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Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems. Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes. Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities. Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems’ performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine. [ABSTRACT FROM PUBLISHER]

INTRODUCTION: This study focuses on the quality of interaction in interactive TV (ITV), WebCT bulletin boards (BBs) and chat rooms (CRs) and addresses the question of how effectively new collaborative electronic technologies have been married with new pedagogical ideas to create effective learning for distance education students. METHODS: Fifteen (out of 68) BB, 14 (out of 32) CR and 13 (out of 25) ITV conversations were randomly selected for coding using a modified exchange structure analysis. The roles that students and lecturers took in the conversations were determined from this. RESULTS: The percentage of turns made by lecturers as opposed to students was 51% in CRs, 14% in BBs and 68% in ITV. The percentage of turns spent on actual coursework was 73% in CRs, 89% in BBs and 82% in ITV. Comparisons between tutors' and students' roles within as well as between ITV, BBs and CRs were all statistically significant with P < 0.05. In CRs the main roles of both students and lecturers were those of elaborators, inquirers and explainers. In BBs the main roles of students and lecturers were those of explainers and evaluators. In ITV sessions students' main roles were those of elaborators and explainers, whereas lecturers' main roles were those of lecturers, elaborators, inquirers and evaluators. CONCLUSION: In terms of creating a constructivist and active learning community that can operate within a distance learning paradigm, WebCT appears superior to ITV. [ABSTRACT FROM AUTHOR]

Objective: Type 2 diabetes is a leading contributor to the burden of disease in South Africa. Primary care is struggling to support self-management and lifestyle change. Group empowerment and training (GREAT) for diabetes is a feasible and cost-effective intervention in our setting. This study aimed to evaluate the implementation of GREAT for diabetes., Design: A convergent mixed-methods study evaluated a range of implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, reach and cost., Setting: Ten primary care facilities from a district in all nine provinces of South Africa., Participants: Descriptive exploratory individual semistructured interviews were conducted with 34 key stakeholders from national policy-makers to primary care providers. Three focus group interviews were held with 35 patients., Results: The National Department of Health saw GREAT as an acceptable and appropriate intervention, but only five of the nine provinces adopted GREAT. District-level and facility-level managers also saw GREAT as an acceptable and appropriate intervention. Factors related to feasibility included physical space, sufficient staff numbers, availability of resource materials, the health information system, adaptation to the model of care (selection of facilities, patients, adjustment of patient flow and appointment systems, leadership from local managers and the whole clinical team) and inclusion in systems for quality improvement. No major changes were made to the design of GREAT and fidelity to the session content ranged from 66% to 94%. Incremental costs were US$494 per facility. Due to disruption from the COVID-19 pandemic, only 14 facilities implemented and reached 588 patients at the time of evaluation., Conclusion: Key lessons were learnt on how to implement GREAT for diabetes in a middle-income country setting. The findings informed the design of a programme theory using a health system framework. The programme theory will guide further scale-up in each province and scale-out to provinces that have not yet implemented., Question: This study focused on evaluating how to implement GREAT for type 2 diabetes in primary care and to take it to scale in South Africa., Finding: The findings led to a programme theory on how to successfully implement GREAT for diabetes in the South African context., Meaning: The study demonstrates relevant contextual factors that need to be considered in the implementation of group diabetes education programme in a middle-income country., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background:  Family medicine has trained specialist family physicians in South Africa since 2008, but not investigated their career pathways. The study aimed to determine the career pathways of newly qualified family physicians between 2008 and 2022., Methods:  A cross-sectional descriptive survey of all 186 family physicians via an electronic questionnaire., Results:  Response rate was 44.6% (83/186). Overall, 9.6% emigrated, 10.8% were no longer practising, and 79.5% were still practising in South Africa. Of the latter, 14.5% were in the private sector, 55.4% in the public sector and 9.6% in both. Of those in the public sector, 33.7% were in specialist family physician posts, 12% in medical officer posts, 4.8% in managerial positions and 4.8% in academic positions. Issues relating to safety and security were important to those working in both sectors and relationships with colleagues in the clinical team, to those in the public sector. Overall, participants practised near or within their province of training and were not equitably distributed., Conclusion:  Only a third of graduates were in specialist family physician posts in the public sector. Attention needs to be given to retaining more graduates in such posts to achieve the goals of the national position paper. The proportion in the private sector was lower than expected. The reasons for no longer practising medicine should be further explored.Contribution: This is the first study on the career pathways of family physicians in South Africa since the new speciality was created. Understanding these pathways will assist with human resources for health planning.

Background:  Group empowerment and training (GREAT) for people with type 2 diabetes enables self-management and lifestyle modification. GREAT for diabetes was implemented in primary care facilities in five South African provinces in the beginning of 2022. The aim was to evaluate implementation and to particularly explore factors that influenced the sustainability of implementation., Methods:  An exploratory, descriptive qualitative study conducted semi-structured individual interviews with 17 key stakeholders at the end of 2023. Interviews explored factors within a theory of change framework derived from an initial evaluation in 2022. Data were analysed using the framework method and ATLAS.ti., Results:  Implementation and scale-up was sustained in the Western Cape. Governance and financing at a provincial and district level were key to health system structures. Space, staffing, resource materials and monitoring of implementation were key to the inputs. Facility managers, training and performance of facilitators, including the whole team, selecting patients, patient flow and appointments, stakeholder support and clinical governance were key to service delivery. Facilities that had implemented, reported reaching 300 patients per year. A range of motivational, behavioural and clinical outcomes were reported. Future implementation could include community health workers and group empowerment for insulin initiation., Conclusion:  Implementation and scale-up was only sustained in one province and a range of factors related to sustained implementation were identified.Contribution: The factors identified can guide the successful implementation and scale-up of GREAT for diabetes in South Africa.

Background:  Spontaneous abortions occur in 12.5% of pregnancies and have a significant impact on the well-being of women. Dissatisfaction with health services is well-documented, but no studies have been conducted in district health services of the Western Cape. The aim was to explore the lived experiences of women presenting with spontaneous abortions to the emergency department at Helderberg Hospital., Methods:  A descriptive phenomenological qualitative study used criterion-based purposive sampling to identify suitable participants. Data were collected through semi-structured individual interviews. Atlas-ti (version 22) software assisted with data analysis using the framework method., Results:  A total of nine participants were interviewed. There were four main themes: a supportive environment, staff attitudes and behaviour, the impact of time, and sharing of information. The comfort, cleanliness and privacy of the environment were important. COVID-19 had also impacted on this. Showing interest, demonstrating empathy and being nonjudgemental were important, as well as the waiting time for definitive treatment and the time needed to assimilate and accept the diagnosis. In addition, the ability to give relevant information, explain the diagnosis and help patients share in decision-making were key issues., Conclusion:  This study highlighted the need for a more person-centred approach and managers should focus on changes to organisational culture through training and clinical governance activities. Attention should be paid to the physical environment, availability of patient information materials and sequential coordination of care with primary care services.Contribution: This study identifies issues that can improve person-centredness and women's satisfaction with care for spontaneous abortion.

Background:  Completion of a research assignment is a requirement for specialist training in South Africa. Difficulty with completion delays graduation and the supply of family physicians. The aim of this study was to explore the experience of registrars with their research in postgraduate family medicine training programmes., Methods:  An explorative descriptive qualitative study. Extreme case purposive sampling selected registrars who had and had not completed their research on time, from all nine training programmes. Saturation was achieved after 12 semi-structured interviews. The framework method was used for data analysis, assisted by ATLAS.ti software., Results:  The assumption of prior learning by teachers and supervisors contributed to a sense of being overwhelmed and stressed. Teaching modules should be more standardised and focussed on the practical tasks and skills, rather than didactic theory. Lengthy provincial and ethics processes, and lack of institutional support, such as scholarly services and financial support, caused delays. The expertise of the supervisor was important, and the registrar-supervisor relationship should be constructive, collaborative and responsive. The individual research experience was dependent on choosing a feasible project and having dedicated time. The balancing of personal, professional and academic responsibilities was challenging., Conclusion:  Training programmes should revise the teaching of research and improve institutional processes. Supervisors need to become more responsive, with adequate expertise. Provincial support is needed for streamlined approval and dedicated research time.Contribution: The study highlights ways in which teaching, and completion of research can be improved, to increase the supply of family physicians to the country.

Background:  South Africa is a tuberculosis (TB) high-burden country. In the Eastern Cape (EC), community health worker (CHW) teams implement active surveillance for TB to curb spread in disadvantaged communities. However, achieving the goals of the End-TB strategy require coordinated efforts that implement policy and strengthen health systems., Aim:  This survey described views of healthcare workers (HCWs) in primary care facilities on factors that influence implementation of active surveillance for TB., Setting:  This survey was conducted across two districts, among healthcare workers working in TB rooms at primary health facilities., Method:  A cross-sectional survey of HCW in the EC., Results:  The survey included 37 clinics in the OR Tambo Health District (ORTHD) and 44 clinics in the Nelson Mandela Bay Health District (NMBHD). Routine screening at primary care facilities (88.2%) and contact tracing initiatives (80.8%) were the common modes of TB screening. Tuberculosis screening services in the community were only provided by CHWs in 67.3% of instances. Although CHWs were adequately trained and motivated; the lack of transport, limited availability of outreach team leaders (OTLs) and poor security limited implementation of TB screening services in the community. Comparison between both districts revealed TB screening was limited by lack of transport in the rural district and poor security in the urban context. Community engagement provided a platform for improving acceptability., Conclusion:  Community-based TB screening was limited. Inadequate coordination of services between stakeholders in the community has limited reach. Further research should describe that coordinating resource allocation and community empowerment could improve the implementation of active surveillance for TB.Contribution: This study highlights the views of TB room HCWs who believe the opportunity for community-level TB screening is improved with effective leadership and community engagement for acceptability of these services.

Background:  The African region produces a small proportion of all health research, including primary health care research. The SCOPUS database only lists the African Journal of Primary Health Care Family Medicine (PHCFM) and the South African Family Practice Journal (SAFP) in the field of family practice., Aim:  To review the nature of all original research (2020-2022) published in PHCFM and SAFP., Setting:  African region., Method:  All 327 articles were included. Data were extracted into REDCap, using a standardised tool and exported to the Statistical Package for Social Sciences., Results:  The median number of authors was 3 (interquartile range [IQR]: 2-4) and institutions and disciplines 1 (IQR: 1-2). Most authors were from South Africa (79.8%) and family medicine (45.3%) or public health (34.2%). Research focused on integrated health services (76.1%) and was mostly clinical (66.1%) or service delivery (37.9%). Clinical research addressed infectious diseases (23.4%), non-communicable diseases (24.6%) and maternal and women's health (19.4%). Service delivery research addressed the core functions of primary care (35.8%), particularly person-centredness and comprehensiveness. Research targeted adults and older adults (77.0%) as well as health promotion or disease prevention (38.5%) and treatment (30.9%). Almost all research was descriptive (73.7%), mostly surveys., Conclusion:  Future research should include community empowerment and multisectoral action. Within integrated health services, some areas need more attention, for example, children, palliative and rehabilitative care, continuity and coordination. Capacity building and support should enable larger, less-descriptive and more collaborative interdisciplinary studies with authors outside of South Africa.Contribution: The results highlight the strengths and weaknesses of family practice research in Africa.

No abstract available.

No abstract available.

Background: Treatment of non-communicable diseases (NCD) requires patient education and counselling (PEC). Initiatives have focused on Group Empowerment and Training (GREAT) for diabetes and Brief behaviour change counselling (BBCC). However, the implementation of comprehensive PEC in primary care remains a challenge. The aim of this study was to explore how such PEC could be implemented., Methods: This was a descriptive, exploratory, qualitative study at the end of the first year of a participatory action research project to implement comprehensive PEC for NCDs at two primary care facilities in the Western Cape. Focus group interviews were held with healthcare workers and reports from co-operative inquiry group meetings were used as qualitative data., Results: Staff were trained in GREAT for diabetes and BBCC. There were problems with training appropriate staff and sufficient numbers and a need for ongoing support. Implementation was limited by poor internal sharing of information, staff turnover and leave, rotation of staff, lack of space and fears of disrupting the efficiency of service delivery. Facilities had to embed the initiatives into appointment systems and fast track patients who attended GREAT. For those patients that were exposed to PEC, there were reported benefits., Conclusion: Group empowerment was feasible to introduce, while BBCC was more challenging as it required extra time in the consultation.Contribution: Implementation of PEC requires alternative approaches that do not extend consultations (such as GREAT and maybe digital solutions) as well as commitment to facility organisation for PEC from managers.

Background: Diabetes is a major public health problem. During the coronavirus disease 2019 (COVID-19) pandemic, patient education and counselling (PEC) for diabetes were curtailed. This project explored the possibility of offering group empowerment and training (GREAT) for diabetes via computer or tablets and Zoom video conferencing. The aim was to explore whether this was feasible in the low-income community context of primary health care in Cape Town, South Africa., Methods: Three dieticians facilitated four sessions of GREAT for diabetes with a group of five patients with type-2 diabetes. Once the programme was completed, focus group interviews were held with the facilitators and the patients to explore their experience. Interviews were recorded and analysed using a simplified framework method., Results: Usual primary care was not offering PEC and service delivery was brief and mechanistic. The content, resources and group processes were successfully translated into the virtual environment. The guiding style of communication was more difficult. Patients reported changes in their self-management and appreciated being able to save time and money while participating from home. Patients required considerable support and training to use the technology. All participants were concerned about safety and crime with the hardware., Conclusion: It was feasible to conduct GREAT for diabetes via tablets and Zoom video conferencing in this low-income community. To implement at scale, a number of concerns need to be addressed. The feasibility of conducting the sessions via smartphone technology should be evaluated.Contribution: Demonstrates how digital technology could be used to develop new ways of empowering people with type 2 diabetes.

Background: The World Health Organization recommends medical male circumcision (MMC) to prevent human immunodeficiency virus (HIV). More research is needed in South Africa on factors influencing the uptake of MMC., Aim: To evaluate factors associated with uptake of MMC., Setting: Diepsloot, Johannesburg, South Africa., Methods: An observational case-control study. Cases (men attending a private general practice (GP) offering free MMC) were compared to controls (uncircumcised men attending a local shopping mall) for a variety of demographic, sociocultural and financial factors. Factors were analysed using bivariate and multiple-variable binary forward logistic regression with the Statistical Package for Social Sciences., Results: There were 350 cases and 350 controls. Four factors were associated with the uptake of MMC: being a student (adjusted odds ratio [AOR]: 6.29, 95% confidence interval [CI]: 2.29-17.26), attending a mainline Christian denomination (AOR 2.85, 95% CI: 1.39-5.78), speaking an African language other than Zulu (range of AORs: 2.5-6.8, p 0.05) and being South African (AOR: 2.50, 95% CI: 1.58-3.96). MMC was associated with feeling susceptible to HIV, seeing it as a serious health problem and being encouraged by partners. Men who were sterilised, not sexually active and without symptoms of a sexually transmitted infection felt less susceptible. Other barriers included the pain of the procedure, indirect costs, anticipated impact on sexual activity, lack of information, cultural beliefs, embarrassment and access to health services.

Background: The high burden of tuberculosis (TB) in South Africa (SA) is associated with uncontrolled transmission in communities and delayed diagnosis of active cases. Active surveillance for TB is provided by community-based services (CBS). Research is required to understand key factors influencing TB screening services in the CBS. This study explored the implementation of active surveillance for TB where community-oriented primary care (COPC) had been successfully implemented to identify these factors., Methods: This was a qualitative study of four established COPC sites across two provinces in SA where active surveillance for TB is implemented. Semi-structured interviews were conducted with purposively selected healthcare workers in the CBS and citizens in these communities. The recorded interviews were transcribed for data analysis using ATLAS.ti software., Results: The factors influencing active surveillance for TB were directly related to the major players in the delivery of CBS. These factors interacted in a complex network influencing implementation of active surveillance for TB. Building effective relationships across stakeholder platforms by community health workers (CHWs) was directly influenced by the training, capacity building afforded these CHWs by the district health services; and acceptability of CBS. Each factor interplayed with others to influence active surveillance for TB., Conclusion: Community health workers were central to the success of active surveillance for TB. The complex interactions of the social determinants of health and TB transmission in communities required CHWs to develop trusting relationships that responded to these issues that have impact on TB disease and linked clients to healthcare.

Introduction: Attainment of universal health coverage is feasible via strengthened primary health systems that are comprehensive, accessible, people-centred, continuous and coordinated. Having an adequately trained, motivated and equipped primary healthcare workforce is central to the provision of comprehensive primary healthcare (CPHC). This study aims to understand PHC team integration, composition and organisation in the delivery of CPHC in India, Mexico and Uganda., Methods and Analysis: A parallel, mixed-methods study (integration of quantitative and qualitative results) will be conducted to gain an understanding of PHC teams. Methods include: (1) Policy review on PHC team composition, organisation and expected comprehensiveness of PHC services, (2) PHC facility review using the WHO Service Availability and Readiness Assessment, and (3) PHC key informant interviews. Data will be collected from 20, 10 and 10 PHCs in India, Mexico and Uganda, respectively, and analysed using descriptive methods and thematic analysis approach. Outcomes will include an in-depth understanding of the health policies for PHC as well as understanding PHC team composition, organisation and the delivery of comprehensive PHC., Ethics and Dissemination: Approvals have been sought from the Institutional Ethics Committee of The George Institute for Global Health, India for the Indian sites, School of Medicine Research Ethics Committee at Makerere University for the sites in Uganda and the Research, Ethics and Biosecurity Committees of the Mexican National Institute of Public Health for the sites in Mexico. Results will be shared through presentations with governments, publications in peer-reviewed journals and presentations at conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: An adequate health workforce is an essential building block of effective health systems. In South Africa, medical officers (MOs) are a key component of service delivery in district health services. The Stellenbosch University Family Physician Research Network in the Western Cape identified that retention of MOs was a key issue. The aim of this study was to explore the factors that influence the retention of MOs in public sector district health services in the Western Cape, South Africa., Methods: This is a descriptive exploratory qualitative study. Medical officers were purposefully selected in terms of districts, facility types, gender, seniority and perceived likelihood of leaving in the next four years. Semi-structured interviews were performed by family physicians, and the qualitative data were analysed using the framework method., Results: Fourteen MOs were interviewed, and four major themes were identified: career intentions; experience of clinical work; experience of the organisation; and personal, family and community issues. Key issues that influenced retention were: ensure that the foundational elements are in place (e.g. adequate salary and good infrastructure), nurture cohesive team dynamics and relationships, have a family physician, continue the shift towards more collaborative and appreciative management styles, create stronger career pathways and opportunities for professional development in the district health services, be open to flexible working hours and overtime, and ensure workload is manageable., Conclusion: A number of important factors influencing retention were identified. Leaders and managers of the healthcare services could intervene across these multiple factors to enhance the conditions needed to retain MOs.

Background: Referral systems play a pivotal role in coordination and quality of care and should be evaluated for their utility. The Vula App is used by various disciplines and hospitals in South Africa to refer patients. The aim was to explore the perceptions of medical practitioners regarding the use of the Vula App in the West Coast District., Methods: A descriptive, exploratory qualitative study used semi-structured interviews with 11 medical practitioners. The highest and lowest users of the Vula App were selected from seven district hospitals. Qualitative data analysis used the framework method and Atlas-ti., Results: There were five themes: impact on the referral process, quality of care, coordination of care, continuous professional development, and how to improve the Vula App. Its use was well established in the outpatient and semi-urgent setting, but participants were hesitant to rely on it for immediate advice. Specialist advice via the Vula App enabled practitioners to manage patients remotely. The referral hand-over function had a positive impact on the coordination of care. Advice and feedback via the Vula App assisted with continuous professional development., Conclusion: The Vula App is a useful tool to refer patients to the emergency centre and outpatient departments. It can improve the immediate quality of care and sequential coordination of care. It has the potential to enable continuous professional development. There is a need to standardise its use, to ensure electronic information flows back to the district and to integrate the data into the district's health information system.

Introduction: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions., Methods and Analysis: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (T P ), initiation of implementation (T 0 ) and 1-year postinitiation (T 1 ). We will extract project-related data from secondary documents at T P and conduct multistakeholder qualitative interviews to gather data at T 0 and T 1. We will undertake descriptive statistical analysis of T P data and analyse T 0 and T 1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks., Ethics and Dissemination: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network., Competing Interests: Competing interests: JvO reports Horizon2020 grants (643 692 and 825432) outside the submitted work. AGT declares funding from the National Health & Medical Research Council (NHMRC, Australia: GNT1042600, GNT1122455, GNT1171966, GNT1143155, GNT1182017), Stroke Foundation Australia (SG1807), and Heart Foundation Australia (VG102282) outside the submitted work. ML-P declares support from Fogarty International Centre, National Institutes of Health [R21TW009982], under the Global Alliance for Chronic Diseases (GACD) Diabetes ProgramProgramme. MEE reports grant funding from the Argentinian Ministry of Health (MoH) under the GACD program. AS declares funding from the Japan Agency for Medical Research & Development, as part of the GACD, outside the submitted work. FJH is partially funded by the National Institute for Health Research (NIHR) and the Medical Research Council (MRC), and is a member of the Action on Salt, and World Action on Salt, Sugar and Health (WASSH). AB declares grants from the MoH Argentina, National Institutes of Health, and World Diabetes Foundation, outside the submitted work. AP declares grant and fellowship support from the NHMRC outside the submitted work, Member of the Board of Directors, The George Institute India, and past Member of the Board of Directors, Heart Health Research Center, Beijing, PRC. RJ declares grant, outside the submitted work, from WHO Geneva, WHO South-East Asia Region (SEARO), Elrha Research for Health in Humanitarian Crises (R2HC), (Wellcome Trust, UK AID and NHS), DBT/ Wellcome Trust India Alliance and Gates Foundation. In the past 3 years, MDH has received research funding from American Heart Association, Verily, and AstraZeneca for research unrelated to this manuscript and has patents pending for heart failure polypills. The George Institute for Global Health has a patent, license, and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. None of the others authors has any conflict of interest to declare., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Primary care services in South Africa have been challenged by increasing numbers of people with communicable and non-communicable chronic diseases. There was a need to develop alternative approaches for stable patients to access medication. With the onset of the coronavirus pandemic there was an urgent need to decongest facilities and protect people from infection. In this crisis the Metro Health Services rapidly implemented home delivery of medication by community health workers. This study aimed to evaluate the implementation of home delivery of medication by community health workers during the coronavirus pandemic in Cape Town, South Africa., Methods: A convergent mixed methods study evaluated six implementation outcomes: adoption, feasibility, fidelity, coverage, cost, and sustainability of the initiative. Data sources included routinely collected data, a telephonic survey of 138 patients, an analysis of set-up and recurrent costs as well as 17 descriptive exploratory qualitative semi-structured interviews with 68 key informants., Results: Over a 6-month period 1,054,657 pre-packaged parcels were sent to primary care facilities, 819,649 (77.7%) were delivered and of those 97,297 (11.9%) returned. The additional costs were estimated as 1.3% of a total health budget of R2,2 billion. The initiative was rapidly adopted as it decongested facilities and protected vulnerable patients. Although it was feasible to implement at scale, numerous challenges were encountered, such as incorrect addresses and contact details, transporting parcels, communicating with patients, having a reliable audit trail, and handling out-of-area patients. All role players thought the service should continue and 42.3% of patients reported better adherence to their medication., Conclusion: Home delivery of medication by community health workers is feasible at scale and affordable. It should continue, but as one of a menu of options for alternative delivery of medication. The following need to be improved: efficiency of the system, the audit trail, adequate support and resources for community health workers, transport of medication, communication with patients, empanelment of patients, governance of the system and training of the community health workers., (© 2022. The Author(s).)

The World Health Organization states that essential, cost-effective surgical care should be delivered at district hospitals. In South Africa significant skills gap exist at district hospitals, particularly in the area of surgery and anaesthesia. These small to moderate sized hospitals are too small to support a range of full time specialists even if they could be recruited and were cost-effective. Family physicians (FPs) are trained in the clinical skills required for district hospitals and primary health care. Clinical associates have also been introduced to perform procedures at district hospitals. This report illustrates the contribution of a FP to surgical care at Zithulele Hospital in the Eastern Cape. Family physicians not only bring the necessary clinical skills set but also increase the confidence and capacity of the whole team. Outreach and support by surgeons, as well as continuing professional development, are important. Surgical and anaesthetic skills must be developed together. Family physicians also bring leadership and clinical governance skills that ensure the inputs to support surgery, such as equipment and information systems are available. The contribution of FPs to surgery and district hospitals is overlooked in both policy and practice. Human resources for health policy should recognise their contribution and increase the numbers available and FP posts at district hospitals. There is also a need to update the package of emergency and essential surgical procedures in policy.

Objectives: To describe the characteristics, clinical management and outcomes of patients with COVID-19 at district hospitals., Design: A descriptive observational cross-sectional study., Setting: District hospitals (4 in metro and 4 in rural health services) in the Western Cape, South Africa. District hospitals were small (<150 beds) and led by family physicians., Participants: All patients who presented to the hospitals' emergency centre and who tested positive for COVID-19 between March and June 2020., Primary and Secondary Outcome Measures: Source of referral, presenting symptoms, demographics, comorbidities, clinical assessment and management, laboratory turnaround time, clinical outcomes, factors related to mortality, length of stay and location., Results: 1376 patients (73.9% metro, 26.1% rural). Mean age 46.3 years (SD 16.3), 58.5% females. The majority were self-referred (71%) and had comorbidities (67%): hypertension (41%), type 2 diabetes (25%), HIV (14%) and overweight/obesity (19%). Assessment of COVID-19 was mild (49%), moderate (18%) and severe (24%). Test turnaround time (median 3.0 days (IQR 2.0-5.0 days)) was longer than length of stay (median 2.0 day (IQR 2.0-3.0)). The most common treatment was oxygen (41%) and only 0.8% were intubated and ventilated. Overall mortality was 11%. Most were discharged home (60%) and only 9% transferred to higher levels of care. Increasing age (OR 1.06 (95% CI 1.04 to 1.07)), male (OR 2.02 (95% CI 1.37 to 2.98)), overweight/obesity (OR 1.58 (95% CI 1.02 to 2.46)), type 2 diabetes (OR 1.84 (95% CI 1.24 to 2.73)), HIV (OR 3.41 (95% CI 2.06 to 5.65)), chronic kidney disease (OR 5.16 (95% CI 2.82 to 9.43)) were significantly linked with mortality (p<0.05). Pulmonary diseases (tuberculosis (TB), asthma, chronic obstructive pulmonary disease, post-TB structural lung disease) were not associated with increased mortality., Conclusion: District hospitals supported primary care and shielded tertiary hospitals. Patients had high levels of comorbidities and similar clinical pictures to that reported elsewhere. Most patients were treated as people under investigation. Mortality was comparable to similar settings and risk factors identified., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The achievement of the World Health Organization's END TB goals will depend on the successful implementation of strategies for early diagnosis and retention of patients on effective therapy until cure. An estimated 150,000 cases are missed annually in South Africa. It is necessary to look at means for identifying these missed cases. This requires the implementation of active surveillance for TB, a policy adopted by the National Department of Health., Aim: To explore the views of managers of the TB program on the implementation of active surveillance for TB in the resource constrained setting of the Eastern Cape, South Africa., Methods: A descriptive, explorative, thematically analysed qualitative study based on 10 semi-structured interviews of managers of the TB program. Interviews were transcribed verbatim and analysed using the framework method and Atlas-ti., Results: Active case finding of people attending health facilities was the dominant approach, although screening by community health workers (CHWs) was available. Both government and non-government organisations employed CHWs to screen door to door and sometimes as part of campaigns or community events. Some CHWs focused only on contact tracing or people that were non-adherent to TB treatment. Challenges for CHWs included poor coordination and duplication of services, failure to investigate those identified in the community, lack of transport and supportive supervision as well as security issues. Successes included expanding coverage by government CHW teams, innovations to improve screening, strategies to improve CHW capability and attention to social determinants., Conclusion: A multifaceted facility- and community-based approach was seen as ideal for active surveillance. More resources should be targeted at strengthening teams of CHWs, for whom this would be part of a comprehensive and integrated service in a community-orientated primary care framework, and community engagement to strengthen community level interventions., Competing Interests: The authors have declared that no competing interests exist.

Background: Effective primary care is vital for improving health outcomes. Patient-centred consultations are important and one way of assessing this is to evaluate patient satisfaction. The Medical Interview Satisfaction Scale (MISS) has not been used in South Africa., Aim: To test validity and reliability of the MISS and evaluate patient satisfaction with consultations., Setting: Primary care facilities in the Helderberg sub-district, South Africa., Methods: The MISS tool was adapted and validated by a panel of experts. The internal consistency was evaluated on 150 consultations. The level of patient satisfaction on 23 items, in consultations by nurses and doctors, was measured. Respondents indicated agreement with each item on a scale (1 = very strongly disagree, 7 = very strongly agree)., Results: The wording of the items were adapted and translated into Afrikaans and Xhosa. There was good overall internal consistency (Cronbach alpha 0.889), but not in all subscales. Patients were most satisfied with rapport (Median score 6.2 (IQR 5.3-5.9)) and understanding of their concerns, fears and beliefs (5.7 (IQR 5.1-6.3)). They were less satisfied with the ability to foster an acceptable management plan (5.5 (IQR 4.5-6.5)) and with accuracy of information (5.0 (IQR 4.2-5.8)). Scores for nurses and doctors were not significantly different., Conclusion: Further work is needed to improve the reliability of MISS subscales in the South African context and the best internal consistency was found with 21 items. Patients showed high levels of satisfaction with primary care consultations, although other studies suggest this may reflect low expectations rather than high quality consultations., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Evidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province., Methods: A cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool., Results: A total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SD = 3.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP's impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥ 2011)., Conclusions: The findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper.

Purpose: Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system., Methods: We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size., Results: Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02)., Conclusions: In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level., Competing Interests: Conflicts of interest: authors report none., (© 2018 Annals of Family Medicine, Inc.)

Africa's health care challenges include a high burden of disease, low life expectancy, health workforce shortages, and varying degrees of commitment to primary health care on the part of policy makers and government officials. One overarching goal of the Medical Education Partnership Initiative (MEPI) is to develop models of medical education in Sub-Saharan Africa. To do this, MEPI has created a network of universities and other institutions that, among other things, recognizes the importance of supporting training programs in family medicine. This article provides a framework for assessing the stage of the development of family medicine training in Africa, including the challenges that were encountered and how educational organizations can help to address them. A modified "stages of change" model (precontemplation, contemplation, action, maintenance, and relapse) was used as a conceptual framework to understand the various phases that countries go through in developing family medicine in the public sector and to determine the type of assistance that is useful at each phase.

Aim: To evaluate the effectiveness of group education, led by health promoters using a guiding style, for people with type 2 diabetes in public sector community health centres in Cape Town., Methods: This was a pragmatic clustered randomized controlled trial with 17 randomly selected intervention and 17 control sites. A total of 860 patients with type 2 diabetes, regardless of therapy used, were recruited from the control sites and 710 were recruited from the intervention sites. The control sites offered usual care, while the intervention sites offered a total of four monthly sessions of group diabetes education led by a health promoter. Participants were measured at baseline and 12 months later. Primary outcomes were diabetes self-care activities, 5% weight loss and a 1% reduction in HbA(1c) levels. Secondary outcomes were self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c and mean total cholesterol levels and quality of life., Results: A total of 422 (59.4%) participants in the intervention group did not attend any education sessions. No significant improvement was found in any of the primary or secondary outcomes, apart from a significant reduction in mean systolic (-4.65 mmHg, 95% CI 9.18 to -0.12; P = 0.04) and diastolic blood pressure (-3.30 mmHg, 95% CI -5.35 to -1.26; P = 0.002). Process evaluation suggested that there were problems with finding suitable space for group education in these under-resourced settings, with patient attendance and with full adoption of a guiding style by the health promoters., Conclusion: The reported effectiveness of group diabetes education offered by more highly trained professionals, in well-resourced settings, was not replicated in the present study, although the reduction in participants' mean blood pressure is likely to be of clinical significance., (© 2014 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

The largest impact on the South African burden of disease will be made in community-based and primary healthcare (PHC) settings and not in referral hospitals. Medical generalism is an approach to the delivery of healthcare that routinely applies a broad and holistic perspective to the patient's problems and is a feature of PHC. A multi-professional team of generalists, who share similar values and principles, is needed to make this a reality. Ward-based outreach teams include community health workers and nurses with essential support from doctors. Expert generalists - family physicians - are required to support PHC as well as provide care at the district hospital. All require sufficient training, at scale, with greater collaboration and integration between training programmes. District clinical specialist teams are both an opportunity and a threat. The value of medical generalism needs to be explained, advocated and communicated more actively.

Introduction: Religion is important in most African communities, but faith-based HIV prevention programmes are infrequent and very rarely evaluated., Objective: The aim of this study was to evaluate the effectiveness of a church-based peer education HIV prevention programme that focused on youth., Design: A quasi-experimental study design compared non-randomly chosen intervention and control groups., Setting: This study was conducted in the Cape Town Diocese of the Anglican Church of Southern Africa., Participants: The intervention group of 176 teenagers was selected from youth groups at 14 churches and the control group of 92 from youth groups at 17 churches. Intervention and control churches were chosen to be as similar as possible to decrease confounding., Intervention: The intervention was a 20-session peer education programme (Fikelela: Agents of Change) aimed at changing risky sexual behaviour among youth (aged 12-19 years). Three workshops were also held with parents., Primary and Secondary Outcome Measures: The main outcome measures were changes in age of sexual debut, secondary abstinence, condom use and numbers of partners., Results: The programme was successful at increasing condom usage (condom use score 3.5 vs 2.1; p=0.02), OR 6.7 (95% CI 1.1 to 40.7), and postponing sexual debut (11.9% vs 21.4%; p=0.04) absolute difference 9.5%. There was no difference in secondary abstinence (14.6% vs 12.5%; p=0.25) or with the number of partners (mean 1.7 vs 1.4; p=0.67) and OR 2.2 (95% CI 0.7 to 7.4)., Conclusion: An initial exploratory quasi-experimental evaluation of the Agents of Change peer education programme in a church-based context found that the age of sexual debut and condom usage was significantly increased. The study demonstrated the potential of faith-based peer education among youth to make a contribution to HIV prevention in Africa. Further evaluation of the effectiveness of the programme is, however, required before widespread implementation can be recommended.

Objectives Intimate partner violence (IPV) is an important contributor to the burden of disease in South Africa. Evidence-based approaches to IPV in primary care are lacking. This study evaluated a project that implemented a South African protocol for screening and managing IPV. This article reports primarily on the benefits of this intervention from the perspective of women IPV survivors. Design This was a project evaluation involving two urban and three rural primary care facilities. Over 4-8 weeks primary care providers screened adult women for a history of IPV within the previous 24 months and offered referral to the study nurse. The study nurse assessed and managed the women according to the protocol. Researchers interviewed the participants 1 month later to ascertain adherence to their care plan and their views on the intervention. Results In total, 168 women were assisted and 124 (73.8%) returned for follow-up. Emotional (139, 82.7%), physical (115, 68.5%), sexual (72, 42.9%) and financial abuse (72, 42.9%) was common and 114 (67.9%) were at high/severe risk of harm. Adherence to the management plan ranged from testing for syphilis 10/25 (40.0%) to consulting a psychiatric nurse 28/58 (48.3%) to obtaining a protection order 28/28 (100.0%). Over 75% perceived all aspects of their care as helpful, except for legal advice from a non-profit organisation. Women reported significant benefits to their mental health, reduced alcohol abuse, improved relationships, increased self-efficacy and reduced abusive behaviour. Two characteristics seemed particularly important: the style of interaction with the nurse and the comprehensive nature of the assessment. Conclusion Female IPV survivors in primary care experience benefit from an empathic, comprehensive approach to assessing and assisting with the clinical, mental, social and legal aspects. Primary care managers should find ways to integrate this into primary care services and evaluate it further.