa. A case study approach was used. Participants were selected from a population group of doctors. Ten doctors were selected from ten government-owned hospitals for interviews. Data was collected using semi-structured open ended interview questions. Doctors were asked to rate their knowledge on computer and e-health skill and indicate if they need training. The findings revealed that majority of the doctors in rural hospitals (n=75%) are computer illiterate. When those with computer skills were asked to rate their knowledge in computer usage, 46% said they were novice, 42% were average and only 12% stated that they were experienced. The results led to a proposed virtual ICT training framework to provide basic ICT training through virtual tutoring to support doctors in rural hospitals.

Infectious complication of Blunt head injury

A middle-aged man presented to a rural hospital in South Africa with a history of head trauma. He reported being attacked and stoned 2 weeks prior, and subsequently noticed drainage...

Reflections on a hospital information committee support project in a rural hospital in South Africa

Background: This paper presents an overview of support offered to a hospital information committee by a Hospital Information Committee Support Project (HICSP) in a rural area of South Africa. A specific focus is on the support required at various stages of the project, which was underpinned by Change Theory: any change in practice should be an on-going, phased process (pre-contemplation, contemplation and action). Additionally, change must be seen as having some benefit. Methods: A cross-sectional, mixed-methods evaluation was conducted to determine whether the project had met its aims and to explore participants’ experiences. Quantitative data included: number of meetings held, number of workshops held to develop templates, number of templates developed and in use, and number of action plans developed and implemented. Qualitative data included participants` views of the HICSP. In relation to Change Theory, data was analysed to summarise the type of support required during various stages of the HICSP. Results: Quantitative data revealed that the aims of the HICSP were met. In accordance with Change Theory, support must be regularly provided and must be on-going over a relatively prolonged period of time. Qualitative data illustrated that, generally, the support given was considered to be appropriate and participants continued to collect, analyse, use and monitor data and information on completion of the HICSP. Discussion and conclusions: The need for the strategic use of data at a local level to inform decision making and action is unquestionable. The study demonstrates that in an isolated, rural area an information committee can, in accordance with the stages of Change Theory, be supported and empowered so that hospital and nursing managers can confidently use data in a way that is locally meaningful and responsive.

Improving Drug Prescription through Computer-Mediated Asynchronous Communication: A Case Study of Rural Hospitals in South Africa

This paper investigated how doctors in state owned hospitals in South Africa communicate with pharmacist inside and outside the hospital regarding drug prescription to patients. A case study approach was used. Nine participants were purposively selected from three rural communities' in the North West Province. Data was collected using semi-structured open ended interview questions. The interviewees (3doctors, 3pharmacists and 3patients) were asked to tell in their own words the processes of prescribing medicine and transmitting of prescription forms to a pharmacist; the process of dispensing medication to patients; and how patients collect and administer the prescribed medication respectively. The findings revealed that paper based prescription were given to patients by the doctors to collect medication at any nearby pharmacy. However patients sometime did not present the paper prescription to the pharmacy for their medication because of their deteriorating health conditions. It was revealed that doctors receive no feedback after medication is dispensed to patients. The results led to a proposed computer-mediated asynchronous communication framework to provide systematic capturing, transferring, and effective communication between doctors and pharmacist to improve the process of drug prescription and dispensing to patients in rural hospitals.