South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge. The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model. The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes. The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process.

Background: An integrated chronic disease management (ICDM) model consisting of four components (facility reorganisation, clinical supportive management, assisted self-supportive management and strengthening of support systems and structures outside the facility) has been implemented across 42 primary health care clinics in South Africa with a view to improve the operational efficiency and patient clinical outcomes.Aim: The aim of this study was to assess the sustainability of the facility reorganisation and clinical support components 18 months after the initiation.Setting: The study was conducted at 37 of the initiating clinics across three districts in three provinces of South Africa.Methods: The National Health Service (NHS) Institute for Innovation and Improvement Sustainability Model (SM) self-assessment tool was used to assess sustainability.Results: Bushbuckridge had the highest mean sustainability score of 71.79 (95% CI: 63.70–79.89) followed by West Rand Health District (70.25 (95% CI: 63.96–76.53)) and Dr Kenneth Kaunda District (66.50 (95% CI: 55.17–77.83)). Four facilities (11%) had an overall sustainability score of less than 55.Conclusion: The less than optimal involvement of clinical leadership (doctors), negative staff behaviour towards the ICDM, adaptability or flexibility of the model to adapt to external factors and infrastructure limitation have the potential to negatively affect the sustainability and scale-up of the model.

Context: Oral health knowledge, beliefs, and attitudes of parents have a direct influence on their child’s oral health maintenance, dietary habits, and oral health behaviors. Aim: The aim of this study was to assess the knowledge, and attitude of parents with regard to the oral health practice of their children and its associated factorsMaterial and Methods: A self-administered structured questionnaire was administered to parents or guardians of learners aged 5–12 years at a low socioeconomic rural primary school in the Ugu district, KwaZulu-Natal, South Africa. In addition to demographic variables, knowledge of dental health, use of toothbrush, use of toothpaste, dietary practices, and dental visits; practice with respect to dental care; and attitudes toward oral health were requested. Results: One hundred and forty-four completed survey instruments were received with an 80% (118) representation of mothers. Ninety-five percent of the parents (136) had a positive attitude toward oral health with 86% (124) of the children brushed their tongue and 89% (128) of the children brushed their teeth happily. The mean knowledge score was 70%. Children were significantly more likely to brush their tongues (adjusted odds ratio [AOR]: 3.20 95% confidence interval [CI]: 1.06–9.66 P < 0.001), be happier when brushing their teeth (AOR: 4.65 95% CI: 1.41–15.38 P < 0.001) when the caregivers were their mothers, had an above-average knowledge score (AOR: 1.86 95% CI: 0.72–4.85) and positive attitudes (AOR: 3.20 95%CI: 0.46–22.00). Conclusion: Parents in the rural community have satisfactory knowledge and a positive attitude toward oral health and children display good practices; however, there are a number of gaps noted in overall parental knowledge.

INTRODUCTION: Self-referrals to inappropriate levels of care result in an increased patient waiting time, overburdening of higher levels of care, reduced primary healthcare utilisation rate and increasing healthcare costs. Furthermore, self-referral places an additional encumbrance on various levels of care as allocation of resources and infrastructure cannot be accurately planned, based on the facility catchment population. The aim of this study was to determine the prevalence and determinants of patient self-referral at the out-patient department of Stanger Hospital, KwaZulu-Natal between January and June 2017. METHODS: a cross-sectional study was conducted at the out-patient department in Stanger Hospital, using interviewer administered questionnaires to collect information from 385 patients, through convenience sampling, between January and June 2017. Multivariable regression analysis was used to test for factors associated with self-referral. RESULTS: of the 385 patients interviewed 36% (n = 138) were self-referrals. Most of the self-referrals were male (51.5%) and of the African race (57.2%). Five institutional factors namely: care received from healthcare workers (91.3%); waiting times (88.4%); help offered (87%); treatment and attitude of healthcare workers (63%) and availability of medication (55.8%) were considered as the main drivers of self-referral. Multivariable regression analysis established a significant positive association between patient self-referral and age (40 years and below), attitude of healthcare workers, quality of care received form healthcare workers, waiting times and the availability of diagnostic tests. CONCLUSION: this study indicates that most patients attending Stanger Hospital do comply with the prescribed referral pathway, however a significant proportion still bypass the referral system.

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020–March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35–44 years (OR: 3.38; 95%CI: 1.15–9.88), >55 years (OR: 4.75; 95% CI 1.08–21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08–4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

Background: Tuberculosis (TB) is the most common presenting illness among people living with human immunodeficiency virus (HIV), with co-infection occurring in up to 60% of cases in South Africa. In line with international guidelines, South Africa has adopted an integrated model at primary healthcare level to provide HIV and TB services by the same healthcare provider at the same visit.Aim: The aim of the study was to conduct a rapid appraisal of integration of HIV and TB services at primary healthcare level in eThekwini District in 2015.Setting: The study was conducted in 10 provincial primary healthcare clinics in the eThekwini Metropolitan Health District in KwaZulu-Natal Province.Methods: An observational, cross-sectional study was conducted. Key informant interviews with operational managers and community health workers were conducted, as well as a review of registers and electronic databases for the period of January to March 2015.Results: Two clinics complied with the mandated integrated model. Three clinics were partially integrated; while five clinics maintained the stand-alone model. Possible constraints included reorganisation of on-site location of services, drug provision, TB infection control and inadequate capacity building, while potential enablers comprised structural infrastructure, staffing ratios and stakeholder engagement.Conclusion: HIV and TB integration is suboptimal and will need to be improved by addressing the systemic challenges affecting health service delivery, including strengthening supervision, training and the implementation of a change management programme.