Theses and Dissertations (Family Medicine)

Permanent URI for this collectionhttp://hdl.handle.net/2263/32512

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A survey on factors for late antenatal booking amongst pregnant women attending a Community Health Care Centre in Tembisa, Gauteng Province, South Africa
(University of Pretoria, 2023-09) Ibeziako, Ozoemena Joan; leanoluciano@gmail.com; Mlambo, Siphesihle
Introduction Maternal and perinatal deaths remain a major issue in South Africa regardless of various strategies that are in place. Antenatal care (ANC), which is care given to a pregnant woman during pregnancy, and ANC is vital in reducing maternal and child mortality. Late antenatal care is associated with several maternal and foetal complications which are preventable with timely care. Previous studies identified several factors contributing to late antenatal care booking. Hence, the survey identifies, ranks the importance of the factors for late antenatal care booking and also elicits, from participants what can be changed to improve and sensitize pregnant women on the importance of early antenatal care booking. Methods A cross-sectional survey was conducted amongst pregnant women attending their first antenatal care at Ebony Clinic in Ekurhuleni, Gauteng Province, after 20 weeks of gestation. A questionnaire was used to obtain participants' socio-demographic characteristics, assess factors for late antenatal care, and to rank the participants responses on the factors for late antenatal care booking. Data analysis was done using descriptive statistics. Results A total of 150 participants took part in the survey. All participants booked after 20 weeks’ gestation.The socio- demographic factors of maternal age, marital status, level of education, and occupational status did not show any relationship with late antenatal care booking. Health care workers’ behaviour and negative attitude were ranked as the most critical factors, with participants communicating fear of being hit or humiliated by workers as a leading factor in the delay in seeking antenatal care. Operational management group of factors of waiting in long queues and time spent in clinic were ranked group of factors, and its individual factors such as waiting in queues and time spent in clinic were ranked relatively high overall. The third highest-ranking group of factors was socio-economic status, especially not having a permanent address. At the same time, personal factors, religious beliefs and cultural issues were not 10 acknowledged as factors affecting decision-making to initiate antenatal care. Participants suggested that on- going staff empowerment, wellness and health educational information can expedite positive outcomes and encourage early antenatal booking. Conclusion The socio-demographic factors of maternal age, marital status, level of education, distance travelled, household income, and parity did not show any affiliation to late antenatal care booking. Factors for late antenatal care booking that were mostly rated by participants were negative experiences from the healthcare workers’ behaviour and attitude, operational management, and socio-economic factors. Staff empowerment, wellness and health educational information can expedite positive outcomes and encourage early antenatal booking.
The demographic characteristics, practice experiences, roles and development needs of family physicians who graduated between 2008-2018 from the Family Medicine Blended Learning 2 Year Diploma run by the Christian Medical College, Vellore, India
(University of Pretoria, 2023) Marcus, Tessa S.; jachin.velavan@cmcdistedu.org; Velavan, Jachin
Preamble: The ongoing professional development of India’s lean cadre of 250,000 General Practitioners and 30,000 Government doctors is constrained by limited options to update themselves. This negatively impacts on the ability of the country to create a critical mass of Family Physicians (FPs) who can clinically lead quality primary health care. Since 2006 the Christian Medical College (CMC) Vellore has run a 2-year blended learning Post Graduate Diploma in Family Medicine (PGDFM). In 2012 this offering was extended to the Medical University, Tamil Nadu, as a Master in Medicine in Family Medicine (M.MED FM). Between 2006 and 2016 they trained around 3000 private practitioners and 250 government doctors in Family Medicine. The Study: Globally, graduate follow-up surveys explore the contribution of qualifications to professional life and inform curricular modification to support intended educational and practice outcomes. Notwithstanding extensive anecdotal information and a 2013 demographic survey of PGDFM & M.MED FM students, this is the first study to systematically assess FP graduate distribution, wellbeing, experiences of practice, their roles in the national health system and their professional development needs. A purposively designed, cross-sectional survey of all PGDFM & M.MED FM graduates who qualified between 2008 and 2018 was undertaken between March and July 2022. Data were descriptively analysed and the results constitute the substance of this dissertation. Study findings: Of a population of 1213 FP graduates, 48% (n=581) responded to the study and 36% (438) completed the questionnaire. Most FPs were urban based, were relatively poorly paid, with female FPs earning significantly less than their male counterparts. FPs were largely hospital based and served mostly adult patients. They were under resourced, lacked technological support and most worked with an inadequate toolkit. Though well trained in consultation skills and the principles of FM, in practice their consultations were compromised by extreme time constraints and care continuity was hampered by an inadequate, patient held paper-based record system, poor back-referrals, and the impediments to relationship continuity characteristic of hospital settings. FPs did not engage adequately with polypharmacy. Most FPs engaged regularly in continuous professional development activities, but involvement in teaching, research and publication was confined to the few those who participated in faculty development programmes. High uptake of places and gender parity in enrolment suggests that the blended learning model made the qualification accessible to working doctors, especially women. The majority of FPs rated the influence of the PGDFM/M.MEDFM highly on their practice. They also identified important gaps, especially in respect of procedural skills and team management as learning areas that reflected common conditions seen in their work contexts. Conclusion: The curriculum is inadequately synchronised with the reality of practice. This challenge is not unique to India and has implications for the meaning of Family Medicine as a discipline. It is important to understand what is central to the practice of a Family Physician and then to focus on developing the competencies needed to render these skills.
The application of two capability models to support fourth year medical students' learning.
(University of Pretoria, 2021) Delport, Rhena; Bezuidenhout, Juanita; marietjie.vanrooyen@up.ac.za; Van Rooyen, Marietjie
Background: The Longitudinal Clinic attachment program for students (L-CAS) offers opportunities for students to visit complex and diverse learning sites in primary care settings where they can acquire and practice consultation skills. The three-stage assessment and plan were used as an objective indicator of the development of a number of competencies over the course of a year. Problem statement and research question: The aim of this study has been to explore and better understand learning related to L-CAS activities, so that the L-CAS curriculum can be planned and executed to specifically support learning with the question: How does the application of the two capability models support fourth-year medical student learning during and after L-CAS visits? Theoretical underpinning: Two models, namely the Medical Education Model of Capability and the Department of Family Medicine University of Pretoria (DoFMUP) Capability Approach to Learning, were identified, with capability as the theoretical basis, to describe the learning process. The Medical Education model provides a framework for planning and evaluating curricula. This model was used to identify and understand students’ aspirations and capability sets, their perceptions of enabling and hindering factors and the attainment of aspirations. The DoFMUP Capability Approach to Learning is a practical way of understanding the process of learning in a complex world. This model was used to determine the development of students’ competence to perform a three-stage assessment and management plan (3SAP) for patients encountered in various primary healthcare settings over one year, and scaffolding deemed necessary to support learning. Methods: Qualitative and quantitative methods were employed. Content analysis and grounded theory underpinned the qualitative analysis. Data from the questionnaire, focus groups and interviews was used to explain and understand students’ perceptions about their own development and learning in L-CAS, enabling and hindering factors, and how learning can be optimized. Quantitative analysis was used to report on students’ aspirations and their perceptions of attainment of those aspirations. Patient case reports were analysed to asses change in competencies over one year. Results: It is clear that L-CAS offers students ample opportunities to learn, but because of all the challenges they face, most students did not choose to address their learning needs personally but responded with being demotivated. Students were able to identify significant resources that can enable them but failed to use these in dealing with their challenges. Most students perceived growth, and reported learning, but unfortunately this was not evident in their patient cases. It is clear that the aspirations students set for themselves are different from what we expect of them. Discussions and Conclusions: A novel model is derived from both the capability models and aspires to support and enable the learning process before, during and after L-CAS visits. Better planning of the timing of L-CAS sessions and weighting of the credits are suggested as well as better preparation and empowerment of students using the “CHILL” acronym with focus on the resources available at the sites, like peers, community healthcare workers (CHWs) and electronic devices. The research question has been answered in that both the models highlighted challenges and potential areas of improvement of the L-CAS curriculum that could be addressed by the implementation of the novel model.
Learning of person-centred practice amongst clinical associate students at the University of Pretoria
(University of Pretoria, 2019) Marcus, Tessa S.; Hugo, Johannes Fredricus Marais; Murray.Louw@up.ac.za; Louw, Jakobus Murray
Aim: This is a study of the extent to which clinical associate students learn person-centred practice (PcP) as well as the curricular elements that may facilitate such learning. Methods: A quality improvement intervention by students on their own medical consultations was explored in focus group discussions. The learning of PcP were analysed using the capability approach framework. PcP was measured in consultations during Objective Structured Clinical Examinations (OSCEs) before and after the intervention in both intervention and control groups. Results: Disruptions to students’ abilities, knowledge, identity and relationships triggered learning. The quality improvement process functioned as a learning cycle scaffolded by peer feedback and assessment tools during which students reviewed disruptions and developed improvement plans. Even though students articulated their passion for PcP in focus groups, few actually demonstrated these skills during OSCE consultations with simulated patients. An increase in PcP was observed but the difference between intervention and control groups was not significant. Students’ sense of self was disturbed when they were unable to help patients. In response, self-directed students devised learning strategies involving relationships with peers and facilitators. Relationships are thus both triggers for learning and a means to learning. Conclusion and recommendations: The significantly better improvement in third year students, compared to those in second year, suggest that learning PcP is grounded in increased confidence in biomedical knowledge and skills, motivation and sense of self-efficacy. Students learn and practice PcP best in authentic encounters with real patients. Therefore, student learning and practice of PcP should be evaluated in such encounters and, to achieve PcP, the student-patient relationship needs to be given primacy in professional identity formation as patients and their needs transform student apprentices into caring, solution-seeking clinicians who engage with rather than other patients in the therapeutic alliance.
An evaluation of the National Certificate (Vocational) Primary Health qualification for community health workers in South Africa
(University of Pretoria, 2019) Marcus, Tessa S.; u01264109@up.ac.za; Janse van Rensburg, Michelle Nedine Schorn
Background: In South Africa, the re-engineering of primary health care (PHC) includes establishing PHC teams, also called ward-based outreach teams (WBOTs), which consist of community health workers (CHWs) who perform health promotion, disease prevention and disease management in households in defined areas. The need to train CHWs properly has been recognised and various training programmes currently exist. A qualification developed by the Department of Higher Education and Training (DHET) to educate potential CHWs is the National Certificate (Vocational) Primary Health programme. Registered on NQF Levels 2, 3 and 4, subjects include Community Oriented Primary Care, Public Health, Human Body and Mind, South African Health Systems, English, Mathematics, and Life Orientation. It has been offered since 2013 on a full-time basis over three years at various Technical and Vocational Education and Training (TVET) Colleges across South Africa. In 2014 the Department of Family Medicine at the University of Pretoria entered into a partnership with the City of Tshwane and Gert Sibande TVET College to present the NC(V) Primary Health curriculum to a cohort of existing CHWs on a part-time basis over four years. Aim and objectives: This research aimed to evaluate the NC(V) Primary Health qualification to determine whether it is adequate, appropriate, effective, and relevant training for CHWs in PHC teams in South Africa. The objectives of the research were 1) to evaluate the NC(V) Primary Health programme; 2) to determine how the NC(V) Primary Health programme contributed regarding PHC provided to individuals and families in defined geographical areas, curriculated qualifications and human resource development, and individual learning, employment and personal aspirations; 3) to document lessons learnt from the implementation of the NC(V) Primary Health qualification nationwide; and 4) to make recommendations regarding CHW training for South African ward-based outreach teams. Methodology: The pragmatic evaluation used qualitative methods to gain information from participants in three provinces, from both the full-time and part-time offerings. There were 65 participants in the research, including TVET college managers, NC(V) Primary Health lecturers, curriculum experts, a government consultant, a PHC team leader, NC(V) Primary Health students, and existing CHWs doing the programme part-time. Thirteen in-depth interviews, seven focus groups, five written lecturer reflections, nine written student reflections, and various fieldwork notes were used as sources of data. Thematic analysis of data was performed, and relevant theoretical frameworks were used to make sense of the data. Various policy and curriculum documents were also analysed. Results: The NC(V) Primary Health programme was well-structured to produce workers with the required competencies in primary health. Students’ understanding and application of theory and practice contributed to growth in critical thinking and development of agency. Participants expressed deep commitment to and belief in the programme. Although the full-time programme did not have sufficient fieldwork learning opportunities, a unique strength was the interprofessional nature of teaching and students benefitted from exposure to various health professionals. Improving English, mathematics and computer skills were also advantageous. Hope at the possibility of second chances and a better future was evident, and some students were able to access further educational opportunities. The programme was regarded by participants as transformative, empowering and, thus, of value to communities. However, frustration and disappointment were apparent from those who had experienced criticism of their participation in the programme or when their learning and contribution was not valued in PHC teams. Disappointment and despondency were palpable among participants regarding the unfolding uncertainty about the future of the programme, and also their own futures. Conclusion: This study contributes to the ongoing discourse around the education and training of CHWs in South Africa. Careful, respectful and thoughtful regard must be given to the training as people’s lives – individuals, families, and communities – are deeply and directly affected by the training and associated vocational prospects (or lack thereof). CHW education and training programmes should be based on the community oriented primary care (COPC) approach and consider the capabilities of CHWs in context. Novel partnerships and interprofessional contributions will optimise education and training and produce well-rounded and competent CHWs. Structuring of programmes should be in line with the NQF to facilitate career progression and pathways. These findings are in line with policy recommendations from the recently published WHO ‘Guideline on health policy and system support to optimize community health worker programmes’. CHWs should not be underestimated and their voices need to be heard, especially in terms of their contributions and valuable work, their learning needs, and as advocates for the communities they serve. Keywords: NC(V) Primary Health, Community Health Worker, Education and Training, Primary health care re-engineering, Ward-based primary health care outreach teams
Understanding the role of maps in community oriented primary care (COPC) : a case study of mapmaking in ward-based outreach teams in Mamelodi
(University of Pretoria, 2018) Marcus, Tessa S.; Reyburn, Duncan; nina.honiball@up.ac.za; Honiball, Nina Marí
This study addresses an observable problem, which is that community health workers (CHWs) struggle to understand medical data maps and healthcare related statistics in community oriented primary care (COPC). COPC is a model of healthcare that was implemented in the city of Tshwane by the Department of Family Medicine (University of Pretoria), the City of Tshwane and Tshwane District Health (Gauteng Provincial Department of Health) as part of a national government drive to reform primary healthcare services in South Africa. COPC is an internationally recognised model of care that is patient-centred and focuses on bringing healthcare to the home. To address the above-mentioned problem, the purpose of the study was to explore if and how different types of participatory mapmaking projects and discussions about these maps could help healthcare team members to make sense of medical data and other healthcare related maps in a different way. The study was conducted in Mamelodi, a township located in the City of Tshwane, South Africa. Participants who took part in the study were nurses, CHWs and registrar medical doctors who deliver COPC. To gather data for the study, three participatory mapmaking projects were designed and implemented by both the researcher and those who took part in each project. In addition to the mapmaking projects, participants also took part in focus group discussions or semi-structured interviews and completed reflective writing about their mapmaking experience. The focus group discussions and interview data were transcribed, and a thematic data analysis was used to analyse both the transcriptions and participant reflective writing. Data generated led to the discovery of several themes, which were grouped under two headings: map and mapmaking and map discussions. Themes identified under the heading, map, included (a) identifying and locating information, (b) using the maps to plan healthcare interventions as well as (c) to assess and evaluate the performance of healthcare team members. Themes identified under mapmaking and map discussions were linked to more tacit qualities such as (d) learning, (e) group work, (f) idea generation and problem solving and (g) team motivation. Findings from the study reveal the value of working with both the map and mapmaking simultaneously to enable ward-based outreach teams (WBOT) to better understand both the work that they do and the area where they work. These findings have a significant value to offer in both the delivery of COPC as well as to other primary healthcare projects where maps and mapmaking can be utilised to not only improve service delivery but also to foster team building and workplace-based learning amongst healthcare service providers.
Civil servant and professional – understanding the challenges of being a public service doctor in a plural health care setting in rural South Africa
(University of Pretoria, 2014) Marcus, Tessa S.; Health Sciences theses SDG11; Gaede, Bernhard Martin
Using insider-ethnography the study is an exploration of the experiences of public sector doctors in a rural hospital in KwaZulu-Natal. In the context of a complex policy environment as well as a stressed public sector struggling to meet its constitutional obligations, the daily work of public sector doctors is at the civil service professional intersection. Engagement at this intersection is strongly influenced by the local context of the individuals and communities served. Interactions are also shaped by the local plural health care system where public sector doctors, private general practitioners and traditional healers form complex networks that are largely informal and dependent on personal relationships. The study uses Lipsky’s street-level bureaucracy as a theoretical framework to understand and explore the challenges of being a professional, a bureaucrat and a public official in the public health care sector. In interpreting the rules of their various roles they make many complex decisions that require considerable discretion. In this, their daily work as civil servant doctors remains largely regulated and managed locally by the doctors themselves. The convergence of the roles of professional and civil servant provides public sector doctors leverage to synergistically use discretion individually and collectively within their daily work. While discretion is abused at times, in the setting of a larger system struggling to deliver services, many of public sector doctors voluntarily align their activities and practices with the ideals of providing a high quality care to the population served. In this discretionary practice is vital for the service to function. While bureaucratic and professional standards of practices create distance and detachment from the people they serve, in their interaction with colleagues and the public care and caring is evident. Critically, caring is contingent on the space that discretion provides doctors to engage. These findings have considerable implications for how the work of public sector doctors is conceptualized, planned and managed.

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