South African Public Health Sector Research Articles

Conceptualizing a model for cloud-based hospital management systems for the South African public health sector

Background and Aim of Study: Real-time access of information in the healthcare environment is essential, as it not only helps medical personnel to have adequate and timely information, but it also assists patients to be served more easily. Hospitals in rural areas are operating at a low bandwidth and have poor IT infrastructure that causes intermittent networks leading to disruptions and slow service delivery. This necessitates the Hospital Management System (HMS) to be deployed in the cloud environment to reduce the challenges leading to poor service delivery. The aim of the study: to develop a model for cloud-based HMS for the South African public health sector. Material and Methods: This study identified three public district municipality hospitals in Gauteng Province, South Africa, that were already using HMS and used them for data collection. Each hospital had up to 50 healthcare workers, and this formed the population of 150 from the three hospitals, from which a sample size of 108 respondents was selected. Data were collected using a closed-ended questionnaire and analyzed quantitatively using SPSS v25. Results: The results demonstrated that the suggested model has a good prediction power of 60.9% (R2=0.609) and that with the exception of environmental aspects, the rest of the constructs has a significant contribution to the successful implementation of the cloud-based HMS. Social aspects had the highest prediction power of 60.0% (β=0.600) at p=0.001; followed by risk analysis and control with 41.3% (β=0.413) at p=0.009. On the other hand, environmental aspects had the least and non-significant prediction of 12.3%. Conclusions: This study contributes to the ongoing call to have seamless healthcare provision systems. The model developed in this study extends the research of modernizing healthcare provision by leveraging technological innovations.

A cross-sectional study on factors influencing patient participation in undergraduate medical education in a public and private hospital in Johannesburg, South Africa

BackgroundThe active involvement of patients in medical education is a common practice globally. Despite this, there is a global paucity of data on patients’ views on their role in medical education. As such this study aimed to identify factors that influence patient participation in undergraduate medical education in public and private hospitals in Johannesburg.MethodsA cross-sectional study was conducted, using a 23-question, self-designed, paper questionnaire to collect data on patients’ perceptions of student involvement in their care – with regard to consent, confidentiality, ethics, and patient preferences. Participants were recruited on a voluntary basis in the Departments of Medicine, Surgery, and Gynaecology, at selected hospital sites. Fisher’s Exact and Chi-Square statistical tests were used where appropriate.ResultsTwo hundred and one adult patients, comprised of 150 public sector patients and 51 private sector patients, completed the questionnaire. One hundred and sixty-nine patients (84,1%) were willing to participate in undergraduate medical education and no notable difference between these sectors was demonstrated (p = 0,41). The results further demonstrated that the main factors influencing patient participation in undergraduate medical education across both sectors were (1) the presence of a supervising professional, (2) the perceived degree of invasiveness of a procedure, and (3) the perceived expertise of the student. In addition, data across other key themes such as consent, confidentiality, ethics, and patient preferences and perceptions were elucidated.ConclusionsThis study demonstrates that the majority of inpatients across the public and private sectors are willing to participate in undergraduate medical education to facilitate the development of healthcare professionals. It also demonstrated that most patients have a positive experience. However, more measures of quality informed consent need to be instituted to optimise the current role of the South African public health sector, whilst facilitating the development of a similar role for the South African private sector in future clinical education. In addition, further research is necessary to evaluate these findings in a South African context.

Between suffering and coping: burnout in female medical doctors in South Africa.

Burnout is described as emotional and physical exhaustion, reduced accomplishment, together with an outlook of inadequacy and cynicism related to job stress. It has a harmful impact globally, especially in developing countries, such as South Africa. This study is a phenomenological collective case study focusing on burnout experience in a sample of female medical doctors working in a South African public hospital. Based on ongoing explorations of burnout themes, empirically based intervention strategies are needed to be developed and presented for the South African public health sector to prevent stress-related burnout. The findings support the trend in literature that burnout is an overwhelming experience for female medical doctors in South Africa. The study presents voices of female medical doctors, their concerns, the causes for burnout and their coping mechanisms. It provides a strong contribution to exploring and presenting women's experiences in working in the medical field in South Africa from a positive psychology perspective. The findings indicate the struggles and the coping mechanisms of female medical doctors working in the field.

Health Care Resource Utilization in Adults Living With Type 1 Diabetes Mellitus in the South African Public Health Sector: Protocol for a 1-Year Retrospective Analysis With a 5-, 10-, and 25-Year Projection.

Type 1 diabetes mellitus (T1DM) is less common than type 2 diabetes mellitus but is increasing in frequency in South Africa. It tends to affect younger individuals, and upon diagnosis, exogenous insulin is essential for survival. In South Africa, the health care system is divided into private and public health care systems. The private system is well resourced, whereas the public sector, which treats more than 80% of the population, has minimal resources. There are currently no studies in South Africa, and Africa at large, that have evaluated the immediate and long-term costs of managing people living with T1DM in the public sector. The primary objective was to quantify the cost of health care resource utilization over a 12-month period in patients with controlled and uncontrolled T1DM in the public health care sector. In addition, we will project costs for 5, 10, and 25 years and determine if there are cost differences in managing subsets of patients who achieve glycemic control (hemoglobin A1c [HbA1c] <7%) and those who do not. The study was performed in accordance with Good Epidemiological Practice. Ethical clearance and institutional permissions were acquired. Clinical data were collected from 2 tertiary hospitals in South Africa. Patients with T1DM, who provided written informed consent, and who satisfied the inclusion criteria were enrolled in the study. Data collection included demographic and clinical characteristics, acute and chronic complications, hospital admissions, and so on. We plan to perform a cost-effectiveness analysis to quantify the costs of health care utilization in the preceding 12 months. In addition, we will estimate projected costs over the next 10 years, assuming that study participants maintain their current HbA1c level. The cost-effectiveness analysis will be modeled using the IQVIA CORE Diabetes Model. The primary outcome measures are incremental quality-adjusted life years, incremental costs, incremental cost-effectiveness ratios, and incremental life years. Ethical clearance and institutional approval were obtained (reference number 200407). Enrollment began on February 9, 2021, and was completed on August 24, 2021, with 224 participants. A database lock was performed on October 29, 2021. The statistical analysis and clinical study report were completed in January 2022. At present, there are no data assessing the short- and long-term costs of managing patients with T1DM in the South African public sector. It is hoped that the findings of this study will help policy makers optimally use limited resources to reduce morbidity and mortality in people living with T1DM. RR1-10.2196/44308.

The Risk Implications of Ineffective Use of Human Resource Information Systems in the South African Public Health Sector

The Risk Implications of Ineffective Use of Human Resource Information Systems in the South African Public Health Sector

HTA57 Recommendations for Evidence Generation Activities Supportive of National HTA in the South African Public Health Sector

HTA57 Recommendations for Evidence Generation Activities Supportive of National HTA in the South African Public Health Sector

Quantifying the burden of the post-ICU syndrome in South Africa: A scoping review of evidence from the public health sector.

Background The post-ICU syndrome (PICS) comprises unexpected impairments in physical, cognitive, and mental health after intensive care unit (ICU) discharge, and is associated with a diminished health-related quality of life (HRQOL). A Cochrane review recommended more research in this field from low- and middle-income countries. Objectives This review aims to examine the extent and nature of publications in the field of PICS in the South African (SA) public health sector. Findings of available local research are contextualised through comparison with international data. Methods A comprehensive literature search strategy was employed. Inclusion criteria comprised publications enrolling adult patients following admission to SA public hospital ICUs, with the aim to study the main elements of PICS (ICU-acquired neuromuscular weakness, neurocognitive impairment, psychopathology and HRQOL). Results Three studies investigated physical impairment, 1 study psychopathology, and 2 studies HRQOL. Recommended assessment tools were utilised. High rates of attrition were reported. Neuromuscular weakness in shorter-stay patients had recovered at 3 months. Patients who were ventilated for ≥5 days were more likely to be impaired at 6 months. The study on psychopathology reported high morbidity. The HRQOL of survivors was diminished, particularly in patients ventilated for ≥5 days. Conclusion This review found a paucity of literature evaluating PICS in the SA public health sector. The findings mirror those from international studies. Knowledge gaps pertaining to PICS in medical, surgical and HIV-positive patients in SA are evident. No publications on neurocognitive impairment or the co-occurrence of PICS elements were identified. There is considerable scope for further research in this field in SA. Contributions of the study This review identified the available publications investigating the post ICU syndrome (PICS) in the South African public healthcare setting. A small number of ground-breaking studies were found. Knowledge gaps in this field were identified.

Triage and dysphagia: Are hospitals in the South African public health sector ready?

Dysphagia screening is unequivocally beneficial for individuals who may be at risk of swallowing impairment. Benefits range from capitalising on early intervention, facilitating hydration and nutrition, reduced financial costs for the patient and prevention of dysphagia-related complications. Why then is there a need for triage? Inefficiencies and often non-existence of screening and referral processes require one to consider if triage may be a more viable option in the public healthcare context. Dysphagia triage could potentially prioritise emergency swallowing care and identify patients who need immediate swallowing attention because of the nature or severity of dysphagia. The use of a dysphagia triage checklist could have implications for patient health outcomes in terms of the safety of oral diets, development of aspiration pneumonia, malnutrition, administration of oral medication and overall patient prognosis.

Cervical cancer in women living in South Africa: a record linkage study of the National Health Laboratory Service and the National Cancer Registry.

IntroductionIn countries with high HIV prevalence, it is important to understand the cervical cancer (CC) patterns by HIV status to ensure targeted prevention measures. We aimed to determine the factors associated with CC compared to non-infection related cancer in women living in South Africa.MethodsThis was a cross-sectional study of women aged 15 years and older diagnosed with CC and non-infection related cancer in the South African public health sector from 2004 to 2014. The National Cancer Registry provided data on cancer, whilst HIV status was determined from routinely collected HIV related data from the National Health Laboratory Service. We explored the association of HIV infection, age, ethnicity and calendar period with CC compared to non-infection related cancer.ResultsFrom 2004 to 2014, 49,599 women were diagnosed with CC, whilst 78,687 women had non-infection related cancer. About 40% (n = 20,063) of those with CC and 28% (n = 5,667) of those with non-infection related cancer had a known HIV status. The median age at CC diagnosis was 44 years (interquartile range (IQR): 37–52) and 54 years (IQR: 46–64) for HIV positive and negative women, respectively, and for non-infection related cancer, 45 years (IQR: 47–55) and 56 years (IQR: 47–66) for HIV negative and positive women, respectively. Diagnosis of CC was associated with HIV positivity, Black ethnicity, earlier calendar period (2004–2006) and the ages 30–49 years. In comparison with Black women, the odds of CC were 44% less in Coloured women, 50% less in Asian women and 51% less in White women.ConclusionsHIV positive women presented a decade earlier with CC compared to HIV negative women. A large proportion of women with CC were unaware of their HIV status with a disproportionate burden of CC in Black women. We recommend women attending CC screening facilities to be offered HIV testing so that recommendations for their follow-up visits are given according to their HIV status.

Trends in the prevalence of microscopically-confirmed schistosomiasis in the South African public health sector, 2011-2018.

BackgroundSchistosomiasis, also known as bilharzia, is a chronic parasitic blood fluke infection acquired through contact with contaminated surface water. The illness may be mild or can cause significant morbidity with potentially serious complications. Children and those living in rural areas with limited access to piped water and services for healthcare are the most commonly infected. To address the prevalence of the disease in parts of South Africa (SA) effective national control measures are planned, but have not yet been implemented. This study aimed to estimate the prevalence and trends of public sector laboratory-confirmed schistosomiasis cases in SA over an eight-year (2011–2018) period, to inform future control measures.Methodology & principal findingsThis is a descriptive analysis of secondary data from the National Health Laboratory Service (NHLS). The study included all records of patients for whom microscopic examination detected Schistosoma species eggs in urine or stool specimens from January 2011 to December 2018. Crude estimates of the prevalence were calculated using national census mid-year provincial population estimates as denominators, and simple linear regression was used to analyse prevalence trends. A test rate ratio was developed to describe variations in testing volumes among different groups and to adjust prevalence estimates for testing variations.A total number of 135 627 schistosomiasis cases was analysed with the highest prevalence observed among males and individuals aged 5–19 years. We describe ongoing endemicity in the Eastern Cape Province, and indicate important differences in the testing between population groups.ConclusionWhile there was no overall change in the prevalence of schistosomiasis during the analysis period, an average of 36 people per 100 000 was infected annually. As such, this represents an opportunity to control the disease and improve quality of life of affected people. Laboratory-based surveillance is a useful method for reporting occurrence and evaluating future intervention programs where resources to implement active surveillance are limited.

Infants 21-90days presenting with a possible serious bacterial infection - are evaluation algorithms from high income countries applicable in the South African public health sector?

BackgroundYoung infants with a possible serious bacterial infection (SBI) are a very common presentation to emergency centres (ECs). It is often difficult to distinguish clinically between self-limiting viral infections and an SBI. Available evaluation algorithms to assist clinicians are mostly from high-income countries. Data to inform clinical practice in low- and middle-income countries are lacking.ObjectivesTo determine the period prevalence of SBI and invasive bacterial infection (IBI) and describe current practice in the assessment and management of young infants aged 21–90 days presenting with a possible SBI to a Paediatric Emergency centre (PEC) in Cape Town, South Africa.MethodsA retrospective cross-sectional review of infants 21–90 days old presenting to the Tygerberg Hospital PED between 1 January 2016 and 31 May 2016.ResultsA total of 248 infants 21–90 days were included in the study. Sixty-two patients (25%, 95% CI 20–30) had an SBI and 13 (5.2%, 95% CI 3–8) had an IBI. One hundred and sixty-five infants had a possible SBI based on WHO IMCI criteria. The sensitivity of the WHO IMCI criteria in detecting SBI was 82.3% (95% CI 70.5–90.8) and the specificity 38.7% (95% CI 31.7–46.1). More than half (51.2%) of the infants received antibiotics within the 48 h prior to presentation, of which 33.5% included intramuscular injection of Ceftriaxone. Only 20 (8.0%) patients in this age group were discharged home after initial evaluation. A significant relationship was noted between fever and the risk of SBI (p-value 0.010) and IBI (p-value 0.009). There also appeared to be a significant relationship between nutritional status and IBI (p-value 0.013).ConclusionPeriod prevalence of SBI and IBI was higher compared to that published in the literature. Validated evaluation algorithms to stratify risk of SBI are needed to assist clinicians in diagnosing and managing infants appropriately in low- and middle-income settings.

Combating Corruption in the South African Public Health Sector

Combating Corruption in the South African Public Health Sector

Resisting abortion stigma in situ: South African womxn's and healthcare providers' accounts of the pre-abortion counselling healthcare encounter

Abortion providers and pregnant people who undergo abortion potentially face significant stigma. Researchers have started to explore how womxn respond to abortion stigma, usually focusing on individual strategies in managing or reducing stigma effects. Drawing on narrative data from research conducted on womxn’s and healthcare providers’ experiences of the pre-abortion healthcare encounter in the South African public health sector, we highlight how stigma may be resisted in social ways within this context. Everyday chatter and informal social support amongst womxn in the waiting room provided a counterpoint for health service providers’ ascription of shame to the womxn, and a sense of solidarity amongst the womxn. Health service providers narrated their decision to do abortion work through the socially affirming hero canonical narrative, and womxn described their counselling as helpful. These social and discursive practices resist the awfulisation of abortion and provide relief for the womxn and the healthcare providers in particular contexts.

Hepatitis A virus seroprevalence in South Africa - Estimates using routine laboratory data, 2005-2015.

IntroductionSouth Africa is considered highly endemic for hepatitis A virus (HAV) although few seroprevalence studies have been conducted over the past two decades. The World Health Organization recommends integrating HAV vaccination into national childhood immunization schedules where there is transition from high to intermediate endemicity. As a means of gauging age-specific rates of infection, we report HAV seroprevalence rates among specimens tested for HAV serology within South Africa’s public health sector from 2005–2015.Materials and methodsHepatitis A serology results (Anti-HAV IgM, IgG and total antibody) from 2005–2015 were extracted from South Africa’s National Health Laboratory Service’s Corporate Data Warehouse (NHLS CDW), the central data repository of all laboratory test-sets within the public health sector. Results were extracted according to test-set, result, date of testing, health facility, name, surname, age, and sex. Anti-HAV IgG results were merged with total antibody results to reflect anti-HAV seroprevalence. Testing volume, positivity rates and age-specific anti-HAV seroprevalence rates by year and geographic distribution are described.Results and discussionA total of 501 083 HAV IgM results were retrieved, of which 16 423 (3.3%) were positive, 484 259 (96.6%) negative and 401 (0.1%) equivocal; and 34 710 HAV total antibody/IgG tests of which 30 675 (88.4%) were positive, 4 020 (11.6%) negative and 15 equivocal. Whereas IgM positivity was highest among the 1–4 year age group (33.5%) and lowest among patients >45 years (<0.5%), total antibody positivity ranged from its lowest level of 52.7% in the 1–4 year age group increasing to levels of >90% only after 25 years of age.ConclusionAnti-HAV total antibody testing within the South African public health sector demonstrates seroprevalence rates reach levels >90% only in adulthood, suggesting South Africa could be in transition from high to intermediate endemicity. Prospective studies with geographically representative sampling are required to confirm these findings and evaluate provincial and urban/rural heterogeneity.

Epidemiology and clinical profile of individuals with cleft lip and palate utilising specialised academic treatment centres in South Africa.

ObjectiveThe study was conducted to determine the epidemiology and clinical profile of individuals with cleft lip and/or palate (CLP) utilizing specialized academic treatment centres in South Africa’s public health sector.Materials and methodsThe Human Research Ethics Committee of the University of the Witwatersrand in Johannesburg provided ethical approval for the study. We conducted a retrospective record review of all cases of CLP treated at the specialised academic centres for the two-year period from 1 January 2013 until 31 December 2014. We used a structured, pre-tested record review form to obtain demographic, clinical and treatment information on each CLP case. We used Stata 13 to analyse the data and conducted statistical tests at 5% significance level.ResultsWe analysed 699 records of individuals with CLP. The estimated prevalence of CLP in the South African public health sector was 0.3 per 1000 live births, with provincial variation of 0.1/1000 to 1.2/1000. The distribution of clefts was: 35.3% cleft palate; 34.6% cleft lip and palate; 19.0% cleft lip and other cleft anomalies at 2%. Of the total number of CLP, 47.5% were male and 52.5% female, and this difference was statistically significant (p<0.001). The majority of clefts occurred on the left for males (35.5%) and palate for females (43.4%), with a male predominance of unilateral cleft lip and palate (53.3%).ConclusionThe study findings should inform the implementation of South Africa’s planned birth defect surveillance system and health service planning for individuals with CLP.

The burden of cancers associated with HIV in the South African public health sector, 2004\u20132014: a record linkage study

IntroductionThe impact of South Africa’s high human immunodeficiency virus (HIV) burden on cancer risk is not fully understood, particularly in the context of antiretroviral treatment (ART) availability. We examined national cancer trends and excess cancer risk in people living with HIV (PLHIV) compared to those who are HIV-negative.MethodsWe used probabilistic record linkage to match cancer records provided by the National Cancer Registry to HIV data provided by the National Health Laboratory Service (NHLS). We also used text search of specific HIV terms from the clinical section of pathology reports to determine HIV status of cancer patients. We used logistic and Joinpoint regression models to evaluate the risk and trends in cancers in PLHIV compared to HIV-negative patients from 2004 to 2014. In sensitivity analysis, we used inverse probability weighting (IPW) to correct for possible selection bias.ResultsA total of 329,208 cancer cases from public sector laboratories were reported to the NCR from 2004 to 2014 with the HIV status known for 95,279 (28.9%) cancer cases. About 50% of all the female cancer cases (n = 30,486) with a known status were HIV-positive. PLHIV were at higher risk of AIDS-defining cancers (Kaposi sarcoma [adjusted OR:134, 95% CI:111–162], non-Hodgkin lymphoma [adjusted OR:2.73, 95% CI:2.56–2.91] and, cervix [adjusted OR:1.70, 95% CI:1.63–1.77], conjunctival cancer [adjusted OR:21.5, 95% CI:16.3–28.4] and human papilloma virus (HPV) related cancers (including; penis [adjusted OR:2.35, 95% CI:1.85–2.99], and vulva [adjusted OR:1.94, 95% CI:1.67–2.25]) compared to HIV-negative patients. Analysis using the IPW population yielded comparable results.ConclusionThere is need for improved awareness and screening of conjunctival cancer and HPV-associated cancers at HIV care centres. Further research and discussion is warranted on inclusive HPV vaccination in PLHIV.

The direct medical cost of type 2 diabetes mellitus in South Africa: a cost of illness study

ABSTRACTBackground: Type 2 diabetes mellitus (T2DM) is known to require continuous clinical care and management that consumes significant health-care resources. These costs are not well understood, particularly in low- and middle-income countries.Objective: The aim of this study was to estimate the direct medical costs associated with T2DM in the South African public health sector and to project an estimate of the future direct costs of T2DM by 2030.Methods: A cost of illness study was conducted to estimate the direct medical costs of T2DM in South Africa in 2018 and to make projections for potential costs in 2030. Costs were estimated for diagnosis and management of T2DM, and related complications. Analyses were implemented in Microsoft Excel, with sensitivity analysis conducted on particular parameters.Results: In 2018, public sector costs of diagnosed T2DM patients were approximately ZAR 2.7 bn and ZAR 21.8 bn if both diagnosed and undiagnosed patients are considered. In real terms, the 2030 cost of all T2DM cases is estimated to be ZAR 35.1 bn. Approximately 51% of these estimated costs for 2030 are attributable to the management of T2DM, and 49% are attributable to complications.Conclusion: T2DM imposes a significant financial burden on the public healthcare system in South Africa. Treatment of all prevalent cases would incur a cost equivalent to approximately 12% of the total national health budget in 2018. With rising prevalence, direct costs will grow if current care regimes are maintained and case-finding improved. Increased financial resources are necessary in order to deliver effective services to people with T2DM.

Leveraging the Road to Health booklet as a unique patient identifier to monitor the prevention of mother-to-child transmission programme.

Currently there is no unique patient identification system in the South African public health sector. Therefore, routine laboratory data cannot effectively be de-duplicated, thereby hampering surveillance of laboratory-diagnosed diseases such as mother-to-child transmission of HIV. To determine the uptake of Road to Health booklet (RTHB) identifiers at HIV polymerase chain reaction (PCR) birth test and describe their performance in linking follow-up test results in the early infant diagnosis programme. Between May 2016 and May 2017, Tshwane District Clinical Services implemented a unique patient identifier pilot project in which a sticker-page of unique, readable, barcoded patient identifiers was incorporated in the patient-retained immunisation record (the RTHB) before distribution. Uptake of RTHB identifiers at birth was calculated as the proportion of HIV PCR tests in infants aged &lt;6 days registered with an RTHB identifier over the total number of registered HIV PCR tests. Descriptive analysis of demographic details was performed among infants with two registered HIV PCR tests linked by the RTHB identifier, and performance of the National Health Laboratory Service Corporate Data Warehouse (NHLS CDW)-linking algorithm in matching RTHB-linked results was calculated using a 2 × 2 table. A total of 5 309 HIV PCR birth tests registered with an RTHB identifier were extracted from the NHLS CDW over the 13-month period of the pilot project. The number of registered RTHB identifiers increased from 24 (2% of birth PCR tests) in May 2016, peaking at 728 (56% of birth PCR tests) in May 2017. Among infants with a registered RTHB identifier at birth, 635 (12%) had a subsequent linked HIV PCR test, as indicated by the same RTHB number registered for a later specimen. Demographic details at the time of birth and subsequent PCR test were compared, demonstrating that &lt;4% of infants had exact matches for name, surname, date of birth and sex; 74% of birth tests had variations such as 'born to' or 'baby of ' in place of a first name; surnames matched exactly in 61% of cases; 18% (n=116) of infants had both tests performed at the same facility, of which only 27% (n=31) had the same patient folder number on both test results. Leveraging RTHBs as unique patient identifiers, even if used temporarily until linkage to other future national unique identifiers, promises to be an effective scalable approach to laboratory-based surveillance, facilitating healthcare provider access to all test results from birth.

Teledermatology scale-up frameworks: a structured review and critique

BackgroundThe South African public health sector embarked on a National Telemedicine System implementation program in 1999 and although unsuccessful, the Province of KwaZulu-Natal subsequently implemented teledermatology in 2003, with two currently active services (synchronous and asynchronous). Although sustained these have not been scaled-up to meet the needs of all hospitals in the Province. A recent teledermatology scale-up design requirements elicitation process within KwaZulu-Natal confirmed the need for a framework, and identified requirements through key stakeholders, programme observations, the literature, and experts. This study aimed to identify and characterise existing teledermatology or related eHealth scale-up frameworks, determine whether any met the previously elicited scale-up framework requirements, and were suitable for use in the KwaZulu-Natal public health sector.MethodsA structured literature search was performed of electronic databases (Scopus, Science Direct, IEEE, PubMed, and Google Scholar) seeking proposed or developed teledermatology or related scale-up frameworks. Global public health publications were also hand-searched. The teledermatology or telemedicine, telehealth or eHealth related scale-up frameworks identified were critiqued against the previously elicited teledermatology scale-up framework requirements to determine their suitability for use.ResultsNo specific teledermatology scale-up framework was found. Seven related scale-up frameworks were identified, although none met all the previously identified teledermatology scale-up framework requirements. The identified frameworks were designed for specific scale-up phases and lacked a more holistic and comprehensive approach.ConclusionsThere is an evidenced-based need for the development of a health sector aligned, holistic framework that meets the identified teledermatology scale-up framework requirements. The findings of this paper will inform development of such a framework.

Six hours of task-oriented training optimizes walking competency post stroke: a randomized controlled trial in the public health-care system of South Africa

Objective: To evaluate a minimal dose intervention of six 1-hour sessions of task-oriented circuit gait training including a caregiver over a 12-week period to persons post stroke in the South African public health sector. Design: Stratified, single blinded, randomized controlled trial with three intervention groups. Participants: Persons post stroke (n = 144, mean age 50 years, 72 women), mean 9.5 weeks post stroke. Interventions: Task group (n = 51)—accompanied by a caregiver; task-oriented circuit gait training (to improve strength, balance, and task performance while standing and walking). Strength group (n = 45); strength training of lower extremities while sitting and lying. Control group (n = 48); one 90-minute educational session on stroke management. Measures: The six-minute walk test (6MinWT) was the primary outcome; the secondary outcomes included comfortable and fast gait speeds, Berg Balance Scale (BBS), and Timed Up and Go (TUG). Particpants evaluated at baseline, post intervention (12 weeks), and at follow-up 12 weeks later. Change scores were compared using generalized repeated measures analysis of variance (ANOVA). Results: Task group change scores for all outcomes post intervention and at follow-up were improved compared to the other groups (P-values between 0.000005 and 0.04). The change scores (mean, 1SD) between baseline and follow-up for the Task, Strength, and Control groups, respectively, were as follows: 6MinWT:119.52 m (81.92), 81.05 m (79.53), and 60.99 m (68.38); comfortable speed 0.35 m/s (0.23), 0.24 m/s (0.22), and 0.19 m/s (0.21); BBS: 9.94 (7.72), 6.93 (6.01), and 5.19 (4.80); and TUG: –14.24 seconds (16.86), –6.49 seconds (9.88), and –5.65 seconds (8.10). Conclusion: Results support the efficacy of a minimal dose task-oriented circuit training program with caregiver help to enhance locomotor recovery and walking competency in these persons with stroke.